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General Category => Functional Surgery Questions => Topic started by: logan on June 24, 2020, 12:54:39 PM
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Hi! I'm trying to decide whether to do surgery for an anterior open bite, vertical maxillary excess, retrusive chin/maxilla. I'd love to hear your opinions on whether surgery makes sense
Photos attached. I recently finished a year of invisalign to camouflage the open bite (they pulled the lower anterior teeth up), before I learned surgery was an option. The open bite is better but still there, and I have lip incompetence, dry mouth at night, perceived nasal airway resistance (but no sleep apnea), molar tooth wear, and gummy smile especially posteriorly. I now realize these are probably all related to my facial structure. (I had 18 years of untreated chronic allergies growing up which I think caused this bc I look different from everyone else in my family.)
My main priorities are to fix 1) the remaining open bite and 2) gummy smile. Improvements on the other complaints would be a welcome bonus
Is surgery overkill? I'm not worried about time or money or temporary discomfort, but am worried about the chance the aesthetics could come out WORSE than before (I try not to care too much about appearance and am ~generally~ ok with my face, but the gummy smile and retrusive chin has always bothered me and if I CAN fix them than I really want to - but I don't want to make anything worse!)
I'm in NY and have spoken to Dr. Neugarten who wants to do surgery, and seems very competent based on online reviews. I haven't been able to find any other highly rated surgeons nearby to get a second option from yet. Half the orthodontists I've spoken to agree, the other half don't or could go either way. Thoughts?
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Treatment for you, most likely would be an overall impaction. MORE from the back and LESS from the front. This entails removal of excess maxilla bone. Some front part to correct gummy smile in front and more from back to correct excess gum show in back. So, you have maxillary excess in 2 verticals, the anterior and posterior maxilla.
Posterior impaction for anterior open bite will allow the lower jaw to swing up (and close bite) because it's being pushed down by a long posterior maxilla which you can see in your smile because there is a LOT of excess gum show in BACK. It will also make the steep mandibular plane LESS steep (because the mandible can swing up more without the back teeth area forcing it so downward).
Once they 'level out' the maxilla, they can bring both jaws forward and do a sliding genio to the chin which is combination of outward and upward. That will give more of a look of counterclockwise rotation.
Invisiline, even if it made your bite better didn't fix the skeletal pattern. So, the surgery should make your skeletal pattern more 'right'.
I don't think these things are overkill. Theoretically, it should kick up an improvement in both the bite/smile and profile.
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Thank you that is reassuring to hear!
Do you think it is likely that I would need a lower jaw BSSO as well as impaction of the maxilla?
It sounded like the plan would probably be to impact the maxilla ~4 mm in the back and less in the front, as you say, and advance it ~4 mm. That all makes sense to me, but I'm confused by the lower jaw and couldn't get a straight answer other than "we'll decide after your pre-surgical ortho". Currently, I have ~5 mm overjet, so combined with the maxilla advancement that would be ~9 mm total. As I understand it, when the lower jaw is able to swing up farther it also moves forwards. Somewhere I read for every 1 mm of posterior maxilla impaction, the pogonion (anterior-most point on chin) ends up 3 mm more anterior on it's own -- that would mean it moves 12 mm without any lower jaw surgery, can that be right??
He also mentioned the sliding genio and that part makes sense to me
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Some unstructured comments
1.) Looks like your lower front 4 teeth were extruded up significantly as part of your ortho only open bite closure. The concern here is that your roots may be shortened and shouldn't be exposed to more significant orthodontics movement. Most likely you need to de-compensate here?
2.) Your bite is level at the molars, your problem is a significant curve of spee with the front upper teeth thrusted up. You will probably need a segmental 3 piece lefort for at least that reason.
3.) Lastly, seeing as you're in NYC I'd be remiss not to mention that I had a horrific experience with Dr. D B from NYP (I have no problems naming him, just don't want to pollute search results) and would not recommend him.
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Thank you that is reassuring to hear!
Do you think it is likely that I would need a lower jaw BSSO as well as impaction of the maxilla?
It sounded like the plan would probably be to impact the maxilla ~4 mm in the back and less in the front, as you say, and advance it ~4 mm. That all makes sense to me, but I'm confused by the lower jaw and couldn't get a straight answer other than "we'll decide after your pre-surgical ortho". Currently, I have ~5 mm overjet, so combined with the maxilla advancement that would be ~9 mm total. As I understand it, when the lower jaw is able to swing up farther it also moves forwards. Somewhere I read for every 1 mm of posterior maxilla impaction, the pogonion (anterior-most point on chin) ends up 3 mm more anterior on it's own -- that would mean it moves 12 mm without any lower jaw surgery, can that be right??
