Soft or hard tissue problem?

[Dogmatix]

I'm trying to wrap my head around whats actually going on with my face and try to pin-point exactly what I'm not happy about.

It's hard for me to be very precise on my description of what I'm not happy with, it just feels off when I look at it. I'll try to explain what I see atleast.

I feel that I have "feminine" features, small/narrow jaws, bad jaw line and lack of contours in the face.

I've made a cepth scan in profile (attached), where these things kind of can be seen. I've marked out some of the things with the lower jaw. On the upper face I can feel similair things with the cheek bones not being very visible. Even though I'm not overweight at all, it's like the face is round and small however I look at it, and not the sharp well defined face one would like.

There are of course dental problems as well, but I was thinking about having focus on the aesthetical in this post, but sure it needs to be possible to wrap up with the teeth as well.

When looking at my face and I pull my entire face forward, then atleast I think it looks much better, the jawline gets enhanced etc.
So to me there are 2 approaches to the pure aesthetic problem. Either you can perform a bimax surgery and move both lower and upper jaw forward, maybe do some rotation etc to get good facial structure. I dont understand all the proportions that needs to be considered, but is there room for a procedure like this. To me it seems like if the upper jaw is advanced, it might come out of proportion with my forehead?

Or maybe it's more of a soft tissue problem. Maybe the area marked in red still will have the same problem if the jaws are advanced? How far would a plastic proceducedure that only focus on the soft tissue bring me?

What I'm trying to understand is what part of the aesthetic features that are connected to skeletal problems, and what parts that are more soft tissue problems. How will the face change with different procedures?

[kavan]

It looks like you have class2 Div2 deep bite with short chin.

Your maxilla (ANS-PNS) is rotated counter clockwise to a significant degree.

You would probably need a down graft and alteration of the anterior nasal spine in order to push maxilla forward if that were needed to 'match' advancement of lower jaw. If not your nasial labial ange would get excessively obtuse which it is already. Your upper front teeth would need to pushed forward for an angled out overjet and your lower teeth pushed backwards in braces to accommodate a bi-max surgery.

The line of the anterior cranial base is 11 deg away from the horizont and the norm is 7 degrees away.

Can't elaborate on everything. But it looks to be a case for a good maxfax surgeon who would be able to compensate of the excess inclination both the anterior cranial base and the maxilla has and also do rhinoplasty techniques so the nasial labial angle gets more CLOSED than more OPEN during the bi max surgery.

[Dogmatix]

It looks like you have class2 Div2 deep bite with short chin.

Your maxilla (ANS-PNS) is rotated counter clockwise to a significant degree.

You would probably need a down graft and alteration of the anterior nasal spine in order to push maxilla forward if that were needed to 'match' advancement of lower jaw. If not your nasial labial ange would get excessively obtuse which it is already. Your upper front teeth would need to pushed forward for an angled out overjet and your lower teeth pushed backwards in braces to accommodate a bi-max surgery.

The line of the anterior cranial base is 11 deg away from the horizont and the norm is 7 degrees away.

Can't elaborate on everything. But it looks to be a case for a good maxfax surgeon who would be able to compensate of the excess inclination both the anterior cranial base and the maxilla has and also do rhinoplasty techniques so the nasial labial angle gets more CLOSED than more OPEN during the bi max surgery.

Wouldn't a rotation this way make the jaw line even less defined? Or do you mean that this is handled later with advancement forward?

[kavan]

Well, there is somewhat of a mechanical conundrum because counter clockwise rotation is often needed to get a good advancement to the lower jaw but you already have excessive CCW to the ANS-PNS (maxilla). So, more CCW or even linear advancement along the inherent incline of your maxilla would tend towards making the overly obtuse nasial labial angle more obtuse. So, maybe some clockwise rotation with the bi-max advancement. Either way, the orientation of the anterior nasal spine is not a good one and it would probabably have to be cut down/reduced to close the excessive nasial labial angle with any kind of advancement.

As to soft tissue, well the part we see from the ceph, expecially the nasial labial angle is clearly a function of the bone structure underneath.

