jawsurgeryforums.com
General Category => Aesthetics => Topic started by: Pipilika on February 03, 2020, 07:55:19 AM
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Hello ,I have some problems with my face ,my face is too short ,my bone cheeks are promminent ,but I have a mandibular assymmetry( my left mandibular ram is shorter than the right mandibular ram ).
So ,what should I do? What procedures?
Excuse me ,but I m new to max fac surgery
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Nobody can help me with a few hints?
Should I post here my ceph and radiographies plus tomography 3 d( i have tomographic 3D reconstruction too
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Nobody can help me with a few hints?
Should I post here my ceph and radiographies plus tomography 3 d( i have tomographic 3D reconstruction too
Post your ceph. Closeups of your bite.
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I will post few radiographies of my skull and 3d Ct , if someone with some experience can tell me his opinion.
https://i.imgur.com/4Kh1Mp2.jpg
https://i.imgur.com/t4viVTd.jpg?1
https://i.imgur.com/g1bDhCL.jpg
https://i.imgur.com/THwt0R0.jpg
https://imgur.com/xQeUmh1
https://imgur.com/JJk7X41
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If your bite and airway is fine, which it appears to be, I would stay away from orthognathic surgery, not worth the risks for your case. To address the lower asymmetry look into a chin wing, and for that you'll have to go to Europe as I'm not aware of any US surgeons that perform it.
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You should also post face pictures.
For future reference, you should look straight ahead in CEPHs with neutral head posture. You're staring at the ceiling in the one you posted
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hello guys again, I was very busy these days,I will post ssssome real pics with me.
But ,I had consulted a plastic rhino surgeon 8 years ago, and told me my nose is overporjected.
Is iit that true?
Could someone tell me how is my ANS(anterior spine nose)?
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You should also post face pictures.
For future reference, you should look straight ahead in CEPHs with neutral head posture. You're staring at the ceiling in the one you posted
His doctor might want him to do that because the doc probably wants to rotate CLOCKWISE due to the deep bite, low MPA and the short lower 1/3.
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His doctor might want him to do that because the doc probably wants to rotate CLOCKWISE due to the deep bite, low MPA and the short lower 1/3.
That's possible. Though in every surgeon's office I've been to, the CEPH room has a fixed point to stare at and encouragement to look "straight" (granted my growth pattern is the opposite of his). It just seems as though the the wacky CEPH angles typically come from orthodontists or other non-maxfac sources.
The 3D scan indicates he got these at a surgeon's office so maybe that really is what he wanted.
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I will post here a few pics ,also, and orthopantomogram.
Pics are some newer,some older.
https://i.imgur.com/H179lsm.jpg
https://i.imgur.com/M4KjlAI.jpg
https://i.imgur.com/rNqQzfa.jpg
https://i.imgur.com/FsA21uw.jpg
https://i.imgur.com/m1s4KLs.jpg
https://i.imgur.com/x3duXNy.jpg
https://i.imgur.com/pSHT7TM.jpg
https://i.imgur.com/nDtKT91.jpg
https://i.imgur.com/4Kh1Mp2.jpg
Let me tell one more time what bothers me, I think my faace is too short ,too broad,my zygoma are too low set ,that asymetry and lack of definition to the mandible(lack of definition to the lower thrid).
Wshat could I do?Please recommend me something.
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I will post here a few pics ,also, and orthopantomogram.
Pics are some newer,some older.
https://i.imgur.com/H179lsm.jpg
https://i.imgur.com/M4KjlAI.jpg
https://i.imgur.com/rNqQzfa.jpg
https://i.imgur.com/FsA21uw.jpg
https://i.imgur.com/m1s4KLs.jpg
https://i.imgur.com/x3duXNy.jpg
https://i.imgur.com/pSHT7TM.jpg
https://i.imgur.com/nDtKT91.jpg
https://i.imgur.com/4Kh1Mp2.jpg
Let me tell one more time what bothers me, I think my faace is too short ,too broad,my zygoma are too low set ,that asymetry and lack of definition to the mandible(lack of definition to the lower thrid).
