Class II mandible/Set back lower jaw. Long face. Deep bite. What are my options?

[jamone]

Hi everyone. First time poster here.

I feeling a bit lost about my situation and the more I read on the internet the more confused I get.

My orthodontist has told me I have a class II mandible (set back lower jaw), a deep bite, spaces between upper front teeth and although they feel proclined- the radiograph and analysis showed that they are almost correct, possibly retroclined (leaning back). The models showed that the maxilla and mandible are under developed in the transverse section (by about 3mm).

He wanted to use an ALF to expand my palate for 10 months and then slap some braces on to sort my teeth out. He also said he could re open the gaps where my molars were extracted when I was a kid and put implants in. He was very anti surgery and believed in the holistic approach. I wanted to increase my facial width to help balance out my long face, asked him about face pulling and would this all help my recessed chin and facial width. At this point he seemed a bit out of his element. His dental plan proved this as it was very basic just mentioning the ALF and braces. 

I was all for the holistic approach but now I just dunno, man. I dunno if its wasting time and money for little results, if any. I have now read the palate cant be expanded in adults just teeth tipping, face pulling sounds great but I've yet to see concrete results. Would it fix the set back lower jaw? Read up on the infamous Mike Mew but some people say he doesn't promise changes in adults anyway. Some people say he is a scammer 

If I went down the surgery route, what would my options be?

[XXRyanXXL]

The whole holistic approach is predicated upon the fact while our bodies (and bones) are still growing (18 stop for male), we can condition our situation using mouth exercises and orthodontic appliance to correct a skeletal issue. These do not work past 18. Surgery is needed to correct these underlining skeletal issues. I had 10mm overbite and my ortho was requested to put on Forsus to correct it. I got second hand advice telling me this would only move my jaw forward (by training the muscles in my mouth to adapt to new bite) of only 1 mm per year.

Based on a prima facie written explanation of what you've described here, it seems as if surgery is needed in your case. Would help to see your cephs and xrays though if your willing to put out your HIPAA information voluntarily.

[jamone]

Managed to get hold of this x-ray free of charge from the place where the dentist sent me to have it done. It is the only x-ray I remember being taken. I spoke to the receptionist at the dental practise and she said there would be a charge to release my x-ray and notes. Would it be useful to have the notes now that I have the one x-ray? I don't even know what's in my notes so not sure if its worth paying for...

Anyway, here is the x-ray. What do you guys think?

http://imgur.com/k4C5AEm

[idk]

As long as your maxilla is not retruded, your ramus is normal, your mandibular plane is not very hyperdivergent, and your anterior facial height is not excessively elongated,   non surgical approach is possible.  You need to move your lower jaw down and forward and increse posterior vertical dimension by means of molar extrusion or crowns/overlays.  If you cant stand any more anterior opening because of labial incompetence or too elongated face, maybe intrusion of the anteriors would be needed but Idk how can be done (tad anchorage?).  If you could upload front and side pic would be good.

[jamone]

I will try to upload some front and side pictures later. Not exactly thrilled about having my face plastered over the net but needs must I suppose.

Anything that is going to make my face longer will make me look worse as I already have a long face. Ideally increasing the width of jaw and cheekbones would help counter the excessive length.

[XXRyanXXL]

OP

Have you seen an Oral and Maxillofacial Surgeon, or been evaluated by one recently? You can actually find some surgeons who are willing to give you a complete diagnosis and treatment plan free of cost. I've come across 3 surgeons.

[jamone]

I have not yet seen a surgeon. I didn't no any of them did free diagnosis and treatment plans free of cost so that's interesting. If you don't mind me asking, who were they and how did you find them?

[Wheatsnax]

is your lower jaw/arch narrow too?

[kavan]

What I see in the ceph is excess vertical down growth of the maxilla in the area of the upper central incisors and also some retro-inclination of them.

From a mechanical perspective, that would tend to act as a clasp to push your mandible backwards. I would attribute the retrusion of the mandible to it being clasped backwards by excess vertical down growth of an isolated segment of it. Segmental maxillary osteotomy looks to be a surgical option. 

