Bimax or just BSSO? Conflicting opinions are making decision difficult

[emanresu]

Hey all,

Some of you may remember me from the posts I made last year looking for advice, and I’m back because after speaking to several surgeons I’m now trying to decide between two of the plans presented to me, the first being bimax and the other being a BSSO. However I’m having a difficult time deciding, as the surgeons behind each plan downright contradict one other and I have no idea who’s right, with one saying a Lefort would benefit me and the other saying it would be detrimental. I’m hoping you guys can help me determine which path is right… or at least more right? (PICS: https://imgur.com/a/pVPFG)

The Plans

The first suggestion of bimax comes from Dr. Gunson. He said my upper jaw is so underdeveloped that it’s concave (see second last photo in album), and the crowding in the upper jaw is so severe that the front teeth are entirely outside of the marrow space (third to last photo). His plan was to do upper and lower premolar extractions, followed by bimax advancement with a posterior downgraft for 4 degrees of CCW (maximum amount of rotation my flat occlusal plane will allow). He’d also do a sliding genioplasty forward and upward to flatten my mandibular angle, and HA paste to augment the cheek bones.

The second suggestion of a BSSO comes from Dr. Caminiti. He suggested lower premolar extractions followed by a BSSO with genioplasty. No upper jaw surgery. He said I shouldn’t have a Lefort unless I first try CPAP to confirm my (currently moderate) sleep apnea is obstructive, as my airway already looks quite large, and the aesthetic repercussions of a Lefort aren’t worth it unless serving a functional purpose. He said a Lefort + upper extractions would make my face look too full and make my cheeks look even bigger, and also cause my upper teeth to look “flat and weird”. He also said a Lefort would make my nose 5% wider even with an alar cinch, and make it even more upturned, which basically means I’d need a rhinoplasty afterwards, something which terrifies me. On a side note, he mentioned he could get rid of my “baby” cheeks with “fat removal”, and I’m not exactly sure what he meant by that, but if it’s fat pad removal I’m pretty sure I don’t want it. After surgery he said he’d put me in touch with a cosmetic surgeon to address my submental fat, which I definitely need.

Contradictions

Dr. Caminiti’s concerns about the nose sound reasonable, except Dr. Gunson said the Lefort would actually make my nose smaller and have no effect on the turn of my nose other than it not turning down as much when smiling. Gunson also said a Lefort would bring some much-needed support to my midface, but Caminiti said it would cause my already large cheeks to look even fuller than they currently are.

Soft tissue aside, Gunson pointed out several skeletal indicators that my upper jaw is underdeveloped (concavity in upper jaw, teeth outside marrow space) implying a Lefort with extractions would correct these things, but Caminiti said it would cause the teeth to be too far forward and look “flat and weird”. Basically, Gunson seems to be saying a Lefort would normalize my skeletal relations, both curing my sleep apnea (well, assuming it’s obstructive) and giving an optimal aesthetic outcome, whereas Caminiti seems to be saying a Lefort would actually deviate my skeletal relations ("flat and weird" teeth), and while it would cure my apnea, it would result in a less ideal/aesthetic skeletal structure.

I don’t want to over-advance/deviate my upper jaw just to potentially cure a medical condition, I just want to normalize it, but I’m not sure if that involves having a Lefort or not. Gunson says it would, Caminiti says it wouldn’t.

Bimax Questions/Concerns

• So who’s right about the Lefort’s effects on my skeletal relations? When Caminiti said a Lefort + upper extractions would cause my teeth to look “flat and weird”, what has he saying and is there any merit to it? Or do the skeletal indicators which Gunson pointed out honestly call for a Lefort?
• Who’s right about the Lefort’s effect on the soft tissue? Perhaps Gunson has a method which prevents the nose from widening and upturning? What about Gunson’s remark about it bring support to my midface versus Caminiti who says it’d cause my face/cheeks to become too full?
• If bimax is my best choice, do you think local “no-frills” bimax is acceptable in my case, or is a downgraft for 4 degrees of CCW worthwhile? I’m not sure I can afford Gunson so my only choice besides Caminiti (who said he’d still do bimax, he just doesn’t recommend it) would be a doctor outside of the country (perhaps Sinn, Antipov, or Raffaini?) to carry out a complex Gunson-esque plan.

