jawsurgeryforums.com
General Category => Aesthetics => Topic started by: InvisalignOnly on September 08, 2019, 12:19:08 AM
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I am a middle aged female with a class 2 malocclusion and gummy smile / upper lip incompetence (see photos attached - will upload x-ray in a separate post). I am in the process of selecting a surgeon in Europe for a double jaw surgery and need some advice before my upcoming consultations. Apologies in advance for my ignorance, I am new to all this.
First of all, I understand that my mandible needs to be brought forward but is the best way to do this in my case in a 'straight line' or is it possible / a good idea to rotate or lift it somehow? Most importantly, do I need / should I ask for a genioplasty? As you can see, I have a weak chin and mentalis strain.
Secondly, I was told my maxilla needs to be rotated, is this the same as Le Fort? (Sorry if this is a dumb question.) Would they also need to do any 'impaction' in this area / remove a part of it, or is that not necessarily the case? I am asking this so I can understand and evaluate what the surgeons will tell me at the consultations.
Thank you for any advice in advance.
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Here is my ceph x-ray
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From this point on, it’s truly hard to tell wether you’ll require a genio. I am in a similar situation, however, I had upper arch retracted with braces, in my childhood. You may want to read some replies I’ve got too, so I’ll leave a link:
http://jawsurgeryforums.com/index.php/topic,7810.0.html
Now, take anything I say with a grain of salt but in my perspective, you might get maxillary anterior impaction to deal with a gummy smile and a mandibular advancement with counterclockwise rotation.
Depending on how much your teeth will be decompensated and how much mandibular rotation will be done, you might need or not need a genio because your chin will naturally stick out due to advancement and rotation.
What’s more important, prior to a surgery you will have a full facial analysis done, where a surgeon will do his best to balance out your profile on paper before proceeding with a surgery.
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The chin bone doesn't look too bad. It looks weaker than it is because the bottom teeth are so proclined. Uprighting them will improve the chin.
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My opinion is that women should be careful with augmenting chin and/or jaw. As a woman, the ideal is kind of a weak (usually heartshaped) bonestructure. I've seen some genios and implants (mostly implants) with women that I didn't like cause it gave them too much chin/projection.
It's hard to tell based on these pics, but you might look at your teeth first instead, like previous posters said. They are not aligned and you have a bit of a gummysmile (which is not very destracting tbh). Maybe posting a better pic of full face (eyes blurred) could give you more accurate opinions.
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Thank you so much for those that took the time to comment so far, I truly appreciate it! I am now inclined to think I will definitely not ask for / not need a genioplasty, I do not want my chin to be too strong / pointy. If it turns out to be still too weak after braces and surgery, I can make small corrections with fillers etc., will be easier than dealing with a chin that's too big for my face.
you might look at your teeth first instead, like previous posters said. They are not aligned and you have a bit of a gummysmile (which is not very destracting tbh). Maybe posting a better pic of full face (eyes blurred) could give you more accurate opinions.
The reason we did not touch the teeth yet is that the ortho said I need to decide on the surgeon first and then him and the surgeon will work out a plan. I understand that they will definitely need to push the lower teeth inwards to create more space and align the teeth - ortho said that it will take 6-9 months before surgery depending on whether the surgeon wants to extract teeth from the lower jaw or not. Of course he wants me to go with the surgeon he usually works together with, but seeing this is major surgery and I am paying for it privately, I would like to speak to a few doctors before making a decision.
I am quite confused about whether or not tooth extraction is necessary and if so, from where. My wisdom teeth have already been removed a long time ago. The first surgeon I went to told me he wanted to extract four premolars, two from the top and two from the bottom. I really did not like that idea and another said he would need to take two from the bottom only, while my ortho thinks it might be done without any extractions - so confusing for me.
Re: photos, I am a bit paranoid about privacy but will consider posting some more. I know that 'camouflage treatment' with braces / lip and chin fillers is an option, but decided to go for the surgery because I also have breathing issues and want a long term solution.
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You look like your case could resolve to anterior impaction which is type of CCW in venue of most maxfax docs (as opposed to CCW posterior downgraft). Any CCW rotation to the maxilla will allow the lower jaw to swing in a more forward direction and take the chin point along with that.
Genio advancement is not really something one needs to ask for simply because it's often planned into the surgery. Extent of genio depends on whether or not the lower jaw advancement brings the chin point out enough and also if the protrusion of the lower teeth can be made less in preparation for the surgery.
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You look like your case could resolve to anterior impaction which is type of CCW in venue of most maxfax docs (as opposed to CCW posterior downgraft).
Thank you - I assume this would be Le Fort 1?
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yes.
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Your face looks short as-is, so I'd be careful with any impaction. Your smile is only very slightly gummy. It's making you look younger.
I don't see a strong need for jaw surgery. Who said you need it and what was their reasoning / proposed movements?
I'd have to see more photos. From what I see the chin is recessed but not abnormal for a female.
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I think you have a cute, feminine lower face. Nice lip curvature, dainty chin and youthful gum show. Be careful which rabbit hole you go down-jaw surgery often is not a fix all, end all and if anything can create more issues and/or negative aesthetic insecurities.
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Your face looks short as-is, so I'd be careful with any impaction. Your smile is only very slightly gummy. It's making you look younger.
I don't see a strong need for jaw surgery. Who said you need it and what was their reasoning / proposed movements?
I'd have to see more photos. From what I see the chin is recessed but not abnormal for a female.
I think you have a cute, feminine lower face. Nice lip curvature, dainty chin and youthful gum show. Be careful which rabbit hole you go down-jaw surgery often is not a fix all, end all and if anything can create more issues and/or negative aesthetic insecurities.
Thank you both - I am grateful for your input, this is exactly why I am so confused but I mean in a good way... Much better to be confused than making the wrong decision. It's like this: unfortunately in childhood, I was not taken to the dentist at all and did not get any opinions or help with my teeth / jaws. As a young adult, I went to ask what could be done about my teeth sticking out (which was the problem as I saw it at the time) and was told straight away I needed jaw surgery. Since then, every single dentist or orthodontist I saw told me the same thing, apparently I am a textbook case of someone that 'needs' double jaw surgery.
At the same time while I am not a model or Miss World, I have always been considered reasonably attractive and whenever I tell any of my friends / partners I want a surgeon to break my jaws and screw them back together to make me look better, people are horrified and tell me DO NOT DO IT. I am now in the position where I have both the time and the money to get it done but honestly, it's so confusing. I am posting more photos here that highlight the problem:
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An additional photo of me laughing - this is 'as bad as it gets' lol. By the way, psychologically, I do not feel insecure about my looks at all, I am fine as I am. (Yes, I know there are plenty of people out there that would call me ugly and a freak but that says more about them than about me, the way I see it.) I just feel like if there is a good chance my looks could be improved, why not? Especially as the doctors keep telling me I will have functional problems down the line and I already noticed I have some breathing issues.
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I think you look pretty cute as-is.
So really it's a question of how much risk you want to take. To me jaw surgery is a great temptress in that if you have the right plan and everything goes right, sure, you will likely look better. It's all about whether you want to take that gamble. When weighing that risk, make sure not to convince yourself of problems that might arise down the road because they might not, too. You seem to want to do it, though, from what I'm reading. Do you really want to, or is it the allure and mystery of "what if?".
Regarding your case. I now see better why they want to do impaction. Still think it's risky (aging), though, given your short face. Might run into problems with your nose that you're not expecting, too, from the impaction. But technically, yes, that would be the best plan on paper, IMO.
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You seem to want to do it, though, from what I'm reading. Do you really want to, or is it the allure and mystery of "what if?".
Regarding your case. I now see better why they want to do impaction. Still think it's risky (aging), though, given your short face.
Exactly, I am quite worried about the aging effect. Right now I am always told I look a lot younger than my age and obviously as a woman, I do not want to lose that advantage. Do you think the less impaction they do, the smaller the risk? Or is it not that simple?
You summed it up perfectly re: 'allure / mystery'. Doctors keep telling me I will look different after the surgery and I am very intrigued by that - I would like to try it for a few days to see what it's like to live with a different face. However, this is not a video game and I will not be able to go back to this face if I do not like the new one. So yes, it is very much like gambling. Not to mention that so many people have complications like chronic pain or numbness etc. for years after the surgery. So I kind of want to do it but still have my doubts.
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Exactly, I am quite worried about the aging effect. Right now I am always told I look a lot younger than my age and obviously as a woman, I do not want to lose that advantage. Do you think the less impaction they do, the smaller the risk? Or is it not that simple?
You summed it up perfectly re: 'allure / mystery'. Doctors keep telling me I will look different after the surgery and I am very intrigued by that - I would like to try it for a few days to see what it's like to live with a different face. However, this is not a video game and I will not be able to go back to this face if I do not like the new one. So yes, it is very much like gambling. Not to mention that so many people have complications like chronic pain or numbness etc. for years after the surgery. So I kind of want to do it but still have my doubts.
Well the surgery isn't going anywhere, so think it over and weigh the risk/reward vs that allure. I could read between the lines and sensed that allure was getting you. I understand that, but it's not a great reason to have surgery; yet I think everyone with a "deformity" has those thoughts. We then convince ourselves of medical problems (e.g. apnea) that might happen down the road to justify the surgery. Get ready for mental torment like that while figuring all that out.
But the bottom line is once the new face is in place it's a bell you can't un-ring so be sure you'll have no regret if it goes awry.
And yes, the less impaction the less aging, in theory at least.
PS. This might help with the mental part: https://humanhow.com/en/list-of-cognitive-biases-with-examples/
Especially understanding things like decision fatigue and optimism bias, but several others as well.
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This might help with the mental part: https://humanhow.com/en/list-of-cognitive-biases-with-examples/ Especially understanding things like decision fatigue and optimism bias, but several others as well.
You made some excellent points and the link has been really useful as well! 'Decision fatigue' definitely applies to my case. I feel like every time I go to the dentist they keep telling me 'hey did you know you need jaw surgery' and it's really getting to me in the sense that it seems like 'the right thing' to do, like, society sort of expects me to do it so I can look 'normal' like other people. I honestly wish the surgery would have been done to me when I was still a teenager and someone else would have made the decision so I would not have to.
Regarding the optimism bias, I actually had 'pessimism bias' about this for several years. I used to dismiss surgery thinking it was just too risky (especially in terms of pain and other physical problems, nerve damage, speech issues etc.) but I am now more inclined to see the big picture in terms of, if it's done by a 'good' surgeon, chances are the benefits are likely to outweight the risks. Then again, the risks are still there and the older I get, the more risk there will be.
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You've got yourself into a very complex field. The thing about surgery and orthodontics is that best result is achieved if it's done before you get a problem, but the motivation is also less if you don't have a problem. The thing is trying to look into the future and try to see if it will cause a problem. I always promote doing it sooner than later. I would try to get more information from those you've consulted and ask what the effects of not having surgery is. Have they measured your airways and do they see tendency to narrow airways? Do you bite up in the palate with your lower incisors and have a deep bite? Will you likely get crowding problems in the upper arch with age?
You also need to be very careful who you listen to and understand what's going on. I was offered braces as a teen. Today I regret not having fixed my problems earlier, as it has evolved into a compensated deep bite, which could've been prevented. But I definitely don't regret denying the extraction treatment they offered me as a teen.
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If your surgeon is competent I think your plan will be 'relatively' straightforward.
CCW via anterior impaction is more stable than a posterior downgraft, so you've got that going for you. The surgeon should be able to tell you exactly how much gum-show you'll have post-op so that's another plus.
I would decline any advancement of the maxilla if that's proposed. The aesthetic risks probably outweigh any benefits there. Personally, I don't think you need a genio. The impaction will give you a more 'natural' rotation of the jaw and further chin augmentation may be masculinizing.
