braces + lower jaw surgery or braces only?

[Ginger]

Hi, I'm looking for a little wisdom. I plan to have braces put on this month to fix my bite. My bigger issue is that my lower jaw is asymmetric... underbite on one side with a slighter underbite on the other side. Also lovely TMJ on one side. My options are 1) braces with lower extractions or 2) braces with lower jaw surgery. Here are some of the opinions I've heard:

Ortho 1: Braces with lower extractions. She said I was a difficult case and didn't even want to deal with the asymmetry. (Not going with her.)
Ortho 2: His preferred option - jaw surgery and braces. Alternate option - braces with 2 lower extractions (I'm going with this ortho.)
Oral surgeon: Says I'm a candidate for lower jaw surgery, but said my bite can probably be fixed with braces alone.
Dentist: Advised me to stay away from surgery if it can be done with braces only. (However, she also mentioned that she doesn't know anyone who regrets jaw surgery.)

I had pretty decided on jaw surgery before I saw my dentist this week for a cleaning before my braces, and she tried to talk me out of surgery.

I can see only getting braces. However, braces without jaw surgery will only fix my bite, not the facial asymmetry. If I'm embarking on a 2+ year journey, I'd really like things to be functionally and aesthetically pleasing at the end of it. Any thoughts?

A couple of pics below:

[pekay]

Were you told by all your orthos and surgeon the pros and cons of surgery? such as; chin + lower lip numbness? relapse? chance of asymmetry being amplified?

If you have sleep apnea I would be really careful with mandibular set back since it can be worsened by moving the lower jaw back.

[sean89]

Braces + surgery are the only option if you want to maximise your looks and are prepared to bear the risks (which only increase as you get older). You don't have much of a chin though, so you might go from underbite to having a weakish profile.

[LoveofScotch]

It may just be the pictures, but it actually looks like you have a small upper jaw cant. If that's the case, it's my understanding that you would require bi-max (double jaw surgery). I assume you'll also need a genioplasty, too.

It's also my understanding that often when the jaws are advanced (if you were to need that) it can actually make asymmetry appear worse (in some cases). I too have some frontal asymmetry and have been told, a few times, that it's incredibly difficult to correct. With that said, I've seen several cases where it was essentially corrected. I just can't yet figure out why sometimes it works, and other times it's made worse.

I was also wondering about sleep apnea based on your profile picture. Those are awkward to take yourself, so it could just be you positioning to make sure your whole face is in the picture.

[sean89]

It looks like upper jaw might be an option as well.

It may just be the pictures, but it actually looks like you have a small upper jaw cant. If that's the case, it's my understanding that you would require bi-max (double jaw surgery). I assume you'll also need a genioplasty, too.

It's also my understanding that often when the jaws are advanced (if you were to need that) it can actually make asymmetry appear worse (in some cases). I too have some frontal asymmetry and have been told, a few times, that it's incredibly difficult to correct. With that said, I've seen several cases where it was essentially corrected. I just can't yet figure out why sometimes it works, and other times it's made worse.

I was also wondering about sleep apnea based on your profile picture. Those are awkward to take yourself, so it could just be you positioning to make sure your whole face is in the picture.

Was just about to say this.

You could be looking at upper, lower and genio, which is gonna cost a lot. You've then got to worry about numbness, relapse, (seemingly unavoidable) nose changes, bite and speech problems.

You might be able to get away just doing upper, because lower might be resolved with braces, and if you do decide to setback lower, the case for genio becomes pressing.

I'd consult with more surgeons before you make a decision.

[Ginger]

Thanks for all the replies. They're really quite helpful. Let's see if I can answer some questions:

• Risks - The oral surgeon discussed adverse effects with me, except I don't think we talked about relapse. Now to read up on that... 
• Profile Yeah, those pics aren't great. Attached are a few more but not sure they're any better. I have some chin and jaw. No sleep apnea and no snoring.
• Cant - You guys may be right about a slight upper cant. I can see how upper jaw surgery may be needed for this and even a little impaction. Still I'm not sure I'm up for having the upper jaw done. 
• Asymmetry LoveofScotch - Yeah, it's weird how unpredictable the surgical results are with asymmetry. I've seen some results where they say they are fixed but only look slightly better. It's definitely a risk.

My face is kind of asymmetrical all around. It's like that quote from Clueless about Amber: "From far away, it's OK, but up close, it's a big old mess." lol. Upper midline to the left, while nose, chin, and lower midline are to the right.

Oh well, I'm not looking for perfection or anything... just a better functioning bite and maybe better jaw alignment in the process. Would like to go as minimally invasive as possible to achieve those goals. And I'm almost 40... while my face is kinda wonky... I'm used to it and I'd like to look like me at the end of this : )

[Gregor Samsa]

How much movement do you think you need? I don't think you need much of anything done in terms of how you look. If you have an underbite then my main concern would be which jaw to move because it doesn't look like you have a big skeletal underbite.

[PloskoPlus]

You have attractive features and you are well preserved (almost 40!?). Only your bite needs correction, and you can probably get away with very small movements (which hopefully will not radically alter your features - widen, tip up nose, etc..)  Your teeth are almost straight, so I don't believe in 2 years.  My teeth were much more crooked, and my underbite much bigger and I'm ready for surgery after 12 months*.  In orthodontics, closing extraction spaces takes more time than anything.  Find a good surgeon first and go with his recommended ortho.  Don't bother with invisalign or lingual braces.  They are not as accurate as traditional braces, take longer and linguals are hard on your tongue and hard to keep clean.  Ceramics only over the top front teeth (but they may be hard to debond later and could strip some enamel!)

