jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: m20marianna on January 17, 2022, 07:18:52 AM
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Any advice or help would be really appreciated.
I have an open bite, lip incompetence, long face but no gummy smile and generally recessed maxilla and mandible. I don't have sleep apnea or any tmj issues.
I've been to two surgeons; one in the UK and one in Spain. The plans are similar enough however, the movements vary considerably.
The surgeon in the UK has suggested an impaction of 4mm which would consider tooth show and the fact that I don't have a gummy smile. He has drawn out a surgical plan with and without a genioplasty but I'm not knowledgeable enough to really know if the plans are good. It seems like his plan is reasonably conservative and that it would fix my issues without radically changing my face. I've included the pictures of the plan. If anyone could comment on them, I would really appreciate it.
The second surgeon in Spain has suggested bigger movements. I would also get both jaws moved forward, and an impaction of 6-8mm or even 1cm and also he mentioned shaving some amount off my chin. I'm slightly worried by this plan for a few reasons. I have a high forehead (evident in attached pictures) and I don't want to make the middle and lower thirds of my face so small so that the result will look weird. Also, the amount of movement for the impaction seems quite a lot more than the UK surgeon, especially seeing as I don't really have a gummy smile. This surgeon also suggested I would look very different after surgeon.
I'm just wondering if people could advise on the plans and what movements/options might better suit for my face.
Thanks so much in advance
https://imgur.com/a/e0jczbD (pictures of face & X-ray)
https://imgur.com/a/cOg8vWK (side profile pictures)
https://imgur.com/a/0RtzzGb (wide smile pictures)
https://imgur.com/a/fWbqLOe (drawings/plans of UK surgeon)
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What is your goal with the surgery? The openbite looks mild. Maybe ortho alone could fix it if you didn't want surgeon and just wanted to fix the bite.
Some observations...
In the flesh, it almost appears you have an underbite, but on the x-ray, it looks like your bite is more edge to edge. It sounds like you don't want to change your face radically, so that should rule out surgeon #2. 6-8mm of impaction is usually excessive. It's impossible to tell based on the records you posted, though. Hand drawings always make me nervous. It's the sign of an old school surgeon. What is confusing is the drawing of the mandible. He draws the cut, and then has an arrow showing he wants to move it back? The arrow is pointing posterior. That makes no sense. But anyway, this is how an open bite is corrected surgically:
https://www.youtube.com/watch?v=VzUmMOCyBTA
That movement would result in the mandible swinging up a little once the posterior contact is out of the way, which would be good, so long as there isn't anterior incisor contact afterwards. I do think any plan should include a genio. Your chin is very flat.
I'd like to know your goals with the surgery and what type of facial changes you'd be willing to accept before commenting further. Reading between the lines, I get the sense you want to fix something (but I'm not sure what), yet you don't want to change your face.
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Thanks for your reply. I'll try answer as best I can.
My goal would be to fix my bite, get a better profile (which I currently hate), more lower jaw support for my face, shorten my face somewhat if it is possible with good results, decrease/fix the lip incompetence and overall get the best possible aesthetic results. If that requires big movements and a genio then I'm happy to consider that. However one surgeon seems quite conservative, to the point that I'm unsure if big aesthetic changes would happen and the other one seems to be all about making big movements but I'm not sure if it would look good afterwards.
For example, the UK surgeon doesn't want to shorten my face or is very keen on the genio. Apart from moving my jaws forward and the impaction, he's not recommending much more. He felt that shortening my chin would make the lower two thirds of my face be disproportionate to the upper third. I'm finding it hard to agree or disagree with him as the drawings are hard for me to imagine in real life.
However the Spanish surgeon seems to have bigger movements, but I don't like the fact he didn't consider my higher forehead/facial thirds or my lack of a gummy smile. Felt a little like a stock default plan. Again it's hard to imagine if the outcome will look good.
I would like if it's possible to get an idea of what sorts of measurements and movements I would need for a good aesthetic result.
