Post double-jaw surgery concern: Upper jaw/lower jaw moved up too much?

[rtjawsurgery]

Hi guys,

I did my double jaw surgery and genioplasty 4 months ago in July. As the swelling went down, I began to see the results of the surgery and, to be honest, I am really not happy with it. My movements were, according to my surgeon, upper jaw 1mm forward, 3mm upwards, and lower jaw 5-6mm back. Genio was done to move my chin to where it originally was, so that I don't look too different (according to my surgeon). I don't know if they did any rotation (they probably did, because my lower jaw looks like it has been rotated/turned inwards).

My issues are:

1) When I talk, or when my mouth is slightly open/relaxed, i show mostly my lower teeth and all the way down to the bottom gum. Which is really bizarre. My bottom teeth is also bent unusually inwards in an unnatural way, but if that's something orthodontics can solve I am not concerned. I am more concerned about the fact that when I open my mouth, you see so much of my lower teeth. I have attached some pictures for you to see what I mean. In some of these pictures, I'm not straining at all, just opening my lower lip slightly. -- https://imgur.com/a/aXxfa

2) My upper lip now feels like it juts out a lot. I am not sure if this is because of the braces (then fine), or it has something to do with the surgeon impacting my maxillary and moving my lower jaw back at the same time. So now, when I am at my most natural rest, my lower lip often looks like it's tucked under my upper lip, resulting in a very weird look. Again, attached photos. I feel like I don't have a balanced looking profile at the moment - instead of an underbite (which is what I used to have), I now have my upper lip jut out over my lower lip, which totally defeats the purpose of doing this surgery. Could it also be that my lower lip looks smaller also because of how dented my lower teeth are, so they have nowhere to rest on? Or is this the kind of thing that can be resolved once my braces are off? I really don't like this protrusive profile. I mentioned this to my surgeons and they said it looks normal and not protrusive at all (and if it does, after braces things will get better). -- https://imgur.com/rD7nQ6F / https://imgur.com/y0G12hg (when i don't rest my lower lip under my upper lip, it looks more normal)

3. I used to show quite a bit of upper teeth but didn't really have a bad gummy smile. I think I did show a little too much teeth before surgery, so I was okay with the surgeon moving my jaw up, but now I feel like my upper teeth show has been reduced too drastically. I look really strange when I'm laughing with my mouth open. I have attached some before and after images. https://imgur.com/DORNpNi (I have to really strain my smile to look like the last picture)

Now, I am wondering if all these issues have to do with the same thing: over-impaction of my upper jaw. From what I know (please correct me if I'm wrong), the lower jaw follows the upper jaw right? So if my upper jaw moves up, my lower jaw moves up as well right?

To be clear, I think I do look better after the surgery, especially when I am not talking. I also look way better in 2D (in pictures). If it were not for what I believe is over-impaction of the upper jaw, I think this would be a surgery with an outcome that I'm happy with. The over-impaction, however, makes me look really weird when I am talking, with so much of my lower teeth showing and my upper lip/jaw jutting out.

I have some before and after images of my jaw here that do show the improvement -- https://imgur.com/DeawDEe / https://imgur.com/qwnXjPp /

In any case, I will be going to another jaw surgeon for a second opinion to make sure that I am not just being paranoid and complaining about what is a good result.

The thing is, I don't want to go through a revision surgery if I don't absolutely have to. So if this is indeed over-impaction, and my lower teeth really IS showing too much, is there any way orthodontics can help improve things?

My surgeon is quite a good surgeon and has done many jaw surgeries with beautiful results, so I'm not sure why this is happening to me.

Oh well. Looking very much forward to your input and what you guys think. Thank you in advance!

[Lazlo]

Your results are fantastic. You don't have any complications except for the ones in your head. Aesthetically the outcome is a triumph and you're still too early to judge all the sensation issues.

[kavan]

Hi 'rt',
I removed the same post from the other section as it was double of this.

I too, think your outcome is great compared to your starting point. Lower teeth show could just be a trade-off of maximizing the other aesthetic improvements or could resolve in time. If you still have this in a year, revision max fax would NOT be the procedure to consider. Instead, the procedure to consider would be one to attach the soft tissues higher on the chin aimed at reducing lower tooth show.  It is called; mentalis re-suspension.

[rtjawsurgery]

Thank you Kavan and Lazlo for your reassurance. I feel a lot better now. The thing is, I do see that there is a great improvement from before, but I guess it is human nature to want to have "perfect" results, whatever that might mean. I guess perhaps I am nitpicking a little too much. I will wait a little more to see if my excessive lower teeth show and my slightly protrusive upper lip resolve with time (or if orthondontics helps). In the meantime, I shall be grateful for the improvement and also be grateful that I was not left with more complications, if any.

Have attached more before and after images here if you guys have any more comments about my results: https://imgur.com/C3gJnyI / https://imgur.com/VIMufBo / https://imgur.com/NHkIxi9

Before and after comparison of candid shots: https://imgur.com/kSV9hB6

This montage is a comparison of my starting point (right before braces) and recently, 4 months post-op: https://imgur.com/1EP0cms

[kavan]

You have no more a 'protrusive' upper lip after the surgery than you had before it. In fact the soft tissue of your upper lip is thick and angled forward before surgery.

