Braces/SARPE, etc. UPDATED (again) PG 3

[KJNELLAMORE]

I could really use some fast opinions!

To make a long story short, I have gone on two consult. visits. One was with an Ortho who is well-known and respected, who felt that he could correct my very high, narrow, collapsed palatte with just an RPE/braces (since I am fairly young).. he seemed very confident. Then, we moved. I went to another Ortho. who feels that SARPE + RPE + another surgery (expansion and advancement) + braces is the way to go to try to fully correct both my bite AND my palattal issues. He seemed very confident. Tomorrow, I have a consult. with the oral surgeon.

Now, here is the kicker. My husband will be beginning a new job next week. So, our insurance with THAT job will begin on 9/1. It will be Humana for dental (I am not sure if the dental would cover any of the surgery or ortho at all) and United for medical (from what I have read, they may only cover accidental dental stuff.. but, not totally sure.. however, how bizarre!). But, right now- we have United Concordia for dental (no ortho covg, and I am maxed out) and BCBS for medical (they covered my wisdoms.. so I am assuming they MAY cover this). Our current insurance will run until the 9/31.. so, we will be dually insured for one month.

Now, my question is.. if you've had Sarpe, did you have braces on FIRST, or no? I *thought* that I heard the ortho say I'd have braces for 3 months, THEN Sarpe. However.. I am wondering if there is any way that I can have it done in the next 1.5 months, while I am still covered on BCBS, if United does not intend to cover it. Does that make sense? I am sure that I will find out tomorrow (however, this oral surg. will not accept the new insurance, and there is only one other here that does.. so bizarre!). I wonder if my ortho would make an exception for my case? I am just wondering NOW, before I find out tomorrow!

[phil]

Hey, KJNELLAMORE.

SARPE was the FIRST thing I had. I'm sure that there are differing philosophies, so you will have to ask your OD and OS. It may be an option.

Good luck!

[smile2006]

I'm not sure if insurance coverage for SARPE is the same as for jaw surgery but my jaw surgery was covered by by my major medical insurance not dental because it was viewed as a medical necessity (insurance companies look at how far the bit is off in mm to determine medical necessity or the number of teeth in a functional position). You might want to ask your insurance company about this or the oral surgeon's office.

[Brandyleigh35]

Kim,
I would think that you could get it done soon. A lot of people have the SARPE done before the top braces are even put on. I had my braces on for exactly 1 month prior to having it done, and only wore the RPE for 2 days before my surgery. They can't move your top teeth around anyway, for 4-6 months after the surgery as the bones have to be completely healed. I would ask the OS about it. They could put the lowers on, then do the SARPE, then put your uppers on 3-4 months down the road. That is what many of us SARPE people have had done.

Brandy

[joplin]

Now, my question is.. if you've had Sarpe, did you have braces on FIRST, or no? I *thought* that I heard the ortho say I'd have braces for 3 months, THEN Sarpe.

I too had SARPE done first. Braces went on over 8 months later, but there were other dental surgery issues I had to deal with first, which held the actual process back. Some people get braced first, some soon after the SARPE. Depends on the overal plan your ortho has for you. In orthodontics there seems to be no "average way" to do things, but everyone's case is more or less unique.

I hope you're getting all your questions answered and things will start rolling smoothly soon!

[KJNELLAMORE]

Here is an update, guys ::sigh::

So, I went to the OS yesterday. Before divulging the actual visit information, do you think it's odd that an older, clearly established OS (who is 'one of the best' here), would have very yellow, crooked teeth with a very large space in between his front tooth? Maybe I pay too close attention, but that just doesn't add up.. and doesn't make me too confident!

Okay, here goes.

Honestly, he didn't even really TALK to me. First off, apparently this office is a 'teaching' office, fulllll of residents (which I guess explains why my consultation could ONLY be between 2:15 and 3:30 ). So, that was bizarre enough.. all of these residents just standing in the halls, waiting to get 'called' in to poke and prod at patients, etc. Just weird.

