SARPE vs Extractions

[C4lifornian]

My surgeon (Gunson) wants to remove teeth prior to jaw surgery, due my front 6 teeth protruding out. He says that because my maxilla was too small to fit my teeth, my orthodontist forced the front teeth to protrude out in order to make my bite fit. There is some protrusion on the bottom teeth, but not as dramatic as the upper teeth.

I am hesitant to get teeth extracted as I don't want to narrow my smile or create buccal corridors. I'm wondering if SARPE can be used instead of extractions. I am willing to undergo an additional surgery and pay the additional costs as long as it provides a better aesthetic outcome. I also raised this alternative to an orthodontist and he seemed unsure if SARPE could be used. At first he stated that SARPE couldn't be used and extractions weren't that bad, then said he was unsure. He also said surgical expansion wouldn't create as much space as extractions, then claimed that SARPE could also end up making my arch too wide. He also said there was no way to expand the lower jaw as well, but later said there actually was. So I got sort of a conflicting message.

[Lazlo]

So if Gunson is suggesting it (Arnett by the way told me taking out bicuspids was like a 1940s practice and said I shouldn't have had it done) I would consider it okay. Yes, I do believe sarpe could work to accomodate the teeth, but you should really ask him and press him on this point.

On the whole extractions issue, I got stuck in the elevator today with a guy I learned was a very prominent dentist with five practices in the city and tons of associates and various experts. I told him about my situation and the look of horror that passed briefly across his face when I told him I had four bicuspids taken out on the direction of my orthodontist was so heartbreaking for me to see. He said it's a horrible practice, it's just easier for the orthodontist to do that and that quote "destroys the architecture of the face," (are you listening Tumerican?).

Hopefully I can get some of this fixed with the jaw surgery, but f**k, I really don't think taking teeth out is a good idea. It's just f**ked up to take those bicuspids out. It's really f**ked. And I'm surprised Gunson is recommending it cause I remember someone saying he in particular had told a patient the bicuspids are crucial for keeping up the corners of the smile.

I can tell you my lips are like a 60 year old's now without the bicuspids and all the decompensation. We'll see what happens.

[thinkingme]

If ur mandibula large and maxilla narrow u can sarpe but if your double palate is same and have protruding teeths u must extract biscupids. Yes if u have big jaw or if u have space or if u dont have protruding teeths extracting teeth give u bad lips bad profile. U can read arnett gunson website for extractions. Im in the same boat and still thinking options but there is no. If i want fix my profile i must get all wisdom and first premolars out.

[Lazlo]

If ur mandibula large and maxilla narrow u can sarpe but if your double palate is same and have protruding teeths u must extract biscupids. Yes if u have big jaw or if u have space or if u dont have protruding teeths extracting teeth give u bad lips bad profile. U can read arnett gunson website for extractions. Im in the same boat and still thinking options but there is no. If i want fix my profile i must get all wisdom and first premolars out.

All four premolars out? or just on one jaw?

[marcus3415]

Sarpe is outdated. A surgeon can segment the maxilla through a segmented osteotemy while performing the surgery. This can help the top arch fit the bottom

[thinkingme]

All four premolars out? or just on one jaw?

symetrical extraction. Like extraction orthodontics. They can widen upper palate. Not lower palate U cant sarpe if ur maxilla already fit ur lower arch.

[Tezcatli]

Sarpe is outdated. A surgeon can segment the maxilla through a segmented osteotemy while performing the surgery. This can help the top arch fit the bottom

You cannot achieve the same amount of expansion with a segmented Lefort as you can with SARPE.

[C4lifornian]

I reviewed Gunson's surgical plan for me, and he stated my Lefort 1 would be multi-segment. Would this widen the palate, so after my extractions the difference in the width of the smile is negligible?

In any case, I'm worried though that a SARPE would be impossible because my bite is Class I, with noticeable flaring of the upper teeth, and minor flaring of the lower. As I understand it, SARPE by itself would mess up my bite, making my upper palate too wide for my lower palate. Is there anyway to address that, or is it not even a concern in the first place?

[molestrip]

I haven't heard of Dr Gunson doing SARPEs, doesn't mean it doesn't happen. Dr Posnick advocates for extractions when indicated. I hate the idea too but I know many people who've had it done and it's not the end of the world. If your lower arch can accomodate all your teeth, then you can do a SARPE or multi-segment LeFort and keep all your teeth. If your lower arch cannot accomodate them, then your best option is extraction. One alternative would be to flare the lower arch and accept the periodontal and root blunting consequences when you're older. If the discrepancy is small, then you could look into surgically faciliated orthodontic expansion but you can only get about 5mm that way and it makes the gums look puffy. 3-piece LeFort is used up to 5-7mm, SARPE for 7+mm. Multi-segment LeFort is also used for fixing two-plane occlusions. There are differences of opinion regarding how and when to take risk.