A well-done bimax alone will fix your issue, insofar as you have one. The bigger risk, imo, is that you are already comfortable with your face as it is. Any change is going to cause you some psychological stress if you're attached to your current look, even if it's technically an improvement. Consider that before you do something.
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A well-done bimax alone will fix your issue, insofar as you have one. The bigger risk, imo, is that you are already comfortable with your face as it is. Any change is going to cause you some psychological stress if you're attached to your current look, even if it's technically an improvement. Consider that before you do something.
Thanks so much for the detailed info and suggestions, this is really useful and I will refer back to it once I got some plans from surgeons!
Regarding the psychological impact: you are right, this is an important aspect and I have read about people that could not get used to the new face even if they looked better according to pretty much everyone else. I do not think this would happen to me though as I feel mostly 'neutral' about my face, if that makes sense... I do not think it is either ugly or beautiful, it is just the way it is and if it can be improved from an 'objective' viewpoint that's great, but obviously I would be very upset if I ended up looking objectively worse after investing time and money in the surgery.
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I feel like every time I go to the dentist they keep telling me 'hey did you know you need jaw surgery' and it's really getting to me in the sense that it seems like 'the right thing' to do, like, society sort of expects me to do it so I can look 'normal' like other people.
I think you're pretty and have a great smile. I never even knew a gummy smile was considered a problem (maybe also because I don't have one) until I entered the jaw surgery world and saw everyone getting it corrected by their surgeons. I know VME causes lip incompetence so there are some valid reasons for correcting it, plus impacting also enables the lower jaw to rotate. The problem is some surgeons go overboard and take too much of the gum/tooth show away (maybe in an effort to get more rotation) I think any female getting impaction needs to be careful and really convey to surgeon/ortho about concerns with aging. You want the right balance. If you like the way you look now, then less of it will be much easier to adjust to.
PS. This might help with the mental part: https://humanhow.com/en/list-of-cognitive-biases-with-examples/
Especially understanding things like decision fatigue and optimism bias, but several others as well.
That's a really helpful link. Thanks for posting. I recognise so many of those in my own attempts at decision-making.
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I think you're pretty and have a great smile.
Thanks for that, I certainly wasn't fishing for compliments :). I must say though, loads of people - men and women - that I meet in real life tell me that I have a great smile, so yes I am quite worried about losing that feature after the surgery.
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I would try to get more information from those you've consulted and ask what the effects of not having surgery is. Have they measured your airways and do they see tendency to narrow airways? Do you bite up in the palate with your lower incisors and have a deep bite? Will you likely get crowding problems in the upper arch with age?
As far as I am aware, I do not have any crowding problems and right now my lower incisors are inclined so they aren't causing any problems either. If I decide to go for the surgery, they will 'decompensate' them so they will probably end up making my bite worse before, hopefully, making it better.
They haven't actually measured my airways but the 'last straw' that made me strongly consider the surgery was a visit to an ENT specialist for my breathing issues. I have been noticing more and more in recent years that I cannot breath properly through my nose, sleep less well and feel tired in the morning etc. He said he thought it was connected to the position of my jaws and will likely get worse with age.
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They haven't actually measured my airways but the 'last straw' that made me strongly consider the surgery was a visit to an ENT specialist for my breathing issues. I have been noticing more and more in recent years that I cannot breath properly through my nose, sleep less well and feel tired in the morning etc. He said he thought it was connected to the position of my jaws and will likely get worse with age.
Hospitals are businesses these days, and surgery is their most expensive product. So keep that in mind. Nobody "needs" this surgery -- people lived with these deformities and had healthy lives for centuries (before 1970, when the surgery was modernized from war injury emergency surgery and essentially invented for the every day patient). So you don't "need" it, but you could "benefit" from it if everything goes right. I wouldn't personally listen to an ENT. Listen to your heart and gut and then weigh it against all those biases and the risk/reward. At the end of the day your decision will likely come down to whether you give in to the great temptress of jaw surgery and the big "what if?" or live with the unknown, because you seem to be content with yourself as-is and realize you don't "need" it. Seems the only thing confusing that belief are doctors who want to sell you their expensive procedure. Ask them to prove you'll get apnea or any of the other scare tactics they're using to make you get surgery.
Again, in short: you can benefit from it if everything goes right, but you don't "need" it. So it's really your own risk/reward tolerance and how much not knowing what it might look like will eat at you. Those would be the reasons you'd do it, from what I'm reading between the lines.
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That's a really helpful link. Thanks for posting. I recognise so many of those in my own attempts at decision-making.
You're welcome. Very useful for day to day life as well. There is also a great video lecture on YouTube called "Your deceptive Mind", which is worth watching in it's entirety (very long, but maybe at night before bed put it on for a bit each night).
https://www.youtube.com/watch?v=CGMZL7aAauc
https://www.youtube.com/watch?v=qoquCUn4kVE
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A maxfax once told me that there are plenty of people walking around with deviations/ facial imbalances that could be addressed via bi-max surgery. BUT there are enough so that anybody else with with a deviation can easily 'blend in'. It's not as if someone with some deviation from an ideal is going to be stigmatized for having it because it's not a thing where everyone else is totally absent of some kind of jaw imbalance.
That said, you have a common deviation (gummy smile and recession to lower jaw) that they can give a 'YES' to addressing via surgery. So, when they tell you that your deviation would 'NEED' CCW (most likely anterior impaction), that's what is done to address what you have.
There is a big DIFFERENCE between what kind of surgeries or displacements would need to be done to address some kind of jaw imbalance or deviation from balance and YOUR 'need' to have the surgery for it. If you're actually CONSULTING with maxfax docs, it's IMPLICIT to them you are considering surgery for what you have. They're just telling you what the imbalance is and what would BE NEEDED to be done (what they would need to do) to address the imbalance you have. They are just confirming that if you WANT it to address your deviation, they can do surgery for what you have. So, I don't think this is a thing where you're going to a dentist or something like that for a cleaning and their telling you that you 'need' max fax surgery. It's gotta be something where you're actively seeking advice about facial balance.
Given that there are plenty of other people (as in average population) walking around with some form of facial imbalance and are 'surviving aesthetically' with one such that others would still find them attractive in some way despite having some imbalance and/or they are not BOTHERED enough by it to bother with having surgery for it OR to even ask a maxfax what their deviation is, the question you need to ask YOURSELF is what bothers YOU so much that you WANT surgery for it.
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There is a big DIFFERENCE between what kind of surgeries or displacements would need to be done to address some kind of jaw imbalance or deviation from balance and YOUR 'need' to have the surgery for it. If you're actually CONSULTING with maxfax docs, it's IMPLICIT to them you are considering surgery for what you have. They're just telling you what the imbalance is and what would BE NEEDED to be done (what they would need to do) to address the imbalance you have. They are just confirming that if you WANT it to address your deviation, they can do surgery for what you have. So, I don't think this is a thing where you're going to a dentist or something like that for a cleaning and their telling you that you 'need' max fax surgery. It's gotta be something where you're actively seeking advice about facial balance.
Given that there are plenty of other people (as in average population) walking around with some form of facial imbalance and are 'surviving aesthetically' with one such that others would still find them attractive in some way despite having some imbalance and/or they are not BOTHERED enough by it to bother with having surgery for it OR to even ask a maxfax what their deviation is, the question you need to ask YOURSELF is what bothers YOU so much that you WANT surgery for it.
You are making good points, however - perhaps surprisingly - it did actually happen to me more than once that general dentists told me I 'should' get this surgery, without me asking, and offered to refer me to a surgeon. This might have something to do with the fact that as GJ mentioned,
Hospitals are businesses these days, and surgery is their most expensive product.
I should add that this happened in non-Western countries and I can actually imagine that the dentist would get a commission for referring patients for surgery. Even when I went to the ENT doctor, it did not cross my mind that the breathing issues had anything to do with my jaws or bite and he started telling me that he thought it was related to that and it would be a good idea for me to get the surgery.
There was even a young male dentist years ago - I went to see him for a filling - that told me really enthusiastically (without me even mentioning the subject) that if I got this surgery I would be stunning and look like a model or something like that. I got quite angry actually and tried to explain to him that it was really unprofessional and also irresponsible to say something like this to a patient but he did not understand what was wrong (again, this happened in a non-Western setting, in other countries I would probably make a formal complaint).
Regarding how I feel: yes, it bothers me that my teeth 'stick out' / are visible even when not smiling, and this is something I wanted to address. That's why I spoke to orthodontists, and without exception they have told me that braces would not really solve this issue. They also told me lots of other scary things like my teeth will 'fall out' if I do not get the surgery, I will have TMJ pain, headaches, digestive problems and so on. The first time they told me all these was over 20 years ago and so far my teeth did not fall out :) and I do not have any pain anywhere but I do have the breathing issues now... So I am hoping that if the surgery goes well, it could improve my breathing and my appearance too.
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Breathing could have something to do with weight, too. I have no idea your weight from the photos, but getting to your ideal weight and muscle tone would help with breathing. Apnea has a lot to do with neck size and tongue size. It can be the jaws, too, but it's important to know the cause before trying to fix it.
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Breathing could have something to do with weight, too. I have no idea your weight from the photos, but getting to your ideal weight and muscle tone would help with breathing. Apnea has a lot to do with neck size and tongue size. It can be the jaws, too, but it's important to know the cause before trying to fix it.
I've been trying to figurer out. Does everyone benefit from having the airways opened more, or is it only those with severe obstruction such as OSA? It's clear that someone who have such sever problems that they stop breathing have terrible problems. But let's say you have somewhat narrow airways compared to norm, no apnea etc. Do you still benefit in different ways and feel a relief of having less strained breathing and getting more volume in your lungs?
Maybe a bad comparison, but I'm thinking like testosterone. Some people have sever deficiency and will get medical help. But some athletes take it to another level and go on "treatments" and benefit even though their baseline is good. Can it be same with airways so opening up give benefits or performance in general in some aspect?
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Breathing could have something to do with weight, too.
You are absolutely right - however, in my case, I am very slim and fit actually. The ENT doctor even mentioned that saying, he typically sees these problems in overweight women, but seeing I am slim, he suggested it must have another cause. He used to work at a large clinic in Taiwan where they performed lots of jaw surgeries and according to him, most people reported that the surgery had a positive effect on their breathing after the mandible was brought forward.
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Does everyone benefit from having the airways opened more, or is it only those with severe obstruction such as OSA? It's clear that someone who have such sever problems that they stop breathing have terrible problems. But let's say you have somewhat narrow airways compared to norm, no apnea etc. Do you still benefit in different ways and feel a relief of having less strained breathing and getting more volume in your lungs?
Good questions, I have been thinking about the same and have to do more research on it. I have definitely noticed in recent years that I run out of breath quite quickly while doing sports, feel excessively tired in the morning and so on. I do not know how to explain but I have a feeling like I do not get enough air when I breathe in... The ENT doctor I saw was confident that these symptoms would improve after my jaw surgery and said he has actually treated several patients with issues like mine and they improved after surgery. But this was only one doctor that told me this so who knows...
I am also thinking whether I might have a deviated septum that is getting worse with age. I will try to look into this as well as jaw surgery options.
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Did the ENT check you for enlarged turbinates. I have the same symptoms as you, and I have both hypertrophied turbinates and a deviated septum. I'm tired always and feel out of breathe doing basic physical activity.
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Did the ENT check you for enlarged turbinates. I have the same symptoms as you, and I have both hypertrophied turbinates and a deviated septum. I'm tired always and feel out of breathe doing basic physical activity.
I'm honestly not sure! He poked around in my nose and now wants to do a sleep study but I have kind of not been bothered enough to arrange that yet. Did they suggest any treatment for you?
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I've been trying to figurer out. Does everyone benefit from having the airways opened more, or is it only those with severe obstruction such as OSA? It's clear that someone who have such sever problems that they stop breathing have terrible problems. But let's say you have somewhat narrow airways compared to norm, no apnea etc. Do you still benefit in different ways and feel a relief of having less strained breathing and getting more volume in your lungs?
