Mandible Extractions to Decompensate Bite Prior to Surgery

[JayJaw]

What are your thoughts on this?

My teeth are flared greatly in order to "fit" my lower arch. In order to decompensate and get them to the proper angle, my orthodontist and surgeon have suggested pulling 2 teeth. This seems to make sense since even with my impacted wisdom teeth removed I have zero room to pull all my teeth back and make space.

Is this generally accepted to be the only way forward?

Or are there other ways to give more space in order to keep all the teeth? It seems perhaps only two options exist, both of which perhaps more risky than they are worth.

1. SARPE on the mandible to widen the arch and give more space. This would need to be done concurrently with SARPE on maxilla so that they both could be widened. This would be almost on par with double jaw surgery... so not a fun option. Since would still need to get double jaw to rotate and move both jaws forward.

2. Distraction on mandible to lengthen jaw while simultaneously fixing the angle. This really only seems to be done on people with severe recession / missing bone (i.e. can't perform BSSO) or adolescents / children. I'd need to still get double jaw to rotate the jaws CCW.

It seems like risk/reward isn't there for these options. Am I right in thinking that?

It's a big decision since once I remove teeth and go forward... well, it's tough / expensive to go back from that!

[kjohnt]

The user PloskoPlus explained to me in another thread there are two surgical options to widen the mandible: 1) subapical mandibular osteotomy and 2) surgically assisted mandibular expansion.  I don't know much about either except that the latter includes a cut directly down the center of the chin and a tool is adjusted from time-to-time to widen the gap.  This results in a gap between the lower middle-front incisors but the teeth are then pulled back to fit the arch and that gap is filled in. 



Anyway, he said nerve damage and risk of complete numbness makes these surgeries extremely rare, which also tells me that they're going to be expensive.  Furthermore, I think there could be potential joint complications, but that's just speculation.

I'd get a second opinion from a surgeon (not ortho), but if extractions are needed, I'd reluctantly go forward.  I've seen before/afters that included extractions as part of the treatment plan and they look good... you'll just be missing teeth (which are premolars I think usually but after braces and BSSO  it ends up meaning you have space in the back of your mouth).  A wider jaw would be nice, but it's just not something that's commonly prescribed.  At least not in present day.

Also, you'd probably have an even tougher time finding someone to widen both jaws simultaneously.  I'd think it would be more likely to widen the maxilla if too narrow for the mandible, and then mandible if too narrow for the maxilla, but probably not both.  This would be two serious procedures just to set up for another serious operation, and basically total lower facial reconstruction.  I'm not saying it's not a nice idea if needed, but you're talking serious time and money and depending on how your face is currently, it may be overkill.  A couple of extractions sounds like a better option IMO.

[thinkingme]

I think if they pull 2 teeth from backlower jaw, should they pull 2 teeth from top too? And widen mandible u can see they pull 1 front teeth from lower jaw. Its for very narrow jaw people for fix them.

[JayJaw]

kjohnt,

I think you're probably right that it's not worth all the expense and risk. I agree about widening the mandible too... I can't see how it wouldn't impact your joints in some way. Also, some sort of lengthening distraction that replicates BSSO doesn't really seem worthwhile if I need rotation anyhow and would therefore need jaw surgery.

I will probably get second opinion before pulling teeth, maybe send files to A&G perhaps. Still, the surgeon and ortho I spoke to did give me all the options. My own opinion is to agree, honestly. Even with wisdom teeth removed, there is no space. The wisdom teeth and highly impact and at an angle because there is no room after my last molars. The jaw bone goes vertical at that point. They mentioned shaving enamel off each tooth but that wouldn't give me enough movement, so my teeth would still be angled and my final result far less dramatic. I could accept the angle of my teeth, but that isn't really ideal either since I'd probably get some sort of bimax protrusion if jaws were properly aligned.

It isn't ideal. I'd love if I have a bit more space... but it seems the only reasonable solution.

I just really wanted to confirm that with some of you guys here to see. I will likely look to confirm that with A&G as well.

My upper jaw won't need braces at least. Well, not until right before surgery... at least that's a plus. I could even get braces behind my lower teeth too. Ultimately, it makes the time in braces better if it's not upper. The upper will be expanded though once the lower is brought forward since you are, in effect, widening the front of your mandible. Once decompensated, the front portion of the arch is wider. When moved forward in surgery it then is wider then the front of the maxilla, which is widened slightly to fit.

It all makes me a bit nervous, but I really do see it fixing my issues (hopefully!).

[JimmyTheGent]

JayJaw are you in NYC?   

[JayJaw]

Yup, I am in NYC.

[JimmyTheGent]

Yup, I am in NYC.

So who in NYC suggested pulling teeth?  Is this because you have a narrow lower jaw?  I have  narrow lower and upper jaws too and sleep apnea.  I am going to start consulting with surgeons in NYC so I'm wondering who you went to?

[JayJaw]

I saw Dr. Sachs (NYCOMS). He seems like a great guy and the practice in general is highly respected. I do trust his opinion on this one (although still never hurts to get a second opinion on something this major). It's really a combination, likely, of both a narrow jaw AND a short jaw. I'm sure that there are those with wider jaws perhaps could allow them to fit the teeth without being flared. My teeth were flared before any form of orthodontics as a kid (~12). This is due to tongue thrust and the way my jaws developed as a result of said tongue thrust / mouth breathing. Obviously the orthodontist kept these extreme flare because it is better functionally to have that then it is to have an overjet.

I think my situation (perhaps yours) is one where jaw surgery requiring pulled teeth is simply the best option available. Sure, if I could somehow widen and lengthen the jaws while simultaneously reducing the angle of my lower front teeth, that'd be awesome! However, there isn't any reliable way to replicate that (other than having grown right in the first place!) it seems. The solutions in my OP are, technically, something that could be done... but risk/reward/expense is an issue. Sure, I could spend a lot of money to get someone to expand both upper and lower via SARPE (user chicago29 at archwired forum had this done) and then get double jaw surgery. However, I don't think my case is extreme enough to warrant that.

In the end, even looking at my ceph myself (probably will post them here), I can't see anyway I could get enough movement to warrant keeping all my lower teeth. I have zero room and even shaving down each tooth won't give me the space. Also, I certainly will get better results due to increased BSSO movement too, which is ideal.

Sorry for the rant!

I wish you the best and feel free to PM me for more information.

[JayJaw]

Anyone have opinions on this?

[thinkingme]

similar situation with me. But still im not sure i go surgery because my jaw is narrow. Pulling premolar and wisdoms let me 24 teeth total and i have not wider smile. Im afraid of maximum top 4 + 2 semi teeth and bottom 6 teeth show when i smile. And i have fear of pulling teethts wisdoms surgery healings and family supports .
And your case, i think sarpe on mandible not possible in normal people. but i find http://forum.dentalxp.com/case/details/distraction-osteogenesis-orthodontics-a/4479 that thing the boy was not anormal so much and they sarpe both arches.