Revision jaw surgery, would appreciate some Feedback. Pictures and ceph

[thinkimightneedjawsurgery]

Hello all, I posted at the beginning of the year about getting revision jaw surgery. I'm almost ready too bite the bullet. I have been in contact with Dr ramieri in rome for almost a year now. Have had many consults and email conversations. I can't help but feel super nervous though not for the surgery or the traveling but for the results. I've read this forum top to bottom, asked all the questions I could think of but I still have the "what If I misunderstood something" scenario playing in my head. And would like some outside advice if possible.

My biggest concerns are.

1. The thickness in my philtrum, I'm not sure if it's because my upper jaw was advanced to much, or if it's teeth related. My ans is not very prominent as seen in the xray it also sits quite far back from my front incisors (ideally it should line up?) So I'm not sure if my ANS is the problem.

2. My lower jaw is still recessed and my lower lip sits behind my upper lip. This will be corrected with BSSO

3. The area beside my nose looks kind of "sunken in" giving an appearance that my nose is kind of "buried" in my face. I'm not sure if that's jaw related or I have a short nose? I will mention I will also be getting a rhinoplasty at the same time.

 I have an orthodontist and have my first appointment to start treatment on Friday. I've been told I need a 7mm advancment to my lower jaw so my lips lime up. My occlusal plane is around 10ish I believe. His plan is too do about 6° ccw rotation through a posterior downgraft, then the rest created by moving my teeth. He said he'd put the rotation point at the incisor to help with the protruding philtrum. I'm not entirely sure what to do with my upper jaw if anything other than downgrafting? He's willing to setback my maxilla if necessary.

I'm not sure if my teeth are in a good position or if there's too much protrusion/retrusion? I have attached some pictures and x rays for you guys too look at. As well as my VSP from my first surgery.

Thank you for reading this huge rambling post. I tried to space it out to make it easier too read! Thanks again 🙂

https://imgur.com/a/PG5vtiE

[GJ]

Is this just for aesthetics? Bite looks good.
I see the issue in profile with the lower lip being a bit further back - what went wrong with the first surgery to create that situation?

[thinkimightneedjawsurgery]

Yes just for aesthetics, the lower lip being behind the upper lip makes it so I have to jut my lower jaw forward because it feels like my upper lip "eats" my lower lip otherwise. As for what went wrong with the first surgery? Biggest problem I'd say is I blindly followed the surgeons plan without questioning. I figured who am I to question the professionals? Big mistake. I had braces put on but no decompensation. So I essentially ended up in the exact same situation as pre surgery I just look like a better "still recessed" version. Which is why I'm so nervous, Now I'm questioning everything and I've just confused myself. Which is why I posted here. Lots of people here who know tons about this (you included) and it's unbiased opinions!

[varbrah]

1. The thickness in my philtrum, I'm not sure if it's because my upper jaw was advanced to much, or if it's teeth related. My ans is not very prominent as seen in the xray it also sits quite far back from my front incisors (ideally it should line up?) So I'm not sure if my ANS is the problem.

Primarily teeth-related - with the upper incisors appearing a bit too retroclined - I think? Secondary to the ANS-incisor relationship. The proposed CCW rotation w/ axis at the incisors would help with both.

2. My lower jaw is still recessed and my lower lip sits behind my upper lip. This will be corrected with BSSO

Yep, and the CCW will improve the relationship between the upper and lower lips further.

3. The area beside my nose looks kind of "sunken in" giving an appearance that my nose is kind of "buried" in my face. I'm not sure if that's jaw related or I have a short nose? I will mention I will also be getting a rhinoplasty at the same time.

This is mostly due to your under-projected ANS. This is more of a genetic/hereditary thing and not jaw-related.

Note also that your nasolabial angle is very 'sharp' looking, with the transition from your nose to upper lip occurring immediately. This is a tell-tale sign of an under-projected ANS. Contrast this to patients with a "tethered upper lip" (google search), which occurs  due to an overly prominent ANS.

What specifically is going to be done during your rhinoplasty?

I've been told I need a 7mm advancment to my lower jaw so my lips lime up. My occlusal plane is around 10ish I believe. His plan is too do about 6° ccw rotation through a posterior downgraft, then the rest created by moving my teeth. He said he'd put the rotation point at the incisor to help with the protruding philtrum. I'm not entirely sure what to do with my upper jaw if anything other than downgrafting? He's willing to setback my maxilla if necessary.

I'm not sure if my teeth are in a good position or if there's too much protrusion/retrusion? I have attached some pictures and x rays for you guys too look at. As well as my VSP from my first surgery.

Teeth look fine. The proposed CCW rotation + posterior downgraft is solid. The rotation is going to project your chin, so a setback/downgraft genioplasty is probably going to get thrown into the mix. This'll look good, I think - it should increase your lower third height which is the main issue I see from the front.

I am going to be having DJS with Ramieri in a few weeks btw. Knowing quite a bit myself, my impression from working with him is that he's very, very solid. You're in good hands so I wouldn't overthink it.

[kavan]

Philtrum thickness could be a function of soft tissue there being thick. However, what looks to be 'teeth' related with regard to the philtrum is that your upper teeth are aligned either on or behind a VERTICAL plane--like they look to go straight down but could be angled backwards a little. The relationship to the position of front upper teeth is one where the philtral region is slightly conVEX and that can make the philtrum APPEAR thicker. The conVEXity to the philtral region could be addressed by 'bucking out' (angling out) the upper front teeth. That would occur with CCW-r around the ANS point.

Since some of your complaint is the ANS, itself, is too far backwards, the ANS could be advanced forward in addition. Rotation around the ANS point in addition to bringing it forward will allow for a greater advancement of the lower jaw and a better lip to lip 'line up'. Keep in mind, that when ANS is brought forward, that includes the upper jaw being moved forward and that aspect would tend to address your complaint of recession beside nose.

In the event the CCW-r combined with maxillary advancement and the BSSO that would go with that brings the chin point (pogonian) either 'too far' forwards OR not enough, a compensatory genio could be involved to put chin point in good position.

As to the rhinoplasty, it looks like much to most of the correction to the nose would be to its BASE which would be achieved by advancing the ANS forward. That is to say...I think the maxillary (which includes ANS) advancement could be sufficient to improve your nose area since much to most of the nose issue is at BASE of nose. So, you should ASK the doctor WHAT OTHER things is he going to do to your nose in addition to the improvement the advancement to the ANS would do with JUST the maxfax aspect of the surgery. In my personal opinion, I think nasal refinements (rhinos) are best done after maxfax and as separate procedures. Also, you want to rule out a situation where you are being billed for a rhino (with the maxfax surgery) when the advancement of the ANS (part of the maxfax surgery) would tend to correct the nose aesthetic without having a separate rhino. So, you should 'grill' the doctor for an explanation of all the proposed rhino maneuvers that he plans to do in this rhino.