Surgery Advice + questions (Pics included)

[SantanDJ]

Hi all,

Just want to say thanks to the active members of the forum who share their knowledge with all of us. I've been learning from the content here for a little while and debating about what I need to get done to fix my own flaws, and I think I'm ready to make a decision and start the process.

I had great potential as a kid which was squandered by some lifestyle  and external factors in my opinion. One was my extraction driven orthodontist whose standard procedure is pulling every patient's 4 molars before braces, purely to prevent possible wisdom teeth impaction years later, along with the combination of a soft diet and poor posture growing up.


This has led to a general recession of the midface and jaws and significant asymmetry. The whole maxillary area is recessed, probably most so in the upper maxillary region. My mandible is less so in comparison but still underdeveloped in my opinion. The recession across the board is worse on the right side of my face and I also have a deviated septum. I've attached some front and side photos to show the above.

I think that my lower third looks short, especially from the side,  so I'd be a good candidate for a bimax surgery to slightly lengthen the lower third of my face and increase the amount of teeth show I have when smiling and talking. I don't think I need CCW rotation as my gonial angle is not too bad and I've heard it shortens the face. I also think a genioplasty would be beneficial for a better defined chin. Any thoughts on all this?

I think my jaw case looks similar to some of the patients here: https://pocketdentistry.com/23-short-face-growth-patterns-maxillomandibular-deficiency/
One question I had about these cases was that they are using clockwise rotation instead of CCW which I would have thought would reduce teeth show, so I'm a bit confused about which would be more suitable in my case if necessary.

The last question I had was whether my nose will be too upturned after bimax since it already points upwards slightly. If so, I assume this is something which can be corrected with a rhinoplasty? Or is it likely to be too steep an angle to amend satisfactorily?


I realise jaw surgery would make the midface deficiency even more apparent, so I would plan to address this separately using implants/fillers after recovery. I also plan to fix the deviated septum and have a forehead reduction. My goals from all this are to get a more balanced, masculine looking face.

Just to add also, I don't have any serious functional issues, although I have noticed that my breathing is poor, having done extensive cardio and still getting out of breath quicker than some of my friends who don't train at all!

Thanks in advance for the help!

[GJ]

Hey there. Your case appears very mild, but when you smile I can notice the maxillary recession. Bordeline case, IMO, that could be more justified with functional problems. But, to answer your question, your face is short, so given all things I think a very mild CW rotation would fix the upper jaw and add some length to your face.

When you say the ortho pulled molars, you meant to say pre-molars, correct? Because pulling molars is even more of a problem. If he pulled anything it should have been the second pre-molars, as they have less root structure, and therefore less influence on facial soft tissue collapse, etc.

The odds are your nose will widen and turn up a bit. Ask the surgeon if they use an alar stitch. IME, it helps.

[kavan]

I see you have SELF ASSESSED by identifying with an article where the patients in it have 'short face'. However the COMMON factor used for assessing 'short face' in that article is that the shortness of total ANTERIOR FACIAL HEIGHT is attributable to the lower '1/3rd'.

The Pocket Denistry link conveys that they CONFIRM 'short face' by measuring the ratio of the lower facial height (i.e., the subnasion to the menton) to the upper facial height (i.e., the glabella to the subnasion). Your ratio = 1. So, there is NO confirmation that your LOWER '1/3rd' (lower height) is diminished as is the case of the patients in the link.

In that regard, you DON'T have 'short face' as is accessed in that article.  What you have is in common with the patients in the article is a compact midface which for the most part is a GOOD thing. But there does not look to be the same need for clockwise rotation to elongate the lower '1/3rd' as was the common factor for the patients in that article.

As to increasing tooth show, maxillary advancement will increase tooth show by bringing your teeth closer to your lips. It is not definite that clockwise rotation would be needed to increase tooth show in the vertical direction. It would depend on the actual orientation of your maxilla whether or not just advancement alone would bring the front teeth further down in addition to further outward.

Your case looks to be one of maxillary recession. Your bite as in how the teeth mesh would be taken into account as to whether your surgery also required a BSSO to balance the upper jaw displacement with the bite or whether you could have single jaw surgery. That can't be predicted from here based on your soft tissue photos alone.

Your alar base (width from nostril to nostril) is WIDE. It could get WIDER with maxillary advancement or could remain the same width if the surgeon uses a technique aimed at preventing the alar base from getting wider and/or you could need a rhinoplasty to narrow the alar base.

Additional procedures you could pursue would come subsequent to a maxfax surgery whether it was single jaw or bimax. Those would be in the venue of upper midface enhancement and as mentioned prior, perhaps rhinoplasty to address the nasal base if it gets wider from maxillary advancement than it is already.

An illustrated photo is included in this post.