I have learned a lot from reading this forum, and would be grateful for any thoughts, advice, or comments on my case. I apologize in advance for the length of this post!
I am 45 years old and have horizontal and vertical bimaxillary deficiency, and mandibular asymmetry (Class II subdivision right). Also, my nose is significantly overprojected. (Photos and radiographs are linked to below.)
I consulted with an orthodontist last year (Dr. L. in NYC), who took a CBCT, told me that bimax advancement with maxillary downgrafting was indicated in my case, and wrote up a report for orthodontic treatment for before and after surgery.
Also last year, I met with 4 orthognathic surgeons. In order of visits: Dr. N. at NYCOMS in NYC, Dr. T. at Mount Sinai in NYC, Dr. S. at Yale, and Dr. R. in Los Angeles. As far as I can tell, each is well respected (as is Dr. L, the orthodontist I saw).
Dr. N., Dr. S., and Dr. R. all recommended having bimax advancement with maxillary downgrafting. Dr. R. added that he would also rotate the mandible to the left. The orthodontist indicated that the maxillary surgery would/should be a 3-piece LeFort (I assume that this is because of the narrowness of my arch forms, which he mentioned in his report).
I think, though am not totally sure, that all 3 of these surgeons, along with the orthodontist, concur on these surgical plans (of course, I need to find out about that—for example, whether any or all of the 3 surgeons would do the LeFort as a 3-piece (I noticed that the CPT code that Dr. R. put in his report—CPT code 21145—is for a 1-piece LeFort, not a 3-piece)).
Dr. T., however, recommended doing nothing surgically—saying that he worried that he might make me look worse—and said my case was fine for orthodontics-alone. (The orthodontist, however, pointed out in his report that “the underlying problem is clearly skeletal in nature and is related to the difference in the size and position of the jaw structures,” and discouraged orthodontics-alone.)
Note: I had a primary rhinoplasty, chin implant (silicone, medium-size), and submental liposuction 2 years ago (summer of 2019). The rhinoplasty reduced a dorsal hump, but did not de-project the nose (and did not address the asymmetry at the top of the nose, which was caused by a nasal fracture I had in a bike accident many years ago, and did not address the deviation of the dorsum and the tip). And the chin implant (it is an “anatomical” one, i.e., with wings) was placed too high on the chin (as can be seen in the CBCT images and the photos below), which placement exaggerates the depth of the mentolabial fold (and also changes the face shape from oval to square). (The chin implant will most likely need to be removed before jaw surgery—and relevant to this anticipated removal, the “true” degree of my chin’s soft-tissue projection (relevant to any future JS) is shown in the pre-chin-implant X-ray (from 2018) in Image #1 in the imgur album linked to below (rather than in the later radiographs—because the chin’s soft-tissue projection in the later radiographs is exaggerated by the implant).)
Also, I have mild scoliosis, which causes my head to be a bit tilted and off-to-the-side relative to the rest of my body (this is shown in Image #34 in the imgur album linked-to below). (I didn’t think to mention this to any of the surgeons, or to the orthodontist—though I have read a study suggesting a correlation between scoliosis and malocclusion, and perhaps this would be relevant to potential jaw surgery.)
My personal concerns regarding the jaws and teeth are mostly aesthetic, though there are some functional annoyances:
(1) when I bite down, my lower jaw collapses behind (and upward into) the upper jaw;
(2) my lower jaw often slides around, seeking where to meet the upper jaw; and
(3) I routinely posture my mandible forward, without realizing at first that I am doing so.
Below is a link to an imgur album containing the following images, in order: •
Radiographs (X-rays and CBCT images) and ceph analyses with measurements (from Dolphin imaging) (Images #1–#20 of the album—all radiographs are current, except for Image #1)
•
Photos (Images #21–#37) All are current photos, except for those labeled otherwise. The 3/4 view when smiling (Image #33 in the album) seems to be the most unaesthetic of the current photos, and perhaps reveals most clearly that I could benefit from orthognathic (and orthodontic) correction.
•
Treatment simulations, including Dr. R.’s and Dr. N.’s morphs (Images #38–#46)
•
Additional photos (Images #47–#61) These were taken with my phone, so the proportions are a bit distorted—but they show some different angles:
https://imgur.com/a/XTxGfbD Note: adding “/layout/grid” after the url listed above will display the images in a grid view (though in grid view the image-numbers and image captions that I put in below each image are not shown).
Attached is a PDF comprising: Dr. R.’s report (pp. 1–4) and the orthodontist’s report (pp. 5–7)
(I do not have written treatment plans from Dr. N. or Dr. S, the other two orthognathic surgeons who recommended having bimax advancement.)