*Supposedly my ortho uses SureSmile planning software (says so on his website), which is meant to accelerate treatment time.  He never bragged about it to me, but he is a man of few words.  In contrast the other orthos I consulted with just wouldn't shut up (one gushed about SureSmile like it's the second coming of Jesus.  When I mentioned this to another ortho (another big mouth) he said that "J needs it 'cause he needs all the help he can get" between the lines: the incompetent clod grabs onto every new fad that comes along).

[Mark32]

hi Ginger

i think you look very pretty - you kind of have a Kylie Minogue thing going on. can't believe you're almost 40. this just proves that i've aged terribly - at 32 i could easily pass as your older brother!

do you find the prospect of surgery daunting? is it a total surprise to you that it's an option or did you always have an idea in the back of your mind that it might take such a step to get the bite you want?

It's like that quote from Clueless about Amber: "From far away, it's OK, but up close, it's a big old mess." lol.

lol, i love that film - i think i've seen it about 3 times. oh to be rich in SoCal

... and if you do decide to setback lower, the case for genio becomes pressing.

Sean, can a chin advancement (that's a genio, isn't it) somewhat camouflage a slight underbite? the thing i tend to notice most when someone has an underbite is the prominence of the lower lip area in contrast to the upper one. however, when the person has a full, jutting chin i think that your eye gets drawn away from the imbalanced areas above and the underbite can be less noticeable. George Michael seems to have a slightly prominent lower jaw but it's not that obvious in part, i think, due to the shape and projection of his chin.

If you have sleep apnea I would be really careful with mandibular set back since it can be worsened by moving the lower jaw back.

Is there a risk of getting sleep apnea - even if you don't have it to begin with - if you have a mandibular set back?

[Ginger]

How much movement do you think you need? I don't think you need much of anything done in terms of how you look. If you have an underbite then my main concern would be which jaw to move because it doesn't look like you have a big skeletal underbite.

Thanks! Yeah, it doesn't look like much of an underbite but if I try to line up my midlines, I have a noticeable underbite on one side. Pic below.

I don't think I need much movement at all. The surgery would be to fix the asymmetry, which would also take away the underbite on the weird side. The oral surgeon said he might be able to set back just the left side of my jaw, which would fix the asymmetry. It sounded like this would rotate my lower jaw to get the bite and chin centered.


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[Ginger]

hi Ginger

i think you look very pretty - you kind of have a Kylie Minogue thing going on. can't believe you're almost 40. this just proves that i've aged terribly - at 32 i could easily pass as your older brother!

do you find the prospect of surgery daunting? is it a total surprise to you that it's an option or did you always have an idea in the back of your mind that it might take such a step to get the bite you want?

Thanks Mark! Yes, I'm pretty nervous about surgery. While I knew my chin was wonky, I thought braces would improve it along with my bite. So I was rather taken back when the orthodontist suggested surgery. It really surprised me. Oh well, it is what it is, you know? : )

lol, i love that film - i think i've seen it about 3 times. oh to be rich in SoCal

Yes, Clueless is funny and has some great one-liners. As if! lol

[Ginger]

You have attractive features and you are well preserved (almost 40!?). Only your bite needs correction, and you can probably get away with very small movements (which hopefully will not radically alter your features - widen, tip up nose, etc..)  Your teeth are almost straight, so I don't believe in 2 years.  My teeth were much more crooked, and my underbite much bigger and I'm ready for surgery after 12 months*.  In orthodontics, closing extraction spaces takes more time than anything.  Find a good surgeon first and go with his recommended ortho.  Don't bother with invisalign or lingual braces.  They are not as accurate as traditional braces, take longer and linguals are hard on your tongue and hard to keep clean.  Ceramics only over the top front teeth (but they may be hard to debond later and could strip some enamel!)

Thanks Plosko. 12 months - that's good to know. For surgery  I was quoted 1 year in braces, surgery, then 6-8 more months with braces. 2 years if I went with the option of braces with extractions. It sounds like you're right about extractions... those spaces take awhile.

So you're ready for surgery now? That's pretty exciting : )

[Ginger]

Okay, I went back to the orthodontist today for impressions and paperwork.

We talked about pros and cons of both options. Again, he told me he could go with either option. However, the ortho said while he thinks I'm pretty, my asymmetry is visibly noticeable. Braces won't fix it. He let me know if I do surgery, my bite would be excellent AND I would end up being more attractive.

A sound, honest opinion was what I needed to hear. I'm going with the surgery.

[LoveofScotch]

Wow, you really do have an underbite. It was not that noticeable in the prior set of photos.

I cannot stress enough the need to get multiple opinions from different surgeons. I've had many consults, and I received three grossly different plans. Seriously, you wouldn't think they were made for the same person.

Getting multiple opinions has its downside, though. How far down the rabbit hole are you ready to go?

[Ginger]

Wow, you really do have an underbite. It was not that noticeable in the prior set of photos.

I cannot stress enough the need to get multiple opinions from different surgeons. I've had many consults, and I received three grossly different plans. Seriously, you wouldn't think they were made for the same person.

Getting multiple opinions has its downside, though. How far down the rabbit hole are you ready to go?

Thank you, I can totally understand your point about getting several opinions. I plan to get a least one more. Either way, I'm glad I'm going with the surgery. I wanted to do it, but didn't want to seem too vain since it's somewhat optional. Glad the ortho finally gave a solid opinion.

Hmm, good question on the rabbit hole. I honestly don't really want to go down it much more. It's already been a few months of research. That said, I do research for a living and rabbit holes are my specialty