jawsurgeryforums.com
General Category => Aesthetics => Topic started by: eg.1999 on April 26, 2020, 09:35:27 AM
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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
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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.
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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!
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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
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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.
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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.
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Also does anyone have an idea of good jaw surgeons in Europe?
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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'.
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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.
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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.
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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.
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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?
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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.
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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.
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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!
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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.
Gotcha. It's semantics then.
I would not even want to touch extraction site.
You need more info, but in general, once they're out it's over with. Very hard to open and put back in. The one reason to put them back in might be bone support. When the tooth is removed, all the bone at the extraction site reabsorbs (a tooth needs bite pressure to keep regenerating bone). If you notice depressions at the extraction site this is why. First premolars are worse for this than second due to their root structure.
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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!
If they needed to extract the lower wisdom teeth for the BSSO part of the surgery (they don't need to extract the upper wisdom teeth), I guess you could get implants there later down the line.
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If they needed to extract the lower wisdom teeth for the BSSO part of the surgery (they don't need to extract the upper wisdom teeth), I guess you could get implants there later down the line.
For me, so long as upper wisdom teeth can be used as part of my functioning bite, that’s all I care about. Lower wisdom teeth can go, especially if necessary to make BSSO cuts.
I imagine I can make a functioning bite with my upper wisdom teeth?
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Also wondering with double jaw surgery, if I ask my surgeon to pay attention to aesthetics and be more aggressive with bringing both jaws forward to achieve forward growth that this would be possible? I wouldn’t want to go through all the stress of DJS without significant transformation
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Just wanted to let everyone know I have also added some scan pictures from before my orthodontic treatment when I was younger at the BOTTOM of the Imgur link. I think you will notice the shorter ramus on the right side.
Here you are: https://imgur.com/a/CtOUXQm
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Your asymmetry is not that significant. The worst, most conspicuous asymmetry is significant eye asymmetry. You don’t have that.
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Your asymmetry is not that significant. The worst, most conspicuous asymmetry is significant eye asymmetry. You don’t have that.
Would you say surgery is worth the potential aesthetic benefits or would you advise against it? I feel like (and of course I know this is an incredibly RISKY surgery and so I wouldn't rely on feeling alone) getting this surgery done would by far give benefit me in terms of aesthetics. I think I'd also experience functional benefits, particularly in terms of posture and stuff. I also have sometimes have trouble breathing compared to other people my age when exercising.
Also considering I'm really young I feel recovery wouldn't be as bad as it could be, especially if I'm doing it next summer as intended.
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Although I'm over simplifying, Jaw surgery is a multi-factorial equation aimed at balancing form and function. To that regard, 'form'; balance of jaws is your aesthetic part and 'function' is the bite correction part. The general goal is aesthetic improvement along with functional bite. The functional factor; bite, takes priority and is MORE straight forward given it's kind of clear cut to them as how the teeth should 'mesh' or meet. The aesthetic factor is to improve or remove aesthetic IMBALANCES as to bring closer to the 'norm'. Given that patient communication such as; 'give me a significant transformation' is rather VAGUE and undefined as to all the many VARIABLES that go into planning a surgery that balances form and function, surgery is not planned around that.
What you can ask your surgeon for is a ceph displacement diagram for which you would need an X-ray ceph taken. The displacement diagram would have your profile contour along with the proposed profile contour they have in mind.
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Would you say surgery is worth the potential aesthetic benefits or would you advise against it? I feel like (and of course I know this is an incredibly RISKY surgery and so I wouldn't rely on feeling alone) getting this surgery done would by far give benefit me in terms of aesthetics. I think I'd also experience functional benefits, particularly in terms of posture and stuff. I also have sometimes have trouble breathing compared to other people my age when exercising.
Also considering I'm really young I feel recovery wouldn't be as bad as it could be, especially if I'm doing it next summer as intended.
A bigger lower third would definitely balance your nose better and I think you would look better, not just different. Whether it's worth the risk is for you to decide. BTW, your airway does not look small in the ceph.
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What you can ask your surgeon for is a ceph displacement diagram for which you would need an X-ray ceph taken. The displacement diagram would have your profile contour along with the proposed profile contour they have in mind.
