It's relatively common, though rarely acknowledged: patients who have had orthognathic surgery, corrected their bite and improved their chewing function, and who nonetheless feel their face is still long, that the chin projects too much or that the lower third doesn't fit the rest. It isn't a groundless impression: there's a surgical explanation.
What orthognathic surgery corrects, and what it doesn't
Orthognathic surgery repositions the jaws: it moves them up, forwards or backwards, and rotates them, with millimetre precision against the plan. What it doesn't do is change the shape or volume of the bone. It repositions the structure, but it doesn't remodel it.
In patients with a class III malocclusion this can leave a specific problem. The lower jaw moves back to correct the bite, but the pogonion (the most forward point of the chin) sometimes keeps projecting more than the proportions of the face itself allow. The bone sits in its correct functional position and yet its morphology still gives the appearance of a long face.
The sliding genioplasty, the usual tool for this, isn't always enough. And burring the chin without custom guides tends to give unpredictable results: asymmetries, irregularities in the contour, loss of definition along the lower border of the jaw...
Chin contouring
Something I've learned over more than 1,050 facial surgeries is that the lower third can't be treated as a single block. The chin, the body of the jaw and the angles are structures that depend on one another.
Chin contouring, through osteotomies and guided bone remodelling, makes it possible to reduce the height of the chin and modify its shape in a controlled way, preserving function: the muscles are re-anchored in place, the mental nerve is respected and the result remains stable over time.
The difference from conventional burring lies in the planning and the guides. We work with 3D virtual planning on a CBCT scan and cutting guides made to measure for each case. That turns a manoeuvre that has traditionally been unpredictable into a reproducible procedure.
When combined with orthognathic surgery, the order matters
If we decide to do chin contouring and orthognathic surgery in the same session, the sequence is not a matter of indifference.
Chin contouring goes first. The reason is technical: if we remodel the chin before mobilising the maxillomandibular complex, we prevent the tension of the orthognathic surgery from interfering with the fixation and stability of the contour. Once the remodelling is finished, we perform the orthognathic surgery with the maxilla-first protocol, with guides and PSI plates (patient-specific implants) manufactured from the plan.
This order, contouring first and orthognathic surgery afterwards, is the one we described in a paper we published in the British Journal of Oral and Maxillofacial Surgery, titled Combined orthognathic surgery and jaw contouring to improve long face stigma: Lessons learned from facial feminisation, and the one we follow at ARQÉA when the indication justifies it.
When this combination is indicated
Not every patient with a class III bite and a long face needs it. What guides the decision is, above all:
- that the pogonion keeps projecting beyond the desirable proportions after the orthognathic plan is drawn up;
- that the height of the lower third doesn't normalise enough with the planned bone movements;
- that the very shape of the jaw, and not only its position, contributes to the long-face appearance;
- and that the total surgical time remains safely manageable from an anaesthetic point of view.
When these conditions are met, combining both procedures in a single session makes sense: one intraoral access, one recovery, and a result that addresses both the function and the shape of the lower third at once.
What you can expect
In these cases, the improvement in the lower third usually reveals itself over the first year. The long face that orthognathic surgery alone hadn't corrected improves because its cause has been treated: not just the position of the bones, but their shape.
What makes the result predictable are three conditions we never go without: complete virtual planning before entering the theatre, custom cutting guides for every osteotomy, and respect for the muscles anchoring the chin, which is what guarantees long-term stability.
If you've had orthognathic surgery and you're still not happy with the length or projection of your lower third, what's missing may not be more orthognathic surgery, but work on the shape of the chin and jaw. That's what we assess at a consultation, case by case.
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