10 different surgeons, 10 different opinions! What surgery do I really need?

[Jawena2021]

Hello!

I am not sure If I need jaw surgery, total joint replacement, a Genioplasty, a Genioplasty + Lefort 1...
To be honest I am really confused at this point because I don’t really know what to do anymore. I did so much research since months, had consultations with so many surgeons from all over the world and everybody tells me something different.

Some information about me:
- I had braces for 2 1/2 half years (8 years ago). My bite is pretty good now, I don’t have any issues with chewing, speaking etc.
But now that my bite is almost perfect, it makes the whole situation even more complicated.
One thing to mention is that when completely relaxed my mouth is slightly opened. So I have to use my muscles to keep it closed.

- Next thing I need to mention is that my gums are very thin (especially in my lower jaw). Some surgeons I talked to mentioned this as well, others didn’t. Some said that this needs to be fixed before doing any kind of surgery because otherwise I could loose teeth easily.

- My TMJs are not healthy. One surgeon from the US even recommend a total joint replacement. But my orthodontist made a new xray and he says that they didn’t change since 2008.
I have uploaded a comparison picture. He thinks they are not healthy due to my bad bite before having braces but since that was fixed years ago, my TMJs haven’t changed. Of course, they are not healthy but at least they didn’t get worse. That is why he wouldn’t recommend a total joint replacement. The surgeon from the US also recommend to undergo hard and soft tissue grafting around the anterior teeth on the mandible and he considers extraction of upper second premolars and lower first premolars to upright the lower incisors to facilitate additional mandibular advancement above and beyond the counterclockwise rotation.

- One surgeon from Italy recommend not changing the vertical height in the posterior part of the mandible, only the anterior part because that effects the TMJs less.

- Some other surgeons think I shouldn’t undergo jaw surgery at all because my bite is good and they are afraid that I will have more problems after the surgery than before.
They recommend only doing a Genioplasty or doing a Genioplasty + Lefort I.
One surgeons said I have such a delicate thin skin and soft tissues that doing a three max to extend increases the risks considerably of overshooting for little gain.
He said my risks increases that a cascade of irregularities  are created in the inferior border of the mandible.

As you can tell, I got very conflicting advice.
But I know for sure that I don’t feel comfortable and I want to change something. My main issue is my chin as well as the long face appearance.

I have fillers in my nose and my chin. But I don’t like the look of the filler in my chin. I also uploaded a picture in comparison.

Any advice would be appreciated! Thank you so much in advance!

[GJ]

You look nice from the front. In profile, it becomes evident how steep the mandible is. It still doesn't look bad, though, because you have good features.

So this comes down to what you want to risk to potentially gain aesthetics.

Some notes:

1. I don't see the concern over the condyles. Do you have any other images? It's hard to see in the ones you posted, but the right one (for me, your left) looks fine, and the left maybe looks small or mottled but hard to see.

2. If you get surgery, this will be a standard CCW rotation case. How did the one surgeon plan to only move the front of the mandible?

3. What is the point of a Lefort 1 when the mandible is the problem? They think genio alone would look good? Ask for a simulation of that.

4. Don't extract.

5. They're correct that if your skin is thin, it will exacerbate movements. In general, 3mm of bony movement = 1mm of soft tissue movement. If your skin is thin, it might be more like 1.5mm or 2mm (impossible to know, but you get the idea on direction).

6. You're concerned about facial length, but length usually comes from the midface (which can't be changed). CCW will give an illusion of shortening the lower face, but that might actually throw things off balance since your midface is a big long. Make sure you understand all that so you aren't caught by surprise.

More records might help, and these are small so larger versions would help, too.

[Jawena2021]

Thank you so much for your reply, GJ!
I really appreciate it!

1) I have a CT scan and  a MRI, but I don’t have the program to open it on my Macbook and I am not sure if you have it? It is a dicom file.
One surgeon said: "The joints are totally remodelled, completely. There is no joint anymore. It’s like you are 80 years.“
The other surgeon from the US agreed on that and even said that I probably have idiopathic condylar resorption. But it is strange, because my bite is stable since many years (after the braces) and my TMJs didn’t get worse.

