Embarking on potential jaw surgery journey: advice, tips with consultations, etc

[eg.1999]

Hi everyone,

Just wanted to jump on here and ask about some advice for myself with regards to getting double jaw surgery and the like.

I am pretty sure I was born with a condition called Hemifacial Microsomia (a mild case albeit) that basically means the right side of my face has not grown as much as my left. It is not severe but it is essentially meaning I have a cant in my bite towards my left side meaning my maxilla is canted as is my mandible. Furthermore my left ramus is much longer than my right ramus which additionally has resulted in my left side 'overgrowing' into my right and essentially causing my chin to deviate to the right side.

I had braces when I was younger around the age of 13-15 because I had quite a bad occlusion which involved extracting two premolars from my maxilla. After having done extensive reading about the flaws of this, I am very disappointed I had this down without any prior informed consent about what this could do to my upper jaw and to my TMJ joint, which now has a click in the left side. I would like to ideally get this reversed so that I can get dental implants so that I have a proper arch and bite and ELIMINATE the click. However, there is always the potential that this click is actually CAUSED by my mandible which hasn't grown properly on the right side as this is the side the click exists.

In addition to this, my arches I have read are quite narrow. I have read so much about how to expand these with different surgeries and devices but it is all quite confusing and leaves you at a moot point with regards to what to do! I have read about M.S.E., D.N.A., S.A.R.P.E and all these other methods but really not sure what I would want to go for and ultimately what would be most effective.

Essentially, what I would like to do is get bimax surgery to rotate my maxilla and adjust my mandible to the point they are no longer rotated, address the asymmetry of my jaws in addition to potentially advancing both further slightly. I might want a genioplasty also. With regards to reversing my extractions and expanding my arch, I am not sure whether this is something I could get done AFTER surgery rather than before. I imagine that since my bite would be balanced after the surgeries, I could easily expand my arches if I wanted to post surgery.

I live in the U.K. and would ideally want to get everything done here but seeing different forums and different perspectives, it seems I may have to go ahead and get this done in Europe. I have been eyeing up two surgeons in Spain and Belgium but I am concerned about how the orthodontic side of the treatment would proceed: I would hope for the potential to liaise with my orthodontist in the U.K.

I am attaching some images here for people to see of me now, as a kid, etc.

https://imgur.com/a/CtOUXQm

Would also love some advice on how to navigate consultations with surgeons and orthodontists in a way that I can maximise what I get from consultations, perhaps avoiding unnecessary ones and also just make sure me and my surgeon get along well and are on the same page with regards to my treatment.

Looking forward to hear peoples thoughts and stuff

[GJ]

My understanding of this is that lengthening the left side is going to be more unstable than shortening the right side.
Without a ceph, it's hard to say what is going on, but typically this type of pattern has a cant, which can be corrected by shaving bone off the longer said, but also a "yaw", which is very hard to correct.

See this to understand: https://pocketdentistry.com/model-surgery/

Since the yaw is more at the joint, it's hard to correct. Gunson says he doesn't chase the yaw. So you might not be able to fix everything, if you do have a yaw. Ask about all that on consults and get a ceph. Unfortunate you had extractions. You have good features, btw, so don't be too hard on yourself.

[eg.1999]

My understanding of this is that lengthening the left side is going to be more unstable than shortening the right side.
Without a ceph, it's hard to say what is going on, but typically this type of pattern has a cant, which can be corrected by shaving bone off the longer said, but also a "yaw", which is very hard to correct.

See this to understand: https://pocketdentistry.com/model-surgery/

Since the yaw is more at the joint, it's hard to correct. Gunson says he doesn't chase the yaw. So you might not be able to fix everything, if you do have a yaw. Ask about all that on consults and get a ceph. Unfortunate you had extractions. You have good features, btw, so don't be too hard on yourself.

Ok, good to know. I mean hopefully it can be fixed and I will see what surgeons suggest and recommend. Once the lockdown is over, I'll get some scans and post them down here. I have heard good things about Prof. Hernandez in Barcelona?

Yeah, disappointed I wasn't informed about it the extractions. Can these be reversed?

And thank you!

[kavan]

I can give you some PRACTICAL information as it relates to making your presentation less laborious to navigate in the act of querying for advice:

1: IMGUR allows you to put ALL of your photos on ONE imgur link.

2: IMGUR also allows you put descriptions under each photo.

3: Simple photo editing software allows you to CROP OUT extraneous background such as an expansive BRICK WALL, birthday cakes along with other EXTRANEOUS background material not germane to what you're asking people to look at.

In the interim, I'll address some of the content of your query.

If the spaces were closed from the pre-molar extractions, not only would the spaces need to be opened to place the implants, but also the dental implants would need to be added AFTER a maxfax surgery. To the best of my knowledge, dental implants cause a problem when it comes to moving the teeth in preparation for a surgery. So, they are not put in before an anticipated surgery. However, since a bimax surgery can not only include rotating the jaws but also advancing them forward, that ALONE could help compensate for the face having been prior pushed backwards via the prior pre-molar extractions to get the 'bite right'. Hence the bimax surgery, very well might not call for opening the spaces so that dental implants can be placed.