Maybe a bad comparison, but I'm thinking like testosterone. Some people have sever deficiency and will get medical help. But some athletes take it to another level and go on "treatments" and benefit even though their baseline is good. Can it be same with airways so opening up give benefits or performance in general in some aspect?
At a certain point, the amount of air you get to your lungs has virtually no effect on performance because you have reached your VO2 max; or your maximal oxygen uptake in the bloodstream. Cardio and high intensity interval training can help raise your VO2 max and improve your endurance. Opening your airway beyond the normal range is unlikely to enhance performance (in my non-professional opinion).
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I've been trying to figurer out. Does everyone benefit from having the airways opened more, or is it only those with severe obstruction such as OSA? It's clear that someone who have such sever problems that they stop breathing have terrible problems. But let's say you have somewhat narrow airways compared to norm, no apnea etc. Do you still benefit in different ways and feel a relief of having less strained breathing and getting more volume in your lungs?
Maybe a bad comparison, but I'm thinking like testosterone. Some people have sever deficiency and will get medical help. But some athletes take it to another level and go on "treatments" and benefit even though their baseline is good. Can it be same with airways so opening up give benefits or performance in general in some aspect?
I really don't know and that seems hard to know.
I've seen a few people mention they breathe better (SJ comes to mind), but in general I don't hear that often. It could be people are more focused on their looks or bite relief and don't mention that, or they simply don't notice it, or it doesn't happen despite the enlarged airway. I'm not sure.
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At a certain point, the amount of air you get to your lungs has virtually no effect on performance because you have reached your VO2 max; or your maximal oxygen uptake in the bloodstream. Cardio and high intensity interval training can help raise your VO2 max and improve your endurance. Opening your airway beyond the normal range is unlikely to enhance performance (in my non-professional opinion).
Yes, I'm sure there's a point where it makes no more difference. Think of it like trying to empty a glass of water with straws of different dimensions, on the limited time you have for a breath. With a very narrow straw, you need to struggle much harder and push the water through with more speed to get same volume, than with a wider straw. But there is also a limit where it makes no difference, your mouth (lungs) fill up any way without effort.
It interests me because I've done a sleep study that didn't show anything (but I slept very bad that night so not sure how much real sleep it actually got recorded). But I still have these classic OSA symptoms like never feeling rested and adhd and concentration issues. I've looked at my cbct scan and meassured my airways and see that they're outside the normal range, but it's rarely discussed anything else than OSA. It makes sense that if you have airways where you have to struggle like you're being lightly suffocated constantly, that it would cause problems as well. But there's not much research on it or people talking about such benefits.
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Yes, I'm sure there's a point where it makes no more difference. Think of it like trying to empty a glass of water with straws of different dimensions, on the limited time you have for a breath. With a very narrow straw, you need to struggle much harder and push the water through with more speed to get same volume, than with a wider straw. But there is also a limit where it makes no difference, your mouth (lungs) fill up any way without effort.
It interests me because I've done a sleep study that didn't show anything (but I slept very bad that night so not sure how much real sleep it actually got recorded). But I still have these classic OSA symptoms like never feeling rested and adhd and concentration issues. I've looked at my cbct scan and meassured my airways and see that they're outside the normal range, but it's rarely discussed anything else than OSA. It makes sense that if you have airways where you have to struggle like you're being lightly suffocated constantly, that it would cause problems as well. But there's not much research on it or people talking about such benefits.
I wonder if there's a method of measuring the average air volume intake per breath over a period of time. That could be adjusted for body size/weight and possibly give a clearer idea if something is out of the norm.
That seems like it would be a better way to figure out what you're talking about rather than a sleep study which just looks for serious obstructive episodes.
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You are making good points, however - perhaps surprisingly - it did actually happen to me more than once that general dentists told me I 'should' get this surgery, without me asking, and offered to refer me to a surgeon. This might have something to do with the fact that as GJ mentioned,
I should add that this happened in non-Western countries and I can actually imagine that the dentist would get a commission for referring patients for surgery. Even when I went to the ENT doctor, it did not cross my mind that the breathing issues had anything to do with my jaws or bite and he started telling me that he thought it was related to that and it would be a good idea for me to get the surgery.
There was even a young male dentist years ago - I went to see him for a filling - that told me really enthusiastically (without me even mentioning the subject) that if I got this surgery I would be stunning and look like a model or something like that. I got quite angry actually and tried to explain to him that it was really unprofessional and also irresponsible to say something like this to a patient but he did not understand what was wrong (again, this happened in a non-Western setting, in other countries I would probably make a formal complaint).
Regarding how I feel: yes, it bothers me that my teeth 'stick out' / are visible even when not smiling, and this is something I wanted to address. That's why I spoke to orthodontists, and without exception they have told me that braces would not really solve this issue. They also told me lots of other scary things like my teeth will 'fall out' if I do not get the surgery, I will have TMJ pain, headaches, digestive problems and so on. The first time they told me all these was over 20 years ago and so far my teeth did not fall out :) and I do not have any pain anywhere but I do have the breathing issues now... So I am hoping that if the surgery goes well, it could improve my breathing and my appearance too.
OK, here you say (to GJ) a dentist in 'Non-Western' country told you such. My assumption was a US dentist most likely would not have volunteered that out of the blue. Which 'non Western' country? I'm just asking because the term 'non-western' country can often refer to a country with a very rich historical heritage where the country is 'not Americanized' enough. To me, it sounds like this dentist liked you, saw potential for you and told you why and was motivated by his genuine opinion and was not fettered by same constraints as in US. Sounds like you got a genuinely honest tip from him. However, your resenting being the recipient of it and waiting OVER 20 years to consider acting on it, now puts you in a higher risk category than say people in their 20's. Also, some people become attached to their face and even though the surgery makes them look so much better, breath better, corrects aesthetic problems and gives a 'WOW!' factor, there are types that resent being changed. Like there are situations where despite being made look objectively better, they mourn the loss of their aesthetic defects because in retrospect they associate them with their 'uniqueness'.
What I'm picking up here is AMBIVALENCE which is kind of a mixture or resenting being told long time ago about a surgery that would benefit you but you still seem unresolved but still wanting it in some way. Also, you're asking very elementary questions about this type of surgery when you actually had over 20 years to read up on these types of surgeries? Although I do think it's laudable not to automatically 'default' to what a doctor says 'because the doctor said it', IMO, that should (have) come with some academic exploration such as going to a medical library and reading up on maxillo facial surgery as to explore further the advice given.
Being in INDECISION for so long is basically a decision not to decide. My advice is to go to a medical library or any library with books about maxfax surgery. Don't you think that would be a good place to help with what doctors/dentists are telling you and/or to help with some indecision?
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IMO there's a real danger that even if the surgery result is objectively perfect (as in, everyone agrees that it is so), *you* yourself may dislike the result.
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I wonder if there's a method of measuring the average air volume intake per breath over a period of time. That could be adjusted for body size/weight and possibly give a clearer idea if something is out of the norm.
That seems like it would be a better way to figure out what you're talking about rather than a sleep study which just looks for serious obstructive episodes.
I think there is, but not sure anyone does it or have studied clearly how to evaluate it. I think it would be interesting just to look at airway volume and cross section area, and study correlations between different diagnosis.
As to practical measurements, I'm thinking about these masks they sometime put on athletes when they run on the treadmill to meassure air volume consumption. Having one of those when you sleep or just relax would meassure the volume, and maybe also the preassure in each breath. If there would be research interest in it, such measurements before and after surgery would give some clue what's going on. If people suddenly start getting higher volume exchange in each breath after surgery, it's probably a good thing. It seems similar to asthma evaluation actually.
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Also, you're asking very elementary questions about this type of surgery when you actually had over 20 years to read up on these types of surgeries? Although I do think it's laudable not to automatically 'default' to what a doctor says 'because the doctor said it', IMO, that should (have) come with some academic exploration such as going to a medical library and reading up on maxillo facial surgery as to explore further the advice given.
Being in INDECISION for so long is basically a decision not to decide. My advice is to go to a medical library or any library with books about maxfax surgery. Don't you think that would be a good place to help with what doctors/dentists are telling you and/or to help with some indecision?
Totally right and thank you for your input! After reading your comment, I asked myself the question why did I not do more research on it years ago (indeed I did almost none), and I think the answer is I simply wasn't that bothered and was discouraged by people around me. I figured it was very invasive surgery with a high risk of things going wrong and when I mentioned it to friends and partners, they were always very dismissive saying I did not need it etc. So I did not really look into it and forgot all about it for many years and just got on with my life.
Last year I changed dentists and by chance started attending a surgery where one of the doctors is a maxillofacial surgeon. I went there for general stuff like cleaning and fillings but when he saw me there, he asked if I have ever thought about this surgery and I asked him questions and started doing a bit more research on it. Then I had the breathing issues and met the ENT doctor and he mentioned the surgery again, and I thought I now have the time and money to deal with this (which was not the case 20 years ago). Also, I am more independent now and do not care about the opinion of friends etc. like I used to.
Anyway, I have two consultations set up with surgeons next week and another two scheduled within the next month. I will also do more research on my own and then try to make up my mind. I am so glad I registered on this forum, I got more useful advice here than elsewhere in the last twenty years. Will post updates.
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Question, and you don't have to answer this if you don't want to, but when I see "independent, etc" I think "recently broke up with a BF" -- is this surgery a way to stick it to an ex and/or attract new partners?
But either way it seems like you now have your mind set it on it on some level because every reason given you should do it has been met with a reason you should. This to me suggests you've made up your mind and been lured by the great temptress. So it's about going through the process of consultations and finding the right plan. Once you do that post them all here. Get at least three from reputable doctors, and don't tell them what the other doctor said.
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Question, and you don't have to answer this if you don't want to, but when I see "independent, etc" I think "recently broke up with a BF" -- is this surgery a way to stick it to an ex and/or attract new partners?
Valid question and when I re-read my comment, I can see how it could be interpreted like that but it was just a case of expressing myself badly. I am divorced but on good terms with my ex actually, and in a new relationship that I am very happy with. I meant independent in the sense that I can make up my own mind now and do not rely on other people's opinion so much. Previously, I asked my husband 'do you think I should get this surgery' and when he said no, that was that. Now, I first thought it through whether this is something I want for myself or not, and when I decided I probably do, I told my boyfriend that this is what I am planning to do and explained my reasons, rather than letting him decide for me, if that makes sense. So this is how I meant 'independent'.
Once again, thank you so much for all the advice and I'll definitely post if and when I get any plans from surgeons.
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SOOO CONFUSED. Just had a video consult with a German surgeon - I will not name him but it's not Dr Z. He is well recognized and experienced, and has his own private clinic in Germany. A lot of the things he told me are totally different from what everyone else has told me before (he looked at my x-rays, several photos and now saw me on video).
Most importantly - until now, everyone agreed I needed double jaw surgery, except for one surgeon saying I could get away with mandibular advancement only. Now this German guy says I really only need Le Fort 1 and everything else is optional. As far as he is concerned, we could leave the chin / lower jaw as it is and just get rid of the gummy smile / visible teeth thing by changing the maxilla.
He said he uses 3D planning software, and about 2 months before the date of the surgery we could sit down together and decide what movements 'we' are planning and what they would look like on my face. Which sounds really tempting, but I was previously told that it is unpredictable how the soft tissues will respond to the bones being moved around, so this kind of software (that shows the soft tissue movements) is unreliable and leads to disappointment. So now I do not know what to believe. Is it really possible to sit at a computer with the surgeon and plan the face I want and get that result?
