Any advice about surgical plans welcome...

[m20marianna]

Reply to Kavan

Thanks for that.

I suppose my ability to 'see' that, would probably mean I need to receive something similar from other surgeons, in order to 'train' my eye and understand better what I'm looking at.
I can see an improvement in the drawings, but I suppose I was expecting a more realised, or possibly computerised, 3D image with also a front facial image. I'm not sure, however, if surgeons do this and even if they did, if it would be accurate.

One question, I'm curious, when you look at the drawings, are you able to visualise the real-life image of what my profile would be like (not sure how to express that better) and conceptualise what the relative changes would be to the front image?

[m20marianna]

I don't think you're a good candidate for double jaw surgery and I'm confused as to why anyone is recommending any amount of shortening of the upper jaw ("impaction") because your tooth show is absolutely perfect.

Your anatomical abnormalities are a narrow upper jaw and a long chin for a girl. I would live with the long chin because it's a major health advantage both mental and physical. Overall I think you actually have a nicely balanced face, it's just a little different from the norm.

If you want to improve the way you look a little I would try to balance out the lower third by expanding the midface. You are a perfect candidate for upper jaw widening. It's minimally invasive compared to double jaw surgery and I have never seen a case where the patient did not look better afterwards. You can't say that about moving the upper jaw forward. It usually looks worse. You need to use the European type expanders which are a major improvement over the dumb American orthodontic expanders and you need to leave them in for a long time after expansion or else it will just relapse when you do orthodontics to close the tooth gap. Most people with a normal bite can get at least 5mm of expansion without significantly changing their bite. If you want to go beyond that and look better and breathe better at the expensive of a compromised lateral bite that seems like a worthwhile trade off to me. All this stuff about perfect bites is frankly made up orthodontic money grabbing nonsense. There is an entire generation of people living today born before 1950 with bad bites and no bad consequences because of it. And being off laterally is especially meaningless because it doesn't stress the joints like other types of bad bites. This is the type of device I recommend: https://titamed.com/en/smile-distraction/uni-smile Anyone is a candidate but you are a really good candidate.

After that your next step to looking more attractive should probably be hydroxyapitite cheek implants done in the fashion Michael Gunson does them. Better to widen the jaw first though because I think the bone paste implants might get in the way as they cover the sutures utilized in expanding the upper jaw. If you study Gunson's patients you will notice he doesn't do much with their jaws. He figured out it's more about expanding the midface. Almost all the cosmetic improvement is from expanding the midface, not moving the jaws. It's worth noting because a lot of people could save themselves unnecessary jaw surgery and just get his type of cheek implants. The problem with implants though is they are not functional. So for cosmetic improvement I like functional jaw widening first because it improves your health as well as your appearance.

I do find it really ironic that everyone seems to recognize that retrusive orthodontics is terrible but retrusive jaw surgery rarely raises eyebrows. They are both equally bad. The face is all about balance and there is usually a way to balance out the small part by making another part bigger. Don't balance it out by making the big part smaller! Making things smaller is just always a bad idea. Modern day humans with the very best jaw structure have bad jaw structure compared to our very recent ancestors. We grew bigger brains to compensate but you can surgically make yourself a better human by giving yourself better sleep through improved jaw structure. Shaving the chin and jaw impaction should be last resorts and most patients that would look better with these procedures would be better served by learning to live with a larger than normal chin or maxillary excess because they provide significant advantages in terms of better sleep, health and mental functioning and can usually be balanced out by making other parts of the face bigger.

Also, you look like you might have a tongue tie. Hard to tell without seeing the underside of the tongue but it looks like it because your chin is sagging a little. Correctly fixing a tongue tie can do more for lower jaw contour than jaw surgery and it's a 30 second procedure. By do it right I mean use a laser - do not get sutures which will lead to tongue deformation because you need to stretch it while it's healing and you cannot do that with it sutured in place.

Thanks for taking the time to reply. To be honest, you've opened up some possibilities that I hadn't previously thought about but not sure I would know where to start.

When you say upper jaw widening, do you mean or include in that SARPE? I did ask my orthodontist about whether I could get SARPE without jaw surgery to correct my bite and he did say it would be worthless in my case. However, I didn't really question him about this in detail so I'm not sure why he thought doing this procedure alone wouldn't be a good idea in my case. 

I'll be honest, the idea of any type of implants doesn't really excite me. The tongue tie issue I had never really noticed before. But it's definitely interesting. Do you see my chin/lower third appearing shorter if I 'untied' (is this the correct phraseology?) my tongue?

[kavan]

Reply to Kavan

Thanks for that.

