jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: SJay on November 16, 2015, 04:41:24 AM
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Hi,
I'm considering a sliding genioplasty, or possibly jaw surgery. My bite is absolutely fine but my chin is very recessed. The surgery is for cosmetic reasons, and I would obviously rather go with the genioplasty as it is not only far less expensive, but far less invasive. I've consulted with a few surgeons, and will most likely go with Dr Gunson, as he has so many happy patients on this site. He looked at my x-rays and photos, recommended jaw surgery but said we could probably do genioplasty if that's all I wanted. I've just got to send him intra-oral photos and a mould of my teeth.
Anyway, I've provided a morph of what I would like to achieve. Do you think this is possible with a genioplasty alone, and would be a worthwhile improvement? Please let me know what you think. Thanks!
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did he say that your simulation was achievable?
what did he charge you for the call?
are you considering implants? how is your horizontal projection?
best
mike
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Your before looks fine to me. You really want to go through months of recuperation and thousands of dollars when you have the jaw structure of a normal person and a correct bite?
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@ Mike: I've not shown him the simulation, I'd rather see what he comes up with. The call didn't cost me anything, but you do have to pay for a paper consultation. I'm not considering implants, I don't like the idea of having a foreign object inserted into my face, it can slip, cause infection and would most likely give me a very deep mento-labial fold, which I really don't want. I think a genioplasty, performed by a skilled surgeon, would look more natural.
@ Jimmy: Thanks, but I can see a lack in projection. I know it could be a lot worse, but it's definitely noticeable to me, and it does bother me. I'll post my lat ceph, so you can see I have a very flat mandible.
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Occlusal angle looks a bit steep.
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Can you post a pic from the front?
Do you lips meet at rest or do you have to strain them to close with chin dimpling? Your in braces still?
I think a genio would be preferable if you a good bite and no tmj issue even with your clear recession and steep occlusal plane.
I think your profile is still quite attractive because overall the ret of your features look good which is why I'm interested in seeing front pics.
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@ PloskoPlus: Thanks for your input. Does that mean my lower jaw needs a little rotation too? Sorry, I'm a newbie.
@ ForeverDet: Thanks! I think I do have some lip incompetence, which Dr Gunson said he could address during a genioplasty... though I'm not sure how that works? I've been in braces for 18 months now, they should be coming off very soon. However, I did have 4 pre-molars pulled to achieve this... forgive me, I didn't know any better at the time. I've posted the frontal images that you requested. By the way, I read your story with Gunson, I know you had more than a genioplasty but I have to say you got a fantastic result, congrats!
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Yeah CCW rotation could make your face more balanced.
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Your before looks fine to me. You really want to go through months of recuperation and thousands of dollars when you have the jaw structure of a normal person and a correct bite?
I sympathize and yes he looks normal but his face is definitely hypoplastic with a steep occlusal plane as Plosko mentioned. It's not as bad as it looks because his FHP is tilted down a tad but his mandible is indeed underdeveloped. You can tell he's got long face syndrome because of the prominent Ag notching and asymmetry between the two sides and, though he's covered it up, the infraorbital rim deficiency. His lateral cheekbone projection looks borderline normal to me so I'd guess he doesn't have much of a transverse discrepancy. However, from his x-ray it looks like he has a two-plane occlusion. I'd guess he had an anterior open bite like me and the orthodontist has chosen to close it with braces. His airway looks morphologically normal but I'd guess slightly undersized, again like me.
Cases like ours often pass for normal enough because all the relative relationships are where they should be but of wrong nominal values. We compensate by tilting our heads up and it's enough to make us look normal when in reality we are very not. Orthodontists are trained to identify devleopmental pathology and should recognize which cases are unsuitable for simply moving the teeth to fit but it seems that once they leave school they simply revert to making teeth meet without devoting much thought to each case. Surgeons have dire warnings for identifying cases like these and including the surgeon early on in the process to avoid reaching this point. Don't trust an ortho who doesn't or is uncomfortable looking at CBCTs IMO.
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Thanks for the detailed analysis, molestrip. I agree that my mandible is clearly under-developed, but I never noticed anything about my eyes or the long face syndrome thing before... my mandible may also have a little excess length, but this is never something which has bothered me before. Regarding my orthodontics, my back teeth have always fitted just fine but my front teeth met and touched at the tips, rather than having the uppers sit just in-front of the lowers. If my mandible is both too long and under-projected, do you suggest a genioplasty to slide it forward and up, or saw form of jaw surgery?
I'm really interested, you say your case is similar to mind, could you please tell me how you've been addressing your issues. I really appreciate your input, thanks!
