PART 5: My Expectations of the Surgery and Overall Procedure

I have some short term and long term expectations from my operation and the overall procedure. These expectations are based on what I have been told by different people along the way, and I fully realize that some of them may not happen -- and I won't be disappointed.

1) Better bite - a fixed alignment of teeth with a corrected bite
2) Improved physical appearences - fixing the underbite should look better, although after my lower jaw is brought backwards, it's possible that my chin will be a little receeded in spite of being rather forward right now
3) No more jaw locking
4) Reduced clicking - hopefully less clicking when I move my jaw laterally
5) Less skew - my jaw is currently slightly shifted to the right. This should be improved at least slightly.
6) Improved speech - I had a lisp when I was younger. Although I no longer have that lisp, there is some unclarity in my speech (i.e. people can understand me, but there's still a little slur or something), especially around pronouncing "s"s. I believe this slur is due to the underbite which causes my tongue to inadvertently touch my top teeth. With my jaws repositioned, I think my speech will be clearer.
7) Chin numbness - there will be some numbness in my chin, at least for the first 6 months ... possibly longer (possibly forever)

The question I often get asked is whether I'm nervous about it, and to be honest, I haven't been. I've known that I'd have it done since last February. I also know that I'm in capable hands with Dr. Reichman, and there isn't much else I can do to make the process go much smoother. I feel like I have a pretty good idea of what I'm getting into. In fact, it wasn't until this morning that I felt a few butterflies. I'm sure I'll feel more as the next few days roll by. Perhaps it's performance anxiety? After all, I will probably be there in front of a room of students. Hopefully I won't start mumbling in my sleep. That could be embarrassing. :)

PART 4: Odds and Ends

I had my final orthodontic appointment before surgery two days ago on Nov 26th. Another set of molds taken, and steel ties used to keep my braces' arch wire secured instead of the donuts (elastics) that are normally used. The reason for this is because the donuts can come off more easily, and since my operation will be done with the braces, and arch wire, in place, such an occurrence must be prevented. One of the orthodontic assistance has had a similar procedure done, and she tells me that it didn't hurt very much. Nice to know.

I got a call from a nurse yesterday to take and provide information for the surgery. Here's a brief summary of some of the things that were discussed:

------- BEGINNING OF DISCUSSION --------------------------------

Took some information on what kind of medication I take, my height, my weight, medical history, etc.

- I need to have a hemoglobin blood test sometime before the surgery to check red blood cell count. This is common, and there are no problems anticipated because young men usually have fairly high red cell count.

Prior to Surgery:
- Don't take things like echinacea, garlic pills, or ginseng pills for colds because it will increase bleeding
- No aspirin for painkilling (increases bleeding), but tylenol okay
- No eating after midnight the night before
- Drink lots of water the night before, to get nice veins
- Clear fluids okay up to 3 hrs before surgery
- Shower & shampoo hair the evening before or morning of surgery, because I won't get a chance to shower after the surgery until I'm home the next day

Day of Surgery:
- Bring medical card, ID, but no valuables
- Bring a comb if I want
- Surgery is 210 mins (3h30m)

After Surgery:
- Will have a tube in one nostril to help breathing
- Will have a tube in other nostril to prevent vomiting
- Be prepared for humungous amounts of swelling and bruising at the side of the face
- Will be given an ice pack to help with swelling (I can do the same at home)
- Will be some bleeding in the mouth afterwards, they'll teach me how to suction myself with a little vacuum tube
- Big breaths help with the anesthetics
- Wiggle toes to avoid clots in the legs (not really sure what this one's about)
- Tell staff if I feel uncomfortable or nauscious
- Usually won't be much pain, but will feel pressure because of tight skin (from the swelling)
- Will be in the recovery room for 3-4 hrs before being moved to my room
- After nausea subsides, they'll give me some liquids (water) to drinking

- For the first few days, use soy milk to make shakes rather thank regular milk because milk is "mucusy" and the protein will help with recovery
- If hospital gives painkillers, take a liquid one not a pill (because elastics will stop me from taking pills)
- Drink a lot of water to help with constipation
- Swelling down after 4 - 5 days
- When swelling reduces, I might feel more pain - take painkillers as necessary
- Avoid driving (painkillers may make me drowsy)

------- END OF DISCUSSION --------------------------------

Knowing very well that I won't be able to chew for nearly one month, I have started thinking about what foods I can consume during this time. My list is far from extensive and any additional suggestions would be great:

My Menu:
- Ensure (a liquid meal supplement like Boost... usually used for old people, I think)
- Protein shakes (Optimum Whey Protein and Transform+ soy protein powders)
- Meal supplement shakes (Xtreme Power Meal Fuel)
- Cream of _____ soups (I'm looking at some recipes for these because I don't know how to make good rich soups)
- Congee
- Broths (boiling veggies, meats, etc)
- Lots of juices, of all sorts
- Blenderized foods (veggies and fruits mostly)... anyone know any good recipes, mixes, or how to blenderize meats?
- Pudding

The days are slowly ticking away, and I am looking forward to having this done. I'm sure I'll have many photos taken, some of which will be available for public viewing. In PART 5, I'll talk about my expectations from the operation.

