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Probably need *another* double-jaw surgery (cephalogram attached)  

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Mr_Man
Eminent Member

I've been to a couple of orthodontists (the most recent one being through a university), and the consensus is that I need another bimax surgery.  Looking at this cephalogram, I can see that I need to move the palate/maxilla forward (with slight clockwise rotation) and rotate the mandible counterclockwise.  I tend to agree with them, and am beginning to pursue this method of treatment.

Despite having gone through a similar bimax 23 years ago (including a 3-way segmented LeFort1 and BSSO), I still have, as one of the senior orthodontists told me, a mild-to-medium class III relationship.  Over the last 18 months, I've expanded my palate a little (about 2mm) with a transverse-only acrylic expander and hardmewing.  Officially, my upper IMW is 44mm (probably closer to 40 after taking flaring into account).  My lower IMW is officially 50mm (probably closer to 54mm when taking lingual tipping into account; all of the orthodontists tell me they've never seen such a wide mandible before). I believe the mewing has also somewhat improved the upper half of my midface.  My upper incisors have also moved forward about 1mm.  Nevertheless, I clearly need significant saggital movement of my upper jaw, and preferably ccw rotation of my mandible; the lower incisors are also significantly retroclined, to the point of causing some bone loss.

The plan is to move my upper jaw forward 8mm (I've also seen this number in my "wits appraisal"), rotate it slightly clockwise (it's apparent when I smile that my upper teeth are too high), possibly segment it in two pieces (remember my IMW issue), and rotate the lower jaw ccw (which will also bring it forward some).  I'll also have to undergo a procedure at least 6 months before to remove the existing plates/screws.  Of course, this bimax surgery would have to be approved by my medical insurance or there is no way I could afford it.

Anyone have advice for what I could do instead if I cannot pursue this bimax surgery for whatever reason?

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Posted : 06/09/2020 2:20 pm
Limebike
Eminent Member

@Mr_Man was your bimax 23 years ago considered successful? What happened in the meantime? A relapse?

Do you have a bilateral posterior crossbite now?

If you do a clockwise rotation on the maxilla and a ccw rotation on the mandible, you will end up with a posterior open bite. I am not sure why you are thinking of a clockwise rotation of the maxilla. You can have a ccw rotation of the maxilla with a downward translation so as to bring down the upper incisors (which is, as I understand, your concern).

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Posted : 06/09/2020 3:40 pm
Mr_Man
Eminent Member

Yes, there was relapse.  Probably due to my bones being so thin, and possibly subsequent growth of the mandible (even at age 20).  In addition, I probably needed more upper saggital expansion than was possible for a LeFort (I understand there is an upper limit).  After the 1st operation was finished, I was rather ok as far as saggital relationship, but there was still a significant transverse maxillary deficiency.  I also had braces at the time, which probably helped to maintain the arch lengths.

Yes, I still have quite a bilateral posterior crossbite (worse on the left than the right).

I'm guessing if I follow through with the treatment plan, there will be some type of impaction of the lower molars and bicuspids.  The uprighting of the lower incisors will also help the occlusal plane given a ccw rotation of the mandible. 

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Posted : 06/09/2020 10:17 pm
Mr_Man
Eminent Member

To give you some idea of how bad my jaw relationship was before my first operation, take a look at this video.  Sagitally, I was similar to this guy.  Transversely, I was much worse (probably due to, at least in part, my freakishly wide lower jaw).  Sorry if this video is somewhat gory, but be forewarned:

https://youtu.be/oMFzhNKyIug

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Posted : 06/09/2020 11:06 pm
Limebike
Eminent Member

@mr_man Were you resting your tongue in your lower jaw? An IMW of the mandible of 50 mm is enormous (are you measuring between the teeth or between the cusps?)

Have you looked into getting an MSE for the transverse problem?