Now, IF what 'bothers' you is the upwardly angled nose along with the long lip (labial ledge) and you can isolate THAT as the problem when looking in the mirror, that could be addressed by a type of rhino that cuts down the anterior nasal spine to kind of collapse in on the overly wide nasial labial angle. If the 'long lip' after doing that bothers you, then a lip lift decreases the longness there.

For other 'soft tissue' issues, that is assessed via a face photo and not a ceph.

[Dogmatix]

Well, there is somewhat of a mechanical conundrum because counter clockwise rotation is often needed to get a good advancement to the lower jaw but you already have excessive CCW to the ANS-PNS (maxilla). So, more CCW or even linear advancement along the inherent incline of your maxilla would tend towards making the overly obtuse nasial labial angle more obtuse. So, maybe some clockwise rotation with the bi-max advancement. Either way, the orientation of the anterior nasal spine is not a good one and it would probabably have to be cut down/reduced to close the excessive nasial labial angle with any kind of advancement.

As to soft tissue, well the part we see from the ceph, expecially the nasial labial angle is clearly a function of the bone structure underneath.

Now, IF what 'bothers' you is the upwardly angled nose along with the long lip (labial ledge) and you can isolate THAT as the problem when looking in the mirror, that could be addressed by a type of rhino that cuts down the anterior nasal spine to kind of collapse in on the overly wide nasial labial angle. If the 'long lip' after doing that bothers you, then a lip lift decreases the longness there.

For other 'soft tissue' issues, that is assessed via a face photo and not a ceph.

The nose doesn't bother me and an isolated nose job is not gonna happen. There may be angles etc that can be drawn, but it has never been an issue for me and it would rather be taking a step backwards for me starting focusing on this as well. Of course it have to be considered if the structure of the face is going to be remodelled however.

Whats actually bothering me is what I marked in the picture. You can see that the skin on the throat is not "attached" to the jaw, hiding the entire jaw line.
Taking the first picture I found on google shows similair. On the picture to the right you can see that the jaw line is fully visible from the ear to the chin, opposite to what you see on the left. This is obviously before and after pictures of a surgery case, and it seems like there's some weight loss as well. But what I wonder, is the visibility of the jaw line actually a result of the surgery, or is it more weight loss, and bringing the head forward and maybe other procedures? When I'm evaluating my face in the mirror I think it looks resonable if I throw my head forward like an osterich, then I get the jaw line as in the after picture below, and I'm thinking if this is what's bothering me aesthetical, will I be disapointed by the result of a jaw surgery and maybe can address this by liposuction of the jaw line, stretching the skin or similair? I'm not overweight at all, so it's not as you can see in the picture where one might suspect that general weight loss solves some of the problem.
I'm trying to understand if jaw surgery is like throwing my head forward (literally)?

[kavan]

The person in the photo most likely had bi-max surgery and chin advancement.

[Dogmatix]

The person in the photo most likely had bi-max surgery and chin advancement.

I'm sure he did, but is that actually whats enhancing these lines of the jaw bone? I mean, the bone is there before as well, just at another angle and position. Does the bi-max actually stretch the skin and make it "attach" more to the these lines this much?



[attachment deleted by admin]

[kavan]

I'm sure he did, but is that actually whats enhancing these lines of the jaw bone? I mean, the bone is there before as well, just at another angle and position. Does the bi-max actually stretch the skin and make it "attach" more to the these lines this much?

It does what you see in the photo of THAT patient.

[Dogmatix]

Your maxilla (ANS-PNS) is rotated counter clockwise to a significant degree.

Would you be able to elaborate further on this? I've recently had a consultation and got a suggestion on a bi-max surgery. But the suggestion I got was to rotate the maxilla counter clockwise to open the bite further and would also close the nose angle and he didn't see any problem with the nose and was rather working in a direction where both the maxilla and mandible is rotated counter clokwise and the mandible advanced forward. The maxilla will probably be rotated further than the mandible to accomodate the curve of the lover jaw. But then it worries me when it seems like you suggest the opposite and point out that the maxilla is is already excessively rotated and that doesn't make me feel good about rotating it further.

