This week I spent 5 half days at work after more than 5 months at home (and one night in the hospital). I dreaded this, looked forward to it, worried about it - and then just got up and did it.
What can I say about it? I was totally unsure how I would cope physically. Sitting at a desk can actually be pretty taxing, and I haven't really spoken that much in one day in a while, at least not without being able to tell people that I couldn't anymore. I know, I know...I can always say that I'm too sore to talk, but if you think that then you don't really know me that well. I can't simply say that I can't talk anymore, especially when all my coworkers were asking me how I was, telling me that they missed me and were happy to see me back, bringing me sweets (!) and generally being as wonderfully kind as they all are naturally. It was pretty great to get up with a purpose, and not to be just wallowing in pity and/or worrying about myself was awesome. At one point my jaw was so sore that I just held it reflexively and that was the perfect way to beg off of another conversation. I also ducked out of a sushi lunch that I wanted to attend socially, but just don't want to deal with in public with both braces and a mouth that doesn't chew or manipulate very well.
I was definitely sore after the first day, moreso the second day, and by Friday I was exhausted and in quite a bit of pain in my jaw. Today, being Saturday, I'm tired and grumpy but hopeful that I'll recover over the wknd. Next week is another 5 half days, so I'll judge by mid-week how things are going and make a determination about what to do going forward.
Monday was a pretty big day for me actually, since I had to get to downtown Toronto for 7pm to have an MRI that was ordered by my oral surgeon. I had it done, and I have to say that having an MRI with braces in your face is pretty terrifying. They give you a thorough screening to ensure that you don't have any implanted devices, or random metal pieces in your eye, or tattoos...but braces are ok? My heart was beating pretty quickly when they slid me into the machine with double hearing protection on (ear plugs and muffs), a cage over my face and a little bulb to squeeze just in case I needed to communicate with the outside world. I thought that somehow the machine would turn on and my face would be magnetically sucked to the side of the machine or something. Turns out it was fine....noisy and a little claustrophobic, but I just kept my eyes closed and breathed. They took images of my face and then stuck a foam popsicle in my mouth to get images with my jaw open. It was all over in about 15 minutes and it was totally painless. Braces and all.
Actually, it turns out that the concern with braces (or any metal, including any makeup you're wearing that might have metal in it) is that it can cause what they call "artifacts" on the MRI images and obscure what they're trying to see. Hopefully the technician can get good enough images in spite of that. Now I have to wait until my follow up with the oral surgeon at the end of February to find out what it shows.
The purpose of the MRI is to see what might be happening with the soft tissues in my TMJs, including the discs (it's a joint after all, and one that moves in different planes, so the discs are important), tendons and ligaments. So far I've only had X-rays and CT scans, both of which only show hard and bony structures. This will give a more complete picture of what's going on inside my head.
More to come on a few things: my second week at work, my first wire change on my top braces, hopefully news about my lower braces and what I've learned so far with having braces and jaw limitations...and the deal with clear braces. I hope to share a lot of tips and tricks on having these....many more of which I'll have to share when I have a full mouth of brackets.
Saturday, January 31, 2015
Thursday, January 15, 2015
I can't believe it
I'm getting used to my braces. And, what's more, I don't hate them! Despite how uncomfortable they were at first (and still are at times), they are getting easier to live with and I don't think about them every second of the day. In fact, I was out this morning with my son at an indoor playground (it's too darn cold to go outside, and 3 year olds boys are restless!) and I realized that I had been smiling to the other parents there without even thinking about the braces. What a relief! It's exhausting to be hyper-conscious of your appearance all the time.
It might also be because I'm noticing some positive changes in my teeth already. There is still LOTS of movement left to happen on the top (and on the bottom, but there are no braces there yet!) but I already see that the front teeth are in more of an arch, rather than a straight line across, and one side is looking straighter. It encourages me to be patient for the rest of the movement to happen, because when it does, it will look so good!
