Surgery for moderate function + aesthetics

[logan]

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?

[kavan]

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.

[logan]

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

[ArtVandelay]

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.

[Post bimax]

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.

[kavan]

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.

[logan]

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!!

[logan]

@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

[Post bimax]

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.

[logan]

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

[kavan]

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.

[kavan]

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.

[GJ]

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.

[Post bimax]

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.

[GJ]

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.