Question re: The impact bimaxillary protrusion has on soft tissue post impaction

[natenerva]

Hi all,

I'm curious to know people's thoughts on my titled question. For the those of you who don't know bi-max protrusion is a *condition* which is common in certain ethnic groups and tends to increase the fullness of the lips quite dramatically.

What I would like to know is: Is it possible that after, say a CCW rotation via anterior impaction, the projection that was once seen in the lips would perhaps move to the lower midface area, due to the new dentoalveolar position of the maxilla? I hope this make sense. If so, should that have an impact on the amount of advancement after the CCW movement.

[GJ]

From what I've seen, ethnic cases are some of the most difficult.

A surgeon might try to force their idea of beauty, which seems to be Scandinavian/Caucasian right now, onto someone with ethnic traits that don't fit that vision. This is particularly noticeable in ethnic noses. But it can be anything.

Regarding bimax protrusion, we'd have to see your case. Any records?
In general I associate bimax protrusion with thick soft tissue, so if that's the case, figure 3mm of bony movement equals about 1mm of soft tissue movement. That's a general guideline. In a CCW rotation scenario, what are you looking at, maybe 3 to 5mm of upper jaw bony movement in the rotation plane? So that's about 1 to 1.5mm of soft tissue movement. In theory that could make the lip more concave. I don't think the convex lip area would move to the lower midface, though. I can't see how that would happen.

My advice is to consult with some surgeons and ask questions specific to ethnicity.

[kavan]

the treatment for bimax protrusion is segmental osteotomies......commonly done in Korea.

[natenerva]

Thank you both for your responses. I am familiar with the treatment to treat bixmax prostrusion, however as you probably can see from my ceph below, it's not my only issue with my jaw.

 I suppose what I'm saying is, I'm certain I need DJS and definitely would not consider Korea for *that* sort of operation so essentially if I wanted to address my concerns, this would require 2 separate operations in different countries. I understand that certain max fax may say they can address it in during DJS, but I'd rather see someone who does the bimax operation frequently, as opposed to someone who 'reckons they can do it'.

Further to your information Kavan, do you know if there is anything that would prevent segmental osteotomies being done after DJS at a later date?

I've attached my Ceph's below GJ, comments are appreciated by all. As it stands, I believe I have a steep OP and have a gummy smile (5mm) and would require CCW via impaction and BSSO, maybe a genioplasty. I say all this not to limit your input but rather show i've done research into my own case. Any input is much appreciated.  Ceph below

[GJ]

Yes clear CCW case there, and you're right, a steep plane.

Your upper lip is flat, so it should theoretically become more concave with the CCW movement. The lips can retract and thin from the surgery, though that's more unpredictable. But if you're looking for thinner lips it might happen. Genio, yes, because it limits the jaw movement needed, and your chin is flat - you could probably get away with a larger than normal genio.

Overall I think it would be a benefit if you have functional problems that justify it. Your bite looks fine, but your airway does look small. Any issues?

[natenerva]

Gotcha, thanks for the input GJ. Yes bite is class 1 I believe, ceph was taken immediately after orthodontic treatment.

I recently had a virtual consultation with Van der Dussen and will book one with Dr Birbe (once travel isn't so prohibitive) as I really liked their results, so I'm sure I'll be able to discuss this with them however it's great to be able to converse with people with 'no skin in the game'.

I wouldn't say I have functional problems, I habitually adopt a forward leaning posture to compensate though but I've not known any different. I'm in my early 20's and have heard a small airway can be an issue down the line though. At the same time I'm not sure if I'd go through with it if it didn't yield an aesthetic benefit.


Are you aware what effect an anterior impaction has on the soft tissue, similar to a posterior downgraft? Or does it also require an advancement to any noticeable change?

[kavan]

Some notes here:

1: In your first post,in the absence of presenting your ceph, you stated you had bimax protrusion. So, the feedback from me was LIMITED to what the correction of bimax protrusion usually is and also where a lot of Asians who DO have it go for surgery. Now that's just generally correct information. It isn't a personalized suggestion that you go to Korea and have the surgery aimed at correcting bimax protrusion. It just takes the information you assert (bimax protrusion) at face value.

2: When you introduced your ceph, it didn't look to me like excess proclination/dentalaveolar protrusion. I checked that with some angle measures corresponding to bimax protrusion. Although approximate, they didn't confirm bimax protrusion. Your OP angle looked to be close to outer range of norm but within the norm as in not overly steep. I did approximate measures for those things. But not to provide a ceph analysis and/or tutorials as to where to look for the angles and not to refute any body else's of those assessments but rather to CROSS REFERENCE those  assertions, assessments or beliefs of what you have with my own observations. So, I didn't find what you're telling me you have. Again, not getting into a refutation as to say you don't have what you say you have. Just saying it doesn't really cross reference with my observations.

3: Presently, you put forth you have a 5mm gummy smile which is something, I don't see either given that Gum show of a FRONTAL SMILE doesn't show on a ceph. All one sees on a ceph is whether or not there is a lot of excess TOOTH below the top lip. So, your ceph doesn't confirm (to me) that you would have a lot of excess incisor show at rest when the lips are slightly parted. For example, IF you had about 5mm (or less) of front tooth show at REST with lips slightly parted, you would have NO TOOTH SHOW at rest if 5mm were removed on the basis of 5mm excess gum show when smiling.

