has anyone had a repeat BSSO after having a relapse?

[marc]

Hello all,

I had orthognathic surgery done back in 2005. Le Forte I (maxillary impaction to correct vertically long maxilla), BSSO (mandibular extraction to correct class 2 retrognathia), and genioplasty (to correct retruded chin). For me, the worst part of recovery was the excessively dry mouth due to constantly breathing through my mouth (my nose was plugged up for about a month or so post-op). I recall at least one of my bands snapping from what I imagine was caused by the dryness, and every morning my mouth felt like it was entirely devoid of moisture. (For those of you contemplating this surgery, you should consider getting a humidifier to counter this possible issue.) Pain, on the other hand, wasn't a problem for me. Never had to use a drop of the prodigious amount of pain-killers I was prescribed for the recovery period. I had numbness in the upper and lower mouth areas at first (lower cheek area down to chin, and some teeth/gum areas along with lips); most of these started to show noticeable improvement during the first month post-op, and now many years later, all of the sensation has pretty much returned to normal, save for the left chin, left lower lip and left lower labial gum area. These parts have partial numbness, but they don't bother me much anymore (I do have to be more mindful when eating though, as I will sometimes not feel it when there is something stuck to my lip or dribbling down my chin).

I don't know when it started (it was well after I had my last post-op appointments with my surgeon and orthodontist), but at some point my mandible started relapsing, and now the overjet seems to be about 6.5 mm. I have gone back to having a dual bite, where my mandible is in its retruded position when chewing/at rest, and in a 'forced' forward position when biting with my incisors and when I try to mask my retrognathia (never thought I'd be doing that again after the long, difficult, and expensive orthognathic journey I'd been on). For a couple of years now, I've been trying to convince myself that I should just 'be OK' with the relapse, but in truth I am not. I am not sure what my options are (yes I know I should see an orthognathic/craniofacial surgeon), but I assume that a repeat BSSO is a possibility and perhaps the only way to correct the relapse. I suppose a chin implant could be put in, but that would only 'hide' the retruded mandible and I'd still have the overjet.

I am hoping to find a few people (at the same time, I hope there aren't TOO many of you) who've had a relapse following BSSO for mandible lengthening and then subsequently had a repeat BSSO done to correct the relapse. I want to hear about your experiences, any complications, whether you feel it was worth it the second time around. If a repeat BSSO can be done in my situation to correct my relapse, I'd probably go right for it if it weren't for: 1) possibility of TMJ problems developing (I don't have any at the moment), 2) possibility of additional nerve damage, 3) possibility of yet another relapse. I look forward to hearing from some of you, before I make the move to start looking for surgeons to make a consultation appointment. (I no longer live where I did when I had my surgery done, so I can't go back to see my original doctor.)

Thanks very much for reading this far! I know it was quite the long post.

- Marc

[freakyteeth]

Mark,

That totally stinks! I didn't know this could happen after a BSSO so far out. Has it been gradual or just all of a sudden?

[beowulf68]

Man that sucks that you suffered a relapsed!! I just had a Lefort 1/BSSO three months ago and was told by my surgeon that I ran only a very small percent chance that I would relapse. The surgeon said the way they keep relapse rates down (especially in my case because I had both of my jaws moved 12mm forward which I guess is considered a big move) is by wiring one's jaw shut for at least 6 weeks.....And in my case 10 weeks. I don't know if the surgeon you are going to wires his patients jaws shut?? It seems many surgeon don't do this anymore because rigid fixation (I had this too) is supposed to be good enough. Again, my surgeon said that in his research, rigid fixation does gurantee that the jaw bones heal correctly but doesn't stop one's VERY VERY strong jaw muscles from actually pulling the bones back into their original place a couple years down the road. If you have your jaws wired for a couple of months it gives the the bones time to really heal well and the muscles can't do anything to sidetrack this. Thus pretty much ellimating major relapse (most people, no matter what, will relapse 1-2mm but surgeons always over-correct for this contingency).

[qwertz1]

The surgeon said the way they keep relapse rates down (especially in my case because I had both of my jaws moved 12mm forward which I guess is considered a big move) is by wiring one's jaw shut for at least 6 weeks

I suppose your surgeon has a good reason for wiring, but the type of fixation doesnt change the chance for late relapse.

the bones are most likely healed by now (or you would have had other problems).
google "condylar resorption". there might be other causes for late relapse, but this seems to be the most important one and is also mentioned in my consent form.

I dont have any experience myself but I do know a patient who had a second BSSO a few years later because of late relapse, and everything seems to be fine now.

1) possibility of TMJ problems developing (I don't have any at the moment), 2) possibility of additional nerve damage, 3) possibility of yet another relapse

1) if I understand condylar resorption correctly, you might also develop TMJ problems if you do nothing 2) possible 3) possible

good luck!

