Bimax revision for 2mm impaction & retraction? After a "good" orthodontic outcom

[Vincent999]

After double jaw surgery + genio my face is strikingly much longer to the point it really bothers me. I was a class ii and steep occlusal plane case. My surgeon did a posterior downgraft only, no impaction which in hindsight was a mistake. I believe my front incisors were lowered 1mm due to the natural advancement plane. Now, at nearly 6 months post OP and still in braces - half of my teeth show at rest, and a large smile shows 1mm of gum above front incisors. This would be fine if I was female, or someone with a short upper lip. However I may be in the minority (especially if in the company of maxfacs), being of the belief optimal aesthetics for a male with a long philtrum like myself is little if any teeth show at rest. It would certainly solve my issues, in addition to my maxillomandibular complex moving back a couple of mm to reintroduce harmony with the rest of my features. My genio was done poorly, I would like a few mm of chin height gone as well.

I'm wondering if anyone has done a revision bimax after a good functional result? Are there surgeons who would agree to operate on me? Is the risk of permanent numbness a real risk to consider with revisions? I'm not over-advanced like those horror cases you occasionally read about, and had a solid orthodontic outcome. Simply my face just looks off and I want it fixed.

[Gadwins]

It is hard to judge your case without any pictures. Everything what you write sounds good to me. I am myself male and have a really long philtrum. I got a bit more tooth show after orthodontic and it really looks better than before. Also I will have a genioplasty, but instead being afraid to get too much height, I am afraid to get too much height reduction, because it would look unbalanced to my long philtrum.

Really don't know what I should think about your case, because it sounds your surgeon really considered your long philtrum and balanced everyting out.

[Vincent999]

It is hard to judge your case without any pictures. Everything what you write sounds good to me. I am myself male and have a really long philtrum. I got a bit more tooth show after orthodontic and it really looks better than before. Also I will have a genioplasty, but instead being afraid to get too much height, I am afraid to get too much height reduction, because it would look unbalanced to my long philtrum.

Really don't know what I should think about your case, because it sounds your surgeon really considered your long philtrum and balanced everyting out.

I think you misread or misinterpreted my post. Increased tooth show in my case made me WORSE off. My surgeon's philosophy when determining teeth show is flawed for patients like me.

Really, surely when correcting faces that have grown retrusive and down, it is logical to expect some degree of face shortening to mimic natural growth. It's either forward and compact, or back and long. Not forward and long like my outcome.

[kavan]

After double jaw surgery + genio my face is strikingly much longer to the point it really bothers me. I was a class ii and steep occlusal plane case. My surgeon did a posterior downgraft only, no impaction which in hindsight was a mistake. I believe my front incisors were lowered 1mm due to the natural advancement plane. Now, at nearly 6 months post OP and still in braces - half of my teeth show at rest, and a large smile shows 1mm of gum above front incisors. This would be fine if I was female, or someone with a short upper lip. However I may be in the minority (especially if in the company of maxfacs), being of the belief optimal aesthetics for a male with a long philtrum like myself is little if any teeth show at rest. It would certainly solve my issues, in addition to my maxillomandibular complex moving back a couple of mm to reintroduce harmony with the rest of my features. My genio was done poorly, I would like a few mm of chin height gone as well.

I'm wondering if anyone has done a revision bimax after a good functional result? Are there surgeons who would agree to operate on me? Is the risk of permanent numbness a real risk to consider with revisions? I'm not over-advanced like those horror cases you occasionally read about, and had a solid orthodontic outcome. Simply my face just looks off and I want it fixed.

1mm of gum show with a LARGE SMILE is also fine for a male.

I would surmise that a responsible surgeon would suggest some botox to reduce 1mm of excess gum show (makes it harder to lift the upper lip and thereby reduces the gum show when smiling) and perhaps also talk to you about possibility of a revision genio that includes shortening the chin if indeed the chin itself has vertical excess.

[PloskoPlus]

If you really want to go through it all again... You could get a lip lift before surgery, let it heal, then have a revision with anterior impaction.

BTW, how far are you out of surgery? Showing only 1mm at full smile is actually quite good, but showing "half your incisors" at rest is probably excessive for a male... If you're not long out of surgery, your smile tooth show may increase as the muscles recover.

[Vincent999]

If you really want to go through it all again... You could get a lip lift before surgery, let it heal, then have a revision with anterior impaction.

BTW, how far are you out of surgery? Showing only 1mm at full smile is actually quite good, but showing "half your incisors" at rest is probably excessive for a male... If you're not long out of surgery, your smile tooth show may increase as the muscles recover.

6 months

[PloskoPlus]

Do you have cephs? Do you know for sure that you had a posterior downgraft? Surgeons can be unreliable.

[kavan]

Is it possible you might have a long midface? If you draw 2 horizontal lines that span the face, one at the root of nose (where nose meets the forehead) and the other at the base of nose, that span is the midface area or middle '1/3rd' which can NOT be made shorter. So, if your face is long beside where the nose starts and ends, that area can't be shortened with surgery.