BSSO Questions/Concerns

• If a Lefort with upper extractions would cause my teeth to look flat and weird, doesn’t that mean a BSSO with lower extractions would have the same flattening effect on the lower teeth? Would proceeding with just the lower jaw surgery cause a noticeable discrepancy in the angle of my teeth?
• Will having just lower jaw surgery effect my tooth show negatively? My smile is pretty balanced right now. Any other aesthetic repercussions from having just lower jaw surgery, like it causing a weird lip relation?
• Aesthetics aside, does it appear that lower jaw surgery alone could adequately address my sleep apnea (assuming it’s obstructive)? Most of the narrowness in my airway seems to be near the lower jaw.
• Could advancing just the lower jaw, and therefore the entire tongue, create a tongue thrust issue if the upper jaw isn’t advanced as well?

So what do you guys think? I realize I’m asking a lot of questions, but this is hopefully the decision which will allow me to finally move forward with all this. Any insight would be greatly appreciated.

As always, thanks for reading, and thank you for your help.

[kavan]

'A Lefort'.

[/b]

That's part of your confusion right there. You're assuming the term; 'A Lefort' is consistent with both doctors. One's telling you to have 'a lefort' and the other not.

The term; 'A Lefort' is NOT consistent with both doctors. Because there are just many permutations of displacements that can be done in 'A Lefort'. So, the Lefort Caminiti does not want to do is NOT the same as the one Gunson wants to do.

Caminiti is probably looking at the ANB and SNA values and noting that your A point (point on maxilla) is way beyond the norm and probably thinking in terms of linear advancement where the SNA values would go even further beyond the norm to give a weird look. Especially so, if he's telling you the nose would look much worse. Hence, he's thinking in terms of linear advancement lefort which very well would make that area look much worse on you. That's why he's thinking in terms of moving only the lower part of face. He seems to be also thinking in terms of just what 'medically' needs to be done for sleep apnea.


Gunson sees the same excessive SNA values but the lefort he is wanting to do is a POSTERIOR DOWN GRAFT which is one where he can maximize the BSSO advancement but also MINIMIZE the maxilla advancement. Basically, he can do something, the other one probably CAN'T do; CCW via the posterior downgraft which is done for people who would not look good with linear advancement of the maxilla.

So NEITHER want to do a linear advancement type of Lefort. The difference is that Gunson's posterior downgraft lefort is a lefort but one with minimal advancement and done to maximize the lower advancemnt. That's clearly visible on Gunson's displacement proposal. The other guy didn't even give you a displacment proposal!

Gunson is noticing that in terms of aesthetics and NOT JUST SNA, SNB, ANB angles, BOTH of your jaws are undeveloped.

IMO, Gunson would stand to improve your appearance much more than the other guy will or can.

Since a lot of your other questions implicity assume that the 'A lefort' being advised for or against means the SAME thing to both of them, they are extraneous questions (for me to address) predicated on an erroneous assumption.

The BETTER choice is Gunson.

[PloskoPlus]

How much does Gunson want to to advance the jaws linearly (beside the downgrafting) in mmm ?

[emanresu]

Wow, kavan, thank you so much. That really does clear up a lot of my confusion.

No doubt Gunson is the better choice, but unfortunately I cannot afford him (especially with the low Canadian dollar). Do you know of any surgeons who could perform a posterior downgraft besides him? Reading online, so far the only alternative surgeons I have found are Raffaini, who I’ve read has trained with Arnett (but only does in-person consultations unfortunately), and Sinn, who I’ve read is known for doing complex cases. I’m not 100% certain they can perform one, but I imagine that they can.

As well, after hearing your explanation, I am definitely veering away from Caminiti’s BSSO plan (and sprinting far, far away from his bimax) but I can’t help but be curious: do you think a BSSO could still be a reasonable choice to consider? A BSSO would not open my airway as much, but most of my airway’s narrowness seems to be near the lower jaw anyway. Also, it would still greatly improve my lower third, the only aesthetic difference I can think of between Gunson’s bimax and Caminiti’s BSSO is that with the BSSO I would just have slightly less nasal base support and a slightly less protrusive upper lip.

