Advice on jaw surgery pre-orthodontics (pics)

[Harsturomai]

Hi all,

I have had a consultation with two surgeons. The first dropped me as a patient because (as the second surgeon supposed), I was asking too many questions. The second is a more senior surgeon in Melbourne, Australia but he has not taken any measurements or scans. Presumably, he already had the measurements from the first surgeon, but he is also very much of the opinion, "I am not going to do anything until your teeth have moved" - fair enough I think.

I am actually a few months into orthodontic treatment, although the pics are before I began. It makes me anxious not knowing whether my concerns can be addressed. Both surgeons said that I am definitely a candidate for LJS, but I know that only DJS has the potential to fix my issues (or those that can be fixed...) My current surgeon says he'll wait for the teeth to move before making further decisions.

I actually "like" how the left side of my face looks. Sure, there are imperfections, my jaw isn't straight etc. But I get caught up on how the right side of my face looks. Now, sure, I might have some body dysmorphia and am booked in to see a psych (at my surgeons request.) However, I know what I can see, and I don't like how it looks. The right side of my face looks relatively flat and depressed. I feel like my face lacks much anterior projection and I have always hated my smile. My face is asymmetrical. According to my surgeon, my maxilla has grown downwards to compensate for my recessed mandible and thus my teeth point inwards - which I dislike.

The issue I am having, is that I feel like my case is less optimistic than most. Sure, some people have terrible malocclusion, but they can be surgically fixed. In my case, I know there is nothing that I can do to correct my orbital asymmetry. Now, if my cant is corrected by, in part, lowering the right side of my jaw relatively, then it is going to increase the vertical height between my lips and my right eye, which is already "higher" and more "recessed" than my left eye. I have just been struggling to put this all aside and wait for my orthodontics to be completed. Because until then, I don't really know what can be fixed.

My surgeon advised that he could perform a malar osteotomy pioneered by Maurice Y.Mommaerts to help with some mid face projection and under eye support. If I was told that, "your jaws will be brought forward to align your teeth correctly and in doing so, in addition to some malar augmentation, your asymmetry can be decently addressed by improving the harmony of your facial elements", then I would probably be okay. But as it stands, I am completely in the dark about what can and can't be fixed.

TBH, I also can't articulate what I dislike about my face properly. I don't have the medical training to be able to do so. That's why I'd like a CBCT scan to at least be able to see, unbiasedly, without lighting artifacts and interactively, what my face looks like. However, my surgeon also said that he would not refer me to the imaging clinic until my teeth have moved, claiming that "I will be a different person after orthodontics". Sure, I get that logically, I need to get my front teeth projecting, create an overjet etc. before any surgical analysis is relevant. But I find the waiting part difficult. I don't want to look like a supermodel, but I'd like each side of my face to look more the same and be confident with my smile.

From a functional POV:
- I have never been able to bite on both sides of my molars simultaneously
- I don't feel like I have a natural resting position for my jaws
- Occasional jaw aches

Below is a series of images and scans prior to orthodontics. I noticed that I have pretty bad forward head posture in these images, and when I hold my head properly, my jaw recession becomes far more evident. When holding proper posture, my ears do top above my eyes. The two skull x-rays are from when I was about 12 lol because I got concussed at school, but they might help show the asymmetry.

https://imgur.com/a/EqtBUud

Any advice on surgery, questions to ask my surgeon and coping with getting through the "orthodontics stage" would be greatly appreciated.

Cheers

[GJ]

Your teeth pointing inward can be fixed via orthodontics (i.e. procline the teeth). That would be relatively easy compared to surgery. You can maybe balance the jaws with implants. The strange thing is, I think the right side of your face looks better. The left size looks a bit thin with what looks like a more under-developed ramus. The left side looks longer to me; it would be nice to see a better scan of the joints. You appear to have a cant, which I don't see diagnosed in your notes.

Did you have wisdom teeth removed before ortho treatment?

All said, I don't see this being a jaw surgery case. You have nice lips and a proportional nose, and I think jaw surgery could mess up what you have going for you. I do think proclining the teeth and maybe a custom implant to balance out the asymmetry that bothers you could be a decent path to some improvement. I also think doing nothing would be fine. But double jaw? I don't see it. What justification did these surgeons give for double jaw surgery?

