Is DJS my best option ? Pics included

[thinjw]

Hi folks,

I'm still on the fence about proceeding with DJS and I really need some objective opinion from people who are not trying to sell me any surgery.

A little background, I have a class 2 bite which was unsuccessfully treated by a couple of orthodontists, I had 5 teeth pulled out before braces - 4 molars and 1 premolar! It makes me furious just thinking about why would someone do that  - I think the uneven number of teeth has caused asymmetry in my jaws and shifted my midline. Both my jaws are noticeably down-swung and my gonial angle is very steep. In addition I have a deviated septum shifted toward the same side so I think that might be related as well.

I believe I am a solid candidate for DJS with CCW. I tried fillers in my chin, which did next to nothing. I used a DNA device for expansion which did help a little, especially in bettering my tongue posture. I've considered genio and a nosejob but with my steep gonial angle I'm not sure a genio would look good and I'm afraid it would further lengthen my face. Could I get away with LJS and a nose job maybe? 
Are there any other options out there that would produce a favourable aesthetic result in my case?

Pics in the links below


https://imgur.com/a/1crLDfY 


Thank you for your valued opinion 

[GJ]

Unfortunately, I think this is a DJS case. It's very unfortunate when orthos misdiagnose patients (to their benefit). This is what happens, and it becomes a mess to fix. IMO to get your lower jaw and chin out more the only thing that will work is DJS with counter-clockwise rotation. A genio would likely look out of place, and maybe make things worse. Let Kavan chime in, though.

You don't look too bad, though, so don't get so down on yourself.

PS. Scans/x-rays would help more than photos.

[kavan]

I think you could get away with no surgery and look within the norm of everyday people who are walking around, all of whom don't have 'perfect' jaw balance. If you wanted jaw surgery, it would be an 'aesthetics only' case and you would be looking at the guys who do lots of cases just for that which is BIG $$$$. The surgery would most likely be in venue of double jaw, CCW-r posterior downgraft and maybe a tad impaction with 3 piece lefort. The jaw and chin would be brought forward with the BSSO, perhaps a bit of upward and outward sliding genio might be added.

[GJ]

Kavan, do you think a genio would look strange on her?

[PloskoPlus]

Jaw surgery.

[kavan]

Kavan, do you think a genio would look strange on her?

Well, I said: 'Perhaps a bit of upward and outward sliding genio might be added.' Key word was 'perhaps'. So, it would be something that MIGHT be added to give more of the look of CCW-r to the lower face in the event the CCW-r to the maxilla could not achieve the extent of rotation needed to decrease the HIGH inclination of the mandibular plane angle. Her chin is recessive in its own right and her MPA has a HIGH inclination.

Keep in mind that pronouncing out the chin point (pog) SOLELY via the BSSO so the chin is no longer recessive and also REDUCING the HIGH MPA will be a DIRECT FUNCTION of the extent of the CCW-r done to the maxilla (lefort). It's also a function of getting the teeth to mesh (bite right). So, let's say, the extent of the CCW-r at maxilla (posterior downgraft + possible impaction) would be 'too much' (for ANY REASON) to be SOLELY depended on to REDUCE the HIGH inclination of the MPA. In THAT case, the surgeon might elect to ADD the sliding genio to assist in the goal of reducing the high MPA.

Hence, it's really not a matter of my thinking it would 'look good'. Something looking good is a function of the displacements that in turn, are functions of all the multiple variables. So, for now, we can say it's a displacement of the chin that could/would look good in the event the CCW-r (and BSSO) alone could not be SOLELY depended on to reduce the high MPA.

Let me put it this way: What can look good (or bad) is WHERE THE POG (chin point) is. So, there is going to be an aesthetically preferable place for the POG point to be. So, it will be a matter of whether or not double jaw surgery ALONE will decrease the MPA enough so the POG point is 'put where it should be put' to look good. If for any reason it can't, the sliding (upward and outward) genio could be used toward that goal.

It's also a matter of it being very common for a genio (even very small ones) to be added to DJS which resolves to the possibility it might be added to the surgical proposal. So, it's something she should be 'braced for' when she consults around and gets surgical proposals.

 

[thinjw]

You don't look too bad, though, so don't get so down on yourself.

PS. Scans/x-rays would help more than photos.

TBH I'm not THAT self-conscious about it, which is precisely why I'm hesitating. Would I like to get it fixed - yes, but then again I'm thinking if it's worth the risk, the pain, the putting my life on hold for a couple of months, my life savings ... But I guess noone can answer that question for me.

Scans I don't have yet but I can post when I get them. Also the prospect of a CT scan scares me... I don't want all that extra radiation 

[thinjw]

I think you could get away with no surgery and look within the norm of everyday people who are walking around, all of whom don't have 'perfect' jaw balance. If you wanted jaw surgery, it would be an 'aesthetics only' case and you would be looking at the guys who do lots of cases just for that which is BIG $$$$. The surgery would most likely be in venue of double jaw, CCW-r posterior downgraft and maybe a tad impaction with 3 piece lefort. The jaw and chin would be brought forward with the BSSO, perhaps a bit of upward and outward sliding genio might be added.

