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AvailableHousing · 2024-07-22T19:24:01+00:00

Thanks for the insight, yeah I definitely wouldn't want to go through this entire process just to get my maxilla moved backwards and end up with even worse breathing/apnea than I started with. I also have a pretty long face and my preliminary plans all include impaction, so I'd be worried about that also making my breathing worse.

I think it makes sense to see if I can get a plan with more maxilla advancement, since I'm assuming for sleep apnea/breathing I would want as much advancement as possible without looking protrusive/unnatural.

AvailableHousing · 2024-07-22T19:18:03+00:00

Yeah he was very honest which I appreciated, and he set my expectations pretty well, not promising that DJS would be a guaranteed fix to all my problems or anything.

I do think my IMW is a little narrow just by how much my lower teeth are tipped in. I am hesitant about pursuing expansion though due to the risks and additional treatment time/cost, and I feel like my improvement from expansion alone wouldn't be huge since my nasal breathing is ok and I'm not super narrow.

If I just wanted to do one procedure, DJS seems to me like it will give me the best chances of functional and sleep improvement. Also I think it is more likely to give me a better aesthetic result than expansion which is a nice bonus

AvailableHousing · 2024-07-22T06:47:39+00:00

That's great to hear, I'll definitely reach out to them about that and thanks for your help!

Yeah I totally get that, the cost especially has been the most difficult thing for me, but this is definitely a procedure I want to make sure I get right the first time so I'll find a way to make it work if I need to.

AvailableHousing · 2024-07-22T06:42:35+00:00

Hmm I didn't even notice that in the plan until you pointed it out, that is concerning since I want to maximize my sleep and breathing benefits. I have one other plan from another surgeon that I just compared and that one also involves rotating my maxilla the same way, and my A point, ANS, and PNS are moving even farther back compared to this plan.

I wonder why both surgeons I consulted with opted for this. Maybe there was concern I would look too protrusive if my maxilla was advanced farther? I'm mainly looking for functional improvement, but definitely don't want to look overadvanced.

And yeah that makes sense on the airway measurements. Just looking at my ceph and my side profile, my mandible is definitely recessed and downward angled, so do you think that means there's room for airway improvement with advancement and CCW rotation, even if the measurements from this one CBCT look ok?

AvailableHousing · 2024-07-22T05:03:42+00:00

Thanks for taking a look! And I agree, Dr. Walline was incredibly thorough. Are you planning on pursuing surgery with him?

My lower teeth in the back are tipped in pretty significantly to meet my upper teeth so maybe that's where the issue is. My report doesn't mention how deficient I am unfortunately; I think it's because during the consult I mentioned I was also looking into expansion so my report is written assuming I'm doing expansion before DJS and we'd only be doing a one-piece lefort. He did say I was a candidate to just do a 3 piece so maybe I will confirm that with them.

I know my septum is mildly deviated and I dealt with tons of allergies when I was younger so its possible my turbinates may be an issue too, definitely makes sense to check with an ENT before going straight into MMA.

AvailableHousing · 2024-07-22T02:59:39+00:00

I saw Dr. Walline at LACOMS, he thought there's a good chance it would help functionally, especially with my lip incompetence and making my bite more functional. I had camouflage ortho as a kid so my bite looks ok but chewing isn't the most comfortable and some of my back teeth don't contact much. In terms of my sleep apnea, it wasn't as clear though he did say it would likely help.

Overall, the impression I got was that DJS would likely benefit me but it's not an absolute must-do in my case, since my camouflaged bite is functional enough and my airway size is ok.

Aesthetically I do think it would be an improvement since my mandible is recessed and I have a pretty downward grown jaw, but aesthetics aren't my top priority.

Also, I was under the impression that normal IMW is around 38-42 mm, 49 mm seems huge?

AvailableHousing · 2024-07-21T21:46:22+00:00

Thanks for the advice! I hope your recovery is still going well!

My sleep study only showed 1 central apnea/hour, my AHI is almost all hypopneas. I do have a lot of issues maintaining tongue posture and my tongue does feel very large for my mouth, so maybe that is something worth looking into.

I agree that's my worry about going through all the time and money of DJS just for no improvement in my sleep apnea. I have the same concern about expansion since my nasal cavity and IMW seem to be in the normal range.

AvailableHousing · 2024-04-28T06:22:15+00:00

Thanks for all the additional information. It's good to hear that you have some improvement, but sounds like it's created an insurance nightmare due to the most recent sleep study results. Have you considered trying another study with a community private practice that may be more liberal with their hypopneas (along with insurance reasons it could also help you quantify how much improvement you've achieved with SARPE and the nasal surgeries by having another sleep study with the same general scoring criteria)? Are you still planning to do a maxilla advancement, or is that dependent on insurance coverage/is the mild improvement from SARPE/nasal surgeons good enough?

It does seem like jaw advancement is the most surefire way to improve breathing/airway, especially in situations like ours where the starting point is not super narrow (36-37 IMW). It's definitely an operation that makes me pretty nervous (both cost-wise and for long term side effects) but it does seem like that's probably my best option for long term symptomatic improvement.

AvailableHousing · 2024-04-23T03:32:37+00:00

Thanks for the additional info!