You had a RETRUSIVE Lefort 1 area before the surgery and that was corrected. Perhaps you are used to seeing your prominent upper lip along side retrusion above it and your mind is playing tricks on you.

Class 3 'frog bite' with protrusive mandible/chin often COVERS the lower teeth. So, you might have become used to not seeing them when they were covered by the lower protrusion you started with. I think more lower tooth show is a trade-off.

[JawKid7]

dude these are epic results

[girl]

Admittedly from your pictures, I can see what you mean about the slightly over impacted maxilla (for your case) and the lower tooth show. I don't see any real protrusion from the side - it could be your natural anatomy.

The good news is that lower tooth show can possibly be fixed with a resuspension of the mentalis muscle.

You might also benefit from a very very minor length reduction to the chin, if the maxilla was impacted, to balance things out but it's really difficult to say with cropped pics.

[rtjawsurgery]

hi kavan, thanks for the analysis. I do think that it could be my lower lip being smaller now, hence making me appear to have a protrusive upper lip. it's slightly more obvious in real life than in photos. that's why even my sister and one of my friends pointed out to me that i do look like my upper lip is slightly protrusive, and it looks almost like it's because of its relationship to my now more inward lower lip.

hi jawkid7, thanks for your kind words!

hi "girl", thanks for your honest answer! i will be seeing another jaw surgeon for a second opinion on whether it's really over impacted, but from what i can see (and i try to be as objective as possible), i think it's quite clear that my lower tooth show is much more than is what is considered normal or average, which can't be good. it does make me look very weird when i am talking. i also hate that i show considerably much less upper teeth than before - i really, really wish i could show more upper teeth when i talk and smile. i think i would definitely look so much better. but yeah, i will see another surgeon to see what he thinks. i definitely am not in favor of doing another surgery; my hope is for things to resolve over time, since i am now at 4 months and things might still change!

i have some more uncropped pics here: https://imgur.com/a/j6dC2

[kavan]

With a class3 'frog bite' and very PROTRUSIVE lower jaw/chin, the BIG bone structure of that and the soft tissue modeling over it is often one where the lower lip totally covers the lower teeth.  Excess lower lip coverage is a function of excess protrusion. When the excess protrusion is reduced, there is soft tissue re-modeling. If the function is one where soft tissue lower tooth coverage is directly proportional to the underlying bone structure, less bone protrusion is consistent with less lower tooth coverage.

Some of these trade-offs are even predicted on the ceph displacement diagram used as a planning 'map' or proposal for the surgery where the 'pay-off' of correcting a massive deviation of the bone structure will kick up a trade-off somewhere else.

IMO, what you have is soft tissue remodeling as a function of what was needed to do rid you of the massive jaw IMBALANCE you started with.

[rtjawsurgery]

hi kavan,

thanks for that. i see what you mean!

i guess my issue is, i feel like my upper tooth show is also not satisfactory. so i was wondering if the position of the lower jaw (and hence my excessive lower tooth show) is also related to the now higher position of my upper jaw?

what i really wanna know is, when it comes to moving the upper jaw UPWARDS, is it always an aesthetic choice? in my case, my surgeon felt that i was showing too much teeth at rest, so he decided to move my jaw upwards. but as for the precise movement, i am wondering if he really needed to move it that much, or if it was simply bad judgement on his part. from my conversations/consultations with him, i understand that they go by the numbers. the idea is to move my facial proportions into what is deemed as average/normal.

but when i look around at people around me with so-called average/normal jaws, i do feel like i see a lot of examples of more satisfactory tooth show, with their smiles looking natural and their upper teeth showing almost fully. that's unlike what i am experiencing now - right now i have to strain quite a bit to show even half the height of my upper teeth.

i also liked my original tooth show, even if it was a little excessive. i would have wanted to reduce it, but not so drastically.

anyway, i am very cautious of being overly paranoid, but i really do think that i would be happy if this were indeed a satisfactory result, but it is a fact that when i look into the mirror, i do feel like something is off, especially when i catch glimpses of myself talking/laughing. and it's not just about not being used to a new face.

again, as a disclaimer, i must say that i understand that my facial proportion has been drastically improved (as well as my facial asymmetry before the surgery), but my dissatisfactory / strange-looking upper tooth show is rather disappointing. among the issues i listed in the original post, this is almost what bothers me the most.

[tdawg]

I feel you brotha. I have the opposite issue. I still have slightly excessive tooth show and significant lip incompetence after my surgery. Personally I feel like for men its better to be in your situation than mine, but I see why it bothers you. Some things to keep in mind though are that they only impacted you 3mm and they moved you forward 1 mm so the effect is less than 3mm impaction. That isnt a huge movement and it looks like you had a slightly gummy smile before. I dont think its out of the realm of possibility that your muscles havent adapted to your new bone structure yet. Think about it, you were probably compensating for your slight VME with slightly extra contraction of your lips(probably without even realizing it since you didnt have a big interlabial gap). All of a sudden you wake up one day with that excess gone but your muscles are still conditioned to contract slightly. 4 months probably isnt enough time to unlearn a lifetime of a habit. With time your upper lip might relax a bit and get you to ideal incisor display. But you are doing the right thing in seeking a 2nd opinion. If you really want to know you should probably book a consult with Gunson. It will be about 500 dollars and a trip to California but he will give it to you straight.

