jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: eastcoastian1 on October 07, 2015, 04:07:55 PM
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Hi everyone,
I have a bit of an overbite which I think is causing the lack of a masculine jawline and bit of receded chin. I'm trying to decide whether or not the best approach would be jaw advancement surgery which is quite involved, or chin/jaw implants which, while still involved, is a bit less dramatic of procedures. Would you give me your feedback based on my photos? Really seeking a more masculine facial profile......
http://imageshack.com/a/img909/479/e7qzNN.jpg
http://imageshack.com/a/img912/5815/986jZA.jpg
http://imageshack.com/a/img912/6939/is94bb.jpg
http://imageshack.com/a/img631/360/sjg6st.jpg
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How is your bite ?
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Here is a picture with me biting full down: https://fi.realself.com/full/43400d3084fdc42c7b79be3c6b2e07aa/f/9/8/userimage-1191962.jpeg
https://fi.realself.com/full/43400d3084fdc42c7b79be3c6b2e07aa/a/2/a/userimage-1191959.jpeg
You can see there is a slight horizontal misalignment and a bit of an overbite.
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Any sleep apnea ?
I have seen a lot worse - - that ended up with very good results after jaw surgery. Prefer moving the jaw or jaws to just trying to do something with implants.
Go find a good orthognathic surgeon - - see that surgeon and let them recommend to you. If they think surgery then let them also recommend an orthodontist they work with and then get the ortho's buy-in to the surgeon's plan.
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No sleep apnea.
Was just hoping to avoid possible 6 months of braces and long recovery, especially when I don't have any pain from the overbite. You think jaw surgery is a better option than a sliding genioplasty as well?
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No sleep apnea.
Was just hoping to avoid possible 6 months of braces and long recovery, especially when I don't have any pain from the overbite. You think jaw surgery is a better option than a sliding genioplasty as well?
What I think is really not very helpful. A sliding genio may improve the appearance. And you may not need the braces in advance. But rather than agonizing over the uncertainties - - it is really easier to find a good surgeon and get some advice - - If you think the surgeon is exercising good judgment in his or her advice - - then you probably ought to follow that advice - - not mine for sure.
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Just wanted to provide an update.
I had a consultation with Yaremchuk today. While I understand he's a PS, and in the business to make money, he strongly advised against any kind of jaw advancement/BSSO surgery, especially for cosmetic reasons, as he said by advancing the lower jaw forward I would actually have a more narrow/feminine jawline. He suggested jaw/chin implants. Seems very knowledgeable.
Anyone has any experience with him?
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I tend to suggest going the corrective route with dentofacial defects where the root of the problem is treated rather than camouflaged. However in your case..
-You don't seem to have noticeable vertical issues e.g. lip incompetence, chin strain, gummy smile, maxillary retrusion, etc
-You say you don't have sleep apnea
-I'm assuming you don't have TMJ issues
-Your teeth are off center yet your jaw line is fairly symmetrical even tho your chin does veer a bit to one direction. It's not severe at all.
-Your bite looks solid despite appearing to maybe be mild class II
-Your mental-labial fold (that's the area between your bottom part of your lower lip and top of chin) isn't deep because you don't an overbite (deep bite). This is important because if you had that, it would not only indicate a bad bite that orthodontics probably alone couldn't solve, requiring jaw surgery to correct. But with a deep mental-labial fold, a chin advancement would most likely worsen it which is not aesthetically pleasing.
-Your chin retrusion is moderate and an isolated chin advancement would probably put it in a almost ideal position.
So I actually agree with a sliding genioplasty. Jaw implant are up to you obviously but I would do one procedure at a time because you never know how you'll feel after. You could love your new chin and be fine with your jawline after.
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I tend to suggest going the corrective route with dentofacial defects where the root of the problem is treated rather than camouflaged. However in your case..
-You don't seem to have noticeable vertical issues e.g. lip incompetence, chin strain, gummy smile, maxillary retrusion, etc
-You say you don't have sleep apnea
-I'm assuming you don't have TMJ issues
-Your teeth are off center yet your jaw line is fairly symmetrical even tho your chin does veer a bit to one direction. It's not severe at all.
