Camouflage in Orthodontics

[notrain]

http://orthocj.com/2009/10/camouflage-in-orthodontics/

I found this while researching questions for my consult next week. Here is basically what happened to me (I am class 2 div 1 and had orthodontics without extractions as a teen):

Displacement of the teeth of both arches moving the upper teeth back and the lower teeth forward.
With fixed appliances, this is accomplished by class II elastics, The typical response to class II elastics, or their equivalent, is modest retraction of the upper arch, major forward displacement of the lower arch, elongation of the upper incisors and lower molars and rotation of the occlusal plane down in front /up in back.
The two big problems with doing this are that the result is likely to be neither stable nor esthetically acceptable. First, moving the lower arch forward place the incisors in an unstable position, so that either the patient wears retainers forever or there is relapse toward increased overjet and lower incisor crowding as these teeth tip lingually. If a deep bite was corrected with this pattern of tooth movement, it is also likely to recur as the lower incisors erupt after moving back. Second, the tooth movement tends to accentuate the chinless appearance of the patient, because the lower lip goes forward but the soft tissue chin usually goes backward as the mandible rotates downward and backward. Extrusion of the upper incisors increases tooth display and may lead to a gummy smile.
For these reasons, giving the dentition a class II elastics trip is almost never satisfactory. Not only is the result unstable, it fails the test of concealing the underlying deformity and can make the deformity more obvious. The implementation of a genioplasty to move the chin forward sometimes can make treatment of this type esthetically acceptable.

So, basically my orthodontist made me uglier during the most important time (puberty) by camouflaging my skeletal overjet dentally which enhanced my chinless appearance and flattened my upper lip which also appears longer now because it isn't curled outwards anymore. This has also caused a slight midface deficiency because of the now slightly retrueded maxilla. Also, I will now need bimax surgery because he retruded my maxilla a tiny bit (2 or 3mm) and the surgery is more complex because all my upper teeth are too far back and all my lower teeth too far in front in their relative arches. I literally would have only needed a simple BSSO without ortho camouflage treatment.

I just wanted to leave this here to prove, that even without extractions, class 2 / 3 orthodontics are detrimental if they aren't coupled with surgery.

[notrain]

Do you happen to know if class 2 elastics treatment can be reversed?

I am going to need extraction of 2 lower premolars anyway, so could the lower segment be pushed back and the upper arch brought forward by applying class 3 elastics ? Basically I'd like to undo what was done before. I also wasn't in elastics for very long during my first treatment. Maybe 3-6 months during the end of treatment.

If you don't know, I will ask the ortho next week and share his answer.

[Tiny]

Sounds like my treatment plan, too.  I'm class 2 and also had elastics PLUS upper and lower molar extractions.  I am quite sure that did no favours to my face.  My upper lip is much narrower than it should be due to my incisors being pulled in and the lip following them under.  I was having a close look at my Father the other day, we have very very similar teeth and facial bone structure.  However, although his chin is small, it's not receding in profile like mine is.   I am sure that moving molars and closing up that huge gap when I was 14 didn't exactly do a lot for my bone development 

Honestly, a quite lot of people who are significantly class 2 or class 3 should just get surgery at 16 (girls) or 18 (guys).  If I'd got a BSSO at 16 or 17 then I would have had room for my wisdom teeth without the need for extractions.  Luckily for kids now, it's becoming more routine.  I mean I went to highschool with a girl who had a major open bite and even she didn't get surgery on the NHS whereas now, I think she definitely would.

 

all my upper teeth are too far back and all my lower teeth too far in front in their relative arches. I literally would have only needed a simple BSSO without ortho camouflage treatment.

Yup, same, I think.  Now I will struggle getting enough overjet to correct the profile deficiency.  And extractions are not an option as the f**kers already yanked out my molars. 

[notrain]

I'm going to ask if it's reversible. In theory, class 3 elastics should reverse class 2 elastics and closing the extraction spaces in the lower arch takes time anyway, so it shouldn't take additional time. Furthermore, the text says class 2 elastics reverses itself partially anyway without a permanent retainer which I never wore / had.

Also, elastics don't cause much skeletal change. I read a study that compared elastics to the herbst appliance and the occlusion changes for elastics were 4% skeletal and 96% dental. Since elastics don't have absolute anchorage against the bone like TADs or headgear, the ortho should be able to undo all or at least most of the movement. I don't even understand how they can move molars a significant distance by using elastics. I hope the ortho can shed some light on it.

But it's still ridiculous how they treat people without even telling them that only surgery would provide the best outcome. I probably would have needed only like 3-6 months braces, surgery and another 6 months braces back then (see childhood pictures thread in the private forum). Also my 3rd molars had room in my upper arch but i got all of them extracted because they were lying flat in the lower.

