jawsurgeryforums.com
General Category => Aesthetics => Topic started by: face_backward on August 11, 2017, 02:34:50 AM
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Hi folks,
After lurking intensely for a couple of weeks, this is my first post. I'm a late-20's guy, 5'9" 175 lbs, in reasonable physical shape, struggling to finish a graduate degree, with a slightly odd-looking face and a lifelong history of gradually-worsening depressive/spaced-out/fatigue symptoms. I am coming to believe that these symptoms are mostly the result of poor sleep breathing, and that the poor sleep breathing is rooted in the shape of my face and jaw (I'm pretty confident on the first claim, less so on the second).
PICS
Here's a lateral ceph, which I got at a recent orthodontic consultation:
http://i.imgur.com/eFVTEHk.jpg
And here's a profile:
http://i.imgur.com/AUQSvYz.jpg
and a head-on:
http://i.imgur.com/bONDCFM.jpg
Functionally:
My untreated sleep quality sucks, and as far as I can tell has always sucked. I snore/snort/gasp/"rattle" in my sleep loudly enough to wake others (but not myself) and have recently concluded that I have mild apnea/UARS (though despite several tests I can't seem to get a formal diagnosis, for frustating reasons involving my inability to sleep representatively under observation -- worst observed AHI was 10 with minimum O2 saturation of 85%, but it "didn't count" for diagnostic purposes). "Refreshing sleep" is not something I remember ever having experienced more than a few times before the past few months.
The sleep problems are partly alleviated with a jaw advancement splint (which I built myself because none of the medical people I talked to seemed interested in pursuing this after the first OSA-negative sleep study). It turned out that holding my jaw/tongue forward while I slept was better than taking the amphetamine which I got for my diagnosis of "inattentive ADHD" (I've also been diagnosed with unhelpful bulls**t like "persistent depression" and "idiopathic hypersomnia"). This jaw-advancement discovery was what got me thinking about my facial skeleton.
I bought myself a CPAP machine recently and I'm still experimenting with it, but no matter how I set it up it doesn't seem to help as much as holding the jaw and tongue forward does. It's hard to make it through a full night while using any of these uncomfortable interventions -- sleep quantity vs quality is a hard tradeoff that I haven't yet overcome.
Bite is fine, chewing is fine. I have all 32 teeth, and only one has any major issues (lower right wisdom tooth is crooked). I have never had orthodontic work, and am not prone to tooth decay (though I have some damage from nocturnal bruxism, probably related to the sleep breathing problem). I don't have any noticeable soft-tissue abnormalities in my mouth, besides slight enlargement of the tonsils and a fairly large tongue. I am somewhat prone to sinus problems, but I can usually breath through my nose alright (though I always breathe through my mouth at night unless I tape it shut). I have a deep voice for my size, and I speculate, from my incomplete understanding of the pharyngeal anatomy, that the corresponding position of the larynx doesn't help with the airway patency.
Besides the sleep problem, I have some other minor jaw-related functional issues:
- Left TMJ pops (painlessly) every time I open my mouth more than an inch. This seems to be the end of the jawbone actually popping out laterally, not just a disc displacement internal to the joint.
- Minor lip incompetence, which I can usually compensate without excessive mentalis strain, but probably contributes to my loss of lip seal and mouth falling open during sleep.
- My typical head/neck posture sucks, despite prolonged efforts to improve it. Partly it's because I'm slouching from being tired all the time (see above) and partly because standing more upright sucks my jaw uncomfortably far into my neck.
In my own assessment, I also have some jaw-related
Aesthetic issues:
- My chin seems fairly weak -- indeed, the projection is short enough beyond my neck, and sufficiently angled up, that I cannot comfortably strap on a bike helmet without impinging on my neck.
- Though I am obviously not blessed with strong beard genes (I'll take the not-balding genes instead) I am consistently told that I look worse (or "like you're 12") when I shave.
- There is a minor but noticeable-from-the front asymmetry of the lower jaw. Ortho observed that lower incisor midline was offset from upper incisor midline. This may just be may a dental issue, however. Sometimes by biting hard on incompressible material between the right molars, I can make the right TMJ pop, and after that I can open my jaws without popping on either side for a few hours. My face is noticeably more symmetrical when this happens, but it soon relapses into asymmetry and the left joint starts popping again.
- My nose sort of turns up at the tip. I usually see this feature in *after* profiles from linear bimax advancement, so I assume a linear bimax would make that worse.
- I have relatively flat cheekbones/weak suborbitals,, but I'm not really concerned about that unless inasmuch as it would make any advancement of the jaws look apelike. I do think my skull looks a little strangely apelike already on the ceph.
- I barely show any teeth when I smile, as though the teeth are not pushing out from behind the soft tissues far enough.