Thanks again.

How much does Gunson want to to advance the jaws linearly (beside the downgrafting) in mmm ?

He never specifically stated the linear amounts, he just said that with extractions I could get approximately 7mm for the upper and 16mm for the lower. Whether or not that was in reference to the linear movement, I’m not sure. I looked through the documents he gave me and it’s not specifically stated anywhere there either, unfortunately. He also mentioned if I didn’t want extractions (he recommended extractions though), I could get approximately 4mm in the upper and 7mm in the lower.

[kavan]

Wow, kavan, thank you so much. That really does clear up a lot of my confusion.

No doubt Gunson is the better choice, but unfortunately I cannot afford him (especially with the low Canadian dollar). Do you know of any surgeons who could perform a posterior downgraft besides him? Reading online, so far the only alternative surgeons I have found are Raffaini, who I’ve read has trained with Arnett (but only does in-person consultations unfortunately), and Sinn, who I’ve read is known for doing complex cases. I’m not 100% certain they can perform one, but I imagine that they can.

As well, after hearing your explanation, I am definitely veering away from Caminiti’s BSSO plan (and sprinting far, far away from his bimax) but I can’t help but be curious: do you think a BSSO could still be a reasonable choice to consider? A BSSO would not open my airway as much, but most of my airway’s narrowness seems to be near the lower jaw anyway. Also, it would still greatly improve my lower third, the only aesthetic difference I can think of between Gunson’s bimax and Caminiti’s BSSO is that with the BSSO I would just have slightly less nasal base support and a slightly less protrusive upper lip.

Thanks again.

He never specifically stated the linear amounts, he just said that with extractions I could get approximately 7mm for the upper and 16mm for the lower. Whether or not that was in reference to the linear movement, I’m not sure. I looked through the documents he gave me and it’s not specifically stated anywhere there either, unfortunately. He also mentioned if I didn’t want extractions (he recommended extractions though), I could get approximately 4mm in the upper and 7mm in the lower.

Well, the BSSO is a given since both would be doing that. (bimax=lefort + bsso) With Gunson, you will get more advancement due to the TYPE of lefort he's doing with it. Raffaini is not cheap. Nor is going abroad and staying there in plenty of time to hang around just to be on safe side for any after issues. Not to mention, the other guys will want to do their own plan.

Gunson would be pushing your teeth backwards (braces plus extractions) so he can move the maxilla forwards and in turn give MORE BSSO advancement. The downward tilt (tilt down) of the posterior down graft would effect an upward and outward tilt (tilt up) of the pushed back front teeth (it's a rotation) such that they would not project 'flat' as what the other doctor said. When the other doctor told you the teeth would look flat to the face (with the push back of braces), it was in REFERENCE to linear advancement which is another point of confusion for some people. 'Linear advancement', as the term applies to maxfax surgery refers to a type of advancement (to the maxilla) where there is NO rotation done. The act of advancing along the 'line'  the maxilla already has; the act of advancing along the angle of inclination (with a horizont) the 'line' of the maxilla has, to move the maxilla WITHOUT rotating it.

[emanresu]

Well, the BSSO is a given since both would be doing that. (bimax=lefort + bsso) With Gunson, you will get more advancement due to the TYPE of lefort he's doing with it. Raffaini is not cheap. Nor is going abroad and staying there in plenty of time to hang around just to be on safe side for any after issues. Not to mention, the other guys will want to do their own plan.

Gunson would be pushing your teeth backwards (braces plus extractions) so he can move the maxilla forwards and in turn give MORE BSSO advancement. The downward tilt (tilt down) of the posterior down graft would effect an upward and outward tilt (tilt up) of the pushed back front teeth (it's a rotation) such that they would not project 'flat' as what the other doctor said. When the other doctor told you the teeth would look flat to the face (with the push back of braces), it was in REFERENCE to linear advancement which is another point of confusion for some people. 'Linear advancement', as the term applies to maxfax surgery refers to a type of advancement (to the maxilla) where there is NO rotation done. The act of advancing along the 'line'  the maxilla already has; the act of advancing along the angle of inclination (with a horizont) the 'line' of the maxilla has, to move the maxilla WITHOUT rotating it.

