Metal Mouth Message Board

Hi, still new to all of this. I was wondering if anyone's surgeon is still opting for having their mouth wired shut as opposed to heavy duty rubber bands. I had only one consultation with an oral surgeon so far on Monday for my underbite and he told me that he would like to have my jaws wired for 6 wks after the surgery. He said that he could use heavy duty rubber bands if i wanted but from his experience he's found they have a 25% greater chance of temporary or permanent numbness of the lip. This as opposed to wired he said where he's only seen about 2% of the time this happening. Has anyone heard this before. I'm not very familiar with the whole procedure of orthognathic surgery but from reading after stories and watching youtube vids i really only see individuals with the rubberbands so i thought wired was the old school way of jaw surgery. Also, he thought it would be a good idea with moving my low jaw back to move my chin forward to enhance my profile does that make sense?

Can anyone provide their thoughts on this or chime in if they know more about this. thanks!

I have heard nothing indicating that using wire will reduce the chance of numbness but maybe someone else has.
I was banded completely shut for 4 weeks.

I'm with one of the top surgeons in the country and he bands with no splint, so I'm pretty sure your surgeons comment, while well intentioned, is erronous.

I'll also mention that as someone who has been wired with a splint, being banded with no splint is a million times easier after surgery (still stinks though!)

Whether you get banded or wired shut depends on the procedure used to move your lower jaw. The two most popular techniques are Bilateral Sagital Split Osteotomy (BSSO) and Intraoral Vertical Ramus Osteotomy (IVRO).

In a BSSO, the surgeon cuts your jaw roughly below where your wisdom teeth sit and slides your lower jaw backward (or forward). In a IVRO, the cut is further back, roughly where your jaw starts curving up, and the lower jaw tilted backwards.

The BSSO cut goes right through the path of a major nerve that runs along your lower jaw. A IVRO is far enough back in the jaw where it can completely avoid this nerve. This nerve is connected to the chin and the lower lip, so since the IVRO cut doesn't go directly through the nerve, it reduces the risk of numbness.

However, with an IVRO, the cut is in a position where the surgeon can't see very well. It is also in a structurally awkward position at the end of your jaw bone, so they can't use plates & screws to fix together the two sides of the cut jaw bone. Instead, your entire jaw is wired in a fixed position until the bone heals - which takes several weeks. The BSSO on the other hand cuts in the middle part of the jaw bone, where the surgeon can access more easily and screw a plate across the cut. This keeps the two sides of the cut jaw bone together, meaning you don't have to be wired shut.

There are also some minor aesthetic differences, mainly that an IVRO creates more of a square jaw angle than a BSSO.

So in summary, a BSSO has a greater chance of nerve damage than an IVRO, but has a much easier recovery time since you don't have to be wired shut for six weeks. Also most surgeons perform many more BSSOs than IVROs, so they will be much more familiar with the former. Either way, I would talk with your surgeon about what is best for you.

Wow! Thanks LAJaw that was such a great explanation. I've been trying to figure out what BSSO meant and now I finally understand. I think for this particular surgeon he prefers IVRO for his lower jaw surgeries. As far as if that's best for me not sure. But I have consultation with a another oral surgeon today so i will make sure to ask about this.

There are also some minor aesthetic differences, mainly that an IVRO creates more of a square jaw angle than a BSSO.

What do you mean by square jaw angle ?, can you please elaborate on this issue a bit ?

Thanks!

I'm always surprised when I hear that IVRO is still used in the US on a regular basis.
imho there has to be a MAJOR advantage to make a patient go through the hell of being wired shut for 6 weeks.
I don't know a single surgeon who uses IVRO regularily in my country. I know of one patient who had it done, but only because he had an exceptionally thin jaw bone.

qwertz1 wrote:I'm always surprised when I hear that IVRO is still used in the US on a regular basis.
imho there has to be a MAJOR advantage to make a patient go through the hell of being wired shut for 6 weeks.
I don't know a single surgeon who uses IVRO regularily in my country. I know of one patient who had it done, but only because he had an exceptionally thin jaw bone.

Being wired shut for 6 weeks, imho, is still better than permanently damaging the nerve in your lower jaw. My surgeon told me he can do either BSSO or IVRO, but chances for nerve damage are much higher with BSSO.

