Orthoganathic Surgery (Jaw Surgery) & Health Insurance

Sigursdan

Good Morning Everyone,

I am hoping to find some clarification and advice from people with personal experience or professional interests in the area of Orthoganathic surgery. I will try to give some background information here also, so I apologise for the length of the post - it goes on and on!!!

I am 34 years old and have never had 'good' teeth. I experienced severe crowding as a child and teenager - but not severe enough to qualify for free treatment. My parents could not afford orthodontic treatment and under the advice of our dentist (also a family friend) they allowed him to attempt his own version of orthodontics. This involved extracting many teeth and various removable appliances - similar to hawley retainers. These had very little effect. This dentist is now deceased and unfortunately all records have been destroyed.

In my 20's when I had my own source of income I decided to seek out proper orthodontic treatment. The ortho treatment plan included 3 extractions: 2 pre molars on lower arch and 1 molar on the upper arch - right side, I wore a fixed appliance (metal brackets) top and bottom for 2+ years. My chief concern was the crowding and the fact that my midline was off ad did not match top and bottom.

Following treatment my upper and lower teeth were straight but my bite did not align comfortably. My upper and lower midline also still did not match. I remember that at every 'tightening' the ortho would push my lower jaw to the right every time he asked me to 'bite' together - accompanied by a hmmmm... but never offered an explanation for this and when I asked muttered something about meshing. The final result was such a huge visual improvement on my starting point and I was so relieved to be OUT of the braces (as I was 26 at this point and working as a teacher) that I didn't really question these seemingly minor issues. I was fitted with a permanent retainer top and bottom on the front 6 teeth.

I wore my removable retainers as instructed (essix) and for the first year or so everything was fine. Fast forward 5 years and I was still wearing my retainers at night 3 or 4 times a week. I was noticing however that the retainers were becoming very tight - particularly on the right upper and left lower sides. I could force them to fit by clenching my jaws, but it began to feel a lot like when the brackets had been tightened during treatment. When I took them out I would feel that 'relaxing' sensation in my teeth. I began to notice, firstly in photos and then in the mirror that the left side of my teeth were more prominent in my jaw and my bite had moved much further out of alignment. I revisited my ortho at this point and he agreed that there had been some shifting. He made me a hawley retainer and I had two further appointments to have it adjusted. He didn't think that the shifting on the lower arch was significant so did not treat this. After 2 adjustments he removed and replaced the upper permanent retainer and extended it further to the right, I received a new essix retainer for the lower arch and continued to use the hawley on top.

However, the shifting of my teeth has continued. And I DID wear my retainers. At this point neither the upper or the lower retainer will fit onto my teeth.

I did not revisit the ortho again - life got in the way. I lived in the US for a couple of years and then had a baby. Things were too busy to dwell on my smile and my uncomfortable bite - my own needs were no longer a priority. I began to notice increasing discomfort when chewing and biting, my jaw clicks and pops constantly, sometimes painfully and locks if I open too wide (eg to bite or floss my back teeth).

Last September I made an appointment for a routine dental exam. I mentioned my concerns (shifting teeth, prominence on left side, discomfort biting and chewing, clicking and popping jaw) during the check-up and the dentist recommended I see their in-practice ortho. My previous ortho had been in Newry, travelling to and from no longer suited my work and family commitments (living in louth) so I thought that a local practice would be better and decided to go along with the recommendation.

At this consult I had barely sat in the chair before the ortho declared he could not help me. He told me I had an asymmetry to my lower jaw and that my teeth were in crossbite. He mentioned jaw surgery and maxillo-facial surgeons. He talked about full orthodontics with an ortho specialist. He said 3 years! I was shocked. I had been thinking I might need another retainer - maybe 6 months of invisalign. I left with a referral to see an ortho-specialist in Dublin: and a ringing in my ears!

