Camouflage orthodontics

[ascolta]

Hi everyone. Some people here seem more knowledgeable than most doctors so I'd be really grateful if I could leverage the collective wisdom of the forum for some advice.

I had camouflage orthodontics for an overbite which developed as a result of allergies and mouth-breathing. One of the appliances I wore forced me to jut my lower jaw, and I think it prevented both jaws from developing properly but I'm not sure. I was left with a class I bite but an unsatisfactory aesthetic result and also some functional issues.

I had a sliding genioplasty a year after getting my braces off and it was a big improvement aesthetically. Two years later I got custom malar + infraorbital rim implants, and jaw + chin implants, which was probably a mistake. The lower ones got infected so I had to take them out. I still have the malar + infraorbital rim implants.

The sliding genioplasty doctor said the ideal treatment would be to remove two lower premolars to recreate the overbite and then have both jaws advanced (I don't remember exactly what he recommended for the upper jaw). I did not do this at the time but it was always something I thought of doing eventually, and I think the time has come.

The problem is I think my maxilla is both short and recessed. It just didn't grow. What is the standard treatment for that? I don't have a gummy smile. My upper lip has normal length, but I think my midface/nose is long. The mandible is obviously recessed and I think it's simpler in that you just have to move it forward, right?

I'm consulting with 4 doctors in NYC, where I currently live, but the surgeon that did the sliding genioplasty is great and I'd love to use him again if he's willing to work with me — he's located in Brazil.

I met with my first NYC doctor yesterday and he basically said "don't do anything, you look fine." He barely listened to anything I said, though. And he seemed surprised when I told him of the premolar extraction possibility. It seemed like he'd never heard of it before.

I have some root resorption in the lower teeth, which I think could be a problem. It seems like a lot of it is due to the fact that the teeth are too far forward, so it's probably better to correct it even if it means having to go on braces again.

Here are some photos. Hopefully you can make sense of it, I'm not very well versed. I'm getting new x-rays taken on Monday, so I might post those. I'm posting 1) profile before SG; 2) bite models in 2012 (probably same as now); 3) profile now. I'll also post pictures of a CT scan I had done for the implants.

Functional problems are forward head posture (not in the recent picture I posted); bad sleep; often wake up with headaches, dry mouth etc.; just not ideal breathing, effortful mouth closure. My cheek muscles are hypertrophied due, I think, to improper swallowing. My chin muscles are also hypertrophied and the skin is thick because, I think, it's taking on the effort of closing the lips.

What would be the recommended treatment plan in terms of fractures etc.? What's the diagnosis? I just hate that the surgeon I went to immediately thought I was doing this just for cosmetic reasons and that I had BDD or something. I'm willing to go through with it because I think it would improve my quality of life. Anyway, I'd be really grateful for some advice and explanations. Thank you!

[ascolta]

(I don't think the server is letting me upload pictures but I'm working on it)

Let's see if this works: http://imgur.com/a/lhXjL

[kjohnt]

Braces to upright the teeth (decompensate) within their respective arches.  BSSO for mandibular advancement.  Assuming the decompensation didn't result in a large enough of an overbite to only move the mandible with satisfactory result, maxillary advancement via Lefort I fracture.  This will allow for a larger mandibular advancement.  It sounds like you believe this will be the case; I can't tell but you're probably correct.

If vertical lengthening of the maxilla is needed, downgrafting with cadaver bone, hip bone, HA paste, or some combo of these things.  Note that horizontal maxillary advancement will stretch the upper lip and produce more tooth show, so you may think you need advancement plus downgrafting when you really just need advancement.

I think your occlusal plane is fine based on the CT scan of your skull.  I drew the applicable lines where I believe they should be.  This is good news because it seems from my research that linear bimaxillary advancement can be performed by any competent surgeon but the rotational surgeries are relatively new in practice and few surgeons perform them, many of whom charge a s**tload of money.  I'm not an expert though and you might consult with someone who can do CW/CCW rotations if you want to be absolutely sure.  Maybe you can send a surgeon the CT scan and ask for a cursory analysis regarding your occlusal plane angle.



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[Icy]

Hmm it appears that you and I are in a similar situation , except my camouflage orthodontics failed altogether and I was left with a class 2 but retroclined teeth. We have similar profiles and I also find my midface looks too long despite showing too little tooth. I also had the same reaction from the first surgeon I consulted with; he ended up referring me to my current orthodontist who is reversing the camouflage orthodontics which you will need to do as well I believe.
The best thing to do is to find an orthodontist who works with a surgeon and who will consider the impact on your face as well as your teeth. Best of luck to you!

