Confused on where to go from here..how did you get started?

[2ndtimesthecharm]

Hello!

I had a consultation with an orthodontist last Friday and I guess I'm feeling a little lost. I was under the impression that you needed to start with an orthodontist if jaw surgery was the goal, but I guess I was was mistaken? The doctor told me that I have a narrow maxilla and a retrognathic mandible, but because there are no real issues with my bite there's nothing he could do for me at this time. He did refer me to a surgeon, however on the form he didn't list any treatment recommendations under the "Oral and Facial Reconstructive Surgery" category, but instead checked the "Other" box under the "Cosmetic Procedures" box citing "Sleep Apnea, Retognathic Mandible and Narrow Maxilla".

I got the impression the consultation was a bit of a waste of time for him, so I didn't ask as many questions as I should have.

Did I do this in the wrong order? Was I supposed to start with an oral surgeon and then find an orthodontist after that? I've since looked at more surgeons and it appears you need a referral for all of them. Are you able to book consultations on your own if you'd like to speak with more than one surgeon, or do you need a referral for each one? Are procedures for widening your airways to correct sleep apnea considered cosmetic, or is that all left up to insurance?

Sorry for the 500 questions, but any help anyone would have would be appreciated. Thank you for your time!

[bighoss]

Generally jaw surgery patients are referred to surgeons by their orthodontists as orthodontics is virtually always necessary prior to the surgery. In other words, you followed the standard path. I highly recommend seeking additional opinions from other orthodontists. As for the widening of the maxilla, the insurance company would ultimately determine whether or not this is a cosmetic procedure. The surgeon's office will likely have an insurance coordinator that will try and convince insurance companies to cover the procedure as corrective in nature (in your case sleep apnea) with study models, x-rays, etc. If your bite measurements are within a "normal" deviation and there is no need to move the jaws laterally it might be difficult to get the procedure covered by insurance.

Personally, I was immediately referred to a surgeon following a consultation with my orthodontist and my surgeon essentially gave orders to the orthodontist in regards to arch correction and what teeth needed to be extracted prior to surgery. Surgery was within the Kaiser Permanente network and fully covered but I had significant movements of my jaws for eating, speech, breathing, etc.

[Nozzelnut]

If you get into braces and ortho treatment expecting or wanting jaw surgery; but not for a health reason, it would probably be a cosmetic. Most/some ortho treatments are cosmetic; of course some aren't. If you have TMJD or sleep apnea that would be a medical reason. Have you ever had a sleep study or do you have sleep apnea? Jaw surgery can me a treatment for that, but without a sleep study, or a consult with an ENT Dr there's no way to know if your small jaws are the reason for the sleep apnea. It could be lots of things; enlarged tonsils, enlarged turbinates... Medical treatments or surgery can be covered under insurance; cosmetic would more than likely be out of pocket.

Most folks here spoke with an orthodontist first and were then referred to a surgeon for further treatment. Maybe the orthodontist can widen jaws and move teeth enough without surgery. A lot of different factors come in to play; your age, dental health, length of time you'd want to be in braces... There might be a way to achieve your desired results without going under the knife that does have a whole list of potential side effects or lifetime problems. Get a couple more orthodontic consults; if most say they can't fully fix things without surgery, there's a pretty good chance you'd be a surgery candidate.

It's not really a reconstructive procedure; more of a didn't grow as it should have and fixing it with surgery now. Reconstructive would be more for facial trauma and that sort of thing.

[snapdresser]

Unfortunately there is no simple answer, as it depends on the specifics of your insurance. What insurance do you have? I'll kind of lay out here the order I went through, which it sounds like could be a good path forward for you depending on if your insurance allows the surgery for sleep apnea or not. Not all insurances do. Your path is probably different than what a lot of people on this forum went through since you don't have a Class II or III malocclusion.

Does your insurance require a referral to see a specialist? If it does, you should tell your primary care physician about your sleep apnea symptoms and get a referral to a sleep medicine doc to get a sleep study. If they do indeed confirm you have sleep apnea, a sleep medicine doc may suspect it's at least complicated by (if not caused solely by) your facial bone structure. I concur with what Nozzelnut said about other possible causes. At some point your surgeon (or someone else along the path) will probably send you to see an ENT to see if the sleep apnea is truly due to your bone structure, or if it's something else, or a combination of things. There's a good chance the sleep medicine doc will prescribe you a CPAP to treat the sleep apnea. Some insurances insist that you first try the CPAP treatment before they'll cover orthognathic surgery as a treatment for sleep apnea. If the sleep medicine doc sends you to an ENT or straight to a surgeon without CPAP treatment, then that's cool, but mine didn't. I did 6 months with the CPAP and then discussed the surgical treatment with my sleep medicine doc and they suggested I see a maxillofacial surgeon. If your insurance allows you to see specialists without a referral, you can go to the surgeon yourself without any recommendation from anybody, then they'll tell you what stops you need to make (a sleep med doc, an ENT, etc.). NOTE: Not all surgeons are familiar with orthognathic surgery to treat sleep apnea. Most of their cases are usually to fix bite issues. You may have to visit a couple to get a treatment plan you find acceptable. I visited 2 surgeons without ever having a paper referral to see one. One was out-of-network and I had to shell out $500 for the referral. It was a great consultation though, so it was probably worth more than that

