Long Maxilla but no Gummy Smile

[neferkitti]

I'm not sure. He looks like a challenging case.
If the lower jaw is advanced, then his face will become longer, and it's already too long. His upper jaw is very long, but the excess length is all in his nose. He probably has no gummy smile.

I'm not yet convinced that his face is too long. You wouldn't happen to have a front view photo, would you? Without an xray, it's hard to say if his maxilla is long. The upper lip region is very short, and this is what, IMO, makes his case difficult. I mean, how would its shortness be addressed? How does your upper lip compare to his?

My guess is that he needs counter clockwise rotation. His upper jaw needs to be shortened a lot and then advanced some to compensate for the impaction. His lower jaw and chin need to be advanced substantially.

Again, I'm wondering what an impaction and CCW would do the the upper lip. The lower jaw seems to be a straightforward fix.

After all of this, I still think he'd look unattractive because the rest of his face is messed up. He'd need a rhinoplasty to shorten and deproject his nose and raise his dorsal line. He also needs brow augmentation as well as an otoplasty.

I don't think he's messed up now. A front view of the nose to see its width would be helpful. But, if bimax could be achieved, I think the nose would be more balanced. I know that you like a higher dorsal line, but I don't think it's necessary on this guy. Maybe a conservative dorsal shave would look good.

I think the challenge lies in the region between the base of the nose and the upper lip. Shortening the soft & hard tissues of the nose, I would think, is not going to elongate the soft tissue of this region.

Edit to add: why the otoplasty?

[neferkitti]

Here's another example of what I'm talking about.

Describe what you see here. I'm not following.

[Heavyweight]

This is the best I can do with him. His long, low nose will prevent him from ever being good looking. It's as if the base of his nose just grew too far downward as he was developing.

[neferkitti]

This is the best I can do with him. His long, low nose will prevent him from ever being good looking. It's as if the base of his nose just grew too far downward as he was developing.

I strongly disagree. He looks great here! What else besides the dorsal bump and the lower jaw did you change?

Edit to add: Okay, now I see the otoplasty and maybe a slight upturn to the nose. Why did you shorten the earlobes? What else am I missing?

[Heavyweight]

I strongly disagree. He looks great here! What else besides the dorsal bump and the lower jaw did you change?

Edit to add: Okay, now I see the otoplasty and maybe a slight upturn to the nose. Why did you shorten the earlobes? What else am I'm I missing?

I shortened the earlobes and brought out the upper jaw. Long earlobes are really bad because they make the jaws look smaller and give a rather vacuous look to the face. Conversely, short earlobes and high ears make people look intelligent and alert.

Here's a morph I did with free rein. Unfortunately, most of the things I did are impossible. It just goes to show you that very often the things that make us unattractive are things that can never be changed.

[neferkitti]

I shortened the earlobes and brought out the upper jaw. Long earlobes are really bad because they make the jaws look smaller and give a rather vacuous look to the face. Conversely, short earlobes and high ears make people look intelligent and alert.

This guy already has an intelligent appearance, especially in the eyes. I would not touch the earlobes.

Here's a morph I did with free rein. Unfortunately, most of the things I did are impossible. It just goes to show you that very often the things that make us unattractive are things that can never be changed.

I realize this PS is free form but, even so, this does not look good at all, with all due respect. Does this look good to you? Also, how tall are you? I came across a very tall young man with a small face/head and it looked unnatural. Keep in mind that the head has to fit the body. I liked the first morph sans otoplasty and with slightly less of a dorsal shave

[Sharptoys]

HW, I hope your expression of preference for this very specific and fairly uncommon aesthetic is merely academic in nature, and not one of aspiration or expectation.  In terms of aesthetics, especially in complex or reconstructive cases, most surgeons attempt only to approximate a normal aesthetic, rather than a specific aesthetic.

Realistic expectations are essential to satisfaction in a great many things, and orthognathic surgery all the more so.

[neferkitti]

I agree with Sharptoys. I tend to think HW understands the limitations involved, at least I hope so. HW?

