10 Years Later - Full Prep, Ceph, and Final Planning Help

[Breakingbad]

Hey everyone,

I’ve been on this forum for about 10 years — mostly reading and learning, with the occasional post. I originally started a thread back in 2021 (linked below) when I was feeling stuck and overwhelmed, and I’m still grateful for the thoughtful feedback I received, which has meaningfully guided my treatment.

https://jawsurgeryforums.com/index.php/topic,8437.0.html

Since then, a lot has changed. I was eventually diagnosed with moderate sleep apnea and decided to move forward with treatment. I began orthodontics in 2022 and have now been in active prep for over a year and a half. Things are moving toward surgery, and I wanted to return here to both share an update and ask for help thinking through a few unresolved questions.


Quick Recap of Where I Am Now

• Orthodontic prep: lower incisors retracted significantly (approx. 5–7 mm), braces still on
• TADs used for en-masse retraction (no premolar extractions)
• Confirmed plan for maxillary and mandibular advancement
• Diagnosed mild gummy smile with upper lip hypermobility
• Still trying to finalize any additional dental or skeletal adjustments pre-surgery
• I had a long travel gap of 1 year but am trying to get back on track for surgery with Dr. Gunson

Just a side note that may help others: I was told by several surgeons that retracting my lower teeth without premolar extractions would be impossible. But I really wanted to avoid extractions if possible — and my orthodontist, Dr. Vince Kokich suggested we could use the space from my previous wisdom tooth extractions. With TADs, we were able to achieve significant en-masse retraction. I just wanted to share that in case someone else is facing the same dilemma.


What I’m Still Trying to Figure Out

1. Should I be retracting my upper incisors pre-surgery?
Most surgeons I’ve consulted with agree that I would benefit from a small maxillary advancement (around 3–5 mm). But my mouth already appears somewhat full in profile, and I’m concerned that advancing the maxilla without adjusting the upper incisors could make my lips appear too prominent.

On the other hand, I don’t want to lose upper lip support or prematurely age my mouth by over-retracting. I’m trying to understand whether the mouth-dominant look is due to true protrusion — in which case, retraction would help — or if it’s more of an illusion caused by a recessed ANS/paranasal/midface area.

Right now, I’m debating whether a small incisor retraction (1–3 mm) is the right move, or whether it’s better to preserve incisor position and instead address facial imbalance post-op through ANS advancement or paranasal/midface augmentation. My orthodontist says we can affect retraction either through tipping or retracting en-masse.

2. Should I allow a controlled relapse in lower incisor angulation?
My lower incisors are now very upright — my orthodontist even mentioned they might be too upright. I’m wondering whether allowing a small controlled relapse might actually improve lower lip support and facial balance post-BSSO. My main concern is avoiding a lower third that looks overly tucked under.

3. Managing gummy smile and incisor show
We’ve considered mild maxillary downgrafting to improve incisor display, as mine is slightly low for my age. But I already show some gum when I smile naturally. I’ve also looked into lip repositioning surgery post-op.

I’m wondering if the gum show I have now is mild enough that I could afford a slight increase (via downgraft) to improve incisor show at rest — and still be able to manage the result with lip repositioning surgery later. I’d love input from anyone who’s tried this combined approach or has thoughts on how to assess whether it’s a good fit.

4. Would MSE offer any aesthetic benefit?
I originally tried MSE under Dr. Gunson’s guidance, but the suture failed to open and the appliance was removed. My understanding is that it could still be reattempted using corticotomies. I’m trying to determine whether MSE would actually benefit me aesthetically.

On one hand, it could offer paranasal expansion, which I’d welcome. On the other, all of my upper teeth are visible when I smile widely — and I’m unsure whether widening my arch further would create aesthetic issues or instability. Any thoughts on this trade-off would be appreciated.

5. High vs. low Lefort I?
From what I understand, a high LeFort I could help address my relatively retrusive paranasal and midface area, and I’ve seen it recommended in similar cases to improve support and projection.

What makes me cautious is that my nose is already slightly upturned (though I suspect that may be related to the ANS). I’m trying to determine whether a high LeFort I would be the right choice if I’m given the option — or whether it might introduce aesthetic risks that outweigh the midface gains.


Photos & Materials (Link below):

Recent frontal and profile images taken by my orthodontist

Updated ceph

Candid photos that give an idea of my gum show at full, natural smile

https://imgur.com/a/VvQ5Sus

For context, these photos were taken at 25%+ body fat (work in progress).