I say why take th risk ?, what are 6 weeks of inconvinience in comparison to a whole life without the ability to feel with your lower lip/chin ?

By jaw angle, I'm referring to the gonial angle:



IVRO tends to decrease gonial angle more than BSSO. In this paper, BSSO resulted in an average 2.1 deg decrease in gonial angle vs a 7.4 deg decrease with a IVRO. A lower gonial angle should correspond to a "squarer" jaw line.

I definitely plan on talking with my surgeon about the possibility of an IVRO, since it seems everyone who has a BSSO suffers from some degree of permanent nerve damage. 6 weeks doesn't seem like such a long time in the grand scheme of things ... although it's easy to say that now! I've only had braces for 2 weeks and already I'm ready to get them off

it's not an inconvinience, it is possibly traumatic.
I could point to a report by a patient who had this done when BSSO wasn't so widespread yet and he had psychological problems years later, traumatized by throwing up blood without being able to open your mouth, depression because of not being able to eat properly, and all that while not being able to talk to anyone.
but the report is not in english.

what is the source of the lower risk of numbness by the way?
damaging the nerve is highly unlikely with both techniques and an experienced surgeon. the numbness is usually caused by stretching/compressing the nerve, which is unavoidable when you move a jaw.
so why is IVRO supposed to have a lower risk of permanent numbness?

I have to add that he also wasn't prepared properly, so he didn't know that you might throw up blood through your nose. it's only natural that you panic then when it happens.
so you certainly can go through this better prepared and without a trauma...but still. 6 weeks.

I did a quick google search that turned up a few papers about IVRO and BSSO nerve damage:

Neurosensory Disturbance after Bilateral Sagitall Split Osteotomy:

The vertical ramus osteotomy (IVRO) divides the mandibular ramus from the sigmoid notch down to the angular region. The bony cut is made posterior to the point where the mandibular nerve enters the bone, and this is why it has lower incidence of IAN [inferior alveolar nerve] injury than BSSO.
...
After IVRO, obvious intraoperative IAN damage is uncommon, and long-term sensory disturbance varies between 2% and 14%. In 1986, Zaytoun and co-workers testing with brush directional stroke, found a significantly higher long-term incidence of IAN injury a mean 3.2 years after BSSO (63.6% of the 22 operated sides) as compared with transoral vertical ramus osteotomy (0% of the 30 operated sides).

From an oral & maxillofacial surgery textbook at http://dentistry.tums.ac.ir/Files/lib/M ... s/ch56.pdf:

From studies that have been done the incidence of damage to the inferior alveolar nerve is low with the VSO compared the sagittal osteotomy.86,87 The patient, however, should be warned that shortterm sensory loss is a definite risk, permanent neuropathy is possible.

The general consensus seems to be that IVRO (aka VSOs) have less risk of permanent nerve damage. However I'm not a surgeon and I don't assume I know more than they do after just a few hours of googling. I just plan on doing my research so I will be informed enough to discuss all my options and their pros and cons with my OS.

Hi everyone. I had my 2nd oral surgeon consultation today and I discussed with him about what the other surgeon's preferences on being wired shut due to greater chance of nerve damage. So here is what he told me. He said that he's had experience with performing both BSSO and IRVO but he recommends BSSO. If I understood everything correctly with BSSO yes there is a greater chance of numbness in the lip and chin area because where they are cutting is in the area of the nerve and this can't be avoided doing BSSO. With IRVO like LAJaw stated the cut is further back completely avoiding the nerve. However, he says that he still recommend's BSSO over IRVO. With IRVO he said there is a much greater chance of relapse because your jaw is only being wired shut for 6 weeks while it gives your jaw bones a chance to heal and fuse together. However, with this method there is nothing holding the jaw bones together after the wires are taken out. Unlike, BSSO where there are plates and screws to keep your jaw bone together. So im guessing that is why more surgeon's choose BSSO over IRVO and also the recovery period with IRVO.

So to me it's almost seems as though your either accepting a greater possibility of a relapse with IRVO vs higher probability of temporary or permanent numbness with BSSO. Therefore, like everyone here that is willing to or choosing to do this surgery I will just have to acknowledge the fact that there will be some risk involve. I have another oral surgeon consultation to go to because the one i saw today does not take my insurance so he referred me to another surgeon in NYC who he said performs around 250-300 orthognathic surgeries a year so im hoping that he can give me more answers regarding IRVO and BSSO. I'll keep everyone posted.

