Daedalus Journey

[Daedalus]

As a premises:
Long story short, I was a mouth breather during childhood due to adenoids and developed a common mouth breather face ” with underdeveloped mandible. Fast forward to my early teens I get braces and two upper premolar extractions to pull my more developed maxilla to meet retruded mandible.

Today, I constantly have a problem with snoring (I still open my mouth during sleep) which snowballs a variety of other issues. Not so long ago I tried to fix my problem with a new orthodontist using  a palatial expander but I was warned that at my age (20 y.o) it will not be able to change the bone, it will rather shift the teeth. Furthermore it will not help out with the mandible.

Now, functional problem out of the way. I would really like discuss and more than glad to hear out opinions about the aesthical side of the issue.  Here is an X-ray (half a year old, now the wisdom teeth are extracted)  https://imgur.com/a/WRUv29W

After I've done some research and  I have reached a conclusion that  I will require some sort of double jaw advancement with a genioplasty  and possibly some malar augmentation with implants or bone grafts to even out the mid face . Of course the final plan will be set by the specialist of choice, but for now I'm also interested in hearing out your  opinion on the matter.

In conclusion, I intend to keep updating this post and overviewing the entire process.

[kavan]

I agree. You would benefit from double jaw surgery and those with whom you plan to consult all are good with optimizing aesthetics via CCW rotations if that is needed.

[Daedalus]

Thank you for your reply, appreciate it.

[Daedalus]

I agree. You would benefit from double jaw surgery and those with whom you plan to consult all are good with optimizing aesthetics via CCW rotations if that is needed.

Hello, Kavan. I hope you will have some spare time to read through my comment.

Recently, I was extensively researching about orthodontic decompensation before the surgery. I just see no way they can decompensate my upper jaw, as then it would require  protraction with skeletal growth to reverse it back. Alternatively they might want to extract lower premolars to reduces the lower incisors tipping and then advance both jaws with or without rotation. I would definitely like to avoid extractions beyond all, so I'd like to ask if potentially retracting entire lower arch is possible, or the advancement and rotation of existing occlusion is  sometimes possible? Of course I understand that prior to any orthognatic treatment, orthodontics should ensure the stability of the entire structure.
On the other hand, what do you think about surgery first approach? I personally see it as inferior, since its impossible to reverse everything back after the surgery have been conducted.  Thank  you in advance!

[kavan]

Hello, Kavan. I hope you will have some spare time to read through my comment.

Recently, I was extensively researching about orthodontic decompensation before the surgery. I just see no way they can decompensate my upper jaw, as then it would require  protraction with skeletal growth to reverse it back. Alternatively they might want to extract lower premolars to reduces the lower incisors tipping and then advance both jaws with or without rotation. I would definitely like to avoid extractions beyond all, so I'd like to ask if potentially retracting entire lower arch is possible, or the advancement and rotation of existing occlusion is  sometimes possible? Of course I understand that prior to any orthognatic treatment, orthodontics should ensure the stability of the entire structure.
On the other hand, what do you think about surgery first approach? I personally see it as inferior, since its impossible to reverse everything back after the surgery have been conducted.  Thank  you in advance!

They might elect to 'buck out' the upper front teeth somewhat to get some more forward movement to the lower jaw. The doctors you consulted with use CCW posterior downgraft where they don't need to rely on extracting more pre-molars from lower jaw to bring it forward.

Post surgical braces move the teeth faster into place with surgery first method. However, even with doctors who do use that method,  they need to determine which patients can have it or not.

[Dogmatix]

Hello, Kavan. I hope you will have some spare time to read through my comment.

Recently, I was extensively researching about orthodontic decompensation before the surgery. I just see no way they can decompensate my upper jaw, as then it would require  protraction with skeletal growth to reverse it back. Alternatively they might want to extract lower premolars to reduces the lower incisors tipping and then advance both jaws with or without rotation. I would definitely like to avoid extractions beyond all, so I'd like to ask if potentially retracting entire lower arch is possible, or the advancement and rotation of existing occlusion is  sometimes possible? Of course I understand that prior to any orthognatic treatment, orthodontics should ensure the stability of the entire structure.
On the other hand, what do you think about surgery first approach? I personally see it as inferior, since its impossible to reverse everything back after the surgery have been conducted.  Thank  you in advance!