[jamone]

is your lower jaw/arch narrow too?

Yep. I have overcrowding of the lower central incisors. Narrow arch. My ortho suggested fitting an ALF in the lower jaw after the upper jaw had been treated. As far as I know this would just move the teeth and not expand the lower jaw. As the lower jaw is one bone it's impossible to expand without surgery.

What I see in the ceph is excess vertical down growth of the maxilla in the area of the upper central incisors and also some retro-inclination of them.

From a mechanical perspective, that would tend to act as a clasp to push your mandible backwards. I would attribute the retrusion of the mandible to it being clasped backwards by excess vertical down growth of an isolated segment of it. Segmental maxillary osteotomy looks to be a surgical option. 

I can see what you mean about the excess vertical growth of my maxilla perhaps acting as a 'clasp' and pushing/locking my mandible backwards. My upper lip doesn't cover my front teeth at all (more than half of upper central incisors still show) and the top teeth more or less cover my bottom ones when I bite together. Also, when I bite my teeth together, I have to make a conscious effort to cover the rest of my front teeth with my bottom lip so my lips touch. If I'm completely resting, my lips don't touch and it looks like I have buck teeth (even though the front teeth are a bit retroclined).Weirdly for someone who has a long face due to the maxilla growing excessively downwards, I don't have a gummy smile. Not sure why.

You mention excessive downward growth of the maxilla in the area of upper incisors only, is it possible for only one isolated area of the maxilla to suffer from excessive downward growth and the rest to be ok? If so, what causes this as I was under the impression the whole maxilla suffers from downward growth...

[kavan]

yes. one area can have more downward growth than the rest.

I can see what you mean about the excess vertical growth of my maxilla perhaps acting as a 'clasp' and pushing/locking my mandible backwards. My upper lip doesn't cover my front teeth at all (more than half of upper central incisors still show) and the top teeth more or less cover my bottom ones when I bite together. Also, when I bite my teeth together, I have to make a conscious effort to cover the rest of my front teeth with my bottom lip so my lips touch. If I'm completely resting, my lips don't touch and it looks like I have buck teeth (even though the front teeth are a bit retroclined).Weirdly for someone who has a long face due to the maxilla growing excessively downwards, I don't have a gummy smile. Not sure why.

You mention excessive downward growth of the maxilla in the area of upper incisors only, is it possible for only one isolated area of the maxilla to suffer from excessive downward growth and the rest to be ok? If so, what causes this as I was under the impression the whole maxilla suffers from downward growth...

[Wheatsnax]

If I went down the surgery route, what would my options be?

think best course would be to decompensate your bite to reveal its true skeletal and dental disrepency, trying to figure it out with the deep bite atm will complicate things

[kavan]

There are some things I'm not sure of here. Although I'm sure you have Class2 Div 2 malocclusion deep bite, I'm not sure you have:

a: 'long face'

You could think you have long face because your face is narrow, because your chin might look longer in frontal view because the back part of it that is downward will project in frontal view as a longer chin or because your transverse maxilla (back teeth and supporting bone) caves inward. That's narrow face.

When I think of 'long face', i think of uncorrectable long face where the excess length is between the root and the base of the nose, in place that can't be made shorter and/or the eyes are too close set. Something where adding width doesn't offset it or can make the eyes look closer set.



b: have already had some orthodontics/braces that pushed your front teeth backwards.

Like I don't know if you started with something like bi-max protrusion, the tooth you got pulled prior was to make room to push the teeth back.

So, I don't know if you have what I would call 'long face' or if you prior got ortho work to compensate for some other dental deviation. I don't know it because you don't show a frontal or reveal any prior ortho work.

What I can tell you is that deep bite is not a matter of the entire maxilla growing downward. It's more of a matter of the anterior maxilla having vertical excess, sometimes isolated to region of front teeth in addition to the back part of the maxilla NOT growing down enough and also caving inward. That limits the mandible orientation where it gets pushed backwards and has to conform to fit by getting narrow.

You can get some correction by shoving up the upper front teeth and shoving down the bottom front teeth 'intrusion' and pulling down the upper back teeth, 'extrusion'. To that, braces to push out the upper front teeth and orthopedic dental appliances aimed at directly pushing out the bone support of the back teeth and/or making the palate a little wider.