I suppose my ability to 'see' that, would probably mean I need to receive something similar from other surgeons, in order to 'train' my eye and understand better what I'm looking at.
I can see an improvement in the drawings, but I suppose I was expecting a more realised, or possibly computerised, 3D image with also a front facial image. I'm not sure, however, if surgeons do this and even if they did, if it would be accurate.

One question, I'm curious, when you look at the drawings, are you able to visualise the real-life image of what my profile would be like (not sure how to express that better) and conceptualise what the relative changes would be to the front image?

I don't know about how seeing a computerized image is going to 'train' your eye. However,if you need something like a morph that takes your real life starting point photo and from there, changes it to reflect how it fits into the contour line, you will probably need a doctor in possession of the type of software needed to produce one.

Ability to 'see', observe is often associated with those with a proclivity in direction of both art and science and those proclivities (or abilities) demonstrate early on in life. For example kids that can draw can often do that without being first taught. They are good at observing relative distance relationships. Likewise with scientific aptitude where it demonstrates early on in life by observing and being very curious about physical phenomena. So basically, it's a type of aptitude for something and it's usually the case of something being very EASY for them. But very hard for them to actually identify and articulate all the neural pathways at play that made it easy for them as to transfer those to another.

As to your question about my looking at the drawings and visualizing the your 'real life' profile, I will tell you that in order to draw something, for example a 'real life' portrait, it STARTS with observing the contours and the distance relationships.

[thedude]

Thanks for taking the time to reply. To be honest, you've opened up some possibilities that I hadn't previously thought about but not sure I would know where to start.

When you say upper jaw widening, do you mean or include in that SARPE? I did ask my orthodontist about whether I could get SARPE without jaw surgery to correct my bite and he did say it would be worthless in my case. However, I didn't really question him about this in detail so I'm not sure why he thought doing this procedure alone wouldn't be a good idea in my case. 

I'll be honest, the idea of any type of implants doesn't really excite me. The tongue tie issue I had never really noticed before. But it's definitely interesting. Do you see my chin/lower third appearing shorter if I 'untied' (is this the correct phraseology?) my tongue?

Yes, by jaw widening I mean SARPE. It's also called palate expansion, and there are other acronyms as well. SARPE is usually is a little more invasive in that they make surgical cuts under anesthesia similar to upper jaw surgery. It can also be done in a minimally invasive fashion where they just make small punctures along the palatal suture instead of sawing it open with a bone saw. They have their pros and cons. I'd just stress the importance of using a European type expander that I linked to as you will get twice the amount of expansion using that method within the same amount of space and it just looks better because it keeps the teeth from flaring out unnatually. At least in the US most orthodontists are not familiar with it though so you might have to ask around or specifically request it. It takes some experience to get it right though. Being in Europe maybe you want to visit that Belgien guy Joel Defrancq. I've never seen him mentioned much on these forums. He claims to have popularized that type of palate expansion but I don't know if that's true or if he's well regarded as a surgeon here.

With regards to the tongue tie, this is a good example of what it would look like if you are in fact tongue tied. https://dentalsleeppractice.com/the-importance-of-orofacial-myofunctional-therapy-before-and-after-co2-laser-frenectomy/  Notice how in the second profile picture she has a more contoured chin. If your chin sags in pictures it might create the illusion of a longer chin and this might help. I'm not really sure but regardless it usually looks attractive to have a well contoured and taught underside of the chin. You will see people recommend myofucntional therapy with tongue tie surgery which in my opinion is nonsense. You just need to stretch your tongue like crazy when it's healing.

I'll admit the conventional approach with you would be to shave down the chin a little and do a genioplasty like the doctor sketched out for you. You could then advance the jaws a little too without having your chin stand out. I feel like that's going to be a lot of shaving in your case though. Shaving down the chin in very popular in Asian countries. It's even what Kylie Jenner did and she turned out looking quite nice. I'm not sure if she was quite as bright afterwards but we won't go there. Hopefully the advancement compensates for the loss but it seems dangerous to me to mess with the part of the face where the tongue muscle literally attaches to the chin bone.

I think what particularly catches your eye with regards to you chin profile other than the size is you do not have a Western European style point on your chin. I think that's why in the picture of your proposed genioplasty you see the doctor rotating the chin bone a little to get you that kind of point at the end. That kind of has become the aesthetic ideal but I think what you have is a natural variation that just isn't as popular. I notice people with this variation sometimes have a forehead that slopes back a little bit at the top like you have. They kind of work together. You might want to make sure changing the shape of your chin doesn't mess with that harmony. Sometimes there are little things like that at work that we don't notice.

