Читать книгу 6Ways to Design a Face - Paul Coceancig - Страница 7
ОглавлениеFor over a decade my wife has been persistently asking me to write a book about corrective facial skeletal surgery. I resisted for a while, thinking the process to be too big, too elaborate, and too broad. After all, the writing process is very introspective, which for me is very isolating, and requires significant time and dedicated sustained concentration. As my wife can attest, to successfully write a book comes at the sacrifice of children, parents, friends, referrers, business associates, and patients.
Over the course of my career up to this point, certain commonly held philosophies, tenets, and basic ideas concerning what is a face, what is abnormality, and what is considered corrective have all needed alteration. These questions and their evolving answers have shaped my thinking and conceptualization of the necessary solutions.
I suppose, in formulating a basis for what follows in this book, I first need to introduce who I am, where I came from, and what made me.
MY STORY
I began dentistry when I was 17 at the University of Sydney in Australia. The Australian profession was then, as it is now, extremely conservative. The professors all hailed from the Commonwealth, so we students became an ordered, intellectualized, and socially privileged group focused on the community benefit of uniformly applied oral health care. Australian style.
At 23, and newly graduated as a “dental surgeon,” I took a job at the local public dental hospital, and while my classmates were entering private practice and buying new cars and homes, I learned to extract teeth and started my fellowship studies with the Royal Australasian College of Dental Surgeons, which opened the door to specialist training positions in oral surgery. This led me to meet Professor John Edgar deBurgh Norman AO, Associate Professor Geoffrey McKellar, and Drs Alf Coren and Peter Vickers, independently brilliant people who would take me into their hospitals and show me orthognathic surgery. I held a retractor and listened while they talked; they advised me to forget about extracting teeth and formed my intellectual connection to orthognathic surgery. Their confidence and mentorship supported an offer for me to enroll in a 5-year specialty oral and maxillofacial surgery (OMS) program across the Tasman Sea in New Zealand. I was the only applicant.
So at 25 I flew to Otago University in Dunedin, where I was enrolled in a shortened medical degree program and also started a combined 3-year specialty degree in oral surgery. I was transferred to the Christchurch Medical School the following year, and with my new girlfriend (now wife) beside me, over the next 4 years I continued to study undergraduate medicine part-time and extracted a lot of teeth, fixed broken jaws, and learned the Kiwi public hospital version of surgically working alongside orthodontists. New Zealand style.
I was 29 when I eventually graduated from both programs. I was a dental surgeon, I was a medical doctor, and now I was a Kiwi version of an oral and maxillofacial surgeon. I was also now married to a Kiwi and had a firstborn Kiwi daughter.
I wanted to return to Australia, so we packed up and headed home. After 2 years of certifying my New Zealand medical degree in Australia, I knew I needed just a couple more years of dedicated jaw surgery mentorship. Not wanting to pursue further training in the United Kingdom, luckily I received an offer from the Singapore General Hospital to work in a private-public capacity under Dr Raymond Peck Hong Lian, a British-trained maxillofacial surgeon. He was to become my final teacher. After almost 2 years of constant operating in this vestige of England surrounded by Asia, I came to practically learn everything there was then to know about corrective jaw surgery. Singapore style.
Sixteen years after starting my training in dentistry, I had completed my Australian specialty qualification in maxillofacial surgery (the FRACDS-OMS) and opened my private specialty office shortly thereafter in Newcastle, Australia. Mostly I extracted diseased teeth for dentists and perfectly good teeth for orthodontists. As it is for most maxillofacial surgeons worldwide, the majority of those teeth were crowded premolars and impacted third molars. Slowly, as confidence grew among my referring orthodontists, a small trickle of corrective jaw surgery cases came through my doors too.
Today my private practice is almost entirely derived from corrective jaw surgery. I now rarely extract teeth.
REFERRAL MODEL FOR CORRECTIVE JAW SURGERY
Because orthognathic surgery is rare, and because it is basically used only following failed specialist orthodontics, the general professional dental view of orthognathic surgery is mostly negative. There is little dental understanding of what corrective jaw surgery is. Rather than seeing orthognathic surgery as being therapeutic, medical, necessary, or something of high reliability or functionality, a referral for orthognathic surgery is often discouraged by the dentist as an unnecessary and highly risky extreme. This pervasive dental view that reduces all forms of jaw surgery to a limited role of only removing teeth means that orthognathic surgery is extremely rare. In all practicality, and regardless of training, most oral and maxillofacial surgeons are reduced only to the role of an oral surgeon.