Wshat could I do?Please recommend me something.
You know what bothers me? People who put their photos on SEPARATE links when they can put all of them on SAME link. Sorry dude. Won't be keeping multiple tabs open just to look at someone's pics.
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You have a SHORT MIDFACE. But not any to much jaw recession. The main thing that can be done via maxfax surgery is an over-all DOWN GRAFT to the MAXILLA which will in turn, kind of thrust the lower jaw area downward to give more length to the face.
For SHORT FACE, the down grafts are usually with more to the front than to the back which is a clockwise rotation. How much tooth show you have when lips are open and/or when smiling will determine the extent of the down graft as to whether it's a uniformly down or if it's more down in the front than in the back. IF you have NOT MUCH tooth show when lips are slightly parted, then the downgraft can be thicker and/or more in CW direction. IF you have a lot of tooth show, then too much of a down graft would give too much tooth show. The IDEAL combination for downgrafting the maxilla for SHORT FACE is when the person also has MINIMAL tooth show.
So, over-all DOWNGRAFT to the maxilla, thickness of it and also whether uniform or in clockwise direction to be determined via measures that take into consideration your TEETH.
With SHORT FACE, in addition to the downgraft, the chin is often brought in diagonally downward direction. It is a type of genio that is NOT a sliding genio (which brings forward BUT also shortens). But rather the type of genio that 'advances' chin in diagonally downward direction is one where a BONE BUTTRESS needs to be sandwiched between the cut. Said bone buttress can be a 'block' made from hydroxyappatite.
You will need to find a surgeon who does DOWNGRAFTS to the entire maxilla
For lower jaw ASYMMETRY, this may be addressed during the surgery or just left there and addressed via custom jaw implants later down the line. Soft tissue fillers can be used to MASK residual asymmetry there.
OTHER:
Your nose is NOT over projected. It is just that you don't have enough 'face space' which can make even a NORMAL NOSE look 'bigger' due to the smaller face space. You are NOT a candidate for rhino first. Your nose would most likely look better to you after a surgery that addresses SHORT MIDFACE.
Your jaw to jaw balance looks 'even' from profile soft tissue perspective. That is to say, recession of one or both jaws is not the key aesthetic culprit to your aesthetics. However, some minor advancement could be done if that factored into balancing the bite.
Assessment based on 2 face (soft tissue) photos. Limit for looking is 2 photos per poster when every photo is on a separate link.
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Kavan, thanks for your input and thousands of excuses for not uploading to a single post.
Now ,I ve learned my lesson.
I ve uploaded again (to a single post this time),I ve posted there my radiographies, CT ,and some pics ,one of them smiling, as you can see)
My doc told me also to increase the teeth show by a bimax procedure, in order to get me look younger.
Although ,he told me this surgery has an effect of lifting ,diminishing nasolabial folds.Is this valid?
I am a bit tired now,but tomorrow I will post my surgical plan, I dont remember exactly ,but he *my surgeon) had told me about a CCW rotation, not CW,and logically you re right ,CCW is for longer faces to make them shorter, not opposite.
Here it s the post on imgur
https://imgur.com/a/p2PZRWk
Also, I am waiting for the others input ,just curious
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Kavan, thanks for your input and thousands of excuses for not uploading to a single post.
Now ,I ve learned my lesson.
I ve uploaded again (to a single post this time),I ve posted there my radiographies, CT ,and some pics ,one of them smiling, as you can see)
My doc told me also to increase the teeth show by a bimax procedure, in order to get me look younger.
Although ,he told me this surgery has an effect of lifting ,diminishing nasolabial folds.Is this valid?
I am a bit tired now,but tomorrow I will post my surgical plan, I dont remember exactly ,but he *my surgeon) had told me about a CCW rotation, not CW,and logically you re right ,CCW is for longer faces to make them shorter, not opposite.
