jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: introspect160 on December 29, 2014, 02:09:26 PM
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Hi everyone.
I need some opinions on this. Every since I've been a teenager I had problem with tooth grinding, clicking or locking jaw, headaches, mouth breathing, constricted airway, and forward head posture. The thing is my bite has been perfect. I've had invisalign to correct some minor crowding, but overall my occlusion is good. Two of my friends are dentists are have said I have a basically have a normal occlusion but a class 2 skeletal pattern. I have a very weak/non-existent jaw line. Can you spot the issues in the ceph X-ray and what is involved in correcting this?
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you have a steep occlusal and mandibular plane which presents itself in a skeletal class 2 pattern (mandible behind maxilla) but if you were to rotate your jaws counter clockwise, they would have a good relationship.
so you would need bimax surgery with counter clockwise rotation advancement.
edit: you didn't really ask, but your chin bone is also deficient.
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you have a steep occlusal and mandibular plane which presents itself in a skeletal class 2 pattern (mandible behind maxilla) but if you were to rotate your jaws counter clockwise, they would have a good relationship.
so you would need bimax surgery with counter clockwise rotation advancement.
edit: you didn't really ask, but your chin bone is also deficient.
Thanks notrain. Would such a surgery, if successful, solve most of the issues I mentioned above (airway, posture, etc.)? Could the deficient chin bone be solved with a genioplasty or implant? Also, the bimax surgery, I'm assuming this would be a pretty invasive, extreme surgery, right? Would going with a jaw distraction surgery through Profilo in Australia be a more precise way of accomplishing the rotation?
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Thanks notrain. Would such a surgery, if successful, solve most of the issues I mentioned above (airway, posture, etc.)? Could the deficient chin bone be solved with a genioplasty or implant? Also, the bimax surgery, I'm assuming this would be a pretty invasive, extreme surgery, right? Would going with a jaw distraction surgery through Profilo in Australia be a more precise way of accomplishing the rotation?
Distraction makes little sense for adults, given the small movements required. You still need to cut bones, and you double the surgeries (dustractirs put in, dustrsctors taken out).
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I've noticed as well that the back of my jaw (ramus) is so far back it actually overlaps the spinal column. I've never seen a ceph X-ray in which that ramus wasn't ahead of the spine other than my own. Is there a name for this issue and can it be corrected?
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Are you guys able to look at the x-ray and able to see if the airway is good/bad? I don't have the knowledge or know what to look for.
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Thanks notrain. Would such a surgery, if successful, solve most of the issues I mentioned above (airway, posture, etc.)?
yes
Could the deficient chin bone be solved with a genioplasty or implant?
both, but i would avoid implants and do genio.
Also, the bimax surgery, I'm assuming this would be a pretty invasive, extreme surgery, right?
yes
Would going with a jaw distraction surgery through Profilo in Australia be a more precise way of accomplishing the rotation?
distraction osteogenesis can't rotate the maxillo mandibular complex. you can only do linear advancement with it. you don't need linear advancement.
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So I finally had a consult with the oral surgeon today, and he recommended a mandibular advancement with ortho in advance to remove bottom premolars and create room for the lower jaw to move forward. He also recommended a genioplasty. He said the upper jaw is fine where it is. Supposedly he is one of the top guys in my area and teaches university classes on the subject. Thoughts? Get a second opinion?
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So I finally had a consult with the oral surgeon today, and he recommended a mandibular advancement with ortho in advance to remove bottom premolars and create room for the lower jaw to move forward. He also recommended a genioplasty. He said the upper jaw is fine where it is. Supposedly he is one of the top guys in my area and teaches university classes on the subject. Thoughts? Get a second opinion?
And a third and a fourth.
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So I finally had a consult with the oral surgeon today, and he recommended a mandibular advancement with ortho in advance to remove bottom premolars and create room for the lower jaw to move forward. He also recommended a genioplasty. He said the upper jaw is fine where it is. Supposedly he is one of the top guys in my area and teaches university classes on the subject. Thoughts? Get a second opinion?
Disclaimer: I am not a doctor.
I think the treatment plan (extractions lower jaw + bsso) is wrong for you. Extractions are usually indicated when the curve of spee is excessive and the lower incisors are severely proclined. You don't have either of these conditions.
You should be treated non extraction and with ccw rotation of the maxillo mandibular complex. The treatment plan that was proposed to you would probably end up giving a somewhat odd appearance with a too long lower third and the chin would still be too far back but too prominent because the lower incisors would be retroclined. It's hard to explain, but I would get more opinions. If you are US based then go to A&G.