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The Spanish surgeon's plan is not here to refer to. But that's OK because I think I can address some of your concerns as to the differences regarding the EXTENT he wants to move things that are more than the UK surgeon.
1: There is a relationship between the amount of maxillary advancement and increased tooth show. For every 'X'mm of maxillary advancement, there will be 'Y' mm of increased tooth show.
Y will be less than X. Although I've heard, on this board, something to the effect of; For every X mm of max advancement there will be Y mm of increased tooth show where an 'exact' mm measure of Y was given for each X, I have no reason to believe that would be the same in each individual. However, there is still a (general) relationship which can be stated as; 'For every X mm of max advancement, there will be Y mm of increased tooth show'. However, what 'X' is going to be for 'Y' to be what it's going to be will be specific for each individual and will depend on the orientation of one's maxillary plane and is something the surgeon figures out, especially those with the high tech planning programs.
2: What to glean from the above is although the Spanish surgeon is impacting MORE than the UK surgeon, he's also ADVANCING more so that there is enough tooth show. So, due to the relationship as stated above, one can't conclude that just because he's impacting more than the UK guy you'd be left with that much less of tooth show that the UK doc would give.
3: As to having a long face where the forehead, in it's own right is 'absolutely' long (high forehead), it is not a good (aesthetic) idea to stick to the 'rule of 1/3rds' in any attempt to 'balance' the lower 2/3rds with the upper 1/3rd (the high forehead) because it resolves to the act of trying to balance the lower 2/3rds with an IMBALANCE the upper 1/3rd has as to being too long in its own right. So, to actually want the lower 2/3ds to 'balance' with an IMBALANCE to the upper 1/3rd resolves to wanting to be STILL left with an overall LONG FACE. It is preferable to balance the lower 2/3rds (shorten them, advance them) and be left with harmony/balance to the mid and lower 3rds and just keep the high forehead or elect, later down the line to bring that into balance with the lower 2/3rds which can be done by bangs or a hairline lowering procedure. Besides, neither Leonardo DaVinci nor Durer (who came up with the rule of 1/3rds) ever said that equal 1/3rds equaled ideal balance. Instead, it was a DRAWING guideline for drawing a face. So, having equal 1/3rds is PART of the 'formula' but NOT all of it as it relates to aesthetic balance and especially not if upper '1/3rd' is 'long' or 'too long'. Trust me, I studied Fine Arts at Harvard. Also a high forehead can be considered associated with high intelligence, so you could keep it and need not fret that it remains relatively longer looking due to aesthetically balancing the lower 2/3rds IN THEIR OWN RIGHT and not with reference to balancing with forehead.
4: As to shaving part of the chin down, that might not translate into a 'bad thing' or the act of lopping of the base of the chin to make it 'too short'. The relationship at play is that with the BSSO, the chin point (pogonian) moves 'forward' along with the mandibular advancement. The 'forward' advancement is going to be outward AND downward because the mandibular plane is oriented on a downward diagonal (even after it's inclination is made less from the impaction). Technically speaking a BSSO alone can make the chin cast BOTH longer and of course, more outward. However, just like an advancement genio can be ADDED to a BSSO if the BSSO itself, cant achieve an 'ideal' balance as to chin pronouncement (the BSSO also has to balance the BITE), any EXCESS to either the outward displacement of the chin point or the downward displacement to the base of chin can be SUBTRACTED by shaving down where the excess is. It could be to the front of the chin or to the base of the chin. It does not necessarily 'translate' to lopping off the base of the chin to make it 'too short'
Although these types of relationships don't predict how you are going to look, they should assuage some of your concerns that (to me) reflect you didn't realize those relationships existed.
5: As to the UK surgeons displacement diagram, that looks like a very conservative yet an aesthtically improving one also. My reference is bimax plus genio contour displacement diagram (the 4th one in the series). With a contour displacement diagram, you don't have to concern yourself with the numbers and arrows on it because the DISPLACEMENT CONTOUR of the SOFT TISSUE PROFILE is DRAWN in which is the brown contour. So, the brown contour is a great improvement over the present contour (the green one). However, SEEING that the brown soft tissue contour is an IMPROVED one is a matter of how well you can see aesthetic relationships.
