Mixed on MMA surgery, advice needed

I've been researching MMA surgery for some time now. It started with some orofacial pain about a year ago.

I first visited Dr Scrivani at the MGH pain clinic for advice. He had a very strong anti-surgery stance. I put it off for a while, visited a local oral surgeon, and then did physical therapy. That helped some. My bite isn't too bad - anterior open bite 3-4mm and class 3 maloclussion 2mm. One ortho said it could be fixed with braces but two others suggested surgery. I've worn down my rear teeth and I'm told I'll need 6-8 crowns since the enamel is gone. I've also got pelvic pain, which a therapist said is connect to jaw pain. I have a lot of acid damage but symptomatically controlled by behavioral changes (not eating after 8pm, maybe subclinical still). Nocturnal clenching/grinding comes and goes, causing tooth sensitivity, sore gums, and jaw muscle pain at times. I've had my joints imaged and they're in great shape. I just had a sleep study done at Stanford and with CPAP at their recommended pressure of 13cm, I still have an AHI of 6.5, all hypopneas (untreated it's 50). I'm only 34 right now. Plan from surgeons is a 12mm advancement of both jaws w/CC rotation to close my open bite. My minimum airway size is 209mm^2 right now so my surgeon guesses that I just have a large tongue.

I come from a family of doctors and dentists and they aren't too thrilled about the risks, complications, and recovery that comes with a surgery like this. Nerve damage is common (~10%-50%), osteomyelitis and osteonecrosis less so (~1%). Success rate for curing sleep apnea is 60-70%, maybe higher in my case.

What are your thoughts? Would you do it? Would you hold out or just crown/braces for now?

When I researched options prior to going on cpap, I decided I would never do the MMA procedure... it sounds ghastly, and I knew it would change the shape of my face. I finally realized, with all of the options I researched, that cpap, the gold standard of treatment for apnea, is noninvasive, and the best option, especially since there is still a chance after the surgery that cpap treatment will still be needed.

In your situation, I would hold out for crowns and braces. Much, much safer and easier than MMA.

It sounds like you're considering MMA for jaw problems, not for apnea treatment. Is that so?

Many of us object to surgery for apnea treatment. If the MMA makes sense for your jaw problems, that's a different set of tradeoffs of risk/reward/cost/benefits.

It sounds like a major medical procedure, so don't do it lightly. Watch out for chop happy surgeons with delusions of grandeur and visions of dollars dancing in their heads.

Yes I'm considering MMA for jaw problems. Fixing the sleep apnea would be icing on the cake. However, the jaw surgeries would be quite different. Absent the sleep apnea, it would be a single jaw with only a small movement. Little facial profile change and lower risk to nerves. For sleep apnea, it's a much bigger movement. Still, it's hard to get the MGH doctor's advice out of my head. That I should endeavor to tolerate the chronic pain rather than go through surgery. It's continuous but at low intensity. I'm not so concerned about my joints anymore but I am concerned about what the progression would look like absent intervention now. Don't forget that pain and bruxism impact sleep too. It's hard to measure the risk of doing nothing but it's likely better than the worst MMA surgery outcomes (there's one really bad case on realself right now, poor girl).

Then I got the sleep study results. They told me I only bruxed a bit falling asleep and waking up but haven't seen the data myself. My mouthguard tells a different story. I guess one of my remaining concerns is the outstanding hypopneas that CPAP doesn't seem to address. How terrible is it to go on with an effective AHI of 6.5? Will that change in 10-20 years? That's still mild OSA. They're claiming it's obstructive but on the study it didn't look like it was impacted by pressure (they stopped titrating at 13cm). I'm suspicious that they may be CPAP induced central apneas and so no additional pressure will help. In that case, surgery may actually be my only option for treatment

Are you in a position to see Kasey Li at Stanford? He seems to be the best surgeon for this procedure. Interestingly, I forgot how long ago this was but a surgeon posted on the needsleep.net board about picking him to do his MMA surgery. Of course, if he isn't in your insurance plan and is an out of network provider, it could be quite costly.

Best of luck.

49er

balor123 wrote:Yes I'm considering MMA for jaw problems. Fixing the sleep apnea would be icing on the cake. However, the jaw surgeries would be quite different. Absent the sleep apnea, it would be a single jaw with only a small movement. Little facial profile change and lower risk to nerves. For sleep apnea, it's a much bigger movement. Still, it's hard to get the MGH doctor's advice out of my head. That I should endeavor to tolerate the chronic pain rather than go through surgery. It's continuous but at low intensity. I'm not so concerned about my joints anymore but I am concerned about what the progression would look like absent intervention now. Don't forget that pain and bruxism impact sleep too. It's hard to measure the risk of doing nothing but it's likely better than the worst MMA surgery outcomes (there's one really bad case on realself right now, poor girl).