Also attached are a jpeg of Dr. R.’s proposed surgical movements and a jpeg of Dr. R.’s simulation (these jpegs also appear as Images #38 and 39 in the imgur album, but I wanted to highlight them by also attaching them).
The following is a
SUMMARY OF Dr. R.’s FINDINGS (as on pp. 3–4 of the attached PDF of his report):
• Mild brachyfacial pattern with short lower face height
• Horizontal and vertical maxillary deficiency ICD-10 CM M26.02
• Horizontal mandibular hypoplasia (camouflaged with chin implant) ICD-10 CM M26.04
• Nasal asymmetry (tip and dorsum to right)
• Mandibular asymmetry (more fullness on right side, midline slightly right) ICD-10 CM M26.12
• Excessive horizontal overlap ICD-10 CM M26.23
• Anomalies of interarch distance (impinging deep bite/constricted envelope) ICD-10 CM M26.25
• Class II subdivision right dental relationship ICD-10 CM M26.212
• Narrow arch forms
• Masticatory dysfunction ICD-10 CM R13.10
• Crowding of fully erupted teeth ICD-10 CM M26.31
• Spacing of fully erupted teeth ICD-10 CM M26.32
• Upper anterior tooth wear
• Retained unerupted upper third molars
Additional aesthetic (and some functional) concerns of my own:
• Obtuse chin-throat angle. Looking at the X-ray in Image #1 in the imgur album, it may be that it is the low position of the hyoid bone (together
with the short neck-to-chin distance), rather than much remaining neck fat (including subplatysmal fat), that makes the chin-throat angle obtuse
and makes the submental tissue hang and bulge.
• Deep mentolabial fold. As mentioned above, the chin implant is placed too high on the chin and exaggerates the mentolabial fold, and, if anything,
makes the lower face look even shorter than it looked before the implant was inserted.
• Substantial gap between the upper central incisors (the orthodontist’s report indicates that he can close that gap).
• “Over-closed” feeling (and appearance) created by the deep bite
• Lower lip is canted (downward on the right side) when smiling (as in Image #24). (This may be a muscle issue, and is perhaps uncorrectable.)
• Upper lip is flat and doesn’t shown much of the vermilion.
• Dark buccal corridors—narrow smile (Dr. R. noted this in his report [which, again, is in the PDF attached to this post])—this is most apparent in the
left photo in Image #24 in the imgur album.
• When I smile, the upper teeth are only partially visible (low smile line) (as in Image #24)
• Nose is too far projected, and the tip droops slightly when smiling (as in Image #26)
• Lateral discrepancy between the nasal tip and the maxillary midline (as in Image #24)—this seems primarily due to the nose, rather than the
maxilla itself, being deviated relative to the facial midline.
• That without bimax advancement, my face may age more quickly, because the jaws are recessed and unable to provide skeletal support for the soft
tissues when those tissues begin to sag and descend.
• A note on self-perception: I had always thought that my maxilla was protruded relative to my mandible (based on my own perception of my facial structure). The orthodontist’s report contradicts that self-perception, however—he writes: “Deficient development of the upper jaw structure … Excessive forward growth of the lower jaw relative to the upper jaw …The cephalometric radiograph demonstrates: The tendency towards excessive forward growth of the lower jaw relative to the upper … This specific skeletal pattern is most prone to problems with the joint of the lower jaw.” The surgeons (Drs. R., N., and S.) didn’t describe my jaw situation in quite the same way as the orthodontist did, but they did emphasize that both jaws are retruded.Dr. R.’s surgical plan is the following (as on p. 4 of the attached PDF of his report):
• Midface reconstruction, Le Fort I maxillary osteotomy with graft- advance and downgraft CPT code 21145
• Mandibular reconstruction, bilateral sagittal osteotomies of the mandibular ramus with rigid fixation- advance, clockwise rotation, and rotate to left CPT code 21196
• 3-D virtual surgical planning and interocclusal surgical guides CPT code 21085
It seems like I have 2 options:(1) Have bimax advancement (with maxillary downgrafting, CW rotation of the mandible, and rotation of the mandible to the left), with or without an accompanying genioplasty (out-and-down direction)—followed a year later by rhinoplasty (to de-project the nose)
Or(2) No jaw surgery; instead, have rhinoplasty (to de-project the nose), re-placement of the chin implant (with better positioning, lower on the chin), and possibly a procedure to lift or tighten the soft tissues below the mandible.
The ENT surgeon whom I met with in 2018—and liked (but who, unfortunately, I didn’t choose for the rhinoplasty and chin implant that I had in 2019)—showed me a simulation of what he would do (without any jaw surgery). (This simulation is Image #41 in the imgur album). This simulation closely represents what I would hope for IF choosing option #2. (This result might be more difficult to achieve now than it was 3 years ago, however, because since then I have already had primary procedures (in 2019) to the nose and chin (and submental lipo), and a surgery now would be a revision of these procedures, and consequently would have to contend with the scar tissue that formed as a consequence of those primary procedures.)
