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General Category => Functional Surgery Questions => Topic started by: kjohnt on February 17, 2016, 12:48:22 AM
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I recently went to my childhood ortho to ask some questions about my treatment. He provided a current ceph and some photos. I've attached an untouched copy of the ceph plus a version with which I did a cursory analysis.
I think it's obvious I need bimaxillary advancement. My maxilla is horizontally recessed and I can tell because I have no upper lip support and my philtrum basically goes straight down. My mandible is also horizontally short.
Assuming I've drawn the Frankfurt plane correctly and the picture doesn't need rotated, my occlusal plane is about 9° relative to it. Normal is 8° +/- 4° according to Wolford's papers, so I'm there, but I don't understand then why the lack of chin projection since it seems my menton (button of chin) is projected adequately relative to my lower incisors. Arnett's papers say 5° +/- something like 1.5° (or actually 95° but comparing to a vertical line so same difference) for occlusal plane is ideal, so I believe CCW rotation to bring my occlusal plane to that would help bring my chin forward a bit. Though perhaps a small sliding genio in conjunction with bimaxillary advancement which includes CCW rotation. My lower lip curls out a lot though and I don't want to end up with a huge labiomental fold. Maybe the BSSO will help the lower lip so I wouldn't have to worry about that?
It sure would be nice if I just needed straight advancement, but I think the amount of mandibular advancement needed would bee too much for my maxilla and I'd end up with an upturned nose and "chimp lip."
My mandibular plane is near normal range from my research (read 21° from Down's analysis which was conducted about 50 years ago or so but another source said 25°). But it is weird in that there is a significant chunk missing on either side directly in front of the gonial angles so it makes it appear steeper. I speculate the is where my vertical maxillary growth (partially because of cervical pull headgear) pushed my mandible downward, but I could be wrong. I suppose the "why" doesn't matter now in any case.
My ortho said I have a class I occlusion and braces would not be necessary for surgery; rather, I'd be fitted with arch bars by the surgeon. I've done a little research but don't know the implications thereof. I like the idea of not having to go through braces again, and I'd save some cash. Anybody have experience with or know anything about arch bars? Do they stay on for a long time after surgery? Any negatives?
TLDR:
- I think I need bimaxillary advancement with CCW rotation and possibly a genio in addition to balance my chin. Thoughts?
- Any insight regarding arch bars in lieu of braces for jaw surgery?
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I think if there is no healt issues. dont go surgery. U seem good i think.
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Your ceph analysis is correct and you have no issues really. Both the hard and soft tissue indicate a normal orthognathic retro profile. Unless you have sleep apnea, you don't need surgery.
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Arch bars shred gums. Another fixation option is IMF screws. Whatever your ortho says, the bite will most likely require fine tuning after surgery (surgical movement aren't perfect), so you may need braces anyway.
I don't think you will gain much from jaw surgery. You will just look different, possibly worse. I think your upper lip support is fine. You don't want your upper lip stretched over your teeth.
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Not saying it's right or wrong, but I can see why people with obvious facial deformities and functional problems get frustrated when good-looking people with a good bite and no other functional issues feel they need to get surgery.
OP, you are a good-looking man with strong facial features. Sure you can go from a text book about what the perfect measurements are and apply it to everyone, but you honestly look good. Why go through the hassle of spending a tonne of money to cut your skull open for a minor subjective improvement? Especially considering the health risks. Seems like the risk/cost outweighs the reward/benefit.
Feel free to correct me if I'm missing something though.
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I had arch bars. They were a nightmare on my soft tissue, I was so relieved to have them taken off.
Not saying it's right or wrong, but I can see why people with obvious facial deformities and functional problems get frustrated when good-looking people with a good bite and no other functional issues feel they need to get surgery.
OP, you are a good-looking man with strong facial features. Sure you can go from a text book about what the perfect measurements are and apply it to everyone, but you honestly look good. Why go through the hassle of spending a tonne of money to cut your skull open for a minor subjective improvement? Especially considering the health risks. Seems like the risk/cost outweighs the reward/benefit.
Feel free to correct me if I'm missing something though.
^ Yeah.
