Uncertainty after initial consultation

[Tom199358]

Hi,

I had my appointment with the maxillofacial surgeon recently to discuss my options in more detail. Since my sleep apnea test came back negative, the surgeon seemed less concerned about going through with any maxillary adjustment. I have concerns over my gummy smile (roughly 3mm of gum), but he didnt seem very concerned about that, focusing more on function.

He referred me to a orthodontist who was really good at listening to my concerns. He believes that the best approach would be to remove two pre molars and bring my bottom teeth back. This would give the surgeon the ability to move my mandible further forward. He said that if I do double jaw surgery, my front top teeth can be adjusted outward through a CCW, creating more room for adjustments. The orthodontist said they could bring my maxilla forward a little bit too. I have a few questions and have attached some edits

1. Will my philtrum change if i get a CCW and bring my front teeth more outward through surgery/braces? I hate how it sits currently and in my edit it shows my desired look
2. Is this amount of projection possible with the approach of removing pre molars, bringing teeth back, then doing double jaw surgery?
3. Looking at my current x ray, do you believe the computer software will recommend maxillary adjustment based on my current angles?

In my edit, I have done impaction of the maxilla with a CCW, and slightly brought the maxilla forward. I have brought my lower teeth backwards, and then moved the jaw forward to accommodate the new bite. Is this a reasonable edit?

Thanks for your time. The replies i got last time were very informative. Looking forward to reading your replies

Regards Tom

https://imgur.com/a/ImJNoUZ

[Lazlo]

definitely never remove premolars. see a different orthodontist. it's terrible for your facial aesthetics to remove teeth. the guy doesn't know what he's doing, no matter how much he seems like he does.

[Tom199358]

definitely never remove premolars. see a different orthodontist. it's terrible for your facial aesthetics to remove teeth. the guy doesn't know what he's doing, no matter how much he seems like he does.

In what way does it impact your facial aesthetics?

[Gadwins]

definitely never remove premolars. see a different orthodontist. it's terrible for your facial aesthetics to remove teeth. the guy doesn't know what he's doing, no matter how much he seems like he does.

Is that really true? If you have really strong proclined teeth, but no crossbite, how do you want to solve that? (without mid split and sarpe).

[kavan]

Firstly, I'm not going to opine on the changes you made to your ceph.

What I'll shed some light on here is the issue of pre-molar extraction. The main problem with that is when orthos do it ONLY to get the BITE RIGHT in a situation where getting the bite right IS NOT to prepare for a later surgery and not with objective of balancing the jaws, it can result in PUSHING the face BACKWARDS. That's what leaves people with the same jaw IMBALANCE they started with and can leave a WORSE aesthetic to the facial contour than the person started with. So the 'cost' of getting pre-molar extractions ONLY to get the bite right can come along with the rest of the face going 'WRONG' aesthetically.

Now that's not universal in all pre-molar plucking cases for ortho ONLY. But it's the main one where people regret the aesthetic consequences of ortho only. Those people regretting ortho only are ofen the ones who get their faces PUSHED BACKWARDS from it. Advice to avoid pre-molar extraction at all costs' often comes from people who got that initially for ORTHO ONLY to get the bite right who's faces may have gone 'wrong' due to that. Hence that type of advice is not directly applicable to pre-molar extractions where the objective is to get the FACE balance right.

Getting the the pre-molars plucked out to the LOWER JAW has a different objective which is to push the lower jaw FORWARD in a surgery. The space left behind from plucking the pre-molar allows the lower teeth to be pushed backwards leaving more 'room' to bring the lower jaw forward. So, it has with it the objective of BETTER facial balance.

As to question # 1 of your initial post. Yes, the philtrum area can change from movements aimed at bringing the teeth more outward. It can change for the better because when the philtrum is angled outward with that it will look LESS long when it's angled out and away from being oriented on a vertical plane.

[Tom199358]

Firstly, I'm not going to opine on the changes you made to your ceph.

What I'll shed some light on here is the issue of pre-molar extraction. The main problem with that is when orthos do it ONLY to get the BITE RIGHT in a situation where getting the bite right IS NOT to prepare for a later surgery and not with objective of balancing the jaws, it can result in PUSHING the face BACKWARDS. That's what leaves people with the same jaw IMBALANCE they started with and can leave a WORSE aesthetic to the facial contour than the person started with. So the 'cost' of getting pre-molar extractions ONLY to get the bite right can come along with the rest of the face going 'WRONG' aesthetically.

