How should I approach my case of bi-dentoalveolar protrusion?

[TheZillip]

I apologise in advance for the length of this post...

I recently went to see a maxfac surgeon, to see if I can improve my overall aesthetics. Taking my pictures into account, I've always had a protruding lip appearance, which is most obvious with a side profile picture, possibly this looks more protrusive due to my weak chin or jaw generally. This is my biggest gripe.

I have a basic understanding of the issues with my jaw/teeth but I wonder how best to approach my situation to get the best results, but I'm not as well informed as many of the people on this forum so I'm probably not even aware of many of the issues.

I have many questions but I'll try to focus on: What is possible/the best option to treat my issues?

- Orthodontically (I know I have dental problems so I will definitely need orthodontics regardless, but I recognise that before resolving these I must be absolutely sure that any changes to jaw alignment surgically must be considered first so they can harmonise together)
- Camouflaging using a genioplasty so my lips look less protruded
- Jaw surgery
- Ignore it as surgery is too invasive and will not provide a good result

If there are other options, I'd happily consider those also. Which treatment option is most appropriate? Purely treating this potential issue isn't my only concern, however, I would also like to have a much stronger and defined chin/jaw overall, to hopefully remove the fatty look to my lower face that you can see on the side profile. Although, I recognise this could be a case of tongue positioning which I'm not sure can be corrected?

I'm also not sure if these end results would look natural or not, which is another concern.
 
Below are some other key things my maxfac surgeon mentioned

- I have an underdeveloped chin
- I have a lot of teeth that I have lost posteriorly
- I have overcrowding, particularly in the maxilla anteriorly in my top jaw
- My anterior bite is classified as a Class II Division 2 deep bite. My top teeth are retroclined and go straight down onto my bottom teeth and my bottom teeth will have a tendency to bite into the palatal aspects of my gums.
- I have bi-dentoalveolar protrusion which gives me a prominent perioral appearance.
- I have maxillary hypoplasia.

I have attached my Xrays, my profile, and a crossfade between, and a forward-facing picture that I hope are sufficient.

I would also appreciate any other positive criticism or recommended surgeries to improve my aesthetics overall, as I'm very open-minded to such things and I am keen to learn about more avenues for improvement.

Thanks!

https://imgur.com/ltTkyIF
https://imgur.com/LiYwRua
https://imgur.com/Zvk7ijZ
https://imgur.com/vC7ngJY
https://imgur.com/cxELusN
https://imgur.com/Qs6Dt91

[kavan]

Looks like you have bimax protrusion which your doctor called; 'bi-dentoalveolar protrusion ' (same thing). The treatment for that is to remove a track of tooth bearing alveolar bone (top) or just track of bone to bottom where the teeth are  missing (in your case) and to bring the front teeth backwards. That can be combined with Lefort 1 and BSSO to bring both jaws forward in addition to a genio. However the maxillary hypoplasia does not look that way because of the protrusion to the alveolar bone bearing teeth there. So, maybe neither track of bone removal there nor Lefort 1 to the maxilla because the protrusion there is masking what ever recession you might have. The chin looks MORE retruded than it actually is because of the protrusion of the alveolar bone bearing teeth.

See if you can get a track of alveolar bone to the lower jaw removed so the front lower teeth can be pushed back, then also BSSO. Treatment for bimax protrusion is called either 'anterior segmental osteotomy' or 'sub apical osteotomy'. Not sure how many docs in US or UK do it. They do it a lot in Korea because it's a common problem for Asians.

[TheZillip]

Thanks for your response! This has really cleared things up, and now things are making a lot more sense to me. I'm still learning, though.

Do you think there is really any good method of treatment for my maxillary hypoplasia? It might be somewhat camouflaged by my other issues, ironically, however, I do have large bags under my eyes (I assume due to the hypoplasia). My doctor suggested filler or an implant but said he doubts it would really look natural. Is a Lefort definitely out of the question? (and would even this be a good solution if it wasn't). Basically I'm wondering if anything can and should be done with the maxilla.

Regarding any jaw movements, my doctor amusingly said if I did that I would end up looking like a baboon. However, he didn't mention an anterior segmental osteotomy, so perhaps he wasn't considering that. I am curious though, how would a BSSO plus an anterior segmental osteotomy differ materially from a genioplasty? Would the BSSO bring the lower jaw forward and the anterior segmental osteotomy move the teeth backward, therefore, giving the chin more prominence? Would this be an overall more aesthetic result versus just a simple genioplasty?

