Monday, December 10, 2007

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.

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