Too laborious to write out how it's measured in relation to other landmarks given it's something I can see readily ID in a photo. Long midface is something doctors don't always tell patients they have (because it's something they can't shorten). But it's also something where patients still see length to the whole face after surgery. It is something people don't realize they have but will CHASE with revision surgery and get little satisfaction from revisions.

No idea if you have this or not (frontal photos in the flesh are needed to look for it).
Just sayin' that IF you do have excess length to the midface, making the chin shorter would just accentuate it by relative comparison. So, you should find some way of determining that the excess length to the face actually comes FROM a chin being too long and not from a long midface.

[kavan]

I think you misread or misinterpreted my post. Increased tooth show in my case made me WORSE off. My surgeon's philosophy when determining teeth show is flawed for patients like me.

Really, surely when correcting faces that have grown retrusive and down, it is logical to expect some degree of face shortening to mimic natural growth. It's either forward and compact, or back and long. Not forward and long like my outcome.

Here is the logic.

Downward growth comes from the MAXILLA. When the face grows DOWN, it DEPENDS on where the excess growth to the maxilla is actually coming from. If it's coming from the midface (middle '1/3rd), that area to the maxilla can't be shortened. (See my prior post on this string.) If the excess downward growth comes from the lower '1/3rd' (area between base of nose and base of chin,), then the part of the maxilla that is long and can be shortened is the 'gummy smile' excess area of the maxilla. So, if one actually does not start off with a gummy smile, it's likely the excess length to the maxilla contributing to downward growth is above the 'gummy smile area' and that would be the middle 1/3rd of face, for all intents and purposes, that can't be shortened to bring much relief to a long midface. Long midface is often the case when people expect to see a shorter face after surgery but don't.

[GJ]

After double jaw surgery + genio my face is strikingly much longer to the point it really bothers me. I was a class ii and steep occlusal plane case. My surgeon did a posterior downgraft only, no impaction which in hindsight was a mistake. I believe my front incisors were lowered 1mm due to the natural advancement plane. Now, at nearly 6 months post OP and still in braces - half of my teeth show at rest, and a large smile shows 1mm of gum above front incisors. This would be fine if I was female, or someone with a short upper lip. However I may be in the minority (especially if in the company of maxfacs), being of the belief optimal aesthetics for a male with a long philtrum like myself is little if any teeth show at rest. It would certainly solve my issues, in addition to my maxillomandibular complex moving back a couple of mm to reintroduce harmony with the rest of my features. My genio was done poorly, I would like a few mm of chin height gone as well.

I'm wondering if anyone has done a revision bimax after a good functional result? Are there surgeons who would agree to operate on me? Is the risk of permanent numbness a real risk to consider with revisions? I'm not over-advanced like those horror cases you occasionally read about, and had a solid orthodontic outcome. Simply my face just looks off and I want it fixed.

It sounds like you got a linear or clockwise movement. Likely because the surgeon doesn't know how to do CCW movements.

The only way to fix that, if true, will be revision. Records would help because all we can do is speculate here.

[kavan]

It sounds like you got a linear or clockwise movement. Likely because the surgeon doesn't know how to do CCW movements.

The only way to fix that, if true, will be revision. Records would help because all we can do is speculate here.

Well, it's possible he thought he had a posterior down graft when he actually didn't. But if you go with the salient things he said he had, in particular; posterior downgraft and a face that had grown both RETRUSIVE and DOWN, makes perfect sense to me why his face got longer and without his mistaking he got what he said (posterior downgraft) and/or because the doctor didn't do one.

He could have started with a long midface (long middle 1/3rd) which won't get any shorter with L-1 advancement and CCW downgraft. The posterior downgraft will decrease the OP which will, in turn, decrease some unwanted extra  downward vertical displacement when the maxilla is advanced. But if the midface is long (where it can't be shortened) and also if the MPA is also high, the CCW-r from the posterior downgraft doesn't compensate for the extra downward growth coming from the midface that can contribute to a high MPA.

A long midface can contribute to a high MPA. Although the CCW-r PDG will, in turn, decrease the inclination of the MPA, it can't decrease it enough to eliminate what ever steepness comes from the long midface. So, the BSSO would be advanced over a LESS high incline but over an incline that is still on the high side (or can't be decreased enough to compensate for what ever extra steepness the long midface contributes). Hence a BSSO advanced over an incline that still has residual steepness to it from a long midface WILL make the face longer. Displacement vectors for the BSSO are out and DOWN. So, an MPA that still has some residual highness to it FROM a long midface will also have an UNWANTED downward displacement vector which is why the face will be longer after bimax advancement with ccw-r in a person with long midface. BSSO....OUT and DOWN and down goes the chin with the BSSO which is where the longness he sees comes from.