Surgery in 2 weeks - how to maximize outcome? (sever asymmetry/downswung jaw)

[skybizz]

I've gone down the rabbit whole a little bit and realized that something I really want is to reduce the protrusion of my mouth/lips, which I assume is something that can only be done be retracting the upper/lower jaw (not something I'm interested in as it could cause sleep apnea and reduce the overall "volume" of my jaws) or extracting my teeth and pulling them in to combat flaring.

I tend to think CCW (posterior downgraft) would not be the magic bullet for him. It's because in his ceph, his lower lip is somewhat AHEAD of his upper lip. CCW w PDG minimizes upper jaw advancement and allows for maximization of lower jaw advance. But if that happened (without extractions), his lower lip soft tissue would be MORE ahead of his upper lip and it could look like class 3 soft tissue profile contour. It's possible to get the CCW but possible= removing lower pre-molars to push the lower teeth backwards as the surgeon told him. However, I don't see that possibility accommodating (all of) the aesthetic desires he'd like.

Would extracting the lower pre-molars to pull them in have a noticeable impact on how far out my mouth protrudes? Or would that only be useful for ccw rotation if I were to pursue it?
Again, I fully understand that you're not personally recommending anything beyond the genioplasty

Edit: I found this: https://www.sylvainchamberland.com/en/avant-apres/bimaxillary-dentoalveolar-protusion/ that kind of answers my question, not sure how legit the source is though
"Extraction of 4 first premolar won’t have an effect on the vertical dimension. It will not increase or decrease. However, in some case with deep overbite and low mandibular plane, it might be ill advice to extraction in the lower arch.

The goal, in a patient that have bimaxillary trotrusion is the reduce that protrusion. Therefore, it is expected that the extraction of 4 firs premolar will permits to rectract the anterior teeth and reduce the dentoalveolar protrusion, hence reducing the protrusion of proclination of the lips. This is somthing we want to happen in such cases. The thickness of you lip will remain about the same, but they will be less protruded."


This attached before/after looks really similar to my current profile. If I could get similar results through extraction, I might actually seriously consider it

[GJ]

As someone who had both a little bit of protrusion and extractions, I can tell you in my case the extractions definitely got rid of the protrusion. There are major tradeoffs, though, like tongue space and the teeth being retroclined, due to the forces involved in space closure. Wouldn't recommend it for comfort. The surgeon should ideally put the models on an articulator, or use software, and perform model surgery to see if you can extract those teeth and still have enough space. If not, and you want the extraction treatment plan, then you're looking at something like segmenting the upper jaw.

You might have tongue discomfort/tongue space issues once you extract.

I'm against extractions except for linear advancements where they only pull two lower 2nd bicuspids. Very specific cases. I don't see that here, but if protrusion is a major concern then maybe it becomes an option, but you need to discuss all that with your surgeon.

And for the record, I wasn't recommending CCW necessarily - just that it would fix some of your major concerns. I think you need to slow things down and learn more, and maybe go on more consults. You're getting a lot of information from us, and you're concerns are changing as you learn more. To me this always means slow things down, learn more, and get more consults.

I also think it's important you get confirmation from the surgeon that your condyles can handle the proposed movements. They're not pictured in your scan, and that's concerning given your symptoms with the joints.

[skybizz]

As someone who had both a little bit of protrusion and extractions, I can tell you in my case the extractions definitely got rid of the protrusion. There are major tradeoffs, though, like tongue space and the teeth being retroclined, due to the forces involved in space closure. Wouldn't recommend it for comfort. The surgeon should ideally put the models on an articulator, or use software, and perform model surgery to see if you can extract those teeth and still have enough space. If not, and you want the extraction treatment plan, then you're looking at something like segmenting the upper jaw.

You might have tongue discomfort/tongue space issues once you extract.

I'm against extractions except for linear advancements where they only pull two lower 2nd bicuspids. Very specific cases. I don't see that here, but if protrusion is a major concern then maybe it becomes an option, but you need to discuss all that with your surgeon.