My mistake, when I asked “do you think a BSSO could still be a reasonable choice to consider?” I meant to ask “do you think a lone BSSO could still be a reasonable choice to consider?” in reference to Caminiti’s plan. Sorry about that. Caminiti’s lone BSSO plan would include extraction of the lower premolars, so it would still achieve a decent amount of movement, but I can see how Gunson rotating the structure counterclockwise with his bimax plan would allow for even greater lower jaw movement compared to Caminiti’s lone linear BSSO plan, and I guess Caminiti’s work-around for achieving a decent profile/end-result with the lone BSSO would just be to then achieve the rest of the forward projection through a larger genioplasty? So if Gunson’s bimax was to achieve a total of, say, 20mm (just as an example) of anterior pogonion displacement, it would maybe be achieved with something like 14mm from the BSSO and 6mm from the genioplasty, and with Caminiti’s lone BSSO plan it would maybe achieve a total of 16mm of displacement, with 8mm from the BSSO and 8mm from the genioplasty. I’m not sure if those numbers are even slightly close, I’m just using it as an example to suggest that perhaps Caminiti’s plan (while no doubt inferior) may be able to still achieve close to the same aesthetic results through slightly different means, but not cost 100k CAD?

If I had the money I’d go to Gunson in a heartbeat, but now I’m just trying to figure out the next best choice, which is either the lone BSSO plan with Caminiti, or another surgeon who can perform a posterior downgraft. The prices I found online for Raffaini are about a third of Gunson’s, which as you said, don’t including travel/hotel expenses, but it’s a price I could more reasonably afford. It’s still not as good as the price I’d pay locally, and I also really didn’t want to go overseas, but it may be the next best choice I have.

[PloskoPlus]

Have you considered Alfaro? He's known for agressive CCW rotation. There was a member here with a similar profile to yours. He suggested a similar treatment plan - extractions in both arches, followed by CCW.

[CCW]

Have you considered Alfaro? He's known for agressive CCW rotation. There was a member here with a similar profile to yours. He suggested a similar treatment plan - extractions in both arches, followed by CCW.

https://www.institutomaxilofacial.com/en/caso-clinico/pauline/

Dr. Relle could be another one to consider.

[emanresu]

Have you considered Alfaro? He's known for agressive CCW rotation. There was a member here with a similar profile to yours. He suggested a similar treatment plan - extractions in both arches, followed by CCW.

https://www.institutomaxilofacial.com/en/caso-clinico/pauline/

Dr. Relle could be another one to consider.

Hey guys, thanks so much for the suggestions, I'll look into them.

[kavan]

My mistake, when I asked “do you think a BSSO could still be a reasonable choice to consider?” I meant to ask “do you think a lone BSSO could still be a reasonable choice to consider?” in reference to Caminiti’s plan. Sorry about that. Caminiti’s lone BSSO plan would include extraction of the lower premolars, so it would still achieve a decent amount of movement, but I can see how Gunson rotating the structure counterclockwise with his bimax plan would allow for even greater lower jaw movement compared to Caminiti’s lone linear BSSO plan, and I guess Caminiti’s work-around for achieving a decent profile/end-result with the lone BSSO would just be to then achieve the rest of the forward projection through a larger genioplasty? So if Gunson’s bimax was to achieve a total of, say, 20mm (just as an example) of anterior pogonion displacement, it would maybe be achieved with something like 14mm from the BSSO and 6mm from the genioplasty, and with Caminiti’s lone BSSO plan it would maybe achieve a total of 16mm of displacement, with 8mm from the BSSO and 8mm from the genioplasty. I’m not sure if those numbers are even slightly close, I’m just using it as an example to suggest that perhaps Caminiti’s plan (while no doubt inferior) may be able to still achieve close to the same aesthetic results through slightly different means, but not cost 100k CAD?

