No more bands!

So, good news, no more bands as long as everything keeps fitting together right, which I'm pretty optimistic that it will.  Also, I've had improvement in my mouth opening, so good news all around.  I started mouth exercises today and will likely get set up with physical therapy next week.  Yeah!  My lower jaw does deviate to the right a bit when I open my mouth, but it comes back together when I close it, so it won't affect function. I may get my arch bars off in two weeks, just depends on how things go I guess.  If it turns out that I have some kind of heart problem I may get them removed at the hospital instead of the office.

I'm liking my doctor and the staff there more and more.  While I was waiting I heard her explain the same thing in 5 different ways to another patient.  I admired the patience, and it reminds me of why I didn't want to be a clinical dietitian, or any other kind of health professional. I really shouldn't judge the patient though, I've probably been like him at some of my appointments :) Two other patients were speaking with nurses trying to decide what kind of pain relief they wanted on the spot: anestesia vs numbing shots + laughing gas and another laughing gas vs numbing shots only.  I can't imagine not deciding this before I went in for whatever procedure they were having, but perhaps I think about this crap too much.

Hoping that my cardiology appt. on Wednesday goes well and everything is normal.  Although if everything with my heart is normal, what is causing me to feel lightheaded when I stand up?  I'm so thankful there are doctors to figure all this stuff out.  I just hope that I get an answer in the end, and that it ends up being something easy to treat.

Orthostatic tachycardia

Back from my PCP and I actually have orthostatic tachycardia.  So, my blood pressure is normal, but my heart rate is going up too much when I stand up. I had an EKG done in the office and it was normal.  Now I get to see a cardiologist next week.  Yeah, more doctors.  Not too worried, my doc said that 90% of the time everything is normal.  And the rapid heart beat and mild nausea I've been feeling and attributed to anxiety probably isn't.  So, less mentally ill and more physically ill?  Yeah?  For now I'm on a high salt and fluid diet as that should help with my symptoms.

another boring update

I am very happy that my bite seems totally stable.  Hopefully this means that I will be able to stop wearing the bands at night and then get my arch bars removed soon.  The past few night I've been waking up a couple of hours early 'cause my teeth hurt from the pressure of the bands, taking them off and then going back to sleep.  Last night I woke up at 3:00, decided that I couldn't really take them off yet, slept until 6:00, woke up again and took them off and slept another couple of hours.  I am really tempted to leave them off at night, but I'll be a good patient.  Maybe if I take some aleve before I go to bed tonight I'll be able to sleep without annoyance.  Despite this, I am so totally psyched to have freedom from the bands during the day and not have to worry about my jaw going where it shouldn't.  I still can't open my mouth very far at all, but hopefully soon I will see some improvement. At least I should be able to start doing mouth opening exercises after my next appointment since everything seems to be going well.

Tomorrow I have to see my primary care doctor as I've been feeling lightheaded when I go from sitting/laying down to standing.  This happens occasionally to everyone, but I've been having it a lot the past week or so, probably about half the time.  The medical term is orthostatic hypotension.  It hasn't been a big deal, I feel fine after a few seconds, but is a bit worrisome since my jaw fractures happened from fainting.  I certainly don't want a repeat of that.  I know from my last visit that all of my blood work is normal.  The doctor said at that time that I would need to get an EKG if I started feeling faint again, so I guess that is in my future.  Hopefully nothing is wrong and I'm just reacting to my weight loss or something.  Really tired of going to see doctors at this point.

And they're off again

So, my appointment was yesterday and meh, more waiting essentially. New band arrangement, and I'm to leave them off during the day unless my bite gets really off in which case I'm to call and come in again. Basically its a balancing act between trying to get more mobility in the joint without having my bite shift over. She said my bite might be off initially and then improve once the muscles start to relax. Also, the joint noise may or may not get better and I may or may not need surgery later on. Just a lot of unknowns. Oh, also, I asked her about the possibility of orthodontics correcting the teeth shifting I had from my front fracture and she said yeah, but that I'd likely need jaw surgery to correct my openbite/overjet (unrelated to my injury) before getting braces. hahaha FML  Anyway, that's down the line, I just want to get to somewhat normal functioning and go from there.


