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My Double Jaw Surgery: The Why

January 31, 2018

Jaw surgery (called orthognathic surgery) is no small endeavor.  Especially double jaw surgery (upper and lower jaws being moved concurrently).  There are many risks and the recovery can be intense with risk of permanent nerve damage, significant post-operative swelling and pain, and very strict diet protocols.  Despite being in the dental field and knowing these things, I just went through my own procedure in an effort to treat my narrow airway, in an effort to treat a lifelong sleep issue. 

 

Even as a child I considered myself a "poor sleeper", but with no history of snoring, sleep apnea was never on my radar.  It wasn't until several years ago when I started listening to dental podcasts which address this issue, that I actually considered that I may be suffering from sleep apnea.  I finally did a home sleep test about 2 years ago and it reported severe apnea, and it was indicated that I go for an in-office overnight lab test with a sleep physician.  Despite being hooked up to many machines and having someone watch me on a monitor all night, I recall feeling like I had actually had one of my better nights of sleep that night.  The doc asked me how many times I felt like I had woken up in the middle of the night, and I told him I thought it was slightly less than normal.  I had been tracking my sleep patterns for quite awhile using apps on my phone and usually felt as though I was waking up an average of 30 times per night but that I night I thought it was closer to 25.  He informed me that I was very close in my guestimate, and that the actual number of times I physically woke up was 27 times that night.  What I didn't realize though was how often my brain was waking up even though I wasn't conscious of it.  It turns out my AHI (Apnea Hyoponea Index) was 50, which is considered severe.  This means that almost once a minute my brain is deprived of oxygen enough that it cannot go into normal sleep patterns.  Basically, my brain wakes up many more times than I do consciously.  

 

Sleep apnea may be commonly overlooked, but is a major medical concern due to its association with many other long term health conditions. 

Plus, it's just no fun to wake up not feeling well-rested on a regular basis.  I'm lucky, as I've been able to compensate for this pretty well - people often comment on how much energy I have, and it's true - I don't slow down much.  But I just think about how much more energy I could have: maybe I would feel less irritable after a long day, maybe I would have more patience, maybe I could drive for more than an hour without feeling exhausted, maybe my memory would improve, maybe it could help me live longer and spend more time with my grandchildren and great-grandchildren down the road.  It was time to start doing something about this problem. 

 

Unfortunately, there are not a lot of treatments for severe sleep apnea in my case.  I already had my massive tonsils and adenoids removed many years ago, but as you can see here they are a common risk factor. 

 

Sleep medications are generally only meant to be used short-term, and when I did use them I felt like I fell asleep faster and I slept for longer periods, but never actually felt like I awoke rested.  I was not overweight and it was not a soft palate issue.  I was not a good candidate for an oral appliance, so that left me with the options of no treatment, a CPAP, or orthognathic (jaw) surgery. 

 

I had done no treatment for years, and that hadn't been great for me, and I kept jaw surgery on the back burner just in case.  Afterall, I never had braces growing up since my teeth appeared fairly straight, although I was aware that I had a unilateral crossbite, which means that my mandible was wider than my maxilla on one side - basically my hard palate and maxilla were too narrow.  So after dental school I looked into having orthodontics done and was told I would be an orthognathic case due to my narrow maxilla.  So when in the Army, I started to go through the planning process of having this done, although at the time I knew I had sleep problems but was not aware of the apnea.  It didn't end up working out for several reasons, and it turned out to be many years later when I seriously reconsidered it again, but this time to treat the apnea.  

 

In the meantime, I've been using a CPAP for about a year and a half, and it took me about 9 months to find a mask I liked.  I tried about 15 masks, and they all had their challenges.  My apnea was particularly severe when in REM sleep, so my machine would autocorrect and force more air when I needed it - but on every mask I tried, the mask would leak air in the middle of the night and the heavy airflow and squeaky air sounds would wake me up multiple times.  The nasal pieces would simply fly off my face.  I tried taping my mouth shut to decrease air escape through my lips, although this was not recommended by my doc.  Didn't have much success with that, plus it's annoying to do and supposedly could be dangerous.  I tried a chin strap to put pressure on my lower jaw, again to help prevent air espcape out of my lips, and I did finally find one I liked and used that consistently.  What I ended up with was a mask that covered both my nose and my mouth and had a foam cushion, and put the chin strap around that.  I'm a side-sleeper though, so even with the chin strap the mask would still move around at night as I flipped to a new sleep position, and would wake me up.  My sleep doc worked with me patiently through all of these issues and we finally went to a continuous pressure that I could tolerate, rather than a variable pressure that ramped up when I needed it most, which was during REM.  This was a compromise though, as I was still having apnic events when in REM since the pressure wasn't actually ramping up during those times. 

