Second time around, just 8 months after first...

[pcspinheiro]

Hello everyone,
I had a consult at a new ortho's office, following the disastrous first "treatment" with the worst ortho ever, that caused way more problems than I started off with. This new ortho explained that my situation is now complicated due to the missing premolar (that I should not have extracted!) and that full treatment to make things right will take 30-36 months, will involve 4 TADs and self-ligating braces to distalize the left arch by about 1/2 tooth, elastics, and whatnot... I'm gutted by this but it was to be expected. I was right all along that I needed lower incisor intrusion, NOT molar extrusion (which was disastrous for my TMJ and arch form and fully relapsed in no time), and that simply resolving the crowding would have given me a satisfactory outcome. But my former idiot ortho couldn't care about my goals and left me like this.. I asked this new ortho about fixing my collapsed arches (also the fault of previous ortho) and the reply was not very enthusiastic... This is one of the main problems bothering me, as it causes speech issues. I told her I was not mentally prepared for 36 months f braces so I also pushed for the possibility of just top braces, realign teeth and close gap as best as possible, which should take about 8 months. She seems OK with this if I take responsibility that it's not ideal. But I'm so torn... The 1/2 class II bite never bothered me, and before orthodontics I even thought it was the norm since I chewed better on that side. But by now trying to fix the gap without distalizing the left side I fear that the result might be aesthetically unacceptable. I think her idea is not even to close the gap with orthodontics but with a bridge, as there may not be enough room for an implant after alignment. But I'm sick of things going wrong so I'll probably just ask her to minimize the gap as much as possible and then do some ceramic fillings on the adjacent teeth or whatever...

What would you do if you were in my shoes?

[Mpkh]

My personal credo is that if you’re going to do something, do it right.

With regards to your case, I would do the 36 months, as that seem to be the most comprehensive way to fix your teeth. I know that being in 3 years of braces is daunting at best, and I understand that after your first go around with braces, you’re a bit apprehensive about further treatment. I think 36 months of braces would get you a more stable outcome than if you were to do a short course of braces. And a stable result is one that would prevent further work down the road.

With just having braces on the top arch, you are only moving your top teeth. This could result in worsening your bite as your bottom teeth not aligning with the top. Correcting the bite is one of the most important aspect of orthodontia; having a comfortable and functional bite is an ideal outcome of braces.

Like you, my malocclusion never bothered me, but after I straightened my teeth and corrected my edge to edge bite and crossbite, I noticed an improvement in the way I bite and chew food and the overall improved comfort of my bite.

I would not pick the 8 months option as that sounds like a quick fix, and it doesn’t address your bite at all. Also I’d imagine not distalizing the non extracted side while closing the gap on the extracted side may shift the balance of your teeth/bite towards the extracted side, and that may lead to bite issues.

[assertives]

My vote goes to getting the full 30 - 36 months treatment. As you have already experienced first hand, an unbalanced bite causes tmj issues over time. So I'd put focus on truly fixing the bite in the best functional way possible to alleviate some of that. A 8 months partial treatment of just the top arch doesn't sound like a very good idea because then your top and bottom arch may not fit together properly, which will in turn cause tmj and more teeth wear.

I know you feel like your maloccusion never bothered you all your life, and frankly, me too. I only noticed how much damage and premature wear I had done to various teeth now that my bite has been corrected. So I do think the benefits and in turn the detriment of your maloccusion may be something you can only see after the bite has been corrected.

Given what you have been through the first time around, I feel it's better to take this opportunity to fully correct whatever maloccusion you have and the residual unwanted side effects from the first treatment. Instead of a partial treatment which may have stability issues and cause more problems down the line.

