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Background: The ideal male jaw angle has not been established. With the advent of additive manufacturing, precise customized shaping is a reality. This study aimed to define the ideal masculine mandibular angle as an aid for 3-dimensional (3D) design. Methods: An Internet survey was conducted using black/white photographs of celebrities and non-celebrities. Preferences regarding gonial angle (profile and frontal views), intergonial width and vertical jaw angle position (face frontal view), and angle curvature and definition in oblique views were obtained using simplified, unbalanced Likert scales. Constructs were defined for planning 3D implant designs. Results: The preferred jaw angle had these characteristics: 130° in face profile view, intergonial width similar to facial width, vertical position in frontal view at the oral commissure or at least not below the lower lip, jawline slope in the face frontal view nearly parallel to (with a maximum 15° downward deviation from) a line extending from the lateral canthus to the alare, ascending ramus slope 65°-75° to the Frankfort horizontal, and curvature in the oblique view visible from earlobe to chin and not pointy. Conclusions: Photogrammetric analysis of panel preferences lead to constructs with values useful for the design of 3D printed jaw angles.
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The ideal male jaw angle eAn Internet survey
Maurice Y. Mommaerts
*
European Face Centre, Universitair Ziekenhuis, Brussels, Belgium
article info
Article history:
Paper received 30 October 2015
Accepted 23 December 2015
Available online 21 January 2016
Keywords:
Jaw
Mandible
Aesthetics
Male
Data collection
abstract
Background: The ideal male jaw angle has not been established. With the advent of additive
manufacturing, precise customized shaping is a reality. This study aimed to dene the ideal masculine
mandibular angle as an aid for 3-dimensional (3D) design.
Methods: An Internet survey was conducted using black/white photographs of celebrities and non-
celebrities. Preferences regarding gonial angle (prole and frontal views), intergonial width and verti-
cal jaw angle position (face frontal view), and angle curvature and denition in oblique views were
obtained using simplied, unbalanced Likert scales. Constructs were dened for planning 3D implant
designs.
Results: The preferred jaw angle had these characteristics: 130
in face prole view, intergonial width
similar to facial width, vertical position in frontal view at the oral commissure or at least not below the
lower lip, jawline slope in the face frontal view nearly parallel to (with a maximum 15
downward
deviation from) a line extending from the lateral canthus to the alare, ascending ramus slope 65
e75
to
the Frankfort horizontal, and curvature in the oblique view visible from earlobe to chin and not pointy.
Conclusions: Photogrammetric analysis of panel preferences lead to constructs with values useful for the
design of 3D printed jaw angles.
©2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.
1. Introduction
Batides and Zide wrote in 2014,Esthetically, a fuller,
augmented gonial angle portrays a look of masculinity, and a
strongerjaw is often desired.To underscore their statement, the
authors referred to articles published at least 12 years earlier
(Whitaker, 1989; Aiache, 1992). Indeed, no reports regarding the
aesthetic appraisal of the male jaw angle have been publishedsince
1994 (Ousterhout,1991; Whitaker, 1991; Taylor and Teenier, 1994).
The sparse articles published more recently regarding jaw angle
augmentation have emphasised implant shape (Terino, 1994;
Ramirez, 2000) and surgical complications (Semergidis et al.,
1996; Thomas and Yaremchuk, 2009).
The emergence of 3-dimensional (3D) printing based on
computed tomography (CT) and cone-beam CT segmentation al-
lows the design of patient-specic implants, but specications
regarding the ideal jaw shape are clearly lacking. As noted by
Adrien Aiache in 1992, no cephalometric standards are available, so
surgeons must depend on the ideal concept.The ideal concept
according to Aiache (1992) is a jaw angle well below the ear ,
long and low in prole and less than 105
when measuring the
slope of the lower border and the ascending process. In front view,
the bigonial distance should be as wide as the bitemporal distance
usually less than or equal to 10% less than the bizygomatic dis-
tance These guidelines are rather vague for use with contem-
porary computer-aided designs, which have a precision of 0.1 mm.
The aim of this study was to determine specications that can
assist in designing ideal jaw angle patient-specic implants for
men. We performed a contemporary appraisal of the aesthetically
ideal male jaw angle and created constructs for use when guiding
the planning of implants.
2. Methods
An Internet survey was established at www.netq.nl to reach a
database of 770 consenting people. The database was based on the
author's professional and personal list of contacts. Study partici-
pants were recruited by email with a request to assist in completing
a survey regarding facial contours and denition. The survey was
*European Face Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit
Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgium. Tel.: þ32 02 477 60 12.
