Revision double jaw surgery - advice

[GJ]

Gunson told me the info above, if that means anything to you. Basically the lower lip can be pulled down by plates, especially with a vertical genio. I think a conservative approach of removing the plates, and if anything surgical, just redoing a more horizontal genio is the best option if your bite is good. Not seeing a needed revision here.

The strange thing is I know one of Gunson's patients very well and she had the plates removed because she was showing too much lower tooth, and it did nothing to help. And she had a horizontal genio. So there must be more to it. Likely impaction and rotation and how they interact.

[Brachy]

Thanks GJ. I would appreciate if you could reply what do you mean by horizontal genio - is it advancement? I was hoping that chin wing could bring tissue and lowe lip up. Thank you very much.

[GJ]

Like Kavan described, a genio that shortens or moves upward and with some forward projection rather than the opposite movements (in theory these could make lip incompetence worse).

[Brachy]

Please correct me if I am wrong, kavan suggested vertical shortening and I understood backward chin movement as a help in camouflage. I understood you were suggesting vertical reduction as well but with small forward movement (so up and forward). I believe this would be the main intension of the chin wing - bring the issue and lower lip up. Hope it is possible in my case..thank again

[GJ]

Please correct me if I am wrong, kavan suggested vertical shortening and I understood backward chin movement as a help in camouflage. I understood you were suggesting vertical reduction as well but with small forward movement (so up and forward). I believe this would be the main intension of the chin wing - bring the issue and lower lip up. Hope it is possible in my case..thank again

My bad, I looked at the photos again, and yes, more upward and reduction.
But honestly, if you remove the plates and it turns out it's the muscles balling up causing lip strain, that might fix things, so I'd try that first. If that doesn't work, try the genio revision. I don't think chin wing is going to help. It probably would make things worse.

You look pretty good overall, but to me your jaws look a bit too large for your overall structure. It's not something I'd notice in day to day life, nor will anyone, but if you post photos on a JSF and ask we'll see it then. Keep that in mind.

[Brachy]

GJ, thanks, very kind of you. Movements were too big for me and I have hard time dealing with big jaws. Currently, I would revise both jaws slightly back and believe these 2mm can have impact on overall balance and lips. But first will consult with other surgeons and share their treatment plans with you. I read on realself that ir is better to revise genio as soon as possible, don't know what to think. I just wish to have softer, "cuter" lower third

[GJ]

GJ, thanks, very kind of you. Movements were too big for me and I have hard time dealing with big jaws. Currently, I would revise both jaws slightly back and believe these 2mm can have impact on overall balance and lips. But first will consult with other surgeons and share their treatment plans with you. I read on realself that ir is better to revise genio as soon as possible, don't know what to think. I just wish to have softer, "cuter" lower third

Yeah, big jaws don't look good on everyone. Only if you're a big guy and you're entire gestalt matches the jaw. Also the forehead's depth determine how far the jaws can go out. If your forehead slopes and is weak a strong jaw tends to look odd and very "anti face". A fine look for a body builder type but not for most males. For an average guy the jaws should just be aligned and balanced with one another and the forehead. I'm not sure surgeons consider all this, even the best surgeons. They tend to have their idea and go with it on everyone.

[kavan]

From my perspective, I have NO IDEA if any of my advice has been 'helpful'. That's because I have NO IDEA if you actually understand what the SALIENT problem is in terms of DISPLACEMENT vectors.

Let me first say that it doesn't matter what the surgeons tell you if YOU don't understand what the salient problem is and how it can be addressed. This is especially true if your told different things by different surgeons. If the number of surgeons telling you different things = 'X', you will have a '1/X' chance of choosing the right one if you don't understand what your salient problem is. If you understand what the salient problem is and how it can be addressed, THAT will allow you to ID which surgeon is on target with that.

Midface deficiency is NOT your salient problem. It can be addressed at a LATER time where you can explore the OPTIONS for it.

I will try ONE MORE TIME:

Your SALIENT problem, as I would define it is a BIO-MECHANICAL one. Basically a MECHANICAL problem that can be isolated to your CHIN and the type of genio you got. A DIAGONAL cut was made to the chin bone and your chin slid 'backwards' along that cut. 2 directional vectors; VERTICALLY downwards and HORIZONTALLY backwards. [I assume you have a high school education so that I don't have to explain why a DIAGONAL VECTOR of displacement is a combination of a 'pure' vertical vector and a 'pure' horizontal one.]

Your chin muscle, the ORIGIN of it 'goes along with the ride' hence, it was displaced vertically downward and horizontally backwards when your chin segment in your genio was displaced DIAGONALLY BACKWARDS.

Mechanical EFFICIENCY with regard to using the chin muscles to move the lower lip vertically upward is when the orientation of the muscle is basically aligned with a VERTICAL. It's more mechanically efficient to move your lip VERTICALLY UPWARD when the muscles don't have to strain over a DIAGONALLY upward path that you now have to struggle to move them over. The former is a SHORTER path. The latter is a LONGER path.