Here it s the post on imgur
https://imgur.com/a/p2PZRWk
Also, I am waiting for the others input ,just curious
Assuming the doctor had you tilt your head upward for the FIRST ceph in series of photos, which is the CCW direction, leads me to believe he's wanting to do a CW rotation. He's looking at your low mandibular plane angle which is close to HORIZONTAL=0= very LOW with that head rotation.
When doctors want to do the CCW rotation of the jaws, they either have the patients rotate the head downward in CW direction or they rotate the ceph more in that direction.
Regarding the THIRD ceph in series, like I said prior, jaw recession is not really an issue.
As I said prior, the SALIENT 'thing' is an OVER ALL DOWN GRAFT. The thickness of it can be uniform, more in front or more in back. If thickness is uniform, there is no rotation. If thickness is more in front, the rotation is CW. If thickness of it is more in back, the rotation is CCW.
Since all 3 are OVERALL THICKNESS grafts, all of them would increase the facial height and more 'face space' as to diminish soft tissue crowding. Which one will depend on tooth show/orientation.
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I have not found yet my surgical plan.
I wiill post it later.Doctor was telling about downgraft,you have told me I have to find a surgeon who perform downgraft to the entire maxilla, it s posibble to make downgrafts only localized?
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You appear to have normal tooth show, so not a short face. You look fine.
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I have not found yet my surgical plan.
I wiill post it later.Doctor was telling about downgraft,you have told me I have to find a surgeon who perform downgraft to the entire maxilla, it s posibble to make downgrafts only localized?
Yes, it's possible to localize the thickness of a downgraft. But the issue here would be a 'thick' down graft. For example, a surgeon in the capacity to do a 'thick' CCW posterior downgraft where most of the thickness is in the very back would also be in the capacity to do an overall downgraft where the thickness is graduated on a continuum from one area to the other. In that way, you INCREASE total facial HEIGHT whether or not the direction is CCW or CW. An isolated CCW posterior downgraft is NOT what to do for a short face needing more tooth show and an isolated CW (anterior downgraft for more tooth show) only elongates the anterior face but doesn't 'drop'/elongate the whole jaw area as would as would an overall downgraft whether the direction be CW or CCW.
Your shortness is to the OVERALL jaw area and the way to increase the total facial height is via an overall downgraft whether the rotation be neutral as in 0 rotation, CCW with a little more in back than front or CW with more in front than back.
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You appear to have normal tooth show, so not a short face. You look fine.
Yes, he looks fine. BUT tooth show, in it's own right, does NOT negate short face. It just limits the extent the facial height can be increased via the maxillary down graft.
One way to evaluate short face is to look at the division of '3rds' in profile, in particular the middle '1/3rd' and the lower '1/3rd'. When the middle '1/3rd' is less than lower '1/3rd', it's an indicator that the shortness in facial height arises from the middle third. His mid 3rd is significantly shorter than the lower 3rd. (This is a soft tissue distance relationship analysis).
To confirm shortness of middle 3rd being culprit of over all short facial height, we do same division on a frontal photo.
Another cross reference, I use for aesthetic analysis is to draw a straight line through midpupils to the outer edge of the irises; 'line H'. At midpoint of that line, another line perpendicular to it is drawn to where the lips meet each other, 'line V'. If line 'H' is longer than line 'V', it confirms short middle '1/3rd' which was case of the OP when I used methodology in aesthetic analysis.
It's not my intent to draft out an illustrated tutorial in basic aesthetic analysis. But suffice to say, my findings confirmed he indeed had short facial height where shortness was arising from the 'middle 3rd'.