My self-analysis at this stage:
I strongly suspect the known functional issues (sleep, TMJ, head posture) are related to shape of the face bones themselves, but I've been wrong hundreds of times before and I could easily be wrong with this too. Maybe if I cut away at the tonsils or soft palate I'd sleep better, but I sort of doubt it.
I'm under no illusion that I am deformed. I don't want to be one of those unreasonable people saying they need the kitchen sink when it's clear to everybody else that they're making mountains out of molehills, so please check me right now if I "actually look fine", I'll believe you (almost). The orthodontist I recently consulted didn't see anything abnormal about my profile, occlusal plane angle, or bilateral symmetry -- however, to my eye, photos of many of his other "successful" patients showed pretty goofy skeletal structures.
It just strikes me that there's room for improvement aesthetically, and it would be great if the form and function could be improved together.
On the ceph, I measure the angle between the Frankfurt horizontal and the bite plane (at level of premolars) to be about 17 degrees, which I take to be a bit outside the normal range, but not extreme. I'd say the steep occlusal plane angle does not mainly reflect excessive anterior facial height -- in that case, I would expect excess upper gum show (actually have incomplete upper tooth show) and straight or humped downturned nose (actually have upturned nose). On the contrary, I think the steep plane is a more a result of deficiency at the rear of the maxilla, and corresponding deficiency of the mandibular ramus height
(though with this flat gonial angle, the ramus is barely distinguishable from the mandibular body). I suspect the deficiency in the posterior face/jaw might be what's cramping the airway.
I think my lower jaw needs to rotate CCW a little and come forward to get a jawline and some chin projection, but I can't see how to move the upper jaw forward much without pushing the already-prominent and upturned nose even further up and out. I certainly wouldn't want to impact the anterior maxilla and lose my teeth entirely behind my upper lip.
Maybe downgraft the anterior maxilla slightly and the posterior maxilla significantly? I don't know, I suppose that could make the lip incompetence worse.
On the "face" of it, does this look like a potential jaw surgery case at all? Should I email some photos to Arnett/Gunson or something? Or am I completely barking up the wrong tree? I'm pretty sure that straight linear bimax would be aesthetically worse, even if it were a functional improvement.
Thanks for reading, I know this was long.
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Sorry I don't have much to add here (you seem to have a pretty good analysis), but I would book some appointments with a few maxfacs to see what they think. Also, I have read that people who practice proper tongue posture have noted improvements in sleep quality, perhaps seek out a myofunctional therapist if you are having trouble maintaining proper posture during the night.
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Did you end up seeing a surgeon?
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I have not seen a surgeon, but my sleep doctor is referring me to Stanford sleep medicine, where hopefully I can at least get somebody to acknowledge the functional problem -- I still haven't even been able to get any diagnosis, possibly because the facility I go to is not really equipped to identify UARS.
I'm not very hopeful at this stage of anything usefully moving forward, but I believe my best chance to convince a surgeon to do something, and to convince insurance to contribute to doing it, is if I actually had some kind of sleep-disordered breathing diagnosis, and if Stanford (where the diagnoses of OSAS and UARS originated) can't figure that out, nobody will.
Since I'm pretty sure the jaw is source of the sleep problem, I've already tried every non-surgical treatment for sleep apnea without lasting success, and my life is effectively over if I don't make this improve (there's no way I can hold a job with the level of fatigue I experience untreated, and all the treatments have been unreliable at best), I'll still probably try to see a surgeon even if Stanford doesn't come through diagnostically (like if I'm unable to sleep representatively in their lab).
Of course, I'd have no way to pay for what would need to be done in that case, so I'd be SOL anyway.
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Your face really does not look that much backwards to an extent that one would choose that screen name. However, aesthetically, I think a more forward lower face with chin would suit you well especially given the sleep apnea.
From your X rays, it does look like they could do MMA (bi max, linear advancement where both jaws are equally advanced) which is kind of the easiest thing some maxfax docs, especially the ones with insurance paying for it, want to do for sleep apnea. However, some aesthetic trade-offs with that is look of 'longer' lip or more exaggeration of high mandibular plane from the front.
Not saying that the linear advance MMA would look bad on your or anything like that but just look for a doc who has the option of CCW (counter clockwise rotation) which would tend more toward offsetting the potential aesthetic disadvantages of MMA.
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Update:
About a week ago, I finally managed to construct a jaw-advancement/tongue-holding device that seems to reliably improve my sleep and daytime symptoms. Not the best ever, but works every day. This was the kind of evidence I had been looking for in order to be fully convinced that this jaw-based sleep-breathing thing really has been the source of my problems, in spite of all the treatment failures and inconsistent test results in the past.
Also, I just got back from Stanford sleep medicine, where I made my case to the trainee doctor I got to see. To my complete amazement, he left and came back with Dr. Guilleminault -- The Dr. Guilleminault who first proposed the diagnoses of sleep apnea and UARS, and without whom the whole field might not exist. I didn't think he was even practicing anymore -- he's been a doctor since my parents were in kindergarten, so he's absolutely ancient now.