Bonus: Tools That Helped Me

Just in case it helps someone else — I’ve used a couple of basic tools to visualize angles and soft tissue balance while working through planning:

GiniFab Angle Tool - https://www.ginifab.com/feeds/angle_measurement/: Good for checking nasolabial angle, IMPA, and simulating CCW rotation changes.

Eleif Ratio Tool - https://eleif.net/photomeasure: Useful for analyzing facial thirds and soft tissue harmony using a known scale.

Of course, none of this replaces proper ceph tracing or clinical planning — and I know nothing beats sitting down with a pen, paper, a geometry set, and an x-ray. But these tools helped me stay organized and visualize things quickly when I only had digital materials on hand.


If anyone has thoughts on the upper incisor retraction dilemma, how best to address paranasal/ANS support in tandem with a LeFort, has dealt with balancing downgraft vs gummy smile, or doing MSE without a typically narrow mandible, I’d be really grateful to hear from you. I’m not looking for a perfect answer — just trying to make sure I don’t miss anything critical before locking in surgical plans.

Thanks again to the people here who helped me stay grounded through the past few years.

[Breakingbad]

Quick update:
I overlaid my old ceph with my current one and estimated that the true retraction of my lower anterior teeth is around 5.5 mm.

For any patients who might want to try the same thing digitally — I used Canva to do this by giving one X-ray a blue cast, the other a red one, and then overlaying them with 50% transparency. Of course, this isn’t a substitute for formal tracing or ceph analysis, but I thought I’d share in case it helps anyone visualize changes more clearly between time points.

Reflecting on that:
Given that I’m probably not a great candidate for significant CCW rotation (due to a relatively flat occlusal plane), and the fact that 5.5 mm of retraction is already a very respectable amount, I’m realizing I may not have much room to allow lower incisor relapse without compromising valuable advancement space.

So I guess the question now becomes: Is my current incisor angulation actually optimal?
And if not — what can I realistically do about it without giving back space I’ve gained through retraction?

I’ve been wondering if something like SFOT (specifically, an allograft or bone paste to the alveolar area) could help me change the axial inclination slightly without destabilizing the posterior anchorage or sacrificing linear advancement.

[kavan]

I'm just going to address the FIRST question here.

Since the relationships in maxfax are geometrical; a study that uses points, lines, angle, planes, rotations...etc...many of which are very basic and fundamental, it follows that basic geometrical concepts are applicable to basic observations one can make on a ceph.

For example the answer to your question: 'Should I be retracting my upper incisors pre-surgery?' is YES. You would have arrived at the same answer of 'yes', without any on line tools by using the same type of deductive process that people who have some geometry under belt use.

The answer of YES arises from following the LINE of the upper lip and looking to see if you can find a PARALLEL line drawn through the incisor inclination. Thing is to do that, one needs to be looking for RELATIONSHIPS one line has with another line. That involves looking at the ceph in terms of it being a GEOMETRIC CONSTRUCT.

2 diagonal lines can be found on your ceph that are parallel to each other. One drawn along the outer contour of the mouth/philtrum (which is a diagonal line) and the other drawn through the incisors (another diagonal line parallel). It doesn't matter where to draw the line through the incisors. What matters is whether a line parallel to the line that can be followed along the 'mouth area' can be found through the incisor area and the answer is YES. That right there tells you there is a RELATIONSHIP between the 'mouth area' and the incisor area the mouth area is inclined on/ resting on, ORIENTED on.

There is no requirement here to measure the angles. What's required is to OBSERVE the lip area is angled/inclined outward because it's resting on an incisor area that's angled/ INCLINED outward. Although there is no requirement to measure the angles, what's required to know is that when a line is INCLINED, the angle of inclination is relative to another line. So, here the inclination is relative to a vertical and a vertical is used to look at profile orientation.

 'Retraction' as it applies to the incisors means to disincline or REDUCE the angle of inclination. So, if you wanted to RELATE any concerns you had about the mouth area being brought 'forward' and looking to 'protrusive' (with maxillary advancement) you would have to RELATE BACK to the INCLINATION it has relative to a vertical. Again, you don't have to  ponder how many mm or wonder about 'illusions' or measure any angles you just need observe that reducing the angle of inclination the 'mouth area' has (with a vertical) is also RELATED to reducing the angle of inclination the incisor area has (with a vertical).

Hence, the ONLY way to mitigate the 'mouth area' looking too protrusive subsequent to the maxilla being brought forward is to reduce its angle of inclination by reducing the angle of inclination of the 'plane' it's inclined on (incisor area) which is what RETRACTION means. That's why the answer is 'Yes'.