I think I had kind of prepared myself in my mind for something really awful to happen. Either somehow the braces weren't going to "work" on my teeth due to the trauma, or take twice as long as normal...something like that. But no! It seems that my luck is turning in 2015 and this is, so far, a painful but positive experience.
It might also be because I'm noticing some positive changes in my teeth already. There is still LOTS of movement left to happen on the top (and on the bottom, but there are no braces there yet!) but I already see that the front teeth are in more of an arch, rather than a straight line across, and one side is looking straighter. It encourages me to be patient for the rest of the movement to happen, because when it does, it will look so good!
I think I had kind of prepared myself in my mind for something really awful to happen. Either somehow the braces weren't going to "work" on my teeth due to the trauma, or take twice as long as normal...something like that. But no! It seems that my luck is turning in 2015 and this is, so far, a painful but positive experience.
Tuesday, January 13, 2015
The official word
In his own time, Dr. P sent a letter to my dentist regarding my initial consultation with him and the results of his review of my diagnostics and recommendations for treatment. It came this past week, but is dated November 26. I found it really interesting and informative, so I thought I'd post it here.
I'm probably the only one who finds it fascinating....so feel free not to read on if you don't want to!!
Here's the letter:
As you know, Tiffany fell while running on August 12, 2014. She sustained severe injuries to her maxilla and mandible with a dentoalveolar fracture (fracture of the teeth & bone in which they reside) in the anterior maxilla. There was a body fracture in the anterior mandible as well as bilateral condylar fractures. Apparently, there was minimal condylar displasia initially so she was treated with arch bars to stabilize the segmental fractures and a soft diet. A month later it became apparent there had been displacement of the condylar segments. She was, therefore, taken to hospital and, under general anaesthesia, closed reduction was carried out. She was kept wired for two weeks and then wore tight elastic fixation for another two weeks followed by light elastic fixation. When the arch bars were removed there was a persistent malocclusion with anterior open bite and deviation of the mandible to the left.
Tiffany has severe pain affecting both temporomandibular joints as well as the temporalis and masseteric regions (the muscles of chewing, that go up to your temples and down under your jaw). This pain limits her range of motion as well as her ability to chew. She has quite a bit of dental pain. She has received a number of root canals and dental restorations and there are more planned.
Clinical examination showed the patient to be normo-cephalic (see that?? I'm normal in the head!) with normal eyes, ears, nose and throat. Cranial nerves II through XII are grossly intact. She had mild facial asymmetry with deviation of the chin to the left. The was a healed scar in the chin region.
Palpation of the muscles of mastication elicited two plus pain. She had three plus pain in both TMJs. Her range of motion was markedly limited at 20 millimetres. I could detect no clicking or crepitus (grinding) with this opening.
Intraorally she had a crowded, Class II malocclusion with deviation to the left and crossbite and anterior open bite. The only teeth in occlusion were the first and second molars. The oral mucosa and periodontal status were grossly normal. I did manipulate the mandible as well as the anterior maxillary teeth. There was no mobility, suggesting bony union of the anterior mandibular and maxillary fractures.
I had a chance to review the cone beam CT scan, which shows malunion of a right condylar fracture with loss of vertical dimension of the ramus condyle unit. On the left side there is a non-union a condylar neck fracture with malposition. I also noted the body fracture of the mandible, which did go through the cuspid region on the left side. External resorption of the 33 is evident.
DIAGNOSIS:
Previous bilateral condylar fracture with right-sided malunion and left-sided non-union. Multiple dental trauma. Secondary TMJ fibrosis and probable disc damage with secondary hypo mobility and anterior open bite.