Your question ASSUMES you need anterior impaction CCW along with other assumptions, assertions that I don't see myself or can't confirm by looking at your ceph. That said, I hesitate to answer/address any questions predicated on things you say you have or need that I don't see.

What I will say though that it makes absolutely no sense to me why or how someone would even get the idea that excess soft tissue bulk to the lip would possibly some how find it's way to the lower midface after any max fax surgery.

Sorry. As it stands, I'm not able to do much with this presentation.

[natenerva]

Hi Kavan,

Thanks for your response. I've found your contributions most valuable to myself and reading your correspondence with others.

I know you weren't suggesting I go to Korea. I think the first part of my response was an attempt to transition the conversation to discuss the possibility of having the two surgeries separately.

Rereading my response I can definitely see how I may have come across dismissive to your information, that was not my intention or reaction at all. My thank you wasn't merely a social nicety but a genuine show of appreciation. I suspect there's no more reason to discuss how the miscommunication occurred, but I apologise.

Thank you for the time you put looking into my case and providing feedback.  The Bimax diagnosis was told to me by my orthodontist and I took that at face value. I did read in a slide share that "it can't be made accurately ceph radiographs" (attached image below).
I can post a side profile image if you would like.


I didn't post a frontal smile because I wasn't sure you or anyone else wanted to see and the *presence* of a gummy smile is something I'm already aware of and I didn't for-see anyone being able to confirm my measurements by me posting an image. I have attached the image in this post though, I measured it from top of incisor to the bottom of the lip. If you know of more appropriate reference points please let me know. Visually do you believe 5mm is an over/underestimation of amount of gum show?

The assumption of anterior impaction being needed actually came from reading this forum, I read that its the appropriate movement when a gummy smile present.

Re the excess soft tissue bulk. Since the increased fullness in the lips can be caused by dentalaveolar protrusion if this protrusion was rotated/sat higher on the face, i thought it might be possible the excess soft tissue bulk would be seen in a different reason. Similar effects can be observed in physical phenomena outside of anatomy.

Again, in case its not clear, the intended tone of my post is appreciation.

Any input to the above is most valued

[kavan]

I took no umbrage to your response to my initial post.

Thing is when I looked at your ceph, I didn't see an extreme 'angle OUT-ness' (exaggerated proclination of the tooth bearing alveolar process). In the screen shot of slide share photo of bimax protrusion (which incidently, I've come across prior), the extreme outward angulation of the alveolar process of both maxilla and mandible is clearly seen in there. That is to say bimax protrusion is clear as day in the screen shot you entered. Everytime i see those slide share things, they seem to be coming out of non English speaking countries. So, maybe something gets lost in the translation. So, no idea why they said the bimax protrusion wasn't visible in the ceph photo shown of that patient.

Also, in your initial posts, you didn't mention you had prior orthodonture. Although you mentioned ortho later down the line, my respose was to reply #3.

Now, I'll tell you what I saw in your ceph which I didn't mention because I was cross referencing assessments of things I didn't see in your ceph and your mention of prior orthodonture came after I started my observations. There is somewhat of a 'forced downward' chin contour that's common with Anterior Open Bite. In fact your smile shot shows a lot of POSTERIOR gum show which is also consistent with AOB. So, it's quite possible you started with both AOB and some bimax protrusion and the ortho corrected the bite. So, maybe the ortho engaged the frontal maxilla area downward to help close the open bite.

There's nothing 'wrong' with the prior ortho work and the fact that the angles I looked at relative to the type of angles associated with bimax protrusion didn't cross reference enough with bimax protrusion would be consistent with an ortho correction of it. Also, having a gummy smile (where your reference seems to be the FRONT part of it and not the back) possibily could be consistent ortho work bringing down the alveolar process of maxilla.

Basically, IF your 'natural' pre-ortho condition included AOB, although surgery might include some reduction of the anterior maxilla, it might NOT be CCW impaction and instead might be a combination of of BOTH anterior AND posterior impaction with a NET CW (clockwise rotation) where the posterior impaction part of it allows the chin to swing up somewhat (because a long posterior maxilla (lot of posterior gum show to the smile) is what forces the lower jaw (and chin) backwards like I see on your ceph.

That said, the DECOMPENSATION process which is basically braces aimed to UNDO what ortho did prior is with the aim restoring your natural skeletal contour/bite and proceed with a surgical correction of the skeletal imbalance.

ETA: The soft tissue thickness to the lip 'is what it is' (common with some groups). So, I don't see that being reduced.

[GJ]

The angle of the incisors will have some effect on the fullness of the lips, so your ortho could retrocline them if lip retraction is an aesthetic goal.

[kavan]

The angle of the incisors will have some effect on the fullness of the lips, so your ortho could retrocline them if lip retraction is an aesthetic goal.

The thickness of his upper lip area is a racial characteristic and he reveals he's already had ortho which most likely retroclined his teeth already. There's no proclination to his teeth on the ceph, Yet the nose to lip angle is acute, his philtral area angles diagonally outward as opposed to being  aligned in the vertical direction. It's the MASS of the upper lip that's doing that.

ETA: Take for example someone who gets a 'fat lip'; swollen from something, their lip is going to angle outward which will be a function of the MASS as opposed to incisor inclination. Here is example of someone having a swollen lip on one side.

https://ohgodmywifeisgerman.files.wordpress.com/2015/12/swollen-fat-lipallergic-reaction.jpg