Bimaxillary Advancement

Q: Dr. Eppley, What bothers me most is my side facial profile. My nose looks big because my teeth were pushed back so far with braces as a kid. I realize it was the common practice decades ago to pull teeth instead of widening the arch and pulling my lower jaw forward. I know it’s possible for a maxillofacial/craniofacial surgeon to slide the upper jaw and lower jaws forward but since my bite is actually good, I have had a hard time finding a surgeon in Oklahoma to do it. They don’t want to mess up my teeth but I am willing to do braces or Invisalign if possible and get teeth implants if needed to replace the ones that were pulled out when I was a kid. Basically I’d like to make my jaw more defined and more pronounced mandible.

A: Since you have identified your major concerns, a perceived midface deficiency, I can make the following comments:

1) With a stable and orthodontically corrected bite, your only option is a bimaxillary advancement surgery. (both and lower jaws moving forward together since the bite must remain unchanged) While this can certainly be done (and your chin position would actually benefit by it as well), this does require the application of braces immediately before and for a short time after surgery to correct any potential minor changes in one’s bite. 

2) I would agree that your fundamental facial issue is the overall upper and lower jaw horizontal deficiency. A bimaxillary advancement certainly addresses this fundamental problem. It is the harder road to take so to speak but may be worth it at your age if one is so motivated.

3) Be aware that a bimaxillary advancement will not make your look smaller as the entire base of the nose is carried forward along with the maxillary advancement. The only way the nose can look smaller is by not moving its base and changing everything around it. (see #4 below)

4) In fairness and to give you the complete picture, there is also completely alternative treatment strategy which includes paranasal-maxillary augmentation, reductive rhinoplasty and chin augmentation. This is a different way to achieve many of the same results without going through a major maxillofacial osteotomy procedure and its potential associated morbidity. This will also do what a bimaxillary advancement surgery can’t do…make your nose look smaller.

5) These two approaches to your facial concerns represent a diametric and completely opposite treatment strategy…correct the bony foundation or an augmentative camouflage approach. Neither one is right or wrong, each has their own distinct advantages and disadvantages. Understanding what they are is the key to making the best treatment choice for you.

Dr. Barry Eppley

Indianapolis, Indiana