Should I Have One or Both Jaw Angle Implants Adjusted?

Q: Dr. Eppley, I have a question/concern about my jaw implant revision coming on on the 14th of this month. 

I initially raised a concern that the left implant seemed too low. While there is definitely an asymmetry/difference, I was wondering if the right could also possibly be too high? The reason is the right jaw angle does seem quite high compared to the design, image predictions, etc. 

I previously assumed it would be almost impossible for an implant to be too high, since the implant appears to wrap around the bone in the design. But on the other hand I’m not sure if this part is trimmed during insertion? Is it possible that the right is also too high? 

A: In answer to your custom jaw angle implant revision questions:

1) In 3D CT reconstructions of implants, they will not look like implant design drawings. The very thin edges of the implant are often missing as there is not enough material information present to be ‘seen’ in reconstructed images. That is also why they look fuzzy and irregular unlike the smooth and confluent design they have both in the design drawings and in real life. Thus I would not over interpret the finer details of the scan.

2) What counts at this point is what it looks like on the outside and not the inside. In other words treat the patient and not the x-ray.

3) The most successful facial implant asymmetry corrections comes from taking the ‘bad’ side and trying to match it to the ‘good’ side.  When you try and move both implants you dramatically increase the risk of ongoing facial asymmetry…just of a different kind. This applies to custom as well as standard implants.

4) I would be very hesitant at trying to lower the right implant because of two potential risks: 1) infection. (you double your risk of infection by operating on both sides) You just got away with it the first time on one side. I would be very cautions at spinning the ‘roulette wheel’ the second time. 2) Masseteric muscle dehiscence. You have to break though the surrounding capsule as well as do further release of these soft tissue attachments. It is hard enough to avoid it the first time. But releasing the scarred capsule which is attached to the thin muscle layer at the inferior border makes that more precious the second time. The latter risk is one you don’t have on the lower side because it is an upward release and movement, not a downward release and implant movement.

In summary, implant surgery is all about the benefits to be obtained vs the risks involved in doing so. While this is true of all surgery, the stakes in implant surgery are much higher since it is an unnatural implant being used rather than just using one’s natural tissues. The balance of those two issues is much more precarious on your right side than it is on the left. I have seen far too many patients with overall good results, and in the pursuit of a small incremental benefit, incur the downsides only to look back and wish they had left their ‘90% good result’ alone.

Dr. Barry Eppley

Indianapolis, Indiana