PART 3: Pre-Surgery Information

Around April 2003, Dr. Chiang said to me that he would only need 3 months before we would be ready to get our surgeon involved. I was happy to hear that, hoping I might be able to get the operation done before the end of the summer. Unfortunately, life wouldn't be so good. By the time Dr. Chiang got Dr. Mark Reichman's (his preferred dental surgeon) office to call me, it was mid-July and the earliest consultation I could get with Dr. Reichman was September 18th. My expectations would get jostled even further when I spoke to Dr. Reichman's receptionist who's best guess was that I wouldn't have my surgery until Spring 2004, and was totally dependent on hospital operating room availability. I was rather peeved to hear that, to say the least, because I felt like I would be sitting ready for surgery for half a year before I would actually get operated on.

Finally, my consultation with Dr. Reichman rolled around. The $175 consultation would basically be a one-on-one chat to have him explain what the procedure would be, what the risks are, what the options are, how much it would cost, and to have all my questions answered.

The surgery, as described by Dr. Reichman, would be mostly done inside the mouth, with minor incisions on the outside, slightly beneath the bend in my lower jaw (on each side). The mandible (lower jaw bone), when viewed from the side, is shaped like the bottom of a hockey stick, and will be sliced in the same plane as viewed from the side. In other words, if you put your hands together in a praying position (with fingers together pointing up) in front of your face, and then separate your hands by approximately the width of your face, then bring your hands directly back into your face such that your index fingers contact the corner of your jaw, then the plane made by your hands would be the plane of the cut. At that point, the middle part of the mandible will be free to slide forward, back, or at any angle forward. After it's adjusted to the right position, it is secured back to the other parts of the mandible through metal screws. I'm not sure if some kind of glue is involved. Probably not. In necessary, the upper jaw is broken just behind the upper lip and moved forward.

After surgery, there will be a good amount of swelling and bruising. Basically, Dr. Reichman said I'd feel like crap and it would get progressively worse over the first 4 days or so before getting better. Nausea and lack of energy are some of the symptoms. I will have some tight elastics holding my upper and lower jaw together, which will be switched out to progressively looser elastics after the first week. They no longer "wire" the jaw shut. I would have weekly checkups with Dr. Reichman, and there will be no chewing for 4 weeks. He tells me that by the 4th week, I'll be regretting have had the surgery done -- being absolutely sick of eating non-solids. It takes roughly 6 months for the bone to completely fuse to the strength that it had once been. Dr. Reichman also mentioned that more of his patients have told him that the recovery was less painful then they thought it would be, which I was glad to hear because I believe I have a higher pain tolerance than most.


For the maxillofacial surgery, I had two main choices, and some other choices which I chose to ignore.

1) One jaw: Operation only on the lower jaw ($3,800)
2) Two jaws: Operation on both upper and lower jaws ($5,800)

For the one jaw operation, the lower jaw would be shifted back. For the two jaw operation, the upper jaw would be brought forward, and the lower jaw shifted back, but not as far as if it had been only a one jaw operation. Naturally, a two jaw operation is more complicated and requires a longer operation and recovery time -- however it would provide more balance to the facial profile, especially in my case where my upper jaw is a little bit recessed.

Dr. Reichman also mentioned that I may choose to have some additional cosmetic surgery done as well, while I'm at it. Things like having a little bit of fat put into the chin to give it some fullness after the lower jaw bone is moved back ($2,000), or having some hard material put into my cheeks to bring out my cheek bones more ($3,500), or widening my face ($3,500)... none of which I was interested in.

There are five risks associated with this type of operation, regardless of whether it is one or two jaws:

1) Infection, not too uncommon.
2) Jaw joint problems could occur.
3) Jaw memory can cause jaws to move back towards their original position -- in a rare case, may be necessary to re-operate.
4) Cosmetic effects, for better or for worse. Usually better in the surgery I'm getting.
5) Numbness, always -- chin will lose feeling for 6 months before coming back... sometimes feeling will never come back.

Again, Dr. Reichman's best bet for an available surgery date was Spring 2004 at best for a two jaw operation, and slightly earlier for a one jaw operation (different operating rooms in each case, with more availability for the one jaw job).