I also feel like you just have an absolutely perfect smile that is situated just where it should be to show the right amount of tooth show. That's rare and pretty special and it's not usually something even the best doctors consistently get right with jaw surgery. I think if you move your jaw up your going to look worse because you're not going to see your teeth when you smile. There is a guy on a forum that posted recently that did just that and he really seems to regret it. So be careful. I'm very confused about why that is being recommended for you. Moving the jaw forward doesn't seem to expose that much more gumline when you smile compared to vertical movements up and down.

Most people that get jaw surgery for recessive jaws also have sleep apnea. The fact that you don't kind of is a hint that you don't really need it. The reason I mentioned some of the theory around why size is ultimately more important than shape in jaw structure is because I feel like you're kind of a case where if you could come to believe the way you look serves a nice purpose you might come to appreciate it. I don't really look at you and think "she needs jaw surgery" like I do a lot of the other posters with sleep apnea on here. What you have might just be a little better than you realize, even if it's a little different than the norm for women.

I am curious about the so called lip incompetence you mention. I don't think it looks that bad either, but I am curious what do doctors or posters here attribute that to? I've never really understood the mechanism behind that.

[m20marianna]

I don't know about how seeing a computerized image is going to 'train' your eye. However,if you need something like a morph that takes your real life starting point photo and from there, changes it to reflect how it fits into the contour line, you will probably need a doctor in possession of the type of software needed to produce one.

Ability to 'see', observe is often associated with those with a proclivity in direction of both art and science and those proclivities (or abilities) demonstrate early on in life. For example kids that can draw can often do that without being first taught. They are good at observing relative distance relationships. Likewise with scientific aptitude where it demonstrates early on in life by observing and being very curious about physical phenomena. So basically, it's a type of aptitude for something and it's usually the case of something being very EASY for them. But very hard for them to actually identify and articulate all the neural pathways at play that made it easy for them as to transfer those to another.

As to your question about my looking at the drawings and visualizing the your 'real life' profile, I will tell you that in order to draw something, for example a 'real life' portrait, it STARTS with observing the contours and the distance relationships.

I don't mean to say that seeing computerised images would train my eye, rather seeing other similar drawings or whatever the usual plan for surgeons is would help me to view those images in a way that I can better comprehend the facial changes.

I am absolutely certain that I have no latent talent for art. I would find it hard to recall what something familiar looks like to be able to reproduce it on a page.

So it's interesting then, is someone's objective attractiveness based on mathematical principals regarding the relationship between the contours of the face in relation to distances and angles?

[kavan]

I don't mean to say that seeing computerised images would train my eye, rather seeing other similar drawings or whatever the usual plan for surgeons is would help me to view those images in a way that I can better comprehend the facial changes.

I am absolutely certain that I have no latent talent for art. I would find it hard to recall what something familiar looks like to be able to reproduce it on a page.

So it's interesting then, is someone's objective attractiveness based on mathematical principals regarding the relationship between the contours of the face in relation to distances and angles?

Yes.

[thedude]

https://img.i-scmp.com/cdn-cgi/image/fit=contain,width=425,format=auto/sites/default/files/styles/768x768/public/d8/images/methode/2020/10/01/fca3a1d2-03aa-11eb-88c7-25dcd0ae6080_image_hires_143806.jpeg?itok=_kZDNzK9&v=1601534293

You have to admit he is a pretty handsome fellow.

[kavan]

You have to admit he is a pretty handsome fellow.

 

[m20marianna]

Yes, by jaw widening I mean SARPE. It's also called palate expansion, and there are other acronyms as well. SARPE is usually is a little more invasive in that they make surgical cuts under anesthesia similar to upper jaw surgery. It can also be done in a minimally invasive fashion where they just make small punctures along the palatal suture instead of sawing it open with a bone saw. They have their pros and cons. I'd just stress the importance of using a European type expander that I linked to as you will get twice the amount of expansion using that method within the same amount of space and it just looks better because it keeps the teeth from flaring out unnatually. At least in the US most orthodontists are not familiar with it though so you might have to ask around or specifically request it. It takes some experience to get it right though. Being in Europe maybe you want to visit that Belgien guy Joel Defrancq. I've never seen him mentioned much on these forums. He claims to have popularized that type of palate expansion but I don't know if that's true or if he's well regarded as a surgeon here.