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Your head is slightly tilted down in the pictures. I really do believe bottom ear hole and bottom of nose is "level" for everyone. This would bring your chin in line with your forehead and wouldn't look as recessed when analyzing it in the vertical.
I think you look good. You have the width and enough forward growth. Do you have ante face? No. You'd need your chin/mandible to extend further forward to come more in line with your maxilla (both being ahead of forward when head properly tilts level) to have that.
Is surgery worth it for that? I don't think so... but that's up to you to decide.
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sometimes a camouflage orthodontic treatment doesnt treat the underlying problems, achieving a class I dental occlusion but staying with a weak jaw, retruded chin and a small airway of 4 mm that gives me severe sleep apnea says the treatment wasnt effective. see more maxfac surgeons and listen to what they have to say.
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Have you had a sleep study? The airway looks a few mm too small to me. Your occlusal plane looks great. I see the antegonial notch, commonly found with vertical growth patterns and your jaw looks like [it had some](http://fx.damasgate.com/wp-content/uploads/5-15-2011-11-09-25-PM.jpg). Normal is 25-30deg I believe. I would at least keep a close eye on your sleep, get a study every 5 years. But I think everyone should get regular sleep studies at least with every colonoscopy.
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Thanks for the replies.
Regarding my aesthetic motives, it really has to do with the space between my chin and my neck - there isn't much. Add to that that my mandible is narrow at the gonial angles and it appears my neck blends right into my face in pictures and on video, and I've hated it for as long as I can remember. This on top of being very lean. For the longest time I thought I just had a weakly projected chin, but I now know there's more to it.
I don't think I look horrible, but I do feel there is room for improvement.
I had arch bars. They were a nightmare on my soft tissue, I was so relieved to have them taken off.
^ Yeah.
How long did you have to have them? I'd think at least a few months in order to ensure the jaws are stabilized? Did you have an option of IMF screws?
Your head is slightly tilted down in the pictures. I really do believe bottom ear hole and bottom of nose is "level" for everyone. This would bring your chin in line with your forehead and wouldn't look as recessed when analyzing it in the vertical.
I think you look good. You have the width and enough forward growth. Do you have ante face? No. You'd need your chin/mandible to extend further forward to come more in line with your maxilla (both being ahead of forward when head properly tilts level) to have that.
Is surgery worth it for that? I don't think so... but that's up to you to decide.
It isn't. My ceph is exactly horizontal as I can tell and the pictures I had posted match it. The bottom of the orbital rim to the pogonion (which can be seen only in a ceph and it is difficult even then) is horizontal.
Have you had a sleep study? The airway looks a few mm too small to me. Your occlusal plane looks great. I see the antegonial notch, commonly found with vertical growth patterns and your jaw looks like [it had some](http://fx.damasgate.com/wp-content/uploads/5-15-2011-11-09-25-PM.jpg). Normal is 25-30deg I believe. I would at least keep a close eye on your sleep, get a study every 5 years. But I think everyone should get regular sleep studies at least with every colonoscopy.
I just had an at-home study done a few days ago and will get the result in a couple of weeks. I'm 95% sure I have sleep apnea, and it runs in my family, though both obstructive and central. If I have it, I sure hope it's the former.
Normal airway is 10mm I've read; mine's 6.5.
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I realize most feel I'm not a candidate aesthetically but I want you guys to look again at my morph and tell me if you still feel the same.
I did a morph predicting STRAIGHT MMA without genioplasty. I first slightly CCW rotated the lower half of my nose to the bottom of my upper lip since that soft tissue should rotate CCW even with straight advancement since above the advancement will naturally rotate. This includes desireable upper lip projection and undesireable nose upturn. Then I advanced from the top of the lower lip on down straight horizontally. Finally, I pulled the lower lip in a bit since I think it won't curl out so much after mandibular advancement.
This is the result. I roughly measured 10mm advancement at the chin by sizing my cephalometric x-ray to my profile shot and using the ruler on the ceph machine to compare the space between before and after. I've also posted the photo I used to do this. I realize it's probably not exactly 10mm, but I think it's close, say within 1mm either way.
I'd also hope that my jawline would pop slightly more with the advancement due to tightening skin, but I didn't try to create that effect.
