Considering SARPE / Revision Orthognathic Surgery

[David_D]

I've already had two-jaw surgery to correct a class III (underbite) malocclusion.  Additionally, I've had sliding genioplasty to further reduce the vertical length of my face.

I'm relatively comfortable with how I look in repose, and also recognize that I don't like my smile.  I believe that my upper palate is too narrow, especially toward the front of the palate; for instance, I think my canine teeth are not frontally-oriented enough to contribute to a broader smile line.  I'm considering SARPE surgery and have a consultation in two weeks.  Another orthognathic surgeon, Dr. Gunson, recommended a multi-piece LeForte on my upper jaw.

I'm unsure which would be the best way to proceed - multi-piece LeForte or SARPE.

I also wonder if my maxilla is too retruded.  I think I have a pretty flat midface, and wonder if the maxilla can or should be brought forward a couple mm if I opt for a multi-piece LeForte.

So my goals are a broader more aesthetic smile and looking better generally.

An alternative is to try to attempt what I want to achieve with veneers or orthodontic devices.

I understand that there may be some experts on this forum.  Does anyone have any thoughts or recommendations?

[attachment deleted by admin]

[attachment deleted by admin]

[LeFort 3000]

ridiculous. spend your money elsewhere

[GJ]

I can see what you mean. The upper jaw is more narrow than the lower, but it's on the back molars not the front teeth. The upper back molars are tilted inward. Did the ortho try to do some compromise technique?

If the bite feels good as is you probably shouldn't mess with it, but if the bite isn't comfortable explore the options with Dr. Gunson (he's a great clinician and won't steer you wrong). Are those veneers on the front teeth? Just wondering why there is a yellow line in the scalloped upper area. Looks like a veneer and/or gum recession is beginning.

[David_D]

I can see what you mean. The upper jaw is more narrow than the lower, but it's on the back molars not the front teeth. The upper back molars are tilted inward. Did the ortho try to do some compromise technique?

If the bite feels good as is you probably shouldn't mess with it, but if the bite isn't comfortable explore the options with Dr. Gunson (he's a great clinician and won't steer you wrong). Are those veneers on the front teeth? Just wondering why there is a yellow line in the scalloped upper area. Looks like a veneer and/or gum recession is beginning.

I imagine that this is an intentional crossbite that was used to correct the bite.  My braces came off a decade ago, and I recently spoke with my orthodontist and he doesn't recall.  He said that he could address the crossbite if I got SARPE, and he referred me to the maxillofacial department of my HMO, which will see me in two weeks.

The bite does feel fine.

Yes, I have veneers on the upper four front teeth.  They aren't looking so good to me (they're from 2007).  I got those after I broke the central two teeth.

I got concerned about Dr. Gunson's recommendation that I get clockwise rotation, and also that I didn't get a sense of his aesthetic vision.  In additional to the multi-piece upper LeForte, he also recommended jaw angle and cheek implants using HA paste.

I do think I have some midface weakness.  I'm not sure that's it's so much a matter of retrusion as a matter of the narrowness of the maxilla.

Anteriorly, the maxilla seems narrower to me than the maxilla.  The anterior (non-central) mandibular teeth are inwardly-tilted.  I'm not sure if that's how "normal" teeth are or not.  I suspect not.

[marcus3415]

Same thing happened to me...bite was tight because of poor planning. looks similar to yours after djs nand genio

[David_D]

Same thing happened to me...bite was tight because of poor planning. looks similar to yours after djs nand genio

By "tight" do you mean narrow?  If not, what do you mean?

Also, did you fix this?  If so, how?  What do you think the solution is?

Thanks so much.

[marcus3415]

Yes narrow. It's aligned and stuff but here's not enough of an overbite. Would love to have a really wide Hollywood smile haha

Can't fix it unless the maxilla is expanded surgically. I don't have it in me to fix this haha, just let it be

[GJ]

I imagine that this is an intentional crossbite that was used to correct the bite.  My braces came off a decade ago, and I recently spoke with my orthodontist and he doesn't recall.  He said that he could address the crossbite if I got SARPE, and he referred me to the maxillofacial department of my HMO, which will see me in two weeks.