I am inclined to go with option #1, however, because
• I would like for my jaws to be balanced, both in relation to each other and in relation to the rest of
my face and head;
• I would like for my bite to be aligned and to feel more comfortable with my appearance when smiling
(and the orthodontist told me that orthodontics alone, without surgery, wouldn’t work well);
• I would like to avoid future jaw-joint problems and tooth wear that may be more likely to occur if I
don’t have corrective jaw surgery to balance the jaws; and
• I would like for there to be more skeletal support for the soft tissues of my face, especially as I age;
Also, I notice that if I drop a vertical line down from the base of the nose in Image #1 (the pre-chin-implant lateral X-ray)—as Kavan has done for illustration in JSF posts—the most anterior point of my upper lip, lower lip, and chin lies quite far behind that line (a mitigating factor in this observation could be, however, that in that X-ray my head seems slightly downward-pointing). I think this suggests that bimax advancement is in fact appropriate and indicated in my case.
QUESTIONS:(1) I suppose that, at this early stage, the main question I should be asking is not precisely how many millimeters the surgical movements should be, but rather
whether or not I should have jaw surgery at all—because I have to decide whether or not to begin (decompensatory) pre-surgical orthodontics, and in order to make THAT decision I need to have decided whether or not to have jaw surgery (because it would not make sense to begin decompensatory orthodontics if I’m not sure whether it is a good idea to have the surgery).
To get at the aesthetic advantages and disadvantages of a potential DJS, in Image #42 in the imgur album I have juxtaposed a photo of the ENT surgeon’s simulation next to a photo of Dr. R.’s jaw-surgery simulation COMBINED with my simulation (made in facetouchup.com) of an added genioplasty and post-jaw-surgery rhinoplasty (i.e., I took Dr. R.’s simulation and added a hypothetical genioplasty and rhinoplasty to it).
I’m comparing the ENT surgeon’s simulation with Dr. R’s jaw-surgery simulation PLUS a rhinoplasty simulation, rather than with Dr. R’s jaw-surgery simulation ALONE (which is shown in the attached file, and in Image #39), because I plan on having rhinoplasty whether I have jaw surgery or not (because it seems to me that de-projecting the nose, if done well, will be aesthetically beneficial either way—though the
extent of de-projection performed will depend on whether I will have had bimax surgery). Regarding genioplasty, Dr. R. mentioned it but didn’t include it in his simulation, because of the option of leaving the chin implant in place—in (p. 4 of) his report, he wrote: “There would be no reason to remove [the implant] if Christopher is satisfied with the current shape of his chin. It could be alternatively removed and then there would be consideration of genioplasty.” Since I DO in fact dislike the current shape of my chin created by the implant—though unfortunately I forgot to mention that to Dr. R. during the consultation—I WOULD want it removed (or at least re-positioned), so that it why I altered the chin shape in my addition to his morph (of course, the addition I made to his morph might not be something that is actually possible, surgically).
It is not clear to me which of these 2 simulations in Image #42 works best, aesthetically.
I’m concerned that the simulations by Dr. R. and Dr. N. (in images #39 and #40)—especially the simulation by Dr. N. (perhaps because he may not have incorporated CW rotation in his morph, and because his advancements are larger than Dr. R.’s)—make me look “cro-magnon”-like, whereas the ENT surgeon’s simulation looks more “natural.” It may be, however, that I am just unused to seeing myself with more forward jaws, and that, objectively, the increased jaw projection that Dr. R. and Dr. N. are proposing does indeed produce a more balanced profile. (Incidentally, I saw in a video of a lecture by Alfaro that he, Alfaro, sees aesthetic judgement of frontal and occlusal relations as “objective,” but that of sagittal relations (“A-P and vertical”) as “subjective”: at 7:55 in this video:
https://www.youtube.com/watch?v=TJUK6WZ07fM)
Also, I realize that this comparison of the two simulations is probably NOT a fair comparison, because jaw-surgery morphs don’t accurately depict/predict the soft tissue changes that are likely to occur as a result of the orthognathic-surgical movements. (Dr. N. said that the actual surgical result “always looks better than the computer simulation”—though I can’t imagine that is truly always the case.) I think I can assume that the reason that the ENT surgeon’s morph looks more natural than Dr. R.’s and Dr. N.’s is BECAUSE of this inability of jaw-surgery morphs to accurately depict the soft tissue changes that are likely to result from the orthognathic-surgical movements. (Dr. N. mentioned that the lips, in particular, are difficult for a jaw-surgery morph to depict).
