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

[kavan]

To my post above, I will add that what the doctor told you is basically what I was saying which is advancement wouldn't be for aesthetic reasons as in not something to request and not something the doctor would do towards FOR aesthetic reasons. The reason to advance would be to avoid the BSSO and so the teeth mesh. But since the extent of the advancement would tend towards being minor, so would the trade-off and it's not a bad trade-off for avoiding the BSSO.

What they are doing is basically AUTO-ROTATION of the lower jaw which is something where the maxillary impaction gets the lower jaw to rotate CCW (upward) to decrease excess length to the lower 1/3rd. It's a '2 for 1' type surgery which addresses both the gummy smile and the long lower 1/3rd.

[PloskoPlus]

If your maxilla is not level, you'll need a BSSO. Anyway, I'd do nothing.  Odds are you won't look any better, just different.

[alivein05]

Thanks. All this makes sense and is useful context. I'm thinking about it the decision as follows. Possible outcomes:

1. I look better
2. I look different but not better
3. I look worse

If odds were 90%+ in bucket 1, I'd do it. The cost and recovery time are not a big deal to me.

But I think the odds are more like 30%/30%/30% or perhaps worse, especially over the course of my whole life when considering the impacts of age on philtrum length and lip mobility. For #3, I'm in particular worried about my nose being noticeably more projected horizontally than the vertical distance from the bottom of my nose to the bottom of my top teeth. That would be an odd look. I have a long nose already, advancement of maxilla would project it further, and of course removing some of my upper jaw would make my teeth even closer to my nose.

It's really interesting hear from people who had surgeries like this and regretted them.

So I think my aesthetic approach will be as follows:

- Use botox to limit upper lip mobility. I've gotten this in the past and like the results, I just don't like the impermanence. This may not be necessary as I get older.
- Gum contouring to even out the gum line.
- Unrelated to what we've discussed so far, but filler to balance asymmetric chin.

@Kavan, I was a bit surprised by your comment here:

The photos reveal; long teeth

I perceive my lateral incisors in particular to be rather short and have considered gum contouring to reveal more tooth. Perhaps my teeth are long on aggregate though?

[kavan]

Thanks. All this makes sense and is useful context. I'm thinking about it the decision as follows. Possible outcomes:

1. I look better
2. I look different but not better
3. I look worse

If odds were 90%+ in bucket 1, I'd do it. The cost and recovery time are not a big deal to me.

But I think the odds are more like 30%/30%/30% or perhaps worse, especially over the course of my whole life when considering the impacts of age on philtrum length and lip mobility. For #3, I'm in particular worried about my nose being noticeably more projected horizontally than the vertical distance from the bottom of my nose to the bottom of my top teeth. That would be an odd look. I have a long nose already, advancement of maxilla would project it further, and of course removing some of my upper jaw would make my teeth even closer to my nose.

It's really interesting hear from people who had surgeries like this and regretted them.

So I think my aesthetic approach will be as follows:

- Use botox to limit upper lip mobility. I've gotten this in the past and like the results, I just don't like the impermanence. This may not be necessary as I get older.
- Gum contouring to even out the gum line.
- Unrelated to what we've discussed so far, but filler to balance asymmetric chin.

@Kavan, I was a bit surprised by your comment here:

I perceive my lateral incisors in particular to be rather short and have considered gum contouring to reveal more tooth. Perhaps my teeth are long on aggregate though?

Long teeth. Central incisors.

I think the odds are in your favor of looking better. My 'sample size' is looking at tons and tons of photos (like the one you showed) and seeing the cases look much better. Also, odds get better when the appropriate surgery targets the aesthetic issue and what was suggested to you is the type to be done for a case like yours. You might want to increase your sample size. But of course, it's true that that the odds of being dissatisfied with outcome of a surgery are 0 if you don't get the surgery. Then there are plenty of people walking around with all different types of maxfax imbalances and they blend in or don't even know they have them. So, it's all good whether you get it or not.

[ghiggson90]

I think you will look worse because you (a) don't have a long maxilla or face, just a short/hyperactive lip, and (b) the Lefort will shorten your face, widening your buccal corridors, and sharpening your mentolabial fold.  I find it quite telling that even your surgeon is saying that this has more to do with soft tissue (yet he's totally fine taking your money so long as he's addressing your concerns, WTF...)  Aside from looking worse--this forum is littered with bad gummy smile results, mine included--there's the real possibility of nerve damage, tooth damage, plus the time and money wasted.  I say run for the hills. Feel free to PM me.