And for the record, I wasn't recommending CCW necessarily - just that it would fix some of your major concerns. I think you need to slow things down and learn more, and maybe go on more consults. You're getting a lot of information from us, and you're concerns are changing as you learn more. To me this always means slow things down, learn more, and get more consults.

I also think it's important you get confirmation from the surgeon that your condyles can handle the proposed movements. They're not pictured in your scan, and that's concerning given your symptoms with the joints.

Yeah I would hate to not have enough space for my tongue  to rest in my mouth, I feel like that could cause issues with my teeth later on. Are there any drawbacks to the 4 extractions besides decreased tongue space?
At this point, I only have 1 more meeting with my surgeon (pre-op meeting a couple days before surgery). AFAIK that's my last opportunity to sit down with him and go through planning, which is why I'm somewhat relying on the internet until then so I can spill all of my concerns to him in one meeting. Would it be uncommon to request another meeting with him before the surgical planning meeting? I know his time is extremely valuable and wouldn't be surprised if they didn't allow something like that.

Do you really not see any mouth protrusion in my pictures? It might help to take a look at the side profile pics I linked in the reddit post, I thought I fit the description perfectly (and my x-rays definitely make it seem like my teeth are flared outward more than average). I feel like my lips naturally separate a little at rest, and I have to apply a small amount of force to get them to meet normally, I regularly drool when I sleep. I did some reading and discovered that could cause strain on the temporalis muscle, would could cause temple headaches (I get these a lot, along with other types of headaches).

I'm a bit desperate to fix my headaches at this point in my life, so i'm looking for ways to remove ANY form of unneeded pressure/force/tension in any parts of my jaw, I feel like my protruding/flared mouth could be a potential pain point.

I'll make sure to bring up my condyles the next time we meet.

edit: I did some reading on how extractions can age you prematurely and yeah, it doesn't look pretty. I'm wondering how much this applies to someone who's teeth flare out a bunch to begin with

[GJ]

Are there any drawbacks to the 4 extractions besides decreased tongue space?

Yes, the bite will likely never line up perfectly.

Do you really not see any mouth protrusion in my pictures?

I don't think I ever said this or anything like this. I see it. It's just what can realistically be addressed...since much of it is from thick tissue, there aren't a ton of options. At least I don't know any to reduce the tissue itself.

edit: I did some reading on how extractions can age you prematurely and yeah, it doesn't look pretty. I'm wondering how much this applies to someone who's teeth flare out a bunch to begin with

I had minor protrusion, and premature aging wasn't an issue for me. I think that's more with people who have a normal/flat mouth to begin with. Though, honestly, everyone reacts differently so you never know.

[skybizz]

Yes, the bite will likely never line up perfectly.


I don't think I ever said this or anything like this. I see it. It's just what can realistically be addressed...since much of it is from thick tissue, there aren't a ton of options. At least I don't know any to reduce the tissue itself.

I had minor protrusion, and premature aging wasn't an issue for me. I think that's more with people who have a normal/flat mouth to begin with. Though, honestly, everyone reacts differently so you never know.

Yeah, I can't do anything about protrusion due to the soft tissue and honestly wasn't interested in looking into that or anything plastic surgery related.
I guess what i'm really asking is whether you think a significant amount of the bimaxillary protrusion is due to bone that can be moved in surgery (in a way that does not include moving either jaw backwards - I'd hate to reduce my airway size), and whether its worth exploring during surgical planning.

[kavan]

Let's get back to the drawing board here.

You are getting surgery for FUNCTIONAL reasons. That is the main priority of the surgery.

With this surgery where the PRIORITY and FOCUS of it is FUNCTIONAL, your focus SHIFTS too much to FORM.
With this SHIFT of focus, you toss in a bucket list of aesthetic outcomes you would like the surgery to achieve so you can discuss them with your surgeon. You are told which particular goals on your bucket list would be off the discussion table as far as what you can expect such as 'square' wide jaw and reducing overall round appearance of the cheeks. You were also told which procedure; the CHIN work would help address the asymmetry there and also move the chin up and outward for a better aesthetic.

