Bimax or BSSO Surgery for functional and aesthetics?

[drobi]

All pictures -> https://docs.google.com/document/d/e/2PACX-1vQ3QA3p2endrvrm23SAaSTjmmgpbwnUhvB-CvrsQkALD-D9UdGnk7VNxpRP-3d04zmq0zZCAgTs6d54/pub

Hi Members,

I am a 27M.
I request your advice and help please.
I was unhappy with my looks and thought it was my teeth. Consulted with an ortho and he said my teeth look good except for skeletal overbite and told me he could extract and push my upper teeth back. My eye area always feels tired and my doctor referred me to a maxfac who ordered a sleep study and I was diagnosed with moderate sleep apnea.
My body is lean muscular but my face betrays me. I will be consulting again with my maxfac this week but I am sure his focus will be more on the functional side.
What do you all suggest that would help me with the aesthetics in addition to the functional aspects?
I have attached all the pictures I thought would be useful and feel free to let me know if I need to add anything else.

Note: I got a down and out genioplasty by the same maxfac surgeon 1.5 years ago with measurements 7mm down and 5mm forward, no contact and with a bone graft in between. He initially had recommended jaw surgery for me but I did not have enough knowledge/confidence then to go for the full fix and thought a genio would solve my problems. Now I realize my teeth and face feel wrong i.e it is the jaws that is the issue.
Do I also have recessed orbitals, cheekbones etc?

[GJ]

You have some eruption of the lower incisors. Maybe ask the ortho how things will change if they intrude those.

Looking at you in the flesh, it seems to me the best plan is intruding those teeth and then moving the lower jaw forward to close the overjet. I'd also think filling in the labiomental groove with grafting material makes sense.

[drobi]

You have some eruption of the lower incisors. Maybe ask the ortho how things will change if they intrude those.

Looking at you in the flesh, it seems to me the best plan is intruding those teeth and then moving the lower jaw forward to close the overjet. I'd also think filling in the labiomental groove with grafting material makes sense.

Thanks GJ.
Is my maxilla also recessed? Would CW rotation be needed? I have a crossbite on my left side. Segmental lefort would be needed right?
I feel before the genio my whole face was short and had less teeth show. Would an overall downgraft with more in anterior be needed or just an anterior downgraft is sufficient?

[drobi]

All pictures -> https://docs.google.com/document/d/e/2PACX-1vQ3QA3p2endrvrm23SAaSTjmmgpbwnUhvB-CvrsQkALD-D9UdGnk7VNxpRP-3d04zmq0zZCAgTs6d54/pub

Hi Members,

I am a 27M.
I request your advice and help please.
I was unhappy with my looks and thought it was my teeth. Consulted with an ortho and he said my teeth look good except for skeletal overbite and told me he could extract and push my upper teeth back. My eye area always feels tired and my doctor referred me to a maxfac who ordered a sleep study and I was diagnosed with moderate sleep apnea.
My body is lean muscular but my face betrays me. I will be consulting again with my maxfac this week but I am sure his focus will be more on the functional side.
What do you all suggest that would help me with the aesthetics in addition to the functional aspects?
I have attached all the pictures I thought would be useful and feel free to let me know if I need to add anything else.

Note: I got a down and out genioplasty by the same maxfac surgeon 1.5 years ago with measurements 7mm down and 5mm forward, no contact and with a bone graft in between. He initially had recommended jaw surgery for me but I did not have enough knowledge/confidence then to go for the full fix and thought a genio would solve my problems. Now I realize my teeth and face feel wrong i.e it is the jaws that is the issue.
Do I also have recessed orbitals, cheekbones etc?

Kavan or other experienced mods, any inputs please?

[kavan]

From your soft tissue profile, it clearly looks like you got a diagonally downward genio to OVERLY COMPENSATE for mandibular recession.The mandibular recession in soft tissue profile is EVIDENCED by the LOWER lip being BEHIND the upper lip.

Your ceph shows class 2 skeletal/occlusion. Angle measures as to where the mandible should be relative to the maxilla convey mandible is RECESSIVE. Occlusion also shows class 2 pattern where your lower back molar is BEHIND your upper back molar and your FRONT upper incisors are AHEAD of your front LOWER incisors. So, your start point was one where a BSSO was needed to balance the jaws and the occlusion, which would of course addressed the recession. Because you are also have low mandibular plane angle (MPA) which is associated with SHORT lower '1/3d', a down and out genio would/could have been added to your BSSO advancement. BUT it would NOT be as much out and down as it is now. So, if you got a surgery WITH the BSSO advancement to the mandible, the genio would have to be REVISED to be LESS down and LESS outwards. Although your ceph shows a good possibility for single lower jaw (BSSO), there is always a possibility that the surgeon might need to do a Lefort 1 for the teeth to mesh in place or for other functional reasons. As to orbital and cheek bones which are NOT 'jaw surgery', they are procedures best done AFTER jaw surgery. I DON'T see any 'need' for them based on your post op photos taken at the doctor's office.

