how-to: orthognathic surgery/braces/general face-fixing for adults?

April 11, 2013 2:05 PM

I have seriously messed-up teeth that make me absolutely despise the way I look and continue to make me increasingly unable to eat pizza, sandwiches, or any other food whose consumption requires front teeth that come within a quarter-inch of each other. A visit to the orthodontist has alerted me to the fact that I may require maxillofacial/orthognathic/corrective jaw surgery ($$$$$$$$$$$$) in addition to braces ($$$). While I live in the U.S. and am lucky enough to possess fairly decent medical and dental insurance, I don't have very much money to throw at the problem. What should/can I do next? If you've had a similar experience, what did/would you do?

With several degrees of overjet, a massive overbite, a rather huge (over 1/4") open bite, and class II malocclusions all up in the place, I went to an orthodontist today for the very first time. I was sent home with a very, very strong recommendation for orthognathic surgery (specifically this procedure; my back teeth are A-OK, but my front bite is nearly identical to that one) followed by standard braces, as well as a rather overwhelming number of informational pamphlets on various procedures, post-orthodontia home care, expected recovery time, possible complications, and costs.

As in this question (circa 2004), the suggested surgery is a Le Fort I osteotomy. The orthodontist suggested that I check ASAP to find out whether my medical insurance would cover even part of the surgery, as it is extremely expensive -- "easily" upwards of $50,000. The surgery would be preceded and proceeded by 12-24 months of wearing braces. Oof.

The only other option presented to me involves extracting two or more perfectly healthy middle molars in order to make room for the way the remaining teeth will shift, then enduring five (5!) years of braces. This approach would cost about $8,000 -- better than $50k, to be sure, but still a decidedly unfriendly sum -- and, according to the ortho, would only fix the overjet, not the open bite or overbite.

As has become increasingly clear, cheaping out is not an option in this situation, but I'm not sure I can psychologically handle agreeing to go into debt for nearly ten grand just because I'd like to fix the face I've had for 30+ years, no matter how much looking in a mirror makes me want to punch it or how many slices of awesome 'za I have to eat with a goddamned fork and knife. O, adult procurers and possessors of braces, orthodontics, and/or messed-up teeth: How do you decide whether to take the plunge, get a second/third/fourth opinion, or just live with your mouth as-is? (FWIW, my three wisdom teeth are fully intact, albeit growing in sideways, and only occasionally bothersome but, as the ortho said, "We're not even close to getting to those yet.")

Finally, I live on my own, am at work 50+ hours/week, and there is no one on earth who could take care of me, drive me to/from appointments while I am still anaesthetized and swollen, etc. (I am also so terrified of general/blackout anaesthesia that I will do anything to avoid it, so hopefully I'd be a bit perkier than the average patient.) I didn't really have parents per se, and remain fiercely independent to a bitter, gasping fault. Assuming I get at least some of this work done, is all of the post-orthodontia caretaking I'm reading about in these pamphlets really necessary, or something I could wing on my own through raw willpower?

As always, thanks very much for your insight and experience!

posted by divined by radio to Health & Fitness (16 answers total)

Your first order of business is a second opinion, perhaps even a third.

I would also recommend against surgery, if at all possible.
posted by infinitywaltz at 2:10 PM on April 11, 2013

I don't know if this would appeal to you even remotely, but my family got a LOT of extremely low-cost/free (and relatively high quality) much-needed dental work when my uncle went through dental school back in the 80s.

It may be an attractive option, cost-wise, to look into.
posted by phunniemee at 2:11 PM on April 11, 2013

Hi there! I am in the process of getting new bridge work. While not as extensive as your issues, in total it will cost a about $6,500. I understand how you are feeling. I have decided it is worth it to me. My insurance is paying about a third of that, leaving me with a $4K bill. Mouth/teeth health are so crucial to the body's overall health that I don't feel it's something I can skip or skimp on. So I'll pay a little in cash and take the rest in debt. I'll work to pay that off quickly and I think I'll be very happy in the end.

