Intermaxillary fixation without rigid plates with Dr. David Behrman

[ArtVandelay]

Recall I had double jaw surgery followed by a revision one week later. In the revision my surgeon opted not to use any rigid fixation in the mandible and opted for IMF (inter-maxillary fixation) instead. After speaking with other surgeons (will not name them) and reviewing my x-rays immediately after it's now clear to comment on the drawbacks of this approach.

Some comments:

1.) Using IMF instead of rigid fixation is an incredibly out of date practice. This was done in the last century but doctors were horrified someone was still practicing this approach today.
2.) My ramus/condoyle (the mandible piece left free floating) was pulled forward and rotated due to lacking rigid fixation. Muscles will always win here. This destroys jaw line definition since soft issue now sags.
3.) It is evident that point 2.) is true by examining my x-rays from immediately after my surgery when the cuts are still visible and my bones have not fused.
4.) It is possible to undo this movement in a revision (not sure if fully or partially.
5.) It's honestly just sad that a doctor is so out-of-date and doesn't feel a duty to give their patients the best practices available.

Not sure what others can learn from this, it's not like you're going to ask if in a revision will they abandon rigid fixation. But summarizing my findings here as it perplexed me for a while,  I did not suspect the extent of my ramus excess rotation here. Can post xrays later if there is interest.

[Dogmatix]

Can you elaborate what IMF is and show show it looks on your x-ray? Is it like they skip the plates and just band it with the maxilla?
My surgeon explained that former approach was to fully fixate the maxilla, and not the mandible to be able to make small adjustments with elastics after surgery. But that they abandoned that approach and now instead do it the other way by fully fixate the mandible and have some semi-rigid fixation of the maxilla instead to guide the healing. I think you need to have some mobility either in the maxilla or mandible after surgery, as we're working with accuracy under a mm to have the teeth meet properly and you just can't do that by hand. Since your revision was only on the mandible, maybe he had to use some semi fixation as the maxilla was already fused, but it doesn't sound right if it was only 1 week after. Wonder if that's how they do it if they do only lower jaw surgery.

I'm just speculating, but maybe the other surgeons you've asked don't have full insight in your case and just think this fixation was done right away in first surgery, and also want to criticize to gain your trust that they can sell you something better. It's like when I had a painter to help me paint my living room. First thing he did was to criticize my paint job in another room that I by the way was very happy with. I thought wow, this guy must be good if he have that high standards. Turns out, my own job was way better and I had to go over and fix his work after he was done.

[Post bimax]

maybe the other surgeons you've asked don't have full insight in your case and just think this fixation was done right away in first surgery, and also want to criticize to gain your trust that they can sell you something better.

+1

This is a common and effective sales tactic

[Gadwins]

+1

This is a common and effective sales tactic

That makes me sad. Do you think they are despaired enough to make such a move?

[Post bimax]

That makes me sad. Do you think they are despaired enough to make such a move?

The top surgeons (at least in the US) typically run their own practice and are businessmen as well as medical professionals.  They have an interest in promoting their own style while being critical of alternative approaches.

Because it's such a frontier procedure with large aesthetic considerations, JS is much more of a 'product' than other medical procedures.  Like, nobody is out there marketing hip replacements.  But you see it with jaw surgery all the time.

[ArtVandelay]

Sure I attached my xrays, one after my first surgery and another for a week later after my revision.
 
IMF- you are banded or wired fully shut. In my case four screws were attached to place strong rubber bands. I could not speak or open my jaws for 3 months and lost almost 50 pounds peak to trough in the process. IMF is independent of rigid fixation. You can and should also do the titanium plates if IMF is called for.

Lack of plates in my mandible rotated my ramus up and forward and it looks like it doesn't exist anymore. I looked much better before in that area. See the second xray and the blue arrows.

I'd be looking to undo as much as possible of this movement in my revision.

Since your revision was only on the mandible,

I had a full revision, he unscrewed the maxilla to reposition it too.

They have an interest in promoting their own style while being critical of alternative approaches.