E-mail address: maurice.mommaerts@uzbrussel.be.
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery
journal homepage: www.jcmfs.com
http://dx.doi.org/10.1016/j.jcms.2015.12.012
1010-5182/©2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 381e391
available online during the entire month of May 2015. After
informed consent was obtained, the survey began with questions
about the participants' age, sex, and occupation (facial surgeon or
non-facial surgeon). These personal data remained anonymous.
In addition to the participants' personal data, the survey con-
tained nine questions, each based on a set of facial pictures. All
pictures used in the survey were non-copyrighted images obtained
from the Internet. They were modied (mainly cropped and con-
verted to black and white), and the eyes were covered when
necessary to reduce the likelihood of confounding relationships
between other facial features than aimed for. Many of the pictures
were images of celebrities, as they were the most readily available
pictures that demonstrated features appropriate for this study. The
pictures of celebrities were interspersed with pictures of non-
celebrities. The celebrities were Ben Afeck, Brad Pitt, Colin
O'Donoghue, Colton Haynes, Dean Winchester, Hrithik Roshan,
Jensen Ackles, Liam Hemsworth, Matthew Bomer, Michael Fass-
binder, Richard Armitage, Tahmoh Penikett, and Tom Hiddleston.
Some individuals were included in more than one question (using
the same or another image) to distract the study participants.
Two initial questions were asked to sensitize the participants to
subsequent questions focussing on the mandible (questions 1 and
2). Further questions were posed to retrieve information about the
ideal intergonial width (question 3), ideal inclination of the jawline
in the face frontal view (question 4) and face prole view (question
6), ideal vertical position of the gonial angle in the face frontal view
(question 5), relationship between the inclination of the forehead
and inclination of the posterior border of the mandible (question 7),
opinion regarding the angle and posterior border of the jaw when
the forehead is taken into account (question 8), and shape of the
mandible angle in the face oblique view (question 91aef). The re-
sponses for questions 3 to 8 were rated on a 3-item Likert scale,
Fig. 1. Constructs used in the study. a. Construct showing the intergonial width vs interzygomatic width. b. Construct showing the angle between the lower mandibular border and
a line connecting the lateral canthus with the ipsilateral alare. c. Construct showing the level of bigonial plane in relation to the lips. d. Construct A shows the angle between the
posterior border of the mandible and the Frankfort horizontal plane. Construct B shows the gonial angle, between the posterior and lower borders of the mandible. e. Relationship
between the slope of the posterior border of the mandible and the slope of the forehead. f. Pointiness of the jaw angle, whether judged using the radius of a circle segment or the
distance between the posterior end of the lower straight mandibular border contour and the lower end of the straight posterior border contour.
M.Y. Mommaerts / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 381e391382
with items tailored toward the specic question (e.g., for question
3, the items were too wide,”“good,or too narrow).
Constructs were created to be used during 3D print planning of
patient-specic implants. The constructs are displayed in Fig. 1aef.
Ideal aesthetics for the male jaw were dened by transposing the
survey results onto the constructs. Based on qualitative apprecia-
tion assessments and quantitative measurements with Image J, a
public domain, Java-based image processing program developed at
the United States National Institutes of Health, we developed a set
of guidelines for the ideal male jaw.
3. Results
A total of 770 persons were inclined to participate in the study.
Of these, 124 (16%) startedthe survey,115 continued it (82 males,33
females), and 81 (11%; 82 males, 33 females) completed the survey.
Fig. 2. Question 1 eNot considering the chin or cheek shadows, which is most appealing for a male model?This question was used to sensitize the study participants. Shown are
the percentage of respondents who considered the pictures to be the most appealing.
Fig. 3. Question 2 eA hypoplastic angle produces a concealed jaw (1 &2). A jaw angle can be concealed by fat, sagging skin, and/or a beard, and this is not aesthetically pleasing.
Do you agree?This was also used as a sensitizing question. Overall, 74% of those who answered the question indicated that a concealed angle was not aesthetically pleasing.
M.Y. Mommaerts / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 381e391 383
For those who completed the survey, the mean completion time
was 11 min 15 s and the mean number of sessions was 1.3. Nearly
half of the respondents who completed the survey were facial
surgeons (48%). Overall, 29% of respondents who completed the
survey were younger than 40 years of age and 61% were between 40
and 60 years old.