The Lefort 1 and also the BSSO would be with aim to improve your function and to address what ever asymmetry that relates to function and also that that relates to form. Neither you nor the audience here has  knowledge of what the surgical displacements are going to be. All we know is the surgery is for FUNCTION and what ever form arising from the surgery or that can be requested of the surgery will be that which also improves function.

As to CCW and how it relates to form and function, it relates to people who have a high OCCLUSAL plane and who would also benefit from the lower jaw being advanced MORE than the upper jaw as in people with a recessive lower jaw. Their form improves from that as does their function especially if they have narrow airways. Another relationship with CCW is that it is something that AVOIDS extractions.

Presently, your form (profile) and occlusal plane (which would not be considered high) doesn't correspond directly with the need for CCW as it would in someone else who needed more lower jaw advancement than upper jaw and also had a high occlusal plane angle. Furthermore, you would need extractions to have CCW with bimax advancement. So, the need to have extractions to have CCW (because of the lip protrusion) is yet another thing where you DIFFER from the type of relationship others have who are primary candidates for CCW.

Since most of your questions are about FORM when the objective of the surgery is FUNCTION, I prefer not to be engaged too much about how this or that jaw advancement will do this or that to your form. Why? Because a focus on jaw advancement whether it be via CCW or linear advancement doesn't appear to be the goal of the surgery. Unless the surgeon told you; 'Your jaws are recessive and your lips are too far behind a reference line and that's why you need bimax advancement', there's no need to go down a rat hole to engage in how this or that advancement to this or that jaw is going to do this or that to your lip area. Why? Because it's highly likely the goal of the Lefort 1 and the BSSO isn't directed toward prioritizing advancement.

It's highly likely the surgical displacements via the Lefort 1 and BSSO will be directed to addressing the form that is directly related to FUNCTION such as asymmetry found to the JAWS where both a Lefort 1 and BSSO would be needed to address the parts that relate to a dysfunctional bite and/or disproportional stress to the condyles arising from the jaws and/or bite. What ever advancement that goes along with it will answer to correcting the FUNCTION. As to ADVANCEMENT to improve form, the CHIN advancement (and correcting it's asymmetry) would be that.

Lip protrusion is NOT a problem for you given it's within the norms of racial type. So, it's not something you need to push backwards via extractions and to do that just so you can have CCW. It's just something where there is no aesthetic 'need' for bimax advancement.

A Lefort 1 is a cut to the upper jaw to DISPLACE it in some way. Likewise with a BSSO which is cut to lower jaw to DISPLACE in some way. Not all Leforts and BSSOs are directed towards bimax advancement. Some are directed towards targeting asymmetry and addressing FUNCTION. I think the latter is your case.


That said, that's all of the info I'm providing here.

[thedude]

Is a bimax advancement likely to have a better aesthetic outcome because of my thick soft tissue around my lips/nose, or worse because of my thick lips/wider nose? I was under the impression that thicker tissue disguises boney movement more than thinner tissue, but i'm also getting the sense that people here think the outcome would be worse because of this.
Just to clarify, better in this context for me would mean minimal increase in lips size/nose width.

Moving the jaws forward will make your lips bigger and nose wider.

Instead of jaw surgery I think you would be happier with a genioplasty if you want a slightly more pronounced lower third of the face and then maybe think about hydroxyapitite cheek augmentation. These are less invasive procedures that would do more for your appearance and have less risk of facial changes you don't like. My hunch is it's the cheek area of your face that is bothering you more than your jaw.

Take a look at the gallery of Arnette/Gunson patients. https://www.arnettgunson.com/before-and-after-gallery-faces Almost every one of their patients also get cheek augmentation. Most of the improvement in looks actually comes from the cheek augmentation. You'll notice all those people in those pictures have a more projected mid face after surgery. That's the cheek augmentation you are seeing. They generally do pretty small jaw movements to fix bad bites and then supplement it with cheek augmentation for cosmetic improvement. It's actually pretty rare to be able to dramatically improve facial appearance with jaw surgery. You have to have jaws that are really messed up with a giant underbite or huge vertical excess to really be impressed with the difference after jaw surgery. Someone like you that has perfect jaw structure doesn't have much to gain cosmetically from it.

[PloskoPlus]

Actually lip reduction is definitely a thing.