If I had the money I’d go to Gunson in a heartbeat, but now I’m just trying to figure out the next best choice, which is either the lone BSSO plan with Caminiti, or another surgeon who can perform a posterior downgraft. The prices I found online for Raffaini are about a third of Gunson’s, which as you said, don’t including travel/hotel expenses, but it’s a price I could more reasonably afford. It’s still not as good as the price I’d pay locally, and I also really didn’t want to go overseas, but it may be the next best choice I have.

Well, my telling you that Gunson would be the BETTER choice (and explaining why) meant, NO, I don't think Caminiti (his plan for only BSSO) would be the better choice.

Gunson's plan would give more structural support to the soft tissues of your face. Can't opine on what Caminiti's genio would be in the absence of any displacement proposal. In general, it's a 'no no' to over compensate with a LARGE chin advancement in the event the mandible itself is very retrusive which your's is. So, can't validate you 'guess' that he would do so.

I can tell you that Gunson's MAXIMIZATION of the BSSO advancement is done so he does NOT have to over compensate via a large chin advancement. That's the SALIENT concept and no specifities of 'exact' yet HYPOTHETICAL mm displacements are needed for me to engage in to convey that concept.

I think the info I gave you was sufficient enough to clear your initial confusion as to 'A Lefort' and also convey why I think Gunson would be the BETTER aesthetic choice. But there's not much I can do to assist if Gunson is out of your financial ball park or if you want to spin your gears as to hypothesize (speculate?) how the other guy could acheive something similar via other means.

Basically, you got a GOOD and BETTER plan for correction from Gunson (who's very expensive) than you got from Caminiti (whom you can afford) as far as aesthetic improvement goes. Hence, I think you just have to resolve to having LESS of an aesthetic improvement in the event Caminiti is your only option due to finances. Resolving to that is more realistic than trying to spin your gears as to why Caminiti would give you just as good an aesthetic result. As to spinning your gears as to how the other guy can kick up similar aesthetic results, you're one your own with that.

In essence, it's looking like you will need to SETTLE for what ever Caminiti can do due to financial limitations. You will most likely have some improvement. But not as much as you would be getting via Gunson.

You wanted opinions on the better choice. I gave you my take on what it was. But there's nothing I can do about the limitations that preclude the better option(s).

[notrain]

Imho you'd be able to get almost the same aesthetic benefits from doing a bsso + genio and leaving the upper jaw alone. Gunson would fix the underdevelopment with HA-Paste during the surgery, but the actual lefort osteotomy wouldn't do anything for your looks other than allowing for a larger lower jaw movement (which would still be good).

My main concern would be the quadruple extractions and the entire ordeal of a treatment that entails. I can see from your pics that you still have all your wisdom teeth: These would have to come out before any treatment can begin. Then you are looking at 2 years of pre op ortho in order to close all those gaps in both your jaws. Lastly, CCW Bimax + genio is a much riskier surgery than a linear bsso + genio. Your airway looks large already, imho lower jaw surgery will suffice to fix OSAS. Not to mention that single jaw surgery is much cheaper. But the CCW double jaw plan would maybe deliver more of an eye-popping result.

[haven]

I'm guessing you want to undergo all this because you don't like the way you look? IMO extracting teeth feels like overkill. I was presented with that option when I got braces years ago, but thought it was too much. I don't consider myself to be unattractive, but I certainly don't look like a model, ya know? I've spoken to a few surgeons and other orthos the last few months and they've said they wouldn't recommend it. I haven't had any functional issues up to now. I'm 28. I'm back and forth between getting a genioplasty. Have you considered getting that? Especially if you don't have any problems. Are you currently overweight? Losing weight would help out too. Trust.

Honestly I think a lot of people would hate the way they look if they used "proper posture". That's just my option though.

[emanresu]

I think the info I gave you was sufficient enough to clear your initial confusion as to 'A Lefort' and also convey why I think Gunson would be the BETTER aesthetic choice. But there's not much I can do to assist if Gunson is out of your financial ball park or if you want to spin your gears as to hypothesize (speculate?) how the other guy could acheive something similar via other means.

