Increasing mandibular length backwards, rather than only forwards

[tweaqo]

Many people have very short mandibular length, and often get length added on to the pogonion (through genio or BSSO), but this might not be enough to be able to get the admirable long mandible which people desire.

This is why I thought, why can’t you just add length to the back of the mandible.

It’s very hard to find literature and before/afters on this, so I want to get more peoples opinions on it. Including @RealSurgerymax any thoughts?

I would like to know if a jaw angle implant which wraps around the back of the ramus, in order to give a more posterior flare of the mandible. Such as this:



As you can see the implant flares backwards, extending the length of the mandible.

It can also be shown from a vertical scan of the skull.


Again, the implant is wrapping round the back of the ramus, extending the length of the posterior mandible, rather than just the pogonion.

Could this be consistently be done cosmetically?

Would there be any complications of this sort of implant, such as masseter muscle dehiscence?


Obviously this would be paired with adding length to the pogonion to fix recession.

 

[tweaqo]

@lurking truecel

 

[everyone]

you just want the mandible to be longer?

it could matter about your masseter insertions

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

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...

looksmax.org

 

[everyone]

@RealSurgerymax did you solve masseter dehiscence?

 

[RealSurgerymax]

Posterior augmentation of the ramus is nothing new. Even off the shelf implants have versions for this which have been available for years (Implantech has one for this)

However we are now in the age of custom PEEK & Titanium implants. Off the shelf silicone implants for anything other than chin will soon be obsolete or for poorer patients who will usually upgrade to custom years later.

Sometimes I design implants to go in this area:

• I decide by measuring the ramal angle against Frankfurt.
• The masseter muscle will not adapt very well or cover the new area so the implant needs to have the perfect balance of blunt and sharp, in the right areas to be natural
• Masseter dehiscence risk is increased
• a 90-100mm 2D Mandible is usually more than enough for aesthetics and should be created with BSSO/Bimax and Genioplasty/Chin advancement before augmenting the back of the ramus
• The ramal angle can be adjusted by pushing/rotatiing the ramus back slightly in BSSO (Custom plates will reliably position it) and the masseters will adapt better.

 

[RealSurgerymax]

@RealSurgerymax did you solve masseter dehiscence?
View attachment 3913901

This was 2 years ago, and with mixed success. This technique still fails some of the time.

I solved it another way now.

 

[tweaqo]

I’m glad that it is well known and practiced among top professionals, but it is hardly talked about on any forums and very hard to find results on it.

Why do you think it’s so hard to find people talking about this? I think it could be very beneficial for those with shorter mandibles, especially when I morph peoples gonions and ramus backwards more.


Would around a 5-6mm posterior flare be possible with these implants?


And what is the incidence of these types of custom implants (peek or titanium, not silicone)? Is it common for you or surgeons who do custom facial implants? Or is it quite uncommon to see someone getting a posterior flare and widening of jaw implant?

@RealSurgerymax