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@ ForeverDet: Thanks! I think I do have some lip incompetence, which Dr Gunson said he could address during a genioplasty... though I'm not sure how that works? I've been in braces for 18 months now, they should be coming off very soon. However, I did have 4 pre-molars pulled to achieve this... forgive me, I didn't know any better at the time. I've posted the frontal images that you requested. By the way, I read your story with Gunson, I know you had more than a genioplasty but I have to say you got a fantastic result, congrats!
Thanks! Yeah I had upper and lower and the genioplasty I had done years before, Dr. G just took out most of the hardware because he thought the chin's soft tissue was getting trapped in it and f**king up my lower lips posture.
I'm going to be completely honest with you having seen your front pics... I don't think you should pursue jaw surgery if your bite can be normalized with braces and Dr. G is confident you can still get a good result with only the genio.
Molestrip's analysis is valid but remember, you already have a balanced face despite the recession. You would be paying 50k plus (if you went with the Dr. G, arnett or Wolford) and months/year of recovery and then at the end of it, it's highly likely you'll end up with some minor side effects that'll be permanent (muscle tightness, partial numbness, etc.). Not to mention the risk of your nose changing (getting wider so not for the better) which can still happen even if the surgeon does everything to prevent it.
I'm definitely pro-surgery though... when the aesthetic and functional concerns are justifiable. If I was in your shoes, I wouldn't get double jaw surgery.
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Yeah, to be honest I'm quite looking forward to finally getting my braces off, and the last thing I want is to have to start that all over again. I'm okay with the profile of my nose so don't want to mess with that, but I hate the frontal view... it's already way too wide so I certainly don't want to exacerbate that problem.
I'm really hoping that genioplasty will suffice, but feel I would need quite a significant advancement, and there's only so much it can be brought forward until it starts looking odd. I've been told by another surgeon they could bring it forward 8mm at an absolute max... I'm just not sure that's even enough, and I also really don't want to create a deep mento-labial fold. I guess jaw surgery would give the best cosmetic result, but like you say it's so expensive and also very invasive. Fingers crossed, Dr Gunson can come up with a solution!
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8mm isn't really the max but beyond 9-10mm you will likely have a visible step-off (space) where your chin was advanced and the mandible.. so I understand the claimed limit. The other reason is most docs in the past and present don't utilize CCW rotation which often leaves the patient still recessed so they'll compensate with a large genio. That is definitely incorrect to do. However if you aren't having jaw surgery and are fairly recessed then a relatively large genio can be appropriate. And as far as the potential step-off...that can be filled in during or with another minor surgery with something (paste, implant, etc.) to smooth it out.
I don't agree with Dr. G/arnett's tendency to be conservative with chin advancements in isolation, especially if the person doesn't have a deep bite/severe mental-labial fold. I think they usually don't ever move the chin beyond 6mm. I had my genio with a local doc and my chin was moved something like 8-9mm and aesthetically it was good even tho it was insufficent/didn't address my root defect.
So I would suggest getting consults and contact other docs who also do good work, especially if they focus on genioplasties. I believe there's world renowned chin doc in new york I think. That way you can compare all the docs and make am ore informed decsion.
I understand about the mental-labial fold concern because yours is already kind of prominent however since your chin does look a bit short vertically from the front, I think a decent advancement with lengthening will give a good result. Certainly no less than 6mm of forward movement but vertically I'm not sure.
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j594, which king of jaw surgery did he advise you to get? BSSO or both?
And also, how did you manage to get a phone consult? I would be really interested to read about your consultation experience, because I can't reach their front desk, seems always busy.
Anyway, good luck, if you ask him to cut far back enough (does this make sense) you would probably get a significant improvement.
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By the way, I had sliding genio 6 weeks ago, so feel free if you need any info...
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Definitely achievable with genioplasty only. Your face is perfectly balanced and you don't have problems with your bite, getting jaw surgery is a bit extreme in your case.
I think you look great as it is but if the slight recession bothers you, a genioplasty can do the trick. Good luck!
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@ForeverDet: Yeah, I'm hoping to go for something around the 8mm mark, but I've not heard Dr G do more than 6mm, and I've not got my paper consult back from them yet. SGSeeker recently got 6mm advancement with Dr Gunson, plus HA paste and I think her result is absolute amazing... this is one of my main motivations for going with Dr Gunson. I know many people are against the HA paste, but it seems A/G know what they are doing with the stuff and can create smoother, more naturally looking results as a consequence. Regarding other surgeons, I've consulted with three and one of them was in NYC – Dr Majid Jamli, is he the guy you are referring to? He has some good results and has provided me with a quote, but he doesn't provide morphs and I would like to see what we are shooting for before letting someone take a knife to my chin... another reason for my preference for Dr Gunson.