Further questions:
1) Is this achievable/realistic? Did I underestimate the amount the top of my philtrum will advance (i.e. under-project "chimp lip")?
2) If it is achievable, how does my morph look? Do you think it looks better than my current profile?
3) Is 10mm bimax considered a large advancement? How much could I expect this much advancement to affect my airway?
If you guys think I'm crazy, well, let me know that too I guess.
edit: removed my pics. Message if you want to see them.
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I don't think you're crazy, and I get annoyed when other people get annoyed at someone who wants surgery mainly for aesthetic reasons.
There's nothing wrong with wanting to look better, and just because ones issues aren't a medical necessity, it doesn't make it wrong want to improve.
On the facebook jawsurgery group i've seen lots of people who look very 'normal' and would probably get told by people here that they would never find a surgeon to operate on them as they look fine, but they all do fine a surgeon and get surgery done, and most of them look better after.
I'm not gonna try to get technical with you because you clearly know a lot more about all of this stuff than me, but I'd say that morph is a fair possibility based on the various 'before and afters' i've seen from people.
In your particular case (and in my personal opinion) you look different in the after, but i'm not sure you look that much better. Maybe very slightly. But it's all about personal preference, I guess. I think you look pretty good already.
Good luck!
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I realize most feel I'm not a candidate aesthetically but I want you guys to look again at my morph and tell me if you still feel the same.
I did a morph predicting STRAIGHT MMA without genioplasty. I first slightly CCW rotated the lower half of my nose to the bottom of my upper lip since that soft tissue should rotate CCW even with straight advancement since above the advancement will naturally rotate. This includes desireable upper lip projection and undesireable nose upturn. Then I advanced from the top of the lower lip on down straight horizontally. Finally, I pulled the lower lip in a bit since I think it won't curl out so much after mandibular advancement.
This is the result. I roughly measured 10mm advancement at the chin by sizing my cephalometric x-ray to my profile shot and using the ruler on the ceph machine to compare the space between before and after. I've also posted the photo I used to do this. I realize it's probably not exactly 10mm, but I think it's close, say within 1mm either way.
I'd also hope that my jawline would pop slightly more with the advancement due to tightening skin, but I didn't try to create that effect.
Further questions:
1) Is this achievable/realistic? Did I underestimate the amount the top of my philtrum will advance (i.e. under-project "chimp lip")?
2) If it is achievable, how does my morph look? Do you think it looks better than my current profile?
3) Is 10mm bimax considered a large advancement? How much could I expect this much advancement to affect my airway?
If you guys think I'm crazy, well, let me know that too I guess.
What software did you use to do he MORPHS - - ?
Nicely done, BTW. I suspect they are reasonable.
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What software did you use to do he MORPHS - - ?
Nicely done, BTW. I suspect they are reasonable.
MS Paint, actually. To rotate the nose and upper lip, I just Googled "rotate picture" and used one of the links. I rotated, saved as new image, and used said pieces from it.
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I don't think you're crazy, and I get annoyed when other people get annoyed at someone who wants surgery mainly for aesthetic reasons.
There's nothing wrong with wanting to look better, and just because ones issues aren't a medical necessity, it doesn't make it wrong want to improve.
On the facebook jawsurgery group i've seen lots of people who look very 'normal' and would probably get told by people here that they would never find a surgeon to operate on them as they look fine, but they all do fine a surgeon and get surgery done, and most of them look better after.
I'm not gonna try to get technical with you because you clearly know a lot more about all of this stuff than me, but I'd say that morph is a fair possibility based on the various 'before and afters' i've seen from people.
In your particular case (and in my personal opinion) you look different in the after, but i'm not sure you look that much better. Maybe very slightly. But it's all about personal preference, I guess. I think you look pretty good already.
Good luck!
There is a difference between wanting to look better when you are not very attractive to begin with and when you are attractive to begin with. Double jaw surgery is a major surgery. If you are willing to have both your jaws cut open and spend thousands of dollars to change your face when you are already good looking, I would suggest you have some underlying self-esteem issues that your confidence is hanging on.
It is a dangerous road, and many people don't stop with one surgery and end up looking much worse than when they started. In theses cases I think it is not only justified to warn people against it but morally irresponsible to encourage people to go down this path.
