Need opinions based on Xray?

[alexismg2]

Hello guys, was hoping someone (or a few people) may have some experience with looking at xrays. I was here a few months back and posted some pics but figured an xray would be more helpful.. was curious if I may possibly look like a jaw surgery candidate or not? Thanks in advance!




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[kjohnt]

Absolutely.  Lip incompetence looks severe.

You need your wisdoms pulled.  You need sliding genioplasty to reduce chin height and add horizontal projection.  Impaction to shorten midface assuming gummy smile.

[kjohnt]

BTW who took the x-rays?  Certainly that person informed you about orthognathic surgery?

[alexismg2]

Wow you're awesome, I was shocked when you mentioned the wisdom tooth thingy. Been avoiding that for 3 years now but am planning to get it removed really soon.

I visited 4 surgeons total. The one who did this xray, looked at my xray and said "its not that bad". He then asked what I wanted him to do. I told him and he informed me that he can only shorten my face by about 2mm through impaction because I don't have a gummy smile, which he said will not make a noticeable difference in my appearance. He didn't notice my mouth protrusion and seemed confused when mentioned that I had an overjet. But then he said I should just get braces and extractions to push the mouth back completely,  and then come back to get sliding genioplasty.

The weird thing is, another surgeon I visited (who I found through this forum) said I did have a gummy smile, especially when I laughed, and that my face would need to be shortened. Without seeing an xray he said he noticed the lower jaw going downward and that the plan would be to turn the steep angle into a horizontal one. He also mentioned softening the mouth protrusion which I didn't have to bring up; he saw it while I was laying down being examined.
 
Now I'm not too sure whether I have a gummy smile or not..

Both surgeons were nice.

Both mentioned that I had a wide palate. I brought up CCW rotation. The first one mentioned that because I had no gummy smile, that if he did CCW rotation that my upper teeth would not show after surgery which would look horrible. The second surgeon said he wouldn't recommend CCW rotation because of my 5'11" frame and a small head not looking proportionate with my body.


The other two surgeons I axed because they couldn't see anything wrong with me just by looking at my face and said my profile looked normal.

I did an at home sleep study (took the machine home, used it and returned to hospital). It said I had very mild sleep apnea. My mom has sleep apnea but more towards moderate.

So far these are my stats:

-5mm overjet
-Lip incompetence
-Vertically maxillary excess
-Recessed chin
-Possible gummy smile (or not, who knows)
-2 bad wisdom teeth which I'm planning to remove this year
-Mild sleep apnea

I set up an appointment with the 2nd surgeon for the end of July to get molds and some other stuff done because he wants to map a plan for surgery. His friendly assistant said that because my sleep apnea was mild that the office would have to 'fight hard' to get insurance coverage but they will try for me. I'm not thinking too far ahead though because I want to see what the surgeon says once he sees my xrays. I plan to bring them to him so I don't have to pay for another round. This is all I know for now.

[Veuve]

I have similar issues. First surgeon just recommended extractions and braces to bring the teeth back, second said impaction with no rotation. I think LF1/impaction+CCW+braces is probably the best plan though

[kjohnt]

You'll need all four wisdoms pulled, generally as a separate operation a few months prior to the big one.

A wide palette is good so you have that in your favor.

Without drawing lines and breaking out my protractor, it appears your occlusal plane is within the ideal range of about 5 degrees off of horizontal and you are not a candidate for ccw rotation.  Any impaction will be even front to back.  Your curve of spee is exaggerated but will be pretty level once wisdom teeth are out.

The odd thing going against you is that while your occluded plane is good, your mandibular plane is steep.  This is due to short ramus, and I honestly don't know if there is anything that can be done about that.  As far as I k ow, the only option for your steep mandibular plane is to smooth it out at the chin by reducing its height.  This will be necessary to help the lip incompetence as it appears most of yours is actually cause by that which is rare from my research.  It will be especially necessary given that you will need bsso to close your overjet.

Finally, because your case is a little odd, the best advice I can give is to consult with Dr. Gunson's team.  It is 175 if you do it without visiting and I think 250 or so if you fly in.  I haven't yet but so many folks give him and Arnett high praise that you might as well see what they have to say.

[kjohnt]

And again, the chin will need to come forward as well such that the gonian sits under your lower incisors.  I just don't know how this would affect your lower lip.

Do you have front and side pictures?  Front with normal smile would be helpful to see gumminess.