That said (like I said prior in another post), TOOTH SHOW is a limiting factor for how much you can drop down the maxilla with the down graft. With lack of tooth show, you can drop down more to get a better increase to total facial height. Conversely, drop down would have to be less on a person who didn't lack a lot of tooth show. BUT having tooth show does NOT NEGATE short middle 1/3rd when a soft tissue distance relationship analysis confirms it. Tooth show, extent thereof, just limits the extent you can increase the overall facial height with the down graft.
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Hello again,
I have found the surgical plan, I will try to translate it.
So:
Patient with class 1 dental and skeletal, slightly hypodivergent, with mandibular and skeletal asymmetry, without occlusal edge(cant)
Intervention on the base of the mandible, on the left side, for symmetrization.
Lefort 1 intervention with downgrafting (and CW) can be considered to increase the vertical distance at the lower floor level possible with exposure of incisors to 2 mm (and to give a younger look).
Exaggerating CW downgrafting will reduce chin exposure and require bimax with advancement (being biretrusive).
What do you think about this surgical plan?
I am a bit afraid, I can say ,I want everything to be ok, and to have the desired look ,because this surgery is an expensive one.
Also what do you think about my philtrum?*please examine all the pics)
The philtrum will get longer or shorter after such an intervention?
The lips will get thinner after this surgery?
I thank you one more time for your effort to answer me,you have helped me very much
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also ,I dont like the manner how he perccceive to do the so called symmetrization of mandible on ,what will he do on the left of the mandible to straighten the mandible....
I dont understand.
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This not really a 'plan'. It's more of him toying with idea of what to do. A plan involves a ceph tracing and proposed displacement overlayed to a ceph tracing CONTOUR DIAGRAM along with all the displacements charted out. So, this is not a plan anyone can look at.
Since there is NO 'plan' to look at, no definitive answers to how philtrum or lips will look.
Intervention to the LEFT mandible where it is SHORTER there could mean he's got some way of making it longer to match the right so that area looks more symmetric.
Exaggerated CW downgrafting most likely refers to isolated downgraft of anterior maxilla and would require (as he said) lower jaw surgery advancement with it (to compensate for an exaggerated push back to the mandible). It also fits into what I mentioned in a prior post which is that I thought he was anticipating CW direction because he had your head tilted UP for a ceph.
An OVERALL downgraft to the entire maxilla need not be exaggerated in CW direction as in much more in front direction than back.
My advice is to re-read my prior posts to 'digest' the info and to also consult with a maxfax who does overall downgrafts to get a real plan.
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hello again Kavan, thanks for your answers and effort put in answering my questions.
I would like to ask you a few more things(or other forum members, if they agree to answer me).
First, I wanna say I dont want model look , I want just a new improved version of mine.
Could it be possible?
Kavan, in other thread you was telling about a wrap a round implant it has to harmonizes well with the bone structure of the face, soft tissues and eye area.What do you think in my case ,examining my pictures?
what could I do to improve eye area?I know we are on a jaw surgery forum but I trust you as being very competent as regarding aesthetics .
So what could I do to improve me ,except elongating my face?
I am waiting also for other members' answers , I will not be upset, you could recommend me what you sincere think
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He seems to have lack of dymorphic traits. That makes this case difficult. For example low cheekbones, lack of definition/angularity. From profile, his lower third does seem too short.
You also have excess fat in the face/under the chin/jaw, so I think you could lose some weight before assessing what to do exactly.
I don't know if his midface is too short, could be. Difficult to say.
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hello again Kavan, thanks for your answers and effort put in answering my questions.
I would like to ask you a few more things(or other forum members, if they agree to answer me).
First, I wanna say I dont want model look , I want just a new improved version of mine.
Could it be possible?
Kavan, in other thread you was telling about a wrap a round implant it has to harmonizes well with the bone structure of the face, soft tissues and eye area.What do you think in my case ,examining my pictures?
what could I do to improve eye area?I know we are on a jaw surgery forum but I trust you as being very competent as regarding aesthetics .
So what could I do to improve me ,except elongating my face?
