~1 year post-op - Over-impaction nightmare w/ 2nd surgery

[ImpactedMood]

Hi all, I'm looking for guidance, insight, opinions, advice, anything really.

Background

Had my 2nd jaw surgery with same OS (very experienced, renowned) here in Toronto in Feb, 2020, nearly 10 years after 1st jaw surgery with him (2011) - he didn't charge me anything btw, but spent nearly ~7k for braces again.  I was never happy with profile from first surgery, but given the large emotional commitment and life events I didn't pull the trigger until last year.  The ONLY objective was to move jaws forward.  However I also talked to my ortho about tooth-show and the aging process and figured I could use a little MORE tooth-show (to achieve 1-2 mm of gum above front teeth in smile) which would help defend against aging.  I brought this up in my consultation with OS.  He told me since I was moving my top jaw forward ~6 mm it would increase tooth show, and he might even need to shorten top jaw, which surprised me.

Fast forward to day of surgery.  He tells me the final measurements of moving top jaw forward 6mm, bottom jaw 10 mm, and shorten top jaw 3mm - I was shocked.  I nervously asked him again - so this is to offset the forward movement? He reiterated that was the case so not to have a gummy smile..

Literally the moment I was able to see my mouth in the hospital I knew something seemed very off - my top teeth were way up high under my top lip, which was noticeably different from Surgery 1.  Of course, OS said it's just lots of swelling, everything will be fine. 

Longer story short - I have battled this depression and stress from the beginning.  The first couple months were very hard, it was all I could think about and consumed me.  OS always would say, give it time - he even said if he were to do it again he would use the exact same measurements.  I haven't seen him in maybe 4+ months and the last time he was still saying give it time.  He also said he had to impact also so I could close my mouth etc (but wouldn't that mean he completely ignored my wishes of 1-2mm gum show and did his own thing without telling me?).  It is obvious now he really messed up.

Present

The pictures I'm attaching don't even do the damage justice imo, but I'm too lazy to take updated pictures.  Suffice to say you see NO top teeth at rest or at any time (even when talking for the most part) unless I start to smile, and even then you see only half of my front teeth unless I try smiling extra hard.

I'm so unhappy with what's happened, especially because this is a NEW problem I never had before.  I enjoyed smiling and now I don't - only closed mouth smiles for pictures.  I feel so much anger and can never accept how this OS could have been THAT off - like 4+mm imo and in the wrong direction than what I asked (to reveal more tooth/gum, not much less).

Even worse, I'm very nervous, fearful, and emotionally unprepared to have a third jaw surgery, especially with a supposedly very risky downgraft procedure, which may leave me unhappy again after #3.  But to be honest, that is what I wish to do, I don't want to live being unhappy with my smile and black hole in my mouth when it's open.  Not to mention this will get worse as I age I would think.

Ugh.  Anyway, I'm open to any advice, suggestions, etc. I plan on organizing several consultations with new OS's here in Toronto as soon as covid calms down a bit, to see what they think about the risks of a third surgery, etc.  This OS has said he would do it if I wasn't happy again and also said I would not need braces as it's just one movement with top jaw, but I don't know how I could possibly trust him again.

Edit: I cannot stress how much the AFTER smile in this picture doesn't look as bad as how it seems 95% of the time.  Maybe because I was smiling harder and teeth were just polished/cleaned, I don't know.  Also, my nose is noticeably a lot wider post-op which I obv don't like either, but would not care at all about it if I were happy with my jaw outcome.

Edit #2: I should also note I AM happy about my profile improvement and have relayed that to my OS along the way.  This was the reason I got a revision and I'm pretty happy with the profile positioning.  It's a shame this other problem out of the blue has really erased much of this joy and any excitement post-op

[GJ]

I understand your concern. The bottom right picture is definitely off, and it's not BDD or anything like that. If that picture is accurate, you have way to much lower tooth show (might be okay if you had upper tooth show along with it). 100% valid. But a video of this situation would help even more to see what is going on. Did you have a genio? I think that can pull the lower lip down, so we need to know.

Seems you're correct, and it is due to over-impaction.

Seems you're also correct that fixing it requires another surgery, and likely a downgraft.

My advice would be to pursue all of that, and while doing it work on mental health somehow (meds, therapy, etc). I get the depression, but you appear to be in prime years. Even if you don't want to go out, be productive at home so you don't look back after all this and realize you wasted years. Do something...anything...to stay productive. I'll ask a surgeon to chime in on your case.