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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 Gunsons 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 unnecesarry 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.
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the long chin because it's a major health advantage both mental and physical.
How?
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How?
Probably not the explanation you would like but you just kind of have to look at a lot of circumstantial evidence and come to believe it. It's well documented in medical literature that people with bad sleep apnea are less intelligent and often live decades less than people without sleep apnea, but then when you look closely at what "not having sleep apnea" means in those studies they are using the medical definition of stopping breathing less than 5 times per hour. Nobody is looking at people that don't stop breathing at all in their sleep, and the more I investigate the more I come to find it's because that is incredibly rare. And the same way being at the extreme of having really bad sleep apnea is unusually bad for you, having almost no apnea looks to me like it's incredibly good for you.
Everyone on this forum would probably agree it's incredible how jaw surgery will completely change the way you look and your perceived level of attractiveness. So that the structure of your jaws can determine how attractive you are tells you that for some reason humans have come to decide over millions of years that jaw structure is probably the most important criteria in choosing a mate. And since the only compelling medical benefit to jaw surgery to date is an improvement in sleep apnea, I think it's reasonable to assume that humans are subconsciously trying to pick a mate with as little sleep apnea as possible. The ability to sleep without interruption is just that important. If you come to believe that theory you'll realize that getting bogged down worrying about a few mm here and there is the wrong approach. What really matters is how big your jaws are, and you would be smarter to put up with looking abnormal and reaping the underlying benefits that have led us to subconsciously select for good jaw structure to begin with.
I think it's clear throughout most of human history men have been smarter than women. Is it a coincidence that one of the main roles of testosterone in men is to make the lower jaw and chin grow? Is that merely cosmetic or does it confer an advantage? I would argue it confers an advantage in better sleep which leads to deeper REM sleep which is known to be correlated with spacial intelligence which is where men have the biggest advantage oven woman. Cruel to think nature would give men an advantage by such a silly means but I'm pretty sure that's one of the mechanisms behind it. It works for woman too though. Woman with bigger jaws are considered more attractive. In women we tend to focus more on the upper jaw, but you'll notice woman with stronger lower jaws are smarter. They are more assertive as well. They act a little more like men. I think people would be surprised just how big a role anatomy plays in shaping our personality.
Then just look at the people we admire in society. The human social hierarchy is based mostly on jaw structure. Look at past presidents of the United States. They all have big jaws. Looks at CEOS. Big jaws. Look at great mathematicians. Big jaws. Great athletes. Big jaws. Current chess champion Magnus Carleson? Hugely overgrown upper jaw. I'm telling you once you see it you'll never unsee it. You just have to look.
These people sleep less too. Look at say Tony Robbins. He's like the poster boy of what having big jaws does for you. He must have the biggest jaws I have ever seen on someone. Lots of positive energy and he is on record sleeping 4-5 hours a night. Jay Leno with his giant chin? On record 4-5 hours a night sleep. I'm amazed people cannot make the connection to their anatomy as the reason for their success.
Study centenarians. Rarely will you find a man that lives to 100 years old that does not have really good jaw structure. It plays a big role for woman by then too. People with big jaws live longer and when they die it's not usually of heart disease unlike most of the rest of the population.
Just a theory but I'm pretty sure I'm right. In your day to day life start sizing people up based on their jaw structure. I think you'll quickly find the ones with bigger jaws are the ones in charge.
That's a simplistic explanation. You can break it down further. Start looking at people with small jaws. They are much more neurotic. Less positive emotion. More introverted. A lot of your personality is based on your jaw structure. And unfortunately moving things a few mms here and there doesn't do that much. You need to start thinking in cms if you really want to reap the full benefits to be had from jaw surgery, and be willing to look a little bit different. You want to look like your ancestors, like a neanderthal. And that's hard to do since the medical establishment won't see it that way and you'll be made fun of. But I think over time things will move in that direction.
