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Archive for the ‘jaw angle implant’ Category

The Jaw Angle Cap Implant

Wednesday, May 31st, 2017

 

The contemporary desire for a well defined jaw angle rivals that of the more well established demand for increased chin projection. Even though it is on the back part of the jaw, its influence on the perception of the lower face is significant as there are two jaw angles that project out from the side of the face. Between the chin and the jaw angles, these three lower jaw bony projections influence how well defined the lower face is.

While most people understandably perceive that a prominent jaw angle means one this is wide, this is not absolutely so. A prominent jaw angle, particularly in females, may be one that has a good definition and is clearly seen. It does not need to be excessively wide or unduly vertically long. It may just need to have a good and visible shape.

The typical Caucasian jaw angle is usually more rounded than square. It is often rounded at the corner (junction of the inferior and posterior borders) and may even bow inward than being flush with the face or bow outward. Creating angular definition in such a jaw angle requires an implant that provides a little of both vertical and horizontal dimensional augmentation. I call this type of jaw angle implant a ‘cap’ (jaw angle cap implant) as it merely covers the corner of the jaw angle and provides a 3D augmentative change.

Such a small vertical jaw angle cap implant is most commonly used in females to create an angular appearance but without adding an appreciable size increase. Like all jaw angle implants it is placed from incisions inside the mouth and is best secured with a small microscrew to ensure the stability of its placed position on the bone. Positioning over the jaw angle point requires release of the tendons that adhere to the bony jaw angle point.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Jaw Angle Implant Screw Fixation

Saturday, April 22nd, 2017

 

Jaw angle implants are one of the most unique facial augmentation techniques given its posterior jaw location. Placed under the thick masseter muscle and having a remote and limited access to do so from inside the mouth, the placement of the implant on the exact and symmetric position on the jaw angle bone can be challenging. This is made even more challenging with new implant styles such as the vertical lengthening jaw angle implant in which a portion of the implant is deliberately designed to sit off the lower edge of the bone.

Beyond intraoperative implant positioning concerns, there is also the potential for the implant to move from its desired position. Such implant displacements always occur in an anterior and superior towards the location of the vestibular incisions. Undesired implant movements naturally occur towards the direction in which they were inserted.

To prevent jaw angle implant displacement, screw fixation is almost always used. Over the years I have developed a screw fixation technique that is both reliable and rapid to perform. Trying to insert screws from inside the mouth is both difficult and cumbersome to perform. What works best is a percutaneous technique.

Using a 1.5mm screwdriver, it is inserted through a small 3mm skin nick through the masseter muscle in a perpendicular orientation to the bone’s surface. Once inside the implant pocket it is turned and pointed out of the mouth. A self-tapping screw is placed on the screwdriver blade which is self-retaining. The screwdriver is pulled back into the mouth and turned towards the bone where it its inserted through a superior edge of the implant and driven into the bone. This same technique is repeated for as many screws as one needs to place for optimal implant security. (I have never placed more than two screws

With this jaw angle implant s crew fixation technique, which takes just a few minutes to perform for both sides, one can be assured that the implants will not shift from where they were positioned on the bone.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Facelift with Jaw Angle Implants

Sunday, April 16th, 2017

 

Background: The facelift is a well known surgical rejuvenative procedure that primarily creates a smoother jawline and a more defined cervicomental angle. For some facelift patients the addition of a chin implant, if their chin is short, helps improve the jawline by adding increased projection at its anterior edge. This is why many facelifts particularly in women also include a chin augmentation.

While chin augmentation provides an aesthetic benefit to the front end of the jaw during a facelift, the rest of the jawline remains neglected. Some aging patients have weak or high jaw angles. Pulling the facial skin back up and over a weak posterior jaw angle fails to make it more defined. It often only gives it a sweeped look from the skin pull.