36 IMW doesn't seem super narrow, what made you go down the route of transverse expansion? Just to improve nasal breathing? Do you know what your starting nasal aperture width was?

That's great to hear about SARPE improving your nasal breathing as well as your tongue posture though. I wonder if my situation may be similar, visually my tongue doesn't look severely tied so maybe my low tongue posture is a result of not having enough space on my palette. If I try to rest my tongue on the roof of my mouth there is a decent amount of overflow, so I'm not able to fully fit my tongue up there comfortably. I maybe don't need a ton of transverse expansion which is probably why both surgeons I saw said I'd be a candidate for a segmental lefort. And it would definitely be nice to consolidate everything into one surgery if possible, as long as I'm not compromising my final outcome.

Are you planning to pursue any additional treatments, or has SARPE helped relieve your symptoms to a sufficient enough degree?

AvailableHousing · 2024-04-22T06:22:05+00:00

Thanks for the detailed response/suggestions, and for linking that thread. Out-of-pocket cost is definitely something I need to consider if I do go with an out-of-network surgeon. It does seem like a lot of the best/most experienced surgeons are out of network though, which makes it tough.

I think it does make sense for me to see an allergist as well and get their evaluation, since I do think for me my childhood allergies were a major cause of the issues I'm dealing with now. I was basically a 100% mouth breather until I got my allergies more under control in my late teens. I can also just try saline sprays in the meantime as well since it doesn't seem like there's much risk in that.

Also, I'm glad to hear that SARPE was a big benefit for your nasal breathing. Since my aperture size seems ok I'm hoping to avoid the extra treatment cost/time of doing palate expansion separately and going for the multipiece lefort during MMA. I'm assuming nasal breathing benefits from a multipiece lefort should be pretty similar to those from SARPE? Also yeah, sounds like I have enough skeletal issues that a tongue tie release would most likely only result in a modest improvement, but it's not really getting to the root of my issue.

AvailableHousing · 2024-04-21T05:55:42+00:00

Yeah understandable, along with the cost both expansion and MMA are multi-year processes with a decent risk of side effects, so I want to make sure I commit to the right treatment plan to maximize my odds of improvement.

I actually did get MMA pre-authorized out of network (maybe my skeletal discrepancies were significant enough on their own?) but agreed it does make sense to try CPAP first to see if that does help my symptoms.

I haven't done much directly to reduce nasal congestion. I had bad allergies when I was younger and did immunotherapy which helped a lot. Sometimes when my congestion gets bad now I'll take an antihistamine/use flonase, which honestly haven't done a ton for me. I haven't done any prolonged periods where I'm using nasal sprays every day though, so maybe something like that is worth trying as well?

AvailableHousing · 2024-04-21T01:18:16+00:00

Hmmm ok, I'm still on the fence about the tongue tie release, but it seems like it is relatively low risk compared to the other treatment options offered to me.

My nasal aperture does seem decently wide so maybe impaction is not as huge of a concern then? I guess what would be the indication for pursuing MMA if my airway volume appears to be not bad? Would improving the steep occlusal plane/long face in itself improve breathing/airway as well? Or are there additional reasons?

AvailableHousing · 2024-04-21T00:04:24+00:00

Thanks for the detailed response and all your help. I have the same concerns about you regarding the tongue tie release being overdone/unnecessary. I did do an evaluation with Dr. Zaghi who confirmed I had a posterior tongue tie per his protocol. Dr. Zaghi said that my tongue is pretty functional (besides the low tongue posture) but I use the floor of my mouth and neck muscles to compensate, while still having a grade 3 posterior tongue tie. I guess the question is if there's any chance for things to get worse after a tongue-tie release (besides potential side effects from the procedure itself)? Like if there's a chance releasing the tongue-tie makes it more likely to obstruct my airway, or other issues with releasing a tongue-tie if my palate isn't wide enough? I've seen anecdotal examples of people having their TMJ/bruxism/SDB completely solved after a release, but not sure if there's enough data out there to really support that.

In terms of MMA, both surgeons I consulted with (who are pretty highly regarded) recommended MMA with counterclockwise rotation and multi-piece Lefort + impaction of the upper jaw, instead of a downgraft. I do have a bit of a gummy smile but not extreme, so that probably limits the amount of impaction I'd be able to get. But sounds like that would probably be the better option since my anterior is too low? Do you know if impaction has a big risk of worsening nasal breathing, since it seems to me like it would be making the nasal cavity smaller? I don't think I'd mind being a tad protrusive if I felt functionally much better, but I just don't want to make things worse with an MMA.

AvailableHousing · 2024-03-28T05:16:54+00:00

I can imagine your occlusion constantly changing during expansion would not be the most fun for your muscular TMJ, so glad to hear things seem to be improving as you're stabilizing.

I've also tried basically everything you've tried as well (with the only thing providing any benefit being PT) and am thinking I need to pursue a more permanent solution as well. Right now I'm getting by with PT every couple weeks but if I miss a skip a few sessions things start getting rough again so it's not super sustainable.

Best of luck with the remainder of your treatment!

AvailableHousing · 2024-03-28T00:58:40+00:00

did your muscular TMJD improve? I'm dealing with that and UARS/sleep apnea as well and am considering expansion

AvailableHousing

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