The new ortho repeated the above diagnosis and added some new terms for me to 'chew on'. My midline is now off my almost 6mm. I have an overjet on the left again of 6mm and an underbite tendency on the right. Due to the asymmetric extraction of teeth during previous ortho treatment my upper arch has drifted significantly to the right. My canine teeth are positioned opposite each other but at an angle in my jaws. Ortho has said he *hopes* to reopen the space where my right first molar was removed and insert an implant to rebalance the arch. He says that in order to make any improvement I must accept that I will need lower jaw surgery at a minimum. If his plan to rebalance my upper jaw by creating space and ultimately using an implant to balance the upper arch doesn't work I may even need surgery to the upper jaw too. I will need to spend 18-20 months in braces (damon metal), have surgery to realign me jaw or jaws, and then another 9 months of braces to fine tune my bite. That while my teeth were 'superficially' straight, they were in a terrible position in my jaws. All of this was driven home when he revealed the impression models of my teeth and the terrible (crushing!) photos taken at his first consult. When forced into the closest I can manage to a normal bite (which feels un-natural and uncomfortable) my face is noticeably crooked, my mouth is crooked and lips do not close on one side. One side of my upper face looks sunken.

Ortho referred me on to a maxillo-facial surgeon (Frank Brady). I had a consult before Christmas and the surgeon seemed a little reticent re: treatment. He said that subtle asymmetries are much more difficult to correct than major issues. This has me in a panic that he will refuse to treat me and that I will not be able to correct any of the issues I have with my bite. The ortho tried to reassure me that it is common (and prudent) for a surgeon to take time to consider a surgical case before offering a treatment plan. He also says he can refer me to another surgeon if Dr. Brady refuses treatment. However, I believe that Br. Brady is one of the most experienced maxillo-facial surgeons we have in Ireland - and if he doesn't want to treat me then I would be so afraid to let someone else "have a go". My early experience of "have a go" dentistry has left me with an absolute horror of anything dental. I am due to see Dr. Brady again tomorrow and I am now in a complete spin.

I have decided that I wish to proceed with treatment because:
-Now that I have seen these things I can't un-see them. They look more obvious to me every day. I realised that I never fully close my mouth - purposely to disguise the fact that my face looks 'a bit odd' when I do.

-I can only bite through something on the right side of my mouth and chew on the left, but the jaw clicking is painful and constant. When biting on the right however I often damage the roof of my mouth which is always tender and swollen, and I regularly bite my cheeks and lip on this side when biting and chewing. Whilst I know that the TMJ issues may not be helped by the surgery, I think that having a better bite will help to alleviate the symptoms and hopefully reduce the pain.

-I am afraid that as I get older these issues will grow worst and become more noticeable. If I need a surgery, then the younger I am the better surely? Even though 34 is hardly a spring chicken!

So after all of this very extensive backstory (or rambling) I have some questions that I hope some of you will be able to answer:

1) The ortho treatment will cost €5300 - does this seem reasonable?

2) I have private health insurance with Laya is the jaw surgery likely to be covered? I am seriously concerned that it may be deemed a 'cosmetic' procedure and refused. Our policy booklet says they will not pay benefit for:

"Any dental or orosurgical or orthodontic
treatment or procedure unless it is a surgical
or medical procedure listed in the schedule
of benefits."

But I don't understand this - the schedule of benefits has no mention of dental surgery?
(I have been covered privately with vhi since childhood with no breaks in cover, we changed our policy to laya this year as vhi seem to have got a bit stingy over the last few years and removed cover for private and hi-tech hospitals from our old plan)

3) If the surgeon decided that treatment should go ahead, is it him who decrees whether the procedure is cosmetic or medically necessary? Can he 'make a case' to the insurer to cover it? Or do Laya decide?

4) Has anyone been down this road and had a successful outcome? Was it all worth it?

5) Finally, from a purely vain perspective - I am 34 and a Mom, can I really do the full metal mouth braces again and for so long? I felt like I could just about pull them off in my twenties but the thoughts of going there again...

If you read all of this and still have any energy left I would really, really appreciate any input you might have or advice you could offer.

Thank you so much for taking this time to read this post!

Dianthus

Sigursdan wrote: »

1) The ortho treatment will cost €5300 - does this seem reasonable?
You would have to have further consultations with other orthodontists to compare& contrast.

2) I have private health insurance with Laya is the jaw surgery likely to be covered? I am seriously concerned that it may be deemed a 'cosmetic' procedure and refused.
3) If the surgeon decided that treatment should go ahead, is it him who decrees whether the procedure is cosmetic or medically necessary? Can he 'make a case' to the insurer to cover it? Or do Laya decide?
Surgeon should be able to clarify both these points tomorrow

4) Has anyone been down this road and had a successful outcome? Was it all worth it?
Lots of patients. Some yes, some no. Depends on expectations, anatomical limitations, communication, personality, priorities. In general, adults are far more aware of adjustments& results(down to the millimetre!), far more so than a teenager.

