Advice on upcoming surgery and surgeon

[Wksos]

Hey, so I recently saw an oral surgeon over at Rutgers University and the orthodontist that he works with. My bite is fine but my mandible is pretty recessed. I've also been diagnosed with minor sleep apnea and have all the common symptoms that come with it. They believe I'm a good candidate for double- jaw surgery and I'm just waiting to hear back from my insurance company at this point.

http://imgur.com/a/D13GRF8
http://imgur.com/a/igYr8Id

The plan is to move my mandible 14mm forward and my maxilla a few mm as well. They also want to remove my 2 lower *premolars*, which is something I'm really against, but apparently it has to be done since my upper premolars have already been removed in the past (over ambitious orthodontists).

I've read some great information on this forum and wanted to get some opinions/advice from some of the knowledgeable members; especially since my insurance doesn't give me too many options so I've been having trouble finding 2nd opinions. Do I look like a good candidate for surgery? Do you believe my lower incisors need to be removed? Is that a proper amount of advancement? Is a university professor/surgeon a good choice?

Thanks, looking forward to hearing from you all.

[kavan]

It's more likely that they want to MOVE your lower incisors backwards and need to remove your first pre-molars to make room to do that. Unlikely they want to remove your lower incisors.

[Wksos]

It's more likely that they want to MOVE your lower incisors backwards and need to remove your first pre-molars to make room to do that. Unlikely they want to remove your lower incisors.

Yes you're right, I corrected my post. What do you think of the surgical plan itself? Judging from my photos. You seem knowledgeable, would love your opinion.
Thanks.

[kavan]

Yes you're right, I corrected my post. What do you think of the surgical plan itself? Judging from my photos. You seem knowledgeable, would love your opinion.
Thanks.

You look like a good candidate for double jaw surgery for sleep apnea.

[GJ]

If your upper premolars are removed, it makes sense they want to remove the lowers. In theory this could allow them to get the bite better. If they do this, it should be/have been the second premolars, though.

We're not for extractions here. In some limited cases it makes sense to just pull lower, second premolars.

Regarding your jaw, you are a very clear candidate for CCW double jaw surgery. Are they doing CCW? To get 14mm lower and 2mm upper that's the only way I know. If so, it's probably an appropriate plan.

Regarding universities...I haven't seen any great cases from them. I think this is because universities have students operate on the patient. If you go this route, make sure to get in writing that you'll only approve the head doc/professor operate on you. I'm not sure you won't still wind up with a student. Some of that will depend if the surgery is filmed or dictated honestly.

[kavan]

If your upper premolars are removed, it makes sense they want to remove the lowers. In theory this could allow them to get the bite better. If they do this, it should be/have been the second premolars, though.

We're not for extractions here. In some limited cases it makes sense to just pull lower, second premolars.

Regarding your jaw, you are a very clear candidate for CCW double jaw surgery. Are they doing CCW? To get 14mm lower and 2mm upper that's the only way I know. If so, it's probably an appropriate plan.

Regarding universities...I haven't seen any great cases from them. I think this is because universities have students operate on the patient. If you go this route, make sure to get in writing that you'll only approve the head doc/professor operate on you. I'm not sure you won't still wind up with a student. Some of that will depend if the surgery is filmed or dictated honestly.

I realize you feel that it 'should' be the 2ncd pre-molar to be pulled (because it has one root where as first PM has 2). But to the best of my knowledge, IN PRACTICE, they pull the 1rst PM to create the immediate space needed for the braces to move the teeth in front of it backwards. If they removed the 2nd PM INSTEAD of the first, it would be harder to move the 1rst PM along with the braces BECAUSE it has 2 roots. Besides, it's the incisors, (central and lateral) and canines (one root teeth) that need to be angled backwards to create the over jet and not the pre-molars.  To do that, they need the tooth CLOSEST to the one root teeth to be removed and that is the 1rst pre-molar.

[GJ]

Every ortho whom I've spoken with (and it has to be over ten in-person) has said 2nd premolar is the one to pull. Only justification for the first is something like a failing tooth.