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@asphyxia: Double jaw surgery, my bite is good so both jaws would need to be advanced, plus some rotation. They are in high demand and are therefore very busy, but everyone at the office has been very polite and friendly, Dr Gunson seems to have a warmth and understanding to him, which I really like... I don't know, perhaps I just got lucky!
Oh right, well I really hope that it went well and you're healing nicely! How far were you advanced? Do you mind sharing photos?
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@Aleina8586: Thanks for your comments... you're far too kind! I really do hope that you're right. I don't even know how I'd even find the money for the jaw surgery, but I'm determined to fix the issue, one way or another, as it does bother me a lot. Hopefully the genioplasty will indeed do the trick!
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@ForeverDet: Yeah, I'm hoping to go for something around the 8mm mark, but I've not heard Dr G do more than 6mm, and I've not got my paper consult back from them yet. SGSeeker recently got 6mm advancement with Dr Gunson, plus HA paste and I think her result is absolute amazing... this is one of my main motivations for going with Dr Gunson. I know many people are against the HA paste, but it seems A/G know what they are doing with the stuff and can create smoother, more naturally looking results as a consequence. Regarding other surgeons, I've consulted with three and one of them was in NYC – Dr Majid Jamli, is he the guy you are referring to? He has some good results and has provided me with a quote, but he doesn't provide morphs and I would like to see what we are shooting for before letting someone take a knife to my chin... another reason for my preference for Dr Gunson.
No not Jamli.. I forget his name and I just searched a bit but can't find him. He was known as the chin doctor or something due to his expertise/experience. r.
Did gunson mention any vertical lengthening? I would push for 8mm. I had a bad reaction to HA (swelled/brused up way more than most people and still have a little bit of swelling on my cheek 2+ years later) so I would be cautious with that altho Idk if he would operate without it.
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Sorry to hear about your bad reaction to the HA paste... I hope everything has settled down now though? I think I'd rather use it, if it's safe, as it seems it can certainly improve the cosmetic result! No, he actually mentioned a little shortening... sliding forwards and upwards, but I don't have exact measurements yet. I'm still waiting for my ortho to send them the models of my teeth.
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also keep in mind that if he moves the bone 8mm you will only see about 75P.C. of that flowing through.
you are good looking from the front nicely proportioned between lower middle and upper but could use some lateral projection - have you discussed this also? i think it could boost your looks quite a bit.
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Thanks! You mean lateral projection of the jaw/chin, when viewed from the front... widening? No, it's not something I've discussed with Dr Gunson. I hear it is possible with a sliding genioplasty, but it's not something I've seriously looked into.
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also keep in mind that if he moves the bone 8mm you will only see about 75P.C. of that flowing through.
you are good looking from the front nicely proportioned between lower middle and upper but could use some lateral projection - have you discussed this also? i think it could boost your looks quite a bit.
75p.c.?
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75 percent? I've not heard this before... is it common knowledge?
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If he means percent, that's false. Genio has 1:1 ratio (bone/soft tissue) up to 8mm.
Which is consistent when I had mine and it was moved 8-9mm.
References: http://archfaci.jamanetwork.com/article.aspx?articleid=479824 (http://archfaci.jamanetwork.com/article.aspx?articleid=479824)
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I take it you guys are strictly talking about forward movement with SG right? I will soon get a SG with vertical movement as well. If I were to get 8mm for both movements won't there need to be bone grafting done as well? Same with a standard 8mm forward SG like TS I'm assuming.
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@ForeverDet: I also heard that it was 1:1, thanks for the link.
@needadvancement: Yes, we're talking about forward movements, but I'd imagine you could have a vertical advancement of 8mm without grafting. I guess the question is, how far can osteoblasts jump? I mean, how far can you be advanced with a BSSO without the insertion of a graft? I'm no expert, so maybe someone with more knowledge can tell us...
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Regarding BSSO, is it even still possible now that I've had 4 pre-molars (2 top, 2 bottom) removed? I only had them removed 18 months ago, so where does the space actually go, is it (or some of it) still there, perhaps in the back of the gums? If so, then couldn't I have my lower teeth pulled back to create an overbite, then have my lower jaw brought forward, perhaps with a small genio too? I think this would achieve a much better cosmetic result, it would avoid a large genio thus avoiding the problems with the metoloabial fold and it should also give me a stronger face when view from the front. It seems a BSSO can sometimes give the allusion of a wider jaw, and more define jaw structure in general. As always, your input is much appreciated!