Few private surgeons practically or routinely offer corrective jaw surgery procedures because orthognathic surgery is seen as secondary to orthodontics. The teeth are always corrected first, followed reluctantly by the jaws.
Rather than seeing orthognathic surgery as being therapeutic, medical, necessary, or something of high reliability or functionality, a referral for orthognathic surgery is often discouraged by the dentist as an unnecessary and highly risky extreme.
In all of my training, I was taught that orthognathic surgery was based upon a pragmatic premise of performing to what an orthodontist wanted. There was simply no other source of referral. And to an enormous degree, this repeat stream of action-reaction generated a master-servant relationship. Orthodontists literally fed oral surgery practices, albeit with dental extractions and mostly impacted third molars, and to a much smaller degree with remedial orthognathic surgery when extraction-based orthodontics simply didn’t work. To run a successful surgical business, I had to fundamentally believe in the orthodontic interpretation of everything to do with impacted and crowded teeth and in the primacy of orthodontists being the first to treat, examine, and interpret.
The major problem with this model, however, is that it traditionally ignores the face and the airway.
MY FIRST ORTHODONTIC EXPERIENCE
When I was 13 years old, my impacted canine tooth erupted extremely high behind my upper lip, and my mother recognized that it would never spontaneously be normal. In 1957, her 14-year-old sister had had an impacted and badly erupted canine removed on the advice of her orthodontist, and at 76 years old my Aunty Pam still complains bitterly of its effects on the symmetry and attractiveness of her face. As a surgical nurse trained at Sydney Hospital in Macquarie Street, my mother resolved in 1982 that her sister’s fate would not also befall me, so she took me to a highly recommended Macquarie Street orthodontic specialist in Sydney.
He advised against my mother’s proposal that expanding my maxilla would allow enough room to easily fit all my crooked teeth. He also said it was fanciful to believe that stimulating my maxilla to expand would somehow correct the underbite I was developing. He believed her proposal very controversial, impractical, and unfeasible. He further explained that I had a very flat middle face, that my cheekbones were naturally small, and that extracting the canine would indeed be a terrible idea and make the whole appearance of my face worse. I remember feeling very ugly.
My father was very skeptical about removing four perfectly good premolar teeth in order to orthodontically bring down a single impacted canine tooth. It was at this point that my mother asked if there was any way to surgically bring my maxilla forward. She suggested that this would improve my facial proportions and possibly make my nasal breathing better.
You see it was no coincidence that on this same famous Sydney street worked my allergist, who every month would give me a needle against my dust mite allergy. Further down in another building was my respiratory specialist who treated my chronic asthma. Next door to that was the ENT surgeon who had removed my tonsils when I was 4 years old. And of course there was also my pediatrician who tried to help me grow normally despite my early recurrent croup, ongoing throat infections, stuffy nose, bad bite, crooked teeth, low energy, chronic snoring, and everything else.
The blank look, slight facial twitch, and total quiet of the orthodontist spoke everything in his mind about that horrible suggestion. His considered reply, confident and calm and practiced, was to explain that my mandible was too big, and when I was old enough I could have it broken surgically to bring it backward. He commented that this operation was horrible and full of risks; it sounded dreadful. It was obvious that extracting some premolars was the infinitely lesser of two evils. He said it would give me a perfect smile. He had dental models that explained the logic of it all. A lateral cephalometric radiograph explained his mathematics. He gave examples. He gave prices. He was a highly regarded dental specialist.
My father wanted another opinion, but my mother wanted to go ahead. In the end they said it was my decision, and my 13-year-old brain certainly didn’t want my jaw broken, and I certainly didn’t like my underbite or the look of my impacted canine, and I certainly didn’t want to look like my flat-faced aunty either. So I decided it was best to remove my premolars. Two visits, two needles, and two teeth on each side. They put them in a jar for me to take home. My mother cried.
