"When dealing with patients who want to improve the appearance of their smile and lower facial relationships, plastic surgeons often focus on soft tissue techniques and ignore the skeletal and dental elements," says Dr. Wexler, regional director of craniofacial services for Kaiser Permanente Southern California. "The reason for this is that too often, plastic surgeons are less fluent with the dental alveolar anatomy and less comfortable with the maxillofacial surgical techniques used to change the skeletal relationships. Understanding all of the anatomical issues and the dynamics between the dental, skeletal and soft tissues will enable the surgeon to create a better solution for each patient's problem."
SURGICAL SOLUTIONS Speaking at the 2010 annual meeting of the American Society of Plastic Surgeons in Toronto, Dr. Wexler reviewed various techniques for adjusting skeletal components that might be used by plastic surgeons for correcting lower facial disharmony to improve the appearance of the smile. In the case of lower face asymmetry, some plastic surgeons may perform soft tissue augmentation using an injectable filler or placement of an alloplastic chin implant. If the asymmetry is due to a skeletal deformity, however, these techniques would ignore the root of the problem, and an osseous asymmetric genioplasty would be a better corrective solution."By advancing the menton, the osseous genioplasty effectively addresses many facial plane discrepancies, and compared with use of an implant, it has an added benefit of improving the cervical mental angle. Establishing the proper foundation first using a technique that changes the bony facial skeleton can yield a much better result for patients with lower facial asymmetry, and the appropriate surgery is not that difficult to do," Dr. Wexler says.
Another situation in which plastic surgeons can expand their skill to improve lower facial architecture is for patients who present with a class 3 malocclusion. With a class 3 malocclusion, patients present with either mandibular prognathism or maxillary retrusion and display the classic underbite profile, with the tip of the nose posterior to the facial plane and the tip of the chin anterior to it.
Optimally, combined orthodontia with orthognathic surgery to change the skeletal foundation and maxillary and mandibular relationship are indicated to address this malocclusion and improve perioral aesthetics. If the patient with a retrusive profile does not desire the costly dental correction, however, there are aesthetic-only correction options that can be performed, Dr. Wexler says.
"For example, onlay bone grafting to the maxilla may correct the facial plane. Alternatively, a maxillary distraction at the LeFort I level may yield tremendous aesthetic improvement, even though the patient has traded one form of malocclusion for another," he says.
SMILES AND SELF-ESTEEM When seeing patients with lower facial aesthetic concerns, plastic surgeons should keep in mind that people's perceptions about the attractiveness of their smile has an impact on self-esteem and their ability to communicate with others.
"The function of the facial organ is social interaction, and a smile is a universal sign of acceptance between people. Improving the quality of the smile through surgical intervention has tremendous potential to not only improve attractiveness but also success in achieving positive social interactions," Dr. Wexler says.