Improving upper teeth show + (Rhinoplasty)

[DV310]

I find that I don't show enough upper teeth when I smile normally/talk even though I have long teeth (age 27). I have to 'force my smile/smile widely' or/and move my lip to see my teeth which doesn't look/feel natural and causes my nose to flare a lot and pull/droop downwards a little. Seems as if I have the opposite of a Gummy Smile. I understand this can possibly be due to/involve lip, jaw, teeth size/position/angle, facial muscles etc. Looks like I also have some asymmetry to my smile.


Brief History:
I had traditional metal braces (elastic bands also used) around 10 years ago/2012 (NHS). They were removed around mid 2014. Prior to/during treatment I had two upper teeth removed (upper second premolars). This was the result after initial braces treatment (I don't really have any photos prior to extractions/braces): https://drive.google.com/drive/folders/1H7CH66DS8VSAyBVF5rfXfwWTIVtSfZZk?usp=sharing

Unfortunately I wasn't happy with the results. Looked like my dental arch/smile width had been narrowed too much and I couldn't really see much upper teeth when talking/smiling. I saw several other orthodontists in London several months after braces removal and they said my concerns can be improved with Orthodontics so I ended up getting braces again for the second time (damon self-ligating braces this time. Elastic bands also used again)

Here was what one of the Orthodontists reported (not the one I had treatment with but they all had similar opinions):
''On examination it is evident that your upper second premolars are not present and all four wisdom teeth are not fully erupted. Your x-ray showed you have an impacted lower right second molar tooth. Your center lines are positioned correctly. You have an overjet of approximately 2 mm. An overjet is the horizontal projection of upper teeth  over lower teeth. You have an overbite of approximately 10% which is classed as normal. An overbite is the vertical overlap of upper teeth over lower. You have mild upper and lower crowding. As discussed with you it is possible to address your main concern with orthodontics.. This would be based on a non-extraction (without any further teeth removal) basis. As shown to you there are still significant improvements that can be made to your existing alignment and overall smile. I would suggest the following options. Treatment options: 1- Upper and lower damon metallic (self-ligating, with memory shaped wires) fixed appliances.''

I had bottom wisdom teeth extracted prior to getting braces the second time.

I finished treatment in 2016 (have fixed retainers behind front teeth and was given retainers to wear at night which I still use most nights as I'm concerned teeth overall may move again). [/size][/size][/i][/i][/i]




Here are current photos: https://drive.google.com/drive/folders/16i-6Fi5TRg4dX_afitQ4-N-lxu6jhc-b?usp=share_link
(I don't have any up to date scans but can get them done)


Although getting braces for the second time seems to have certainly improved my overall smile, I was wondering whether anything further can be done to improve the amount of upper teeth I show (and/or anything to further improve facial aesthetics). Ideally would like smile to be a bit more like photo 2c (see link with photos) but I am obviously lifting my nose/lip on that photo.  I'm not sure if the upper premolar extractions contributed to my issue since extractions can supposedly affect smile width, lip support and facial aesthetics. Is it possible that I have slight maxillary deficiency?
Not sure if I have space for a lip lift or perhaps reduction. I've seen some people get a frenectomy ((100) smile analysis not enough teeth showing - YouTube) to try and increase upper teeth show but not sure if it would help.

I am considering having SeptoRhinoplasty to improve both function and aesthetics of my nose (Crooked nose and deviated septum with breathing problems mostly on the left side, Dorsal hump, Slightly droopy and bulbous/thick nasal tip/hanging columella, Little tip support, Nostril size?, Projection?)

Thanks

[GJ]

Your tooth show looks within normal to me. I think the only treatment to elongate them any further would be to do crowns or veneers, but then you're damaging healthy teeth. Did the ortho say they extruded (pulled them down) as much as possible within norms?

From what I can tell in those photos, your jaws look normal. Do you have any records of your jaws? Scans, x-rays, etc.

[DV310]

I did consider crowns or veneers but then I'm damaging healthy long teeth as you said.

I remember the orthodontist mentioning extruding/pulling the upper teeth down to show more teeth and that the 4 upper front teeth roots look short, whether they extruded them or not I'm not 100% sure.

From looking at my old emails I did actually contact some maxillofacial surgeons regarding this prior to getting braces again for the second time, though I sort of ignored what they said in the reply's.
Here is what they said from looking at photos I sent them (not sure if I should/can mention surgeon names here):

Surgeon 1 reply:
''This is called maxillary insufficiency. Your upper jaw did not grow down as much. I believe you might need upper and lower jaw surgery to give you a better facial harmony and smile. Orthodontics alone would not be able to assist you.  I recommend seeing an orthognathic surgeon in your country and seek their advice. They would need to see you clinically for better evaluation.''



Surgeon 2 reply:
''Your orthodontics(??), above all is s**tty low profile. That’s the least you can say.
They extracted 2 upper premolars, and the rest has followed. Total dental compensation. No care.
(did you have an informed consent??)
Your upper front has enough show. They are long enough, and bringing them down will -believe me- will worsen your case.
You have nice lips but your teeth are to much backward, starting with the cause: your lower jaw too small (mandibular retognathia). They adjusted the upper teeth (extractions) to a too small lower jaw).
Treatment plan should be bringing forward the upper front teeth, and a substantial BSSO (lower jaw advancement.). So reopen the spaces in the upper, or maxillary advancement with lower jaw adv. (is the base).
You clearly can see this on your first pictures.
I bet you snore….''


Surgeon 3 reply:
''In broad terms yes but it would require an operation to your top jaw.  An operation to the nose and or botox can also be of value''.



