jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: Tetley on April 02, 2016, 08:13:16 AM
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Hello,
This is my first time posting so I hope to not mess this up too badly. I have a question of which route to go with a desired surgery. My bite is good from past orthodontics (twice) , but my upper jaw is too long by 7mm. I was told by the surgeon that my lower jaw is actually the right size but that I have a flat chin. My orthodontist believes the best route to get the desired aesthetic result is to pull two teeth at the bottom to create more of an overbite and move both jaws, lower forward and the upper one up. Not ideal from my perspective just because we would basically be making it worse before better. The surgeon I think is leaning towards just doing the upper jaw and probably doing a sliding genioplasty as well. He believes he could get the lower jaw to rotate forward this way. This sounds better, but I'd hate to do all that and then be disappointed. I just have no idea how either of these things would look, and was hoping to get feedback from people that have a better handle on these things then I do. Any help would be hugely appreciated. I don't know how these pictures are, hopefully they give a decent idea. :)
Thanks SO much!
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Oh, I also have this if it helps.
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It's hard to tell if your facial thirds are in balance as a significant portion of your face is blacked out. From the lat ceph, the mandible, maxilla and the brow bone all seem to roughly align, perhaps your chin is a bit flat and could come forward. Why pull teeth though? If you want a stronger profile, more of an ante face, then why can't both jaws just move forward plus maybe a small genio, as the bite is good and the jaws seem to roughly align already. You also appear to have some lip incompetence, which any surgery should aim to address.
It's hard for me to see the issue with the long upper jaw, but it's not really my area of expertise. All I can really see is that the chin is slightly recessed and that there is lip incompetence, both of which could be fixed with a sliding genioplasty. Or maybe advance both jaws if you like more of the ante face look.
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Thanks for the response. Sorry, I guess I blacked out too much there. I will attach more clear ones. The upper jaw surgery would be to address the lip strain and the gummy smile and to allow the lower jaw to come forward more I was told. I don't know what ante face is? I am not sure why the tooth extraction was recommended, I was just told there wasn't enough room. Are there pictures more helpful? I don't really need a "perfect" appearance but I would like to be able to close my mouth and have a somewhat better profile/ less gum.
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I'd avoid the extractions.
You need double jaw surgery basically. Upper jaw up and a bit forward. Lower jaw forward with ccw rotation. Sliding genioplasty to bring the chin forward.
See this for a similar case
http://m.imgur.com/a/mUclH
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Thanks for getting back to me. If i went that route (double jaw. no extractions ) would that allow my bite to stay pretty much as it is? I'd hate to have it get worse before it gets better. I'll see what my orthodontist says, maybe there is some reason they didn't suggest that
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The results on that girl are incredible. Her whole face looks a million times better. Jaw surgery is scary and difficult enough now we have to pick which route the surgeon takes? How the hell should we know which movements are the best for us. Ughhh!
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There are a couple of ways you could go and different surgeons may give slightly different treatment plans. But the ideal result would be less gum show and more chin projection.
Based on your ceph and what I've seen before, I think you're looking at a 6mm anterior maxillary impaction resulting in CCW rotation, then BSSO to fit the mandible to the newly-positioned maxilla. No maxillary advancement, no extractions, no genioplasty.
I have a good example that I can show but let me get permission from the person first. I'll follow up.
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There are a couple of ways you could go and different surgeons may give slightly different treatment plans. But the ideal result would be less gum show and more chin projection.
Based on your ceph and what I've seen before, I think you're looking at a 6mm anterior maxillary impaction resulting in CCW rotation, then BSSO to fit the mandible to the newly-positioned maxilla. No maxillary advancement, no extractions, no genioplasty.
I have a good example that I can show but let me get permission from the person first. I'll follow up.
I think she needs maxillary advancement, she looks to be a somewhat young person yet she already has nasolabial folds due to a retracted maxilla. Advancing the maxilla would make her look younger.
Thanks for getting back to me. If i went that route (double jaw. no extractions ) would that allow my bite to stay pretty much as it is? I'd hate to have it get worse before it gets better. I'll see what my orthodontist says, maybe there is some reason they didn't suggest that
You would need dental decompensation, so you would have more of an overbite before the surgery.
The problem with orthodontists is that they are not surgeons and usually only know what they learned about surgery decades ago in college. In the past it was routine to extract teeth to "make room", however that is avoided nowadays because it makes your smile smaller and can even change your entire face for the worse.
If you are dealing with socialized medicine they also want to do the easiest route possible, so they may try to do single jaw surgery instead of double jaw surgery, so he would need to extract teeth in order to get a good forward movement of the lower jaw.
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Get a sleep study.
