How Far Can I Move Jaws Forward for Sleep Apnea? Ceph for Review

[thedude]

Hey guys,

Any thoughts on what the best plan of action is given my anatomy? I have really stubborn sleep apnea so I would like to move my jaws as far forward as possible. I'm a little worried that counterclockwise rotation is going to look bad since I already have a flat occlusal plane but it sounds like it's the best for expanding the airway.

[Post bimax]

Looks like CCW or a genioplasty is out of the question for you.  Linear MMA (bimax) seems like the best option.

CCW is only 'better' for the airway in that it allows for more advancement of the mandible per unit of maxilla advancement, which is usually a big aesthetic concern for people with sleep apnea.  Generally, sleep apnea patients have a recessed chin/mandible and steeper occlusal plane coupled with a smaller airway.

Honestly things look so good other than your apnea that it's a shame you have to do anything.  It's hard to give an exact number for how far you 'could' be advanced.  Really it will depend on what the surgeon is willing to do, and what aesthetic changes you are willing to tolerate.

Be advised that linear MMA is going to make your nostrils more flared and your philtrum may be come flat or convex, which could make it appear longer.

Since you don't need CCW (IMO), don't worry about splurging on one of the top 5 docs who do complex movements.  Any good, experienced surgeon should be sufficient.  My very rough estimation would be a range of 5-7mm. But be careful.  More advancement means bigger airway, but also more potential aesthetic downsides.

[kavan]

I would say linear advancement with a diagonally down and out genio to offset the shortness of the lower '1/3rd'.

[thedude]

That is good to hear that straight bimax might be the way to go and that it’s a less complicated surgery. Counterclockwise is going to lead to that weird cross faced look where it’s like your mouth is pointed in the opposite direction of your eyes right? I’m telling myself fixing the apnea is worth it at any cost but maybe a few extra mm of advancement isn’t worth that sacrifice.

From what I have gathered it seems like the most anyone seems to move the maxilla forward is about 7mm, and that with straight advancement over a flat occlusal plane that probably would lead to around 10-12mm of advancement of the mandible. I’m hoping with orthodontics creating a 3-4mm overjet I could get about 15mm advancement of the mandible. I kind of have 15mm of lower jaw advancement in my head as the minimum of being enough of an improvement to make the surgery worthwhile.

I agree my ceph X-ray looks misleadingly good, but unfortunately there just isn’t room for my oversized tongue and excess soft tissue. I had almost continuous orthodontics from age 5-15, including bizarrely having my palate reduced in width at a young age to close a gap in my front teeth, and then the usual retrusive headgear, braces and retainers. Seeing how good looking and healthy I was at 5 compared to how things turned out really is the most depressing thing ever.

[Post bimax]

It's possible to move the maxilla further (my own operation included 10mm advancement).  IMO you're just risking a lot aesthetically after a certain point.

Also, Kavan's suggestion of the 'out and down' genioplasty is useful for balancing the lower 3rd if you think it's short as well as giving you more advancement.  Your chin is already pretty strong at least from the CEPH though, so use discretion.

[thedude]

That’s good to know. I wish I could better understand how the larger upper jaw movements affect aesthetics. I cannot seem to find good examples of people going too far with that. I’ve looked at a lot of underbite cases with presumably large upper jaw movements and none have shocked me. Usually it is the opposite it looks to me like they set the mandible too far back and I’m like ugh I would have just kept the underbite. I always figured it must be some limitation other than aesthetics. Are the consequences really that bad?

Thanks for the tip on the genio too. If you look close on that X-ray you can see I had a chin implant years ago hoping to extend my face downward which obviously didn’t work at all and was a horrible mistake. I’ve wondered if a genio would be necessary since it seems like moving the lower jaw forward strengthens the lower third a bit on its own. So I appreciate the input. You guys are good.

[Post bimax]

That’s good to know. I wish I could better understand how the larger upper jaw movements affect aesthetics. I cannot seem to find good examples of people going too far with that. I’ve looked at a lot of underbite cases with presumably large upper jaw movements and none have shocked me. Usually it is the opposite it looks to me like they set the mandible too far back and I’m like ugh I would have just kept the underbite. I always figured it must be some limitation other than aesthetics. Are the consequences really that bad?

Thanks for the tip on the genio too. If you look close on that X-ray you can see I had a chin implant years ago hoping to extend my face downward which obviously didn’t work at all and was a horrible mistake. I’ve wondered if a genio would be necessary since it seems like moving the lower jaw forward strengthens the lower third a bit on its own. So I appreciate the input. You guys are good.

I'll PM you

[kavan]

TBH, For the most part, I avoid giving someone an exact mm measure because the concepts behind how a number is arrived at are more important. Besides, imagine some people just getting a number and then telling their surgeon they exactly need 'X' mm and 'because someone told them so on the internet'.

