Orthognathic Surgery

     Not all bite problems are a result of improper tooth alignment. There are certain individuals who have bite problems because of misaligned jaws. In other words, the upper and lower teeth don’t fit together properly because the bony bases that support the teeth are not properly positioned relative to one another. In orthodontics, we call this type of problem a “skeletal dispcrepancy.” This simply means that the upper and lower jaws have not developed in harmony with each other. Typical presentations of these jaw problems include underbite, overbite, crossbite, or jaw asymmetry.

     People who have severe skeletal discrepancies also have poor facial balance which negatively affects their appearance. When severe, surgical correction of the jaw positions is necessary to achieve proper facial balance. This type of surgical procedure is called “orthognathic surgery.” In our day and age, all orthognathic surgery must be done in conjunction with orthodontic treatment. Orthodontics is a crucial part of the process because the teeth must fit together perfectly when the jaw bones are reset. Therefore, every patient that needs jaw surgery will also have at least some movement of the teeth prior to the surgery being performed. This allows for a proper bite at the time of surgery. In addition, the attachments on the braces and wires allow the oral surgeon to use miniature elastics to hold the jaws closed during healing. The patient can then recover without having the mouth wired closed.
    
     The patient below is a professional singer who is in the public eye every day.  She had braces as a child but was unhappy with the way that her teeth looked.  She came to my office for a consultation hoping to resolve her concerns by wearing braces.  In every case, and especially in a situation like this, it is very important as an orthodontist to really understand the chief concern that each patient would like addressed.  As I looked in her mouth, I did see that she had some bite problems but they were not severe.  If my goal was only to fix the bite, I could have done that easily with braces alone. 

As we talked, however, it became clear to me that she was more unhappy with the structure of her jaws and lower face than the position of her teeth. 

In this picture you can see that in order for her to close her lips together, she has to flex the muscle of her chin. If the lips do not come together comfortably when all of the facial muscles are relaxed, it requires the chin muscle or "mentalis" muscle to flex in order to get the lips closed.  This is called mentalis strain or lip strain.  It can result from two skeletal problems.  First, the height of the lower face is too large requiring the lips to "reach" further to keep the mouth close. Second, when the lower jaw is behind the upper jaw, the lower lip can get "trapped" below the upper teeth requiring the chin muscle to flex and force the lower lip forward and up to get the lips together. In her case, both of these problems were present causing significant mentalis strain on lip closure.   

You can see from this picture that when she smiles, she shows an excessive amount of gum tissue. In orthodontics this is known as a "gummy smile." It can be the result of a very mobile upper lip that lifts higher than normal but more commonly is it a result of the upper jaw being positioned too far below the nose and cheeks. That is the case with this patient and it is a problem with structure of the craniofacial bones, not the position of the teeth.

In the profile view, the retruded position of the mandible is apparent.  The mentalis strain mentioned above is also evident.  A more forward position of the lower jaw and chin would go a long way to achieving proper facial balance.

A view of the occlusion shows that the lower front teeth are positioned behind the upper front teeth.  In orthodontics, this is called overjet but "overbite" is the term used in the general populations.  If facial structure were not an issue, the bite could be corrected using braces alone.





 

These views show that the jaws were somewhat narrow along with mild irregularities in the positions of several teeth.

This x-ray is called a panoramic x-ray and it shows that the wisdom teeth have been extracted.  Also, four premolar or "bicuspid" teeth were removed prior to her first set of braces when she was a child.  The orthodontics used the spaces gained from those extractions to align the teeth.

This x-ray is called a cephalometric x-ray and is very useful to the orthodontist and the oral surgeon in determining the position of the jaws and in planning the jaw movements that need to be made.

You can see the facial changes that were made using combined orthodontic treatment and orthognathic surgery.  The lower facial height decreased allowing for more relaxed lip closure.

The jaws were expanded resulting in a broader smile.  The upper jaw was also lifted resulting in less gum display when smiling.

The lower jaw and chin projection increased dramatically taking away the lip strain that pre-surgically was needed to close her mouth.  This procedure was done without any implanted chin material so the results will last a lifetime.

After removal of the braces, the teeth are well aligned

The overbite is no longer present

The width of the jaws has increased as well

The oral surgeon uses many plates and screws during surgery that stabilize the jaws while they are healing.  This "hardware" does not need to be removed.

This is the final cephlometric x-ray after the braces have been removed. 

The braces are removed several months after the surgery once the bones are totally healed and the bite has completely stabilized. Successful treatment of severe skeletal deformities of the lower face requires a team approach and precise planning on the part of the orthodontist and the oral surgeon. Those who undergo this treatment experience possibly the most dramatic improvements in facial appearance that exist in medicine today. While surgery is an amazing tool to restore harmony in jaw relationships, some bites that appear to be far off can be corrected using orthodontic treatment alone….especially in young people. We can help you determine if orthognathic surgery is right for you.

