Understanding my bite issues better

[Optimistic]

So according to my orthodontist there is not enough room to decompensate the lower teeth for a BSSO. I'm also edge to edge. So basically if I deduce that I'm led to believe my mandible is roughly in the correct position but with poor chin development.

He has stated that dealing with my edge to edge bite "is his next big challenge" after levelling my dental arches and impacting the third molars back to where they should be.

What I'm starting to wonder and worry is that he's really decompensating what he can with my lower teeth and making up the difference by flaring my front teeth out. I never understood why each new wire kept hurting my top set of teeth when they're already perfectly straight. This could be why. I've seen this before in people and it tends to look crap and lead to gum recession.

Is this something I should confront him about and ask? and what would my options be if he's right?


As I think about it seems a le fort i would deal with the situation nicely. It could fix my maxillary cant, it could rotate the maxilla so as to allow some auto-rotation of the mandible and improve occlusion, plus advancing it slightly would then give me a proper amount of overjet. The movements would undoubtedly be minor. Perhaps just a couple mm. However, this I'm guessing would result in a skeletally proper class I without any orthodontic magic that might lead to problems down the line.

Whilst he may characterise it as extreme and unnecessary I honestly don't care. If I'm going under for a chin wing and ZSO then a le fort to boot makes zero difference to me. Might as well I say.

Reasons for bringing this up are that Dr Triaca in fact suggested this method of Le Fort I and chin wing  after seeing scans as being sufficient to fix my bite despite only ever asking about chin wing, then as I thought about it I tend to agree. He said if the occlusal plane is oblique then a BSSO is also necessary.

[Optimistic]

My only concern with all this would be that my nasolabial angle is already at 90?. Whilst soft tissue is unpredictable I'd have to have it anything less than that. 90? is ideal. Under 90? and you start to look a bit strange if you ask me.

Edit: And would there be any reason to consider something like a high lefort i over and above a normal one? I never looked into this stuff much as I always considered upper jaw surgery as being off the cards. I'm asking from an aesthetics and anti-ageing point of view. I understand a le fort i would fix my bite perfectly.

[ForeverDet]

Do you have pics or an x-ray? Hard to give even a educated guess without one unless you've posted it before. I will say I would be wary of a an ortho saying this or that isn't possible. Before I found my surgeon, a couple orthos and the surgeon I originally asked about jaw surgery told me it wasn't possible to rotate my jaws to get the result I wanted since my bite was "good".

My only concern with all this would be that my nasolabial angle is already at 90?. Whilst soft tissue is unpredictable I'd have to have it anything less than that. 90? is ideal. Under 90? and you start to look a bit strange if you ask me.

I wouldn't worry too much about this, you'll see tons of variation in natural class I people's nasolabial angle because that landmark in isolation means very little even though there is "ideal" range (96-114 according to some docs). Only in extremes does it become aesthetically an issue and can indicate dentoskeletal deformity. Plus I think the angle becoming to obtuse, meaning really flat and retracted in class III cases for example or class II convex cases, then it looks like the person has maxillary deficiency which looks worse then being more acute which a lot of attractive faces have.

[PloskoPlus]

I thought your ortho said you're now a class I?  What kind of Le Fort I movements are we talking about.  BTW, I've seen Le Fort I advancements (class III, albeit) and the cheekbones pop after it.  No implants, not HA paste, just moderate ("mickey mouse" according to the surgeon) advancement.  Frankly I don't think any operation can change the face as much as Le Fort I.

[Optimistic]

Do you have pics or an x-ray? Hard to give even a educated guess without one unless you've posted it before. I will say I would be wary of a an ortho saying this or that isn't possible. Before I found my surgeon, a couple orthos and the surgeon I originally asked about jaw surgery told me it wasn't possible to rotate my jaws to get the result I wanted since my bite was "good".

I wouldn't worry too much about this, you'll see tons of variation in natural class I people's nasolabial angle because that landmark in isolation means very little even though there is "ideal" range (96-114 according to some docs). Only in extremes does it become aesthetically an issue and can indicate dentoskeletal deformity. Plus I think the angle becoming to obtuse, meaning really flat and retracted in class III cases for example or class II convex cases, then it looks like the person has maxillary deficiency which looks worse then being more acute which a lot of attractive faces have.