To me, it seems that I have so many issues that treating them all would be difficult to impossible.

[GJ]

Why are you missing molars in the lower arch?

I'll have to think about what I think is the best treatment after you give a full story as to what happened. In general, retracting the remaining teeth into that space left by the molars should decrease protrusion of the lower lip. In general, extractions to accomplish this are not a molar because that's too much space. Usually it's a second bicuspid that's extracted because it has less root structure than a first bicuspid and is slightly smaller. One non-surgical option is to implant molars and then extract second bicuspids and retract via orthodontics.

Surgically I need to think about it more. I'm not sure it's a surgical case.

[kavan]

Thanks for your response! This has really cleared things up, and now things are making a lot more sense to me. I'm still learning, though.

Do you think there is really any good method of treatment for my maxillary hypoplasia? It might be somewhat camouflaged by my other issues, ironically, however, I do have large bags under my eyes (I assume due to the hypoplasia). My doctor suggested filler or an implant but said he doubts it would really look natural. Is a Lefort definitely out of the question? (and would even this be a good solution if it wasn't). Basically I'm wondering if anything can and should be done with the maxilla.

Regarding any jaw movements, my doctor amusingly said if I did that I would end up looking like a baboon. However, he didn't mention an anterior segmental osteotomy, so perhaps he wasn't considering that. I am curious though, how would a BSSO plus an anterior segmental osteotomy differ materially from a genioplasty? Would the BSSO bring the lower jaw forward and the anterior segmental osteotomy move the teeth backward, therefore, giving the chin more prominence? Would this be an overall more aesthetic result versus just a simple genioplasty?

To me, it seems that I have so many issues that treating them all would be difficult to impossible.

When I speak of the 'maxilla' it is in reference to the part of it displaced by a Lefort 1. The part above that near the eye and cheek area is not moved during a Lefort 1. So, the part of the maxilla that does NOT look recessed is the part with the bimax protrusion to it. I would want to leave that 'as is' because any maxillary retrusion to the L1 part of the maxilla is already masked by the bimax protrusion to that level. Also, a forward advancement there would make your nose even WIDER than it already is. That's why I suggest leave the upper jaw 'as is' IF possible. Although whether or not you can just have the lower jaw (and chin) worked on will depend on calculations done by a high tech surgery planning program and whether or not the bite will be 'right' so the teeth mesh.

It is possible your surgeon is referring to the the part of maxilla ABOVE L1 area if he's suggesting implants near the eye and cheek area.

I'm not convinced you want to push back the lower teeth via braces as that will RETROCLINE them and the retroclining could make a straight line between the lower lip and chin where as somwhat of an 'angle' or 'groove' formation should be found between the lower lip and chin. For that reason, I suggest you explore the sub apical osteotomy or anterior segmental osteotomy I mentioned in my prior post because it retains some of the inclination of the lower teeth but just pushes a whole segment of alveolar bearing teeth backwards and that will mitigate the bimax protrusion you see to the lower lip which makes your chin look more recessive than it is.

As to looking like a 'baboon', that's part of reason I say NOT to advance the LEFORT 1 AREA OF maxilla forward and also to look into the SAO and ASO which is the surgery to address BIMAX PROTRUSION. That's because you can't push out those areas with either a BSSO or Lefort 1 when the protrusion is there. The type of protrusion you have, especially to the lower teeth area is addressed by the SAO and ASO which can be done either first or sometimes with a BSSO.

If your surgeon did not mention that, he probably does not do it because for US and UK docs it's kind of an esoteric surgery. But rather common in Korea given bimax protrusion is common with Asians. You would have to do your research and search for a surgeon who does the type of surgery I mention for bimax protrusion.

A BSSO brings your whole lower jaw forward and can take the chin with it. A genio alters the chin orientation if need be along with the BSSO. You CAN'T have a BSSO with the PROTRUSION there. Surgery for the protrusion is needed before the BSSO in your case (or during depending on skill of surgeon).

The ASO will bring the lower teeth backwards (en bloc with the alveolar bearing segment) and make the chin look less prominent. But you probably need a BSSO in addition to that. You can't just get a sliding genio (which goes UP in addition to out). That's because your have what is called 'short chin' which is what people with class 2 DIV 2 have and the UP part of the sliding genio would make your chin too short which is why you most likely would need the BSSO with it and it would be contingent to get the ASO to target the protrusion before any of that.

