Tuesday, December 18, 2007

Pokey wire ...

I finally was able to see last night what was going on in the back of my mouth. I tried to take a picture of it tonight, but I wasn't able to get my camera to focus on the back of my mouth. Basically, on the right lower, the wire is very neatly folded in behind my last tooth. On the lower left, she had just put the dab of glue on the tip of the wire, but that doesn't stop it from poking my cheek and creating a very nice sized sore in the back of my mouth. So I am trying to load it up with wax, which helps, but I can't always get it to stick on back there for very long. So now I need to figure out if I can deal with this until the end of January at my next adjustment, or if I need to go in. I have already been in twice since getting my braces on not even three weeks ago, and I don't want to be labeled as that "problem" patient ... so I am going to see if I can stick it out. I will need to get some more wax, though ... since I think I will be going through it pretty quickly! The good news is that the canker sores in the front of my mouth have healed up, so they luckily didn't take too long to go away ... now let's just hope they stay that way.

Minimal Progress ...

I finally got a better picture with the braces. At almost 3 weeks, I don't see a lot of movement yet, but it looks like things are stretching out a bit on the lowers, trying to make some room.

I can't get over the difference in the color ... I am hoping it is just the lighting, or maybe the reflection of the clear brackets, because they just look horrible compared to my pre-braces photo and I have been very diligent about my brushing and flossing. After braces and surgery I will get all of my silver fillings replaced with composite ones so I can finally have a 100% white smile!

Monday, December 17, 2007

Appeal Letter from OD ...

I thought I would post the appeal letter from my OD, first as an example for those who are seeking an appeal with their insurance company, and second, because it discusses in detail the issues I have with my jaw ...

To Whom It May Concern:

Stephanie is a very pleasant thirty-three years old female who initially visited our office for an orthodontic evaluation in July of 2001. Please let this letter serve as an appeal to denial of insurance coverage for the recommended surgery.

Clinically, Stephanie currently presents with a Class II division I subdivision left malocclusion in the permanent dentition stage. She has an overbite of eighty percent with six millimeters overjet. An increased mandibular curve of Spee exists. There are arch length deficiencies of five millimeters in the maxillary arch, and seven millimeters in the mandibular arch. Her maxillary and mandibualar arches are both asymmetric and tapered in arch form. In addition, her maxillary lateral incisors (7,10) are narrow in width.

Cephalometric measurements indicate a Class I skeletal relationship with ANB=9. Stephanie possesses a high mandibular plane angle that is indicative of an openbite skeletal pattern.

With the exception of the previous removed third molars (1,16,17, and 32) evaluation of Stephanie’s panoral film indicates all remaining permanent teeth present and accounted for with normal root form and structure and proper alveolar bone support.

Soft tissue profile evaluation indicates a slightly retrognathic profile with a recessive chin. Her upper and lower lips are both incompetent in their positions at repose with a seven-millimeter interlabial gap present. Her nasolabial angle is within normal limits at 130 degrees.

Evaluation of Stephanie’s upper smile line indicates a slightly high upper lip position with excessive gingival tissue displayed when smiling (four millimeters excess gingival tissue displayed when smiling). Evaluation of her lower smile line indicates an acceptable position of the lower lip with the maxillary dentition approximating the border of the lower lip. However, buccal corridors are evident upon smiling due to her asymmetric and tapered arch forms.

In addition to the above, Stephanie has had ongoing temporomandibular joint dysfunction concerns. Therefore, when Stephanie initially visited our office we recommended conservative measures for her TMJ discomfort which included: Aleve (2 tablets twice daily with food) or Ibuprofen (3 tablets three times daily with food), Glucosamine (as directed on package), moist heat applications (20 minutes two times daily), Soft diet (no gum, or sticky, chewy, crunchy foods), increased vitamin C (1,000 mg per day), journaling for one week, post-it notes and an increased awareness of her habits. When these conservative measures did not afford Stephanie relief, we fabricated a centric relation splint. Utilization of this appliance also did not prove to be successful in gaining Stephanie long-lasting relief from her TMJ symptoms. In addition, lower incisal wear has occurred. Stephanie relates that the right pre-auricular region of her TMJ’s has chronic discomfort. She also has migraine headaches, the right condyle is arthritic (indicated on the tomos we obtained), and her mandible deviates three millimeters to the right upon opening.

