genioplasty or jaw surgery, with simulation.

[SJay]

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!

[mike888miller]

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

[JimmyTheGent]

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?

[SJay]

@ 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.

[PloskoPlus]

Occlusal angle looks a bit steep.

[ForeverDet]

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.

[SJay]

@ 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!

[PloskoPlus]

Yeah CCW  rotation could make your face more balanced.

[molestrip]

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.

[SJay]

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!

[ForeverDet]

@ 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.

[SJay]

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!

[ForeverDet]

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.

[asphyxia]

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.

[asphyxia]

By the way, I had sliding genio 6 weeks ago, so feel free if you need any info...