When Should I Bring My Child In For An Orthodontic Consultation? By trumanorthodontics on 2/20/2012 11:21 AM

One of the most common questions that people ask me is: When should my son or daughter get braces?

One of the most common questions that people ask me is:  When should my son or daughter get braces?  This question has several variations which include:  Why are people getting braces so young now days? or Didn't people used to get braces when they were in middle school?

No matter how it is phrased, what parents really want to know is why some people are getting braces in 2nd or 3rd grade and others are getting their braces in 7th or 8th grade.  Naturally, they also want to know in which of these groups their child belongs.

In order to understand the answer to that question, it is first important to understand something about dental development.  Most children begin losing their front teeth at about 6 years of age.  By 8 or 9 years old, eight permanent front (incisor) teeth have replaced the front baby teeth.  At the same time, four new permanent molars are growing in behind the back baby molars.  So at about 8 or 9 years old, a child usually has twelve permanent teeth and twelve baby teeth in the mouth at the same time.  In dentistry this is called "the mixed dentition" because there is a mix of permanent and baby teeth.

This x-ray shows permanent teeth (which have no tooth buds underneath) as well as baby teeth (which have the buds of permanent teeth underneath them)

At this point, there is typically a window of 2-3 years before the child will lose anymore baby teeth.

It is also at this time that problems of crowding and misalignment of the front teeth become apparent because the size of the permanent teeth is so much larger than the teeth that they replace.  Children who did not have spaces between their baby teeth will develop crowding of the front teeth simply because the permanent teeth are so much bigger.  Because of the development of these and other problems as the new teeth grow in, it is the time when "early intervention" or "phase I treatment"  is usually performed.  Because only half of the permanent teeth have grown in, only partial orthodontic treatment can be rendered at this stage.  It therefore becomes necessary to complete the treatment with a second stage of braces that is worn after the growth of the remaining teeth at approximately the age of 12 or 13. 

While certain children benefit from early intervention as described above, the majority can wait for the eruption of all of the permanent teeth before beginning orthodontic treatment which can be accomplished in a single stage. I recommend two-phase orthodontics for two reasons:

     1.     A better end result can be achieved by intervening early

     2.    Patients and their parents have cosmetic concerns that are affecting the self-esteem of the child. (For example: an 8-year old child is being made fun of at school and does not want to wait 4 more years to begin correcting the problem)

Those children who come to the office in the mixed dentition stage of development who do not meet the criteria above are placed in our observation program. Their parents are re-assured that everything will work out fine and treatment will be more efficient if it is done at a later time. Parents really appreciate the opportunity to discuss their child’s specific situation and understand the course for the future. That is why we like to see children for the first time when the top front teeth start to grow in. Periodic imaging of the developing teeth will be done at follow-up appointments so that treatment can begin at the most efficient time.

Happy New Year!

We are excited to announce our new VIP Rewards Card.

When you come to your next appointment you will be given your VIP Rewards Card!  All you have to do is bring your card to each appointment and watch the points pile up! Earn more points at each appointment for things like; having excellent oral hygiene, getting great grades, referring a friend or seeing your dentist for a dental cleaning.

The great thing about our new program is that you can swipe the card at each visit and earn points.  You can redeem those points on-line at countless stores.  Your hard-earned prizes will then be sent directly to your home!

This new program will take the place of our wooden nickels. Bring your wooden nickels in to redeem for points on your new VIP Rewards Card. We just ask that you try to redeem your old nickels by March 31, 2012.

We look forward to seeing you soon and showing you how fun and easy it is to use your new VIP Rewards Card.

Underbite

Underbite is when the lower front teeth are in front of the upper front teeth.

Often, it is not so much a problem with the teeth as it is with the jaw structure.  Underbite patients usually have either an under-developed upper jaw, an over-developed lower jaw or some combination of the two. In orthodontic terms, this jaw growth discrepancy is called a skeletal class III malocclusion and it usually runs in families.  Precise measurements of cephalometric x-rays of the patient's face and skull like the one shown above can help the orthodontist understand the growth pattern and predict the effectiveness of treatment.

Early treatment is aimed at orthopedically enhancing jaw growth of the upper jaw and retarding growth of the lower jaw.  This is typically accomplished using a reverse pull headgear that the child wears at night while sleeping.

An underdeveloped upper jaw that is not growing forward in harmony with the lower jaw will also often be under-developed in a transverse dimension as well.  In other words, the upper jaw is too narrow. This can be seen as a crossbite of the posterior teeth with the upper back teeth biting on the wrong side of the bottom back teeth.  In the image above, this can be seen on the right side (which is the patient's left side).

The narrowness if the upper jaw can also lead to crowding of the top teeth.  In this case, there is not enough room for the new incisors to grow in correctly.