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Posted : 01/10/2020 12:12 am
auxiliary
Estimable Member
Posted by: @mr_man

To give you some idea of how bad my jaw relationship was before my first operation, take a look at this video.  Sagitally, I was similar to this guy.  Transversely, I was much worse (probably due to, at least in part, my freakishly wide lower jaw).  Sorry if this video is somewhat gory, but be forewarned:

https://youtu.be/oMFzhNKyIug

Somewhat gory? You can literally see them cut into his face like a piece of meat for an hour long...

 

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Posted : 01/10/2020 4:06 pm
Mr_Man
Eminent Member

@limebike

Yes, since I was hardly able to breathe through my nose until less than 2 years ago, my tongue did rest on the lower jaw, especially in my youth.

Not sure if IMW is cusps or inner edges of teeth, but you can see here in this photo that my lower molars are lingually tipped, so I don't think there's much difference.

 

I'm willing to consider MSE.  I do need my palate to come forward 8mm, which probably precludes doing ONLY MSE, but maybe I can find a provider that will at least use MSE for the transverse expansion alone and do a different procedure for the forward placement.  Not sure who to turn to in order to do that though, as the university orthodontics didn't offer that as an option in my particular case.

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Posted : 01/10/2020 4:39 pm
Limebike
Eminent Member

@mr_man Thanks for providing the additional info! I guess your mandibular arch got widened from your tongue being in there. Your tongue is also on the chunkier side, as is mine. I definitely advise you to think of the transversal problem. To see why I am emphasizing this, here is a blog ( http://doublejawsurgery.samansari.info/) that I recently came across. The guy went through surgery and all, but look at how narrow his arches are. Besides fixing the underbite, the before and after almost look the same.

As an alternative to surgery, I also recommend thinking about proclining your upper incisors. It also seems that you have enough bone up there so you could additionally give them some labial root torque. I would not be too surprised if you could gain around 8 mm by doing this alone. I just feel that surgery is rather intense and want to offer you with an alternative. Orthodontists are often rather unimaginative regarding how far forward your maxillary dentition should be or how wide your arches should be. I don't think your lower arch is particularly wide. It is as wide as your tongue. Had you had your tongue in your palate, your upper arch would have been that wide and the lower arch similarly. 

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Posted : 02/10/2020 12:21 am
Mr_Man
Eminent Member

Now I have a new dilemma:  Should I continue protraction with reverse headgear attached to acrylic expander, or wait a year for my MMA surgery (8mm maxillary advancement, based on cephalometric analysis) and do nothing in the meantime?

Since I began the whole process of mewing and using an acrylic expander w/ protraction headgear, beginning in May 2019, my palate came forward by, as I estimate, about 1mm.

I stopped the acrylic and headgear in the middle of July, and had orthodontic/orthognathic consults between then and early September.  I continued mewing though.

I figured, since there will be a lot of waiting to see if I can even proceed with the MMA, to at least continue the reverse headgear protraction with the acrylic expander.  This time, though, I cut off the acrylic behind the central and lateral incisors (but keeping all acrylic from the canines back), to make sure that the protraction wasn't just pulling or tipping the 4 front incisors, and am not laterally expanding either.

Since then, I'd say I've come forward another 1/4 to 1/2 mm (I've been rather aggressive with the amount of elastic force, and been wearing it every night).  I can't tell if the movement is alveolar bone, maxillary bone, or some of both, but now I know that the protraction since early September cannot possibly be simple tipping of the incisors, due to no acrylic being behind them.  Also, the space between my canines and lateral incisors seems to have remained the same, making me think that all the teeth from the canines back aren't just colliding forward with the incisors.

The MMA surgery is NOT a guarantee.  Certain factors could prevent it from happening (periodontal issues and insurance approval are two that come to mind).  Therefore, my backup plan is to keep protracting as long as possible (though I may never reach 8mm, but something is better than nothing).  However, if I can in fact go forward with the MMA, which, if it does happen, will be at least a year from now, would the surgeon decide to advance my maxilla LESS than 8mm if I've advanced by, say, another 1mm?  Do maxillofacial surgeons adjust their forward advancement measurements AFTER the cephalometric analysis?  I'd hate for that to be the case, since whenever I stop the facemask protraction, there is relapse.  But on the other hand, I don't want to waste a year or so of potential protraction (I'm 43 and not getting any younger).  