He also mentioned the sliding genio and that part makes sense to me
I very much doubt you're getting 12mm at the pogonion from 4mm posterior impaction. You can calculate your net horizontal advancement from 4mm impaction given the head posture in the CEPH if you want.
Also, be aware that the presurgical orthodontics are effectively going to reverse most of what your invisalign did since your teeth are very compensated at the moment. This is necessary for a successful surgery.
A combination of posterior/anterior impaction would definitely help bring your MPA into the normal range. even if your OP may end up being slightly steep anyway. A posterior downgraft + anterior impaction + large CCW rotation of the mandible is probably not an option here given your posterior gum show.
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Thank you that is reassuring to hear!
Do you think it is likely that I would need a lower jaw BSSO as well as impaction of the maxilla?
It sounded like the plan would probably be to impact the maxilla ~4 mm in the back and less in the front, as you say, and advance it ~4 mm. That all makes sense to me, but I'm confused by the lower jaw and couldn't get a straight answer other than "we'll decide after your pre-surgical ortho". Currently, I have ~5 mm overjet, so combined with the maxilla advancement that would be ~9 mm total. As I understand it, when the lower jaw is able to swing up farther it also moves forwards. Somewhere I read for every 1 mm of posterior maxilla impaction, the pogonion (anterior-most point on chin) ends up 3 mm more anterior on it's own -- that would mean it moves 12 mm without any lower jaw surgery, can that be right??
He also mentioned the sliding genio and that part makes sense to me
Yes to BSSO if you want to look better because your lower jaw is posterior to (behind) a type of vertical jaw to jaw 'balance' line. So, yes to BSSO (moving mandible forward) to counteract recession to it.
I didn't mention any exact mm measures. I just gave the general CONCEPT behind my reasoning process of what would benefit you. So, 'somewhere you read something' and 'somewhere something someone said or did not say confused you'. The confusion generated ELSEWHERE is not from the CLARITY I gave in my post. So, unless something in my post was 'confusing' or not clear, I don't do calculations based on numerical confusion generated elsewhere.
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Haha absolutely, your post was very clear Kavan! Just trying to get my own mental clarity. I understand from you that a BSSO would probably be needed for the best outcome.
Regarding numbers - I like having a sense of the numbers even if the details will change, but I'm not enough of an expert to estimate how much lower jaw movement I should expect, and just confused myself trying to synthesize lots of new information. Good to know that my estimate of 12 mm is too big & that I'd still probably need the BSSO
Decompensation - yeah I was told that I need to decompensate the lower front teeth to prepare for surgery. Also it sounds like my insurance won't cover any part of the surgery as it stands, but they might after decompensation. Hopefully the decompensation doesn't do too much additional harm to the roots
Wish I had known about the surgical option earlier... A year ago, I really thought my only option was one-size-fits-all-invisalign. Trying to be more careful this time around and understand the whole process as much as possible -- this forum is proving so helpful already, so thank you!!
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@ArtVandelay I just read your post about Dr. B. I'm so sorry you had a bad experience, that sounds incredibly stressful. I've now been to several orthodonists in NY (easier to find than surgeons!) and most of them also mentioned working with Dr. B. But based on reviews (probably including yours!) I decided to not even consult with him. I couldn't find good reviews for other NY doctors on this forum, but Neugarten gets good reviews elsewhere online. Have you consulted with anyone else in NY for your potential 3rd revision? (Sorry if this is off-topic, feel free to pm me if so.)
Not sure if it's possible or worthwhile to get a virtual consultation with the famous Gunson -- I probably wouldn't go out there for surgery but maybe he could help develop/confirm a plan? I'm just not *that* unhappy with my appearance to start, I've learned to smile in a way that hides the gumminess and doesn't look as terrible as in the record photo, so I'm just scared of accidentally making things worse
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Haha absolutely, your post was very clear Kavan! Just trying to get my own mental clarity. I understand from you that a BSSO would probably be needed for the best outcome.