Do you think the surgeon is right with his plan to not increase the posterior height but to decrease the anterior height?
Because that gives the same counter clockwise rotation without an overcharge of the TMJs and he says that is the only option in my case, otherwise I could risk a potential relapse.

2&3) Hm.. actually I don’t really know. That confused me as well. When I asked him, he said: "You need a Lefort I intrusion and a genioplasty. If you prefer to do a lower jaw as well (BBSO) then this is not for resolving the problem of the high angle, but for the reason that you find that your upper jaw is now in a retruded position. If during the surgery the autorotation of the mandible would come out as a setback of the upper jaw, instead of anticipated advancement, this indeed would be an indication to advance the upper jaw at the moment as well.
The chin advancement with the BSSO advancement will make the inferior border line longer. This lengthening will accentuate that long line and this will not be nice. You can work with peek implants afterwards, to create some more angles. But my hope is with upper and chin we can avoid this: making you shorter, will make you relatively broader en face.“
He also said I could benefit from a Lefort 1 because it would vertical shortening the upper jaw to eliminate a bit of gingival smile, to enable natural lip closure and in general to shorten the length of the face.

I did receive some simulations for a Genioplasty from another surgeon but he was very carefully in general. He thinks only a movement of 4-7mm would be possible and he is not even sure if he can achieve this. He would do a Genio and a "mini mini Chin Wing“ (only the first cm of a Chin Wing) to move the chin forward and up and shorten it a little bit. But he also mentioned the thin skin appearance.

6) Thank you! That makes sense. But as long as it would give the illusion of a shorter face after surgery, I would be really happy! The one surgeon who wants to do the CCW rotation also mentioned that it will give me more projection to the whole mid face, especially to my cheek bones, which I would love!


This simulation is from the surgeon who didn't recommend jaw surgery because my bite is good and who is afraid of other possible issues that might occur after surgery. He only recommend doing a Genioplasty and also only if we would meet half and my expectations are realistic.. 

I also edited my first post, so the pictures are now bigger than before.

Thank you again for your valued opinion!

[GJ]

Ps. How old are you? Those wisdom teeth should probably be removed whether you get surgery or not.
Also, your front incisors have blunting/root resorption. Is this from past treatment or do your front teeth hit?

[Jawena2021]

I am 27. My wisdom teeth are removed. The first xray is very old (from 2008) before my braces and before I got my wisdom teeth removed.
On the other xray you can see that the wisdom teeth have been removed  .

My front incisors hit before my braces, but now they don't.
My gum in my lower jaw is very thin and there is also some exposed tooth necks, which is why I need to undergo soft tissue grafting around the anterior teeth on the mandible, but my upper incisors/upper gum should be fine.

[GJ]

Now that the images are larger I can see the joints better. I still can't tell exactly what's going on there. If that spotted area is the fossa, then I agree with them the joints are in bad shape. But I'm not sure. There are surgeons who post here, so maybe they will chime in.

Idiopathic condylar resorption is usually from a trauma (cheerleading is the infamous one). Did you have anything like that happen?

I noticed your upper jaw is slightly retruded. It's almost like a class 3 position, yet you have the high mandibular angle that suggests class 2. I haven't seen many cases like this. The problem is the upper jaw is where most unaesthetic changes occur (e.g. nose issues, over-advancement, etc). And you might not get enough rotation to swing the mandible around, and also the bite might not be ideal if just moving one jaw. I think this is a balancing act between your mandibular angle flattening and your current compromised position with the joints and root resorption. You have to figure out the risk/reward of all that, and maybe you don't know yet because you don't have opinions you trust yet. So keep looking and educating yourself.

All that said, you have a nice (imo at least) face shape from the front, especially when smiling, and appear to look good thanks to nice features (hair, nose, skin, etc), so I'm wondering if this is all worth the risk. Personally, I'd not want to risk the change to face shape, and might just try to live as-is unless there's a functional reason for the surgery.

[GJ]

I am 27. My wisdom teeth are removed. The first xray is very old (from 2008) before my braces and before I got my wisdom teeth removed.
On the other xray you can see that the wisdom teeth have been removed  .

My front incisors hit before my braces, but now they don't.
My gum in my lower jaw is very thin and there is also some exposed tooth necks, which is why I need to undergo soft tissue grafting around the anterior teeth on the mandible, but my upper incisors/upper gum should be fine.