See the attached photos, one from May 2019 (right before I began mewing) and another from today, to get an idea of my upper protraction.  Also, the cephalogram in the original post is from late July of this year.

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Posted : 15/10/2020 9:56 pm
Limebike
Eminent Member

@mr_man That's amazing! I am also a strong proponent that even in adults, you can still protract the maxilla (even if it just the alveolar part, which is also bone at the end of the day) to a large degree.

Could you please let us know about your reverse pull headgear protocol? What type of headgear are you using?

The results look very good!

A thing that I noticed is that it seems you have a gap between your left lower canine and the left lower premolar. If this is the case, you can also look into retracting the lower teeth.

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Posted : 16/10/2020 2:16 pm
Mr_Man
Eminent Member

@limebike

For the headgear, I just have the basic kind that rests on the forehead and chin w/ padding; I think I paid $22 for it.  Lately, I wear it only when in bed, so maybe 9 hours a day.  I also only wear the expander during this time.  I use the "monkey" elastics (there are different animal logos for different lengths of orthodontic elastics, like squirrel, fox, etc).  On each side, I attach one 6.5 oz and two 3.5 oz "monkey" elastics to the active Schwartz expander.  With this basic type of headgear/facemask, I can't really get an upward vector (it slips down if I try), so the vector is basically straight ahead.  I occasionally hold the chin part up with my hands to get a temporary upward vector when I feel like it (sometimes I get tingly sensations through my various facial bones when I do this).  Like I said before, I used to use the whole Schwartz expander, with acrylic behind all upper teeth.  Since September 2020, I removed the acrylic behind the 4 incisors, but this didn't seem to affect the protraction (and I no longer worry about tipping the incisors).  Also, I used to wear the expander close to 20 hours a day, even when not using the headgear, with elastics still attached (I don't use paperclips; I just loop the elastics thru the metal and pull tight to make a knot).  I used to break elastics like every other day.  Now, they tend to last at least a week.

There are two particular aspects of my facial bones that makes me unusual.  One is that I have exceptionally thin bones (my first maxillofacial surgeon remarked about this a lot).  The other is that I still have the L-shaped plates along w/ screws in the zygomatic buttress and piriform rim areas.  These two factors probably affect my outcome (not exactly sure how).

The gap you're referring to, I actually have one each on both sides of my lower teeth.  The 2 gaps are from having my 1st premolars removed when I was 14.  The gap is between the lower canines and lower 2nd premolars.  Though I had all 4 removed, the gap on the upper teeth closed completely.  Of course, it sucks only having 24 teeth and I had them removed during the "old days" when it was common to do so orthodontically.  In fact, it was the 2nd orthodontic "procedure" I've ever had done (the first being a hyrax-like expander when I was 9).  I will give thought into retracting the lower teeth (I assume that's "distallizing" them).  I also need to have the lower 4 incisors uprighted to 90°.  Right now, they're severely retroclined at 58° (meaning they're tilted back by 32°), which causes periodontal issues, so I have to factor that in. 

Thanks for the input!

ReplyQuote
Posted : 16/10/2020 6:16 pm
Limebike
Eminent Member

@mr_man Thanks for the additional info! Yes, I am also using these types of elastics myself. I am also an adult patient. We seem to be interested in similar types of approaches and should keep this in mind for possible future exchanges of valuable tips and tricks.

Regarding the lower teeth: I think the gap that you have on both sides between the lower canines & premolars plays in your advantage. By closing the gap, i.e., distalizing the lower canines, as well as retracting the lower incisors, you would gain about 1-2 mm that you do not need to compensate by mesializing your upper arch. Even If your protraction of the maxilla continues to work well, having that 1-2 mm extra cushion in a class III case like yours will give you a bit of leeway. I see no disadvantage at all with distalizing the lower canines and retracting the incisors other than the danger or pushing the incisors too lingually (out of the bone) but as long as you are aware of your buccal plate, you should be fine.

