Jaw is so underdeveloped...Many Pics...Plz help (+ Intermolar maxilla DO)

[Suchislife]

Hello All,

I'm a 24 y/o male looking for a way to enlarge my extremely small and underdeveloped jaw.

The imgur link features a number of pictures of me, an x-ray showing how damn small my jaw is and also a picture of my father and his near perfect jaw development.

[deleted by user]

So where to begin...



When I was around 19 y/o I started to realise that my jaw had not developed like other ppl. I had braces that has given me a Class I bite and my teeth were made to mesh near perfectly with a slight overbite, just as they do now. No extractions.

I always kind of knew I had a small jaw but it was never an issue until I started getting older and thinking and wishing to be seen as a grown ass man - like I am.

Anyway I stupidly got a chin implant which has changed my face forever and honestly looked pretty messed up so I got it rapidly removed after a month. My problem as I have come to realised is not the chin being recessed but the entire jaw being too small. I did not research it much and just jumped quickly into it like a real fool. Turns out if u get the implant removed your face doesn't perfectly go back to how it used to be as the scar tissue and the fact that they detach the chin pad from your chin bone causes the skin to never rest firmly and properly back on your face - it also makes your cheeks slightly chubbier which is half residual swelling, half the scar tissue has taken up space that was previously occupied by other things. The rounded implant shape is still somewhat present on my face but I know that it will keep changing, even after 3+ years as the scar tissue hardens (atm its still squishy) it'll keep slightly changing shape. I preferred how I looked before but it is not dramatically different...


So to my jaw.

What cannot be seen in this picture is my jaw width. My incisors and canine teeth protrude a fair bit out of my mouth both upper and lower forming a kind of bimaxillary protrusion. My upper and lower palate both narrow as they go back along my molars. The intermolar width at the very rear of my upper palate is ~43mm. I have large teeth, especially the incisors and canine teeth. My tongue cannot rest on my upper palate as the rear molars block it being too narrow.

At this time I have TMJ because I have been forcing my jaw forward (something I cannot be bothered so much to do anymore) which has caused me to only be able to open my mouth about 2 fingers wide. I can go further but I can feel both my condyles unhinging going in front of their sockets. This happens involuntarily if I do not control my yawning. Eating is also sometimes uncomfortable as I have some clicking and it feels like it is wearing my jaw out, especially with harder stuff.

The dimensions of my mandible, ramus etc. as far as I can tell are very small and I do not have good maxilla forward growth. It is rather just the protrusion of my upper incisors that push out.

In the x-ray you will see that my occlusal plane angle and gonial angle are pretty square on however note that I was actually looking slightly up in the x-ray cos the ortho I went to is trash. Basically he told me there is no problem you have a perfect bite and you can't have everything lol. He also did my braces, if I actually went to a better ortho (Im from Syd, Aus) when I was young instead of this backwater one IMDO could have ez fixed all of this. Other than this I'm not too fussed by the small ramus.

Another little point is I've looked at pictures of me from when I was like a 10-12 y/o. Even at this time I had slight bimaxillary protrusion (just like my mum) so it seems to have been a way that my jaw was always inevitably tending towards from that point on.

I want to solve this now or soon but I have discovered it will be rather tricky. Please advise what you think.

Plan 1:
This was the initial, crappier plan. extract 2 pre-molars from mandible -> pull lower forward incisors back -> BSSO. I think this will be crap as since my upper palate is too narrow I will still not have enough room for my tongue. I will push my front teeth as I apparently did as a child (I don't really do it anymore although in saying this my tongue can really fully rest on my palate either although I actively try to). This will quite possibly cause relapse.

Plan 2 (best hope):
SARME/SARPE to expand upper jaw -> IMDO/DO for lower (I'm hoping to have a consult with Paul C soon but this corona stuff pushing it around) -> Lefort 1 and BSSO or potentially just Lefort 1 depending on the DO capability -> Braces (not sure when else braces might be needed in this process, maybe also after the SARPE?)

Plan 3:
SARME -> ?Mandibular expander? (dont know much about this yet) -> double jaw surgery -> braces

What do you guys think. Please any advice or discussion will be of great help. This stuff has got me super down atm...can't stop thinking about it...worse still that stupid chin implant removed my old look that some girls actually found cute now I'm just hoping it keeps going back...But anyway. I want to get things moving and see what can be done. I'm praying that IMDO will be offered and it will work for me. As far as I have heard Paul C has done it on a 23 y/o man, a 30 y/o women some others and also there is a pretty amazing image of an apparently successful adult IMDO (he looks about 25y/o) on the Profilo facebook uploaded in July 2019. Unfortunately I am not so sure after seeing a bunch of stuff about it on this forum and also by the lack of clarity Paul C seems to provide with his amazing, breakthrough adult cases...