My orthodontic appliances were placed a month later, and when they were eventually taken off 2 years later when I was 15, it was not the pretty smile result my parents or I had expected. Even my schoolteachers expressed dismay at the cosmetic result. Four on the floor, braces in 24. All my school friends had had it too. We all had the same straight-teeth, flat-face look. And so too did every other school kid on the Sydney train network. One treatment fitted all. The famous Sydney smile was everywhere. I hadn’t escaped my aunty’s fate.
The orthodontic retainer was very hard to wear. My teeth moved; they became crooked again. The positive overbite the orthodontist had struggled to gain by pulling my mandibular anterior teeth backward and maxillary anterior teeth forward gradually, relentlessly became edge-to-edge. Eventually I had a reverse bite again. My troublesome canine popped out of alignment. I saw my orthodontist every 6 months for follow-up, and every time he just told me to keep wearing my retainer. It was unbearable.
When I finished school and started university, I started experiencing jaw pain. After fabricating my own bite splint, which turned out to be useless, I visited my orthodontist, telling him that I was now a dental student. Essentially I was asking him as a mentor now to help me put all the random problems together, to help me fix them, to fix me. He smiled, said he was proud of me, said I must be stressed from all the study, and promptly referred me to an oral surgeon down the street to have my third molars removed.
When I turned up, the oral surgeon simply filled out a Sydney Hospital booking form. When I asked why I had to get my third molars removed, he told me that my parents had paid for braces and the orthodontist had asked, and of course because of the tooth crowding that came from not wearing my retainer. He wasn’t interested in my jaw pain, saying it would clear up after the third molars were removed anyway. The fact that he was too busy and important to look at me for all the 5 minutes I was in his office made me start to doubt these people. All of them. The dentists who taught me. The dentists who treated me. The science that surrounded everything to do with how faces and bites developed and how they developed together. No one ever really explained anything to me, either as a patient or as a dental student. It was all a complete and illogical mystery to me. Why did everyone need braces for crowded teeth? Why did every kid I know have to have their premolars and third molars removed? Why did everyone need their tonsils out? Why did everyone have allergies, asthma, stress, and jaw pain? Here I was surrounded by books and people and institutions that should have been able to explain it all logically and coherently and scientifically, but they didn’t. I kept wondering how I could have all of these unrelatable separate diseases affecting me? It was like one diagnosis per doctor. Damn was I unlucky.
I decided not to get my third molars removed, and they erupted normally (and I still have them). My jaw pain resolved by simply not chewing anything, my nasal allergies cleared up when I moved out of my parent’s home and into a series of new student houses, and coincidentally I discovered a love for lap swimming, which also saw my allergic rhinitis, atopic eczema, and chronic asthma all miraculously clear up. It seemed all I had to do was escape Macquarie Street and my mum’s insistence on the perfection of a Macquarie Street medical mind.
MY SECOND ORTHODONTIC EXPERIENCE
After moving to New Zealand and talking with many surgeons about what jaw surgery really was, I was still too afraid of it for myself. There was just so little known about it, and the jaw surgeons I worked with in training were mostly operating on syndromal kids and car accident victims. Besides, pushing my mandible backward simply to get a better bite seemed the opposite of what I needed, and my surgical mentors agreed. I was convinced it would surely choke me too, wouldn’t it? No one seemed to agree with me on the potential breathing issues, but nonetheless I thought it was my maxilla that needed to be brought forward, which supported my mother’s original, though very radical suggestion some 12 years previously. In the meantime I had orthodontic appliances put back on to see if I could achieve at least a stable bite and a smile I could live with.
In 1995 my new orthodontist was adamant that the science and predictability of maxillary surgery was still a long way off. The SARME (surgically assisted rapid maxillary expansion) operation was just getting a foothold in the United States, Professor Maurice Mommaerts in Belgium was still 5 years away from developing his bone-borne palatal expansion device, jaw distraction technology was just starting (and badly), routine jaw correction surgery was just beginning a radical renaissance via Bill Arnett in the United States, and custom titanium plates for midfacial surgery wouldn’t be developed in France for another 20 years.