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Just a theory but I'm pretty sure I'm right. In your day to day life start sizing people up based on their jaw structure. I think you'll quickly find the ones with bigger jaws are the ones in charge.
Ok. I report from the field. This morning I saw my GF with her normal Jaw. She is one of the most intelligent people I know and does her master in math at one one the "best" or most competitive programs in the world.
Then I tought about my friend who has the biggest jaw I know, to the point where it looks comical. He's cognitive abilities are the same as our ancestors 1Million years ago (I am sorry).
But: I will ask my boss today if I could be in charge because I have the bigger jaw. Thanks for the advice!
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Probably not the explanation you would like
But he said a "long chin", not a projected/outward chin. I am asking how a long chin is a good thing. The OP doesn't have a projected chin, and he told her to keep it because a long chin is advantageous somehow.
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Reply to Kavan,
Thanks very much for the detailed reply. It's very interesting. You are correct; I wasn't aware of those relationships between movement and tooth show. This was the most helpful for me.
I have a few comments to your points if that's ok.
1. & 2. I wasn't aware of this relationship in the amount of tooth show with advance movements. It's actually very helpful as I was initially concerned about why the Spanish surgeon didn't mention anything about this. I will confess that I didn't properly ask questions during that consult. I felt I had asked everything but realised afterwards, I came away with very little information about a surgical plan. I probably will have another consultation to get some concrete measurements, etc.
Am I correct in thinking that there would also be a relationship between impaction with advancement in relation to tooth show. For example, if my maxilla is impacted by xmm and advanced by ymm then my resulting tooth show is zmm?
3. Regarding the thirds, the UK surgeon actually didn't directly mention this. (It was a previous surgeon I went to, which I've excluded from my options.) When I asked about my face being long and wanting to shorten it somewhat, the UK mentioned that the lower thirds would look 'squished' and not balanced if I did that, due to my high forehead. I wasn't entirely convinced by this as I feel (and maybe I'm wrong) that the surgery is dealing with mms and not extremely large movements and so to take a few more mms off my lower thirds surely wouldn't give that 'squished' look. Probably my thinking is too simplified but I do appreciate your response because it makes sense to me.
4. This part is a little technical and difficult for me to understand but I get the general gist. As far as I can understand this, what you are saying is with the mandibular advancement my chin point will also move forward and down (due to the downward diagonal) and actually this could make my face longer without some chin shortening. This is interesting as I actually thought that due to my maxilla impaction and advancement plus my mandible coming up to meet the maxilla that overall I would have a ‘shorter’ face (even if only by a few mms), whereas it is possible due to the downward diagonal and mandibular advancement, that my face/chin might appear the same or even longer. Is that correct?
5. Out of curiosity, when you mention very conservative, what do you mean by that exactly? As in, playing it safe, not highly focused on aesthetic results, or cautious in regards to preforming the surgery? I will mention also in this regard the UK surgeon said that perhaps a genio would not be necessary and he would see on the day of surgery if I indeed needed it.
Regarding the 4th image, I’m happy to hear his plan is an aesthetically pleasing one. The fourth image is an overlay of my baseline with the bimax + genio mockup. Is this what is called a displacement contour? The image itself is a bit grainy. I’m seeing a red line which I’m guessing is what you are seeing as brown.
I know that I need to get more particulars from the Spanish surgeon, but can I ask your personal opinion on which option (conservative or larger movements?) you might prefer aesthetically-speaking as I indeed find it difficult to see the aesthetic relationships from just looking at the drawings and that seems to be something you excel at. Is it too simple to ascertain that greater movements equal greater aesthetic results?
Thanks again!
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Do you know if they plan to fix the open bite surgically or with braces? And do you know why the 4mm on the lower jaw has an arrow pointing back (toward posterior)? This would be the opposite of what you need. So it needs clarification.
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Reply to GJ
As far as I'm aware the open bite will be corrected through braces and I'm also assuming (but perhaps incorrectly) that the impaction will also help? I'm recommended to get SARPE first, followed by braces for approx 18 months and then DJS.