So here's this godfather of sleep medicine, a guy whose textbook chapters I'd read to learn about my condition, and he's actually there in person looking in my mouth and examining my ceph. He agreed that my jaws are retruded, and initiated a referral to a sleep surgeon, Dr. Kasey Li, for evaluation -- with the caveat, of course, that nobody would operate until I had a positive sleep study (scheduled another one for the end of August), but said it was possible that I would be a candidate for MMA even with UARS/mild apnea.
Highlights from exam notes:
Oral:
High & narrow hard palate: yes
Elongated soft palate/uvula: no
Mallampati score: 4
Tonsil size: 1
Malocclusion: Class 2 modified by oral appliance
Edge to edge
Crossbite: yes
Craniofacial:
Maxillary deficiency: yes
Retrognathia: yes
Micrognathia: yes
Physical examination consistent with small retrognathic airway that definitely place him at risk for sleep breathing disorder. We will reevaluated him with new sleep study and referral to Dr. Li will be place for evaluation of airway anatomy that could account for his symptoms.
That's the good news.
Bad news: said godfather of sleep medicine told me that I had to stop using the oral appliance, which I have finally gotten to work reliably, and which is the only thing that's ever helped, in favor of resuming CPAP, which has never helped much and always had intolerable side effects. He didn't like that my bite has become edge-to-edge from using the jaw advancement. I'm certain (based on the fact that current, professionally-made dental casts can be made to fit together correctly, and also reproduce my malocclusion when the lower cast is pushed forward) that the edge-to-edge bite reflects a change in jaw posture (the nightly advancement has become residual during the day, possibly through remodeling of the jaw joint), whereas he seemed to think it was a matter of tooth movement. We seemed to have some miscommunication about this.
I'm worried now that since my jaw posture is noticeably further forward after using appliances for a year, and can no longer be pushed back to its original fully-retruded position, my untreated sleep breathing problem may not appear, on the next test, bad enough to operate -- even though it can only be as good as it is in the context of a device-induced malocclusion. Very frustrating.
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Aesthetically, I think you would benefit from a sliding genio to advance out and shorten the chin. Often this has some improvement to the airways.
IDK. So what if your bite became edge to edge if your airway is still too small. Like someone could have an edge to edge bite anyway as a start point whether or not a device 'did it'.
Maybe consider using the CRAP (mispelling intended) device with the NOSE PILLOWS and just telling them that you 'no longer' use your own device. Who knows? Maybe the pros just BRISTLE when a patient does something to improve thier own breathing and didn't go through a dental pro to do it.
Do you think he would have said what he said if he didn't know you made your own device?
Consider that you STILL have indication for the whole surgery despite your moving your jaw or teeth a tad forward.
I know it sucks when all is contingent on insurance paying for it.
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Aesthetically, one of the worst parts is that when I stand up fully straight and look straight ahead, I have a double chin and no jawline at <15% body fat. This is usually concealed by my terrible neck posture, but is immediately corrected by protruding my jaw. Sliding the chin only, without the rest of the jaw, seems like it would just put my "first chin" further ahead of my "second chin" without actually resolving the double-chin/no-jawline issue.
I know the device did cause my edge-to-edge bite, because I didn't have it before. It should still be *less* of a problem for a surgeon than a "natural" edge-to-edge bite would be, because I can demonstrably still fit the arches together into a normal interlocking occlusion if they're isolated and free to move relative to each other -- the way they would be if my jaws were sawn off. I get that it could become a problem if the surgeon couldn't "find" a stable occlusion to fit the loose parts together in, but that's a non-issue in this case, so I don't get why he was so bent out of shape over it. At worst, the surgeon would end up fitting the pieces together in way that made a minor forward dislocation at the joint permanent, which doesn't seem like a huge problem -- my TMJ is better with the minor forward dislocation than it was with the old occlusion.
Regarding medical advice -- I actually did try going through a dental pro some months ago. I paid one out of my own pocket to make me an oral appliance after my attempts had been unreliable, figuring maybe the unreliability was because my craftsmanship just sucked and a pro could do it better (particularly with respect to incorporating tongue-holding along with the jaw advancement). Turned out the pro's device wasn't any better for me than mine were, so I went back to making my own, and ended up improving on it.
I don't think whether or not I had done it myself or with a dentist's approval would have had any bearing on this sleep doctor's opinion of it, though. I think what we had here was the typical combination of
(1) misaligned incentives -- doctors care more about measurable/objective problems, patient cares more about subjective symptoms/quality of life, and when these trade off to suggest different treatments, doctor and patient have conflict of interest.