There are a lot of orthopedic dental appliances that can move the supporting bones of the teeth which are not braces or 'teeth tippers'. But when they are marketed with the MYSTIQUE of stuff like 'cranial equilibrium', 'holistic solutions', 'myofunctional balance', 'mimicking the subtle biological forces of nature'..etc and stuff like that, it's to remove you from knowing that it's just another orthopedic dental appliance of which there are many that do similar. At that point, you might be dealing with a FOO FOO ortho an not a nuts and bolts type who works with or in conjunction with a max fax surgeon.

What you want to determine from your ortho is whether or not they actually work with a max fax surgeon. Consider that there are orthos who 'save' people from surgery and there are many patients so saved that their facial appearance is all pushed in for the ortho to get 'the bite right' and now they have to reverse the ortho to get the max fax surgery. It's just better to have an ortho that works with a max fax rather than one aimed at 'saving you' from surgery unless of course, you are a little kid when the bones are more movable in the forward direction. Anti- surgery combined with foo foo holistic therapy doe not sound like good combo to me.

With deep bite, I don't think that intruding the anteriors and extruding the posteriors in addition to orthodontics to push the front teeth forward and orthopedics to move the bone support in a better orientation would later preclude you from max fax or require a reversal of the displacements. However, your ortho doesn't say anything about intruding and extruding.

 You might even like the outcome and elect no surgery later down the line. It might tend to spare you from a 3 piece segmental lefort where they have to shorten an isolated part of the anterior maxilla, downgraft the posterior and expand the palate to widen it.

If I were you, I'd consult with a brass tacks, nuts and bolts ortho who works with a max fax or just consult directly with a max fax and then more of them because deep bite is challenging.

[jamone]

I have now added some pictures of my front and side profile with lips closed/relaxed and of my teeth/bite. Hopefully this gives you guys a bit more clarity on my situation.

http://imgur.com/a/g74AE

There are some things I'm not sure of here. Although I'm sure you have Class2 Div 2 malocclusion deep bite, I'm not sure you have:

a: 'long face'

You could think you have long face because your face is narrow, because your chin might look longer in frontal view because the back part of it that is downward will project in frontal view as a longer chin or because your transverse maxilla (back teeth and supporting bone) caves inward. That's narrow face.

When I think of 'long face', i think of uncorrectable long face where the excess length is between the root and the base of the nose, in place that can't be made shorter and/or the eyes are too close set. Something where adding width doesn't offset it or can make the eyes look closer set.

I think I have both a narrow and long face but take a look at my pictures to see what you think. I don't have close set eyes though. One thing you will notice is the right side of my face is wider than my left-from the eyes downwards the left side seems not only narrower but everything seems to droop down compared to the right making my face look asymmetrical. The asymmetry problem has gotten worse over the last few years. Even the right side of teeth/gums seems higher than the left side and are clearly not level.

Would the asymmetry be caused by the jaw not being aligned properly or the maxilla growing further down on one side?

b: have already had some orthodontics/braces that pushed your front teeth backwards.

Like I don't know if you started with something like bi-max protrusion, the tooth you got pulled prior was to make room to push the teeth back.

So, I don't know if you have what I would call 'long face' or if you prior got ortho work to compensate for some other dental deviation. I don't know it because you don't show a frontal or reveal any prior ortho work.

Sorry, I was a bit vague before. I am not sure what the exact dental terminology was for my condition when I was a kid but my front teeth protruded and I had 'goofy' teeth. You will have to forgive me as you seem very knowledgeable and I am not familiar with a lot of these dental words/phrases, however, I google them so I am always learning! With that said, bi-max protrusion looks like it might have been the same thing I had/still have.