[kavan]

Would you be able to elaborate further on this? I've recently had a consultation and got a suggestion on a bi-max surgery. But the suggestion I got was to rotate the maxilla counter clockwise to open the bite further and would also close the nose angle and he didn't see any problem with the nose and was rather working in a direction where both the maxilla and mandible is rotated counter clokwise and the mandible advanced forward. The maxilla will probably be rotated further than the mandible to accomodate the curve of the lover jaw. But then it worries me when it seems like you suggest the opposite and point out that the maxilla is is already excessively rotated and that doesn't make me feel good about rotating it further.

Yes, rotating CCW will open the bite, angle out the lip which, in turn closes in on the nose angle and also allow the mandible to come forward more even if the maxilla is already rotated in same direction he wants to rotate it more.

[Dogmatix]

Yes, rotating CCW will open the bite, angle out the lip which, in turn closes in on the nose angle and also allow the mandible to come forward more even if the maxilla is already rotated in same direction he wants to rotate it more.

Yes, I understand this perfectly and it makes sense to me. Rotating this way would decrease the 11 degree angle you marked out at the maxilla and also have the effects you mentioned above. Wouldn't it be impossible to handle this in any other way, as rotating the maxilla clockwise would only increase this angle further, and the corresponding angle at eye level cannot be reached anyway(?), or is there any other way to think about this?

What I'm trying to understand is if this is considered a compromise from what is considered normal skeletal and kraniofacial relation. When I read your previous comment that it's rotated counter clockwise to a significant degree already, it makes me think that the suggested approach to normalize this would be to rotate the maxilla clockwise.
I mean, apart from the academic discussion, I'm just hoping for a "normal" look and want to understand the relations and figure out if there are different approaches and if they differ to a degree that it can be "correct" to both rotate clockwise and counter clockwise.

[kavan]

OK, my prior statements said 'maybe' some clockwise rotation and pointed out you had CCW inclination already. Your CONSULT with the maxfax cross referenced that 'maybe' and resolved to getting CCW as part of the correction and I confirmed that made sense to me.

Now the 11 degree angle I marked out is one where the GREEN line is an absolute horizont where the BLUE line is a basic line from anterior to posterior nasal spine (ANS-PNS)--maxillary--showing you have CCW orientation already. So, if the blue line is rotated in a ccw direction, there would be more CCW orientation than you already have and since the green line is a constant relative horizont, the angle would INCREASE with more CCW.

So, your docs findings (at least to me), convey that more CCW than you already have is needed to open the bite so the deep bite is not 'IN THE WAY' of advancing the mandible. So, that RULES OUT the 'maybe' clockwise. So, he's saying he's got to angle UP the ANS-PNS MORE to get the DEPTH of teeth overlap OUT OF THE WAY in order to advance the mandible. If not, the mandible can't be advanced as the deep bite makes too much of an overlap that gets in the way of lower jaw advancement.

Hence, based on your doc's findings that basically tells us he HAS to rotate CCW to OPEN the deep bite INORDER TO move the mandible forward, we have to RULE out the 'maybe' of clockwise rotation.

Although the CCW rotation (along with braces to angle out the front teeth) will help close in on the overly  obtuse nasial labial angle, the nose also can rotate upward with that. But still, there would be a net decrease in the NLA.

[I remember, over 11 years ago, when I first consulted with a maxfax about getting my jaw advanced where at the time, I didn't know I had a deep bite, he asked me what did I like best about my face and I told him' 'my NOSE'. He told me the rotation he would have to do to advance out my lower jaw would be rotating my nose upward and it seemed at the time, his implicit assumption was that I would NOT like that look because my nose was great which is probably why he asked me what I liked best about my face. That said, I KEPT my maxfax deformity because I did not want to alter my nose.]