There's no way first premolars is standard, nor should it be given how much bone and root loss comes with it.

[SMSOMS]

Upper second premolar and lower first premolar extraction is absolutely the correct extraction pattern. The lower first pre-molars are removed upright the lower incisors to create additional sagittal discrepancy. The upper second pre-molars are removed to maintain the upper incisor positions as best you can and the molars are slipped forward again to create as much sagittal discrepancy as you can so you have maximum flexibility and forward movement of the lower jaw.

Leaving the lower incisors too flared. An IMPA that is beyond 90° will not allow you to get adequate incisor depth of bite and sagittal correction. It often leaves the canines struggling to get to class one after the mandible is advanced.

[GJ]

Upper second premolar and lower first premolar extraction is absolutely the correct extraction pattern.

That's great to have clarified, thanks.

Do the first premolars result in more bone loss due to their roots having more mass?

[Wksos]

If your upper premolars are removed, it makes sense they want to remove the lowers. In theory this could allow them to get the bite better. If they do this, it should be/have been the second premolars, though.

We're not for extractions here. In some limited cases it makes sense to just pull lower, second premolars.

Regarding your jaw, you are a very clear candidate for CCW double jaw surgery. Are they doing CCW? To get 14mm lower and 2mm upper that's the only way I know. If so, it's probably an appropriate plan.

Regarding universities...I haven't seen any great cases from them. I think this is because universities have students operate on the patient. If you go this route, make sure to get in writing that you'll only approve the head doc/professor operate on you. I'm not sure you won't still wind up with a student. Some of that will depend if the surgery is filmed or dictated honestly.

Hey thanks for the info. I just saw the surgeon again today and he updated my plan as follows:
-Lefort Osteotomy w/maxilliary advancement
-Bilateral Sagitial Split osteotomies
-Septoplasty, inferior turbinectomy
-Genioplasty

He will be the one conducting the surgery. He said all I need to do is send him my sleep study so he can contact my insurance. I took a sleep study 2 years ago and only had an AHI of 7 and an RDI Of 16, so honestly I'm worried that I won't get approved. Do you know how strict insurance tends to be with allowing coverage? I'm thinking of taking another study and hoping I get more pressing results. I honestly feel like my sleep is more severe than the test said.

[kavan]

Every ortho whom I've spoken with (and it has to be over ten in-person) has said 2nd premolar is the one to pull. Only justification for the first is something like a failing tooth.

There's no way first premolars is standard, nor should it be given how much bone and root loss comes with it.

Well, the salient point I was wanting to make was which pre-molar he should EXPECT to be the ones to be removed as to retrocline his proclined lower teeth in order to create a sufficient overjet for advancement via the BSSO

My web research of 'Which teeth are the most often/frequently extracted for braces?' kicked up plenty of sites that said the first pre-molars are the most frequently removed for orthodontic reasons. Of course, that doesn't preclude the second one from being selected for the right reasons, nor does it preclude what ever circumstances orthos you consulted with conveyed it 'should' be the 2nd PM to extract. Not to mention that for this particular poster who intially confused a pre-molar with an incisor to be extracted, I just wanted to pass along the MOST LIKELY PM he would be having extracted. Here's an example of sites kicked up that mention which PMs have high frequency of being extracted.

"....CONCLUSION
The number of orthodontic cases involving extractions has decreased over time. The frequency of tooth extraction observed in this study, over a period of 32 years, decreased by approximately 20%.

The teeth most often extracted were four first premolars, followed by the option of extracting only maxillary first premolars...."

Ref=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4816586/

Thing is the OP's ceph for the lower jaw where his teeth are to be extracted for the BSSO show an obtuse angle formed by the MPA and the inclination of lower incisor. So, I do think the pre-molar that will be extracted would be the 1rst PM which will give immediate relief as to closing in on that angle. Basically, I'm thinking in terms of which PMs do they most often extract for immediate relief for over proclined front lower teeth as to which ones he can expect to be removed. Since extraction refers to the lower jaw for advancement BSSO and his ceph shows an obtuse angle the inclination of the lower incisor makes with the MPA and that's the one they like to 'close in' on via plucking out the 1rst PM, I think it's fair to say IN PRACTICE, it's the 1rst PM they pluck and he can expect that one to be targeted for the extraction whether or not it has 2 roots.

