Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I'm Bill Klaproth. And with me is Dr. Steven Roser, who's here to discuss jaw surgery, everything you need to know about an overbite and an underbite. Dr. Roser, thank you for being here.

Steven Roser: Bill, thank you for having me.

Bill Klaproth (host): Yeah. It's great to see you. So, let's jump into this. What is the difference between an overbite and an underbite?

Steven Roser: An underbite, simply put, is where the lower teeth are out in front of the upper teeth. An overbite is just the reverse, where the lower teeth are back too far from the upper teeth.

Bill Klaproth (host): So, I would imagine most people are born with this and think they have to live with that. Is that correct?

Steven Roser: It is, but maybe it's a little easier to think of this problem in really three different groups. There's the group where kids are born with these discrepancies right away. And they're congenital anomalies and they can interfere with function at birth. The dental facial deformities, the larger group, are developmental whereas you might see a little bit when they're young, as the child grows, the lower jaw can grow out further, and that's the larger group. And then, the third group are people as a result of traumatic injuries who wind up with discrepancies in their jaws secondary to the injuries that then need to be further repaired.

Bill Klaproth (host): Well, it's great to know those three distinctions. So then, there is surgery to help people with an overbite or an underbite.

Steven Roser: Yes, there is, it's called orthognathic surgery. Ortho-, it's Greek. Ortho- meaning straight, -gnathic meaning jaw, which makes sense. It's a little hard to pronounce. Orthognathic surgery is available for folks in the correction of these discrepancies when they're too large, too great to be handled by orthodontics alone. And they interfere with function. There's some compelling reason for the person to want to have a better quality of life.

Bill Klaproth (host): Absolutely. Well, let's talk about that. I'm sure there are varying degrees of this condition, having an overbite or an underbite. How would a person know when they need to go under surgery to treat this?

Steven Roser: That's a great question, Bill. This is elective surgery. You can elect to do this. And elective surgery, people misinterpret as being cosmetic or something that's not necessary, but that's far from the truth. Elective surgery just means you can elect to do it. It’s not urgent. It’s not a life-threatening problem, a life-saving procedure or limb-saving and so on. But it could be very medically necessary. And the functional problems that the discrepancies can cause interfere with some of the major things that we do: eating, speaking and breathing. And this misalignment can have significant effects on all three.

Bill Klaproth (host): So, someone's quality of life can be severely impacted by having an overbite or an underbite.

Steven Roser: Yes. For example, one of the variations of that could be that the teeth don't meet, they're open, either too front, too back. And so much socialization's done around food. You know, if you go to somebody's house and you're there for two hours and you're not offered something to eat or drink, you either leave or you wonder--

Bill Klaproth (host): Right. What's with this host? Come on.

Steven Roser: Right. But you think about the person who can't bite into a sandwich or a pizza. And so, their work-arounds are done during that meal or during that socialization. So, they're taken out of the rewards that one gets from socializing because they have to think about what they have to eat and how they eat it and how that's being presented for example.

Bill Klaproth (host): Yeah, I would imagine there's an aspect of being self-conscious about this as well.

Steven Roser: Very much so. And so often, when we see this, especially in the teens, in the teenage group, when the correction’s done in combination with the orthodontist and the surgeon team, the kids blossom. You know, their trajectory just goes straight up. And they just pick up where everybody knew they had the potential, but that self-confidence wasn't there.

Bill Klaproth (host): Yeah. Well, there's the physical aspects. And then, I would think the mental, "I look weird" or "My jaw's out. I'm lacking self-confidence because of that," I would imagine is a big part of this too.

Steven Roser: It is, Bill. When you and I are talking right now, we're either looking at our eyes or looking at our mouth, for example. If I ate a bagel, a poppy seed bagel for breakfast and I had a poppy seed between my front teeth, and I don't realize that until the evening.

Bill Klaproth (host): Right. Why didn't somebody tell me?

Steven Roser: Right.

