Mandibular Advancement Jaw Surgery (BSSO) Case Study

Case Study – Sabrina
Mandibular advancement jaw surgery (BSSO)
Surgery date: February 12, 2008
Age at surgery: 32 years old

Hi, my name is Sabrina and in February 2008, I had my lower jaw broken, moved forward four millimetres and wired shut. Why would I do this, you ask?

It all started in 2003. I had a job with great benefits, so I decided to look into something that I had wanted to do for a long time: get braces. I had always wanted them growing up, so now that I had the resources, I was considering braces at the age of 27.

I made an appointment with an orthodontist to see what it involved. I expected it to be a few thousand dollars, half of which would be covered by my insurance, and maybe a year or two of braces. I did not get the answer I had been hoping for.

Instead, he told me that I had a Class II malocclusion (overbite) that couldn’t be treated with braces alone. I would need surgery to move my lower jaw forward, in addition to braces. The cost of the braces would be around $7,500, though the surgery would be covered by our provincial health care plan (hooray for Canadian health care!), as it is correcting a functional deformity of the jaw and not just for cosmetic purposes 

Here are before and after x-rays:

Before

After

This news caused me to politely run screaming in the other direction. I’d take my crooked teeth and overbite, thank you very much. So, I shelved that thought and went on with my life. Two years later, I was cast in the chorus of the Wizard of Oz, my first musical. However, this was a show with three-hour-long rehearsals, four times a week. Once the show opened, we performed five days straight, a day off, and then four more performances in a row. About this time, I started having horrible migraines and tension in my jaw.

Something the orthodontist had said came back to me. He had mentioned that some people with the same bite problem as mine end up having TMJ and migraine problems when they’re older. I wasn’t having any problems at the time, so I didn’t really pay attention to what he was saying. But now…

 

I met with the orthodontist again, two and a half years after my first appointment, and told him about my jaw problems. He took pictures and impressions of my teeth and referred me to a physiotherapist.

I didn’t know there were jaw physiotherapists before. What were they going to do? Did they massage your jaw muscles? Give you exercises to do? Or were there mini jaw weights to lift? I had no clue. But it was worth a shot.

I discovered that the procedure consists of someone pushing on the parts of your face that hurt, putting rubber-gloved hands inside your mouth and attempting to pull your jaw out of your head. Apparently, the musical theatre experience created tension in my jaw and made my TMJ problems worse. As the physiotherapist held my face, she kept telling me to stop clenching my jaw. “But it’s not clenched,” I said.
Her response: “Oh dear.”
Fortunately, the first session was the worst of it. My muscles were the tensest they’ve ever been before I went to physio. Over the five years in which I went regularly, I began to look forward to the sessions, as the relief I got from them was amazing. However, it soon became clear to me that the physiotherapy wouldn’t be enough. There was something wrong with my jaw, and I had to do something to fix the problem.

I went for a consultation with the orthognathic surgeon my orthodontist had recommended and asked him a ton of questions. The one that was most important to me was whether correcting my overbite through lower jaw surgery would also correct my TMJ problems. The surgeon said that there is a lot of debate on this topic in the orthodontic/orthognathic surgery fields. He said that there is evidence that people with overbites have more TMJ problems than other people. But, at the same time, there are people who have these bites who never have any problems. He also stated that, statistically, 90 per cent of people who have the surgery see their TMJ problems get better or stay the same, while 10 per cent of people’s problems get worse. Based on that information, it was up to me to make the decision.

The next day, I called and booked the appointments to have four of my teeth removed to prepare for the braces and surgery. Something in my gut very strongly told me that my bite was causing my problems. That, and I had been reading the online stories of others whose TMJ problems were helped by the surgery. Of course, there were some who had more problems as a result of the surgery, but, as the surgeon said, that does happen. Ten per cent is low, but it’s still a possibility.

