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Dentistry/RPE, tooth tilting and sunken cheek

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Expert: - 12/18/2009


Question

AP X ray Dec 4 09
Hi,
BACKGROUND:
I am 40 years old, in good health, no underlying medical issues. I had unilateral crossbite (right lateral) with moderate Malocclusion III or underbite. Treatment included braces, upper and lower, which began July 07 then RPE implanted in Nov 07 then surgery Dec 07 to free maxilla. RPE turning began about 8 days following surgery. Expansion of maxilla included 1 turn per day and was completed in about a month. No problems encountered at this point. RPE was removed about 4 months later. Braces went on upper teeth immediately following removal of RPE. Met with orthodontist once every 6 weeks thereafter (as well as before) and no issues with braces so far. Second surgery to move maxilla forward about 6mm to correct class III bite presently scheduled for Feb 10. Orthodontic treatment will continue for about 6 months thereafter and treatment should end by July 10.

Ok now here are my concerns. The RPE appears to have successfully widened my upper jaw but now I have about a 5 degree tilt in my upper teeth, premolar and back, bilateral. Why did my teeth tilt and will the orthodontic treatment following my second surgery in Feb 10 correct this? If not, can anything be done now to correct the tilting as it gives an illusion to how wide my maxilla truly is. As well, about 15 months after my first surgery, or about June 09 I began to lose what appears to be soft tissue in the left cheek, or just under the zygoma. As a result my left cheek is visibly sunken. I had an Xray and nothing showed up as per my family physician assessment. My doctor also physically assessed me and concludes that I have lost some soft tissue in my left cheek resulting in a depression. Did the surgery cause this, otherwise known as surgical stress? Did the surgeon damage the nerve which then led to the loss of soft tissue ie., fat? Note, I have no pain or sensory deficits in my left and right maxilla. I am thinking about delaying my second surgery until I get a thorough evaluation of my current treatment to see if it meets minimum standards and to see if anything needs to be corrected before moving forward.

Thanks, Rod  

Answer
Rod - After RPE, it is not unusual for the teeth to not be in a good position.  The orthodontist, since the surgery will be Feb 10, will do minimal movements now, but after the surgery, the orthodontist really comes into play.  That is when the orthodontist aligns the teeth to the newly positioned bones to facilitate a good occlusion.  If your orthodontist is skilled you have nothing to worry about.  It may not be a bad idea if you made an appointment and spoke with him about the flaring of the teeth.  You should say you just want to make sure that they won't be after the final orthodontics is finished.  That is a normal and good question.

As far as the loss of cheek, you actually did not lose any teeth, but the expansion of the maxilla with the RPE increased the width of the maxilla and it can almost form a pocket under the cheek bone.  Nothing to worry about.  After the final surgery is finished, the muscles and tissues become adapted to the new position and fill the space.  If it is not fully filled, an injection of a spacer or even fat can easily build it up.

If you have additional questions, feel free to contact me again.

Joel S. Teig, DMD, Diplomate ABOMS, retired

Expertise

I am a board certified oral and maxillofacial surgeon and I am available to answer questions related to tooth extractions, implant insertion, facial recontruction, facial and oral tumor removal, TMJ dysfunction and various successful treatments, including surgery if all else fails, and occlusal discrepancy requiring orthognathic or jaw surgery.

Experience

Board Certified Oral and Maxillofacial Surgeon practicine for over 20 years. Assistant Clincal Professor and State University School of Dentistry.

Organizations
American Dental Association, American Association of Oral and Maxillofacial Surgeons, American Board of Oral and Maxillofacial Surgeons

Education/Credentials
BA -University of Connecticut DMD - University of Pennsylvania School of Dental Medicine

Awards and Honors
National Honor Society (OKU), Philadelphia County Dental Society, Mosby Book Award, Oral Surgery Honors, Summa Cum Laude

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