A picture is worth 1000 words

after: 03-04-10
before: 10-15-10

jaw exercise

I had my 6 week check-up yesterday. The good news is how I now can eat anything I want. The other news is that getting food in my mouth and between my teeth, in order to chew it, is still a challenge. I need to work on lengthening my chew muscles. Eating, talking, and stretching are good places to begin.

The only other thing that comes to mind now is how just when I think all of my stitches are gone I discover a few more. These days each time I brush my teeth a few more stitches seem to work their way out.

6-weeks post-op

the last time

While organizing old photos to scan I started thinking about the last time, before now, that I was happy with my smile, intrinsically happy. I figure I was five. Even by the time I was seven photos reveal that I had started to hide my teeth, or try to. Or it may have been more a matter of simply being unable to close my mouth with my teeth inside. Without a doubt the last time I could close my lips naturally was before or shortly after my permanent central incisors erupted. That would have been second grade. I was six.























Photos from only a few years later show the obvious signs of overcrowding in my mouth, not to mention the tetracycline stains which appeared with my permanent teeth. I am not sure if, as a child, I was given tetracycline or if it was prescribed to my mom when she was pregnant with me. Either way, were its effects widely unknown prior to 1970?

An Update and More Photos

I must be feeling better because I've been remiss in posting here lately. Here are a few more pictures to show where I am now. Last week at my 4-week post-op appointment my doctor advanced my diet such that I can now eat ground meats. As long as it does not require a lot of chewing I can eat anything, the exceptions being good bread and raw vegetables, both of which require lots of chew action.






02-16-10, 34-days post-op

I still have slight facial swelling, particularly around my nose. My face is also still a little tender to the touch where my lower jaw was screwed back together. I'm also still rather stuffed from sinus drainage. I can't wait for my lymph tissue to learn how to re-drain again!

Most of my stitches have fallen out or dissolved by now. Just a couple knots left behind the left end of my lower jaw. One of these days my toothbrush will drag those out. Last week my doctor pulled out the remaining knots along my upper jawline. While the stitches had dissolved the knots which were not embedded in tissue remained. He said those knots were what were keeping my incision a little sore. He was right though it hurt somewhat to have those knots pulled out. The good news is that my incision is pain free now.

As for the numbness, I'm still quite numb on the left side of my face, on the right side of my chin, in the corners of my lips, and on the right side of my lower lip. I have some sensation everywhere but those areas are still more numb than not. This means I can still drool or wear my food without even knowing it. Thankfully the right side of my face has regained sensation almost entirely, the exceptions being just below my eye and my lip and chin. My teeth however still have that wooden feel such that when I brush them it feels like I'm brushing the teeth of someone else. Hopefully they will feel like my own again soon.















02-12-10, 30 days post-op


02-07-10, 25 days post-op

Goodbye Baby Spoon

I'm so happy to be using an adult sized spoon again. Yesterday at my follow-up appointment Dr Ueeck placed rubber bands such that I no longer have bands in the front. This means I can just barely get a regular sized spoon in my mouth. Soft foods here I come.

I also found out yesterday that my TADs (Temporary Anchorage Devices) were removed during my surgery. Again, this is more good news as I will now not have to have those removed later. You would think I would have been able to tell that two screws are missing from my upper jaw but I could not. With the stitches I haven't wanted to even try to put my finger between my lip and maxilla. Given the loss of sensitivity from the surgery I had no other way to find out.

My surgeon said that during the surgery he impacted my maxilla 4mm (presumably on the left side only), advanced my maxilla 3 mm, and then brought my mandible forward to align with my maxilla. I think this means my mandible was brought forward 10mm or more. I need to check to be find out for sure. All I know is that my tongue is now in a different place in my mouth.

Well, it's time to work out my jaw muscles. Macaroni and cheese here I come!

Here's where I am today...

15 days post-op

Only a photo for today. I have cheekbones again. Still swollen around my mouth and nose but so much better!

Adventures with a Blender

Yesterday I made a hot breakfast beverage based on a favorite feel better food from childhood: milk toast. It was surprisingly good and satisfying. Enough such that I made it again this morning. If you've had and enjoyed milk toast, this tastes just like it! If you haven't had milk toast, you've been missing out. Recipe: 2 slices bread, 1 cup milk, 1 Tbsp sugar, 1 Tbsp butter. Toast bread. Butter bread then sprinkle sugar over the toast. Cut toast into quarters. Process toast in blender until finely chopped. Heat milk until scalded. Add milk to blender and mix until smooth. Enjoy!

