tads as an alternative to impaction

[falcao]

After my lower-only-jaw surgery (+genioplasty) more than a month ago now, I have been left with (unexpectedly - no one warned me about this) a significant anterior open bite. The surgeon recommended wearing tight elastics immediately. I'm seeing my orthodontist for the first time after the surgery next week. After some research, I realized that I do not want to close the bite by wearing elastics. Elastics pull the upper teeth down to close the bite (I've watched several youtube videos on this that visualize the process). There is an alternative for closing anterior open bites - TADS. This is supposed to have the same effect impaction in surgery does (and even the process is called impaction by some orthodontists).  TAD Open Bite Furthermore, I think my current profile warrants this approach - having had no surgical impaction, my jaw angles are now steeper (although the HA that was applied helped balance the lower third with the rest of the face) and the chin itself could use coming a bit forward (despite the fact that I did have a genioplasty).

So, I have not been wearing the elastics. This is because of an infection I developed three weeks after the surgery and decided to take them off until everything heals and is back to normal; the elastics were painful and uncomfortable only aggravating the very unpleasant situation with the infection. The infection is gone now, I pray that it never comes back. Then in the meantime, after reading about TADS (there is more than one type for open bites, this is another type TAD Molar Intrusion Open bite) I realized that it may be for the better that I haven't. The elastics tend to close the bite quite fast, and aesthetically I'd rather have my lower jaw come up a bit (we are talking here about a significant 4mm or so), then have my upper teeth come down. I don't think I want this Elastics (anterior open bite)

I hope I can find a way to make my orthodontist (not an easy guy to deal with) see my point with this.

Do you think I have a valid point here? Do you have any information/experience on these TADS?

[falcao]

It could be a good alternative for you. I wish I knew more about it to advise you. For open bites, TADs definitely will impact the position of your lower jaw, as few studies (with photos) I have come across say. It is also evident in the youtube videos I linked to. Yes, they move only the teeth in the upward direction, but as they do and the bite closes, the lower jaw comes up significantly (the effect is visually appreciable as impaction is) and the chin a bit forward (I could also benefit from this). The effect is similar to surgical impaction - the face is shorter, more compact. Of course, you need a significant anterior open bite as I have for this to work. Most people who have double jaw surgeries don't, and hence the need for surgical impaction.

I have just gone through a very invasive surgery and I am very surprised i'm left with this much of an open bite (I had NONE before the surgery). But now looking at the alternatives to deal with it, I think elastics are the fast and inferior way out of it, while TADs could be aesthetically and functionally much superior. Please let me know what you think. I want to go armed with knowledge to my appointment with the ortho, as he, of course, will be looking at the easy way out.

If anyone is interested, I could email them my latest x-ray (post surgery). The file is too large to be attached here.

[Modigliani]

I don't understand why you have been left with a 4 mm open bite...what explanation did the surgeon give?

[Optimistic]

Well what is the actual cause of your open bite now? Sorry if you already explained this and I missed it. I know it came after surgery, but are there any more details than that? Over-erupted third molars? Simply an altered occlusal plane?

[falcao]

Yeah, I think it's a case of simply altered occlusion plate. I don't have the surgeon anywhere near to ask him. But this is how I understand it - along with the advancement of the lower jaw, some CW rotation must have happened. This must have been deemed as ideal, but has left me with an open bite. As there was no impaction, the plan must have been to close this with elastics, and I was instructed to wear them post-op. Now, TADs might have the opposite effect of the CW rotation, and that's why I don't know what to do now - wear the elastics and fix the bite by pulling the upper teeth down, or implement TADs. Aesthetically, they are very different options, although functionally they will both close the anterior open bite.

Also, I wouldn't say my open bite is 4mm now. I don't know, it might be around 3mm. By saying 4mm above, I meant the lower jaw should move that much up with the TADs - at least. This is because you allow for them not only to close the bite, but get the upper teeth cover a bit (1/3 or so) of the lower when the mouth is closed (normal occlusion). So, I don't know, the whole movement up may be more than 4mm for me if I choose TADs.

[falcao]

Thanks for the advice, that was very helpful. I will talk to the orthodontist next week and will not insist on TADs. I will let him judge what the best approach is, although I will ask for an explanation.

No, I wouldn't say I regret the surgery. It's too early to talk about the final result aesthetically, and I know my face will change in the months to come. I wouldn't say I had high expectations from the surgery - the movements were quite modest - BSS0 + genioplasty 4.5mm and 3mm respectively. My overbite before the surgery was a bit over 8mm and now I don't have any (I have an open bite but no overbite). The difference between the BSSO of 4.5mm and eliminating the overbite of 8mm I guess could be explained by the fact that there was CW rotation as well. I don't know, I'm making a lot of guesses here. In the weeks after the surgery I have been busy surviving - literally. As you know, the post-surgery period can be very difficult, and the infection I developed with the visits to the ER didn't help either. But even before the infection, recovery has been very, very difficult. Not eating, feeling dreadful, looking dreadful, stomach problems... Only now I'm starting to ask questions and evaluate things slowly.