 

Nevertheless, despite the inconvenience, bulkiness, embarrassment (my husband lovingly/jokingly referred to me Darth Vader as I would don the mask each night), and awkwardness of wearing the CPAP, I do have to admit that I slept much better with it than without it.  So much so that even if we just left for an overnight trip I would bring it with me.  Despite a definite improvement in sleep quality, I still only had a handful of nights where I felt well-rested with the machine.  Which brought me back to months of pondering orthognathic surgery. 

 

I finally got a 3D scan and check out how narrow my airway space is at the base of my tongue!  Just 3mm!!!

No wonder I was having sleep apnea!  During the day the musculature will compensate for this, but at night the muscles are relaxed and this already narrow airway gets worse!

 I started talking to some orthodontist friends about my case, and began gathering some data.  Initially, I thought there may be an option to be treated non-surgically, through palatal expansion.  There are not many orthodontists that do this on adults, as it's a pretty new procedure.  It turned out though that this would not provide the forward expansion that I needed and I would need orthognathic surgery anyway.  

 

Here's the pre-invisalign pic.  You can tell the upper teeth all have a lingual inclination (angle inward toward the palate) and that the maxilla is a bit narrow.  In dental terminology, we would say that my buccal cooridoor was too large - see how my beautiful friend, Robyn, has the corner of her lips more filled with those pearly whites?  Well that, my friends, is something that this surgery would help me to fix aesthetically.

 

After deciding on my orthodontist (Dr. Camille Walker from Walker Orthodontics) and my oral surgeon (Dr. Brett Ueeck from Sunset Oral Surgery), we all agreed upon an invisalign surgical case.  We knew that the maxilla and the mandible would both have to be brought forward about 10mm and that the palate would need to be expanded as well.  These procedures are called a BSSO (Bilateral Sagital Split Osteotomy) for the mandible:  

and a 2 piece Lefort 1 for the maxilla:

I got the invisalign started and the first week, boy did I think I was in trouble!  They were SO sore. 

I could hardly get them out as it felt like I was extracting my own teeth!  Then magically, one day after about a week, the pain started to dissipate.  Then it only came on when I changed to a different tray set, which was about once every 10 days, and then it only lasted a day or two.  And after several months of doing this, they stopped hurting even with new trays, thank goodness.  Here's a pic with the trays in.  See how they are starting to straighten out already and fill in the void at the corners of my mouth?  That buccal cooridoor is decreasing!

 

Part way through the teeth movement phase, I started to notice that my lower front teeth were showing signs of root recession.  This was not a big surprise to me, as my gum tissue is naturally very thin, called a thin biotype.  Plus 3-D imaging had shown that I have very thin bone around these teeth in particular, again, no history of a problem in the area, I just naturally have thin jaw bone in that area,  So it was time to have my awesome periodontist partner, Dr. Duy Anh Tran, perform some of his magic.  He did a gum tissue allograft (human donor tissue) from #20-29 (lower premolar across the arch to the other lower premolar).  The nice thing about this is that he did a conservative tunnelling procedure where the incisions are all in the natural pockets around your teeth anyway, so there are no large open wounds.  Did it on a Friday and I was back to work by Monday, never took any pain meds other than a few ibuprofen.  I was strict about a liquid diet for a week, and it healed very well.  However, we started to move my lower teeth buccally (meaning towards the lips) again, which again created more recession, but I knew I was going to need to wait until after the double jaw surgery before we could do a second procedure to help correct this.  

 

So we continued through the first set of invisalign trays until we got the bite well aligned for the upcoming surgery.  I was in a holding pattern for about 2 months prior to the surgery date because the surgeon needed to time to evaluate the models and use his software to make sure that the bite would indeed align after the surgery, and if we needed to make any changes we would still have time to get those done without changing the surgery date.  I have patients of my own that often book their surgeries several months in advance, so it was important for me to try to stick with the original surgery date if possible since I was needing to take 2 full weeks off for healing. 

 

And one day it hit me that I was actually going to have my mouth and face undergo a huge transformation.  So I needed to start getting ready.

 

 

 

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