[pcspinheiro]

Thanks for both your replies! I hear what you're saying and while I fundamentally agree with your opinions I know I don't have the mental availability for another 3 years of braces... The first round of 2 years was already a mental pain for me, as braces was never something I wanted and only did it out of necessity to save my bottom incisors from wear. If you asked me back then if I had any problems with my teeth/bite that's all I could ever come up with. The truth is that now I'm way worse than before braces, since my former ortho messed things up a lot, but funnily the relapse that's still going on a little is fixing some issues. The one things that still bothers me a lot is some speech problems due to narrower arches, but that's not what's going to convince me to get braces for yet another 3 years as it won't solve it anyway. In the meantime I had a another talk with the new ortho and, although she strongly recommends that I get the full treatment, or nothing, she does agree that if I'm not mentally into it I should not do it (for example, I told her right away that I would not stand bite turbos for a week, let alone 3 years! My molars need to touch so that feel comfortable, and if they don't I'll just ruin my TMJ). In the end I proposed that we try to get the bare minimum that I want (ie, close extraction gap, solve some canine conflicts and make the vertical proportions of my font teeth normal again) BUT using the self-ligating braces that were recommended for the full treatment in case this get's me an unacceptable result, aesthetically and/or functionally. I don't think I'll mind that my midline shifsts 2 mm to the right, it's worse having a gap of a full missing tooth right behind the canine. The work I want done on the top arch alone would have to be done anyway if were I to go with the 3 years plan, so I may either save myself from 2 years in braces if I get acceptable results, or end up getting bottom braces, TADs and whatnot and the full sentence... She finds this plan to be a reasonable compromise and if it doesn't work we do it her way. I've had many problems with the former ortho that caused much damage; This one knows about this and that I'm alert and educated to recognize them, so we'll work together and she promised to listen if I have complaints, something that the other ortho NEVER did. It could have saved me 2 healthy teeth, and a whole lot of other problems, and a second round of braces. I start my sentence on Monday.
We'll see how it goes... I'll keep you updated on the progress.

[pcspinheiro]

By the way @ assertives, I can assure you I've done more wear to my teeth while in braces and post braces (relapse period) that in the other 40 years of my life... So I'm 100% sure braces were bad for me. The first time around I really trully only needed to solve the upper crowding to continue living a happy life, but I'll probably be forever denied of that. Even if I take the 3 year plan there's no guarantee of fixing it all, so why bother diving right in? Let's see how it goes.

[pcspinheiro]

Braces are on. Self-ligating are rather bulky... Now that I see them on,there is not a lot of alignment to do, though correcting the angle of one central incisor may be more time consumingThere could be less still but somehow I was just not able to convey strongly enough that I wanted a normal, natural smile, not an orthodontic smile. I communicate research in various ways, I teach and my students get good grades. I'm good at explaining, yet somehow I'm not able to convey my personal wishes in the orthos offices... When I looked in the mirror I immediately saw the outcome of the alignment (a flat smile) and told her this was not what we talked about several times before I decided to go on braces again. I even reminded her of this before she began!!! So I did not leave without telling her that I'm not going to be happy with the outcome again. On my next appointment I'm asking to get the brackets changed slightly so that I don't get a flat smile. There's no point in moving teeth one way now just to move them in the opposite direction later and waste time and possible root health. After so many talks conveying my unhappiness with specific aspects of the previous treatment this should have started a little better...

[assertives]

Have you tried drawing? Or taking photos and notating which teeth/how you want/do not want them to move? This was what I did with my ortho when he could not see what I was talking about. I ultimately took pictures of my actual teeth and compared it side by side with my moulds and added arrows, dots and lines. My ortho said it was helpful for him. Perhaps you can try that if you haven't already.

Another thing to take into consideration also is sometimes there needs to be some movements to be had before other adjustments can be made, for e.g., moving a tooth out of alignment to make space for an impacted tooth.

[Mpkh]

I second assertives’ suggestion of using photos to demonstrate to the orthodontist what you do and don’t want. The orthodontist can’t know what you want your smile to look like if you don’t explicitly show her—a “natural” smile is vague and can be interpreted in multiple ways by different people.

Though, keep in mind that braces are limited in what they can and can’t do.