The panoramic x-ray shows the crowding of the lateral incisors that want to come in but are not because of the crowding.

After expansion of the upper jaw and braces on the top teeth, space was created for the teeth to be aligned.

Night-time wear of a reverse headgear allowed for the jaw growth to be modified and returned to normal.

Now he can't stop smiling....

Unilateral Crossbite With a Functional Shift

Unilateral crossbite with a functional shift is a very common problem that is best corrected early because it affects how the jaws develop.  The cause of the problem is a narrow upper jaw.  Because it is narrow relative to the lower jaw, the upper teeth are not wide enough to form a perimeter around the lower teeth.  Essentially, the upper and lower dental arches do not match when the teeth come together.  This mismatch causes the child to compensate by shifting the jaw to one side or the other in order to chew.  This shifted position eventually becomes a habitual rest position for the jaw as well.  Clinically, this habitual position is evident when the back teeth on one side of the mouth fit normally with the upper teeth forming a perimiter around the lower teeth and there is a crossbite on opposite side with the upper teeth fitting inside the perimiter of the lower teeth.

Another indicator that there is a "functional shift" of the lower jaw is the child's facial appearance.  Examination of facial symmetry shows the lower jaw to be sitting off to one side.

Correction of the problem is achieved by using a palate expander to widen the upper jaw.  In children and adolescents, the upper jaw consist of two bones that are connected by ligaments.  A palate expander is a metal appliance that anchors to upper back teeth on either side of the upper jaw and traverses the roof of the mouth next to the palate.  In the center of the appliance is a screw mechanism that can be turned at regular intervals (usually once or twice per day) that causes the bones of the upper jaw to gradually separate.  As the two bones move apart, a space opens between the top front teeth (which is very helpful when there is crowding of the front teeth).  After the desired amount of expansion has been achieved, the palate expander is left in place to hold the expansion for at least 3 months during which time new bone fills in where the expansion has occurred and the space between the front teeth gradually closes.  While the child does feel pressure when the expansion mechanism is turned, the whole process is typically painless.

 When the upper jaw has been widened to the correct size, the lower jaw will naturally find the proper position within the perimiter of the upper jaw and facial symmetry returns to normal.  The longer a unilateral crossbite with a functional shift is allowed to go uncorrected, however, the more ingrained the "habitual assymetry" becomes.  If such a bite is left untreated into adulthood, what was once a habitual position becomes a true skeletal position to which the body has adapted and a return to normalcy with upper jaw expansion will no longer occur. 

Several years after the expander treatment, once all of the permanent teeth had grown in, a second phase of orthodontic work was performed using braces and elastics to finalize bite correction.

Without early intervention to correct her crossbite, it would have been difficult to achieve such good bite and facial symmetry.

All In The Family

My daughter has been growing up.  She was late getting her permanent teeth so...in the same month she started high school, she got her braces on!  It is fun to actually treat my own daughter!  I get to see progress every day rather than once every six weeks.  I'm sure I am driving her crazy telling her to open her mouth so I can see.  She has been very accomodating, though, and a very good sport about wearing braces.  I was expecting her to complain but she has been very positive and says that it does not hurt nearly as much as she thought it would.

Congratulations Rachel!  On high school and on braces.....

Adult Multidisciplinary Treatment of a Severe Malocclusion

This patient was concerned with crowded teeth and an underbite.

Upon Examination, he was found to have a crossbite of the back teeth and the front teeth.  A crossbite is when the upper teeth do not fit around the lower teeth.  Instead, the upper teeth are positioned closer to the tongue than the lower teeth.  In the front of the mouth, this is called an underbite.  In the back of the mouth, this is called a posterior crossbite.

 He was also found to be missing one front tooth and a tooth on the right side of his mouth near the back.

In order to expand the upper jaw, we placed an appliance called a rapid palatal expander.  This appliance works in youth and adolescence simply by turning the screw mechanism once or twice per day.  In adults, because the bones are not as malleable, an adjunctive surgical procedure is needed to weaken the upper jaw so that it can be expanded.  Once the expansion is complete, the bones heal in the new expanded position.  This patient underwent maxillary (upper jaw) expansion surgery at the time the appliance was placed.

This is a picture of the lower teeth.  There was significant crowding of the lower teeth.  Because of the missing teeth in the upper jaw, it was decided that two teeth would be removed from the back of the lower jaw to create room to resolve the crowding and to match the number of lower teeth to the number of upper teeth.

After tooth alignment, the teeth were ready to have veneers placed.  The veneers were designed to make the teeth that were substituted to replace the missing front tooth look more natural.  They also were made longer so that more teeth were exposed when he smiles.

The veneers also provided a whiter tooth color to enhance his smile.

A happy patient who now can't stop smiling!!!