Like chin implants, jaw angle implants have a role to play in facial rejuvenation and facelift surgery. Their only drawback is that they will cause a moderate amount of facial swelling over the posterior part of the face during the early recovery period.  Good compression facial dressings during the first few days after surgery is very helpful in this regard.

Case Study: This 68 year-old female wanted a lower facelift to remove loose skin along the lower part of her face and give her a more defined jawline. But she had a high and ill defined jaw angle area and opted for the placement of jaw angle implants at the time of her facelift.

Under a general anesthesia and through an intraoral approach, small vertical lengthening jaw angle implants were initially placed. Thereafter a lower facelift was performed with SMAS plication. Her long-term results show improved jaw angle definition and a well defined jawline from chin back to the ear.

Like chin implants, jaw angle implants are aesthetically beneficial in a minority of facelift patients. But in the properly selected patients and in thinner faces, they can add bony definition of the lower face which has a distinct rejuvenative facial effect.

Highlights:

  1. Augmentation of the jawline at the time of a facelift or after has long been recognized as an aesthetic benefit.
  2. Creating a more defined jaw angle builds up the back part of the jawline.
  3. Most jaw angle enhancements in aging require a vertical jaw angle implant style.

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Angle Deformity after Sagittal Split Osteotomy

Saturday, March 25th, 2017

 

sagittal split mandibuar osteotomyThe sagittal split mandibular ramus osteotomy (SSRO) is the most commonly performed osteotomy of the mandible. It is done to either move the lower jaw and its attached teeth either forward or back to correct dentoalveolar deformities and bring the teeth into a better interdigitating relationship. It is a very cleverly designed osteotomy that splits the ramus of the mandible in a sagittal dimension into inner and outer cortical halves. One of the most important maneuvers during its execution is to avoid injuring the inferior alveolar nerve that runs through the bone.

In looking at diagrams of the bone put back together and even early after surgery x-rays, there is a smooth inferior border between the proximal and distal segments. One of the key elements during surgery is to ensure there is good alignment along the inferior border in most cases.

Jawline Irregularities after Sagittal Split Osteotomies Dr Barry Eppley IndianapolisDespite this bony alignment during surgery it is not rare that long-term healing leads to notching along the once smooth inferior border. Thus undoubtably occurs due to some bone resorption from partial devascularization to the outer half of the bone. The outer bone segment has had the masseter muscle stripped off during the procedure, and in conjunction it being split away from its inner half, it has become partially like a free bone graft near the anterior vertical bone cut.

Such notching along the inferior border can be an insignificant issue or can cause  a visible external deformity. I have observed it numerous times in the creation of custom jawline implants and has often been a reason for the implant to recreate a visible and well defined jaw angle shape. Between creating better jaw angle shape and improving the notching the lies anterior to it, a custom implant design may be need in any cases.

Dr. Barry Eppley

Indianapolis, Indiana

Female Jawline Enhancement

Thursday, March 9th, 2017

 

The presence of a discernible chin has always been an important aesthetic feature of the lower face in both men and women. While the desired amount of projection will vary between the genders, it is clear that having some chin projection is better than having little or none.

While the chin has always been perceived as an important facial feature, the perception of the entire jawline has taken on greater aesthetic significance today. This means the shape and projection of the back part of the jaw, known as the mandibular ramus or jaw angle, also gives the lower face a fuller and more pleasing appearance. Just like the chin that projects the front part of the lower face, the jaw angles project the back part of the lower face.

Angelina Jolie Square Jaw Angle Dr Barry Eppley IndianapolisWhile stronger jaw angles have been historically associated with men, it also equally applies to women today as well. This can be seen in many well known female celebrities such as Angela Jolie, Olivia Wilde and Hiliary Swank, to name just a few. They all have a  distinct and well defined jawline because they have a vertically long and almost squared shaped jaw angle. It does not necessarily have to be very wide but it is its vertical length and defined posterior and inferior ramus outlines of the bone that give a ‘cut look’ to the jawline. In essence it makes the jaw stand out distinctly from the neck below it.

mandibular plane angleA strong and defined jaw angle is associated with a low mandibular plane angle. The mandibular plane angle is a measurement introduced in orthodontics many decades ago to assess the steepness of the jaw in relation to the base of the skull. (normal is around 30 degrees) It is the anterior angle formed by the intersection of the Frankfort horizontal plane and a tangent to the lower border of the jawline. (in orthodontics it is the angle formed by the intersection of SN and GoGn) The Frankfort-mandibular plane angle is affected by the vertical development and length of the mandibular ramus.