The above was all related to getting a LeFort osteotomy, a BSSO, and possible a sliding genioplasty. Addressing your narrow maxilla is a tricky thing. I'm not surprised that they wouldn't fix it considering your bite is good. Unfortunately, a narrow maxilla can also make your nasal passages more narrow (according to some ENTs I spoke with). I have that issue too. A lot of people on this forum have had SARPE to treat a narrow maxilla, but IIRC it was always for bite issues, not as treatment for sleep apnea. You should read up on it and see if it's right for you. Personally, I decided that it wasn't for me. I'm not sure if SARPE is covered by insurance as a sleep apnea treatment. I don't believe it is by my insurance, but I could be wrong. One more little note: Some people have complained that SARPE made them look worse than they did with the narrow maxilla. I'd just recommend you read up on it and make as informed a decision as possible.

[kcjawjourney]

Everyone's experience is so different, but I can share with you mine.

I'm 12 weeks post-op. I had a BSSO and 3-piece Lefort in January 2017. As with most jaw surgery patients, my journey started LONG before that

In my case, I had braces when I was younger for several years. Unfortunately, my jaw (one side) continued to grow after my original orthodontic treatment. Because one side of my jaw was longer than the other, I had an posterior open-bite on the right side, my upper jaw was too narrow, and I had a wicked cross-bite (my midline was 6mm off center...yikes!). Dentists told me for many years the only way to correct it was surgery, but I ignored it.

Finally, in May 2016, I saw an oral surgeon to get my wisdom teeth pulled. He told me my bite was causing all sorts of issues (my headaches, jaw pain, uneven tooth wear, damaging the joint) and that I should seriously consider surgery. Long story short, I went to see two other oral surgeons to confirm the diagnosis. I felt the most comfortable with the third surgeon, and HE referred me to an orthodontist that he works with often for surgical cases. It's IMPERATIVE your oral surgeon and orthodontist work closely together and communicate often. I've read horror stories of patients who have extended treatment times for the sole reason the ortho and surgeon weren't on the same page.

My oral surgeon submitted a pre-authorization to my insurance company (BCBS), which was approved solely on my measurements alone. However, I was extremely lucky. Know your policy before you get started. Orthognathic surgery is often an excluded service, OR they require measurements AND proof its medically necessary. I got my braces put on in August 2016 and was ready for surgery in November 2016. I spent December 2016 in the surgical planning phase, and had my actual surgery in January 2017. I'm now 12-weeks post-op and I only have about 6-8 more weeks in braces. Total out-of-pocket for braces and surgery cost me around $9,200 ($3,100 for surgery, $6,100 for braces).

As a quick side note: I do not regret having this surgery, as I have a functional bite for the first time in my life. But as others can probably attest, this surgery is intense. It's a long process between pre-op, recovery, and post-op orthodontics. If my surgery was not medically necessary, I would not have done it. I urge everyone to explore all of their options before committing to this process.

[2ndtimesthecharm]

Thank you all so much for the thorough responses!

I'm definitely going to be visiting a sleep specialist with the hopes of having a sleep study next. My insurance is through Humana and as far as I can tell it is pretty bare bones. It doesn't appear that they will cover the cost of the sleep study, which does make me a little nervous (this does not bode well for future procedures, too). Did anyone have any issues with falling asleep during their study? It seems like a lot of pressure to not eff it up, especially because they are so expensive. I've read some stories about people having to go back for a second round after not sleeping enough the first time

That is good to know about sleeping with a CPAP machine for a while before consulting with a surgeon, too. It's really stupid but I am dreading needing one if that's what the results inevitably call for, but I know the benefits far outweigh any reservations I have.

[snapdresser]

Yessssss... I had a super hard time sleeping at my first sleep study. I thought I'd be fine so I turned down the Lunesta they offered. Big mistake. I slept for about 3 hours, woke up, and couldn't get back to sleep. I laid there awake trying to fall back asleep for 6 hours before they said I was done... They said those 3 hours were enough to tell I had it tho, so they gave me a CPAP and had me do it again with the CPAP. I accepted the Lunesta that time Then after a while I got another one done (cuz those first 2 were a couple years old and my surgeon wanted a new one before she operated), no Lunesta allowed at the new location (much to my chagrin) but I was able to fall asleep and sleep through the night. Probably cuz I made a point of getting very little sleep the night before. I wouldn't worry about it too much. Like you said, laying awake for 6 hours in a small price to pay in the long run!

[Nozzelnut]

The first sleep study was horrible for me! At the time I needed very specific room conditions to fall asleep; cool, the right pillows, noise, a fan... I think I only got about 30 minutes of fractured sleep. But the EEG showed that I was "sleeping" a lot longer. Didn't know I could fool that test. All the cords wires and gizmos they use can be very noticeable when trying to sleep. They wanted me to do the followup sleep study to get the pressures right but with the autoset machines they can pretty much do it on their own; so I declined.

For the sleep study after my surgery, I got very little sleep the night before like Snapdresser, took some advil pm and ambien. I still have very mild OSA; FWIW. I take advil pm just about every night to help me fall asleep.

There's a chance your first sleep study will be the take home kind. There's a nasal canula, a chest strap, finger probe for O2 levels. You put all that stuff on then try to sleep for at least 6 hours or something.

Call you insurance company if you have any questions about what you'd be responsible for. Good luck.