Looking for advice - X-ray+photos

[MaryPoppins66]

Hi everyone!

English is not my first language so I apologize for my mistakes in advance. Also, thank you for all the advice I had found here, I've learned a lot from you in the past month.

I attached my cephalometric and panoramic X-rays and a couple of photos and I would be really thankful if somebody could help me with the analysis. I'm class II/II with a short/er face.

What I would like to know is

1.   What kind of procedure do you think I could benefit from? Can BSSO alone improve my lower facial height at all? The thing is - my orthodontist is suggesting just getting BSSO because of my profile but I was always much more self conscious about the frontal view because my deep bite is making me look angry. I didn't post the photo but there's my profile pic and a pic of what my profile should look like to get my frontal view also in balance. I kind of overdid it but I guess I would be happy with as much of lower facial height I can get without going through multiple procedures. So - how to make a small improvement on lower facial height without touching the maxilla and by only adjusting the mandible?

2.   Also, all of my angles are messed up – gonial, articular (and mandibular) – so I think my overbite in itself maybe isn't even that bad but is visually exacerbated by this. What do you think? Can BSSO improve any of those?
 
3.   Could you please comment on my airway?
 
4.   Is it possible to measure the absolute length of both of my jaws from the X ray? Also my upper and lower facial height? Could you please do that if it is possible?

Thank you for reading my post, I'm pretty new to all of this so I apologize if it is non-coherent or faulty. And thank you in advance for your answers, I'm looking forward to reading them very much.   

[Daedalus]

First of all, your gonial angle is good. You don’t want it too sharp, especially as a female. What I see is a mild lack of mandibular projection. The least invasive rout would be a geniolasty, where they cut your chin and reposition it forward and down. Genioplasty might also make your jaw look sharper by tightening the muscles and skin under your mandible.

From the point I see it right now  I’d advise against any jaw intrusion. As far as I’m concerned, you have a functional bite, no sleep problems, no TMJ.

[PloskoPlus]

How's your tooth show at rest? Smiling?

[Lefortitude]

Welcome.  You should post smiling and front view photos too.

First I see you posted about profilos sugical, which is Dr Paul Coceancigs practice.  Hes got a bad reputation on here, and i personally have a bad experience with him.  I recommend you avoid him.

Your occlusional plane seems pretty flat, so its going to basically require your lower teeth to be moved forward in order to improve that projection with just a bsso.  That will probably require some lower tooth extractions in order to move your jaw a meaningful ammount.  Depending on your teeth, id lean more towards double jaw. Ofcorse talk to your ortho about this.

Airway looks ok, its basically impossible to tell if you have disordered breathing without a sleep study.

There is technology to measure the lengths of your jaws and compare them on a statistical distribution.  Ask your ortho for a cephalometric tracing of your landmarks.  I will say that alot of the tracing methods are basically obsolete now, and measurements relative to the cranial base in general have fallen out of favor among maxfac surgeons (in the US atleast).

[kavan]

Let's see...to look at your photos, I've gotta keep 6 individual tabs open because instead of all your photos being placed on the same IMGUR link, you put on separate ones. Did you know that IMGUR lets you post ALL your photos on the SAME link and also allows you to describe each photo? So, no comment from me other than that.

[kavan]

Let's see...to look at your photos, I've gotta keep 6 individual tabs open because instead of all your photos being placed on the same IMGUR link, you put on separate ones. Did you know that IMGUR lets you post ALL your photos on the SAME link and also allows you to describe each photo? So, no comment from me other than that.

I will address ONE thing here that doesn't involve opening 6 different links and flitting back and forth to address all your questions. That ONE thing is about Class 2 Division 2, deep bite.

In general, people who have that have a short lower facial height, recessive mandible with short recessive chin and low mandibular plane angle. Effective treatment proposals I've seen for that in the past involve CCW posterior downgrafts (to the maxilla) along with BSSO and a type of chin augmentation that AVOIDS vertical shortening. Not a sliding genio but rather what is called an 'oblique' genio where the chin is moved diagonally downward and a 'buttress' is placed between the cut sections. So bimax with chin work that AVOIDS shortening.