Question 1, regarding which image was most appealing, was
answered by 114 study participants: 52% chose picture #1 and 36%
chose #5 (Fig. 2). A total of 108 responses were obtained for
question 2 regarding a concealed jaw angle, 74% of which indicated
that a concealed angle was not aesthetically pleasing (Fig. 3). Re-
sponses to question 3, comparing the intergonial width to the
Fig. 4. Answers to question 3 regarding the aesthetics of bigonial width compared to bizygomatic width in the face frontal view: Compared to the total facial width at the malar
level, how do you score the lower jaw width at the jaw angle level?
M.Y. Mommaerts / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 381e391384
interzygomatic width, were obtained in 103 respondents, as shown
in Fig. 4. Question 4, about the ideal inclination of the jawline in the
face frontal view, was answered by 94 people, the results of which
are displayed in Fig. 5. The vertical position of the jaw angle in the
face frontal view (question 5) was assessed by 93 study
participants; these results are shown in Fig. 6. The inclination of the
lower jaw border in the face prole view (question 6) was
answered by 89 participants (Fig. 7). Question 7, comparing the
slope of the posterior border and the slope of the forehead, was
answered by 84 people; their responses are shown in Fig. 7a and b.
Fig. 5. Answers to question 4 regarding the inclination of the lower border in the face frontal view: Is the inclination of the lower border in the face front view too steep, neutral, or
too at?
M.Y. Mommaerts / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 381e391 385
Fig. 6. Answers to question 5 regarding the ideal vertical position of the jaw angle in the face frontal view: Is the vertical position of the jaw angle too high, good, or too low?
M.Y. Mommaerts / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 381e391386
Fig. 7. Answers to question 6 regarding the inclination of the lower border in the face prole view: Is the inclination of the lower border in the face prole view too at, good, or
too steep?
M.Y. Mommaerts / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 381e391 387
Fig. 8. Answers to questions 7 and 8 regarding comparisons between the posterior border of the mandible and forehead in the face prole view and opinions regarding the jaw
angle and posterior border when recognizing the forehead as a possible confounding factor: 7.) Compared to the forehead slope, is the posterior border of the lower jaw steeper,
parallel, or atter?; 8.) Now that you appreciate the relationship with the forehead, can you again indicate your opinion regarding the angle and posterior border of the jaw? Is it
nice, neutral, or ugly when taking the forehead into account?
M.Y. Mommaerts / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 381e391388
This assessment prepared the participants for question 8, in which
the forehead was noted as being a confounder in the judgement of
the inclination of the posterior border of the jaw; question 8 was
answered by 82 respondents (Fig. 8). Question 9 regarding the
shape of the angle judged in the face oblique view was answered by
81 participants, the responses of which are shown in Fig. 9.
Fig. 10 shows the set of guidelines we developed for the ideal
aesthetics of a male jaw angle, based on transposing our panel
survey results to our series of constructs.
4. Discussion
Designing the ideal jaw is not an easy task. Determining
aesthetic appreciation is preferably performed using panel studies
and Likert or visual analogue scales (Mees et al., 2013). In this study,
we used an Internet survey approach to create a panel of in-
dividuals who assessed the aesthetic characteristics of the ideal jaw
angle. However, it was not possible to use an assessment scale that
separated the jaw angle from the overall facial features of the
models, nor was it possible to use a completely balanced scoring
system. Hence, we decided to use photographs of many individuals
and to ask the panel to score each variable on a symmetrical, yet
unbalanced 3-item Likert scale. The scale was simplied from 7 to 3
grades, so the survey could be nished within a reasonable time
(15 min). This was important because the attention and focus of
respondents were found to be relatively low during a test run of the
survey. The low response rate is to be linked with the difculty of
the task, which proved to be mentally exhausting according to the
feedback we received. This may also be the reason for the
decreasing response during the answering procedure. We used
copyright-free pictures that were readily available on the Internet
because clinical studio pictures tend to obliterate facial denitions,
and although standardized (Ettorre et al., 2006), they do not
necessarily provide appealing images with strong characteristics.
Most of the pictures used in the study were images of celebrities.
Although we tried to reduce the possibility that they would be
recognized, this was likely not always successful and it may have
been a source of bias. Gender, age, and occupation of the partici-
pants were other potential confounding factors that could not be
excluded.