Things like arch expansion and addressing what ever asymmetry that may come from the maxilla often include MULTI SEGMENT Lefort 1.

Hemifacial Microsomia not only can include less bone growth on one side but also less soft tissue on that side. So, a bimax surgery might not result in total symmetry. Residual asymmetry could be addressed later down the line with various modalities for such, including but not limited to such things as custom implants, soft tissue fillers etc.

Your frontal asymmetry is not that bad. Your profile could be improved, most likely with bimax advancement via CCW rotation

[GJ]

Regarding opening the space and putting in implants, an average premolar is about 8mm. So you'd have to open 16mm on both top and bottom arches. The fact you had extractions probably means you had crowding. So how would such a large space be opened? You might wind up with tooth flare and other unstable conditions. I think there might be mini implants that are 4 or 6mm, so you could ask about those. I really doubt you could open a full 8mm. Moving molars back (say into a wisdom tooth space) is almost impossible given their root system and size. Something like TADs or springs could help with that. It won't be a pleasant or easy process, even if it's possible.

[eg.1999]

I can give you some PRACTICAL information as it relates to making your presentation less laborious to navigate in the act of querying for advice:

1: IMGUR allows you to put ALL of your photos on ONE imgur link.

2: IMGUR also allows you put descriptions under each photo.

3: Simple photo editing software allows you to CROP OUT extraneous background such as an expansive BRICK WALL, birthday cakes along with other EXTRANEOUS background material not germane to what you're asking people to look at.

Sorry about that; I’d used some of these photos at different times so didn’t have them under the same link.

Things like arch expansion and addressing what ever asymmetry that may come from the maxilla often include MULTI SEGMENT Lefort 1.

Hemifacial Microsomia not only can include less bone growth on one side but also less soft tissue on that side. So, a bimax surgery might not result in total symmetry. Residual asymmetry could be addressed later down the line with various modalities for such, including but not limited to such things as custom implants, soft tissue fillers etc.

Your frontal asymmetry is not that bad. Your profile could be improved, most likely with bimax advancement via CCW rotation

Yes. Having done a bit of hunting on Google, I would also say my asymmetry is similar to the ones on here: https://www.cincinnatijawsurgery.com/case-study-c-shaped-facial-asymmetries/

I don't have the ear tag issues that others with HM have. My ears are fine albeit the one on the affected side (right side) is just slightly more tilted than is the other ear.

Regarding opening the space and putting in implants, an average premolar is about 8mm. So you'd have to open 16mm on both top and bottom arches. The fact you had extractions probably means you had crowding. So how would such a large space be opened? You might wind up with tooth flare and other unstable conditions. I think there might be mini implants that are 4 or 6mm, so you could ask about those. I really doubt you could open a full 8mm. Moving molars back (say into a wisdom tooth space) is almost impossible given their root system and size. Something like TADs or springs could help with that. It won't be a pleasant or easy process, even if it's possible.

I mean honestly like I said I am just concerned about the best aesthetic and functional outcome. Ultimately my wisdom teeth have come through both front and bottom so if they do the trick in terms of maybe realigning my bite, I am happy. I just don’t know why my orthodontist tried to make my upper jaw match my lower jaw which clearly was affected by SOMETHING.

If I can avoid getting implants in if I do decide to go ahead with the DJS, that would be incredibly ideal.

[eg.1999]

Also does anyone have an idea of good jaw surgeons in Europe?

[kavan]

Regarding opening the space and putting in implants, an average premolar is about 8mm. So you'd have to open 16mm on both top and bottom arches. The fact you had extractions probably means you had crowding. So how would such a large space be opened? You might wind up with tooth flare and other unstable conditions. I think there might be mini implants that are 4 or 6mm, so you could ask about those. I really doubt you could open a full 8mm. Moving molars back (say into a wisdom tooth space) is almost impossible given their root system and size. Something like TADs or springs could help with that. It won't be a pleasant or easy process, even if it's possible.

Although I agree that it is unlikely that a full 8mm could be opened to place a dental implant, I'm unclear as to where the 16mm figure comes from. The OP said:

'I had braces when I was younger around the age of 13-15 because I had quite a bad occlusion which involved extracting two premolars from my maxilla.'

I'm assuming he had 1 pre-molar extracted from each side of the maxilla and not 2 pre-molars extracted from each side of the maxilla. So, if it's one pre molar from each side to add up to 2 pre-molars extracted, the opening would be 8 on each side.  For example when whole maxilla is advanced, it's 'X' mm on one side and 'X' mm on the other for a total advancement of 'X'. But not 2 'X'.

[eg.1999]

Although I agree that it is unlikely that a full 8mm could be opened to place a dental implant, I'm unclear as to where the 16mm figure comes from. The OP said:

'I had braces when I was younger around the age of 13-15 because I had quite a bad occlusion which involved extracting two premolars from my maxilla.'

