Aesthetic and functional surgery suggestion - Class II malocclusion, MSE/MARPE

[Salemare]

Hi all,

I would really appreciate if you could take a look at my photos and x-rays and give me some feedback on my situation and suggestions as to a course of action might be.

My issues:

Class II Malocclusion  (1cm originally)

Small palate – difficulty opening mouth wide, eating and sometimes choking on food.

Breathing problems - Deviated septum and sinus problems, had septoplasty surgery in my late teens, it didn’t work and made a mess of my nose, the base of my nose and nostrils became distorted and twisted and my breathing didn’t improve.

Aesthetic issues - discussed in further detail below

Current status

Being treated by an orthodontist and wearing braces since 2020, initiated under the intention of being treated on the national health for the malocclusion, but have concerns due to a lack of planning and communication. My ortho said I am nearly ready for surgery, but when I got a second opinion from another ortho (who wouldnt take me on), they said I needed at least another year or two treatment. Due to this I am investigating other options.

7 teeth extracted, 1 wisdom tooth extraction outstanding.

Following wearing braces my two upper front teeth have moved over to the left and my teeth have gone from being proclined to currently inclined to the point that one surgeon said he wouldn’t recommend performing surgery with them in the current position.

I should have been treated as a child, but I was not and over time I believe this has affected my face in a number of ways.

My eyes are sunken in and under the orbit of my eye, I have very little cheekbone at all, there is like a ridge where the orbit is, and then directly under that I can push my fingers deep underneath. I believe this may have been something congenital as even as I had a these prominent downward angled bones under my eyes creating a kind of inverted V shape shape coming down from the bridge of my nose and coming down from the orbits. I believe this has resulted in a lack of support for my cheeks, periorbital hollowing and lowering of the malar fat pad from an early age.

I have prominent nasolabial folds and following extractions in the past year I have noticed volume loss all around my jaw and further sagging and increase in the nasolabial folds. I have a short face, which was round but now the lower part of my face is more sucked in and gaunt.

Functionally I want to correct my jaw and breathing and of course get a good aesthetic result. I would like to fix the other aesthetic aspects including my nose and especially my cheeks and midface area issues. I would prefer something like a fat graft but as my issue maybe more structural, I assume some kind of implants would be more appropriate.

I am particularly interested if MSE/MARPE would be beneficial to improve my breathing but to also improve my cheeks by way of lateral expansion.

I would also like to know if following surgery, can extractions be reversed?

I have uploaded some photos

Jaw photos
https://ibb.co/album/q7wkR3

Lat Ceph and OPG
https://ibb.co/album/nN4W1T

Dental Imprints
https://ibb.co/album/nzJCY3


Any thoughts and opinions appreciated. Thanks.

[GJ]

I haven't had a chance to look at anything you wrote yet, but just looking at your x-ray, it looks like your curve of spee should be flattened, and then the lower jaw moved linear forward.

[GJ]

Skimming through now with the limited time I have...

I would also like to know if following surgery, can extractions be reversed?

In theory, but it depends on many factors. It's a long process from what I have read and heard. Maybe 2 years to reopen the space. Since the arch was too small to begin with, it's very possible a normal size tooth won't fit in the reopened space. There are mini-implants, if the space can't be opened enough for a full size tooth.

[kavan]

I've reviewed your history. On past threads, you have asked about bone grafts for extracted teeth. The answers were that bone grafts are used WHEN an implant is to be placed AFTER the extraction. So, if your extractions were not due to infected teeth (for example) to be replaced soon thereafter with implants but were instead to make room to advance your jaws forward in preparation for surgery, that is not a case for getting bone grafts to the extraction sites. Bone grafts are placed in the EMPTY tooth socket soon after an extraction in order for an implant to take. Otherwise the bone grafts will resorb if there is no bite force on the area grafted.

Presently, it looks like those spaces were pretty much CLOSED in preparation for your lower jaw to be advanced and despite the teeth being extracted (I'm referring to all the pre-molars here) and you would stand to have a workable bite after the surgery.

Even if your upper jaw does not also get advanced during your surgery, you would stand to get close to a 10mm advancement of the lower jaw which will be an improvement. To that, a diagonally downward genio could be added to give more projection and more frontal length to the face and those 2 things would be an improvement and quite possibly help give more support to where you see the nasial labial folding.

The other issues you speak of like cheek bones and bones below the lower eye are not going to be addressed by maxfax surgery. So, you would have to put those on the back burner to re-evaluate after jaw surgery. Likewise with opening up extraction spaces.

As to 'other people' getting 3-D plans,those more are associated with the high price SELF PAY surgeons and less associated when insurance is paying for the surgery.

Aside from 1 wisdom tooth needing to be extracted in preparation for the lower jaw surgery, it looks like you are pretty close to having surgery and it would result in SOME improvement where it is MOST needed which is to the lower jaw and chin area.

[Salemare]

I haven't had a chance to look at anything you wrote yet, but just looking at your x-ray, it looks like your curve of spee should be flattened, and then the lower jaw moved linear forward.

Thanks GJ, that is what one of the other surgeons I visited advised. He also said that my teeth are now angled too far back to perform surgery and that they should be angled forward somewhat so they are straight.

