Gummy smile LeFort 1 questions (with pics + CT scan)

[alivein05]

Hi, I am considering aesthetic jaw surgery. The primary reason to reduce the amount of gum visible when I smile. A surgeon has quoted me 2 piece LeFort 1 osteotomy & rigid fixation. I believe this would involve forward advancement the lower section of the maxilla to ensure bite alignment with the lower jaw.

Overall I'm not sure whether to proceed, and I'm curious to hear what this forum thinks.

Background: I had braces as a teenager and was a chronic mouth breather until getting allergy shots and fixing deviated septum. I have a good bite according an orthodontist I visited a few months ago as part of the initial consultation. Gummy smile is common in my family.

CT scan pics: https://imgur.com/a/tS5pvRA
Selfie pics attached to this post.

Questions/observations:

- Regarding the gummy smile, does it appear be caused more by soft tissue or hard tissue? My perception is that it is a combination of: my philtrum is short (hence the lip incompetence in repose), my lip smile muscles are hyperactive (hence gum display during smile in excess of the incompetence gap in repose), and there is some mild hard tissue vertical maxillary excess of ~2mm. Together, these factors compound to yield a rather gummy smile.
- Is my upper maxilla recessed? In in side profile, I perceive my upper maxilla to be recessed and my lower maxilla to protrude forward at an angle.
- I perceive myself to have a "chimp lip" upper lip in that it protrudes forwards and downwards. This is especially noticeable to me in the last two CT scan pics with the soft tissue visible. Is this a reasonable assessment? How would a LeFort 1 with advancement affect this? I could imagine it "fixing" it if the cut is high enough or making it worse if the cut is too low.
- Do I have a "long" face? I am worried about messing up my facial thirds. I don't feel that my face is particularly long and worry that impacting my maxilla could make it too vertically short relative to width.
- My nose is projected from my face quite a bit and has a "ski jump" shape. If I were to advance the maxilla, would it make these factors more pronounced?
- If you were in my situation, how would you proceed? I'm on the fence between doing jaw surgery vs just getting upper lip botox every four months until I age to the point that my philtrum lengthens and muscles weaken and less gum is shown, or until this no longer bothers me psychologically (doesn't seem likely...).
- Anything else to consider in this situation?

Thanks so much!

 

[GJ]

It's actually pretty normal to have some parting of the lips at rest. People think this is abnormal, but it's not.

Your philtrum length looks average. I don't think that is causing the gummy smile. It must be a long maxilla, relative to everything else, or your muscles when you smile contributing to this. The fix for this is a few mm of impaction - you look to "need" about 2mm. "Need" in quotes because I'd do nothing in this case. I agree with your ortho your bite looks good.

Your face doesn't appear long. Regarding your nose, it will change. Likely 1 to 2mm of widening. Impaction can upturn the nose.

For all these reasons, I'd just do nothing - the plus side is when you age the lip will drop, so it will fix on it's own to some degree, and you'll likely look younger than all your friends. This is a youthful look to show a little tooth and gum.

[alivein05]

Thanks! My thinking is that with some gum line recontouring and periodic upper lip botox I can reach an aesthetic for the smile that I am comfortable with. It's unfortunate that botox only lasts a few months.

Any thoughts on the comments/questions related to "chimp lip" and upper maxilla recession?

[GJ]

Thanks! My thinking is that with some gum line recontouring and periodic upper lip botox I can reach an aesthetic for the smile that I am comfortable with. It's unfortunate that botox only lasts a few months.

Any thoughts on the comments/questions related to "chimp lip" and upper maxilla recession?

I definitely don't see chip lip, and if anything you have a concave philtrum.

If you have midface recession, it looks higher up where a Lefort 1 wouldn't address it. Maybe some very mild recession up higher, but this is normal for guys.

[alivein05]

Thanks. Regarding "chimp lip", I might be misunderstanding the concept. Is there a term for the kind of protrusion of the upper lip shown below? Maybe it's just normal...

[GJ]

Thanks. Regarding "chimp lip", I might be misunderstanding the concept. Is there a term for the kind of protrusion of the upper lip shown below? Maybe it's just normal...

Chimp lip is usually used to describe a convex philtrum area, and usually it's caused by bone (i.e. too much projection).

That image just looks like full lips to me. Kavan knows more about soft tissue, so maybe they will chime in. Maybe there's a better term for that.

[kavan]

Good photo presentation; the act of knowing to put your photos on the same link and also announcing that more photos are attached to your post.


The photos reveal; long teeth, gummy smile, buccal corridors (black spaces to the smile seen at corners of lips). That seems consistent with what the surgeon generally suggested but did not specifically elaborate on. I am assuming the Lefort 1 would be to reduce the gummy smile (anterior impaction) and also to widen the smile at the sides (buccal corridors).


There is not enough information (from the doctor) for me to engage in your 'beliefs' that the lefort 1 would also involve forward advancement to the extent I would be inclined to enter discussion as to 'is my maxilla recessed?' or 'will I get a chimp lip?' OR ANYTHING ELSE in the venue of 'will maxillary advancement do this or that to me?'