[ImpactedMood]

I understand your concern. The bottom right picture is definitely off, and it's not BDD or anything like that. If that picture is accurate, you have way to much lower tooth show (might be okay if you had upper tooth show along with it). 100% valid. But a video of this situation would help even more to see what is going on. Did you have a genio? I think that can pull the lower lip down, so we need to know.

Seems you're correct, and it is due to over-impaction.

Seems you're also correct that fixing it requires another surgery, and likely a downgraft.

My advice would be to pursue all of that, and while doing it work on mental health somehow (meds, therapy, etc). I get the depression, but you appear to be in prime years. Even if you don't want to go out, be productive at home so you don't look back after all this and realize you wasted years. Do something...anything...to stay productive. I'll ask a surgeon to chime in on your case.

Thanks so much for your feedback GJ, I truly appreciate it a lot.  I made a short clip...

https://www.youtube.com/watch?v=Sx2Z4EfvJqo&feature=youtu.be

I did not have any genio, no.

Yeah, I know it's not BDD but I appreciate the confirmation because the only person I'm able to share these feelings with are my GF - my parents were very against me getting a 2nd surgery and I can't imagine their reaction telling them my consideration for a 3rd, but what can you do.  My GF also does not want to see me go through the risks and emotional roller-coaster again (she was on the receiving end of a TON of venting over the past year), but this has never been about anyone else and just my own happiness.

I just can't understand how my OS missed by so much? It drives me crazy thinking about it.  It seems at LEAST like a 4+ mm miss, if not more.  Instead of impacting 3 mm it seems he should have downgrafted 1+ mm.  As your signature says, when mm are like miles, how do you mis-calculate to that degree?  The worst part is he knew how important this 2nd surgery was in "getting it right" and we talked about that.  I distinctly told him I wished 1-2 mm of gum show when I smile - I'm just at a loss, really.  And all of that when I was the one who was shocked and questioned him about 3 mm impaction, yet trusted a veteran OS obviously over my own worries.

I honestly don't care about going through the recovery, pain, discomfort, etc. - my biggest fear of a 3rd surgery is a relapse or another poor result.  I've been let down twice by supposedly one of my city's best OS'.

I can keep my mental health sanity only by trying to assure myself this is just temporary, but I know that I don't really know whether that's the case, and feel there's a chance he permanently screwed me with this mistake.

[Luka2020]

I agree that you show too much lower teeth after 2nd surgery, but honestly overall you look good.
What exactly you didn't like after the 1st surgery? In my opinion your profile was normal even after the 1st surgery.
What aesthetic/ functional problems you had before the 1st surgery?

[Lazlo]

I agree that you show too much lower teeth after 2nd surgery, but honestly overall you look good.
What exactly you didn't like after the 1st surgery? In my opinion your profile was normal even after the 1st surgery.
What aesthetic/ functional problems you had before the 1st surgery?

yeah exactly, why did you even want a second surgery? your profile was perfect, now it looks unnatural.

[kavan]

I disclose that the emotional support posts are the hardest ones for me to sift through to find the facts. I can't find the time frame of your before photos as to  WHEN, within the time of 10 years, they were taken before the second surgery.

I understand that the second set of photos is after your SECOND surgery and this second surgery was about 10 years after the first surgery. But there is some uncertainty as to what TIME frame, relative to the afters, I'm looking at regarding the photos you label; 'before'.

Please clarify the time frame of 'before' photos. Although it could be assumed they are after the first surgery, the question is how close in time were they before the second surgery as in WHEN before the second surgery; close to 10 years after the first surgery as in pretty close to SOON before the second surgery or close to 10 years before the second surgery?

[ImpactedMood]

I agree that you show too much lower teeth after 2nd surgery, but honestly overall you look good.
What exactly you didn't like after the 1st surgery? In my opinion your profile was normal even after the 1st surgery.
What aesthetic/ functional problems you had before the 1st surgery?

Thanks for your feedback.  After the first surgery I felt my jaws were too far back and thus the plan was to move both jaws forward.  Prior to the first surgery my jaws were even further back, and had long, narrow maxilla (gummy-ish smile), so he shortened top jaw, widened top jaw, and moved both jaws forward.  I also had a genio during first surgery.  Functionally, I couldn't close my mouth well (severe lip incompetence) so I was a mouth breather my whole life, and also had cross bite.

[ImpactedMood]

yeah exactly, why did you even want a second surgery? your profile was perfect, now it looks unnatural.

As I mentioned in OP, the objective was to move the jaws forward - the bottom jaw lagged quite a bit behind the top jaw even (moved bottom jaw 10 mm forward and top 6 mm) and as I mentioned I'm very happy with that outcome.  Couldn't disagree more with it looking unnatural now vs. before.

