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BSSO (Bilateral Sagittal Split Osteotomy) and Genioplasty

I’ve known for 22 years that my jaw relationship was incorrect and that I needed a combination of braces and surgery to fix this.

In other words my lower jaw was slightly underdeveloped and receded too much for good occlusion and too far back for a good occlusion. Aesthetically I was quite happy with my smile and my look and the idea of splitting my jaw and moving a segment forward seemed absolutely absurd.

During my student years and later as a practicing dentist, I was picked as the classical Class ll dentition needing intervention at every orthodontic course I attended.

And finally at the age of 42, I decided to go for it.

I was still happy with my look, but I noticed that my teeth started looking dark on photos. This was due to the fact that my upper incisors started tipping backwards - something that typically happens in a Class ll dentition. Suddenly light is not reflected back at the observer or the camera and teeth appear darker. The new angle they were now at also made them look shorter, giving the impression that I had short or worn teeth.

As a dentist I have also observed countless patients with this type of occlusion causing problems as they got older. These cases classically show heavy wear of their front teeth, excessive clenching and grinding due to the locked-in position of the lower jaw, a collapse of the bite and eventually the fascial height, neck problems, snoring and sleep apnea, to name a few.

Bilateral Sagittal Split Osteotomy (BSSO) results are amazing but the surgery is ponderous and a lot of patients shy away from it.

Here are my experiences of the year leading up to the surgery and the ten days post surgery:

Orthodontic Phase

Once you decide to go for this procedure, your Orthodontist will fit fixed braces on your top and bottom teeth.

I chose clear brackets, which are slightly more expensive but much less visible than the metal brackets.

Initially the braces feel uncomfortable and irritate your mouth, but you get used to it very quickly. Every time the wire gets changed to a thicker one, your teeth will be sensitive for up to five days. The aim of the braces is to tilt the incisors forward to their ‘normal’ position in order to create space for the lower jaw once it’s surgically moved forward.

Surgery

I was very calm up until about 15 minutes before the operation when they came to fetch me in my room. This is probably because the 12 months of braces have given me enough time to get used to the idea. Luckily the pre-meds had already kicked in by then. I shed a tear while waiting to be pushed into theatre. A friendly doctor on her way out, stopped and asked if I was okay and kept me company for a bit, which completely calmed me down. From there on things are a blur.

You are moved onto the operating table, the anaesthetist says hello and before you know it this warm and fuzzy sensation overcomes you and you are out. You briefly wake up in the recovery room but only start registering what is going once you are back in the ward.

I experienced a feeling of tremendous relief that everything was over and was quite surprised that I had no pain and only slight discomfort. You wake up with a huge ‘plaster’ over your entire lower part of the face and ice packs on either side of your jaw to minimise post operative swelling. Two elastics across the upper and lower canines guide your jaw into position and keep your jaw together. However, you are able to open your mouth to eat, drink and talk.

The day was a blur of visitors, nurses coming in to check on you, and sleep. The gave me plenty of IV pain medication to keep me comfortable which made me rather quite drowsy. I was able to get up and take a shower in the afternoon and even managed to eat some soup later that evening. You are encouraged to sleep with your head as high as possible to prevent further swelling.

Day 1 Post Op - The first 24 hours

I woke up feeling refreshed and positive. The Physiotherapist arrived and removed the plaster and I was pleasantly surprised at how little swelling there was. Little did I know that the swelling was still to come. The surgeon came to see me for a follow up and I was released from hospital.

The rest of the day was spent on the couch and in bed at home, and I managed to eat a bit of soup with a teaspoon. By early afternoon I could detect a little bit of swelling.

I was completely surprised by the lack of any real pain. I did, however take pain medication prophylactically for the first two days as prescribed. They made me feel dizzy and slightly nauseous, but also helped me to sleep a lot which was great. The first night at home I really missed the hospital bed. I propped myself up with some pillows as best as I could but it was not nearly as comfortable as the hospital bed.

Day 2 Post Op

And so the swelling began… I still had no pain but I can honestly say that I was very uncomfortable.

I had arranged for an additional physiotherapy session in hospital. The Physiotherapists used a combination of ultrasounds, lasers and EMS (electrical muscle stimulation) to increase blood flow to the wound and swollen areas, which reduces swelling and promotes healing.

After the little excursion it was back to the couch and by early evening I had a few tears streaming down my face. I felt very vulnerable and relieved that it all was over all at the same time.

Day 3 Post Op

The swelling was even more pronounced on day 3 which was to be expected.

My jaw joints were hurting from low grade inflammation of the muscles having to adapt to the slight new jaw position. Everything felt tight, swollen and hot. I had to apply ice packs all the time to counter the swelling.

My family left for Namibia and I spent the rest of the day on the couch receiving my first visitor. It was very nice to have someone pop over but it was also strenuous and I was exhausted after the visit.

The quality of your sleep is affected during the first 3 days, as you can’t really lie on your side because it feels uncomfortable and painful. After 4 days of lying only on my back in a slightly upright position, my back started hurting.

Day 4 Post Op

Day 4 was the most pronounced in terms of swelling, but I stopped taking pain killers completely and the drowsiness and fog lifted off my brain.

My bruises started to turn yellow and the swelling also spread slightly down my neck. I had more visitors but pretty much still stayed in my PJ’s on the couch all day. I knew that this was as bad as it was going to get and that I would feel improvements from here onwards. This had a very positive effect on me psychologically. I also finally managed to sleep in a more comfortable position without hurting.

Day 5 Post Op

I woke up and felt like a new human. The difference to the previous day was evident with the swelling significantly reduced. My neck was completely yellow but that was a small price to pay for the reduction in swelling.

I had my first proper post op consultation with the surgeon (they know why they wait for 5 days) and I was in high spirits. I got dressed, took an Uber and made my way to his consultation rooms at the hospital. My bite was fabulous and the surgeon was super happy with the result. I had another session with the Physio and then had more couch time for the rest of the day. It is surprising to realise how much your body needs to rest during the first week, and how easily you get jittery and dizzy.

Day 6 - 10 Post Op

After day 5 the improvements every day were pronounced. My chin remained numb due to the swelling, and feeling is expected to come back within the next 5 weeks to 5 months. There is still a lot of healing that has to happen and my jaw mobility is still limited but i see improvements every day.

I started getting up a bit more but still refrained from driving up to day 8 as I still felt dizzy at times.

Going forward I will have a final follow up consultation at 3 weeks post op and then roughly another 4 months of braces to give the bone time to heal before removing the brackets. During this time we will focus on fine tuning the bite and settling it in.

If you would ask me now if I would do this again, I can only say yes. Everyday I’m more pleased that I finally made the move and my new bite feels simply fabulous - like it should have always been like this.