Thanks for this piece of advice!
A bigger lower third would definitely balance your nose better and I think you would look better, not just different. Whether it's worth the risk is for you to decide. BTW, your airway does not look small in the ceph.
I’m pretty sold on the surgery and I’m sure that having this done over the summer would make recovery smooth for me. Think I just need to get some consultations first.
And so you’re telling me I’m just unfit then? ;D
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Thanks for this piece of advice!
I’m pretty sold on the surgery and I’m sure that having this done over the summer would make recovery smooth for me. Think I just need to get some consultations first.
And so you’re telling me I’m just unfit then? ;D
Mind you, I am not a doctor. Although having met some moron doctors, I have lost all faith in the medical profession. I don't think you should rush into this. You are young and nothing is going to change if you have surgery 12 months later. Don't get yourself into braces before you have settled on a surgeon, because then you will just want to get it all over and done with and ignore any warning signs you may get from bad surgeon choice.
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Mind you, I am not a doctor. Although having met some moron doctors, I have lost all faith in the medical profession. I don't think you should rush into this. You are young and nothing is going to change if you have surgery 12 months later. Don't get yourself into braces before you have settled on a surgeon, because then you will just want to get it all over and done with and ignore any warning signs you may get from bad surgeon choice.
That is a fear I'm conscious of. I really want this to work out the best way possible so I am just trying to be calculated with it so far. I have a good feeling with the surgeon I am about to consult with so let's see how it goes!
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For me, so long as upper wisdom teeth can be used as part of my functioning bite, that’s all I care about. Lower wisdom teeth can go, especially if necessary to make BSSO cuts.
I imagine I can make a functioning bite with my upper wisdom teeth?
You asked this question before you had X rays up. Looking at the X rays, your wisdom teeth are not part of your bite, functional or otherwise, because they don't touch each other.
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Or
You asked this question before you had X rays up. Looking at the X rays, your wisdom teeth are not part of your bite, functional or otherwise, because they don't touch each other.
I meant the upper wisdom teeth with my second lower molars. Plus these were from 2012 and prior to extractions.
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Or
I meant the upper wisdom teeth with my second lower molars. Plus these were from 2012 and prior to extractions.
Doesn't look like they will touch.
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Doesn't look like they will touch.
They’re actually touching in my mouth right now! My teeth have flared in a bit so I imagine when they open up they’ll touch
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Hi all,
I have literally just realised I think I am born without wisdom teeth?
I was counting my botttom teeth (I didn’t have premolars extracted here) and essentially I’ve realised my second molars haven’t erupted properly... they are hidden underneath gummeaning my wisdom teeth probably aren’t even there...
That means on my upper jaw what I thought were my wisdom teeth are actually just my second molars...
What does this mean? does this mean I’ll have to expand my mandible and maxilla? This is all so crazy
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Hi all,
I have literally just realised I think I am born without wisdom teeth?
I was counting my botttom teeth (I didn’t have premolars extracted here) and essentially I’ve realised my second molars haven’t erupted properly... they are hidden underneath gummeaning my wisdom teeth probably aren’t even there...
That means on my upper jaw what I thought were my wisdom teeth are actually just my second molars...
What does this mean? does this mean I’ll have to expand my mandible and maxilla? This is all so crazy
It could mean you're more highly evolved. https://science.howstuffworks.com/life/evolution/no-wisdom-teeth1.htm
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To this, I would add, it would be best for you to just CONSULT with a maxfax to determine if the back molars teeth presented any issues with doing a surgery. The back lower molar does very much look like where one would find a wisdom tooth (which they like extracted before a surgery because it can interfere with cut) and the top back upper molar could be in way of maxillary cut. Hence, it would be best to consult to see IF those things presented limitations to performing a surgery.
It could mean you're more highly evolved. https://science.howstuffworks.com/life/evolution/no-wisdom-teeth1.htm
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I’ll definitely do that.
I am however considering getting a distractor installed on my left side instead to match the growth of my right side as I am pretty sure I have a real mild form of hemifacial microsomia