Another key thing with the better plan. I NEED HELP GETTING MY HEAD AROUND DO, not IMDO but just regular DO. I've seen a number of papers about it but it's hard to find surgeons who will do it. If anyone has good papers, names etc. IMDO info as well however of course is also very welcomed.

Thanks and God bless.

[Suchislife]

Just a quick bump on this. But also looking at Paul Cs videos in a bit more depth it seems IMDO could quite possibly be done on adults. Look at the attached pictures.

The 3d ceph scan actually shows what looks like intermolar maxilla distraction. The fellow in the video had an extremely large overbite and his midface had to be moved 12-15mm which is not achievable with a Lefort 1. In the video it is indicated that the left/right side was advanced 12/13mm. He looks like hes mid late 20s.

And the other image shows a 29 y/o man apparently getting IMDO with pretty amazing results.

https://imgur.com/a/jWBBgzH

[kavan]

The only thing I'm going to entertain here is your ceph X ray where I see you have somewhat of a flat occusal plane angle (OP), a LOW mandibular plane angle (MPA), perhaps not enough tooth show when smiling. It's looking like what you have is 'short lower 3rd' or 'short chin'.

If that is the case, the correction would resolve to a 'drop down' to the maxilla along with a CLOCKWISE rotation to elongate the lower 3rd and to also make steeper the MPA via the rotation at the maxilla. The bone separation GAP left at the maxilla would require GRAFTING to buttress the separated bone sections. The BSSO advancement over the the steeper MPA will give elongation to the lower 1/3rd where it is short. A genio could also be done.

So, what you would want to look at in terms of procedures that might relate to what you have is procedures that rotate maxilla in CW direction and ALSO add downgrafts to the maxilla along with the BSSO over a steeper MPA (arising from the maxilla work).

Here's a link to one of my other posts which explained what the patient in the photo had done.
Reply #14 on the thread in response to a LINK within my quote of what a patient with 'short chin' had. http://jawsurgeryforums.com/index.php/topic,7954.msg73760.html#msg73760

So, IF what that patient had done was something you could identify with on your OWN face, you would be looking for doctors who did that sort of thing, in particular significant downgrafts to the maxilla.

[Suchislife]

They honestly really messed up my x-ray with regards to making it line up in accordance with the Frankfurt plane. When I align my bottom eye and mid ear it looks very different. See attached for rotated version.

In this one my nose is basically flat with the horizontal which it is just about when I view the alignment with the Frankfurt plane myself.

Since fixing this up and thinking about it I think that CCW rotation of both jaws should work as well with a reduction in the protrusion of my front incisors via widening or extractions I guess?

I honestly really don't know how I am going to move my incisors (top and bottom) back without extractions cos my teeth right now mesh perfectly. If I get SARME for maxilla but there is no good way to expand lower jaw I am rightly fked as far as I understand.

With your recommendations taken into account, and whether CW or CCW rotation is required, would you recommend that I widen my jaws? Ideally I think I would but as far as I have seen on this forum it is risky as fk as maxilla can be expanded easy but mandible is not easy...

[GJ]

The only thing I'm going to entertain here is your ceph X ray where I see you have somewhat of a flat occusal plane angle (OP), a LOW mandibular plane angle (MPA), perhaps not enough tooth show when smiling. It's looking like what you have is 'short lower 3rd' or 'short chin'.

If that is the case, the correction would resolve to a 'drop down' to the maxilla along with a CLOCKWISE rotation to elongate the lower 3rd and to also make steeper the MPA via the rotation at the maxilla. The bone separation GAP left at the maxilla would require GRAFTING to buttress the separated bone sections. The BSSO advancement over the the steeper MPA will give elongation to the lower 1/3rd where it is short. A genio could also be done.

Agree this is what I'm seeing, except that movement will have to include a fairly large CCW genio, too.
My concern would be the interlabial gap gets larger at rest due to the CW movement.
Tough case. Extracting two lowers could be an option.

Widening the upper jaw via a 3-piece is probably what you'll be recommended to handle any discrepancy between upper and lower. To me, this is a risky procedure. You'll have to read up on it and decide. Gunson has very good results with it and little risk, but I don't think most surgeons can perform it that well. I'm not sure what his trick is but he does it second nature.

[kavan]

You rotated your ceph about 12 degrees. I can't confirm on whether that is the exact rotation needed (of the ceph) to plan around because I can't confirm you found the exact porion point for the Frankfurt horizont.

But if it's true you found one of the hardest points to find in a ceph X ray, then you should be able to find all the other points, angles, planes, norms thereof and draw where the TVL (true vertical line) should be.

If your 12 degree ceph rotation (based on the exact porion point) is correct (which I can't confirm if it is or not) it would factor into how many degrees to rotate the jaws. However, the question is whether or not it would change the DIRECTION of the rotation from CW to CCW.

