Author Topic: Deep Overbites and BSSOs (+ wilckodonitcs/segmental subapical osteotomy/crowns?  (Read 1177 times)

Tiny

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Hello all, my first post here.

So, my story. My lower face/mandible is pretty underdeveloped both vertically (ramus) and horizontally (mandibular body) (i.e.retrognathia and microgenia). This is mainly genetic as I have the same face shape as my father (ie round and IMO very unattractive)

I had my original braces on the NHS a teen, starting around 13 with retainers and finishing at 16. I had 4 molars removed due to crowding. No palate expansion, MARA, twin block, dahl appliance or headgear - just retainers and archwires. I got my wires later than most as I was waiting for my 2nd molars to be fully erupted - my ortho chose to remove the first molars as they had developed with poor enamel. The 2nd molars were then moved forward, so that my wisdom teeth had space to come in (which they did at 17.)

I don't really remember what my teeth were like before the braces - despite the retrognathia I don't recall having a huge overbite, but I would have had some. I can't recall what the depth was like before and after the braces either.

Currently my top teeth are basically fine, but I have a slight overbite and crossbite with significant deep bite (about 80%), and a tiny posterior open bite on one side. My face looks absolutely awful front and side when I fully close my mouth :(  Like a frog!  I am going to assume that it's skeletal (rather than dental or soft tissue) as I have a deep sublabial fold and everted lower lip. I recently got a chin implant+neck lipo+sublabial filler to improve the retrognathism - it looks better but it didn't help with the length of my face (maybe I should have got a custom made one). The sublabial fold is still significant despite getting radiesse put in it.

According to all the reading I've done, traditional treatment of deep bite is - anterior intrusion (in the case of gummy smile) or posterior molar extrusion (in the case of short face, like me). HOWEVER, molar extrusion via braces is apparently not terribly stable in adults and will often relapse. It also rotates the mandible down (good) and back (bad) ie. makes the face longer but the overbite/retrognathism worse (which would be desirable if I was going to get the BSSO as my overbite at the moment is not that bad, even though my profile is!)


I want to get a BSSO to improve my profile, so am seeking experiences of people who also had deep bite and short face and needed extrusion of the posterior molars rather than intrusion of the anterior incisors to correct the deep bite.  I would like both more vertical length and horizontal length but think it would be unlikely that I can extrude my back molars enough to still meet if I got a ramus BSSO to lengthen.

Questions
- to those who had a deep bite and an underbite, how did you do your extrusions, has is been stable, and did it result (as it is supposed to) in increasing the overbite?
- does anyone know if it's possible to get wilckodontics before a BSSO?  The way I see it this would speed up the time in braces and also make the extrusion more stable, but does it mess up the jaw too much to get further surgery?
- has anyone had their deep bite corrected with crowns or segmental subapical osteotomy as opposed to regular extrusion using braces?
- has anyone used powerprox to speed up braces?
- has anyone with a lower lip significantly behind the upper lip had significant improvements without surgery?  Custom facial implants can massively improve the jawline but I don't see them improving lip position

thanks all for any insight  :)

overbiter

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Hi, I have similar problems to you. I don't look like a frog lol, I just have an ugly short face. My overbite was corrected with extractions/braces but my facial aesthetics are now screwed.

As many people on this board will tell you, your getting a chin implant was a mistake. You should have researched more and done your homework. If only you had read more posts here rather than on plastic surgery forums you would not have had that done. You should have had jaw surgery and genioplasty, that is always preferable to any implant. Plastic surgeons try to sell you the idea that implants are a safe/good alternative to orthognathic surgery because it is something that they can do. In short they are quacks.

I don't know anything much about Wilckodontics. I stumbled across a mention of it on Archwired when I was reading something about SARPE. It sounded very strange to me, like some kind of voodoo orthodontics. It is in no way a standard procedure from what I've read about JS in the past 12 months. It seems to come from an orthodontics background, and is therefore probably complete bullshit. Other posters here will tell you that orthos are never to be trusted, they have ruined more than one face, mine included. Don't get this procedure - AVOID.

If you want to correct your deep bite/short face you probably need your maxilla lowered a few mm, as well as advancing it. Something like this guy got. By the way, some of your ideas about how to fix your facial problems seem wrong to me. You need to go for a purely orthognathic approach. Don't just try to mask your skeletal problems with orthodontic work/plastic surgery. Do some more research before you ruin your looks for life.