Yes, grafting would resolve the gum recession, and it's a good solution. Be careful when brushing. Maybe look on YouTube at proper brushing technique before more damage occurs. Your teeth in gums look in great shape and well cared for otherwise.

Your root resorption will limit what you can do with braces. Have they told you this? They're short, and losing teeth might be an issue with more orthodontics. That short root will have to move through bone to set you up for surgery, and that will result in more root loss. You should ask several orthos about this before starting treatment.

[kavan]

I would ask; IF 'differing' opinions from EXPERTS have resulted in uncertainty as to what you 'need', why would you expect even MORE (differing) opinions from non experts to result in certainty?

Although it seems pretty clear you have ample resources to consult with top docs and to finance surgeries in the pursuit of an 'ideal' in a circumstance where you are already very attractive, I'm NOT going to answer 'need' in terms of which 'differing' advice you got accommodates an aesthetic ideal. That's because I don't see the advice you got as 'conflicting' or 'differing' at all. I see it as all giving you the SIMILAR message that you are not the ideal candidate for pursuing an aesthetic ideal via double jaw surgery.

So, instead, I'm going to address the question of 'NEED' in terms of ability (or inability as the case may be) to DIGEST information. So, what you need is the ability to DIGEST information from differing sources. This should not be too difficult because all it involves is looking for SIMILARITIES in the info you already got from 10 different doctors. Like what info is SIMILAR.  Although to YOU they all seem to be telling you 'differing' or 'conflicting' things, to ME, all the MEDICAL advice you got is SIMILAR and NON CONFLICTING. That's because all of it DOVETAILS on telling you that you are at HIGH RISK for complications in pursuit of double jaw surgery for an aesthetic ideal.  After all, if one expert told you that you would need TOTAL JAW REPLACEMENT because your TMJs are not healthy enough, or you got advice that you would need to have MORE things done just as a CONTINGENCY for pursuing the aesthetic you want because of the unhealthy TMJs and/or you could lose teeth easily OR you could have a cascade of irregularities, that is NOT 'conflicting advice'. It all DOVETAILS on SIMILAR information which is to stir you away from pursuing double jaw surgery for a beauty ideal.

If you went to 10 different maxfax medicos and NOT ONE OF THEM suggested you undergo double jaw surgery (ostesibly in pursuit of a beauty ideal) in the absence of 'other surgeries' that would be needed just to have it and  most to all of them stirred you AWAY from double jaw surgery, there doesn't seem to be much 'conflicting' advice. There would only be conflicting advice if some of them told you that you had the ideal MEDICAL STABILITY START POINT to pursue a low risk double jaw surgery (with posterior downgraft CCW) as do others who go into it ABSENT of the pre-existing issues you have which makes it MORE RISKY for you. Perhaps I missed something as to WHICH DOCTOR told you that you had the ideal dental and TMJ stability start point to undergo a low risk double jaw surgery and in the absence of having other procedures just to have it? If none of them told you that you were the ideal candidate as to avoiding the risks with double jaw surgery and to get the most out of it (in pursuit of an aesthetic ideal), then I see little conflict in the the info you got. It's not so much 'different'. They are all suggesting, in one way or the other, that it would come with either increased 'other' procedures to have just to have it and/or INCREASED RISKS.

Even though I know WHICH surgery, from the possibilities you listed, would carry the least risk yet have some potential for improvement, I also think you should be able to figure that out for yourself given the information you have already obtained from the consults you went on.

[Jawena2021]

I just saw that there is the possibility to reply to a quote from someone, that is why I accidentally sent my answer to GJ two times. Sorry for that! 

[Jawena2021]

Now that the images are larger I can see the joints better. I still can't tell exactly what's going on there. If that spotted area is the fossa, then I agree with them the joints are in bad shape. But I'm not sure. There are surgeons who post here, so maybe they will chime in.

Idiopathic condylar resorption is usually from a trauma (cheerleading is the infamous one). Did you have anything like that happen?