I was lucky enough to have a brand new girl take me to get my X-Rays. Well, she messed up and had me do them with my mouth open. A resident came in to prod at me and kept looking back at my X-Rays, saying 'uhm, this isn't what she has..'. Meaning that the X-Rays showed an open bite. Uhm, durrr, my mouth was open, lol. So, I had to re-do them all.

Now, the OS.. really didn't talk to me. I told him that my first ortho thought an RPE would be enough.. he said he didn't think it could expand as much as I need. I asked how much I needed to be expanded.. he said he didn't know. (???) Basically, he dodged every question by saying that my Ortho would know and that they'd talk. O-kay, then.

I told him about my insurance issue. Our current medical (BCBS) is going to be ending on 9/31. Our new medical, United, will begin on 9/1. However, apparently, United SUCKS and there is only one OS provider in this whole city.. and apparently they won't cover anything without a fight.

So, the OS said that I definitely can NOT have the surgeries BEFORE braces.. he said that my Ortho has to get a nice, round arch first (??).. or something like that. Then, he said that he could probably talk my ortho into getting me to a point where I can have SARPE & the expansion/advancement surgeries done in ONE.. , but that it'd be a huge surgery for someone who is 22. The complicating factor is that I can not pay for the ortho treatment AND pay for these surgeries out of pocket.. it's one or the other or neither (if our new insurance wouldn't cover it). He couldn't talk to my ortho this week because apparently HE just had OS and his son broke his arm, so he said he would Monday. I think that we are going to decline my husband's new insurance until open enrollment, and keep our current insurance.. which will go from $250 to $700 (eeeeks), but.. surely that has to be better than paying for the whole surgery out of pocket, right? I told him that we could keep it IF I had a definite date.. i.e. if it's going to be November, we'd only have to pay for a few months out of pocket, kwim? Please someone tell me that my logic sounds right, because I was up all night sick about this. We just can't swing paying for the surgeries (which are, I am assuming, very $$$) AND making ortho payments (which, if financed, would be about $300/mth) at the SAME time.. but, we can manage to swing the extra insurance hike for a few months if it means it will be covered.

Honestly, I just want it done. I think I'd rather have both surgeries in one.. but, I just want it FINISHED. However, I was up crying all night. I just don't understand why there is always something wrong with me (it's hard to have a husband who never even sneezes)... I just want straight, pretty teeth. I don't want a huge gap in the middle of my teeth for months on end, or big appliances in my mouth, or huge surgeries, or crazy debt.. but, I also don't want this all done at 30.. and I'd rather HAVE teeth at 50.. as is, I am in SO much constant pain.. there is just SO much pressure in my mouth, it's overwhelming (does anyone else have this)?

Ugh, so.. that sucked.. my OS doesn't have the best.. bedside manner.. which I knew going in.. but, I just want to wake up and have it be over.

[nvcarissa]

A quick question for you: have you even gotten approval from BCBS for your surgery? And, are you talking about United Healthcare? If so, they may approve your surgery if it can be shown to be medically necessary. I originally had UHC and they approved my BSSO. Then I switched jobs and hence, insurance which then became BCBS. I actually held on to my UHC policy and paid the COBRA amount until I got confirmation that BCBS would also cover my surgery. The thing is, until your OS submits a pre-authorization for your surgery, you have no way of knowing, and it appears that your OS doesn't seem to be in any big hurry to do so. I can just imagine your frustration.

[KJNELLAMORE]

My OS didn't preauthorize yet, because I think that he said that once he did, I couldn't switch to another insurnace carrier.. that it'd be pre-existing. Does that sound right? I am just not sure what to do.. the problem is not so much if United Healthcare WILL cover it.. it's that the only OS in this entire city (Baton Rouge) that takes it is about 40 minutes away, and my Ortho didn't recommend him. Blah.

[KJNELLAMORE]

Oh, I meant to add that I can't imagine them NOT thinking it's medically necessary, lol.. my palatte is tinier than the smallest ones that I have seen here that have been covered, by far! I need to expand 12+ mm .

