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1: Ok, something started when you were 33; extreme pain subsequent to a filling. Said pain is or can be associated with TGN, Trigeminal neuralgia, damage to it or some kind of interference with it that constantly triggers facial pain.

2: During the years, you had 5 molar extractions. Maybe due to infection causing pain. Maybe due to pre-existing pain from the trigeminal nerve for a tooth having no infection. Basically a circumstance where you thought removing the tooth would remove the pain. Pain from a tooth infection affects a nerve in the tooth and that nerve connects to another one found in either maxilla or mandible depending on where the tooth is. In that circumstance, removal of tooth removes that type of nerve connection that signals pain. So, if removal of the teeth gave no pain relief, then some OTHER nerve could/would be the pain generator.

3: Bottom line is that after multiple extractions of teeth due to PAIN, there was no relief of that pain. Hence a suspicion of Trigeminal neuralgia.

4: Removal of molars = removal of bite force needed to preserve bone. The tooth bearing part of the bone; the aveolar process of the jaw/s resorbs. So, facial length is lost. The facial proportions change unfavorably because the soft tissue of the face loses support due to the lost teeth and bite imbalances that arise from using the 'left over' teeth to chew.

5: So, the aesthetic problems are due to loss of facial bone support from dental losses. There is also existing PAIN, chronic pain and the stress of that in addition.

6: Because of the aesthetic problems, you are going around to doctors who are known to 'fix' aesthetic problems whether they be maxfax or plastic surgeons in Europe or elsewhere. It doesn't matter who or where they are. What matters is that they would look at your medical history which includes chronic facial pain. If they had any reason to believe the surgery for aesthetics would not address the pain condition OR could make it WORSE, they wouldn't offer it.

7: Your primary focus is on aesthetic (loss). BUT since the focus on that is directly related to tooth loss in a circumstance where removing teeth didn't remove the pain that was felt to them after removal and also since the pain condition is STILL THERE, quite possibly due to Trigeminal nerve pain of some kind, you would need to shift your focus on types of possible source of the pain.

8: To the best of my knowledge, there are types of surgeries for TGN. So, you would need some kind of diagnosis that you had that. One surgery said to relieve that is microvascular decompression which is when a blood vessel is pressing down/irritating the nerve. There could be maxfax surgeons who do can address TGN or work in conjunction with others who do. So, that is for you to explore.

9: You are spinning your gears looking for surgeons; maxfax or plastics based on aesthetics alone. I mean that if you are going to consult with them, especially a maxfax, you would need to SHIFT the FOCUS of the consult to whether or not he/she had any leads on surgeons who could address the TGN and ALSO IF that would come FIRST to possibly allow for a future maxfax surgery. I mean that if they are not offering to do aesthetic surgery on you due to another condition (pain condition) where that could get worse with surgery, then you have to look for surgical possibilities to directly address the pain condition first.

10: Another possible option that probably doesn't include surgery is dental prosthetics, dentures, false teeth designed to elongate parts of face that got shorter due to tooth loss and also designed to construct a bite to help aesthetic facial support. Sometimes that sort of thing is marketed as a 'dental face lift'. So, you could look around for the types of dental pros who design dentures and ask if they can design something that could better support your face. I mean the FACT that you have MISSING teeth and the fact that they would know bone loss and lack of facial support resulted from that and also that they are in business of designing dentures would justify consults within venue of dental prosthetics (dentures).

This can happen to the upper jaw, and it's called a "non-union"...your jaw would wiggle when pushing on the teeth or pallet. Do you see anything like that?

I don't think it's possible on the lower jaw (maybe early on after surgery if a screw didn't take or something like that).

Hey everyone,

I’ve been on this forum for about 10 years — mostly reading and learning, with the occasional post. I originally started a thread back in 2021 (linked below) when I was feeling stuck and overwhelmed, and I’m still grateful for the thoughtful feedback I received, which has meaningfully guided my treatment.

https://jawsurgeryforums.com/index.php/topic,8437.0.html

Since then, a lot has changed. I was eventually diagnosed with moderate sleep apnea and decided to move forward with treatment. I began orthodontics in 2022 and have now been in active prep for over a year and a half. Things are moving toward surgery, and I wanted to return here to both share an update and ask for help thinking through a few unresolved questions.

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Quick Recap of Where I Am Now

• Orthodontic prep: lower incisors retracted significantly (approx. 5–7 mm), braces still on
• TADs used for en-masse retraction (no premolar extractions)
• Confirmed plan for maxillary and mandibular advancement
• Diagnosed mild gummy smile with upper lip hypermobility
• Still trying to finalize any additional dental or skeletal adjustments pre-surgery
• I had a long travel gap of 1 year but am trying to get back on track for surgery with Dr. Gunson

Just a side note that may help others: I was told by several surgeons that retracting my lower teeth without premolar extractions would be impossible. But I really wanted to avoid extractions if possible — and my orthodontist, Dr. Vince Kokich suggested we could use the space from my previous wisdom tooth extractions. With TADs, we were able to achieve significant en-masse retraction. I just wanted to share that in case someone else is facing the same dilemma.

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What I’m Still Trying to Figure Out

1. Should I be retracting my upper incisors pre-surgery?
Most surgeons I’ve consulted with agree that I would benefit from a small maxillary advancement (around 3–5 mm). But my mouth already appears somewhat full in profile, and I’m concerned that advancing the maxilla without adjusting the upper incisors could make my lips appear too prominent.