Lastly (ccg pay attention), I read that for perfect results bimax is always needed, because a skeletal deficincy of one jaw always causes an adaptation in the other jaw. So for class 2 a mandibular retrognathia will cause some alteration to the normal development of the maxilla. it will obviously less severe than in the originally affected jaw but still requires surgical repositioning for a perfect aesthetic result. if you were brutalized by ortho treatment, then bimax is a no brainer.

[Gregor Samsa]

This can happen naturally as well as it happened to me.

[Tiny]

I don't even understand how they can move molars a significant distance by using elastics. I hope the ortho can shed some light on it.

I'm not sure but it can obviously be done...on me they closed the gap between my bicuspid and 2nd molar with wires and elastics and that had to be 7mm or so.

It's interesting to note that my sister had class 2 elastics as well and although her bite is not as bad as mine, she does still have a slight overjet, overbite and profile recession.   However, neither of our parents, not grandparents, have a skeletal overjet that's visible in profile.

[notrain]

I'm not sure but it can obviously be done...on me they closed the gap between my bicuspid and 2nd molar with wires and elastics and that had to be 7mm or so.

Yes, but most of this space closure was the front segment moving back. Molars are usually used as anchorage because the move very slowly or not at all. From what I understand, class 2 elastics share the compensation between the arches, i.e. the lower moves against the upper and vice versa but the lower arch takes the brunt of the compensation (moves forward a lot). This is most likely the cause for both our gum recession (yours at the incisor mine at the canines). I had never had crooked teeth either, they were all pretty and straight. No problems biting and chewing either, just an overbite.

It's interesting to note that my sister had class 2 elastics as well and although her bite is not as bad as mine, she does still have a slight overjet, overbite and profile recession.   However, neither of our parents, not grandparents, have a skeletal overjet that's visible in profile.

That's the whole point of elastics. To eliminate (mask) the dental overbite but at the cost of unmasking / accentuating the skeletal overjet. I also read that patients (who show up for their initial treatment assessment) whose lower lip is well behind the upper lip and above their chin are IDEAL candidates for surgery and very poor candidates for class 2 orthodontics (upper teeth extractions and front segment retraction). This was my situation pre orthodontics and probably yours as well.
That's why you and I did not have bicuspids extracted. We should have had surgery but ended up with the only (and very inferior) orthodontic solution of class 2 elastics - a very expensive and time consuming uglyfication process. I can only imagine that BSSOs were way more brutal 15 years ago when I had my orthodontics, maybe that's the reason why I wasn't recommended doing it. Still would have been nice to have been given the option....

[notrain]

the last thing i haven't figured out yet, is how much overjet they can actually reduce by doing a class 2 elastics treatment if they don't extract any teeth.

The only space in the upper arch available in cases like these to retract the upper front segment are the tiny spaces between each tooth + whatever you can reduce by retroclining the incisors.

For the lower arch, you can move the back molar maybe 1 or 2mm doing this and tilt the lower incisors and canines outward.

Looking at my ceph, I can clearly see that that the lower molars are upright and starting with the bicuspids everything starts leaning forward, my incisors are severely proclined. I only think it's stable because I have crowding in my lower arch and the incisors can't upright by themselves because they can't go anywhere.

I have 4mm overjet right now, so if they reduced it by 6mm /w class 2 elastics, then I originally had 10mm overjet. Is that a feasible guesstimation ? I think if I could get a surgical lower jaw expansion (like SARPE but for lower jaw) I wouldn't even need extractions because the lower teeth could be pushed back and uprighted to give me the 12-14mm overjet which is the amount needed for the BSSO portion of my bimax surgery. My surgeon offers this procedure, it's called mediane Unterkieferdistraktion. They cut the bone between the lower incisors and put a distractor in your mouth which widens the lower arch over the course of a couple of weeks. The other thing is that I don't remember being in elastics that long. The page I quoted in the op says another effect of class 2 elastics is "rotation of the occlusal plane down in front /up in back". This means a clockwise rotation of the occlusal plane, making it steeper. From my ceph, I do not have that. Mine is horizontal, which would indicate the class 2 elastics portion of my treatment wasn't that long because it didn't significantly extrude my lower molars to rotate the occlusal plane.

If I do indeed need extractions, I figure the ortho will propose removing the lower bicuspids next to the canines and rotate the canines back into the vacant space while simultaneously pulling my lower front back with class 3 elastics and pushing my upper front outwards.

Do I qualify as deputy orthodontist ?

[notrain]

Found something else (class 2 elastics without extractions on class 2 div1 patients):

http://www.angle.org/doi/full/10.2319/071006-283

Note how the lower face height angle changes as well, so this treatment plan is also used to turn class 2 div 2 people into class 2 div 1.