[KJNELLAMORE]

A quick question for you: have you even gotten approval from BCBS for your surgery? And, are you talking about United Healthcare? If so, they may approve your surgery if it can be shown to be medically necessary. I originally had UHC and they approved my BSSO. Then I switched jobs and hence, insurance which then became BCBS. I actually held on to my UHC policy and paid the COBRA amount until I got confirmation that BCBS would also cover my surgery. The thing is, until your OS submits a pre-authorization for your surgery, you have no way of knowing, and it appears that your OS doesn't seem to be in any big hurry to do so. I can just imagine your frustration.

I have looked over the UH information.. and it seems that they will only cover 'accidental dental' without a fight. There coverage doesn't seem very good at all. Fortunately, my DH's employer is thinking of switching over to BCBS.

I just don't know what to do! We can't afford to pay for both insurance policies at the same time, but we will not have to pay for our BCBS until October (I think).. so should I keep BOTH and try to Pre-Autho both? can you even do that?

[ohmyjaw]

hi Kim,

I wish I could help with your insurance woes, but I am in Canada and things are way different here.

I just wanted to say, I am sure you will find a way to make this happen. Just keep at it.

In the meantime, focus on the positive things in your life - like your gorgeous daughter. You are so lucky!

[Brandyleigh35]

Hey Kim,
I can only imagine your frustration! Not to be annoying, but is there another ortho, or os you could get a consult with? I'm certainly not a doctor, but with your palate as small as it is, I quite frankly think that the ortho doesn't stand a prayers chance in hell of getting your palate expanded and your arch in line without a SARPE to allow for the expansion to happen. If they do use an RPE without surgery it is going to take freakin ever to get you expanded. I was expanded 9mm, and the SARPE had to happen before the braces or the jaw surgery could take place. Most of the people I have seen have done the SARPE right away, or within a couple of months of getting braces. The braces at that point really aren't doing anything but sitting there with the very first archwire (which just begins to loosen your teeth but not really move them.) YOu can't move teeth that are in bone that is not fused, or you risk serious damage to the root and possible loss of the teeth.

It has been my understanding that doing surgery (upper and lower) where they expand the jaw at the same time, is done for people who don't have to gain too much space so the teeth can be mostly lined up and then finished after the actual surgery. This is not possible for someone who needs 12mm of room! If that was the case I guarantee that all of us who had SARPE would just wait and avoid having separate surgeries. IT just doesn't make any sense! My ortho is shooting for May for my BSSO, but can't even guarantee that at this point as it depends on how close he can get my teeth lined up by then....and mine are pretty darn straight for the most part.

Are they thinking because of your age that you don't need a SARPE but could just expand with an appliance? I'm confused, its like they do not want to help you at all. Given your mouth situation I would think they could certainly make a case for medical neccesity. You said you are in pain......that is enough I would think. I mean it doesn't take a rocket scientist to figure out why when you look at your palate an bite for goodness sakes! I'm wondering if maybe your ortho is feeling a bit intimidated by your case and trying to sabotage your following through with it so he doesn't have to deal with it.

I know it sucks, but I would totally try a different ortho! You could even ask the one you are seeing now for your models and tell him that you want to get a second opinion. You don't have to tell him who you are seeing, just that you would like to get a second, maybe even a third opinion. This is big money, time, and committment on your part. You want to be sure you are going with the best person for the job, like doing a job interview on your ortho. I can tell you that it was over a year in the planning with lots of appointments and hoops I had to jump through before I finally got my braces on and decided to follow through with treatment.

It really sounds like this ortho and OS are working against you. I would totally try and get another consult. Also yes you can send in for pre-approval from both companies. It is just a pre-auth not a guaranntee of payment. That may give you a better idea of where to go with the insurance. I would just ask the ortho point blank if he would write a letter of medical neccesity for your treatment. That is what mine did. My insurance doesn't cover ortho so they denied that portion of it, but agreed to cover the medical surgery portion. I knew they would not pay for the braces so that was no surprise.

Look forward to hearing back from you!

Brandy

[KJNELLAMORE]

Brandy,

I was waiting for you to respond! Your blog is such an inspiration to me!!

You are right about a lot of points (and I totally agree). I think you may have misunderstood one factor, though.

The FIRST Ortho that I had a consultation with thought that he could expand with just an RPE.