Also, the level of risk I'm willing to take with myself while accountable to myself, to fix a problem that's nearly driven me to suicide, is always going to be higher than the risk a doctor is willing to take with somebody else while accountable to his colleagues. Closely related,
(2) asymmetrical information -- doctor knows more in general, patient knows more in specific. Especially given that this doctor was a celebrated expert with a lifetime of experience, he had little time for the details of my case (getting some of them objectively wrong in his statements to other people), but knew (correctly) that he knew better which type of treatment works better for most people. He has to assume I am more like most people than I say I am (including being about as ignorant as the average person), and he doesn't have the benefit of the fine-grained knowledge I have acquired from my own observations.
Which means when I say I'm doing something weird to treat a problem that I can't objectively demonstrate, and the treatment is visibly messing me up, the doctor is pretty much obligated to say I should stop using that treatment in favor of a more common and less objectively damaging approach, even if that approach subjectively doesn't work for me.
I get why he has to tell me to do it, doesn't mean I'm going to. I'll give it another shot, but I have to do what works most of the time. Last night I tried CPAP again and didn't even make it 3 hours total -- I tore it off my face twice.
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Do you use the nose pillows or the mask? If the latter, try the former and see if that is anymore comfortable.
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I do use nose pillows, I have two kinds of nose-pillow masks, including a dreamwear and some minimalist one that's basically nothing but the nose pillow and some straps around the back. I learned to put pads in front of my cheeks under the straps or the pillows push too hard into my nose and limit the air flow by scrunching it up (loosening the straps instead just makes it leak).
Still, I can never manage to stay asleep with the damn thing longer than 5 hours tops, and if I ever set inhalation pressure higher than 10 I reliably wake up with my stomach and guts filled with air.
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Having tried CPAP for a few months as well, it's funny what alluring and luxurious names manufacturers give their CPAP masks even though they're typically no better than the last one a patient's tried, all told, save for your facial features meshing better with a particular shape. Too bad insurance doesn't really cover custom designed masks. Hell it took me a week+ just to get used to sleeping with a smartwatch on my wrist. I don't get how you can mess with inhalation pressure, that must be unique to your machine. Mine was set by the doctor. But the air problem is something you get accustomed to and resolves over time, IIRC.
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Regarding medical advice -- I actually did try going through a dental pro some months ago. I paid one out of my own pocket to make me an oral appliance after my attempts had been unreliable, figuring maybe the unreliability was because my craftsmanship just sucked and a pro could do it better (particularly with respect to incorporating tongue-holding along with the jaw advancement). Turned out the pro's device wasn't any better for me than mine were, so I went back to making my own, and ended up improving on it.
I don't think whether or not I had done it myself or with a dentist's approval would have had any bearing on this sleep doctor's opinion of it, though.
Sharing my two cents, as I just had bimax surgery + genio and suffered all the same symptoms you described (albeit to a greater degree, but trust me - this gets worse the longer it's untreated).
Yes, you might be right on both misaligned incentives/information BUT your doc's disproval of the homemade oral device is also for your benefit. If you're trying to get this procedure covered by insurance (I did), you will most likely need to prove that you exhausted all other treatment options, including CPAP and an oral device. And you will need official documentation proving that these treatment options failed. No doctor is going to provide you that documentation for a homemade device. If you're seriously considering this procedure and don't want to pay out-of-pocket, then I'd go back to using the dental pro's device and do what you need to do to get documentation to show that it's not an effective treatment for you. Same goes for CPAP (I'd actually prioritize this, as most sleep doctors consider this to be the gold standard for OSA and you WILL need to prove non-compliance to get your surgery covered).
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And you will need official documentation proving that these treatment options failed.
If you're seriously considering this procedure and don't want to pay out-of-pocket, then I'd go back to using the dental pro's device and do what you need to do to get documentation to show that it's not an effective treatment for you.
I'm sure I can't do that, except insofar as "documentation" is "somebody else writing down the words coming out of my mouth". I know I won't be able to show objectively that current treatments aren't good enough. I can't even reliably show objectively that I have apnea when I'm untreated. Using the dentist's device, I'll probably look pretty well treated on any test on most nights. It is subjectively pretty good, occasionally. I just strongly suspect it could be better, more reliably, if there was more space in the airway to begin with.
I'm getting the sense that while I might be able to convince a surgeon to operate for this (as long as I can eventually show that I actually have apnea during a lab test, and show that I am otherwise a good candidate for surgery by being young, normal-weight, having clearly-retrusive jaws, etc), I'll never get insurance to cover it because the apnea will
(a) never look objectively "bad" enough even untreated (low AHI), and
(b) appear to be "resolved" objectively with the non-invasive methods I've already used, even though the subjective quality of that resolution is very hit-or-miss
One of the most frustratingly no-win parts about this whole affair has been that in light of the inconclusive sleep study results, I've had to make my case that I have a sleep-breathing problem at all by arguing that at least some of these breathing interventions subjectively do help me a lot. But now to make the case that anything more should be done, I might have to prove that they objectively don't help me enough. I don't think that can happen.