I reviewed these findings today with Tiffany. I explained my concerns about the biological predictability of condylar stability for her over the long run. I am concerned that these condyles have been severely damaged and there is now fibrosis in both joints. I think the probability of getting predictable adaptive changes with good joint function is poor. Any attempt to correct her malocclusion with surgical movement of the mandible would have a high degree of unpredictability over the long run because of the unpredictable behaviour of the condyles. To this end, I think the most predictable thing we can do for her is to plan on replacing the TMJs with alloplastic, custom temporomandibular joint total joint replacements. I explained to Tiffany that these custom implants could be designed to allow simultaneous repositioning of the mandible into an optimal occlusal relationship.
I have recommended proceeding with completion of the necessary dental repair work as quickly as possible. I have also recommended simultaneous orthodontic treatment to level and align the arches. I stressed that the purpose of orthodontics is not to correct the malocclusion, but rather to align the teeth to prepare for surgical repositioning of the mandible. The mandible will be shifted to close the open bite and also to correct the asymmetry. This will be done at the same time as removal of the damaged TMJs. The new, custom, alloplastic total TMJ implants will be designed to hold the mandible in this new, corrected position. Tiffany understands there will be some finishing orthodontics following this surgical procedure. Definitive prosthodontics can be carried out at this time.
I agree that the 33 should be removed. Please let me know when you would like to have this done and we will arrange to do it for Tiffany.
The details of the TMJ alloplastic total joint reconstructive surgery were reviewed today with Tiffany. In particular, I discussed the placement of facial incisions, surgical technique, postoperative healing and sequelae and potential complications. Risks and benefits were reviewed. Rare, though possible, complications were discussed, including bleeding, transfusion, infection, temporary or permanent numbness or facial weakness and foreign body reaction. Websites were given to Tiffany for her review. Costs were discussed.
I have given Tiffany a referral for an MRI scan of the TMJs. I have also given her a prescription for Vimovo for NSAID therapy and Flexural as a nighttime muscle relaxant. I will see her in a couple of months to see how the preparatory work is coming along. Together, Dr O and I will determine a surgical date for her, which will likely occur in about one year.
Thanks again for the opportunity to assess and treat this very pleasant lady. Your confidence in my surgical practice is deeply appreciated.
Best personal regards,
Dr. P
As you know, Tiffany fell while running on August 12, 2014. She sustained severe injuries to her maxilla and mandible with a dentoalveolar fracture (fracture of the teeth & bone in which they reside) in the anterior maxilla. There was a body fracture in the anterior mandible as well as bilateral condylar fractures. Apparently, there was minimal condylar displasia initially so she was treated with arch bars to stabilize the segmental fractures and a soft diet. A month later it became apparent there had been displacement of the condylar segments. She was, therefore, taken to hospital and, under general anaesthesia, closed reduction was carried out. She was kept wired for two weeks and then wore tight elastic fixation for another two weeks followed by light elastic fixation. When the arch bars were removed there was a persistent malocclusion with anterior open bite and deviation of the mandible to the left.
Tiffany has severe pain affecting both temporomandibular joints as well as the temporalis and masseteric regions (the muscles of chewing, that go up to your temples and down under your jaw). This pain limits her range of motion as well as her ability to chew. She has quite a bit of dental pain. She has received a number of root canals and dental restorations and there are more planned.
Clinical examination showed the patient to be normo-cephalic (see that?? I'm normal in the head!) with normal eyes, ears, nose and throat. Cranial nerves II through XII are grossly intact. She had mild facial asymmetry with deviation of the chin to the left. The was a healed scar in the chin region.
Palpation of the muscles of mastication elicited two plus pain. She had three plus pain in both TMJs. Her range of motion was markedly limited at 20 millimetres. I could detect no clicking or crepitus (grinding) with this opening.
Intraorally she had a crowded, Class II malocclusion with deviation to the left and crossbite and anterior open bite. The only teeth in occlusion were the first and second molars. The oral mucosa and periodontal status were grossly normal. I did manipulate the mandible as well as the anterior maxillary teeth. There was no mobility, suggesting bony union of the anterior mandibular and maxillary fractures.