Apart from that old x-ray of my teeth prior to second orthodontics treatment, I don't have any other records of my jaws. Will try and get a scan done, a CBCT perhaps?

[GJ]

Wow, surgeon 2 didn't mince words.

[kavan]

If you had the type of ortho that removed some teeth, it was because your jaws could have been too small to fit them. I agree with the reasoning of the surgeons, especially the second one. Although you don't show your profile, you probably have recessed jaws and would be a candidate for maxfax surgery, double jaw. Rhino, in your case would come AFTER jaw surgery because it can change the nose: make it look better or different to you.

If you didn't want to have jaw surgery and just wanted to show more upper central incisors, you could explore a lip lift (plastic surgery venue as is rhino) to the central area of the lip because that's the area below where you lack some tooth show.

[DV310]

My first ortho extracted 2 upper premolars because I think there was some crowding but some orthos 'supposedly' extract when it may have not been necessary. Not sure if I have a narrow palate.
Yeah, if I was to have Rhinoplasty it would be AFTER and its mainly the front teeth I would like to show more so possibly a lip lift to the central area of the lip (not sure if there is enough space though) as you said or perhaps slight reduction of the central lip tubercle area (mine is a bit like this although you probably can't 100% tell from my photos): https://www.realself.com/question/ernakulam-13-upper-lip-hangs-teeth-smile-unattractive


I posted this same question on reddit /jawsurgery and this was what someone said on reply:

''Showing less teeth after upper premolar extraction apparently is common, as many report it. The standard solution is jaw surgery with downward rotation. Rotating the jaw down will show the teeth, just as rotating the jaw up will show less teeth.
Why is it that some people get less teeth show with premolar extraction? Can only guess that it is because the teeth retract, and the lip flattens down, and hides the top of the teeth. (Or it could be the jaws grew differently due to the retraction, am only guessing here).
Now if you do not want jaw surgery what can you do?
I imagine your ortho work is expanding the arch, but not advancing the teeth? To get your lip support back you would also need to protrude the teeth forward. Teeth support will lift up the lips and probably more of the teeth will show. But not entirely, as retraction with ortho is about 6 mm, which is a lot.''


Sort of agree with what they are saying, not sure about protruding the teeth forward though.



Suppose next step would be to get up to date scans of both upper and lower jaws perhaps a CBCT (which I think requires referral)?  or/and possibly consult a maxfax surgeon who perhaps has interest in cosmetic/plastic surgery or possibly another ortho.   
(If I was to have any surgery done though it would be with someone who specializes in that area e.g., for Rhinoplasty I would go with someone who has specific interest in performing Rhinoplasty rather than some random maxfax/Plastic Surgeon/ENT who doesn't do Rhinoplasty that often)

This is actually similar to what I find my issue is perhaps: https://www.reddit.com/r/jawsurgery/comments/pnset0/little_upper_teeth_show_maxillary_vertical/

[kavan]

My first ortho extracted 2 upper premolars because I think there was some crowding but some orthos 'supposedly' extract when it may have not been necessary. Not sure if I have a narrow palate.
Yeah, if I was to have Rhinoplasty it would be AFTER and its mainly the front teeth I would like to show more so possibly a lip lift to the central area of the lip (not sure if there is enough space though) as you said or perhaps slight reduction of the central lip tubercle area (mine is a bit like this although you probably can't 100% tell from my photos): https://www.realself.com/question/ernakulam-13-upper-lip-hangs-teeth-smile-unattractive


I posted this same question on reddit /jawsurgery and this was what someone said on reply:

''Showing less teeth after upper premolar extraction apparently is common, as many report it. The standard solution is jaw surgery with downward rotation. Rotating the jaw down will show the teeth, just as rotating the jaw up will show less teeth.
Why is it that some people get less teeth show with premolar extraction? Can only guess that it is because the teeth retract, and the lip flattens down, and hides the top of the teeth. (Or it could be the jaws grew differently due to the retraction, am only guessing here).
Now if you do not want jaw surgery what can you do?
I imagine your ortho work is expanding the arch, but not advancing the teeth? To get your lip support back you would also need to protrude the teeth forward. Teeth support will lift up the lips and probably more of the teeth will show. But not entirely, as retraction with ortho is about 6 mm, which is a lot.''


Sort of agree with what they are saying, not sure about protruding the teeth forward though.



Suppose next step would be to get up to date scans of both upper and lower jaws perhaps a CBCT (which I think requires referral)?  or/and possibly consult a maxfax surgeon who perhaps has interest in cosmetic/plastic surgery or possibly another ortho.   
(If I was to have any surgery done though it would be with someone who specializes in that area e.g., for Rhinoplasty I would go with someone who has specific interest in performing Rhinoplasty rather than some random maxfax/Plastic Surgeon/ENT who doesn't do Rhinoplasty that often)

This is actually similar to what I find my issue is perhaps: https://www.reddit.com/r/jawsurgery/comments/pnset0/little_upper_teeth_show_maxillary_vertical/

Reduction of the protrusion (central lip tubercle area) is in the venue of a 'lip lift' procedure because it 'lifts' the part of the lip that is covering the central incisors.

More upper tooth show is a function of maxillary advancement. How much more tooth show given how much the advancement depends on the angle of inclination the maxilla has over which its advancement takes place. If angles of inclination of maxilla; 'ANS-PNS' need to be adjusted, the Lefort 1 aspect of the maxilla displacement can include rotations.

NOTE: Responses from me are not an 'invitation' to go through posts on other boards and evaluate what other people say.