I also have deteriorating bone in my jaws due to a medical issue. Right now I have a molar that is loose, wiggling in the socket. When it comes time to remove it, I'll be in for about $1K.

Dental work/surgery is so expensive! Be sure to get more than one opinion and make sure you are comfortable with your provider.

As far as accepting help from others, how do YOU feel about providing help if someone needs it? Many people, including myself, view it in a positive and want to be helpful to others. Supporting someone in a time of need can be a gift to the giver. Try to think of it that way.

Best of everything to you. It's a real process.
posted by michellenoel at 2:16 PM on April 11, 2013

First of all, start with a second and third opinion. Then file it all with every kind of insurance you've got. Then you'll have a better idea of where you really are. Then if it is something you need to do for health and/or self-esteem issues or just because you want to, then start saving, get credit cards, get a second job, whatever you can do. Don't be afraid of the general anesthesia though. That's the easiest part. You start counting backwards and then you wake up.
posted by tamitang at 2:16 PM on April 11, 2013

I had my wisdom teeth out with just novicaine, that was no biggie. You're going to want real anesthesia for this procedure.

For sure, get a second opinion, but this is something you want to do sooner, rather than later.

I had a hideous overbite when I was a kid. I wore the headgear and then braces, I think it was 8 years in total. I have a nightguard/retainer that I wear at night. I have perfect, beautiful teeth and I'm so happy I did all of that stuff.

Your problem isn't just cosmetic, it can really screw with digestion and it can get worse, so you really need to talk not only to your dental insurance folks but your medical insurance folks. Here in Atlanta, there's a maxillofacial/oral surgeon who is also a cosmetic surgeon. It's all very interconnected.

Once you do it, you won't regret any part of it though. But discuss with your surgeon, and ask all the questions you have.

Good luck!
posted by Ruthless Bunny at 2:26 PM on April 11, 2013

I had orthognathic surgery a few months back to fix an open bite. The surgery involved both the upper and lower jaw and I did it primarily to relieve my back teeth from receiving the full pressure of my bite and to be able to eat properly.

Overall I would say that the procedure was worth it. You will absolutely want someone to stay with you at least for the first week, if not longer. It was not a fun recovery and I was on liquids or blended food for a month. I was out of work for about 3 weeks before returning. There are a lot of jaw surgery blogs out there if you want to get a better feel for the procedure and recovery.

Hopefully with your insurance you won't pay anywhere near $50,000 for the surgery. As someone else mentioned, dental schools do offer significant discounts on procedures. You'll have your teeth for the rest of your life so it would be a good investment.
posted by algal bloom nightmare at 2:52 PM on April 11, 2013

As in this question (circa 2004), the suggested surgery is a Le Fort I osteotomy. The orthodontist suggested that I check ASAP to find out whether my medical insurance would cover even part of the surgery, as it is extremely expensive -- "easily" upwards of $50,000. The surgery would be preceded and proceeded by 12-24 months of wearing braces. Oof.

Hey there -- that was my original question. As it turned out, my surgery was almost entirely covered by insurance (which was a good thing, because I had a complication during it that put me in ICU for several days), because my surgeon made the argument that it was medically necessary, not cosmetic. I put the braces (and the portion of the surgery that wasn't covered) on a monthly payment plan and just worked it into a budget for three years.

Even though I was extremely swollen and bruised from the surgery for much longer than is normal afterwards (this was related to the complication I had and not a typical outcome), I can still tell you it is one of the two or three greatest decisions I ever made in my entire life. Dealing with appointments for a few years, dealing with a liquid diet for a few months, etc. was all a challenge at the time but the results are that I can eat without jaw pain, I have far fewer migraines, and I feel more comfortable about my appearance than I did for the first 35 years of my life. It was completely worth it.
posted by scody at 3:00 PM on April 11, 2013

Talk to your dentist about how much work can be spread over time in order to maximise the per-year allowances for your insurance. I use this method (I go over my dental insurance coverage every year) and sometimes schedule half a procedure in December, with a follow-up in January in order to get 2 year's worth of coverage.

