Failed orthodontics - repeating treatment, class II advice?

[Icy]

Greetings

I have been a victim of some irresponsible camouflage orthodontics and would like some feedback on whether or not surgery is always necessary to fix a class II skeletal pattern, asymmetry and dental overbite. My current overbite is sitting at 4mm with severely tipped in teeth that have been retracted backwards in my jaw, my new orthodontist believes it will expand to up to 7mm once the teeth have been restored to the proper angle and placement. My nasolabial angle is abnormally large due to the lack of tooth support, and my lower jaw is 'trapped'. I also have peg lateral incisors which have thrown my whole bite off drastically to the point of damage to all of my teeth due to a shearing effect while chewing, none of my teeth meet correctly. My smile is also narrow and unattractive and I am not sure if orthodontics alone will be able to fix the abnormal way my mouth sits on my face when compared to a normal person.

I have been told that I am a borderline surgical case (i.e. by a few degrees) and my orthodontist seems to want to avoid surgery if she can. She is a face-focused ortho so I do trust her judgement but I am concerned that this is potentially camouflage treatment all over again as I am technically class II but I do not present like any other class II person I have ever seen. In any case, I will be informed whether I need surgery in 4-6 months and I currently have braces on again. I took these pictures before the braces were installed and though I appear to have a short facial growth pattern it is apparently within normal limits which I find strange as I certainly did not look like this as a child.









In order, top is a normal spontaneous smile, middle is profile (taken close up I know, but you can see the lack of lip support), and my smile next to a normal attractive friend. My chin is in a normal position and my profile is apparently straight, yet my jaws are recessed and the surgeon I consulted seemed concerned that I would end up with a witch chin with bimax advancement, but he did say there was no telling until the teeth had been moved into the correct positions. As part of my treatment plan they will be bringing the tipped in teeth (top and bottom) forward in the jaws and making space in my upper jaw to widen and bond the peg laterals, this should broaden my smile but will it be less narrow altogether? It seems like my teeth are both too far backwards in my face and also too far up giving the illusion of a short maxilla; if you look at my smile next to my friend's my entire mouth and jaw seems to be positioned too shallowly in comparison.

Some feedback would be greatly appreciated, as you all know a confident and pretty smile is relatively priceless and I have now suffered a total of 4 years of braces for nothing, I don't want to be making the same mistakes again.

[PloskoPlus]

Your tooth show is really poor for your age especially.  Braces won't fix that.  You need surgery.

[Breakingbad]

Your tooth show is really poor for your age especially.  Braces won't fix that.  You need surgery.

What movements might be indicated in this case, assuming surgical treatment is necessary?

[PloskoPlus]

What movements might be indicated in this case, assuming surgical treatment is necessary?

Maxilla forward, down. Forward movement alone increases tooth show and may be enough.

[Icy]

Your tooth show is really poor for your age especially.  Braces won't fix that.  You need surgery.

That was my fear, I am just worried if I push for surgery that I will be shut down and have to go elsewhere , but I will allow them to correct my functional  issues first and then reinforce my concerns as I have hated my smile since the braces came off the first time round. I am not yet 23 and I look old. It doesn't help that my midface is horribly dished in and unsupported either so the overall effect is that I look exhausted and sad all the time. 

[Bobbit]

Icy - -   

Would suggest that you only work with an orthodontist who routinely sends patients to  surgeon.   

If your orthodontist is not comfortable working with a surgeon to plan the ultimate outcome - -   that is very limiting.   My understanding is that orthodontists often send an early patient for a first consultation with a surgeon a year or more before they are actually ready for the surgery as a result of the orthodontist work to move the teeth.

It should be a team effort in an ideal world.

[PloskoPlus]

Icy - -   

Would suggest that you only work with an orthodontist who routinely sends patients to  surgeon.   

If your orthodontist is not comfortable working with a surgeon to plan the ultimate outcome - -   that is very limiting.   My understanding is that orthodontists often send an early patient for a first consultation with a surgeon a year or more before they are actually ready for the surgery as a result of the orthodontist work to move the teeth.

It should be a team effort in an ideal world.

+1
It boggles the mind that some orthos insist on "fixing" what they can't by putting people through years and years of braces, extractions, only to end up with unstable occlusions, resorbed roots...  What causes this? Hubris, ignorance?  I've seen much worse ortho arrogance than OP's case.  Girl from UK, with a MASSIVE class III, who went through years and years of braces.  That was just ridiculous.  Her ortho should have been drawn and quartered for this.  At least with class ii, some kind of denial is plausible.

[Bobbit]

That was my fear, I am just worried if I push for surgery that I will be shut down and have to go elsewhere , but I will allow them to correct my functional  issues first and then reinforce my concerns as I have hated my smile since the braces came off the first time round. I am not yet 23 and I look old. It doesn't help that my midface is horribly dished in and unsupported either so the overall effect is that I look exhausted and sad all the time.

Icy,

More:   

I do not know where you live.   But keep in mind that there are  at least a few good plastic / orthognathic surgeons that are perfectly willing to work with orthodontists who work near you - - even if the surgeon works  across the country from your orthodontist.   Computers and digital modeling enable that flexibility.

You just have to find an orthodontist that has the "right attitude"  towards solving your problem.

[buzzhead]

I have to agree with everyone.  Definitely find an ortho/surgeon team.  I had extractions and teeth pulled back for a class 2 and it not only did NOT fix the bite but it raised  hell with aesthetics. I just had done what PloskoPlus is telling you to do. DO NOT go the ortho route only, you will not be happy.  Your young and that is in your favor for healing.

[molestrip]

As I understand it, 5mm is the max camoflouge that's safe for gums and stable long term. But I wouldn't call it a great bite. There's going to be compensations, lower molars tipped inward and uppers tipped outwards. Not so easy on the jaws but, then again, either are the risks of multi-segment LeForts. You can't do orthodontics forever, check your roots and if it looks risky then opt for more surgical movements.

[Icy]

Thank you all for your help, I think at my next appointment I will strongly reiterate my feelings on surgery as my ortho is not closed entirely to the idea, she told me from the beginning that it may very well be required, her first concern is reversing the damage that's been done to my teeth and arches. I did express to her my worries about camouflage treatment. If the time comes and she categorically rejects it then I will seek a second opinion; I am a university student who lives ten hours away from home so I have limited access to orthodontists and surgeons in general, I also live in South Africa so I am not fortunate enough to have access to international surgeons

[molestrip]

There's a famous surgeon in South Africa but I don't recall the name. Just look for dental schools and you'll find good surgeons.

[PloskoPlus]

There's a famous surgeon in South Africa but I don't recall the name. Just look for dental schools and you'll find good surgeons.

Johan Reyneke.

[notrain]

There's a famous surgeon in South Africa but I don't recall the name. Just look for dental schools and you'll find good surgeons.

Jordan Reynecke I think.

@OP: http://pocketdentistry.com/23-short-face-growth-patterns-maxillomandibular-deficiency/

[Icy]

Me too 

Actually even back when I was 18, only 5 years ago - I had enough incisor show as not to warrant a 'short face' diagnosis. Literally in the last few years my septum became more deviated and I lost tooth show.

Anyway, I'd go for the surgery if I was you. Where in S A are you based?

I attend university in the Eastern Cape, but home Base is Gauteng (Pretoria, close to Johannesburg ). I do find my incisor show has become progressively worse since debracing the first  time round,  but  I also curled my upper lip a lot to show more teeth when they came off initially. I also had a deviated septum which has since been corrected and a very drooped nose prior to surgery.I will look into dr reyneke , thank you for the information!