[ghiggson90]

The fact that a surgeon would cut up the bones in your perfectly fine face on account of the highly dubious probability of achieving an aesthetic improvement for a quick hit of cash just gets to me.

[kavan]

The fact that a surgeon would cut up the bones in your perfectly fine face on account of the highly dubious probability of achieving an aesthetic improvement for a quick hit of cash just gets to me.

Excuse me but why not just focus on sharing your personal experience (over impaction) with your surgeon as opposed to projecting on to his surgeon not only dubious probability but also dubious intent. Why the need to cast his surgeon  in an unfavorable light. The most certain 0 probability with NO chance of dissatisfaction with a surgery is not to get one.

[ghiggson90]

Excuse me but why not just focus on sharing your personal experience (over impaction) with your surgeon as opposed to projecting on to his surgeon not only dubious probability but also dubious intent. Why the need to cast his surgeon  in an unfavorable light. The most certain 0 probability with NO chance of dissatisfaction with a surgery is not to get one.

You are excused.  His surgeon has admitted that it’s a soft tissue issue and suggested he consider not getting the surgery at all, so I think I’m on solid ground questioning the merits of this surgery, which is what OP asked us to do in the first instance.  The unpredictability of this surgery with respect to soft-tissue changes and co-morbidities is well documented, and since it’s not clear at all to the patient, the surgeon, and everyone but you in this thread whether there is even a skeletal problem to remedy in the first place, then  I think I’m on solid ground questioning the probability of success of this surgery.  And yes, I question the ethics of a surgeon willing to perform a surgery with unclear probabilities of success.  There is, after all, a principal agent problem here, as in all doctor-patient relationships.

[ghiggson90]

OP also has available a non-invasive alternative in Botox that seems to have a reasonable probability of success.  It seems prudent to at least recommend he exhaust that alternative before jumping into this costlier and way more invasive procedure.

[ghiggson90]

Let me also just add that because OP suggests some psychological distress about his smile, which I sincerely believe is not severe, it also wouldn’t hurt to consider some psychological screening, which is recommended in a recent body of  literature, given the high prevalence of OCD, BDD, and other depressive disorders among the patient population.

[kavan]

You are excused.  His surgeon has admitted that it’s a soft tissue issue and suggested he consider not getting the surgery at all, so I think I’m on solid ground questioning the merits of this surgery, which is what OP asked us to do in the first instance.  The unpredictability of this surgery with respect to soft-tissue changes and co-morbidities is well documented, and since it’s not clear at all to the patient, the surgeon, and everyone but you in this thread whether there is even a skeletal problem to remedy in the first place, then  I think I’m on solid ground questioning the probability of success of this surgery.  And yes, I question the ethics of a surgeon willing to perform a surgery with unclear probabilities of success.  There is, after all, a principal agent problem here, as in all doctor-patient relationships.

My response to your prior post was directly about your casting the surgeon's intentions in an unfavorable light.

The facts and the circumstances the OP conveyed about his communications with surgeon/orth DON'T reveal advice he was given was with aim of their getting 'quick cash'. The fact that the surgeon did not try to 'sell him' on the surgery and actually suggested he not get it at all demonstrate that.

All they reveal is the OP consulted about surgery and they conveyed the type of surgery applicable to cases like his (gummy smile, long lower 1/3, narrowness to the back part of the smile) and also conveyed to him he could have the surgery or 'consider not'. So, there is really nothing about what the surgeon conveyed to him for you to attribute a type of dubious intent ('quick cash') to the surgeon.

As to chances of success, they are never going to be as estimable as rolling the dice or card counting at the casino or things like that because there's no way to know what the probabilities  are as in situations where mathematical probabilities do exist. So, we don't actually know the probabilities, nor are they something where your personal (unfavorable) experience predicts them.
So, probabilities, the type they use in DECISION ANALYSIS are by definition 'unclear' and do not impute the surgeon with 'dubious' ethics not to know them.

The way to approach is more of an empirical/intuitive one where one just looks at gads and gads of outcomes of people who had big gummy smile and long lower 1/3rd and very little maxillary advancement with the surgery; patients with similar input in appearance and surgical treatment. It was the method I used because I know there are no mathematical probabilities out there to be used.

As to your other commentary on this string for example BDD possibility. It's most likely the USUAL thing with most people on here. They want to be CERTAIN that they will like what they see in the mirror. So, they need to be certain about something that  can't be predicted with absolute certainty. As to his using other things like the Botox, he has ALREADY said he was resolving to just that which was another reason why I didn't know where your casting his surgeon as one with 'dubious' intent was coming from since the OP did seem to appear to have resolved to living with his imbalance and addressing via other modalities.