[alexismg2]

Veuve, I was interested in getting braces with extractions before, but was informed by a resident (jaw person) in training that it could relapse, so there is no guarantees going that route. Do you have a gummy smile/long face and are planning for CCW rotation with impaction? I definitely feel my face is too long (in the mid-face) but if I have no gummy smile then don't want to risk getting the incorrect treatment. For me while having a short face would be great, I don't care to look perfect. Just looking for a balanced face. The less brutal the treatment the better lol. 

kjohnt, are you a doctor? Just wondering. I'm a complete noob so let me just try to understand.  From the info you provided, even though my lower jaw growth is kinda abnormal, and different from both my parents who have the regular horizontal jaw growth (along with shorter faces), mine was meant to be that way.. But if I fix my chin with sliding genioplasty, where it is cut on the bottom and then moved forward,  then it would shorten my face somewhat, fix the lip incompetence and improve my profile from the front and side. Which makes sense. This is also level with what the first surgeon told me.

As far as bsso, if it would improve my overjet or eliminate I'm all for it!!! I am so self-conscious about that.

I'm in NY so visiting Dr. Gunson's team would be quite a trek. Does he take insurance? I hope he's not expensive but I will definitely get in contact with him and see what he says about my face/jaws.

I forgot to mention, I'm sure my jaw is lopsided but an orthodontist told me that cannot be fixed. *sigh* lol

My pics below.



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[Vic]

You should consult with Dr Z straight away. I've got mouth protrusion and a steep mandible plane like you and I'll be having surgery by him in a couple months. To to fix the mouth protrusion, he's going to do a segmental osteotomy of the upper and lower jaws and also setback the mandible. To fix the steep mandibular plane and give my ramus more vertical length and also fix the recessed chin, he'll be doing a chin wing osteotomy.

[kjohnt]

Ah yes I remember you.  Your lip incompetence looks much worse in the lateral x-ray.

Given pics and x-rays, I think lefort 1 impaction of 2mm with no rotation to slightly reduce maxillary height, bsso mandibular advancement to close overjet, and a large sliding genioplasty to reduce height and add projection.  Regarding the genio, the chin will be cut diagonally like a backslash (but not as steep) if looking at your right side, so the cut piece will "slide" both forward and upward.

The genio plus bsso should help uncurl your lower lip.

As Vic said, you could do some implant work to artificially lengthen the ramus, but that's not my thing personally.

I don't see "lopsided jaw."

Gunson is not affordable for most and will not take insurance.  I recommend a consultation just as a way to get a detailed, well-regarded opinion.  You'll likely have to get surgery elsewhere.

I'm not a doctor, just an obsessive researcher

[alexismg2]

At first I didn't know who Dr. Z was (sorry I'm a complete noob) but I saw another person mention Zarrinabal? I think that's who Dr. Z is. I couldn't find his website but found out he is in Berlin! Woah I am not rich guys. Unfortunately doubt I could make a trip that far (broke college student). I also don't know what his pricing is. I hope your surgery is a success though, Vic (and I look forward to seeing if you update on your journey). It seems like he may be a great doctor since he is popular for his work.

I think I may just keep things simple and go for a sliding genioplasty, and have both jaws moved forward. I go to visit doc in 3 weeks (Sachs) and he can see the x-rays. I'm praying he can remove enough chin bone to make a noticeable difference in the steep appearance of the lower jaw and give a more balanced look with projection. My cheeks are flat with no volume (non-smile), so maybe that's what makes the mid-face look longer, not necessarily that it needs an impaction although I wouldn't mind getting the impaction (I think I will even if only a tiny difference). But I think moving both jaws forward would be enough to put volume back into my cheeks (because the bone will finally support it instead of being flatish from the side profile) making it look rounder and balanced, not so horsey. The one thing that would make me sooooooo thrilled would just be to get rid of the overjet though. So when the jaws are moved forward my face from the front will be balanced and I won't be afraid to take pictures anymore. My confidence will be better.

I am still going to contact Dr. Gunson (doubt I can afford Gunson but if he has another opinion I can take that to the doc I'm seeing too).

The only thing that I may focus attention on is the nose. Will look to see what happens (if things even end up getting approved). Hopefully it'll be the same way. But if it becomes wider idk. I love my nose now and don't want any change.

I have realistic expectations and not looking to seek perfection, not that there's anything wrong with that, but I don't want to drive myself crazy trying to look like a barbie doll supermodel (not that I ever will anyway). I realize there is only so much that can be done and I'll be happy with even a slight improvement. Thank you to kjohnt for the knowledge.

[Vic]

You should contact Dr Dechamps Braly in San Fransisco. He's just as good as Gunson and is a lot cheaper

[JimmyTheGent]

At first I didn't know who Dr. Z was (sorry I'm a complete noob) but I saw another person mention Zarrinabal? I think that's who Dr. Z is. I couldn't find his website but found out he is in Berlin! Woah I am not rich guys. Unfortunately doubt I could make a trip that far (broke college student). I also don't know what his pricing is. I hope your surgery is a success though, Vic (and I look forward to seeing if you update on your journey). It seems like he may be a great doctor since he is popular for his work.