I have recommended treatment for Stephanie with full fixed orthodontic appliances in conjunction with a two-jaw surgical procedure with a maxillary advancement and impaction and mandibular advancement with chin augmentation. Stephanie does understand that while this comprehensive orthodontic/surgical treatment cannot guarantee a cure for her temporomandibular joint dysfunction, correcting her malocclusion may leave to improved symptoms.

Stephanie is aware that stellar elastic wear will be mandatory in order to reach her orthodontic goals. In order to address arch length deficiency, interproximal reduction in the mandibular arch will be necessary at the onset of her treatment.

The estimated length of treatment for Stephanie should be approximately twenty-four months. Upper pressdown and bonded mandibular lingual retainers will be utilized for retention. In addition, we may need to fabricate a centric-relation splint for retention, dependent upon the TMJ response to comprehensive orthodontic/surgical care.

Thank you very much again for consideration of insurance coverage for Stephanie’s surgery. In the absence of sugery Stephanie’s malocclusion puts her at increased risk for continued TMJ dysfunction and the potentioal for breakdown of her posterior detition (lower incisal wear is already noted). Should you have any questions or concerns in regards to my recommendations for Stephanie, or if we can provide additional diagnostics aside from those we have already submitted, etc., please do not hesitate to give me a call. I would be most happy to discuss the need for Stephanie’s surgery in conjunction with her comprehensive orthodontic care with you in person.

Oral Hygiene ...

I read somewhere that plaque slows the movement of teeth when your braced. I never was an avid flosser before I got my braces on, but now i won't go a day without flossing ... I want to do everything possible to make sure that I am doing my part in making this process as speedy as possible, as well as ensuring optimal results. A lot of good it would do to have the surgery and a perfect bite if I didn't take care of my teeth.

The first day I flossed with my braces on, I think it took about 20 minutes. I bought some of the Superfloss and tried that, since I thought it would be much more convenient then using a threader and save some time. Well, it was convenient, but when I got back to my molars (especially where I had fillings), sometimes it was hard to get it between my teeth, and my teeth just shred it. So then I bought the Crest Glide Threader Floss. It is quite a bit more expensive than the Superfloss, but it is worth it! It is so easy, I can get it in between my teeth more easily, and it doesn't shred! So that is my plug for the day ...

Loose Hardware

It will be 3 weeks on Thursday since I got my braces on. Last Friday, I had to go in to the ortho because one of my brackets came loose after brushing my teeth. It was on my lower left molar, all the way in the back. I was worried that one of the right ones would come off where my tooth came down on the bracket ... or one of my front teeth since they are crowns and brackets don't always bond with the crown. Hopefully that will be the only bracket that comes loose on me. So they put the new bracket on, and since the wire was too short to turn under like they had done the first time around, she put a dab of glue on the tip, but I feel like it is poking me. I have been getting one canker sore after another on my upper lip, and have another in the back where the bracket/wire is rubbing. I guess I should put some wax back there. The sides of my cheeks are pretty torn up right now, they get caught in between my back molars when I chew, and my bite now has changed where it feels like only my back molars touch when I bite down, provided I move move my cheeks out of the way first.

My TM Joints seem to be acting up as well. They are sore and achy. I don't know if it is from the increased clenching I seem to be having at night, or the fact that my bite is changing from the braces and straining my joints more.

So, other than the canker sores and achy joints, I think things are going pretty well.

Monday, December 10, 2007

Predicted Profile ...

Although I am doing this for functional reasons, I can't help but look forward to the cosmetic result. Below is my current profile along with the predicted profile after surgery. What a difference a chin makes!



I’m Braced!

As soon as I received the approval from insurance, I scheduled an appointment to get my braces on, and called my OS to start my meds. The first day on the meds was a little strange, I think the muscle relaxer made me feel a little weird but it didn’t take too long to get used to. I decided to take the doxicyclene and feldene at noon, because I had read about someone getting ulcers in their throat if they took the doxy at night and laid down. You also should not have calcium within 2 hours of the doxycycline because it inhibits absorbtion. The amitriptyline should be taken at night to reduce clenching. So far so good on the meds, and I’ve been on them almost a month now.