I'm getting really tired of this but all I can do is what I'm told and try to be patient.  I am encouraged that my jaw doesn't seem to be moving over today with the bands off.  Tried chewing a bit today and really found myself annoyed by the "stuff" on the left that is making noise and feels icky.  Mental state has improved as well.  I'm trying to keep perspective on the whole thing.  Yes, its a pain in the ass, but its not life threatening or even particularly painful. 

Bands back on

I unfortunately had to start wearing the bands during the day again because my lower jaw is still trying to shift to the right, which causes my bite to be misaligned. I am happy to have my appointment tomorrow so that I can discuss this with my doctor. I am getting very aggravated with my lack of progress.  I've been in the bands for 3.5 weeks now and can still only open 1cm.   I am still hopeful that exercises/physical therapy will do the trick for me in terms of mouth opening, but that likely won't solve the problem of my jaw trying to move to the right.

It also occurred to me why my doctor would wait so long to get an MRI to check for soft tissue damage if I continue to have limited mouth opening  (she previously told me 3 months). The arch bars are likely made of steel that would be subject to the magnetic field of the MRI and would therefore need to be removed before I could have an MRI.  Just a guess, and another thing to ask my doctor about.

On Friday I had lunch with a friend who has had corrective jaw surgery (jaw advancement) and just about everything else done to her mouth (braces twice, wisdom teeth extraction, gum surgery).  It was nice to talk with someone who has been through a similar experience.

First day without bands

Today is the first day I get to take the bands off during the day and only wear them at night.  Hoping my bite doesn't start shifting on me and that I will have improvement in my mouth opening (currently around 1cm).  My teeth don't really fit together perfectly on the right anyway, and I don't know if that is a pre-existing condition (I never really paid attention to how my teeth fit together before), or a result of the front fracture I had.  I can feel a little bump where the fracture was/is so while it was pushed back into place and plated during surgery, its not perfect. Anyway, its probably not a big deal and I've read that adjustments in how the teeth fit together can be corrected with orthodontics.

My main concern with the jaw right now is the noise/feeling on the left.   In addition to the noise, I can feel mild resistance when I close my mouth. Not all the time, it only happens when my jaw is moved far over to the left, and happens naturally  ~3-4 times each time I eat.  It's not painful, just very weird and feels creepy, almost like I'm chewing on the inner workings of my mouth, haha.  I don't know if that's scar tissue or what, if it will get better with time, and if that is what is preventing me from opening my mouth further.  It's definitely top on my list to talk to my doctor about at my Monday appt. Otherwise I'm doing well, just getting tired of eating the same kind of thing. I really think that even another 1/2-1cm mouth opening would really improve my ability to eat different types of foods. At that point I'd likely be able to chew a bit.

Causes of jaw fractures/crap on the internet

According to an article referenced in http://emedicine.medscape.com/article/1283150-overview the most common causes of jaw fracture are 1) car accident 43% 2) assault 34% 3) work accidents 7% 4) falls 7% 5) sporting incidents 4%.

With these stats in mind, I wonder how many of the healthcare providers were skeptical when I told them how I broke my jaw.  If I hadn't been in so much pain myself, I would have felt sorry for my husband as he recognized that some people probably wondered if he was a wife beater.  Everyone was very professional/nice though and I think they accepted my account of what happened.  The fact that I had multiple fractures likely made it more credible as assaults tend to result in one fracture and not typically in the places on the mandible where mine are.  Car accidents and falls are more likely to result in multiple fractures as the impact force is greater.  Who knew that falling and hitting a sink is generally worse than being punched in the face?  It's certainly not something I would have guessed.

The stats explain all the stories I found on this forum from people who claimed they were "sucker punched" that resulted in a broken jaw. Also, in searching for how they remove arch bars (in terms of what is used for pain control) I stumbled across a dental student forum with generally negative impressions of patients with mandible fractures.  One even said that he heard another dentist state that he'd never met a mandible fracture that didn't deserve it.  Nice.  From their descriptions most didn't really provide adequate pain control, but that most people could take it.  One even described how he had one patient remove them himself.

