Feedback on proposed plan correction of LFS

[XXRyanXXL]

I had an unsuccessful BiMax Surgery last year.
Had no plans on sharing my information but thought it may help other people. So I learned the Surgeon who did my case, just completed his residency, he was training and learning off his mistakes on me. Surgeon did not complete the operation as agreed to, because he doesn't know how, and he tried to make me think his job was excellent and I look great and should NOT pursue any revision, and he claimed to go to conference with other surgeons, where they all suggested I look great and don't undergo any future surgery. This may sound strange to people on this forum, but because the Surgeon lacked the skills to do any rotation, the surgeon tried to give me a jaw line by offsetting the long face appearence he made worse by advancing the lower jaw in the direction of the deformed jaw growth by giving me a massive chin (genio) and moving that forward past my lower lip (2 mm). The Surgeon also sliced the mental nerve, so I have no sensation running to my lower lip, or chin area.
Approximately 5 months AFTER the surgery, the surgeon finally released my VSP, the virtual surgical planning, which I requested I see before I go under the knife. So I had NO idea what he had planned for me. I had long face syndrome (high MP and OP angles), with Class II (10mm overbite). All the surgeon did was elongate my face even more to slide (BSSO) the lower mandible into place.
I am going to be working with other Residents, unfortunately, due to my insurance, so I have to be really cautious on proceeding with another surgery.
My problem is this. I have 3 plans in place from 3 different oral surgeons. They all pretty much converge on this plan.
1. CCW rotation with posterior downgrafting with anterior impaction
2. Upper lip lift (I have long upper lip, and to help with the anterior impaction to show more teeth)
3. Mandibular Inferior Border implants (I have notches below the lower mandible)
4. cheek lift  (cheek pads look descended)
5. Inverted L-osteo
6. mentoplasty (chin reduction)
My MP angle right now is 35 degrees, I was told at BEST, I can achieve a 10 degree improvement, however I want to be in the 23 degree range (normal for my age). I'm afraid of the dreaded "monkey nose" due to the anterior impaction, as this would be impacting my upper jaw into the nasal passage (Alar stich won't help long term). Also according to an article by Wolford on correct OP (occlusional plan) for optimal smile, it stands at 10 degrees, am I correct?
My problem right now, is that when I'm being evaluated by OMS, if a surgeon doesn't have the skill set to perform those operations I listed, they will remain silent and come up with a different plan. I want to stick to this plan though, it makes logical sense to me, and achieves my goals here. I am looking for feedback on this proposed procedure to correct a long face appearence and achieving a sharp jawline (I have no jawline), and some expectations of soft tissue changes I can expect.

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[kavan]

I can tell you that the bone displacements in the '3d' proposal to the lower jaw correspond to appox 5 degree angle decrease. Perhaps the proposed implant overlays make up the other 5 degree decrease.

[Lefortitude]

its unfortunate you had to trust an inexperienced surgeon due to your insurance.  if i was you, i would save up until i could afford a private surgeon to perform a revision 

[ditterbo]

That ramus of yours saved you a few MP angle degrees. Jealous.

[kavan]

I'm not clear on a few things. Although, it's clear you would need a lip lift and probabably similar you might need a cheek lift, I'm not clear if insurance pays for that. But perhaps that is neither here nor there.

I'm also not clear whether or not this VSP is a new proposal or the old one

What I'm clear on is that the the VSP photo reflects a 5 degree decrease in the MPA in the direction of CCW (when it's turned to the right). Also, the 'slide UP' to the chin assists in the look of CCW. Although this 'slide' up technically is not an 'absolute' reduction, since it's a displacement of what is already there and nothing is off, the slide up aspect of it is to make the chin look less long from the front. However, whether or not this VSP photo is your PAST one or a NEW proposal, it would be hard to 'see' (in the mirror) the 5 degree decrease simply because the EYE 'wants to see' a 12 degree decrease. I don't actually see an inverted L oesteo on this VSP. So, PERHAPS this was your PRIOR plan.