The surgery lengthens the lower face height by virtue of NOT having to lift the lower jaw up so high to occlude with the deep bite. However, it doesn't physically increase the distance between the roots of the lower teeth and the mandibular border.

[Lefortitude]

I will address ONE thing here that doesn't involve opening 6 different links and flitting back and forth to address all your questions. That ONE thing is about Class 2 Division 2, deep bite.

In general, people who have that have a short lower facial height, recessive mandible with short recessive chin and low mandibular plane angle. Effective treatment proposals I've seen for that in the past involve CCW posterior downgrafts (to the maxilla) along with BSSO and a type of chin augmentation that AVOIDS vertical shortening. Not a sliding genio but rather what is called an 'oblique' genio where the chin is moved diagonally downward and a 'buttress' is placed between the cut sections. So bimax with chin work that AVOIDS shortening.

The surgery lengthens the lower face height by virtue of NOT having to lift the lower jaw up so high to occlude with the deep bite. However, it doesn't physically increase the distance between the roots of the lower teeth and the mandibular border.

Ive seen something similar except it involved downgrafting to both the anterior and posterior maxilla, which the posterior one being larger and to create ccw while also increasing the lower anterior facial height. I suspect this is uses more when the maxilla is short vertically, and your genioplasty technique is used when the mandible is short vertically?

[kavan]

Ive seen something similar except it involved downgrafting to both the anterior and posterior maxilla, which the posterior one being larger and to create ccw while also increasing the lower anterior facial height. I suspect this is uses more when the maxilla is short vertically, and your genioplasty technique is used when the mandible is short vertically?

A downgraft that also includes the anterior maxilla can also be considered a (net) CCW rotation if the downgraft is more to the back than the front. The genio technique is when the mandibular plane angle is considered 'low'.

[kavan]

Ive seen something similar except it involved downgrafting to both the anterior and posterior maxilla, which the posterior one being larger and to create ccw while also increasing the lower anterior facial height. I suspect this is uses more when the maxilla is short vertically, and your genioplasty technique is used when the mandible is short vertically?

People with low mandibular plane angles (and deep bite) can be described as having 'short chin'. The overall facial height can be increased with a uniform downgraft but if the rotation is needed to be CCW, the downgraft has to be more posterior than anterior, in which case there would still be an increase in total facial height. The increase is coming from the alteration of the maxilla. But the height of the mandible bone itself isn't being increased. The distance between the lower border of mandible and the roots of the molars will remain constant. Since the CCW rotation tends to DECREASE the mandibular plane angle, someone who has an MPA on the LOW SIDE already, usually benefits from the oblique genio to both advance and elongate the chin because it gives 'look' of steeper MPA.

[MaryPoppins66]

Welcome.  You should post smiling and front view photos too.

First I see you posted about profilos sugical, which is Dr Paul Coceancigs practice.  Hes got a bad reputation on here, and i personally have a bad experience with him.  I recommend you avoid him.

Your occlusional plane seems pretty flat, so its going to basically require your lower teeth to be moved forward in order to improve that projection with just a bsso.  That will probably require some lower tooth extractions in order to move your jaw a meaningful ammount.  Depending on your teeth, id lean more towards double jaw. Ofcorse talk to your ortho about this.

Airway looks ok, its basically impossible to tell if you have disordered breathing without a sleep study.

There is technology to measure the lengths of your jaws and compare them on a statistical distribution.  Ask your ortho for a cephalometric tracing of your landmarks.  I will say that alot of the tracing methods are basically obsolete now, and measurements relative to the cranial base in general have fallen out of favor among maxfac surgeons (in the US atleast).

Thank you.

I posted that picture only because I wanted to show you what I think I need visually. I wasn't researching on who did it or how it was done.

I'll ask my orthodontist about the cephalometric tracing of landmarks, thank you.

It's a bit hard for me to follow your advice at this point so I apologize for the dumb question. What do you mean by 'depending on my teeth' that I should look into double jaw surgery? Can you tell approximately how much of mandibular advancement am I looking into?

I put more pictures as you advised so take a look. Also, I'm not sure if this matters but all of those 'smiles' are forced, I do not usually smile like that. I've been told all my life actually that my smile seems fake. I guess it's because when I do it, it doesn't really seem effortless. And it's not, I have to try pretty hard to show some teeth.