I am glad that my doctor offers the option of being put under for removal  (other option is numbing shots and laughing gas).  Both of these options are superior to what a lot of other patients seem to get.  I think the difference is likely the fact that I have insurance and can go to a private doctor rather than a county hospital.  Perhaps I am wrong, I hope so.

I feel that since I am concentrating on the negative that I should note that all of the other information I have found on the internet has been very helpful :)  There's lots of great tips out there for maintaining dental health while wired, advice on eating and what to expect throughout the recovery process.

Anyway, finally got around to watching the Simpsons episode where homer breaks his jaw.  It's not the funniest Simpsons episode, but I did laugh when Dr. Hibberd gave Marge a pamphlet about broken jaws that said on the front "so now your life is ruined".  I am also very thankful that I did not have hideous headgear as Homer did in addition to having his mouth wired shut.

Yeah for Elmo!

Today is a major breakthrough, I was able to fit my elmo toddler toothbrush in my mouth and brush the inside of my teeth!  I couldn't get to the bottom front ones, but all the others were accessible!  Yeah!  I'm pretty sure this is even better than eating pizza.

Back from the doc part deux

Back from the doctor and everything is progressing fairly normally, though she did say I'd likely be in the arch bars longer than the original plan was. It's not unusual to have little progress in opening until when one is only taking the bands off for eating.  So hopefully I'll see more progress when I'm able to wear them at night only. I'm not ready for that at this point, 'cause my bite is trying to pull to the right, and the bands will help prevent that from happening. In one week I'm supposed to wear the bands only at night and see how that affects my bite, then my appointment is a several days after that and she'll check my progress.

Depending on how things are going she said she'd probably start me on some jaw exercises then.  If that fails, I'd see a physical therapist. I asked for worse case scenario and she said it would be basically a joint replacement (if I'm remembering correctly), but she really doesn't think its going to come to that.  If I did need surgery down the line it would most likely just removing scar tissue to regain better mobility in the joint. But hopefully time and exercises will allow me to regain function and it won't come to that either. Of course I wish she or I could predict the future, but sadly that is not possible.

Good news is that the noise I'm hearing from my jaw probably isn't an indication of disc damage, I don't remember exactly what she said could be causing the noise, but it seemed plausible.  I wish I had a better memory :)  I also have a new rubber band position.  I've gone from two diagonals to one rectangle to a triangle on the left, the right side has consistently been one diagonal.  This new configuration feels the most natural to me.
Totally random, but why does the plastic thing I use to put my bands on glow in the dark?  I can't imagine having any success trying to put bands on in the dark.  Maybe there people out there that are more talented than I am.

little noises, jaw moving to the right

First off, spirits are much improved.  I think I've reached the "I'm broken, screw it" stage of acceptance lol.  Of course that doesn't mean I'm not trying to think of a million questions to ask my doctor at the appointment tomorrow.  Knowledge is power and whatnot :)

Newest development is that I've noticed that with my bands off my jaw wants to move to the right, which I know is not a good thing.  At least the bands keep it in place otherwise.  It may be due to the fact that I am capable of moving of moving my jaw ~4 mm or so to the right and have zero movement to the left, as in can't go past center alignment.  Perhaps that's why the new band configuration hurt quite a bit for the first a few days, it keeps me more aligned to the left. Also noticed that if I move my jaw downward to the right, no noise, if I try to move it to down to the left I get a slight creaking noise, which is also I'm guessing not good. I wonder what the physiological age of my TMJ is going to be after all of this...I'm "only" 32 so that joint needs to last me a long time.  Doc did mention at last visit the possibilty of arthritis in the joint down the line.  But honestly I could care less at this point...I just want to have a good outcome in the interim.  If I have to get tmj replacement, or whatever the heck they do at some point I'll deal with it then.  Hopefully if its far enough down the line they can fix it with lasers or something really high tech, cool and pain free, haha.