I had these thoughts when I saw your x-rays first as well. You have a molar class II bite, that has been compensated by extraction in the upper jaw. So the bite fits, but in class II. I'm not sure how they normally handle a case like that. One option could be to accept the class II occlusion and displace the entire complex, but not sure if they do that. You'd have to get an expert opinion. It could be that they can decompensate to give space to advance the mandible. But it could also be that they have to make space, either by extraction in the lower jaw, or reverse the extraction in the upper jaw and put implants. I don't know what your extraction case looked like, but likely the teeth were extracted to reduce the arch in the upper jaw, which is the opposite of what you want to do when you want to open up to give space for the mandible to be moved to class I from class II.

[Daedalus]

Thank you for reply.
!

They might elect to 'buck out' the upper front teeth somewhat to get some more forward movement to the lower jaw. The doctors you consulted with use CCW posterior downgraft where they don't need to rely on extracting more pre-molars from lower jaw to bring it forward.

Post surgical braces move the teeth faster into place with surgery first method. However, even with doctors who do use that method,  they need to determine which patients can have it or not.

Definitely would be a great option if they can keep the bite and just do the advancement and CCW

[Daedalus]

I had these thoughts when I saw your x-rays first as well. You have a molar class II bite, that has been compensated by extraction in the upper jaw. So the bite fits, but in class II. I'm not sure how they normally handle a case like that. One option could be to accept the class II occlusion and displace the entire complex, but not sure if they do that. You'd have to get an expert opinion. It could be that they can decompensate to give space to advance the mandible. But it could also be that they have to make space, either by extraction in the lower jaw, or reverse the extraction in the upper jaw and put implants. I don't know what your extraction case looked like, but likely the teeth were extracted to reduce the arch in the upper jaw, which is the opposite of what you want to do when you want to open up to give space for the mandible to be moved to class I from class II.

First of all, thank you for a reply!

Well that’s exactly what my thoughts were. I had class II division I, where the upper incisors were greatly tipped out. What worries me the most is the lower incisor tipping, I believe that if they can decompensate it without extractions, then I may have a shot, if not, then lower premolars will have to go. I’ve read some articles about a case similar to mine where no further extractions were necessary, and the needed space was acquired by CCW rotation and a bit of lower arch decompensation.
A factor that gives me hope is that my occlusion stood quite firm after the orthodontics, almost no relapse even though I didn’t wear a retainer in more than 4 years,  according to the comparison of old and new X-rays, except for some minor lower incisors tipping.

Last but not least, as you’ve mentioned, an expert opinion will be required to set it down.

Thanks again for taking your time to write a reply!

[Dogmatix]

Don't take my meassurements as accurate, but just to show a bit what's going on.

The angle that meassures ~100 deg is the impa-angle. The angle of the lower incisor with reference to the mandible. This is as you point out a bit high and could be decreased to increase the overjet. My meassurement is surely not accurate, but norm value is in the region 90 +-5, so regardless of my meassurement, there is some to take of.

The upper incisor angle is about 30deg with reference to NA, with a norm of 22. This is also a bit high, but decreasing it would close the overjet which would not be the objective if you want to advance the mandible. Flaring it out further doesn't seem very good either as the angle already is high.

The mark at the molars show approximately how the molar relationship should change when moving the class II to class I.

So yes, angling the lower incisors inward is probably the best chance.

https://imgur.com/OIGWEGZ

[kavan]

The NAMED surgeons do the advanced downgraft CCW rotations which more often than not SPARE people from having to do the pre-molar extractions to push lower teeth backwards IN ORDER TO DO the lower jaw advancement which is the case with linear advancement type surgeries. But of course, they are more expensive due to that given they are sought out more due to that and there are not an extensive number of maxfax docs who do the downgrafting to the extent the docs you named do it.

The ortho you had to make your 'bite right' made your face 'wrong' and also your airway because it pushed things backwards. So, you will most likely need the posterior ccw downgrafting which should SPARE you from needing the premolars extracted so the lower teeth pushed backwards so they can push the lower jaw forwards.

So, the aim of the surgery would be to AVOID removing any more pre-molars and to push the face forwards again with more forward movement to the lower jaw area and LESS to upper jaw which is the whole concept of CCW (posterior down graft). What ever they need to do to get you ready for that via braces.

Also, as to Korean doctors, no opinion on some who knows who doctor in Korea. But the ones you named are the CCW docs who use a system that opens the airways and optimizes aesthetics.