[pcspinheiro]

Thanks again for both your replies. I do agree that asking for a "natural" smile can be somewhat vague, but I was super specific about what i wanted. I told her that one of my greatest disappointments with the previous treatment was to get all the front teeth leveled by their tips, making for an old, plastic smile. When I went in to get the braces on I reminded her not to mess with the vertical proportions of my front teeth, since I was mostly happy with what relapse brought about. I even specified that, at best, I wanted my central incisors to extruded a tiny bit to be more visible. When I looked in the mirror I could immediately predict an even worse outcome than before; not only would she level my front 4 by their tips, but to the same size as the canines too! I mean, what the hell! How could my smile be made more plastic than that! I talked to this woman 4 or 5 times before getting braces, she seemed understanding toward all of my concerns and then she slaps this one me. I just can't believe it... I went right back into the office after my consult and complained about this, as the outcome was too obviously predictable. And in fact today, just 2 days later, the teeth have almost aligned to their new vertical positions (yes,that freakin' fast) and I hate them. I need to go in to see her as soon as possible about a molar bracket that isn't right and I guess I'll just take your advice and draw for her or take a picture and draw on that. I will not settle for this, nor will I "wait and see" like the first time, which was basically wait and suck it, as my teeth were never changed to the way I wanted them. In retrospect, when leaving the appointment I should not have paid for the braces if they were not the way I specifically asked. But thanks for your suggestions, I think they have been helpful. Maybe I'll even Photoshop what I want on an actual photo of my teeth.

[pcspinheiro]

Oh, and in reply to Mpkh, I know braces are limited in what they can do, but here we're talking about moving teeth up or down, it's no biggie. It's really just about gluing the brackets further up or down on the crown. Or, as I asked her very specifically, "don't move them vertically as I like them OK as they are or, please even make my central incisors stand out a bit more."

[wendydong]

i know how it feels...

I am in a similar situation as you. my first ortho didn't even notice my crooked jaw at first.. only after like 4 months when i brought up the issue that my bite seems way off, only then he said that I have a crooked jaw..

I have been to so many consults, only been told that now I am a complicated case. I am told that braces probably relaxed my jaw so much that my left side has sort of gone back to the "natural" state where it's more recessed than the right side.

now almost every ortho suggest jaw surgery right off the bat. and i have been giving time estimates like 2.5 years...

somtimes when i think back the times I complained to my old ortho about my ever protruding upper incisors, he would tell me it's just the "braces".. but actually, i now have an overjet like 6mm... i had a normal overjet like 2mm before...

and now my teeth are not even flush. some teeth are more pushed in than others...

this just sucks

curious, how long did you wait to start the second treatment? i have been hoping for relapse, but seems like it's getting worse...

[pcspinheiro]

Hi wendydong,
I waited about 8 months but I suppose I didn't have to. It's just that I needed to check on my TMJ and getting the MRI took a while, then back to the occlusion specialist and only then to the ortho, who's always extremely booked months in advance, so most of the time was pointless waiting. However, I couldn't book in advance not knowing when I would get the MRI and the consult after that, so everything had to be done one step after the other. I had a significant relapse and my front teeth went almost back to their "normal" crooked self. I would say most relapse happened in about 3-4 months and my teeth were pretty much stable in their current positions. If I had to put a number to it I would say my teeth relapsed about 50-60%. I was mostly happy with the vertical proportion of my front 6 after relapse. That is, until this ortho also completely ignored my aesthetical concerns and placed the brackets so as to completely flatten my front 6! I just measured the distance of the brackets to the tooth tips and it's about 3.5 mm in all of them (with very sight changes due to normal placement error, as it's not machine work). My god, what a despair! All those talks with her BEFORE I decided to get braces and she does even worse than the first one, who at least left the canines a bit bigger. I'm trying to get some time with her today between her consults to fix a wrongly placed molar tube and, in the meantime, I opened the slots on the lateral incisors, removed the wire and placed it in the slot UNDER the bracket so as to stop and slightly undo the wrong movement until she repositions these brackets to my liking.