The spacers went in on November 15th. The assistant had a hard time getting them in on my upper right because one of my fillings was creating a very tight space. She slipped and hit my upper palate pretty hard, and asked another assistant who is known for being able to place the “troublesome” ones. She tried a few times and finally got it in … I was a bit gun shy by that point and afraid of slipping. But she got them placed. I had some minor pain with the shifting of my teeth from the spacers, but so far so good. No pain no gain, right?

On November 29th, I got braced! I have clears on both uppers and lowers. Even though I had them before, it has been over 20 years and I didn’t particularly remember the details. I can really feel my lip incompetence exaggerated with the braces … I feel I have to stretch my lips over my braces to close my mouth. Overall, a week and a half into it, it hasn’t been so bad. Day 3 was my worst day … I was still trying to eat things like normal and finally gave up and realized I couldn’t. The most painful part at first was the hooks on the inside of the bands on my molars. I was told that they are normally filed off, but Dr. L (my orthodontist) wanted to keep them on because apparently he will need them when I get into elastics. Oh, joy. Overall, I can’t complain too much. They have not torn up the insides of my mouth too much, and I already can see some movement on my bottom teeth. I am still not eating as normal, but I figure I should be within the next week or so. Below are pictures the day before I got my braces on and the day after.

The bottom picture is a little blury ... but the lower wire and brackets look like a roller coaster ride. I guess for now I can be happy to have an 80% overbite to hide them while they are straightening out.
I did go to see my OD a week after I got them on, because I started clenching at night again and my teeth were hitting a bracket on the right side, so the left side did not close. Well, with all of the changes going on in my mouth, the clenching was not uncommon, and the amitriptyline should help. And not to worry about biting down on the bracket ... if it breaks off he will fix it ... and my bite is sure to get worse before it gets better. I can expect to have times where my bite does not fit together at all.
My next appointment is January 28th, and I am looking forward to it! Let’s get these babies moving!

The Details ...

Since I had read so much about the surgery, I had many more questions than answers on the surgery specific to me. So I scheduled an appointment with my OS to go over my case. Below are the photos of my bite and teeth.

I assumed I would be having a LeForte I and BSSO based on what I had read, and the fact that I would be banded but not wired. But I had a lot of questions about all of the details in between. So here it goes. I have a 6 mm overjet, ideal is considered 2 mm. 7 mm of crowding on my lower teeth, and 80% overbite (ideal is 20%). I was particularly concerned with my nose, as I had read some comments by people who have had Le Forte I advancement and they were not happy with the change to their nose. He confirmed that he does a stitch (I believe it is the alar stitch) so the nose doesn’t widen, however it is a bit unpredictable if the nose will turn up with the Le Forte, and they don’t always know until they get in there. He said that once I get the orthodontics and my teeth are in place, he will have a better idea what he will do with my upper jaw. Right now, my Le Forte could be any where between 2 to 4 pieces, and he will possibly do palate expansion as well. But he won’t know exactly what his procedure will be on the upper until my teeth are in place, so I will have to wait. So the official list of procedures I will have done are: two to four piece Leforte I (upper impaction and advancement, with possible palate expansion), Bilateral Sagittal Split Osteotomy (Lower Advancement), and Genioplasty (Chin Augmentation). He won’t know the actual movements in mm until closer to the surgery when my teeth are in place.

I asked about the meds I would have to take pre and post op, because in my prior consult he mentioned I would need to be on long term meds (6-12 months before and after surgery) to stabilize my TM joints, since I have a degenerative right condyle. He told me I would be on low doses of Feldene, Doxycycline, and Amitriptyline. This is the protocol Dr. Arnett uses, and he told me that he puts all of his female patients on these meds that have TMJ problems to stabilize the joints. Otherwise, you run the risk of relapse, in my specific case if the TM joint continues to degenerate it could cause me to have an open bite. He spoke of resorption, that I am at high risk for significant boney changes, thus the meds. Specifically, doxycycline is an antibiotic (100 mg – it apparently has a secondary effect of joint stabilization), feldene is an anti-inflammatory (20 mg), and amitriptyline is a muscle relaxant (10 mg – has a secondary effect of reducing clenching at night). He also will put me on Vitamins C and E, which I am already taking anyway.