I noticed your upper jaw is slightly retruded. It's almost like a class 3 position, yet you have the high mandibular angle that suggests class 2. I haven't seen many cases like this. So his idea is to impact (shorten) the anterior maxilla and move the posterior down? That is net effect a CCW movement, and he's correct it's probably less risk to the joints. I think this would make a lot of sense if you have a lot of tooth show, joint issues, etc. The problem is the upper jaw is where most unaesthetic changes occur (e.g. nose issues, over-advancement, etc). And you might not get enough rotation to swing the mandible around, and also the bite might not be ideal if just moving one jaw. I think this is a balancing act between your mandibular angle flattening and your current compromised position with the joints and root resorption. You have to figure out the risk/reward of all that, and maybe you don't know yet because you don't have opinions you trust yet. So keep looking and educating yourself.

All that said, you have a nice (imo at least) face shape from the front, especially when smiling, and appear to look good thanks to nice features (hair, nose, skin, etc), so I'm wondering if this is all worth the risk. Personally, I'd not want to risk the change to face shape, and might just try to live as-is unless there's a functional reason for the surgery.

Thank you so much for your replies! I am really happy to talk to an external person. That is really helpful! 

No, nothing like that happenend to me. The surgeon said the reason for idiopathic condylar resorption is not known yet but they think it happens due to hormone changes.

Yes, I think that is his plan. But could you maybe explain what exactly he would do? I am from Germany so it is not that easy for me to understand. You make the upper jaw loose and swing the mandible around, so that the anterior part of the mandible comes more forward?
I am also really afraid of the unaesthetic changes for example to my nose. I also asked him about that and he said there are some techniques to limit this with some sutures that are done inside the mouth to limit the flaring of the nose, but it still might happen 

May I ask why do you think the bite might not be ideal if just moving one jaw? The surgeon said I don't have to wear braces again If I don't want to. He could also leave the occlusion as it is.

Thank you! The thing is that many people tell me this, but I don't feel comfortable and that is the reason why I want to change it.
Furthermore I am in a model agency (music videos etc.) and I actually really love to do photoshoots etc. but I always feel self conscious when someone sees me from my side profile. That is why I usually don't apply for these kind of jobs (even If I would like to!) and that really affects me in my life.

I really want to change it but it is so hard to decide which way to go. I would like to only do the Genioplasty because I initially thought that this would improve my chin and shorten my face at the same time a little bit. It might not be perfect but it would be an improvement with relatively low risks. BUT then some surgeons said it would be a failure because only the chin comes forward but the whole face stays back so I won't have a real improvement, just more projection but I would need fullness in the mandible, I don't need just projection.
What do you think? I am so confused because I actually kinda like the edited pictures from the two surgeons who suggested only a Genio.

[Jawena2021]

I would ask; IF 'differing' opinions from EXPERTS have resulted in uncertainty as to what you 'need', why would you expect even MORE (differing) opinions from non experts to result in certainty?

Although it seems pretty clear you have ample resources to consult with top docs and to finance surgeries in the pursuit of an 'ideal' in a circumstance where you are already very attractive, I'm NOT going to answer 'need' in terms of which 'differing' advice you got accommodates an aesthetic ideal. That's because I don't see the advice you got as 'conflicting' or 'differing' at all. I see it as all giving you the SIMILAR message that you are not the ideal candidate for pursuing an aesthetic ideal via double jaw surgery.

So, instead, I'm going to address the question of 'NEED' in terms of ability (or inability as the case may be) to DIGEST information. So, what you need is the ability to DIGEST information from differing sources. This should not be too difficult because all it involves is looking for SIMILARITIES in the info you already got from 10 different doctors. Like what info is SIMILAR.  Although to YOU they all seem to be telling you 'differing' or 'conflicting' things, to ME, all the MEDICAL advice you got is SIMILAR and NON CONFLICTING. That's because all of it DOVETAILS on telling you that you are at HIGH RISK for complications in pursuit of double jaw surgery for an aesthetic ideal.  After all, if one expert told you that you would need TOTAL JAW REPLACEMENT because your TMJs are not healthy enough, or you got advice that you would need to have MORE things done just as a CONTINGENCY for pursuing the aesthetic you want because of the unhealthy TMJs and/or you could lose teeth easily OR you could have a cascade of irregularities, that is NOT 'conflicting advice'. It all DOVETAILS on SIMILAR information which is to stir you away from pursuing double jaw surgery for a beauty ideal.

