What's my best option?

[Tetley]

Thanks for the reply. I am getting the idea it would probably be best to do double jaw surgery. Because of my living situation, the time involved for that I am discovering is a bit of an issue for me. If I were to just do upper jaw, would I see an improvement? Or would it make me look worse then I do now to do upper jaw and not lower. Thanks again.

[kjohnt]

Trust me, you want both jaws.  Lefort I for anterior maxillary impaction and bsso for advancement.

[kjohnt]

Okay check this out.  This is an example from a person I'll call "J".  I think not only is this a good example for the case at hand but a good example in general of CCW rotation achieved using anterior maxillary impaction.  Please note that I asked J to use her radiographs and pictures as an example on this forum and she graciously gave me her consent.  I sent her a link to this thread as part of that so she could read about this case.  If you do not like her outcome or do not agree with my analysis in any way, please be courteous regarding her pictures.

Attachment A is a before/after radiograph of J.  She underwent 5mm impaction along with 5mm mandibular advancement.  That's it.  I drew vertical lines from the nasion for easy reference of horizontal jaw projection.  Attachment A.1 and A.2 are her profile before/after pictures.  Attachment A.3 is her frontal before/after.

From the original radiograph and picture, it would be easy to think she needed bimax advancement and genioplasty.  I saw her before/after prior to the radiographs and assumed she'd gotten both.  Note the CCW rotation achieved also results in some "maxillary advancement" of the soft tissue even though the molars are in the same (albeit rotated) position. 

Anyway, I think her result is one of the best I've seen; IMO she looks absolutely stunning.  Her surgeon's plan of attack was spot-on.

Attachment B is Tetley.  I drew a vertical line from the nasion for easy reference of horizontal jaw projection.

When comparing to J's pre-op, you can see Tetley's similarities.  It's super close.  J may have had 1-2mm more maxillary projection.  Tetley's maxillary vertical height is 1-2mm more if you compare the upper incisors to the lower lip. 

Given this information, again, I think Tetley would best benefit from 6-7mm anterior maxillary impaction resulting in CCW rotation along with a BSSO mandibular advancement to then close the resulting overjet to class I.  I think the post-op ceph would look nearly identical in terms of occlusal plane and horizontal jaw projection.  No maxillary advancement or genioplasty needed (except maybe genioplast for mild vertical height addition which could help the lower lip curl).


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[kjohnt]

Here's a J pre-op to Tetley to mine comparison.  These are not to scale.

Mine shows more of a need for horizontal advancement along with the CCW rotation (but perhaps from posterior downgrafting instead of anterior impaction - this is something I'm trying to wrap my head around in that if I advancem the jaws horizontally, will gum show and lip strain then occur and I should get impaction even though current tooth show is good and no lip strain... for another thread).

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[Lazlo]

wow kjohn, j's results are PHENOMENAL she looks incredibly beautiful now.


only really unfortunate about the upper lip lengthening like that. f**k i wish that could be changed. she'd be perfect.

[Lazlo]

wait is that frontal second picture a "morph" of Tetley done by you Kjohn?

[kjohnt]

wait is that frontal second picture a "morph" of Tetley done by you Kjohn?

No, I've done no morphs here.  That's the after result of J.

[Lazlo]

oh i see well she's friggin beautiful.

[Tetley]

Thank you so much for taking the time to get those, and thanks to your friend as well for the permission. I really appreciate it, and she does look totally amazing. She was pretty before too though! Yes, I can see this is probably the way I want to go. Just to clarify, she did not get extractions? I spoke to my orthodontist again, but he seems convinced the extractions are an absolute necessity. He says my previous orthodontist overcompensated for the overbite by pushing all my teeth forward so this is the only way to go. I am going to see if I can ask the surgeon what he thinks. Do you think I should get a second opinion? Thanks again for all your advice. Do you know how long her treatment was?

[Tetley]

Oh , and the ortho I am with does offer damon braces, although he did not mention it to me.

[kjohnt]

No problem.  You have pretty eyes and the rest of your features are goodm, so you too are going to look great when you get done with all of this.

She didn't have any teeth extracted, and not sure about timeline.

It's not really fair of your current ortho to blame your prior ortho for pushing the teeth forward as a reason your teeth don't fit into your arches... he could simply pull them back.  If they don't fit within the arch, it's your genetics and or growth.

I'd always recommend surgeon>orthodontist>dentist.  So that's to say it's up to the surgeon as to whether or not extractions are needed.  I think most try to avoid them if possible.  There are some other options (mandibular widening, enamel cutting) but they are all worse from what I've gathered.  But yeah, please don't let your ortho or dentist do anything to your teeth without prior approval from your surgeon.  If your surgeon says you need teeth extracted, I'd listen, but would ultimately get a second opinion from another surgeon first just to be sure.

[Tetley]

I just spoke with the surgeon again and he is strongly recommending just the upper jaw and possible Genioplasty. He believes that this will allow the lower jaw to move forward counter clockwise? This is the second surgeon who has given me that opinion, the first one said he was not comfortable doing both jaws at all, as he did not see a benefit. Do you think they are wrong?

[kjohnt]

Like I said there are different approaches one could take.  Some are more ideal than others.

Did you bring in copies of my example to show the surgeon?  I could certainly be incorrect about your case, but my biased opinion says otherwise.  I'm wondering what they'd be doing if only moving your maxilla.  If just impaction, once the mandible rotates forward at the joint to cover the new space, I think you will have some overjet.  So they'd have to also bring the maxilla back a bit when fixating if not touching the mandible.  That's not aesthetically ideal at all.

You need to be asking lots of questions.  Also you need to do lots of research.

Again, I'm no surgeon, but many of these guys seem to have very little clue about aesthetics, unfortunately.  Your local surgeon just down the road may won't cut it.

You said you're in Canada right?  IDK if close, but Google Dr. Hohn in Saskatoon and get in touch with his office.  He did the exampled case.

[molestrip]

I just spoke with the surgeon again and he is strongly recommending just the upper jaw and possible Genioplasty. He believes that this will allow the lower jaw to move forward counter clockwise? This is the second surgeon who has given me that opinion, the first one said he was not comfortable doing both jaws at all, as he did not see a benefit. Do you think they are wrong?

Surgeon is wrong. This is a very common mistake they make, trying to look at you and deduce what would look good. The goal here is to make you normal like everyone else, as if you never had deformity in the first place. To do that you need to understand the nature of the deformity - what went wrong with your face. What you have is VERY common and very routine. You have long face syndrome. You have or had bad allergies as a child and in the first few years of life your face grew down instead of forward and as a result both jaws are underdeveloped. The upper jaw continued growing down to meet the lower jaw, hence the gummy smile. Impaction would solve many but not all of the problems. The biggest one it won't solve is the airway. There's no scale in your xray so I can't measure it but without double jaw, you'll likely have sleep apnea when older if not now, that's why Plosko said get a study. It sounds innocuous but it's not, it's a very serious medical condition which underlies so many other disorders, you do not want it. Single jaw is penny wise dollar stupid in your case. You likely have transverse discrepancy and a steep occlusal plane as well because they come as a package. And your gum tissue is of thin type and your bones are thin. As for extractions, that's a function of arch length. Removing teeth is unaesthetic but it's health and stable for the teeth long term when there isn't space. You can expand upper jaw arch length but not lower jaw.

You need to decompensate the teeth so surgeon can see the most stable position for them. That takes 6-12mo. Then another 6-12mo after surgery in braces. Multi-segment LeForts are often needed in cases like these, depends just on how steep you are (determines the curve of Spee).

You are pretty btw, despite the protrusion. You'll be even prettier after surgery