How are masseters attached to the jaw (avoiding masseter dehiscence after implant)?

[NoPainNoChick]

It is not very clear where exactly the superior masseter connects to the jaw skeleton.

In some illustrations, it appears to start from the side of the mandible, leaving the edges of the jaw bone still visible:

In others, it gives the impression of wrapping the mandible including its angle without letting any part of the bone visible:

I know it doesn't fully surround the bone, as explained here:

1. Is one of these representations plainly wrong or is the masseter insertion very variable from one person to another?

The reason I am asking this question is related to jaw (angle) implants and a recurring problem known as "masseter dehiscence" / "masseter disinsertion" / "implant reveal":

Here are a few examples of what looks like masseter dehiscence, with a masseter sitting very high while clenching:

While usually the masseter contraction fully covers the jaw angle:

It is said that disruption of the "pterygomasseteric sling" during insertion of the implant could cause the masseter to retract upper that it should.

2. If masseter insertion is already high before implant, could masseter dehiscence after vertical lengthening implant be due to anatomical reason and not from a surgical error?

Basically, if we just extend the bone while the masseter are attached well above (like in the first illustrations), we can't expect them to go down and wrap the new implant, right?

Actually I got jaw angle implant 1 month ago. When I'm not clenching, it look good. However, although the implant was not even big, I can see the masseter which does not cover the lower mandible and jaw angle while I clench my jaw. I'm coping thinking there is still swelling and the masseters need time to stretch, but I doubt it will change much over time. I feel really bad about it and my cortisol levels are through the roof right now.

Pinging @RealSurgerymax as you are probably the most knowledgeable user about this.

 

[LowTrust]

Nice thread, but if you have implants then ideally your jaw will look good regardless of if you are clenching or not, so you just need to remember not to, also it isn't like girls have a wide in depth knowledge of the blackpill and will instantly spot that you have implants because of the masseter not matching it

 

[wificonnector]

I heard somewhere (so there was a thread with reference to another looksmaxing site) that low and high set masseters are related to fast and slow muscle fibers. And fast muscles fix on low position

 

[politically correct]

if you get dihescence, you can mask it by just putting botox into the massetter

that said, in general the main risk is the size of the implant ie the amount of vertical / horizontal augmentation, as well as the length of the implant (how long it goes along the mandible)

I got dihescence when I had my implants put in as well, didnt effect the look from the side nearly as bad as the examples you showed but it caused my massetter to bunch up and hid my gonions from the front

 

[RealSurgerymax]

It is not very clear where exactly the superior masseter connects to the jaw skeleton.

In some illustrations, it appears to start from the side of the mandible, leaving the edges of the jaw bone still visible:
View attachment 2136537View attachment 2136518View attachment 2136545


In others, it gives the impression of wrapping the mandible including its angle without letting any part of the bone visible:
View attachment 2136520View attachment 2136527View attachment 2136530


I know it doesn't fully surround the bone, as explained here:
View attachment 2136515


1. Is one of these representations plainly wrong or is the masseter insertion very variable from one person to another?

The reason I am asking this question is related to jaw (angle) implants and a recurring problem known as "masseter dehiscence" / "masseter disinsertion" / "implant reveal":
View attachment 2136551


Here are a few examples of what looks like masseter dehiscence, with a masseter sitting very high while clenching:
View attachment 2136569View attachment 2136575View attachment 2136563


While usually the masseter contraction fully covers the jaw angle:
View attachment 2136553View attachment 2136562View attachment 2136586


It is said that disruption of the "pterygomasseteric sling" during insertion of the implant could cause the masseter to retract upper that it should.
View attachment 2136665

Yes the ones showing the pterygomasseteric sling are correct and the others are less accurate although there is variation in muscle insertion. Even when the masseter is high-set it is still technically attached to a layer of periosteum which always goes all the way around the jaw angle. This periostea’s layer, with no muscle attached to it between the masseter and the pterygoid muscles is the so-called pterygomasseteric sling. Masseter dehiscence happens when it literally rips from be overly stretched by an implant or traumatized during surgery.

2. If masseter insertion is already high before implant, could masseter dehiscence after vertical lengthening implant be due to anatomical reason and not from a surgical error?

Basically, if we just extend the bone while the masseter are attached well above (like in the first illustrations), we can't expect them to go down and wrap the new implant, right?