APPROXIMATIONS ONLY:

The OP norms are about 4 degrees to 12 degrees.
Your UN rotated ceph has your OP at about 0 degrees and your rotated ceph about 12 degrees.

MPA norms are about 17 to 28 degrees.
Your UN rotated ceph has your MPA at about 14 deg and your rotated ceph has the MPA about 26 deg.

So, your 12 degree rotation of the ceph might not necessarily mandate a change to CCW direction for the jaws. Reason being, the OP and MPA with a 12 deg rotation of ceph are WITHIN the norm and the 12 deg ceph rotation neither demonstrates a steep OP nor a steep MPA. Also, any apparent look of steepness from the BSSO could be easily offset with a sliding genio to give the 'look' of CCW.

The salient point here that I'm making whether, it's CW or CCW, is that it looks like you would need a DOWN GRAFT and a significant one and hence might want to entertain seeking out doctors who can do significant down grafts.

Lower face contour looks wider with BSSO because recessed parts look wider when they are brought more into the foreground. That is to say, things in the DISTANCE look wider the CLOSER they are to your eye.

[Suchislife]

Thanks for the replies.

I have a few points that I would like to clear up if possible.

1) When I smile my teeth actually show quite perfectly, upper and lower. I don't know if that is due to the way my incisors protrude out or what but yes.

2) With regards to the short lower 1/3, flat OP etc. I have seen a similar case to what I think you guys were describing here: https://www.drantipov.com/cases/corrective-jaw-surgery/oms000025/. You can see the flat OP and MPA. In a video about this man Dr Antipov also showed that he could not smile properly. Without the rotation my ceph looks pretty similar to his ceph except my lower incisors stick out eliminating the overbite. It's pretty hard for me to tell exactly however I think I have over-rotated my ceph in the attachment but only slightly whilst my original is still highly under-rotated. I have viewed myself in multiple videos and in the mirror quite comprehensively and I am 90% sure my MPA is between 17-24 degrees. Regardless, you can see here that they moved his upper jaw forward and down, big forward movement of the mandible with some CW rotation it appears and a big CCW genio. So from this I believe I require advancement with still little change in MPA but there is lee-way.

An extra point about this, weird thing about the guy's ceph, it doesn't seem to be along the frankfurt plane either.

3) GJ has suggested a 3 piece lefort for widening the upper jaw. I still really do not understand why widening of the upper jaw is required if the bite it perfect as it is currently. It is true that my palates are narrow and overall the entire jaw is small both in forward extension and width, but if you widen the upper jaw and the lower jaw is only advanced via bsso/genio wouldn't that make it impossible to correct the bite? I really do not understand this. It is a major concern for me because I think one of the first steps for me is widening of the upper jaw via SARME, lefort etc. But if they widen the upper and the lower cannot be widened then thats fked...again IMDO seems to be the only thing that widens mandibles.

4) GJ you commented this would be quite high risk. I kind of got the feeling of this myself as I have seen quite a number of cephs now and mine is pretty dissimilar to most people. It seems that the most common overbite issue relates to too high MPA requiring CCW rotation. One thing that I have heard as passing remarks is that if the person's jaw is more delicate or smaller, risks are usually increased as it is more challenging to operate on a smaller jaw. Is this something that you guys have heard?..or is it bs.

5) Downgrafting. Kavan, do you still recommend downgrafting if I do not have trouble smiling etc? When I smile right now I see the slightest bit of gum above my upper teeth. Keep in mind if I do get my upper palate expanded it's likely that my front teeth will move back with braces to reduce the protrusion, idk that could be changing things with my smile. I have seen cases where the lower and upper jaw is recessed (basically my case) and they cannot smile however they do not have such a high incisor protrusion as I do. Perhaps that is the reason that I can still smile because of how forward the teeth are... Furthermore after reviewing myself more closely and the ceph, making the MPA steeper with maxilla movement to match is actually not what is required I think...However in saying this, I think you are still going to be correct. The movement I require for my lower jaw would be quite dramatic and not really changing the MPA, OP much so the upper would have to match with similar movement. Both jaws recessed, both advanced requiring bone grafting.

[kavan]

I suggest you consult with doctors that do down grafting and see what they say.

[Hopeful]

Just a quick bump on this. But also looking at Paul Cs videos in a bit more depth it seems IMDO could quite possibly be done on adults. Look at the attached pictures.

The 3d ceph scan actually shows what looks like intermolar maxilla distraction. The fellow in the video had an extremely large overbite and his midface had to be moved 12-15mm which is not achievable with a Lefort 1. In the video it is indicated that the left/right side was advanced 12/13mm. He looks like hes mid late 20s.

And the other image shows a 29 y/o man apparently getting IMDO with pretty amazing results.

https://imgur.com/a/jWBBgzH

Could you please provide a link to the video?