Issues

[introspect160]

Hi everyone.

I need some opinions on this.  Every since I've been a teenager I had problem with tooth grinding, clicking or locking jaw, headaches, mouth breathing, constricted airway, and forward head posture.  The thing is my bite has been perfect.  I've had invisalign to correct some minor crowding, but overall my occlusion is good.  Two of my friends are dentists are have said I have a basically have a normal occlusion but a class 2 skeletal pattern.  I have a very weak/non-existent jaw line.  Can you spot the issues in the ceph X-ray and what is involved in correcting this? 

B

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[notrain]

you have a steep occlusal and mandibular plane which presents itself in a skeletal class 2 pattern (mandible behind maxilla) but if you were to rotate your jaws counter clockwise, they would have a good relationship.

so you would need bimax surgery with counter clockwise rotation advancement.

edit: you didn't really ask, but your chin bone is also deficient.

[introspect160]

you have a steep occlusal and mandibular plane which presents itself in a skeletal class 2 pattern (mandible behind maxilla) but if you were to rotate your jaws counter clockwise, they would have a good relationship.

so you would need bimax surgery with counter clockwise rotation advancement.

edit: you didn't really ask, but your chin bone is also deficient.

Thanks notrain.  Would such a surgery, if successful, solve most of the issues I mentioned above (airway, posture, etc.)?  Could the deficient chin bone be solved with a genioplasty or implant?  Also, the bimax surgery, I'm assuming this would be a pretty invasive, extreme surgery, right?  Would going with a jaw distraction surgery through Profilo in Australia be a more precise way of accomplishing the rotation?

[PloskoPlus]

Thanks notrain.  Would such a surgery, if successful, solve most of the issues I mentioned above (airway, posture, etc.)?  Could the deficient chin bone be solved with a genioplasty or implant?  Also, the bimax surgery, I'm assuming this would be a pretty invasive, extreme surgery, right?  Would going with a jaw distraction surgery through Profilo in Australia be a more precise way of accomplishing the rotation?

Distraction makes little sense for adults, given the small movements required. You still need to cut bones, and you double the surgeries (dustractirs put in, dustrsctors taken out).

[introspect160]

I've noticed as well that the back of my jaw (ramus) is so far back it actually overlaps the spinal column.  I've never seen a ceph X-ray in which that ramus wasn't ahead of the spine other than my own.  Is there a name for this issue and can it be corrected?

[needadvancement]

Are you guys able to look at the x-ray and able to see if the airway is good/bad? I don't have the knowledge or know what to look for.

[notrain]

Thanks notrain.  Would such a surgery, if successful, solve most of the issues I mentioned above (airway, posture, etc.)?

yes

  Could the deficient chin bone be solved with a genioplasty or implant?

both, but i would avoid implants and do genio.

  Also, the bimax surgery, I'm assuming this would be a pretty invasive, extreme surgery, right?

yes

  Would going with a jaw distraction surgery through Profilo in Australia be a more precise way of accomplishing the rotation?

distraction osteogenesis can't rotate the maxillo mandibular complex. you can only do linear advancement with it. you don't need linear advancement.

[introspect160]

So I finally had a consult with the oral surgeon today, and he recommended a mandibular advancement with ortho in advance to remove bottom premolars and create room for the lower jaw to move forward.  He also recommended a genioplasty.  He said the upper jaw is fine where it is.  Supposedly he is one of the top guys in my area and teaches university classes on the subject.  Thoughts?  Get a second opinion?

[PloskoPlus]

So I finally had a consult with the oral surgeon today, and he recommended a mandibular advancement with ortho in advance to remove bottom premolars and create room for the lower jaw to move forward.  He also recommended a genioplasty.  He said the upper jaw is fine where it is.  Supposedly he is one of the top guys in my area and teaches university classes on the subject.  Thoughts?  Get a second opinion?

And a third and a fourth.

[notrain]

So I finally had a consult with the oral surgeon today, and he recommended a mandibular advancement with ortho in advance to remove bottom premolars and create room for the lower jaw to move forward.  He also recommended a genioplasty.  He said the upper jaw is fine where it is.  Supposedly he is one of the top guys in my area and teaches university classes on the subject.  Thoughts?  Get a second opinion?

Disclaimer: I am not a doctor.