I have loaded some updated photos of my brace and teeth showing the current backward incline. I dont know if its normal to have them angled in such a way. Unfortunately I dont have a before to show, but have uploaded a before just from a random photo of my upper teeth.

https://ibb.co/album/bWGB6Q

[Salemare]

Skimming through now with the limited time I have...

In theory, but it depends on many factors. It's a long process from what I have read and heard. Maybe 2 years to reopen the space. Since the arch was too small to begin with, it's very possible a normal size tooth won't fit in the reopened space. There are mini-implants, if the space can't be opened enough for a full size tooth.

Thanks, I should add my surgeon originally suggested expanding my palate as he said it was very small (there was nothing discussed as to the method of this expansion, ie MARPE or otherwise, but he was proposing this to the dentist) but the dentist then chose to do extractions instead.

As I understand to accomodate upper jaw expansion its necesseary that the lower jaw needs to be be able to support the lower teeth being moved out enough to match with the upper jaw.  Is this something that can be assessed from x-rays or is it necessary to have a 3D cbct to understand that?

[Salemare]

I've reviewed your history. On past threads, you have asked about bone grafts for extracted teeth. The answers were that bone grafts are used WHEN an implant is to be placed AFTER the extraction. So, if your extractions were not due to infected teeth (for example) to be replaced soon thereafter with implants but were instead to make room to advance your jaws forward in preparation for surgery, that is not a case for getting bone grafts to the extraction sites. Bone grafts are placed in the EMPTY tooth socket soon after an extraction in order for an implant to take. Otherwise the bone grafts will resorb if there is no bite force on the area grafted.

Presently, it looks like those spaces were pretty much CLOSED in preparation for your lower jaw to be advanced and despite the teeth being extracted (I'm referring to all the pre-molars here) and you would stand to have a workable bite after the surgery.

Even if your upper jaw does not also get advanced during your surgery, you would stand to get close to a 10mm advancement of the lower jaw which will be an improvement. To that, a diagonally downward genio could be added to give more projection and more frontal length to the face and those 2 things would be an improvement and quite possibly help give more support to where you see the nasial labial folding.

The other issues you speak of like cheek bones and bones below the lower eye are not going to be addressed by maxfax surgery. So, you would have to put those on the back burner to re-evaluate after jaw surgery. Likewise with opening up extraction spaces.

As to 'other people' getting 3-D plans,those more are associated with the high price SELF PAY surgeons and less associated when insurance is paying for the surgery.

Aside from 1 wisdom tooth needing to be extracted in preparation for the lower jaw surgery, it looks like you are pretty close to having surgery and it would result in SOME improvement where it is MOST needed which is to the lower jaw and chin area.

Thank you for the detailed response and explanations Kavan, its good to know that things are not heading in the totally wrong direction.

In terms of the downward angled genioplasty, I was trying to look for that online, would either of the images I attached be an accurate representation of what you are describing?

Would I be correct to assume you dont consider MSE, MARPE to be of benefit to potentially improving cheek area/adding some lower mid face volume?
Some people seem to have reported increased mid face volume following this treatment. Its difficult to find a provider of this in my country thats near me, I have found only one MSE provider and another expander variant called HIMAME but I have found limited info on the success of this. They all seem to follow similar principles, but using various different device designs. I imagine palate expansion would need to be done before surgery and not after, as it could throw off all the prior work that was done before?

[Tomasjohn]

Regarding the genioplasty images: This doctor has a section on his homepage where he explains in detail in what direction the chin segment moves, how many mm and how much bone he grafted for this. For each case.

Best to look directly there because you will find the answer.

 
 

[kavan]

Thank you for the detailed response and explanations Kavan, its good to know that things are not heading in the totally wrong direction.

In terms of the downward angled genioplasty, I was trying to look for that online, would either of the images I attached be an accurate representation of what you are describing?

Would I be correct to assume you dont consider MSE, MARPE to be of benefit to potentially improving cheek area/adding some lower mid face volume?
Some people seem to have reported increased mid face volume following this treatment. Its difficult to find a provider of this in my country thats near me, I have found only one MSE provider and another expander variant called HIMAME but I have found limited info on the success of this. They all seem to follow similar principles, but using various different device designs. I imagine palate expansion would need to be done before surgery and not after, as it could throw off all the prior work that was done before?

'Down and out' genio is just my term to describe the combined directional displacements. The chin is displaced in a downward diagonal direction where there is a combo of BOTH horizontally outward advancement and some vertical elongation.

You could be spending TOO LONG in BRACES in the process of going to doctor to doctor.  There are different ways and times to expand a narrow palate. From your tooth models, it looks like there was some expansion to it. What ever you do, in terms of surgery should be part of a TEAM process where the ortho, expansion procedures and practitioners doing them should be part of a TEAM working WITH the doctor who will be doing the surgery.

[kavan]

Regarding the genioplasty images: This doctor has a section on his homepage where he explains in detail in what direction the chin segment moves, how many mm and how much bone he grafted for this. For each case.

Best to look directly there because you will find the answer.

Great answer.