Wow, thank you so so much for your replies! I really appreciate it. I can see that this took a lot of time - the applaud is definitely more than well deserved!
Your notes all make sense and I understand your point of view.
I went through all my notes again this morning (I have two full folders already with all the information from my appointments) and I thought it would be a good idea to sum it up one more time. Because one thing I wanted to mention is that not all the doctors who suggested a Genio based their opinion on a possible treatment on the fact that my TMJs are not healthy, my gum is very hin or I have some root resorption. I had the feeling they just suggested it and didn’t even properly look at my CT scan or my teeth/occlusion. Of course not all of them, but some of them.
1) The first surgeon I visited suggested a Genioplasty and he didn’t say anything about my TMJs or my gingival situation. The thing I liked about him was his technique because he mentioned that he wouldn’t detach the mentalist muscle which will prevent the chin from dropping („witch chin“).
2) The second surgeon suggested a chin implant. But he was very open regarding other possibilities. However he also mentioned that he wouldn’t suggest the Bimax because my occlusion is really good already.
3) The third surgeon suggested the Lefort 1 and the Genioplasty. The one thing I am not sure about is the Lefort 1 because as GJ mentioned the most unaesthetic changes can occur. But he also didn’t see or didn’t mention (?) my TMJ situation. He said the following: „Your teeth are beautiful, the occlusion is fine, so I will not aim to change that at all. But to keep the bite where it is now, we need some arms to fight, to hold the occlusion. The safest is to have brackets on the teeth and then you can manage during the surgery when you put the jaws together or after surgery with some Elastics you can guide the Bite in the old position. If you don’t want to get braces on, I need to put on an Iron Bar on the gingival margin for a period of one month.“
That leaves me to the conclusion that he isn’t afraid of the health of my teeth because he considers the braces or the iron bar (which I am not sure what it is, to be honest?).
But he was also the one who didn’t suggest to advance the mandible due to my thin skin appearance (risk —> cascade of irregularities)
4) The next surgeon I visited was a strange experience. I didn’t even had the chance to talk to him (just for a few minutes), only to his wife. She suggest jaw surgery, jaw implants as well as cheek implants. I would never do that.
5) The 5th surgeon suggested the djs with the anterior impaction. He was also the first one who noticed how bad my TMJs look. He mentioned I can decide whether I want to wear braces again or not. He said he can also leave the occlusion as it is.
6) The next surgeon was really cautious. He agreed that the best treatment would have been the djs but since my occlusion is now fixed after having braces, he wouldn’t suggest it anymore. He said the Genio would be the best option now but it would be a compromise since we would try to solve a complex problem with one isolated surgery.
7) The next surgeon is a really famous one but unfortunately he didn’t mention my bad TMJs or my gum/teeth situation even though I sent all my records. But I also only had one consultation via Skype with him. He suggested a Bimax (surgery first) with maxillary and mandibular osteotomy and a possible genioplasty.
8 ) The next surgeon suggested a Chin Wing. We had another call after a week and then he suggested jaw surgery as well as the chin wing. But he also didn’t mention my TMJ/gum situation. Could be due to the fact that he said my CT scan isn’t the best and he requested doing a new one. Maybe he uses a different program.
9) The next surgeon also suggested a chin implant. I didn’t like him at all, so the appointment was really short and not really helpful.
10) The last surgeon I talked to suggested the total joint replacement. And it was not Wolford. When reading my notes again this morning one question regarding the genie came to my mind…
„ Your angel is very steep. When you look at it in relationship to the lower teeth have been moved out and you don‘t have hardly any bone on the facial aspect. Ideally we would have these teeth uprighted so they were almost at 90 degrees to this line and to do that you would have to have some teeth brought back and maybe you need to have some grafting on the bone of these anterior front teeth, otherwise you would be prone to loosing them especially if we choose to do a genioplasty. The thing that I wanna put out to you is your lower incisor angulation is about 104 degrees it should be 90 to 95 so that’s 3 or 4mm that you would actually be able to advance the lower jaw if you had the teeth removed and it would also probably mean you wouldn’t have to have your chin done.
Because as those teeth came back the chin becomes more prominent, more shapelier.
I am just really worried about the health of these teeth especially if we had to do a genioplasty in advance. I am afraid that you would loose all of this gum tissue attached and then these teeth could be compromised.