This evening when I was craving a snack I turned to another feel better food from my childhood. Rather tired of the sweetness of smoothies and milkshakes, I wanted something light and refreshing for a change. I'm happy to report that Pear Cheese Salad in its blenderized form is quite tolerable. Not something I'd make if instead I could have it in solid form but a decent snack alternative to a milkshake. Recipe: 1/2 cups canned pears, 1/2 cup pear juice, 1/8 cup grated cheddar cheese, 1 Tbsp mayonnaise. Process cheese in blender until finely chopped, add remaining ingredients and blend until smooth.

As a certain smoothie company claims, "chewing is overrated."

Rubberbands

Now 11 days post-op and, despite looking like I could be related to Shrek, I'm feeling good. I am still having a bit of pain in my ear and more mucous than normal but overall there's been a huge improvement in one week. My surgeon told me my eustachian tube isn't working as efficiently. Between being pushed out of place from the swelling and drowning in extra mucous, my eustachian tube has a lot to adjust to. Apparently it's all perfectly normal and only a matter of time until it's functioning well again. I also still have a lot of swelling around my nose and mouth which makes for a goofy smile.

The other news is that my jaws are now aligned and held together with rubberbands. My surgeon seemed to imply that I'd be able to eat with the rubberbands in place. How to do so is still a mystery to me. Let's just say that I won't be having blenderized mac & cheese again any time soon. Rice was also a no-go but chocolate pudding and Jell-o were something of a messy success. For now though I'm sticking with soups, smoothies, shakes.


And lastly, here is today's profile photo. Note, at the left edge you can see a small pink blemish along my jawline. That is where my mandible was screwed back together. It's no wonder my jaws feel squishy--they're held together with screws and rubberbands!

One Week After--Shrek Green

My surgery was a week ago today. Seems like forever and yesterday both at once. The first few days were difficult. The biggest problem I had was taking my medication--antibiotic and pain. Thankfully mouth has figured out how to swallow again.

I'm not sure if it was due to the swelling, sinus congestion, numbness, rearrangement of my mouth, or some combination thereof but for the first couple of days drinking from a cup was almost impossible. At my 24-hour checkup my surgeon told me that drinking thicker liquids would be easier. Definitely true but, thick or thin, any liquids were difficult to get down for the first few days. Jell-O was the only thing I could eat with relative ease. The other lifesaver was a stainless steel flip-top cup my orthodontist had given me. It delivered water just far enough into my mouth that it neither came shooting out the sides nor choked me.

At this point I'm eating soft foods like mashed potatoes, eggs, pasta, meatloaf, shakes, and smoothies. Eating is a messy and slow process. My mouth hasn't learned to chew yet so I'm just cutting stuff into pieces small enough to swallow.

Pain-wise I'm happy to report that I really never had severe pain. Swelling and bruising continues to be a cause of discomfort but, as the pictures show, the worst of that is definitely over. It's wonderful to be on the downhill side of this process.

Tomorrow I will have my 1-week checkup appointment with my surgeon. I'm curious to know the cause of my Shrek green color so I'm going to ask him why I'm bruised half way down my chest?? I'll report on that next time. For now I'll just post some pictures to show where I've been and where I'm at now.





Today--Shrek Green, 7 days post-op




Jan 16, 2010--Swelling, 3 days post-op
profile and a blurry attempt at a smile




before BSSO & LeFort 1 on January 13, 2010

Official Ortho Pics

Pictures from my ortho file prior to any surgery. Note open bite, overjet, and incompetent lips. Though some men would refute the later fact! :)

There isn't enough room in here for that lip stretcher thing!

maxilla with mirror image

Look Mom, no cavities!

mandible with mirror image

Boo!

Insurance Criteria & My Stats

What follows are the details of my particular case. Not especially interesting to read, simply the facts.