ETA: As to the second part of your first question where it sounds like you could be hinging a decision for retraction on whether or not you have 'true protrusion':

Since the decision to retract is based on decreasing the angle of inclination the upper lip area has (because it's resting along the inclination of the incisor area ), it's irrelevant whether or not it's called 'true protrusion'. Even if it was, like in bimax protrusion, most US dentists retract the area. Hence pondering whether or not to hinge a decision on that is extraneous.

As to the other second part of your first question where you ponder if the 'mouth dominant' area could be an 'illusion cause by a recessed ANS/paranasal/midface area'. Since the angle of inclination the mouth area rests on is NO 'illusion' and the decision to retract is based on the need to disincline it (decrease its inclination) SO the maxilla can be advanced forward BUT NOT exaggerate the 'mouth dominant' area, pondering illusions..etc is also extraneous.

In closing, since the answer to 'should I be retracting my upper incisors' is YES, any more pondering that might hurl you into indecision as to 'yes' or 'no' based on what ever 'this or that' you might generate, would also be extraneous.

[Breakingbad]

I'm just going to address the FIRST question here.

Since the relationships in maxfax are geometrical; a study that uses points, lines, angle, planes, rotations...etc...many of which are very basic and fundamental, it follows that basic geometrical concepts are applicable to basic observations one can make on a ceph.

For example the answer to your question: 'Should I be retracting my upper incisors pre-surgery?' is YES. You would have arrived at the same answer of 'yes', without any on line tools by using the same type of deductive process that people who have some geometry under belt use.

The answer of YES arises from following the LINE of the upper lip and looking to see if you can find a PARALLEL line drawn through the incisor inclination. Thing is to do that, one needs to be looking for RELATIONSHIPS one line has with another line. That involves looking at the ceph in terms of it being a GEOMETRIC CONSTRUCT.

2 diagonal lines can be found on your ceph that are parallel to each other. One drawn along the outer contour of the mouth/philtrum (which is a diagonal line) and the other drawn through the incisors (another diagonal line parallel). It doesn't matter where to draw the line through the incisors. What matters is whether a line parallel to the line that can be followed along the 'mouth area' can be found through the incisor area and the answer is YES. That right there tells you there is a RELATIONSHIP between the 'mouth area' and the incisor area the mouth area is inclined on/ resting on, ORIENTED on.

There is no requirement here to measure the angles. What's required is to OBSERVE the lip area is angled/inclined outward because it's resting on an incisor area that's angled/ INCLINED outward. Although there is no requirement to measure the angles, what's required to know is that when a line is INCLINED, the angle of inclination is relative to another line. So, here the inclination is relative to a vertical and a vertical is used to look at profile orientation.

 'Retraction' as it applies to the incisors means to disincline or REDUCE the angle of inclination. So, if you wanted to RELATE any concerns you had about the mouth area being brought 'forward' and looking to 'protrusive' (with maxillary advancement) you would have to RELATE BACK to the INCLINATION it has relative to a vertical. Again, you don't have to  ponder how many mm or wonder about 'illusions' or measure any angles you just need observe that reducing the angle of inclination the 'mouth area' has (with a vertical) is also RELATED to reducing the angle of inclination the incisor area has (with a vertical).

Hence, the ONLY way to mitigate the 'mouth area' looking too protrusive subsequent to the maxilla being brought forward is to reduce its angle of inclination by reducing the angle of inclination of the 'plane' it's inclined on (incisor area) which is what RETRACTION means. That's why the answer is 'Yes'.

ETA: As to the second part of your first question where it sounds like you could be hinging a decision for retraction on whether or not you have 'true protrusion':

Since the decision to retract is based on decreasing the angle of inclination the upper lip area has (because it's resting along the inclination of the incisor area ), it's irrelevant whether or not it's called 'true protrusion'. Even if it was, like in bimax protrusion, most US dentists retract the area. Hence pondering whether or not to hinge a decision on that is extraneous.

As to the other second part of your first question where you ponder if the 'mouth dominant' area could be an 'illusion cause by a recessed ANS/paranasal/midface area'. Since the angle of inclination the mouth area rests on is NO 'illusion' and the decision to retract is based on the need to disincline it (decrease its inclination) SO the maxilla can be advanced forward BUT NOT exaggerate the 'mouth dominant' area, pondering illusions..etc is also extraneous.