If I understand correctly - and please correct me if I am wrong - the situation of my teeth would be a problem for the genioplasty? My orthdontist here in Germany scheduled a meeting together with an oral surgeon and a periodontist expert and she confirmed that my gum is really thin, especially in my lower jaw. She suggested a gum augmentation, but no grafting. Grafting is not very usual in Germany so I think it won’t be easy to find a doctor here. Now my question is: after receiving your advice, which I highly appreciate, I think the Genio alone might be the best option (maybe not the best outcome, but the safest and hopefully some improvement) but would it be even possible to do the Genio - of course after the gum augmentation?
Here is another picture, totally unedited, after the first time I had fillers to my chin. In the beginning it looked great, but unfortunately it doesn’t stay like that, it kinda saggs down which emphasizes the steep angel even more, if that makes sense. But if the outcome of the Genio would look somehow like that, I would be really happy.
The thing that worries me the most at the moment about the genioplasty is that the surgeons I talked to either say go for the Bimax or go for the Genio.
Especially the surgeons who recommend the djs have a very, very negative attitude towards only the Genio.
And it is so hard for me to differentiate if that is because they want to sell me their surgery or if they really believe it would be a failure in my case.
But if second is the case, I don’t understand why? Of course the djs (if it would turn out good) would be the ideal solution, but I believe the Genio could be also an option for me.
And maybe the Genio doesn’t look good with a high angle case like mine, but whenever I edit a picture or even the ones from the surgeon the steep mandible does look improved to me - at least it gives the illusion of an improvement.
Sorry if my english is not the best!
Hi,
It's quite a task to attempt to unconfuse you amoung 10 different doctors telling you different things. My concern is this could go down a 'rat hole' if I attempt to explain something in terms of angle relationships and then THAT kicks up more confusion which often does and then positions me to fill in elementary geometry concepts because those things are not under belt. So, I'm going to operate on the assumption that you have some basic geometrical concepts underbelt. Also, I will LIMIT my assessment to 2 surgeons; #1 who suggests the genio and #10 who scared you about the genio. The others are all somewhere between those two and the task to differentiate between all of them to clear up confusion of all 10 is not something I'm offering to take on.
First and formost, my suggestion is for the genio; a SLIDING GENIO involves a (positive slope) diagonal cut with 2 displacement vectors; vertically UPWARD and horizontally OUTWARD. That would SHORTEN your chin and ALSO advance forward and give somewhat of the 'look' of a less inclined mandibular plane angle. That is because the MPA is measured from LINE formed by a point at the BASE of chin (menton, ME) to a point to the back angle of the jaw (gonian GO) whereas this line is measured RELATIVE to a horizontal to form the ANGLE known as the MPA. So, when the chin is displaced in an UPWARD and OUTWARD combination of displacement vectors, the BASE of chin (and the ME point found there) will shift upwards and hence the LINE formed by ME-GO relative to a horizontal forms gives appearance of a LESS inclined MPA.
As to this sliding genio, IMO, it is best to do it with a SUBMENTAL approach which means cut under the chin and not one inside the mouth because sometimes the cut made inside the mouth can result in more lower tooth show because there is disruption to some attachment there whereas the one done via under chin incision preserves that attachment. Not to mention it doesn't disrupt near the lower teeth because the cut is NOT NEAR THEM.
It very much appears that Surgeon #1's statement that he would not be disrupting the the attachment of the mentalis muscle implies he's not going to make the incision inside the mouth. Hence, you would not have to worry about thin gum tissue to the lower teeth or much else about altering the integrity of the lower teeth via an incision that is NOT NEAR THEM. Also, surgeon #10 who is kicking up concerns about a genio, most likely is referring to one done via an incision INSIDE THE MOUTH. I shall discuss that later down the line.
Correction of 'witches chin' or even prevention of that is often done via the incision under the chin. Sometimes, that involves removal of an errant flesh pad; some soft tissue that kind of 'hangs down' past the chin bone. Although the sliding genio can result in a step off, the surgeon has the option of contouring part of the bone to mitigate it, using HA paste or granules to mitigate it OR just leaving it there where it can be MASKED with FILLER.