Regarding numbers - I like having a sense of the numbers even if the details will change, but I'm not enough of an expert to estimate how much lower jaw movement I should expect, and just confused myself trying to synthesize lots of new information. Good to know that my estimate of 12 mm is too big & that I'd still probably need the BSSO
Decompensation - yeah I was told that I need to decompensate the lower front teeth to prepare for surgery. Also it sounds like my insurance won't cover any part of the surgery as it stands, but they might after decompensation. Hopefully the decompensation doesn't do too much additional harm to the roots
Wish I had known about the surgical option earlier... A year ago, I really thought my only option was one-size-fits-all-invisalign. Trying to be more careful this time around and understand the whole process as much as possible -- this forum is proving so helpful already, so thank you!!
You should get a better idea of this with the surgeon/ortho before starting ortho treatment again. If you have decent insurance, the hospital fees should be covered by insurance because the underlying skeletal issue causing the AOB still exists.
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I've asked the surgeon's office about insurance, and apparently they've dealt with my insurance before and it's not the best. They think I'll have a better shot if I wait until AFTER presurigical ortho to submit for approval. My numbers (especially before invisalign) are technically within range for coverage but apparently they sometimes deny anyway. And even if it is covered, Dr. N is out of network/doesn't accept insurance so it'll be costly no matter what. But it would be nice to not have to worry about hospital/anesthesia fees
I've already used up orthodontic coverage but the orthodontist *might* be able to transfer my previous case since it was never closed out and I still have attachments on (thanks pandemic!). I'll find out soon
Of course I want to keep costs down but I'm determined to make it work regardless if surgery is really the best option
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Haha absolutely, your post was very clear Kavan! Just trying to get my own mental clarity. I understand from you that a BSSO would probably be needed for the best outcome.
Regarding numbers - I like having a sense of the numbers even if the details will change, but I'm not enough of an expert to estimate how much lower jaw movement I should expect, and just confused myself trying to synthesize lots of new information. Good to know that my estimate of 12 mm is too big & that I'd still probably need the BSSO
Decompensation - yeah I was told that I need to decompensate the lower front teeth to prepare for surgery. Also it sounds like my insurance won't cover any part of the surgery as it stands, but they might after decompensation. Hopefully the decompensation doesn't do too much additional harm to the roots
Wish I had known about the surgical option earlier... A year ago, I really thought my only option was one-size-fits-all-invisalign. Trying to be more careful this time around and understand the whole process as much as possible -- this forum is proving so helpful already, so thank you!!
ETA: The simple answer is NO. You will most certainly not be getting a 12 mm advancement of the lower jaw in the absence of a BSSO to advance it forward. What you will get from the combined IMPACTION (front and back) is a DECREASE in the STEEP mandibular plane angle because the amount it is being thrust diagonally downward will be offset by the combined impaction. So the mandible will be able to swing 'up' more so a BSSO can take place over a LESS STEEP MPA.
After the combined impaction, there should be ONE occlusal plane angle (with AOB there are actually 2 separate OPs.) From there, the surgeon could elect to do linear advancement along the NEW OP angle. For example if the new OP angle is 'theta' degrees an advancement of the maxilla of 'X' along OP angle 'theta' will allow the surgeon to also advance the mandible by 'X' along this angle. Depending on what angle 'theta' is, an advancement of 'X' over angle 'theta' will have have both a horizontal and vertical component.
Since the rotation at the maxilla is a NET clockwise via posterior impaction (due to more posterior impaction than anterior impaction) that provides an 'up'swing, it's NOT same thing as as a net CCW posterior downgraft rotation that has an up and OUTWARD swing. So, you won't be getting the up AND OUTWARD part to same extent as posterior downgraft CCW based on rotation of triangle in CCW direction.
What ever can be done as far as advancements go will depend on HOW pre-surgical braces move the teeth in preparation for the surgery. It isn't something that can be calculated the god knows what way (lol) you tried to calculate it via confusion. Calculations are based on where the surgeon wants the teeth to be in prep for the surgery and unless your invisiline braces were put it specifically to prepare you for a maxfax surgery, braces to prepare for a surgery, most likely would need to be in a different direction.
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By the way logan, there is a Dr. Steven Sachs at same practice (NYCOMS) as Dr. Neugarten. Dr. S did a member here ('earl', who's not that active of recent) to good effect. So, if you wanted to, you could consult within same practice.
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I was going to mention Earl and Sachs. Might be worth writing Earl to ask about him. I think Earl only had one jaw (lower, I think) corrected.
The risk to your case is you wind up with a CW or steeper angle/longer face.