In closing, since the answer to 'should I be retracting my upper incisors' is YES, any more pondering that might hurl you into indecision as to 'yes' or 'no' based on what ever 'this or that' you might generate, would also be extraneous.

Hi Kavan,

First off, I want to say that I genuinely respect the depth of knowledge you bring to the forum. Your posts over the years have shaped how many of us understand facial geometry and orthognathic mechanics — myself included. You’ve consistently brought clarity to complex topics, and I really appreciate that.

Thanks for your detailed reply — I appreciate the effort and clarity you brought to breaking down the geometric relationships. You’re absolutely right that incisor inclination determines the lip’s orientation to vertical, and I’ve actually used the exact same reasoning — the parallel diagonals and lip-incisor alignment — when discussing my case with surgeons. (And yes, I know — no online tools required to see that.)

What’s been difficult, though, is that several of the most respected maxillofacial surgeons I consulted (including names regularly cited as among the best globally) didn’t agree that retraction was necessary in my case. One (Dr. Alfaro) repeatedly told me that my lip projection was a “racial trait” and should be preserved, while others warned that retraction might cause unwanted flattening in the upper lip region, as well as visual lengthening of the philtrum.

Even a number of the surgeons who were ultimately on board with retracting my upper teeth only agreed after I explained that I didn’t want my upper teeth to end up further forward than they are pre-surgically. Prior to that, they didn’t see a strong aesthetic reason to retract — they simply planned to advance the maxilla by a few millimetres with the dentition as-is. But I’ve since let go of that hard line. I’m no longer set on keeping the teeth in the same anteroposterior position — I’m open to either outcome, as long as it leads to the best aesthetic result in the context of my face.

Don’t get me wrong — I actually made the same observations you laid out in your reply several years ago, and I’ve been heavily leaning toward upper incisor retraction ever since. My confusion doesn’t come from a lack of conviction in that logic, but from trying to reconcile it with the strong — and often contradictory — opinions I’ve received from respected surgeons. I’m simply trying to make the most precise, balanced decision I can in light of all the variables.
In fact, a number of those surgeons expressed genuine surprise at how analytically I approached my case — particularly my ability to apply geometric reasoning to assess incisor inclination, lip orientation, and facial plane relationships. That’s part of why their pushback was so confusing: they acknowledged the logic, but still advised against retraction, often citing ethnic soft tissue norms or risks of flattening and loss of incisor show. It left me wondering whether certain anatomical or aesthetic variables override what would otherwise be a straightforward geometric prescription in this case.

Even if it’s true that “most US dentists retract that area,” I’m less concerned with what’s typical and more interested in what will create the most harmonious, structurally coherent result. I do recognize that beauty is subjective and culturally mediated — but I also believe that in the context of orthognathic planning, general aesthetic principles do exist. And in cases like mine, where the midface is underdeveloped and the lip full, I’m trying to understand whether a degree of lip protrusion might actually be the lesser trade-off compared to flattening or tension loss.

I’ll admit I was a little surprised by how strongly you framed everything else as “extraneous” or over-thought — especially since these weren’t speculative musings but grounded questions I raised after serious consults with global experts and years of research.  I say that with respect — just hoping to keep the dialogue as thoughtful and two-sided as your geometric breakdowns always are.

I also remember that back in a 2021 thread, you cautioned me that retroclining teeth too much could lead to aesthetic compromises. That stuck with me — and it’s also why I’ve started wondering about the inclination of my lower teeth now that they’ve been retracted en-masse. I’m not sure if they’re overly upright now — that's why I asked about that as well.

I hope it’s clear I’m not trying to be difficult or chase perfection for its own sake. I’m just a patient who’s done what so many others on this forum are advised to do — see the best surgeons I can, educate myself thoroughly, and ask critical questions. But I’ve found it genuinely difficult to figure out the right path given the conflicting opinions I’ve received. That’s why perspectives like yours are so valuable — they help cut through some of the noise.

So while I agree with your geometric framing in theory, I’d still really value your insight — especially on how to reconcile the need to reduce inclination (to avoid excessive mouth dominance post-advancement) with the counter-risk of soft tissue flatness and reduced incisor show. Do you think there’s a threshold of safe retraction that still allows for lip support, or that some minor protrusion should be accepted when midface support is limited? Perhaps asking Dr. Gunson whether it might make sense to retract the upper teeth by a couple of millimetres while trying to preserve their current inclination — or, if that’s mechanically unavoidable, to re-establish a more favorable inclination after retraction — could be a useful way to approach it?

Would love to hear your take.