You have to search around for a doctor who can treat the bimax protrusion. Don't get any implants. Those come LATER when the jaw balance is all worked out.

[GJ]

I'm not convinced you want to push back the lower teeth via braces as that will RETROCLINE them

That's true, but they can be proclined later assuming the roots are healthy.

[kavan]

That's true, but they can be proclined later assuming the roots are healthy.

But with bimax protrusion, a separate SURGERY needs to be done below the roots to push them back EN BLOC. The illustration I put up in the educational section is gone. So, the OP would need to look up/search what it's about. There is a specialized surgery for what he has and it isn't the kind where they can just push back with braces.

[InvisalignOnly]

I had bimax protrusion and I’m Caucasian too. All I can say is, this is rare in Caucasian people and treatment is not straightforward, so you should try to go to the best and most experienced maxfax you can find, and ask for different opinions from surgeons before doing anything.

[TheZillip]

When I speak of the 'maxilla' it is in reference to the part of it displaced by a Lefort 1. The part above that near the eye and cheek area is not moved during a Lefort 1. So, the part of the maxilla that does NOT look recessed is the part with the bimax protrusion to it. I would want to leave that 'as is' because any maxillary retrusion to the L1 part of the maxilla is already masked by the bimax protrusion to that level. Also, a forward advancement there would make your nose even WIDER than it already is. That's why I suggest leave the upper jaw 'as is' IF possible. Although whether or not you can just have the lower jaw (and chin) worked on will depend on calculations done by a high tech surgery planning program and whether or not the bite will be 'right' so the teeth mesh.

My maxfac said I have 3-4mm of incisor show at rest, so movement in the maxilla might give me no show at all which he said is a very poor cosmetic result. I do have quite a gummy smile (around 4mm also) generally which I would like to improve (I forgot to mention). I suppose I can only hope this can be resolved in some other way then, if the maxilla is basically untouchable.

It is possible your surgeon is referring to the the part of maxilla ABOVE L1 area if he's suggesting implants near the eye and cheek area.

Yes you are correct - it's my mistake for confusing things, I thought the maxilla entended up to that area, doh.

I think my doctor knew of some of the procedures you referred to - he didn't mention them by name but he said there are ways to resolve the issues, but that he wasn't comfortable doing them (as you say, perhaps a lack of experience). His thesis was it's better to do as little as possible for the maximum benefit and he wasn't convinced that these complex and expensive procedures were worth it.

I am hoping though that these surgeries can be done simultaneously so as to not go through the discomfort a second time.

Would you say that I should approach orthodontics later after I've had the appropriate surgeries then? I will need orthodontics regardless because my teeth are crooked, but I think the point you're making is that it shouldn't be as an attempt to push the lower teeth backward. So my question is if I get these potential surgeries done in South Korea (as from what you're saying they'll likely do a better job), will this need to be harmonised simultaneously with an orthodontist, or will my teeth alignment likely be fine after the surgeries and the orthodontics can be approached afterwards?

Why are you missing molars in the lower arch?

I'll have to think about what I think is the best treatment after you give a full story as to what happened. In general, retracting the remaining teeth into that space left by the molars should decrease protrusion of the lower lip. In general, extractions to accomplish this are not a molar because that's too much space. Usually it's a second bicuspid that's extracted because it has less root structure than a first bicuspid and is slightly smaller. One non-surgical option is to implant molars and then extract second bicuspids and retract via orthodontics.

Surgically I need to think about it more. I'm not sure it's a surgical case.

I believe it was a pretty terrible case of stress-induced bruxism (And maybe the wisdom teeth might have overcrowded things which possibly made it worse? Not totally sure). Without going into too much detail I just didn't take care of myself as my life was pretty much a mess at one point.

I had bimax protrusion and I’m Caucasian too. All I can say is, this is rare in Caucasian people and treatment is not straightforward, so you should try to go to the best and most experienced maxfax you can find, and ask for different opinions from surgeons before doing anything.

Did you get your treatment in the west or did you go to South Korea? Do you have any forum posts about your case/experiences generally? I'd be very interested in reading about it.

For future reference, the doctor I consulted with was https://manolisheliotis.co.uk/ He is excellent, for anyone reading this thread.

Again thanks for taking the time to respond, guys, I really appreciate it.

