What do I need? (Pics, Ceph+)

[ditterbo]

See post on 11/26 (page 4) for latest updates and images.

Preamble and context: I had orthodontics completed by age 14 (ortho pic included)which appear to have given me a decent smile and bite, without extractions.   4 impacted wisdom teeth were pulled in 2010. A year ago (I’m 26, btw), I got a rhinoplasty with a large (7mm) terino anatomical chin implant.  Not to get too into this surgery, but the left half of the implant is not in its designated pocket. The left wing is way up in my cheek, so the whole thing is contorting my lower lip movement pretty severely.  As I'm also in pain from who knows what happening with the implant, I think my immediate need is to have the implant revised with the option for removal during jaw surgery. 

Before and after plastic surgery I consulted with at least a dozen plastic surgeons and a few maxillofacial surgeons.  Jaw surgery was never really brought up until one or two consultations I’ve had post plastic surgery, as I was looking to have the chin implant revised or removed.  Two local max facs didn't recommend jaw surgery, but Dr. Posnick wants me to get double jaw surgery with 2 lower bicuspids probably extracted for maximum movement.  Using “Andrews facial analysis”, he observed a class 2 malocclusion with significant maxillomandibular deficiency and clockwise rotation of the jaws.   Two plastic surgeons recommended jaw surgery, solely from a cosmetic perspective.  I live in DC with immediate family in NY, btw.

Per Dr. Posnick, I had a sleep study followed up with a CPAP titration study, as well as a visit with an orthodontist and ENT of his choosing.  Below are the outcomes of those appointments:

I have very mild insomnia and some general anxiety, which I wonder how it might have affected my score, but I got a AHI of 9 and 14 on the two sleep studies, respectively (14 AHI with 4cm pressure.  12cm pressure got my score under 5).  I only slept on my sides, which is pretty typical for me unless I'm extra tired.     

The ENT noted nothing in my nose really causing sleep apnea, but the sleep study doctor (Dr. O'Donnell) noted in her medical records that my sleep apnea is caused by my set-back jaws.  I do not know the size of my airway, but below is a ceph taken shortly after my plastic surgery.    I'm a very thin guy (~140lbs, 5' 9.5") with a neck circumference of like 12”.  The apnea score isn't very high but I do worry a bit how another 10-20 pounds might affect my AHI#, say if my metabolism slows or if I try to get into shape and pack on some muscle weight (in my dreams). 

As for my teeth alignment, the orthodontist noted my lower jaw slides forward by 2-3mm (I've never noticed/voluntarily do so), and my bite is off on both sides. When I bite, I may hit certain teeth before others (notice this more after wearing my retainer).  He recommended, ideally, double jaw surgery and bicuspid extractions, but that braces with bite correctors could work as a "limited treatment" option.

I don’t have any TMJ at all, but I do have fatigue on a daily basis that I'm going to see if a CPAP machine can correct (at least as an interim solution until jaw surgery, if I do it).  I'm really struggling here on the medical necessity justification for jaw surgery, and wanted your guys' holistic opinion on it, versus just ‘camouflage’ treatment for vanity.  I believe Dr. Posnick will do jaw surgery with little to no medical justification, but he didn’t have all the reports from the sleep doctor and ortho when I last saw him. 

I just scheduled an appointment, in late July, with Dr's. Arnett & Gunson.  Their direct assistant reviewed my pictures, ceph, etc. and told the scheduling assistant I should "definitely" see them for an appointment.   I don't know if they do double jaw surgery for solely cosmetic reasons?  I don’t intend to do this surgery if my insurance doesn’t cover it (predetermination, medical necessity, etc. etc.).  I might try to get a phone consultation to see if they are thinking jaw surgery or just like a sliding genioplasty.

I look forward to reading what you guys suggest!  Posting pictures from before plastic surgery in this post, and post op/very recent pics, and ceph in the following.

[ditterbo]

A post plastic surgery pic taken the other day and ceph below.

[attachment deleted by admin]

[ditterbo]

Not sure you can see my current profiles well with the ortho pics, so here's the rest of what I took the other day.

