Revision double jaw surgery - advice

[kavan]

Orbital rims will still be recessed, i.e. eyes could easily appear sunken (left behind)

OK. That's a legitimate opinion to have concerning that possibility.

Now, given that you spent some time, perhaps a large chunk of it, grilling the doctor as to whether or not this 'modified' L3 would be making your zygoma to zygoma distance WIDER, in which case he told you it would not but instead would project out your malar area,

a: did you forget to ask about what would happen to the rest of the orbital rim area (medial part that is comprised of maxilla bone)
                                                                                OR
b: were you just MORE concerned that this procedure would give anterior projection to zyg. (malar) area INSTEAD of more width such that that particular concern took time PRIORITY over any concern of what would happen to the rest of the orbital rim area.
                                                                                OR
c: did you only recently form this opinion subsequent to this QUIZ using the Socratic method to stimulate critical thinking.

[Brachy]

100% b
I am in process of learning and was unhappy with questions asked on cons.. I was very much surprised that conventional LF3 was offered to me.. I am planning trip to dallas for another opinion

[jawguy123]

I think you getting a mLF3 would be absolutely absurd and a huge mistake.

If you want to address upper midface deficiencies, given that you already have a history of being dissatisfied with surgery results (and are even contemplating a second jaw surgery), why would you choose by far the most invasive -- and very possibly irreversible -- procedure?

If I were you, and I knew I was getting a revision jaw surgery no matter what, I'd start with the revision jaw.

If I were you, and I thought that the upper midface augmentation would have a chance (even if it's not that high) at fixing my issues without the jaw, I'd start with cheek implants or maybe even filler. These procedures wouldn't preclude jaw surgery and are also reversible / revisable if you don't like the results.

[kavan]

I think you getting a mLF3 would be absolutely absurd and a huge mistake.

If you want to address upper midface deficiencies, given that you already have a history of being dissatisfied with surgery results (and are even contemplating a second jaw surgery), why would you choose by far the most invasive -- and very possibly irreversible -- procedure?

If I were you, and I knew I was getting a revision jaw surgery no matter what, I'd start with the revision jaw.

If I were you, and I thought that the upper midface augmentation would have a chance (even if it's not that high) at fixing my issues without the jaw, I'd start with cheek implants or maybe even filler. These procedures wouldn't preclude jaw surgery and are also reversible / revisable if you don't like the results.

He's been told many times and many ways it's poor logistics on his part to be throwing a wrench into the gears regarding pursuing L3 surgery (questions here and consultations with docs) in the absence of  processing information as to what is to be done regarding correcting the FIRST jaw surgery (or parts of it such as the chin). He doesn't get much out of the consults he goes on because he doesn't know much about L3 at all (or it's modifications) to ask the right questions.  Given his history of being unhappy with his surgery (and also what I picked up on as asking for surgery for the wrong reasons--or who knows what the reasons he asked for the first surgery--), I reduced the SALIENT question for him to ask as to L3 to: 'Ask him how easy it is to revise IF you don't like it.' But I don't think he asked THAT one on his consult(s).

[Brachy]

Thanks on all the comments.
To begin with, since 3 surgeons responded positively on my request for midface operation in general (whether some modified version of LF3), it is certainly true that I have midface defficiency at level which justifies the operation.
But what I am trying to say that I regret my initial jaw surgery and before which my midface problems were not so visible, it is all relative and what draws intentions to the eyes is that I have big, wide, protrusive jaws and severly underdeveloped zygoma and orbital rims.
I really regret jaw surgery and ortho process and before revision just wanted to hear your thoughts on my midface problems and seek opinions from craniofacial surgeons.
I would never put implants and I want my old face back.
It is the fact that anterior cranial length is 71,5mm - so less developed and followed by smaller midface and jaws (vertically). So middle and lower third were less developed, but it kind of matched together in a short, brachy facial appearance. (no teeth exposure, although incisors were 11mm long)
Augmenting just jaws made for me such imbalance that I started seeking opinion whether it is justified to have midface osteotomy at any point in time. Since I have bite issues (open posteriorly), asymmetryies, too much clockwise rotation and anterior face height was performed (two highly skilled doctors, together with my original surgeon and myself share this opinion) I will revise my jaw surgery certainly.
It is just the questions of movements and how much of initially performed:
maxilla downgrafting,
mandibula advancement,
clockwise rotation of the occlusal plane
and genioplasty (back and down)
should be revised to have balanced face at rest (not the amount of teeth exposure when smiling).