Regarding the arrow pointing backwards, I was actually confused myself with this. I had my appointment just before Christmas so this is something I will follow up on if I decide to go back to that surgeon.
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But he said a "long chin", not a projected/outward chin. I am asking how a long chin is a good thing. The OP doesn't have a projected chin, and he told her to keep it because a long chin is advantageous somehow.
Long and projected serve the same purpose, stretching and tensioning the tongue muscle and soft tissues in that area so they don’t fall back into the throat while you sleep.
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I think it's reasonable to assume that humans are subconsciously trying to pick a mate with as little sleep apnea as possible. The ability to sleep without interruption is just that important.
It's certainly important to the MATE who doesn't want to be woken up several times a night.
I think it's clear throughout most of human history men have been smarter than women.
What's been clear is men are physically stronger. Physical strength can easily overpower intelligence capacity and lead to 'might makes right' societal institutions.
As to spacial intelligence, that usually shows up on an IQ test where a lot of the questions involve ability to observe which figure is same as other one but rotated spatially and things having to do with capacity for math. Now based on my experience (years back) at MIT where people were off the charts with the highest IQ scores possible (and SAT scores), there seemed to be an INVERSE correlation with high levels testosterone. That is to say, a contained population of the uber bright (which, ya, mostly males at the time) had no direct correlation to robust physicality, including but not limited to jaw size. More like the the converse of that as in more of a correlation of low testosterone with uber bright and less robust physically and facially.
As to Tony Robbins, he has some ACROMEGALY as to overgrowth of some bone structure including the jaws (due to a lot of growth hormone coming from pituitary gland). Fortunately, he carrys that well in terms of looks,as opposed to Rondo Hatton, actor of past, often cast in horror movies due to the distortion affects of acromegaly. Acromegaly certainly yields a very BRUTE appearance and associated physicality. Jay Leno has what's called; LANTERN CHIN. Be that as it may and undoubtedly, those people have admirable qualities (and probably sleep well at night), I think you need to consider that people seeking out aesthetic improvement are not seeking out facial DISTORTIONS in venue of acromegaly and or Neanderthals.
That said, I think people reading your aesthetic advice, which links primitive appearance to superior intelligence, form and function, will be needing to have at least an average IQ to determine whether they should pursue your looks theory. However, I personally laud you for the entertainment value.
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
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Reply to Kavan,
Thanks very much for the detailed reply. It's very interesting. You are correct; I wasn't aware of those relationships between movement and tooth show. This was the most helpful for me.
I have a few comments to your points if that's ok.
1. & 2. I wasn't aware of this relationship in the amount of tooth show with advance movements. It's actually very helpful as I was initially concerned about why the Spanish surgeon didn't mention anything about this. I will confess that I didn't properly ask questions during that consult. I felt I had asked everything but realised afterwards, I came away with very little information about a surgical plan. I probably will have another consultation to get some concrete measurements, etc.
Am I correct in thinking that there would also be a relationship between impaction with advancement in relation to tooth show. For example, if my maxilla is impacted by xmm and advanced by ymm then my resulting tooth show is zmm?
3. Regarding the thirds, the UK surgeon actually didn't directly mention this. (It was a previous surgeon I went to, which I've excluded from my options.) When I asked about my face being long and wanting to shorten it somewhat, the UK mentioned that the lower thirds would look 'squished' and not balanced if I did that, due to my high forehead. I wasn't entirely convinced by this as I feel (and maybe I'm wrong) that the surgery is dealing with mms and not extremely large movements and so to take a few more mms off my lower thirds surely wouldn't give that 'squished' look. Probably my thinking is too simplified but I do appreciate your response because it makes sense to me.