Then I got the sleep study results. They told me I only bruxed a bit falling asleep and waking up but haven't seen the data myself. My mouthguard tells a different story. I guess one of my remaining concerns is the outstanding hypopneas that CPAP doesn't seem to address. How terrible is it to go on with an effective AHI of 6.5? Will that change in 10-20 years? That's still mild OSA. They're claiming it's obstructive but on the study it didn't look like it was impacted by pressure (they stopped titrating at 13cm). I'm suspicious that they may be CPAP induced central apneas and so no additional pressure will help. In that case, surgery may actually be my only option for treatment

Yup I already saw Dr Li (along w/Dr Gunson and a local surgeon). They're all comparably experienced (~1k surgeries) with similar plans so I'm thinking right now that if I do it I'd go with the local surgeon. None of them ventured to advise as to whether it's necessary. Dr Li is out of all networks. I didn't get a price but I've read as high as $50k - $100k. As to the risks, both Dr Li and Dr Gunson seemed to think that they're minimal. Dr Li says on a podcast that it's less painful than tonsil removal.

People don't talk about it much but braces have their own risks too. Gum recession, root resorption, and decalcifications are all possible. In cases needing anchorage (like mine), drilling into the bone presents some additional risks (osteomyelitis, bone resorption, and inflammation). Risks increase with time and its not uncommon for adults to be in braces for 2-4 years but newer techniques and technologies (Acceledent) may be bringing that down. Past that point and a good orthodontist will just say that you're not a good candidate. Stability is also of concern, as soft tissue around teeth act like rubber bands. TADs are still relatively new so there isn't consensus on how stable it is long term, my surgeon's caution. For some braces alone may be sufficient but probably not me with my AHI.

In the late 1980's (1988?) I had jaw surgery to lengthen my lower jaw. I was wired shut for 7 weeks. my lower jaw was split and moved forward about 15 mm IIRC. That's a bunch and was approved though 2 different HMO's (fun insurance change in the middle)This was done to allow my front teeth to touch. Was not too painful but I heal very very quickly. I was back at work part time on a conference call within a week of the surgery with someone to translate what I said. for my extreme example it was worth it.

If you or anyone else have surgery where you are wired shut, please feel free to message me. There are lots of tricks I learned in the 7 weeks. And get a magna-doodle (http://www.walmart.com/ip/26012797?wmls ... 68&veh=sem) so much better than dealing with paper and pencil when trying to communicate.

Oh I have apnea now so it did not prevent it.

So you were retrognathic? I can definitely see it in that case. Arthritis and joint problems are common as well in those cases. My cousin had that surgery done and said about the same. My jaws are actually quite large already, with space for wisdom teeth. It's going to feel weird having the wisdom teeth out and having an extra 12mm added to it. Maybe I'll ask for a second opinion on braces. I don't expect to cure my apnea but perhaps with a few more mm I could get the AHI below 5 w/CPAP.

Never heard the term before but it sounds like it could be right. The surgery I had was just out of the experimental stage at the time. I have a very small mouth but you would not be likely to notice it unless you measured.

The path I took to getting it approved was dentist, orthodontist (who said he could not even fit me for dentures.) Then primary care doctor, then specialist. The Primary care doctors would talk to me in a very skeptical voice then finally say something like “Ok, well lets look at this…” then hold the lips back and say “OH, I see” and do the referral. I still have a grove in the roof of my mouth where the lower teeth used to hit. I could not properly take a Panorex x-ray because I could not bite the peg with both upper and lower teeth at the same time.

The process took over 3 years when you include the tooth work, removal of 8 teeth. Wearing a wire cutter around my neck while wired shut for 7 weeks then all the other braces adjustments. Temporally lost feeling in my chin which made shaving a pain. For me the worst part was going back to the surgeon’s office weekly to get the wires tightened. Very glad when I got unwired but could only open my mouth about a ¼ inch at first.

Someone in the hospital seemed to have gone around with a head cold as all of us got massive nasal congestion at the same time. The majority of the people on the floor were having TMJ surgery and could open up a little. Not me. I had no movement at all. They gave me food the first day that I could not possibly eat but I figured they must know what they were doing so I tried and that was a big mistake.

If you have any claustrophobia at all do not do this if possible. It makes any smothering feeling caused by a CPAP mask nothing at all by comparison!

Today if they catch this before the face is done growing they put some sort of adjustable device in the mouth with screws to force the lower jaw to expand. In my case it was worth the effort because it was so extreme.