[Eugae93]

Really these orthodontic treatments are freaking me out, there are a lot of people who are not satisfacted by their post-ortho look..
and me too...
As your orthodontist, my ortho as well said I look fine and don't want me to have a treatment for advancing the maxilla.
I also used to have the problem of sleeping (like you do) untill I gave up the retainer and let my teeth move alone...
It's difficult to find a doctor who has the same thought of the patient unfortunately.
[/quote]

he ended up referring me to my current orthodontist who is reversing the camouflage orthodontics which you will need to do as well I believe.

how to find such a doctor?.. Few doctors complain about the already done work, they usually say that it would be better leave like it is.

[Icy]

Really these orthodontic treatments are freaking me out, there are a lot of people who are not satisfacted by their post-ortho look..
and me too...
As your orthodontist, my ortho as well said I look fine and don't want me to have a treatment for advancing the maxilla.
I also used to have the problem of sleeping (like you do) untill I gave up the retainer and let my teeth move alone...
It's difficult to find a doctor who has the same thought of the patient unfortunately.
how to find such a doctor?.. Few doctors complain about the already done work, they usually say that it would be better leave like it is.

To be honest, for me it was purely luck. I hated the results of my previous orthodontic work from the time my braces came off, I just knew there was something wrong but I didn't know anything at the time. Assembly line orthodontic practice didn't explain jack to me, so I was left at the age of 17 hating my (very expensive) results for two years until I finally stumbled across some jaw surgery before and afters online, taking particular note of people with short maxillas and thought "Holy s**t they look like me!". I'm 23 now and if I hadn't come across this orthodontist I would still be humming and hawing over 'maybe' doing something about it. The best thing you can do is start phoning around and trying to find an orthodontist who is face-focused, mine has accreditation from various organisations which focus on growth modification and increasing facial harmony as part of orthodontic work - there may be something similar in your country?

[Eugae93]

I hated the results of my previous orthodontic work from the time my braces came off, I just knew there was something wrong but I didn't know anything at the time.

Exactly the same thing, no difference, really... and nobody explained anything to me as well (apart from internet)

I'm 23 now and if I hadn't come across this orthodontist I would still be humming and hawing over 'maybe' doing something about it.

We are at the same age! It gives me hope!

The best thing you can do is start phoning around and trying to find an orthodontist who is face-focused, mine has accreditation from various organisations which focus on growth modification and increasing facial harmony as part of orthodontic work - there may be something similar in your country?

Thank you for the advice I think I'm going to start phoning around again, are these organisation international so that I can search in the internet if somebody of my place is in there?
You know? because for what I found untill now.. in my city, they usually don't appear to be very confortable in complaining about the others orhodontists job (not so big town).. when speaking to new orthos I eventually found a friend of my old one who said that it was a good job (spoke about the malocclusion, not face focused), seems like everybody knows each other here. must be prudent ahah!

[ascolta]

Thanks so much for your assessment, kjohnt. That just makes the surgeon I went to sound even more misinformed — he basically told me that since I did not have a gummy smile, there was little that he could do. It seems that his area of expertise was not orthognatic surgery.

I'm consulting with Dr Sachs (NYCOMS) tomorrow, and I'll be taking x-rays then. I'm excited about this treatment plan. I'll probably only need "heavy duty" braces on the lower teeth, and I could probably get more discreet clear braces on the top ones.

Does anyone know what the time estimate would be for the pre-surgery orthodontics phase? Could it be done in less than a year?

[kjohnt]

No prob.  Note that I only wrote what could be done to achieve what you desire.  Any two surgeons could give you different treatment plans.  You need to search for surgeons who are well versed in bimaxillary surgeries, and of those, you should filter out the ones who don't place a high value on aesthetics.  Your local doc probably won't cut it, unfortunately.

Regarding pre-surgical ortho, could be no time at all or could be over a year.  It depends on how your teeth sit currently and whether or not you need extractions. 

I see it like this - don't worry about the braces, the post-surgical nausea, speech recovery, liqui diet, etc.  These are relatively short-term issues.  Instead worry about how successful the surgery will be long-term (form and function).  How you will look, whether or not your functional issues are remedied, nerve damage, surgical complications... these are the things to worry about.

[notrain]

What would be the recommended treatment plan in terms of fractures etc.? What's the diagnosis? I just hate that the surgeon I went to immediately thought I was doing this just for cosmetic reasons and that I had BDD or something. I'm willing to go through with it because I think it would improve my quality of life. Anyway, I'd be really grateful for some advice and explanations. Thank you!

I had a similar starting situation to you and went with the lower premolar extractions and bimaxillary advancement. Since your (and mine) occlusal plane is normal, you just need to create a large enough dental overjet via means of extractions and then advance both jaws linearly. The Lefort 1 fracture will naturally be at an angle (because of the occlusal plane) so the upper jaw will come forward and down. Your lower jaw needs probably a 10mm advancement and the upper like 4mm. Linear advancement is relatively easy for the surgeon and the patient, since there aren't any grafts to relapse - just 2 bone fragments pressed together via osteosynthesis which will induce primary bone healing. I felt 100% back to normal after 8 weeks.