4. This part is a little technical and difficult for me to understand but I get the general gist. As far as I can understand this, what you are saying is with the mandibular advancement my chin point will also move forward and down (due to the downward diagonal) and actually this could make my face longer without some chin shortening. This is interesting as I actually thought that due to my maxilla impaction and advancement plus my mandible coming up to meet the maxilla that overall I would have a ‘shorter’ face (even if only by a few mms), whereas it is possible due to the downward diagonal and mandibular advancement, that my face/chin might appear the same or even longer. Is that correct?
5. Out of curiosity, when you mention very conservative, what do you mean by that exactly? As in, playing it safe, not highly focused on aesthetic results, or cautious in regards to preforming the surgery? I will mention also in this regard the UK surgeon said that perhaps a genio would not be necessary and he would see on the day of surgery if I indeed needed it.
Regarding the 4th image, I’m happy to hear his plan is an aesthetically pleasing one. The fourth image is an overlay of my baseline with the bimax + genio mockup. Is this what is called a displacement contour? The image itself is a bit grainy. I’m seeing a red line which I’m guessing is what you are seeing as brown.
I know that I need to get more particulars from the Spanish surgeon, but can I ask your personal opinion on which option (conservative or larger movements?) you might prefer aesthetically-speaking as I indeed find it difficult to see the aesthetic relationships from just looking at the drawings and that seems to be something you excel at. Is it too simple to ascertain that greater movements equal greater aesthetic results?
Thanks again!
1&2. Correct assumption.
3. If the UK doctor mentioned the lower 2/3rds of the face would look 'squished' due to your highh forehead, he WAS applying the rule of 1/3rds and hence wanting to 'balance' with an IMBALANCE to the upper 1/3rd (tall forehead).
4: Basic geometrical priciple. Advancing 'forward' along a downward incline has 2 displacements; horizontally outward and vertically downward.
5: There is no 'exact' meaning to conservative to convey here. I'd say that in general and within the context of max fax surgery, it would relate to keeping within the status quo of facial NORMS. For example, extreme 'homeliness' or extreme 'beauty' is in the direction of outside of the norms but of course, on opposite sides of the spectrum.
As to the displacement diagram, yes what shows up on your screen as red, shows up in mine (old computer) as brownish.
There is no patent assumption to be made that larger movements always 'equal' more aesthetic results. It's just that some surgeons who do provide larger advancements yield more striking results as in more of dramatic difference. However, you would need to EASILY 'see' the differential improvement in the UK displacement contour diagram to determine if you wanted more of a (dramatic) difference to what was shown in it.
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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?
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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?
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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.
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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.
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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?
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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.
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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.
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You have to admit he is a pretty handsome fellow.
;D
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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.
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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.
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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.
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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.
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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
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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
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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.
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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.
I saw a 2nd surgeon, he mentioned maybe more than 5mm anterior impaction based on my current tooth show (around 8mm), and also some posterior impaction.
He was vague about the amount of CCW achievable with the differential impaction, but he said i would need a big advancement and autologous bone graft on the BSSO sites to favor healing
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I saw a 2nd surgeon, he mentioned maybe more than 5mm anterior impaction based on my current tooth show (around 8mm), and also some posterior impaction.
He was vague about the amount of CCW achievable with the differential impaction, but he said i would need a big advancement and autologous bone graft on the BSSO sites to favor healing
Well, it's hard for them to be precise until an actual pre-surgical plan is charted out. With combined CCW anterior impaction + CW posterior impaction, anterior impaction , the rotation is net CCW if there is more anterior impaction than posterior impaction. If your maxilla was uniformly long both anteriorly and posteriorly and they removed a uniform segment from it, net rotation would be zero.
If the surgery is DJS where the maxilla is advanced after the combined impaction, there will be some gain in tooth show which was 'lost' from the anterior impaction. For example, if tooth show after anterior impaction was reduced by 5mm but the excess was 8mm, you wouldn't be left with 3, you would gain more than 3 as a function of the maxillary advancement. For every X mm of maxillary advancement, you gain Y mm of tooth show. There is no specific Y with each X because it's a function of the inclination of the maxilla (or Occlusal Plane) which is being advanced.
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edit : put the post in my thread