Vertical Lengthening Jaw Angle Implant sizes Dr Barry Eppley IndianapolisFemale Square Jaw Angle Implants result oblique view Dr Barry Eppley IndianapolisFemale Jaw Angle Implants result right side view Dr Barry Eppley IndianapolisThe high and indistinct jaw angle can be treated by a vertical lengthening jaw angle implant. This is a special jaw angle implant that drops down the jaw angle by the lengthening provided by the implant. Most women need the vertical jaw angle implant as opposed to the more traditional widening jaw angle implant. While the implant does not look very big, it is surprising how powerful an effect it can have on the shape of the lower face.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Dermal Graft for Jaw Angle Asymmetry

Tuesday, February 14th, 2017

 

Background: Asymmetry of the lower third of the face is common. While there can be a soft tissue component to it, more times than not it is caused by asymmetry of the bone. the most common location for jaw asymmetries is in the angle area. The mandibular ramus is the L-shaped portion of the jaw and is prone to differences between the two sides in length and/or width.

Jaw angle asymmetry is best appreciated from the front view. Patients particularly notice it in pictures where the face becomes ‘frozen’ and is most easily seen. But because everyone of us knows our faces so well (and more so today because of smart phones and selfies) patients can see it even when others can’t.

The treatment for a jaw angle symmetry due to a deficiency is an implant. Provided the location is known and the implant is the right shape and size, good correction can be expected. But not everyone likes the concept of an implant so alternative options may be considered.

Case Study: This 32 year-old female had a modest jaw angle asymmetry with a deficiency on her left side. The inferior border along the angle lacked the fullness and jawline that the opposite side had. She preferred to use a more ‘natural’ material rather than an implant.

Dermal Graft for Jaw Angle Asymmetry Correction Dr Barry Eppley IndianapolisLeft Jaw Angle Dermal Graft Implant for Asymmetry Dr Barry Eppley IndianapolisUnder general anesthesia an intraoral approach was used to access the left jaw angle bone. Using allogeneic dermis (Alloderm), a 1.5mm thick section was layered into a thicker implant and sutured together to create a linear graft for the inferior border of the jaw angle. It was inserted and laid along the border. No form of fixation was used.

Jaw Angle Asymmetry Correction result Dr Barry Eppley IndianapolisHer 6 month result showed better jaw angle symmetry and an apparently stable result without resorption.

An allogeneic dermal graft would not ordinarily be a preferred facial bone augmentation material. It is a soft tissue augmentation material that purportedly is integrated into the recipient site and replaced by natural tissue. (scar) In my experience it more often behaves like an implant and becomes a well tolerated tissue filler with some fibrovascular ingrowth. For minor facial bone asymmetries where an implant is not preferred, these dermal products can be an option to consider.

Highlights:

1) Lower facial asymmetry is most commonly caused by a bony asymmetry of the jaw.

2) Jaw angle asymmetries can be treated by a variety of implant materials placed on the bone.

3) For patients wary of synthetic implants on the jawline, an allogeneic dermal graft can be used for smaller jaw asymmetries.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Sliding Genioplasty for Chin Implant Replacement

Monday, February 13th, 2017

 

Background: Chin implants in females is a common lower facial reshaping procedure. While they add desired amounts of horizontal projection and improve the facial profile, the extended wing designs of today’s chin implant designs can have adverse effects on they look in the front view. While the extensions on the implants are designed to create a natural transition into the jawline bone without a visible stepoff, they add chin width to do so. While this is rarely an issue in men, it can be more frequent aesthetic problem in women.