-Your bite looks solid despite appearing to maybe be mild class II
-Your mental-labial fold (that's the area between your bottom part of your lower lip and top of chin) isn't deep because you don't an overbite (deep bite). This is important because if you had that, it would not only indicate a bad bite that orthodontics probably alone couldn't solve, requiring jaw surgery to correct. But with a deep mental-labial fold, a chin advancement would most likely worsen it which is not aesthetically pleasing.
-Your chin retrusion is moderate and an isolated chin advancement would probably put it in a almost ideal position.
So I actually agree with a sliding genioplasty. Jaw implant are up to you obviously but I would do one procedure at a time because you never know how you'll feel after. You could love your new chin and be fine with your jawline after.
Thank you for such a detailed response. It rivals that of the surgeon I saw today!
I forgot to mention in my previous post that I also had a consultation with an oral/maxiofacial surgeon over at Boston Medical. Her diagnosis was the same as yours (mild class II malocclusion with slight jaw misalignment). That said, she said it was "up to me" whether I wanted to do the surgery and I could pretty much go either way.
I do have TMJ issues (clicking on the right side when I open my mouth) but it doesn't interfere with my bite or cause sleep issues and is mostly just an annoyance for the people around me who have to put up with my clicking! Also, she told me there is no guarantee that my TMJ would be resolved and it could actually get worse, so NOT to do it for that reason alone. If I wanted it done for bite/jaw alignment, then thats a different story. I really just dont want to do the 6 months of braces before and after to be honest, which she said was needed.
To be frank, I'm really considering surgery for cosmetic purposes only, to add more balance to the lower part of my face. Yaremchuk did say though he elects to do chin implant rather sliding genioplasty along with jaw implant since he said they go hand and hand (he said if I were ONLY to do the chin implant, while adding more prominence, it could actually made the jaw seem narrower. Highyl advised doing both the same time in my case)....
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Stop, stop, stop, stop. You have either a skeletal or dental discrepancy. One side of your face is very slightly larger. That is what is causing the trouble with the joint. The facial difference will continue unless the discrepancy is corrected. At some point the work load on the joint with overtake it's capacity to adjust and you will have problems. It may take a decade or two, may not. You need that joint in order to be able to eat. Most max-fac surgeons will not even attempt to treat TMJ issues because they are complex and cannot always be successfully treated. Google condylar hyprplasia for an idea of what could happen. Is there canting or tilting on one side of your molars? The fix is to stabilize the bite/joint either thru dental work or skeletal correction, depending on where your issue is.
Of course Yarmachuk suggested facial implants. That's what he does. Before you go any farther use the search function so you can understand why it is a very bad idea to put implants in your face. In short, they will look good for 7 to 10 years, then you will begin to have problems.
You face shape is the upside down triangle from the cheeks which is not the currently "in style" face shape for men. You are going to have to go with it. Even with implants, you will not be able to obtain the hyper-masculine prognathic dick-tracy type jaw that everyone wants right now.
You won't listen to me, but you need one of the better surgeons who does treat TMJ to evaluate you and determine where the issue is. If not, you can go ahead and get the genio or implants, but will have to deal with this issue later on and it will be worse at that time. If I were you, I would fix the function first, then consider the aesthetics.
Thanks for the reply.
Last week I saw a Dr. Gerald Maher who supposedly is an expert in TMJ and actually invented a mouthguard many NFL players use to prevent concussions (the Maher Mouthguard).
He examined me and said the TMJ issue would be resolved by using a MORA mouthguard at night (it supposedly helps line the top teeth bite up). He was very confident it would relieve symptoms within a few months.
In fact the oral surgeon I saw at Boston Medical said they usually treat TMJ with just sprints and muscle relaxers. Doesn't seem like an approach that could fix skeletal deficiencies. What are some of the procedures you know of that would be used to treat me for my case?
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I would recommend a genio over a chin implant simply because it always looks more natural. Every chin implant outcome I've seen looks a bit off.
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Thank you for such a detailed response. It rivals that of the surgeon I saw today!
I forgot to mention in my previous post that I also had a consultation with an oral/maxiofacial surgeon over at Boston Medical. Her diagnosis was the same as yours (mild class II malocclusion with slight jaw misalignment). That said, she said it was "up to me" whether I wanted to do the surgery and I could pretty much go either way.