The sliding genio should NEVER attempt to compensate for mandibular recession. That means that a point on the chin, the pogonian; POG point, (a different one than the other two I mentioned prior) should go NO FURTHER than the chin recession ITSELF. So, the genio would be ONLY to address the recession at the chin as to put the chin (and it's outer most POG point) where it should/could be FOR THE CHIN and this is so EVEN IF the mandible is also recessed. Where to put the POG point in a sliding genio is relative to a vertical dropped down from the lower lip. In a female, the POG point should be found BEHIND that line. Even if it can't be brought forward enough to get where it 'should be' (which can be the case when the more you go OUTWARDS, the more you go UPWARDS where the upward displacement vector would make chin too short and/or make too big of a step off), it STILL is an IMPROVEMENT for someone (like you) who has some chin recession and also extra length to the chin. Very likely it would give more advancement than FILLER does and will decrease extra longness to chin which filler DOES NOT do.
That said, suggestion from surgeon # 1 is the CLOSEST suggestion to MINE which is why I'm more inclined to elaborate on that more than I am to elaborate on suggestion of others which I don't suggest myself.
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Now, I will choose ONE OTHER of these 10 (because it's quite a task to attempt to un-confuse as to all of them). But if you are still confused by what the others told you, it would be YOUR task to reconsult with the surgeon/s and ask them to un-confuse you based on what each and every other surgeon told you.I have selected Surgeon #10 for my comparison.
Surgeon #10 is telling you something in reference to the POG point (outer most point of the chin) and also in reference to (double?) jaw surgery involving a BSSO, in particular the BSSO. When you get a BSSO, they can bring the POG point out without having to also do a genio and/or they can do a very minimal one when the BSSO does most of the advancement of the POG point.
He's telling you your lower teeth are PROCLINED too far relative to the POG point and also that an angle formed from the lower incisor line and the mandibular line (ME-GO), which together form the lower incisor inclination angle, are in excess of the optimal 90 degree angle which is why he suggests PUSHING THEM BACK to UPRIGHT them in order to perform the BSSO.
I've included an approx. illustration to this regard. It' isn't exact but it gives an idea of what is being referred to when he says your lower incisor line ,relative to to mandibular line which both together form the lower incisor angulation and notes it's more than the optimal angle.
OK, that's true BUT uprighting the lower front teeth when they are PROCLINED as they are involves EXTRACTION of a pre-molar to do it because it's pretty hard to push the lower front teeth back when there is not enough room to do it and making room involves pre-molar EXTRACTION. In addition to TOOTH LOSS when your bite has already been made right, these lower incisor teeth would have to be brought back with BRACES and the push back of the braces THEMSELVES will stress the lower teeth, and kick up more root show exposure than they have now. That in turn introduces the CONTINGENCY of GUM GRAFTING because not only does he want to pluck out your (1rst) premolar teeth to do do it but he also wants you to get gum grafting so he can do it. So, this suggestion TAXES the stability of your lower teeth and to COMPENSATE for the AMOUNT he's going to TAX the stability of the lower teeth, enter the contingency of gum grafting and who knows if it will tax the gum graft you get just to do it. So, OF course, IF you get the genio (which would most likely be via an INSIDE THE MOUTH incision) in addition to all this TAXING and STRESSING the lower teeth he's anticipating doing in order to get the BSSO to put the POG point where it is better put, you can risk losing the lower teeth. Basically, he's referring to doing the BSSO to advance the POG point and doing it without a genio in a situation where IF he also added the genio (via the incision inside the mouth) along with what he's doing which is ALREADY TAXING the integrity of the lower teeth, you very well could lose the lower teeth.
Also, the fact that this was the surgeon who suggested a total jaw replacement because of the issues with the TMJ tells me he won't be doing the 'magic bullet' surgery which is CCW-r via POSTERIOR DOWNGRAFT which just happens to be the type of CCW-r that would benefit you greatly IF YOU DID NOT HAVE the type of TMJ issues that PRECLUDE IT. So, in effect, he can't offer you the type of surgery that would decrease your high MPA because it's a 'no no' when someone has TMJ issues. So, IMO, his 'work around' that issue is TOO MUCH for not enough potential gain. That is so because he can't maximize your potential gain due to the preclusion of the TMJ problem.