I had a chance to review the cone beam CT scan, which shows malunion of a right condylar fracture with loss of vertical dimension of the ramus condyle unit. On the left side there is a non-union a condylar neck fracture with malposition. I also noted the body fracture of the mandible, which did go through the cuspid region on the left side. External resorption of the 33 is evident.
DIAGNOSIS:
Previous bilateral condylar fracture with right-sided malunion and left-sided non-union. Multiple dental trauma. Secondary TMJ fibrosis and probable disc damage with secondary hypo mobility and anterior open bite.
I reviewed these findings today with Tiffany. I explained my concerns about the biological predictability of condylar stability for her over the long run. I am concerned that these condyles have been severely damaged and there is now fibrosis in both joints. I think the probability of getting predictable adaptive changes with good joint function is poor. Any attempt to correct her malocclusion with surgical movement of the mandible would have a high degree of unpredictability over the long run because of the unpredictable behaviour of the condyles. To this end, I think the most predictable thing we can do for her is to plan on replacing the TMJs with alloplastic, custom temporomandibular joint total joint replacements. I explained to Tiffany that these custom implants could be designed to allow simultaneous repositioning of the mandible into an optimal occlusal relationship.
I have recommended proceeding with completion of the necessary dental repair work as quickly as possible. I have also recommended simultaneous orthodontic treatment to level and align the arches. I stressed that the purpose of orthodontics is not to correct the malocclusion, but rather to align the teeth to prepare for surgical repositioning of the mandible. The mandible will be shifted to close the open bite and also to correct the asymmetry. This will be done at the same time as removal of the damaged TMJs. The new, custom, alloplastic total TMJ implants will be designed to hold the mandible in this new, corrected position. Tiffany understands there will be some finishing orthodontics following this surgical procedure. Definitive prosthodontics can be carried out at this time.
I agree that the 33 should be removed. Please let me know when you would like to have this done and we will arrange to do it for Tiffany.
The details of the TMJ alloplastic total joint reconstructive surgery were reviewed today with Tiffany. In particular, I discussed the placement of facial incisions, surgical technique, postoperative healing and sequelae and potential complications. Risks and benefits were reviewed. Rare, though possible, complications were discussed, including bleeding, transfusion, infection, temporary or permanent numbness or facial weakness and foreign body reaction. Websites were given to Tiffany for her review. Costs were discussed.
I have given Tiffany a referral for an MRI scan of the TMJs. I have also given her a prescription for Vimovo for NSAID therapy and Flexural as a nighttime muscle relaxant. I will see her in a couple of months to see how the preparatory work is coming along. Together, Dr O and I will determine a surgical date for her, which will likely occur in about one year.
Thanks again for the opportunity to assess and treat this very pleasant lady. Your confidence in my surgical practice is deeply appreciated.
Best personal regards,
Dr. P
Teeth are moving!!
written Jan 8
Yes, it seems that ever so slightly, almost imperceptibly, my teeth are moving. Dr O confirmed my suspicions when I saw him this week, and it's pretty exciting! Finally there is some forward progress. I also makes me feel better about the pain that I'm feeling in my upper teeth. See, I know that your teeth are supposed to hurt, at least be uncomfortable, when you have braces, but it's not so simple for me. Because of all the previous damage to my teeth, pain can also mean that things are going very wrong with the actual health of my teeth, and could mean that they won't survive. So whenever I feel pain in my teeth, particularly my front ones, I start to panic a little. They obviously hurt when the braces first went on, but everyone told me that the pain would go away. And it did...but then it came back, in a different way. It didn't feel quite the same as the pain was the first few days, and I didn't know whether it was normal, or scary. I guess it was normal, because it's waning to.