[drobi]

From your soft tissue profile, it clearly looks like you got a diagonally downward genio to OVERLY COMPENSATE for mandibular recession.The mandibular recession in soft tissue profile is EVIDENCED by the LOWER lip being BEHIND the upper lip.

Your ceph shows class 2 skeletal/occlusion. Angle measures as to where the mandible should be relative to the maxilla convey mandible is RECESSIVE. Occlusion also shows class 2 pattern where your lower back molar is BEHIND your upper back molar and your FRONT upper incisors are AHEAD of your front LOWER incisors. So, your start point was one where a BSSO was needed to balance the jaws and the occlusion, which would of course addressed the recession. Because you are also have low mandibular plane angle (MPA) which is associated with SHORT lower '1/3d', a down and out genio would/could have been added to your BSSO advancement. BUT it would NOT be as much out and down as it is now. So, if you got a surgery WITH the BSSO advancement to the mandible, the genio would have to be REVISED to be LESS down and LESS outwards. Although your ceph shows a good possibility for single lower jaw (BSSO), there is always a possibility that the surgeon might need to do a Lefort 1 for the teeth to mesh in place or for other functional reasons. As to orbital and cheek bones which are NOT 'jaw surgery', they are procedures best done AFTER jaw surgery. I DON'T see any 'need' for them based on your post op photos taken at the doctor's office.

Thanks for the reply, Kavan!
I have a crossbite on my left side. Segmental lefort would be necessary to avoid tooth removal from lower?
Is my maxilla also recessed slightly? Do you recommend a slight CW rotation because my occlusal angle is too flat?
I feel before the genio my whole face was short and has lesser upper teeth show. Would an overall downgraft with more in anterior be needed or just an anterior downgraft is sufficient?
Also, you mentioned the genio might need to be slightly reversed. Would that affect healing a lot or is it a safe risk?

Your response on this post - https://jawsurgeryforums.com/index.php/topic,7889.0.html is from where I got the overall downgraft with slightly more anterior idea I mentioned on the last line above but as you already said on the post the pictures have been removed by the OP so I couldn't confirm.

Finally, thanks for confirming that the orbitals/cheekbones need not be touched.

[kavan]

Thanks for the reply, Kavan!
I have a crossbite on my left side. Segmental lefort would be necessary to avoid tooth removal from lower?
Is my maxilla also recessed slightly? Do you recommend a slight CW rotation because my occlusal angle is too flat?
I feel before the genio my whole face was short and has lesser upper teeth show. Would an overall downgraft with more in anterior be needed or just an anterior downgraft is sufficient?
Also, you mentioned the genio might need to be slightly reversed. Would that affect healing a lot or is it a safe risk?

Your response on this post - https://jawsurgeryforums.com/index.php/topic,7889.0.html is from where I got the overall downgraft with slightly more anterior idea I mentioned on the last line above but as you already said on the post the pictures have been removed by the OP so I couldn't confirm.

Finally, thanks for confirming that the orbitals/cheekbones need not be touched.

Leforts whether they be one piece or segmental or to affect a rotation, getting teeth to mesh etc..are examples of possibility the doc might elect to do them for functional reasons or additional reasons. So, that's not something I'm going to predict here.

I suggest you spend your thought energy and the TIME during your consultation focusing on correcting your mandibular recession and discussing revision of the chin that OVER COMPENSATES for the mandibular recession.

I also suggest that people don't apply to themselves what I say to any one particular person.

[drobi]

Leforts whether they be one piece or segmental or to affect a rotation, getting teeth to mesh etc..are examples of possibility the doc might elect to do them for functional reasons or additional reasons. So, that's not something I'm going to predict here.

I suggest you spend your thought energy and the TIME during your consultation focusing on correcting your mandibular recession and discussing revision of the chin that OVER COMPENSATES for the mandibular recession.

I also suggest that people don't apply to themselves what I say to any one particular person.

I will focus on the functional aspects definitely, Kavan.
I was asking would you suggest anything to do with the maxilla like forward, rotation etc for the aesthetics?
The reason I am asking is, the surgeon might overlook the aesthetics so along with the suggestions for aesthetics I receive here I can come up with the necessary questions to ask him regarding the aesthetics side.
Thank you in advance.

[kavan]

I will focus on the functional aspects definitely, Kavan.
I was asking would you suggest anything to do with the maxilla like forward, rotation etc for the aesthetics?
The reason I am asking is, the surgeon might overlook the aesthetics so along with the suggestions for aesthetics I receive here I can come up with the necessary questions to ask him regarding the aesthetics side.
Thank you in advance.

no