I do have TMJ issues (clicking on the right side when I open my mouth) but it doesn't interfere with my bite or cause sleep issues and is mostly just an annoyance for the people around me who have to put up with my clicking! Also, she told me there is no guarantee that my TMJ would be resolved and it could actually get worse, so NOT to do it for that reason alone. If I wanted it done for bite/jaw alignment, then thats a different story. I really just dont want to do the 6 months of braces before and after to be honest, which she said was needed.
To be frank, I'm really considering surgery for cosmetic purposes only, to add more balance to the lower part of my face. Yaremchuk did say though he elects to do chin implant rather sliding genioplasty along with jaw implant since he said they go hand and hand (he said if I were ONLY to do the chin implant, while adding more prominence, it could actually made the jaw seem narrower. Highyl advised doing both the same time in my case)....
Your welcome! :)
FaceNit - While I can understand why you are pushing for him to see a maxillofacial doc to treat his dentofacial issues and like I said, I too will usually strongly suggest that because for optimal aesthetics outcome and functional/long-term stability. You're exaggerating about an isolated genioplasty being necessarily wrong in this particular case.
Clicking in joints and natural jawline asymmetry by itself is not the slightest sufficient to predict his joints will deteriorate or lead to other skeletal issues. He doesn't mention pain (correct me if you do OP), no interference with bite or mastication and no breathing issues. All good. He is also doesn't have an open/cross bite. Also very good.
Drawing on my personal experience, I had joint clicking and symmetry before surgery and I still have it after successful double jaw surgery. Dr. Gunson told me that even without surgery my joints would be fine. I even had a small airway (I had mild sleep apnea).
Of course there's individual variation and everyone's developmental trajectory won't be the same. Good thing we aren't all basing our opinions off personal outcomes. OP, has you jaw unevenness of your visibly worsened over time? Or the clicking?
OP I would do three things:
1. Avoid any kind of TMJ treatments for now. Maybe forever. Unless your currently benign symptoms worsen.
2: Avoid jaw implants, I'll agree with Facenit on this point. Not that jaw implants can't give a good result for some people. And while I don't know Dr. Y's history, plenty of doctors will operate on a person even though it's contra-indicated, either out of genuine ignorance or because they just don't care.
3. If you do not want to go the jaw surgery route, go have at least several consultations with competent, experienced surgeons with good reputations about having a sliding genioplasty.
Then re-asses 6 months to a year down the line, both how you look and your functioning. Be prepared to have some residual partial numbness on your chin and lower lip that may be permanent. This happens in many cases even when the doc does everything right.
And finally a sliding genio, while not an insignificant surgery, will have no affect of potential future jaw surgery if needed. Other positives is that it's your own bone and it's a very stable procedure that will not negatively affect your bite or joints.
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OP,
If you don't want a full on jaw surgery, then consider a chin wing osteotomy. It would improve your whole jaw line. You'd have to go to Europe for this. It can also be combined with traditional jaw surgery, so you will not end up with a long narrow jaw that Yaremchuk is talking about.
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I can't quite get my head around the chinwing i've seen mentioned a few times.
I've seen these pics:
(https://upload.wikimedia.org/wikipedia/commons/thumb/b/b3/Chin_Wing.svg/220px-Chin_Wing.svg.png)
But i'm still not sure how that would have the desired effect that lots of people seem to want.
I've attached a little pic I made, lol
(http://i.imgur.com/jjD34x5.png)
OP,
If you don't want a full on jaw surgery, then consider a chin wing osteotomy. It would improve your whole jaw line. You'd have to go to Europe for this. It can also be combined with traditional jaw surgery, so you will not end up with a long narrow jaw that Yaremchuk is talking about.
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@facenit - what if you have no joint clicking or pain but just random muscular fatigue from grinding teeth at night and limited opening? (PM me if you dont want to talk about tmj here thx)
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Just wanted to update. Having a consultation with Dr. Jamali (Max/Fac) tomorrow. Seems to be an expert in jaw surgeries and sliding genioplasties. Would like to hear what he says.
Getting so many mixed opinions on whether an implant or sliding genio would be better.
