Unhappy with surgery results, help?

[Samster]

I'm 17, got upper and lower jaw surgery + sliding genioplasty on July 15th (almost 3 weeks post-op) to fix my underbite and openbite.

The surgery went well and I'm recovering pretty quickly, but I've been really depressed about the results of the surgery. My midlines are off by a little bit but I'm assuming that's something my orthodontist will fix with braces (?), what's really bothering me though is that my surgeon moved my upper jaw forward and UP when I was only expecting him to move it forward. Because of this when my mouth is relaxed you only see my bottom teeth and when I smile (even if I lift my lip up as far as it'll go) my top lip covers most of my top teeth. This is really getting me down because I absolutely hate how it looks now, it makes me look like I have an "old lady" kind of smile when I'm still just a teenager! I did NOT have a gummy smile beforehand (you could see 1, maybe 2 mm of gums when I smiled) so I'm really at a loss about what I should do now.

I'm hoping that my upper lip is still swollen and that in a few weeks I'll be able to see more of my teeth when I smile, but I think most of the swelling is gone. My next appointment with my surgeon is on the 6th so I'll discuss it with him then (I decided not to mention it last time I saw him because I figured it was just because of the swelling but now I really don't think so), but until then I'd love some imput from other orthognathic surgery patients. I'm seriously considering getting a second surgery to bring my upper jaw down a few mm so that I can see my teeth when I smile again, but before I jump into that I want to know if there are any other options. Is there any way my orthodontist could pull my teeth down with braces? Is there some kind of headgear I can inquire about to bring the jaw down while the bones are still healing?

Sorry about the long post, I'd really appreciate any answers! Thank you!

[Tctjh0]

You are less than three weeks post op. Generally, you need to wait couple months before your true results will show up, sometimes as long as 6 months. It seems common that people who get jaw surgery go through a little bit of depression about their results from the 2 week through month and half period. That is the period where your swelling has gone down but your facial tissue and muscles haven't acclimated to their new positions. Your upper lip may go up a few mm's as the tissue adjusts. Give it some time before making a judgment. I am sure that is what they will say at your next appointment. Bottom line... ride it for a couple months, then evaluate.

[mmkay]

Your upper jaw (maxilla) should go up, but it's a question of back/front and how much.

To fix an open bite involves impaction mainly at the back:
http://www.youtube.com/watch?v=5Ys0CAp61Vo

Open bite + gummy smile would involve removal at the front also:
http://www.youtube.com/watch?v=F-Dg2GMsPAg

Sounds like you feel he treated you as if you had a gummy smile.

That's pretty much restating what you know.

Ask your surgeon how many mm he impacted you at the front and ask him to explain that decision in detail in the context of you not having a gummy smile. If he is able to sensibly explain what he did (get the mm figure/s) and why it should make you sleep better.

If he did mess up, in terms of solutions:
-Extruding front teeth is not stable - this is what used to be done to close open bites.
-Veneers can be used to lengthen teeth, but if you don't have short teeth to begin with you could end up looking horsey.
-Some people who have short midfaces get it enlarged - bone is cut out from their hip I think - using grafting.

To state the obvious a top notch surgeon (e.g. teaches this type of surgery at a university) is who you should speak to in future if it transpires you were "overimpacted". Revision surgery would be a big deal.

[Samster]

Tctjh0:
Alright, thanks for answering! I didn't know about the facial tissues and muscles adjusting, I guess that makes me feel a bit better about it. Hopefully my upper lip will go up a bit eventually.

mmkay:
I do have fairly large teeth so I feel like veneers would look kind of awkward, plus from what I've read they're not permanent and they have to shave down the enamel on your natural teeth before you get them on (correct me if I'm wrong though) so I don't think I can commit to that. Surgery was bad enough the first time, a bone graft sounds pretty scary. I guess I'll just wait it out like Tctjh0 said. If I'm still unhappy about it in 6 months time I'll look into the grafting. Thank you for your answer! Is it common for surgeons to miscalculate how much they move the jaws (requiring a second surgery)?

[bmueller]

I had a lefort I impaction and I decided it was best to hold judgement until after 2-3 months and I'm glad I did. I took daily pictures for the first month and then occasional pictures after that. Even though I thought the swelling was all gone by week 6, you would not believe how different my upper lip looks now (8 months out) from week 6. I was kinda bummed because I thought my lip was uneven, but it wasn't! It was just the swelling. Now I look totally normal.

So I did have a big gummy smile (8 mm of tooth showed when my lips were at rest). The surgeon explained to me that the proper way to determine how far he will impact is to find an amount that allows about 2mm of tooth to show at rest. He took measurements along the front two teeth and the canines both with my lips at rest and BIG smile to get this measurement. They ended up impacting 7 mm.

Did your surgeon do something like this? He probably should have to achieve the best aesthetic result.

[Atrium]

I echo the sentiment of withholding judgement until the swelling is gone.

Generally a surgeon would want to close an open bite by impacting the back of the maxilla more than the front, allowing the back to rotate up and the front to rotate down, closing the bite. In theory, coupled with the advancement, this should've increased your upper incisor show at rest, not decreased. Unless too much of the anterior maxilla was impacted, in which case it would be a failure on the part of the surgeon to account for your individual soft tissue aesthetics, seeing as that is the guideline by which surgeons operate (in addition to occlusion). You say the gumminess of your smile was normal pre-op, so the amount of anterior impaction should have been minimal, a Lefort I naturally impacts 1 mm solely from the cutting of the maxilla.

At any rate, you have a valid complaint but please try and hold off on stressing about this stuff until the swelling has gone down. Do bring it up with your surgeon, but in all likelihood he will also tell you to wait for the swelling to settle.