If you went to 10 different maxfax medicos and NOT ONE OF THEM suggested you undergo double jaw surgery (ostesibly in pursuit of a beauty ideal) in the absence of 'other surgeries' that would be needed just to have it and  most to all of them stirred you AWAY from double jaw surgery, there doesn't seem to be much 'conflicting' advice. There would only be conflicting advice if some of them told you that you had the ideal MEDICAL STABILITY START POINT to pursue a low risk double jaw surgery (with posterior downgraft CCW) as do others who go into it ABSENT of the pre-existing issues you have which makes it MORE RISKY for you. Perhaps I missed something as to WHICH DOCTOR told you that you had the ideal dental and TMJ stability start point to undergo a low risk double jaw surgery and in the absence of having other procedures just to have it? If none of them told you that you were the ideal candidate as to avoiding the risks with double jaw surgery and to get the most out of it (in pursuit of an aesthetic ideal), then I see little conflict in the the info you got. It's not so much 'different'. They are all suggesting, in one way or the other, that it would come with either increased 'other' procedures to have just to have it and/or INCREASED RISKS.

Even though I know WHICH surgery, from the possibilities you listed, would carry the least risk yet have some potential for improvement, I also think you should be able to figure that out for yourself given the information you have already obtained from the consults you went on.

First of all I want to thank you for taking the time to reply, kavan.
I can understand where you are coming from but I think there might be a small misunderstanding.
Maybe this is my fault because my first text lead to these misunderstandings, BUT none of the surgeons didn't understand where I am coming from. They ALL confirmed my mandible retrusion, my receding chin and my long face appearance. The only thing that was different was how they wanted to treat it. Some said they wouldn't suggest the double jaw surgery, that is correct, BUT not because I don't need it or because I am already attractive but because my bite is good, it is difficult in my case because of my thin skin and gum and because this surgery in GENERAL has very high risks.
The title of my thread was a bit ironic, of course there are not 10 different opinions but they are four different ones, for sure. In brackets how many surgeons recommend that specific surgery.
1) Only Genioplasty (3)
2) Genioplasty & Lefort 1 (1)
3) Double jaw surgery (4)
4) Total joint replacement (1)

I also have some fillers in my chin at the moment, which is why it looks a bit better than it actually does. But I want to find a solution where I don't have to get any more fillers.

I would still like to hear which surgery you think would carry the least risk yet have some potential for improvement. Thanks.

[GJ]

I think your idea to pursue genio only might not be a bad option if the chin movement is the same as it would be if you had jaw surgery. That way if you decide to get surgery down the line your chin is already in position and doesn't have to be redone. It also allows you to do the least possible for potential improvement. I don't think genios generally work well with that high a mandible, but you might view it as an improvement. Ask for a projection of what it would look like. They should be able to produce that for you.

I am from Germany so it is not that easy for me to understand. You make the upper jaw loose and swing the mandible around, so that the anterior part of the mandible comes more forward?

My understanding is he wants to shorten the front of your jaw (shorten vertical height where your anterior teeth are located)...as the maxilla moves up, the back moves down (imagine a pivot point in the center). The back will require grafting to stabilize it. The front will show less tooth (could be aging).

[kavan]

First of all I want to thank you for taking the time to reply, kavan.
I can understand where you are coming from but I think there might be a small misunderstanding.
Maybe this is my fault because my first text lead to these misunderstandings, BUT none of the surgeons didn't understand where I am coming from. They ALL confirmed my mandible retrusion, my receding chin and my long face appearance. The only thing that was different was how they wanted to treat it. Some said they wouldn't suggest the double jaw surgery, that is correct, BUT not because I don't need it or because I am already attractive but because my bite is good, it is difficult in my case because of my thin skin and gum and because this surgery in GENERAL has very high risks.
The title of my thread was a bit ironic, of course there are not 10 different opinions but they are four different ones, for sure. In brackets how many surgeons recommend that specific surgery.
1) Only Genioplasty (3)
2) Genioplasty & Lefort 1 (1)
3) Double jaw surgery (4 surgeons)
4) Total joint replacement (1 surgeon)

I also have some fillers in my chin at the moment, which is why it looks a bit better than it actually does. But I want to find a solution where I don't have to get any more fillers.