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ploskoplus
you mention:
a long narrow jaw that Yaremchuk mentioned
as a result of a chin wing.
could you provide a source for this? in a chin wing you could actually widen the ramos, and therefore i would expect that the jaw actually looks shorter
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Just as I was starting to lean more and more toward a sliding genio, I had a Skype consultation with Dr. Jamali today and he said the only route he would recommend is jaw surgery, which is very disappointing. Even though my overbite is pretty moderate, he said because I have a bit of a deep labiomental fold, both an implant and sliding genioplasty would simply make this worse and more obvious. I've seen seen people so far and none of them have mentioned this being a problem so this really makes me feel like I'm back at square one.
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I had a very deep labiomental fold as well, and was recommended against getting a genioplasty for that exact reason. Fixed it (plus a weak chin) with a BSSO + a chin wing.
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Just as I was starting to lean more and more toward a sliding genio, I had a Skype consultation with Dr. Jamali today and he said the only route he would recommend is jaw surgery, which is very disappointing. Even though my overbite is pretty moderate, he said because I have a bit of a deep labiomental fold, both an implant and sliding genioplasty would simply make this worse and more obvious. I've seen seen people so far and none of them have mentioned this being a problem so this really makes me feel like I'm back at square one.
The deep fold will not only be prevented from deepening, but it will actually get rid of it if you're also getting vertical advancement on the sliding genio.
This could however be a problem if you feel that you already have a 'long face' because this method will surely lengthen the face visually as well. But if your chin itself is below average height I would still say go for it.
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The deep fold will not only be prevented from deepening, but it will actually get rid of it if you're also getting vertical advancement on the sliding genio.
This could however be a problem if you feel that you already have a 'long face' because this method will surely lengthen the face visually as well. But if your chin itself is below average height I would still say go for it.
Thanks.
Thats just the thing. One oral surgeon said I need a little vertical lengthening, another (Jamali) said I don't need any, just horizontal which is why he said I should only do jaw surgery (despite Yaremchuk and the other oral surgeon saying this was way too extreme for my case), and then Yaremchuk said I need only some horizontal projection BUT, like you said, heavily suggested I do manidbular implants as well or else I WOULD look very narrow. Here is why he suggests an implant rather than a sliding genioplasty for my case:
"Your chin would only be augmented a small amount since it is in the range of normal projection now.Also importantly, it would be augmented at its inferior aspect thereby having minimal, if any, impact on your labiomental fold."
Getting told different things but almost everyone I have consulted with is making this a real frustrating experience.
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^I see, it must be tough. My advice is if you truly have a vision and idea of what you want to achieve, you should go with the surgeon who's plan fits with your desired results. I'm having consultations for SG soon too and really need vertical lengthening, and if aesthetically the surgeon doesn't think I should do it then I'm not going to get surgery from him, I'll look for the person who agrees with me and is willing to help.
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You do not have a deep mental labial fold. The doctor is wrong. It may not be ideal but google image search it, people with moderate to severe deep bites or short face syndrome or VME with lipcompetence/very crappy lower lip posture have it (I did).
And while a modest chin implant or horizontal sliding genio would deepen it slightly as expected since your advancing the chin point, it would not be aesthetically detrimental as far as I can tell from your pictures.
And just to demonstrate two cases NOT like yours but with Class II jaw/bite issues where one had the right treatment and the other didn't. The following patient is an example of adding chin projection to someone with an already prominent chin and deep fold:
(http://www.lovethatface.com/files/2013/04/chin2.jpg)
And then here's a patient with a deep fold who correctly had a mandibular advancement instead of just chin augmentation. The lower lip fold is normalized and lower 1/3rd looks pretty perfect.
(http://a360-wp-uploads.s3.amazonaws.com/wp-content/uploads/plastics/2012/01/2012-01_03-02.jpg?5036bc)
At this point I'm not going to further recommend anything, just to say that adding moderate projection to your chin via any stable method (if you're really against jaw surgery) is not contra-indicated if we're going by your mental labial fold alone.
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my case is very similar to yours.
when i asked my surgeon about the potential increase in labial fold, he said we could address it by filling out the area with bone graft. but seeing the photo above, it is clear that you are very much limited by how much forward projection you need, i.e. if you need more than 8mm the sliding g. starts looking weird.