You’ve basically decoded my vague suspicions into concrete considerations, and I think that’s exactly what I needed to hear to come to terms with all this. Yes, the info you have provided has absolutely made things more clear, and has completely blown open my understanding of how a Lefort (if used correctly with rotation) can be beneficial in a case such as mine, and I’ll definitely be referring to this approach as the gold standard for bimax as I continue to meet with potential surgeons. Thanks so much for all your help.

Imho you'd be able to get almost the same aesthetic benefits from doing a bsso + genio and leaving the upper jaw alone. Gunson would fix the underdevelopment with HA-Paste during the surgery, but the actual lefort osteotomy wouldn't do anything for your looks other than allowing for a larger lower jaw movement (which would still be good).

My main concern would be the quadruple extractions and the entire ordeal of a treatment that entails. I can see from your pics that you still have all your wisdom teeth: These would have to come out before any treatment can begin. Then you are looking at 2 years of pre op ortho in order to close all those gaps in both your jaws. Lastly, CCW Bimax + genio is a much riskier surgery than a linear bsso + genio. Your airway looks large already, imho lower jaw surgery will suffice to fix OSAS. Not to mention that single jaw surgery is much cheaper. But the CCW double jaw plan would maybe deliver more of an eye-popping result.

Hey notrain, thanks for your response. As I was just saying to kavan, I really appreciate the insight. You’ve aptly summarized my thoughts about the opposite side of the coin: the prospects of a lone BSSO. It’s certainly a compelling thought isn’t it? A significant aesthetic improvement (albeit less significant than bimax) at a fraction of the price, all while not having to worry about potential complications from an additional surgical cut. It’s almost irresistible. But do you really think the lone BSSO could help with my OSA? I emailed Caminiti a few weeks ago asking this exact question, but I never received a response. If so, it would make the idea of a lone BSSO even more compelling.

My current plan is to speak to some of the other (less expensive) surgeons about a posterior downgraft as suggested, and if that doesn’t pan out, the lone BSSO plan is still very much a consideration. And while I think it’s been settled that Gunson’s bimax plan is better, if end up having to compromise by doing the lone BSSO, there’s some concerns from the initial post I had about it, which if anyone could provide some insight on, I would greatly appreciate—specifically, its potentiality of negatively effecting my tooth show/lip relations, and possibly causing a tongue thrust issue. Does anyone know if these are valid concerns? For the first issue, I think that my tooth show/lip relation would end up being fine, as the teeth will essentially be in the same place they are now. But the second issue seems like a legitimate concern, because if the upper jaw is left behind while the lower jaw—and therefore the entire tongue—is brought forward, I could see how it would then create less anterior space for it to move and rest.

IMO extracting teeth feels like overkill.

Are you currently overweight?

Thanks for the response haven. It took me a year to come to terms with extractions, but at this point I firmly believe it is the right choice, as Gunson pointed out several skeletal anomalies indicating severe crowding/underdevelopment, and a lone genioplasty would only be able to give me something like 9 mm of projection, whereas I need approximately twice that to normalize my profile. Also I wish it were a weight issue, but my underdeveloped jaws make me look 30 pounds heavier than I actually am. In those photos I was approximately 165 lb @ 5’10”.

[notrain]

Hey notrain, thanks for your response. As I was just saying to kavan, I really appreciate the insight. You’ve aptly summarized my thoughts about the opposite side of the coin: the prospects of a lone BSSO. It’s certainly a compelling thought isn’t it? A significant aesthetic improvement (albeit less significant than bimax) at a fraction of the price, all while not having to worry about potential complications from an additional surgical cut. It’s almost irresistible. But do you really think the lone BSSO could help with my OSA? I emailed Caminiti a few weeks ago asking this exact question, but I never received a response. If so, it would make the idea of a lone BSSO even more compelling.

FWIW I had a very similar starting position as you (flat occlusal plane, severely proclined lower jaw incisors, double chin). During the "set up" phase of my treatment, upper jaw (in addition to the unavoidable lower jaw extractions in both our cases) extractions were discussed but I managed to get away without them - partly because of a 2 piece lefort osteotomy which widened my upper arch bit which in turn increased the space available for the teeth.