So I went home and thought about what I wanted to do, one jaw or two. While I could care less about the additional cost to have a second jaw broken, I wanted to make sure I made the right (health and cosmetic) decision. After doing some simple simulations on my computer with the digital photos I had taken, I decided on the two-jaw operation -- because I preferred to have it done as well as possible the first (and only) time. So, two weeks after the consultation, I called Dr. Reichman's office and told them my decision, so that I could be put on the waiting list for the two-jaw operation.

Low and behold, only a few days later, I got a call from Dr. Reichman's assistant saying that I could have my surgery on December 4, 2003 if I should so choose to. Of course I chose to! The reason that the space became available was because the patients ahead of me on the waiting list couldn't take that slot for one reason or another (possibly to close to Christmas time?). So I jumped at the opportunity, knowing it was only 2 months away and would force me to miss out on the foods from Christmas dinners and parties, not to mention my own birthday party/dinner. Alas, the sacrifices we make.

About one month after my consultation with Dr. Reichman, I went in for my final visit before my surgery. At that time, Dr. Reichman reminded me of the risks, and took some measurements, photos, and X-Rays... the usual stuff. He also mentioned that for a two-jaw surgery, I would have it done at the UBC hospital and that there is a fair chance that my operation would also be observed by a class of students. If I knew anyone that would be in that class, they would have to leave (for confidentiality reasons). And that was that.

So now, I am waiting for my surgery date to quickly come around. One week exactly from today.

PART 2: The Orthodontics

The four broad stages of having my underbite and diastema corrected are:
1) Orthodontics in preparation for jaw surgery: This involves getting the upper and lower teeth in a position such that when the surgery occurs, there will be three points of contact between the upper and lower row of teeth. The more points of contact, the better. In my case, this required more than just brace work.
2) Surgery: The surgery itself, which requires very little on my part.
3) Detailing: After surgery, the orthodontic work to get all the teeth into their final positions through brace work.
4) Retention: After the braces are removed, I'll need to wear a retainer for an additional 24 months - this is very common for any orthodontics requiring braces, and is to ensure that the teeth do not fall back towards their incorrect places.

Due to a narrow upper jaw, the first task was to widen the upper jaw such that it would fit over the lower jaw. An expansion of approximately 1 cm was required, and would be accomplished by using a fixed jackscrew expander. The first jackscrew expander used was a new device, and I was the first patient for Dr. Chiang to use it. Essentially, it was a mechanical device that was fixed to my upper molars (2nd from the back) through the use of metal bands around the molars. The expander extended was composed of two metal stems joined through a threaded "screw" in the middle. The stems connected to the molar band, and the screw was positioned near the roof of the mouth. So the shape of the device when viewed from the front was like: _/````\_ The center section (the screw) was a thin cylindrical screw with holes in the center all around the tube (roughly 3 holes around the circumference); and the idea was that by inserting a little key into the hole and turning it, the screw would expand or contract. In essence, I needed to crank my own shaft every few days to expand my upper jaw.

Now having a little device like this fixed in one's mouth has an incredible impact on one's ability to eat and speak properly. In eating, I had to learn how to eat differently, because I could no longer use my tongue to push food to the back of my mouth without having it get stuck between the expander and the roof of my mouth. So, I learned to chew and eat foods by slowly moving food back with my tongue but without pushing it up, or by pushing it up and back and tilting my head back so it would fall to the back of my mouth. In either case, it because a chore to eat... and furthermore caused me to never talk when I ate (because I'd usually have food cause between the apparatus and the roof of my mouth). My speech would be different as well. Sounds like a hard "g" and "k" would be extremely difficult to pronounce because they required contact between my tongue and the top of my mouth. One word I struggled with was "geek", which started and ended with a hard constant.

After 2 or 3 months of doing this, we decided it wasn't working and that my jaw hadn't expanded as much as we had hoped when we first started. So Dr. Chiang replaced that newer and less intrusive expander with a heavier-duty jackscrew expander, as shown in the types of appliances section of Dr. Chiang's website. This expander was secured in four spots, was bulkier, and sat a little lower from the roof of mouth. And one could expect, this was even harder on speech and eating. Fortunately, the older and more reliable device did the trick. In fact, it was too efficient, and I ended up over extending the upper jaw -- so I needed another month to bring it back down to the correct size. Overall, withholding the agony from eating and talking, the physical pain was not that bad at all. Each time I cranked, I would feel a tightening of the gums, and I would feel some discomfort when I went to bed, but it would be more or less fine the next morning. But finally, the worst was over, and it was great to be able to feel the roof of my mouth once again. By this time, I had already felt like we wasted too much time and that we were falling behind schedule. It was naturally one of my priorities to get the whole thing over with as soon as possible, but without comprising the quality of work.

In October 2002, I got braces for the first time. I won't go into the pain of having braces put on for the first time or having them tightened periodically, because most teenagers have been through it and can tell you what that's like. With the clear braces, which aren't quite clear but are really teeth-coloured, it really isn't too obvious that you have braces at all; the only thing visible is the arch wire. In fact, most people don't even notice I have braces until we've talked for a good while.