If you know in advance you are going to get expensive medical work done, can you take out a HSA in advance through your job? Or did those go away recently, I can't remember. But I did this for the births of my children.

Finally, if the cost is going to massively exceed your insurance coverage, it might be worth at least looking into medical tourism, to see if there is another country you can go to to get the work done at a much lower rate.
posted by Joh at 3:04 PM on April 11, 2013

Oh, as for the post-surgical care: I didn't really need much help after the first couple of weeks, but I did need help -- but again, I had complications (with bleeding) that are due to my own goofy medical problems and not typical, so it's possible that you'd do fine without help. But it might be worth considering if you would be willing to set aside your fierce independence for a short period to see if there are some friendships that you might be able to rely on for a little support -- someone to drive you home from the hospital, for example, or to help out with the grocery shopping for the first week or so, or to drive you to the first couple of follow-up appointments in case you're a little woozy from painkillers.

Also: if you do it and need to be on a liquid diet, I used this method because it doesn't use a straw (sucking on a straw, after having jaw and mouth surgery, isn't advised because it can slow healing) and is easier than using a syringe.
posted by scody at 3:09 PM on April 11, 2013

Hoo boy. So, my boyfriend had to have corrective jaw surgery--one side of his jaw was uneven from the other, along with some other overbite things or whatnot. When I met him and we first started dating, he had braces in preparation for the surgery; we were dating for around a year and had moved in together when he got the surgery, and he still has braces about half a year after the surgery that hopefully come off in the next few months. Whether or not to get the surgery was not in question: his problems were causing him headaches and would only get worse down the road, and he had health insurance to cover it, and a HSA to help pay for his side of the costs, and got paid enough to do it without going into debt. The surgery you need sounds less extensive than his, however, so you might need braces less if you do it.

If you have this surgery, you WILL be going through general anesthesia. There is no way around it. They are taking a bone saw to your face. They are not going to do that while you are conscious.

For his situation, post operative care was an absolute necessity. I took a week off from work to take care of him, and it ended up being absolutely needed and I was exhausted to the bone. (And I worked from home during the following week, no less.) On his part, I think he was so eager to just hit the milepoints of recovery that he eagerly decided to get checkout out of the hospital the day after the surgery, and it was a huge mistake. He was used to the pain killing drugs from the IV and going straight from that to a regimen of liquid hydrocodone every X hours left him in too much pain; additionally, the hospital had equipment for the efficient removal of blood and muscus build up that I couldn't replicate at home (he was not allowed to cough or force it out, just spit, and it was difficult with the plastic splint in place; the makeshift spit suction I made with a baby aspirator and rubber tubing wasn't strong enough), and I ended up taking him back to the emergency room at 11 that night when he started getting scared about not being able to breathe. So I would be very careful about making sure you are able to handle being off the IV meds and not relying on their suction to be able to breathe before you check yourself out.

A surprising amount of the caretaking work I had to do in those first few days in the hospital took the form of advocacy--in the hospital, my being there meant I could instruct each new shift of nurses as to the particulars of his care (get him apple juice, and lots of it!). He was so miserable, and in such pain, and started out not even being able to walk unassisted.

And there is no way he would have been able to drive himself home from the hospital, either, between the pain and the painkillers and the disorientation. He had difficulty just sitting upright in the car as I drove him and every little bump was agony.

I will say that he rented one of these cooling face masks (not covered by insurance) and it was worth every goddamn penny for the amount of relief it gave him.

He did end up being very frustrated and depressed at the inability to talk. Additionally, his lips were numb (which is a common side effect for up to a year and potentially permanent) and this really took him aback at first--I think he still does have numbness, but he's adjusted and it doesn't bother him anymore, which is pretty much what all the literature says happens.

So in short: it was an utterly miserable, wretched experience for us both, but I think he'd do it over again in an instant--and I don't even think he hated his jaw problems as much as you hate yours, he had less trouble eating normal foods, and your recovery would be quicker than his. It's a long term commitment, but I think once it was done, you'd be a lot happier about your life in general--ten grand of debt divided by all the years of your life that would be improved.