My only regret may be the extremely small genio - I wonder if it was worth the pain and the money. But I had a chin to begin with (I was not one of those cases with no chin) so 3mm might make a good difference after all the swelling goes down. It's hard to say now what it will look like after few months, as this is one area where swelling persists longer. It's the only area (along with the lower lip) where my feeling is not back 100%.

The HA along the jaw angles and the paranasal area turned out good so far - I can't see any assymetries and the paranasal area was especially successful - along with the stronger jaw/chin it does make me look younger/more attractive if I can say so myself. I like the effect so much that I might even get small silicone implants there in future (easily put and removed under local anesthesia). This is if the HA gets reabsorbed with time or I like a bit more of an enhancement as I age.

[Optimistic]

@falcao that sounds great. Can we expect any before and afters of what the HA paste has done?

[Modigliani]

How's the bite doing?

[falcao]

Sorry for not responding earlier. The bite is closing although slowly thanks to the elastics. The orthodontists explained that the elastics in my case will not pull my upper teeth down to close the bite as I feared they would. He doesn't know why the open bite occurred but he said he would talk to a maxfac surgeon that works next door to him and is familiar with my case as he had seen me before few times. He took x-rays and we discussed various things, including condular stability. He seemed very disappointed with the result of the surgery, but said these things happen (either nature or improper planning) and now we have to deal with them. He said a lot of work remains ahead.

The lower teeth are painful all the time while the upper are not. I assume this is because the pressure is on the lower teeth to move up to close the bite.

I'm having the TADs installed on 11 February - the type where they drill on the palate. The ortho did warn me about the screws getting loose and the possibility of (yet another) infection. He did agree with me that this is the best way to proceed.

On the positive side, as the swelling goes down and the bite closes, even fractions of millimeters, I do look better and more normal every day. I guess that's how much a long face (caused by the dramatic anterior open bite in my case) screws the way you look.  There is also the effect of the chin coming more forward. I hope the TADs will accelerate and finish off this process in 4 to 6 months so that I can finally go back to looking and feeling good.

I have had no subsequent communication with M, although I did give my orthodontist his contact details and told him he could contact him at any time if he needed any clarifications. I'm not sure if he has.

[Modigliani]

You should join the private forum falcao, there are others that have been left in your position and worse.

[falcao]

Thanks for the suggestion, I'm not sure how to do that, but I'll look into that next weekend or so.

[Optimistic]

Hey everyone, just got back from the maxfac surgeon who assessed my cant in more detail. He described it as being mild in nature, and wouldn't recommend upper jaw surgery for something so minor as it'd only cause more complications with aligning the upper and lower jaw. He believed my idea of using TAD's would be a sensible alternative.

I'll update with where they are going to be placed exactly.

He spoke to me about the unknown stability of TAD's when impacting teeth, however said that generally for such a movement, and when the teeth are touching, there should be a reduced chance of any relapse. I asked if I could simply get it done again if I did relapse some years later and he said that this would be an option too.


One thing I didn't find out is how do they determine whether to impact or erupt more? Is it simply the side with the vertical excess that gets the teeth impacted?

I asked too about whether this would improve my lip cant and he said he couldn't tell me. That it's possible, though may well do nothing. He said that when an asymmetry forms the soft tissue can grow around that, in a way. And therefore movement of bone might not help the lip cant. I'm hoping it does. He did mention too that I have full movement of the canted side of my face. It makes me wonder if all else fails, then maybe there would be a kind of botox-like surgery I could get to raise that side of the lip? Anyone know of anything similar to what I'm talking about?

[sean89]

I considered TADs myself because I have a 5.5mm overjet as well as an overbite. I also have excessive front tooth show (I am male), but TADs aren't going to solve that problem, I don't think. Impaction would. I think around 2mm impaction would be really good in terms of orthognathic and orthodontic aesthetics, but the nasal flare is what is putting me off. All the surgeons I have spoken to have said I need to be especially mindful of it. Does anyone have any experience of how bad it can actually be?

[Modigliani]

Falcao, is it possible you could have had a secondary fracture, high on the ramus or even condylar? This often results in an an open bite. Have you been x-rayed post op yet?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052650/

[DrBirbe]

Hi there!
Flaring of the nose after a maxillary impaction is a well known indirect effect of the maxilla movement. In my experience, I have good control of it with 3 surgical manoeuvers: piriform rim remodeling, caudal septum triming and good nasal alar elevators muscles repositioning. If there is concern also about thenaso labial angle, we should do some triming of the anterior nasal spine.
Hope I helped to clarify some doubts.