I'm assuming he had 1 pre-molar extracted from each side of the maxilla and not 2 pre-molars extracted from each side of the maxilla. So, if it's one pre molar from each side to add up to 2 pre-molars extracted, the opening would be 8 on each side.  For example when whole maxilla is advanced, it's 'X' mm on one side and 'X' mm on the other for a total advancement of 'X'. But not 2 'X'.

Indeed it was one on each side. My wisdom teeth have now also grown out quite comfortably next to my existing teeth in alignment so I’m not sure how an orthodontist would feel about messing with those.

[kavan]

Indeed it was one on each side. My wisdom teeth have now also grown out quite comfortably next to my existing teeth in alignment so I’m not sure how an orthodontist would feel about messing with those.

Recall what I said in my prior post to you. Basically, the bimax with CCW rotation will very much help compensate for what the early ortho did to your face. There would be no need to open up the spaces to put in dental implants. Doing that first would would preclude preparatory ortho work for a surgery because dental implants can't be moved with the braces.

Presently, your wisdom teeth may very well be part of a present post ortho functional bite. But with the BSSO part of the bimax, the CUT for it is often too close to the wisdom teeth and they often want them removed before the surgery.

[GJ]

Yes, 1 on each side = 8mm per side, or 16mm for the entire upper arch. That is large and hard to open enough to fit normal size implants when there was crowding to begin with. Mini implants (I think these are ~4) might more of an option.

[kavan]

Yes, 1 on each side = 8mm per side, or 16mm for the entire upper arch. That is large and hard to open enough to fit normal size implants when there was crowding to begin with. Mini implants (I think these are ~4) might more of an option.

So, what is it if someone gets their whole maxilla advanced 8mm and the A-P reads 8mm. Since each side of it is advanced 8mm, why isn't the total 16mm?

[GJ]

So, what is it if someone gets their whole maxilla advanced 8mm and the A-P reads 8mm. Since each side of it is advanced 8mm, why isn't the total 16mm?

Cutting the maxilla from the skull and moving it forward 8mm isn't the same as dentally opening a space in arch 8mm. The arch (the area to fit teeth) is fixed at whatever he's genetically born with. He likely had teeth removed because his arch was too small. Let's say it was 4mm too small on each side, so he had crowding that flared the teeth those 4mm in some manner to fit them. The ortho can't straighten them in the arch because there is no space. So he recommends extracting them. When the ortho extracts them, he creates the inverse problem where he now has too much space (i.e. why they have to close it). To reopen that space for an ideal fit, the proper space is probably something in between, hence the 4mm mini implant recommendation. Ideally an ortho would extract and put in mini implants directly into the space. This would reduce treatment and allow the patient to keep their teeth, the bone around the extraction sites, and avoid the negatives of extractions while fitting the proper number of teeth in the arch.

If you mean a 3 piece lefort, then you could get some space opening along the tangent/curved area of the arch where the cut is done and widened. But it wouldn't be 8mm on each side or even 4mm. Probably closer to 1mm. This is why people who get three pieces are rarely happy with tongue space issues, etc. You really don't gain much width.

[kavan]

Cutting the maxilla from the skull and moving it forward 8mm isn't the same as dentally opening a space in arch 8mm. The arch (the area to fit teeth) is fixed at whatever he's genetically born with. He likely had teeth removed because his arch was too small. Let's say it was 4mm too small on each side, so he had crowding that flared the teeth those 4mm in some manner to fit them. The ortho can't straighten them in the arch because there is no space. So he recommends extracting them. When the ortho extracts them, he creates the inverse problem where he now has too much space (i.e. why they have to close it). To reopen that space for an ideal fit, the proper space is probably something in between, hence the 4mm mini implant recommendation. Ideally an ortho would extract and put in mini implants directly into the space. This would reduce treatment and allow the patient to keep their teeth, the bone around the extraction sites, and avoid the negatives of extractions while fitting the proper number of teeth in the arch.

If you mean a 3 piece lefort, then you could get some space opening along the tangent/curved area of the arch where the cut is done and widened. But it wouldn't be 8mm on each side or even 4mm. Probably closer to 1mm. This is why people who get three pieces are rarely happy with tongue space issues, etc. You really don't gain much width.

I understand all of the above. I've just never come across the convention to call an opening of 'x' on each side a total of 2x. It's just referred to as  a space opening of x on both sides.

[eg.1999]

Recall what I said in my prior post to you. Basically, the bimax with CCW rotation will very much help compensate for what the early ortho did to your face. There would be no need to open up the spaces to put in dental implants. Doing that first would would preclude preparatory ortho work for a surgery because dental implants can't be moved with the braces.

Presently, your wisdom teeth may very well be part of a present post ortho functional bite. But with the BSSO part of the bimax, the CUT for it is often too close to the wisdom teeth and they often want them removed before the surgery.

I hope that they are! If that's the case, I would not even want to touch extraction site. If extracted then I would most definitely want to get implants in.

Thanks for the information!