With regards to the tongue tie, this is a good example of what it would look like if you are in fact tongue tied. https://dentalsleeppractice.com/the-importance-of-orofacial-myofunctional-therapy-before-and-after-co2-laser-frenectomy/  Notice how in the second profile picture she has a more contoured chin. If your chin sags in pictures it might create the illusion of a longer chin and this might help. I'm not really sure but regardless it usually looks attractive to have a well contoured and taught underside of the chin. You will see people recommend myofucntional therapy with tongue tie surgery which in my opinion is nonsense. You just need to stretch your tongue like crazy when it's healing.

I'll admit the conventional approach with you would be to shave down the chin a little and do a genioplasty like the doctor sketched out for you. You could then advance the jaws a little too without having your chin stand out. I feel like that's going to be a lot of shaving in your case though. Shaving down the chin in very popular in Asian countries. It's even what Kylie Jenner did and she turned out looking quite nice. I'm not sure if she was quite as bright afterwards but we won't go there. Hopefully the advancement compensates for the loss but it seems dangerous to me to mess with the part of the face where the tongue muscle literally attaches to the chin bone.

I think what particularly catches your eye with regards to you chin profile other than the size is you do not have a Western European style point on your chin. I think that's why in the picture of your proposed genioplasty you see the doctor rotating the chin bone a little to get you that kind of point at the end. That kind of has become the aesthetic ideal but I think what you have is a natural variation that just isn't as popular. I notice people with this variation sometimes have a forehead that slopes back a little bit at the top like you have. They kind of work together. You might want to make sure changing the shape of your chin doesn't mess with that harmony. Sometimes there are little things like that at work that we don't notice.

I also feel like you just have an absolutely perfect smile that is situated just where it should be to show the right amount of tooth show. That's rare and pretty special and it's not usually something even the best doctors consistently get right with jaw surgery. I think if you move your jaw up your going to look worse because you're not going to see your teeth when you smile. There is a guy on a forum that posted recently that did just that and he really seems to regret it. So be careful. I'm very confused about why that is being recommended for you. Moving the jaw forward doesn't seem to expose that much more gumline when you smile compared to vertical movements up and down.

Most people that get jaw surgery for recessive jaws also have sleep apnea. The fact that you don't kind of is a hint that you don't really need it. The reason I mentioned some of the theory around why size is ultimately more important than shape in jaw structure is because I feel like you're kind of a case where if you could come to believe the way you look serves a nice purpose you might come to appreciate it. I don't really look at you and think "she needs jaw surgery" like I do a lot of the other posters with sleep apnea on here. What you have might just be a little better than you realize, even if it's a little different than the norm for women.

I am curious about the so called lip incompetence you mention. I don't think it looks that bad either, but I am curious what do doctors or posters here attribute that to? I've never really understood the mechanism behind that.

Thank you for the advice regarding the expander. I'll ask my ortho about this.

That's interesting about my chin profile. I never really noticed that. So essentially I have a more curved chin point rather than the V-line point at the end?

Yes; I do like my smile but my teeth moved a bit in the last few years and as a result my midline is not centred. That was originally the reason I went to see an ortho and he recommended jaw surgery. Also my bite is edge-to-edge so is this why they recommend impaction typically? I would be nervous about losing my tooth show and I think it makes me look younger-looking too.

Yes; I don't really have any major functional issues. I'm not 100% decided on the surgery at the moment as, like everyone else, I don't want to be left with more issues afterwards and ultimately regret it. The Spanish surgeon did however mention my airway looked a little narrow in the X-ray and I might develop sleep apnea in the future. I'm not sure how honest that is. The UK surgeon kind of scoffed at that, when I told him what the other surgeon had said.

[CCW]

Thank you for the advice regarding the expander. I'll ask my ortho about this.

That's interesting about my chin profile. I never really noticed that. So essentially I have a more curved chin point rather than the V-line point at the end?

Yes; I do like my smile but my teeth moved a bit in the last few years and as a result my midline is not centred. That was originally the reason I went to see an ortho and he recommended jaw surgery. Also my bite is edge-to-edge so is this why they recommend impaction typically? I would be nervous about losing my tooth show and I think it makes me look younger-looking too.

Yes; I don't really have any major functional issues. I'm not 100% decided on the surgery at the moment as, like everyone else, I don't want to be left with more issues afterwards and ultimately regret it. The Spanish surgeon did however mention my airway looked a little narrow in the X-ray and I might develop sleep apnea in the future. I'm not sure how honest that is. The UK surgeon kind of scoffed at that, when I told him what the other surgeon had said.

Kavan explained the reason for the impaction.

Your lower anterior facial height is very long, so you'd need big movements to fix your lip incompetence. I also agree with the Spanish surgeon (Alfaro?) your airway looks smallish, so I'd want to get that fixed if I were to get jaw surgery in the first place.