Finally, regarding orthodontic treatment: according to him no extractions are needed and he does not even need to communicate with the orthodontist until shortly before the surgery. My teeth (especially the lower ones) need to be pushed inward and the arches need to be widened, making sure there is enough space between the upper and lower teeth at the front and that's it.
I do not know what to think. He really impressed me by saying he uses the latest technology and 3D planning that helps him to avoid cutting the nerves, and he said that practically all his patients gain back feeling in their lower jaw (if that is operated on). Any opinions?
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SOOO CONFUSED. Just had a video consult with a German surgeon - I will not name him but it's not Dr Z. He is well recognized and experienced, and has his own private clinic in Germany. A lot of the things he told me are totally different from what everyone else has told me before (he looked at my x-rays, several photos and now saw me on video).
Most importantly - until now, everyone agreed I needed double jaw surgery, except for one surgeon saying I could get away with mandibular advancement only. Now this German guy says I really only need Le Fort 1 and everything else is optional. As far as he is concerned, we could leave the chin / lower jaw as it is and just get rid of the gummy smile / visible teeth thing by changing the maxilla.
He said he uses 3D planning software, and about 2 months before the date of the surgery we could sit down together and decide what movements 'we' are planning and what they would look like on my face. Which sounds really tempting, but I was previously told that it is unpredictable how the soft tissues will respond to the bones being moved around, so this kind of software (that shows the soft tissue movements) is unreliable and leads to disappointment. So now I do not know what to believe. Is it really possible to sit at a computer with the surgeon and plan the face I want and get that result?
Finally, regarding orthodontic treatment: according to him no extractions are needed and he does not even need to communicate with the orthodontist until shortly before the surgery. My teeth (especially the lower ones) need to be pushed inward and the arches need to be widened, making sure there is enough space between the upper and lower teeth at the front and that's it.
I do not know what to think. He really impressed me by saying he uses the latest technology and 3D planning that helps him to avoid cutting the nerves, and he said that practically all his patients gain back feeling in their lower jaw (if that is operated on). Any opinions?
I asked one of the surgeons I consulted if I could get away with only lower jaw surgery, and he responded something like this. "Well, if your question is if I can solve your bite with single jaw surgery, then the answear probably is yes. But with the aesthetic concerns you're asking about, no."
And I later asked an orthodontist same question, and got something like below.
"If you're getting yourself into this, go for a double jaw surgery", without more explanation.
If you think about it, if you losen one of the jaws, you can almost always displace it in the anticipated oclussion and get the bite right. If you losen the bottom jaw, it will be the upper jaw that is fixated and directs where the lower jaw needs to be displaced to fit, and vice versa. If you losen both jaws, you gain the degree of freedome that you can put the teeth in the anticipated oclussion, and then displace the entire complex, any way you like.
So the surgeon is probably right, you can get away with a upper jaw surgery, but it might not give you the result you're expecting or solve the issues you want solved. E.g, if you have restricted lower airways and OSA, then you need to advance the mandible for this to open, and a single LeFort surgery won't do anything for this. If your concern is the gummy smile, you might not be able to adress this to full extent if you're restricted to the mandible being fixed (or maybe you will, depends on the case). I'd say it sounds irresponsible to "promise" on a video consultation that you only need an upper jaw surgery, and that it's something that needs to be decided when you do the actual planning and you can communicate all your expectations and concerns. I would be concerned with a surgeon that have a predefined opinion that he will not do double jaw surgery.
How did you communicate with the surgeon? What records did you send in and what concerns did you communicate you wanted to adress? Did you say that you're concerned about your airways? Did you discuss any aesthetic concerns? Or did you mostly ask what he would do without giving any directions why you're looking into this?
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So the surgeon is probably right, you can get away with a upper jaw surgery, but it might not give you the result you're expecting or solve the issues you want solved.
How did you communicate with the surgeon? What records did you send in and what concerns did you communicate you wanted to adress? Did you say that you're concerned about your airways? Did you discuss any aesthetic concerns? Or did you mostly ask what he would do without giving any directions why you're looking into this?
I never told him I only 'wanted' one jaw being moved; I assumed he would definitely suggest double jaw surgery as everyone else did that so far. I just told him something vague like I wanted to improve aesthetics and had no functional problems apart from the breathing. He did not rule out double jaw surgery and when I asked, he said that would be an option along with genioplasty, but he was just saying that Le Fort 1 on it's own could solve the aesthetic issue. Which I find very hard to believe - I imagine I would end up with a flat face and totally recessed profile and a big looking nose. Then again, who knows.
I sent him ceph x-rays, photos from different angles (smiling / at rest etc.) and during the video call he asked to see my teeth and profile from different sides (was the most awkward video call I ever made lol, but I guess there is no other way to do it).
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I imagine I would end up with a flat face and totally recessed profile and a big looking nose. Then again, who knows.
So you clearly can't jump into surgery with this surgeon at this moment. Either you continue with one of the other surgeons who you think have made more sense when you talk to them, or you send your questions and ask for clarification on what's worrying you after the description in the call.
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I'm pretty sure I said impaction only with the lower jaw rotating very slightly and naturally from that impaction.
Seems like the only way to fix your issue given you have a short face already. And to me that's risky with the aging/nose issues mentioned.
If it's not enough later down the road you could do the chin. I think bimax would be very masculine.
Just my .02. I'd get more opinions and more records.
I do not know what to think. He really impressed me by saying he uses the latest technology and 3D planning that helps him to avoid cutting the nerves, and he said that practically all his patients gain back feeling in their lower jaw (if that is operated on). Any opinions?
Everyone should be using the latest technology, so you shouldn't let that effect your decision in any way.
No extractions is a good thing. But you need to ask if the traverse (width) discrepancy, if there is one, can be stably addressed orthodontically. Else you need a multi-segment lefort, and that's not something everyone can do safely.
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Just double checked what I wrote. I said no surgery, but added if you do want it:
Regarding your case. I now see better why they want to do impaction. Still think it's risky (aging), though, given your short face. Might run into problems with your nose that you're not expecting, too, from the impaction. But technically, yes, that would be the best plan on paper, IMO.
His plan fits my thoughts on it.
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SOOO CONFUSED. Just had a video consult with a German surgeon - I will not name him but it's not Dr Z. He is well recognized and experienced, and has his own private clinic in Germany. A lot of the things he told me are totally different from what everyone else has told me before (he looked at my x-rays, several photos and now saw me on video).
Most importantly - until now, everyone agreed I needed double jaw surgery, except for one surgeon saying I could get away with mandibular advancement only. Now this German guy says I really only need Le Fort 1 and everything else is optional. As far as he is concerned, we could leave the chin / lower jaw as it is and just get rid of the gummy smile / visible teeth thing by changing the maxilla.
He said he uses 3D planning software, and about 2 months before the date of the surgery we could sit down together and decide what movements 'we' are planning and what they would look like on my face. Which sounds really tempting, but I was previously told that it is unpredictable how the soft tissues will respond to the bones being moved around, so this kind of software (that shows the soft tissue movements) is unreliable and leads to disappointment. So now I do not know what to believe. Is it really possible to sit at a computer with the surgeon and plan the face I want and get that result?
Finally, regarding orthodontic treatment: according to him no extractions are needed and he does not even need to communicate with the orthodontist until shortly before the surgery. My teeth (especially the lower ones) need to be pushed inward and the arches need to be widened, making sure there is enough space between the upper and lower teeth at the front and that's it.
I do not know what to think. He really impressed me by saying he uses the latest technology and 3D planning that helps him to avoid cutting the nerves, and he said that practically all his patients gain back feeling in their lower jaw (if that is operated on). Any opinions?
For someone who's vague in what they want, the doctor is better off sticking to the minimum of what can be done. That minimum would be addressing the gummy smile (too much gum and tooth show) with Lefort 1 impaction.
When a doctor tells a patient how they can maximize aesthetics (which takes more surgeries), it can back fire on them with only a vague request. Can give appearance of trying to upsell. Some of them are 'tuned in' to the phenomenon of the longer someone has to get used to their face, the less likely they are to appreciate a significant aesthteic improvement because with that comes an significant aesthetic change. So any attempt to tell them that they need something more and more specific than what they are asking for, positions them to 'sell' the patient on that or to be perceived as such by the patient. Hence, it's better to suggest the minimum UNLESS the patient can TARGET and make CLEAR what changes they want.
The reality of this is that sometimes, it actually takes MORE time to show someone a maximum aesthetic improvement and to EXPLAIN to them all the things that would be needed to do that than to actually DO a surgery. So, from a doctor's perspective, it's best to reserve the maximum aesthetic improvement stuff--even if they can do it-- to patients who know what changes they want and why, can be specific about it where said specifics are on target with the type of stuff the the doctor does.
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I'm pretty sure I said impaction only with the lower jaw rotating very slightly and naturally from that impaction.
Everyone should be using the latest technology, so you shouldn't let that effect your decision in any way.
Ok, I guess I'm so dumb when it comes to this that I did not understand what you meant when you wrote that the first time. It's still not totally clear to me - would this mean that the lower jaw would not be broken and advanced? All the other people (orthodontists and surgeons) I spoke to before said straight away that the lower part should be advanced because it is too far back. So, according to you and this German guy, this might not be a good idea?
Re: technology - the surgeon in the country where I currently live told me he only uses dental casts for planning and no computers / no 3D planning. He even told me this fancy stuff is unreliable and it is not possible to predict how the soft tissue will respond and so on so he can't see the point of the planning software or something like that. Which is one of the many reasons I never seriously contemplated doing the surgery with him and / or here, and am looking for someone in Europe.
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For someone who's vague in what they want, the doctor is better off sticking to the minimum of what can be done.
The reality of this is that sometimes, it actually takes MORE time to show someone a maximum aesthetic improvement and to EXPLAIN to them all the things that would be needed to do that than to actually DO a surgery. So, from a doctor's perspective, it's best to reserve the maximum aesthetic improvement stuff--even if they can do it-- to patients who know what changes they want and why, can be specific about it where said specifics are on target with the type of stuff the the doctor does.
Oh that would totally explain it, I was certainly very vague on what I really wanted out of this. I guess it can be a cultural thing too - Germans are not famous for trying to 'sell' you stuff you might not want or need and he also mentioned that one jaw (obviously) would be cheaper and would not even require an overnight stay in hospital. I guess I'll continue with consultations and maybe try to be more specific next time about what I want.
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You're not dumb. It's just that this stuff is a lot more complex and complicated than it first appears, and some surgeons don't show or explain the reasonings & geometry behind their suggestions esp not in a 1st consult. So you are kinda forced to attempt to understand it yourself, which isn't easy at all, and never fully a complete understanding either.
I think when the maxilla changes height (in your case re-positioned upwards) it results in an auto-rotation and slight advancement of the lower jaw. I imagine it won't be as much compared to as if they cut and advanced the lower jaw forward though. But I also don't know - the auto rotation might also depend on how the maxilla is impacted (the whole maxilla impacted up VS the front of the maxilla impacted).
Re: technology - the surgeon in the country where I currently live told me he only uses dental casts for planning and no computers / no 3D planning. He even told me this fancy stuff is unreliable and it is not possible to predict how the soft tissue will respond and so on so he can't see the point of the planning software or something like that. Which is one of the many reasons I never seriously contemplated doing the surgery with him and / or here, and am looking for someone in Europe.
Out of curiosity, was he old?
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I think when the maxilla changes height (in your case re-positioned upwards) it results in an auto-rotation and slight advancement of the lower jaw. I imagine it won't be as much compared to as if they cut and advanced the lower jaw forward though. But I also don't know - this auto rotation might also depend on how the maxilla is impacted ( the whole maxilla impacted up vs the only the front of the maxilla impacted).
Out of curiosity, was he old?
I think I understand it a lot better after your explanation, thank you!
The 'local' surgeon I mention is about 60. It's tricky because you don't want a surgeon just out of medical school that's great with computers but has no experience. On the other hand, older doctors might be set in the ways they have been doing certain procedures for several years, even if there are better ways.