Something I am also considering is that although the ENT surgeon’s morph may look better than the “bimax advancement + rhinoplasty” morph NOW, in 10 years from now (at age 55) I might regret not having had the bimax advancement, as my face might have aged quickly/prematurely, without the skeletal support for the aging soft tissues that the bimax surgery could have provided. (Of course, I might additionally regret not having had my occlusion fixed!)
MY WORRIES ABOUT UNWANTED EFFECTS OF THE SURGERY:
• Concern about potential permanent numbness of the lower lip, especially given that this is a greater risk in older patients. Related to this, I play the trumpet (though it is not my career), and Dr. R. warned me that I might not be able to play the trumpet (ever) again after surgery, because of potential permanent numbness of the lower lip. (He wasn’t discouraging me from having the surgery, but he did mention this as a risk.)
• Genioplasty (if a genioplasty was added to the bimax surgery): If I remember correctly, Dr. R. suggested that a genioplasty could be more difficult in my case, because of the scar tissue that has (inevitably) formed in that area, as a result of the insertion of the chin implant two years ago.
(2) I read the jawsurgeryforums posts (and read the article and watched the video that Kavan linked to) on
Piezo ultrasonic surgery. Given my concerns (described above) about potential permanent numbness of the lower lip, the possibility of Piezo is very appealing (for its greater potential for avoiding permanent damage to the inferior alveolar nerve during SSO than with traditional surgical instruments).
In my case, might it be better to go with a surgeon who, like Dr. R., does not (yet) use ultrasonic techniques but does have a lot of experience and seems to have a good aesthetic sense? (Also, I really liked and felt good about Dr. R. when I met with him.) Or, given my priority of avoiding permanent numbness to the lower lip, would it make best sense for me to prioritize finding and using a surgeon who does Piezo surgery? (Unfortunately, I don’t know which surgeons in the US use Piezo.)
(3) Given that my philtrum is currently straight, rather than concave, I am concerned about “chimp lip” (i.e., a convex philtrum) resulting from the maxillary advancement and downgrafting. (I have read, and am grateful for, the JSF threads on chimp lip, and for Kavan’s diagrams on rotation.)
The following is a link to an album I put together of 3 photos that seem to me to be examples of chimp lip (though, as far as I know, none are JS patients; and I’m not sure whether my interpretation of these as “chimp lip” examples is accurate):
https://imgur.com/a/l7ZXtJtThe Holdaway soft-tissue analysis of my ceph (in Image #18) indicates that my maxillary/superior sulcus is very shallow/forward (norm is 3 mm deep; mine is 0.4 mm deep) and the maxillary-sulcus angle (ULA–A’–Sn, from the Bergman analysis in Image #19) is abnormally obtuse (norm is 151
o; mine is 175.2
o). (And this is obvious from the photos, even without the measurements from the analysis.) I imagine that this would put me at risk of chimp lip.
If I understand them correctly, however, I think that Dr. R.’s plans (described below) may lessen this risk. In his preliminary plan of movements (attached, and in Image #38), both the ANS and the PNS are downgrafted and advanced by the same amount (looks like +4.8 mm forward and +1.3 mm down for both ANS and PNS in the plan), which I think means that the maxilla would NOT be rotated clockwise. (Dr. R. did indicate, however, that the MANDIBLE would be rotated, clockwise.) I notice that in Dr. R.’s plan for surgical movements (in the attached jpeg), “Rotate
Md @ Hinge axis” is set to
-1.6, but “Rotate
Mx+Md @ Hinge axis” is set to
0.0.
Maybe the reason that Dr. R indicates CW rotation for the mandible, but not for the maxilla, is because he is taking into consideration the deep-bite—maybe rotating the mandible clockwise but keeping the maxilla on its original plane is a way of opening the bite (?). (This is just my naive guess—I hadn’t previously heard or read about the possibility of rotating the mandible without also rotating the maxilla, and I didn’t think to ask Dr. R. about this aspect of his plan.)
Also, I see that in Dr. R.’s morph (and in his displacement diagram) my philtrum is actually more CONCAVE after surgery than before—which would be great! I just can't figure out how an increase in concavity could result from downgrafting and advancing the ANS and PNS by the same amount, because I thought that would simply push the philtrum as a whole forward, along the maxillary plane. I did notice, however, that in his morph (and in his displacement diagram), the upper incisors are more proclined post-surgery than they are at present (pre-orthodontics), and perhaps it is that increased proclination (which maybe the pre-surgical orthodontics could provide me) that creates the concavity of the philtrum in the morph?
I would be grateful for any thoughts you would be willing to share!