Risk and stability of down-graft to improve tooth-show

[JigJaw_:/]

Kavan :    Yeah sometimes I misunderstood stuffs !

Well, I talked about facelift dentistery because it functions with veneers helping to restaure the vertical dimension. It's not just mere veneers aiming at lenghtening teeth, it also reestablishes a good occlusion. As eranthe was descibing issues with his occlusion, I thought you were talking about that.
...
indeed you talk about a genio just after and not a bsso.

I didn't know that genio had a function, I thought it was just something do for aesthetical reasons.
(In my case, one surgeon told me that my chin should me moved backward while another said it should be moved forward after surgery.... So I'm a little confused about that, still don't know what's the point. But that's another subject.)

Anyway, I'm sorry for you eranthe and I hope you will find a solution

I made the mistake of putting 10 veneers on my upper. To compensate for long upper lip and mild short maxilla/cant etc, I got Gary Busey like choppers, ended up hating them. I'm going to eventually replace them and go through with lefort 3 piece downgraft.. Makes me nervous though, I also keep reading about stability issues. Veneers can be tricky (hella expensive to get wrong). I paid nearly 18 g when said and done.

[eranthe]

If your bite fits (and maybe even if it doesn't), you may have trouble finding another surgeon in Australia to revise your surgery.  "Go back to your surgeon" is the standard answer.  Directing you to plastic surgeons after your surgery is also the norm.  IOTW, standard procedure in Australia is:

* Withhold information (detailed surgical plans, even cephs) - a good patient is an ignorant one.  Say something in passing about potential permanent numbness (it'll certainly be in the consent form), but certainly say nothing about potential aesthetic downsides. "Anything I'll do is an improvement" is implied.

* Make the bite fit with the simplest laziest surgery possible - no down grafting ("it's unstable!", although some will do down grafting for short face syndromes), certainly no CCW rotation with posterior down grafting. I have not seen your pre-op ceph, but I suspect you probably should have had less anterior impaction and some posterior down grafting to affect the same amount of CCW... But when all you have is a hammer impaction in your toolbox, you tend to overuse it.  Steep occlusal planes are hard to make look good (even more so when there is no gummy smile, so there is nothing to impact).  AFAIK, no surgeon in Australia will do CCW with posterior down grafting.

* Deny that any aesthetic issues may have been caused by their surgery - "wait till the swelling comes down", etc., etc..

* Tell you to see a plastic surgeon. "The things you're complaining about were pre-existing and unaffected by my surgery" is implied.

If you show your lower teeth when talking, you will probably end up with lip incompetence after a lip lift.

Yep that pretty much covers it Plosko!  Incredible ... your points describe my experience to a T!  I take it you're in Aus then?

[PloskoPlus]

Yep that pretty much covers it Plosko!  Incredible ... your points describe my experience to a T!  I take it you're in Aus then?

Yes. There is a member here who tried to talk me out of having surgery in Australia (I could afford any surgeon back then). I didn't listen. Having surgery by "one of the best surgeons in Australia" was a terrible mistake.

[eranthe]

Well, having a lip lift would not result in (lower) lip incompetence which is what you are describing. But it does sound that if you have to force your lower lip to meet your upper lip, you ALREADY have lip incompetence. That's a function of how the chin lines up with the lower lip. Shortest path is close to a straight vertical line such that a vertical line dropped from lower lip has the chin close to it and NOT too diaganally oriented behind or forward to that imaginary line.

Since one of your problems is you feel your lower jaw was not brought forward enough, it would follow your chin might be too far back, especially coupled with the complaint of lip incompetence and NO MENTION of genioplasty with either of your surgeries.

BASED on your descriptions, it sounds like an advancement genioplasty would help and also allow for the lip lift. Perhaps explore that option. Also ask if having veneers to lengthen the teeth is an option to compensate for the 2ncd revision surgery which left you with little tooths show.

It kind of sounds like your maxfax hesitates to do a 3rd cut through the maxilla but is SHIFTING all the risk to the act of getting a down graft. In terms of people who do get downgrafts, WHEN DONE by docs who are good at doing them, they can be stable.