What I look at are ANGLES which are not actually mm measures. However, mm measures as to advancements are FUNCTIONS of what the angles are and how they are to be changed via the surgery.

what I can tell you, is what you probably know already which is that you are LOW ANGLE for both OP and MPA. On CLOSER INSPECTION, your maxillary plane; (ANS-PNS) is oriented in the CCW direction. So, that combo veers in the direction of getting a CLOCKWISE rotation. For example, the max. plane angle is approx 6 deg in CCW direction. The OP is approx 0 deg and MPA approx 14 deg. A CW rotation to bring your maxillary plane closer to 0 (meaning closer to the horizontal plane) would bring the OP closer to the norm and yOUR MPA closer to the norm. So, with a CW rotation of maxillary plane, linear advancement from THERE would be preferable to linear advancement (in your case) over your present maxillary plane angle.

With that, will come some 'straightening' of the nose to lip conCAVITY which will go towards getting closer to norm for nose to lip angle. So, there is some 'room' to advance maxilla along very close to a horizontal plane if it's present CCW orientation is counter rotated to be closer to the horizont. Do that and the bimax advancement could be linear to GOOD effect UNTIL it reaches a mm amount where the nose to lip angle goes beyond 90 deg.

Now, under those circumstances that would be favorable to your aesthetics, what the near equal bimax linear advancement would be (after the maxillary plane was de rotated to be closer to 0 inclination with horizontal plane) will depend on how much they need to open the airway/s.

I've read that an adequate posterior airway diameter is about 12mm. Your airway on the ceph doesn't look like a narrow straw. But your airway diameter would need to be a KNOWN in order to know how many mms to increase it which, in turn would directly relate to how many mms the maxilla would need to be advanced. IF Not 'that much', THEN an overall aesthetic improvement could be had. IF 'a lot', then with that can come trade off conVEX nose to lip contour.

That said 'How far can you move your jaws...' (and get an aesthetic improvement from it) in terms of an 'exact' mm amount will depend on an UNKNOWN (to anyone on here) which is your present airway diameter.

[thedude]

Another thing I was wondering is how much extra lower jaw advancement I could I get by getting orthodontics first to move my lower teeth back, where were flared forward for cosmetic reasons. The one surgeon I consulted kind of scoffed at the ides and said 2-3mm, but it looks to me like it could be more. Can you ever tell by that xray?

I am having some difficulty getting this surgery approved by my insurance and have read of people "compensating" their bite first with orthodontics to give themselves a deep bite and qualify that way as well. Does that seem remotely possible in my case?

[GJ]

It doesn't look like you have much room to move teeth, unless you go the route of extracting lower premolars.
Agree with the others linear looks like the best approach, but you risk the chimp issue and overadvancement when dealing with apnea. They will advance you far enough to correct the apnea, and that might be too far to be aesthetic...

[PloskoPlus]

If your occlusal plane is flat, chimp is much less likely. I've seen 10mm advancements on a flat occlusal plane with not a hint of chimp lip.

[kavan]

It doesn't look like you have much room to move teeth, unless you go the route of extracting lower premolars.
Agree with the others linear looks like the best approach, but you risk the chimp issue and overadvancement when dealing with apnea. They will advance you far enough to correct the apnea, and that might be too far to be aesthetic...

'Far enough to correct the apnea' doesn't look too far at all. Take a look at his airway. The OP's airway looks pretty open to me compared to a lot of narrow airways I've seen on here from people with apnea.  If he gets the (linear advancement) surgery, they might not need to advance him much at all to increase the airway (correct tha apnea) which would put his chimp lip risks on the low side because the mandible advancement needed would be on the low side too.

To the OP:

If you are having a hard time with the insurance approval for bimax advancement, my hunch is that they might not be seeing a narrow airway on the ceph.

[thedude]

Do you guys have any recommendations where to get this surgery done if you're going to have to foot the hospital bill for this? So far it seems like most hospitals charge around $160,000 for the procedure, and some will take half of that off if you're paying out of pocket.

I know one particularly well know forum member had his surgery done with Sinn in his office. I wonder if that was under general anesthesia or deep IV sedation. With sleep apnea the latter would make me nervous since airway collapse is the biggest risk with in office dental IV deep sedation.

I'd even consider going out of the country, but would really rather not. I was thinking Alfaro in Spain had a good reputation for sleep apnea cases. It looks to me like he operates out of his office as well though with the same riskier deep IV sedation.

Are there any surgeons in the US that have negotiated a reasonable out of pocket rate with hospitals in the US? There must some option in the US for paying entirely out of pocket without a $160,000 hospital bill.

[ArtVandelay]

I was thinking Alfaro in Spain had a good reputation for sleep apnea cases. It looks to me like he operates out of his office as well though with the same riskier deep IV sedation.

Alfaro's office is inside a hospital, http://www.teknonbarcelona.com/

[ODog]

If your occlusal plane is flat, chimp is much less likely. I've seen 10mm advancements on a flat occlusal plane with not a hint of chimp lip.

My OP was flat and I got a bit of a chimp lip with 6 mm advancement.