What really grinds my gears though is that with my degree, I could actually get a job that would make me enough money to pay for this procedure out of pocket in a reasonably short time, and I would not hesitate to do that work to save that money, but I'd only be able to hold such a job if the symptoms could be reliably resolved now, and I don't think that's going to be possible without this procedure.
My last shot would be if my parents could loan me to pay for it out of pocket, which I think they might actually be up for. But that's absolutely a last resort. And there's always the chance that I'm wrong, and that I borrow a tremendous amount of money to do something that doesn't fix the problem and doesn't actually enable me to hold a job that could ever pay it back.
Personally, I'd gladly bet my very life on such a procedure being a success (indeed, I'm already in the position of betting my life on it, because I can't keep living like this and I've tried everything else) but I get that this isn't going to convince anybody else to spend their hard-earned money on it.
@ ditterbo,
I don't get how you can mess with inhalation pressure, that must be unique to your machine. Mine was set by the doctor.
My understanding is that there is always some machine-specific "secret code" that the provider enters to adjust the settings, and which isn't supposed to be given to the patient because [bulls**t]. On my machine (respironics system 1) if you select "settings" on the screen and then hold down both of the two buttons on the machine simultaneously for a few seconds, the "secret menu" will come up that lets you change the pressure and whatnot. Try googling "[your machine here] provider setup" or some such -- at your own risk, of course.
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I'm sure I can't do that, except insofar as "documentation" is "somebody else writing down the words coming out of my mouth". I know I won't be able to show objectively that current treatments aren't good enough. I can't even reliably show objectively that I have apnea when I'm untreated. Using the dentist's device, I'll probably look pretty well treated on any test on most nights. It is subjectively pretty good, occasionally. I just strongly suspect it could be better, more reliably, if there was more space in the airway to begin with.
I'm getting the sense that while I might be able to convince a surgeon to operate for this (as long as I can eventually show that I actually have apnea during a lab test, and show that I am otherwise a good candidate for surgery by being young, normal-weight, having clearly-retrusive jaws, etc), I'll never get insurance to cover it because the apnea will
(a) never look objectively "bad" enough even untreated (low AHI), and
(b) appear to be "resolved" objectively with the non-invasive methods I've already used, even though the subjective quality of that resolution is very hit-or-miss
I'm confused. You demonstrated an AHI of 10 and min oxygen saturation of 85% - what about this "didn't count," as you say? And why would you have an issue getting documentation from a doctor to show that other (physician-approved) methods are not helping? If all this were true and you meet any other requirements for surgical intervention as outlined by your insurance company's policies, then have your doctor file an appeal with your insurance company. Yes, this requires a lot of work on your part, but in my experience, it was more than worth it to not have to pay $100k out of pocket.
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The recording of an AHI of 10 and min O2 sat of 85% didn't count because it was only an at-home overnight oximetry, not a full "at home sleep study" -- i.e., I wasn't wearing the chest strap and nose-air-flow sensor to verify that these were actually obstructive events/breathing disturbances. I don't know what the hell else they would have been, except instrument malfunction, but for purposes of officially diagnosing OSA they need to see that the blood desaturations are accompanied by measurable air-flow abnormalities.
I was given a full at-home sleep study after this positive oximetry, to confirm the diagnosis. During that confirmatory study, the problem basically didn't show up, just like it hadn't during my in-lab study (when I barely slept at all).
The trouble is that there are two things that seem to resolve this problem for me, in terms of making the nighttime breathing irregularities stop and making me feel better the next day: jaw advancement, and being really amped up nervous/anxious/insomniac before I go to sleep. Like, I'll conveniently always feel my best the day of a big exam or job interview, despite having had what most people would call a pretty terrible night's sleep (light, fragmented. long periods of wakefulness) before. I think it has to do with not reaching such a deep stage of sleep meaning that my airway muscles don't relax as much.
Unfortunately, this effect is usually happening during my sleep studies too, and making it look like the problem is least bad during the times that it matters most that I demonstrate it. Knowing that my sleep is being observed to determine whether I'll ever get treatment makes me nervous, so I sleep an uncharacteristically short time, wake up uncharacteristically many times during the night, and feel uncharacteristically great in the morning -- and then extremely pissed-off that I again "failed" to demonstrate the problem.
For my upcoming in-lab sleep study at Stanford at the end of the summer, I'm planning to have somebody help me stay awake (without stimulants, of course) for 40+ hours before the study, so that I'm physically incapable of not sleeping deeply when I'm being observed.
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Got it, that makes sense. Well - of the three tests, the overnight oximetry is likely the least exact/accurate, so I wouldn't necessarily put too much stock in that being the correct result.