OP is a very good looking man, but in my opinion is blaming his appearance for other self-esteem issues.
Do you feel your appearance is holding you back anywhere in life OP?
Do you really hate your appearance that much? Ask anyone and they will tell you that you are attractive by any objective standards.
Kjohnt, again feel free to correct me if you feel I am wrong and explain your rational for this.
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I realize most feel I'm not a candidate aesthetically but I want you guys to look again at my morph and tell me if you still feel the same.
I did a morph predicting STRAIGHT MMA without genioplasty. I first slightly CCW rotated the lower half of my nose to the bottom of my upper lip since that soft tissue should rotate CCW even with straight advancement since above the advancement will naturally rotate. This includes desireable upper lip projection and undesireable nose upturn. Then I advanced from the top of the lower lip on down straight horizontally. Finally, I pulled the lower lip in a bit since I think it won't curl out so much after mandibular advancement.
This is the result. I roughly measured 10mm advancement at the chin by sizing my cephalometric x-ray to my profile shot and using the ruler on the ceph machine to compare the space between before and after. I've also posted the photo I used to do this. I realize it's probably not exactly 10mm, but I think it's close, say within 1mm either way.
I'd also hope that my jawline would pop slightly more with the advancement due to tightening skin, but I didn't try to create that effect.
Further questions:
1) Is this achievable/realistic? Did I underestimate the amount the top of my philtrum will advance (i.e. under-project "chimp lip")?
2) If it is achievable, how does my morph look? Do you think it looks better than my current profile?
3) Is 10mm bimax considered a large advancement? How much could I expect this much advancement to affect my airway?
If you guys think I'm crazy, well, let me know that too I guess.
Hi, from my knowledge soft tissue cannot be predicted with too much certainty, it's unfortunate but no morph is perfect because of that. The surgeon can put your bones in the position he wants down to 0.1 of a mm, but he cannot predict the soft tissue to such a degree. However some things are to be expected, your nose should widen but not upturn so much, I've seen hundreds of before and afters and no nose has upturned that much, most of the time the tip stays in the same place after swelling goes down, but the alar almost always flares and lifts a little bit. That's also somewhat bad but in my case my nose is pretty narrow so it's not a big problem.
My nose IS naturally upturned(genetics, my mother and dad are the same) and it scares me a bit that it may become piggy but my surgeon said he can control it and in fact his patients looked fine after it. Worst case scenario I get a derotation rhinoplasty as an upturned nose is terrible for a guy.
Your morph looks better, except the nose, but I think surgery would be even better because your jaw would pop out more and the upper lip would probably be a little more forward than the lower one. I think it's not properly rotated. Moreover the cheeks seem to pop out more after a lefort I advancement because some of the muscles in the cheek are attached to the lower maxilla.
Look at this cherrypicked example(the girl is gorgeous):
http://imgur.com/a/mUclH
Alar flare, but her already upturned nose stays the same, no piggy nose.
See how her cheeks are more prominent now, the line is almost near the mouth when she smiles.
10mm is a large advancement but you also need to consider the original size of your bones, only the surgeon can really determine it.
About craziness...jaw surgery evolved a lot in the last decades, it's very likely since your bite is fine that you will not need to stay in braces for years and most likely you will only need rubber bands, not wire shutting your mouth and eating through a straw for months. Advancing both jaws is also much less likely to relapse than setting back the lower jaw.
Having said that, it's still a pain in the ass but after a few years you will not even remember it.
Now, you cannot become too fixated on that, you're a normal looking person to begin with, it's not like you have a major deformity, if you think your face right now is creating you tons of problems it's most likely in your head. Somebody with Crouzon or a severe under or overbite can suffer discrimination, people staring, and so on, it's not your case, your face blends in the general population.
I also realized you may have a slight negative orbital vector, it may get somewhat better after surgery or you could look into infraorbital implants or a lefort 3(but no doctor will do it in your case). That will also give your face a sunken look if that's what you want to fix.
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I wonder if that girl simply had additional bone growth to account for some of the facial changes. Her face just appears wider.
I'm not overly worried about my nose too much TBH, a small upturn wouldn't be horrible and it's already narrow, though if it didn't change much that would be cool since I feel it's good as is.