I don't think the real issue here is 'stability of a downgraft'. I think it's more of a matter of a 3RD CUT to the maxilla whether or not it's for a downgraft.

Kavan, please forgive my delayed reply. 

It's really interesting that you suggested I may already have lip incompetence.  TBH I didn't think that I did, however, a few weeks ago my surgeon asked me to stop wearing elastics (as we had done the pre-operative radiology and he didn't want any further dental movements to happen between now and the revision surgery).  Since I've stopped sleeping with elastics (which were holding my mandible forward) I have found it impossible to keep my mouth closed when I lie down to sleep. I have also started snoring again and waking up with a sore throat, dry mouth and dried-out sinuses.  I'm also having nightmares where I wake up choking again and I'm tired all the time.  This is absolutely devastating for me as the sleep apnea was the reason I had this surgery in the first place.  I seemed to be sleeping and breathing quite well after the original bi-max surgery, but since the revision Lefort where my maxilla was further impacted, all the old symptoms seem to have returned.  I always thought the position of the mandible was responsible for my sleep apnea as I could clearly feel it collapse on my airway when I lay down on my back (and you could see the narrowing of my airways on xray), but now I'm wondering just how much the position of the maxilla also affects breathing and whether that revision maxillary impaction has made my breathing worse again. 

As I feel my mandible was not brought forward far enough in the bi-max (and no, I've not had a genio), I'm now wondering if I should be considering a maxillary advancement (without the down-graft), and an advancement genio - that way I would be doing all I could to protect my airway?  The only problem with that is that I've lost so much mid-face length that my face is now quite short and square and flat looking - that makes me a bit scared to lengthen my chin.  I wish there was some way of knowing the aesthetic outcome of those movements prior to surgery ...

[kavan]

Kavan, please forgive my delayed reply. 

It's really interesting that you suggested I may already have lip incompetence.  TBH I didn't think that I did, however, a few weeks ago my surgeon asked me to stop wearing elastics (as we had done the pre-operative radiology and he didn't want any further dental movements to happen between now and the revision surgery).  Since I've stopped sleeping with elastics (which were holding my mandible forward) I have found it impossible to keep my mouth closed when I lie down to sleep. I have also started snoring again and waking up with a sore throat, dry mouth and dried-out sinuses.  I'm also having nightmares where I wake up choking again and I'm tired all the time.  This is absolutely devastating for me as the sleep apnea was the reason I had this surgery in the first place.  I seemed to be sleeping and breathing quite well after the original bi-max surgery, but since the revision Lefort where my maxilla was further impacted, all the old symptoms seem to have returned.  I always thought the position of the mandible was responsible for my sleep apnea as I could clearly feel it collapse on my airway when I lay down on my back (and you could see the narrowing of my airways on xray), but now I'm wondering just how much the position of the maxilla also affects breathing and whether that revision maxillary impaction has made my breathing worse again. 

As I feel my mandible was not brought forward far enough in the bi-max (and no, I've not had a genio), I'm now wondering if I should be considering a maxillary advancement (without the down-graft), and an advancement genio - that way I would be doing all I could to protect my airway?  The only problem with that is that I've lost so much mid-face length that my face is now quite short and square and flat looking - that makes me a bit scared to lengthen my chin.  I wish there was some way of knowing the aesthetic outcome of those movements prior to surgery ...

Lip incompetence is associated with chin position.

[kavan]

Risk and stability of down graft is like risk and stability of SKIING.

First you want to know IF the person is actually a skier.
Then you want to know how good of skier they are as to master steep and slippery slopes.

Moral of story is that the risks and stability will depend on who's doing it and whether or not they are good at doing it. In your case revision surgery.

[JigJaw_:/]

Risk and stability of down graft is like risk and stability of SKIING.

First you want to know IF the person is actually a skier.
Then you want to know how good of skier they are as to master steep and slippery slopes.

Moral of story is that the risks and stability will depend on who's doing it and whether or not they are good at doing it. In your case revision surgery.