The reason I had to see Dr. O again this week is because since having the lower canine tooth removed, my bite plate (once I felt brave enough to put it back in...) was so painful I couldn't stand it. It seems the teeth next to it were being crowded (big surprise for my mouth, lol) and now that it's gone, they have some space to....move. Everything's moving. Well, this is a problem. I love that damn bite plate!! I didn't expect that the first day I got it, but I came to adore the damn thing. Having a mouth that feels normal again was so nice. The pain in my jaws and all the head muscles almost went away and I could sort of forget about all those problems. Which is ironic, since a massive appliance in my mouth did all that, but I sort of forgot about it too. So Dr. O tried to change the shape of it, but it didn't really work so he is making me a new one. Ahhhhh!
Like I said, all those benefits of the bite plate made me sort of forget about my TMJ problems, and it wasn't on consciously, but I think I had sort of tricked myself into thinking that things weren't so bad after all. Well now that it's not in, all the issues are back. My jaw is super sore and my temporal muscles are really tight and painful. Joy! Then I was looking at photos of my son on our camera and didn't realize there were photos of me on there too. I saw one of myself and noticed how different the shape of my face looks now. It made me so sad...and realize that nothing had gone away.
Yes, it seems that ever so slightly, almost imperceptibly, my teeth are moving. Dr O confirmed my suspicions when I saw him this week, and it's pretty exciting! Finally there is some forward progress. I also makes me feel better about the pain that I'm feeling in my upper teeth. See, I know that your teeth are supposed to hurt, at least be uncomfortable, when you have braces, but it's not so simple for me. Because of all the previous damage to my teeth, pain can also mean that things are going very wrong with the actual health of my teeth, and could mean that they won't survive. So whenever I feel pain in my teeth, particularly my front ones, I start to panic a little. They obviously hurt when the braces first went on, but everyone told me that the pain would go away. And it did...but then it came back, in a different way. It didn't feel quite the same as the pain was the first few days, and I didn't know whether it was normal, or scary. I guess it was normal, because it's waning to.
The reason I had to see Dr. O again this week is because since having the lower canine tooth removed, my bite plate (once I felt brave enough to put it back in...) was so painful I couldn't stand it. It seems the teeth next to it were being crowded (big surprise for my mouth, lol) and now that it's gone, they have some space to....move. Everything's moving. Well, this is a problem. I love that damn bite plate!! I didn't expect that the first day I got it, but I came to adore the damn thing. Having a mouth that feels normal again was so nice. The pain in my jaws and all the head muscles almost went away and I could sort of forget about all those problems. Which is ironic, since a massive appliance in my mouth did all that, but I sort of forgot about it too. So Dr. O tried to change the shape of it, but it didn't really work so he is making me a new one. Ahhhhh!
Like I said, all those benefits of the bite plate made me sort of forget about my TMJ problems, and it wasn't on consciously, but I think I had sort of tricked myself into thinking that things weren't so bad after all. Well now that it's not in, all the issues are back. My jaw is super sore and my temporal muscles are really tight and painful. Joy! Then I was looking at photos of my son on our camera and didn't realize there were photos of me on there too. I saw one of myself and noticed how different the shape of my face looks now. It made me so sad...and realize that nothing had gone away.
Friday, January 2, 2015
Extraction and Bone Grafting
Today marks 3 days since my tooth extraction and bone grafting at tooth #33, the lower left canine tooth. The procedure was delayed by 2.5 hours, which was not super awesome. By the time the girl offered me "one last chance to use the washroom" before hooking me up to all the monitors for the surgery, I told her it had been over 10 hours since food or drink had entered my body.....nothing was coming out at this point!! I was starving and ready to get this show on the road.
This was my first procedure with Dr. P, the TMJ specialist that I began seeing in November. While sitting in the waiting room, reading every magazine they had, I felt pretty overwhelmed. My original surgeon, Dr. M has his own office, and a small staff. They know me by name and ask how I am when they see me. Dr. P's office has 4 surgeons, and therefore 4 times the staff required for such a busy place. I know that on one hand, all that staff and experience is a benefit to me, but on the other, it's hard not to wonder if you're just a number. Well, as soon as I saw Dr. P before the procedure, he was very warm and obviously remembered me...my fears were put aside. The nursing staff was outstanding, so professional and kind. He had an anesthesiologist there just to put me out (Dr. M did that himself) and he was pretty awesome too. He saw that my husband was reading World Without End, the sequel book to Pillars of the Earth and when I was ready for the procedure he told the hubs to leave the room...."It's book time, Bro!"