Seems the best plan would be to impact/level the maxilla and then rotate the entire complex (both jaws) slightly CCW. If you get enough auto-rotation from the maxilla shortening, great, but I'm skeptical that. Do you have a surgical plan?
Regarding if it's worth it, I think you're borderline, but it's probably worth it. That's really up to you, though. A lot can go wrong, and if you're fine with your face and the bite functions well-enough it might not be worth the risk. If all goes well, you should look more balanced in profile and have all teeth touching properly -- so is the risk worth those things to you? That's for you to decide. Expect your nose to widen a bit, too. Females get away with this less than males. Expect to look a bit older (you have a young/girly look now) once the jaw is in balance. A recessed jaw has that look to it, whereas a jaw in balance can look rigid or older, like an anchorwoman type look. It probably won't be that extreme in your case. But these are the two aesthetic issues I'd be concerned about, so harp on them during consultations. Get at least three consultations with the best people in your area.
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I was going to mention Earl and Sachs. Might be worth writing Earl to ask about him. I think Earl only had one jaw (lower, I think) corrected.
The risk to your case is you wind up with a CW or steeper angle/longer face.
Seems the best plan would be to impact/level the maxilla and then rotate the entire complex (both jaws) slightly CCW. If you get enough auto-rotation from the maxilla shortening, great, but I'm skeptical that. Do you have a surgical plan?
Regarding if it's worth it, I think you're borderline, but it's probably worth it. That's really up to you, though. A lot can go wrong, and if you're fine with your face and the bite functions well-enough it might not be worth the risk. If all goes well, you should look more balanced in profile and have all teeth touching properly -- so is the risk worth those things to you? That's for you to decide. Expect your nose to widen a bit, too. Females get away with this less than males. Expect to look a bit older (you have a young/girly look now) once the jaw is in balance. A recessed jaw has that look to it, whereas a jaw in balance can look rigid or older, like an anchorwoman type look. It probably won't be that extreme in your case. But these are the two aesthetic issues I'd be concerned about, so harp on them during consultations. Get at least three consultations with the best people in your area.
Doesn’t she risk worsening or failing to eliminate posterior gum show by following up with CCW?
The only way her face would actually appear longer is if the autorotation is offset by too great a linear MMA movement. Short of that she will be better off without a posterior downgraft even if her maxillary OP is technically more clockwise oriented post impaction.
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Doesn’t she risk worsening or failing to eliminate posterior gum show by following up with CCW?
The only way her face would actually appear longer is if the autorotation is offset by too great a linear MMA movement. Short of that she will be better off without a posterior downgraft even if her maxillary OP is technically more clockwise oriented post impaction.
If she doesn't get any impaction, she'd risk worsening posterior gum show with CCW, yes. But the impaction should take care of that.
Look at the angle of her jaws - it is very steep. So she needs the impaction to take care of the overgrowth, but then CCW rotation to take care of the steep angle. I don't see how you can move the jaws linearly or CW given the steepness of that angle. If the idea is auto-rotation takes care of that after some anterior impaction, maybe. I'm skeptical that would line up right.
I could be wrong. I'd like to see a final plan.
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I was going to mention Earl and Sachs. Might be worth writing Earl to ask about him. I think Earl only had one jaw (lower, I think) corrected.
The risk to your case is you wind up with a CW or steeper angle/longer face.
Seems the best plan would be to impact/level the maxilla and then rotate the entire complex (both jaws) slightly CCW. If you get enough auto-rotation from the maxilla shortening, great, but I'm skeptical that. Do you have a surgical plan?
Regarding if it's worth it, I think you're borderline, but it's probably worth it. That's really up to you, though. A lot can go wrong, and if you're fine with your face and the bite functions well-enough it might not be worth the risk. If all goes well, you should look more balanced in profile and have all teeth touching properly -- so is the risk worth those things to you? That's for you to decide. Expect your nose to widen a bit, too. Females get away with this less than males. Expect to look a bit older (you have a young/girly look now) once the jaw is in balance. A recessed jaw has that look to it, whereas a jaw in balance can look rigid or older, like an anchorwoman type look. It probably won't be that extreme in your case. But these are the two aesthetic issues I'd be concerned about, so harp on them during consultations. Get at least three consultations with the best people in your area.
