Two major concerns

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#1 Post by **Mandibleless** » Thu Jul 24, 2008 7:53 pm

I have two rather large concerns about this entire process.

First, what if during the pre-surg bite decompensation phase of orthodontics they discover that I am in root resorption?! (via radiograhpic monitoring) Then the braces will have to come off right away, and my bite will be a mess. What then?! I would be totally screwed then, right?!!

Then there is the concern about the TMJs. I have mild TMD. I know a lady who had surgery by one of the country's "top docs" but everything is crooked -- her upper, chin, everything! This most likely happened is because when they laid her down on the operating room her TMJs became unstable (she has TMD too).

Is there anything the surgeon can do to stabilize the TMJs while the patient is on the table?

#2 Post by **Happysmiler** » Fri Jul 25, 2008 1:16 am

With regards to root reabsorption - I agree with Meryaten . I think it is pretty rare these days - however it is still one of the risks that they HAVE to warn you about before treatment.

You know what its like when you look at the possible side effects of any tablet these days, there are lists and lists of possible things that could happen.

They just have to tell you of all the possibilities, however unlikely you are to get them.

Try to remain positive - I have never heard of anybody who had this problem.

Unfortunately I can't offer any help regarding TMJ/TMD - sorry

Good Luck
Happysmiler

#3 Post by **amd** » Fri Jul 25, 2008 4:29 am

Hi,
I don't know how to address your questions around TMD exactly. I had my surgery done on July 17th (upper/lower/genio/cheek implants-grafts taken from genio area, some corrective work on joints.)

One of the major issues for me with TMJ was the sensation of my jaw wanting to lock, and not being able to hold my mouth open for things like a dental exam etc. Jaw fatigue was always an issue.

Since surgery the pain on my left side - right in the ear - has been almost unbearable at times. However, according to all of the xrays etc the surgery has had the desired result- the joint is now in proper position etc and my disk "popped" open. It was slightly flat prior to surgery. The pain is a result of movement of the jaws combined with the "pop" of the disk (an actual good thing). The pain they tell me is a really good sign and I have to be patient for things to settle and the pain should slowly subside.

Root resorbtion is a huge issue for me. I have a 40% periodontal loss on the upper right back 2 molars. They have kept the braces on and proceeded with surgery and will continue with braces. It just means for me that my ortho is very careful on how she moves teeth, how quickly etc. I am monitored very closely.

If you do a search you should find another lady here who has root resorbtion issues as well, I can't remember her name. It is an issue but from what I understand it doesn't mean the braces are simply removed "at once", it just means the treatment plan is altered to accommodate this.

#4 Post by **Mandibleless** » Sat Jul 26, 2008 6:33 am

Thank you for your replies.

Modern OD treatment methods still result in root resorption -- I personally know three young people in full-blown RR, one of whom had to have his braces yanked off *immediately.* One of those three is a cousin of mine who now has grade 4 tooth mobility and needs dental implants. !!!

This will be my third round of OD treatment. I have researched RR rather extensively (an OMFS whom I saw didn't know some of the stuff that I did), and most studies indicate exactly what a dentist told me last week --- there is some root resorption with every single round of OD treatment. Teeth are made of dentin, not bone, and dentin does NOT remodel.

There is really nothing else to say about it. It will be a risk no matter what.

What to do about the horrible bite if the RR is discovered during pre-surgical decompensation is a huge unanswered question for me.

My understanding is that splints don't actually stabilize the TMJs, only the jaws. Various methods of stabilizing the TMJs include meds and hormones (Dr. Arnett's method of choice) and imaging while the patient is on the OR table to make sure the joints are in proper position (Dr. Gary Wolford's method). I am talking condyles and disks here, not jaws and teeth.

#5 Post by **suetemi** » Sat Jul 26, 2008 7:28 am

How is root resorption diagnosed? Is it something that has to be actively looked for via x-rays and whatnot, or are there telltale external signs that it's happening? I don't think my ortho is monitoring this. When I went for my consult though, they said the risk was greater for people with short roots, which I don't think I have.

#6 Post by **Mandibleless** » Sat Jul 26, 2008 10:11 am

suetemi wrote:How is root resorption diagnosed? Is it something that has to be actively looked for via x-rays and whatnot, or are there telltale external signs that it's happening? I don't think my ortho is monitoring this. When I went for my consult though, they said the risk was greater for people with short roots, which I don't think I have.

Hi Sue,

Yes, they can monitor your root length by obtaining periodic monitoring x-rays.

Yep, the shorter the roots the higher the risk. Certain root shapes are more prone to it than others as well.

Someone above mentioned that they are supposed to warn you about this risk, and I agree that they SHOULD. (No way would you undergo a medical procedure without a thorough explanation of risks, benefits, alternatives, and possible complications, followed by your signing an informed consent.) As stated above, I have undergone OD treatment twice, many many years apart and in two different states. The first treatment was during childhood, but the second was as an adult and it was never mentioned! (I still have the paperwork, and it's not included in that either.) Also, I asked the three individuals whom I know who have RR, and NONE of their treating ODs (again, in different states) mentioned RR prior to treatment.