The worst results I have seen have been by UK surgeons who don't seem to care about aesthetics at all, so I'd scratch him off the list if you're getting surgery for aesthetics. You should get a third and fourth opinion from Raffaini and Ramieri.   

[m20marianna]

Kavan explained the reason for the impaction.

Your lower anterior facial height is very long, so you'd need big movements to fix your lip incompetence. I also agree with the Spanish surgeon (Alfaro?) your airway looks smallish, so I'd want to get that fixed if I were to get jaw surgery in the first place.

The worst results I have seen have been by UK surgeons who don't seem to care about aesthetics at all, so I'd scratch him off the list if you're getting surgery for aesthetics. You should get a third and fourth opinion from Raffaini and Ramieri.

Do you mean the reason Kavan gave, is that I have to move my jaws forward and this will create more tooth show and therefore I will also need impaction to offset this? Is it not also to fix the open bite?

Yes, it is Alfaro. Both him and the UK surgeon said that my lip incompetence won't be completely 'fixed' (just decreased) and Alfaro said I shouldn't wish for it to be. He mentioned that most women my age (30s) have some tooth show when face/lips at rest (apparently?).

I would like to get another opinion but I've heard some bad reviews of Raffaini. Never heard of Ramieri.

[CCW]

Do you mean the reason Kavan gave, is that I have to move my jaws forward and this will create more tooth show and therefore I will also need impaction to offset this? Is it not also to fix the open bite?

Yes, it is Alfaro. Both him and the UK surgeon said that my lip incompetence won't be completely 'fixed' (just decreased) and Alfaro said I shouldn't wish for it to be. He mentioned that most women my age (30s) have some tooth show when face/lips at rest (apparently?).

I would like to get another opinion but I've heard some bad reviews of Raffaini. Never heard of Ramieri.

Yes. You fix the open bite by either a posterior impaction or downgrafting. An old-fashioned surgeon would do a posterior impaction and create more problems in the process whereas a surgeon like Alfaro will level the occlusal plane with a posterior downgraft.

By lip incompetence I mean mentalis strain. Some tooth show at rest is normal and desirable for both men and women.

All surgeons have unhappy patients, but I rate Raffaini and Alfaro as the best surgeons in Europe.

[m20marianna]

Yes. You fix the open bite by either a posterior impaction or downgrafting. An old-fashioned surgeon would do a posterior impaction and create more problems in the process whereas a surgeon like Alfaro will level the occlusal plane with a posterior downgraft.

By lip incompetence I mean mentalis strain. Some tooth show at rest is normal and desirable for both men and women.

All surgeons have unhappy patients, but I rate Raffaini and Alfaro as the best surgeons in Europe.

Does downgrafting include some form of impaction or is merely the ccw/cw rotation movement around the ANS point plus the graft?
An earlier surgeon I went to wanted to do an impaction plus mandibular setback. Is this what you mean by posterior impaction?

Out of curiosity, is downgrafting always done as a fixed point around the ANS or can it be done around another point? If so, what would be reasons for different points?

Thanks for the replies

[TWGOAT]

Yes. You fix the open bite by either a posterior impaction or downgrafting. An old-fashioned surgeon would do a posterior impaction and create more problems in the process whereas a surgeon like Alfaro will level the occlusal plane with a posterior downgraft.

By lip incompetence I mean mentalis strain. Some tooth show at rest is normal and desirable for both men and women.

All surgeons have unhappy patients, but I rate Raffaini and Alfaro as the best surgeons in Europe.

If there is vertical maxillary excess due to downward growth, impaction is warranted though, right ?

the 2 surgeons i've seen so far said i wasnt a case for posterior downgrafting because of the vertical maxillary excess

[kavan]

If there is vertical maxillary excess due to downward growth, impaction is warranted though, right ?

the 2 surgeons i've seen so far said i wasnt a case for posterior downgrafting because of the vertical maxillary excess

Correct. Vertical maxillary excess (VME) = 'long' anterior face (long face from the front) from excess downward growth of the anterior maxilla. Solution= removal of section from anterior maxilla= anterior impaction.
Rotational direction of anterior impaction = CCW. 

With reference to a CLOCK , divided vertically between 12 and 6 , counter clockwise direction (relative to the 'anterior half' of the clock) is between  6 and 12 (from 6 swinging up to 12) and is an upward swing. Counterclockwise direction (relative to the 'posterior half' of the clock) is between 12 and 6 (12 swinging down to 6) and is a downward swing.