Posterior impaction although it's CW-rotation makes the MPA LESS steep because it's removing the posterior EXCESS that's thrusting it down. Think of a CLOCK. Divide vertically in 1/2 as to draw line from 12 o'clock to 6 o'clock. From 12 to 6 the CW rotation is on the down swing. But from 6 to 12, the CW rotation is on the upswing. Such is the case with posterior impaction. It's CW rotation on the upswing. Not same as anterior downgraft which is CW rotation on down swing. So, no risk the posterior impaction CW will give steeper angle (MPA) or longer face. Quite the opposite.
Earl had a bird face (his words). Sachs really improved him.
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If she doesn't get any impaction, she'd risk worsening posterior gum show with CCW, yes. But the impaction should take care of that.
Look at the angle of her jaws - it is very steep. So she needs the impaction to take care of the overgrowth, but then CCW rotation to take care of the steep angle. I don't see how you can move the jaws linearly or CW given the steepness of that angle. If the idea is auto-rotation takes care of that after some anterior impaction, maybe. I'm skeptical that would line up right.
I could be wrong. I'd like to see a final plan.
See my other post to you. Although posterior impaction is technically CW, it's CW-r on the UPSWING just like a hand of a clock going from 6 to 12 in CW direction is on the upswing, not the down swing.
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Posterior impaction although it's CW-rotation makes the MPA LESS steep because it's removing the posterior EXCESS that's thrusting it down. Think of a CLOCK. Divide vertically in 1/2 as to draw line from 12 o'clock to 6 o'clock. From 12 to 6 the CW rotation is on the down swing. But from 6 to 12, the CW rotation is on the upswing. Such is the case with posterior impaction. It's CW rotation on the upswing. Not same as anterior downgraft which is CW rotation on down swing. So, no risk the posterior impaction CW will give steeper angle (MPA) or longer face. Quite the opposite.
Earl had a bird face (his words). Sachs really improved him.
I think the risk is that her OP could still be somewhat steep after impaction, and that linear advancement along that equalized OP could increase real and perceived facial length.
So I would say probably minimize linear advancement (of maxilla) as much as possible and get some CCW effect from the genio.
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I think the risk is that her OP could still be somewhat steep after impaction, and that linear advancement along that equalized OP could increase real and perceived facial length.
So I would say probably minimize linear advancement (of maxilla) as much as possible and get some CCW effect from the genio.
Keeping in mind that linear advancement would take place over a LESS STEEP MPA, (due to the posterior impaction + anterior impaction) if the linear advancement is in 5mm range or less, she should be fine. She doesn't need that much for her lower lip to line up with her upper lip.
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Keeping in mind that linear advancement would take place over a LESS STEEP MPA, (due to the posterior impaction + anterior impaction) if the linear advancement is in 5mm range or less, she should be fine. She doesn't need that much for her lower lip to line up with her upper lip.
I mostly agree, just emphasizing that even a 'less steep' MPA/OP could still be 'too steep' for a larger linear advancement. I would suggest 4mm be the absolute maximum under consideration, or maybe even less to be conservative. That + autorotation + small SG should be enough to give a balanced feminine look. I'm very concerned about maxilla advancement in female cases, especially when the individual is risk averse. 5mm is enough to potentially cause notable side effects to the nose and lip.
Hopefully the impaction will also allow lip seal at rest. A conservative plan could do very well here I think.
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Do you have some pictures where some patient got a large advancement and had a steep mandible?
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I mostly agree, just emphasizing that even a 'less steep' MPA/OP could still be 'too steep' for a larger linear advancement. I would suggest 4mm be the absolute maximum under consideration, or maybe even less to be conservative. That + autorotation + small SG should be enough to give a balanced feminine look. I'm very concerned about maxilla advancement in female cases, especially when the individual is risk averse. 5mm is enough to potentially cause notable side effects to the nose and lip.
Hopefully the impaction will also allow lip seal at rest. A conservative plan could do very well here I think.
Her jaw recession is quite modest and I think she mentioned her doctor estimated about 4mm maxilla advancement which would be within a safe aesthetic zone for her. So, IF linear advancement, mandible would be similar advancement and rest would be sliding genio which would give ample balance. I guess if she wanted more lower jaw advancement, she'd have to sacrifice a few lower pre-molars for that. But given she's on the conservative side herself, I think she would do fine with the modest advancement. So, I guess we are on same page here.