[ImpactedMood]

I disclose that the emotional support posts are the hardest ones for me to sift through to find the facts. I can't find the time frame of your before photos as to  WHEN, within the time of 10 years, they were taken before the second surgery.

I understand that the second set of photos is after your SECOND surgery and this second surgery was about 10 years after the first surgery. But there is some uncertainty as to what TIME frame, relative to the afters, I'm looking at regarding the photos you label; 'before'.

Please clarify the time frame of 'before' photos. Although it could be assumed they are after the first surgery, the question is how close in time were they before the second surgery as in WHEN before the second surgery; close to 10 years after the first surgery as in pretty close to SOON before the second surgery or close to 10 years before the second surgery?

My apologies, I should have referenced the date of those photos.  So all Before photos are from 2019, so very recent but before any orthodontic treatment in preparation for early Feb 2020 surgery.  The After photos are from early December 2020, and the video from yesterday.

[kavan]

Thanx for the clarification.

I can understand your being happy with the profile in the after but unhappy with the frontal smile issues you articulate. But consider the possibility of the reverse; being happy with the frontal smile but unhappy with profile.

I tend to think that the issue is a TRADE-OFF when the pursuit/goal of getting the advancement you wanted for both jaws came with some extra impaction as the 'cost'. For example, the act of increasing frontal tooth show is clockwise rotation (CW-r) whereas counter clockwise-r (CCW-r) in an impaction might have been needed to advance both jaws as 'horizontally' outward as you wanted. So, more tooth and gum show could be achieved in a revision surgery. But a typical way to achieve it is via CLOCKWISE rotation (anterior downgraft to reverse the anterior impaction). But that, in turn could set the lower jaw back somewhat.

[Luka2020]

Thanks for your feedback.  After the first surgery I felt my jaws were too far back and thus the plan was to move both jaws forward.  Prior to the first surgery my jaws were even further back, and had long, narrow maxilla (gummy-ish smile), so he shortened top jaw, widened top jaw, and moved both jaws forward.  I also had a genio during first surgery.  Functionally, I couldn't close my mouth well (severe lip incompetence) so I was a mouth breather my whole life, and also had cross bite.

Would you be willing to post pictures of front/ side before any surgery? I am also struggling with lip incompetence my whole life and my maxilla is somewhat on a longer gummy smile side.

[SMSOMS]

Lots at play here.  An important lesson I learned early in my career was that vertically long adult patients do not tolerate over impaction well at all.  They have years vested in looking at a long face and dramatic changes in vertical are often met with displeasure.  First you can control the vertical dimension and improve the profile at the same time.  It all comes down to occlusal plane.  You look high angle so that gives one lots of flexibility to do both.  To undo the current situation one would need to  bring the anterior maxilla down which is not the most stable movement especially if not done as a DJS.  I too agree that you need more tooth display at rest so a revision is your only option. 

I would be curious if your surgeon used an external reference for measurement?  If external measurement were not used it is very easy to invoke errors in the vertical.  This is especially an issue with CCWR and advancement and advancements.

I am at a loss to explain why you have lower incisor display in the absence a genioplasty in which the mentalis muscle was not adequately re-suspended.  It may be that you are compensating for the over closure by rolling the lower lip out.  It would be most helpful to see the preoperative lateral ceph and one now to ascertain the actual amount of impaction. 

[ImpactedMood]

Thanx for the clarification.

I can understand your being happy with the profile in the after but unhappy with the frontal smile issues you articulate. But consider the possibility of the reverse; being happy with the frontal smile but unhappy with profile.

I tend to think that the issue is a TRADE-OFF when the pursuit/goal of getting the advancement you wanted for both jaws came with some extra impaction as the 'cost'. For example, the act of increasing frontal tooth show is clockwise rotation (CW-r) whereas counter clockwise-r (CCW-r) in an impaction might have been needed to advance both jaws as 'horizontally' outward as you wanted. So, more tooth and gum show could be achieved in a revision surgery. But a typical way to achieve it is via CLOCKWISE rotation (anterior downgraft to reverse the anterior impaction). But that, in turn could set the lower jaw back somewhat.

Thanks for your input kavan, it's much appreciated.