Actually I got jaw angle implant 1 month ago. When I'm not clenching, it look good. However, although the implant was not even big, I can see the masseter which does not cover the lower mandible and jaw angle while I clench my jaw. I'm coping thinking there is still swelling and the masseters need time to stretch, but I doubt it will change much over time. I feel really bad about it and my cortisol levels are through the roof right now.

Pinging @RealSurgerymax as you are probably the most knowledgeable user about this.

Yes it is more or less always due to anatomy and not because of surgical error. It is a known complication that can happen even in perfectly executed surgery, regardless of whether it is high or low set.

The risk is quoted as high as 10% by even the “best” and busiest implant surgeons in the world, and from what I have seen I think that is true.

It’s an alarmingly high risk which is why I am trying to develop a solution to reduce this risk. I designed special holes into the implant with the idea of using suture-anchorage of the masseter to the corner of the jaw. After a Few weeks, scar tissue ingrowth grows into the perfusion holes and provides permanent living anchorage so you are not relying on sutures to hold up for life. This is only possible as peek or titanium custom implants (not silicone or medpor.)

So far we have done it in 1 person (collaborated with Italian surgeon) so I can’t say it’s a definite solution. Only after several dozen cases with this method can we start to compare the outcomes. (Although the case we did use this on got no Masseter Dehiscence)

That is just 1 of my many design tricks and I am always coming up with more

 

[Octavian_Augustus]

Yes the ones showing the pterygomasseteric sling are correct and the others are less accurate although there is variation in muscle insertion. Even when the masseter is high-set it is still technically attached to a layer of periosteum which always goes all the way around the jaw angle. This periostea’s layer, with no muscle attached to it between the masseter and the pterygoid muscles is the so-called pterygomasseteric sling. Masseter dehiscence happens when it literally rips from be overly stretched by an implant or traumatized during surgery.


Yes it is more or less always due to anatomy and not because of surgical error. It is a known complication that can happen even in perfectly executed surgery, regardless of whether it is high or low set.

The risk is quoted as high as 10% by even the “best” and busiest implant surgeons in the world, and from what I have seen I think that is true.

It’s an alarmingly high risk which is why I am trying to develop a solution to reduce this risk. I designed special holes into the implant with the idea of using suture-anchorage of the masseter to the corner of the jaw. After a Few weeks, scar tissue ingrowth grows into the perfusion holes and provides permanent living anchorage so you are not relying on sutures to hold up for life. This is only possible as peek or titanium custom implants (not silicone or medpor.)

View attachment 2137147View attachment 2137148View attachment 2137149View attachment 2137151

So far we have done it in 1 person (collaborated with Italian surgeon) so I can’t say it’s a definite solution. Only after several dozen cases with this method can we start to compare the outcomes. (Although the case we did use this on got no Masseter Dehiscence)

That is just 1 of my many design tricks and I am always coming up with more

This guy can get you to write an in depth reply for free within a day yet you keep me hanging for 3 months even though I've paid?

 

[RealSurgerymax]

This guy can get you to write an in depth reply for free within a day yet you keep me hanging for 3 months even though I've paid?

Do you want a 10 minute write up or a 1-2 hour consultation ? (That’s how long it always is even when you don’t think it’s that complicated) I have your original write up but as discussed it’s better to get on zoom because it will just create too many follow up questions (and the original write up you requested was mostly questions about orbital box Osteotomy which you don’t even need at all)

 

[Wallenberg]

So masseter dehiscence is purely an aesthetic issue? Is it a big looksmin?

 

[Gaygymmaxx]

They're trainable why get surgery?

 

[RealSurgerymax]

They're trainable why get surgery?

Lol. Masseter hypertrophy is usually a bloated look, not a sculpted one

 

[RealSurgerymax]

So masseter dehiscence is purely an aesthetic issue? Is it a big looksmin?

Yes justvaesthetic

It’s not great

 

[lasnt]

This guy can get you to write an in depth reply for free within a day yet you keep me hanging for 3 months even though I've paid?

If i paid him and he leave me hanging for 3 months and post memes instead i will pay cartel to skin him alive

 

[RealSurgerymax]

If i paid him and he leave me hanging for 3 months and post memes instead i will pay cartel to skin him alive

All it takes is asking to cancel

 

[Octavian_Augustus]

If i paid him and he leave me hanging for 3 months and post memes instead i will pay cartel to skin him alive

Service has been rendered. It was of a very high quality.

 

[Chinlet Ascension]

Here are a few examples of what looks like masseter dehiscence, with a masseter sitting very high while clenching:
View attachment 2136569View attachment 2136575View attachment 2136563

If these are considered significant examples of masseter dehiscence, then it is a complete non-issue. Just lol thinking people are going to spot that in meatspace.