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(http://a360-wp-uploads.s3.amazonaws.com/wp-content/uploads/plastics/2012/01/2012-01_03-02.jpg?5036bc)
that guy looks brilliant now. Do you know exactly what he had done?
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that guy looks brilliant now. Do you know exactly what he had done?
The caption of the pic said lower jaw surgery (BSSO) without mentioning anything else. I can believe that, he just got lucky.
His decompensated bite made room for a lot of forward mandible movement via the overjet. And he probably didn't have any upper jaw issues. So the isolated BSSO corrected the retrognathia, deep mental labial fold and overbite which gave a very aesthetically pleasing result.
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You do not have a deep mental labial fold. The doctor is wrong. It may not be ideal but google image search it, people with moderate to severe deep bites or short face syndrome or VME with lipcompetence/very crappy lower lip posture have it (I did).
And while a modest chin implant or horizontal sliding genio would deepen it slightly as expected since your advancing the chin point, it would not be aesthetically detrimental as far as I can tell from your pictures.
And just to demonstrate two cases NOT like yours but with Class II jaw/bite issues where one had the right treatment and the other didn't. The following patient is an example of adding chin projection to someone with an already prominent chin and deep fold:
(http://www.lovethatface.com/files/2013/04/chin2.jpg)
And then here's a patient with a deep fold who correctly had a mandibular advancement instead of just chin augmentation. The lower lip fold is normalized and lower 1/3rd looks pretty perfect.
(http://a360-wp-uploads.s3.amazonaws.com/wp-content/uploads/plastics/2012/01/2012-01_03-02.jpg?5036bc)
At this point I'm not going to further recommend anything, just to say that adding moderate projection to your chin via any stable method (if you're really against jaw surgery) is not contra-indicated if we're going by your mental labial fold alone.
Thanks again for your detailed feedback as always.
Honestly, if I walked into a max fac or orthodontist and they told me, "yes, you should consider jaw surgery, you'd see a difference", I'd already be in braces getting ready for my surgery for the end of 2016! Haha.
The fact is, I've already gone to two orthos, two max fac, and all 4 told me I would see very little difference if I were to do jaw surgery as my jaw is only slightly recessed and said if anything I should consider chin augmentation and MAYBE invisalign to fix the class 2 on the right, but even that they said wasnt too vital. I don't want to feel like I'm "pushing" someone to perform jaw surgery on me if I really don't need it. If I was told to go for it, trust me, I would.
As it stands though, I'm mostly just getting differing opinions on implant vs genioplasty. Still not sure which route to take honestly.
Also I forgot to ask. Are there any wearable devices out there that might slightly improve the recessed lower jaw since mine is not an extreme case? Something I could wear at night like a mouth guard that might move it forward? I've seen some things out there like SomnoDent which claim to move the jaw forward, but wondering if it's a gimmick or not.
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For anyone who has the ability to analyze an x-ray, I've uploaded a scan of my lateral ceph CT for reference.
[attachment deleted by admin]
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For anyone who has the ability to analyze an x-ray, I've uploaded a scan of my lateral ceph CT for reference.
Steep occlusal plane.
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Steep occlusal plane.
Not really sure about that. I spoke with Dr. Stephen Schendel last week, another maxillofacial surgeon who primarily focuses on jaw/chin, and he told me my maloclussion was very mild and mandible advancement would only result in advancement of about 3mm, so not to even bother. He actually suggested implants.
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Not really sure about that. I spoke with Dr. Stephen Schendel last week, another maxillofacial surgeon who primarily focuses on jaw/chin, and he told me my maloclussion was very mild and mandible advancement would only result in advancement of about 3mm, so not to even bother. He actually suggested implants.
He's not exactly the greatest max fac. If you had CCW rotation, you'd end up with a very strong projected jaw. See Arnett and Gunton in california, wolford and Sinn in dallas. They specialise in this.
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He's not exactly the greatest max fac. If you had CCW rotation, you'd end up with a very strong projected jaw. See Arnett and Gunton in california, wolford and Sinn in dallas. They specialise in this.
CCW rotation? This is the first time I've even heard that mentioned.....
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Will contact Arnett. Do you happen to know if this can be done without BSSO (meaning I can avoid the whole 1 year of braces)?
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Will contact Arnett. Do you happen to know if this can be done without BSSO (meaning I can avoid the whole 1 year of braces)?