We're not talking about differences in the movements. We're talking about a surgical technique for handling complications that was abandoned by almost every other surgeon because of the drawbacks.

I'm just speculating, but maybe the other surgeons you've asked don't have full insight in your case and just think this fixation was done right away in first surgery,

Over half the surgeons I spoke with were hesitant to criticize another surgeon, especially the ones from the same area. One actually recommended an upper jaw only plan (with massive impaction which would have been an aesthetic disaster for tooth show) just to avoid touching the lower jaw because he didn't understand what exactly went wrong.

But the others that were more interested in my history and willing to speak about it had no ambiguity about the details.

Lol about the painter.

[Dogmatix]

Sure I attached my xrays, one after my first surgery and another for a week later after my revision.
 
IMF- you are banded or wired fully shut. In my case four screws were attached to place strong rubber bands. I could not speak or open my jaws for 3 months and lost almost 50 pounds peak to trough in the process. IMF is independent of rigid fixation. You can and should also do the titanium plates if IMF is called for.

Lack of plates in my mandible rotated my ramus up and forward and it looks like it doesn't exist anymore. I looked much better before in that area. See the second xray and the blue arrows.

I'd be looking to undo as much as possible of this movement in my revision.

I had a full revision, he unscrewed the maxilla to reposition it too.

We're not talking about differences in the movements. We're talking about a surgical technique for handling complications that was abandoned by almost every other surgeon because of the drawbacks.

Over half the surgeons I spoke with were hesitant to criticize another surgeon, especially the ones from the same area. One actually recommended an upper jaw only plan (with massive impaction which would have been an aesthetic disaster for tooth show) just to avoid touching the lower jaw because he didn't understand what exactly went wrong.

But the others that were more interested in my history and willing to speak about it had no ambiguity about the details.

Lol about the painter.

I didn't mean to in any way miscredit what you were saying or diminish that there is a problem. I was genuinely interested in how the fixation was made, and also genuinely wanted to point out that these are very hard consultations to do and to know who to trust. It seems like you've made a good research and understand your situation.

[ArtVandelay]

Sorry if I came off as hostile. I've been dealing with this issue again recently and it's been frustrating.  I can't find a local oral surgeon willing to take out my wisdom teeth. I've just about resigned myself to getting them out during surgery since apparently they are easier to access during a BSSO. My surgeon couldn't care less about what he did, he only cares about performing surgeries, the second you're out of the OR is the second he disappears.

[ArtVandelay]

An email from my surgeon:

"Non-rigid Intermaxillary Fixation with rubber bands  was used instead of Rigid Fixation with hardware to better ensure that  the correct surgical occlusion was established and maintained during  healing.”

Translation:

I did such a poor job planning that your bite didn;'t have any chance in hell of fitting properly so I needed let your lower jaw float around and settle in an unnatural position to get any marginal occlusion. It rotated in all 3 axes and is as a result asymmetric but I don't care about any of that, also go f*** yourself.

[Dogmatix]

Sorry if I came off as hostile. I've been dealing with this issue again recently and it's been frustrating.  I can't find a local oral surgeon willing to take out my wisdom teeth. I've just about resigned myself to getting them out during surgery since apparently they are easier to access during a BSSO. My surgeon couldn't care less about what he did, he only cares about performing surgeries, the second you're out of the OR is the second he disappears.

Why don't they want to remove your wisdome teeth? I thought that was what 95% of the surgeons spend their days doing. I had both lower removed during surgery and wouldn't say it was a problem, but most of my pain probably came from this and not the actual jaw surgery.

When was your surgery? Sounds like it was recent if you still have contact by mail? What you write kind of put the finger on what I wanted to highlight. Your surgeon probably made a good impression and told you how wrong everything was and how he was going to make it perfect before surgery. Just so you don't fall for that again, and understand what expectations that are reasonable.