Before Exam
The results of the physical exam I had prior my SARPE and subsequent orthodontics are given here:

facial profile: convex
type: dolichocephalic
lower facial height: increased
symmetry: fair
lip competence: open at rest
nasolabial angle: normal
upper lip: retrusive
lower lip: retrusive
gingival display: normal
overjet: 15mm
overbite: -5mm
midlines: on
classification (molars): class II
classification (canines): class II
crowding (upper): mild
crowding (lower): mild
arch form (upper): narrow tapered
arch form (lower): broad square
frenum: normal
teeth abnormalities: only occludes on her second (3rd) molars, significant wear to all of her molars that have been taking the brunt of her bite of many years
curve of spee: moderate
tonsils: normal
perio concerns: lower 3-3, mild to moderate generalized recession
caries: none noted
oral hygiene: good
jaw joints: no clicking or popping today, good range of motion, good straight opening and closing, no hitches or stops

Diagnosis
The diagnosis given following the examination: Class II division 1 total open bite malocclusion with chronic temporomandibular dysfunction, and a history of facial trauma

Insurance
I am covered under a Blue Cross Blue Shield of Oregon health insurance plan with a 20% co-pay. Below I have pasted their policy/criteria regarding orthognathic surgery as pertains to my plan and I have noted in red the criteria relevant to my case.

Orthognathic surgery may be considered medically necessary to correct jaw and craniofacial deformities in the absence of obstructive sleep apnea when all of the following criteria (A-C) are met:

1. Significant functional impairment is documented as a result of illness, injury, congenital anomaly, or developmental anomaly. Significant functional impairment must be directly attributable to jaw and craniofacial deformities and must include one or more of the following:
   1. Chewing-induced trauma secondary to malocclusion
   2. Significantly impaired swallowing and/or choking due to inadequate mastication secondary to malocclusion
   3. Significant speech abnormalities (e.g., sibilant distortions or velopharyngeal distortion) which have not responded to speech therapy and are secondary to malocclusion
   4. Loss of masticatory or incisive function due to malocclusion or skeletal abnormality
   5. Airway restriction
      
2. Significant over- or underjet as documented by one of the following:
   1. In mandibular excess or maxillary deficiency, a reverse overjet of 3mm or greater
   2. In mandibular deficiency, an overjet of 5mm or greater
   3. Open bite of 4mm or greater
   4. Deep bite of 7mm or greater
   5. Less than six posterior teeth in functional opposition to other teeth secondary to a developmental or congenital growth abnormality (as opposed to a consequence of the loss of teeth)
3. The functional impairment and over- or underjet are not correctable with non-surgical treatment modalities.

New Year, New Bite

The date is set: January 13, 2010. It has been a long time coming but now it's only ten days away. Yikes! I will undergo BSSO (Bilateral Sagittal Split Osteotomy) and LeFort 1 or, in other words, double jaw surgery. I previously underwent SARPE (Surgically Assisted Rapid Palatal Expansion) on October 28, 2008. When all is said and done, I will have underwent two surgeries, the extraction of eight permanent teeth (as a child), and seven years of orthodontics to correct my bite.

How did I arrive here? As a kid I had braces from age 10 to age 14, nearly five years. The day my orthodontist removed my braces he announced that I would need jaw surgery in order to correct my bite. Ker-wham!, there had been no mention of surgery prior to then. He told me to just pick a good time, "spring vacation, Christmas break, summer," and then proceeded to inform me of how the procedure would involve breaking my jaw and being wired shut for six weeks. I wanted nothing to do with it and left in tears.

I did not realize then how correcting my bite is much more than a cosmetic issue. My bite, or lack thereof, has affected my chewing, eating, and speech for as long as I can remember. My bite has issues, functional ones.

When my retainer broke in college I went to see a new orthodontist about getting another retainer. This new orthodontist told me a retainer would not help to maintain the alignment of my teeth due to the relationship between my jaws. He explained how my lower lip would likely push my front teeth right back to where they had been prior to braces, all because my lower jaw set back so far. In assessing the severity of my case he asked me to pronounce my name, "Suzi." He was quite surprised to hear me enunciate my own name as well as I could. Unknowingly, I had adapted. My tongue had accommodated to my bite. This orthodontist too recommended jaw surgery. Still, I could only see jaw surgery as a cosmetic fix and not as way to correct the function of my bite. In my mind I could pronounce my name well enough, thank you!

A few years later my dentist suggested I see an orthodontist because of how my teeth were wearing. He explained how my molars, which bore the brunt of my chewing, had worn flat already and that this could be expected to accelerate as enamel is worn away. For me chewing consisted of crushing food between my molars or simply using my tongue to mash food against the roof of my mouth. What? Are you telling me that's not normal for most people? I had done this for so long I didn't know it wasn't normal. It was all my mouth knew and it worked.