Tiny

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Actually the chin implant and lipo did improve my profile a lot.  I think that chin implants, while not ideal for most people with retrognathism, actually look pretty similar to a plain genioplasty.  I think I got a better result with an implant than I would have with a genioplasty because the implant I got extends to the prejowl area - a genioplasty would have just given me a pointed chin.   I am aware that implants have their issues but they do remain an alternative for those who are not ready to commit to surgery.

I agree that Wilckodontics is not a standard procedure but I don't think it's total bullshit.  It's a periodontal surgery that works by partially degrading the bone, allowing for teeth to move faster, and then bone is naturally remineralized.  I am interested in it because I think it will make any extrusions I have done faster and more stable.  I can't exactly avoid orthos entirely as I will need to see one or more if I do decide to get surgery

I presume you mean advance the mandible, rather than maxilla?  This guys profile is similar to mine but I don't have nearly such a protruding chin pad.  I think my bottom lip is about 8 or 9mm behind my top.  My overbite really isn't that significant which makes me worry that I will need a long time in braces to move everything back before a BSSO

grossjaw

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It sounds like a posterior open bite (back teeth don't touch). I have that. It is not that big a deal for me because they touch enough to chew food. How big is your gap?

I wouldn't extrude those teeth because pulling down on them will intrude the anterior teeth (i.e. every wire force has an equal and opposite force). You'll have less frontal tooth show. If you get counter clockwise rotation via jaw surgery, the posterior teeth should drop down a bit.

Surgery is a big decision so I understand why you're hesitant. But don't extrude molars by more than .5mm, imo.
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Tiny

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It sounds like a posterior open bite (back teeth don't touch). I have that. It is not that big a deal for me because they touch enough to chew food. How big is your gap?

I wouldn't extrude those teeth because pulling down on them will intrude the anterior teeth (i.e. every wire force has an equal and opposite force). You'll have less frontal tooth show. If you get counter clockwise rotation via jaw surgery, the posterior teeth should drop down a bit.

Surgery is a big decision so I understand why you're hesitant. But don't extrude molars by more than .5mm, imo.

Posterior gap is small, maybe 1mm on the right side.  How am I supposed to open the deep bite without a good amount of extrusion, given that I have a short lower face and intrusion at the front will surely make it worse?  If I get jaw surgery and they drop, that would leave more of an open bite not less.  Confused now!!!!

It wouldn't be a total disaster to intrude the anterior teeth - I don't have any gum in my smile but I'm very close and the lower gums are slightly receded due to the deep bite.  So could probably take 1mm of intrusion top and bottom...if it were not for the short frog face.  I really need more vertical length.  I'm starting to get nasolabial and marionette lines and jowling because of my underlying bone structure (I have quite a lot of buccal fat)

grossjaw

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The posterior gap of 1mm should not be a big deal. Not even sure that's worth fixing. It could also be due to a cant or asymmetry tilting that side up. Why are you keen on fixing it? Does it cause any problems?

I'm not exactly sure how to lengthen a short, compact face. I imagine it would be the opposite of shortening a long face, so probably clockwise rotation. But, since you have a deep bite I don't see how that is possible. Maybe by downgrafting the maxilla in a new, vertical position. I'd worry about stability, though. What is your occlusion plane like? Is it flat or typical class2 steep? That would probably determine the possible movements. You could also advance linearly as much as possible, then use the genio work to lengthen a bit. This would maintain or slightly increase length while giving projection.

I know I wrote ccw in the original post, but I was thinking about fixing your posterior open bite. Forgot your face was already short. Now I am not sure...seems complex and unique. Consult with some good surgeons and figure out the options.
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Tiny

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The posterior gap of 1mm should not be a big deal. Not even sure that's worth fixing. It could also be due to a cant or asymmetry tilting that side up. Why are you keen on fixing it? Does it cause any problems?