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Thanks again everyone . I'm in Canada, so it's partially socialized for the actual surgery. But the plan that is being suggested by orthodontist is to do both jaws AND extractions . I would like to avoid extractions. Does anyone have an idea of how long I would need braces before the surgery if I were to do both jaws , no extractions ? Kjohnt, that might be close to what the surgeon suggested (except w. Optional genio) thanks for trying to get example . What does a sleep study do?
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Thanks again everyone . I'm in Canada, so it's partially socialized for the actual surgery. But the plan that is being suggested by orthodontist is to do both jaws AND extractions . I would like to avoid extractions. Does anyone have an idea of how long I would need braces before the surgery if I were to do both jaws , no extractions ? Kjohnt, that might be close to what the surgeon suggested (except w. Optional genio) thanks for trying to get example . What does a sleep study do?
About 1 year in braces if self ligating braces are used.
I'd def get a genio too and some max advancement, but yeah, its mostly maxillary impaction and mandibular advancement
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Thanks again everyone . I'm in Canada, so it's partially socialized for the actual surgery. But the plan that is being suggested by orthodontist is to do both jaws AND extractions . I would like to avoid extractions. Does anyone have an idea of how long I would need braces before the surgery if I were to do both jaws , no extractions ? Kjohnt, that might be close to what the surgeon suggested (except w. Optional genio) thanks for trying to get example . What does a sleep study do?
without any doubt you DO NOT NEED EXTRACTIONS trust me. tell them to make it work with all your teeth.
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When I had braces as a teenager, they pushed my bottom teeth sort of to the farthest point they could forward to get them to match my upper teeth to reduce the over bite. Could this be why he is saying I need extractions? (no room)
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When I had braces as a teenager, they pushed my bottom teeth sort of to the farthest point they could forward to get them to match my upper teeth to reduce the over bite. Could this be why he is saying I need extractions? (no room)
find a different ortho, preferably one who uses "damon" braces --and I do agree you need double jaw surgery.
I mean you don't NEED it. You're attractive and if you have no sleep apnea issues than who cares, but you know if you want to take a shot at maybe changing your look a bit it might be worthwhile.
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Thanks for the reply. I am getting the idea it would probably be best to do double jaw surgery. Because of my living situation, the time involved for that I am discovering is a bit of an issue for me. If I were to just do upper jaw, would I see an improvement? Or would it make me look worse then I do now to do upper jaw and not lower. Thanks again.
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Trust me, you want both jaws. Lefort I for anterior maxillary impaction and bsso for advancement.
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Okay check this out. This is an example from a person I'll call "J". I think not only is this a good example for the case at hand but a good example in general of CCW rotation achieved using anterior maxillary impaction. Please note that I asked J to use her radiographs and pictures as an example on this forum and she graciously gave me her consent. I sent her a link to this thread as part of that so she could read about this case. If you do not like her outcome or do not agree with my analysis in any way, please be courteous regarding her pictures.
Attachment A is a before/after radiograph of J. She underwent 5mm impaction along with 5mm mandibular advancement. That's it. I drew vertical lines from the nasion for easy reference of horizontal jaw projection. Attachment A.1 and A.2 are her profile before/after pictures. Attachment A.3 is her frontal before/after.
From the original radiograph and picture, it would be easy to think she needed bimax advancement and genioplasty. I saw her before/after prior to the radiographs and assumed she'd gotten both. Note the CCW rotation achieved also results in some "maxillary advancement" of the soft tissue even though the molars are in the same (albeit rotated) position.
Anyway, I think her result is one of the best I've seen; IMO she looks absolutely stunning. Her surgeon's plan of attack was spot-on.
Attachment B is Tetley. I drew a vertical line from the nasion for easy reference of horizontal jaw projection.
When comparing to J's pre-op, you can see Tetley's similarities. It's super close. J may have had 1-2mm more maxillary projection. Tetley's maxillary vertical height is 1-2mm more if you compare the upper incisors to the lower lip.
Given this information, again, I think Tetley would best benefit from 6-7mm anterior maxillary impaction resulting in CCW rotation along with a BSSO mandibular advancement to then close the resulting overjet to class I. I think the post-op ceph would look nearly identical in terms of occlusal plane and horizontal jaw projection. No maxillary advancement or genioplasty needed (except maybe genioplast for mild vertical height addition which could help the lower lip curl).
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Here's a J pre-op to Tetley to mine comparison. These are not to scale.
Mine shows more of a need for horizontal advancement along with the CCW rotation (but perhaps from posterior downgrafting instead of anterior impaction - this is something I'm trying to wrap my head around in that if I advancem the jaws horizontally, will gum show and lip strain then occur and I should get impaction even though current tooth show is good and no lip strain... for another thread).
