Ok, so this is probably too little too late, but I figured I would throw it out there anyway. This reply is from a very prominent world reknown orall maxiollofacial surgeon. He does literally 300 of these surgeries a month and is considered a serious expert in the field! Here is the message I posted:
I have a question for you regarding healing from MMA. A friend of mine recently had an MMA done, he did not need a huge amount of advancement on top so he had a pretty straight forward Lefort 1 and was only advanced 5mm forward.
He is 8 weeks post op and noticed that his maxilla was feeling quite loose. When he went to see his surgeon he told him that he has a maxillary "fibrous union" or "delayed union," We cannot find any info on this condition.
Can you tell me what could cause this or how this would happen? Is this a common thing? Also, what is the treatment for this? Will he have to have more surgery to fix it?
Thank you so much for your reply!
This was the reply I got:
Fibrous union after an osteotomy is very uncommon. The potential causes are that there is insufficient amount of bony contacts or excessive amount of movement of the jaw causing mobility at the osteotomy site.
I would first recommend no chewing for a few weeks to minimize the amount of stress placed on the jaw to see if it “firmsâ€
Thank you so much! It sounds as if we are doing everything that we possibly can at this point.
My surgeon told me I could "soft chew" again, but I am refusing. I don't care what he says! My notion is that I will not chew until January, and if things have not resolved themselves, I will pursue a surgical resolution with another surgeon. I figure taking the conservative route will not hurt me, and it might help.
OMG Phil! My compuer was down for a couple of weeks and I have been slowly catching up on old news. I just wanted to say that I am so sorry you have to go through all this. As if jaw surgery wern't enough ....lets throw in some complications. As usual, you seem to be handeling thie situation with wit, and serenity (or you are a really good faker). I wish you all the best. After all this....the pizza will be my treat!
Thanks for the well wishes. I am nearly going out of my mind with this right now. We're all hoping that it will resolve itself by the end of October at the latest. I have an appointment in two weeks for a second opinion.
Best of luck to you, Phil. It sounds like you are doing all of the right things, and you really do just need some good luck now !
Do you feel you've read every possible thing about maxillofacial surgery now ?? Or are you still discovering new resources ? That Peterson book was so amazing, I ended up reading every chapter and rereading a few of them.
Nov 1960: born
1973 ?: palate expander
1973-1977: braces
Aug 1981: Le Fort I, posterior impaction to correct anterior open bite and class II malocclusion
Aug 2007: braces again to correct various alignment issues and class II malocclusion
I'm still trying to find new things. Supposedly there's a new article in the September issue of the Journal of Oral and Maxillofacial Surgery--it's on rare complications from LeForte I (I doubt that nonunion is considered "rare"). I don't know if I'd be able to get a copy of it or not, but I suppose I could try. I did get an article by Van Sickels that is basically the longer, more detailed version of the chapter in Peterson's Principles. I don't think I gained a lot of new information from it, but it was good to read, anyway.
Right now, I'm just wishing I could do a forward time warp, and be at the afternoon of September 24th, when I get my second opinion. Playing the waiting game...sigh.
I'm sorry to hear that you're still waiting to hear of some improvement in your maxilla. I'm glad you'll be seeing a specialist soon, though, and may find more answers then. Can you feel your jaw getting more stable at all as time goes by?
I wish you well and good news shortly! Your jaw is probably healing as we speak (or type).
I wish that I could say I felt improvement. Both I and my surgeon agreed at my visit nine days ago that there was no change.
I had a phone conversation with my OD this morning (Senior), and he sounded hopeful. He told me that he thought the chance of me needing another surgery was remote. He also assured me that once my maxilla is healed, the elastics will indeed pull my mandible back into place, and my bite will improve greatly. This is a good thing, becuase right now it's a mess! Without elastics, my incisors are basically end-on-end and I have a bilateral posterior open bite. It's very uncomfortable!
A few days ago I noticed my lower incisors shifting about a bit, so I went in today for a quick check-up with the orthodontist. Evidently my WONKY bite (caused by my mandibular shift caused by my lack of elastic use caused by my delayed union--HUH!) has caused them to start to flare OUT a bit. Not what we want! So, the OD chained 'em and ZOOOOOOOOOP, no more flared incisors. Amazing!
I'll save you the photo. It really wasn't a Kodak moment.
I just returned from my "second opinion" consultation.
First of all, Dr. X (I'll call him) is concerned about my bite. He doesn't believe that my current position is acceptable postoperatively, and that with elastics my mandible will go where it is supposed to go. He attributes the problems to post-operative torque on the Ramus which resulted from the attempted correction of asymmetry. He said that mandibular asymmetrical setbacks are notoriously problematic, and that because of the force exerted on the mandibular from the ramus, the bone was somewhat pulled back to the right side, where it was pre-operatively. He also said that if my mandible is successfully healed, and the orthodontist agreed, he would NOT recommend reoperating on it to correct this small problem. He agreed with me that it was probably a 1-2 mm shift at the most, and in the bigger picture, that is a small problem. The nearest he can tell from examining me, and looking at my X-rays, is that the condyles ARE in the correct position.