Good analogy.. So, kavan, who's the best skier you know of?

[kavan]

Good analogy.. So, kavan, who's the best skier you know of?

I guess those who make the Olympic team.

[PloskoPlus]

Probably Wolford because he does so many.

[eranthe]

Bit of an update! 

A colleague recently invited me for dinner to meet a friend of his - a semi-retired Professor of Maxfac who taught at one of our top Universities for many years. He has been living and practicing in Asia for years but is still maintains connections here.  I showed him my radiology, before and after photographs and took him through the last five years of my treatment.  He agreed that, whilst it was 'good surgery generally', it was a poor aesthetic result.  He said something along the lines of "originally I'd planned to advise you today against further surgery, but after meeting you and hearing you speak, and after seeing your before and after photographs, it's pretty clear that you will never be happy trying to live with this result - therefore I think the potential benefit is worth the risk in your case.  He then said that another reason he changed his original position was that he had worked out who had done my surgery whilst we were talking (as I had mentioned the hospital where I'd had my surgery). He told me that my surgeon is extremely highly regarded and reassured me that, if I were to proceed with such delicate surgery, then my surgeon really was the ONLY person he would recommend to do it (no they are not friends, although they have met on occasion, he is just aware of him professionally)! However, he also agreed that surgeons who do a lot of trauma work can sometimes develop a blunted aesthetic over time and noted that my surgery - whilst good in functional terms, was not a good aesthetic outcome.  He advised me to go back to my surgeon with very specific instructions "just go back and tell him what you want him to do - be specific.  If anyone can do it, he can!" 

A couple of days later, I met with my surgeon and he appeared to have a renewed sense of enthusiasm about my case.  It seems as though he has accepted the situation and stopped trying to talk me out of surgery and is now directing that energy towards looking for new approaches and workarounds.  He seemed enthusiastic!  He mentioned that this time he would be using Patient Specific Implants, saying that he felt this new technology would be extremely helpful with my case and arranged my workup with the registrar.  A few days after that, I met my new registrar for this year - a lovely woman!!! (the first female registrar I've ever seen in the maxfac clinic in over five years) who wants to specialize in cosmetic max-fac surgery.  She was kind, whip smart, extremely thorough and spent THREE AND A HALF HOURS with me looking at radiology and old photos and asking me what I disliked about my face and function!  Whilst my surgeon will be performing the actual surgery, she will help me in terms of examining the realms of possibility in terms of what I hope to achieve.  I really look forward to working with her!

I'm booked in for plate removal surgery next Monday 6th (as we will need 3 months healing time after that), and jaw surgery in June.  I am hoping that now - with my new registrars interest in  aesthetics, my surgeons confirmed expertise (which has renewed my confidence in him) and this new technology - along with the knowledge and support I receive from you guys here - I may actually have a fighting chance at a good outcome this year! 

All appendages crossed etc

[eranthe]

It kind of sounds like your maxfax hesitates to do a 3rd cut through the maxilla but is SHIFTING all the risk to the act of getting a down graft. In terms of people who do get downgrafts, WHEN DONE by docs who are good at doing them, they can be stable.

I don't think the real issue here is 'stability of a downgraft'. I think it's more of a matter of a 3RD CUT to the maxilla whether or not it's for a downgraft.

Kavan, could you possibly explain the specific danger in re-cutting the maxilla for a 3rd time please?  In my mind, during each revision surgery I imagine they re-cut through the previous cut-line, debride the area and then re-plate (I know they also made a platelet rich plasma paste with my blood to apply to the area during my last revision also).  Obviously I know nothing at all about surgical techniques, but is there a specific reason why a 3RD CUT through the maxilla is inherently more dangerous than a 1st or 2nd cut (also, including the SARME surgery this will be my 4th cut).  Instinctively I understand that the more surgeries one has in any area of the body, the weaker that area becomes and thus the more potential for issues, but is there something specific to the maxilla that I need to understand about this? Until your comment, I was focusing my concern on the stability of the graft post-surgery, not so much the cut.  Many thanks to you as always.