My new orthodontist was convinced he could “grow” my small maxilla with a slower treatment cycle and edgewise brackets. I decided to believe him, and I endured another 2 years of orthodontic appliances, which didn’t manage to grow anything of course. Silly me. I still had a flat midface, a too-big mandible, and a weird smile. And I snored. But I did have straight front teeth in a barely normal positive overbite.
SELF-REFLECTION AND FRUSTRATION
What this repeat orthodontic experience did for me was point out that I could not explain my own face to myself. I could not form a rational argument with an orthodontist. I could not see how all of my component layers and the interrelated parts fitted together three dimensionally. I could not see how my teeth sat in my dental bone, or how the dental bone sat in my jawbones, or how my jawbones sat in my face. I could hardly dissect myself. I could not see where my symmetry or proportionality or bite issues began or ended. And if I couldn’t see them or simply describe them, how could I direct myself to seek the treatment that I needed or understand or critically examine the orthodontic advice I was receiving? And how could I seek to describe anyone’s bite or jaw problems or aim to surgically treat what was evidentially a complex interrelational set of anatomical issues involving many medical and dental and cosmetic themes?
In the 1980s and 1990s there was very little known about how anyone could dynamically see inside a person. There were radiographs of course, but these produced flat 2D views. What I wanted to know was how to construct a whole face, how teeth sat three dimensionally in the pattern of the midface, and how that related to all the structures inside it and outside of it.
Having maintained a schoolboy interest in optics and physics and mathematics, I wanted to build a stereoscopic device to create 3D radiographic images so that I could demonstrate to my teachers my ruminative concepts on volumetric facial radiology. Eventually I made a simple 3D radiographic model of a face. With it I could effectively demonstrate the acquisition and diagnostic simplicity of volumetric imaging. This thing seemed real. It shimmered just in front of the viewer and showed everything in perfect fidelity and accuracy; behind to front, side to side. It was very dramatic when I first saw it, and for everyone since that has seen it too.
After contacting a German engineering scientist who had written on a similar concept decades earlier, soon enough I had a couple of German employees of Siemens visit me in New Zealand to see my setup. I used my physical model as a visual means of explaining the mental image of the future of maxillofacial surgery that I had. I explained that digitizing a series of plain radiographs from a rotating x-ray machine, assigning numerical values to the grayness of the pixels in the image, and then cross-referencing the values to adjacent images obtained in a circle and traveling around an object would enable a suitably powerful computer algorithm to build up the pixels (now voxels) into a 3D space. The Germans were developing this same idea for use in cardiothoracic and arterial imaging using the 1984 work of Feldkamp, Davis, and Kress. While I had no idea how to develop an algorithm to accurately 3D fix the gray value points, I was adamant that the technology, if developed, would be extremely useful in dentistry and for maxillofacial surgery in particular.
I was sure that a dentist could have a unit in the office no bigger than an orthopantomogram machine and three dimensionally image things as fine as a tooth’s root canal system or see entire dental arches and bites.
For me, all I wanted was a simply acquired means of explaining that the face, teeth, jaws, and everything else were part of one complex 3D object. I wanted to be able to see into, expand, revolve, and better imagine facial growth disorders and the corrective jaw surgery steps needed to manage them. Once I had that, I could then describe the symmetry and proportions of the skeleton and dentition of a face. And then I could scan many people and compare them, and see patterns, and maybe move on from there. But I never heard from the German Siemens scientists again.
Many years later, I ran into my old boss, Leslie Snape, at a conference. He told me he still has my invention sitting on a bench in a closed room somewhere in the bowels of Christchurch Hospital. He calls it the original cone beam. I just laugh. I call it a Kiwi version of cone beam. If it can’t be made with pantyhose and sheep-fencing wire, it’s not worth calling it a practical invention. (That’s a Kiwi joke.)
PUTTING IT ALL TOGETHER
Today of course, we have software applications much more sophisticated than cone beam that can accurately duplicate the entire head, segmentalize it, and separate the component parts. It’s upon this digital version of the patient that we can replicate real-life surgery and the volume changes affecting tongues, airways, faces, temporomandibular joints, and bites. One of the best things about digital imagery is that you can start explaining complex things to your patients. It means that I can reduce a compound anatomical narrative to the common language of the visual medium. I still need a certain kind of intellectual ability on the part of my patients, but increasingly the patients who do independently find me are naturally skilled in broad research and innate logic.