I think I may just keep things simple and go for a sliding genioplasty, and have both jaws moved forward. I go to visit doc in 3 weeks (Sachs) and he can see the x-rays. I'm praying he can remove enough chin bone to make a noticeable difference in the steep appearance of the lower jaw and give a more balanced look with projection. My cheeks are flat with no volume (non-smile), so maybe that's what makes the mid-face look longer, not necessarily that it needs an impaction although I wouldn't mind getting the impaction (I think I will even if only a tiny difference). But I think moving both jaws forward would be enough to put volume back into my cheeks (because the bone will finally support it instead of being flatish from the side profile) making it look rounder and balanced, not so horsey. The one thing that would make me sooooooo thrilled would just be to get rid of the overjet though. So when the jaws are moved forward my face from the front will be balanced and I won't be afraid to take pictures anymore. My confidence will be better.

I am still going to contact Dr. Gunson (doubt I can afford Gunson but if he has another opinion I can take that to the doc I'm seeing too).

The only thing that I may focus attention on is the nose. Will look to see what happens (if things even end up getting approved). Hopefully it'll be the same way. But if it becomes wider idk. I love my nose now and don't want any change.

I have realistic expectations and not looking to seek perfection, not that there's anything wrong with that, but I don't want to drive myself crazy trying to look like a barbie doll supermodel (not that I ever will anyway). I realize there is only so much that can be done and I'll be happy with even a slight improvement. Thank you to kjohnt for the knowledge.

Since you are in NY like me maybe you should go see Derek Matthew Steinbacher, DMD, MD, FACS in CT.  I think he takes insurance and his credentials are quite impressive.  Being an oral surgeon, a medical doctor, and a plastic surgeon he should have a pretty good eye for soft tissue aesthetics with bone movements. I asked him how many jaw surgeries he performs per year and he said over 100 in addition to other types of facial reconstructive surgery.   As for the nose doesn't an Alar cinch keep the nose from changing drastically?

[molestrip]

We have to be careful giving advice to you because most of us aren't familiar with the norms for black people. Protrusions are common for example. You do have a gummy smile, not bad enough to be worth fixing IMO but a nice benefit if you get surgery anyway. I would have said that your airway looks good but if you tested positive with mild sleep apnea that's a concern, especially if you aren't CPAP tolerant. It gets worse with age and you could become intolerant at any time. With a steep mandibular incline like that I would think that you'd be at greater risk if I had not seen the airway. How are your joints? Those tend to be at greater risk with malocclusions and it is suspected that the adaptive capacity of them degrades with age though I haven't seen any evidence of that. Your wisdom teeth look fine to me. I kept mine for a long time too and they were awesome but they'll need to come out in preparation for jaw surgery, mostly due to limitations in the current technique. Some surgeons are willing to leave them in though. Most prefer to get them out 9mo before surgery and only real high volume guys will remove them during surgery. Certainly the dental compensations we have aren't wonderful long term, leading to problems with the teeth and gums but that's also common in the general population.

I would say you're a good surgical candidate but not for any one particular reason, just a bunch of minor things that can all be fixed at the same time. Where are you located? In general, all things being equal staying close to home is better and there's probably a big name nearby if you do a little research. I met Dr Gunson and he is a fine choice as well if you want an easy choice and don't mind the cost/travel. One area that practices excels in is in customer service, which does matter. Dr Gunson is supremely nice and patient, rare traits in surgeons today. And reassurance knowing that you won't be botched. I have yet to hear of a single careless mistake made from that practice but like I said, there are other surgeons with similar attention to detail that are closer/cheaper. Each practice has it's own unique set of tradeoffs.

[alexismg2]

You should contact Dr Dechamps Braly in San Fransisco. He's just as good as Gunson and is a lot cheaper

He has plenty of positive reviews! I'll check him out along with Gunson, but just for opinions. Ultimately if insurance can cover this I'll take it though. Even 15k is way too high for me. I know others on here are probably ballin with cash but not me unfortunately.. 

Since you are in NY like me maybe you should go see Derek Matthew Steinbacher, DMD, MD, FACS in CT.  I think he takes insurance and his credentials are quite impressive.  Being an oral surgeon, a medical doctor, and a plastic surgeon he should have a pretty good eye for soft tissue aesthetics with bone movements. I asked him how many jaw surgeries he performs per year and he said over 100 in addition to other types of facial reconstructive surgery.   As for the nose doesn't an Alar cinch keep the nose from changing drastically?

Have you visited him for a consultation? If so, did you like him? He also has positive reviews, no negative ones in sight from what I see. I'll keep him in mind, especially because being in proximity helps. He also takes my insurance- Yay! Regarding the alar cinch, I don't know what that is (noob), but if it works that'd be something to bring up before surgery.


This is a little overwheming.. sorry guys. Like I said, I'll be happy to just look improved, perfection doesn't matter.