Stability Questions, LeFort I--Life with a delayed Union

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#61 Post by **SandraJones** » Fri Aug 24, 2007 1:02 pm

Having more than my share of facial asymmetries, I'm very interested in chapter 58. Aside from the chin deformity, I am not too dissimilar to the young girl in Fig 58-1, and my skull probably resembles that of Fig 58-6 on page 1209. When I lower my mandible it swings to my left. Unfortunately the copies of the medical records I received make no mention of my asymmetries. Surely they were calculated in. I received no paperwork regarding the modelling or planning, unfortunately.

I want a 3-dimensional computed tomographic scan !!!

I wonder how I can get one.

Phil, thank you for making me less productive at work today.

#62 Post by **phil** » Fri Aug 24, 2007 1:35 pm

SandraJones,

Now, now, you can't blame ME for YOUR level of productivity!

By the way, don't take it the wrong way, but your face sounds positively fascinating!

#63 Post by **SandraJones** » Fri Aug 24, 2007 4:35 pm

From a purely scientific point of view, my skull probably is rather interesting !

What is most interesting to me though is how my eyes have adjusted to seeing my reflection in a mirror. I can barely see the asymmetry that way, but when I look at a photo of myself I'm shocked ! That's because everything is going the opposite direction. Like when I look at my teeth avatar I clearly see how my upper central incisors swing to my right, but I don't see it at all when I look at my reflection. In fact, I wasn't aware of how wonky my teeth are until I saw the orthodontic photos ! I was only aware of a couple of issues (upper lateral incisors, one goes in, the other goes out, and some lower crowding).

Tell me how horrible this sounds ... I want to approach my GP and complain of increasing facial asymmetry and see if I can go through some diagnostics. I read about this syndrome called "silent sinus" syndrome which causes the orbital floor to sag and one eye drop lower than the other. One of my eyes is a bit lower than the other and to be honest I think it's always been that way, but in the interest of self-obsession about one's asymmetries and wishing to see some really cool CT scans or X-rays, I'm compelled to register this complaint. Am I a bad person ?

Sorry to hijack your thread, btw ! Will get back on topic now ...

Btw, I've read more of that document ant it's the greatest !!! Thank you so much for posting the link, it's providing some really fascinating reading !

#64 Post by **phil** » Fri Aug 24, 2007 4:50 pm

SandraJones,

Hijack away! I know how to take back a thread when I want to!!!

Well, I'm not one to judge about the "silent sinus syndrome." Have you noticed any functional problems that would indicate that?

About the asymmetry thing...before surgery, my chin pointed to the right 3 mm. They corrected it (sort of--without the elastics it's shifted back about .5 mm), but I NEVER noticed it until they brought it up.

After my surgery, I noticed some other facial asymmetry in my jaw that I had never noticed before. I guess once you're made aware of it, you see all sorts of things, which is a pain! I really would have rather not known, in a way. But, the orthognathic surgery was to correct my bite, not give me a perfect face! So, I'm perfectly happy with that aspect. Truth be told, with all the trouble I'd been through, if my treatment were purely for aesthetics, I don't think I would have ever done it. It's just been too difficult. Now, the prospect of having a healthy, well-functioning bite...that's another matter entirely! Talk about something that really gets me excited.

So, we must not look back. Learn from the past, live in the present, hope for the future. That is the mysterious balancing act!

#65 Post by **SandraJones** » Fri Aug 24, 2007 5:09 pm

I do have a lot of sinus problems and can only ever breathe out of one nostril, so something is wrong. It's probably not silent sinus but you know what, I should just go have it checked out. I've paid a heck of a lot for health insurance and hardly used it at all.

I know what you mean about becoming or being made aware of some physical anomaly ! I became aware of body-position asymmetry when I started horseback riding, I tended to sit a bit askew in the saddle with one leg a bit higher than the other. The instructor positioned me as symmetrically as she could and it felt like I was twisted ! I haven't scrutinized my photos yet to figure out what's going on, I think I'm too afraid.

When I ordered my Le Fort I medical records I was expecting there to be some mention of my asymmetry, like "This young woman has the most asymmetric face we've ever seen, we've taken photos and submitted them to a medical journal !" or "Patient requires total skull overhaul, but due to lack of time we've decided to focus just on the maxilla". Alas, no mention at all. With all of the molds and photos and x-rays and facebow and other pre-surgery preparations, SURELY the asymmetry came into play. I wish I could get my hands on those molds. Unfortunately the surgeon is dead, or I'd pay him a visit !

#66 Post by **phil** » Sat Aug 25, 2007 8:17 am

The more I read from "Peterson's Principles," the more I learn. From the section about bone healing in chapter one, I learn the difference between direct healing, and the kind of healing of bones which fills in gaps, and progresses much more slowly. Both eventually end in the formation of bone, one just takes much longer than the other. Evidently, there was some "microinstability" at the fracture site of my LeFort I, which caused this to happen. Why? Who knows. As long as the blasted thing eventually heals!

For information about the above, read pp. 6-7 of chapter 1:

http://dentistry.tums.ac.ir/Files/lib/M ... s/ch01.pdf

#67 Post by **SandraJones** » Sat Aug 25, 2007 10:24 am

So I'm reading this statement: "The organizing hematoma serves as a fibrin scaffold over which reparative cells can migrate and perform their function. Invading inflammatory cells and the succeeding pluripotential mesenchymal cells begin to rapidly produce a soft fracture callus that fills up interfragmentary gaps. Comprised of fibrous tissue, cartilate, and young immature fiber bone, the soft compliant callus acts as a biologic splint by binding the severed bone segments and damping interfragmentary motion."