I had braces on my teeth for two years before surgery. My teeth were in the proper position for surgery after about six months of braces, but because of the long surgical waiting lists surgery in my province, I had to wait. I was fine with that – it gave me more time to get used to the idea of the surgery, to research and to prepare.

I was given the surgery date (February 12, 2008) a month in advance. In that time, I made frantic preparations: booking time off work, making tons of pureed soups and freezing them, compiling recipes for soft and liquid foods from friends and family, and buying a really good blender. I also talked to health care practitioners: my naturopath ordered homeopathic remedies to help healing, bruising, swelling, scar tissue and nerve damage post-surgery; and I booked appointments with a manual lymphatic drainage massage therapist, who can help drain the swelling from the face after the surgery.

The big day came faster than I had imagined. I had to travel two hours to the city where my surgeon is based and stay in a hotel the night before the surgery. I went to the hospital in the morning and waited for three hours before going into surgery. In that time, I was asked the same routine questions several times by a number of different people. Right before the surgery, the anaesthesiologist and my surgeon spoke to me to make sure I understood the surgery risks and to answer any last minute questions I had. I made sure they all gave me a pre-surgery high-five. Anything to lighten the mood and keep my mind off all the things that could potentially go wrong.

One thing that surprised me about going into surgery was that I was not wheeled in on a bed like you see in the hospital shows on television. I walked into the operating room and lay down on the table myself. The table had two arm pads on either side. I stretched my arms out and waited for something to happen. The anaesthesiologist used a small needle to freeze the top of my left hand, then put in a very large needle for the IV (and missed the vein, which hurt and left a horrible bruise afterward.) Soon, he put an oxygen mask over my face.

I breathed into the mask. It was fine, until they let the anaesthetic loose in my veins. I felt as though I were drowning, choking on water. I felt like I was fainting and coming to at the same time, before I was hit by a wave of nausea. I started coughing and gasping for air and looked up pleadingly at the anaesthesiologist to save me.

“Don’t worry, Sabrina, we…” And then everything went black.

The next thing I remember is waking up in the recovery room. The room seemed wavy and spun around me. A nurse asked how I was doing. I mumbled, “High five” and held my hand up. I felt a bit of pain, but not much; however, my entire body was really itchy and I started scratching my face and arms. The nurse noticed, said the pain medication can cause that reaction, and added some Benadryl to my IV line. The itching went away quickly. My bed was then wheeled into my hospital room, where I would stay for three days.

A nurse brought ice packs to wrap around my head and introduced me to the morphine dispenser. Anytime I felt too much pain, I could push this button and it would dispense morphine. I quickly fell in love and named him George.

My surgeon came to visit later that day to tell me that the surgery went really well and there were no complications. I, of course, high-fived him.

After three days in the hospital and a two-hour drive back to my city, I was home. My jaw was wired shut for the next two weeks, which made eating very interesting. In the hospital, I was given a syringe and tubing that I could manoeuvre behind my back molars to get liquids like soup and smoothies into my mouth. I also had special jaw surgery feeding bags with tubing.

 

It took a long time to eat anything, but it wasn’t as bad as I thought it would be. There are always milkshakes, smoothies, soup, hot chocolate with whipped cream, and pudding. Plus, when you’re hungry enough, you’ll put just about anything in a blender (I’ve read some crazy blender concoctions on message boards – steak, pizza, pasta – you name it, they’ll blend it.) And if you’re really desperate, you will melt chocolate in the microwave and attempt to slurp it through your wires, with limited success. True story, and it was worth the effort.

The swelling peaked on the third day after surgery and started going down from there. I noticed a major reduction in swelling once I started going to lymph drainage massage sessions. Two weeks later, my swelling and bruising were gone.

 

Ten days after surgery, I crashed physically and emotionally. I didn’t know what was wrong until I did some research and found that during surgery, they use steroids to reduce swelling. These make you feel great until a week later, when you go through withdrawal. I was glad to know I wasn’t going crazy.

