Revision surgery with decompensation(Ceph attached)

[Jan9x1]

Hello,
i need your help for a possible revision surgery with dental decompensation before.

I already had jaw surgery with anterior impaction, mandibular advancement , slightly maxilla advancement and up-sliding Genioplatsy.
I'm not quite satisfied with the result because i still have some kind of projection deficit.

I'm considering dental decompensation before with lower premolar extraction. This would give me a class3 molar relationship because I'm now in class1 but it would also allow for lower jaw surgery only.
I dont see a reason to touch the upper jaw again, i think my occlusal plane isn't steep. My upper lip is a bit too long but i don't have any teeth show at rest, so a lip lift might be a solution later.


What do you think would be the best solution?

I have also attached a frontal scan because i have an asymmetry at my right gonial angle. Either I'm going with a side wing only on the right side or an implant..... Chin Wing is possible, already had a scan for my mandible nerve position.


https://drive.google.com/file/d/15mBsHutJB92Q08-AF2ECAiqdag_atVky/view?usp=sharing
https://drive.google.com/file/d/1Huyo3ato_891Zuf_GCG2rh09kJ4ZBBAG/view?usp=sharing

[kavan]

It's not uncommon for people with deficits post maxfax surgery to address them via some plastic surgery procedures. For example, lack of tooth show due to longer lip is addressed as you say via a PS procedure (lip lift). The other example of this as to deficits are custom made implants to jaw/chin area. Chin wings get more challenging to do (higher risks) when the cut of the chin wing has to go through (intersect) a PRIOR cut like that of a BSSO and genio.

[GJ]

Hello,
i need your help for a possible revision surgery with dental decompensation before.

I already had jaw surgery with anterior impaction, mandibular advancement , slightly maxilla advancement and up-sliding Genioplatsy.
I'm not quite satisfied with the result because i still have some kind of projection deficit.

I'm considering dental decompensation before with lower premolar extraction. This would give me a class3 molar relationship because I'm now in class1 but it would also allow for lower jaw surgery only.
I dont see a reason to touch the upper jaw again, i think my occlusal plane isn't steep. My upper lip is a bit too long but i don't have any teeth show at rest, so a lip lift might be a solution later.


What do you think would be the best solution?

I have also attached a frontal scan because i have an asymmetry at my right gonial angle. Either I'm going with a side wing only on the right side or an implant..... Chin Wing is possible, already had a scan for my mandible nerve position.


https://drive.google.com/file/d/15mBsHutJB92Q08-AF2ECAiqdag_atVky/view?usp=sharing
https://drive.google.com/file/d/1Huyo3ato_891Zuf_GCG2rh09kJ4ZBBAG/view?usp=sharing

That's a tough call. You could try premolar extraction with lower jaw only, but your bite relationship will likely get worse from that. I'd view it as a compromise "solution" - should improve projection, but not the perfect solution. Ideally you would have had more CCW rotation with your original surgery.

You look within normal-ish. I've never seen a good lip lift in the 10+ years of running this site, and therefore wouldn't consider it.

[Jan9x1]

I dont see another solution tbh.

I could still consider CCW Rotation but I don't think it would be a good idea to give me a positive Occlusal Plane?

The thing is, my lower Incisors are really proclined in my opinion, not something unusual for a class2 but it's really noticable on the Ceph.

I could extract my 3rd Molars and distalisize the lower arch..but i have read somewhere that Molar retroclination is really difficult on the lower jaw and the chance for a relapse is high.

So the only option left would be either mandibular mid split with arch widening or lower premolar extraction.

Arch widening surgery would mean i need more width on the upper jaw as well and I already had expansion before and my width is fine in my opinion.

What's the negative aspect of a class3 molar relationship? I have found a paper("Orthodontic Preparation for
Orthognathic Surgery" )about that specific topic(they have done premolar extraction with mandibular advancement and a class3 molar relationship)

Two surgeons suggested a second Genioplasty, but I already had a genioplasty....and I don't know if it's a good idea because the cut has to be done different.

What do you think?

[GJ]

Two surgeons suggested a second Genioplasty, but I already had a genioplasty....and I don't know if it's a good idea because the cut has to be done different.

What do you think?

A second one is possible. You just need an experienced surgeon who will reattach the mentalis in the proper location, else you get lip droop and too much lower tooth show. Your labiomental groove isn't that deep, so you could probably get some advancement there. The main risks I can think of would be mentalis not attached at the correct location and/or ptosis. I don't think it's a bad compromise if you want to avoid jaw surgery.

[kavan]

The cut through the chin would be different for a chin wing. However for a revision genio, often, the cut doesn't need to 'cross' the cut of the original genio (be a different cut). It can go right through the original cut--like through the SAME prior cut and from there, the chin segment can be displaced to a more favorable position. It might need a bone buttress between the cut and the displaced bone segment though if there is too much of a gap between the cut and displaced bone segment. You should double check whether or not a different cut is actually needed.

[Jan9x1]

Hello, thank you very much for your answers

I already have more lower tooth show than before. Its roughly 3mm lower tooth display and 0-0.5mm upper(depends on the angle)
Lower lip ptosis is already present to some degree from the genioplasty. I dont know if its a good idea to have second one.
Still, this would not give ma a class1 lower-and upper lip relationship. That annoys me the most, otherwise i would already done a revison Genioplasty.

I dont know if its a big thing to have a Class3 molar relationship?
Two profile shots attached to give a better picture.  As you can see the lips are more class2 than class1, with a slightly protrusive/upturned nose(im aware of this).

Im considering a tip derotation Rhinoplasty because my nose tip/upper lip angle was completley normal before jaw surgery. I still can decide afterwards if i want a Lip Lift or if it makes sense.