[kavan]

Kavan, could you possibly explain the specific danger in re-cutting the maxilla for a 3rd time please?  In my mind, during each revision surgery I imagine they re-cut through the previous cut-line, debride the area and then re-plate (I know they also made a platelet rich plasma paste with my blood to apply to the area during my last revision also).  Obviously I know nothing at all about surgical techniques, but is there a specific reason why a 3RD CUT through the maxilla is inherently more dangerous than a 1st or 2nd cut (also, including the SARME surgery this will be my 4th cut).  Instinctively I understand that the more surgeries one has in any area of the body, the weaker that area becomes and thus the more potential for issues, but is there something specific to the maxilla that I need to understand about this? Until your comment, I was focusing my concern on the stability of the graft post-surgery, not so much the cut.  Many thanks to you as always.

No. Because I'm not your doctor and also because my statement was that I thought it 'sounded like' (seemed like to me) that your doctor was shifting (the mention of risk) to just the act of a down graft when the salient circumstance also included a 3RD time cut.

If I've said anything that you feel needs surgical descriptions of the techniques used to lower your risks of a 3rd surgery, it would be in the spirit of you're inquiring further to the surgeon who would be in a better capacity to explain/tutor if that's what you need to make your decision.

[eranthe]

Thanks Kavan, so just to clarify, are you saying that there are two separate areas of potential risk:  the re-cutting and subsequent healing of bones and soft-tissue AND the possibility of a failed down-grafting procedure, and that my surgeon is possibly confounding the two but shifting the main focus onto the latter?

[kavan]

The risk of a down graft is a function of the capacity of the doctor doing it. Risks are lower with doctors who have experience enough to be more successful with them. There are also risks involved with multiple surgeries to similar areas. In your case, you're getting a surgery to a similar area you've had prior and getting that for a down graft. I can't tell you what your specific risk factors are or how they relate to the capacity of your surgeon. I'm just saying is these are things you should explore further with the doctors advising you.

You have more information about your situation than I do. You also have access to the professor you mentioned in another post who has viewd your medical file in addition to the attending surgeon. I'm suggesting you explore what ever your risk is WITH those doctors. You relay one of them who viewed your case told you the risk was worth it. What did he tell you the risk was?

[eranthe]

Thanks for the clarification Kavan.  Before I go on, I just want to thank your for all the time and effort you dedicate to responding to these questions!  It's extraordinarily generous work that you do here and I am very greatful for it!

After speaking with the professor, I felt reassured in terms of the 'capacity of the doctor doing it'.  It is the risk with multiple surgeries that I am now trying to unpack and examine.

  You relay one of them who viewed your case told you the risk was worth it. What did he tell you the risk was?

Thanks for this question as it prompted me to go back over my shorthand notes. Initially on the phone the Prof said "based on what you've told me I don't like the idea, you've already had a downward fracture of the maxilla and that cut off all the blood supply to the face (except for the greater palatine artery?), then they've gone in again to do the bimax, so they've cut the blood supply off again, that's twice! Then they've gone in a third time!  Every time they do it, you're getting more and more fibrous tissue and less and less chance of healing". 

However after we met in person the following day and talked for a couple of hours, and he had a chance to look at my pre and post surgery photographs, he changed his tune and said "oh yeah ... that is an extremely disappointing result. After meeting you and watching you speak, I think there is good reason to do it and your surgeon really is the best person to do it.  He's given you a good functional result, but it's not at all what you would want ... anyway the new 3D technology will give you a much more predictable result.  I'd say go for it ... you'll never be happy if you don't give it a try, I can tell that just by talking to you!" (verbatim)

So I guess this is why I'm still searching for additional opinions/advice ... my surgeon was strongly  opposed to the idea of this revision for a long time, focusing on the risks ... however, he is now 'on-board'.  Likewise the Prof. began with a conservative view in theory but changed it when he met me.   Because both doctors initially expressed reservations, it's left me with some residual uncertainty I guess.