At the end of the two weeks, I went to my surgeon to have the wires removed. I was excited at the thought of opening my mouth, gumming soft food, and brushing my teeth. It’s hard to keep your teeth clean when your jaw is wired shut; my attempts to brush around the wires and rinse thoroughly with antibacterial mouthwashes only went so far. I could feel the fuzz on the backs of my teeth and see brown crud on the fronts. The first thing I did when the wires were cut was brush my teeth for 15 minutes straight, which was amazing. Though the meal of bean, salsa and cheese dip that followed, (eaten with a spoon instead of the supplied tortilla chips, of course), was pretty great, too.

Many people may not realize that when you get your jaw unwired, you can’t go back to eating regular food right away. The jaw is still healing and you can’t put pressure on it, nor would you want to, because it hurts! I was on a soft diet for about six weeks after having my jaw unwired. This means I could eat soups, mashed potatoes, pasta and other things that didn’t involve chewing. Eating consisted of mashing food with my tongue against the roof of my mouth. It hurt too much to try and chew with my teeth at first, but it got better as the days and weeks went on and my jaw healed.

People also don’t realize that once your wires have been cut off, you’re unable to open your mouth more than a few millimetres, because your muscles have atrophied in the time that your jaw was wired shut. Before surgery, I could open my mouth 50 mm (at the high end of normal range of motion, which is 40-50 mm); after surgery, I could only open it the width of my pinkie finger. My surgeon gave me some exercises to help stretch my jaw muscles, which I did several times a day. I also went back to physiotherapy to help rehabilitate my jaw and make sure the TMJ problems didn’t return.

After one month, I could only open my mouth 15 mm, or one thumb width; at six weeks post-surgery, I could open my mouth 25 mm, or two finger widths. By three months, I made it to 32 mm, which was just enough for my surgeon to clear me to go back to the orthodontist so I could get my surgical hooks off and begin having my braces adjusted again. At four months, I was at 40 mm (considered a normal range of motion), and by ten months, I was up to 46 mm – all the painful exercises and physiotherapy had paid off!

With the wires off and my range of motion taken care of, there was only one thing left for me to worry about: the possibility of permanent nerve damage in my lower lip and chin. My orthodontist told me the likelihood of permanent nerve damage increases with your age. As a 32-year-old undergoing the surgery, I had a 32% chance of permanent numbness. This prospect was thoroughly unacceptable and made me determined to be in the 68% of people who regain full feeling in their lips and chin.

I talked to a friend who had the surgery in her 40s and ended up with permanent nerve damage in her chin. When she finally discovered acupuncture, which helped her get some of the feeling back, the practitioner told her that he could have helped her get all of it back…if she had only come to him one month after the surgery, instead of one year later. I immediately booked an acupuncture appointment for two weeks after the surgery.

I wasn’t sure what to think about the acupuncture at first – someone sticking needles into your face is usually not my idea of a good time. However, before I went for the treatment, I had about 75% of the feeling back in my chin and lower lip. In the days following the first acupuncture treatment, my feeling came back rapidly. After a few more treatments, by the one month post-surgery mark, I had 95% of the feeling back, and at six weeks out, I was at about 98%. That final 2% came back very gradually, and by two years after the surgery, the nerves in my lower lip and chin were completely healed. No permanent numbness!

I am really happy with the results of the surgery. The recovery was difficult, but it was all worth it for me. Most importantly, I no longer have problems with TMJ or migraines; I don’t have to go home early from a party with a migraine because I’m laughing, talking and smiling too much, as that used to aggravate my TMJ.  I have the beautiful smile and straight teeth that I’ve always wanted, which means that I no longer have difficulty chewing, as my bite fits together perfectly. And, added bonus, I have a great profile with a chin that is just slightly more prominent than before (4 mm to be exact), which I love!

While this surgery isn’t for everyone, and is not something to be taken lightly, I am glad I did it. It has changed my quality of life for the better. If you would like to know more about my experiences or get in touch to ask questions, visit my jaw surgery blog at www.smilingbella.com.