Now that's not universal in all pre-molar plucking cases for ortho ONLY. But it's the main one where people regret the aesthetic consequences of ortho only. Those people regretting ortho only are ofen the ones who get their faces PUSHED BACKWARDS from it. Advice to avoid pre-molar extraction at all costs' often comes from people who got that initially for ORTHO ONLY to get the bite right who's faces may have gone 'wrong' due to that. Hence that type of advice is not directly applicable to pre-molar extractions where the objective is to get the FACE balance right.

Getting the the pre-molars plucked out to the LOWER JAW has a different objective which is to push the lower jaw FORWARD in a surgery. The space left behind from plucking the pre-molar allows the lower teeth to be pushed backwards leaving more 'room' to bring the lower jaw forward. So, it has with it the objective of BETTER facial balance.

As to question # 1 of your initial post. Yes, the philtrum area can change from movements aimed at bringing the teeth more outward. It can change for the better because when the philtrum is angled outward with that it will look LESS long when it's angled out and away from being oriented on a vertical plane.

Thanks for the response. Thats exactly what he told me with the extraction of the pre molars. By pushing my lower teeth back, it creates an overbite, which can then be corrected through bring forward the mandible.

My SNA angle is ok at 82*. My SNB angle is roughly 75*, with an ANB of 7*. This is just my rough calculations based on software i have used. The orthodontist was comfortable with not putting braces on my top teeth straight away, as the CCW would change the angle of the teeth. However, I am thinking now a standard impaction to reduce the gummy smile, whilst anchoring the teeth outwards with braces would provide a similar result. My occlusal plane is about 19* and my mandibular plane is 37*. Both are slightly on high side. Do you think I would benefit from CCW with these angles?

Thanks 

[kavan]

Thanks for the response. Thats exactly what he told me with the extraction of the pre molars. By pushing my lower teeth back, it creates an overbite, which can then be corrected through bring forward the mandible.

My SNA angle is ok at 82*. My SNB angle is roughly 75*, with an ANB of 7*. This is just my rough calculations based on software i have used. The orthodontist was comfortable with not putting braces on my top teeth straight away, as the CCW would change the angle of the teeth. However, I am thinking now a standard impaction to reduce the gummy smile, whilst anchoring the teeth outwards with braces would provide a similar result. My occlusal plane is about 19* and my mandibular plane is 37*. Both are slightly on high side. Do you think I would benefit from CCW with these angles?

Thanks

Somewhat, if it's anterior impaction when you only have 3mm excess gum show. But more benefit from CCW with posterior downgrafting.

[Tom199358]

Somewhat, if it's anterior impaction when you only have 3mm excess gum show. But more benefit from CCW with posterior downgrafting.

With the CCW and posterior downgrafting, would my teeth sit lower at the back because of the downgrafting? I'm trying to visualise it in my head, but I'm struggling. If my maxilla has excess verticle growth, wouldn't it be beneficial to do impaction across the whole upper jaw, but more so at the anterior end. This would create a CCW rotation. Where would the downgrafting be needed in this scenario?

Cheers

[kavan]

With the CCW and posterior downgrafting, would my teeth sit lower at the back because of the downgrafting? I'm trying to visualise it in my head, but I'm struggling. If my maxilla has excess verticle growth, wouldn't it be beneficial to do impaction across the whole upper jaw, but more so at the anterior end. This would create a CCW rotation. Where would the downgrafting be needed in this scenario?

Cheers

Yes to the first question. Yes. It would still have benefit to remove a wedge from the whole maxilla. More from the front than from the back.

[Tom199358]

Yes to the first question. Yes. It would still have benefit to remove a wedge from the whole maxilla. More from the front than from the back.

I have read that posterior downgrafting isn't common in Australia. Do you know if I will find it difficult to get this done in Aus?

[kavan]

I have read that posterior downgrafting isn't common in Australia. Do you know if I will find it difficult to get this done in Aus?

I don't know.

[PloskoPlus]

I have read that posterior downgrafting isn't common in Australia. Do you know if I will find it difficult to get this done in Aus?

Only a couple of surgeons doing it and they haven’t done it for long. Unfortunately Australia is a backwater. But we seem to be on track to eradicating the virus, so they may be your only option.

[Tom199358]

Only a couple of surgeons doing it and they haven’t done it for long. Unfortunately Australia is a backwater. But we seem to be on track to eradicating the virus, so they may be your only option.

Do you happen to know which surgeons do it?