Pic of my X-ray-more confused than ever.

[talia7]

I posted before, but now I have an X-ray. I had two ortho consults so far, waiting on surgeon consults.
I had braces twice. Once around 15. Wore rubber bands. That never fixed my mandible issue though...also didn’t keep up with retainers. Braces again around 5-6 years ago to straighten teeth that got all crooked. Didn’t understand at the time that my retruded  mandible/chin and overbite/overjet wouldn’t get any better with this method.
Now, my mandible and chin continue to retrude. Got two very different ortho consults. First guy said:
Bottom front teeth are tipped out and top front teeth are tipped in. Front bottom teeth are overerruptted and hit tissue on top of mouth. Apparently my overjet is only 3mm?! How is this possible with my profile looking as awful as it does? I’m thinking maybe past ortho tried to camo my overjet a bit by tipping the front teeth, and due to that, my overjet is now smaller than what it would be if my teeth were totally vertical.
He said he’d have to extract a bottom tooth to increase overjet for pre op and this is the only way. Otherwise I only have 3mm of mandibular movement available for surgeon.
Huh? I asked: what if maxilla is moved forward too, then surgeon would have more room to play with for mandible advancement. He said that wouldn’t make a difference and he’d still have to pull a tooth.
This ortho said insurance would never approve me. Also that a surgeon would likely not consider me surgical either.  My case isn’t severe. I look fine. Ugh.
Second ortho was much more receptive. Said, let’s wait to see what surgeon says. And that she probably would NOT have to pull any teeth. She also quoted me $2,500 more for 18 months in braces if I pursue this.
I just don’t get how some people getting surgery have overjets way bigger than me and yet their profiles don’t look as bad; their mandible and chins aren’t as retruded?
I have pain in jaw muscles, sleep with mouth open often (sleep apnea ruled out but may need testing somwhere else to check for upper airway resistance syndrome- requires special equipment), eating and speaking have gotten tiresome and uncomfortable, etc.
If I stop wearing my retainers from previous ortho work, my teeth start shifting in a matter of days. Wondering if I should stop wearing them, then my bite might get worse, bad enough for insurance to approve maybe.
I have Aetna and their policy explicitly states that surgical pre authorization  must be made BEFORE braces are put on, due to braces often making bites dysfunctional right before surgery, and it can be misleading.
Ugh any thoughts on this? Not only do I have functional issues, I can’t stand looking at my face. I have tmj symptoms too, need to talk to surgeon. 

[kavan]

I posted before, but now I have an X-ray. I had two ortho consults so far, waiting on surgeon consults.
I had braces twice. Once around 15. Wore rubber bands. That never fixed my mandible issue though...also didn’t keep up with retainers. Braces again around 5-6 years ago to straighten teeth that got all crooked. Didn’t understand at the time that my retruded  mandible/chin and overbite/overjet wouldn’t get any better with this method.
Now, my mandible and chin continue to retrude. Got two very different ortho consults. First guy said:
Bottom front teeth are tipped out and top front teeth are tipped in. Front bottom teeth are overerruptted and hit tissue on top of mouth. Apparently my overjet is only 3mm?! How is this possible with my profile looking as awful as it does? I’m thinking maybe past ortho tried to camo my overjet a bit by tipping the front teeth, and due to that, my overjet is now smaller than what it would be if my teeth were totally vertical.
He said he’d have to extract a bottom tooth to increase overjet for pre op and this is the only way. Otherwise I only have 3mm of mandibular movement available for surgeon.
Huh? I asked: what if maxilla is moved forward too, then surgeon would have more room to play with for mandible advancement. He said that wouldn’t make a difference and he’d still have to pull a tooth.
This ortho said insurance would never approve me. Also that a surgeon would likely not consider me surgical either.  My case isn’t severe. I look fine. Ugh.
Second ortho was much more receptive. Said, let’s wait to see what surgeon says. And that she probably would NOT have to pull any teeth. She also quoted me $2,500 more for 18 months in braces if I pursue this.
I just don’t get how some people getting surgery have overjets way bigger than me and yet their profiles don’t look as bad; their mandible and chins aren’t as retruded?
I have pain in jaw muscles, sleep with mouth open often (sleep apnea ruled out but may need testing somwhere else to check for upper airway resistance syndrome- requires special equipment), eating and speaking have gotten tiresome and uncomfortable, etc.
If I stop wearing my retainers from previous ortho work, my teeth start shifting in a matter of days. Wondering if I should stop wearing them, then my bite might get worse, bad enough for insurance to approve maybe.
I have Aetna and their policy explicitly states that surgical pre authorization  must be made BEFORE braces are put on, due to braces often making bites dysfunctional right before surgery, and it can be misleading.
Ugh any thoughts on this? Not only do I have functional issues, I can’t stand looking at my face. I have tmj symptoms too, need to talk to surgeon.

A lot of your mandible retrusion seems to be relative to the excess protrusion of the upper jaw area. That is to say; in terms of the basic angle measures, it is your upper jaw area that protrudes beyond the norm and enough so, a lot of the lower jaw retrusion is by RELATIVE COMPARISON.

A you noted, the prior braces most likely pushed out the lower teeth and pushed backwards the upper teeth to mask the overbite (reduce the overjet).

Your ceph reveals that your maxilla area is protrusive (SNA angle in excess of norm) which could help explain why they might not want to move it forward to get more forward advancement of the mandible. Also why they would want to push your lower teeth backwards to increase the amount they can move the mandible forwards. The assessment of 2 (pre-molars) plucked would have to do with their seeing crowding or not enough room to push the lower teeth backwards ENOUGH to MAXIMIZE the lower jaw advancement where they would also want to MININIZE the upper jaw advancement due to your high SNA angle.