My procedure should take about 4-6 hours, but again this depends on the actual procedure he performs. He does require a catheter for all patients who have upper and lower, but it will be inserted after I am out and before I wake up.

He performs one surgery per week in the summer months, and one every two weeks the rest of the year.

I knew that I was not going to be wired, that I would only be banded. But I was very happy to know that I will not have a splint! They will have to put one in during the surgery but it willbe out before I wake up. It is amazing to me that he can make so many cuts and not need a splint. He explained that Dr. Arnett's procedure is to do the lower jaw first, and then the upper.Sometimes with the splint on the upper, it actually works against the surgery with an advancement because it pulls things back. They will also place 4 TADS (temporaryanchorage devices) in my gums, 2 on the upper, 2 on the lower. They are little screws that some of the bands will be connected to, so they are pulling on bone vs. my teeth. Otherwise there is some risk that when my braces come off, my teeth will move as they settle back into the bone. The idea is for the bone to be in the right place, which keeps the teeth in the right place. It sounds like I will be banded for a couple months, and maybe after that can wear them just at night.

The steroid they will use for surgery is Decadron, 16 mg. My ortho will have to put on the surgical hooks pre-surgery.

We also discussed the letter of medical necessity for my insurance company, and what I thought he should be sure to put in there. It sounds like he's had to write quite a few of these before, so hopefully it will do the trick! Total treatment time is estimated to be 2 years, with surgery around the 12 month mark.

Insurance Woes ...

And so the process begins … my OS’ office submitted the paperwork to insurance at the end of July. After much back and forth between the insurance company, my OS’ office and my OD’s office to receive X-ray, molds, etc., I finally received a response on September 20th, stating coverage denied. The most disturbing part of the denial letter was that my case was reviewed by “a physician reviewer specialized in general surgery”. The surgery was deemed cosmetic because the physician specialized in general surgery did not feel that the proposed procedures would alter my documented symptoms.

So thus began my appeal. Since my meeting mid-July with my treatment coordinator, I had begun to do extensive research on the surgery as well as insurance. I pretty much expected a denial letter, so I wanted to understand what insurance companies look for to make sure that my appeal was as complete as possible. Two sites (The orthognathic surgery support site on Yahoo and the Archwire site) have been very helpful to me in understanding what patients go through, the risks involved, the rollercoaster of emotions through this process, the ins-and-outs of the insurance process (thanks Shayna :)), and tons of questions to ask my OS and OD on how specifically things apply to my situation.

I learned the following relative to the appeal:

*Request review by an Oral and Maxillofacial surgeon specialized in these procedures, they are the only professionals qualified to make a determination in your case.
*Outline that the condition is caused by a congenital deformity and the purpose of the procedure is to control pain and minimize further deterioration.
*Send a letter from your OS, your OD, and yourself (it is best if these letters arrive together)
*Establish medical necessity. Outline all problems that have been caused by your malocclusion (in my case, wearing of the condyles, TMJ dysfunction, lower incisor wear, migraine headaches).
*Illustrate the potential complications if you do not have the surgery (such as tooth loss, further degeneration of the condyles, increased TMJ dysfunction, continuation of migraines)
*Explain that you understand that the surgery may not cure TMJ dysfunction, but correcting the malocclusion may lead to improved symptoms.
*Show that non-surgical treatment (conservative treatment) was unsuccessful.
*Make reference to any other health professionals you have visited to improve symptoms (migraine specialist, chiropractor, etc.)

The letter from my OD was brilliant. It was very detailed and addressed many of the points listed above. My OS’ letter was much shorter and to the point, but it did the trick! I received the approval on November 9th for my upper and lower jaw surgeries. The genio was denied (this was expected) along with the temporary anchoring devices, which were considered “unbundled” from the main surgery.

Oral and Maxillofacial Consult …

My orthodontist only works with one Oral Surgeon. Apparently the two of them have been to many seminars by Dr. William Arnett in Santa Barbara who is a leader in the field of orthognathic surgery, so they are very much on the same page in terms of treatment and procedure. This gives me confidence that they are working together as a team, which ultimately can only be to my benefit. Coincidently, Dr. P, the surgeon he referred me to, is a network provider in my insurance plan. That will at least help to reduce out-of-pocket expenses if I can get my surgery approved.

