Double jaw surgery vs. MSE then surgery (NYC)

[JawDude]

I've had a history of oral / dental issues which unfortunately I didn't correct as a teenager. My parents are simple people and we never really went to doctors much as a kid. I'm in my mid 20s now and want to take care of the many functional and aesthetic issues I've had.

These issues came to a head in college when I had:
- significant gum recession on my canines
- a wide anterior open bite
- cross bite due to narrow palate

The periodontist who did my gum grafts immediately noted that I was a surgical case and said we would coordinate with an orthodontist and jaw surgeon to fix things. We had a consultation with a jaw surgeon and the agreement was that I would have orthodontics prior to moving forward with jaw work, but for whatever reason my orthodontist decided to:
- extract my wisdom teeth
- use Invisalign to close my bite.

While they did an exceptional job of closing my bite, the functional issues became worse:
- significant tinnitus
- trouble breathing
- TMJ headaches

I also have torticollis so my face is bent to the right. See the right SCM muscle in my photos. Does anyone have experience with getting this fixed? Most surgeons only work on pediatric cases as far as I can tell... As a sidenote, I've been recommended for septoplasty and will be going through with it after DJS / MSE.

I've made significant progress in reducing headaches and TMJ pain through myofunctional work + tongue release.

My narrow palate is still blocking my breathing and my midline shift is still noticeable. Bbringing my maxilla forward will also lift my nose a bit and help with the dark circles under my eyes. My smile right now shows no gum at all and brings down my nose a lot.

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tl;dr

I've had consultations with Dr. D B at Mount Sinai and Dr. Jay Neugarten (OMCS) and both guys have basically been reluctant to move forward with DJS because my sleep studies haven't shown sleep apnea. I personally think the study was BS - it said I snore. Everyone I've slept with has noted I don't snore, while some have noted I gasp for air from time to time.

(What annoys me the most is my discrepancies prior to my first orthodontic treatment would have easily qualified me for insurance coverage. Is there any way to convince insurance to use these photos as pre-orthodontic work prior to a surgery? )

Dr. Neugarten initially recommended MSE to expand the ~6-8mm discrepancy between my upper and lower jaws. This will almost certainly expand my airway, but I know that the recessed jaws are still going to be an issue and make my smile super unnatural and my nose is significantly hooked.

I convinced Dr Neugarten that $$ wasn't a concern. He seems compotent, but the fact that he's not super invested is concerning: his financial coordinator sent me the financial letter with different prices for different options (1 jaw, 2 jaws, genioplasty which we never even discussed). This rubs me the wrong way - I'm not shopping, I want to correct my functional + aesthetics issues. Anyone else have this experience? I guess it's just the nature of surgeons / dentists in the US in my experience. Is there a different practitioner who takes into account patient input and functional concerns? Happy to travel outside the city to get the best result.

Please take a look at my photos (chronological) and let me know what you think I should do (upper jaw / lower jaw/ MSE / CCW all that jazz). MSE is cheaper, but only fixes half of the problem.

Thanks!

https://ibb.co/xXT3KLk
https://ibb.co/6rfZv2p
https://ibb.co/YRP2L6T
https://ibb.co/ZL7ZN3S
https://ibb.co/Zx0PwGr
https://ibb.co/xDRDsTn
https://ibb.co/HrHbvVY
https://ibb.co/PjdhFj6
https://ibb.co/yXmtWZS

[aestheticseeker]

Ive been to Dr. Jay Neugarten personally and he is not the guy to go to as an adult wanting jaw surgery thats just my 2 cents

[GJ]

You look great.

Not a surgical case based on those records.

[aestheticseeker]

You look great.

Not a surgical case based on those records.

No offense to you GJ but you told me the same thing and I can definitely relate to this dude wanting surgery esp cause we look similar...

Our lower thirds are longer than they need to be due to the sloping of the mandible...

[Rodin]

No offense to you GJ but you told me the same thing and I can definitely relate to this dude wanting surgery esp cause we look similar...

Our lower thirds are longer than they need to be due to the sloping of the mandible...

Your cases look nothing alike to me.

[JawDude]

While I'm flattered on the one hand, I'm actually a little disappointed because this is how dismissive doctors have been with me... let me give better context. I know it's not as clear cut of a case as some other people here since my occlusion has been masked and needs to be decompensated. Three wisdom teeth were removed to cram my bite into place. You can't jam teeth into place without addressing the underlying jaw issues (see my original open bite + recession) if you want to solve the issue at its core.

My frontal profile doesn't really convey the real issues, but off the bat you can tell my facial fifths are grossly out of proportion http://pioneer-cosmo.net/english/beautym.php (both doctors agree with this) - apologies can't find a better link. In my experience, this type of strong asymmetry is more obvious to the naked eye as jarring / pathological so it's actually more damaging than most of the cases we see on here imo. Clearer picture of the asymmetry + lip incompetence: https://ibb.co/w4HM5D3

I obviously need a septoplasty, but you can see the real issue with my right sternocleidomastoid muscle : my torticollis has made the right half of my skull flat (which unfortunately can't be fixed I don't think) and has tilted my jaw slight clockwise (midline shift) and to the back. My left TMJ cracks significantly when I eat and clicks even when I sit normally. The key issue is that the nose rests on the palate and since I have a narrow palate, my breathing won't improve just by a septoplasty unless the jaw is expanded (Dr. N agrees with this) and smiling will not be natural highly unnatural. My smile shows an obviously retrusive maxilla: top lip pulls back and nose humps over it. https://ibb.co/6nQRW3m https://ibb.co/60bPBKP As noted above, my mandible is longer downward, and both the mandible and maxilla are recessed. Dark eye circles are obvious.

Could you take a look at the cephalogram and give more precise thoughts? Even Dr. B agreed that both upper and lower are recessed, just not in a way that we can justify to insurance anymore. Anyone get away with speech issues / difficulty chewing? I have a lisp and you can't see my tongue at all when I'm speaking (like I mentioned, working on tongue tie release). Thanks

I just want to note that this is not genetic: I look nothing like my parents and my growth was significantly abnormal: see this photo from elementary school https://ibb.co/CQyN1rx. Notice again the tight right SCM muscle and discrepancy in the ears. This made the growth worse over time.

[thedude]

MSE seems like it might be a good starting point for you. It’s a lot less risky than double jaw surgery and the results are more predictable. It would compliment the myofunctional work you have done as well. It usually significantly improves sleep apnea and nasal breathing if you use a bone base expander. I’d recommend finding a surgeon that can use a distractor designed like the Titamed smile distractor as it’s the only design I’ve seen that offers pure bone based expansion. All the rest have these bizarre orthodontic focused designs that push the teeth as well which is just wasted expansion that won’t improve your airway or appearance.