Weak and recessed lower jaw-health problems.

[kavan]

Sure. The name is Dr. Dror Allon.

He keeps a group chat with over 300 of his patients and he encourages us to speak to other patients and review photos. As I said, my main worry is the limit of his surgical skill, because that is what he does and learned here. If he only knows how to advance jaws, so he recommends what he think is best and will probably do a very good job with it, but’s it’s also not the best option out there possibly. He is definitely the best in my country, but what is being the best in my country VS being good in Europe.
He worked with the university of Texas and also in Italy, so I am sure he is well aware of the concept of CCW.

The question I feel will come down to how much I care about the best possible result vs price and convenience.

Never heard of him. I looked him up. I think he can do what he told you he would do. If he has a group of patients you can speak to and review photos, well that should be sufficient to eyeball his outcomes. But do explore options you mentioned in prior post.

[CCW]

I will contact Gunson, Raffiani, zarrinbal and a doctor in Belgium to get just more options. I will make sure to update.

Nah, Zarrinbal is not the right doc for you because he's a chin wing guy. Your issues are both functional and aesthetic, so you need a surgeon who takes both of them into account. I'd recommend Raffaini and Alfaro in Europe and Gunson and Relle in the US.

[Dutcherhatcher]

Okay guys, i had my first consultation with a big name doctor as recommended here.
I wont name him as i have no idea if any doctors check this forum, but i can pm him if you want.

He said the following.

On the surgical plan, what he said was identical to my doctor. Move the lower jaw by 8-10 mm forward, if i suffer from severe sleep apnea advance the upper jaw around 3 mm. Really against touching the upper jaw if there is no medical need since 3 mm will barley make any difference on the face and it is a very difficult cut (le fort 1). So far so good, so he pretty much confirmed the plan my doctor proposed was ideal and the correct route.

However he was shocked that the first molars were removed. He said that he is not sure that the gap can be covered by moving the teeth alone and i might need implant. Once i explained to him that one the teeth was heavily infected and the other was also post root treatment he agreed with me that there was no easy choice here. He recommended to continue with the braces (invisalign) and see if i need a dental implant and to contact him in 6 months for a new evaluation.

I had a few questions @kevan. i hope you can help me clear a few things.

1)Do you think in the grand scheme of things it was a mistake to remove the first molars? there was a 50/50 chance one of them was going to go anyway, so my doctor convinced me it was needed. However i keep reading in this forum that extracting any teeth beside the wisdom will lead to collapse of the face. Will this happen to me? Is there anything i can do to prevent it? What would be the correct course of action in your opinion?

2) I keep running into the SNA and SNB angles. Is there any ideal figure for them?

I am going to update in the next 2-3 weeks as i am going to see 3 more highly rated doctors in Europe.

[GJ]

That's why I asked on page 1 "why you're missing premolars?"

You said they were back molars (wisdom teeth), but clearly there is a black spot where your premolars should be.

To answer your question: yes it's a mistake to remove those. The proper fix if the teeth won't fix is a 3 piece to widen the arch. If the bottom teeth don't 't fit as well, it gets more complex as you can't widen the arch; but, if anything they should have tried IPR or removed the 2nd premolar rather than the 1st (more root structure compared to the 2nd and thus more bone loss when pulled).

Whether it will cause the face to sag depends on many things. I've seen it do that, and I've seen it cause no issues. I had four 1st premolars pulled, so I can tell you in my case the face didn't sag. But I have great skin, and I had advancement that offset it a bit. You can also accept some space between the premolar and molars so as to not retract the teeth as much -- this is an option, too, but if the surgeon is Gunson he won't allow that and will want spaces closed. If the spaces are still wide enough, you can put implants in them as well. This is difficult but possible.

[Dutcherhatcher]

That's why I asked on page 1 "why you're missing premolars?"

You said they were back molars (wisdom teeth), but clearly there is a black spot where your premolars should be.

To answer your question: yes it's a mistake to remove those. The proper fix if the teeth won't fix is a 3 piece to widen the arch. If the bottom teeth don't 't fit as well, it gets more complex as you can't widen the arch; but, if anything they should have tried IPR or removed the 2nd premolar rather than the 1st (more root structure compared to the 2nd and thus more bone loss when pulled).

Whether it will cause the face to sag depends on many things. I've seen it do that, and I've seen it cause no issues. I had four 1st premolars pulled, so I can tell you in my case the face didn't sag. But I have great skin, and I had advancement that offset it a bit. You can also accept some space between the premolar and molars so as to not retract the teeth as much -- this is an option, too, but if the surgeon is Gunson he won't allow that and will want spaces closed. If the spaces are still wide enough, you can put implants in them as well. This is difficult but possible.

Sorry, i was sure i had it cleared up. He removed the first molars instead of the wisdom teeth simply because they were heavily eroded. One of them was far gone and was going to be removed anyway, the other one was hanging there. So he offered to either try to save them, do a half a year treatment and best case scenario remove 2 wisdom teeth and stay with 2 rotten teeth (that might be removed anyway) or simply remove the molars. Of course that in an ideal situation i would have extracted the wisdom, but that was not in the cards.