Additive manufacturing from a 3D-computer aided design can
create patient-specic jaw implants of titanium, tantalum, and
ceramic (Büttner and Mommaerts, 2015). The shape of the implants
can be liberally chosen to provide augmentation in a lateral, dorsal,
and/or caudal direction. This freedom in design poses an artistic
challenge. When facial symmetry constitutes the main indication,
then mirroring the healthy or most pleasing side solves the issue of
shape. When the wish is to enhance gonial denition bilaterally,
then the surgeon is faced with the issue of the denition of an ideal
customized shape. A jaw angle is by denition the angle within the
jaw. Izard (1927) cited normal angles of 120
e130
at 12 years of
age and 120
e150
in the elderly. Using Indian dry skulls, Upadhyay
et al. (2012) measured an average jaw angle of 129
(standard de-
viation 7.6
) in a group of 17e35 years old, with no signicant
differences observed between males and females. This nding was
conrmed by Raustia and Salonen (1997), Ceylan et al. (1998), and
Al-Faleh (2008). The literature norm seems to be far from Aiache's
(1992) ideal of less than 105
, with a long and low mandible in the
facial prole view. The panel in our study also chose a less angu-
lated ideal shape in the face prole view, which more closely
approached the normal values. Lateral projection, however, co-
incides with Aiache's (1992) statement. In the face frontal view, the
ideal jaw angle should approach the face width, from zygion to
zygion.
Fig. 9. Answers to question 9 regarding the shape of the jaw angle in the face oblique
view: What do think of the shape of these angles enice, neutral, or ugly?
M.Y. Mommaerts / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 381e391 389
The vertical position of the jaw angles and the slope of the
mandibular borders in the face frontal view often pose a dilemma.
The slope of the mandibular plane is determined by both the ver-
tical position of the jaw angle and the height of the chin. Chin
height is determined by the growth pattern and whether the face is
long or short; it can also be surgically altered. Height reduction of
the bony chin does not change the vertical position of the gonial
angle. In the current study, we found that the ideal vertical position
of the jaw angle was at the level of the oral commissure or lower lip.
The ability to change chin height by reduction chin osteotomy and
alter gonial position by shaping a 3D printed implant permits
correction of a long face either without, or as an adjunct to, a
bimaxillary procedure.
The radius of the gonial curvature is still an enigma. While many
patients seeking enhancement prefer pointiness, the survey indi-
cated that a wide curvature is preferred. Qualitative judgement
indicated that the mandibular border should cast a shadow
extending from the earlobe to the chin. A clear distinction between
the face and neck, with no fat or sagging tissue obliterating the
retromandibular fovea or interrupting the mandibular border,
projects a youthful appearance.
One can ask why a strong jaw angle is preferred for the modern
man. It may be an indicator of youthfulness and, hence, strength in
general. When teeth are present, muscular activity associated with
mastication maintains a constant angle magnitude. With the loss of
teeth, bone at the muscular attachments resorbs, leading to an
increase in jaw angulation. Casey and Emrich (1988), using ortho-
pantomograms, found that the mean size of the gonial angle was
126.3
for edentulous patients and 123.9
for those with teeth.
Similarly, Ohm and Silness (1999) found that the mean gonial angle
was 131
degrees for edentulous patients and 127
degrees for
partially dentate adults, and the angles were similar for men and
women. Although all existing studies indicate that the normal
gonial angle does not differ between sexes, males wishing
mandibular accentuation generally prefer more extreme features.
The study results will form the basis for a prospective study in
our male patients receiving jaw angle implants. Especially the
already predicted skewness of the individually desired deviation to
the now proposed ideals will be intriguing.
5. Conclusion
Using an Internet-based survey to conduct a panel study, we
found clear indications of the preferred characteristics of a male
jaw angle. These included a 130
gonial angle, intergonial width
similar to the facial width, vertical position of the angle at the level
of the lips, slope of the jawline in the face frontal view nearly
parallel to (with a maximum 15
downward deviation from) a line
extending from the lateral canthus to the ipsilateral alare, slope of
the posterior mandibular border 65
e75
to the Frankfort hori-
zontal, and a wide diameter curvature of the gonial angle in the
oblique view. This information will be helpful in generating 3D
print designs for men desiring mandibular aesthetic surgery.
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... One of the potentially affecting anatomical factors that has not been assessed is the gonial or jaw angle [35]. The gonial angle is formed between the mandible's inferior border and the ramus's posterior border. ...