I think the treatment plan (extractions lower jaw + bsso) is wrong for you. Extractions are usually indicated when the curve of spee is excessive and the lower incisors are severely proclined. You don't have either of these conditions.

You should be treated non extraction and with ccw rotation of the maxillo mandibular complex. The treatment plan that was proposed to you would probably end up giving a somewhat odd appearance with a too long lower third and the chin would still be too far back but too prominent because the lower incisors would be retroclined. It's hard to explain, but I would get more opinions. If you are US based then go to A&G.

[introspect160]

Another update.  I went and talked to my orthodontist who previously gave me invisalign, and he didn't agree with the treatment plan of the oral surgeon.  He said he was opposed to doing the lower extractions because then there wouldn't be enough room for my tongue.  He did say that he thought genioplasty alone could achieve OK results in terms of facial profile, but also said that bi-max surgery would be an option if I wanted to go more extreme.  He did refer me to another oral surgeon, so I'm going to get a second consult. 

No train, I'm based in Canada, so A&G is out of the question.  If I stay in Canada, I can probably get medicare to cover most of the costs.  Know any good surgeons in Canada that would be willing to do a ccw rotation?

[notrain]

No train, I'm based in Canada, so A&G is out of the question. 

I am european, so I can't help you with canadian surgeons.

If I stay in Canada, I can probably get medicare to cover most of the costs.  Know any good surgeons in Canada that would be willing to do a ccw rotation?

What's the point of having free surgery if the result is s**t? You should decide if you want full blown bimax or camouflage treatment. Your bite is solid, I would actually recommend getting camouflage with a chin wing in germany (recommendation: Ramin Zarrinbal). It costs 6-7k € plus your travel expenses obviously.

[dantheman]

Another update.  I went and talked to my orthodontist who previously gave me invisalign, and he didn't agree with the treatment plan of the oral surgeon.  He said he was opposed to doing the lower extractions because then there wouldn't be enough room for my tongue.  He did say that he thought genioplasty alone could achieve OK results in terms of facial profile, but also said that bi-max surgery would be an option if I wanted to go more extreme.  He did refer me to another oral surgeon, so I'm going to get a second consult. 

No train, I'm based in Canada, so A&G is out of the question.  If I stay in Canada, I can probably get medicare to cover most of the costs.  Know any good surgeons in Canada that would be willing to do a ccw rotation?

I'm not sure public health would pay for this surgery unless there is a clear indication.

I have a very similar profile to yours, probably worse.

Your airway looks fine, you don't have obvious forward head posture, in fact your cervical column is quite straight which can make the ramus look further back. Your ramus is actually more vertical than most (mine is as well) and this is actually contributing to the recessed look (as the angle between mandibular plane and the plane of the ramus becomes more acute, the chin has less projection).

I think a CCW is also the answer. You don't need to mess with extractions in my (layman) opinion.

[dantheman]

i should also mention that you have a downgazing head posture in that ceph (the sella-nasion plane is almost level when it should be going up from sella to nasion). This exaggerates the steepness of the mandipular plan

[introspect160]

Hi everyone:

Appreciate all the responses and opinions.  I just had a consult with a separate oral surgeon that my orthodontist recommended.  He wanted to perform the exact same surgery as the previous oral surgeon (BSSO plus genioplasty) but was much more forthcoming in explaining why he didn't want to perform a Bimax ccw rotation.  The surgeon told me that CCW rotation of the lower jaw is not a stable movement because the muscles in the area tend to want to pull the jaw back into its original position resulting in a high amount of relapse.  Again, he recommended lower premolar extraction and moving the lower jaw forward with BSSO.

I'm pretty confused about how to proceed. 

Here is one study on the stability: "Maxillomandibular advancement with counterclockwise rotation of the occlusal plane is a stable procedure for patients with healthy TMJs and for patients undergoing simultaneous TMJ disc repositioning using the Mitek anchor technique. Those patients with preoperative TMJ articular disc displacement who underwent double-jaw surgery and no TMJ intervention experienced significant relapse." J Oral Maxillofac Surg. 2008 Apr;66(4):724-38. doi: 10.1016/j.joms.2007.11.007.

Seems like there are stability issues if there are TMJ issues at the same time.

Thoughts?