Advices needed on potential aesthetic complications (jaw surgery for OSA / UARS)

[rafaaa]

Hello everyone !

Hope you are doing alright in these troubled times.


-- BACKGROUND

So after a lot of fight with the medical world, I got diagnosed with mild OSA / UARS at 21yo. I am fit, and healthy (173cm for 62kgs). My father most likely has sleep apnea, because of lack of jaw and a lot of soft tissue genetic. (bulldog look).
I had braces when I was younger, because my teeth were really crowded / crooked, but my bite is okay. I do have TMJ a lot, when putting headset for example, or doing nothing special.
I had this sleep issue probably since primary school, I was dozing in class all the time and always felt absolutely awful. But due to poor parenting and my ADHD preventing me from napping, it was not seen. After getting Crohn, I got to 32kgs, with a look like model jawline, but sleep wasn't better at all.
My symptoms now are severe. I can't list everything but this thing is becoming life threatening. I also had to drop out because of the physical and psychological toll this is putting on me.


-- Lack of jaw -> sleep issue

Anyway. I met with a maxillo facial surgeon who get me through all this process, sleep tests, etc. He told me right away that my issues were indeed coming from a narrow airway. My issues are not related to adenoids, nose, or anything.

My AHI was mild on the test (6), but it was not a normal night for me, and surgeon told me on the phone "do you want to do bimax, if you have severe symptoms, we can do it", which I was super excited, since I did not want to have a machine at 21yo.
Fast forward, I met with him, but he was looking stern.

---- Esthetic > function ?

He told me that we couldn't do bimax / ccw, because I have already an "harmonious profile", which I don't think is true (IRL pics at the end).
Where I live, they are used to do bimax only on high/severe apnea case and on people with severe bite issues.
He told me that this would not be worth it, and that it could result in a chimp lip look. So he offered me a genioglossus advancement and rhinoplasty, which I am gonna refuse.

I immediately went to a second surgeon, who went more thoroughly through my scans, and told me that indeed there was an esthetic risk, but that I did have a lack of jaw, despite a normal bite, and that it was causing the airway issues, and that 1st surgeon proposition would not change anything. He offered me to do a PSG study, to detect UARS which I have.
He did told me that, again, I could end up with a "chimp lip" look. But both surgeons didn't seem to really have think this through, they only told me about bimax but not about CCW, for example. I trust the surgeons with their job. But if my issues come indeed from my "lack" of jaw, I have a hard time thinking that a jaw surgery wouldn't be worth it, and that esthetic wouldn't follow function.

Therefore I am looking for advices on how we could mitigate this esthetic issue while still getting the right airway.
I think the issue is that I got already big lips, my chin is basically the only "forward" movement on my face, and my jaw is ridiculously steep / lack horizontality. I also believe that the orthodontic and braces done younger might have pushed my teeth forward, because of the lack of space inside my mouth. Though this also might be a s**tty theory. I am open to discussion !

Obviously, I trust surgeons about this issue. I just wonder if more could be done about it. They really didn't "try", either because didn't take sleep issues seriously (UARS barely recognized in France), or lack of time (second surgeon).

PS: this is not a post about whether or not I have OSA/UARS, and what could cause it, please do not suggest "try to lift" or "diet", as experienced on reddit  . I also apologize for any orthographic mistakes, english isn't my first language, and writing with sleep issues and ADHD isn't easy

IRL pics : https://imgur.com/a/kPZidXX
3D xrays : https://imgur.com/a/t5W1nUS

[kavan]

It's sounding like 'where you live' they don't do the CCW-r via posterior downgraft. Sounds so if they are citing aesthetic risk of 'chimp lip' which is usually associated with advancing the upper jaw the same amount the lower jaw would need to be advanced to open the airway in situations where the upper jaw is advanced over the aesthetic limit of what would look good.

Lots of people on JSF end up TRAVELLING to docs known to do the CCW-r posterior downgrafts when seeking an opinion as to if they are a good candidate for that when the situation is one where local doctors don't use the technique.

The board has a search function where you can plug in 'CCW' to find plenty of threads on that topic matter. There is also material to be found in the 'Educational' section of the board. Those should help with info and leads.