So what do you recommend i do now to "Save" it? the extraction happened in late march, so i dont think too much damage was done. What can i do now? Or is it too late? Implants i assume wont covered the root of the bone that was loss?

I assumed that there was no difference between extracting molars and third molars since the end situation is the same, you stay with 2 molars. If you extract the wisdom thats it, but if you extract the first molars the second take their place and third take the second place.

[GJ]

Sorry, i was sure i had it cleared up. He removed the first molars instead of the wisdom teeth simply because they were heavily eroded. One of them was far gone and was going to be removed anyway, the other one was hanging there. So he offered to either try to save them, do a half a year treatment and best case scenario remove 2 wisdom teeth and stay with 2 rotten teeth (that might be removed anyway) or simply remove the molars. Of course that in an ideal situation i would have extracted the wisdom, but that was not in the cards.

So what do you recommend i do now to "Save" it? the extraction happened in late march, so i dont think too much damage was done. What can i do now? Or is it too late? Implants i assume wont covered the root of the bone that was loss?

I assumed that there was no difference between extracting molars and third molars since the end situation is the same, you stay with 2 molars. If you extract the wisdom thats it, but if you extract the first molars the second take their place and third take the second place.

I see. Well he should have removed the wisdom teeth rather than the first molars (though, I'd have to see what you mean by "rotten teeth"). If they truly were rotten, how did they get that bad? Do you brush, floss, etc? If they needed to be extracted (dubious), then so be it, but likely you could have filled any cavity or put a crown on them if they were chipped. Unless the roots were destroyed there's no reason to extract them, and roots rarely get destroyed from routine wear but rather usually from orthodontics (root resorption).

In terms of what you can do, have someone measure the space and see if an implant will fit. They can be implanted with bone grafts attached if there isn't enough bone at the site. The screw in the implant simulates a root. Usually the bone reabsorbs within 3 months, so you might be low on bone there. What keeps the bone from reabsorbing is the biting force itself on the tooth, so if you lack a tooth there is no force to keep regenerating bone. This is the main reason extractions lead to sagging face. The bone reabsorbs without that biting force to keep it regenerating. The body basically assumes it doesn't need to keep producing bone since there is no force at that spot.

[april]

So what do you recommend i do now to "Save" it? the extraction happened in late march, so i dont think too much damage was done. What can i do now? Or is it too late? Implants i assume wont covered the root of the bone that was loss?

Is it better to have implants done before surgery or after surgery? I feel like after-surgery makes more sense because there's often a lot of bite adjusting by the ortho that happens post-surgery too. And I'm assuming when an implant is in, it can't be moved?

[kavan]

Okay guys, i had my first consultation with a big name doctor as recommended here.
I wont name him as i have no idea if any doctors check this forum, but i can pm him if you want.

He said the following.

On the surgical plan, what he said was identical to my doctor. Move the lower jaw by 8-10 mm forward, if i suffer from severe sleep apnea advance the upper jaw around 3 mm. Really against touching the upper jaw if there is no medical need since 3 mm will barley make any difference on the face and it is a very difficult cut (le fort 1). So far so good, so he pretty much confirmed the plan my doctor proposed was ideal and the correct route.

However he was shocked that the first molars were removed. He said that he is not sure that the gap can be covered by moving the teeth alone and i might need implant. Once i explained to him that one the teeth was heavily infected and the other was also post root treatment he agreed with me that there was no easy choice here. He recommended to continue with the braces (invisalign) and see if i need a dental implant and to contact him in 6 months for a new evaluation.

I had a few questions @kevan. i hope you can help me clear a few things.

1)Do you think in the grand scheme of things it was a mistake to remove the first molars? there was a 50/50 chance one of them was going to go anyway, so my doctor convinced me it was needed. However i keep reading in this forum that extracting any teeth beside the wisdom will lead to collapse of the face. Will this happen to me? Is there anything i can do to prevent it? What would be the correct course of action in your opinion?

2) I keep running into the SNA and SNB angles. Is there any ideal figure for them?

I am going to update in the next 2-3 weeks as i am going to see 3 more highly rated doctors in Europe.

1: No 'mistake' to remove infected teeth when one still got infected even after trying to 'save' with root canal. So, what if people say extracting teeth will lead to collapse of face.  Were they referring to HEALTHY teeth or INFECTED teeth? Sure tooth loss can lead to some loss of bone support. But the risk of keeping infected teeth in is Ludwig's Angina. (See photo below)


I'm not sure if tooth implants are to be put in before or after the BSSO. I would imagine afterwards. If the other doctor mentioned he wanted to do a tooth implant, cross reference that with the first doctor in your country. Sailent course of action, IMO, would be to use other consults as cross reference of what your other doctor wants to do. Here you got a cross reference that what your doctor's plan was a good one. Personally, I think the doctor in your own local is offering the most straight forward low risk option with biggest bang for the buck.

