Surgery Recommendations? (Pics & X-Ray Inside) + Consultation Next Week

[emanresu]

Hey all,

So I finally have my first consultation with Dr. Caminiti (a prominent maxfac in Toronto) next week. Unfortunately I won't have my sleep study results back before then, but I'm not rescheduling because it took 5 months to get this consultation in the first place (costs $350 BTW) and at the very least I'll ask him to take a look at my ceph analysis to see if my airway is narrow.

Anyway, I'm mainly posting because I was hoping to get your guys opinions on a few things:

• What surgeries do you think I need, jaw/non-jaw related? More specifically how badly is jaw rotation needed in my case? I ask this because I read a post from Lazlo saying that the top maxfacs in Canada (namely Caminiti and Tocchio) don’t even do jaw rotation. Dr. Stephen Ho apparently does surgical rotation but he has pretty bad reviews. With that being said…
• If I do indeed need surgical rotation, does anyone have any recs for a surgeon who performs it and is located in Canada, or if not in Canada is at least less expensive than someone like Gunson?
• My orthodontist mentioned I’d probably need teeth extracted with jaw surgery. Is this standard procedure? Are some teeth fine to extract but not others (wisdom, premolar) or should I avoid extractions at all costs? As abysmal as my lower third is I’m not sure it’s worth trading for a flat face.
• Finally, what questions should I ask Dr. Caminiti when I see him next week?

Any advice would be greatly appreciated. Thanks guys.
PICS:
https://imgur.com/a/pVPFG

[slysurfz]

IMO you could use bimax advancement with ccw rotation for aesthetic purposes.

However,  your bite doesn't seem so bad and could possibly be fixed with orthodontics and if you don't have sleep apnea I would not recommend going under the knife. The way the surgery is done today is risky and has collateral damage with nerves in question.

If you have moderate to severe sleep apnea or speech issues go for it.

Also, go to Gunson or somebody who can do it without extractions.

[ditterbo]

IMO you could use bimax advancement with ccw rotation for aesthetic purposes.

However,  your bite doesn't seem so bad and could possibly be fixed with orthodontics and if you don't have sleep apnea I would not recommend going under the knife. The way the surgery is done today is risky and has collateral damage with nerves in question.

If you have moderate to severe sleep apnea or speech issues go for it.

Also, go to Gunson or somebody who can do it without extractions.

Where do you see room for CCW?  His occlusal plane is practically flat. Your airway looks huge, but sure rule out sleep apnea before you do anything around your jaw.  All you need is a chin. There's a number of grooming issues you've got that detract way more than your jaw.

[emanresu]

If you have moderate to severe sleep apnea or speech issues go for it.

Also, go to Gunson or somebody who can do it without extractions.

Interesting, I never thought about it before, but I do often have trouble enunciating words.

So surgery is possible without extractions?

All you need is a chin.

So sliding genio? I also have no jaw though. Perhaps it's being hidden by fat and submental lipo would be beneficial.

There's a number of grooming issues you've got that detract way more than your jaw.

I'll be entering the workforce soon and definitely will be neatening up.

[slysurfz]

Interesting, I never thought about it before, but I do often have trouble enunciating words.

So surgery is possible without extractions?

Yes, I have read of cases where its possible where certain surgeons recommend extractions and other have a way to go around it. I am not a doctor or a medical professional all my comments are based on stuff that I have read from other peoples experiences or research articles. Please do consults with a few doctors before trusting something and read all the research you can.

[emanresu]

biprotrusion?
You kinda look like me and a surgeon I talked to said I have severe dental biprotrusion and advised that I get 4 premolars extracted before a bimax.
https://imgur.com/a/lAF4t

It seems biprotrusion is caused by crowding (or really, the jaw being too small) so extractions would probably make sense. That is unless there is some way to lengthen the jaw bone and then push the teeth back, but I’m not sure if such a thing exists.

I know it's frequently mentioned that extracting teeth flattens the face, but if you also bring the jaw forward it would sort of counteract that I guess? Still, pulling perfectly good teeth seems wrong to me. I suppose that leaves the choice of not extracting and still having bimax, but your teeth then appearing protrusive, or bimax with less movement to prevent your teeth from appearing protrusive, but then having less significant results with the jaw.