As to your self assessment that seems to imply you might THINK your middle '1/3rd' is equal to your lower '1/3rd' and now you gotta worry that impaction will mess up your facial 1/3rds balance, an assessment done by someone who KNOWS HOW to do it (me) reveals your lower 1/3rd is significantly LONGER than your middle 1/3rd. So, I would not worry about an impaction upsetting an IMBALANCE you have to the lower 1/3rd in a situation where some of the excess length is directly related to the downward growth of the anterior maxilla and BOTH the gummy smile AND excess length to lower 1/3rd would tend to be IMPROVED balance wise via the impaction.

[alivein05]

Thanks, kavan. This is the first time I have been made aware of the buccal corridors, and, yes, I believe you are right in that this what the surgeon intends to address with a with the "two-piece" aspect of the LeFort 1.

>your lower 1/3rd is significantly LONGER than your middle 1/3rd

Noted. Is the measurement of about 1:1.5 mid third to lower third correct in the attached picture?

What are your thoughts on the soft tissue upper lip protrusion that GJ confirmed is not chimp lip? Do you know of a name for that phenomenon? Thanks.

Regarding recession, I was hoping someone could confirm from the CT scans whether my bones appear recessed, independent of the surgical plan. GJ's assessment that there may be mild recession in the upper maxilla in above the LeFort 1 area is consistent with my understanding.

Thanks again.

[kavan]

Thanks, kavan. This is the first time I have been made aware of the buccal corridors, and, yes, I believe you are right in that this what the surgeon intends to address with a with the "two-piece" aspect of the LeFort 1.

>your lower 1/3rd is significantly LONGER than your middle 1/3rd

Noted. Is the measurement of about 1:1.5 mid third to lower third correct in the attached picture?

What are your thoughts on the soft tissue upper lip protrusion that GJ confirmed is not chimp lip? Do you know of a name for that phenomenon? Thanks.

Regarding recession, I was hoping someone could confirm from the CT scans whether my bones appear recessed, independent of the surgical plan. GJ's assessment that there may be mild recession in the upper maxilla in above the LeFort 1 area is consistent with my understanding.

Thanks again.

Ya, your measure reflects the concept that the lower 1/3rd is not 'equal' to the middle 1/3rd and lower 1/3 is longer.

Chimp lip is like what a chimp has which is a very long and conVEX lip. Yours is short and conCAVE. I would just call it 'thick lip'.

I use this basic vertical line on the soft tissue contour to look for recession to the  Lefort 1 area. I didn't find it. I do so to determine if I'm going to indulge in questions based on assuming one has recession and is going to have advancement due to that and then what should they do about the part above the lefort 1 area. I didn't find anything that would allow me to conclude maxillary advancement was going to be part of the surgeon's plan. Hence any pondering of should you do 'this or that' based on maxillary advancement was MOOT for me to engage in.

ETA: Illustration included with this post.

[ghiggson90]

Hi, I am considering aesthetic jaw surgery. The primary reason to reduce the amount of gum visible when I smile. A surgeon has quoted me 2 piece LeFort 1 osteotomy & rigid fixation. I believe this would involve forward advancement the lower section of the maxilla to ensure bite alignment with the lower jaw.

Overall I'm not sure whether to proceed, and I'm curious to hear what this forum thinks.

Background: I had braces as a teenager and was a chronic mouth breather until getting allergy shots and fixing deviated septum. I have a good bite according an orthodontist I visited a few months ago as part of the initial consultation. Gummy smile is common in my family.

CT scan pics: https://imgur.com/a/tS5pvRA
Selfie pics attached to this post.

Questions/observations:

- Regarding the gummy smile, does it appear be caused more by soft tissue or hard tissue? My perception is that it is a combination of: my philtrum is short (hence the lip incompetence in repose), my lip smile muscles are hyperactive (hence gum display during smile in excess of the incompetence gap in repose), and there is some mild hard tissue vertical maxillary excess of ~2mm. Together, these factors compound to yield a rather gummy smile.
- Is my upper maxilla recessed? In in side profile, I perceive my upper maxilla to be recessed and my lower maxilla to protrude forward at an angle.
- I perceive myself to have a "chimp lip" upper lip in that it protrudes forwards and downwards. This is especially noticeable to me in the last two CT scan pics with the soft tissue visible. Is this a reasonable assessment? How would a LeFort 1 with advancement affect this? I could imagine it "fixing" it if the cut is high enough or making it worse if the cut is too low.
- Do I have a "long" face? I am worried about messing up my facial thirds. I don't feel that my face is particularly long and worry that impacting my maxilla could make it too vertically short relative to width.
- My nose is projected from my face quite a bit and has a "ski jump" shape. If I were to advance the maxilla, would it make these factors more pronounced?
- If you were in my situation, how would you proceed? I'm on the fence between doing jaw surgery vs just getting upper lip botox every four months until I age to the point that my philtrum lengthens and muscles weaken and less gum is shown, or until this no longer bothers me psychologically (doesn't seem likely...).
- Anything else to consider in this situation?