When I was a kid I always I remember mouth breathing a lot and sucking my thumb. Dentist told me I couldn't get a brace until all my adult teeth had come through. Around the age of 12, the dentist extracted some upper premolars to create space for pulling my front teeth back with a brace. The brace wasn't even a brace, it was basically a retainer like this one http://www.powellortho.com/assets/uploads/images/retainer-instructions.png except it didn't have any metal wiring going across my upper front teeth. Mine used mini elastic bands that fitted onto the metal hooks on each side of the retainer. Had to change the elastic bands twice a day. The elastic bands never seemed to stay in the centre as it always used to slide up my two front teeth. It was a real cheap piece of equipment, probably didn't get fitted metal braces because my dentist was lazy, incompetent and wanted to cut costs. I was suppose to wear it 24/7 but I wore it off and on for about a year.

That was it. My treatment finished. Dentist even said the gaps remaining between the canines (shown in pics) will close naturally as the bottom lip will act as a brace. That never happened, surprisingly. Years later after treatment my old man says people nick named our dentist 'The Butcher'. FML. Guess I was just another victim. After teeth extractions and treatment I noticed my face get longer and narrower, black bags under eyes which have got worse etc. I have not had any work done since.

There are a lot of orthopedic dental appliances that can move the supporting bones of the teeth which are not braces or 'teeth tippers'. But when they are marketed with the MYSTIQUE of stuff like 'cranial equilibrium', 'holistic solutions', 'myofunctional balance', 'mimicking the subtle biological forces of nature'..etc and stuff like that, it's to remove you from knowing that it's just another orthopedic dental appliance of which there are many that do similar. At that point, you might be dealing with a FOO FOO ortho an not a nuts and bolts type who works with or in conjunction with a max fax surgeon.

Guess you are not much of a fax of Mike Mew then? Haha. I appreciate the advise and that's the main reason I am on here. Initially after reading about the stuff on claiming power and breakthematrix I got excited and thought the solution would be palate expansion and face pulling. However the more I read and learnt, the more it started to sound to good to be true. Lack of evidence in regards to significant change in adults has led me to this forum. I love the holistic approach to solve my problems but I fear it won't or the changes will be only satisfactory. It seems a combination of a skilled ortho who concentrates on bite as well as aesthetics working closely with a skilled max fax surgeon might get optimal results which is what I'm looking for.

With deep bite, I don't think that intruding the anteriors and extruding the posteriors in addition to orthodontics to push the front teeth forward and orthopedics to move the bone support in a better orientation would later preclude you from max fax or require a reversal of the displacements. However, your ortho doesn't say anything about intruding and extruding.

No he didn't mention that at all. He just wanted to concentrate on expanding my palate to create sufficient space/gaps and then for braces to be put on. When I questioned him about the deep bite/recessed chin he said sometimes as the upper palate is expanded, the lower jaw slides forwards and the bite naturally comes together. However, he said this isn't guaranteed. He was just a normal ortho who had taken a few Skipp Truitt courses and had being fitting ALF's to patients for TMJ issues, narrow arches etc. Philosophy wise was he didn't want to extract teeth unless he had to and it was the last resort which I respected. He had an ALF on himself actually. He didn't seem to concentrate on facial aesthetics at all though and when he put in my dental plan 'do nothing' as one of the 3 options going forward, I did a runner.

[kavan]

I have now added some pictures of my front and side profile with lips closed/relaxed and of my teeth/bite. Hopefully this gives you guys a bit more clarity on my situation.

http://imgur.com/a/g74AE

I think I have both a narrow and long face but take a look at my pictures to see what you think. I don't have close set eyes though. One thing you will notice is the right side of my face is wider than my left-from the eyes downwards the left side seems not only narrower but everything seems to droop down compared to the right making my face look asymmetrical. The asymmetry problem has gotten worse over the last few years. Even the right side of teeth/gums seems higher than the left side and are clearly not level.

Would the asymmetry be caused by the jaw not being aligned properly or the maxilla growing further down on one side?

Sorry, I was a bit vague before. I am not sure what the exact dental terminology was for my condition when I was a kid but my front teeth protruded and I had 'goofy' teeth. You will have to forgive me as you seem very knowledgeable and I am not familiar with a lot of these dental words/phrases, however, I google them so I am always learning! With that said, bi-max protrusion looks like it might have been the same thing I had/still have.