This situation differs from cases where the SNA angle is within the norms but the SNB is below them in which case it's more clear cut or straight forward that the mandible is 'absolutely' retrusive. So, a lot of your lower jaw 'retrusion' is relative to the protrusion of the upper jaw area. So, people with overjets way bigger than yours could look that way due to the SNB angle measures being clear cut retrusive.

[talia7]

Wow, Kavan, I never in a million years would have thought I had upper jaw protrusion! Thank You for the help in understanding. I feel like I’m screwed. Do you think that braces/rubber bands can bring back the upper jaw at all? Then maybe a genio? Or: I’ve also been seeing women use cosmetic fillers for my defined jaws and chins.

[talia7]

At the same time...I have jowls and pre mature sagging around lip folds: I figured this was due to mandible retrusion. . I feel like If anything is brought “back” my sagging would get worse. I don’t know that I want to go that route. Ugh.

[kavan]

Wow, Kavan, I never in a million years would have thought I had upper jaw protrusion! Thank You for the help in understanding. I feel like I’m screwed. Do you think that braces/rubber bands can bring back the upper jaw at all? Then maybe a genio? Or: I’ve also been seeing women use cosmetic fillers for my defined jaws and chins.

Well, bringing the upper jaw backwards is most likely what they were trying to do with the braces prior. Braces for jaw surgery would be in the direction of angling forward the upper teeth in hopes of maximizing the lower jaw advancement. That in addition to pushing the lower teeth back and removing the pre-molars to maximize lower jaw advancement. I'm just telling you why they are not wanting to move the upper jaw forwards to facilitate further advancement of the lower jaw and also why they would want to pluck the pre molars in process of pushing lower teeth backwards to make enough room. Chin advancement should be done with BSSO.

[talia7]

Thanks. The one ortho that mentioned tooth extraction said he’d likely only remove one bottom tooth. Wouldn’t this negatively affect the occlusion-how will the bite properly line up with only the removal of one tooth on bottom? Seems weird to me. Seems like it would need to be two like you stated. Do you think a BSSO is justifiable from a competent surgeons perspective?

[talia7]

Also seems like my anb angle is really off? I wonder if this discrepancy warrants the BSSO?

[haven]

Thanks. The one ortho that mentioned tooth extraction said he’d likely only remove one bottom tooth. Wouldn’t this negatively affect the occlusion-how will the bite properly line up with only the removal of one tooth on bottom? Seems weird to me. Seems like it would need to be two like you stated. Do you think a BSSO is justifiable from a competent surgeons perspective?

I'm curious on how extractions for jaw surgery work. Is the amount of space created from the extraction more or less the amount they move the jaw forward? Thats what I understood from speaking with surgeons, which is why I felt it was overkill in my case.

[kavan]

Thanks. The one ortho that mentioned tooth extraction said he’d likely only remove one bottom tooth. Wouldn’t this negatively affect the occlusion-how will the bite properly line up with only the removal of one tooth on bottom? Seems weird to me. Seems like it would need to be two like you stated. Do you think a BSSO is justifiable from a competent surgeons perspective?

That usually means one on each side=2. They do it so they can get occlusion after the BSSO.

[kavan]

Also seems like my anb angle is really off? I wonder if this discrepancy warrants the BSSO?

The anb angle is SNA-SNB

[talia7]

That usually means one on each side=2. They do it so they can get occlusion after the BSSO.

Ah. That makes sense. Losing two teeth scares me, but I guess That would be my only option for good results. I hate how camo orthodontics make this so much more convoluted. I’m in a grey area, I feel like. The one ortho told me that I don’t look like a surgical case, not extreme enough. I’m discouraged.

[talia7]

I'm curious on how extractions for jaw surgery work. Is the amount of space created from the extraction more or less the amount they move the jaw forward? Thats what I understood from speaking with surgeons, which is why I felt it was overkill in my case.

yes. My previous ortho work camouflaged my class II bite. Extractions, along with pulling up my lower incisors and tipping back my upper front teeth would be the only way to create enough overjet to be able to surgically pull my mandible forward into a good occlusion.

[haven]

yes. My previous ortho work camouflaged my class II bite. Extractions, along with pulling up my lower incisors and tipping back my upper front teeth would be the only way to create enough overjet to be able to surgically pull my mandible forward into a good occlusion.

Is your jaw in frequent pain? I have some on and off clicking on my right side, but it's never bothered me. I think it would make the most sense to pull two teeth prior to surgery. How far back are your teeth relative to the upper ones? I really can't tell through the x-rays.

[ditterbo]

You might want to check up with a doc that frequently employs CCW to see if you're a candidate for that.  Your OP seems similar to mine, so from that perspective you could maybe negotiate enough CCW rotation to avoid tooth extractions. The draw back to CCW maybe is the added risk to the TMJ.

..preempting the MPA rebuttals, CCW would barely change it. Maybe no need for SG since the chin bone looks well formed.

[talia7]

Is your jaw in frequent pain? I have some on and off clicking on my right side, but it's never bothered me. I think it would make the most sense to pull two teeth prior to surgery. How far back are your teeth relative to the upper ones? I really can't tell through the x-rays.

they line up fairly well, due to previous orthodontics. Had I not had orthodontics, I’m guessing the mandibular teeth would be much further behind the maxillary teeth: they’d be in a natural overjet position. Since my bite was compensated with ortho, now I likely have to decompensate with extractions.
Yes, my pain is becoming more frequent. Masticatory muscle pain and then a feeling of pressure in my left tmj which also clicks. I need to have the tmjs evaluated.