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Wow so much good info. I need to do some more reading before I understand *everything* in this discussion
But overall Kavan's argument makes intuitive sense to me -- a posterior impaction will allow the *lower jaw* to rotate more CCW, even if the upper jaw is technically moved CW. So overall the lower face should be shorted. But I also understand PB's caveat that if the maxilla is advanced *a lot* at a downward angle, that could increase length (at least could increase the distance from my forehead to my upper teeth), but hopefully that can be accounted for when calculating the amount of anterior impaction. E.g. more maxilla advancement at a downward angle, more anterior impaction to offset vertical addition from the advancement. It seems like it should be possible to fully account for this.
Tbh, in general, I don't understand what the problem is with a "steep occlusal angle" (I believe occlusal angle = angle of your bite), other than the fact that it is correlated with having a long face. Don't teeth normally go up in the back in a healthy bite? (See attachment). Sorry if this question is off topic, I can post elsewhere if so!
One thing I'm worried about, speaking of feminine aesthetics, is that both age and orthognathic surgery can lengthen the philtrum, and result in less upper incisor show while speaking. I hope that fixing my bite will get rid of the gummy smile, but I don't want to impact SO much anteriorly that my upper lip covers my teeth. Anyway, I guess this will come down to the exact plan, which I wish I could have BEFORE committing to decompensating orthodontics! But as you can tell I am leaning toward the surgery regardless, since it sounds like *some* solution should be possible
I agree with some of the posts that I would tend to be on the conservative side -- I do want the best aesthetic result possible, but only within a reasonable range of what I would naturally have had, if my jaw had developed normally without chronic allergies. E.g. I especially don't want a large chin even if that is technically more "correct". But hopefully I can communicate all this when decision time arrives
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Wow so much good info. I need to do some more reading before I understand *everything* in this discussion
But overall Kavan's argument makes intuitive sense to me -- a posterior impaction will allow the *lower jaw* to rotate more CCW, even if the upper jaw is technically moved CW. So overall the lower face should be shorted. But I also understand PB's caveat that if the maxilla is advanced *a lot* at a downward angle, that could increase length (at least could increase the distance from my forehead to my upper teeth), but hopefully that can be accounted for when calculating the amount of anterior impaction. E.g. more maxilla advancement at a downward angle, more anterior impaction to offset vertical addition from the advancement. It seems like it should be possible to fully account for this.
Tbh, in general, I don't understand what the problem is with a "steep occlusal angle" (I believe occlusal angle = angle of your bite), other than the fact that it is correlated with having a long face. Don't teeth normally go up in the back in a healthy bite? (See attachment). Sorry if this question is off topic, I can post elsewhere if so!
One thing I'm worried about, speaking of feminine aesthetics, is that both age and orthognathic surgery can lengthen the philtrum, and result in less upper incisor show while speaking. I hope that fixing my bite will get rid of the gummy smile, but I don't want to impact SO much anteriorly that my upper lip covers my teeth. Anyway, I guess this will come down to the exact plan, which I wish I could have BEFORE committing to decompensating orthodontics! But as you can tell I am leaning toward the surgery regardless, since it sounds like *some* solution should be possible
I agree with some of the posts that I would tend to be on the conservative side -- I do want the best aesthetic result possible, but only within a reasonable range of what I would naturally have had, if my jaw had developed normally without chronic allergies (my parents were anti-medicine and I guess thought my constant stuffy nose was normal :/). E.g. I especially don't want a large chin even if that is technically more "correct". But hopefully I can communicate all this when decision time arrives
It's not just the increase in 'real' facial length- LF1 advancement will also tend to cause the philtrum to be more convex which will increase perceived philtral length. This effect is sometimes called 'chimp lip' and is more likely to occur with 1) larger advancement and 2) steeper occlusal plane. Luckily your philtrum is presently concave, so you have some leeway. LF1 advancement can also cause nostril flare, which typically also correlates with degree of advancement.
Both of these are more tolerable in male than female cases, even if generally undesirable in both. That's why I'm advising keeping the LF1 advancement as small as is acceptable for proper function. You should be okay with 4mm or less, but you should also be aware of these potential side effects. I can share I can share with you my own case over PM as an example if you're interested, though mine is on the more extreme end (10mm). It will still give you a reference on what to consider in terms of these aesthetic hazards.
