Suggested movements?

[Estephany2507]

Hi everyone! Hope you’re doing well!

I'm a 27F, and I have my bi-maxillary surgery + genioplasty scheduled for next week. This week, I have an appointment with my surgeon to review the movements he will perform during the procedure.

I’d like to be prepared for this meeting and would love to hear your recommendations based on what you can see in the photos. As you can see, I have a Class 2 bite + Long Face Syndrome + Gummy smile. My premolars were extracted when I was 12 years old during my first orthodontic treatment, and my wisdom teeth were removed a few years later to prevent them from pushing my other teeth. Clearly, that wasn’t the right approach for my situation, so a few years later, I was able to start over with a new treatment to prepare for orthognathic surgery.

I'm now very close to surgery, and I have high expectations along with some anxiety, as I'm worried that my surgeon might take a conservative approach to my case. I want to be as clear as possible with him in medical terms to communicate my expectations for the surgery. That's why I'm reaching out to hear all your recommendations regarding my case.

My expectations/questions for this surgery are:

1) Achieve a 1:1:1 ratio in my face, while maintaining good jaw projection (can this be achieved only with CCW rotation?).

2) Correcting my slightly canted smile.

3) My upper teeth are also very protruded, is there a specific technique that can achieve a better jaw projection without making my upper teeth look more protruded?

4) Which would be the best movement for my genioplasty?

I am also very interested to know whether my situation requires any unconventional methods to achieve the best results to discuss this with my surgeon. For example, I've seen a case where a patient with a long face and a gummy smile underwent a quadrangular osteotomy, which significantly changed her appearance (Reference link to that case: https://www.reddit.com/r/jawsurgery/comments/18xg6uc/le_fort_3_midface_shortening_surgery/)

I also have my CT scans to share. Thanks a lot in advance!

[GJ]

Your appearance is going to change a lot. If you want this "corrected", you'll need CCW rotation. In terms of your teeth, the ortho probably should have retroclined them for a CCW movement. Was that done?

Cants are tricky to fix. I wouldn't expect perfection there.

[kavan]

I don't think it's a good idea to be asking for directives from others if you already have a surgery booked. Better idea to have some GENERAL grasp of how things work before attempting to talk specifics via medical terms with your doctor. Here goes:

A '1 to 1' ratio is a distance relationship that someone already has or doesn't have to start with. It refers to a horizontal distance between 2 landmarks on the eye vs. vertical distance from mid-pupil line to the opening between the lips. Surgery isn't going to change that type of distance relationship. (It's one that is looked at in the FRONTAL perspective.)

From your profile perspective, it doesn't look like you have a 'long' face. If it looks 'long' to you in the frontal perspective, that would be due to the slack under your chin (due to recession) giving appearance of extra length in the frontal perspective. Slack there would tend to be mitigated with lower jaw and chin advancement. 'What type of genio' would depend on the extent of CCW (if that is done) and also extent of advancement. There is option for an UPWARD SLIDE if appearance of a shorter lower 1/3d of face is needed and option for a downward slide if more length to lower 1/3rd of face is needed. Also, sometimes the lower jaw advancement along with the CCW-r can set the chin point at optimal height with no genio.

You have bi-max protrusion. But targeted correction for that is more common in Asian countries than elsewhere. It involves removing not only pre-molars but also the tooth bearing bone above the tooth which allows the protruded part to be pushed backwards. Once the protrusive part is moved backwards by removing a track of tooth bearing bone that houses a pre-molar, THEN they can move the jaws forward without exaggerating more protrusion. That type of protrusion can make the chin look more recessive via RELATIVE comparison in which case you would need a significant advancement of the lower jaw/chin to MASK it. eg. a CCW rotation.