Sharp, what are your thoughts on HW's first morph? Possible?

[Sharptoys]

Sharp, what are your thoughts on HW's first morph? Possible?

Certainly. I would also imagine that the fellow in HW's picture would look significantly better after bimaxillary/chin work than HW's projection would suggest. The most software can really do is stretch the profile border to approximate the projected movements, as it cannot possibly project how the soft tissue drape will be changed.

[neferkitti]

Certainly. I would also imagine that the fellow HW picture would look significantly better after bimaxillary/chin work than HW's projection would suggest. The most software can really do is stretch the profile border to approximate the projected movements, as it cannot possibly project how the soft tissue drape will be changed.

Would the short nose to lip region pose a problem, in your opinion? I suppose my concern is that there is not enough upper lip there to accommodate a large forward move. Also, would there be lip strain from the new position of the teeth? FYI, I know nothing  .

[tdawg]

I'm not sure. He looks like a challenging case.

If the lower jaw is advanced, then his face will become longer, and it's already too long. His upper jaw is very long, but the excess length is all in his nose. He probably has no gummy smile. This is the exact same problem I have.

My guess is that he needs counter clockwise rotation. His upper jaw needs to be shortened a lot and then advanced some to compensate for the impaction. His lower jaw and chin need to be advanced substantially.

After all of this, I still think he'd look unattractive because the rest of his face is messed up. He'd need a rhinoplasty to shorten and deproject his nose and raise his dorsal line. He also needs brow augmentation as well as an otoplasty.

I think if he had a genioplasty and rhinoplasty he would look fine. Not male model but normal. I wouldnt touch his jaws because like you said he probably has no gummy smile and it would probably require extreme movements in both jaws. Im going to do a morph to see what he would look like with a rhino and genio.

[Sharptoys]

 

Would the short nose to lip region pose a problem, in your opinion? I suppose my concern is that there is not enough upper lip there to accommodate a large forward move.

I doubt it. A large maxillary advancement is rarely indicated in normal or class II occlusions, and is likely not needed here. In addition, the effect of any advancement on the upper lip will be at least partially offset by the prescribed impaction/CCW rotation of the maxilla.

Even if it were to preclude the necessary linear advancement, counterclockwise rotation of the maxillomandibular complex would serve advance the pogonion significantly without requiring much maxillary advancement. Of course, xrays and professional examination would be needed to see whether such an operation is needed or  practical;. I also imagine that many surgeons would elect to perform a linear advancement with minimal bimaxillary advancement and choose to supplement with more extensive chin work.

[Sharptoys]

Sharptoys, what can be done for this guy?

Xrays would, of course be necessary to assess any malocclusion, excess maxilla growth, ect, but he would likely benefit from traditional maxillary impaction/mandibular advancement which would enhance the soft tissue drape significantly, while eliminating the characteristic rounding of the soft tissue to the sides of the mouth.  We should also consider his microgenia, which might require a inlay bone graft between inferior border and the rest of the mandible to increase the vertical height of his chin.

We should not underestimate the effect (either) jaw advancement has on the soft tissue. Perhaps my favorite case is JSB's HTK, which I'm sure most of you are familiar with:

Before:


After lower jaw advancement and sliding genio:

[neferkitti]

We should not underestimate the effect (either) jaw advancement has on the soft tissue. Perhaps my favorite case is JSB's HTK, which I'm sure most of you are familiar with:

I had not seen these. Here's HTK at nearly 7 months:

[neferkitti]

Even if it were to preclude the necessary linear advancement, counterclockwise rotation of the maxillomandibular complex would serve advance the pogonion significantly without requiring much maxillary advancement. Of course, xrays and professional examination would be needed to see whether such an operation is needed or  practical;. I also imagine that many surgeons would elect to perform a linear advancement with minimal bimaxillary advancement and choose to supplement with more extensive chin work.

Purely in terms of aesthetics, and assuming no anatomic barriers, do you personally think this guy would benefit from maxillary advancement?