[LeFort 3000]

why dont americans work with mandibular midline split + distractors to create space in the lower jaw instead of extractions? Ive had it and it was the easiest surgery of my life. created lots of space too

[kavan]

why dont americans work with mandibular midline split + distractors to create space in the lower jaw instead of extractions? Ive had it and it was the easiest surgery of my life. created lots of space too

It would depend on the reason of why they would need to extract the tooth/teeth and which one/s. If the reason was over crowding of the anterior lower teeth, like incisors that crossed over each other because the anterior mandibular arch was shaped like a 'V' and the crowding at the vertex of that 'V' subjected the anterior teeth to a lot of overlap and later infection and other problems, the mandible split at the base of the chin technique with distractor for distraction osteogenesis (MMDO) would give more room for the teeth and spare them from future demise. But that might not spare someone needing a pre-molar plucked if they needed to get the anterior teeth pushed backwards to accommodate a BSSO when they need to create a space that will allow the push back of the anterior teeth. The premolar is in the way of creating a large overjet when the goal is to create one for a significant BSSO.

MMDO technique is for transverse discrepancies (widths too narrow), transverse direction. The directional displacement in this situation/this thread is anterior/posterior (front to back). As to why  American doctors don't do the MMDO. I don't know. Just to say, it doesn't seem like that technique applies to this situation.

[LeFort 3000]

It would depend on the reason of why they would need to extract the tooth/teeth and which one/s. If the reason was over crowding of the anterior lower teeth, like incisors that crossed over each other because the anterior mandibular arch was shaped like a 'V' and the crowding at the vertex of that 'V' subjected the anterior teeth to a lot of overlap and later infection and other problems, the mandible split at the base of the chin technique with distractor for distraction osteogenesis (MMDO) would give more room for the teeth and spare them from future demise. But that might not spare someone needing a pre-molar plucked if they needed to get the anterior teeth pushed backwards to accommodate a BSSO when they need to create a space that will allow the push back of the anterior teeth. The premolar is in the way of creating a large overjet when the goal is to create one for a significant BSSO.

MMDO technique is for transverse discrepancies (widths too narrow), transverse direction. The directional displacement in this situation/this thread is anterior/posterior (front to back). As to why  American doctors don't do the MMDO. I don't know. Just to say, it doesn't seem like that technique applies to this situation.

i dont know if i understand you correctly, so nevermind if im not making sense.
But in my case, i did get mandibular distraction for the sole purpose of creating space to decompensate in preparation for bsso (anterior teeth pushed backwards as you said it). this goal was achieved very well. I feel like in europe it can be common to do this, but in the US it seems the surgeons just avoid this method, it just has a bad rep there for some reason (which in my experience is not warranted).

[kavan]

i dont know if i understand you correctly, so nevermind if im not making sense.
But in my case, i did get mandibular distraction for the sole purpose of creating space to decompensate in preparation for bsso (anterior teeth pushed backwards as you said it). this goal was achieved very well. I feel like in europe it can be common to do this, but in the US it seems the surgeons just avoid this method, it just has a bad rep there for some reason (which in my experience is not warranted).

You're making sense. Very interesting to hear your experience with it. I've associated it with addressing transverse discrepancies from the journal articles about it as far as tooth sparing techniques go. From what you say, it sounds promising for BSSO decompensation. Was your case a self pay for aesthetic reasons or an insurance case? The OP's case is an insurance case for sleep apnea and even if there were US doctors who do this, it doesn't sound like using MMDO to save a premolar would be something insurance would go for.

US doctors might do it (for adults). I don't know. Distraction osteogenesis procedures do seem to be more commonly used for children in the growing stages than they are for adults though.