That said, it sounds like you have UARS, and hopefully this test will finally be able to determine whether that's the case.
I've also experienced what you've described (re: feeling better on the days that you had a s**tty sleep), but I chalked it up to 1) adrenaline and 2) feeling better with less sleep because I was deprived of less oxygen. If I'm not sleeping, I'm not slowly suffocating myself.
Can you ask about taking a sleep aid before the study? It's my understanding that that's fairly common practice.
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It just sounds like you are able to WILL a good nights sleep WHEN you want to have one, can self assist in pushing out the jaw with your self made device and don't have the type of apnea episodes they are looking for in order for insurance to pay for it.
In terms of your LOOKS, you don't look double jaw recessive and your looks would benefit from an advancement genio, which, who knows, might help the at night breathing.
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Dude, I think you should be careful about trying to rig a situation where insurance pays for double jaw surgery IF your main or even most of the objective is actually AESTHETIC improvement.
In terms of aesthetics ONLY (remember you are on the aethetic section of the board),:
1: your jaw angles are HIGH
2: your jaw to jaw distance could be wider
3: your chin is long
4: your UPPER jaw looks forward enough
5: you have the type of nose that would tend to get wider at base with upper jaw advance
6: you still have your lower jaw WISDOM teeth.
7: your bite looks right
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If insurance does find an indication to do the surgery to increase the airways, they MIGHT just be tempted to give you MMA, basically LINEAR advancement of both jaws equally. Your case looks pretty tempting for them to do just that. Tempting as that may be for INSURANCE to do the linear advancement, in GENERAL, you can't count on insurance to maximize aesthetics when the PRIORITY for them to do it is mostly to OPEN the airways.
Let's see... some of the possible trade-offs would be:
6: 'Good by' to the lower wisdom teeth which are nice and straight and usually have to go before they do the BSSO.
5: A WIDER nose might not look that good BUT from the perspective of insurance doing the surgery to breath better, a wider nose base assists with such.
4: Upper jaw will move more forward which should explain #5 of getting the WIDER nose base. Since it would have to move about as much forward as the forward advancement of the lower jaw, it COULD give you the 'monkey' look with the upper jaw.
2: It will NOT make the jaw to jaw distance (enough) WIDER for any of that wide 'square' jaw angle look.
1: It will NOT drop the posterior jaw angle down (enough) for the 'square' jaw look mentioned in #5
OH, GEE looks like #3 was left out of the count down so let's look at #3.
The surgery WOULD most likely give you a sliding genio along a diagonal cut to both advance out your chin and vertically shorten it. WOOSH... ONE GOOD aesthetic IMPROVEMENT from ALL that surgery which might be croweded out from even appreciating that aspect given the other possible trade-offs.
You very well could rig a situation where insurance would pay for it to expand the airways. But, you might not be able to rig a situation where they maximize aesthetics given it does look like they would be tempted to do linear advancement to both jaws which in YOUR case would NOT tend towards maximizing aesthetics.
That said, you might get the 'MONKEY'S PAW' which is getting what you WISH for BUT the wish comes with an UNWANTED consequence.
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It just sounds like you are able to WILL a good nights sleep WHEN you want to have one
I'm able to "WILL" a night's sleep that most people would call bad (short, fragmented, still tired) but which is much better than my usual untreated sleep. If I could replace all my "sound" nights (with marked breathing problems) with "restless" nights (without), I'd feel better overall, but I'd still be going to the sleep doctor -- complaining about insomnia. "Will" isn't quite the right word though, since it usually happens involuntarily before something stressful, and I can't keep it up for more than a couple of nights. In the context of sleep studies, it's a strong version of the "first night effect", which sleep researchers well know to confound their studies if not accommodated, but which unfortunately can't be accommodated in a clinical setting (it would require being in the sleep lab/hooking up to the rented equipment for two or more successive nights).
Dude, I think you should be careful about trying to rig a situation where insurance pays for double jaw surgery IF your main or even most of the objective is actually AESTHETIC improvement.
You're absolutely right -- IF that were the main objective. Actually, it's a distant second. Maybe I didn't do a good job making that clear, because I started this thread talking about aesthetics -- I just use other forums for more detailed stuff about the functional/apnea aspect, and thought this would be the place to talk about the aesthetic aspect. I've let this thread sort of devolve into more functional/apnea stuff now, when I should have probably shifted it to a different subforum here.
So, to be clear, if I could solve the functional problem (daytime fatigue, mood disturbances, forgetfulness, needing 10+ hours of sleep every night and falling asleep in the daytime if I don't get it, etc) with a purely internal procedure that had no effect on my appearance (e.g. turbinate reduction, tonsil removal, etc) I would unhesitatingly do that. In my case, there doesn't seem to be any indication that anything but the jaw is abnormal enough to be the source of airway problem, nothing but the night airway problem seems to explain (in a "I can actually turn the symptoms on and off by changing this variable" way) the bad daytime problem, and nothing has ever improved the daytime problems as much as shifting the position of the jaw -- but that still doesn't work very reliably.