Because I have a deep bite of about 80% of the front, and it's causing problems with the gums of the lower incisors that will get worse over time. And it means my face is v short. And I have a week chin/jaw.  I do have a crossbite so yet, probably related to a deep bite being worse on one side - but the issue is more the overlap at the front rather than the openness at the back


I'm not exactly sure how to lengthen a short, compact face. I imagine it would be the opposite of shortening a long face, so probably clockwise rotation. But, since you have a deep bite I don't see how that is possible. Maybe by downgrafting the maxilla in a new, vertical position. I'd worry about stability, though. What is your occlusion plane like? Is it flat or typical class2 steep? That would probably determine the possible movements. You could also advance linearly as much as possible, then use the genio work to lengthen a bit. This would maintain or slightly increase length while giving projection.

I think the plane is steep, yes.  The line from base of nose to chin goes distinctly backwards.  I just didn't grow down as much as some class II patients, I think, so have a short face - certainly, the ramus of the mandible seems short, but it's hard to tell - could be in the posterior maxilla.  Opening the bite via extrusion or crowns would lengthen the face (my face looks about the right length if I close my mouth but keep my bite open, which is why I don't want to intrude the anterior teeth).  The face could also be lengthened by ramus BSSO but in my case that would leave me with even more open bite at the back so I don't think that's an option.  Le fort...ideally I'd rather go for single rather than double surgery.  For some reason upper jaw surgeries seem much scarier to me - although I suspect some surgeons will recommend I get both as my upper lip and nose are quite far forward compared to my forehead.  If they did a Le Fort I guess they would move the anterior part inward and then rotate the posterior part downwards, bringing down the back teeth and opening the bite.  The alternative would be do to a subapical block (segmental) osteotomy to bring down the posterior teeth and open the bite - wouldn't help my upper lip position but seems less scary than a Le Fort.  I am not sure how well a lengthening genio would work as it would leave me with a longer, pointier chin when really I need the length at the jaw level.
 
I know I wrote ccw in the original post, but I was thinking about fixing your posterior open bite. Forgot your face was already short. Now I am not sure...seems complex and unique.

Is it really uncommon?  I was under the impression that a lot of class II patients had deep bites and short faces.  Certainly it looks that way from pictures.


Consult with some good surgeons and figure out the options.


Aaaaand therin lies the rub.  I live in the gulf and I don't know how many ortho/maxfac surgeons there are here but certainly it isn't many, maybe 4 or 5.  I'm sure there are some good surgeons in KSA (saudi arabia) because of the high rates of congenital defects but I will never be able to get a visa as I'm female.  The first ortho I consulted here looked in my mouth for 5 minutes, told me 1 year braces, provide no details on teeth movement and charged me $75 - despite me bringing up surgery and them having an consultant ortho in the same practice!  I spend a fair bit of time in London too so could potentially do it there. I'm not against having the surgery in the US but I can't fly out just for consultations - the flight from middle east to California would be 16hours if I get an expensive direct flight.  I could easily travel to Lebanon though.  They love surgery of all kinds!

Anyone know if there are any good surgeons in the US who can consult remotely if I provide them with the relevant CTs an X-rays?

I guess it's time for pictures.  It's actually quite surprising how little overbite I have given my lip positions.  Need to look out some pre-implant and lipo pictures
« Last Edit: May 27, 2014, 05:04:37 PM by Tiny »

pekay

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There are some world class surgeons in Egypt who are on the verge of revolutionizing modern day orthognathic surgery



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grossjaw

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The face could also be lengthened by ramus BSSO but in my case that would leave me with even more open bite at the back so I don't think that's an option.  Le fort...ideally I'd rather go for single rather than double surgery.

Yeah, doing just lower jaw and linear lengthens the face. I will pm you a blog where that happened.
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grossjaw

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on the verge of revolutionizing modern day orthognathic surgery

How?
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pekay

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How?

near accurate 3d imaging (including soft tissue movement) and combination of distraction and surgery
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Tiny

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There are some world class surgeons in Egypt who are on the verge of revolutionizing modern day orthognathic surgery

Any names?  Are they in Cairo? 

pekay

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Any names?  Are they in Cairo?

Yes it's in Cairo, it's a team rather than a single surgeon I think the head guy is Dr. Yehya Mostafa

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grossjaw

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near accurate 3d imaging (including soft tissue movement) and combination of distraction and surgery

any links to that imaging?
i was told the best imagine is 50% accurate.
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pekay

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any links to that imaging?
i was told the best imagine is 50% accurate.

no, you gotta pay to read the entire paper  >:(

i know that Dr Steinbacher over at Yale and Dr SS & Dr RJ use something similar

50% is pretty damn good imo
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