[JimmyTheGent]

Can someone explain (as if I was in the 5th grade) why do some surgical plans entail extractions on the bottom??  Wouldn't the advancement in the lower jaw open up a gap in the teeth so what's the purpose of removing teeth??

[JayJaw]

^ It is because you need your bite to be perfectly stable after surgery to heal. But i'll get back to that.

So, in order to lengthen the lower jaw in more in relation to the upper jaw... you need an overjet (bottom front teeth further back than upper front teeth). Jut your lower jaw forward. How do your bottom front teeth line up in relation to your upper front teeth? Jutting your jaw recreates the forward movement of the lower jaw in relation to the upper jaw. So, it "replicates" a BSSO. If you jut your jaw 10mm, the bottom teeth will be in a similar spot if you had your jaw extended via BSSO by 10mm (while leaving your upper jaw alone).

So, do your lower teeth meet the upper teeth? Well, then your bite after surgery will be stable and you don't need to remove any teeth.

However, what if jutting your jaw gives you an underbite? That indicates that the BSSO will result in the same unless an overjet is create between the front bottom and front top teeth. You need to have that space that is then corrected via lengthening the jaw.

Unfortunately, that overjet is often now there for many with small mandibles? Why? Well, often because either tongue thrust or intentional orthodontics has tilted the lower teeth forward to meet the upper teeth. This helps functionally give you more space and help to bite things. However, it's not the ideal solution. The ideal solution is not to lessen the overjet by tilting the teeth forward but to extend the lower jaw itself.

So, how do we create the overjet? You need to pull those lower teeth backwards to get them upright. Well, unfortunately, a small jaw also often means the arch doesn't fit the teeth upright. This is because when you flare the teeth, you are also artificially creating more space for the teeth. The best way to depict this would be... I guess take your hand and put all your fingertips together (including thumb) like your making a shadow puppet. Let the fingers touch one another. Point the tips to the ceiling. This would be your teeth all next to other in a small arch lower. It's crowded. Now open your fingers... you'll see that you are essentially "flaring" them and now there is ample space between your finger tips. If you were to trace the "arch" created it would be wider.

When someone has crowded teeth and they can't actually expand underlying bone, they tilt the teeth to create space. If your teeth are dramatically tilted to create space to get them to simply not be crowded... then how can you expect to remove the tilt without severely crowding the teeth? There is no space! Sure, sometimes maybe they will shave down all your teeth a bit so they can make room. But usually there isn't a solution.

You say... doesn't the BSSO create room.

Of course it does. However, bringing it back to jutting your jaw, if you were to create the space while your teeth didn't have the necessary overjet, your bottom front teeth after creating the space via jaw surgery would go past the front teeth. Now you have an underbite and your jaws have just been broken. You won't heal properly and it would never be stable. Sure, things like distraction (where they slowly lengthen the jaw) can work to lengthen jaw and bring the lower teeth back simultaneously, but that isn't done because it isn't as exact, it works while your growing, and if you need your upper jaw adjusted then you still need jaw surgery... so what's the point?

Hopefully that helps explain it.

There are still people on here who say extractions never ever and I have yet to hear a response as to how the specific issue I mention can be solved without extractions. I'd love to know because it'd be more choice! However, it doesn't seem very possible. I'm not an expert though... so who knows.

[JayJaw]

To the OP...

You have a similar level of a recession to me and I'd say, yes, you do need jaw surgery without a doubt. Is it worth it? Well, you need to decide if improving aesthetically is worth the expense, recovery, and potential (honestly, likely but generally it seems minor to most) nerve damage. The chin implant looks somewhat unnatural and I feel bad that no plastic surgeon at least mentioned that a genioplasty would be a far better option for someone with a recessed mandible. Still, genioplasty really comes with same risks as jaw surgery since it seems like it's the cutting of the chin that really is where the nerve damage occurs more than anything.

