Long face: open bite but no gummy smile

[Atrium]

Those of you who had surgery to correct an anterior open bite but did not have a gummy smile, did you notice your overall facial height got any shorter from the maxillary impaction and subsequent rotation upward of the mandible? Thanks

[mmkay]

I have a "severe" open bite and some gumminess of smile, although have been advised it is within normal range (especially after looking at close relations). Closure of the open bite by intruding molars has been recommended. The surgeon - who would make more money by performing an impaction - will screw in miniplates well below the molars, to which the molars will be connected.

The surgeon and the orthodontist independently gave the same advice - the lower part of the face will be shorter with the midface unchanged.

If you don't have gumminess of smile, I guess you do not have a long midface, so they won't be removing bone at the front of the maxilla, but rather just cutting way excess at the back.

Whether they impact at the back of the maxilla, intrude the molars, or grind down the molars (terrible idea obviously) then the lower part of your face, and hence the overall height, will shorten. Whether in practice it makes much of a difference to your appearance is another matter.

[Atrium]

I have a "severe" open bite and some gumminess of smile, although have been advised it is within normal range (especially after looking at close relations). Closure of the open bite by intruding molars has been recommended. The surgeon - who would make more money by performing an impaction - will screw in miniplates well below the molars, to which the molars will be connected.

The surgeon and the orthodontist independently gave the same advice - the lower part of the face will be shorter with the midface unchanged.

If you don't have gumminess of smile, I guess you do not have a long midface, so they won't be removing bone at the front of the maxilla, but rather just cutting way excess at the back.

Whether they impact at the back of the maxilla, intrude the molars, or grind down the molars (terrible idea obviously) then the lower part of your face, and hence the overall height, will shorten. Whether in practice it makes much of a difference to your appearance is another matter.

Great response, thanks.

Do you believe intrusion is enough to close a severe open bite? I know it is indicated in cases where they believe the open bite is a result of dentoalveolar hyperplasia, have you gotten opinions from any other surgeons?

I do believe they will for the most part cut out a minimal amount of bone in the front of the maxilla since the gumminess only occurs towards the back, and will rotate the maxilla clockwise to close the bite would be my guess. I don't believe any procedure out there can technically shorten the midface since soft tissue length remains the same no matter how much the maxilla is impacted.

What I'm grappling with is the question of what caused the open bite, I assume this is something a surgeon can determine by looking at my iCat and making the appropriate measurements? If my open bite is a result of vertically short mandibular ramus I don't think much can be done besides compensation with maxillary movements

[mmkay]

One of the problems with second opinions is that you can see a number of different practioners and get the same number of opinions - often based on what they learned way back when rather than what is current practice. In my case I deliberately saw the surgeon and orthodontist independently and they both gave the same advice (in the past it would have been surgery, but now intrusion).

The orthodontist has been using anchorage since 2005 and showed me a number of before and after shots of previous patients. There was someone who had one about as bad as mine, and he believed that my bite could be closed because there was plenty of space to intrude.

In my case I do have some posterior excess, but apparently also something to do with the jaw joints.

Regardless of cause, if the *only* change they are going to make to you is posterior maxillary impaction then provided they can perform enough intrusion then I would have thought it is an option for you. If you think about it the end result is similar in terms of the absolute position of the biting surface of your maxillary molars - the teeth are just pushed into your maxilla instead of being raised up by virtue of the bone above being shaved. But hey I'm no expert. But your orthodontist should be able to tell you why intrusion is not an option (otherwise maybe he just doesn't do it, which is not an acceptable reason).

If they need to advance your maxilla (which seems to be not uncommon) then obviously that isn't an option with intrusion.

[Atrium]

One of the problems with second opinions is that you can see a number of different practioners and get the same number of opinions - often based on what they learned way back when rather than what is current practice. In my case I deliberately saw the surgeon and orthodontist independently and they both gave the same advice (in the past it would have been surgery, but now intrusion).

The orthodontist has been using anchorage since 2005 and showed me a number of before and after shots of previous patients. There was someone who had one about as bad as mine, and he believed that my bite could be closed because there was plenty of space to intrude.

In my case I do have some posterior excess, but apparently also something to do with the jaw joints.

Regardless of cause, if the *only* change they are going to make to you is posterior maxillary impaction then provided they can perform enough intrusion then I would have thought it is an option for you. If you think about it the end result is similar in terms of the absolute position of the biting surface of your maxillary molars - the teeth are just pushed into your maxilla instead of being raised up by virtue of the bone above being shaved. But hey I'm no expert. But your orthodontist should be able to tell you why intrusion is not an option (otherwise maybe he just doesn't do it, which is not an acceptable reason).

If they need to advance your maxilla (which seems to be not uncommon) then obviously that isn't an option with intrusion.

Ah well there you go, I do need my maxilla advanced. I have a skeletal underbite which my ortho attempted to camouflage by flaring my upper teeth forward to meet the lower; obviously that hasn't worked and now I'm here, so impaction it is.

I'm going to send you a pm with some pics of my bite cause you seem to be really knowledgeable, hope you don't mind

[mmkay]

I am not particularly knowledgeable (and "a little knowledge is a dangerous thing" comes to mind) - I have listened to what professionals have told me, and used that as a basis for research to confirm what they have told me and asked questions. But that's with a fairly narrowly defined problem - open bite with slight overjet. Sounds like you have more complex skeletal problems. This is my 7th post so I will able to see your PM now :/

Edit: I'm not qualified to make any comment other than a) my open bite -appears- to be worse than yours and b) if I were you I'd compare your profile to others out there and see if you can get a sense of whether your maxilla is actually recessed and whether you are happy with that part of your face (some people say they believe they look a bit chimpish post surgery). Open bite aside, maybe from an aesthetic point of view moving back the mandible is what makes sense in which case maxillary advancement alone solves one problem (underbite) and creates another.

[Atrium]

I am not particularly knowledgeable (and "a little knowledge is a dangerous thing" comes to mind) - I have listened to what professionals have told me, and used that as a basis for research to confirm what they have told me and asked questions. But that's with a fairly narrowly defined problem - open bite with slight overjet. Sounds like you have more complex skeletal problems. This is my 7th post so I will able to see your PM now :/

Edit: I'm not qualified to make any comment other than a) my open bite -appears- to be worse than yours and b) if I were you I'd compare your profile to others out there and see if you can get a sense of whether your maxilla is actually recessed and whether you are happy with that part of your face (some people say they believe they look a bit chimpish post surgery). Open bite aside, maybe from an aesthetic point of view moving back the mandible is what makes sense in which case maxillary advancement alone solves one problem (underbite) and creates another.

I'm not qualified either but based on 2 opinions I've received, one from that of an orthognathic surgeon and one from an individual who's opinion I hold in high regard, I don't display the characteristic traits of a prognathic individual, and that my mandible has grown normally in spite of the abnormal growth of my maxilla.

I do have the flatish looking face which I so often hear from those dealing with midfacial hypoplasia and I also have pseudoprognathism going on (lower lip ahead of chin) which I've considered a consequence of the clockwise rotation of the mandible. Likewise looking at pics of my profile I'm fairly confident that my lower lip aligns pretty closely with the vertical profile line yet my chin is behind it, not sure if this is a result of clockwise rotation of the mandible or a reverse curve of spee or a combination of the two.

But cliffs is I'm fairly confident the majority of my issues rests in the maxilla, and that my open bite is being camouflaged to some extent by the orthodontic work (occlusion + extrusion of incisors via elastics to close bite). But this is mostly speculation on my part