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Regarding BSSO, is it even still possible now that I've had 4 pre-molars (2 top, 2 bottom) removed? I only had them removed 18 months ago, so where does the space actually go, is it (or some of it) still there, perhaps in the back of the gums? If so, then couldn't I have my lower teeth pulled back to create an overbite, then have my lower jaw brought forward, perhaps with a small genio too? I think this would achieve a much better cosmetic result, it would avoid a large genio thus avoiding the problems with the metoloabial fold and it should also give me a stronger face when view from the front. It seems a BSSO can sometimes give the allusion of a wider jaw, and more define jaw structure in general. As always, your input is much appreciated!
What do you mean by "where does the space actually go" in regards to your molars? Regardless, removing molars doesn't not exclude you from BSSO. I had them removed as a teenager as have many people.
As far as retracting your bottom teeth... I don't know if that is viable although I'm not 100% sure what you mean there either. Do you mean use orthodontics to cause your bottom to shift/tilt backwards to exaggerate the overjet (horizontal distance between lower teeth and upper teeth)?
Generally during decompensation pre-surgery for class II cases like yours, there will always be an exaggeration of your bite to maximize movement during surgery. So the ortho will flare out your upper incisors primarily while straightening any crowding then during surgery, the lower jaw can be moved further forward because the upper teeth were flared, correcting the recession and leaving you in a class I bite position. And using counter-clockwise rotation, you can advance the lower jaw even more forward if needed (in the cases of significant recession, vertical maxillary excess,etc.) which would otherwise not be possible with standard double jaw advancement.
Unfrotunately, occlusal rotation is still not taught or used by many (most?) surgeons so they'll compensate the insufficient lower jaw advancement by adding a large genioplasty which often does not give a optimal aesthetic result.
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I wasn't very clear.
Regarding the removal of teeth:
When the teeth are removed you're left with a gap, say 7mm or so (the width of the tooth). Then you get the braces, and the teeth move within the gum to close that gap. So what happens to the actual size of the gum, does it shrink as it now has to hold less teeth, or are the spaces which were left effectively just moved to the back of the gums so they are not visible. If it is the latter, then I still have space in my gums to play around with, so I could in theory move all my lower teeth backwards to create an overjet?
Regarding the surgery:
My bit is now correct, class I. I'm asking if it is possible to just have BSSO (no upper jaw work), by somehow moving my lower teeth backwards in the gum to create an overjet, then I could bring the jaw forward and still have a correct bite. Clearly, if I move my lower jaw forward without moving the teeth back, I would get an underbite. The reason I ask is that I'm wondering if I can get away with just lower jaw surgery, not double. Perhaps this is a stupid idea, but I'm just trying to understand how it works and what my options are. I hope my question makes sense
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Regarding question 1) your ortho will tell you he's just moving teeth around. BULLs**t. I know cause Ive suffered through this. The space where the gap is shrinks and the gums actually remodel. I know this cause all the latest tests and surgeons have said this. YOu effectively lose 7 mm of jaw bone.
2) Absolutely that can be done by removing teeth from the bottom jaw. I wouldn't advise it though cause you'll then have a much smaller lower arch and it might be very tight for your tongue. ALso you'll just be compensating for what you'v lost through surgery.
Here's what you do. GO to Gunson and have him oversee your ortho work you f**king moron. Have the surgeon (a very good one) oversee what the ortho does. Has this not been emphasized enough on this forum?
GJ we need a f**king FAQ here and that should be one of the f**king first protocols: HAVE YOUR SURGEON PLAN THE ORTHO WORK WITH YOUR ORTHO AND PREFERABLY ONE THE SURGEON WORKS WITH REGULARLY. f**k'N"HELL.
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GJ we need a FAQ here and that should be one of the first protocols: HAVE YOUR SURGEON PLAN THE ORTHO WORK WITH YOUR ORTHO AND PREFERABLY ONE THE SURGEON WORKS WITH REGULARLY.
And... if your local ORTHO is not willing to work with an out of town jaw surgeon - - find a different Ortho that will. Then find a good jaw surgeon that knows how to coordinate the planning and ortho work so the surgeon can do his or her job right.
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And... if your local ORTHO is not willing to work with an out of town jaw surgeon - - find a different Ortho that will. Then find a good jaw surgeon that knows how to coordinate the planning and ortho work so the surgeon can do his or her job right.
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EXACTLY. JUST POST THIS SOMEWHERE SO WE DON"T HAVE TO ANSWER THE SAME QUESTiONS OVER AND OVER AGAIN.
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have seen 3 studies that indicate that you may not get 1 to 1 advancement of bone vs soft tissue, and my swiss doctor said there some margin they can not plan for. you are stretching skin, with has many layers skin, mussle, fat, etc. contact me on pm if studies of interest.
genio will do nother to widen your jaw, you would need extraction or implants.