Here is an x-ray I had taken a quite a while ago, even before I got braces so my bite seems worse. The scan has problems in many ways. My head is face down more than it should and my chin wasn't even included in there. Eventually I got braces to level the dental arches which caused some auto rotation and advancement it seems, because when I look at this compared to my more recent CT scan the angle of the mandible is way steeper. Moreover, it should be clear in even this that there was a lot of lip incompetence which is now gone. Here it is anyway:






Regarding the opinion of the ortho I have to say I'm in a bind. I'm stuck with him. If he doesn't think I need surgery it's going to be very hard to convince him to do anything. Every time I bring it up he goes off about how I look fine and the only thing i MAY need is a sliding genio. Any ideas?


Finally, 96-114 degrees? seems far too obtuse for a male to be ideal. Perhaps in females who have more upturned noses?

[Optimistic]

I thought your ortho said you're now a class I?  What kind of Le Fort I movements are we talking about.  BTW, I've seen Le Fort I advancements (class III, albeit) and the cheekbones pop after it.  No implants, not HA paste, just moderate ("mickey mouse" according to the surgeon) advancement.  Frankly I don't think any operation can change the face as much as Le Fort I.

The situation is muddled as the scans I sent to triaca were from before I had braces, so this could've thrown him. I did include the CT of the mandible only along with a photo so who knows? It may even come down to me just going there and deciding with him during the workup.

My ortho does claim I'm class I edge to edge, however I'm not sure what to believe anymore. I feel as if an ortho would gladly lie to a patient if it meant keeping them in braces and "preventing" them from doing something they didn't agree with.

Would there be much I'd need to do orthodontically in the lead up to such a surgery given the small movements involved? Or could I go YOLO SWAG mode and tell my ortho to deal with it after that fact? lol

I just can't see how he plans on giving me overjet without screwing with my upper set of teeth...

[LoveofScotch]

Are you looking down on purpose, and are you looking down a lot?

Also, I know every situation is so different (me: edge to edge bite after an oops with an appliance to correct TMJ stuff), but I was told I 'should' only need braces for a few months prior to surgery. I only need a tiny surgical movement(s), and also had braces as a teen.

[Optimistic]

Are you looking down on purpose, and are you looking down a lot?

Also, I know every situation is so different (me: edge to edge bite after an oops with an appliance to correct TMJ stuff), but I was told I 'should' only need braces for a few months prior to surgery. I only need a tiny surgical movement(s), and also had braces as a teen.

No, they set up the thing improperly. That's why I'm looking down slightly and my chin wasn't caught on the scan

[ForeverDet]

Here is an x-ray I had taken a quite a while ago, even before I got braces so my bite seems worse. The scan has problems in many ways. My head is face down more than it should and my chin wasn't even included in there. Eventually I got braces to level the dental arches which caused some auto rotation and advancement it seems, because when I look at this compared to my more recent CT scan the angle of the mandible is way steeper. Moreover, it should be clear in even this that there was a lot of lip incompetence which is now gone. Here it is anyway:

OK I have a bit better idea now but yeah still really hard to suggest anything with confidence. So your lip incompetence is fixed and from the pic it looks like your lip posture was good before and now your bite is edge to edge from having an anterior open bite it looks like, correct?

Besides your edge to edge bite, what concerns you specifically? Just trying to get a full picture of your goals and is it possible for you to post a actual pic of your face in profile in repose?

Regarding the opinion of the ortho I have to say I'm in a bind. I'm stuck with him. If he doesn't think I need surgery it's going to be very hard to convince him to do anything. Every time I bring it up he goes off about how I look fine and the only thing i MAY need is a sliding genio. Any ideas?

Why can't you switch orthos?

Finally, 96-114 degrees? seems far too obtuse for a male to be ideal. Perhaps in females who have more upturned noses?

Oops read it wrong. Females - 97 to 111 degrees. Males: 85 to 105 degrees. The second numbers are upper limit of acceptable. Those are arnett/gunson numbers though and other doc's number differ (I've read some as low as 65 degrees, all the way up to 120 degrees!) which is just shows that the normal range is not absolute and just because your angle may be technically too acute or obtuse, doesn't mean it will negatively affect appearance.

[PloskoPlus]

An edge-to-edge is probably the second worst bite after open bite to have.  It's very hard on the roots of your teeth.

[Optimistic]

An edge-to-edge is probably the second worst bite after open bite to have.  It's very hard on the roots of your teeth.

How do you figure? Isn't it all relative? Couldn't my teeth be in a good position and for structural reasons they line up in an edge-to-edge way?

[Optimistic]

OK I have a bit better idea now but yeah still really hard to suggest anything with confidence. So your lip incompetence is fixed and from the pic it looks like your lip posture was good before and now your bite is edge to edge from having an anterior open bite it looks like, correct?

Besides your edge to edge bite, what concerns you specifically? Just trying to get a full picture of your goals and is it possible for you to post a actual pic of your face in profile in repose?

