Oral Surgery/Jaw surgery

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Question
QUESTION: Dr. Teig,

Greetings!

I am reading your answers, since a year ago, and I find them very helpful and informative. I would be very grateful if you can help me. I am a 44 years old female and I am under orthodontic treatment for orthognatic surgery since 2010. My teeth were not very crowded or spaced; just mild dental misalignment. Main problems were the mandibular deficiency, asymmetric smile (due to mild hemifacial microsomia) and narrowness of my upper arch. Many questions aroused since I found out that instead of lower jaw advancement surgery alone (that was recommended by the first orthodontist, based on his own assessment) I will need upper jaw surgical widening (recommendation given by the surgeon with whom I will work with). I am not scared about the surgery itself and I hope that many of my concerns will be addressed with the proper surgery although I will need a more complex one (such the upper and lower jaw surgery). I am more concerned to get under a surgery that might not be appropriate for my condition. However, I would like to better understand the following: for someone of my age, with a narrow palate, upper posterior crossbite and also a mandibular deficiency, the lower jaw advancement surgery alone could successfully replace and provide results as good as the upper and lower jaw surgery? In this regard, I think of: stability/relapse, functionality and facial aesthetics.
I have to mentioned that the orthodontist tried to fix my bite, before surgery, by “widening” my upper dental arch by tilting outward my posterior teeth (using archwires and cross elastics) and by tilting inwards some of my lower posterior teeth. Also, I have to mention that, if I try to simulate the lower jaw advancement (by pushing forward my mandible and to “match” the upper and lower teeth like in a bite) my facial appearance changes and looks very bad: the lower jaw shifts to the left and the facial/lips asymmetry (the cant) becomes more obvious.

Thank you in advance for your time.

Aura

ANSWER: Aura - Orthodontists are aligners of teeth and are not good at knowing the facial changes that will or will not occur with the surgery.  They are not trained in the different facets of orthognathic surgery for the same problem.  Hopefully the surgeon and orthodontist are working close together to decide the proper orthodontic movements and surgical corrections.  

At this time the surgeon should have actually done surgical planning on the xrays.  In addition, the surgeon should have taken an impression of your face and plan the facial results of the proposed surgery.  Your surgeon should be able to correct any changes that you are not comfortable with, by planning an appropriate surgeon.

So communication of the two doctors is important to plan the surgery and advise you now what the anticipated results will be.  They must also be willing to communicate repeatedly to let you know of any potential changes.  Also the communications are important for you to let them know what you want in the results and what you do not want.

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

---------- FOLLOW-UP ----------

QUESTION: Dr. Teig,

Thank you for your response. The information that you provided is useful for me. I do have a follow-up question.

For over 2 years I was treated orthodontically without the guidance of an oral surgeon for lower jaw surgery advancement alone. Just recently I discussed with an oral surgeon and after a couple of consultations and tests he informed me that I have a narrow upper jaw bone (narrow palate) that will require surgical widening. In this instance, I was wondering why the orthodontist chose to flare outwards my upper teeth. Is this orthodontic procedure a valid substitute for the surgical widening of my upper jaw?

I ask this question also because the oral surgeon would like, prior to surgery, my upper flared teeth to be moved back into their original upright position. I would like to understand why flaring out the upper teeth is not appropriate in my case.

Best regards,

Aura

ANSWER: Aura -  Flairing of the upper molars is one of the worst things that any orthodontist should do on an adult.  Flairing of the molars only weakens them and aligns them at an angle that makes them more prone to being prematurely lost.  In addition, the tilting of the teeth lengthens your face and tilts your lower jaw backwards.  Surgical widening maintains the proper alignment of the teeth to create a proper sound foundation for the bite and facial structure.  

It sounds like the surgeon is absolutely correct and the orthodontist is not knowledgeable about more than just moving teeth.  This is one of the reasons that knowledgeable orthodontists get together with surgeons in the planning phase before they move the teeth at all.  The orthodontist is jeopardizing the longevity of the flaired teeth.  I would tend to follow the recommendations of the surgeon.  He should speak with the orthodontist and read him the knowledge "rack".  So speak with the surgeon about his recommendations and about speaking with and trying help the orthodontist do the correct treatment for facilitate a proper and healthy outcome.

---------- FOLLOW-UP ----------

QUESTION: Dear Dr. Teig,

Hello again! Since I have been contacting you via the website, I had to go through a lot to come to the surgery moment. Specifically, I had to undergo a corrective orthodontic treatment, for one year, to have my upper teeth to relapse from the expansion done by the previous orthodontist. To date, I am in the 5th year of orthodontics due to these events. The fact was, even after the oral surgeon told him what to do (align the teeth over the basal bone), that orthodontist refused to do it and did not tell anyone. We (especially I) found this from the orthodontist who performed the corrective treatment on me. Additionally, I found from the letter that the second orthodontist sent me that: “Your orthodontist felt that the surgery can be confined to lower jaw advancement with no surgery to the upper jaw in order to minimize the surgery and potential morbidity associated with two jaw surgery. In order to prepare for the surgery the upper posterior teeth needed to be moved outward or expanded so the teeth would fit together at the time of surgery.”. Apart I being devastated about the whole story, I understood that the first orthodontist tries to hide behind the concept of "standard of care" although I have many medical documents and letters to support my case. I researched the literature with regard to this "standard of care" concept but no one is pointing out exactly how it has to be used; it seems that this concept is open to many interpretations and used and twisted as per everybody's interest/perception/understanding. I know the definition of the standard of care but this is not enough to understand specifically how it applies to some of the facts that happened to me. For example: 1) the orthodontist not doing what the oral surgeon told him to do (to align the teeth over the basal bone) and kept the dental expansion; 2) not informing me, as his patient, for the fact that he felt to confine the surgery to only lower jaw advancement surgery; 3) even the oral surgeon was not telling him about alignment of the teeth over the basal bone, but told him the type of surgery (upper and lower jaw surgery; upper jaw surgical widening), the orthodontist ought to know what he should do in the view of preparing the teeth for the double jaw?

If you like, I can send you some of my medical documents but I will need your email address (of course, if you agree to give it to me. I hope that I am not too daring in asking it from you).

I apologize for the length of my message but I really need to understand some things and, eventually, to get some more scientific literature that can be useful.

Best regards,

Aura

Answer
Aura -  I will be willing to review you medical documents, but I'm not really sure what you truly want.  If you already know that the orthodontist did not appropriately align your teeth for the type of surgery planned by the surgeon, the facts are obvious.  If there are specific facts, I will try to answer them.  

So send me the information you have, but also send me specific questions that you have and I will try to answer them.  Send to - tigertooand2@yahoo.com. Please send me a note on this sight after you have sent me the information to my email site.  I will try my best to answer your questions.

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Joel S. Teig, DMD, Diplomate ABOMS, retired

Expertise

I am a board certified oral and maxillofacial surgeon 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 practicing for over 20 years. Assistant Clincal Professor at 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 Oral and Maxillofacial Surgical Residency - Roosevelt Hospital, NYC

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