Surgical options and opinions

[Tempus]

Hi all, this is my first post on this forum and it would be great to get some feedback to help me decide my next steps.

I’ve got a fairly recessed jaw/chin which has always bothered me but clearly not quite enough to actually do something about it until now. I have also not investigated the corrective options open to me before, so I am playing catch up a bit on jaw surgery terminology and techniques etc.

As a quick background, I have had corrective orthodontics in my teens to correct my bite, which feels good now. As part of this process they removed some of my pre-molars. I have also had all of my wisdom teeth removed.  I don’t think I suffer from sleep apnoea, or at least I am not tired/drowsy in the day and don’t seem to snore. However, due to my recession I tend to push my lower jaw forward to compensate and I do have some clicking noises from my TMJ (which could be worsened by doing so).

Anyway, as a first step I arranged an online consult with Dr. Gunson, which was very interesting. Dr. Gunson pointed out I had a fairly narrow mouth/bite (V-shaped) and that some gum recession on my teeth was actually a function of over-crowding. He noted that while my air pathway is not really narrow I have some characteristics that could put me at risk of sleep apnoea. He also noted that my TMJ joint has some flattening/adaption but didn’t think it was unstable, or would prevent jaw surgery. Subsequently, he put forward a plan that involves some fairly large movements that would widen my mouth, open my airway and look to balance my aesthetics.

I’m interested in investigating the trade-offs between Gunson’s plan and a less-invasive genioplasty given the movements and risks involved. I queried whether a genioplasty would achieve any aesthetically pleasing outcome to Gunson’s staff but they felt it would be inappropriate as the movement would be too large and I would develop a shelf/large step-off.
I have also recently spoken to Dr. Lee of The Face Dental in Seoul, purely focussed on a genioplasty and he thought that an 8mm movement could provide a material benefit. Like Gunson, I think his preference would be for two-jaw surgery.

Attached below is the link to some profile photos, the surgical plan and my ceph.

https://imgur.com/a/cQM8Lko

Any opinions would be greatly appreciated.

Many thanks.

[kavan]

Your photos clearly show there is recession to the lower jaw in addition to the chin. So, most certainly NOT something where 'only' a chin advancement would compensate for the lower jaw recession. Chin advancements when used as single procedures to OVER compensate for lower jaw retrusion look bad. Hence, I see why they did NOT suggest 'chin only'.

Their finding of narrowness to the 'mouth' (upper jaw area/palate) would suggest multi-segment Lefort 1 to correct. Most likely CCW (posterior downgraft) would be used to rotate upper jaw in addition to other movements to it as to maximize advancement of lower jaw which in turn opens up the airway whether or not you have sleep apnea now or if it's anticipated at later time in life. Although (posterior downgraft) CCW can be unstable with 'bad' case of TMJ, he's saying the extent of yours does not preclude cutting into the upper jaw and displacing it.

It looks like you would benefit from the type of surgery he does. I see no significant benefit from 'chin only'. Again, chin only can never compensate for very retrusive lower jaw.

[GJ]

I agree with Kavan 100%

Can you post Gunson's overlay of the after/result?

[Lefortitude]

Yeah I was in a similar situation to you, trying to find less invasive procedures to give a "good enough" improvement like sliding genioplasty, chin wing and implants.  In the end, the results are for life and I dont think DJS in severe class 2 hypoplasia cases like ours is overtreatment.

Also, I noticed several of gunson patients got those forms that outline in detail the surgical plan?  I never got one of those maybe il call the office and ask.

[PloskoPlus]

Genioplasty won't be enough.

[Tempus]

Firstly, apologies to all, as GJ noticed I seem to have left out the final Gunson overlay - use this link to get the updated pics (overlay after the ceph at the end).

https://imgur.com/a/cQM8Lko?

As you can see (hopefully) the upward jaw movement is ~5mm but the overall shift in the position of the chin is closer to 20mm, which seems quite large. Dr. Gunson mentioned that due to the large movement there would be some gap (around the cheek area) that would need to be covered by bone grafts of some form.