I'm still wondering if a sliding genioplasty in conjunction with bimax would be the way to go, e.g. maybe 6mm bimax and 3mm genio or something. I just don't want a deep labiomental fold.
It's weird about the orbital vector and even my cheeks... I feel they look a little worse in that photo than they do in other pictures. Maybe because there are purposely no light shadows. In any case, I'm not seeking anything further than bimax with possible genio. I'm okay with everything else.
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how old are you, OP?
Does the thought of wearing braces for a year or 2 as an adult effect your decision to potentially go through with something like bimax?
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I wonder if that girl simply had additional bone growth to account for some of the facial changes. Her face just appears wider.
I don't think so. Her width at the back stays the same. It's just that before any width towards the front of her jaw was turned down and back. As it was further back, it looks narrow and being grown down... well, the longer overall look projects narrowness. Look at where the gonial angle is in both front and profile pictures. It remains unchanged. It's just that when you rotate the jaw and the anterior part becomes flatter, it creates a sharper angle from the front and reduces the height that was once making the face look longer and narrow. Plus, it brings that and the chin forward, where it also gives "illusion" of width.
You'll notice she still has severe lip incompetence. But it doesn't even matter because it's not lip incompetence on it's own that's necessarily bad. When your jaws are in the right spot, especially when the jaw is rotated and the teeth are upright and chin is further out... the lip doesn't hang outwards as much and the lips aren't unnaturally open/narrow as they were when the jaws were overly long.
Anyway, that's a great result. The real improvement her eyes which now have more support. I wonder what she got done there or if it's just the upper jaw movement?
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I don't think so. Her width at the back stays the same. It's just that before any width towards the front of her jaw was turned down and back. As it was further back, it looks narrow and being grown down... well, the longer overall look projects narrowness. Look at where the gonial angle is in both front and profile pictures. It remains unchanged. It's just that when you rotate the jaw and the anterior part becomes flatter, it creates a sharper angle from the front and reduces the height that was once making the face look longer and narrow. Plus, it brings that and the chin forward, where it also gives "illusion" of width.
You'll notice she still has severe lip incompetence. But it doesn't even matter because it's not lip incompetence on it's own that's necessarily bad. When your jaws are in the right spot, especially when the jaw is rotated and the teeth are upright and chin is further out... the lip doesn't hang outwards as much and the lips aren't unnaturally open/narrow as they were when the jaws were overly long.
Anyway, that's a great result. The real improvement her eyes which now have more support. I wonder what she got done there or if it's just the upper jaw movement?
According to the book she had Lefort I with advancement and vertical shortening, BSSO with advancement and anticlockwise rotation and genio with advancement and vertical shortening.
While a Lefort I doesn't move the orbital rims the impaction does affect the muscles below the eye because everything is connected in the face and there are a few articles in PubMed saying it does reduce scleral show and vertical eye size in around 10%
Not worth it in your case IMO.
People who get straight advancement barely improve aesthetically unless they are deformed before.
Only people who seem to look alot better after are those who have transverse / vertical deformity. Short/long faces etc.
I don't know, I will get double jaw advancement with impaction too(long face) but my ortho and surgeon said my face should change a lot because of the advancement because my face is flat right now. They even said I may need new ID pictures.
I think OP will look great after surgery.
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how old are you, OP?
Does the thought of wearing braces for a year or 2 as an adult effect your decision to potentially go through with something like bimax?
32, and according to ortho no braces needed, but I would get them if needed. The cost of braces would be the biggest issue IMO as I'd already have to pay out-of-pocket for surgery.
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The surgeon can put your bones in the position he wants down to 0.1 of a mm.
Any surgeon who told you this is a liar.
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Any surgeon who told you this is a liar.
Hyperbole, I mean bone is much more precise than soft tissue
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Hyperbole, I mean bone is much more precise than soft tissue
Well, just for the record, probably the best surgeon alive told me he can move to within 1mm.
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There's no question that the morph looks better. But it's really just an incremental improvement and it won't change your life significantly. Personally, I don't think it would be worth it if you don't have any functional issues to resolve.