[C4lifornian]

I haven't heard of Dr Gunson doing SARPEs, doesn't mean it doesn't happen. Dr Posnick advocates for extractions when indicated. I hate the idea too but I know many people who've had it done and it's not the end of the world. If your lower arch can accomodate all your teeth, then you can do a SARPE or multi-segment LeFort and keep all your teeth. If your lower arch cannot accomodate them, then your best option is extraction. One alternative would be to flare the lower arch and accept the periodontal and root blunting consequences when you're older. If the discrepancy is small, then you could look into surgically faciliated orthodontic expansion but you can only get about 5mm that way and it makes the gums look puffy. 3-piece LeFort is used up to 5-7mm, SARPE for 7+mm. Multi-segment LeFort is also used for fixing two-plane occlusions. There are differences of opinion regarding how and when to take risk.

Thanks for the response, I'm getting a 2nd opinion soon, so I'll update on what the doctor says.

I know it's hard to assess my problem with just a description, so I've taken pictures of my models so you can see exactly what I'm dealing with. 

Something interesting I noticed is that my upper 2nd molars are less in line with the arch than the lower ones are.

[attachment deleted by admin]

[thinkingme]

Thanks for the response, I'm getting a 2nd opinion soon, so I'll update on what the doctor says.

I know it's hard to assess my problem with just a description, so I've taken pictures of my models so you can see exactly what I'm dealing with. 

Something interesting I noticed is that my upper 2nd molars are less in line with the arch than the lower ones are.

This 2nd molar thing more promenint at mine and at both jaws. They are like 2-3 mm out of line.

[molestrip]

SARPE makes no sense in this case. You have an exaggerated cruve of Spee, not a transverse discrepancy. I can see how extractions would make sense non-surgically, since there's no room to retract the incisors. However, you're getting surgery anyway and they can be leveled surgically with a 3-piece. I don't understand how they level the posterior teeth, I'd guess they just don't. Can you share the CBCT? We can look at dental models all day but you can't determine if there's a skeletal discrepancy without looking at the skeleton. That's my big gripe with my orthodontist, making clinical judgements that can be better using imaging. Granted, my case appears to be borderline nonetheless. Still, even in that case a 3-piece would solve the problem. You already have proper overjet so really it may only be needed for anterior overbite and to center teeth which may not be centered in bone currently.

[C4lifornian]

SARPE makes no sense in this case. You have an exaggerated cruve of Spee, not a transverse discrepancy. I can see how extractions would make sense non-surgically, since there's no room to retract the incisors. However, you're getting surgery anyway and they can be leveled surgically with a 3-piece. I don't understand how they level the posterior teeth, I'd guess they just don't. Can you share the CBCT? We can look at dental models all day but you can't determine if there's a skeletal discrepancy without looking at the skeleton. That's my big gripe with my orthodontist, making clinical judgements that can be better using imaging. Granted, my case appears to be borderline nonetheless. Still, even in that case a 3-piece would solve the problem. You already have proper overjet so really it may only be needed for anterior overbite and to center teeth which may not be centered in bone currently.

Is a CBCT a 3D image? I don't have any of those, but I do have cephalometric x-rays (though, they don't do a good job of showing the bone, they mostly show the teeth and are different from most I've seen on here), a panorex and the illustrated ceph with the surgeons proposed movements if that's helpful and you think those are worth posting. When you say that the incisors can be leveled with a 3 piece LeFort, what exactly does that mean? From what you've said before (forgive me if I've misunderstood), a multi-segment LeFort could widen the palate, though not to the extent of a SARPE. By leveling the incisors, does this mean pushing them back and making them fit the rest of the arch. And when you say they don't/can't level the posteriors, is this a reason to be concerned?

Aesthetically, my biggest concern with my smile is the upper incisors and cuspids. As you can see from the models, they are flared out and overlap the bicuspids. Would a multi-segment LeFort address these concerns?

[molestrip]

but I do have cephalometric x-rays (though, they don't do a good job of showing the bone, they mostly show the teeth and are different from most I've seen on here), a panorex and the illustrated ceph with the surgeons proposed movements if that's helpful and you think those are worth posting.

Yes, please share both.

By leveling the incisors, does this mean pushing them back and making them fit the rest of the arch.

No they cut the maxilla into 3-pieces and literally slide the front/middle piece straight down to make them match the others around them. There's a few ways surgeons can cut the maxilla so what they do depends on which cut they choose.

And when you say they don't/can't level the posteriors, is this a reason to be concerned?

Not a concern. I just don't know how or if they do it. You can't intrude molars without bone anchorage I think. They might just leave them alone.

Aesthetically, my biggest concern with my smile is the upper incisors and cuspids. As you can see from the models, they are flared out and overlap the bicuspids. Would a multi-segment LeFort address these concerns?

Yes it would. By expanding the arch you can retract the incisors and cuspids or, if they're already centered in the bone, you can rotate the center segment.

[C4lifornian]

Yes it would. By expanding the arch you can retract the incisors and cuspids or, if they're already centered in the bone, you can rotate the center segment.

But if they expand the upper arch, wouldn't a movement also have to occur in the lower arch?

Anyways, here are my records. There are 3 different CTP's, one is as I am right now, one is after the proposed surgery, I'm not sure what the other one his for. I've also included the panorex and ceph x-ray.



[attachment deleted by admin]

[attachment deleted by admin]