Women seeking an improved jawline have a different aesthetic goal than men. They do not necessarily seek an angular jawline with visible corners.  (some women may bit not the majority) Rather they usually desire a V-shape to their jawline with a smooth linear line from front to back. As part of that aesthetic goal the chin must be narrow and may even have a more pointy chin or smaller V-shape appearance. This is in contradiction to the look that many chin implant styles give to the augmented chin.

Case Study: This 35 year-old female had a prior history of having chin augmentation done using a Medpor chin implant of 6mm projection placed through an intraoral approach. She never liked the result as it gave her a wide and boxy chin. This did not fit her small petite face well. While it provided adequate horizontal projection, it made her chin too wide and too vertically long. She also developed some lower lip sag and excess tooth show.

Medpor Chin Implant Removal and Sliding Genioplasty Replacement intraop Dr Barry Eppley IndianapolisChin and Jaw Angle Reshaping result front view Dr Barry Eppley IndianapolisChin and Jaw Angle Reshaping result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia her indwelling Medpor chin implant was removed intraorally. To do so it had to be sectioned into multiple pieces and required the removal of 6 titanium screws. It was replaced by a sliding genioplasty that was brought forward 6mm and vertically shortened 3mms. A mentalis muscle resuspension and vestibuloplasty were performed to help with her lower lip sag. Concurrently, vertical lengthening jaw angle implants were placed through posterior vestibular intraoral incisions. The implants added 7mm of vertical length and 3mms of width.

Any form of chin or jawline augmentation must take into consideration the differences be tween male and female jawline shapes as well as the patient’s aesthetic goals. Even a ‘simple’ chin augmentation must take this into consideration as the operation may be a technical success but an aesthetic failure. (as this case illustrates) The entire jawline from front to back must also be considered in an effort to create an improved jawline that fits the patient’s face.

Highlights:

1) Chin implants in females create horizontal projection but often at the expense of too much chin width.

2) A sliding genioplasty can replace a chin implant by providing horizontal projection but with a more narrow chin width.

3) Jaw angle implants can create vertical lengthening with a sliding genioplasty to give a more defined jawline in females.

Dr. Barry Eppley

Indianapolis, Indiana

Vertical Lengthening Jaw Angle Implants

Sunday, February 12th, 2017

 

While jaw angle implants have been around for over 25 years, they only recently have become more popular and in higher demand for jawline enhancement. Offering augmentation to the often overlooked back part of the jaw, they add dimensions to the lower third of the face that can be primarily seen in front and oblique facial views. This is in contrast to chin implants which create their most profound effect in the side or profile view.

Based on how they impact the face it can be appreciated that the combination of chin and jaw angle implants creates a true 3D total jawline effect through a three-point triangulation effect.

Like many other facial implants, jaw angle implants also come in different styles. Fundamentally there are two different jaw angle implant types, widening (lateral) and vertical lengthening. This distinction is critical as they create profoundly different effects on the jawline.

The original and still commonly used jaw angle implant is the widening version. The implant sits on the outer aspect of the posterior-inferior ramus and gives the jaw angle more width. This is suitable in the patient who already has adequate length to their angles, has a normal mandibular plane angle and just needs augmentation to their natural bony width.

While appropriate for many patients, widening the jaw angle does not work well for everyone. An overlooked aesthetic jawline diagnosis is the patient who has high angles. They may also be too narrow but the jaw angle is almost at the level of the earlobe. This is too high of a mandibular plane angle and requires vertical lengthening. Placing widening angle implants in the high mandibular plane will just make the face look wider/fatter and will not create a more defined jaw angle appearance.