I kind of struggled with capturing the shortness of my face from the exact front so I took some photos from the sides. Again, I overdid it in the 'how it should look like' photo but just to give you a better impression of it all.

And just to add one more thing to my post, maybe it'll help with further advice although from what I've read these cases are treated exactly like recessive mandible. My maxilla seems to be the problem actually - my SNA is 88 and my SNB is 81.

https://imgur.com/a/7QMP7WR

[MaryPoppins66]

How's your tooth show at rest? Smiling?

Hi!

No tooth show whatsoever at rest. But I've gotten used to it. If I can avoid maxillary advancement, I will, regardless of that.

I put new photos, take a look.

[MaryPoppins66]

Let's see...to look at your photos, I've gotta keep 6 individual tabs open because instead of all your photos being placed on the same IMGUR link, you put on separate ones. Did you know that IMGUR lets you post ALL your photos on the SAME link and also allows you to describe each photo? So, no comment from me other than that.

Hi!

I'm sorry, I didn't know that. I made an album with new photos and posted the link in the answer I gave to Lefortitude so if you could take one more look at my photos, I would appreciate.
 

[kavan]

Hi!

I'm sorry, I didn't know that. I made an album with new photos and posted the link in the answer I gave to Lefortitude so if you could take one more look at my photos, I would appreciate.

I took a look at them. The info I gave about class 2 div 2 is applicable. The elongation in your morph is in excess of what surgery would do.

[MaryPoppins66]

I took a look at them. The info I gave about class 2 div 2 is applicable. The elongation in your morph is in excess of what surgery would do.

Thank you. Yes, I am aware I overdid it, in aestethic terms as well.
I hope you won't mind me asking you just a few more questions.
What do you think would happen to my front face if I decide only to do BSSO and possibly that 'oblique' genio you mentioned.
And can you tell from my X-ray what is the root cause of my face being short, is it the vertically short maxilla or is it my mandible?

[kavan]

Thank you. Yes, I am aware I overdid it, in aestethic terms as well.
I hope you won't mind me asking you just a few more questions.
What do you think would happen to my front face if I decide only to do BSSO and possibly that 'oblique' genio you mentioned.
And can you tell from my X-ray what is the root cause of my face being short, is it the vertically short maxilla or is it my mandible?

Please RE-READ what I wrote concerning Class 2 Div 2 to both your post and to Lefortitudes lest I deem taking time to explain how things work an exercise in futility.

Much like similar cases of Class 2 Div2 where SUCCESSFUL surgery involves a CCW DOWNGRAFT, in addition to the BSSO and oblique genio, so does yours. You're not an exception to the general type of surgery used to maximize aesthetic improvement for Class 2 Div 2 DEEP BITE, 'short chin' or 'short face'.

What would you look like WITHOUT the type of surgery needed to address what you have. Someone who still has shortness to the lower '1/3rd' of face. That's because the extra height you would need comes from DOWNGRAFTING the maxilla

Your case is NOT one that would resolve to single lower jaw surgery. It would resolve to CCW DOWNGRAFT. (bimax surgery with oblique chin advancement) Given you have NO front upper teeth show at rest and need to STRAIN a smile to show upper teeth, the downgraft would be MORE in the back than in the front. So, we are talking a CUT to the maxilla and NOT single lower jaw surgery or avoiding a cut to the maxilla. You wouldn't get close to a fraction of the changes on your morph by AVOIDING the maxilla cuts associated with the downgrafts. Without them, you would still look like someone with shortness to the lower 1/3rd of the face. Where do you think the extra height comes from? It comes from the downgrafting to the maxilla. BSSOs don't downgraft the lower border of the mandible. So, it doesn't matter if the vertical shortness comes from the mandible itself. What matters is that NO TOOTH SHOW at rest is consistent with vertically short maxilla and deep bite is consistent with the posterior part needing more of a downgraft than the anterior part in order to acheive a type of net CCW that would address your DEEP BITE and short facial height.

As to maxillary advancement along WITH the cut to the maxilla TO place the downgraft, aim of CCW is to minimize advancement. So, moot point to want to avoid something else that might be needed to do to the maxilla to maximize lower jaw advancement.