The genio you got has displaced the origin of your chin muscles so that they are NO LONGER aligned along a vertical path. The origin of your chin muscles has been displaced vertically downward and horizontally backwards where you now have to strain over a LONG DIAGONAL PATH (instead of a short vertical one) to move your lower lip. This is MECHANICAL INEFFICIENCY.

Who ever did your jaw surgery, elected to give you CLOCKWISE rotation. Maybe that was needed to get the 'bite right'. I don't know. But for BETTER aesthetic results as to OFFSET clockwise rotations of the mandible, one slides the chin upward along the diagonal cut which is a combination of vertically upward to SHORTEN and horizontally forward to project outwards.

DIAGONAL CUT.

Slide 'forward': LIMITED to 2 and only 2 combination displacements which are: vertically upward to decrease length and horizontally forward to increase chin projection.

Slide 'backward': LIMITED to 2 and only 2 combination displacements which are: vertically downward to increase length and horizontally backward to decrease chin projection.

The only option to slide backwards WITHOUT making the chin longer (or to slide backwards and also SHORTEN the chin) is to REMOVE a WEDGE section from the front of the chin so that the base of the chin can be rotated upwards COUNTER clockwise. Presently the area of your chin, where the chin muscle originates is basically diagonally pointing towards the floor. That area needs to be pointing towards the wall so that the chin muscle is on a more mechanically efficient vertical path. A wedge resection from the chin will allow a counter clockwise UPWARD movement to the base of the chin and also a backwards one if that is needed.

Again, you MAY have needed a backwards movement to the chin BUT you DIDN'T need the ELONGATION that came with that. Horizontally backwards and vertical downwards is what is making your lip STRAIN. The only way to move the chin backwards AND ALSO shorten it to reach objective of improving both lip strain AND protrusion of the chin is to remove a wedge section from the front of it.

HINT: The appropriate doctor to make LESS your protrusion at the CHIN and to also make less your lip STRAIN would be the one in the capacity to remove a WEDGE shape section from your chin, to rotate the base of the chin in a counter clockwise direction in order to shorten it in addition to moving it backwards.

If you don't understand why THOSE displacements are important you WON'T be able to choose the appropriate doctor.

[Lazlo]

One thing Sinn did AMAZING is he somehow reattached my lip etc. so that no lower teeth show.

I asked him that I wanted no lower teeth showing when I smile and that's the one thing he delivered on amazingly well.

That and his providing more tooth show at rest and smile was pretty good.

[Brachy]

From my perspective, I have NO IDEA if any of my advice has been 'helpful'. That's because I have NO IDEA if you actually understand what the SALIENT problem is in terms of DISPLACEMENT vectors.

Let me first say that it doesn't matter what the surgeons tell you if YOU don't understand what the salient problem is and how it can be addressed. This is especially true if your told different things by different surgeons. If the number of surgeons telling you different things = 'X', you will have a '1/X' chance of choosing the right one if you don't understand what your salient problem is. If you understand what the salient problem is and how it can be addressed, THAT will allow you to ID which surgeon is on target with that.

Midface deficiency is NOT your salient problem. It can be addressed at a LATER time where you can explore the OPTIONS for it.

I will try ONE MORE TIME:

Your SALIENT problem, as I would define it is a BIO-MECHANICAL one. Basically a MECHANICAL problem that can be isolated to your CHIN and the type of genio you got. A DIAGONAL cut was made to the chin bone and your chin slid 'backwards' along that cut. 2 directional vectors; VERTICALLY downwards and HORIZONTALLY backwards. [I assume you have a high school education so that I don't have to explain why a DIAGONAL VECTOR of displacement is a combination of a 'pure' vertical vector and a 'pure' horizontal one.]

Your chin muscle, the ORIGIN of it 'goes along with the ride' hence, it was displaced vertically downward and horizontally backwards when your chin segment in your genio was displaced DIAGONALLY BACKWARDS.

Mechanical EFFICIENCY with regard to using the chin muscles to move the lower lip vertically upward is when the orientation of the muscle is basically aligned with a VERTICAL. It's more mechanically efficient to move your lip VERTICALLY UPWARD when the muscles don't have to strain over a DIAGONALLY upward path that you now have to struggle to move them over. The former is a SHORTER path. The latter is a LONGER path.

The genio you got has displaced the origin of your chin muscles so that they are NO LONGER aligned along a vertical path. The origin of your chin muscles has been displaced vertically downward and horizontally backwards where you now have to strain over a LONG DIAGONAL PATH (instead of a short vertical one) to move your lower lip. This is MECHANICAL INEFFICIENCY.

Who ever did your jaw surgery, elected to give you CLOCKWISE rotation. Maybe that was needed to get the 'bite right'. I don't know. But for BETTER aesthetic results as to OFFSET clockwise rotations of the mandible, one slides the chin upward along the diagonal cut which is a combination of vertically upward to SHORTEN and horizontally forward to project outwards.

DIAGONAL CUT.