[cvn]

I had a bsso and leforte in 1995, relapsed and had a leforte in 2000, relapsed on that and had a bsso and multipart leforte this past April. So far so good. I did use a new surgeon for the last surgery. He has a very good reputation and I felt comfortable with his approach and results on previous surgeries on other patients. It cost more, but I figure was still cheaper than another 15 years of this crap.

I was wired for the first bsso. This past one I only had bands. My surgeon gets better results with those than wiring and splints. I still wear bands at night because im high risk, but its not a big deal. My bite is better than its ever been. I think the medications my surgeon put me on to prevent relapse helped as well.

[beowulf68]

I suppose your surgeon has a good reason for wiring, but the type of fixation doesnt change the chance for late relapse.

Actually my surgeon said the opposite......The type of fixation has EVERYTHING to do with relapse, even late relapse. He said it was impossible to guarentee 100 percent zero chance of relapse but the research his team did at the University of Michigan over the years showed that when a patient was wired shut for 10-12 weeks the chance of relapse is very minimal as opposed to just rigid fixation alone. I mean that is just a couple of surgeons opinion at one Research Hospital, so i guess you're supposed to take it somewhat with a grain of salt. But my surgeon has a pretty good reputation in the midwest so I'll go with what he says.

I think the medications my surgeon put me on to prevent relapse helped as well.

What kind of medications did your doc put you on? I've never heard of meds actually helping with relapse???

[cvn]

He uses feldene, doxycycline, simvastatin, omega 3, and vitamin D as they all have good side effects on joints. He also uses amitriptylene to prevent bruxism. He also puts women on hrt if their estrogen levels come back low. He's had much improved results at preventing resorbtion with all the meds.

[Nathaniel]

I had a bsso and leforte in 1995, relapsed and had a leforte in 2000, relapsed on that and had a bsso and multipart leforte this past April. So far so good. I did use a new surgeon for the last surgery. He has a very good reputation and I felt comfortable with his approach and results on previous surgeries on other patients. It cost more, but I figure was still cheaper than another 15 years of this crap.

I was wired for the first bsso. This past one I only had bands. My surgeon gets better results with those than wiring and splints. I still wear bands at night because im high risk, but its not a big deal. My bite is better than its ever been. I think the medications my surgeon put me on to prevent relapse helped as well.

cvn, how old were you when you got your surgeries in 1995 if you don't mind me asking?

[hduggan]

Actually my surgeon said the opposite......The type of fixation has EVERYTHING to do with relapse, even late relapse.

I've seen both things in the research - that the wiring helps and that the wiring doesn't matter. And I've seen the same conflict about whether wiring helps prevent non-unions. Unfortunately, medical research (which used to be my field) is just not very good, and it's particularly not good in figuring out what helps prevent rare events.

For my son, his time banded shut was so emotionally stressful that I don't think we would have gone through it even if it did reduce the rate of relapse. The good news is that the odds are really in your favor that you won't relapse, no matter what you do. (And sorry to hear about your twice-unlucky roll of the dice cvn. Here's hoping the third time is the charm.)

[qwertz1]

But my surgeon has a pretty good reputation in the midwest so I'll go with what he says.

good, thats the only thing we can do with these issues anyway: find a good doctor and let him deal with it.

I only "intervened" because you gave the impression that you can just have your jaws wired and prevent relapse. its not as easy as that.
it is rare, but if it already occured once you should try to find out if you are predisposed for this kind of thing. you can even get condylar resorption without any orthognathic surgery, some surgeons seem to use medication to prevent it, ... I dont know what else

[chicago29]

quertz1 said it best...all you can do is pick a doctor you're comfortable with and that you trust.

There isn't a person alive that can tell you if you're going to relapse, and for every surgeon I could find that says "do x to prevent this", I can find another that says "don't do x, do y". This surgery is pretty routine these days, but there are very few studies out there. And the studies that ARE out there have extremely small sample sets. I don't know the first thing about medical research and I can tell that many of them are flawed in some fashion.

There is no fixation method, drug, vitamin, rubber band, mineral, doctor, wire, book, theory, study, exercise (I could keep going) that is guaranteed to prevent relapse. If it helps put your mind at ease, that's great...use or do what you have to.

But the reality is this is something that happens and rarely is there a definitive reason as to why...Not everything our bodies do can be objectified or studied...

[marc]

Wow, thanks for all of the responses! Yeah, having a relapse really sucks after having gone through the whole ordeal. cvn, I'm real sorry to hear that you've had a second relapse...that must've been tough. I do hope this third time proves to be stable, and so far it sounds encouraging.