If it’s suggested that I have premolars extracted, I’ll probably instead opt for keeping them in and just going for less drastic results, or maybe even go with the original movement amount (or close to it) and just embrace slightly protrusive teeth as long as it doesn't risk causing lip incompetence.

Where do you see room for CCW? His occlusal plane is practically flat.

I noticed I have a tendency to tilt my head back in an attempt to camouflage my receding profile, so my occlusal plane may be steeper than it initially appears in the x-ray, but I’m not sure.

[emanresu]

(Just a note for other Chrome users: I don’t know if it’s just on my end, but I wasn’t able to see the video jawjawbinks embedded, but it displays properly in IE and Firefox. Maybe that’s common knowledge around here though.)

So I remembered the term for the idea I was trying to convey yesterday when I suggested the possibility of just embracing slightly protrusive teeth: ante-face.

Perhaps the silver lining of biprotrusive teeth is that I could forego bimax and extractions altogether (and correct me if this whole thing is stupid) as biprotrusive teeth sort of mimic good forward growth anyway. Unless it’s determined that bimax could provide a functional benefit, why would you not trade away two risky surgical movements with bimax (three if you want to include extractions) and instead opt for a simple sliding genioplasty if it were to provide the same or similar aesthetic results? You won’t get the aesthetic benefits for the midface that bimax can provide, but I’ve never been self-conscious of my midface, just my lower third.

This would not always be applicable, but in cases where the upper and lower jaw aren’t severely recessed (although my lower jaw probably is?) and biprotrusion is already somewhat mimicking good forward growth, does bimax really have an aesthetic advantage over a sliding genio?

Also, bimax doesn’t improve the appearance of the ramus, right? So in the case of either bimax or sliding genio, additional work will still be needed to improve it with either a side wing osteotomy or jaw implants? I'm certainly not an expert, but I don't think I have a good enough foundation for a side wing osteotomy, but jawjawbinks, I think you might.

[emanresu]

Bimax is better because you can get bigger movements . . . I'd imagine the jaw line would better because the movements begin further back which would stretch more soft tissue overall.

That totally makes sense to me. I'll be sure to ask the surgeon what he thinks of this idea.

Moves a retruded lower lip forward more and fills in a deep mentolabial fold.

Right, I forgot about that. I'm not sure if it'll be an issue in my case, but again, I’ll ask the surgeon what he thinks. If I were to just get a sliding genio I would probably need significant forward movement, but I definitely don't want that at the cost of a deep fold or pointy chin.

Also I’ll be away for the next few days and probably won’t be able to post as frequently until after my consultation on Monday, but I’ll still be around. After the consultation I’ll probably just make a new post, as I’ll have more details then and hopefully some other members will offer their insight then.

I’ve been working on a list of questions to ask Dr. Caminiti, and I guess I may as will just stick it onto the bottom of this post. It's a work in progress (!) but maybe someone in the future will find some value in it when preparing for their own first consultation. If anyone has any suggestions for the list, feel free to let me know.

Questions for Dr. Caminiti

Basic questions

What is causing my lower third to appear to lack shape/definition?

Does my throat and/or nose airway look narrow?

Bimaxillary advancement questions

Are my upper and lower jaws receded, meaning bimaxillary advancement would give optimal results?

And if bimax surgery is a consideration, would I need premolar extractions due to my biprotrusive teeth, or could extractions be avoided?

Are wisdom teeth always removed with this procedure?

Would proceeding with bimax without extracting biprotrusive teeth mean you would not be able to advance the jaw as much (otherwise risking lip incompetence or unsightly profile), or could biprotrusive teeth be used in addition to bimax to increase/mimic good forward jaw growth?

Does the fact that a bimax movement starts further back stretch more soft tissue to give better results than a sliding genio?

Sliding genioplasty questions

With a sliding genioplasty, how high is the cut made (I’ve read that higher cuts can lessen the potentiality of a pointy chin, not sure if this is true)?

Is step-off mitigated somehow (for example, with hydroxyapatite paste or bone grafts)?

Are there any other aesthetic issues that can be caused by a sliding genioplasty (muscle strain, deep mentolabial fold)?

Will sliding genio even give me the substantial improvements I'm looking for?

General surgery questions

Is CT imaging used prior to surgery to predetermine the location of nerves that are at risk of being cut?

Do you take a hip bone graft or are there alternative options (for example, cadaver or bovine grafts)?

Who performs the actual surgery, and if it’s not you, is there any choice in the matter?