It will without a doubt improve your airway. Whether or not you truly have or will ever get sleep apnea... who knows. It's not guaranteed just because you have recessed jaws. Same with jaw pain and stuff like that. I guess if you really gained a good amount of weight (muscle wouldn't contribute to this) then you'd likely get sleep apnea. CPAP machines seem hellish to me. Not that jaw surgery is a walk in the park either.

Anyway, good luck with whatever you decide. I know, for me (I'm in NY), it's been a tough decision. My insurance currently doesn't cover anything related to "tooth structures" so don't think my out of network (or in network for that matter) covers anything and I certainly cannot afford jaw surgery without insurance reimbursement. It sucks.

For me... sometimes I am happy enough about my looks despite my recessed chin. I can grow a decent beard and that helps. I despise that I can't really hold my tongue properly on the roof of my mouth and have some lip incompetence (you don't seem to have that) that has gotten worse since my bite opened up a bit over past 10+ years since braces removal (I'm 28).

Feel free to message me if you'd like to discuss!

[ditterbo]

We do have very similar profiles, JayJaw! It would definitely be interesting to see if you get a similar score as me in a sleep study (high side of mild sleep apnea to low moderate).  We have similar daytime sleepiness symptoms as you described it in your thread.

What I'm still really struggling to resolve here is proceeding with tooth extractions and jaw surgery to correct what sounds like very mild and low-impacting medical issues.  Am I misunderstanding? 

If this is really just a cosmetic issue, then why not go to like Dr. Yarumchuk in Boston and load your face with implants?  You'll have a 'close enough' outcome with half the cost and risk of double jaw surgery.  If insurance thinks your doing jaw surgery for cosmetic reasons, they won't cover follow on surgery from any of the myriad complications you may incur.

Also, has anyone seen the articles linking memory loss to missing teeth?  Basically, your teeth send signals to your hippocampus.  When they aren't present, your hippocampus gets less stimuli and atrophies. My memory is already plenty bad due to anxiety.

[Tezcatli]

I'd get jaw surgery with Posnick, I've read his book and he is awesome, it will improve your appearance a lot more than any implant.

[ditterbo]

I'd get jaw surgery with Posnick, I've read his book and he is awesome, it will improve your appearance a lot more than any implant.

I've had two consultations with him and he's a little scary in-person... like he's very gruff and all business, almost unsettlingly so.  I get that he's one of the best so I may return to him if I decide to go forward.  My CPAP machine comes in this weekend so I'll see how that goes (again only a 14 apnea score).


What I like about Dr. Gunson is they do a visual morph of how I'll look post op.  Not sure how I'd benefit or want to deal with HA, but they seem to uniquely offer that as well (if I need it?). 

Does my ceph x-ray or anything really indicate a need for jaw surgery though??

I feel like I may just be a case of plain old ugly, and massive amounts of surgery may not help me look much more attractive, just 'normal'.

[Tezcatli]

There are still people on here who say extractions never ever and I have yet to hear a response as to how the specific issue I mention can be solved without extractions. I'd love to know because it'd be more choice! However, it doesn't seem very possible. I'm not an expert though... so who knows.

You can expand your jaw horizontally with SARME, it is like SARPE but for the mandible. It is much more invasive though.

You can also advance the maxilla(most people benefit from a maxilla advancement anyway, ape face is a myth) together with the lower jaw so you can advance the mandible more, of course the end result must be stable so if your lower teeth are extremely crowded or proclined you may need extractions.

I've had two consultations with him and he's a little scary in-person... like he's very gruff and all business, almost unsettlingly so.  I get that he's one of the best so I may return to him if I decide to go forward.  My CPAP machine comes in this weekend so I'll see how that goes (again only a 14 apnea score).


What I like about Dr. Gunson is they do a visual morph of how I'll look post op.  Not sure how I'd benefit or want to deal with HA, but they seem to uniquely offer that as well (if I need it?). 

Does my ceph x-ray or anything really indicate a need for jaw surgery though??

I feel like I may just be a case of plain old ugly, and massive amounts of surgery may not help me look much more attractive, just 'normal'.

Alright, I only know him from the book so I can't tell how he is in person.