I tend to think that Class 2 division 2 which is the deep bite with the retroclined front insisors along with recessive mandible is the most problematic to fix. Consider that to make it look better in the MIRROR one has to lower their jaw in order to advance it out so the upper teeth meet the lower teeth where when doing that, you find that the back teeth are not meeting and there is a big GAP between them and what one is doing is in direction of clockwise rotation of lower jaw. But IF the surgery just advanced out the lower jaw with clockwise rotation of the lower jaw, (as done in the mirror to make face look better) then you would have posterior open bite.

I understand your DILEMMA simply because the DEEP BITE if one had a big extent of it, IS a dilemma where the dilemma arises from their needing to open the bite via CCW in order TO advance the jaw forward, even IF you already have CCW orientation where doing that is not going to give the clockwise rotation to the jaw which one usually does in mirror to make face look better when one has the deep bite with recessive jaw. So, it's a DILEMMA where you might not get what you want out of the surgery.

[Dogmatix]

OK, my prior statements said 'maybe' some clockwise rotation and pointed out you had CCW inclination already. Your CONSULT with the maxfax cross referenced that 'maybe' and resolved to getting CCW as part of the correction and I confirmed that made sense to me.

Now the 11 degree angle I marked out is one where the GREEN line is an absolute horizont where the BLUE line is a basic line from anterior to posterior nasal spine (ANS-PNS)--maxillary--showing you have CCW orientation already. So, if the blue line is rotated in a ccw direction, there would be more CCW orientation than you already have and since the green line is a constant relative horizont, the angle would INCREASE with more CCW.

So, your docs findings (at least to me), convey that more CCW than you already have is needed to open the bite so the deep bite is not 'IN THE WAY' of advancing the mandible. So, that RULES OUT the 'maybe' clockwise. So, he's saying he's got to angle UP the ANS-PNS MORE to get the DEPTH of teeth overlap OUT OF THE WAY in order to advance the mandible. If not, the mandible can't be advanced as the deep bite makes too much of an overlap that gets in the way of lower jaw advancement.

Hence, based on your doc's findings that basically tells us he HAS to rotate CCW to OPEN the deep bite INORDER TO move the mandible forward, we have to RULE out the 'maybe' of clockwise rotation.

Although the CCW rotation (along with braces to angle out the front teeth) will help close in on the overly  obtuse nasial labial angle, the nose also can rotate upward with that. But still, there would be a net decrease in the NLA.

[I remember, over 11 years ago, when I first consulted with a maxfax about getting my jaw advanced where at the time, I didn't know I had a deep bite, he asked me what did I like best about my face and I told him' 'my NOSE'. He told me the rotation he would have to do to advance out my lower jaw would be rotating my nose upward and it seemed at the time, his implicit assumption was that I would NOT like that look because my nose was great which is probably why he asked me what I liked best about my face. That said, I KEPT my maxfax deformity because I did not want to alter my nose.]

I tend to think that Class 2 division 2 which is the deep bite with the retroclined front incisors along with recessive mandible is the most problematic to fix. Consider that to make it look better in the MIRROR one has to lower their jaw in order to advance it out so the upper teeth meet the lower teeth where when doing that, you find that the back teeth are not meeting and there is a big GAP between them and what one is doing is in direction of clockwise rotation of lower jaw. But IF the surgery just advanced out the lower jaw with clockwise rotation of the lower jaw, (as done in the mirror to make face look better) then you would have posterior open bite.

I understand your DILEMMA simply because the DEEP BITE if one had a big extent of it, IS a dilemma where the dilemma arises from their needing to open the bite via CCW in order TO advance the jaw forward, even IF you already have CCW orientation where doing that is not going to give the clockwise rotation to the jaw which one usually does in mirror to make face look better when one has the deep bite with recessive jaw. So, it's a DILEMMA where you might not get what you want out of the surgery.

Thank you very much for your extensive explanation, it really helps me understand. I was thinking that the green lines were relative lines as well and that the rotation would moves the green line in a direction to the blue line.

