jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: Wksos on July 07, 2021, 09:50:01 PM
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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?
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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.
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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.
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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
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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.
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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).
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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.
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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.
my case is an insurance case, typical case of outward leaning incisors due to horrible camouflage orthodontics in the youth. so there wasnt enough space to pull them back in in preparation of bsso. surgery + distractor created about 0.8cm of nominal space in the front, decompensation closed the gap. surgery took less than 30min (according to surgeon) and wasnt expensive at all (insurance paid for it). one negative tho, after surgery you need to wait 3-6months to let the bone heal which delays the djs (which still beats pulling healthy teeth and creating potential boneloss issues)
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my case is an insurance case, typical case of outward leaning incisors due to horrible camouflage orthodontics in the youth. so there wasnt enough space to pull them back in in preparation of bsso. surgery + distractor created about 0.8cm of nominal space in the front, decompensation closed the gap. surgery took less than 30min (according to surgeon) and wasnt expensive at all (insurance paid for it). one negative tho, after surgery you need to wait 3-6months to let the bone heal which delays the djs (which still beats pulling healthy teeth and creating potential boneloss issues)
There aren't a lot of studies on this and of the ones I found, they are studies of other studies and many resolve to calling for more research to be done. They also mentioned a lot in the field have been reluctant to accept it on basis of it not being enough overall studies on it. But it does look to be useful for the right reasons (which do appear to be for severe anterior crowding) and all are not as simple as saving a pre-molar extraction for a BSSO. Also, from reading articles on this, I didn't get the impression the procedure was widely practiced in Europe, albeit it does appear it's more likely to find a surgeon in Europe who does it than in the US.
I put up a link to one journal article on the educational section:
Midline Mandible Distraction Osteogenesis
https://www.jdao-journal.org/articles/odfen/pdf/2016/03/odfen180110.pdf
If you scroll through the article and look for a photo from a ceph where it shows the IMPA (angle of inclination lower incisor has with the mandibular plane), it shows a 98 deg. IMPA being increased to a 99 deg. IMPA. The discussion here, reply #7 (SMSOMS who is a surgeon), makes clear that a goal is to get that angle closer to 90 deg. So, that's an example that the procedure might not be applicable to kicking up all the relationships/angle measures aimed for by a good number of surgeons.
So, since you got this in Europe (Germany?) and insurance paid for it, I'd say you lucked out and got something that worked well for you. But from reading those articles, I don't know if I would extrapolate that this would be the thing for everyone wanting to avoid a premolar extraction to jump into. Of course, if they do, they can read the article I linked to and research more from there. The particulars of all are beyond scope of this string, yet are well contained in the article link.
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There aren't a lot of studies on this and of the ones I found, they are studies of other studies and many resolve to calling for more research to be done. They also mentioned a lot in the field have been reluctant to accept it on basis of it not being enough overall studies on it. But it does look to be useful for the right reasons (which do appear to be for severe anterior crowding) and all are not as simple as saving a pre-molar extraction for a BSSO. Also, from reading articles on this, I didn't get the impression the procedure was widely practiced in Europe, albeit it does appear it's more likely to find a surgeon in Europe who does it than in the US.
I put up a link to one journal article on the educational section:
Midline Mandible Distraction Osteogenesis
https://www.jdao-journal.org/articles/odfen/pdf/2016/03/odfen180110.pdf
If you scroll through the article and look for a photo from a ceph where it shows the IMPA (angle of inclination lower incisor has with the mandibular plane), it shows a 98 deg. IMPA being increased to a 99 deg. IMPA. The discussion here, reply #7 (SMSOMS who is a surgeon), makes clear that a goal is to get that angle closer to 90 deg. So, that's an example that the procedure might not be applicable to kicking up all the relationships/angle measures aimed for by a good number of surgeons.
So, since you got this in Europe (Germany?) and insurance paid for it, I'd say you lucked out and got something that worked well for you. But from reading those articles, I don't know if I would extrapolate that this would be the thing for everyone wanting to avoid a premolar extraction to jump into. Of course, if they do, they can read the article I linked to and research more from there. The particulars of all are beyond scope of this string, yet are well contained in the article link.
I did get this in a large german university hospital. they do this procedure thousands of times a year, so this isnt some experimental procedure they did for my special case. hell the surgeon who did my surgery probably wasnt even 35.
if it can be used for cases of massive overcrowding, why shouldnt it be used for correction of excess forward incisor tilting? what is the goal of tooth extraction or this procedure? creating space. with this procedure you can create as much space as you want bluntly said, so why would the procedure be a limiting factor here in reaching a very well desired 90° IMPA in comparison to tooth extraction? that doesnt make sense to me. The IMPA of atleast 90° should be reached by all means, in my understanding of most optimal aesthetic jaw surgery surgery results, so if this can only be achieved by teeth extractions - im all for it. but in my understanding, this isnt a matter of how you create the space, but just how aggressively you decompensate the incisors, which probably depends on how serious the ortho and/or patient value the matter of aesthetics
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I did get this in a large german university hospital. they do this procedure thousands of times a year, so this isnt some experimental procedure they did for my special case. hell the surgeon who did my surgery probably wasnt even 35.
if it can be used for cases of massive overcrowding, why shouldnt it be used for correction of excess forward incisor tilting? what is the goal of tooth extraction or this procedure? creating space. with this procedure you can create as much space as you want bluntly said, so why would the procedure be a limiting factor here in reaching a very well desired 90° IMPA in comparison to tooth extraction? that doesnt make sense to me. The IMPA of atleast 90° should be reached by all means, in my understanding of most optimal aesthetic jaw surgery surgery results, so if this can only be achieved by teeth extractions - im all for it. but in my understanding, this isnt a matter of how you create the space, but just how aggressively you decompensate the incisors, which probably depends on how serious the ortho and/or patient value the matter of aesthetics
Well, let's leave it as this thread is in the FUNCTIONAL surgery section where the OP is in the US and is an insurance case and since your first question was; 'Why don't American surgeons use the MMDO technique?', you have good reason to know the OP is not going to have that whether or not I know exactly why it's not used in the US.