[rafaaa]

It's sounding like 'where you live' they don't do the CCW-r via posterior downgraft. Sounds so if they are citing aesthetic risk of 'chimp lip' which is usually associated with advancing the upper jaw the same amount the lower jaw would need to be advanced to open the airway in situations where the upper jaw is advanced over the aesthetic limit of what would look good.

I live in France, maybe they do it, idk.
 
Is this intervention the thing I would need, based on my X rays ?
I was wondering about where the problem was coming from. I actually learned a lot from people in these forums answering the specifity of everyone face, and it would really help me with describing the issue to my surgeon.
I am bit lost between orthodontics, if I got a jaw too "steep", or if my nose is the issue, idk.
Apparently the esthetic risk is specific to my case, as I have heard of other people without bite issues getting surgery from the same surgeons than me. But again, more severe OSA, and probably different facial structure. What are the specificities of my facial structure that would make this surgery "complicated" for me esthetically ? I have a hard time finding that everything is alright on my face, judging by both function and looks.
I thought that maybe dental work would make the upper jaw less prominent, but it comes from an ignorant POV.


I will absolutely look into the forum for more information about CCW downgraft, thanks a lot ! .

[kavan]

Presently, I'm just going by what you are conveying where it sounds like you haven't consulted with someone who does the CCW-r posterior downgraft. Hence, I'm suggesting you do and also take a look at the educational section.

[rafaaa]

Presently, I'm just going by what you are conveying where it sounds like you haven't consulted with someone who does the CCW-r posterior downgraft. Hence, I'm suggesting you do and also take a look at the educational section.

I will ask the second surgeon about this procedure then, and then reach out to the forum again.
I still don't understand where the problem / impossibility to do CCW and Bimax lies on my face though :/.
My philtrum doesn't seem flat, so is it my teeth being too much forward ? Or is my occlusal plane too steep ?

"wants to do LINEAR ADVANCEMENT of both jaws by an equal amount when both jaws DON'T 'need' to be advanced equally along their 'native plane'. Classic example of OVER advancement of the maxilla is in a sleep apnea case where one wants to expand the airway where instead of the doctor doing a CCW rotation of the maxilla to minimize unwanted maxillary advancement and maximize wanted mandibular advancement, maximization of the mandibular advancement comes with the aesthetic 'cost' of maximizing UNWANTED maxillary advancement AND along a NATIVE PLANE (diagonal) that's unfavorable to aesthetic optimization."

This is quoted from one of your comments. I think i might be my issue here. Normal bite and just a steep plane / really small lower jaw recession.
Weirdly, when I asked the surgeon about CCW rotation (no downgraft precision), he told me the chimp lip would still be an issue.

[kavan]

Please note that my volunteering to give you an INITIAL response was not an 'invitation' from me to also volunteer to 'unconfuse' you about your prior consults, nor to analyze and explain your cephs and at no time did I or do I volunteer to advise on the basis of what I said to an ENTIRELY different person on another post.

To be honest,I'm CUTTING DOWN on giving analytical type of advice to new posters unless I have good reason to believe from their initial entry that they demonstrate the type of foundation and basis I would need to give them more detailed information. Over 90% of the time, I'm finding that's not the case. Because I'm a VOLUNTEER here, I reserve the right to determine which information to volunteer.

That said, if you seek to know whether or not you are a candidate for CCW-r (posterior downgraft), then you need to consult WITH a surgeon who performs it.

[GJ]

The issue I am seeing with CCW is that your jaws are already pretty flat. In theory, CCW would allow fixing of the discrepancy, but I don't know if it's possible given the MMC angle.

If not, another option would be pulling two (second) premolars on the lower arch, and then advancing the lower jaw.

Usually this isn't a good idea, but it might be a viable plan in this case.

You clearly need to research these things more, and go on more consults, but this should at least guide you in a reasonable direction on what to think about, research, questions to ask on consults, etc.