[kavan]

Thanks on all the comments.
To begin with, since 3 surgeons responded positively on my request for midface operation in general (whether some modified version of LF3), it is certainly true that I have midface defficiency at level which justifies the operation.
But what I am trying to say that I regret my initial jaw surgery and before which my midface problems were not so visible, it is all relative and what draws intentions to the eyes is that I have big, wide, protrusive jaws and severly underdeveloped zygoma and orbital rims.
I really regret jaw surgery and ortho process and before revision just wanted to hear your thoughts on my midface problems and seek opinions from craniofacial surgeons.
I would never put implants and I want my old face back.
It is the fact that anterior cranial length is 71,5mm - so less developed and followed by smaller midface and jaws (vertically). So middle and lower third were less developed, but it kind of matched together in a short, brachy facial appearance. (no teeth exposure, although incisors were 11mm long)
Augmenting just jaws made for me such imbalance that I started seeking opinion whether it is justified to have midface osteotomy at any point in time. Since I have bite issues (open posteriorly), asymmetryies, too much clockwise rotation and anterior face height was performed (two highly skilled doctors, together with my original surgeon and myself share this opinion) I will revise my jaw surgery certainly.
It is just the questions of movements and how much of initially performed:
maxilla downgrafting,
mandibula advancement,
clockwise rotation of the occlusal plane
and genioplasty (back and down)
should be revised to have balanced face at rest (not the amount of teeth exposure when smiling).

Last I checked 71.5mm anterior cranial length (S-N) was within the norm. Where it looks like you deviate from the norm is that your S-N line is basically on a pure horizont.  So, in terms of the S-N line being aligned on a horizont, the angles formed by; S, N, A, and B will be beyond the norm. For that reason and will deviate from the norm approximately by the same extent the S-N line does. S-N orientation is something that can't be changed.

What most advice on here boils down to address what bothers you MOST before pursuing L3 procedures.

You mention your midface 'problems' were NOT visible before your jaw surgery and you wish you DID NOT HAVE the jaw surgery. You also mention that the midface looks RELATIVELY behind compared to the jaw surgery you got. Well LOGIC would have it to FIRST correct the jaw surgery and LATER evaluate midface for any procedures to it aimed at balance since midface issues (or let's call it; 'modified L3 issues') will be relative to displacements to the L1, BSSO and chin area.

ONLY IF someone LIKED what ever balance L1, BSSO and genio brought to the jaws (or already had good balance there) and knew for certain that they had recession to a 'modified L3 area' that was ABSOLUTE (as opposed to RELATIVE to the jaw advancement) would it be logical to pursue mL3 later down the line as 'add on' procedure.

If you think your prior surgery should be revised, then do that FIRST. Otherwise you risk the mL3 procedure to be 'balanced' with the IMBALANCE you presently don't like about the prior surgery.

If you really think you need mL3 where the ORDER of pursuing that is to get the jaws in balance FIRST and you wish to pursue it outside of that order, then don't expect 'coaching' on here or info to fill in the blanks that you might not fully understand as to what docs you consult with are telling you.

[Brachy]

Thanks on all the comments. Furthermore, please find my revision plan:

1.  Le Fort  I Osteotomy  with  slight  counterclockwise  rotation  and  backward  movement  to reduce  the  steepness  of  the occlusal  plane,  to  adjust  the  midline and  to  reduce  the exposure  of  the  entire  upper  dental  arch  when  smiling.

2.  BSSO  to fix  the  occlusion,  to  close the bite  and  to  correct  the  asymmetry  of  the Mandibular Angles  and  Jawlines

3.  Mandibular WingOsteotomy  („Chin  Wing“)  as  far  as  technically  still  feasible  to  futher improve  symmetry  in  lower  third, correct  the vertical  dimension  and  eliminate  lip  strain.