[InvisalignOnly]

Heliotis is one of the best in the UK, however for the price he is going to charge you privately, you can go to any good surgeon in Europe. The problem with going abroad, especially in your case, will be that you need extensive ortho treatment and ortho and surgeon will have to work together, so maybe best to stick to Heliotis if you can afford him. I’d consult others as well just for comparison.
I did not go to Korea and would strongly advise everyone in the same position against it. This is not a surgery you want to do on another continent if you live in Europe, especially when you need complicated ortho treatment. Also, Koreans idea of what looks good tends to be very different of the Western idea, especially for males.
The problem with this whole bimax protrusion thing is that every case is quite different, it’s not a ‘simple’ case like a standard overbite or underbite. I ended up having total maxillary setback which is very uncommon apparently and probably not a good idea in your case (or I have no idea, I’m not a doctor). In any case, consult a few good, experienced doctors and take your time to decide.

[kavan]

My maxfac said I have 3-4mm of incisor show at rest, so movement in the maxilla might give me no show at all which he said is a very poor cosmetic result. I do have quite a gummy smile (around 4mm also) generally which I would like to improve (I forgot to mention). I suppose I can only hope this can be resolved in some other way then, if the maxilla is basically untouchable.

Yes you are correct - it's my mistake for confusing things, I thought the maxilla entended up to that area, doh.

I think my doctor knew of some of the procedures you referred to - he didn't mention them by name but he said there are ways to resolve the issues, but that he wasn't comfortable doing them (as you say, perhaps a lack of experience). His thesis was it's better to do as little as possible for the maximum benefit and he wasn't convinced that these complex and expensive procedures were worth it.

I am hoping though that these surgeries can be done simultaneously so as to not go through the discomfort a second time.

Would you say that I should approach orthodontics later after I've had the appropriate surgeries then? I will need orthodontics regardless because my teeth are crooked, but I think the point you're making is that it shouldn't be as an attempt to push the lower teeth backward. So my question is if I get these potential surgeries done in South Korea (as from what you're saying they'll likely do a better job), will this need to be harmonised simultaneously with an orthodontist, or will my teeth alignment likely be fine after the surgeries and the orthodontics can be approached afterwards?

I believe it was a pretty terrible case of stress-induced bruxism (And maybe the wisdom teeth might have overcrowded things which possibly made it worse? Not totally sure). Without going into too much detail I just didn't take care of myself as my life was pretty much a mess at one point.

Did you get your treatment in the west or did you go to South Korea? Do you have any forum posts about your case/experiences generally? I'd be very interested in reading about it.

For future reference, the doctor I consulted with was https://manolisheliotis.co.uk/ He is excellent, for anyone reading this thread.

Again thanks for taking the time to respond, guys, I really appreciate it.

3-4 mm tooth show at rest is close to normal. So, yes, you would have LESS of that if you removed 4mm of GUM SHOW when smiling. So, that is consistent with my statement about leaving maxilla as is for now. Also, if one has normal tooth show at rest BUT excess gum show when smiling, some BOTOX can be shot it to reduce lip mobility. Some lips move up HIGHER than others when smiling.

The maxilla is a COMPLEX shaped bone. Google it. However the part of it that is displaced with a Lefort 1 isn't the whole bone itself, not the part where the cheeks and orbital rim to the eye area are.

It's not for me to say whether you should approach ortho later 'after the appropriate surgeries'. It would be up to the SURGICAL TEAM which includes the DOCTOR and the ORTHO working with the doctor who can do the type of bimax surgeries I've suggested you look into to tell you whether ortho before, after or during is needed for them.

As to Korea (South), that's just the place where the bimax protrusion surgeries are COMMONLY DONE. However, that does not preclude the possibility of finding a doctor in Europe who also could do them. It's not as if 'only' docs in SK an do them. It's more of a matter, you will have to search HARDER to find doctors in the UK or US who do the bimax protrusion surgeries.

You might need to address the bimax protrusion FIRST and then later get the other maxfax procedures. That's because double jaw displacements (or even single jaw displacements) would look TERRIBLE unless you addressed the bimax protrusion. Might be possible to have all done at same time, I don't know for sure. But I wouldn't suggest you bank on getting all done at same time or have that as a contingency.

The protrusion, especially to the LOWER would be the priority to address. If other displacements/advancements can be done during same surgery, it would depend on the surgical team and other factors unknown to me.

Suffice to say, your ENTIRE case can't be figured out for you here. You would need to do more SELF research and for starters, look specifically for doctors who address bimax protrusion. If your doctor doesn't address it, then of course, you have to search elsewhere.