... Studies on the esthetics of gonial angle are scarce, including nonstandardized ones on the male jaw angle [35]. Due to the importance of the jaw angle in beauty and the increasing demand for its surgical alteration, and in light of the lack of studies on female jaw angle as well as the mentioned shortcomings in the literature, this Perceptometric study is aimed at finding the range of pleasing frontal view and threequarter oblique-view female intergonial width and gonial height comparatively from the perspectives of OMF surgeons, orthodontists, and laypeople of different ages and sexes. ...
... Height. The ideal gonion height was determined as being at the level of the mouth corner [35]. The original oblique three-quarter image taken from the photo model was the image 4 of Figure 2. On the three-quarter oblique view photograph, the location of gonion was gradually altered using Photoshop within the range of normal facial height to obtain 9 photographs ( Figure 2). ...
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Objectives: The jaw angle plays an important role in facial beauty. Therefore, this study is aimed at comparatively determining the range of most attractive female intergonial widths and gonial heights on Perceptometric frontal-view and three-quarter-view images, from the perspective of orthodontists, oral maxillofacial (OMF) surgeons, and laypeople of different ages and sexes. Methods: This prospective multivariate Perceptometric study was performed on 4191 esthetic scores given by 127 individuals to 33 Perceptometric face images. Frontal view and three-quarter-view photographs of a normal young woman were modified by image editing software to create two Perceptometric sets, one for the 24 gradual changes of intergonial width on the frontal view, and the other for the 9 vertical changes of the jaw angle on the three-quarter view. An online questionnaire was designed including 24 frontal and 9 oblique view photographs. The questionnaires' internal consistencies were almost perfect. Enrolled were 127 raters, including 33 orthodontists, 32 OMF surgeons, and 62 laypeople. The esthetics of different images were compared across different professions, across different ages, and between the sexes using 2-way MANCOVA, ANCOVA, and Bonferroni; the zones of esthetic jaw angles and also the sensitivity of judges to Perceptometric anatomical changes were assessed using 2-way RM-ANCOVA and Bonferroni (α = 0.05, α = 0.0056, α = 0.0021, and β = 0.05). Results: Orthodontists and surgeons gave the highest attractiveness scores to intergonial: interzygomatic ratio of 72.53%, while the best ratio was 74.45% for the laypeople. The range of beautiful intergonial is as follows: interzygomatic ratio was 72.53% to 86.03%. OMF surgeons and orthodontists gave the highest score to a gonial height of 4.5 mm above the mouth corner, while the laypeople gave the highest score to the gonial height of 4.5 mm below the mouth corner. The range of beautiful gonial height was from 4.5 mm above the mouth corner to 9 mm below the mouth corner. The education of observers may affect their perception of beauty; orthodontists tended differ from laypeople, overall and also specifically in the case of the highly attractive frontal images concerning the intergonial width changes. However, no such differences were detected between surgeons with orthodontists or laypeople. Although age did not affect the overall esthetic scores, it did affect the sensitivity of the judges to the anatomic changes. So did expertise, i.e., the expertise of judges affected their sensitivity to anatomical changes; orthodontists showed steeper slopes of esthetic preference alterations to anatomical changes, while laypeople had the gentlest slope of preference changes. Judges' sex did not affect either their overall esthetic preferences or their sensitivity to anatomic changes. Conclusion: Narrower female jaw angles and jaw angles that are vertically close to the level of the mouth corner may be unanimously more desirable. Thus, treatments aiming at widening the jaw angle of a woman or lowering it should be discouraged, at least in Persians. Orthodontists, but not surgeons, are more sensitive than laypeople to anatomic changes of the jaw angle. The judges' age can affect this perceptive sensitivity, but their sex cannot.
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... Materials based on polymethyl methacrylate, polyethylene, silicone, and polyether ether ketone (PEEK) have been used to increase facial volume, with their construction varying from those that need some manual work to those manufactured completely by virtual systems. In this sense, PEEK and titanium have been used in completely virtual constructions, [6][7][8][9][10][11] demonstrating precision in the planning stage and the surgery stage, being friendly for installation and good postoperative stability. ...
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... This is usually considered to be an aesthetically pleasing feature in both men and women. 1 Assessment of the jawline is complex because there are many variables to consider, including anatomic features relating to facial type, sex, race and age-associated changes. In particular, facial aging leads to lost skin elasticity; relaxation of ligaments and displacement from their original site, causing a prominent labio-mandibular sulcus; and jowl deformity and submental laxity, leading to the formation of a double chin (sagging jawline). ...