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Another update. I went and talked to my orthodontist who previously gave me invisalign, and he didn't agree with the treatment plan of the oral surgeon. He said he was opposed to doing the lower extractions because then there wouldn't be enough room for my tongue. He did say that he thought genioplasty alone could achieve OK results in terms of facial profile, but also said that bi-max surgery would be an option if I wanted to go more extreme. He did refer me to another oral surgeon, so I'm going to get a second consult.
No train, I'm based in Canada, so A&G is out of the question. If I stay in Canada, I can probably get medicare to cover most of the costs. Know any good surgeons in Canada that would be willing to do a ccw rotation?
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No train, I'm based in Canada, so A&G is out of the question.
I am european, so I can't help you with canadian surgeons.
If I stay in Canada, I can probably get medicare to cover most of the costs. Know any good surgeons in Canada that would be willing to do a ccw rotation?
What's the point of having free surgery if the result is s**t? You should decide if you want full blown bimax or camouflage treatment. Your bite is solid, I would actually recommend getting camouflage with a chin wing in germany (recommendation: Ramin Zarrinbal). It costs 6-7k € plus your travel expenses obviously.
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Another update. I went and talked to my orthodontist who previously gave me invisalign, and he didn't agree with the treatment plan of the oral surgeon. He said he was opposed to doing the lower extractions because then there wouldn't be enough room for my tongue. He did say that he thought genioplasty alone could achieve OK results in terms of facial profile, but also said that bi-max surgery would be an option if I wanted to go more extreme. He did refer me to another oral surgeon, so I'm going to get a second consult.
No train, I'm based in Canada, so A&G is out of the question. If I stay in Canada, I can probably get medicare to cover most of the costs. Know any good surgeons in Canada that would be willing to do a ccw rotation?
I'm not sure public health would pay for this surgery unless there is a clear indication.
I have a very similar profile to yours, probably worse.
Your airway looks fine, you don't have obvious forward head posture, in fact your cervical column is quite straight which can make the ramus look further back. Your ramus is actually more vertical than most (mine is as well) and this is actually contributing to the recessed look (as the angle between mandibular plane and the plane of the ramus becomes more acute, the chin has less projection).
I think a CCW is also the answer. You don't need to mess with extractions in my (layman) opinion.
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i should also mention that you have a downgazing head posture in that ceph (the sella-nasion plane is almost level when it should be going up from sella to nasion). This exaggerates the steepness of the mandipular plan
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Hi everyone:
Appreciate all the responses and opinions. I just had a consult with a separate oral surgeon that my orthodontist recommended. He wanted to perform the exact same surgery as the previous oral surgeon (BSSO plus genioplasty) but was much more forthcoming in explaining why he didn't want to perform a Bimax ccw rotation. The surgeon told me that CCW rotation of the lower jaw is not a stable movement because the muscles in the area tend to want to pull the jaw back into its original position resulting in a high amount of relapse. Again, he recommended lower premolar extraction and moving the lower jaw forward with BSSO.
I'm pretty confused about how to proceed.
Here is one study on the stability: "Maxillomandibular advancement with counterclockwise rotation of the occlusal plane is a stable procedure for patients with healthy TMJs and for patients undergoing simultaneous TMJ disc repositioning using the Mitek anchor technique. Those patients with preoperative TMJ articular disc displacement who underwent double-jaw surgery and no TMJ intervention experienced significant relapse." J Oral Maxillofac Surg. 2008 Apr;66(4):724-38. doi: 10.1016/j.joms.2007.11.007.
Seems like there are stability issues if there are TMJ issues at the same time.
Thoughts?
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Don't mess with muscles.
I have heard many times that muscles want to go back where they were. Maybe some have had luck but personally, that was one of the reasons I avoided this surgery until I assured my surgery wasn't going to do that.
Heck, I've had a hard enough time just teaching my muscles not to push my jaw out to talk, smile and eat.
Consider that you are going for improvement, not perfection. Trust me - that simple mentality will help you in many ways.
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What anatomic landmark do you use to level the head? I've been struggling with this lately.
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Hi,
I live in Toronto now and have a consult with Tocchio next week. I want to make sure I'm ready with questions going in. Some of you suggested previously that the last two oral surgeons I consulted were taking me down a problematic path with lower premolar extractions + ortho + BSSO + genio. The consensus seemed to be that I needed CCW MMA + genio and that my bite was solid. I've uploaded some pictures/ceph to help with some questions I have.
1. Will CCW via anterior impaction alone get me enough rotation based on how gummy my smile is? Will impaction-only make the lower part of my face too short?
2. What is the main problem with extractions + bsso + genio in my case? Would this be an acceptable/stable option for sleep apnea treatment (I have moderate OSA)?