Make sure to go over living alone and factor that into your talks with medical professionals and your insurance. If you want to be independent about it and not lean on friends, work it out so you can hire a home aide for the time you need assistance during your convalescence. Or use a service like TaskRabbit if you can to hire people to do those tasks you need.
posted by foxfirefey at 3:26 PM on April 11, 2013

I had braces as a teenager followed by braces and surgery as an adult to correct TMJ problems. My procedure was minimal compared to what you are considering but here is what my experience can tell you.

1) get a second and third opinion. The prices I was quoted for braces varied by up to 50% and seemed to correlate with the office decor rather than the care I would receive.

2) having braces as an adult is miserable. If you can avoid wearing braces for five years, then do it.

3) I don't know about long term care but you will absolutely need someone to be around you for at least 24 hours post surgery because of the anesthesia.
posted by bq at 3:54 PM on April 11, 2013

I am in the UK, and had adult orthodontic work including maxillofacial surgery through an NHS dental hospital here for free.

The work I had done, I was told, would have cost over £20,000. I had fixed braces for 3 years (2 pre, 1 post surgery) and the bones in my upper jaw were cut, rotated and moved forward to close my underbite.

After surgery I went to stay with my parents for 3 weeks. I lost more than 1 stone in weight due to liquid diet and elastics which were in place to hold my jaw mostly closed for a while. I was given good painkillers for this period, but I definitely needed other people around to help me and I did return to the hospital unexpectedly once. The inability to eat solids was the worst part of the whole process.

4 years post surgery and I have a slight open bite again. The surgeon and orthodontist aren't sure why, but my jaw has moved a little. I have some slight issues with my sinuses, which were cut in the surgery. I also have numbness in the winter through my front teeth and palate when it is cold.

Generally though, I would say the process was a success and I have a much better time eating, smiling, etc. If I was in your position I would do anything I could reasonably afford to get at least one or two of your dental issues seen to. Perhaps you can get some work done in stages?
posted by veids at 4:03 PM on April 11, 2013

A family member just had jaw orthognathic surgery (moving top jaw forward). We had a treatment plan from one orthodontist and got a referral from a primary care physician to a university maxio-facial surgeon. We always knew the orthodontist would not be paid for by insurance, so we had to plan for that expense. We hoped the surgery would be covered - however, it was made clear to us that there would be a battle to get the health insurance company to pay for the surgery, because they view this procedure as cosmetic, even though it wasn't. Apparently, the docs have to write a letter justifying the procedure in terms of the medical well-being of the client.

Frankly, we weren't in love with the orthodontist or the surgeon, so we looked around and got a second opinion from a surgeon we liked much much better (memail me if you'd like the name). The new guy had doubts about the orthodontist's treatment plan, so we got another opinion from a different orthodontist, who agreed with this surgeon.

It was one of those situations where we, as lay people, have no way to know what the right course is. All I know was that we felt much more comfortable with the second set of providers.

We hoped that the surgery would be paid, but it turned out that the surgeon we liked was at a point in his career where he no longer wanted to hassle with being on a panel of insurance providers. We tried to get the medical group to approve him, but it turned out that they had a contract with another surgeon, and they would only pay for surgery done by that person (who had the worst set of yelp reviews I'd ever read). We *then* thought, ok, we'll pay the surgeon out of pocket, and surely the insurance will pay the hospital costs, right?

Wrong - if the procedure is not done by their provider, they won't pay. Keep in mind that they always said they might not pay even if it *is* done by their provider, because they don't cover cosmetic surgery. Anyway, the hospital costs were totally through the roof so it looked like we'd have to go with the earlier providers, who we didn't like, but at least the insurance might pay.

Except, it turns out that new the surgeon had created his own outpatient surgery clinic, where he and his partners could do surgery and people just pay out of pocket. Though it's still a lot of money, it was *much* cheaper than doing it in a hospital. Even though they charge less, they make more, because they get all the money instead of it going to the insurance company and toward supporting hospital infrastructure.

