Do I need surgery?

[twoface25]

https://imgur.com/a/DYtDPMM

Pictures above.

- mouthbreathed through high school because of deviated septum, but kept tongue up on left side of mouth. As a result, left side of face is great (strong jaw, eye, cheekbone, etc), but right side is classic mouth breather (as you can see from front on picture. My upper jaw is too small, and the lower is slightly recessed but not egregious
- got nose surgery to fix septum in June, can finally breathe. The shape is kind of annoying me right now in that it's too ski slope, but hopefully the swelling will go down more and it won't be so bad
- as lower jaw continues to grow (male, age 19), I'm developing an underbite. Teeth currently slightly past edge to edge into very slight underbite
- just had consult with Gunson about surgery, am going to get more measurements in January so he can see if my jaw is still growing. So far, he preliminarily said he'd expand and move my upper jaw forward significantly, move my lower forward slightly, and also maybe make my chin extend further

I'm unsure if surgery is necessary vs an orthodontic way to just push teeth around so the bite works, since bite isn’t horrible yet and the nose surgery made my breathing sufficient now. I can breathe and eat and talk just fine, I've gone though my life without this being a major problem (pisses me off that half my face grew wrong, but ultimately not a huge deal), and I've read about how jaw surgery is super risky both in getting a bad result and in nerve damage. However, if my lower jaw keeps growing, I don't know if orthodontics will be enough. I know that they don't solve the underlying issue, but I'm willing to have the issue since I've had it forever and been fine, and because there's not the risk that comes with jaw surgery. I'm also worried that pulling my upper jaw forward will make my nose even more ski slopey to the point of it being ridiculous

Advice would be very helpful on whether I should do this

[GJ]

Well I looked at your photos first before reading your issues, and I didn't notice the asymmetry. Only after reading about it do I see it. You can get away with a lot of asymmetry before the eye notices it, unless the eye is looking for it.

If you advance the maxilla "significantly" I don't think that would look good. I don't understand the logic there. Generally underbite is fixed by moving the upper a little forward and the lower a little back. This prevents neck/skin sag. Generally no need for rotation of any kind. Moving both forward would require that the upper moves more than it probably needs to. Again, I don't understand the logic unless it's for the airway.

If your function is fine I'd try to solve this via ortho. You're at an age where maybe the bone is still malleable. If so, I'd do that. But that age window is closing rapidly so I'd get consulting on an orthodontic solution asap.

[twoface25]

Thanks for the reply. I hope the logic is flawed, I really don't know that much. I guess "significantly" may be misleading. He said he'd move them both forward, and he'd move the upper jaw forward more than the lower jaw, so that's a relative measure and maybe not significant, but at least move both some.

He does think the airway would be improved, and I can tell that when I move from forward head posture to head back chin tuck posture the airway is much less open, but I haven't done a sleep study and this may be minor

he said that neck and skin sag under my chin would go away if he moved the jaw forward and added to my chin, why do you say that neck/skin sag would be decreased if the lower was moved back? Regardless, I think my current neck/skin sag is fine. It's not perfect, but it's not an egregious double chin, so I consider myself lucky

What ortho solution would you recommend? I have invisalign ready to go as I was doing both consultations in tandem to give myself options. Is there anythign other than invisalign/braces? My function is fine except for the bite

Appreciate your help

[GJ]

Thanks for the reply. I hope the logic is flawed, I really don't know that much. I guess "significantly" may be misleading. He said he'd move them both forward, and he'd move the upper jaw forward more than the lower jaw, so that's a relative measure and maybe not significant, but at least move both some.

He does think the airway would be improved, and I can tell that when I move from forward head posture to head back chin tuck posture the airway is much less open, but I haven't done a sleep study and this may be minor

he said that neck and skin sag under my chin would go away if he moved the jaw forward and added to my chin, why do you say that neck/skin sag would be decreased if the lower was moved back? Regardless, I think my current neck/skin sag is fine. It's not perfect, but it's not an egregious double chin, so I consider myself lucky

What ortho solution would you recommend? I have invisalign ready to go as I was doing both consultations in tandem to give myself options. Is there anythign other than invisalign/braces? My function is fine except for the bite

Appreciate your help

In general, for a class III jaw, they don't want to move the lower back too much because of sag. How much depends on the patient. Some have taught skin and other things that would make it a nothing burger. You'd have to ask him the exact thinking behind his proposed movements, but that's the general gist of it.

Moving the jaw forward would likely null that issue entirely, but your upper jaw already looks in a good place to me, so you risk chimp issues. Did he say forward and linear or forward with rotation? This would be a good question.

Cephs and records would help. Photos aren't too useful.

Personally, I'd try braces. Or at least exhaust those options first.

[twoface25]

In general, for a class III jaw, they don't want to move the lower back too much because of sag. How much depends on the patient. Some have taught skin and other things that would make it a nothing burger. You'd have to ask him the exact thinking behind his proposed movements, but that's the general gist of it.

Moving the jaw forward would likely null that issue entirely, but your upper jaw already looks in a good place to me, so you risk chimp issues. Did he say forward and linear or forward with rotation? This would be a good question.

Cephs and records would help. Photos aren't too useful.

Personally, I'd try braces. Or at least exhaust those options first.

Skin sag explanation makes sense, thanks.

He mentioned that rotation may also be involved, I should know more in January when I see him in person and he takes more detailed measurements.

I've heard that the upper jaw is slightly back and too small, but you're right about pictures not being great. Once I get better scans I'll follow up

Do you have any opinion on braces vs. Invisalign vs. those inside of the teeth braces? I'm in college and would really rather Invisalign to braces right now, since I'll look like a clown. And since I have them already ready, it would be faster as well, but if they're less effective I might reconsider

[GJ]

Do you have any opinion on braces vs. Invisalign vs. those inside of the teeth braces? I'm in college and would really rather Invisalign to braces right now, since I'll look like a clown. And since I have them already ready, it would be faster as well, but if they're less effective I might reconsider

Not really. Self-litigating braces will move things the fastest. Lingual braces are the worst option, but you might want them due to social life.

[InvisalignOnly]

You look totally fine as is - I would just try to get this sorted with braces. Fixed braces will not make you look like a 'clown' - lots of adults, much older than 19, have fixed braces nowadays, it's not an issue at all. The problem with invisalign is that it's less a less flexible treatment option - you have the trays ready for several months in advance, but as you say your teeth are actually still changing and invisalign will be slow to respond to that (you would need a rescan and new set of trays every time they decide to make a change to the plan). Also it's a real pain in the ass that you have to take them out and brush every time you want to eat or even just have a few beers in the bar etc. The ones they put behind your teeth are really not a good option, very uncomfortable and much more difficult for the ortho to work with, it's just not worth it. If I were you, I'd just get fixed braces (self ligating ones - you can choose clear brackets).

[GJ]

Invisalign also can't do certain movements, like torquing teeth. Only useful for simple cases/minor straightening.