Over the years my jaw surgery practice has naturally divided itself between two broad arms.
The first is that I am providing some form of remedial surgical treatment, usually well after orthodontics has come and gone, and usually only in adults who are deliberately seeking my direct care. The majority of these people snore or have health or lifestyle issues related in some way to their ease of breathing. These people find me because they researched their personal symptoms, asked themselves logical questions, and sought a means to explain everything that has and is happening in their lives as one set of interrelated health issues. These people are generally free of an orthodontist referral.
In effect, I offer two ends of a stick. One is a simple end where I use a simple operation to prevent bigger problems, and the other is a complex end where I treat really big problems using really big operations.
The second arm usually involves young adolescents who are accompanied by parents, who have first brought their child to an orthodontist, usually for an overbite correction. These patients usually have an orthodontist’s referral. They are usually the hardest to treat, firstly because they did not independently seek me, secondly because they require a complex and seemingly contrived explanation they do not really want to hear, and thirdly because parents naturally see jaw correction surgery as incredibly invasive.
The ironic thing is that IMDO (intermolar mandibular distraction osteogenesis) is the simplest surgical operation that I offer. It is even simpler than third molar removal, and it usually helps avoid the third molar surgery that is part and parcel of normal orthodontics for overbite correction (not to mention it helps avoid everything else too). But the greatest benefit of IMDO in this second practice arm is that it prevents these adolescent patients from becoming patients in the first practice arm—the adults who come to me for snoring or other problems that lead to jaw surgery remediation through remedial BIMAX (advancement of both jaws).
In effect, I offer two ends of a stick. One is a simple end where I use a simple operation to prevent bigger problems, and the other is a complex end where I treat really big problems using really big operations. Any medical enterprise has two ends like this. At one end are the treatments of the disease after it has occurred. At the other end is the research and the development and the application of treatments that prevent that disease from occurring in the first place.
Why do parents who have children with small jaws and big overbites persist with a belief that orthodontics alone fixes everything? If someone asks me what the true cost is of treating someone with a small jaw, then that total cost must include tonsillectomies, dentistry, oral surgery, orthodontics, TMJ therapy, rhinoplasties, chin implants, sleep studies, CPAP (continuous positive airway pressure) therapy, and finally remedial jaw surgery. But I can only collate these costs if I tie all those things together as one linked or total series. So this question of whether adolescent dental crowding, or bad bites, or even small jaws has any other consequence apart from braces is obviously a very pertinent one. Is there really a link to adult obstructive sleep apnea (OSA)? Will the adult eventually insist on cosmetic intervention? Are impacted third molars inevitable or can they be prevented? Is there any way of correcting a bad bite before it starts? Is there any way to prevent snoring or OSA from ever developing?
There were a number of events that occurred in my life that set me on the intellectual and professional pathway that I now lead. At some point it occurred to me that a narrow dental arch was more a case of a narrow nasal airway. At some point it occurred to me that a small jaw and an obstructing tongue were part of the same condition. At some point it occurred to me that dental crowding and impacted teeth in adolescents presaged the development of OSA in late adulthood. At some point it occurred to me that everything that I was taught in becoming a dentist was not the sum of everything I could know and that it could be built upon.
This book is in effect a chronicle of those ideas and their assimilation into a complex philosophy and then a practical set of new operations and new treatments. My six ways to design a face include IMDO, GenioPaully, custom BIMAX, SuperBIMAX, custom PEEK, and SARME. I am not the inventor of any of these things. The appearance of their originality is a silk screen, behind which lies an indescribably complex history and the serial and compounded efforts and stories of millions of people.
It is unimaginable to me that any person would willingly submit themselves to any of these operations, however simple or complex. Although I have always acted gently and hopefully painlessly, and with compassion and with precision, it is another level completely to trust themselves to be the first to an operation never before performed, let alone believed. So I’d like to thank the patients whose stories illustrate this book. If there is an inventor, it was the individual child who would suggest to me that their condition was curable.
If only I would become as imaginative as their own mind in describing their own condition, and a match to their inspirational hope.