On the other hand, I don’t want to lose upper lip support or prematurely age my mouth by over-retracting. I’m trying to understand whether the mouth-dominant look is due to true protrusion — in which case, retraction would help — or if it’s more of an illusion caused by a recessed ANS/paranasal/midface area.

Right now, I’m debating whether a small incisor retraction (1–3 mm) is the right move, or whether it’s better to preserve incisor position and instead address facial imbalance post-op through ANS advancement or paranasal/midface augmentation. My orthodontist says we can affect retraction either through tipping or retracting en-masse.

2. Should I allow a controlled relapse in lower incisor angulation?
My lower incisors are now very upright — my orthodontist even mentioned they might be too upright. I’m wondering whether allowing a small controlled relapse might actually improve lower lip support and facial balance post-BSSO. My main concern is avoiding a lower third that looks overly tucked under.

3. Managing gummy smile and incisor show
We’ve considered mild maxillary downgrafting to improve incisor display, as mine is slightly low for my age. But I already show some gum when I smile naturally. I’ve also looked into lip repositioning surgery post-op.

I’m wondering if the gum show I have now is mild enough that I could afford a slight increase (via downgraft) to improve incisor show at rest — and still be able to manage the result with lip repositioning surgery later. I’d love input from anyone who’s tried this combined approach or has thoughts on how to assess whether it’s a good fit.

4. Would MSE offer any aesthetic benefit?
I originally tried MSE under Dr. Gunson’s guidance, but the suture failed to open and the appliance was removed. My understanding is that it could still be reattempted using corticotomies. I’m trying to determine whether MSE would actually benefit me aesthetically.

On one hand, it could offer paranasal expansion, which I’d welcome. On the other, all of my upper teeth are visible when I smile widely — and I’m unsure whether widening my arch further would create aesthetic issues or instability. Any thoughts on this trade-off would be appreciated.

5. High vs. low Lefort I?
From what I understand, a high LeFort I could help address my relatively retrusive paranasal and midface area, and I’ve seen it recommended in similar cases to improve support and projection.

What makes me cautious is that my nose is already slightly upturned (though I suspect that may be related to the ANS). I’m trying to determine whether a high LeFort I would be the right choice if I’m given the option — or whether it might introduce aesthetic risks that outweigh the midface gains.

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Photos & Materials (Link below):

Recent frontal and profile images taken by my orthodontist

Updated ceph

Candid photos that give an idea of my gum show at full, natural smile

https://imgur.com/a/VvQ5Sus

For context, these photos were taken at 25%+ body fat (work in progress).

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Bonus: Tools That Helped Me

Just in case it helps someone else — I’ve used a couple of basic tools to visualize angles and soft tissue balance while working through planning:

GiniFab Angle Tool - https://www.ginifab.com/feeds/angle_measurement/: Good for checking nasolabial angle, IMPA, and simulating CCW rotation changes.

Eleif Ratio Tool - https://eleif.net/photomeasure: Useful for analyzing facial thirds and soft tissue harmony using a known scale.

Of course, none of this replaces proper ceph tracing or clinical planning — and I know nothing beats sitting down with a pen, paper, a geometry set, and an x-ray. But these tools helped me stay organized and visualize things quickly when I only had digital materials on hand.

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If anyone has thoughts on the upper incisor retraction dilemma, how best to address paranasal/ANS support in tandem with a LeFort, has dealt with balancing downgraft vs gummy smile, or doing MSE without a typically narrow mandible, I’d be really grateful to hear from you. I’m not looking for a perfect answer — just trying to make sure I don’t miss anything critical before locking in surgical plans.

Thanks again to the people here who helped me stay grounded through the past few years.

Just had a look at Dr. Joël Defrancq site, and in a before after photo this picture came up, https://www.facialsculptureclinic.com/assets/info/8065401406/Dr-Joel-Defrancq-1435930968035467300_8661.jpg
its supposed to be "Lipofilling" and yes maybe there was some of that, but there is no way could make that dramatic change, the whole midface is far more compact in post pic, and the nose has change, philtrum and prob moore rhings aswell. So what do u think? Le fort1?
https://www.facialsculptureclinic.com/en/surgery/aesthetic-facial-surgery/liposuction-lipofilling/

can you please please share the link / pic again ? I'm so intrigued, I think I have simiar problem I need to adress

....... And from what I understood an anterior impaction will have more of the soft tissue effects that I long for: a better 'slope' of the philtrum, more nose support and a fuller upper lip.

Can you explain HOW you 'understood' that anterior impaction; a procedure done for anterior  vertical maxillary excess (VME for gummy smile) that lops off part of the anterior maxilla including part of the anterior nasal spine (which SUPPORTS the nose base) is going to give better nose support? Also, appox how many FEWER millimeters of tooth show do you wish to not be visible anymore when the lips are at rest and the mouth slightly open? Like it's not something where you can request the doctor to give you 'X' degrees of CCW impaction. Instead you just tell him how much excess tooth show you want to reduce so he knows how many mm he needs to lop off from above and below the ANS because they use the amount of mm removal to calculate how many degrees the rotation is.

Also can you explain WHY you think coupling up maxillary advancement with part of the anterior nasal spine lopped off is going to give you the soft tissue effects you 'long for'. Like why do you think that you would be the EXCEPTION to the trade-offs other people do get when coupling up maxillary advancement with maxillary impaction which are unfavorable changes to the nose base?