My relapse was definitely gradual, and thinking back on it now, I should've had pictures taken every year post-op to track the progression to now. I suppose with my last post-op pics, and any recent ones I can get with a new appointment, that an orthognathic surgeon would be able to determine what about my mandible has changed to cause the relapse. From everything I've read thus far on the internet, it sounds like condylar resorption is the most likely cause (at first I was wondering whether my lengthened mandible had somehow returned to its original shorter length). If it is condylar resorption, I'm sure this can be seen in x-rays of the TMJ? I've tried to find reading material on condylar resorption on the web, and so far my understanding on the condition is that the end 'knobs' of the mandible which articulate with the maxilla to form the two TMJs get 'eaten away' by osteoclasts. I suppose what is not understood is why this happens.

I also read somewhere on here about 'muscle memory', and how because of it your bite would 'want to return' to its pre-op, maloccluded state. This does make some sense, but there is one thing. My understanding of the BSSO procedure (for retrognathia correction) is that it involves sectioning your mandible into three pieces, with the center piece brought forward to correct the overjet, and the two side pieces (which have the condyles) left essentially as-is. Now if the chewing muscles attached to your mandible had their attachment points on the 'center piece', I could see how muscle memory might want to pull your jaw back, and perhaps cause condylar resorption due to osteoclast activity to reduce the 'pressure' placed upon the TMJ (purely conjecture). But the attachment points are on the two side pieces, and because these aren't really supposed to move with the BSSO (at least THIS IS SPAM PLEASE REPORT IT TO THE ADMINISTRATOR. THIS IS SPAM PLEASE REPORT IT TO THE ADMINISTRATOR. THIS IS SPAM PLEASE REPORT IT TO THE ADMINISTRATOR. THIS IS SPAM PLEASE REPORT IT TO THE ADMINISTRATOR.), I am not sure how muscle memory would work to pull back your jaw post-op.

Of course, I also had a Le Fort I done in addition to the BSSO (I assume the genioplasty doesn't really factor into relapse), so that probably complicates my already oversimplified (and amateur) analysis. What I want to know in the end is what is the nature of my relapse (is it condylar resorption?), and knowing that, what are the likely causes, and consequently what the best thing to do would be in my case (maybe a second BSSO isn't advisable due to likely repeat relapse). It sounds to me that there isn't any real consensus when it comes to these sort of matters, and I'm not too surprised as you cannot really do controlled experiments when it comes to this sort of thing.

cvn, there is something about your post that I just noticed, and it is that your second surgery in 2000 was a le fort only w/o bsso. Do you mind sharing what the original le fort/bsso in '95 was for, and what sort of relapse occurred to necessitate the 2nd le fort in 2000? For me, the le fort was the one part of my 'triple' operation that seems to have gone perfectly: no relapse (I think?), all related sensation virtually back to normal, great positioning of the maxilla (the position of my upper lip relative to my upper teeth looks so much better now). There is one issue with my nasal septum getting warped, but it isn't something that really bothers me.

I'm currently in South Korea, and orthodontic dentistry and cosmetic surgery is pretty well-developed here, but I'm not sure about orthognathic surgery. I'll have to start looking into that; I hope any consultations won't be too expensive.

chicago29 (is that where you live?...I was in Evanston for many years until 2006), I think your statement regarding relapse is the most accurate. From what I've read so far, a relapse like I've had doesn't happen very often, but the real question for me is that, now that I've had a relapse, does that somehow put me into a 'relapse-prone group' that will likely relapse again with any further procedures done to correct the first relapse? If my chances for another relapse are uncorrelated with having already had one, then I wouldn't be concerning myself much over it.

Once again, thanks for the many replies!

[Vive18]

I'm replying to old posts I know....

But yes, if you do have condylar resorption, you have a high chance of relapsing with any other BSSO surgery. It is to do with loading on the joints, re-activating the resorption. I don't think a Le Fort impacts on loading in the way a BSSO does.

Not sure if you're still around, but would love to know how you're going?

I have condylar resorption, and never had any surgery.
I might be having a BSSO as a last resort, to the real last resort, which is total joint replacements.

[Roy]

I dint read thread, but here is a question for OP: Do you have narrow maxillae and your tong doesn't fit it? Is your tong usually not on the top of the roof of the mouth?

[anonimess]

I had condylar resorption (though only on one side) prior to double jaw surgery and my surgeon says I will need to take care of my jaw joints for the rest of my life. This seems to mean using a splint at night (this will come later, currently less than two weeks out from surgery now) as well as also taking amitriptyline at night (10mg). I'm hoping that being aware of the care my joints need as well as the possibility of relapse will mean I can catch anything before it becomes a bigger issue, because this whole surgery is not an experience I want to repeat!