Before the surgery, the patient had to wear invis-align for about 6 months. The surgery happened in Feb - it worked out very well, and she will have to wear invis-align for another couple of months.
posted by jasper411 at 4:12 PM on April 11, 2013

I had surgery on my upper & lower jaw back in 1998, you can see my before & after Flickr set here. I don't think I can offer much help in the question of "How do you decide whether to take the plunge, get a second/third/fourth opinion, or just live with your mouth as-is?", because as-is wasn't an option -- I'd started with a normal face & bite and then my teeth shifted and my bite & face went all screwy over the course of a couple of years and showed no sign of stopping without some intervention, and braces alone wouldn't have been enough to undo the damage already done.

In my case, I got 6 teeth removed before the braces went on (4 wisdom teeth & two regular ones from the lower jaw), so, I was pretty much committed to the plan from that point on because of the gaps created by getting rid of those two perfectly decent teeth. I would think you'd have to get all the extractions done before the braces could go on, so, I'm not sure what your ortho meant by the "we're not there yet" comment, but my extractions were all done by my maxilofacial surgeon, so, maybe he meant you need to find your surgeon and get the paperwork started on showing that this is a medical issue not cosmetic before you can sign a contract for the orthodontia?

Finally, I live on my own, am at work 50+ hours/week, and there is no one on earth who could take care of me, drive me to/from appointments while I am still anaesthetized and swollen, etc. (I am also so terrified of general/blackout anaesthesia that I will do anything to avoid it, so hopefully I'd be a bit perkier than the average patient.) I didn't really have parents per se, and remain fiercely independent to a bitter, gasping fault. Assuming I get at least some of this work done, is all of the post-orthodontia caretaking I'm reading about in these pamphlets really necessary, or something I could wing on my own through raw willpower?

Not sure what you mean by 'post-orthodontia caretaking'. Getting braces put on, and the monthly adjustments are no fun, but not debilitating. Getting wisdom teeth removed can be extraordinarily sucky, but I got all 6 teeth out in one visit to my surgeon's office, with just a valium beforehand and much novocain. I don't think there's any way of predicting how good or bad anyone's reaction to wisdom teeth extractions will be, some people are out of commission for days, some people bounce right back the next morning, it's just a weird complicated cluster of nerve endings. I was pretty much wrecked for 3 days afterwards, most painful part of the whole process.

For the surgery itself, you are going to be in the hospital under general anesthesia, there is no question about that, so, your fear about it is something you're going to need to work on dealing with, but, that's years away. Same with figuring out who can be found (or hired) to help get you home from the hospital, or re-arranging your work schedule. I don't think you should let that be a real factor in your decision-making process, because, that's something you're going to need to work on anyway. I mean, even if you don't have this surgery, anyone can have an unexpected medical crisis - appendicitis, a bad fall, food poisoning, etc. Learning to ask for and accept help from others is a good long term goal.

So, in your shoes, I would get a second opinion from a surgeon - get a recommendation from the orthodontist (or your dentist?). Find out if they've had success in getting their patients insurance companies to reimburse them. Start building your paper trail of the medical issues having a lousy bite is causing you (TMJ? increased likelihood of arthritis? grinding away your remaining teeth?). And then just try to figure out whether those problems and your dissatisfaction with how you look are worse than the risks of the surgery & the unknowns of the outcomes.
posted by oh yeah! at 8:10 PM on April 11, 2013

Without opining on options -- I think effective dental work is well well worth the money for those who can manage to pay/finance
posted by ClaudiaCenter at 10:32 PM on April 11, 2013

Just wanted to pop in and say that there are a lot of services that can help with not having people to help you -- you can use a taxi or car-sharing service to take you back and forth to appointments and have grocery stores deliver food. Don't let lack of family (I know how that is) limit what you can do. It will cost a little bit, but not a huge amount, and you won't have to worry about it.
posted by 3491again at 1:02 AM on November 16, 2013