3. If Tocchio is willing to do CCW but brushes off my TMJ issues, what should I ask him/say? If he wants to do CCW and place me on Enbrel to mitigate TMJ issues, what should I ask him/say?
4. Could genio alone address some aesthetic concerns and perhaps lip competence?
5. Anything else I should bring up with him?
Thanks, I appreciate all the previous responses! Very helpful.
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Genio ALONE will most certainly NOT fix your class 2 occlusion, recessive mandible and vertically long anterior maxilla. But it WILL help with the lip incompetence.
You most definitely need the FULL package of Lefort 1 with CCW (anterior impaction advance...), BSSO and genio.
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Kavan,
You don't think anterior impaction alone will give my lower face too short an appearance?
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Kavan,
You don't think anterior impaction alone will give my lower face too short an appearance?
I don't think it matters and it's not something to fret about. You need ALL the proposed displacements to look and breath better.
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Hey Introspect,
The rear of my mandibular also overlaps my spine, which i thought was odd and possibly cause for concern but I never found any info about it. I will upload my ceph. I also have narrow airways that require bimax to fix.
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Yeah my jaw overlaps my spine lol
https://imgur.com/a/tJINsQA
Sorry I can't help with your other questions, but I found an interesting link on this forum for average airway sizes
http://www.joomr.org/article.asp?issn=2321-3841;year=2013;volume=1;issue=2;spage=55;epage=60;aulast=Guttal
Did you get your sleep apnea diagnosed?
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Hey Daniel,
Yeah, not sure why we both have that. It does fit with the "everything being retrusive" pattern. Not sure if that is even a concern. Do you also have cervical vertebrae that protrude like a triceratops?
Will take a look at the study you sent. My airway doesn't appear too horrible in my ceph (~5-6mm), but when I stand with good posture I can feel it close off.
My sleep apnea was diagnosed with a in-clinic sleep study. I have 0 apneas per hour on my side and 50-60 on my back, which averaged out to 32 combined. Currently trying a positional belt that keeps me on my side while sleeping. I'm starting to get used to it but I sometimes remove it in my sleep, so I have to go for a follow-up study.
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Yeah I agree with the "everything retrusive" view. Not 100% but I think I read if its less than 11mm in the narrowest area you have greater risk for apnea. How much advancement are you getting to treat the apnea?
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Right now I'm just trying to find a surgeon in Canada that'll do the surgery and address my TMJ issues. I have a consult with Tocchio next Tuesday so will update you.
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Had my consult with Tocchio today and he wants to do CCW MMA with anterior impaction and genio. I asked him about the TMJ issues and he felt that they were stable (no pain, I can open my mouth fairly wide). He was very patient and took the time to answer my questions. He also recommended that I get a consult with Meisami. He said that she is eventually taking over his practice and that they already do surgeries together. Cost is $5000 with no ortho.
My only lingering concern is the stability of the surgery and TMJ. Thoughts?
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Anterior impaction only and no posterior downgrafting? Your OP is so steep that you need posterior downgrafting to level your OP and to maximize your airway and and to correct your profile and for optimal aesthetics.
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re: TMJs, do you know what you're structurally dealing with? Displaced discs? Arthritis?
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I’m not sure about downgrafting--I didn’t ask him. He didn’t mention building up the back. In terms of TMJ, I haven't had anything diagnosed. Popping in my left TMJ and a weird mouth opening angle are the main two issues. Does popping mean the disc is displaced?
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I did bring up the stability issue and he insisted it was a stable movement.
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I've been reading some Wolford studies, and untreated TMJ's is scary stuff. This study has given me major pause with proceeding with this surgery (I have institutional access, but you can read the abstract for free):
https://journals-scholarsportal-info.myaccess.library.utoronto.ca/details/02782391/v61i0006/655_citjdaos.xml?q=Changes+in+temporomandibular+joint+dysfunction+after+orthognathic+surgery&search_in=anywhere&date_from=&date_to=&sort=relevance&op=AND&search_in=JOURNAL&sub= (https://journals-scholarsportal-info.myaccess.library.utoronto.ca/details/02782391/v61i0006/655_citjdaos.xml?q=Changes+in+temporomandibular+joint+dysfunction+after+orthognathic+surgery&search_in=anywhere&date_from=&date_to=&sort=relevance&op=AND&search_in=JOURNAL&sub=)
Assuming I have displaced discs, how much would it cost for me to get Mitek anchor surgery by Wolford? I'm pretty sure no one in Canada will do this. I'm thinking I could get the TMJ dealt with in the US and then get the MMA surgery in Canada.