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Background Aesthetic treatment of the lower face is increasingly in demand, particularly owing to age-related changes in appearance. VYC-25L is a novel hyaluronic acid filler with high G’ and high cohesivity, specifically designed for sculpting and contouring of the chin and jaw. Objective To assess the use of grid traced onto the chin and jaw for guiding treatment with VYC-25L. Methods This was a retrospective, single-center analysis of data from adult patients undergoing treatment of the lower third of the face with VYC-25L. A grid system of horizontal and vertical lines was used to systematize the process of treatment planning and performance. Results Thirty subjects were enrolled (53.3% female; mean age, 34.4 ± 2.8 years). The mean quantity of VYC-25L used was 4.0 ± 0.8 mL. Using the 5-point Global Aesthetic Improvement Scale, 29 patients (96.7%) rated their appearance at 20 days post-treatment as ‘much improved’ or ‘very much improved’. The only complications recorded were early transient soft-tissue edema (n=14; 46.7%) and bruising (n=6; 20.0%). There were no cases of infection, paresthesia, asymmetry, hematoma, necrosis, or skin discoloration. Conclusions Treatment of the chin and jawline with VYC-25L, using a grid-based standardized approach, appears to be effective and safe with high rates of patient satisfaction. It offers a potentially high-impact approach for patients across a variety of biologic and economic circumstances.
Article
The size and shape of the chin and mandible are fundamental to sexual dimorphism. Deficiencies in these structures distract from the male facial esthetic. When deficient, these areas of the facial skeleton can be augmented by alloplastic augmentation or skeletal rearrangement. This article discusses these alternatives with emphasis on the design and techniques of alloplastic skeletal augmentation.
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The field of aesthetic medicine has traditionally focused on improving the physical attractiveness of women. This chapter reviews male anatomy and provides a framework for approaching a cosmetic consultation with a male patient, specifically highlighting differences between men and women with case studies. It is important to note that most research to date is conducted through a heter‐onormative lens, assuming an alignment of biological sex, sexuality, and gender identity. Facial sexual dimorphism is the foundation for perception of attractiveness. A comprehensive understanding of patient motivations and gender‐specific preferences, as well as facial dimorphism is paramount in providing successful aesthetic care to men. Male patients require specialized approaches and altered techniques for neurotoxin injections, soft tissue fillers, and chemical peels, among other procedures. It is critical that aesthetic providers familiarize themselves with ideal male anatomy, as it varies across a spectrum of different gender identities and cultural backgrounds.
Article
Facial asymmetry is a challenge for surgeons. Some surgical strategies could be used involved soft or hard tissue of the face. The aim of this report is to show the use of patient specific implants (PSI) in a puzzle strategy based on computer aided design/computer aided manufacturer to solve a complex structural facial asymmetry after orthognathic surgery. Twenty-five-year-old male patient complain for facial asymmetry after orthognathic surgery; main deformity was related to the shape of mandibular bone in the ramus, angle, and body. After mirror image, was chose an augmentation in the right side using 2-pieces patient specific implants and the bone reduction in the vertical high of the mandibular body in the left side. Surgical technique was realized by intra oral approach installing the ramus segment at first approach and the body segment as second to obtain stability in the fitting implant-bone-implant; the left side was treated using a guide for osteotomy; after 1-year follow-up no infection or complication was observed and facial symmetry was obtained. It is possible to conclude that the puzzle technique using polyetheretherketone can be applied to obtain predictable results in a simple strategy to solve a complex problem.
Article
Contour augmentation and mandibular angle modification surgery is becoming increasingly. The aim of this research is to compare technique and outcomes in augmentations done with standard implants or PEEK-based patient specific implants (PSI) in mandibular angle. Data from surgical planning, operative and post-operative of 6 months follow-up were revised for 21 patients who were submitted to facial surgery using a stock implant obtained from companies currently on the market or 3D implants created with CAD/CAM technology using PEEK 3D printing. Surgical time, intra-operative and post-operative complications were compared, analyzing the advantages and disadvantage of each technique. Statistical analyses using t-test and chi-squared were performed considering P value< 0.05 for statistical differences. Twelve patients were operated on with stock implants and nine patients with PSI. The surgical time was 15 minutes less for the 3D implant surgeries (P = 0.021) and intraoperatively only the stock implants needed modifications with wear and adaptation methods; post-operative infections were observed in both groups with no significant differences (P > 0.05). The 3D implants had greater levels of facial symmetry than the stock implants, although they did not present significant differences.Considering the limitations of this study, mandibular angle implants with a PEEK-based 3D CAD/CAM are efficient, stable and have a low complication rate; the CAD/CAM strategy is useful in facial surgery and can be integrated as a standard for surgical planning in facial makeover surgery.