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There aren't a lot of studies on this and of the ones I found, they are studies of other studies and many resolve to calling for more research to be done. They also mentioned a lot in the field have been reluctant to accept it on basis of it not being enough overall studies on it. But it does look to be useful for the right reasons (which do appear to be for severe anterior crowding) and all are not as simple as saving a pre-molar extraction for a BSSO. Also, from reading articles on this, I didn't get the impression the procedure was widely practiced in Europe, albeit it does appear it's more likely to find a surgeon in Europe who does it than in the US.
I put up a link to one journal article on the educational section:
Midline Mandible Distraction Osteogenesis
https://www.jdao-journal.org/articles/odfen/pdf/2016/03/odfen180110.pdf
If you scroll through the article and look for a photo from a ceph where it shows the IMPA (angle of inclination lower incisor has with the mandibular plane), it shows a 98 deg. IMPA being increased to a 99 deg. IMPA. The discussion here, reply #7 (SMSOMS who is a surgeon), makes clear that a goal is to get that angle closer to 90 deg. So, that's an example that the procedure might not be applicable to kicking up all the relationships/angle measures aimed for by a good number of surgeons.
So, since you got this in Europe (Germany?) and insurance paid for it, I'd say you lucked out and got something that worked well for you. But from reading those articles, I don't know if I would extrapolate that this would be the thing for everyone wanting to avoid a premolar extraction to jump into. Of course, if they do, they can read the article I linked to and research more from there. The particulars of all are beyond scope of this string, yet are well contained in the article link.
Thank you Kavan for sharing this information. It is tremendously helpful to getting a better understanding of the issues at play here.
I did get this in a large german university hospital. they do this procedure thousands of times a year, so this isnt some experimental procedure they did for my special case. hell the surgeon who did my surgery probably wasnt even 35.
if it can be used for cases of massive overcrowding, why shouldnt it be used for correction of excess forward incisor tilting? what is the goal of tooth extraction or this procedure? creating space. with this procedure you can create as much space as you want bluntly said, so why would the procedure be a limiting factor here in reaching a very well desired 90° IMPA in comparison to tooth extraction? that doesnt make sense to me. The IMPA of atleast 90° should be reached by all means, in my understanding of most optimal aesthetic jaw surgery surgery results, so if this can only be achieved by teeth extractions - im all for it. but in my understanding, this isnt a matter of how you create the space, but just how aggressively you decompensate the incisors, which probably depends on how serious the ortho and/or patient value the matter of aesthetics
It’s interesting hearing about your experience. I also don’t understand why this wouldn’t work. It seems like it would just be a question of getting the right and left pre-molars far enough apart so that there’s clearance for the front teeth to be moved back. And space is space, right? I don’t know. Perhaps someone else could chime in.
If you’ve already closed the gap and done orthodontic treatment, could you please confirm whether you were able to reach an IMPA of 90° or close to it? Thanks.
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Well, let's leave it as this thread is in the FUNCTIONAL surgery section where the OP is in the US and is an insurance case and since your first question was; 'Why don't American surgeons use the MMDO technique?', you have good reason to know the OP is not going to have that whether or not I know exactly why it's not used in the US.
yes, maybe you can transfer our posts into the corresponding thread in educational material? Maybe there are some people who are interested in learning more about this. Lets leave this thread to OP then.
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yes, maybe you can transfer our posts into the corresponding thread in educational material? Maybe there are some people who are interested in learning more about this. Lets leave this thread to OP then.
I'd like to keep that thread as a 'depository' for more academic links. But it's a good thing that we are coming to some closure here as to how much we should be going back and forth about this procedure on this thread.
Actually, I'm glad you asked your initial question. However for reasons other than the question being directly applicable to the OP's case. In particular, it was because you stated a TERM for a procedure that US doctors 'don't do'. So, with the term you provided, I did some initial research as to what this procedure actually was. Turned out it resolved to something people sometimes ask about as in 'How do I expand my mandible?', but not by a term/name that is researchable. So, in that sense, it lead to the NAME/s of the procedure people could research if they want to know more about mandibular expansion.
JSF is a US based board and mods here don't claim to be conversant in every procedure out there that aren't commonly done in the US. On my part, when a procedure comes up that seems to be an esoteric one relative to what's commonly done in the US, I look into it when it's referred to by a TERM that would kick up academic articles. That is to say, I was NOT inherently familiar with the procedure you were referring to BUT once there was a TERM to research, I was able to acquire and 'digest' information on it in a short period of time and take an educated guess at why US doctors might not have embraced the procedure, in particular as 'the way' to save a pre-molar.
I think your initial inquiry was useful in the sense that it allowed me to TARGET the name of the procedure applicable to questions that pop up (on OTHER sections of the board) about 'expanding the mandible'and to put up a link to an article about that for others who are CURIOUS about such a procedure.
That said, given that this particular procedure isn't directly on target to the OP's limitations (insurance in US) or his questions I think your personal experience with the procedure would be very helpful/useful in strings where people inquire about 'expanding their mandible' .
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I very much would prefer to have my mandible expanded rather than more extractions, but no surgeon covered by my insurance does that. Worried about possible bone lose, but I'm hoping the overall aesthetics of the surgery will out weigh the extractions.
Right now I just have to do everything I can to get my insurance to cover the procedure. Thanks for the discussions though
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I have a similar issue to you, both jaws recessed with an overbite, will you be getting any rotation in the maxilla?