I think you should definitely get surgery. Just be cautious
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Yeah I am concerned about changes to my nose (a tiny bit of widening would be ok, and examples Dr. N showed me look good in this regard at least) but especially philtrum lengthening (it's already too long I think) and loss of concave curvature/apparent lip size which I currently like for both my lips. PM'd for more info
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Wow so much good info. I need to do some more reading before I understand *everything* in this discussion
But overall Kavan's argument makes intuitive sense to me -- a posterior impaction will allow the *lower jaw* to rotate more CCW, even if the upper jaw is technically moved CW. So overall the lower face should be shorted. But I also understand PB's caveat that if the maxilla is advanced *a lot* at a downward angle, that could increase length (at least could increase the distance from my forehead to my upper teeth), but hopefully that can be accounted for when calculating the amount of anterior impaction. E.g. more maxilla advancement at a downward angle, more anterior impaction to offset vertical addition from the advancement. It seems like it should be possible to fully account for this.
Tbh, in general, I don't understand what the problem is with a "steep occlusal angle" (I believe occlusal angle = angle of your bite), other than the fact that it is correlated with having a long face. Don't teeth normally go up in the back in a healthy bite? (See attachment). Sorry if this question is off topic, I can post elsewhere if so!
One thing I'm worried about, speaking of feminine aesthetics, is that both age and orthognathic surgery can lengthen the philtrum, and result in less upper incisor show while speaking. I hope that fixing my bite will get rid of the gummy smile, but I don't want to impact SO much anteriorly that my upper lip covers my teeth. Anyway, I guess this will come down to the exact plan, which I wish I could have BEFORE committing to decompensating orthodontics! But as you can tell I am leaning toward the surgery regardless, since it sounds like *some* solution should be possible
I agree with some of the posts that I would tend to be on the conservative side -- I do want the best aesthetic result possible, but only within a reasonable range of what I would naturally have had, if my jaw had developed normally without chronic allergies (my parents were anti-medicine and I guess thought my constant stuffy nose was normal :/). E.g. I especially don't want a large chin even if that is technically more "correct". But hopefully I can communicate all this when decision time arrives
Thing is that with Anterior Open Bite (AOB), you have 2 occlusal planes (OPs), the max OP and the mandibular OP, NOT one. This forms and OPEN WEDGE in front where the bite doesn't close in front. It doesn't close in front because the BACK part of the maxilla is too long where only the back teeth meet each other. So BASICALLY what they do to close that open wedge space is to CUT somewhat of a similar wedge from the maxilla; one kind of pointing in the opposite direction. That moves the back of the maxilla UP more than the front of the maxilla. The removal of the wedge of bone along with the net CW rotation is the IMPACTION. The CW rotation of the cut out wedge section is CW rotation on the UPSWING. Just like the hands of a clock travel on the upswing when they travel between 6 and 12 o'clock.
This UPSWING CW rotation is what COUNTER ACTS the DOWNSWING CW (hands of a clock traveling between 12 and 6 oclock) you see to the open wedge in front where the mandible is being forced into more of a CW r because the excess length at the back of the maxilla PRECLUDES it from swinging up.
When the mandible can swing up to close the bite, you will have ONE OP and your MPA will be less steep. From there, they can elect to do linear advancement and the sliding genio. IF NOT linear advancement (eg less advancement to maxilla/more to mandible), the option to move the lower jaw further than the upper jaw (or upper jaw less than lower jaw) would depend on how they prepare the teeth for the surgery. For example if they 'buck out' the front teeth and can manage to also push backwards the lower teeth, then they can move the upper jaw forward less and the lower jaw forward more.
As to your other concerns/questions:
The philtrum does NOT get longer. It just can LOOK longer when it's aligned with a vertical plane or becomes conVEX. Some maxillary advancements can even make the philtrum look shorter like when they buck out the teeth somewhat and advance, then the philtrum is on outward diagonal plane and looks shorter. Also, TOOTH SHOW from the FRONT is part of the plan as to get the optimal amount of tooth show without excess gum show.
Keep in mind:
Presently, with 2 OPs, the surgery goal is a matter of forming ONE OP. So, your OP really can't be measured at this point. The goal of this type of surgery (type for you) is really to 'level out' the MAXILLARY PLANE. The goal is not really to make the OP less steep. Even when the goal is to make the OP less steep, it's the maxillary plane that's really altered. But it's not as if someone is going to suggest a CCW posterior downgraft so you can have MORE posterior gum show than you have now! So, for now, I would not fret about the OP because that's more relative to people who have ONLY ONE OP, not 2 diverging OPs. The 'steepness' that is way beyond the norm is the MPA. It will get less steep but be still outside the norm (because the rotation the impaction does, even though it makes it less steep won't counter-act the excess steepness it has from the norm). In fact it would be the steepness of the MPA and NOT the OP that would tend to LIMIT how much advancement you can have whether it's linear (equal max and mand.) or less maxilla and more mandible. So, I don't think you have to worry about philtral problems, bull's nostrils or 'masculine' jaw. BECAUSE, they are going to want to LIMIT the mandible advancement so they can LIMIT advancing over a steep MPA. Limit would apply to the max. advancement too.