Is this the fibrous union ? And the amount of fiber depends on the size of the gaps ? And normally new bone would grow and harden on this fiber base and complete the healing, but until then it's relatively pliable ? So the surgeon attempts to make cuts and join and afix the bones together in such a way that the gaps are minimized ?

I've never broken any bones. When you have a large break that requires stbilization, does a surgeon go in to do work to smooth the surfaces so they can be joined together better ?

#68 Post by **phil** » Sat Aug 25, 2007 10:57 am

SandraJones,

Well, I'm not sure how to interpret it, but I think I'm still in the stage where it could go either way. That's probably why it's crucial right now that my maxilla is as stable and nonstressed as possible, so that the bone can begin to form.

If you read later on in the chapter, it says,

"fibrous healing and nonunions are clinical manifestations of excessive microstrains interfering with the cellular healing process."

So, I suppose it depends on how extensive my level of microstrain is, as to how well I will heal. Like everything else in life, I imagine it's not a black and white thing, but on some sort of continuum. Ultimately, time will tell what happens, but everyone seems to be optimistic.

#69 Post by **SandraJones** » Sat Aug 25, 2007 12:03 pm

I will never forget when my jaws were fully wired that my jaw would suddenly try to snap open, during yawns and at other times, and I would feel this gross yank on my maxilla and it felt like my maxilla moved. I have the intraosseous wire fixation, not miniplates and screws, so I have no doubt my maxilla was not as fixed as yours and others' these days. At all of my follow-ups, according to my records the healing process went well. I was only 20 and had no chronic health issues. But I wonder if my fixation had been done this way as an adult if I would have also had delayed fusion. That's probably why they switched to miniplates and screws and stopped wiring the jaws for long periods of time. After the first 6 weeks of being totally fixed, I used elastics for another several weeks.

#70 Post by **phil** » Sat Aug 25, 2007 1:19 pm

OK, sheer honesty, everybody? Here it comes.

I'M SCARED TO DEATH! WHAT IS GOING TO HAPPEN TO ME???

There. I've said it.

#71 Post by **phil** » Sat Aug 25, 2007 3:33 pm

Meryaten,

Thanks. I just never in a million years anticipated this complication. I'm hoping for the best, but honestly very afraid.

I definitely couldn't do this without Archwired. Thanks, everyone!

#72 Post by **SandraJones** » Sat Aug 25, 2007 5:21 pm

Oh Phil I feel bad for you.

At least you are armed with tons of knowledge. Do you know what the worst-case scenario is and how that would be treated ? If I were in your position, I would want to know that.

How does it feel now to be without the elastics ? Still uncomfortable ?

#73 Post by **phil** » Sat Aug 25, 2007 6:00 pm

SandraJones,

I think worst case scenario would be surgery again. Van Sickels seems to indicate that it should be treated aggressively, if nonunion results, including a complete release of the maxilla, and removal of any fibrous growth. The thought of it turns my stomach. Of course, that's a LONG ways down the road, and nobody seems to think that's going to happen. I hope they're right!

Life without elastics...well, let's just say that my bite doesn't fit together at all. Even though they restricted my ROM, they were doing a splendid job, and I had made some progress. Oh, well, keeps me from clenching, doesn't it, not having my bite work? I talk to myself every night before going to bed, and remind myself not to clench my teeth, that it's not good for my healing, that I musn't do it. I feel like a real psycho case!

#74 Post by **SandraJones** » Sat Aug 25, 2007 6:55 pm

OK, so at least you know what would happen in the worst possible case. And then hopefully the probability is extremely low that you would get to that point. I'm not a believer but I'll pray for you in that non-believer sort of way that your maxilla is just taking its time to heal and you do make progress ! I wonder how I would feel in your situation (or Renden's, it pains me to think of how I would feel if I had appearance-changing maxilla surgery and didn't like the result). I'm sure I would be afraid too. But as an outside observer I'm optimistic for you, fortunately it's still early and you have a chance of having your situation improve, hopefully a good chance. We're definitely all rooting for you !! Go Phil's maxilla, go !

I don't even know what the purpose of the elastics is. I know I wore them for several weeks after the wires were removed, but I don't remember why. Is it to train the mandible to sit in a particular position ? Or is it to minimize movement ??

#75 Post by **phil** » Sat Aug 25, 2007 7:12 pm

SandraJones,

In my case, the elastics basically retrain the muscles so that the mandible goes where it's supposed to. Think of this: my mandible was shortened 7mm, and rotated 3mm to the left--the BONE, that is. The muscles still want to go to their old home. So, the elastics put the mandible where it needs to go, until the muscles get used to functioning in that way. I had a configuration that basically sort of gently pulled the mandible back, and worked a little stronger on the left side than the right, to address the rotation. Without the elastics, my midlines are off again, and my mandible is about one half to one mm too far forward. With the elastics, things really were going where they were supposed to, even more than I thought they ever would. Supposedly when my maxilla is more rigid, my OD will put the elastics back in, but I think that will be quite a while!