Just as you point out, when sliding the lower jaw forward, the teeth doesn't meet, and a rotation is needed in some way. Before my consultation I assumed that it was going to be addressed either by rotating the lower jaw clockwise, or the upper jaw counter clockwise. Now it seems like I'm looking at a counter clockwise rotation of both the lower and upper jaw, with a bigger rotation of the upper jaw to accommodate the contact of the molars.
I was also informed that part of the reason for this was to open the airways. Even though I didn't seek help for sleep apnea or have these symptoms now (that I know of), he adviced that it might come in the future with this profile and it wouldn't be correct to not address it.

I dont really understand your point that I would get an open bite if the lower jaw is advanced and rotated clockwise to make the teeth meet. Like you say, sliding the mandible forward in the mirror creates a gap, and rotating it clockwise would close the gap. This rotation of the jaws against eachother is needed in any surgical treatment, the difference in the suggested treatment I got now is that they're first rotated for molar contact, and then the entire package is rotated together ccw. The rotation for molar contact would create the same 'open bite' angle of the incisors as I see it, however the jaw bases are rotated.

Isn't there any other way to flatten out the curve of spee so that a rotation isn't needed for contact when sliding the mandible forward? I'm thinking something like a segmentation of the lower jaw where the part with the incisors are surgically moved down?

[GJ]

It seems Kavan has helped you already, though I haven't read anything and went right to ceph.
IMO you don't seem to need surgery. Bite okay? That said, if you opt for it, from the photos I'd say linear movement of both jaws and then a slight CW rotation of the chin.

[kavan]

Thank you very much for your extensive explanation, it really helps me understand. I was thinking that the green lines were relative lines as well and that the rotation would moves the green line in a direction to the blue line.

Just as you point out, when sliding the lower jaw forward, the teeth doesn't meet, and a rotation is needed in some way. Before my consultation I assumed that it was going to be addressed either by rotating the lower jaw clockwise, or the upper jaw counter clockwise. Now it seems like I'm looking at a counter clockwise rotation of both the lower and upper jaw, with a bigger rotation of the upper jaw to accommodate the contact of the molars.
I was also informed that part of the reason for this was to open the airways. Even though I didn't seek help for sleep apnea or have these symptoms now (that I know of), he adviced that it might come in the future with this profile and it wouldn't be correct to not address it.

I dont really understand your point that I would get an open bite if the lower jaw is advanced and rotated clockwise to make the teeth meet. Like you say, sliding the mandible forward in the mirror creates a gap, and rotating it clockwise would close the gap. This rotation of the jaws against eachother is needed in any surgical treatment, the difference in the suggested treatment I got now is that they're first rotated for molar contact, and then the entire package is rotated together ccw. The rotation for molar contact would create the same 'open bite' angle of the incisors as I see it, however the jaw bases are rotated.

Isn't there any other way to flatten out the curve of spee so that a rotation isn't needed for contact when sliding the mandible forward? I'm thinking something like a segmentation of the lower jaw where the part with the incisors are surgically moved down?

Some points:

1: What ever rotation the upper jaw gets, the lower jaw follows because part of movement of lower jaw is an auto rotation in the direction of the rotation of the upper jaw. That's why the entire rotation is either CW or CCW.

2: A person with a DEEP BITE can't slide their lower jaw forward WITHOUT the upper teeth getting in the way. They have to clockwise rotate it (move it in downward direction) FIRST until the lower teeth are edge to edge with upper teeth IN ORDER TO move it foward.

3: Given #2 above, when a person with a DEEP BITE clockwise rotates the lower jaw (move in downward direction) to the point where the upper and lower teeth meet edge to edge, there will be a GAP between the molars. So, this GAP is like posterior open bite if a surgery did what one does in the mirror which is CW of the lower jaw while keeping the upper jaw constant. Hence, you can't pick and choose to get CW for one part and NOT CW for the other.

4: The rotation that is needed to address a DEEP BITE is the rotation the mandible is going to follow.

5: Getting out of the rotation the doctor needs to correct the deep bite is something to discuss with the doctor. I don't have any suggestions to that regard.