[kavan]

hi kavan,

thanks for that. i see what you mean!

i guess my issue is, i feel like my upper tooth show is also not satisfactory. so i was wondering if the position of the lower jaw (and hence my excessive lower tooth show) is also related to the now higher position of my upper jaw?

what i really wanna know is, when it comes to moving the upper jaw UPWARDS, is it always an aesthetic choice? in my case, my surgeon felt that i was showing too much teeth at rest, so he decided to move my jaw upwards. but as for the precise movement, i am wondering if he really needed to move it that much, or if it was simply bad judgement on his part. from my conversations/consultations with him, i understand that they go by the numbers. the idea is to move my facial proportions into what is deemed as average/normal.

but when i look around at people around me with so-called average/normal jaws, i do feel like i see a lot of examples of more satisfactory tooth show, with their smiles looking natural and their upper teeth showing almost fully. that's unlike what i am experiencing now - right now i have to strain quite a bit to show even half the height of my upper teeth.

i also liked my original tooth show, even if it was a little excessive. i would have wanted to reduce it, but not so drastically.

anyway, i am very cautious of being overly paranoid, but i really do think that i would be happy if this were indeed a satisfactory result, but it is a fact that when i look into the mirror, i do feel like something is off, especially when i catch glimpses of myself talking/laughing. and it's not just about not being used to a new face.

again, as a disclaimer, i must say that i understand that my facial proportion has been drastically improved (as well as my facial asymmetry before the surgery), but my dissatisfactory / strange-looking upper tooth show is rather disappointing. among the issues i listed in the original post, this is almost what bothers me the most.

Displacements aimed at optimizing jaw balance are basically  multi-variable functions. Something where they choose the KEY displacements needed to optimize but for which other things may vary as a result. It's like math where one thing is the function of the other and there are constraints. It's like math where they go by the NUMBERS, choose the main constraints aimed at optimizing where you don't get to choose how every other variable in the equation varies.

Your question resolves to referring to a 'precise' movement with assumption I would know what that number was and if it was 'too much'.

Let me put it this way: If you wanted the output to be the exact amount of tooth show as you would like to see it or as you see it in other people, than you 'shoulda' gone in there with LESS retrusion of upper jaw and LESS protrusion of the lower jaw.

Sorry. I don't know any other way to explain this conceptually. You got an OPTIMAL outcome relative to the INPUT. Optimization is not a thing where every variable of the OUTPUT can be controlled or selected and it doesn't equal 'perfect'. The only way to control every variable of the output is to control every aspect of the input.

[girl]

After seeing your full face photos, I think some vertical chin reduction would definitely look good. If this was done right, you'd have a squarer/more angular lower face shape from the front. I think your concerns about the maxilla are valid as well. Seems like certain elements have been overdone, whereas other elements may have been slightly underdone or left alone. The solution is probably a lot more complex than that but it is not looking "bad", don't worry - you just haven't achieved your objectives maybe. Definitely get the opinion of US surgeons suggested by people here.

[kavan]

After seeing your full face photos, I think some vertical chin reduction would definitely look good. If this was done right, you'd have a squarer/more angular lower face shape from the front. I think your concerns about the maxilla are valid as well. Seems like certain elements have been overdone, whereas other elements may have been slightly underdone or left alone. The solution is probably a lot more complex than that but it is not looking "bad", don't worry - you just haven't achieved your objectives maybe. Definitely get the opinion of US surgeons suggested by people here.

Sure it would if you disregard the salient relationship of soft tissue remodeling downward with further reduction of bone.

[rtjawsurgery]

hi "girl", to be honest i'm not that concerned about my chin, but more so about my dissatisfactory upper tooth show and excessive lower tooth show.

i guess what i really would want is to have my surgeon recognise that it is a valid issue, rather than just dismissing it out of hand as my paranoia. or worse, denying the issue even though he knows that it is valid. that's why i'm going to see another surgeon for a second opinion.

as i mentioned, i definitely don't wanna opt for another surgery if i can, so i was wondering if anyone knows if orthodontics can help to improve upper tooth show like in my case to something more optimal.

anyway i dont reside in the US, but this surgeon in my country is supposed to be very good!


kavan, thanks again for your clear explanation. i get what you mean. even if that is so, then i must say the "optimal outcome" is still a little dissatisfactory for me. i truly believe that if my maxillary weren't moved so much, and i dont have what i think is now sub-optimal upper and lower tooth show, i would be very happy with the results, as i like how my front face looks like now, and despite my slight upper lip protusion, i think my profile has been greatly improved too (and i also think the slightly protrusive lip could be partially caused by the braces too, so im okay with waiting that out).