A posterior downgraft of the maxilla was briefly considered by my surgeon but I ended up getting no rotation and my skeletal base was successfully normalized without rotation (ANB angle is 0°, SNA and SNB both 87°) with a linear advancement of both jaws. My result has been generally received positively.

I have come to realize, however, that most if not all of the aesthetic improvement came from the lower jaw advancement (I didn't get a genioplasty). Therefore I think that in your case (a low angle patient) lower jaw premolar extractions, BSSO and a genioplasty will give the improvement you seek with a much easier surgery over all. I think that, had I do it all over again, that I would pick this route for my case.
I think that had I been asked to remove an additional two premolars in the upper jaw, I would not have gone through with jaw surgery (my back up plan was a chin wing surgery instead).

The difference between this and a proper CCW rotation surgery is maybe 3-4mm of additional lower jaw advancement (if that). I highly doubt that this would make a material difference, both in terms of sleep apnea and looks/attractiveness. Would anyone look materially different with a lower jaw that's 3mm more forward? I doubt it.

One last word of caution: Your bite right now seems pretty good, despite the aggressive dental compensation. Mine was the same way, maybe a tad worse than yours. You should fully expect for the post op occlusion to be worse after extractions, especially if you opt to not extract in the upper jaw (which I would recommend).

[emanresu]

FWIW I had a very similar starting position as you (flat occlusal plane, severely proclined lower jaw incisors, double chin). During the "set up" phase of my treatment, upper jaw (in addition to the unavoidable lower jaw extractions in both our cases) extractions were discussed but I managed to get away without them - partly because of a 2 piece lefort osteotomy which widened my upper arch bit which in turn increased the space available for the teeth.

A posterior downgraft of the maxilla was briefly considered by my surgeon but I ended up getting no rotation and my skeletal base was successfully normalized without rotation (ANB angle is 0°, SNA and SNB both 87°) with a linear advancement of both jaws. My result has been generally received positively.

I have come to realize, however, that most if not all of the aesthetic improvement came from the lower jaw advancement (I didn't get a genioplasty). Therefore I think that in your case (a low angle patient) lower jaw premolar extractions, BSSO and a genioplasty will give the improvement you seek with a much easier surgery over all. I think that, had I do it all over again, that I would pick this route for my case.
I think that had I been asked to remove an additional two premolars in the upper jaw, I would not have gone through with jaw surgery (my back up plan was a chin wing surgery instead).

The difference between this and a proper CCW rotation surgery is maybe 3-4mm of additional lower jaw advancement (if that). I highly doubt that this would make a material difference, both in terms of sleep apnea and looks/attractiveness. Would anyone look materially different with a lower jaw that's 3mm more forward? I doubt it.

One last word of caution: Your bite right now seems pretty good, despite the aggressive dental compensation. Mine was the same way, maybe a tad worse than yours. You should fully expect for the post op occlusion to be worse after extractions, especially if you opt to not extract in the upper jaw (which I would recommend).

Thanks for the follow-up! That’s really interesting about the 2-piece Lefort. No one has suggested that to me yet, so I’m not sure if it’s applicable in my case, but I’ll definitely be keeping it in mind. I actually asked Gunson about SARPE + MSDO and he said it’d make my chin too wide, but maybe that was only in reference to the MSDO.

It’s good to hear from someone else that a BSSO isn’t a bad idea, because it’s definitely still on the table for me, and I agree that 3-4 mm seems like a very fair compromise to consider.

My occlusion is actually great as far as my bite goes, so it’s disappointing to hear surgery may make it worse. Is this due to the BSSO making the lower teeth no longer line up with their “corresponding” upper ones? If so, depending on how severe the malocclusion would become, perhaps bimax is worthwhile for this reason alone?

Also, not to push my luck, but could you perhaps PM me the name of the surgeon you chose? With the similarities of our cases, I would love to hear his opinion about mine, as from your description he seems like he’s comfortable suggesting the complex maneuvers which other surgeons would avoid.

Thanks again, I really can’t express how much all this help means to me.