2: There are NORMS for SNA and SNB angles. No single measurement of anything is 'ideal' in it's own right.

[kavan]

ETA: Trying to 'save' the INFECTED teeth and removing other teeth instead could have lead to the ones prone to infection being removed later down the line anyway. So, those would be gone in addition to the other ones moved 'instead'. I guess if you really wanted to 'hold onto' the teeth that got infected, the waiting period could have involved another root canal and further infection and/or just RISKING a very BAD systemic infection. Basically, there's a RISK involved with a 'wait and see' process of removing other teeth INSTEAD that aren't infected and trying to save the infected ones. Wait and see process could just lead to finding out for sure they are can't be salvaged or a serious infection that goes BEYOND the teeth. Like sometimes, the tooth can be cracked and the crack extends to the roots. But cracks are hard to see in an X ray. So, if you kept on trying to save a tooth that had that, the wait and see process would lead to just finding out it could not be salvaged and would need to be extracted and/or infections entering through the crack could lead to much worse things.

1: No 'mistake' to remove infected teeth when one still got infected even after trying to 'save' with root canal. So, what if people say extracting teeth will lead to collapse of face.  Were they referring to HEALTHY teeth or INFECTED teeth? Sure tooth loss can lead to some loss of bone support. But the risk of keeping infected teeth in is Ludwig's Angina. (See photo below)

I'm not sure if tooth implants are to be put in before or after the BSSO. I would imagine afterwards. If the other doctor mentioned he wanted to do a tooth implant, cross reference that with the first doctor in your country. Sailent course of action, IMO, would be to use other consults as cross reference of what your other doctor wants to do. Here you got a cross reference that what your doctor's plan was a good one. Personally, I think the doctor in your own local is offering the most straight forward low risk option with biggest bang for the buck.

2: There are NORMS for SNA and SNB angles. No single measurement of anything is 'ideal' in it's own right.

[kavan]

Sorry, i was sure i had it cleared up. He removed the first molars instead of the wisdom teeth simply because they were heavily eroded. One of them was far gone and was going to be removed anyway, the other one was hanging there. So he offered to either try to save them, do a half a year treatment and best case scenario remove 2 wisdom teeth and stay with 2 rotten teeth (that might be removed anyway) or simply remove the molars. Of course that in an ideal situation i would have extracted the wisdom, but that was not in the cards.

So what do you recommend i do now to "Save" it? the extraction happened in late march, so i dont think too much damage was done. What can i do now? Or is it too late? Implants i assume wont covered the root of the bone that was loss?

I assumed that there was no difference between extracting molars and third molars since the end situation is the same, you stay with 2 molars. If you extract the wisdom thats it, but if you extract the first molars the second take their place and third take the second place.

I also validated that the teeth removed were the first molars. See Reply #12 where I did a count down of the teeth to show ones removed were first pre molars.

As to getting an implant in the space where the 1rst molars are gone WHY would you even want to do that given THAT'S the space to be used to push the lower teeth backwards in order to push the lower jaw forwards. One tooth has to be GONE to push some other teeth backwards for the BSSO. Getting an implant in that space would involve THEN having to have the pre molar removed to make space.

[kavan]

Is it better to have implants done before surgery or after surgery? I feel like after-surgery makes more sense because there's often a lot of bite adjusting by the ortho that happens post-surgery too. And I'm assuming when an implant is in, it can't be moved?

I wasn't sure either at the time I wrote one of my posts saying I wasn't sure. Just looked into it. An implant can't be moved with braces. So, would not be wise to put one in before ortho, in preparation for a surgery, was completed. Also, in his case, the missing tooth is being used as a space so they can push the other teeth backwards to move jaw forward. So,if he gets an implant to fill that space, it could result in having the pre molar removed to make a space and possibly throw a wrench in the gears for ortho prep.

[GJ]

Agree, which is why I said we need to see these "infected" teeth (did he see infected or "rotten"? I think he said rotten, whatever that means). If they were simply cavities or chipped or something like this and the doctor just wanted to pull teeth that's different than an actual infection. Also, how/why did they become infected? If you have poor dental care you're not going to do well in any circumstance.

[kavan]

Agree, which is why I said we need to see these "infected" teeth (did he see infected or "rotten"? I think he said rotten, whatever that means). If they were simply cavities or chipped or something like this and the doctor just wanted to pull teeth that's different than an actual infection. Also, how/why did they become infected? If you have poor dental care you're not going to do well in any circumstance.

Rotten usually means teaming with putrefactive bacteria. So, I took his term of that to imply infection.

[GJ]

Hopefully he'll give more info on what was wrong with these teeth. I took rotten to mean cavities. Rotten isn't really a proper diagnosis. Lol

[Dutcherhatcher]

Here is the picture.
I had 2 root canal treatments+crown in on them and one of them failed.

https://imgur.com/a/QcPOmrJ