When I was a kid I always I remember mouth breathing a lot and sucking my thumb. Dentist told me I couldn't get a brace until all my adult teeth had come through. Around the age of 12, the dentist extracted some upper premolars to create space for pulling my front teeth back with a brace. The brace wasn't even a brace, it was basically a retainer like this one http://www.powellortho.com/assets/uploads/images/retainer-instructions.png except it didn't have any metal wiring going across my upper front teeth. Mine used mini elastic bands that fitted onto the metal hooks on each side of the retainer. Had to change the elastic bands twice a day. The elastic bands never seemed to stay in the centre as it always used to slide up my two front teeth. It was a real cheap piece of equipment, probably didn't get fitted metal braces because my dentist was lazy, incompetent and wanted to cut costs. I was suppose to wear it 24/7 but I wore it off and on for about a year.

That was it. My treatment finished. Dentist even said the gaps remaining between the canines (shown in pics) will close naturally as the bottom lip will act as a brace. That never happened, surprisingly. Years later after treatment my old man says people nick named our dentist 'The Butcher'. FML. Guess I was just another victim. After teeth extractions and treatment I noticed my face get longer and narrower, black bags under eyes which have got worse etc. I have not had any work done since.


Guess you are not much of a fax of Mike Mew then? Haha. I appreciate the advise and that's the main reason I am on here. Initially after reading about the stuff on claiming power and breakthematrix I got excited and thought the solution would be palate expansion and face pulling. However the more I read and learnt, the more it started to sound to good to be true. Lack of evidence in regards to significant change in adults has led me to this forum. I love the holistic approach to solve my problems but I fear it won't or the changes will be only satisfactory. It seems a combination of a skilled ortho who concentrates on bite as well as aesthetics working closely with a skilled max fax surgeon might get optimal results which is what I'm looking for.

No he didn't mention that at all. He just wanted to concentrate on expanding my palate to create sufficient space/gaps and then for braces to be put on. When I questioned him about the deep bite/recessed chin he said sometimes as the upper palate is expanded, the lower jaw slides forwards and the bite naturally comes together. However, he said this isn't guaranteed. He was just a normal ortho who had taken a few Skipp Truitt courses and had being fitting ALF's to patients for TMJ issues, narrow arches etc. Philosophy wise was he didn't want to extract teeth unless he had to and it was the last resort which I respected. He had an ALF on himself actually. He didn't seem to concentrate on facial aesthetics at all though and when he put in my dental plan 'do nothing' as one of the 3 options going forward, I did a runner.

Ok. I see what you have. Your anterior maxilla is long, especially at the central incisors and they 'curve' more outward than the lateral incisors and canines. Although the central inisors are retroclined, they are very CONVEX in the middle. The part of your maxilla between the canines (it's not just the centrals as I thought prior from the side x ray) is disproportionately longer than the part of it behind the canines.

 You've got what they call a 'buccal corridor' which is a dark hallway past your canines where you don't see the teeth in the back of them. That's from transverse maxilla caving inwards. The deep bite comes from the front teeth acting as clasp to push mandible back and also from the back upper maxilla not growing down enough. Hence, you are forced into deep bite. The surgical fix for that still looks like a 3 piece Lefort where one segment would be the area between your canines shifted upwards and the 2 sides of the palate made wider and also lowered. Surgical widening of the palate will make your face wider.


Braces would be needed to push the upper front teeth outward and the back teeth toward the cheek. Could be single jaw surgery where the lower jaw, free of the clasping action of the upper jaw can swing outward and upward as to rotate itself counter clockwise. But you never know for sure because sometimes they need to do surgery on the lower jaw to get the bite right.

The strain/difficulty in closing your lips looks to be lip incompetence where the mentalis muscle is strained. The fix for that is a diagonal cut to the chin to slide it forward and up which would improve your profile and make your face look less long. That gives the mentalis muscle more of a straight line path where it's easier to move your lower lip up.

Although I don't think you have long face, the widening to the maxilla in addition to to bringing the chin forward and up along with the jaw swing to go forward and up with the maxilla work, will decrease what you see as excess length.

Mike Mew has some good things to say. But also seems to have attracted an addlepated cult following.