If insurance does find an indication to do the surgery to increase the airways, they MIGHT just be tempted to give you MMA, basically LINEAR advancement of both jaws equally. Your case looks pretty tempting for them to do just that. Tempting as that may be for INSURANCE to do the linear advancement, in GENERAL, you can't count on insurance to maximize aesthetics when the PRIORITY for them to do it is mostly to OPEN the airways.
Right, and here I'm not sure I would go for it even if it would be covered, because not only does it seem like it would be worse aesthetically, I don't think it would efficiently address the airway problem -- I've been told multiple times that my tongue is extremely "high" in my mouth (e.g. possible worst Malampati score), and it seems to me that the airway restriction must be somehow related to the vertical posterior maxillary deficiency, which linear advancement wouldn't address. Honestly, I don't think I need *any* linear advancement of the maxilla -- just rotation -- and bringing the mandible forward to meet the maxilla in this more-rotated position would, implicitly, give plenty of advancement there.
My own (linear) advancement oral devices are very "touchy" in their effectiveness. They seem to work best when I'm able to make them produce a delicate effect involving "suctioning" the back of the tongue upward into my top teeth. Devices that protrude the jaw further along the bite plane, or pinch-hold the tongue further forward without pulling it "upward", are not more effective. Unfortunately I can't directly visualize what's happening with my tongue and airway when I do this, but I feel like it suggests a vertical approach to a vertical problem, and argues against linear advancement from a purely functional perspective.
That said, you might get the 'MONKEY'S PAW' which is getting what you WISH for BUT the wish comes with an UNWANTED consequence.
The "MONKEY'S FACE", if you will. :-\
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I'm able to "WILL" a night's sleep that most people would call bad (short, fragmented, still tired) but which is much better than my usual untreated sleep. If I could replace all my "sound" nights (with marked breathing problems) with "restless" nights (without), I'd feel better overall, but I'd still be going to the sleep doctor -- complaining about insomnia. "Will" isn't quite the right word though, since it usually happens involuntarily before something stressful, and I can't keep it up for more than a couple of nights. In the context of sleep studies, it's a strong version of the "first night effect", which sleep researchers well know to confound their studies if not accommodated, but which unfortunately can't be accommodated in a clinical setting (it would require being in the sleep lab/hooking up to the rented equipment for two or more successive nights).
You're absolutely right -- IF that were the main objective. Actually, it's a distant second. Maybe I didn't do a good job making that clear, because I started this thread talking about aesthetics -- I just use other forums for more detailed stuff about the functional/apnea aspect, and thought this would be the place to talk about the aesthetic aspect. I've let this thread sort of devolve into more functional/apnea stuff now, when I should have probably shifted it to a different subforum here.
So, to be clear, if I could solve the functional problem (daytime fatigue, mood disturbances, forgetfulness, needing 10+ hours of sleep every night and falling asleep in the daytime if I don't get it, etc) with a purely internal procedure that had no effect on my appearance (e.g. turbinate reduction, tonsil removal, etc) I would unhesitatingly do that. In my case, there doesn't seem to be any indication that anything but the jaw is abnormal enough to be the source of airway problem, nothing but the night airway problem seems to explain (in a "I can actually turn the symptoms on and off by changing this variable" way) the bad daytime problem, and nothing has ever improved the daytime problems as much as shifting the position of the jaw -- but that still doesn't work very reliably.
Right, and here I'm not sure I would go for it even if it would be covered, because not only does it seem like it would be worse aesthetically, I don't think it would efficiently address the airway problem -- I've been told multiple times that my tongue is extremely "high" in my mouth (e.g. possible worst Malampati score), and it seems to me that the airway restriction must be somehow related to the vertical posterior maxillary deficiency, which linear advancement wouldn't address. Honestly, I don't think I need *any* linear advancement of the maxilla -- just rotation -- and bringing the mandible forward to meet the maxilla in this more-rotated position would, implicitly, give plenty of advancement there.
My own (linear) advancement oral devices are very "touchy" in their effectiveness. They seem to work best when I'm able to make them produce a delicate effect involving "suctioning" the back of the tongue upward into my top teeth. Devices that protrude the jaw further along the bite plane, or pinch-hold the tongue further forward without pulling it "upward", are not more effective. Unfortunately I can't directly visualize what's happening with my tongue and airway when I do this, but I feel like it suggests a vertical approach to a vertical problem, and argues against linear advancement from a purely functional perspective.