CCW requires double jaw surgery by definition. Even if you can get away with single jaw surgery, double jaw almost always gives a better result.
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For anyone who has the ability to analyze an x-ray, I've uploaded a scan of my lateral ceph CT for reference.
Hmmm am I going to have to take back everything I already said? s**t lol. Because here you absolutely see a deep mental-labial fold!
Seriously if this is accurate of how your bite and soft tissue actually sit normally then honestly a chin augmentation is probably wrong. However I've seen a few examples of a lengthening genio with advancement, there's a pic people always use of a tan guy with dark hair, which should avoid any aesthetic issues even tho it won't address the root dentoskeletal issue.
Edit: Avoid any headgear or night time wearing devices, most are bulls**t and dangerous.
I agree with seeing arnett/gunson for at least a consult, it may be eye opening. The cost is steep even for a consultation, 550 but it'll probably be the most comprehensive doc appt you'll ever have and well worth it if you can afford it.
And stay away from Wolford, one of the best docs out there for sure but he'll without a doubt want to do a Total Temporomandibular Joint Replacement with Prosthesis...even if your joints are fine and you just have clicking or some benign symptom. I spoke to him via e-mail years ago before i had surgery and after I told him that I had occasional clicking only, he suddenly acted concerned and suggested seeing him to look at my joints more. Yeah f**king right.
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CCW requires double jaw surgery by definition. Even if you can get away with single jaw surgery, double jaw almost always gives a better result.
Hilarious. I actually just had a phone consultation With Dr. Gunson a few minutes ago that I had booked over a month ago and had completely forgotten about!
First off, WOW. What a doctor. He really, and I mean REALLY knows his stuff. By far the best surgeon I have consulted with thus far. Just from my photos and ceph, he was able to determine so much. He also has a very concise and articulate demeanor. Seems very trustworthy.
Anyway, he said unless my ceph was taken at an angle or my head was tilted, it's pretty much a straight forward case of a recessed/weak chin, mostly unrelated to the jaw. While there is a very mild steep angle, and a very mild recessed jaw and slight overbite (which he actually said looked healthy), he said there's really no reason to touch my jaws. He feels 6mm advancement of the chin via sliding genioplasty would be the way to go.
Again, this is only his first impression via information provided to him, but he seemed rather confident with that recommendation.
This is actually a huge sigh of relief for me to hear from a leading authority of jaw surgery that I really don't need it. Think I'm going to book an in-person consult and try to get the sliding genio done by that team.
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Hmmm am I going to have to take back everything I already said? s**t lol. Because here you absolutely see a deep mental-labial fold!
Seriously if this is accurate of how your bite and soft tissue actually sit normally then honestly a chin augmentation is probably wrong. However I've seen a few examples of a lengthening genio with advancement, there's a pic people always use of a tan guy with dark hair, which should avoid any aesthetic issues even tho it won't address the root dentoskeletal issue.
Edit: Avoid any headgear or night time wearing devices, most are bulls**t and dangerous.
I agree with seeing arnett/gunson for at least a consult, it may be eye opening. The cost is steep even for a consultation, 550 but it'll probably be the most comprehensive doc appt you'll ever have and well worth it if you can afford it.
And stay away from Wolford, one of the best docs out there for sure but he'll without a doubt want to do a Total Temporomandibular Joint Replacement with Prosthesis...even if your joints are fine and you just have clicking or some benign symptom. I spoke to him via e-mail years ago before i had surgery and after I told him that I had occasional clicking only, he suddenly acted concerned and suggested seeing him to look at my joints more. Yeah f**king right.
I think the device used to take the scan also makes the fold more pronounced, since you're pressing your chin hard against.
[attachment deleted by admin]
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did he charge you for the phone call, or is the payment only for the next appointment?
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eastcoastian1 - It crossed my mind that it was being exaggerated a bit which is why I asked. And yes, Dr. G know his stuff. Not that I'm biased... he did my surgery after all :D If he says a genio is best and that opinion is the same after the in-person consult then awesome! I envy you for only needing a isolated procedure, it'll be soooo much easier recovery/cost/everything else wise. One is like being hit by a truck (double jaw surgery) vs punched by a 4th grader in the face (genio only).