On a positive note, I had some cheese fries for lunch today.  I cut them up into tiny pieces and just swallowed them.  Tried to chew on them, but they just got stuck in the back molars so quickly gave that up.  I'm so thankful to whoever invented water piks or I'd spend half the day trying to get crap out of my teeth/arch bars.

I hope that anyone who is reading this with jaw fracture (as if anyone reads this) is having a better time than I am.  I saw someone with a leg on their cast a few days ago and found myself feeling jealous.

Dreams about being wired

Back when I was still wired I had a few really strange and funny dreams.  In the first one I dreamed that while sleeping I decided to cut all of the wires off and then woke up (in the dream) was really pissed 'cause I knew I'd have to get it done again.  Then I realized was dreaming and tried to wake myself up, failed, and then had the same dream over and over with minor differences.  In one I didn't realize I had removed them until I started eating a chicken nugget and at that point recognized the fact that I had cut them off.  This dream happened 6 or so times in one night.  Very weird, lol

The other I recall is that I was chewing really sticky gum and that's why I couldn't open my mouth.  I woke up fighting against the wires.

Tomorrow marks 4 weeks since the accident and 8 days since having the wires removed and bands put on.  No improvement in my ability to open my mouth at all, blech.  Patience...

Open vs. closed reduction of condylar fractures

There's quite a bit of scientific literature out there on whether condylar fractures should be treated closed (wiring/arch bars) or open (surgery where plates/screws are inserted).  Surgery involves more immediate risk (nerve damage etc., unsightly facial scars, infection), but outcomes are slightly better (less chance of limited mouth opening (<4 cm), misaligned bite, chronic pain) and there is quicker return of function to the jaw.  There is some debate/disagreement in the literature that I've read, but overall, most recommend closed reduction since its essentially a toss up unless the patient has mitigating factors like an eating disorder, severe displacement, no teeth, other facial fractures, etc. as surgery is thought to be more tramatic to the patient.

So while I totally think my doctor did the right thing in my case (closed reduction) according to the science that is available now, I do sometimes think that I would have preferred to have my face cut open instead.  This is no doubt colored by the fact that I'm extremely frustrated right now, and that the open reduction I had on my parasymphasis fracture was a very easy recovery (the incision there is invisible, down through the chin, at least in comparison to the primarily mental crap I'm dealing with now. Now its also likely/possible that incisions by the condyle are more risky/more difficult recovery than what I had done on my chin. I think my doctor may have even mentioned this.

However, I do wonder if the people who are conducting these studies may be underestimating how difficult it is to have your mouth wired shut, or have very limited mouth opening.  One study I read did evaluate depression, and only a few patients met diagnostic criteria for depression.  Having some experience with the psychological scales from my previous jobs, I know that I would not qualify as depressed either, but that doesn't mean that my mental state is ideal right now :)  I.e. someone should look at subcliinical and more linear measures of mental status as well, perhaps using the POMS scale that we've used in some of the studies I worked on previously (http://en.wikipedia.org/wiki/Profile_of_mood_states).  Perhaps this has even been done, I have not done an exhaustive search of the literature as 1) I don't have easy access to all journal articles anymore and 2) obsessing over this probably isn't healthy for me right now.

Anyway, overall outcomes at one year follow up are quite good with either method. In one study, only 15% of patients with bilateral condylar fractures had maximal mouth openings less than 4cm,  and this was the most common complication.  Numbers were even better for those with only one fractured condyle. Misaligned bite was the next most common though I don't recall the percent.

I have no doubt that my perspective on all of this will change a year from now and will likely be dependent on my functioning at that time, regardless of what the literature says, 'cause even I (science is my religion lol) am not that objective.

ETA: I've noticed from my blog stats that a lot of people are referred to my blog from this post, so I feel compelled to mention that I am certainly not an expert on this.  I also have questions as to how much the recovery period is shortened with open as opposed to closed reduction.  To me this is a key question as jaw wiring/rubberbands, limited mouth opening is pretty freaking terrible, both physically and mentally from my perspective. I'd have taken several days of being in severe pain if it enabled me to eat more normally a few weeks earlier.