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In terms of TMJ, I haven't had anything diagnosed. Popping in my left TMJ and a weird mouth opening angle are the main two issues. Does popping mean the disc is displaced?
Yeah when my TMJ first started (like 10 years ago) I had a weird mouth angle on opening too. Eventually the opening evened itself out when both sides became displaced... but was left with arthritis.
Can you get an MRI done? That's the best way for them to see your discs etc.
It's a tough predicament. I'm in it too! Once you surgically invade the joint capsule (fat grafts, muscle grafts, miteks, whatever), the fix is usually only temporary. All roads thereon lead to TJR. And if you're not in any PAIN right now, you might be left with it after miteks. I personally don't trust any TMJ research by Wolford on miteks (but that's up to you). Can't see the abstract btw. Can you see Gunson?
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Does Gunson do remote consultations?
In terms of getting on MRI, I'm not sure how I'd go about that in Canada unless an oral surgeon referred it.
Here's a summary of the study:
Changes in temporomandibular joint dysfunction after orthognathic surgery
Authors: Larry M. Wolford, Oscar Reiche-Fischel, Pushkar Mehra
Journal of Oral and Maxillofacial Surgery; June 2003 Volume 61(Issue6)Page, p.655To-660
Purpose: We sought to evaluate the effects of orthognathic surgery on temporomandibular joint (TMJ)
dysfunction in patients with known presurgical TMJ internal derangement who underwent double-jaw
surgery for the treatment of dentofacial deformities.
Patients and Methods: Treatment records of 25 patients with magnetic resonance imaging and
clinical verification of preoperative TMJ articular disc displacement who underwent double-jaw surgery
only were retrospectively evaluated, with an average follow-up of 2.2 years. Signs and symptoms of TMJ
dysfunction, including pain, range of mandibular motion, and presence/absence of TMJ sounds, were
subjectively (visual analog scales) and objectively evaluated at presurgery (T1), immediately postsurgery
(T2), and at longest follow-up (T3). Surgical change (T2-T1) and long-term stability of results (T3-T2)
were calculated using the superimposition of lateral cephalometric and tomographic tracings.
Results: Presurgery, 16% of the patients had only TMJ pain, 64% had only TMJ sounds, and 20% had
both TMJ pain and sounds. Postsurgery, 24% of the patients had only TMJ pain, 16% had only TMJ sounds,
and 60% has both TMJ pain and sounds. Thus, presurgery 36% of the patients had TMJ pain, and
postsurgery, 84% had pain. Average visual analog scale pain scores were significantly higher postsurgery
and none of the patients with presurgery TMJ pain had relief of pain postsurgery. In addition, 6 patients
(24%) developed condylar resorption postsurgically, resulting in the development of Class II open bite
malocclusion.
Conclusions: Patients with preexisting TMJ dysfunction undergoing orthognathic surgery, particularly
mandibular advancement, are likely to have significant worsening of the TMJ dysfunction postsurgery.
TMJ dysfunction must be closely evaluated, treated if necessary, and monitored in the orthognathic
surgery patient.
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Yes, he does.
Popping doesn't mean anything, especially without pain. People with perfect jaws can have it. Jaw deviation on opening can be an indication for disc displacement or just muscle tightness. Get an MRI if you're concerned. Surgeons usually don't care unless you have TMJ arthritis with or without ICR.
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Does Gunson do remote consultations?
In terms of getting on MRI, I'm not sure how I'd go about that in Canada unless an oral surgeon referred it.
Here's a summary of the study:
Changes in temporomandibular joint dysfunction after orthognathic surgery
Authors: Larry M. Wolford, Oscar Reiche-Fischel, Pushkar Mehra
Journal of Oral and Maxillofacial Surgery; June 2003 Volume 61(Issue6)Page, p.655To-660
Purpose: We sought to evaluate the effects of orthognathic surgery on temporomandibular joint (TMJ)
dysfunction in patients with known presurgical TMJ internal derangement who underwent double-jaw
surgery for the treatment of dentofacial deformities.
Patients and Methods: Treatment records of 25 patients with magnetic resonance imaging and
clinical verification of preoperative TMJ articular disc displacement who underwent double-jaw surgery
only were retrospectively evaluated, with an average follow-up of 2.2 years. Signs and symptoms of TMJ
dysfunction, including pain, range of mandibular motion, and presence/absence of TMJ sounds, were
subjectively (visual analog scales) and objectively evaluated at presurgery (T1), immediately postsurgery
(T2), and at longest follow-up (T3). Surgical change (T2-T1) and long-term stability of results (T3-T2)
were calculated using the superimposition of lateral cephalometric and tomographic tracings.
