What would your treatment plan be for this?! Surgery+Braces Vs Braces alone

[sean89]

A lot of people know a lot about orthodontics on this board so I thought I'd ask what you would do in a situation like mine (pics attached).

I really want to avoid surgery, but I'm not sure how effective braces will be. The surgical questions going through my mind are:

1. Are my buccal corridors so bad that I should get SARPE?

2. Should I get lower jaw surgery to cure my 6mm overjet once and for all?

3. As a wildcard option, could I get segmental le fort 1 and at the same time, set the maxilla back 2 millimetres and so cure both problems? Is it worth the nasal flaring?

My lower jaw is 3mm recessed and so I don't think there would be any cosmetic benefit to getting BSSO given that I am already conscious about the prominence of my chin when I smile.

I had a 12mm overjet when I was 11 and this has been halved since having twin blocks around that period, but I'm not sure braces alone can be as effective given that I am now in my twenties.

For braces, I was thinking of ceramic Damon, with many orthodontists telling me 2mm overjet reduction is likely from lower arch braces only, but it would come at the expense of gum recession.

On the uppers, I could either:

1. Extract premolars to allow the upper arch to retract

2. Interproximal reduction to allow some upper arch retraction, but possibly at the expense of tooth sensitivity

3. None of the above, but accept that my upper arch can retract maybe 1mm at most due to the presence of crowns on my front two teeth cancelling out the force from the braces

With non-extraction, non-surgical treatments, I reckon the overjet would likely reduce by around 3mm. And even if I do wear my retainers, there's a chance of this relapsing 10 years down the line. How much the arch would widen, I don't know but then again, stability is a big issue there.

I am really unsure what to do, and have been pondering it for months...any ideas would be warmly welcomed. What would you do?

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[sean89]

Another pic of arch width.

I think I might need to get some thinner crowns if that is possible. Maybe zirconium will be thinner rather than porcelain fused to metal.

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[notrain]

I know a bit about orthodontics and tooth movements and i'd love to help.

But dude, are you serious with those crumpled up copies of your cephs on regular paper which you didn't even bother to scan but are rather holding with your own hand into a cellphone camera at an angle ?

It's impossible to tell anything with the materials you supplied. it's 2014, get some digital copies so the x-rays are visible and at their proper clinical angulation.

FWIW, you are angle II/1 with two very narrow dental arches and a high palatal vault. didn't you get a chin wing? imo you should have gone the long route with palatal expansion and bimax, because how the teeth are positioned in the face is equally important to the skeletal relationship for overall attractiveness. both your incisors (upper and lower) are already flared outwards, flaring the lowers even more to mask the overjet is a bad idea for the reasons you mentioned (among others you didn't). the thing is, flaring the teeth outwards gives arch length, so you cannot pull them back in because the arch cannot accomodate them right now. so you either need extractions or expansion. i would get expansion because the smile is narrow as is.

so to answer your question, i think orthodontic camouflage would be a poor choice for your situation.

[sean89]

I know a bit about orthodontics and tooth movements and i'd love to help.

But dude, are you serious with those crumpled up copies of your cephs on regular paper which you didn't even bother to scan but are rather holding with your own hand into a cellphone camera at an angle ?

It's impossible to tell anything with the materials you supplied. it's 2014, get some digital copies so the x-rays are visible and at their proper clinical angulation.

FWIW, you are angle II/1 with two very narrow dental arches and a high palatal vault. didn't you get a chin wing? imo you should have gone the long route with palatal expansion and bimax, because how the teeth are positioned in the face is equally important to the skeletal relationship for overall attractiveness. both your incisors (upper and lower) are already flared outwards, flaring the lowers even more to mask the overjet is a bad idea for the reasons you mentioned (among others you didn't). the thing is, flaring the teeth outwards gives arch length, so you cannot pull them back in because the arch cannot accomodate them right now. so you either need extractions or expansion. i would get expansion because the smile is narrow as is.

so to answer your question, i think orthodontic camouflage would be a poor choice for your situation.

haha, thanks notrain, you should see the faces of the maxfac surgeons when I pull out those same pieces of paper to show them what they have to work with.

I know the gold standard in this case is surgery, but I really wanna try and avoid it because it won't make any difference to my external appearance (or an extremely negligible improvement if my nose doesn't get worse). Getting surgery would be to achieve stable smile aesthetics and I'm not sure it's worth it, when SARPE itself is limited by the width of my lower arch and seems such a horrible process to go through. I know orthodontic expansion isn't gonna get me near to surgical expansion, but it might get me close to normal. I agree that getting chin-wing in isolation was a bad idea.

At the minute, I'm thinking braces alone, with IPR and expansion to allow more room in the arch for the uppers to come back. But I'm gonna consult with (even) more orthos to see what I should do. As I mentioned in the other thread, I am even considering segmental setback le fort because the lip support that my teeth provides is too feminine so I'm not worried about the profile appearing flat.

[Optimistic]

haha, thanks notrain, you should see the faces of the maxfac surgeons when I pull out those same pieces of paper to show them what they have to work with.

I know the gold standard in this case is surgery, but I really wanna try and avoid it because it won't make any difference to my external appearance (or an extremely negligible improvement if my nose doesn't get worse). Getting surgery would be to achieve stable smile aesthetics and I'm not sure it's worth it, when SARPE itself is limited by the width of my lower arch and seems such a horrible process to go through. I know orthodontic expansion isn't gonna get me near to surgical expansion, but it might get me close to normal. I agree that getting chin-wing in isolation was a bad idea.

At the minute, I'm thinking braces alone, with IPR and expansion to allow more room in the arch for the uppers to come back. But I'm gonna consult with (even) more orthos to see what I should do. As I mentioned in the other thread, I am even considering segmental setback le fort because the lip support that my teeth provides is too feminine so I'm not worried about the profile appearing flat.

It was a nice way of telling you take proper photos if you want people to take you seriously and give you advice.