#7 Post by **Mandibleless** » Sat Jul 26, 2008 2:26 pm

Meryaten wrote:Medications do not help hold the joints in place during surgery - they stabilise in the sense of managing/controlling an existing process of deterioration in the joint, if such is going on.

Yes, I know -- they are given preopeatively.

Neither does imaging on the table help in any direct way - all that can do is give an extra data point about the positioning - the positioning that frankly can usually be managed sufficiently with splints.

Sorry, but Dr. Gary Wolford (Larry's bro) says otherwise, and on this one I will go with the doc's opinion.

As I mentioned above though, previous root resorption is a strong indicator for a higher chance of it occuring in treatment today. Especially if that first round of orthodontia you had was during the "bad old days" of old-fashioned arch-wires, I can see where you may be at higher risk. Perhaps this treatment is not for you.

Previous history of RR can be ONE indicator -- along with calcium level, estradiol level, previous extractions, and a lot of other things. Fact is, after years of study they really do not know what causes it. The three individuals I mentioned were all in round one of OD treatment, and one is a male -- and not an effeminate one, either.

Again, even "modern-day" OD can result in RR.

#8 Post by **Steph-in-WI** » Sat Jul 26, 2008 3:36 pm

My OS follows Dr. Arnett's protocol for joint meds. I am on a protocol of Doxycylene, Feldene (piroxycam) and Amitriptyline for a year prior to surgery (it'll actually end up being about 9 months) to stabilize the joints. My OS told me at my first consult with him that he puts all of his female patients with TMJ issues on this med protocol. From what I hear, the doxycycline is the most important med. Below are the bullet points in my post-operative care instructoins regarding Joint Medications:

*Start 2nd week after surgery
*LOWER JAW MOVES BACKWARDS WITHOUT JOINT MEDICATIONS
*joint medications taken for 12 months following surgery unless told otherwise
*it is the patients responsibility to maintain prescriptions for joint medicationsÂ¨
*call for new prescriptions if your joint medications run out
Doxycycline - maintains bone and connective tissue in jaw joint
*Vitamin C and E - antioxidants which stop joint deterioration
*Feldene (piroxicam) - not taken after surgery unless joint pain occurs
Simvastatin (Zocor) - used for unusually bad jaw joints; many patients do not take
*rheumatoid arthritis medications - prescribed by the patients rheumatologist when indicated
*Amitriptyline (Elavil) - medication taken at night for patients suspected of nighttime clenching.

I personally have had a particularly hard time with the doxycycline. In March I had esophageal ulcers and just recently had gastritis/severe inflamation of the stomach with intense abdominal pain. I think I am particularly sensitive to the medication.

I think my OS is being a bit exaggerated when he says that lower jaw moves backwards without joint meds, as it seems there have been many people on this site that had lower jaw advancments that did not see any relapse, but I think he says that so his patients are sure to take the medication and not let it slide after some time.

Even with this protocol, there is no "guarantee" that my joints will be better after the surgery. In fact, the surgery could make them worse. But they will most likely get much worse if I don't have the surgery, so really I don't have much of a choice. Most rewards come with at least some minimal risk, every individual just has to accept if the risks are worth it to them depending on their individual case.

#9 Post by **lionfish** » Sat Jul 26, 2008 3:59 pm

Steph-in-WI wrote:
I personally have had a particularly hard time with the doxycycline. In March I had esophageal ulcers and just recently had gastritis/severe inflamation of the stomach with intense abdominal pain.

If this is the same as the antimalarial drug, gutsache/diarrhoea/vomiting is a known possible side effect. I took it for many years as a prophylactic without incident but stopped using it last year after it cost me a day in bed while on holiday. And I have a stomach of cast iron.

#10 Post by **Steph-in-WI** » Sat Jul 26, 2008 5:26 pm

I just checked and the doxy is used as an antimalarial, although these days mefloquine (Larium) is more commonly used. I also thought I had a stomach of cast iron, after living in Mexico 3 years and never getting sick, but the doxy proved me wrong. Oh well, I had to choose what was more important, the stability of my joints before and after surgery, or some occasional upsets from the meds.

#11 Post by **lionfish** » Sat Jul 26, 2008 7:36 pm

Steph-in-WI wrote:I just checked and the doxy is used as an antimalarial, although these days mefloquine (Larium) is more commonly used.

That's interesting what you say about larium, because no-one in Aussie uses it anymore because it can trigger hallucinations (definitely a no-no for divers). Doxy replaced larium in popularity here in the '90's, but the best is malarone (which I now use) - 99% effective with no side effects, other than a very deep hole in one's pocket.

#12 Post by **Steph-in-WI** » Sat Jul 26, 2008 8:40 pm

I just found that on a random webpage when I did a search on doxy and antimalarial, so maybe it was outdated information. I guess at least I know I am covered if I travel to any areas where contracting malaria is of concern