Now, remember what I said prior about the sliding genio, especially the part where the incision to do it is made UNDER THE CHIN which is the approach that does NOT TAX or stress the integrity of the lower teeth whereas the incision inside the mouth disrupts an attachment quite close to the lower teeth. Now GUESS WHERE the incision would be for a genio WHEN a BSSO is ALSO performed. You got it. It's INSIDE MOUTH. So, OF COURSE, if he goes on to perform the genio via the incision inside the mouth along with the TAXING and STRESSING of the lower teeth that he needs to perform just to do the BSSO, then that indeed increases the risk of losing the lower teeth in your case given the roots are already exposed. He will also be taxing the short root upper teeth with braces too.
As to his suggestion of a joint replacement, this is most likely another way of telling you he can't do the 'magic bullet' type of surgery (due to your TMJs) which is the ccw-POSTERIOR DOWNGRAFT where as that is THE ONE that would work best for you IF you didn't have the TMJ preclusion to doing it. However, IMO, his work around SUBJECTS you to TOO MUCH for VERY LITTLE so WHY BOTHER.
Ya, his surgery would kick up more advancement of the POG point via the BSSO than the genio alone. But I don't think the conditions/contingencies (losing pre-molars, taxing root exposed teeth further via braces and having to get gum grafting just to do it) are worth it. Quite a lot to SUBJECT yourself to in a situation where your TMJs PRECLUDE you from getting the magic bullet ccw-r posterior downgraft.
I would conclude that the genio he is against doing is the genio one does not have to do when they can bring out the POG point to the chin with the BSSO alone. I would also conclude that the reference as to avoiding this genio because it could further compromise the lower teeth (in addition to what he wants to do to do the BSSO which in it's own right will compromise the lower teeth) refers to doing via a cut INSIDE THE MOUTH which indeed IF added with the other ways he's going to TAX the integrity of your lower teeth results in a high risk of tooth loss (in addition to the 2 pre-molars he's going to pluck out to get the braces to push back your teeth.) Hence, his reference to genio avoidance resolves to a reference of one done via an incision INSIDE the mouth which would disrupt the integrity of your lower teeth EVEN MORE that the rest of his surgery TAXES it already. It is unlikely he's referring to a genio performed via an incision under the chin as surgeon #1 seems to be suggesting.
In general, I find that the surgeons who do the 'magic bullet' CCW-r surgery with the POSTERIOR DOWN GRAFT, don't have to worry/be that concerned about potential adverse sequella with a genio included. But that's BECAUSE it's the ccw- posterior downgraft which in turn is the very thing that ALLOWS them to advance out the POG point to the chin WITHOUT a genio (or with a very small one). In your situation with the TMJ's, you CAN'T HAVE the very thing that brings out the POG point and gives it much ccw-r 'upward' rotation and the SACRIFICE to you for the BSSO to advance out the POG point because the TMJs preclude the CCW-r posterior downgraft to do it, IMO, is too much to go through; tooth loss, braces further taxing the lower teeth and potential dissatisfaction with loss of feminine gum show via the anterior impaction.
All that said, it does NOT change my suggestion for the genio only. Surgeon's #1 suggestion is the closest to my own. I have given my reasoning for this. It's very likely Surgeon #1 would do the incision under the chin given he said he wouldn't detach the mentalis muscle (too much stripping from the bone via the inside the mouth incision can contribute to witches chin). So, I would conclude that surgeon #10 is referring to a genio via inside the mouth incision and surgeon #1 is referring to one performed via a cut UNDER the chin. If that's true (and you could check with surgeon #1) then you don't have to worry about applying Surgeon #10's warning about a genio to Surgeon #1's suggestion of genio only. Surgeon #10's warning about genio is most likely in reference to doing it WITH the BSSO (along with all the tooth integrity TAXING that goes with his surgery) and doing it via an incision inside the mouth. Those warnings don't relate to performing the genio via an incision under the chin which is the likely one #1 would be using.
In closing, the genio ALONE would veer in direction of what you like to your chin when you use the filler. Might even be better than that given the vertical displacement vector that shortens the chin would decrease the visual length of the face from the front and also visually decrease the inclination of the high MPA. Any step off could be masked/streamlined with filler.
Illustration included with this post.
