Information and Explanation, Part II

About the surgery:

While I would be lying if I said that this surgery wasn't completely about my appearance, I have discovered symptoms of other medical problems that could be abated or eliminated with this surgery. Not only is my occlusion a problem, I'm also facing a more serious medical problem.

Originally, I was worried that this condition was causing the bruxism (grinding of the teeth) that was causing damage to the occlusal surface of my right mandibular first bicuspid. However, this is not the only dental problem I've been having. Thanks to the mouth breathing, I've also been having periodontal problems. The last two dentists that I have seen have both agreed that inflammation of my gums is caused by my mouth breathing, and this is in spite of brushing and flossing 3 times a day. This, however, pales in comparison to the reason why my physician gave me the referral. The mouth breathing is an indication that I'm still not getting enough air into my lungs, despite a recent septoplasty. Sinus congestion can be partly to blame, but there is still a physical aspect of the diminished sinus area that I have which is causing or contributing to obstructive sleep apnea (OSA).

Sleep apnea is a disorder characterized by pauses in breathing of the patient. One or more breaths are missed for a period of 10 seconds or longer and this can occur several times during a person's normal sleeping period. The patient is often forced to wake up, often several times, during the night, though many people are not aware of ever waking.

Obstructive sleep apnea differs from central sleep apnea, or Cheyne-Stokes respiration, in that OSA is caused by some obstruction in the airway. Central sleep apnea is caused by an imbalance in the brain's respiratory control center. Neurological feedback mechanisms monitor the levels of carbon dioxide in the blood but fail to react properly to keep even respiratory rates. The body will try to compensate for the apnea by increasing the breathing rate (hyperpnea) when breathing has restarted to acquire oxygen and eliminate waste gases. (Episodes may also happen when the patient is awake.) In central sleep apnea, no effort is made to breathe during this pause in breathing.

OSA is caused by some blockage to the airway. This could be caused by something as simple as the position that one sleeps in; the tissues of the throat (i.e. the tonsils or adenoids); being overweight or obese; the tongue or throat relaxing more than is normal; or physical attributes, such as a deviated septum, enlarged tongue and/or the shape of the neck and head.

In my own case, add the constant sinus congestion with the deformation of the bones of my skull which is causing a lack of air being drawn through the sinuses. There's been plenty of mornings I have woken up even after getting 9-10 hours of sleep and still feeling tired, unrefreshed and sleepy throughout the day. This might also explain the dizziness that I feel waking up most mornings. Originally, I thought the feeling of waking up with the feeling of a hangover from an all-night bender when I hadn't been drinking was a result of my cholesterol medication. This has given me pause. OSA may also be contributing to my hypertension. This surgery, as you will read later in the description of the LeFort I osteotomy, will help open the sinus passageway.

Pre-operative:

In order to prepare for the surgery, the Oral Maxillofacial Surgeon (OMS) will have you go to an orthodontist for braces. Often, this is an orthodontist that the dentist works with closely on surgery cases such as these.

Orthodontics is the field of dentistry where the teeth are aligned. Getting braces prior to orthognathic surgery is much the same as braces without the surgery - the goal is to align the teeth to match up and be straight. However, in this case, the doctors want your teeth properly aligned so that the bite will properly match when the surgery is complete. Often times, necessary pre-operative orthodontic treatment can make a patient's bite look like it's getting worse. It is, in a way, but this is not anything to become discouraged about as it is necessary for this surgery. Anyone who is thinking about going through this procedure should not worry about their appearance because the surgery should happen soon afterwards.

Do not be surprised if the orthodontist recommends having teeth removed. This will help increase the room for the teeth to get into position and can save you time wearing braces. In my own case, Dr. Graham stated that he could help me keep all of my teeth and get my maxillary right canine to be exposed for a balanced look. This would add months, if not years, to my pre-operative work, as well as present complications with getting my deviated midline corrected.

Surgery:

The general medical name for the corrective jaw surgery I am looking to have done is known as dentofacial osteotomy. What occurs in this surgery is bone is cut, modified, moved and realigned until it is in the proper place to enable the patient to chew, talk, breathe properly, swallow, etc.

Dentofacial osteotomies have been in use since the 1940's and were developed to correct malocclusions and maxillary and mandibular prognathisms. Technology for these surgeries has greatly improved resulting in ease for the surgeon and comfort of the patient.

20 years ago, I was told that I would be looking to have a surgery known as a bi-maxillary osteotomy. This is actually 2 surgeries, usually performed at the same time; the LeFort I osteotomy and the sagittal split osteotomy.

Le Fort I Osteotomy: this surgery, as well as the LeFort II and III surgeries, were named after René Le Fort (1869 – 1951), a French army surgeon who developed a classification system for fractures of the bones in the face that were usually caused by some form of trauma. The three LeFort surgeries can all be used to adjust the facial area. A LeFort I fracture usually runs above the teeth of the maxillary arch from just below, or including, the nasal entrance.

The LeFort I surgery recreates this type of fracture, but in a controlled setting. When this surgery is performed, it allows mobilization of the palate so that it may be moved up, down, forwards or backwards. Not only does this help to increase the area of the midfacial region of the patient, it also helps to open the sinus cavity, allowing more air through. In my own case, my physician believes that this will help with my obstructive sleep apnea (OSA).

This surgery would be used to bring the maxilla forward and down. My maxillary incisors are behind the mandibular incisors with an open bite (an open space between the maxillary and mandibular incisors) greater than 7 millimeters. The mandibular teeth also come up in front of the maxillary teeth over 5 mm making the upper teeth look completely covered.

Sagittal Split Osteotomy: This surgery is used to correct both overbites and underbites by moving the mandible forward or backward. In my own case, the jaw would be moved back. Cuts are usually made at the bottom of the jaw, usually near the molars, and then up to the center of the jaw and straight back to the ramus (the trapezoidal-shaped part of the bone that connects the jaw to the skull). This keeps as much bone contact as possible to facilitate healing.

The surgeon uses specialized electric saws and burs, as well as manual chisels for this operation. The purpose is to use the saws and burs to make incisions in the bones, but not go through the nerves. When the desired cuts are made, the surgeon then uses the chisels to break apart the bones, sparing the nerves from being severed. However, this does still result in trauma and many patients will feel numb for days, weeks or months after surgery - in some rare cases, the numbness is permanent.

In the case of patients having this surgery to correct an open bite, bone grafts will be used to help fill in the space that is left open between the bones that were cut. The material for the grafts usually comes from the patient's hip. There are also artificial bone materials that can be used. I may need this if the maxilla is moved down to help correct the vertical displacement of my incisors.

When the surgery is completed, the doctor places metal plates and screws to assist in keeping the patient's bones in their proper places until the bone heals. The surgeon will also most likely keep the patients jaw shut. Originally, this was done with wire, and someone having this surgery done would have to carry around wire clippers in the event of vomiting. With the advances in surgery, many surgeons now use heavy elastic bands to keep the teeth together. Also, with the introduction of rigid internal fixation, the amount of time that a patient spends with their jaws closed shut has been greatly reduced.

Post-Surgical:

Once the surgery is completed, you will still need to be seen by the orthodontist. This is to continue to ensure that the teeth are put into their final positions after surgery, as well as to fine tune the occlusion.

Often, the surgery will result in an appearance that is not only different from what the patient originally looked like, but will result in a look that is much more "normal." In some cases, the difference is dramatic, resulting in a heightened sense of self-esteem for most patients. The change in appearance is so great for some, people who have known the patient their entire lives don't even recognize them. Some patients are recommended to see a psychologist during this process.

http://en.wikipedia.org/wiki/Dentofacial_Osteotomy