Vertical lengthening jaw angle implantsVertical Lengthening Jaw Angle Implants Dr Barry Eppley IndianapolisA newer style of vertical lengthening jaw angle implants has been developed for the high angled jawline. In this implant style a portion of the implant sits below the existing angle bone. By dropping down the angle it not only gives it more visible length but also adds width as well. These two dimensional changes put together into an angular shape creates a much more visible jaw angle and fullness to the back part of the jawline.

Most patients who have a short chin usually have a higher jaw angle position. This is a natural part of the L-shape to the lower jaw and the way it develops from its growth center. A chin implant with vertically lengthening jaw angle implants is the best combination for total jawline augmentation in these patients.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Stacked Jaw Angle Implants

Sunday, January 8th, 2017

 

Jaw angles implants are designed to add size and shape to the mandibular ramus area. They are a companion and complement to the more commonly performed and well known chin implant. Together chin and jaw angle implants create a complete jaw augmentation approach.

While selecting the style and size of chin implants is fairly easy, doing so with jaw angle implants is not. Since the chin is a projecting structure on the edge of the jaw, the amount of horizontal projection is frequently the most important dimensional consideration. This is both easy to see, measure as well as perform computer imaging. Jaw angle implants, however, are not an edge enhancement procedure. Rather they provide augmentation to the side of the jaw/face where measurements and even computer imaging is harder to do in a reliable fashion.

Because of the more imprecise nature of jaw angle implant size selection, it is very helpful to be prepared during surgery with multiple implant sizes. Most of the time standard sizes will work (small, medium and large) but this is not always the case. How an implant looks in place can be less than what one would anticipate and there is always the issue of asymmetry which is very common in the jaw angle area.

stacked-jaw-angle-implants-technique-dr-barry-eppley-indianapolisIf necessary it is always possible to stack jaw angle implants together to create the desired augmentation effect. Unlike many other facial implant types, angle implants fit together fairly well… a little bit like nesting dolls. Some trimming does need to be done but the implants can be stacked fairly securely. This will increase the width of the jaw angle augmentation over what any one single implant can do.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Older Female Jaw Angle Implants

Saturday, January 7th, 2017

 

female-strong-jawline-dr-barry-eppley-indianapolisBackground: The strength of the lower jaw is a known favorable feature for a male. But it has become increasingly desired and requested for women as well. Partially spurned on by various well known celebrities and actresses’ jaw shapes, younger women are seeking stronger jawlines as well.

An important part, and until recently overlooked, of a well defined jawline is the jaw angles. When patients refer to a ‘stronger jawline’ they are usually referring to the jaw angle area. A well defined and prominent jaw angle is one that is clearly seen from the front view and often creates more of a V-shape to the jawline. While once considered more masculine, a female with more prominent jaw angles are now seen as youthful and atractive.

One unexpected but favorable effect of jaw angle augmentation is that it provides a lift along the jawline. Making a stronger jaw angle requires increased soft tissue coverage. This recruits tissue from the neck to cover the increased bony prominence. This can have a favorable effect in the older patient who has developed loose skin along the jawline and posterior neck.

Case Study: This 61 year-old female was to undergo a variety of facial rejuvenation procedures. One of her requested procedures was jaw angle augmentation. She wanted more defined jaw angles and v-shaped jawline. She previously had a facelift.

female-jaw-angle-implants-result-front-view-dr-barry-eppley-indianapolisUnder general anesthesia, she had medium widening jaw angle implants placed through posterior intraoral incisions. The implants were placed under the masseter muscle, snuugly fitting up against the existing bone angle posterior and inferior contour.

cw-jaw-angle-implants

A more sharply defined jaw angle has both a jawline reshaping effect and a lower facial rejuvenative influence in older patients. Even in the older female patient who has already had a facelift, a stronger jaw angle adds to a rejuvenated jawline.

Highlights:

1) Jaw angle implants add shape and definition to the back part of the jaw/lower face.

2) Females are having an increased interest in the shape and definition of their jawline.

3) In older females a stronger jaw angle can fill out loose skin and give a bit of a facial rejuvenative effect.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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