I was able to get in for a consult about a week after being referred, so I was excited to get the process moving.

Doctor P went over my tomo with me and showed me my airway … he said it is one of the smallest he has seen. He explained the surgery to me in layman’s terms, the upper surgery would help to reduce my “gummy” smile, and the lower surgery along with genioplasty (movement, in my case extension, of the chin) would correct my recessed chin. Ultimately, the goal is to correct my Class II Malocclusion, while also taking into consideration aesthetics and balance of my facial features.

I would need to be on three different meds for a year prior to the surgery as well as a year after. This is because I have an increased chance for relapse as I have TMJ dysfunction. The meds help to stabilize the jaw before and after surgery.

He explained that he was the only oral surgeon in the area that did not wire the jaws together after surgery, I would be banded instead but still would need to be on a liquid diet for about 6 weeks after surgery.

My Journey Begins ...

So here I am, after reading countless blogs from others embarking on the orthognathic surgery journey, I have decided to start one of my own. My reasons are two-fold: one because I think that writing about the experience may be therapeutic in itself, and it will help me remember details and progress. Secondly, reading about the experience of others has been incredibly educational to me, and hopefully my story can help others.

For those of you who do not know, “orthognathic” is derived from the greek words “ortho”, meaning straight, and “gnathos”, meaning jaws. Orthognathic surgery is surgery performed on the bones of the jaws to change their positions.

So how did all of this start? It started about seven years ago, when I was speaking with my general dentist after a routine cleaning. I had been having some minor issues with TMJ dysfunction, and was not pleased aesthetically with my lower teeth, despite having worn braces for several years as a child. He referred me to an orthodontist, who I went to visit.

After taking molds and x-rays, the orthodontist presented me with two options. The first was a combination of orthodontics (braces) and lower jaw surgery. The second option was orthodontics only, but he would need to tilt my lower teeth forward which could increase the probability I would need some bone grafting done in the future, which would not be the optimal solution. He referred me to an oral surgeon, and I went for a consult.

To make a long story short, the oral surgeon submitted the procedure to my insurance, and they denied coverage. My orthodontist fitted me with a splint to ease my TMJ dysfunction and minimize clenching and grinding when I sleep. The splint to me was incredibly uncomfortable because it held my jaws in what was an “unnatural” position … although that is where my bite actually fit together the best. What I have learned now is that I have been most likely “posturing” my lower jaw forward for many years, even though this led to my bite not fitting together properly. The splint was really just a temporary “fix”, but it certainly did not address the root cause of the problem. I was not at a point in my life to consider paying for surgery out of pocket, so I moved on.

Now fast forward about six and a half years. Over time, I have developed crippling migraines and significant pain associated with my TMJ dysfunction. I can hear grinding in the right TMJ joint, and my left TMJ pops when I open my mouth wide. At times I get a sharp pain in my ear, but I have also found out this has nothing to do with infection, but is most likely a result of my TMJ dysfunction as well. After another routine dental exam in May 2007, my dentist again mentioned that technology has changed much over the last several years, and gave me another referral to the orthodontist. He referred me to the same practice, but a different orthodontist this time … one that my husband had recently been to and would be getting his braces on within the next few weeks.

They were quick to get me in for an appointment just two days later, and in mid June took some molds, x-rays and tomos. In mid-July, I had my consult to go over my treatment plan. I was only presented with one option this time, which was orthodontics combined with both upper and lower jaw surgery. My treatment coordinator showed me my tomo (a cranial scan that shows the joints from different angles), and I was able to see the significant deterioration of my right condyle.

The condyle is basically the bone connecting your mandible (lower jaw) to your skull. Where these connect is called the tempomandibular joint (TMJ). It is similar to a ball and socket … the ball being the condyle and the socket where it connects to your skull, known as the fossa. A healthy condyle is rounded, whereas my right one has been worn flat from the constant grinding. This happens because my occlusion (bite) is not balanced. By correcting my malocclusion (bad bite), my jaw will be in balance which should reduce my TMJ dysfunction. I also was showing wear on my lower incisors, which eventually could lead to tooth loss.

So … my journey begins. After seeing the deterioration in my joint over the last several years, I had decided that with or without insurance, I was going to pursue to correct this … after all it is my health and I own it!