Bill Klaproth (host): You've got a piece of lettuce caught in there. You were with a friend, like, "Why didn’t you tell me I got this lettuce in my teeth? What are you doing?" You're right, you can be very self-conscious about that. "God, I was walking around all day with lettuce in my teeth. Oh, my God. People thought I was a goof."

Steven Roser: Right. And, you know, it's astonishing to you, and it's that small thing. And because it is a very esthetically functionally sensitive area. For example, functionally sensitive, you go to the beach, bite into a sandwich and there's a grain of sand and you know it. So, this mechanism is exquisitely sensitive for function as well as in the overall well-being of the individual.

Bill Klaproth (host): Absolutely. So, can you explain to us, Dr. Roser, how jaw surgery can have a dramatic effect on one's life then?

Steven Roser: I can. We talked a little bit about the teens who are withdrawn and don't have the self-confidence. But, you know, when you think about how much of what we do is through personal contact, we just went through the pandemic and we know that, and we're all wearing masks at the time, which really changed the dynamic, but the masks are coming off. And it's so important for the individual to be able to think, "I can do this and not feel that there's something holding me back."

Bill Klaproth (host): Yeah. It's just nice also to see people's faces again without the mask on, right? But a nice smile and feeling good about your smile is really important. And an overbite and underbite certainly can impact that.

Steven Roser: It can. You know, the smile is the only facial expression that means the same thing around the world, the only one. So, think of how important that is in communication and talking and expression and so on. And if you look at people who have the underbite where the lower jaw is really forward and you look at them at rest, they look serious, almost angry. And in the adult world, people size you up in the first five seconds. And if you look like you're seriously engaged in something, they may avoid even talking to you and giving you the message, so you know, the appearance can affect--

Bill Klaproth (host): How people treat you and interact with you if you're always looking serious with an overbite or an underbite. So then, what is the process once corrective jaw surgery is determined to be necessary with orthodontia work?

Steven Roser: Right. Great question. It's a team sport, so to speak. Again, elective and it involves the sort of macromovements and micromovements. And if you think about it, the orthodontist does the micromovements, gets the teeth lined up in the jaw. I'm the macro guy. I will move the jaws and the teeth and the orthodontist will finish. And so, yes, it's a plan where surgery is usually in the middle, sometimes we do it first, usually in the middle and usually 24, could be 26, 30 months to get things done. And again, the orthodontist sets the arches up, we move the jaws and the orthodontist finishes.

Bill Klaproth (host): So, it's a process kind of like braces. You're slowly moving that jaw into the--

Steven Roser: It's braces, you're moving the teeth into a better position in the jaw. And then, I move the jaw and the teeth and the orthodontist finishes.

Bill Klaproth (host): So, it's a two-step process. Teeth first, then jaw.

Steven Roser: Jaw and then teeth finish.

Bill Klaproth (host): Okay. That's where the orthodontist comes in. So, this happens over a period of months. I think you said maybe years or year and a half, did you say?

Steven Roser: Usually 24 months.

Bill Klaproth (host): Okay. Twenty-four months.

Steven Roser: With surgery being in the middle. And the orthodontist has to know that surgery is part of the treatment plan from the beginning. So for example, if you went to the orthodontist and the orthodontist said, "I can't bend the teeth to meet. They're too far off. I need to have you consider surgery. Have you considered surgery?" And we'll send you to the surgeon because what the orthodontist will do if surgery is part of the treatment plan, you embrace it. You say, "Go." Then, the orthodontist will spend that period of time not trying to fix things and I finish, they actually can make the bite a little worse because they're straightening the teeth and the jaw. Then, I come in and set the jaws in place and the orthodontist now can finish.

Bill Klaproth (host): So, surgery isn't always needed. Sometimes you can do this without surgery.

Steven Roser: Very much so, and that's what the orthodontist would say if you came back from the surgeon. And you said, "Hey, look, this just doesn't fit into me now. I've got a family. I've got this and I'm not insured," things like that. And the orthodontist and you will have a conversation, say, "Okay. What can you do for me?" If the discrepancy is too much, the orthodontist will say, "I can't do anything." And that's okay. I mean, again, this is an elective surgery. There's no right or wrong answer.