[JourneyToSerenity]

I had this sleep issue probably since primary school, I was dozing in class all the time and always felt absolutely awful. But due to poor parenting and my ADHD preventing me from napping, it was not seen. After getting Crohn, I got to 32kgs, with a look like model jawline, but sleep wasn't better at all.
My symptoms now are severe. I can't list everything but this thing is becoming life threatening. I also had to drop out because of the physical and psychological toll this is putting on me.


-- Lack of jaw -> sleep issue

Anyway. I met with a maxillo facial surgeon who get me through all this process, sleep tests, etc. He told me right away that my issues were indeed coming from a narrow airway. My issues are not related to adenoids, nose, or anything.

My AHI was mild on the test (6), but it was not a normal night for me, and surgeon told me on the phone "do you want to do bimax, if you have severe symptoms, we can do it", which I was super excited, since I did not want to have a machine at 21yo.
Fast forward, I met with him, but he was looking stern.

Obviously, I trust surgeons about this issue. I just wonder if more could be done about it. They really didn't "try", either because didn't take sleep issues seriously (UARS barely recognized in France), or lack of time (second surgeon).

PS: this is not a post about whether or not I have OSA/UARS, and what could cause it, please do not suggest "try to lift" or "diet", as experienced on reddit  . I also apologize for any orthographic mistakes, english isn't my first language, and writing with sleep issues and ADHD isn't easy

IRL pics : https://imgur.com/a/kPZidXX
3D xrays : https://imgur.com/a/t5W1nUS

It's odd how UARS isn't well recognised in France given that, Dr.Guillemault, the father of UARS is French. It was observation of children in a French hospital that would lead him to believe children also suffered from sleep disruption...

Also, have you used CPAP/APAP? Has it made a difference? In my experience, it had no effect on my quality of sleep, in fact it probably compounded matters. Be interested to know if a UARS patient has had any success with it, I fail to see how it can be prescribed to people like us when our issues are due to anatomical faults.

[rafaaa]

It's odd how UARS isn't well recognised in France given that, Dr.Guillemault, the father of UARS is French. It was observation of children in a French hospital that would lead him to believe children also suffered from sleep disruption...

Also, have you used CPAP/APAP? Has it made a difference? In my experience, it had no effect on my quality of sleep, in fact it probably compounded matters. Be interested to know if a UARS patient has had any success with it, I fail to see how it can be prescribed to people like us when our issues are due to anatomical faults.

I have bought a APAP for myself recently, and it is making some difference. I do believe I would need BIPAP for more success. France is a really conservative country when it comes to education and medical field, that's probably why Master Guilleminault went to US.

[rafaaa]

Please note that my volunteering to give you an INITIAL response was not an 'invitation' from me to also volunteer to 'unconfuse' you about your prior consults, nor to analyze and explain your cephs and at no time did I or do I volunteer to advise on the basis of what I said to an ENTIRELY different person on another post.

To be honest,I'm CUTTING DOWN on giving analytical type of advice to new posters unless I have good reason to believe from their initial entry that they demonstrate the type of foundation and basis I would need to give them more detailed information. Over 90% of the time, I'm finding that's not the case. Because I'm a VOLUNTEER here, I reserve the right to determine which information to volunteer.

That said, if you seek to know whether or not you are a candidate for CCW-r (posterior downgraft), then you need to consult WITH a surgeon who performs it.

I apologize, I will seek more information then and come back when things are more clear .

Thanks !

[rafaaa]

The issue I am seeing with CCW is that your jaws are already pretty flat. In theory, CCW would allow fixing of the discrepancy, but I don't know if it's possible given the MMC angle.

If not, another option would be pulling two (second) premolars on the lower arch, and then advancing the lower jaw.

Usually this isn't a good idea, but it might be a viable plan in this case.

You clearly need to research these things more, and go on more consults, but this should at least guide you in a reasonable direction on what to think about, research, questions to ask on consults, etc.

Thanks a lot for your help.
I am taking a consultation soon for MSE as it appears nasal cavity / palate / airway issues could benefit a lot from it.
Maybe it could benefit my midface enough so DJS would have less esthetic issues ? I know MSE usually doesn't have dramatic mid face results, but it could make up for existing deficiencies ? Huge shot in the dark here for someone not educated ofc.