The same doctor also told me he wanted to extract four premolars before the surgery (even though my wisdom teeth have already been removed), two from the top and two from the bottom. I imagine this must be some kind of an 'old' technique because the very first time I asked about this surgery twenty years ago, they told me the same thing and another doctor I saw in the country where I now live told me the same again (4 extractions, 2 top - 2 bottom). Whereas Western doctors I spoke to recently all said no extractions or maybe only from the bottom to create more space between the two sets of teeth before surgery.
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I now officially stopped feeling bad about being 'ignorant' and making the 'wrong decisions' about my teeth / jaws previously. Any time I speak to an 'expert', they say something different so it seems there really isn't a consensus on what to do when someone has 'weird' teeth / jaws, everyone wants to try something and it might or might not work. I e-mailed my x-rays and photos to a surgeon in Hungary and he got back to me saying he does not think I need jaw surgery, rather I should get 4 premolars extracted, two from the top and two from the bottom, which would 'improve my profile' and make my upper teeth less visible and that's it. He added that the orthodontic treatment to close the gaps would take 2.5 years (!).
I am a skinny woman with a thin face, so highly doubt that removing those 4 teeth would 'improve my profile' plus I have the upper lip incompetence and gummy smile thing going on which would still be the same even if they removed all my teeth lol. Anyway, I continue my search for the best solution.
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I now officially stopped feeling bad about being 'ignorant' and making the 'wrong decisions' about my teeth / jaws previously. Any time I speak to an 'expert', they say something different so it seems there really isn't a consensus on what to do when someone has 'weird' teeth / jaws, everyone wants to try something and it might or might not work.
Correct. It's a profession full of bulls**t and people who "know" exactly what you "need".
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I would pretty much avoid extractions at all costs in your case.
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I would pretty much avoid extractions at all costs in your case.
Thanks, that's what I'm planning to do, especially from the upper jaw. Will see what the other surgeons come up with.
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It's a profession full of bulls**t and people who "know" exactly what you "need".
That's what I've been discovering in the last few weeks... Guess it comes down to the fact that most people like myself don't actually 'need' anything, but are hoping they could look better or breathe better etc. if only somebody did something about their lower face.
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I now officially stopped feeling bad about being 'ignorant' and making the 'wrong decisions' about my teeth / jaws previously. Any time I speak to an 'expert', they say something different so it seems there really isn't a consensus on what to do when someone has 'weird' teeth / jaws, everyone wants to try something and it might or might not work. I e-mailed my x-rays and photos to a surgeon in Hungary and he got back to me saying he does not think I need jaw surgery, rather I should get 4 premolars extracted, two from the top and two from the bottom, which would 'improve my profile' and make my upper teeth less visible and that's it. He added that the orthodontic treatment to close the gaps would take 2.5 years (!).
I am a skinny woman with a thin face, so highly doubt that removing those 4 teeth would 'improve my profile' plus I have the upper lip incompetence and gummy smile thing going on which would still be the same even if they removed all my teeth lol. Anyway, I continue my search for the best solution.
Well, you seem to know what you don't want as soon as a suggestion is made. Your approach to consults is one where it's implicit that you are depending on them to tell you what you 'need' in a situation where you don't know what you want and why. That, in turn, goes into a perpetual indecision mill. Try defining your own needs and articulating your own aesthetic goals.
A good starting point would be to identify what you have that is most obvious such as: 'I have a gummy smile. I have too much upper tooth show.' Then find out what it's called (Vertical Maxillary Excess) and Google how that is treated. At least that would allow you to understand a suggestion (such as maxillary impaction CCW) to address it. You should also be able to be clear TO YOURSELF whether or not you LIKE or DISLIKE your VME. Likewise with other parts of your face. You like the recession to the lower jaw or you DON'T like it.
You probably won't get much out of any of these consults other than more indecision unless you have a clarified (aesthetic) goal you can convey.
A ship without course has no favorable wind.
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Well, you seem to know what you don't want as soon as a suggestion is made. Try defining your own needs and articulating your own aesthetic goals.
Ok, so I sat down with a mirror today and tried to work out what I want. I want to look as close as possible to how I look in the first picture that I'm attaching to this post (obviously, without the ridiculous looking mentalis strain because here I'm forcing my lips to close - this is a selfie without any 'special effects').
So, I want the lower part of my jaw / chin to come a bit forward and upward. At this point I have absolutely no idea if this is surgically possible. The second picture shows my teeth / jaws as they are now.
What I DON'T want is: tooth extraction, flat face, long face, long and sad looking philtrum, 'man-like' lower jaw, protruding chin.
Now I just need to find out if this is at all possible or not, and if so, who would be the best person to do it.
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Ok, so I set down with a mirror today and tried to work out what I want. I want to look as close as possible to how I look in the first picture that I'm attaching to this post (obviously, without the ridiculous looking mentalis strain because here I'm forcing my lips to close - this is a selfie without any 'special effects').
So, I want the lower part of my jaw / chin to come a bit forward and upward. At this point I have absolutely no idea if this is surgically possible. The second picture shows my teeth / jaws as they are now.
What I DON'T want is: tooth extraction, flat face, long face, long and sad looking philtrum, 'man-like' lower jaw, protruding chin.
Now I just need to find out if this is at all possible or not, and if so, who would be the best person to do it.
Well, if you recall what I said in my early prior post, I mentioned that there are plenty of people walking around with a facial imbalance where having one can 'blend in'. Also there are those who are 'attached' in some way to their imbalance where they will mourn the loss of an imbalance once it is improved. What I can tell you from the frontal view (and your statements) is that it looks like you have an imbalance BUT you are attached to it and quite possibly enough that you would find something 'wrong' with an improvement even if it made something 'right'.
I'm not going to do a full or complex analysis here. Just a basic one having to do with proportional division of '1/3rds' to describe the basic imbalance.
1: Your lower '1/3rd' is shorter than the 2 upper 1/3rds.
2: The shortness can be isolated to the lower jaw.
3: There is also narrowness to the lower jaw area relative to the prominence of the cheeks (yellow diagonals).
Since BOTH the shortness of the lower jaw area AND it's narrowness is a direct function of the lower jaw RECEDING into the background, better balance would be achieved by bringing it MORE into the FOREGROUND. In terms of aesthetics, a better FRAME for the upper 2/3rds and the 'long' distance from the base of the nose to the (red) line that passes through the closing of the lips would be one that brought the lower jaw (and chin) area MORE into the foreground. In terms of surgery to do that, it would relate to a BSSO and possibly some chin augmentation. That would be in addition to reducing the Vertical Maxillary Excess via anterior impaction of the maxilla.
The issue here is that you have an imbalance that can be seen from the front which could be improved by giving you a wider and longer 'frame' to the lower '1/3rd' of the face. BUT you are ATTACHED to it. So, if a doctor corrected that imbalance, you would probably have what is called 'locus of identity' issues which is when one is ATTACHED to an imbalance and mourn it's loss once it's corrected. That is to say, attributing the imbalance to looking 'feminine' would very well result in your attributing correction of it to looking 'masculine' or 'protrusive'.
So, you would have to find a surgeon who is more 'sensitive' to your attachment to your imbalance than one that is honed into optimizing or maximizing aesthetic balance.
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In that photo there appears to be a yaw, too.
This is difficult to address.
Agree with Kavan's analysis. To me your face looks short in all the photos posted, and it's most likely due to the lower third being shorter. Impacting and shortening that even more might be very bad. That's what I was trying to warn against. It's possible it would look good, though. Honestly, I can't envision it. But my gut in shortening an already short face is tread lightly.
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In that photo there appears to be a yaw, too.
This is difficult to address.
Agree with Kavan's analysis. To me your face looks short in all the photos posted, and it's most likely due to the lower third being shorter. Impacting and shortening that even more might be very bad. That's what I was trying to warn against. It's possible it would look good, though. Honestly, I can't envision it. But my gut in shortening an already short face is tread lightly.
Well, my analysis involves both a BSSO and chin displacement along with the impaction to address the VME.
Impaction is done to reduce VME. But after the impaction, the lower jaw can have some auto rotation to swing forward and up somewhat. THEN, after THAT, if it's brought MORE forward (more into the FOREGROUND with a BSSO, it will 'cast' WIDER in frontal view and a little longer to offset both the narrowness to the lower '1/3rd' and the shortness. The chin, itself, could also be brought more into the foreground with a forward and down displacement (oblique genio but not sliding) to further balance the relatively short lower 1/3rd. An oblique genio would tend to work (yes, it elongates) because you'd also be WIDENING the areas beside the chin by the BSSO bringing lower jaw more into foreground and also because some elongation would be needed to offset the length of the labial ledge area or what you call the 'philtral' area. That is because the lower 1/3 is further subdivided into 1/3rds where a LONGER distance between where the lips close and the base of the chin would be needed to offset the long distance between subnasa and the closing of lips.
Some of the shortness to the lower 1/3rd is directly attributed to the recession of the mandible as is the narrowness. But the other shortness that the eye picks up is due to the excess length of the labial ledge area (long upper lip) which could be offset by the oblique genio (genio that brings forward but also elongates for which a bone buttress material needs to be put in between the cuts).
The CCW impaction that WOULD address the VME could also make her lower 1/3rd cast shorter IF done as SINGLE JAW surgery. But doing BOTH the BSSO and oblique genio WITH IT would tend to give better balance and most certainly offset imbalance that could arise from SINGLE (upper) jaw surgery.
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Yeah. But since she doesn't want a masculine jaw, that rules out BSSO unless it's extremely conservative. BSSO with rotation would give her an "anchorwoman jaw." She can get some of that rotation and projection via the impaction, and it would be mild (likely keep some femininity) and with less risk to her nerves. If it's not enough, rotate the chin forward and down as well, as you mentioned, in a follow up procedure. I don't see her coming out of it remaining feminine with BSSO, though, and I don't see her face as overly narrow -- it looks within norms. But I admit, this is a really hard case due to the shortness of the lower 3rd, and I can't envision the end result of double jaw on her. So, maybe what you recommend is the correct plan. I'm skeptical she even needs surgery so I have bias here. Best thing is to probably get three plans from surgeons with a good reputations, and then post those plans.
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Yeah. But since she doesn't want a masculine jaw, that rules out BSSO unless it's extremely conservative. BSSO with rotation would give her an "anchorwoman jaw." She can get some of that rotation and projection via the impaction, and it would be mild (likely keep some femininity) and with less risk to her nerves. If it's not enough, rotate the chin forward and down as well, as you mentioned, in a follow up procedure. I don't see her coming out of it remaining feminine with BSSO, though, and I don't see her face as overly narrow -- it looks within norms. But I admit, this is a really hard case due to the shortness of the lower 3rd, and I can't envision the end result of double jaw on her. So, maybe what you recommend is the correct plan. I'm skeptical she even needs surgery so I have bias here. Best thing is to probably get three plans from surgeons with a good reputations, and then post those plans.
A BSSO doesn't patently give a female a 'masculine jaw'. Not if it's done in accordance to guidelines for females which DIFFER from guidelines for males where the male jaw is absolutely more forward and wider than the female jaw. However, the PERCEPTION of a 'masculine jaw' could arise from an ATTACHMENT to the jaw being recessed or retrusive as it is. That is to say if she's attached to the (faulty) concept of: 'A recessive jaw is therefore feminine.', that's the type of attachment that would result in the PERCEPTION of it looking 'masculine' EVEN IF the BSSO was conservative and done in accordance with guidelines for female (recessive) lower jaws.
Her jaw looks recessive from the front because it RECEDES into the background. (Because it is recessive.) If that's hard to 'see', the profile view shows it better. It's recessive RELATIVE to her upper 2/3rds which are more in the foreground.