Thanks so much!

 

I strongly recommend against this surgery. Your gum show is not excessive and looks youthful.  I went in for the same reasons and it was the worst decision ever.   If anything try Botox and see what you think, but this surgery is way overkill and not worth it in your case.

[alivein05]

Thanks for the replies. Here is another picture with a more full smile, like if I'm laughing. I would be hoping for an outcome similar to this person's: https://www.reddit.com/r/jawsurgery/comments/mn0zdv/lefort_i_and_bsso

ghiggson90, I am sorry to hear of your experience. I would love to learn more. I'm going to read through your post history to see if I can understand your outcome. Any tips or links welcome, thanks.

I spoke to both ortho and surgeon today. Ortho says "If it bothers you now, it's always going to bother you, and this seems like proper fix" (I am in my 30s). Surgeon says "I think this has more to do with soft tissue than your jaw bone, we can do surgery but consider not".

[kavan]

OK, this photo is also quite good the way you lined up with the lines of the tiles. So, the vertical drawn to pass through base of nose is ball park vertical to soft tissue profile to look for recession but in terms of POTENTIAL AESTHETIC BENEFIT of advancing an area. The potential aesthetic benefit of advancing the maxilla would be HIGH for a person who's upper lip was BEHIND that vertical and who's NOSE had a HUMP (conVEX bridge) in it. But you have the REVERSE of that; lips forward to the line and a nose that has a conCAVE bridge. So, what's the aesthetic benefit of making the thick lip stick out more and the conCAVE area to the bridge becoming more scooped in with maxillary advancement? I don't see any and the surgeon probably doesn't either. It would be considered an aesthetic TRADE-OFF if the maxilla needed to be advanced for the teeth to mesh correctly. If the matter is AESTHETICS, I look at SOFT TISSUE profile. Hypothetically, IF someone told you your maxilla was recessed, your next question/s would be: ' Would my nose get more scooped out at the bridge and would my lip STICK OUT MORE with maxillary advancement?' They answer would be YES. It would veer towards that. Because you don't have the soft tissue profile relationship to get a high potential aesthetic benefit from maxillary advancement.

Thing is to evaluate the upper maxilla like area below the eye, the eyeBALL would need to show in that photo for another evaluation line to be made because evaluations for that part are from SOFT TISSUE profile shots. A full face shot is needed (showing the eyes) also. Because the issue could also be a plastic surgery issue or just a filler fix or a bone cut that would come way AFTER any other maxfax surgery and not something to be addressed at this point in time. I use the face photos and NOT the scan photos for that sort of thing.

I've already given my take on the reduction of excess gummy smile surgery and widening of the smile.

Illustration included with this post.

[kavan]

Thanks for the replies. Here is another picture with a more full smile, like if I'm laughing. I would be hoping for an outcome similar to this person's: https://www.reddit.com/r/jawsurgery/comments/mn0zdv/lefort_i_and_bsso

ghiggson90, I am sorry to hear of your experience. I would love to learn more. I'm going to read through your post history to see if I can understand your outcome. Any tips or links welcome, thanks.

I spoke to both ortho and surgeon today. Ortho says "If it bothers you now, it's always going to bother you, and this seems like proper fix" (I am in my 30s). Surgeon says "I think this has more to do with soft tissue than your jaw bone, we can do surgery but consider not".

Although I can't predict your outcome, the change you see on the photo of another person is the GOAL of the type of surgery suggested to you.

[alivein05]

>It would be considered an aesthetic TRADE-OFF if the maxilla needed to be advanced for the teeth to mesh correctly

Yes, that's consistent with my understanding. Surgeon's reasoning, as explained to me by ortho, is as follows:

- Primary goal is impaction of maxilla to reduce gum exposure.
- Question is whether BSSO is needed or not to get the teeth to mesh.
- With a minor forward advancement of the maxilla, BSSO can be avoided. So I think that's the plan.

In other words, the advancement is a side effect of the impaction to ensure alignment. And as you say may have questionable aesthetic impact.

[kavan]

>It would be considered an aesthetic TRADE-OFF if the maxilla needed to be advanced for the teeth to mesh correctly

Yes, that's consistent with my understanding. Surgeon's reasoning, as explained to me by ortho, is as follows:

- Primary goal is impaction of maxilla to reduce gum exposure.
- Question is whether BSSO is needed or not to get the teeth to mesh.
- With a minor forward advancement of the maxilla, BSSO can be avoided. So I think that's the plan.

In other words, the advancement is a side effect of the impaction to ensure alignment. And as you say may have questionable aesthetic impact.

It' a function of the extent of it. So, if it's minor to AVOID the BSSO, it's not going to kick up noticeable/unwanted changes to nose/lip. So, it's like I said.