But, the SECOND Ortho (the one who sent me to the OS), thought that I definitely needed a combination of SARPE/exp. & advan./RPE/Braces to do it 'right' and really fix my palatte and bite. The second Ortho really seemed like he had my best long-term interests in mind. He said that he could make my teeth pretty, but without all of the above, I'd wear retainers for forever.. so, he was very honest.

He did tell me that this OS had no bedside manner, so I wasn't really surprised. However, I was surprised that he didn't TELL me ANYTHING about exactly what would happen, etc. He just kind of brushed it off and said that my Ortho would talk to me about it after the two of them discussed it (Monday).

I told the OS about my insurance issues and he said that depending on what my 'molds said' (they have not been done yet), they may be able to do both surgeries in one. I really don't know, so maybe you can help enlighten me.. but, what EXACTLY does the second 'expansion and advancement' surgery 'DO'? Is there a reason why they can't be done at once? Is that lower jaw surgery? He gave me the complete impression that it was a second upper jaw surgery, to 'expand more'.. but now you have me confused!

I did tell the OS that I had heard of some people having SARPE before anything else, and he said that he couldn't just do SARPE without my Ortho. creating a 'nice round arch'. Does that not seem right (I am really asking bc. I don't know.. not being a witch!)? He said that my Ortho would do the RPE FIRST (and I am assuming braces at the same time.. maybe not though).

I AM convinced now that SARPE is really the way to go (although, trust me.. I don't want it! lol).. but, I need to act quickly because we can not afford to pay for ALL of this out of pocket. For all that I know, my ortho could totally disagree with the OS. I won't know until Monday.. but, hopefully I can make an appt. to speak with him about my million and one concerns next week.

[Brandyleigh35]

Hey Kim,
Now I'm confused! LOL...ok, so the os recommended SARPE/RPE (these sorta go together) Then braces, then upper and lower advancement and more expansion?

Ok...this is so confusing but perhaps the os was just meaning that your ortho has to round out your arch and align your teeth before the major surgeries can be done. If you are having a SARPE they should be able to get all the space they need without additional expansion later on. They are going to fracture your palate, the RPE is used to expand it to the necessary width so that your bite can be aligned. Your arch will be rounded out with the braces once you have expanded to your required distance, and the bones have healed. It is called Rapid Palate expansion for a reason, it is fast. They do that first before they do any rounding of your arch typically. They may put braces on you first, just to have them on for future adjusting, but they won't really be doing anything with them til after you heal up from the SARPE. They could be moving your lowers into position prior to SARPE though so that is the advantage of getting them on first. Also, your upper teeth can be quite sensitive after the SARPE for awhile. Getting them on prior eliminates the pain of getting them on later after surgery.

I can't remember what your bite looks like but do you need lower and upper surgery? or just one or the other? The OS is right about the braces being first, but they don't necessarily have to go on. Many people get them on later after SARPE. If you are going to get braces first (have them on when you have your SARPE) they would fit you with spacers, once they had done their job and made the space, They would remove the spacers, fit you for bands, and take impressions. They might even put the braces on that day also. They would then send you home and construct the RPE. Once that is done you would come back in and get the RPE fitted. This is usually done anywhere from 1 week to 4 weeks prior to surgery. Then a surgery date would be set, and you would go in for the SARPE. During the surgery they crank the appliance a couple times to make sure they got full release of the bones and that things are expanding properly. Then about 3 days later you go back to your ortho, he teaches you the techinque and begin turning the RPE a couple times a day to expand. You do that til you reach the desired width(as per your ortho's recommendationss). During the process you will develop the characteristic gap, and gain the space you need. Once you get to that point they will tie off your RPE so that it doesn't slip, and you will just stop doing anything for a couple of months.

I asked my ortho if I could get my braces on prior to SARPE. I wanted all my pain at once. I didn't want to have SARPE and then have to go through the pain of getting my braces on 3 or 4 months down the road. I also wanted the ortho to be working on my lower teeth right away so by getting braces first they could do that. Having them on can also be an aide in the closing of the gap a bit faster. Once the bones are healed, the RPE may be replaced with a TPA (a trans palatal arch) to hold the space but be less invasive in your mouth. At around 5 months they can start moving your teeth orthodontically. You will have the archwired on before that but they are just basically to loosen your teeth up (starter wires if you will) until they are ready to be moved. They are very thin wires and very flexible, as the big wires that really begin moving your teeth into place cannot be done til after the bones have healed, or you risk root reabsortion or other possible complications.