So, the reason not to get a surgery wouldn't be because a BSSO would make her look more 'masculine'. The reason not to get a surgery would be because she IDENTIFIES with the imbalance or does not perceive as imbalance. 'Rotating' her chin forward and down (it's not a rotation, it's a linear diagonally downward displacement) in the ABSENCE of a BSSO (that would also visually widen the lower face somewhat) could look like a pointy chin in the absence of also bringing the lower jaw more in the foreground.
Basically, my eye 'sees' the imbalance of the front. But as I said in one of my earlier posts on this string, there are plenty of people walking around with jaw imbalance and enough so there is no impending 'need' for each person having one to have surgery to correct. Some people want to maximize or optimize correction of imbalances and some don't.
Let's just say that the face in the photo has an imbalance to the lower 1/3rd that would veer toward better balance by the displacements I mentioned. However the PERSON who possesses the face would have to WANT to DETACH from the imbalance to justify surgery. If instead, they are ATTACHED to the imbalance and don't want to detach, then no surgery at all would be the conservative choice.
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Dear Kavan and GJ, I am so grateful to both of you for the long analysis, and also this was the first time I felt I could actually understand everything you wrote so I'm feeling a bit more in control of the whole process. I will read it all a few more times and try to process it. The German doctor I spoke to was trying to explain stuff about the 1/3 measurements but it was difficult to follow on a video call, I understand it much better now.
I have video consultations coming up with Dr. A in Spain and Dr. D in Belgium within the next 3 weeks, and a couple of others (UK, France). I doubt that I will get detailed plans from them though - at least the ones I spoke to so far said they had to see me and get measurements done to be able to prepare a detailed plan, even though someone has just asked if I could get a full face CBCT done here and send it to him so I'm in search of a hospital that can do that where I live. Will post updates.
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Update: so I had a few more consultations and only have one more scheduled, with Dr A in Spain. So far there are two surgeons I am seriously considering and as usual, they have quite different views on how to fix my face.
Dr D from Belgium is confident that I need Le Fort 1 plus BSSO and genioplasty. He says all three are needed and in addition, he also suggested paranasal augmentation with medpore plus PEEK cheek bone augmentation (all in one operation). It never crossed my mind before to use any implants but he sounded quite convincing.
The movements he proposed are: 4-5mm 'intrusion' of the upper jaw and 1-2mm 'backwards' (English is not his first language so don't ask me what he means by that...). For the lower jaw, alveolar segment osteotomy after removing first premolars. By the way, he wants to do surgery first on me and then braces for a very short time only, like 1-2 months to stabilize the bite. He says since my teeth are already straight, they just need to be repositioned.
I stressed it to him that I'm worried about nasal changes and looking older after Le Fort 1 and he kept saying and included in his written recommendation as well that all things considered, the Le Fort would give me the best aesthetic result.
Now there is a British surgeon I've been talking to that made a great impression on me, and he told me that it would not be a good idea to touch my maxilla at all and I would get the best and safest outcome from orthodontics, mandibular advancement and / or genioplasty. He says that my gummy smile is not bad at all and I am getting to that critical age when my upper lip will start 'sinking' and I will be happy I have a gummy smile and tooth show. Which sounds great and I would be so glad and relieved to avoid Le Fort 1, on the other hand though, I cannot imagine ever being happy about my tooth show as honestly, it is just way too much and if I get it 'corrected' by orthodontics, my teeth will still be visible, only they will be inclined backward.
Right now I am really in two minds, both plans are really tempting to me in different ways. I feel very comfortable with the British surgeon, he was very honest with me about the risks and did not try to 'sell' me anything, quite the opposite in fact. He is well qualified and experienced and was very confident saying just moving the lower part forward would be a great improvement and we would avoid the risks associated with messing with the maxilla. His plan is lower risk, but potentially also 'lower gain'.
If Dr D's plan works out, I believe I would end up looking a lot better than now, and probably better than if I go with the British doctor's plan. On the other hand there are a lot more things that can go wrong, medically and aesthetically. It really is like gambling. Does anybody think the plan of moving the lower part only (with or without genio) can actually be a good one, including from the aesthetic point of view?
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Update: so I had a few more consultations and only have one more scheduled, with Dr A in Spain. So far there are two surgeons I am seriously considering and as usual, they have quite different views on how to fix my face.
Dr D from Belgium is confident that I need Le Fort 1 plus BSSO and genioplasty. He says all three are needed and in addition, he also suggested paranasal augmentation with medpore plus PEEK cheek bone augmentation (all in one operation). It never crossed my mind before to use any implants but he sounded quite convincing.
The movements he proposed are: 4-5mm 'intrusion' of the upper jaw and 1-2mm 'backwards' (English is not his first language so don't ask me what he means by that...). For the lower jaw, alveolar segment osteotomy after removing first premolars. By the way, he wants to do surgery first on me and then braces for a very short time only, like 1-2 months to stabilize the bite. He says since my teeth are already straight, they just need to be repositioned.
I stressed it to him that I'm worried about nasal changes and looking older after Le Fort 1 and he kept saying and included in his written recommendation as well that all things considered, the Le Fort would give me the best aesthetic result.
Now there is a British surgeon I've been talking to that made a great impression on me, and he told me that it would not be a good idea to touch my maxilla at all and I would get the best and safest outcome from orthodontics, mandibular advancement and / or genioplasty. He says that my gummy smile is not bad at all and I am getting to that critical age when my upper lip will start 'sinking' and I will be happy I have a gummy smile and tooth show. Which sounds great and I would be so glad and relieved to avoid Le Fort 1, on the other hand though, I cannot imagine ever being happy about my tooth show as honestly, it is just way too much and if I get it 'corrected' by orthodontics, my teeth will still be visible, only they will be inclined backward.
Right now I am really in two minds, both plans are really tempting to me in different ways. I feel very comfortable with the British surgeon, he was very honest with me about the risks and did not try to 'sell' me anything, quite the opposite in fact. He is well qualified and experienced and was very confident saying just moving the lower part forward would be a great improvement and we would avoid the risks associated with messing with the maxilla. His plan is lower risk, but potentially also 'lower gain'.
If Dr D's plan works out, I believe I would end up looking a lot better than now, and probably better than if I go with the British doctor's plan. On the other hand there are a lot more things that can go wrong, medically and aesthetically. It really is like gambling. Does anybody think the plan of moving the lower part only (with or without genio) can actually be a good one, including from the aesthetic point of view?
'intrusion' usually refers to jamming the teeth up into the aveolar part of jaw bone via appliances to do so. Since a Lefort 1 is mentioned, it probably refers to impaction. In essence addressing too much upper front teeth show and also some protrusion. Sounds like that part addresses part of your face that bothers you most. BSSO and genio would address lower jaw/chin retrusion. He could be up-selling the implant suggestion. Would depend on how convincing he was vs. your own observations. The paranasals could be to potentially offset changes to the nose base by pushing back the maxilla in light of your apprehensions.
As to British doctor, you can lose some lip support when the teeth are pushed backwards. The upper lip can look longer if it's inclined along a vertical plane. Diagonal flare out of upper teeth makes it look shorter from the front.
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Hoping Dr A will help clear things up because there doesn't seem to be too much consensus on what should be done. Have all these consults been these online/phone consults, or have you seen any in person?
The movements he proposed are: 4-5mm 'intrusion' of the upper jaw and 1-2mm 'backwards' (English is not his first language so don't ask me what he means by that...). For the lower jaw, alveolar segment osteotomy after removing first premolars. By the way, he wants to do surgery first on me and then braces for a very short time only, like 1-2 months to stabilize the bite. He says since my teeth are already straight, they just need to be repositioned.
I could be wrong, but if he wants to move things backwards then it sounds like he may think you have bimaxillary dental protrusion (which you may have - your teeth are pretty protrusive!!). What is a alveolar segment osteotomy for the lower jaw - did he explain? Will it move your teeth back or forward?
I came across this video, could alveolar segment osteotomy be something like this on lower jaw? https://youtu.be/ddIXs2eZCaM (although I have no idea how that'd work on you specifically, so I might be way off)
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Hoping Dr A will help clear things up because there doesn't seem to be too much consensus on what should be done. Have all these consults been these online/phone consults, or have you seen any in person?
I could be wrong, but if he wants to move things backwards then it sounds like he may think you have bimaxillary dental protrusion (which you may have - your teeth are pretty protrusive!!). What is a alveolar segment osteotomy for the lower jaw - did he explain? Will it move your teeth back or forward?
I came across this video, could alveolar segment osteotomy be something like this on lower jaw? https://youtu.be/ddIXs2eZCaM (although I have no idea how that'd work on you specifically, so I might be way off)
Yes. That's what it is.
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Hoping Dr A will help clear things up because there doesn't seem to be too much consensus on what should be done. Have all these consults been these online/phone consults, or have you seen any in person?
What is a alveolar segment osteotomy for the lower jaw - did he explain? Will it move your teeth back or forward?
These recent consults have been over Skype (they got my x-rays and several photographs beforehand and saw me on video) but over the last twenty-odd years, I also consulted surgeons and orthos in person and it was my experience that they always tell me different things (bimax, top jaw surgery only, bottom only, pull teeth from top, from bottom, from both, do nothing, get a chin implant, etc. etc. - I got told all these in person before). I think the issue is that whatever is done, I might lose some of my good features along with the bad, at least that's the impression I get. I'm in the process of trying to get CBCT done and will try to arrange some personal consultations before finalizing plans but right now I can't travel because of my work.
Re: alveolar segment osteotomy, yes he explained very well and showed it to me on a model. My lower front teeth are currently proclined and instead of asking me to wear braces for several months to straigthen them, he is planning to extract teeth during / just before the operation and reposition the six lower front teeth so they'll be straight and in a different position. It's pretty much what you see in the video you posted, but only in the lower jaw. He would also bring the lower jaw forward along with it, plus do a genio.
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These recent consults have been over Skype (they got my x-rays and several photographs beforehand and saw me on video) but over the last twenty-odd years, I also consulted surgeons and orthos in person and it was my experience that they always tell me different things (bimax, top jaw surgery only, bottom only, pull teeth from top, from bottom, from both, do nothing, get a chin implant, etc. etc. - I got told all these in person before). I think the issue is that whatever is done, I might lose some of my good features along with the bad, at least that's the impression I get. I'm in the process of trying to get CBCT done and will try to arrange some personal consultations before finalizing plans but right now I can't travel because of my work.
Yes, this is a good insight.
Some things are absolute when designing a treatment, and some things are opinions, preferences etc. Treating narrow airways is absolute, you can see them on the x-ray and after surgery you can do a new scan and see what you achieved. Oclussion of the bite is also absolute, you can see if the bite fits and if the function is good etc.
There can how ever be several configurations that yield such results and when having aesthetic concerns it can be very subjective. The more degree of freedome you add to your treatment, the more configurations are possible. Doing treatment with only braces don't have so much degree of freedome, you're limited to tha plasticity of the alveolar bone. Extracting teeth, cutting the jaws, segmentating the jaws, implants and so forth opens a lot of posibility to different configurations. It is also as you say, you can never come with a picture of someone else and say you want to look like that. You bring the bone structure and tissue and the surgeon will do the best they can figure out and it will be some trades.
Hopefully all proposed treatments meet the absolute surgey goals. Good function. Some surgeons are very restrictive and won't do anything more than what's absolutely necessary. They know about the risk of complications and every cut adds complexity and risk. Also it's often a requirement within the health care system that they only offer to treat the diagnosis and to do it in a cost efficient way even if a more fancy and aesthetic pleasing solution is possible. On the other hand there are more bold surgeons who seem to always do double jaw surgery and segmentations.