[Harsturomai]

So I do have a jaw cant, but encapsulated that under the whole asymmetry because the can’t is congruent with the depression and recession of the right side of my face. It is the cant that I specifically dislike. It is the can’t that makes my jaws “swing” to the right and thus my left side looks the way you described. But also, it swings inwards towards the right, giving my right mid face little projection, lack of under eye support etc.

My surgeon said it’s a fair border line case and could fix the cant  if I really wanted to, but won’t say he definitely will until the teeth have moved. Likely because he needs to determine exactly what feasible range of movement he can perform. He also said that he could do a malar osteotomy to make my cheeks more symmetrical and project a bit more to balance my profile.

I’ve also been told by both surgeons that aesthetically, they wouldn’t advocate jaw surgery, however apparently my teeth are a bit of a mess so functionally, it’s a fair option. Again, I’ve been diagnosed as a border line case. Sometimes I wish I was way worse, so it was obvious that I needed surgery. I feel like cases that go from way worse to way better are better than cases that go from “eh, not the absolute end of the world”, but remain as such.

[Harsturomai]

Also, I haven’t had my wisdom teeth removed yet, and yes, they’re pretty munted and need to go. The idea was that their removal could be done at the time of surgery. Also RE implants, I haven’t seen any implants that aim to correct asymmetry of the maxilla.

[kavan]

Enclosed with this post are 2 images taken from your photos; ASYMMETRY and  MIRROR SYMMETRY.

In the Asymmetry photo:

I looked at the line up RELATIVE to a pure horizont taken from panels in the back drop which are perfectly parallel to the picture plane. I then put in parallel horizonts through the features. So, ya, there's some asymmetry as to how the pupils of the eyes line up relative to a horizont passing through the right pupil and also how the corners of the lips line up relative to a horizont passing through the right corner of the lips. Thing is that the base of the chin rests perfectly on the lower horizont. The curved lines tracing the neck contour show the one on the right is longer. IDK, try taking the photo against the same backdrop and tilting your head a little more to the right to see if there is a better line up. Like I don't know if it's from a postural head tilt or not.

Thing is, IF the asymmetry is coming from the ORBITS, jaw surgery can't change that, nor could surgery aimed at enhancing the upper mid face. Neither would yield perfect line up of the pupils. I'm not saying that either or both would not give some improvement. (for example, more midface enhancement would be an improvement as would more lower jaw advancement) I'm saying that those 2 improvements would not be the solution for someone who's on the QUEST for 'perfect symmetry'.

In the Mirror Symmetry photo:

Well, that shows what the face would look like with perfect symmetry based on the left OR right. It doesn't matter which side you like better. What matters is that a surgeon would not be able to fulfill a request to mirror either side if the quest was perfect symmetry based on preference for one side or the other.

EVERYONE (or most people) have some asymmetry. But there are some people who if they CHASE it too much via surgery, they often end up still seeing asymmetry despite having some parts made more symmetrical.

I don't know if you have BDD. But it's not as if a SHRINK could draft out a mirror symmetry visual (as I've done) and tell you; 'yes, you have asymmetry and your max fax most likely can't match one side with the other...so...are you going to have a melt down if you get it and find out that's not the case?' Some surgeons send patients off to a shrink because they are concerned the patient won't be happy and will pursue a path of multiple revisions ('revision tread mill'), reach law of diminishing returns where no surgery brings them to what they want to see in the mirror. Others fear a type of instability that can (and has) resulted in the patient going ballistic and killing the surgeon.

Maybe the surgeon 'hears' that you like one side better than the other and 'sees' he can't match up both sides equally and is concerned that even if he improved stuff he could improve (like relationship of the TEETH), some more lower jaw advancement and the proposed midface enhancement, you would still see asymmetry, be unhappy and start chasing with multiple revision surgeries which is what BDD patients do. So, even if you don't have BDD, he may have pegged you as a potential 'symmetry chaser'.

So, take a good look at the MIRROR symmetry illustrations and make sure you are NOT EXPECTING the surgery to kick up either one of them.

[Harsturomai]

Firstly, thank you both for your comments.