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wow kjohn, j's results are PHENOMENAL she looks incredibly beautiful now.
only really unfortunate about the upper lip lengthening like that. f**k i wish that could be changed. she'd be perfect.
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wait is that frontal second picture a "morph" of Tetley done by you Kjohn?
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wait is that frontal second picture a "morph" of Tetley done by you Kjohn?
No, I've done no morphs here. That's the after result of J.
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oh i see well she's friggin beautiful.
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Thank you so much for taking the time to get those, and thanks to your friend as well for the permission. I really appreciate it, and she does look totally amazing. She was pretty before too though! Yes, I can see this is probably the way I want to go. Just to clarify, she did not get extractions? I spoke to my orthodontist again, but he seems convinced the extractions are an absolute necessity. He says my previous orthodontist overcompensated for the overbite by pushing all my teeth forward so this is the only way to go. I am going to see if I can ask the surgeon what he thinks. Do you think I should get a second opinion? Thanks again for all your advice. Do you know how long her treatment was?
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Oh , and the ortho I am with does offer damon braces, although he did not mention it to me.
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No problem. You have pretty eyes and the rest of your features are goodm, so you too are going to look great when you get done with all of this.
She didn't have any teeth extracted, and not sure about timeline.
It's not really fair of your current ortho to blame your prior ortho for pushing the teeth forward as a reason your teeth don't fit into your arches... he could simply pull them back. If they don't fit within the arch, it's your genetics and or growth.
I'd always recommend surgeon>orthodontist>dentist. So that's to say it's up to the surgeon as to whether or not extractions are needed. I think most try to avoid them if possible. There are some other options (mandibular widening, enamel cutting) but they are all worse from what I've gathered. But yeah, please don't let your ortho or dentist do anything to your teeth without prior approval from your surgeon. If your surgeon says you need teeth extracted, I'd listen, but would ultimately get a second opinion from another surgeon first just to be sure.
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I just spoke with the surgeon again and he is strongly recommending just the upper jaw and possible Genioplasty. He believes that this will allow the lower jaw to move forward counter clockwise? This is the second surgeon who has given me that opinion, the first one said he was not comfortable doing both jaws at all, as he did not see a benefit. Do you think they are wrong?
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Like I said there are different approaches one could take. Some are more ideal than others.
Did you bring in copies of my example to show the surgeon? I could certainly be incorrect about your case, but my biased opinion says otherwise. I'm wondering what they'd be doing if only moving your maxilla. If just impaction, once the mandible rotates forward at the joint to cover the new space, I think you will have some overjet. So they'd have to also bring the maxilla back a bit when fixating if not touching the mandible. That's not aesthetically ideal at all.
You need to be asking lots of questions. Also you need to do lots of research.
Again, I'm no surgeon, but many of these guys seem to have very little clue about aesthetics, unfortunately. Your local surgeon just down the road may won't cut it.
You said you're in Canada right? IDK if close, but Google Dr. Hohn in Saskatoon and get in touch with his office. He did the exampled case.
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I just spoke with the surgeon again and he is strongly recommending just the upper jaw and possible Genioplasty. He believes that this will allow the lower jaw to move forward counter clockwise? This is the second surgeon who has given me that opinion, the first one said he was not comfortable doing both jaws at all, as he did not see a benefit. Do you think they are wrong?
Surgeon is wrong. This is a very common mistake they make, trying to look at you and deduce what would look good. The goal here is to make you normal like everyone else, as if you never had deformity in the first place. To do that you need to understand the nature of the deformity - what went wrong with your face. What you have is VERY common and very routine. You have long face syndrome. You have or had bad allergies as a child and in the first few years of life your face grew down instead of forward and as a result both jaws are underdeveloped. The upper jaw continued growing down to meet the lower jaw, hence the gummy smile. Impaction would solve many but not all of the problems. The biggest one it won't solve is the airway. There's no scale in your xray so I can't measure it but without double jaw, you'll likely have sleep apnea when older if not now, that's why Plosko said get a study. It sounds innocuous but it's not, it's a very serious medical condition which underlies so many other disorders, you do not want it. Single jaw is penny wise dollar stupid in your case. You likely have transverse discrepancy and a steep occlusal plane as well because they come as a package. And your gum tissue is of thin type and your bones are thin. As for extractions, that's a function of arch length. Removing teeth is unaesthetic but it's health and stable for the teeth long term when there isn't space. You can expand upper jaw arch length but not lower jaw.
You need to decompensate the teeth so surgeon can see the most stable position for them. That takes 6-12mo. Then another 6-12mo after surgery in braces. Multi-segment LeForts are often needed in cases like these, depends just on how steep you are (determines the curve of Spee).
You are pretty btw, despite the protrusion. You'll be even prettier after surgery :)