[alivein05]

Thanks for this exchange. It's useful for me to hear different perspectives.

To be clear: I sought out the orthodontist, I sought out the surgeon -- I have been driving this whole process. The surgeon expressed skepticism about the benefits. He was (and is) pushing me away from surgery, not towards. But if I insist, he said he could do it.

I told the surgeon I was unsure whether hard or soft tissue was the issue. I asked him: imagine you saw the CT scan only and not my face. Would you see anything wrong? From the CT scan, would you think I have a gummy smile? He said the hard tissue all seemed within the range of normal and attributed my gummy smile to muscular issues.

The orthodontist is a bit more nudging towards surgery, but only a bit.

============

What I'm trying to unpack with this thread is whether there is a clearly "fixable" problem that merits jaw surgery. I've learned is that there is multidimensional input and output of the surgery, rather than just being a binary fix of one thing from good to bad. This means that in addition to the cost, recovery, and standard surgical risks, I also need to factor in undesirable unintended aesthetic consequences. This is not something I've given much thought to before.

============

To expand on the concern I mentioned in the earlier photos, I've attached a photo of my smile in more of a profile. I perceive my philtrum to be rather short during smile, especially in relation to the projection of my nose. Compare that ratio to here: https://www.pinterest.com/pin/327918416592959004/

Imagining post-surgery my upper teeth starting where my philtrum ends when smiling ... that seems like a bad look at could result from any impaction (even if it's not considered "overimpaction").

============

Regarding BDD, appreciate the concern. There is a certain degree of objectivity regarded the optimal gum display during smile, and I am several standard deviations from the norm, especially during "full" smile. Some people may be less bothered by this sort of thing than others. I'm on the "more bothered" side of the spectrum. Whether this is merits psychological treatment or evaluation, I'm not sure. Perhaps therapy could be appropriate.

============

So my current plan is to get botox and see how I feel in a bit. I've had it before and liked the result. I just didn't like that it was temporary and that (in my understanding) it didn't fix the "root cause". However, if the root cause _is_ muscular, or at least the muscles are a strong contributing factor, then botox actually does address the root cause. That reframing might be sufficient for me.

This is a lot of new information in the last week, so I'm still processing. Thanks again.

[kavan]

As to this 'soft tissue' thing, are you sure he wasn't trying to convey that your soft tissue profile did not justify the the aesthetic need for bimax advancement?

When a patient is consulting about potential aesthetic advantages of boney displacements as in getting surgery for AESTHETIC benefits, in PARTICULAR advancement of either maxilla or mandible or both, the docs look at the soft tissue profile (similar to your bathroom photo where I drew a red relative line). The soft tissue is where it should be relative to that line. Also, muscles are part of soft tissue and soft tissue (including muscles) follow bone. So, the soft tissue profile really doesn't suggest; 'to ADVANCE FORWARD'.

What the surgeon sees is basically what he can fix. He can decrease the gummy smile and broaden the narrow part of in the back and with that he can reduce the excess length of the lower 1/3rd.

Next thing he would take into consideration is what your own perceptions are or focus is about. Like IF you told him such things as; 'I percieve my self as having a chimp lip' and fretting about a maxillary advancement in a circumstance where it would most likely be minor as to avoid a bsso, he might notice your perceptions are off. Add that you don't 'FEEL' that your lower 1/3rd is long when the ratios (they can see on your face) reveal otherwise. Then there is the major focus you have of whether or not the CT scan reveals your gummy smile is from a vertically long anterior maxilla or a short philtrum and hyperactive lip muscles.

From the surgeon's perspective, he's probably noticing your perspective isn't exactly on target with a surgery that can reduce the gummy smile, widen it and reduce the excess length of lower 1/3rd and do that whether or not the bone scan itself confirms long anterior maxilla. The surgeon wants to see that you are in the head space to make a decision based on wanting to improve your smile, reduce excess gum show and excess length of lower 1/3rd and the more he hears mixed messages, some off target perceptions that dove tail on heightened uncertainty, it positions the surgeon to 'sell you on' the surgery. So, it's a good thing he's NOT doing that. The best way to resolve a lot of uncertainty and heightened expressions of risk aversion in a patient consulting primarily for 'aesthetics only' when he's HEARING that you ONLY want the surgery IF your bones are not in the right place with reference to the scan is to offer NOT to do it. When he says he will do it if you WANT it, he will know when you want it when you make clear you want it for what it  COULD BE DONE FOR; to improve the smile by reducing the excess gum and tooth show and also broaden it in addition to reducing the excess length of the lower 1/3rd. Like he's saying he could do it for THAT if you WANTED it for THAT. He's also saying that if your primary concern is to AVOID a surgery 'because' the scan doesn't reveal the bones are misaligned or in the 'wrong' places, then he has no issue with that.