Article
Introduction and Aims This second part explores perceptions/understanding of clinical performance, turnaround and costs for printed titanium implants/plates in common procedures; evaluating both ‘in-house’ and ‘outsourced’ CAD-CAM pathways. Methods A cross-sectional study was conducted over 14 weeks; supported by the British Association of Oral and Maxillofacial Surgeons and a national trainee-led recruitment team. Results One-hundred and thirty-two participants took part (demographic data is reported in part I). For fibular-flap mandibular reconstruction, most (69-91%) perceived printed titanium as superior to intraoperatively/pre-operatively hand-bent plates for surgical duration, accuracy, dental restorability and aesthetics. There was less consensus over complications and plate-failure risks. Most perceived printed plates as superior to traditional wafer-based maxillary osteotomy for surgical duration (61%) and maxillary positioning (60%). For orbital floor repair, most perceived improved surgical duration (83%, especially higher-volume operators p = 0.009), precision (84%) and ease (69%) of placement. Rarely (<5%) was any outcome rated inferior to traditional techniques for any procedure. Perceived turnaround times and costs were variable, but greatest consensus for 2-segment fibular-flap reconstructions and orbital floor repair. Industry estimates were generally consistent between two company representatives but ‘manufacturing-only’ costs differed when using ‘in-house’ (departmental) designers. Conclusions Costs and turnaround times are questionable barriers since few understand ‘real-world’ figures. Designing ‘in-house’ can dramatically alter costs. Improved accuracy and surgical duration are common themes but biomechanical benefits are less-well understood. This study paints a picture of potentially routine applications and benefits of printed titanium, capacity for uptake, understanding amongst surgeons and areas for improvement.
Article
The main aim of this study was to assess patient-reported outcomes of jawline contouring with patient-specific three-dimensional (3D) -printed titanium alloy implants using validated Face-Q questionnaires. Four FACE-Q questionnaires (Appearance Appraisal Scale, Quality of Life Scales for Psychological and Social Function, and Adverse Effects Scale) were sent to 21 patients consecutively operated on by the same surgeon between 2014 and 2019. Thirteen patients responded. Mean Rasch Transformed Scores for Satisfaction, Psychological Function and Social Function (0–100) were 70.6, 73.2, and 71.1, respectively. These values are difficult to interpret, however, as comparative literature and prospective follow-up scores are lacking. The second objective was to correlate clinician-reported morphology improvement by panel scoring (Likert scale) with patient-reported appearance appraisal. As for satisfaction, we can conclude that an objective acceptable result does not corroborate patients’ perceptions (Spearman Rho test rs = -0.021). Psychological factors and results from previous surgeries probably modulate patients’ views. The mean score for the Adverse Effect Scale (15–45) was low (18.6), indicating that the intraoral drop-in fit of customized titanium implants does not cause major side effects.
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With development and function, the mandibular angle has shown changes in size and shape. A variation in mandibular angle with age, gender, and even the dental status has been observed, which is supported by radiographic and anthropometric studies. The aim of this study were to evaluate relationship between complete loss of teeth and changes in the gonial angle; the study further intends to evaluate any variation in gonial angle with age and gender. The study intends to assess the reliability and accuracy of age and gender determination using gonial angle as a parameter. A total of 185 subjects (91 males; 89 females) were included in the study and were divided into five groups on the basis of the chronological age. Physico-forensic anthropometry and lateral cephalometric methods were used to record the gonial angle. The present study shows a definite decrease in the gonial angle with advancing age, but the intergroup analysis does not follow a significant pattern. The study showed no correlation of gonial angle with gender. However, the study observed a 6° increase in gonial angle for edentulous subjects. Gonial angle has been used as an adjuvant forensic parameter, but its reliability is questionable, as the mandible does not follow one characteristic pattern. Gonial angle does show changes with dentition status, which may be attributed to physiologic function of the mandible. However, when evidence is scanty, it can be used to direct the investigation.