In regards to the idea of "symmetry chasing", or for that matter, any subset of "beauty chasing", I totally understand surgeons' fears. My surgeon told me that he has patients that he advises strongly not to pursue additional surgeries, but they do and end up being more dissatisfied. Look, I am concerned about the degree to which surgery can improve my asymmetry and align my teeth. By showing this concern, I may come acress as having BDD or an inclination to "symmetry chasing". The thing is, I don't know if the asymmetry is coming from my orbits. I don't know how to hold my face perfectly upright. My trapezoids are asymmetrical, as is my entire sekeleton. My clavicles are uneven etc. Osteos have said so and it is visible. It's frustrating that when I raise these concerns to people, people just go "gee he's overthinking this way too much".

I have two issues, one is the actual physical imperfection/deformity, and the other, is actually understanding what that deformity is. Like @kavan said, it's hard to tell due to my posture. Yes, it is! But nobody to date, except you, has even made that point. This is the part that I find frustrating. If the asymmetry is mainly orbital, I wouldn't want to risk any procedures that could damage my eyeballs, so it's something that I will have to come to terms with and learn to live with. But, I don't know if it's mainly orbital or not! Are my malars anteriorly asymmetrical? Vertically asymmetrical? Where does my interpupillary line sit? Are my ears vertically misaligned? Should I be using the base of my ears to align my face? It's the plethora of these questions and thus the uncertainty of what can be surgically fixed, what can potentially be remedied with implants/other techniques and what cannot be fixed at all, that is giving me a hard time. I feel like in a lot of cases where the patient is more symmetrical, they're more easily diagnosable. For me, it's like, I don't really know what is actually wrong and I don't really know what can and can't be fixed.

My surgeon says, "It is medically unprofessional to refer patients to get scans when they don't need to, so you will have to wait until your teeth have moved." Everyone else just slaps me with the BDD label... Like man, I just want a better idea of what my situation is and what can and can't be improved. Unfortunately, I can't get a referral from my surgeon for a CBCT scan and I have to wait another 8 months for my teeth to move...

Lastly, I have no expectation at all that my surgeon could make either side of my face look like the other. Although it might not sound it, I consider myself to be rational. Am I more asymmetrical than most people? Yes. Where is my asymmetry primarily? Idk. What can and can't potentially be fixed? Idk. I just want to get more clarity on those last two answers. It's just annoying that nobody will budge until my teeth have moved. So I looked on this forum to gather some other opinions. It sounds to me like fixing my cant, bringing my mandible out a bit and anteriorly projecting/aligning my malars would get me to the point I want to be at. However, my surgeon said he needs to wait for the teeth to move before saying if he can correct the cant (since I'm a borderline case) (probs my main concern too tbh) and he also said that he would only do the malar correction if he was "already in theatre fixing something major for my bite". Fair enough - if I am already under and having my jaws moved, it makes sense to also fix my malars a bit. But now I'm like, well what if my teeth don't move into a position such that he would fix the cant, and therefore, not fix my malars? Idk, hopefully you can see where I am coming from. I don't meen to rant but this has been seriously eating me up inside for a year...

[kavan]

I made some diagrams from your scull photo to look at. But we don't really know whether they lined up the scull photo with a 'pure' vertical and horizont. So, I did 2 takes on it. I did that to better look at the orbits with reference to orientations of the head.

Photos divided with reference to lines parallel to the picture plane and also one divided with reference 'to itself'. Same points in both. Lines on right are about 4 degrees inclined relative to horizont and vertical. Side to side lines are parallel to each other and are perpendicular to the up and down line.

Photo to the right is more like your full face photo where the front teeth are off center and where eye area doesn't line up with horizontal back drop panels (which were parallel to the picture plane). So, photo on right is more symmetrical with 'itself' than it is with the picture plane.
----------
I don't think the MM Malar osteo would stand to damage your eye balls. It would pronounce out your upper midface more. I was just saying that it doesn't change position of the eyeballs.

The surgeon wants to see if the ortho will make it so a vertical passes through the front incisors so they are no longer askew relative to a midline vertical that passes through the front incisors and the nose aperture. That will give him a better idea if the surgery will give better symmetry to the jaws and also see what asymmetry is not coming from the jaws.

