deep bite - BSSO vs crowns vs segmental osteotomy vs ortho?

[celticcavegirl]

Hi all!

So, my story. My lower face/mandible is pretty underdeveloped both vertically (ramus) and horizontally (mandibular body) (i.e.retrognathia and microgenia). This is mainly genetic as I have the same face shape as my father (ie round and IMO very unattractive)

I had my original braces on the NHS a teen, starting around 13 with retainers and finishing at 16. I had 4 molars removed due to crowding. No palate expansion, MARA, twin block, dahl appliance or headgear - just retainers and archwires. I got my wires later than most as I was waiting for my 2nd molars to be fully erupted - my ortho chose to remove the first molars as they had developed with poor enamel. The 2nd molars were then moved forward, so that my wisdom teeth had space to come in (which they did at 17.)

I don't really remember what my teeth were like before the braces - despite the retrognathia I don't recall having a huge overbite, but I would have had some. I can't recall what the depth was like before and after the braces either.

Currently my top teeth are basically fine, but I have a slight overbite and crossbite with significant deep bite, and a tiny posterior open bite on one side. My face looks absolutely awful front and side when I fully close my mouth :(. I am going to assume that it's skeletal (rather than dental or soft tissue) as I have a deep sublabial fold and everted lower lip. I recently got a chin implant+neck lipo+sublabial filler to improve the retrognathism but it didn't help with the length of my face (maybe I should have got a custom made one). The sublabial fold is still significant despite getting radiesse put in it.

According to all the reading I've done, traditional treatment of deep bite is - anterior intrusion (in the case of gummy smile) or posterior molar extrusion (in the case of short face, like me). HOWEVER, molar extrusion via braces is apparently not terribly stable in adults. It also rotates the mandible down (good) and back (bad) ie. makes the face longer but the overbite/retrognathism worse.

As I understand it, I feel my options are

1) Obwegeser osteotomy - BSSO of the ramus. (as opposed to BSSO of the mandibular body)
Allows for vertical and horizontal enlargement of the mandible.
PROS - I feel this would give me the best cosmetic option in terms of face shape. I would probably follow it with angle implants, depending on how it looked afterwards.
CONS - long time in braces. Lengthening the ramus might require a degree of molar extrusion that isn't possible. Difficult recovery. Expensive.

2) posterior subapical segmental osteotomy to extrude molars
PROS - faster and more stable than braces.
CONS - finding an ortho that can do it (I live in Dubai, UAE and London, UK). Might not be possible to get a BSSO afterwards

3) wilkodontics to extrude molars / improve overbite
PROs/CONs - as above, but worse, as there are no orthos in Dubai or Abu Dhabi that do this procedure and it requires frequent appointments. A segmental osteotomy would be easier to do overseas I think as it's a one-time surgery.

4) Veneers/crowns on molars as an alternative to extrusion
Can't really find much literature than this but this is what Sam Muslin (the face lift dentistry guy) and others do in the case of worn down posterior teeth
PROs - quick, stable?
CONs - might need more augmentation than possible?
I could potentially combine veneers with the BSSO as an alternative to molar extrusion.

5) traditional braces + maybe twin block or dahl appliance
PROS - cheapest and easier. Might improve retrognathia via muscle changes?
CONS - sub optimal cosmetic result, not necessarily stable, long treatment

6) Traditional BSSO of the mandibular body following the correction of the deep bite via extrusion or crowns
PROS - correction of lower lip position. Utilises the increase in overbite that usually results in the correction of deep bite
CONS - painful, expensive. May not get such a good increase in facial length as with ramus BSSO. Might need wisdom teeth removed

7) extensive facial implants ie. wrap around mandible implant that increases jaw angles, height and projection
PROS - no braces! Fast recovery. No waiting.
CONS - deep bite would remain, so would have to fix that, so expensive overall. Lower lip would still be behind upper lip. Implants may need to be replaced.

Basically what I want to achieve is the best cosmetic result in the shortest time but especially with the minimum time in TOP braces. I need to achieve both a vertical and horizontal increase in lower jaw. Vertical can be done with extrusion/veneers but I feel that horizontal increase and improvement in lower lip position can only be done via jaw surgery. I am 25, female, single and have an extremely people facing job and run my own business - it is really NOT a good time to have braces at all.

So to the questions.....

- is there anyone here who had a deep bite/short face corrected with a BSSO of the ramus? Did you require extrusion? How did you get enough extrusion to allow the vertical expansion you got from the BSSO?
- is there anyone who had a deep bite/overbite but had to have a BSSO in the body as it wasn't possible to do enough extrusion to allow the back teeth to still meet after a BSSO in the ramus?
- did anyone have segmental osteotomy to extrude the anterior molars, if so, where and by which surgeon?
- is it possible to have segmental osteo or wilkodontics prior to a BSSO or is this too much interference with the jaw bones? I am assuming it's not possible to do both
- anyone have veneers or crowns as an alternative to extrusion for deep bite?
- for those who had traditional orthodontics and extrusion, how long were you in top braces? How is the stability?
- is there anyone who fixed their deep bite with orthodontics and see an increase in the degree of overbite as a result of fixing the deep bite?
- did anyone who has retrognathia and didn't get a BSSO see a good improvement in the position of the lower lip and teeth using orthodontics alone? How did your ortho achieve this? Adequate jaw projection can be done with implants but this doesn't fix the lip position (and you also wind up with a sublabial fold)
- anyone with retrognathia have twin blocks? How did they change your profile given than they usually rotate the mandible backwards and downwards?
- has anyone had powerprox braces?
- is it possible to have the initial wiklodontics surgery or segmental osteotomy done with one ortho/surgeon, and subsequent appointments with another?
- anyone know any good orthos in London, Dubai or Abu Dhabi?
- invisalign - basically useless for deep bite if you require extrusion?

I feel at the moment it's a toss up between braces/crowns + BSSO or segmental osteotomy/crowns + implants + whatever magic can be wrought to bring the lip and lower teeth forwards. Probably the former as from what I've seen the only way to make the lips line up well is through surgery

If anyone got this far and can answer any of my questions, it would be much appreciated!