The "MONKEY'S FACE", if you will. :-\
You seem pretty insightful as to what the problem is which is great. Maybe set up consult with Gunson just to get a plan to cross reference for the vertical posterior 'shortness' given he's good at doing the posterior downgrafts. I was not actually suggesting linear advancement. Just putting out the caveat that insurance doctors might be tempted to do just that.
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There's a member here who had the option of linear surgery from her local surgeon or CCW rotation from the big bad W. Thankfully she chose the latter. Sleep apnea completely cured. She's thrilled.
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Progress report:
I've gotten better at building joint jaw-advancement and tongue-retention devices -- the last one worked for two straight weeks before crapping out.
I had an in-lab sleep study at Stanford. They saw "mild sleep apnea", AHI of 5 and min sat of 92% -- just at the cutoff to even make a diagnosis. Got assigned another brand-new MD to review the test results. Said MD seemed skeptical that my waking problems could be caused by such "mild" apnea, skeptical that my jaw advancement devices made such a radical difference as I said they did, and irritated by my insistence that CPAP didn't help. I guess I'm not enough like what's in the textbooks. Nevertheless, I did obtain a couple of surgeon referrals -- Wolford and Movahed, at least, as well as another guy who's more of a general sleep surgeon, but, as I since discovered, does not himself perform jaw surgeries (only collaborates with other surgeons to do them). In the end I didn't even try to see A&G -- I don't have years to wait in line for this, and I got jerked around by their office for months when I tried to connect with them in advance of having these referrals.
I also got to talk, for the first time, with a surgeon who does actually perform bimax in the context of sleep disorders (Dr. Kasey Li). On the plus side, he thought my story made sense overall, believed me that the jaw advancement devices worked, didn't think I was crazy for pursuing jaw surgery (though obviously he could not guarantee results), agreed that there wasn't much of anything sensible left to try, understood that there are many people in my position who really can't go on living without something like this, said he regularly performs CCW with downgrafts, and sounded like he could fit me in before my insurance expires without putting me in braces for months beforehand. All great to hear.
On the downside, it sounds like it would be basically impossible to get any insurance to cover *any* surgery even while I still have it, even if my AHI were twice what it was, and I'd be on the hook for up $100k out of pocket. Also, he seems very much like a "I know what I'm doing, I'll work out all the technical details, take it or leave it" kind of guy. I tried to talk to him in particular about the specifics of the posterior downgraft -- what do you use as the bony shim, etc. He says he doesn't graft from other locations (like the hip) and didn't see why anybody else would -- he just takes little wedges of bone out of the nasal septum to fill the gap. This surprised me a lot, because it seems like that's a very thin bit of stuff to wedge into a spot that will bear the bite force of the molars (but I don't have a human skull here to examine, and he's the anatomy expert), and there doesn't seem to be enough bone available from that source to downgraft far enough for a significant rotation. I'd be interested to hear what other guys who do such rotations have to say about this proposal (and whether anybody here has an informed opinion about that technique).
I should know by the end of the week how soon I can get in to see the other surgeons.
Aside, a rant about health insurance:
If the insurance didn't approve this, I'd be charged $100k, but if the insurance approved it, I know *they* wouldn't actually have to pay out $100k -- that sticker price is only for individuals without the negotiating leverage of an insurance company. Imagine, hypothetically (and ignoring copays, for the sake of simplicity) that overall, for everybody actually involved in doing the procedure (surgeon, nurses, anesthesiologist, hospital overhead, etc etc), $30k total is enough to cover their costs and come out ahead (this seems in line with the ratio that hospitals actually collect from insurance when these things are approved). Suppose also that $50k is the most I can personally spend.
Then there are three scenarios:
(1) (Unlikely) The insurance negotiates with the hospital on my behalf and agrees to pay the $30k actual cost, and I have the procedure. The hospital is ahead, I'm way ahead (for having gotten the procedure that was worth $50k to me for free), and the insurance is way behind.
(2) (Most likely) Since the insurance doesn't want to be way behind, they fight me about it tooth and nail until my coverage expires, and I can't have the procedure. The care providers are behind (losing business they would have been happy to take from the insurance), I'm way behind cause my life is still f**ked, and the insurance company is slightly behind for having to pay somebody to argue with me during months of appeals.
(3) (Impossible dream of rationality) I could just agree to pay back the insurance company $31k (or whatever they pay + some margin), and *everybody* comes out ahead -- the hospital recoups their cost and then some, the insurance recoups their cost and then some, and I get something I'd have gladly paid more for.
Alas, it can never be.
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you look fine to me
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I appreciate the input, Lazlo. I probably should have started a different thread somewhere for these updates, but I suppose the thread-title question still stands.
I must disagree with your assessment still. Here https://imgur.com/LECU2y2 (https://imgur.com/LECU2y2) is a current profile without facial hair.
I can't say that looks fine, for values of "fine" in use around here.