Firstly, thank you both for your comments.

In regards to the idea of "symmetry chasing", or for that matter, any subset of "beauty chasing", I totally understand surgeons' fears. My surgeon told me that he has patients that he advises strongly not to pursue additional surgeries, but they do and end up being more dissatisfied. Look, I am concerned about the degree to which surgery can improve my asymmetry and align my teeth. By showing this concern, I may come acress as having BDD or an inclination to "symmetry chasing". The thing is, I don't know if the asymmetry is coming from my orbits. I don't know how to hold my face perfectly upright. My trapezoids are asymmetrical, as is my entire sekeleton. My clavicles are uneven etc. Osteos have said so and it is visible. It's frustrating that when I raise these concerns to people, people just go "gee he's overthinking this way too much".

I have two issues, one is the actual physical imperfection/deformity, and the other, is actually understanding what that deformity is. Like @kavan said, it's hard to tell due to my posture. Yes, it is! But nobody to date, except you, has even made that point. This is the part that I find frustrating. If the asymmetry is mainly orbital, I wouldn't want to risk any procedures that could damage my eyeballs, so it's something that I will have to come to terms with and learn to live with. But, I don't know if it's mainly orbital or not! Are my malars anteriorly asymmetrical? Vertically asymmetrical? Where does my interpupillary line sit? Are my ears vertically misaligned? Should I be using the base of my ears to align my face? It's the plethora of these questions and thus the uncertainty of what can be surgically fixed, what can potentially be remedied with implants/other techniques and what cannot be fixed at all, that is giving me a hard time. I feel like in a lot of cases where the patient is more symmetrical, they're more easily diagnosable. For me, it's like, I don't really know what is actually wrong and I don't really know what can and can't be fixed.

My surgeon says, "It is medically unprofessional to refer patients to get scans when they don't need to, so you will have to wait until your teeth have moved." Everyone else just slaps me with the BDD label... Like man, I just want a better idea of what my situation is and what can and can't be improved. Unfortunately, I can't get a referral from my surgeon for a CBCT scan and I have to wait another 8 months for my teeth to move...

Lastly, I have no expectation at all that my surgeon could make either side of my face look like the other. Although it might not sound it, I consider myself to be rational. Am I more asymmetrical than most people? Yes. Where is my asymmetry primarily? Idk. What can and can't potentially be fixed? Idk. I just want to get more clarity on those last two answers. It's just annoying that nobody will budge until my teeth have moved. So I looked on this forum to gather some other opinions. It sounds to me like fixing my cant, bringing my mandible out a bit and anteriorly projecting/aligning my malars would get me to the point I want to be at. However, my surgeon said he needs to wait for the teeth to move before saying if he can correct the cant (since I'm a borderline case) (probs my main concern too tbh) and he also said that he would only do the malar correction if he was "already in theatre fixing something major for my bite". Fair enough - if I am already under and having my jaws moved, it makes sense to also fix my malars a bit. But now I'm like, well what if my teeth don't move into a position such that he would fix the cant, and therefore, not fix my malars? Idk, hopefully you can see where I am coming from. I don't meen to rant but this has been seriously eating me up inside for a year...

[kavan]

... My trapezoids are asymmetrical, as is my entire sekeleton. My clavicles are uneven etc. Osteos have said so and it is visible. It's frustrating that when I raise these concerns to people, people just go "gee he's overthinking this way too much".

Well, I also said so via tracing the 2 curved white lines to the neck area in the 'asymmetry' photo. The fact that one is shorter than the other where the neck muscles are could mean they are kicking up head tilt or torsion.

ETA: Which is why I told you to take another photo against same backdrop and tilt head a little to the right to see if eyes line up with horizontal backdrop of building.

[Harsturomai]

Okay, so I have attached a photo with my head leaning slightly to the right. If I need to tilt more or less please let me know, but I tried to align my pupils with the parallel of the tiles and thus, camera frame (since the frame is aligned with the background.) I live at a different house so cannot use the same backdrop. This photo used my iPhone's Selfie camera so my facial proportions will be skewed accordingly. Additionally, the original photo is from about a year ago, and I have put on a bit of fat, if that's relevant.