You need to take a "big picture" view of things. Ask yourself this: "How much better would my life have to become for me to consider the surgery worthwhile?" What specific aspects of your life are you hoping will improve? More success with women (or whatever your preference may be)? Making friends easier? Getting promoted at work? Or even just the personal satisfaction of liking your reflection in the mirror better? The surgery would likely improve your life in all of these areas, but only slightly. You need to think very carefully about whether the results obtained will be worth the price paid.
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There's no question that the morph looks better. But it's really just an incremental improvement and it won't change your life significantly. Personally, I don't think it would be worth it if you don't have any functional issues to resolve.
You need to take a "big picture" view of things. Ask yourself this: "How much better would my life have to become for me to consider the surgery worthwhile?" What specific aspects of your life are you hoping will improve? More success with women (or whatever your preference may be)? Making friends easier? Getting promoted at work? Or even just the personal satisfaction of liking your reflection in the mirror better? The surgery would likely improve your life in all of these areas, but only slightly. You need to think very carefully about whether the results obtained will be worth the price paid.
Yes exactly, possible side effects should also be considered. Do not go overboard, in theory you can die during any surgery, but it's very unlikely. However paresthesia, numbness, edema, that is all pretty much guaranteed to some degree.
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Update:
I'm moving forward with the surgery. I've done various analyses with both x-rays and pictures and without a doubt I could use at least 10mm advancement at the chin and probably more. If anybody is interested, I can post examples of my analyses to answer the if, but otherwise am more concerned now with the surgery specifics to answer the how.
It's now been agreed upon by surgeon and ortho that I need braces as part of this. Next Thursday it begins!
Moving Forward:
Using Dolphin imaging software, my orthodontist estimates he can create +4mm overjet (to 6mm overjet from current class I of 2mm) by decompensating my incisors. He'll also slightly tip outward premolars (and perhaps molars, I'm not sure) because they will fit on a wider part of my lower teeth once the mandible is moved forward. This will also give me a slightly wider smile! Anyway, that's set - my mandible will be moved forward +4mm compared to my maxilla at the teeth.
But that won't be quite enough for a nice profile aesthetic. To take care of the rest:
- My surgeon estimates my best option to be CCW rotation by posterior maxillary downgraft of about 3mm. This will move my mandible further yet in comparison with maxilla. No sliding genioplasty. Tooth show is good so anterior maxillary impaction isn't a good option.
- My orthodontist estimates my best option to be sliding genioplasty. No CCW rotation because he thinks the posterior maxillary downgraft will result in excess gum show near my molars when smiling. He checked to see if I have any room to remove some gum tissue on those and I do not; my molars are simply short.
- Neither wants premolars extracted.
So my dilemma is either excess gum show on molars or excess labiomental fold. At this point I'm inclined to agree with my surgeon. I understand analyses will need to be done by all parties once my teeth are ready for surgery. Anyway, I've attached pictures to show current labiomental fold and current gum show (my smile is not usually that lopsided in other pictures and is more symmetrical like my right - or the picture's left - side). I think the truth is that my lower arch just isn't big enough, but I too don't like the idea of extracting teeth.
Which would be worse... more gum show near molars with CCW rotation or deeper labiomental fold with sliding genio? If I decide neither are acceptable, it's lower premolar extractions.
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Who's your surgeon?
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Who's your surgeon?
Bloomquist
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Bloomquist
Good luck, although like I said before, not sure if JS is worth it in your case.
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How much are you paying for this?
Pm sent
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Good luck, although like I said before, not sure if JS is worth it in your case.
I'm certain it is. I can post an analysis of my ceph compared to an ideal case as well as some more morphs if interested.
But what do you think about ccw rotation versus genioplasty?
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Bloomquist
I hear he actually pioneered the CCW rotation, even though another claims it. I think they were both close. Anyway, I hear good things I would go with his recommendations.
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Wishing you every success with this surgery.
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I'm certain it is. I can post an analysis of my ceph compared to an ideal case as well as some more morphs if interested.
But what do you think about ccw rotation versus genioplasty?
If you don't need CCW, then you could probably get away with a less expensive surgeon. CCW with posterior maxillary downgraft is done by probably a dozen american surgeons, that's it. Why that is, I don't know. Unstable or simply too hard for the average surgeon?