5) Finally, from a purely vain perspective - I am 34 and a Mom, can I really do the full metal mouth braces again and for so long?
I've seen patients have braces in their 50s. However, can appreciate that you're experiencing an element of "dental fatigue" having had so much past treatment.

I really would advise that you print off your opening post, & bring it with you to your consultation tomorrow, to be read afterwards& added to your clinical notes. Also to email it/post it to your orthodontist. It's important that both practitioners fully understand your concerns, hopes, reservations, priorities, expectations, past history. And address these as best they can.
With all due respect to the parties involved, I can't see you articulating your post as comprehensively in a 20-30 minute consultation time. Also, by allowing them time to read& digest it, they will be in a better position to allay your fears& explain what's achievable& what is not. Honesty& clarity is vital from the get-go.
Best of luck with everything.

amor3

Not much to input. I was refereed for Jaw surgery nearly 4 years ago. Like you, the surgeon was reluctant to proceed due to possible nerve damage. I didn't go ahead with it and I am raging . I would've been finished treatment and all now. It's something I plan to sort this year. It means going back to the same ortho (seems to be the most regarded one in dublin, was recommended to him twice by 2 different dentists) and ask for another consultation.

Sigursdan

Amor3, thanks for your input. Would you mind me asking who (PM if necessary) is/was your Ortho?
I have seen a couple of different people, but am thinking I'll need to find another!

To update (& thank you also to Dianthus for your guidance):
I met the surgeon and a colleague with whom he often collaborates on Jan. 9th. Like Dr. Brady, he was also cagey about proceeding. Their opinion was that:

1. that the possible complications arising from surgery would out way the benefits of the procedure.
2. that my skeletal base was *just* within the normal range
3. there was a soft tissue problem which was compounding the visible appearance of my jaw/mouth/bite.

I am am now waiting for a treatment plan with various options to be devised. I am due to meet with them again on Feb. 20th. Whilst I appreciate the prudent and considered approach I am also a bit antsy and would really like to just KNOW what lies ahead and get started on the road to fixing it. I have been told that there will be a variety of options to choose from - one of which will be to do nothing. FYI: I'm not interested in doing nothing - I just want to get started and get it over with! I feel that as I get older these issues will become more obvious and if I have to commit several years to treatment then i might as well do it asap.

I am however concerned that if their recommendation is no surgery, and the Ortho does not agree and refuses to treat me then I'm back to square 1 - again. I am hoping that they will also have referrals for a practice or individual who will be able to carry out the treatment for me.

*Sigh* there are only so many times you can pay out €90 for an Ortho consult. to be told that they cannot help you / you need surgery / then referred elsewhere = more consult fees.... And the cherry on top: Oh no, no clear brackets for you. Your case is much too complex for those... Feeling a bit Lisa Simpson: "These pre-date stainless steel; so you can't get them wet"

Ah well. Keep smiling eh!

amor3

Sorry just a quick post, just about to do school **recommendations by PM only** Hope it's OK to post names! He's very good; he did my son's braces.

Dianthus

Try not to panic too much, OP - at least until Feb 20th, when all should become much clearer.
Things are still in the planning stage; measure twice, cut once
It's standard practice for all clinicians to recommend "no treatment" as an option. In fact, they are duty-bound to include it as an option, however ridiculous this might appear to you. Just as there are pros& cons to undergoing treatment, the same applies to *not* undergoing treatment. It's so you as the patient can decide what your priorities are, & what risk you're comfortable taking, what time& cost you're prepared to commit to.
However equally, you want your orthodontist& surgeon to be confident that they can deliver the result you want. If they're not, you have to consider attending yet more consultations for more & varied opinions from consultants, & if everyone is singing from the same hymn sheet, then to accept that what you want isn't biologically achievable, by anyone, & that a compromise has to be made.

amor3

amor3 wrote: »

Sorry just a quick post, just about to do school **recommendations by PM only** Hope it's OK to post names! He's very good; he did my son's braces.

Sorry, wasn't sure if allowed. Will pm you OP.

Sigursdan

Thanks Dianthus. That is helpful advice. My meeting has been brought forward slightly to Feb. 6th, so a little less time to deal with the unknown. I will update with any progress or decisions then. Until that point I think I will hold off on any further consultations (and try to stop reading the entire internet & freaking myself out!)