I'm curious to know why you think I would need a 3 piece lefort? What would be achieved by this?
Excuse my lack of technical knowledge

[kavan]

I'm curious to know why you think I would need a 3 piece lefort? What would be achieved by this?
Excuse my lack of technical knowledge

Keep in mind, nothing I say is predictive of what ever your specific surgeon (who ever that is) will do. However, it is not uncommon for some of the top surgeons doing the double jaw surgeries for aesthetics only cases to SEGMENT the Lefort 1 into more pieces than just one cut. For example when the posterior teeth/gum area is inward so that the smile does not fill out close to the corners of the mouth (buccal corridors) such as what you have to the smile, they might elect to do a multi segment lefort where they can selectively widen the area of the smile where it is narrow.

[thinjw]

Well, I said: 'Perhaps a bit of upward and outward sliding genio might be added.' Key word was 'perhaps'. So, it would be something that MIGHT be added to give more of the look of CCW-r to the lower face in the event the CCW-r to the maxilla could not achieve the extent of rotation needed to decrease the HIGH inclination of the mandibular plane angle. Her chin is recessive in its own right and her MPA has a HIGH inclination.

Keep in mind that pronouncing out the chin point (pog) SOLELY via the BSSO so the chin is no longer recessive and also REDUCING the HIGH MPA will be a DIRECT FUNCTION of the extent of the CCW-r done to the maxilla (lefort). It's also a function of getting the teeth to mesh (bite right). So, let's say, the extent of the CCW-r at maxilla (posterior downgraft + possible impaction) would be 'too much' (for ANY REASON) to be SOLELY depended on to REDUCE the HIGH inclination of the MPA. In THAT case, the surgeon might elect to ADD the sliding genio to assist in the goal of reducing the high MPA.

Hence, it's really not a matter of my thinking it would 'look good'. Something looking good is a function of the displacements that in turn, are functions of all the multiple variables. So, for now, we can say it's a displacement of the chin that could/would look good in the event the CCW-r (and BSSO) alone could not be SOLELY depended on to reduce the high MPA.

Let me put it this way: What can look good (or bad) is WHERE THE POG (chin point) is. So, there is going to be an aesthetically preferable place for the POG point to be. So, it will be a matter of whether or not double jaw surgery ALONE will decrease the MPA enough so the POG point is 'put where it should be put' to look good. If for any reason it can't, the sliding (upward and outward) genio could be used toward that goal.

It's also a matter of it being very common for a genio (even very small ones) to be added to DJS which resolves to the possibility it might be added to the surgical proposal. So, it's something she should be 'braced for' when she consults around and gets surgical proposals.

Correct me if I'm wrong, but I think GJ meant if a genio only, without the JS, would look strange on me? I would like to know your thoughts on that as well.

Thank you for your elaboration above, it makes perfect sense... I am actually prepared for the possibility I would need a genio in addition to JS, even though I'd prefer to have less bone cuts if possible. I do want to add more projection but in the same time I'd like to keep the chin small and feminine. I think ending up with a strong masculine chin would be a bigger disaster for me than my current situation.

Also, I've seen cases of LJS with CCW-r. How can that be achieved if there is no impaction or CCW-r of the maxilla to make room for it ?

[thinjw]

Keep in mind, nothing I say is predictive of what ever your specific surgeon (who ever that is) will do. However, it is not uncommon for some of the top surgeons doing the double jaw surgeries for aesthetics only cases to SEGMENT the Lefort 1 into more pieces than just one cut. For example when the posterior teeth/gum area is inward so that the smile does not fill out close to the corners of the mouth (buccal corridors) such as what you have to the smile, they might elect to do a multi segment lefort where they can selectively widen the area of the smile where it is narrow.

I see... my smile was even more narrow it's widened somewhat with the DNA device I was using. Wouldn't the lower arch need to be widened to match tho ?

[GJ]

Correct me if I'm wrong, but I think GJ meant if a genio only, without the JS, would look strange on me?

Correct - that's what I meant.

[kavan]

Correct - that's what I meant.

Well, you asked if I thought a genio would look strange on her right after my post where I suggested the possibility of a genio being added to double jaw surgery. If you asked whether I thought a genio ALONE would look strange on her, my answer would have been; YES.

[kavan]

I see... my smile was even more narrow it's widened somewhat with the DNA device I was using. Wouldn't the lower arch need to be widened to match tho ?

The lower arch is wider in the back. So when it comes forward, the wideness at the back of it will come forward.

[kavan]

Correct me if I'm wrong, but I think GJ meant if a genio only, without the JS, would look strange on me? I would like to know your thoughts on that as well.

Thank you for your elaboration above, it makes perfect sense... I am actually prepared for the possibility I would need a genio in addition to JS, even though I'd prefer to have less bone cuts if possible. I do want to add more projection but in the same time I'd like to keep the chin small and feminine. I think ending up with a strong masculine chin would be a bigger disaster for me than my current situation.

Also, I've seen cases of LJS with CCW-r. How can that be achieved if there is no impaction or CCW-r of the maxilla to make room for it ?

See my post to GJ. His question came directly after my post where I mentioned the possibility of of a genio and suggested that WITHIN the CONTEXT of double jaw surgery. So, there was no way for me to assume he meant genio ALONE. So, NO to genio alone.

CCW-r in the absence of maxilla impaction is done with a posterior downgraft. You will need to do some self research on what that is.