By this time though I had begun to get the idea that my chewing technique was not as effective as it could be. I accepted the referral from my dentist and went to see yet another orthodontist. Sure enough, I was told I needed jaw surgery right along with what was stated as fact "insurance never covers it." The mis-information of how insurance never covers orthognathic surgery was enough to plant a question of doubt in my mind. Did I really need surgery to correct my bite?

It was not as if I couldn't eat, only that chewing was impossible and my incisors were dysfunctional. I could still swallow barely chewed chunks of food and quickly wash everything down with lots of water. I had even figured out how with some softer foods it was possible to press the food against my upper incisors with my tongue and thereby "bite" off a piece of food, sometimes. Though anything harder than a peanut butter and jelly sandwich required tearing or cutting the food into pieces. Pizza was a knife and fork affair.

My teeth failed at their very purpose of biting, tearing, or chewing because my jaws did not line up side to side nor front to back. My upper jaw was narrow and tapered and my lower jaw wide and broad. With the exception of my two molars which actually made contact my teeth served largely as mouth decor and went unused. In fact, until about eight weeks ago my incisors still had the little projections (mamelons) at their edges, just like a child's. Those ridges had never worn down because my incisors had never bitten into food. My current orthodontist saw fit to grind off the ridges of my undefiled teeth!

But back to my story, the orthodontist my dentist had referred me to sent me to see an oral surgeon. There, again, I heard how jaw surgery was essential to correcting my bite and the familiar refrain "insurance never covers it." As a young teacher there was no way I could afford out-of-pocket surgery so I did nothing.

Fast forward ten years to winter 2008. I'm tired of chewing with my tongue, almost choking because I do not chew my food well, and with not being able to bite into a sandwich or slice of pizza! I'm ready to take out a second mortgage if that's what I need to do in order to have the surgery. Back to the orthodontist, yet another orthodontist. Yes, I'm told I need surgery and once more "surgery never covers it." This time though, when I frown disapprovingly, the last statement is amended to "well, surgery rarely covers it and they never approve it the first time." I'm again referred to an oral surgeon.

This time I go to the same office but I see a different oral surgeon. In questioning me he is surprised to learn I actually had braces as kid! No surprise to me when I'm told need surgery, but I am surprised when he tells me I will more than likely need two surgeries. When I ask about the chances of insurance covering the procedures he informs me that unless my policy specifically excludes orthognathic surgery, "insurance will cover it." He was absolutely right. My bite or lack thereof is severe enough to be considered "medically necessary" per my insurance.

In October of 2008 I had an expander placed in the roof of my mouth followed two weeks later by SARPE surgery. I expanded the entire month of November for a total of 45 turns, the equivalent of 9mm. My gap was wide enough that it looked as if I had lost my front teeth. I discovered quickly how uncomfortable it makes others to look directly at you when you have a big, goofy gap between your front teeth. Aside from family and friends, the store clerks, fuel attendants, and other people with whom I interacted generally avoided eye contact. That is with the exception of the man who nearly got whiplash as he jerked his head around to be sure he'd just seen what he had thought he had seen. "Yes, I lost my front tooth." Closing the gap began when I got my upper braces in early December 2008.

With a mouthful of metal, a palatal expander, and the equivalent of no front teeth my speech was rather unclear. When I would try to explain my situation I may just as well have said I had "saw jurgery." "What?" Anyone who goes through this should buy a puppet and consider a second career as a ventriloquist!

Sometime last spring my lower braces were bonded. In July my expander was finally removed. I had, by then, grown quite adjusted to it. I was even a bit afraid to see it go due to the chance of relapse and, more than that, because it meant my tongue had to learn new tricks. Eventually my tongue stopped doing gymnastics around where my expander had been and learned the new landscape of my wider and unfamiliar palate.

Since then my orthodontist has been working to line up my teeth as best as possible for jaw surgery. At the last adjustment before my surgery the final SureSmile custom archwires were placed and, in addition to the hooks some bands already had, four more hooks were added to my mouthful of metal. Two hooks were placed in front on my upper wire and similarly two in front on my lower wire. All the more points to rubberband me closed!

Now it's only a matter of waiting.