 

[NoPainNoChick]

Yes the ones showing the pterygomasseteric sling are correct and the others are less accurate although there is variation in muscle insertion. Even when the masseter is high-set it is still technically attached to a layer of periosteum which always goes all the way around the jaw angle. This periostea’s layer, with no muscle attached to it between the masseter and the pterygoid muscles is the so-called pterygomasseteric sling. Masseter dehiscence happens when it literally rips from be overly stretched by an implant or traumatized during surgery.


Yes it is more or less always due to anatomy and not because of surgical error. It is a known complication that can happen even in perfectly executed surgery, regardless of whether it is high or low set.

The risk is quoted as high as 10% by even the “best” and busiest implant surgeons in the world, and from what I have seen I think that is true.

It’s an alarmingly high risk which is why I am trying to develop a solution to reduce this risk. I designed special holes into the implant with the idea of using suture-anchorage of the masseter to the corner of the jaw. After a Few weeks, scar tissue ingrowth grows into the perfusion holes and provides permanent living anchorage so you are not relying on sutures to hold up for life. This is only possible as peek or titanium custom implants (not silicone or medpor.)

View attachment 2137147View attachment 2137148View attachment 2137149View attachment 2137151

So far we have done it in 1 person (collaborated with Italian surgeon) so I can’t say it’s a definite solution. Only after several dozen cases with this method can we start to compare the outcomes. (Although the case we did use this on got no Masseter Dehiscence)

That is just 1 of my many design tricks and I am always coming up with more

Thanks @RealSurgerymax . I've been thinking about this a lot, and I have a few followup questions. Can you please enlighten me?

1. Regarding the custom design you made: how are masseters supposed to be sutured to the implant? Why does Eppley say that the masseter reattachment must be done via an external incision, while according to your design, it is possible to attach the masseters to the implant during surgery?

2. Can your design be used for an implant revision following a possible masseter detachment? Or is it only suitable for a first operation?

3. How to diagnose a masseter dehiscence? How to differentiate it from a design problem? Can we see the misplacement of the masseters with a CT scan?

 

[Looksmaxerfr13]

The implant is attached ON the masseter in USA ?

All european surgerons i met, place the implant INSIDE the masseter.
The implant is between the bone and the muscle, pushing the masseter outside.

How the masseter can work if the implant is attached on it ?

 

[jon_chase89]

Yes the ones showing the pterygomasseteric sling are correct and the others are less accurate although there is variation in muscle insertion. Even when the masseter is high-set it is still technically attached to a layer of periosteum which always goes all the way around the jaw angle. This periostea’s layer, with no muscle attached to it between the masseter and the pterygoid muscles is the so-called pterygomasseteric sling. Masseter dehiscence happens when it literally rips from be overly stretched by an implant or traumatized during surgery.


Yes it is more or less always due to anatomy and not because of surgical error. It is a known complication that can happen even in perfectly executed surgery, regardless of whether it is high or low set.

The risk is quoted as high as 10% by even the “best” and busiest implant surgeons in the world, and from what I have seen I think that is true.

It’s an alarmingly high risk which is why I am trying to develop a solution to reduce this risk. I designed special holes into the implant with the idea of using suture-anchorage of the masseter to the corner of the jaw. After a Few weeks, scar tissue ingrowth grows into the perfusion holes and provides permanent living anchorage so you are not relying on sutures to hold up for life. This is only possible as peek or titanium custom implants (not silicone or medpor.)

View attachment 2137147View attachment 2137148View attachment 2137149View attachment 2137151

So far we have done it in 1 person (collaborated with Italian surgeon) so I can’t say it’s a definite solution. Only after several dozen cases with this method can we start to compare the outcomes. (Although the case we did use this on got no Masseter Dehiscence)

That is just 1 of my many design tricks and I am always coming up with more

If I've had masseter disinsertion for years as a result of prior surgeries, is there a decent chance we could still restore them using a design like this, or would the muscles likely be too contracted and noncompliant?

 

[CristianT]

I think best solution is to go with botox, reduce the masseteur muscle in size so it will be more flat.

 

[grooxx]

Bump

 

[politically correct]

Some people naturally have bunched up massetters

Honestly I think unless its super severe it can just be treated with botox

Key thing is to not overdo your design

 

[Looksmaxerfr13]

if jaw implant dehiscence is redone without ramus lenghtening , the dehiscence will still be there ?