I was reading this article and it goes into some of the differences between the BSSO and IRVO if anyone is interested.

http://herkules.oulu.fi/isbn9514267508/html/c237.html

LAJaw wrote:By jaw angle, I'm referring to the gonial angle:



IVRO tends to decrease gonial angle more than BSSO. In this paper, BSSO resulted in an average 2.1 deg decrease in gonial angle vs a 7.4 deg decrease with a IVRO. A lower gonial angle should correspond to a "squarer" jaw line.

I definitely plan on talking with my surgeon about the possibility of an IVRO, since it seems everyone who has a BSSO suffers from some degree of permanent nerve damage. 6 weeks doesn't seem like such a long time in the grand scheme of things ... although it's easy to say that now! I've only had braces for 2 weeks and already I'm ready to get them off

LAJaw, when you reduce the gonial angle, apart from making the jaw more square, does it also shorten the face ?

Ok guys maybe I can help shed some light.

On the wired vs banded (I was wired shut for 6.5 weeks with splint.) Time being wired shut varies quite a bit but your surgeon should know the progress of the bone growth as he/she should be taking xrays along the way. This way it will ensure that your bone growth is solid enough to be unwired.

Is it a pain: yes it does suck but it certainly not something that has traumatized me. I never threw blood up once or had any trouble of that kind. People have been being wired shut for ages. Even people who have accidents these days and end up with a broken jaw get their jaw wired shut. Honestly, it's going to suck whether your wired shut or banded. The difference is that you "may" be able to eat soft food regularly again sooner if you are banded, while you'll be on liquids for the entire time while being wired. This is enough to make most people choose bands.

Why was I wired:
That is just the way my surgeon does his cases. From what I understand he prefers it because (contrary to some post's above) the bone heals stronger in the end and there is less chance of relapse. When wired, there is no possibility for movement unlike being even tightly banded. Once the surgery is complete and your jaws are hanging exactly like the surgeon needs them, you are wired. The idea is that you are wired shut exactly when your jaw is as near perfect as they can get it, and it stays that way until you are healed. Being banded sometimes can allow for shifting during the time where bands are traded for lighter bands and even eating.

FWIW, I think my surgeon sat me up to wire me so that the muscles were hanging the jaw correctly as opposed to wiring or banding the person while they are laying on their back.

What should you choose?
In the end every case is totally different and can necessitate a different method for a good end result. I would go with what my surgeon felt comfortable doing or thought was the best route.

I'm know that both methods usually result in fine results so do what ever you feel comfortable doing. I will say that being WIRED is nothing to be scared of, it seems like it's being hyped up. A lot of patients get scared away by it, and since banding seems "less permanent" most doctors will suggest it to patients who seem worried. Also, banding is newer so you may find that the new crop of doctors tend to use that method more. Again, nothing wrong with it.

I will say though that I personally I wanted as little foreign objects (plates, screws) in my body that I could have. I have no plates or screw anchors, just a couple of ties here and there. It seems to me that people run a higher risk of infection when plates and screws are used. There have been multiple post on here about plates and screws being removed and even relapses after words. IMO, I would rather be wired for 6 weeks using all bone to heal.

IVRO vs BSSO
I had the IVRO in this case as well as SARPE a year prior. My case was fairly complicated from what I have been told. I had a long face, asymmetrical lower jaw and rotated, extremely narrow palate, canted maxilla and more that I can't remember. My gonial angle was pretty sharp as well.

IVRO was chosen in my case because he thought it would render the best results. My jaw line did square off and it's great now. I will say that I do still have slight numbness on one half of my lower lip and chin. It may never come back but I have gotten used to it. I would not steer me away from doing it again if I knew the results before hand.

Results
I am very pleased with my results. Is it perfect, no, but it's as close to perfect as you can get with what I started with. I'd say about 90% to 95%. I had virtually no pain through the entire process. My ortho said that he had pretty much no work to do because the surgeon lined up everything so perfectly. My teeth/occlusion have matched up pretty much perfectly from day one after getting my splint out and right now we're just fine tuning everything.

Hope this helps out