Secondly, thanks for the feedback to date it is very helpful. It kind of shifts the decision towards a move ahead with double jaw surgery, or do nothing (given that I don't seem to suffer any particular functional issues atm). I will look to get another view from a different surgeon for comparison purposes and then re-assess. The idea of getting braces for 9 months to decompensate is not particularly appealing, but I appreciate that if you are going to proceed you need to try and do it right the first time.

Thanks again. 

[april]

If I were you, I'd want him (or another doc you see) to look at your TMJs via a CBCT scan or MRI, because your notes say panorex only.  Your profile would look great no doubt!, but the biggest risk with the plan is going to be to your TMJs. They may be considered stable now but that doesn't 100% guarantee they'll be stable post-op. It's basically a risk you'll have to take.

[GJ]

That plan looks solid.

9 months goes by fast. I wouldn't worry about that. It's the modern age -- you can wear braces, dye your hair purple, or do anything else you want and F people who have issue with it. Rock the braces.

The biggest risk are your TMJs as mentioned and aesthetically I'd be concerned with the nose widening. You don't have much room for error on the nose.

[kavan]

Firstly, apologies to all, as GJ noticed I seem to have left out the final Gunson overlay - use this link to get the updated pics (overlay after the ceph at the end).

https://imgur.com/a/cQM8Lko?

As you can see (hopefully) the upward jaw movement is ~5mm but the overall shift in the position of the chin is closer to 20mm, which seems quite large. Dr. Gunson mentioned that due to the large movement there would be some gap (around the cheek area) that would need to be covered by bone grafts of some form.

Secondly, thanks for the feedback to date it is very helpful. It kind of shifts the decision towards a move ahead with double jaw surgery, or do nothing (given that I don't seem to suffer any particular functional issues atm). I will look to get another view from a different surgeon for comparison purposes and then re-assess. The idea of getting braces for 9 months to decompensate is not particularly appealing, but I appreciate that if you are going to proceed you need to try and do it right the first time.

Thanks again.

Well, since this IS on the AESTHETICS section, the plan maximizes aesthetics. If it's a matter of 'do nothing because my bite function is fine' your entry should be on functional section of board and NOT aesthetics. You presently have function but f**ked up form. Clarify which one you want, form, function or BOTH. If it's both, the plan looks to be on target with that. If it's ONLY function but bad aesthetic, you like, stay as is.

[Tempus]

Ok, thanks for the additional feedback. Gunson did mention the risk of the nose upturning, which he said he would have to manage carefully.

I'll look to follow up on the TMJs as that appears to be a key risk to assess in more detail.

[PloskoPlus]

It's hard to make it out, but I think the posterior down graft is 10 mm which is a hell of a lot.  Did he say what material he'd use for the gap?

[Tempus]

No, unfortunately I didn't ask him at the time of the consult. I followed up afterwards on the type of grafts that would be used, but didn't get a specific response (just that it would vary by size and location).

[PloskoPlus]

No, unfortunately I didn't ask him at the time of the consult. I followed up afterwards on the type of grafts that would be used, but didn't get a specific response (just that it would vary by size and location).

Referring to gaps around the "cheek area", maybe Gunson meant onlay grafts?

[GJ]

No, unfortunately I didn't ask him at the time of the consult. I followed up afterwards on the type of grafts that would be used, but didn't get a specific response (just that it would vary by size and location).

I think he uses BMP (bone morphogenic protein).
I haven't researched that material in a long time, but 5+ years ago it had a correlation to cancer.
Maybe look it up again and also double check with Gunson. He might have moved on to some other material.

[kavan]

AFAIK, he uses porous hydroxyapatite granules for onlay augmentation which need to be mixed with blood (or something in the blood). It's more amenable to molding than other types of 'bone paste' used to fill in dents and dingies.

Porous hydroxyapatite also comes in blocks (that can be carved) and he could use that or MEDPORE for down grafts.