Also, downgrafting of the maxilla is considered a very unstable procedure and is generally reserved for congenital deformities and trauma cases. Worst case scenario, a lip lift might be what you need.

[mmkay]

I do have fairly large teeth so I feel like veneers would look kind of awkward, plus from what I've read they're not permanent and they have to shave down the enamel on your natural teeth before you get them on (correct me if I'm wrong though) so I don't think I can commit to that. Surgery was bad enough the first time, a bone graft sounds pretty scary. I guess I'll just wait it out like Tctjh0 said. If I'm still unhappy about it in 6 months time I'll look into the grafting. Thank you for your answer! Is it common for surgeons to miscalculate how much they move the jaws (requiring a second surgery)?

Yes veneers need to be replaced every (say) 10-15 years and would require destroying your healthy tooth enamel first. Their increasing use is kind of disturbing.

As for miscalculation, I can't imagine it's particularly common - at least amongst skilled surgeons - but "overimpaction" is a known issue. e.g. check out perfectsmile's posts from 2009 here:
http://www.archwired.com/phpbb2/viewtop ... 15&t=32588

Just make sure you ask the question regarding how many mm he impacted you at the front. I suggest writing down the questions you want to ask on a piece of paper and take it in with you. I have no idea what sort of guy your surgeon is, but don't accept a vague reassurance - it's a pretty simple factual question the guy who cut into your head should be able to answer. Ask the question again if he doesn't give you the answer. That way when he says 1mm you can stop stressing

[Atrium]

I do have fairly large teeth so I feel like veneers would look kind of awkward, plus from what I've read they're not permanent and they have to shave down the enamel on your natural teeth before you get them on (correct me if I'm wrong though) so I don't think I can commit to that. Surgery was bad enough the first time, a bone graft sounds pretty scary. I guess I'll just wait it out like Tctjh0 said. If I'm still unhappy about it in 6 months time I'll look into the grafting. Thank you for your answer! Is it common for surgeons to miscalculate how much they move the jaws (requiring a second surgery)?

Yes veneers need to be replaced every (say) 10-15 years and would require destroying your healthy tooth enamel first. Their increasing use is kind of disturbing.

As for miscalculation, I can't imagine it's particularly common - at least amongst skilled surgeons - but "overimpaction" is a known issue. e.g. check out perfectsmile's posts from 2009 here:
http://www.archwired.com/phpbb2/viewtop ... 15&t=32588

Just make sure you ask the question regarding how many mm he impacted you at the front. I suggest writing down the questions you want to ask on a piece of paper and take it in with you. I have no idea what sort of guy your surgeon is, but don't accept a vague reassurance - it's a pretty simple factual question the guy who cut into your head should be able to answer. Ask the question again if he doesn't give you the answer. That way when he says 1mm you can stop stressing

Hey mmkay, I mentioned earlier about CW rotation increasing tooth show which in theory makes sense to me (provided anterior impaction is marginal), but have never been able to confirm it and sometimes it is difficult to tell with b/a's that I've seen

What's your thoughts on CW rotation's effect on tooth show?



I see two counteracting forces here that would simultaneously increase and reduce tooth show. On one hand the anterior part of the maxilla moves downward which in theory would of course increase tooth show. On the other hand, the horizontal projection of the maxilla is lessened which would decrease tooth. So I'm not sure what can be concluded about that.

Of course, maxillary advancement could offer that horizontal projection that is lost during rotation but let's just assume this is a class II open bite relationship, and all that's indicated is the rotation (no advancement and/or setback)

[mmkay]

I think you might have a tough time pursuing that conversation with many surgeons, let alone me :/ Remember there is an "acceptable range" of incisor display, so losing 1mm (for example) may be just fine. Similarly, your nose may get slightly wider and slightly more upturned, which again is likely to be ok depending upon your starting position, but for me that would be the bigger issue. Isn't it fun being a worrier

[Atrium]

I think you might have a tough time pursuing that conversation with many surgeons, let alone me :/ Remember there is an "acceptable range" of incisor display, so losing 1mm (for example) may be just fine. Similarly, your nose may get slightly wider and slightly more upturned, which again is likely to be ok depending upon your starting position, but for me that would be the bigger issue. Isn't it fun being a worrier

No doubt lol. I don't mean to drill you, you just seem to have a decent understanding of these things.

I do wish I was a go-with-the-flow guy but I don't want to end up feeling like OP either (no offense OP)

[Samster]

He said he moved it up 4 mm. When I asked him why he just said "because it was too far down" and kind of rushed me along because his office was busy. I'm really stressed out about it now, it's been almost a month now since the surgery and the swelling's been steadily going down but at rest you still don't see any of my top teeth. Before you could see maybe 3 mm of tooth at rest.

[Samster]

bmueller:
He didn't take any type of measurements beforehand. He made a mold of my teeth but never measured anything in my mouth like you described. He also never discussed with me how many mms he'd be moving everything beforehand.

[mmkay]

He said he moved it up 4 mm.

Sounds like you have your answer...it's just not what you wanted to hear (or what he should have done, I'd think).

What Atrium mentioned above about the lip lift might make most sense in theory. But you should probably see another surgeon to confirm that there are no 'skeletal' options at this point. Maybe he will say 'come back in x months', but IMO it's better to seek advice soon as you have a reasonable basis to do so.

[bmueller]

I'm sorry to hear that! I hope you can figure out what your next step is.

I would definitely consult with another surgeon and pick someone who is really well rated.

[Samster]

Does anyone know if there's a way to lengthen teeth without destroying the tooth's enamel? Bonding maybe? I really don't know how any of this stuff works.