I don't answer a lot of question, but on the other hand you didn't ask any question. But just confirm that jaw surgery is not an easy fix and you need to go through the proposals you got and try to figure out what makes sense to you. Is it an option to not do anything? Yes/no? Can you isolate your concern in a way where an implant would solve your concern? Etc and try to narrow down where you're heading. Hopefully that can narrow it down to understand what you want. You need to be confident before signing up for something like this, it's a long and big process.
A lot of us reject extractions categorically, but also the most common extraction case is alternative treatments to overbite to avoid surgery when it's motivated. I don't know what it looks like in your case, but look into so it really make sense before extracting teeth.
Lastly. I saw you wrote in another thread that you look significantly different from the norm. It's a scientific fact that anyone is unable to evaluate their own appearance objectively. I think you can ask anyone in here and they'll tell you that they have the worst case. If we were able to swap cases on the forum, the need for surgery would probably go down.
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The movements he proposed are: 4-5mm 'intrusion' of the upper jaw and 1-2mm 'backwards' (English is not his first language so don't ask me what he means by that...). For the lower jaw, alveolar segment osteotomy after removing first premolars. By the way, he wants to do surgery first on me and then braces for a very short time only, like 1-2 months to stabilize the bite. He says since my teeth are already straight, they just need to be repositioned.
Suggesting surgery first give the impression of wanting to get you into and out of the surgery room as soon as possible. Orthodontic preparation always give most predictive result. If the teeth are already in a good position, it shouldn't need much adjustments any way and it wouldn't fall under the surgery first approach. SF differs from normal protocol in the sense that the anticipated movements are scheduled after the surgery instead of before. If there are no anticipated movements, then it's just surgery. First anticipate that there is a switch in order from conventional treatment and switching the order can affect the predictability and it's ultimately the orthodontist that decides when it's sensible sending you to surgery, as they're the ones that are handling the case after.
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There can how ever be several configurations that yield such results and when having aesthetic concerns it can be very subjective.
Hopefully all proposed treatments meet the absolute surgey goals. Good function.
Lastly. I saw you wrote in another thread that you look significantly different from the norm. It's a scientific fact that anyone is unable to evaluate their own appearance objectively. I think you can ask anyone in here and they'll tell you that they have the worst case. If we were able to swap cases on the forum, the need for surgery would probably go down.
Thanks so much for your thoughtful response! The thing is, I do not have any functional problems - I wonder how many people on this forum really do? I can eat and speak completely normally, several of my teeth meet at the back and I do not have any pain anywhere. I started having breathing problems recently but I do not have any proof that this is related to my jaws / bite, or that jaw surgery would address that issue.
At this stage, I mostly just want to get surgery to improve my looks. I do not 'subjectively' feel ugly or anything and I get a lot of positive feedback from people about my current looks, but it's a fact I look different, something like an older version of the girl in the article with the teeth sticking out: https://www.daytonfacialsurgery.com/procedures/jaw-surgery/. I definitely do not think my case is really bad or the 'worst', but I definitely have the kind of class 2 bite that is quite noticable to a lay person, especially because of the vertical maxillary excess.
At the same time I'm quite worried about any surgery making my looks worse, not better, on top of all the potential complications, pain, numbness and so on. For example the 'after' pictures of this particular girl look horrifying to me and this is not the first time I see a really bad result for this type of surgery (and I am sure that the really bad ones never make it to the internet so I can only imagine how common it is for people to end up looking worse than before). Anyway, I really don't know what to do.
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Suggesting surgery first give the impression of wanting to get you into and out of the surgery room as soon as possible. Orthodontic preparation always give most predictive result. If the teeth are already in a good position, it shouldn't need much adjustments any way and it wouldn't fall under the surgery first approach.
He said I'd need braces for about 6 weeks in total, mostly during and after surgery. I had braces several years ago and have straight teeth. I believe that wearing braces before the surgery is a relatively new practice and they originally used to do surgery first and then braces, and that's still the case in some countries, especially in Asia. I might be wrong but I personally feel that in many cases Western doctors are really overdoing it with the orthodontics. We can read about several cases on forums where people had braces on for years before surgery and things still went wrong - anyway, just my two cents.
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Thanks so much for your thoughtful response! The thing is, I do not have any functional problems - I wonder how many people on this forum really do? I can eat and speak completely normally, several of my teeth meet at the back and I do not have any pain anywhere. I started having breathing problems recently but I do not have any proof that this is related to my jaws / bite, or that jaw surgery would address that issue.
At this stage, I mostly just want to get surgery to improve my looks. I do not 'subjectively' feel ugly or anything and I get a lot of positive feedback from people about my current looks, but it's a fact I look different, something like an older version of the girl in the article with the teeth sticking out: https://www.daytonfacialsurgery.com/procedures/jaw-surgery/. I definitely do not think my case is really bad or the 'worst', but I definitely have the kind of class 2 bite that is quite noticable to a lay person, especially because of the vertical maxillary excess.
At the same time I'm quite worried about any surgery making my looks worse, not better, on top of all the potential complications, pain, numbness and so on. For example the 'after' pictures of this particular girl look horrifying to me and this is not the first time I see a really bad result for this type of surgery (and I am sure that the really bad ones never make it to the internet so I can only imagine how common it is for people to end up looking worse than before). Anyway, I really don't know what to do.
I often use quotes around words like "need" and "normal". There are a lot of norms on everything that can be meassured on a person. Actually, if you calculate the probability of being inside the norm on many enough meassurements, it's more normal to not be. Norms are calculated by taking the mean value of a random population and looking at the standard deviation. A standard deviation is where 68% of a random population fits. The probability for a random person to be within +-one standard deviation on 2 unrelated measurements, is 0.68^2 = 46%. More probable to not be. Sometimes you use +-2 standard deviations that is 95% or other cut off, but you get the point. However, meassurements when looking at a specific area are not unrelated. If there's a big enough imbalance in the jaws the values are correlated.
It also depends what you mean with need. People lived before surgery was available. There are different clinical criterions when surgery is covered by health care system or insurances. It effectively treats OSA, bite problems can lead to decay in different ways. I personally think aesthetic concerns can be as valid as any as long as you understand the surgery. Aesthetics is definitely one thing that adds up for me when deciding, but also function and aesthetics are often correlated. What is considered aesthetic is normally when things look healthy. Hopefully most surgieries meet the objective of why they're carried out and I don't know who is to judge what is needed except the person having the surgery.
If you don't think the girl on the top on the link you posted have a great improvement, you shouldn't get into jaw surgery. I can't tell if it's the best plan, but a significant aesthetic improvement.
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He said I'd need braces for about 6 weeks in total, mostly during and after surgery. I had braces several years ago and have straight teeth. I believe that wearing braces before the surgery is a relatively new practice and they originally used to do surgery first and then braces, and that's still the case in some countries, especially in Asia. I might be wrong but I personally feel that in many cases Western doctors are really overdoing it with the orthodontics. We can read about several cases on forums where people had braces on for years before surgery and things still went wrong - anyway, just my two cents.
This article have a good summary of orthognatic approach and how it has evolved.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314839/
Presurgical orthodontic preparation was uncommon for patients requiring orthognathic surgery until the 1960's. The patients' and clinicians' desire for optimal esthetic and occlusal results led to the most common current treatment approach presurgical orthodontic decompensation of the occlusal relationships and attainment of normal dental alignment. The disadvantage of having orthodontic interventions both before and after orthognathic surgery include a long treatment time of 7–47 months, dental caries, gingival recession and root resorption.[1,2] Other complications associated with preoperative orthodontic treatment are temporary worsening of facial appearance and masticatory discomfort. When a patient refuses surgery after all the preparations have been made, the results can be catastrophic. Ever since the first orthognathic surgery procedure was performed by Hullihen in 1848, many new techniques and methods have been introduced.[3] As shown by Kondo and Aoba the limits of orthodontic treatment alone to severe malocclusions are broadening, but the underlying skeletal imbalances remain.[4,5] Brachvogel et al.[6] in 1991 proposed concept of “surgery-first and orthodontics second” with the goal of reducing some of the disadvantages and inconveniences of presurgical orthodontics. He claimed that the normalized surrounding soft tissues (lips, cheeks and tongue) settled teeth into better positions after surgery, facilitating remaining orthodontic tooth movement and reducing the total orthodontic treatment period.
Nowadays, the concept of surgery-first followed by orthodontic treatment is applied to orthognathic surgery cases in orthodontic centers in Korea, Japan and Taiwan. This concept and technique are called “surgery-first-orthognathic-approach” or “surgery-first approach” (SFA).
In modern treatment it has definitely been the most common approach with orthodontic preparation and only few cases with surgery first. The article says that before 1960 they apparently did it but then switched to the normal approach of orthodontic preparations. Now it has started to come back again, with all technology and stressed society we live in. Surgery today is more advanced and they can predict a lot better with digital models etc than they could 1960. But the fact remains, doing surgery first includes making assumptions and guessing, while orthodontic preparation aims to have the teeth in final position so the surgeon have no excuse to find the occlusion. Even with surgery first, they bond the braces before surgery if they gonna use braces after, so they can use it as anchorage for elastics and guidance during surgery.
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Thanks so much for your thoughtful response! The thing is, I do not have any functional problems - I wonder how many people on this forum really do? I can eat and speak completely normally, several of my teeth meet at the back and I do not have any pain anywhere. I started having breathing problems recently but I do not have any proof that this is related to my jaws / bite, or that jaw surgery would address that issue.
At this stage, I mostly just want to get surgery to improve my looks. I do not 'subjectively' feel ugly or anything and I get a lot of positive feedback from people about my current looks, but it's a fact I look different, something like an older version of the girl in the article with the teeth sticking out: https://www.daytonfacialsurgery.com/procedures/jaw-surgery/. I definitely do not think my case is really bad or the 'worst', but I definitely have the kind of class 2 bite that is quite noticable to a lay person, especially because of the vertical maxillary excess.
At the same time I'm quite worried about any surgery making my looks worse, not better, on top of all the potential complications, pain, numbness and so on. For example the 'after' pictures of this particular girl look horrifying to me and this is not the first time I see a really bad result for this type of surgery (and I am sure that the really bad ones never make it to the internet so I can only imagine how common it is for people to end up looking worse than before). Anyway, I really don't know what to do.
If you can't make a decision about maxfax and instead be in a state of perpetual indecision the more consults you go on, then what stops you from just ISOLATING the part that directly addresses the bimax protrusion? You could get the same segmental osteotomy on the UPPER jaw to reduce protrusion there too. Also maybe a little bit of the upper segment, which is excess alveolar process, could also be reduced vertically instead of getting the entire lefort to push that area backwards along with suggestion of paranasals to help support the nose area that can change a bit from that. If they can't reduce the alveolar excess with that (which I think they can), then you can get excess upper tooth show reduced by reducing the length of the teeth (shaving them down).
That would allow you to look at your face with the KEY areas that bother you GONE and later decide if you wanted the other things maxfax could do or if you just wanted to leave stuff alone.
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You could get the same segmental osteotomy on the UPPER jaw to reduce protrusion there too. Also maybe a little bit of the upper segment, which is excess alveolar process, could also be reduced vertically instead of getting the entire lefort to push that area backwards along with suggestion of paranasals to help support the nose area that can change a bit from that. If they can't reduce the alveolar excess with that (which I think they can), then you can get excess upper tooth show reduced by reducing the length of the teeth (shaving them down). That would allow you to look at your face with the KEY areas that bother you GONE and later decide if you wanted the other things maxfax could do or if you just wanted to leave stuff alone.
I had no idea this was an option! Sounds great to me, will start doing more research in this direction. I am now getting to the point where I kind of understand what my dilemma is - the 'teeth sticking out' bothers me the most but the classic solution to that - Le Fort 1 - is what scares me most about the surgery. So I'll have to see if there's an alternative, will definitely look into what you suggest here.
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If you don't think the girl on the top on the link you posted have a great improvement, you shouldn't get into jaw surgery. I can't tell if it's the best plan, but a significant aesthetic improvement.