I am waiting also for other members' answers , I will not be upset, you could recommend me what you sincere think
Please know that when I address a person's initial post and explain some general concepts that are applicable to the person's lack of knowledge/information,--and here it was SHORT FACE-- it's not meant to be an invitation to 'spring board' off what I told someone ELSE in THEIR post/query for me to apply what I said to them to you. It also isn't meant to be an invitation to engage me in an over-all aesthetic analysis of other areas of the face.
I consider my 'job' done here on this string. I've confirmed you have short (mid)face. I've exlained the concept of the EXTENT of how much it can elongate will be LIMITED by tooth show. I've explained difference between isolated downgrafting and overall. I've suggested you seek out a maxfax who does over-all downgrafting. So, content applicable to your original and main complaint here has been covered.
That said, if there is anything you don't understand about the CONTENT/general info of my posts addressing your INITIAL query, then you may ask me those types of questions. None of that content says anything about your eyes or suggested you go to another thread where I thought your issue was similar to issue of another somewhere else. Hence, feedback on your main issue is not an invitation to spring board into non related questions.
If you seek feedback on the other parts of your face, you can start another string.
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ok Kavan understood,but one last more question regarding my problem,you stated the downgraft is limited by the tooth show.
you told something about ,also what tooth show when my lips slightly parted.Then , it is very limitted tooth show about 1-2 mm,only when I smile and ,then also ,let s say half of the teeth.
So could be a 10 mm downgraft?
The middle third is elongated too ?that overall downgraft is made to mandible too?
Also how could be a surgical plan ceph?Should I ask him to draw on ceph what will he do?
Thank you and excuse me if I repeated some questions.
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ok Kavan understood,but one last more question regarding my problem,you stated the downgraft is limited by the tooth show.
you told something about ,also what tooth show when my lips slightly parted.Then , it is very limitted tooth show about 1-2 mm,only when I smile and ,then also ,let s say half of the teeth.
So could be a 10 mm downgraft?
The middle third is elongated too ?that overall downgraft is made to mandible too?
Also how could be a surgical plan ceph?Should I ask him to draw on ceph what will he do?
Thank you and excuse me if I repeated some questions.
Downgraft limited by tooth show:
LIMITATION refers to ONE thing that LIMITS the extent of what you can do with ANOTHER thing when both things are RELATED to each other. One thing will LIMIT how much you can maximize another thing. Think basic high school math concept of simple functions where functions Can Be Inversely related or Directly related. So the extent of how much you can increase facial height with a downgraft is proportional to the degree of tooth show. Maximum tooth show will minimize the extent of how much you can increase facial height with the downgraft and minimum tooth show will maximize the the extent of how much you can increase facial height with the downgraft.
The fundamental relationship between tooth show and the extent of a down graft is this:
The MORE the tooth show the LESS thickness the graft can have and therefore the less overall increase in facial height can be achieved with it. The LESS the tooth show the MORE the thickness the graft can have and therefore the more overall increase in facial height can be achieved with it.
To SIMPLIFY further, take the example of a of an overall downgraft of uniform thickness where it's the same thickness to the front of the maxilla as to the back of it; same thickness THROUGHOUT the entire maxilla (which includes the middle part too). The maximum thickness it can have (to increase facial height) is LIMITED by the tooth show.
So, IF 'X'mm EXTRA tooth show than one already had was needed, thickness limitation would be 'X'mm.
As to what is 'X' for you, that is something the doctor would need to determine by doing the appropriate measurements. I just go over the fundamental conceptual relationships and grasping thereof.
Downgrafts and discussions thereof apply to the MAXILLA.
Cephs TRACINGS are done on a CEPH. From there, a PLAN is drafted as to the DISPLACEMENTS to be done. Proposed DISPLACEMENTS of the JAWS are illustrated on the ceph tracing by a CONTOUR diagram that gives a visual of the proposed profile contour.
