Oral Surgery/A few questions
QUESTION: Dear Joel Tieg,
I think I have slight skeletal class ii discrepancy. As you can see in the pic, I have a slightly retrusive lower lip, slightly recessed chin and a mildly deep mentolabial fold. I think I also have a very slight overbite. I've ruled out lower jaw surgery as excessive given the mild nature of the discrepancy. In order to mask the situation, I am thinking about getting a sliding genioplasty. This will obviously extend my chin to the ideal projection. This may result in my mentolabial fold appearing even deeper, but I'm aware of techniques to mask that. My questions are as follows:
1) If I get the sliding genioplasty, would I be able to recalibrate a slightly deviated chin from the front view, as part of the operation?
2) Given the cephalometric aesthetic ideals used in max fax treatment planning, do you think I should incorporate vertical lengthening into my genioplasty?
3) Are there any ways of making a retrusive lower lip appear in aesthetic harmony with the upper lip without resorting to lower jaw surgery?
4) Are there any disadvantages that you can envisage, either in theory or in reality (given my picture), with foregoing lower jaw surgery in favour of masking the mild cosmetic defects of the skeletal discrepancy?
5) Just on a quick look, how does the skeletal structure of my face appear? More specifically (I am aware that it can be difficult to tell due to the overlying soft tissue):
i) How would you characterise the projection of my maxilla?
ii) If my mandible is to be described as 'retruded', how does that explain that it appears to project beyond the nasion-glabella?
iii) Do max fax surgeons deal with the orbital rim area? If not, ignore this part. If yes, I know it's difficult to make out on the picture, but does my inferior orbital rim area appear to be recessed?
iv) Would you be able to offer any comments on why my subnasale appears to be so forward projected (if that is within your remit)? Does this have indiciations towards the development of my maxilla? Do you think this offers an unaesthetic result?
Thank you very much for your time,
PS - apologies if the picture is oriented wrongly, my phone sometimes uploads normally orientated photos in that way
ANSWER: Jafar - It is a little difficult for me to arrive at a true cause for the minor discrepancies you are seeing. Is it a skeletal discrepancy, is it a dental position discrepancy or is it a combination of both. It is important to know that information, to arrive at the true cause of the minor differences from what you think are normal.
Is a sliding genioplasty correct. If the problem is only skeletal yes, but if there are dental causes also, then it may not be. As far as lengthening, is it from dental or skeletal relationships.
Your lower lip is only minimally retrusive. A sliding genioplasty can sometimes have an effect on extending the lower lip.
I wish I could tell you if lower jaw surgery or another approach is appropriate, but without viewing the cephalometric relationship it is inappropriate for me to advise what is necessary and what is not.
The skeletal structure of your face is fairly balanced. True there is no area of accentuation over another, but your facial balance is often attempted by maxillofacial surgeons from surgery. Again, without the cephalometric xray it is difficult for me to be completely accurate.
Most maxillofacial surgeons do not work with the orbital rim , but some do. I did, but made sure it was only with patients who absolutely needed that surgery. The effect of the surgery requires that the surgery is done carefully. Many maxillofacial surgeons are not trained in this surgery.
Again without the cephalometric xray, I cannot fully characterize your maxilla, but from this picture, it looks a little recessive (back).
The retruded appearance is the whole facial balance. The relative forward projection of the subnasale is really not. It just appears that way in relation to the mandible and the maxilla.
So there are many possible approaches to correct what you see as abnormal, but without a cephalometric film and your bite relationship, is difficult to to tell you anything. It would just be an approximation.
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QUESTION: Thank you very very much for the response. I just have a couple of small points/questions if I may.
i) Just for informative/curiosity purposes, what makes you think that my maxilla looks slightly retruded from the picture?
ii) What do you mean by "the retruded appearance is the whole facial balance".
Jafar - the slight retruded maxillary effect is displayed by the angle of the base of your nose to your upper lip. That angle is about 90 degrees, but yours is more than that. That angle is indicative of a slight retrusion of the maxilla. In addition with the retrusion the chin and lower lip is slightly back.
So the combination is was informed me of the retrusion. Your retrusion is minimal and in most no treatment is performed to correct that.