I would still like to hear which surgery you think would carry the least risk yet have some potential for improvement. Thanks.

Well, yes, your title line was '10 different doctors, 10 different opinions'. BUt thanx for the clarification.

Now as to them ALL confirming retrusion, receding chin and long face appearance (high mandibular plane angle) and to someone who already looks really good DESPITE things one could 'nit pick' on with reference to 'ideal model aesthetics', to the best of my understanding (but clarify if I'm off here), those suggesting the double jaw surgery are  also suggesting to avoid the CCW POSTERIOR DOWNGRAFT ,which would elongate the back of the jaw and thereby help with reducing the high inclination of the mandibular plane angle and are suggesting avoidance of that due to the TMJ problem. YET it would be the CCW posterior downgrafting that would yield the most improvement. So the message is that the surgery that would tend to yield the most improvment (ccw POSTERIOR DOWNGRAFT) is the one you need to AVOID due to the TMJ issues. But with anterior impaction (which won't reduce the high mandibular plane angle as much as posterior downgraft CCW (because one can't impact enough without losing all upper teeth show), you would then need to pursue jaw implants for the look you're after (visual reduction of high MPA). Not to mention short roots to upper teeth make the lefort more risky and need for gum grafting to lowers adds complexity to this.

Now you could say the surgery in GENERAL is high risk, but your risk profile for double jaw would be HIGHER because you'd be going into it with additional issues that others don't have. Add the 'need' to look more modelesque and that sets you at higher risk of altering the look of something on your face that you LIKED BEFORE. Let me put it this way: If you like the youthful feminine gum show you have now with your smile, in addition to the nice nose contour, you might not be happy when it's either made less for the impaction or when you see nose changes. You should keep in mind the reason for impaction would be because your TMJ issue precludes the better way to achieve CCW to reduce the high MPA, minimize the lefort advancment and maximize the lower jaw advancement. Impaction isn't really suggested because you 'need' that in its own right or that it's the optimal thing to do for someone with same profile as you BUT who has no preclusions to CCW posterior downgraft. So, if the  the doctors suggesting double jaw are ALSO telling you that you would need to do this that and the other thing before and/or after it to achieve the look you want, the message is that it's not going to kick up the magic bullet for you. Hence, your risks veer in venue of buyers remorse.

My suggestion would be to go with the surgery that is LEAST problematic to UNDO if you are unsatisfied with it which would most likely be the chin implant.

ETA: Although a genio (slide UP and OUT) could work, it could also leave a step off which would later need to be MASKED with a chin implant.

[GJ]

ETA: Although a genio (slide UP and OUT) could work, it could also leave a step off which would later need to be MASKED with a chin implant.

Or HA can fill any step off.

[kavan]

I think your idea to pursue genio only might not be a bad option if the chin movement is the same as it would be if you had jaw surgery. That way if you decide to get surgery down the line your chin is already in position and doesn't have to be redone. It also allows you to do the least possible for potential improvement. I don't think genios generally work well with that high a mandible, but you might view it as an improvement. Ask for a projection of what it would look like. They should be able to produce that for you.

My understanding is he wants to shorten the front of your jaw (shorten vertical height where your anterior teeth are located)...as the maxilla moves up, the back moves down (imagine a pivot point in the center). The back will require grafting to stabilize it. The front will show less tooth (could be aging).

To the best of my knowledge, ccw anterior impaction doesn't need a graft to stabilize it. It's ccw posterior downgraft that does. With impaction, there is no 'dead space' needing to be filled in with a graft. That's why it's an 'impaction'. With anterior impaction, it allows the the lower jaw to rotate upwards as the upper jaw rotates upwards. But her issue is that she's being offered anterior impaction as an alternative to posterior downgraft whereas it's the posterior downgraft CCW that kicks up the most improvement BUT her pre-existing TMJ issues PRECLUDE her from getting the type of CCW that would otherwise better address her high MPA if her TMJ issues did not preclude her. So, in effect, it's a 'cheap substitute' (well probably very $$) for the 'real deal' (posterior downgraft) that can't be availed to her due to her TMJ issues.