I hope that you can get your case sorted. It's a real nightmare when we have small complaints to fix and end up way worse than when we first began... If only I could go back I swear I would leave my teeth alone.

[pcspinheiro]

So, just came from seeing my ortho about the molar that's being angled differently and she says it has to be like this and that once it angles completely it will also be pulled up and solve the conflict. I'm completely unconvinced by this and 100% sure it's pointless to do it. I mean, if the tooth has excellent contact with the lowers why make it so much worse by forcing it to touch only by a small tip??? Plus, when it does, the outer edges will be apart. It's a stupid change and it pains me to see the obvious and be unable to make them see it, and I think I know why: they just can't admit when they are wrong... There is just NO way this can work out like she says. Anyway, I said ok and let it go for now because I almost picked a fight about the front teeth... When talking to her I realized she knew full well what she had done but "it's the rules and there are numbers". If this had been the speech BEFORE I got the braces on I would just NOT have them right now. Just as I was sitting waiting for her to glue the brackets on I specifically asked for her to not change the vertical proportions of the teeth. Today I realized she understood this perfectly, she just chose to ignore it. Anyway, I said I would not have it and that some compromises had to be made; she could not have things 100% the way she wanted and leave me unhappy with my teeth. She said she had left 1/2 mm of difference between my lateral incisors and central incisors/canines but my own measurements showed no difference to the canines, only about 1/2mm to the central ones, which is a completely flat ugly smile. In the end she reluctantly agreed to increase this to 1 mm which is about leaving the teeth as they are now. We'll see.

[assertives]

When you said you don't want a "flat" smile, are you saying you want to end with some kind of an overbite? Actually, if you are happy with your teeth in their crooked positions and vertical proportions, and also don't want your molars moved, is it not possible to make more space of the extracted premolar so that you can get an implant and then call it a day? That may give you the closest thing to your pre-braces teeth.

[pcspinheiro]

Well, I already have a lot of overbite but that requires intrusion of lower incisors to fix, it's not a problem with the uppers and I'm not getting lower braces unless I REALLY have to (before round 1 of braces it was partly a problem of the uppers also sticking a little too far down but that's been remedied). There's nothing that can be done about the overbite without full braces, what I don't want is the front upper 6 lining up by their tips. See the attached pictures. My teeth proportions are about the same as the ones depicted and she was leveling them flat like in the second pictured. I want the other option, where the lateral incisors are slightly but visibly above the central ones and the canines. This does not imply extrusion of central incisors nor intrusion of lateral incisors; just leaving them alone and they are already fine. She claims to have placed the tip of the lateral incisors 1/2 mm above the others but that's not quite so and my own measurements using a precision caliper show no difference to the canines and about 0.4 mm to the central ones, which is the same as nothing. And I can tell you I almost picked a fight for an extra 1/2 mm, which actually means leaving the vertical proportions more or less as they are now. An implant is not a solution for me because 1) I want to avoid the invasive procedure and to have something foreign in my mouth forever, 2) it would not solve the canine conflict on that side and would cause more trouble down the line. Before braces and extraction the upper canine was out of place and did not contact the lower, so this was fine. But after round 1 the canine got into conflict with the lower, so it must be distalized to class I, leaving no room for an implant, or pulled forward to full class II for an implant to work but make everything else worse. It's probably complicated to explain, but looking at it it's easy to see. In the end she did (very reluctantly) agree with an extra 1/2 mm. I really don't see what the heep she wants to make with my teeth that would be ruined by an extra 1/2 mm of tip discrepancy (especially since I opted for a quick fix of the problems bothering me)... It's really just about following the rules: if the bracket's box says x then it must be x regardless of whether the paying patients are happy or not. Anyway, I seem to have won this one and it was really my biggest issue. She took note and will be re-gluing those 2 brackets, something I never got with the other ortho in 2 years of hell... I don't really care about the molar, even if I can't see the point of changing it, and will try to trust she has a an actual plan for it.