I am not going to start an argument about this but I showed those photos to two of my friends just to check whether it's just me and they both agreed she looked terrible after the surgery; I honestly don't think many people would say it was an improvement in any ways, let alone 'significant', with the obvious asymmetry, horrific witch chin, weird nose area and so on. I don't think that my opinion on this is a reason for me not to have jaw surgery, however, as I have seen many before and after pictures where people had a great improvement but this was definitely not one of those.
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I had no idea this was an option! Sounds great to me, will start doing more research in this direction. I am now getting to the point where I kind of understand what my dilemma is - the 'teeth sticking out' bothers me the most but the classic solution to that - Le Fort 1 - is what scares me most about the surgery. So I'll have to see if there's an alternative, will definitely look into what you suggest here.
AFAIR, botox can be used to reduce gum show.
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AFAIR, botox can be used to reduce gum show.
Thanks for the tip! I actually tried that once before and it did work to an extent. Also, it was suggested to me to try lip fillers in my upper lip to make it heavier and cover more teeth (my upper lip is quite thin). I decided to leave both botox and fillers for the time being while I'm doing consultations so that doctors can see what I naturally look like, but my back up plan is just camouflage orthodontics, botox and fillers (in case I decide not to go through with the surgery).
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Even with surgery first, they bond the braces before surgery if they gonna use braces after, so they can use it as anchorage for elastics and guidance during surgery.
Yes, Dr D said they'd put on braces just before surgery, then use them after surgery to finalize the bite.
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If you don't think the girl on the top on the link you posted have a great improvement, you shouldn't get into jaw surgery. I can't tell if it's the best plan, but a significant aesthetic improvement.
I noticed you have a strange taste before. The girl went down at least 1 point due to longer philtrum, upturned nose with visible nostrils and long pointy chin. She's still not ugly cause she had a good base, but this was not a succesfull procedure imo. Only her sideprofile was improved, but profile is overrated. Some people change the front of the face negatively, only to improve a minor profile flaw.
By fhe way, I'd like to see more female surgeons to see if they are better than men. Too many male surgeons fck up too much. Most of the times females are more precise and you need precision with this. But maybe it turns out women aren't better cosmetic surgeons and then we can close that chapter.
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I noticed you have a strange taste before. The girl went down at least 1 point due to longer philtrum, upturned nose with visible nostrils and long pointy chin. She's still not ugly cause she had a good base, but this was not a succesfull procedure imo.
I am not saying she is ugly, what I'm saying is she looks worse after the surgery instead of looking better. I can't quantify it as in it's one point or two or three, but compared to herself she looks worse, which is a devastating result when you go through serious surgery like this mainly to make yourself look better. Of course, she still looks nice in the after picture compared to a lot of other people, but not compared to her previous self. Even though, as you say, she had a good base so I'd have expected her to look way better after.
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I noticed you have a strange taste before. The girl went down at least 1 point due to longer philtrum, upturned nose with visible nostrils and long pointy chin. She's still not ugly cause she had a good base, but this was not a succesfull procedure imo. Only her sideprofile was improved, but profile is overrated. Some people change the front of the face negatively, only to improve a minor profile flaw.
By fhe way, I'd like to see more female surgeons to see if they are better than men. Too many male surgeons fck up too much. Most of the times females are more precise and you need precision with this. But maybe it turns out women aren't better cosmetic surgeons and then we can close that chapter.
I think Dogmatix is just telling her that her reactions to the outcome are enough where she shouldn't get surgery. It doesn't matter whether he likes it or not or what his tastes are. What matters is her reaction to it is sufficient information for him to tell her; 'then don't get jaw surgery'.
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I had no idea this was an option! Sounds great to me, will start doing more research in this direction. I am now getting to the point where I kind of understand what my dilemma is - the 'teeth sticking out' bothers me the most but the classic solution to that - Le Fort 1 - is what scares me most about the surgery. So I'll have to see if there's an alternative, will definitely look into what you suggest here.
he video certainly showed BOTH areas of the bimax protrusion being addressed via the segmental osteo. Here's a link to the maxillary one:
https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAx8jfULsh0VAdAsNSU!/?approach=&bone=CMF&classification=95b-Maxilla%2C%20Sagittal&contentUrl=srg%2F95b%2F05-RedFix%2FP400-SubapicOst%2F03_AntMaxOst.enl.jsp&implantstype=Subapical%20(Block)%20osteotomy&method=Maxillary%20prognathism&redfix_url=1340280307204&segment=Orthognathic&showPage=redfix&soloState=lb&step=3&subStep=11&treatment=
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I think Dogmatix is just telling her that her reactions to the outcome are enough where she shouldn't get surgery. It doesn't matter whether he likes it or not or what his tastes are. What matters is her reaction to it is sufficient information for him to tell her; 'then don't get jaw surgery'.
Yes. I think this discussion is way out of line and below anything I can participate in. Imagine if this beautiful girl were to come and read some of these comments, where we don't even have all the records to know anything about the situation. It also demonstrates not being able to understand the complexity of surgery and I see a big risk getting into this, if this is how the outcome is being evaluated.
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Yes. I think this discussion is way out of line and below anything I can participate in. Imagine if this beautiful girl were to come and read some of these comments, where we don't even have all the records to know anything about the situation. It also demonstrates not being able to understand the complexity of surgery and I see a big risk getting into this, if this is how the outcome is being evaluated.
Funny how nobody objected on other threads where everyone was going on and on about how jaw surgery and implants made some guys' faces less attractive than before, illustrated with real people's photos. Maybe it's because most posters there were male, it's ok for them to say another guy looks worse after surgery, but if I point out that a woman looks objectively worse, then I'm the problem and don't understand the 'complexity' of the surgery etc.? OK, I will drop it and keep my opinion to myself from now on.
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Funny how nobody objected on other threads where everyone was going on and on about how jaw surgery and implants made some guys' faces less attractive than before, illustrated with real people's photos. Maybe it's because most posters there were male, it's ok for them to say another guy looks worse after surgery, but if I point out that a woman looks objectively worse, then I'm the problem and don't understand the 'complexity' of the surgery etc.? OK, I will drop it and keep my opinion to myself from now on.
I'm not a moderator or have any obligation to object any where, I only represent my self and don't read every discussion on the board.
I have no problem discussing aesthetic preferences and different opinions of what they want. Continiously judging someone elses result as "terrible", "horrific", "weird", "She looks so so so f@cked up" etc is not a constructive discussion and just disrespectful. A constructive discussion would resolve to asking about the result, if it would be possible to handle it in an other way and try to understand the displacements and tradeoffs being made. You also jump back and forth between "having very, very serious second thoughts" and argumenting that you don't. With all respect, I just don't think you're ready for this, there's a very big chance you'll wake up after surgery being devestated and psychologically in big trouble.
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I think her result is decent, except for the chin. She should’ve had a bsso instead. Changes to the nose are often unavoidable - all that tissue has to go *somewhere* after impaction or advancement.
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Funny how nobody objected on other threads where everyone was going on and on about how jaw surgery and implants made some guys' faces less attractive than before, illustrated with real people's photos. Maybe it's because most posters there were male, it's ok for them to say another guy looks worse after surgery, but if I point out that a woman looks objectively worse, then I'm the problem and don't understand the 'complexity' of the surgery etc.? OK, I will drop it and keep my opinion to myself from now on.
I had no objections about the photo being used as example and being critiqued. Just to let you know, my point about your reactions had nothing to do with the gal in the photo reading them. Just that they were a strong signal against surgery. I would suggest that, on your next consults with doctors, you SHARE the patient's photos and your reactions to her outcome as in HOW you described your feelings to it such as 'horrified', 'ruined for life' and other such responses. It helps the doctor make a call on your candidacy for surgery. Basically, when you consult with doctors, they're looking at your face and what they can do with it. They need to take a closer look at what your potential reactions would be if you were not happy with the outcome. It's important for a mutual decision for patient AND doctor.
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I think her result is decent, except for the chin. She should’ve had a bsso instead. Changes to the nose are often unavoidable - all that tissue has to go *somewhere* after impaction or advancement.
A bsso and genio are not equivalet so you can change between them. Doing a bsso would alter the bite.
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A bsso and genio are not equivalet so you can change between them. Doing a bsso would alter the bite.
Multi-variable equation based on what one wants the solution to be.
chin only solution + 'bite right' = Fewer variables. easier equation to solve.
BSSO solution + 'bite right' = More variables. harder equation to solve.
Concept: Complex multi-variable equations don't necessarily preclude solutions to them.
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I had no objections about the photo being used as example and being critiqued. Just to let you know, my point about your reactions had nothing to do with the gal in the photo reading them. Just that they were a strong signal against surgery. I would suggest that, on your next consults with doctors, you SHARE the patient's photos and your reactions to her outcome as in HOW you described your feelings to it such as 'horrified', 'ruined for life' and other such responses. It helps the doctor make a call on your candidacy for surgery. Basically, when you consult with doctors, they're looking at your face and what they can do with it. They need to take a closer look at what your potential reactions would be if you were not happy with the outcome. It's important for a mutual decision for patient AND doctor.
I totally agree! In fact, even before I saw your post, I printed those before-after photos and decided to tell any potential surgeons that personally, if I had a result like that, I would be extremely upset. Beauty is subjective, maybe others including this girl herself would be OK or even happy with this, who knows. I would not be happy, and since my starting point is quite similar to hers, I have to think long and hard before I do anything, given how I feel about this particular outcome. I'm still not ruling out surgery though - most before-afters I have seen did look better to me in the after, but some of them looked worse, so I have to talk all this through with the doctor before making any final decisions.
For the record, I think the girl in the photos was very pretty before the surgery and still pretty after, my point was not trying to criticise her or her looks in any ways, was just pointing out that the surgeon could have done better. For example, I feel that the orthodontist that straightened my teeth several years ago did an OK job but not great, especially seeing that my lower teeth are severely projected forward. Some orthos that saw that recently told me things like, 'oh my God your lower teeth are really sticking out, what on Earth happened here' etc. I am not taking this personally, I did not choose to have teeth like this, no idea why the original ortho did not fix this or whatever. It is the way my teeth are now and that's that, I don't get upset if someone points it out.
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I totally agree! In fact, even before I saw your post, I printed those before-after photos and decided to tell any potential surgeons that personally, if I had a result like that, I would be extremely upset. Beauty is subjective, maybe others including this girl herself would be OK or even happy with this, who knows. I would not be happy, and since my starting point is quite similar to hers, I have to think long and hard before I do anything, given how I feel about this particular outcome. I'm still not ruling out surgery though - most before-afters I have seen did look better to me in the after, but some of them looked worse, so I have to talk all this through with the doctor before making any final decisions.
For the record, I think the girl in the photos was very pretty before the surgery and still pretty after, my point was not trying to criticise her or her looks in any ways, was just pointing out that the surgeon could have done better. For example, I feel that the orthodontist that straightened my teeth several years ago did an OK job but not great, especially seeing that my lower teeth are severely projected forward. Some orthos that saw that recently told me things like, 'oh my God your lower teeth are really sticking out, what on Earth happened here' etc. I am not taking this personally, I did not choose to have teeth like this, no idea why the original ortho did not fix this or whatever. It is the way my teeth are now and that's that, I don't get upset if someone points it out.
Glad to hear that. It will help in decision making process since it is mutual one between doctor and patient.
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Multi-variable equation based on what one wants the solution to be.
chin only solution + 'bite right' = Fewer variables. easier equation to solve.
BSSO solution + 'bite right' = More variables. harder equation to solve.
Concept: Complex multi-variable equations don't necessarily preclude solutions to them.
Yes. Just ment to clarify that having a bsso would imply displacing the maxilla in another way as well, but that's maybe obvious and what was implied by having a bsso instead.