Ok...so lets say...braces are on, RPE has been installed, SARPE has been performed, healing has happened and RPE is replaced with TPA, more healing goes on, and gap will most likely start to close on its own, then ortho begins your orthodontic work (i.e braces), He begins to close your gap and adjustments continue for however long it takes to get teeth to their necessary location for proper bite and alignment pre surgery, then surgery happens to physically align the teeth and jaw bones, once sufficient healing has occured post surgery the ortho continues fine tuning your braces/bite/alignment, until the perfect positioning has been reached, finally after all of this braces come off and you have the gorgeous smile you have always wanted, and a bite that fits and works like it is supposed to, plus you look like a fashion model due to all the weight you have lost due to not being able to eat very much for so long! LOL...

(ok...the last part is a bit of a stretch, it's what I'm hoping for though!)

Does this answer your questions? I cannot understand any reason why you would need another expansion once the SARPE is done, that is doing the same thing twice. Like I said in the previous email, usually upper surgical expansion is only done when the amount of expansion necessary is a small distance. When things can pretty much be put where they need to be put prior to the surgery by the ortho (since it is not a huge amount to be moved for those individuals.) For you though....you need roughly 11mm right? That is a lot of space! They cannot estimate that much as far as aligning the teeth go without SARPE. So SARPE would be done in place of the palate expansion done during surgery when they align the upper jaw. If you need upper jaw advancement it would be to align the jaw into its proper position(forward or backward, but not width wise), same with lower jaw advancement. But if your upper jaw is ok position wise, then you would only need (most likely) what I'm having done. SARPE, full orthodontics, then lower jaw advancement (BSSO) no upper would be necessary.

I'm sure I have totally confused you....but hopefully not. Let me know if this answers your questions or if there is anything else I can tell you.

I would talk with my ortho about your insurance dilemma. They may be able to get you on a fast track for some of this stuff, but the truth is that it does take awhile to get the spacers in, then out, then scheduling all the appts, for fittings, etc. Especially since most orthos have a zillion patients and only do appts every few weeks. Mine was very fast, but still took roughly about 1.5 months prior to surgery to get it all done.

Brandy

[JenNicole]

Kim,
After reading over your whole dilemas, and looking at your photos I think that well one Brandy is completely right ( she usually is) but on your insurance and wanting to rush things...it is totally do-able. I am in the military and need pretty much everything you need done. I had my consult in March (thinking I only needed braces) and the whole expansion/surgery thing came up. I told the OD I only had a year or so left in the military...meaning if I needed two surgeries they would have to be completed by June 2007. He sent me in for a consult w/ the military OS, and the next week I was back with the OD getting spacers. This was my timeline. I had spacers put in on 25 May 06, then on the 26th they put my braces on top and bottom. They weren't able to get my brackets on all my back molars (but that is no surprise). I went back to the OD on 1 June. He placed the appliance and placed the remaining bands on the molars. I was scheduled for SARPE on 19 June.

Not to say you should try to rush that fast. Obviosuly make sure you are insured, but to answer your question it can be done that fast.

I am 23 and had very similiar problems with my bite. Unlike you I had braces as a child. Don't think that b/c one Ortho told you he could fix your bite w/ just braces he is actually doing you any good. The reason you would be in a retainer for the rest of your life is b/c he would straighten your teeth w/out alligning the jaw. Honestly, I would either jump on the bull and ride or not do anything at all. It sucks...but if you don't correct these kind of jaw abnormalities as a child you have to go through so much more as an adult. It's tough, but also worth it. Not to mention you will have the support of all the fellow SARPE's on here!

You have a big decision to make, and obviously a lot of hoopes to jump through w/ the insurance bit. I think all of us on here will agree it is worth it..but only if you do it right. (yes, meaning the braces, the big bulky appliance, an awful gap in your front teeth..and then a Hollywood smile to show for your pain).

Good luck!!

JenNicole