If you lack a fundamental grounding in basic geometrical and simple math relationship functions, there will be no base line understanding for you to relate concepts in maxfax to.
ETA: Ave. Crown length of maxilla incisor is about 10.5mm. Average gum show above teeth when smiling is about 2-3mm but not more than 3mm. Average upper incisor toot show at rest is about 2mm.
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as I ve made some gross measurements ,I have noticed the difference between line H and line V is somehow 8 or 9 mm.Am I right?
Is this the ideal thickness of the downgraft?
If the tooth show is not taken into account ,this surgery could introduce gummy smile ,but if it s taken into account ,I could hope for a 7-8 mm ?
Also after this intervention what would happen with my phitlrum ,could it change?My philtrum is 18.5 mm.
and ,another question ,if the face is elongated ,the cheekbones could seem higher?
Is it advisable to elongate the mandibular ramus too by BSSO?
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I can't confirm if you did the measures correctly as to 'H' vs. 'L'. Mine were RELATIVE to your photo and done to confirm you had short face where the shortness was comimg from mid-face. In 'real life' someone would need to take a CALIPER to your face for the measures. BUT a difference of about 8-9 mm (H-V) does seem to be APPROX in the ball park.
Thing is that difference just corresponds to shortness of facial height. But the tooth show will LIMIT the extent of a graft to increase facial height by an approx 8 mm. So, with your present tooth show, you could NOT get the approx 8mm graft.
BSSO does NOT 'elongate' the ramus. BSSO is to bring the mandible forward whereas recessed mandible is NOT your problem.
Elongated face would most likely not make cheek bones look higher.
In a surgery where the maxilla is 'dropped down' (but not advanced forward), it would tend not to alter the philtrum.
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How tall are you?
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I can't confirm if you did the measures correctly as to 'H' vs. 'L'. Mine were RELATIVE to your photo and done to confirm you had short face where the shortness was comimg from mid-face. In 'real life' someone would need to take a CALIPER to your face for the measures. BUT a difference of about 8-9 mm (H-V) does seem to be APPROX in the ball park.
Thing is that difference just corresponds to shortness of facial height. But the tooth show will LIMIT the extent of a graft to increase facial height by an approx 8 mm. So, with your present tooth show, you could NOT get the approx 8mm graft.
BSSO does NOT 'elongate' the ramus. BSSO is to bring the mandible forward whereas recessed mandible is NOT your problem.
Elongated face would most likely not make cheek bones look higher.
In a surgery where the maxilla is 'dropped down' (but not advanced forward), it would tend not to alter the philtrum.
To this I would add, you look to be the facial type/ethnic type, where shorter face (as opposed to taller) is consistant. I don't have my Farkas anthropometric ratios for racial and ethnic groups close by right now. But just to say, you look to be an East European grouping where it's normal not to have the equal division of 1/3rds. That is to say a shorter face is normative for your grouping. Based on your present tooth show when smiling where you don't look to have any gum show, IF you would be OK with 2-3 mm gum show when smiling (which is within norms), you could probably have a 2-3 mm uniform overall graft with NO ROTATION to increase facial height by that amount. For more to the lower face area, you could either have a diagonally downward genio OR a 'chin wing' that just dropped the down the mandible but no advancement. Good combo would be the chin wing of about 3-4mm along with maxillary down graft of about 2-3mm. So, we are talking approx 5-7 mm increase of total face height with the uniform max. downgraft plus the chin wing. There is really no need to advance out your jaws or to change your bite
I would be inclined to suggest the lower end which would be an overall 5mm increase of total facial height to keep within your anthropometric grouping and not veer to close to too much gum show. So I would err on the LOWER END.
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it appears another problem that is unclear for me, I want to undergone orthodontic treatment,could this treatment increase the tooth show and ,so,not be able to elongate my maxilla area by surgery?what do you think?should I abstain from this treatment?
I have forgoten to add, ortho for deep bite class 1 angle