If you are having success with this approach, you can further consider distalizing the whole lower arch. This is what I have been doing as well. It seems that you have 1-2 mm space behind your ower 2nd molars. If you have an appliance for the lower, you can use class III elastics -- But beware that the class III elastics might temporarily pull your lower jaw further back into the joint so that it could temporarily appear that all your problems were solved (i.e., you have a class I occlusion) --> This is not permanent and "relapses" and you need to wear the class III elastics long enough (a few months) until you see the actual dentition moving.

Regarding relapse of your upper arch: If you are able to solve your class III situation solely by using the reverse pull headgear and the lower arch retraction, then I personally think that you can (i) think about not doing the surgery, (ii) expand your upper arch to fix the transverse situation (your crossbite) by using an acrylic expander or an MSE. By having your maxilla forward enough for a good class I bite and a wide enough maxilla to fit in your tongue, by mewing + making sure you keep your teeth together (i.e., mouth shut) most of the time (when not talking or eating, etc.), you should be able to actively prevent the maxilla from relapsing. Do you see what I mean?

Good luck with your journey! It seems that you have researched a lot as well and I applaud your willingness to put in so much effort. We can stay in touch in case you have further questions.

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Posted : 16/10/2020 9:44 pm
Mr_Man
Eminent Member

Thanks again!  Yes, we can keep in touch.  I'll still be posting here when I have updates.

ReplyQuote
Posted : 17/10/2020 3:36 pm
auxiliary
Estimable Member
Posted by: @mr_man

Now I have a new dilemma:  Should I continue protraction with reverse headgear attached to acrylic expander, or wait a year for my MMA surgery (8mm maxillary advancement, based on cephalometric analysis) and do nothing in the meantime?

Since I began the whole process of mewing and using an acrylic expander w/ protraction headgear, beginning in May 2019, my palate came forward by, as I estimate, about 1mm.

I stopped the acrylic and headgear in the middle of July, and had orthodontic/orthognathic consults between then and early September.  I continued mewing though.

I figured, since there will be a lot of waiting to see if I can even proceed with the MMA, to at least continue the reverse headgear protraction with the acrylic expander.  This time, though, I cut off the acrylic behind the central and lateral incisors (but keeping all acrylic from the canines back), to make sure that the protraction wasn't just pulling or tipping the 4 front incisors, and am not laterally expanding either.

Since then, I'd say I've come forward another 1/4 to 1/2 mm (I've been rather aggressive with the amount of elastic force, and been wearing it every night).  I can't tell if the movement is alveolar bone, maxillary bone, or some of both, but now I know that the protraction since early September cannot possibly be simple tipping of the incisors, due to no acrylic being behind them.  Also, the space between my canines and lateral incisors seems to have remained the same, making me think that all the teeth from the canines back aren't just colliding forward with the incisors.

The MMA surgery is NOT a guarantee.  Certain factors could prevent it from happening (periodontal issues and insurance approval are two that come to mind).  Therefore, my backup plan is to keep protracting as long as possible (though I may never reach 8mm, but something is better than nothing).  However, if I can in fact go forward with the MMA, which, if it does happen, will be at least a year from now, would the surgeon decide to advance my maxilla LESS than 8mm if I've advanced by, say, another 1mm?  Do maxillofacial surgeons adjust their forward advancement measurements AFTER the cephalometric analysis?  I'd hate for that to be the case, since whenever I stop the facemask protraction, there is relapse.  But on the other hand, I don't want to waste a year or so of potential protraction (I'm 43 and not getting any younger).  

See the attached photos, one from May 2019 (right before I began mewing) and another from today, to get an idea of my upper protraction.  Also, the cephalogram in the original post is from late July of this year.

To me it seems like you're clenching your lower teeth against your upper ones, pushing your lower teeth backwards and upper teeth forward. This is why your chin is so long in side length, as it's effectively protruded to have good occlusion.

 

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Posted : 26/10/2020 4:48 pm
Mr_Man liked