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Altering the dimensions of the mandibular angle by alloplastic augmentation or skeletal reduction requires elevation of the insertion of the masseter muscle, including the pterygomasseteric sling. Disruption of the pterygomasseteric sling during exposure of the inferior border of the mandible can cause the masseter muscle to retract superiorly, resulting in a loss of soft tissue volume over the angle of the mandible and a skeletonized appearance. Subsequent contraction of the masseter elevates the disinserted edge of the muscle and not only increases the skeletonized area, but also exaggerates the deficiency by causing a soft tissue bulge above it. The authors describe the disinsertion of the masseter and the resulting deformity as a potential complication of mandibular angle surgery and review the technique for repair. The records of 60 patients (44 primary, 16 secondary) who presented for alloplastic mandible augmentation between 2003 and 2008 were reviewed. Nine patients presented with clinical signs of disruption of the pterygomasseteric sling after mandibular angle surgery. Five patients had clinical signs consistent with complete disruption. Two of these patients requested reconstruction. The other four had signs consistent with partial disruption. Through a Risdon approach, the masseter was successfully reinserted using drill holes placed at the inferior border of the mandible. Masseter disinsertion is a previously unreported sequelae after aesthetic surgery for the angle of the mandible. The resultant static and dynamic contour deformity can be corrected by reattaching the muscle to the inferior border of the mandible.
Article
Introduction: Several investigators have compared the perception of profile attractiveness between professional and non-professional people, different groups of clinicians, and different ethnic groups. Our aim was to study preferences for facial protrusion in the lateral view for a straight Class I profile and to study the influence of gender, age, sex preference, and profession. Material and methods: Portrait images of one male and one female model with a Class I occlusal relationship were warped into nine different antero-posterior positions. An internet site was established to reach as many people as possible, and a request was sent by email to participate in a scientific experiment. Finally, 1707 Caucasion assessors could be grouped. Results: The preferred male profile is the straight full ante profile. For a feminine facial profile, the straight average and the straight 2/3 ante profiles were perceived as the most attractive. Surgeons tended to give significantly higher scores to attractive (ante) profiles, which correlated strongly with scores of the orthodontists. Conclusion: Whenever possible with combined orthodontic/surgery treatment, straight ante profiles should be aimed for.
Article
Patients who present for alloplastic jaw angle augmentation have 2 potentially troublesome choices. The use of a silicone implant can mean unpredictable motion, and if the lower pterygomasseteric sling is breached during implant placement, the masseter insertion will ride up without anything to which to adhere. When the patient bites down, a bulge will be present.The porous alternative even has a ledge made to go under the gonial angle, which if not removed, guarantees violation of the pterygomasseteric sling and an implant that is longer than the muscle can cover. The inferior muscle insertion is disrupted and is left to ride up serendipitously.This article presents 5 instances of these issues in which one case required a revision via a modified Risdon approach to access the uncovered material which stuck out beyond the high riding masseter.The basic aim of this article is to advocate the need to maintain the pterygomasseteric sling, and describe the consequences of the failure to do so.
Article
A new type of implant designed to increase the angle of the mandible in three dimensions is described. Made of silicone and shaped like a saddle, this implant makes the technique of implantation relatively simple, and its versatility makes it a desirable addition to the tools for skeletal framework reconstruction of the face. The satisfaction rate has been high and the complications easy to manage. The surgical technique consists of an intraoral incision and the development of a subperiosteal pocket at the mandibular angle area, often performed under local anesthesia.
Article
The posterior mandible begins just behind the mental nerve and second bicuspid bilaterally, extends to the posterior edge of the ramus, and then runs superiorly to the zygomatic arch. Augmentation of the posterior mandible is possible by use of a synthetic implant that is tailored individually to each patient's specific needs. Implant plant thickness varies from 4 to 8 mm, with an average thickness of 6 mm. Careful preoperative planning is done based on an aesthetic assessment of the amount of highlighting desired, thickness of the soft tissues, and the use of life-size photographs and cephalometric and Panorex x-rays. A pattern is cut, and the implant is carved to fit the patient. Insertion of the material after careful tailoring to the individual patient's own mandibular size and configuration requires a generous posterior lower buccal sulcus incision. Antibiotic irrigation and systemic antibiotics are essential, and careful closure in two layers completes the procedure. One implant in the series extruded in a patient who had had radiation therapy, and one patient required repositioning of the implant. Otherwise, in 22 patients there were no infections or permanent morbidity. The procedure seems to be a realistic and safe one for both the youthful and aging face, as demonstrated in patients in this series, with ages varying from 16 to 40 years.
Article
The mandibular angle is receiving more attention as now every area of the craniofacial skeleton is a candidate for aesthetic modification. Both reduction and augmentation of this posterior area of the mandible are addressed. Surgical techniques, results, and complications are described after the cosmetic problems are demonstrated. Representative cases are presented.