The bite does feel fine.

Yes, I have veneers on the upper four front teeth.  They aren't looking so good to me (they're from 2007).  I got those after I broke the central two teeth.

I got concerned about Dr. Gunson's recommendation that I get clockwise rotation, and also that I didn't get a sense of his aesthetic vision.  In additional to the multi-piece upper LeForte, he also recommended jaw angle and cheek implants using HA paste.

I do think I have some midface weakness.  I'm not sure that's it's so much a matter of retrusion as a matter of the narrowness of the maxilla.

Anteriorly, the maxilla seems narrower to me than the maxilla.  The anterior (non-central) mandibular teeth are inwardly-tilted.  I'm not sure if that's how "normal" teeth are or not.  I suspect not.

Well the main things I see are functional. The veneers look to be causing gum recession (Is this an accurate assessment? You'd know how things looked before the veneers), and the upper jaw looks narrower than the lower jaw. The latter seems like a big surgical error. But you aren't reporting any pain or bite issues from it, so then it's just how much you are willing to risk for an aesthetic issue, and nobody can answer that but yourself. If my bite felt good and I looked normal, I'd move on with life, so that's my advice.

PS. Did they say that's a crossbite? Looks more like an edge-to-edge bite (on the back molars).

[David_D]

Well the main things I see are functional. The veneers look to be causing gum recession (Is this an accurate assessment? You'd know how things looked before the veneers), and the upper jaw looks narrower than the lower jaw. The latter seems like a big surgical error. But you aren't reporting any pain or bite issues from it, so then it's just how much you are willing to risk for an aesthetic issue, and nobody can answer that but yourself. If my bite felt good and I looked normal, I'd move on with life, so that's my advice.

PS. Did they say that's a crossbite? Looks more like an edge-to-edge bite (on the back molars).

I got the definition of edge-to-edge bite as "an occlusion in which the anterior teeth of both jaws meet along their incisal edges when the teeth are in centric occlusion."  Anteriorly, my upper teeth do not meet the lower teeth, so I don't think I have an edge-to-edge bite.  I believe that I've had multiple dental professionals refer to my bite as a crossbite.  Perhaps it's not truly a cross-bite as the teeth have been tilted in such a way as to have the teeth meet in a functional way.

I imagine that the surgeon who performed my jaw surgery wouldn't consider there to be surgical error as all my teeth meet in the manner that they do.

My functional concern is limited to any sinus-related benefit related to expansion of the upper palate - which I wouldn't consider to be a trivial one.  My bite is fine.

I am willing to undergo SARPE and orthodontia for aesthetic purposes.  I totally understand how others may come to different conclusions on that matter.

[PloskoPlus]

Your upper jaw does look narrow. I can sort of relate. I was a class iii. As a kid a I wore a palatal  expander to make the teeth meet somehow at the back. But moving the upper jaw forward meant that it had to be narrowed back to its original size.
After surgery I was really surprised to see these ugly buccal corridors and my surgeon messed up my tooth show - 2 mm too short. Needless to say, while I have a solid bite, straight teeth, I do not have a Hollywood smile. My arch looks very narrow for how wide my face is.

[PloskoPlus]

Your nose is perfectly sized in profile. Moving the cheeks forward even a couple of mm via lefort i will make it look positively tiny.

[David_D]

Your nose is perfectly sized in profile. Moving the cheeks forward even a couple of mm via lefort i will make it look positively tiny.

I would think that it's possible that the nose would project outward a bit more if the maxilla was brought forward.  In any case, I strongly doubt I will go through another LeForte procedure, and, if so, would not move things forward.  While it might improve certain soft tissue issues, I think the maxilla is probably where it should be - just too narrow.

I also wonder if I get SARPE and expansion of, say, 6 mm, if this will lead me to want lateral cheek/temple augmentation to balance things.  I've certainly discovered that one change, to me, apparently paves the way for another.

[LyraM45]

I think you look fantastic.  If you're bite is not causing you functional issues/pain, then I would leave well enough alone.  Just my .02 on that.