Slide 'forward': LIMITED to 2 and only 2 combination displacements which are: vertically upward to decrease length and horizontally forward to increase chin projection.

Slide 'backward': LIMITED to 2 and only 2 combination displacements which are: vertically downward to increase length and horizontally backward to decrease chin projection.

The only option to slide backwards WITHOUT making the chin longer (or to slide backwards and also SHORTEN the chin) is to REMOVE a WEDGE section from the front of the chin so that the base of the chin can be rotated upwards COUNTER clockwise. Presently the area of your chin, where the chin muscle originates is basically diagonally pointing towards the floor. That area needs to be pointing towards the wall so that the chin muscle is on a more mechanically efficient vertical path. A wedge resection from the chin will allow a counter clockwise UPWARD movement to the base of the chin and also a backwards one if that is needed.

Again, you MAY have needed a backwards movement to the chin BUT you DIDN'T need the ELONGATION that came with that. Horizontally backwards and vertical downwards is what is making your lip STRAIN. The only way to move the chin backwards AND ALSO shorten it to reach objective of improving both lip strain AND protrusion of the chin is to remove a wedge section from the front of it.

HINT: The appropriate doctor to make LESS your protrusion at the CHIN and to also make less your lip STRAIN would be the one in the capacity to remove a WEDGE shape section from your chin, to rotate the base of the chin in a counter clockwise direction in order to shorten it in addition to moving it backwards.

If you don't understand why THOSE displacements are important you WON'T be able to choose the appropriate doctor.

Kavan, thank you very much. Honestly.

[Brachy]

You have made it very clear to me.. besides genio, I will ask for small backward movement of both jaws
... What about counterclockwise rotation in my case?

[kavan]

You have made it very clear to me.. besides genio, I will ask for small backward movement of both jaws
... What about counterclockwise rotation in my case?

My long post was about counterclockwise of the CHIN via wedge resection.  I've given you enough info to isolate what IMO is the salient problem.

[Brachy]

Thanks, I apologise.

[kavan]

You have made it very clear to me.. besides genio, I will ask for small backward movement of both jaws
... What about counterclockwise rotation in my case?

Instead of asking ME for clarity or explanation on something I did NOT isolate as the salient issue, what about YOU write an explanatory post to demonstrate YOU understand the mechanical principles involved in YOUR double jaw revision proposal.

Basically, if your proposal is to UNDO something, you need to demonstrate what 'should have' been done in the first place and why. Use the concepts of directional vector displacements and rotations that justify UNDOING both jaws to do something else to them.

Avoid subjective material such as: 'I'm bullied', 'I'm too protrusive'. Instead, use the concepts of directional vector displacements and directional rotations that justify UNDOING both jaws to do something else to them.

Here is your HOMEWORK assignment:

Use your BEFORE photos and cephs in your explanation as to WHY:

a: Your upper jaw should have been counter clockwise rotated (CCW). Incorporate the OBJECTIVE of the original surgery aimed at MORE tooth show and getting the bite rite. That is to say, give a good explanation (in terms of directional displacements) WHY CCW would have been the preferable rotation to meet the objective of more tooth show and 'right bite'.

b: Both jaws were over advanced by a distance of 2mm (your request to push backwards by that specific distance.)

In essence, be able to SUBSTANTIATE that you understand what you will be requesting the surgeon to do in your proposal to UNDO the original surgery with explanation as to HOW that would work.

For EXTRA CREDIT, explain the displacements made via a 'chin wing' that would apply to the particular displacements that would be of benefit to you specifically.

[Brachy]

Thanks. 
To begin with, besides jaw (bite) issues I have learnt that I have midface deformity which was not explained to me. Hope with your and other members help, maybe in 5-10 years I could try solve it.
I am almost certain that frontal pictures looked better before - it seems that vertically short (but wide) maxilla was playing the role of zygomas, making impression of wide and square face. At rest it worked, however tooth show was minimal. My occlusal plane was oriented up above horizontal line of 0° Also, retruded mandible "blend in" on somewhat retrussive and short profile.
As for the treatment plan, I am very happy with the tooth show, however, profile is to protrusive in my opinion due to too much maxiliary clockwise rotation which was then accomodated with more mandibular advancement than initially needed. Also, plan included vertically elongation (and backward movement) of the chin
to compensate mentolabial relationship after 6mm bone graft was placed in maxilla. After seeing video one lecture from Mr. Triaca, it seems that only chin wing gives good lip competence for chin reduction (of cource if properly done).
So my thaughts: backward movement of both jaws (and I will definitely ask dr. Z. and B. on reducing tooth size since upper lip is incompetent too - don't know whether small maxiliary backward movement will lengthen upper lip) and vertical shortening of the chin will help lip incompetence. Other possibility, if still feasible, chin wing to decrease visible border of mandible (like in class 3) and bring up tissue around lower lip.

All this could improve profile, but due to short sella nasion line I will still be below average. But hope that lips will have their own function again.. I will post before pictures tommorrow. Thanks in advance.