Results: Presurgery, 16% of the patients had only TMJ pain, 64% had only TMJ sounds, and 20% had
both TMJ pain and sounds. Postsurgery, 24% of the patients had only TMJ pain, 16% had only TMJ sounds,
and 60% has both TMJ pain and sounds. Thus, presurgery 36% of the patients had TMJ pain, and
postsurgery, 84% had pain. Average visual analog scale pain scores were significantly higher postsurgery
and none of the patients with presurgery TMJ pain had relief of pain postsurgery. In addition, 6 patients
(24%) developed condylar resorption postsurgically, resulting in the development of Class II open bite
malocclusion.
Conclusions: Patients with preexisting TMJ dysfunction undergoing orthognathic surgery, particularly
mandibular advancement, are likely to have significant worsening of the TMJ dysfunction postsurgery.
TMJ dysfunction must be closely evaluated, treated if necessary, and monitored in the orthognathic
surgery patient.
I've emphasized the KEY WORDS in this study; [patients with known presurgical TMJ internal derangement]. You need to distinguish whether or not it is actually KNOWN that you have the type of derangement mentioned in the study from you SELF ASSESSMENT of TMJ. I would also suggest digging up studies where the TM Joint takes on a BETTER POSITION via double jaw surgery.
Another KEY PHRASE in the study is; [WITH CLINICAL VERIFICATION]. Presently, you have NO clinical verification that you have the TYPE of TMJ that is a risk for the surgery.
Also, if you're really curious/alarmed by this study and whether or not your situation is a risk for double jaw surgery, you could consult directly with one of the authors; Puskar Mehra who is in Boston MA. (Wolford's protege).
When ever getting freaked out by journal articles of something you THINK you MIGHT have, it's best to consult directly with the authors (or one of them). You should also know that the authors of that article do the TM JOINT REPLACEMENTS.
RE: .... In terms of TMJ, I haven't had anything diagnosed. Popping in my left TMJ and a weird mouth opening angle are the main two issues. ..
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Hi Kavan and CCW,
Thanks, these are both great points. In Canada you can't simply get an MRI by paying...need to get in a queue and be referred by a specialist. What is the best approach? Should I talk to Tocchio and ask him if he could get the joints scanned? What if he refuses? See another surgeon? I'm assuming the wait time for a non-critical MRI in Canada would be up to a year (longer than getting the actual surgery itself).
Also, I will contact the author of that study to get some clarity.
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Sorry. I don't know much to anything about navigating the bureaucracy in Canada (nor in other countries). Maybe just ask the doctor if he thinks you have an arthritis condition to the jaw that would increase your risks for jaw dysfunction after the surgery.
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I'm assuming the wait time for a non-critical MRI in Canada would be up to a year (longer than getting the actual surgery itself).
Wow. They don't do MRI's privately over there?
You could get a cone beam CT (if you haven't already had one). It won't show them the discs, but will show them if there's any bone changes and they can also see the joint space (or in the case of a disc displacement - a LACK OF joint space). Show your surgeon the study and see what he has to say.
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Ok, so they DO have private MRI centres - but holy s**t, they are expensive.
https://canadadiagnostics.ca/services/mri/ (https://canadadiagnostics.ca/services/mri/)
http://www.canmagnetic.com/scans-rates/ (http://www.canmagnetic.com/scans-rates/)
And I was complaining about my $350 (AUD) scan.
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Yeah, it is insanely expensive, but might be worth it rather than waiting forever. I could also go down to Buffalo to get it done.
I just came across this pan xray of me and I took a look at the condyles. My left condyle is shorter than my right and has a abnormal shape. Is this normal variance or is something off? It is my left TMJ that causes issues. Here it is.
Seriously considering a consult with Gunson.
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Another update:
I called Tocchio's office to ask if I could get my TMJ's MRI'ed. His secretaries talked to him (they won't give out an email address), and they called me back and told me that oral surgeons are not allowed to requisition an MRI in Canada. It must be done by a doctor. Is it just me or is that messed up?!
Anyway, I talked to my psychiatrist who diagnosed the sleep apnea, and she said she wasn't willing to requisition it either because it is outside her area of speciality. She recommended that I contact Tocchio again and see if he can get an ENT at his hospital to do it. I doubt my family doctor would requisition it either, but may be worth a try.
Which brings up another point...what do I even say to Tocchio? "Hey, I think you're wrong and I need to have my TMJs assessed." If I were a fax mac of 35 years and having taught at the U of T I would be insulted if someone brought up studies insinuating that my assessment plan was inadequate.