And we do see three groups of folks, the group who are the teens where usually the orthodontist sends the patients to us, that's the biggest group we operate on. But there are a group of people that either don't get that opportunity or just say, "Hey, time out. I can't do this now." That's the second 25 to 35. Now, they've got their own insurance, now have their family life set, come back. And then the third group, smallest, but the 55-plus, same operation that have the excessive wear, the obstructive sleep apnea now because the jaw's too far back and really taking its toll on the patient and they're just stuck. And this is also a group that we operate on. As I said, a smaller group.

Bill Klaproth (host): Let's quickly talk about the operation. Is it where the person can't talk for a couple of days. What happens after the operation?

Steven Roser: Well, simply put, probably going to turn off some folks that are listening. I break the jaws and put them in a new position. And then, let them heal that way. All done from inside the mouth, under general anesthesia. And depending on what you're doing and who you're working with, generally could involve a day surgery. But if you're working on both the upper jaw and the lower jaw, often the patient stays overnight, goes home the next day or the next day.

When I first started, we'd wire jaws together because all broken bones, whether you break them or I break them for you, require the same treatment. Line them up so they're correct and then keep them quiet. That's why you get a cast on your arm. I can't put a cast on your head. So in the old days, we wired jaws together. We still do, but not to the same extent. Now, this operation is all done from inside the mouth. There's nothing on the outside. We'll put some plates and screws in. And that will hold the bone and we can let the patient function. Function is restricted to soft diet, mushy diet. But people can talk right away. They can eat right away.

Bill Klaproth (host): Wow, this is fascinating. So then overall, what are the benefits of corrective jaw surgery overall?

Steven Roser: Overall, you know, we've got the functional component and the esthetic component. And both are equally important. Generally, we talk about function first. And there are people that come to us for esthetic correction only. And we certainly can do this for that. But the vast number of folks come to us with functional issues to start with or looking at their oral health for the future and because of the dysfunction.

And the dysfunction, we talked about sleep apnea, we talked about eating, speaking and also I don't think I included the temporomandibular joints. I mean, those guys open and close your mouth thousands of times during the day. So, those need to work and they're going to work for your lifetime. And if you've known anybody that has TMJ pain or you have it yourself, you know that it can also be debilitating. Much like backs, you don't operate on every back. But there are backs that you do, and that's when the structural problems or such that physical therapy, other things can't fix it.

So, there are functional benefits. And those functional benefits can be perceived right away for sure, as can the esthetic differences. And so, the two of them make it very gratifying for the patients as well as the family and the support and the surgical orthodontic team.

Bill Klaproth (host): Yeah. Well, we talked about the physical and the mental aspect of this. So, this has really been informative, Dr. Roser. So as we wrap up talking about jaw surgery and everything you need to know about an overbite and an underbite, anything you'd like to add at all?

Steven Roser: Yes. Thanks, Bill, for the opportunity. As I said, it's elective. And what our job is, what my job is when I see a patient, as well as my orthodontic colleagues, is just to give patient the information, straight up information on what this involves, what we think the benefits are, listening to the patient all along to see where their priorities are. And then, advising them and empowering them, empowering you to make a decision. As I said, there's no right or wrong. It's a decision, quality of life. And that's our job and not to sell it, but to advise people and to, you know, recommend it and give them the information. And there's a lot of information available online. People who have this type of surgery often post. Some of it is good. Some of it is a little hard sometimes to get through. But in my experience it's been a very rewarding conversation to start with.

Bill Klaproth (host): I bet, and satisfying for you when you see the end results as well. When you have people come to you and say, "Thank you. You've changed my life."

Steven Roser: Very much so.

Bill Klaproth (host): Dr. Roser, this has been fascinating. Thank you so much for your time.

Steven Roser: My pleasure. Thank you so much for having me, Bill.

Bill Klaproth (host): Absolutely. That is Dr. Steven Roser. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast to be interesting, please share it on your social media and don't forget to subscribe. Thanks for listening.