Now whether or not this VSP was your prior plan or your future plan, the situation is that there is NO amount the maxilla can be CCWed to result in the 12 degree decrease you would need. This is because a significant 'drop down' of the back jaw would be needed and that part WOULD correspond with a 'reverse L' type osteo.

When the doc tells you 'at most' you can get a 10 degree CCW of the mandible with inverted L added to the plan, he's telling you that your MPA EXCEEDS what an inverted L, coupled with a decrease in the OP can do.

That said, there are OTHER cuts that can exceed what a reverse L can do.  Let me know if you would like me to give the link of a (research) paper by docs (in FRANCE) who have a different cut that can give more drop and rotation than the reverse L.

[XXRyanXXL]

The VSP that is shown, was the plan the surgeon performed last year. It really just made my face even longer. Again, the surgeon never shared this with me prior to surgery. I would stay away from teaching hospitals as much as possible, but I can also see a staff member and not a surgeon who just completed his residency. The upper lip lift could be covered, but the cheek lift isn't, since it's purely cosmetic.

So this new technique that was described, is it this link?

http://www.sciencedirect.com/science/article/pii/S246878551630009X

What is the name for this new procedure? Just Vertical ramus elongation and mandibular advancement by endobuccal approach?
So it's possible to achieve greater ccw rotation than the inverted L- in all cases? Also would it be better for a patient who needs the bone grafts to use cadaver bone and not just hip bone self-harvested? I've read people who suffer long term pain from the latter approach.

I'm looking at the girl in the last case in general, and I see no functional airway increase, it seems as though it's really constricted? Actually I see no rotation in any of there cases, just the correction of the lower jaw. But the aesthetic look is substantial.

[kavan]

The VSP that is shown, was the plan the surgeon performed last year. It really just made my face even longer. Again, the surgeon never shared this with me prior to surgery. I would stay away from teaching hospitals as much as possible, but I can also see a staff member and not a surgeon who just completed his residency. The upper lip lift could be covered, but the cheek lift isn't, since it's purely cosmetic.

So this new technique that was described, is it this link?

http://www.sciencedirect.com/science/article/pii/S246878551630009X

What is the name for this new procedure? Just Vertical ramus elongation and mandibular advancement by endobuccal approach?
So it's possible to achieve greater ccw rotation than the inverted L- in all cases? Also would it be better for a patient who needs the bone grafts to use cadaver bone and not just hip bone self-harvested? I've read people who suffer long term pain from the latter approach.

I'm looking at the girl in the last case in general, and I see no functional airway increase, it seems as though it's really constricted? Actually I see no rotation in any of there cases, just the correction of the lower jaw. But the aesthetic look is substantial.

Yes, the new technique I saw is described in the link to the paper. I defer to the TITLE of the paper for the name of it. It certainly looks to me that significant elongation of ramus and forward advancement have been combined for a 'rotation' to the posterior mandible given that the mandibular plane angle is significantly LESS STEEP than a CCW at the maxilla alone would do.  Seeing a correction of lower jaw to significantly reduce the STEEPNESS to the MPA is in effect a 'rotation'. I am unable to answer questions for which the information regarding them is not in the article.

[XXRyanXXL]

So that fixes the high MP angle. However, the long face syndrome is still exhibited, and when I smile, my upper teeth look recessed in (my upper lip doesn't drape against them), and I was recommended to have impaction of the maxilla, but this introduces a plethora of problems. One is that when I smile, I barely show even half of my upper front teeth, so impacting would make that even worse, and also anytime you are impacting the maxilla, the widely known "monkey nose" issue is prevelant. One is to use an alar stitch, but even this has limitations.
What I think can offset these issues is that the CCW rotation with downgraft would effectively bring out and tilt up the upper teeth, and to have a upper lip lift. For every 3mm advancement of the upper teeth, there is 1mm increased tooth show, due to the elastic nature of the upper lip (which is non-existent in my case). The video below shows this

https://www.youtube.com/watch?v=fzZNTpklR3E&list=PLGx6L75hAkydVwn0XYGswdbxUDkPgKdN9&index=4

Plus, wolford published an article showing optimal occlusional angle for best smiles, and shows that 10 degree angle are optimal. So a 2 degree decrease in my case.