Sorry if I took so long to answer, received CPAP and was focused on tweaking things and doing research on it.

Again, thanks a lot .

[rafaaa]

The issue I am seeing with CCW is that your jaws are already pretty flat. In theory, CCW would allow fixing of the discrepancy, but I don't know if it's possible given the MMC angle.

If not, another option would be pulling two (second) premolars on the lower arch, and then advancing the lower jaw.

Usually this isn't a good idea, but it might be a viable plan in this case.

You clearly need to research these things more, and go on more consults, but this should at least guide you in a reasonable direction on what to think about, research, questions to ask on consults, etc.

Hello GJ !

A little update : I am going to have MSE + MSDO done to improve my nasal cavity and breathing (MSDO due to not being able to gain enough space on the mandible via sole orthodontics), for my UARS.
An ortho have found on my CT that my tongue was obstructing most of my throat, even standing.
So a surgeon actually offered "bimax rotation" like Sailer does (or Alfaro), which is CCW- posterior downgraft, coupled with genioglossus advancement to maximize the effect.
I asked the surgeon about MMC angle but I haven't got an answer yet, and I figured to come back with updates in the meantime. I am also surprised by this surgeon proposition since I don't know how he would rotate, but this surgeon is not the kind of guy to do desperate things and like every surgeon in France is REALLY careful about esthetics, overdoing things etc.

Do you think CCW Downgraft would be a good solution, or could be done ? On my IRL pics I don't have a lot of "horizontality" to my face, but it's no showing on my scans, where the plane looks alright. Maybe because of head posture ? My ear are pretty backwards.

Thanks a lot for your time !

[GJ]

How many consults have you been on, and how many jaw surgeons have you ran your case by?

I wouldn't rush into a treatment that involves the tongue. I've heard of many complications from those types of procedures. My advice is to see at least three jaw surgeons who do several jaw surgeries per week, and let them propose plans (i.e. don't tell them what the other surgeons said).

You can see the curvature of your back teeth. This is likely due to a tongue thrust, but IMO it's important to know why they have that shape before creating a treatment, else that could come back. Maybe they want to segment the posterior to flatten those teeth via CCW. I don't think that's a bad idea, if that's your question, but then again it might be better to do that orthodontically in the context of a full jaw surgery plan. Or it might not. But I'd get several opinions. I'm not saying the plan you got is bad. I have no idea without seeing the records. But I'm saying tread lightly with band-aid solutions such as tongue surgeries.

[rafaaa]

How many consults have you been on, and how many jaw surgeons have you ran your case by?

I wouldn't rush into a treatment that involves the tongue. I've heard of many complications from those types of procedures. My advice is to see at least three jaw surgeons who do several jaw surgeries per week, and let them propose plans (i.e. don't tell them what the other surgeons said).

You can see the curvature of your back teeth. This is likely due to a tongue thrust, but IMO it's important to know why they have that shape before creating a treatment, else that could come back. Maybe they want to segment the posterior to flatten those teeth via CCW. I don't think that's a bad idea, if that's your question, but then again it might be better to do that orthodontically in the context of a full jaw surgery plan. Or it might not. But I'd get several opinions. I'm not saying the plan you got is bad. I have no idea without seeing the records. But I'm saying tread lightly with band-aid solutions such as tongue surgeries.

I had three surgeons see my case. They all said MMA wasn't a good idea because of chimp lip risk. This one is the only one who knows CCW-downgraft, and bring this solution to me, I didn't ask for it.
I think he wants to do genioglossus advancement to maximize the curative aspect of this surgery for my apnea. The CCW is probably because of the risks of MMA in my case, but I haven't seen any case where the occlusal plane wasn't steep on internet, which makes me wonder about how it would work on a case like mine, both functionally and esthetically.
I was surprised to have MMA refused but CCW accepted, especially since french surgeons are really conservative.
I am super happy that he brought this solution to my attention, but no idea how it could be achieved in my case, and how would the results translate in esthetics.

I am going to come back when I have more precisions about this treatment proposition then. Like how many mm of rotation, etc.
Thanks a lot ! interesting matter.