The big problem is my current bite! He says that in the current position, there is no way my maxilla is going to heal, because of the force put on my incisors when I occlude. It just encourages the mobility. So, here's his recommendation:
PRESENTING, PLAN "A!"
1) Put me BACK in an elastic configuration which gets me in a decent occlusion (he doesn't believe that this is going to happen, but thinks it's worth a try). Hopefully we could do this in two weeks max. If it doesn't happen, immediately skip step 2 and go DIRECTLY to PLAN "B. (see below)"
2) Have me wear IMF for a MONTH! When I told him that I'm an elementary music teacher, he said that given the kind of patient I am, he knew that I would comply, and we could go with a plan of wearing it as many hours as possible. So, basically I would put it in at the end of the day when I was done teaching, and take it out in the morning before I teach, with intermittent breaks for eating and hygiene. He thinks that with a good occlusion and IMF, it should encourage healing. He also says that being in the IMF will discourage me from clenching. That's a good thing!
3) If my bite is stable after a month, remove the IMF, and wait to heal. He has seen patients take up to a year to heal. He also said that would be a VERY long wait, and a more reasonable long wait would be six months.
4) If healing doesn't result within a year at the most, schedule surgery to add more rigid fixation, and possibly bone grafts. Not healing after a second surgery would be EXTREMELY RARE!
NOW, PRESENTING PLAN "B."
1) If we are not able to achieve a decent, stable occlusion, schedule surgery. The maxilla would be completely mobilized, the surgeon should use bone grafts, and additional rigid fixation (four plates, not just two). Postoperatively, there would be NO elastics, so as to not put any stress on the maxilla.
I have an appointment with my surgeon tomorrow, and I put in a phone call to my orthodontist today. I'm anxious to get the ball rolling on this new plan of attack. I asked "Dr. X" if it would be to my detriment to delay surgery, and he said no, except that it's that much more time that I'm not getting any better, and we definitely want me to get better.
I was thoroughly impressed with him, as well as his intern. I spent nearly an hour talking to them, between the two of them, and feel now that we have a new plan of attack to get me on the road to recovery.
I'm glad you got some more expert advice! I hope Plan A works for you. I know you will be so glad when your jaw is finally healed. My jaw still has some asymmetry, too (in the opposite direction), but not like it was pre-surgery.
Symmetry, midlines...it's all rubbish compared to the most important issue--BONE CONSOLIDATION! And, I will do whatever I need to do in order to make that happen.
The total (or near-total) IMF idea seems very sound. That would be very cool if they could rig up something that you could remove when necessary.
Nov 1960: born
1973 ?: palate expander
1973-1977: braces
Aug 1981: Le Fort I, posterior impaction to correct anterior open bite and class II malocclusion
Aug 2007: braces again to correct various alignment issues and class II malocclusion
Well, today was an eventful day for me, dentally (actually maxillofacially) speaking. I saw both of my orthodontists AND my surgeon after I got off work this afternoon, all at once in the same room!
It appears that my surgeon disagrees with "Dr. X's" approach. He feels that the use of elastics could further jeopardize my healing too much. The risk is too great.
So, tomorrow morning, bright and early, I will be at the orthodontist's office to have impressions and a facebow done for an occlusal splint. It will be made of clear plastic, and fit over my upper teeth. Its purpose will be to more evenly distribute the occlusal force, and to make my bite less "traumatic (that's the technical term!)." I think that term actually suits the situation rather well. Hopefully, with more of the force on my molars, and virtually none on my incisors, the bone should begin to consolidate. I think it seems like a reasonable plan, and will be much easier to live with than elastics and fixation for a month.
I should have the splint in by early next week.
I am still glad that I saw "Dr. X" yesterday, even though my surgeon and orthodontists don't seem to want to follow his recommendation. I guess the best thing that came out of all of this is that they all finally put their heads together (after they smoothed out their ruffled feathers!), and came up with a plan to help me heal.
Keep praying(if you're a praying person). We're not out of the woods yet.
It was such a room full of ego this afternoon, I was surprised that there was room for me! In the end, I think that they came up with a strategy that actually has a chance of working, and won't make me much more miserable than I already am--and that's pretty miserable!
I'm not looking forward to an impression of my maxilla tomorrow morning, but sometimes ya gotta do what ya gotta do. Sigh. I can't imagine that's going to feel good when they pull it off! The assistant better be EXTREMELY careful!
As I told all three of them in that room this afternoon (and as I have stated more than once on this message board), from the beginning, the aesthetic component of my treatment has never been at the top of my list. A STABLE, FUNCTIONAL bite has. If we can arrive at that, I will be happy. In the end, my orthodontics may be ever so slightly comprimised to arrive at the desired result, but I don't really care. Symmetry, midlines, incisor angle, these are all details! All I care about are two things:
and I have a bilateral posterior open bite. It's very uncomfortable!