I'm not educated enough to evaluate or comment on your outcome or what techniques are the proper ones. Did your surgeon see the need for a revision him self, or did you have to push for it? Just wonder because if he himself can spot that first outcome was not good and offered trying to fix it, it at least sounds like he doesn't want to give bad outcomes. But that of course doesn't help you if he use bad techniques or if his best is bad. Just wanted to balance the discussion that someone who offers a revision at least make an effort instead of flat out abandoning it.

I sure can understand the stress you're going through. When you do the first surgery you're full of hope and have never been more ready. When you do the second you're exhausted but figure mistakes happen. On the third you just don't know where to turn, who to trust or what to expect.

[ArtVandelay]

When was your surgery? Sounds like it was recent if you still have contact by mail? What you write kind of put the finger on what I wanted to highlight. Your surgeon probably made a good impression and told you how wrong everything was and how he was going to make it perfect before surgery. Just so you don't fall for that again, and understand what expectations that are reasonable.

It was in 2013, that was an older email. I lost about 50 pounds and was too traumatized from the experience to even think about a revision until recently. My airway problems will only get worse with age.

Why don't they want to remove your wisdome teeth?

Two reasons, it's close to the nerve that runs near the bottom or your mandible and they're in a hard to access spot. I can feel them from the inside of my mouth but they have to drill from the top. But since my ramus is shifted up and forward there's a lot of bone to drill through to get them from the top. I'm debating blast emailing other local surgeons to find one willing to get them out from the inside of my mouth but I was told no one does it because there's a 'lingual nerve'? from that side. Haven't researched this yet.

Did your surgeon see the need for a revision him self, or did you have to push for it?

The need for a revision was mutual from the start, they didn't offer any resistance. I went in with an open-bite and after my surgery I still had almost the same open-bite. Also my maxilla midine was way off, visibly past the lip grove. It was apparent to me the very next day things didn't go as planned. I preferred my bite/appearance from before my 1st surgery to after. It was that bad.

[Dogmatix]

Two reasons, it's close to the nerve that runs near the bottom or your mandible and they're in a hard to access spot. I can feel them from the inside of my mouth but they have to drill from the top. But since my ramus is shifted up and forward there's a lot of bone to drill through to get them from the top. I'm debating blast emailing other local surgeons to find one willing to get them out from the inside of my mouth but I was told no one does it because there's a 'lingual nerve'? from that side. Haven't researched this yet.

Sounds like similar situation as mine. I went to the local surgeon to have my impacted wisdome tooth removed. I thought he was gonna remove it directly at my first visit, but he said he wanted to x-ray my nerves first. He then came back with the decision to not remove it, but rather split it and remove the crown and leave the root as it was tangled with the inferior alveolar nerve.

Then I had jaw surgery and woke up to "by the way, I removed both your wisdome teeth as well". Including the one my local surgeon had left in the bone 5+years earlier. Dont seem to suffer from any nerve damage at that side. I thought they always did this either before or during jaw surgery, was surprised to see you still having yours after a bsso. Even my orthodontist told me that they always remove them 6 months prior to surgery if I had done it in the public health care.

So what's your current plan and where are you in the process? Sounds like you've done some consulting and know what you want to do?

[ArtVandelay]

I thought they always did this either before or during jaw surgery, was surprised to see you still having yours after a bsso.

I'm still not sure why they were not removed. My surgeon disappeared after my surgery and the residents were of no help. I had to mention getting a lawyer to acquire my records before he responded to me.

So what's your current plan and where are you in the process? Sounds like you've done some consulting and know what you want to do?

Still haven't fully committed to a plan.The first step was to figure out the wisdom teeth. The second step is the big one and I'm still debating, having 3 choices:
1.) Regular L1 & no braces pre-op
2.) Segmental L1 to widen maxilla, heavy braces to untorque lower tipped molars (should take 6 months of braces I was told). See curve of wilson in post #8 here: http://jawsurgeryforums.com/index.php/topic,7568.0.html
3.) Chin wing, drop at ramus, shorten at front

I've given myself three weeks to figure everything out.

[ArtVandelay]

Could a mod please change Berhman to Behrman in the topic name? thanks

[kavan]

done