So the lower Molars do indeed move quite a bit (~ 2mm). The uppers mostly tip mesially (forward). Looking at my ceph, yes that's true. Here's a table detailing all of the changes (UA means elastics with archwires, RMCC is a chin cup torture device which is probably irrelevant for us older folks):




They managed to reduce overjet by 5.2mm so my 6mm guess wasn't that far off.

[notrain]

Could someone with private forum access verify something for me please?

Look at the cephs of myself, celticcavegirl and dantheman

look at our occlusal planes

look at our spines

my spine is mostly straight with a almost perfectly horizontal occlusal plane
the spines of ccg and dantheman aren't that straight and their planes are steeper

my hypothesis: ccg, dantheman and myself all have the same skull / facial type with naturally (!!!!) low mandibular plane angles and flat occlusal planes.

ccg and dantheman both went through class 2 elastics which artifically steepened their occlusal planes and now their bodies try to compensate for this steepened occlusal plane by altered posture (look at their spines). basically, they are subconsciously altering their posture to flatten their occlusal plane.

my occlusal plane wasn't steepened that much by my ortho treatment, therefore my spine is still mostly straight.

does anybody know if ccg and dan have back pain / posture problems ? am i crazy ? need i be checked into a mental hospital ?

[Tiny]

Could someone with private forum access verify something for me please?

Look at the cephs of myself, celticcavegirl and dantheman

look at our occlusal planes

look at our spines

my spine is mostly straight with a almost perfectly horizontal occlusal plane
the spines of ccg and dantheman aren't that straight and their planes are steeper

my hypothesis: ccg, dantheman and myself all have the same skull / facial type with naturally (!!!!) low mandibular plane angles and flat occlusal planes.

ccg and dantheman both went through class 2 elastics which artifically steepened their occlusal planes and now their bodies try to compensate for this steepened occlusal plane by altered posture (look at their spines). basically, they are subconsciously altering their posture to flatten their occlusal plane.

my occlusal plane wasn't steepened that much by my ortho treatment, therefore my spine is still mostly straight.

does anybody know if ccg and dan have back pain / posture problems ? am i crazy ? need i be checked into a mental hospital ?

It's possible.....I'm not sure - for a couple of reasons
1) the posture in which the ceph was taking is not exactly natural standing posture?

2) if you look at your gonial angle itself, it is quite acute, near to 90 degrees.  Mine is more obtuse.  Consider that I began my braces at 13, and had archwires at 14-16 - this is later than most.  I would have thought that by the time I got my extractions and my elastics (which was when I was either 14 or 15), a significant proportion of my facial bone development would have already taken place, given that most women stop growing at around 15 and I feel that most of the child-> adult facial changes happen between 11 and 14. (having said that, I went through puberty about 2 years later than average so it may be in my case, my face was still changing a bit).  Along with the difference in angle, I have a shortened ramus, and you don't really.  However, I have always had a short, round face...so yeah, it might be orthodontics, it might be genetic, it might be both

As far as I know, I don't have any posture problems.  In fact I always stand up straight.  I only get back pain when I sit at my computer all day.  However, I think my head/neck posture is quite 'forward' -

[notrain]

It's possible.....I'm not sure - for a couple of reasons
1) the posture in which the ceph was taking is not exactly natural standing posture?

I don't know, when they did mine they asked me to stand like I stand normally.

As far as I know, I don't have any posture problems.  In fact I always stand up straight.  I only get back pain when I sit at my computer all day.  However, I think my head/neck posture is quite 'forward' -

I am obviously not an expert, but in that picture your spine is exactly like in your ceph. I tried to illustrate it on the left. I simply used a perfectly vertical line on the right to illustrate the difference, but obviously even a perfect spine would have a slight S-Curve.

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[dantheman]

I dunno man. I had elastics for a few months at night and only at the age of 17.5

Couldnt have done much to my skeleton, and looking at the pre-ceph its not much different. I sometimes wonder if posture messes up the occlusal plane and not vice versa (eg: if you stick your face forwards your muscles are basically pulling down and back on your jaw). And yes i have forward head posture and yes I get horrible upper back pain at times. Parents really need to put more effort into monitoring their children's growth.

Who else has flat feet? I think this messes up the whole posture and maybe even explains everything from the bottom up, literally.

[x]

Who else has flat feet? I think this messes up the whole posture and maybe even explains everything from the bottom up, literally.

Or maybe it's turtles all the way down.

[notrain]

lol, i found a pdf where orthos are admitting their dumb appliances are useless:

More recently, however, reports from substantial
well-controlled research have shown that it is unlikely
for the mandible to grow predictably beyond its genetic
potential.

what a crock of s**te

http://www.ada.org.au/app_cmslib/media/lib/0709/m97674_v1_633250137152187500.pdf