[kavan]

So that fixes the high MP angle. However, the long face syndrome is still exhibited, and when I smile, my upper teeth look recessed in (my upper lip doesn't drape against them), and I was recommended to have impaction of the maxilla, but this introduces a plethora of problems. One is that when I smile, I barely show even half of my upper front teeth, so impacting would make that even worse, and also anytime you are impacting the maxilla, the widely known "monkey nose" issue is prevelant. One is to use an alar stitch, but even this has limitations.
What I think can offset these issues is that the CCW rotation with downgraft would effectively bring out and tilt up the upper teeth, and to have a upper lip lift. For every 3mm advancement of the upper teeth, there is 1mm increased tooth show, due to the elastic nature of the upper lip (which is non-existent in my case). The video below shows this



Plus, wolford published an article showing optimal occlusional angle for best smiles, and shows that 10 degree angle are optimal. So a 2 degree decrease in my case.

The procedure in the article 'fixes' the high MP angle by making the ramus longer, thereby dropping to posterior jaw to lower the angle. It makes hyperdivergence much less than CCW alone would do.

If your teeth don't show when smiling and also are too far back, CCW via anterior impaction stands to make them show less even though the forward advancement will bring the teeth closer to the lips. If CCW via posterior downgraft is not an option, then most definitely a Lip lift would be needed to offset even LESS tooth show that could arise from CCW with anterior impaction. However, let's hope posterior down graft IS an option because that looks like a better one for the CCW.

I can't validate the 'for every 3mm advancement of upper teeth there is a 1mm increase in tooth show' statement. This could not be universally true. Advancement is over an angle of inclination in which the 'pure' vertical element (increased tooth show) and 'pure' horizontal element will be different 'vector components' of forward advancement on a DIAGONAL line where that diagonal line is at an angle from the horizont. Although elasticity modulus of tissue would factor in, there would still be the salient relationship of horizontal and vertical displacements being a function of the angle of inclination the displacement goes along.

[PloskoPlus]

The 1 for 3 mm  rule is what my surgeon told me as well and of course it's bulls**t. If you have a superflat op, you will get much less tooth show from advancement. Anyways, I'm still 2-3 mm short of ideal tooth show (I show none when taking, it's better when I smile due to the hyper mobile upper lip).

[kavan]

The 1 for 3 mm  rule is what my surgeon told me as well and of course it's bulls**t. If you have a superflat op, you will get much less tooth show from advancement. Anyways, I'm still 2-3 mm short of ideal tooth show (I show none when taking, it's better when I smile due to the hyper mobile upper lip).

Yup. Basic concepts in geometry don't bear it out as a 'universal' rule. Could not possibly be true for all angles of inclination of the occlusal plane.

[PloskoPlus]

Yup. Basic concepts in geometry don't bear it out as a 'universal' rule. Could not possibly be true for all angles of inclination of the occlusal plane.

Most surgeons consider it a job well done if your bite meshes.  They couldn't care less about aesthetic effects. If they say they do, it's usually bulls**t to get you into surgery. You know what they say, it's easier to ask for forgiveness than permission. This is especially so regarding permanent numbness. I don't know what the normal lie is these days - "only 10%"?

[kavan]

Most surgeons consider it a job well done if your bite meshes.  They couldn't care less about aesthetic effects. If they say they do, it's usually bulls**t to get you into surgery. You know what they say, it's easier to ask for forgiveness than permission. This is especially so regarding permanent numbness. I don't know what the normal lie is these days - "only 10%"?

So true.