[kavan]

I think it's unlikely that a doc doing CCW down graft is going to need to remove another pre-molar to push your lower teeth backward to prepare to move your mandible forward. The whole concept of the down graft CCW is that the lower jaw gets a 'FREE RIDE' forward JUST WITH the rotation. Also, I'm assuming that the fact you mentioned 3 docs who do that kind of CCW that you are wanting to avoid extraction of another pre-molar.

I've drawn a diagram over your ceph to illustrate the very BASIC concept. It is one that relates back to basic geometry.

Here the green triangle is the SAME as the red one and shows the displacement of the pogonian point to the whole mandible with a CCW rotation that relates to a posterior downgraft. Note that the (bottom) vertex of red triangle is shifted forward (vertex of green triangle). So that's example of 'free ride' to bring mandible forward even before they start the BSSO or move the upper jaw forward to bring them even more forward. So, it's a situation where they don't need to pluck out another pre-molar to push the lower teeth backwards in order to bring lower jaw forward.

As to 'decompensation', the way I look at is the SALIENT concept which is that the ortho made your face WRONG by getting the bite RIGHT. So, what ever the decompensation is, it will be one to make your bite 'WRONG' during time in braces IN ORDER TO get the FACE right (and also the bite with that) during surgery. That will be so with braces before surgery. If it's surgery first, then there will be no time in PRE-surgery braces for the bite to be made 'wrong' in preparation to make it right WITH the surgery. The face will be made right after the surgery and the bite will be wrong and will need to be made right after the surgery.

[Daedalus]

Don't take my meassurements as accurate, but just to show a bit what's going on.

The angle that meassures ~100 deg is the impa-angle. The angle of the lower incisor with reference to the mandible. This is as you point out a bit high and could be decreased to increase the overjet. My meassurement is surely not accurate, but norm value is in the region 90 +-5, so regardless of my meassurement, there is some to take of.

The upper incisor angle is about 30deg with reference to NA, with a norm of 22. This is also a bit high, but decreasing it would close the overjet which would not be the objective if you want to advance the mandible. Flaring it out further doesn't seem very good either as the angle already is high.

Well, that’s close to what I thought. I hope they can incline the lower teeth without extractions, then accentuate it with CCW and then finish of what is necessary with orthodontics again.
Nonetheless, thanks for a reply and an outline.

[Daedalus]

I think it's unlikely that a doc doing CCW down graft is going to need to remove another pre-molar to push your lower teeth backward to prepare to move your mandible forward. The whole concept of the down graft CCW is that the lower jaw gets a 'FREE RIDE' forward JUST WITH the rotation. Also, I'm assuming that the fact you mentioned 3 docs who do that kind of CCW that you are wanting to avoid extraction of another pre-molar.

I've drawn a diagram over your ceph to illustrate the very BASIC concept. It is one that relates back to basic geometry.

Here the green triangle is the SAME as the red one and shows the displacement of the pogonian point to the whole mandible with a CCW rotation that relates to a posterior downgraft. Note that the (bottom) vertex of red triangle is shifted forward (vertex of green triangle). So that's example of 'free ride' to bring mandible forward even before they start the BSSO or move the upper jaw forward to bring them even more forward. So, it's a situation where they don't need to pluck out another pre-molar to push the lower teeth backwards in order to bring lower jaw forward.

As to 'decompensation', the way I look at is the SALIENT concept which is that the ortho made your face WRONG by getting the bite RIGHT. So, what ever the decompensation is, it will be one to make your bite 'WRONG' during time in braces IN ORDER TO get the FACE right (and also the bite with that) during surgery. That will be so with braces before surgery. If it's surgery first, then there will be no time in PRE-surgery braces for the bite to be made 'wrong' in preparation to make it right WITH the surgery. The face will be made right after the surgery and the bite will be wrong and will need to be made right after the surgery.

Gives me hope. I am strongly against any further extractions, thus such a way would be way more favorable. I knew about the concept of CCW, but was rather unaware to what extend it can be utilized, because it seemed like too much CCW results are prone to relapse.

Btw, love the name of the attachment 😄

[kavan]

Gives me hope. I am strongly against any further extractions, thus such a way would be way more favorable. I knew about the concept of CCW, but was rather unaware to what extend it can be utilized, because it seemed like too much CCW results are prone to relapse.

Btw, love the name of the attachment 😄

I knew you would understand the reference.