Dr. P was gracious enough to give us a few minutes of his time to answer my hubby's questions about the replacement surgery. Since we had our busy 3 year old with us during our initial consultation, the hubs wasn't able to stay in the room for the whole thing. As a result, he had lots of questions for Dr. P. Ones that I tried to answer based on what Dr. P had told ME, but my engineer life partner needs to hear these things from the experts. Anyways, Dr. P explained that in his opinion my TMJ's are destroyed. Healed, but not at all the way they were supposed to. He explained that there are other surgeries we could try (including rib bone grafts instead of prosthetic joints....ouch!) but he thought they would fail abysmally (his words) since my joints are in such a poor state. So it sounds like this is happening. At least we know he feels pretty sure of the outcome. He said that he teaches this procedure to surgeons all around the world, and his office is known as a centre of excellence for TMJ-related issues. He was not at all arrogant about it, and I feel that he is empathetic to the seriousness of the situation.
We also got to ask about having another baby, which is a concern for me. We have been trying for a long time, almost 2 years, to have a second baby and nothing has worked. Dr. P told us to "live our lives", we would adjust the surgery timeline as required if I got pregnant. What a relief!! The only issue is that I will be very much out of commission for probably around a month....not capable of caring for a baby much at all after the surgery. Thankfully I have a wonderful support network, my mom, my mother in law, 2 sisters, 2 sisters "in law", aunts, grandmothers, friends....I feel certain that people will help us out. I know it would be hard to give up breastfeeding and being the sole caregiver, but I'd rather have another baby and sacrifice that, than have to wait for either the baby or the surgery. Such is life!
As for the actual procedure of the extraction and graft, it was....well I was asleep. I was definitely not looking forward to GA (General Anesthetic) again, but hopefully this will be the last of it until the big surgery. I am really sad to have a missing tooth, but it's on the bottom and not as noticeable as I had thought. Obviously I am more cautious about opening my mouth as I don't want it to be seen, but it's not any worse than trying to hide the braces! It feels quite good to be rid of the loose tooth, it was pushing into my mouth toward my tongue and generally being a painful nuisance. They sent me home with it, and the resorption that was seen on the CT scans is super-obvious. The tooth was dying. The bone graft is hardly noticeable. There are a few stitches in there, and it's definitely tender, but not bad really. I was sent home with painkillers that I take when I need them, but I am not popping them like crazy like after any other procedures. I am on antibiotics, and they are painful. My stomach is usually ok with ABx, but not this time. Oh well....lots of yogurt and probiotics are on the menu.
I had to eat a liquid/soft diet right after, but I'm kinda back to my new 'normal' since the braces. Brushing is interesting, since the braces have to be cleaned 10000 times a day, but I have to be very delicate about it. I iced my face lots in the first 2 days after the surgery, and haven't had much swelling at all, and no bruising. It's great.
Dr. P says as long as Dr. O thinks he can close the space that was created with braces and get good enough occlusion to bring my teeth together during the big surgery, then I'll be ok. Dr. O seems pretty confident about it....and I would rather avoid an implant. I guess I'll give it a bit more thought after I see Dr. P for my follow up on Monday, and Dr. O for my next wire change in February. I don't have to make the decision right away.
All in all, I'm doing ok. I'm really tired still....I feel like I haven't gotten my energy back 100% since the accident yet. I've still got 2-4 more root canals to go through, and then the bottom braces go on. I am hoping that I'll feel more energetic when I'm done recovering from dental procedures. Here's hoping!
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