About the x-ray you can ask your surgeon or orthodontist to point out your deformities.
It is hard to do here, you need an instrument to measure angles and stuff, also the
 From my ceph the lab that made it sent some information, like my measurements and how they compare with the norm. My gonial angle was alright, my upper airway was 10mm vs the ideal 14mm(IIRC), and my upper incisors are proclined(naturally, but I'd have an underbite otherwise), my ortho and surgeon then used that to plan it, right now I got braces to decompensate my upper teeth so I will develop an underbite lol, then I will get the bimax surgery and advance both, but the maxilla slightly more to correct the underbite.


About HA, it is temporary, I'm not really interested but it gives some good aesthetic results.

About being ugly, having bad bones is the main reason men are ugly, jaw surgery can fix a great deal of that and it is not like you have treacher collins or sth which there is no hope.

Of course you will not become brad and marry angelina.

[strongjawman]

You can expand your jaw horizontally with SARME, it is like SARPE but for the mandible. It is much more invasive though.

You can also advance the maxilla(most people benefit from a maxilla advancement anyway, ape face is a myth)

Do you have any reading material on SARME?

Also, how is ape face a myth? I've seen a butt load of people look like chimps post maxillary advancement. Pulled cheeks and upper lip protruding in front of bottom.

[Tezcatli]

Do you have any reading material on SARME?

Also, how is ape face a myth? I've seen a butt load of people look like chimps post maxillary advancement. Pulled cheeks and upper lip protruding in front of bottom.

Here, about SARME.
http://e-kjo.org/search.php?where=aview&id=10.4041/kjod.2009.39.4.257&code=0123KJOD&vmode=PUBREADER

That is the idea, the upper lip should be in front of bottom. I don't think I've ever saw somebody look worse after surgery, except in cases of a doctor mistake(treating an underbite causing an overbite etc) or some severe complication like a non-union.

For example, that's an extreme advancement:


I still don't think it looks bad lol, but my point is that it seems to become prevalent that if you advance your maxilla 5mm or something you will look like a chimp, Sailer creates those freaks because he advances people over 10mm and give some women chins too big, but for a men I wouldn't worry that much. People get so scared of advancing the maxilla that they prefer to have lower jaw only needing more extractions and ending up with disappointing results.

[strongjawman]

Here, about SARME.
http://e-kjo.org/search.php?where=aview&id=10.4041/kjod.2009.39.4.257&code=0123KJOD&vmode=PUBREADER

That is the idea, the upper lip should be in front of bottom. I don't think I've ever saw somebody look worse after surgery, except in cases of a doctor mistake(treating an underbite causing an overbite etc) or some severe complication like a non-union.

For example, that's an extreme advancement:

I still don't think it looks bad lol, but my point is that it seems to become prevalent that if you advance your maxilla 5mm or something you will look like a chimp, Sailer creates those freaks because he advances people over 10mm and give some women chins too big, but for a men I wouldn't worry that much. People get so scared of advancing the maxilla that they prefer to have lower jaw only needing more extractions and ending up with disappointing results.

Okay, I see what you mean. Thanks for clarifying and the link too.

[kjohnt]

I see that woman exampled a lot and I have to say it is one of the best results I have seen.  I wouldn't call it extreme, just a large advancement.  It was necessary and she went from ugly to good looking. 

[Tezcatli]

I think it is a fantastic change too. The maxilla could've been slightly less for my taste though, imo that would have made her look even better. Her chin and mandible is what looks very good also the angle of her jaw. Lot of change there. If you cover that up it is not only the forward maxilla that looks good. Yeah it looks a lot better and she needed more forward maxilla but it is a bit too much I find and she looks slighty apelike. If you morph that slightly less she looks even better. The mandible is what gave her enormous change. Not just the maxilla.
What did he do to her jaw angle? Looks good. Some people have said some after pictures of Sailer are not completely real and have been touched up: is this true or just something people write?

Just look at the pics, she had bad hair, acne, crap lighting and so on on the before pic. I'd also give her less advancement but my point is that it still doesn't look that bad, it looks better at least.

She had some ccw rotation maybe which flared up her gonial angle,