I can understand the trade-off you're talking about, but I would say that my issue with what happened is that there was no communication to me at all that this outcome could be remotely possible.  I left the consultation conveying my objective of moving my profile further out (which I never listed a goal distance btw, it was my OS that figured he could move the bottom jaw 10 mm and top 6 mm to achieve a more desirable profile) AND that I wished 1-2 mm of gum show when I smiled (which, as mentioned, was more tooth/gum show than I was showing pre-surgery).  That is how things were left and so that is what I believed the main objectives to be.  If he didn't believe that was possible because of the trade-off you speak of, I would think it's his absolute duty to communicate that to me, and not have me wake up to a drastically different result (seemingly off by 4-5 mm of tooth/gum show).

In any event, do you have any insight or input as to the risk of said anterior downgraft as a revision surgery, assuming I'm okay with a "weakened" profile? Is this surgery still considered quite risky, with regards to relapse?  My OS seemed to bring it up in our last visit as something relatively straightforward ("you wouldn't even need braces again, because we would just need to move one jaw vertically") - but I would also add, he traditionally omits talking about any risks or obstacles as if every surgery is a breeze, and yet here we are unsatisfied, aesthetically, after two surgeries.

Bonus question/topic: Are there many additional risks of going under the knife for a 3rd time, despite the first time being all the way in 2011?

[ImpactedMood]

Lots at play here.  An important lesson I learned early in my career was that vertically long adult patients do not tolerate over impaction well at all.  They have years vested in looking at a long face and dramatic changes in vertical are often met with displeasure.  First you can control the vertical dimension and improve the profile at the same time.  It all comes down to occlusal plane.  You look high angle so that gives one lots of flexibility to do both.  To undo the current situation one would need to  bring the anterior maxilla down which is not the most stable movement especially if not done as a DJS.  I too agree that you need more tooth display at rest so a revision is your only option. 

I would be curious if your surgeon used an external reference for measurement?  If external measurement were not used it is very easy to invoke errors in the vertical.  This is especially an issue with CCWR and advancement and advancements.

I am at a loss to explain why you have lower incisor display in the absence a genioplasty in which the mentalis muscle was not adequately re-suspended.  It may be that you are compensating for the over closure by rolling the lower lip out.  It would be most helpful to see the preoperative lateral ceph and one now to ascertain the actual amount of impaction.

Hi SMSOMS, I really appreciate the in-depth thoughts you have here.

"To undo the current situation one would need to  bring the anterior maxilla down which is not the most stable movement especially if not done as a DJS"

If I understand correctly, you're saying an anterior maxilla downgraft is much more stable when done as part of a double-jaw surgery? In my case, where my bite seems perfect, do you have an idea what movement I could have on my lower jaw, with the downgraft to top jaw?  Would all this necessitate wearing braces again, in your opinion?

"I would be curious if your surgeon used an external reference for measurement?  If external measurement were not used it is very easy to invoke errors in the vertical.  This is especially an issue with CCWR and advancement and advancements."

Admittedly, I don't know what you're referring to here.  But I am wildly interested in understanding how such a large error, with respect to toothshow, could have been made.  I plan on meeting with my OS as soon as covid-cases/lockdowns abate a bit in my city, and work to understand what happened, but of course I don't expect to learn anything too insightful.  I also don't understand how I could have realized this error from Day 1 in the hospital, and yet he's tried to preach patience the entire time (up until 4 months ago), remaining confident that impacting 3mm was the right decision.  Though, I realize it's probably in his best interest to preach positivity and patience even if he realized he made a large error.

As far as producing the pre- and post- lateral cephs, I will have to follow up on that in the future.  I do still plan on having a couple consultations with other OS', to get differing opinions, so I will definitely be continuing to update here as things develop.

Lastly, if you had any additional comments or insights on the risks of having a 3rd jaw surgery after two previous double jaw surgeries (2011, 2020), I would really appreciate those!  Or any additional insight on the risks of anterior downgraft surgeries - eg. how common are full relapses, over 50% common? do these particular relapse risks skew the risk/reward of getting this done well to the downside?

[ImpactedMood]

Would you be willing to post pictures of front/ side before any surgery? I am also struggling with lip incompetence my whole life and my maxilla is somewhat on a longer gummy smile side.

Hey Luka, I'd prefer not to really because A. I'd have to dig a bit to find the good ones, and B. I'm not sure what benefit it would produce, even for you. What I would say is after impacting 3 mm in first surgery, and another 3 mm in this surgery, I still have a bit of lip incompetence (eg. when teeth are in bite position, I still need to force lips closed as they do not meet).  So I guess one can have lip incompetence even with a short maxilla! (ie. my present situation).  Obviously goes to show the complexity of all this and how trying to solve all concerns may not be possible.