Also, if you are showing your surgeon photos of BRAD PITT (called 'Chuck Norris') and wanting to indulge in your ratio compared to his, the more you communicate with the surgeon on those sort of terms, the less inclined he's going to be to offer you surgery.

That said, although my 'back and forth' with ghiggson (he's a good guy. he means well.) was about my disagreeing that the surgeon was acting with 'dubious' intent, what's becoming more apparent to me is that you are not in the 'head space' to go forward with a decision to have surgery and easier to just resolve to your not having it whether or not you have BDD or need psyche help.

[Gadwins]

Thanks for this exchange. It's useful for me to hear different perspectives.

To be clear: I sought out the orthodontist, I sought out the surgeon -- I have been driving this whole process. The surgeon expressed skepticism about the benefits. He was (and is) pushing me away from surgery, not towards. But if I insist, he said he could do it.

I told the surgeon I was unsure whether hard or soft tissue was the issue. I asked him: imagine you saw the CT scan only and not my face. Would you see anything wrong? From the CT scan, would you think I have a gummy smile? He said the hard tissue all seemed within the range of normal and attributed my gummy smile to muscular issues.

The orthodontist is a bit more nudging towards surgery, but only a bit.

============

What I'm trying to unpack with this thread is whether there is a clearly "fixable" problem that merits jaw surgery. I've learned is that there is multidimensional input and output of the surgery, rather than just being a binary fix of one thing from good to bad. This means that in addition to the cost, recovery, and standard surgical risks, I also need to factor in undesirable unintended aesthetic consequences. This is not something I've given much thought to before.

============

To expand on the concern I mentioned in the earlier photos, I've attached a photo of my smile in more of a profile. I perceive my philtrum to be rather short during smile, especially in relation to the projection of my nose. Compare that ratio to here: https://www.pinterest.com/pin/327918416592959004/

Imagining post-surgery my upper teeth starting where my philtrum ends when smiling ... that seems like a bad look at could result from any impaction (even if it's not considered "overimpaction").

============

Regarding BDD, appreciate the concern. There is a certain degree of objectivity regarded the optimal gum display during smile, and I am several standard deviations from the norm, especially during "full" smile. Some people may be less bothered by this sort of thing than others. I'm on the "more bothered" side of the spectrum. Whether this is merits psychological treatment or evaluation, I'm not sure. Perhaps therapy could be appropriate.

============

So my current plan is to get botox and see how I feel in a bit. I've had it before and liked the result. I just didn't like that it was temporary and that (in my understanding) it didn't fix the "root cause". However, if the root cause _is_ muscular, or at least the muscles are a strong contributing factor, then botox actually does address the root cause. That reframing might be sufficient for me.

This is a lot of new information in the last week, so I'm still processing. Thanks again.

I would stay away from the surgery. I think, that you are just exaggerating your aesthetical problems.  I would be also very careful, about a possible lawsuit after the surgery (Maybe you want to sue your surgeon after that). I don't know the specific laws in your country. But it is common sense, that you are taking all the risks on your own, if you are insisting on a surgery, which a surgeon didn't want to perform.

Either go to a lawyer before the surgery to inform yourself or maybe go with another surgeon, who would advice this kind of surgery.

[kavan]

 -- I have been driving this whole process. ......... I've learned is that there is multidimensional input and output of the surgery, rather than just being a binary fix of one thing from good to bad. .....Regarding BDD, appreciate the concern.

When you say you've been 'DRIVING THE WHOLE PROCESS', is this something where you chose to provide the doctor with the CT scan or did he choose that instead of a ceph X ray? I ask because there is just something 'off' when you need to insist he focus on the CT scan whereas if he insisted you get one, you wouldn't need to push so hard for him to focus on it. With the ceph X rays, they are taken at an office and it's common for the doctor to have ceph analysis program that charts out all the landmarks which, in turn, give a reading of all the bone and bite relationships.

If that's the case, you probably don't have BDD. More likely it's BSD which means 'Back Seat Driver'
Back Seat Drivers are very common on JSF board. They crowd source on JSF for other back seat drivers to give the 'directions'. That's all well and fine until one person wants to go one way and the other in the opposite direction and then you're left with collision indecision.

My closing comments on this one:

He already gave you the 10 'binary options': Have the surgery or don't.

Consider the 'multidimensional input and output' of the surgery an unsolvable equation.