Also, for what it's worth, some localised asymmetries look natural IMO assuming they're not too prominent. However, in my case, and as you pointed out in the skull-xray photo (skewed lines), I feel like my entire right-side is sloping up and backwards. Obviously the cant amplifies this effect. One thing that I want to emphasise is that it's not only the vertical asymmetry that concerns me, but it's also my anterior asymmetry. My right side looks flatter and more depressed. Now if my maxilla was rotated CCW and my right malar projected, perhaps some of those issues can be improved.

One other thing to mention is that the first surgeon advised that I might need upper palatal expansion. I feel like my smile is very narrow, but my ortho says that she can fix it orthodontically. I doubt this. But I guess I can raise this issue after my incissors are protruded. Also, I would need to be mindful of the fact that it might widen my nose (even more if have MMA.)

RE the malar osteotomy. Sorry, I didn't communicate this clearly. The procedure does seem safe for my eyeballs and my surgeon advised this. I meant to say that I wouldn't want to get an orbital box procedure or some orbital osteotomy.

[kavan]

Okay, so I have attached a photo with my head leaning slightly to the right. If I need to tilt more or less please let me know, but I tried to align my pupils with the parallel of the tiles and thus, camera frame (since the frame is aligned with the background.) I live at a different house so cannot use the same backdrop. This photo used my iPhone's Selfie camera so my facial proportions will be skewed accordingly. Additionally, the original photo is from about a year ago, and I have put on a bit of fat, if that's relevant.

Also, for what it's worth, some localised asymmetries look natural IMO assuming they're not too prominent. However, in my case, and as you pointed out in the skull-xray photo (skewed lines), I feel like my entire right-side is sloping up and backwards. Obviously the cant amplifies this effect. One thing that I want to emphasise is that it's not only the vertical asymmetry that concerns me, but it's also my anterior asymmetry. My right side looks flatter and more depressed. Now if my maxilla was rotated CCW and my right malar projected, perhaps some of those issues can be improved.

One other thing to mention is that the first surgeon advised that I might need upper palatal expansion. I feel like my smile is very narrow, but my ortho says that she can fix it orthodontically. I doubt this. But I guess I can raise this issue after my incissors are protruded. Also, I would need to be mindful of the fact that it might widen my nose (even more if have MMA.)

RE the malar osteotomy. Sorry, I didn't communicate this clearly. The procedure does seem safe for my eyeballs and my surgeon advised this. I meant to say that I wouldn't want to get an orbital box procedure or some orbital osteotomy.

OK, that's a better line up. But you need to  consider drawing the verticals and the horizontals through the face on your own. I'm just showing how to do it. Ideally, a straight line PLUMB LINE (true vertical of gravity) in background would define the true vertical and from there a horizontal perpendicular to it. But horizontal tile lines will do for now. You will need to practice that as to look at things analytically which means with reference to LINES.

Also, since tilting the head slightly to the right as I suggested made much better symmetry, then a lot of the asymmetry is head posture from shortened neck muscles on the left side. So, you would have to do stretches to the left side of neck by cranking your head to the right as far as it will go and also neck rotations. Find some physical therapist for that stuff.

As to other surgical considerations like expansion and other mentions, well doing the photo practice exercises and the muscle ones should help you narrow down things more as to the basic photo analysis used to look at symmetry/assymetry.

[Harsturomai]

Thank you for your help and advice.

In regards to my posture, although I can optimistically hope that it is a muscular thing, it looks to me as if it too, is a skeletal asymmetry. In any case, hopefully doing some physio work will be of some utility.

I suppose I just have to hold out until my teeth have moved, at which point I can get a proper CBCT scan which will provide definitive answers. Maybe I can try to convince the psych to ask my surgeon for a CBCT scan referral.

[kavan]

Thank you for your help and advice.

In regards to my posture, although I can optimistically hope that it is a muscular thing, it looks to me as if it too, is a skeletal asymmetry. In any case, hopefully doing some physio work will be of some utility.

I suppose I just have to hold out until my teeth have moved, at which point I can get a proper CBCT scan which will provide definitive answers. Maybe I can try to convince the psych to ask my surgeon for a CBCT scan referral.

Well, ya, there could be other asymmetries going on and compensations for them. Your teeth look much improved from the first photos you showed.