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Thanks Kavan, that makes sense!
I now have two more local consultations scheduled in the next couple weeks and will hopefully make a decision (whether to proceed, and if so with who) shortly after that
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:)
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Quick update in case anyone is interested. I had a virtual consult with Dr. Steinbacher at Yale, who is an orthognathic + plastic surgeon and seems very competent. I appreciate doctors who publish their research -- in this case including a literal textbook! He does ~120 orthognathic surgeries/year. Two interesting things:
- he takes 3D photographs for planning purposes (like color photographs, in addition to 3D CT scans -- not sure how common this is)
- he uses fat grafts to speed up healing and help give facial support after surgery (also not sure if anyone else does this/how common it is)
Regarding a plan, he echoed what has been said here: le fort 1 + BSSO, with CW rotation of the maxilla and CCW of the mandible. Probably genioplasty depending on aesthetic goals. Not clear how much maxilla advancement he thinks I would need -- "it depends on the angle". But I wasn't expecting to learn anything too specific from a virtual consult.
He thinks orthodontics with TADs alone could close the bite by impacting posterior maxilla, it would just take a long time, and it wouldn't improve breathing at all or aesthetics as much.
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Did he give you any records of the plan?
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No, I've been having trouble getting any detailed plan from my (2) consults so far. Maybe I'm not asking directly enough. We seem to run out of time before there is space to discuss specifics, and they both implied that the exact plan would be determined right before surgery, after orthodontic preparation, so I didn't press it. Ears open to advice about how to get a more specific plan prior to committing to one surgeon.
This was just a 30 min virtual consult, the next step would be to go in person for their 3D images, but I'm not sure I can justify the trip unless I've committed (it's 6 hrs RT, which seems excessive when I already have the cephalometric scan and can talk virtually).
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Just to make sure we are talking about the same person... my consult was with Derek Steinbacher at Yale, and I think the post you linked refers to Douglas Steinbrech in NY?
This is the guy I just video chatted with: https://dereksteinbacher.com/
NOT this: https://www.drsteinbrech.com/about-us/dr-steinbrech
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I also have some skepticism about the fat grafting since this is the first I've heard of it for functional jaw surgery, but Dr. S @Yale has done some reasonably convincing research showing that it helps with inflammation and healing
https://pubmed.ncbi.nlm.nih.gov/28906330/
https://pubmed.ncbi.nlm.nih.gov/30817538/
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Dr. S @ Yale also wrote a text book published last year, "Aesthetic Orthognathic Surgery and Rhinoplasty" which looks like fun light reading ;D
https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781119187127
Ok and last off-topic advertising I will do is to share his instagram which has some fascinating posts including reconstruction of someone born WITHOUT A NOSE https://www.instagram.com/p/CB8u3s6DATt/?utm_source=ig_web_button_share_sheet
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No, I've been having trouble getting any detailed plan from my (2) consults so far. Maybe I'm not asking directly enough. We seem to run out of time before there is space to discuss specifics, and they both implied that the exact plan would be determined right before surgery, after orthodontic preparation, so I didn't press it. Ears open to advice about how to get a more specific plan prior to committing to one surgeon.
This was just a 30 min virtual consult, the next step would be to go in person for their 3D images, but I'm not sure I can justify the trip unless I've committed (it's 6 hrs RT, which seems excessive when I already have the cephalometric scan and can talk virtually).
Ah, the next step is to get a plan in writing. You have to be forthright. Email them and request it. If he doesn't produce a plan, I wouldn't use him.
If you have recent records already, he can probably use those. This is best anyway to keep radiation down.
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Just to make sure we are talking about the same person... my consult was with Derek Steinbacher at Yale, and I think the post you linked refers to Douglas Steinbrech in NY?
This is the guy I just video chatted with: https://dereksteinbacher.com/
NOT this: https://www.drsteinbrech.com/about-us/dr-steinbrech
Thanks for pointing that out. You're absolutely RIGHT. I got the WRONG one due to the names being so similar. So, totally different people. I'll delete my mention of the wrong one.