 The choice also depends a lot upon how comfortable/experienced  your doctor is with surgically fixating condylar fractures. Still, I do think that it's something worth discussing with your doctor, particularly if you have multiple fractures, or some other characteristics that make the choice not so clear cut.  Of course in most cases this discussion is unlikely to occur (at least not by the patient's initiative) as the decision is made quickly after the fracture when the patient is unlikely to have looked into the matter at all.

Bruxism (teeth grinding/clenching) and the broken jaw

So I've had a big problem with teeth clenching on the left side since I broke my jaw.  My husband had mentioned that I would occasionally do this in my sleep prior to the accident, but it wasn't a regular thing and if never caused me problems before.  Well, now its a big pain in the arse, because everytime I do it I wake up in agony.  Last night I only woke up once and fell promptly fell back to sleep so it was a great night.  The night before was terrible, I got around 4 hours of sleep and had one really bad episode where the pain was really terrible. It's hard to go to sleep when you have fear that any second you'll be awoken in pain.  It reminds me of a much less extreme example of what the young people in the nightmare on elm street movies go through :)  Luckily, my doctor said that I'm probably not causing further damage to my jaw, but that obviously I need to be able to sleep/not be in pain.

So, in addition to what my doctor told me to do (valium and heating pads), I looked into what causes/contributes to bruxism and stress and lack of sleep are some of the big modifiable risk factors.  Also mentioned was acid reflux, though I couldn't find a whole lot of scientific evidence for it.  Still, I've been having some major acid reflux lately.  I normally don't have a big problem with it, but stress and certain foods/alcohol bring it on.  I used to take OTC meds for it about 1-2 times/month and had a bad time of it about 6 years ago when I was stressed out at work. So, I contacted a pharmacist friend of mine to find out what would be best to take and he recommend prilosec.  So, I'm not sure if that helped with the teeth grinding or if my effort to calm down and relax for a few hours before helped, but either way I'm happy.  I don't need to be feeling nauseous in the morning from reflux anyway.

Back from the doctor

Well, I'm back from the doctor's office and feeling much better.  Basically I just need to be more patient.  She said its possible that the disc is inflamed/damaged on the left side and that's why I have more resistance on that side.  If its damaged, they can't tell by x-ray, I'd need an MRI for that and its premature to have that done  They'd only consider doing that like 3 months post surgery. I did have another x-ray done and the left condyle is a bit rotated, but that shouldn't affect function, but could explain why I have more pain. She also mentioned the possibility of physical therapy down the line if needed and that the breaks I had were/are bad. At least I think that's the gist of everything she said.  It's hard to remember stuff when your emotions are kind of crazy.  Bottom line is that nothing new to worry about at this point :)  The recovery is just going to be long.  From this I've learned that comparing myself to others with jaw fractures isn't such a good idea 'cause everyone's injury is different.  I just have a hard time dealing with the unknown.

She switched my bands around a bit which is irritating me a bit, but not a big deal.  I now have to fit one tiny band around 3 arch bar loops at the top and 3 at the bottom on the left side.  Hopefully it won't be too hard to do.  Next appointment is in 1 week.

I remembered to ask her about exercise and she said I could, just to take it slow.  I'm also back on the valium (its a muscle relaxer) at night to help prevent the teeth clenching on the left side that I'm still doing.  The past couple of days I'd been waking up with that side feeling sore so I suspected I was still doing it, and then last night it caused enough pain to wake me up. Valium is awesome, but I kind of hate taking it 'cause I've read about how addictive it is.

I'm going on a cruise in 3 months so I better be able to eat somewhat normally by then.  Otherwise I am going to be very sad looking at everyone's delicious food.  I figure it will be a good place to put back on some of the weight I've lost and will likely continue to lose despite my best efforts.  It's time for me to get more creative now that I know that its not going to get significantly better for a while.