Yes that's correct.

My concern occlusion wise is my edge-to-edge bite, and how I question the methods my ortho will attempt to use to fix that. Additionally, I have a small degree of maxillary canting and a bit of an open area in my bite at the front right (lower side of the cant).

Why can't you switch orthos?
 
Paid up front. If I really fought it perhaps I could get a partial refund and see someone else. I'd like to think if I'm adamant enough he will agree to whatever I ask.

Oops read it wrong. Females - 97 to 111 degrees. Males: 85 to 105 degrees. The second numbers are upper limit of acceptable. Those are arnett/gunson numbers though and other doc's number differ (I've read some as low as 65 degrees, all the way up to 120 degrees!) which is just shows that the normal range is not absolute and just because your angle may be technically too acute or obtuse, doesn't mean it will negatively affect appearance.

That sounds more right. More I think about it if the maxilla was advanced then the front teeth could be decompensated the correct amount. All in all it probably wouldn't change the nasolabial angle.

see bold

[ForeverDet]

You should be able to get a refund if your mid way through treatment. It's BS if you can't and I don't see a reasonable doctor saying no, it's your teeth after all. Be stern and aggressive if it comes to the point you need to change orthos.

As far the decompensation pre-surgery, have you found a surgeon? Dr Triaca? If not find a doc that has a surgical plan your comfortable with and he should then send your ortho a orthodontic plan or at least talk to him about it. It all starts with the surgeon and the ortho is secondary, following his or her lead.

Again, hard to even make assessment but I think you could get away with just upper surgery to fix the cant and advance your upper jaw for a proper overjet/overbite. Idk if your mandible is that deficient or a genio/implant could do the trick, especially if your bite is perfect with just upper jaw surgery.

And a mandibular plane/occlusal plane being steep is not abnormal by itself although it correlates strongly with LFS for example and other vertical deformities. Remember, single jaw surgery is so much easier than double jaw surgery and as long as you can get a stable, class I bite with just a lefort then I'd do that even if your mandible is potentially a little deficient.

[notrain]

I can see from the (s**tty) ceph:

- Angle II/1 open bite malocclusion which in plain english means your upper and lower incisors are proclined beyond the bony base of maxilla and mandible. Decompensation for surgery or fixing it orthodontically means retraction and torquing those teeth into their correct position. If your jaws are narrow transversally, this is impossible without expansion (either sarpe or orthodontically if possible which it might not be if you are older) or extracting 4 first premolars.

- Your skeletal base is class 1 on a mesofacial growth pattern (this is good and does not need fixing).

- no clue about chin as it is missing from the ceph


My advice - which you will undoubtedly ignore - would be to only get a chin wing provided the ortho can fix the edge to edge bite without relapse. To be perfectly honest, a normal sliding genioplasty would be more than enough to fix whatever issue you may have, as the posterior parts of your jaws appear fine.

You honestly don't need jaw surgery, if you are a candidate for this procedure then so is 90% of the population. If the ortho cannot fix the edge to edge bite, then it might be worth it to get jaw surgery but the movements will be so minimal, you won't see an esthetic improvement.

[Optimistic]

I can see from the (s**tty) ceph:

- Angle II/1 open bite malocclusion which in plain english means your upper and lower incisors are proclined beyond the bony base of maxilla and mandible. Decompensation for surgery or fixing it orthodontically means retraction and torquing those teeth into their correct position. If your jaws are narrow transversally, this is impossible without expansion (either sarpe or orthodontically if possible which it might not be if you are older) or extracting 4 first premolars.

- Your skeletal base is class 1 on a mesofacial growth pattern (this is good and does not need fixing).

- no clue about chin as it is missing from the ceph


My advice - which you will undoubtedly ignore - would be to only get a chin wing provided the ortho can fix the edge to edge bite without relapse. To be perfectly honest, a normal sliding genioplasty would be more than enough to fix whatever issue you may have, as the posterior parts of your jaws appear fine.

You honestly don't need jaw surgery, if you are a candidate for this procedure then so is 90% of the population. If the ortho cannot fix the edge to edge bite, then it might be worth it to get jaw surgery but the movements will be so minimal, you won't see an esthetic improvement.

Thanks for the detailed analysis. Helps a lot.

Here are some from a CT scan I took which may help you see where my teeth are at now:





Regarding your advice, don't worry I am taking it seriously. My plan before Triaca responded was as you say, just to get a chin wing and let the ortho deal with the rest. I would have no expectations of an aesthetic improvement with a le fort i or BSSO. I am well aware that these will all have to come from the chin wing anyway.