Within the first month of having braces, my diastema had been removed... unfortunately, on the second tightening, a gap started to form between my two front lower teeth, as you will see in my photos. However, I wasn't too concerned with this new gap because it was generally not very visible and would eventually get closed up.

The next 13 months were mostly the same: tightening, retightening, taking molds, taking X-rays, and taking photographs. So there's really nothing much to be said there.

PART 1: The Consultation and Initial Decisions

For as long as I can remember, I've had two issues with my teeth/jaw:
- a gap between my two front teeth (called a "diastema")
- an underbite (called a "Class 3 malocclusion")

At the end of 2001, I was considering having the diastema removed -- given that my extended health plan would cover 50% of the cost for orthodontics. So on January 10, 2002, I called up the orthodontist that both my siblings and I had been to as children for a consultation. Some orthodontic consultations are free, but this one cost $30*. The appointment was scheduled for January 23, 2002 at Dr. Chiang's office in Vancouver.

On January 23, I sat down with Dr. Chiang in a discussion of how the diastema could be filled or removed. There were a few different options including orthodontics and procelain veneers. While I was there, I decided to ask his opinion on my underbite, which I hadn't really thought about fixing, but had talked to my dentist about in the past. The main problem with the underbite, aside from being visually displeasing in my opinion, is that it caused my jaw to grind when moving laterally and lock if I opened it too far, such as when in a dentist chair for a cleaning. I remember asking Dr. Chiang whether it was something he thought I should fix or whether I should just live with it, to which he replied, somewhat chuckling, "No one should have to live with that jaw."

Granted, Dr. Chiang may be out there to make a buck, just like most dentists and orthodontists -- but there were a few reasons I had to consider this seriously: (1) Given that I already have jaw problems at a tender age of 23, I didn't want to run the risk of having far more serious problems when I'm older and (2) my jaw doesn't function the way most people's jaws do. To describe the second point a little more: because of the positions of my top and bottom jaws, when I bite, my front teeth do not touch, but are a couple - few millimetres away from each other. What this means is that when I eat spaghetti or noodles, for example, I don't bite the noodles with my front teeth (the "incisors") to break it. Instead, I'd push the noodle up to my top front teeth with my tongue, and break it in that fashion. Unfortunately, while this method of eating has worked for 23 years, it isn't the right way of using my teeth, and that's a concern.

To have my underbite fixed, I had two options to choose from:
1) Full treatment with braces with removal of teeth
This option meant that I would have one or two teeth removed from each side of the bottom jaw (i.e. 2 - 4 teeth total), and have braces to pull the rest of the teeth together, resulting in the front teeth of my bottom jaw moving back to meet up with the other teeth. The pro being that my jaw wouldn't need to be broken, the con being that I'd lose some teeth.

2) Full treatment with braces and jaw operation
This option meant that I would have, at least, my lower jaw broken and shifted back. With this would also be the required orthodontic treatment to put the teeth in their proper place before the operation. The jaw surgery would negate the need for having teeth removed, and would be able to fix some of skew between my top and bottom rows of teeth. At the same time, this solution would look more natural and would probably improve my facial profile. Dr. Chiang suggested this alternative.

From my Orthodontic Consultation Report To Patient:

"The estimated* length of your treatment is 30 - 36 months; plus another 24 months of wearing of retainers. (*This is just an estimate as treatment can become longer if growth is different than expected, or if patient cooperation is less than required.)"

The cost for treatment would be approximately $6,200, which included $400 for ceramic (clear) braces, which I deemed absolutely necessary for my work which involved meeting with clients.

Over the next month, I had two things to decide:
1) Was Dr. Chiang the orthodontist I wanted to go with?
2) Did I want to have teeth removed or an entire operation?

I spent some time visiting other orthodontists in the Vancouver area as well, so long as their consultations were free. I went to two other offices, including Dr. Virginia Diewert, who is the head of Faculty of Dentistry at the University of British Columbia. Her estimations was in the range of 24 months end-to-end, and at a price of $4,000. Dr. Virginia Diewert is an older woman, who taught Dr. Chiang as a student. Dr. Chiang is also a lecturer at UBC.

I spoke to Dr. Chiang about Dr. Diewert's consultation result and he said the reduced time was probably because she was relying on more work to be done in the surgeon's office and less in the orthodontist's. He believed she was going to have my upper jaw broken in halves (i.e. a left and a right half) because it too narrow; whereas he wanted to try expanding it, which would keep the jaw in one piece.

After a month of due diligence, I decided to stay with Dr. Chiang (for reasons of availability and convenience) and chose to have the jaw surgery over teeth removal.

And so started my orthodontic process...

_{*All prices are in Canadian dollars.}