Counterclockwise Bimaxillary Advancement Surgery: Improved severe sleep apnea and successfully reduced it to cure

release date : 2025-09-23
Updated: August 31, 2026
Author: Fenghua United Clinic

Preoperative symptoms	surgical plan
Severe sleep apnea (AHI=40.5), severe daytime sleepiness (ESS=17), and obvious snoring	Perform a counterclockwise rotational jaw advancement surgery to widen the airway, tighten the respiratory muscles, and improve facial support.

Diagnosis and treatment plan and postoperative changes

This 50-year-old woman suffered from severe sleep apnea (AHI=40.5), with symptoms including severe daytime sleepiness (Excessive Sleepiness Scale=17) and annoying snoring.

This 50-year-old woman was diagnosed with severe obstructive sleep apnea (AHI = 40.5), presenting with symptoms including pronounced daytime sleepiness (Epworth Sleepiness Scale, ESS = 17) and disruptive snoring.

What is more special is that the CT scan showed that in addition to the expected narrow airway, it can be seen that she had undergone the Wassmund and Kole Procedure when she was young. This is a surgery that removes one premolar on each side of the upper and lower jaws, and then moves the upper and lower jaws backwards through bone cutting to solve the protruding mouth.

Notably, her CT scan revealed not only the expected airway narrowing but also evidence of having undergone the Wassmund and Kole procedures in her youth. These procedures involve extracting one premolar from each quadrant of the upper and lower jaws, followed by osteotomies to reposition the maxilla and mandible posteriorly—typically performed to correct bimaxillary protrusion.

While there's no direct evidence that the Wassmund and Kole procedure causes sleep apnea, research does support the idea that shifting the upper and lower jaws backward reduces posterior airway space, indirectly increasing the risk of sleep apnea. Dr. Xie designed a counterclockwise rotational jaw surgery (CCWR-MMA) for her. This procedure successfully separated her compressed upper and lower jaws, widened her airway, and tightened her respiratory muscles (preventing collapse). It also improved her neck-chin line and supported the concavity of her midface and lip area.

Although there is no direct evidence proving that the Wassmund and Kole procedures cause obstructive sleep apnea, existing research does support that posterior repositioning of the jaws can reduce the posterior airway space, thereby indirectly increasing the risk of developing sleep apnea.

Dr. Hsieh designed a counter-clockwise rotational maxillomandibular advancement (CCWR-MMA) surgery for her, which successfully expanded her compressed jaw structures, widened the airway, and tightened the pharyngeal musculature to prevent collapse. The procedure also improved her cervicomental contour and provided structural support to the midface and perioral region.

The postoperative sleep report showed that the AHI dropped to 4.9 (<5 represents cure), the sleepiness scale ESS also dropped to 5 (representing normal without daytime sleepiness), and her snoring problem was also solved.

Postoperative sleep studies showed a reduction in AHI to 4.9 (an AHI <5 indicates resolution), and her ESS score dropped to 5 (within normal range, indicating no daytime sleepiness). Her snoring was also effectively resolved.

A comparison of pre- and post-operative sleep monitoring reports showed that the AHI decreased from 40.5 to 4.9, and the lowest blood oxygen saturation increased from 801 TP3T to 851 TP3T.

Sleepiness scale and assessment before and after surgery

In patients with severe sleep apnea, the total score on the Eppworth Somnolence Scale decreased from 17 to 5 before and after the procedure.

The obstructive sleep apnea outpatient assessment form showed a before-and-after comparison, with items such as daytime fatigue and snoring changing from "yes" to "no".

Comparison of tomography before and after surgery

Comparison of airway CT scans before and after orthognathic surgery in patients with severe sleep apnea; hyoid bone moved forward and upward.

3D tomographic comparison of craniofacial skeleton before and after orthognathic surgery, with red and blue lines indicating changes in facial contour and occlusal plane.

Comparison of 3D models of the upper and lower jaw bones before and after orthognathic surgery; red and blue lines indicate changes in the occlusal plane and chin position.

Warm reminder

Please follow the instructions of the doctor and nursing staff, take medicine regularly, pay attention to dietary taboos and keep the wound clean.
There may be complications such as bleeding, infection, inflammation, etc. after surgery. The degree will vary according to individual physical differences, so careful care is required. If the above situations occur, please contact us as soon as possible.
It is normal for 3 to 6 months after surgery to experience temporary slow sensation and unnatural expressions at the surgical site. Through independent massage and facial expression exercises, most patients will gradually improve within 6 to 12 months after surgery.
Anesthesia has certain risks, which are related to the patient's own physical condition. Patients must honestly and clearly report their health status and treatment history to the treating physician and anesthesiologist, and do not hide anything.
It is recommended to communicate with the doctor before surgery and clearly express treatment needs. However, the aesthetic appearance after surgery is subjective and should not be used as a basis for judgment of surgical results.
The results of surgery vary from person to person and need to be evaluated by a professional physician. Case pictures are publicly used with the authorization of the parties involved as auxiliary explanations of diagnosis and treatment, health education and medical knowledge sharing, and are for reference only.