4.  Malaror teotomies  to  enhance  midface  projection,  eventually  in  combination  with  plate removal,  to  be  discussed  in  a  second  step  6  months  after  the  first  surgery.

Please, I would appreciate your opinion on maxiliary teeth length - mine are 12mm long and I would like to decrease them for 2mm. Teeth are too big for the face I have and, in my opinion, if only impaction of e.g. 2mm is performed they will still be huge. Thankvery much.

[Dogmatix]

Thanks on all the comments. Furthermore, please find my revision plan:

1.  Le Fort  I Osteotomy  with  slight  counterclockwise  rotation  and  backward  movement  to reduce  the  steepness  of  the occlusal  plane,  to  adjust  the  midline and  to  reduce  the exposure  of  the  entire  upper  dental  arch  when  smiling.

2.  BSSO  to fix  the  occlusion,  to  close the bite  and  to  correct  the  asymmetry  of  the Mandibular Angles  and  Jawlines

3.  Mandibular WingOsteotomy  („Chin  Wing“)  as  far  as  technically  still  feasible  to  futher improve  symmetry  in  lower  third, correct  the vertical  dimension  and  eliminate  lip  strain.

4.  Malaror teotomies  to  enhance  midface  projection,  eventually  in  combination  with  plate removal,  to  be  discussed  in  a  second  step  6  months  after  the  first  surgery.

Please, I would appreciate your opinion on maxiliary teeth length - mine are 12mm long and I would like to decrease them for 2mm. Teeth are too big for the face I have and, in my opinion, if only impaction of e.g. 2mm is performed they will still be huge. Thankvery much.

I must wonder, are there actually any surgeons available that will let you come in and dictate what's going to happen like that. I would assume that you would have to go pretty low on the ranking of surgeons for that to happen. I mean, Gunson would for sure send you home before you say hello.

[Brachy]

Sorry, don't understand your comment. These are the recommendations from surgeons.

[Dogmatix]

Sorry, don't understand your comment. These are the recommendations from surgeons.

Ok sorry. Haven't read the entire thread. Thought this was a plan you had figured out and now was going to find a surgeon.

[kavan]

Sounds like you chose one of the chin wing doctors to do your surgery. Sounds also like they even told you that discussion of midface osteos comes AFTER the jaw surgery.

[Brachy]

This is the proposal, I would appreciate your opinion on decreasing teeth length since they are too huge for the face I have (12mm)

[kavan]

This is the proposal, I would appreciate your opinion on decreasing teeth length since they are too huge for the face I have (12mm)

There is nothing in your proposal that indicates the TEETH themselves will be shortened.

[1.  Le Fort  I Osteotomy  with  slight  counterclockwise  rotation  and  backward  movement  to reduce  the  steepness  of  the occlusal  plane,  to  adjust  the  midline and  to  reduce  the exposure  of  the  entire  upper  dental  arch  when  smiling.]

[Brachy]

Kavan, I understand, I was just wondering whether additional shortining of crown size for 1-2mm will help in overall balance.. I have huge upper teeth (maxiliary incisors are 12mm long) and I am self conscius about them..additionally, I have severe lip incompetence and was wondering whether smaller teeth could also help in reducing steepness of the occlusal plane.. so my question is not related to maxiliary impaction..tnx

[kavan]

Kavan, I understand, I was just wondering whether additional shortining of crown size for 1-2mm will help in overall balance.. I have huge upper teeth (maxiliary incisors are 12mm long) and I am self conscius about them..additionally, I have severe lip incompetence and was wondering whether smaller teeth could also help in reducing steepness of the occlusal plane.. so my question is not related to maxiliary impaction..tnx

OK, so you 'understand' that the proposal does not include reducing the actual length of the teeth themselves and it just proposes to reduce the amount of visibility of the entire dental arch when smiling and this would/could include reducing excess gum show if you have that and MAY include reducing excess tooth SHOW when you smile.

You would need to determine from the doctor/s who gave you this plan whether the gum line would not be visible when smiling and what amount of tooth show would be visible when smiling.

Any excess related to cosmetic preferences you might have as to how much tooth show you want could be evaluated at a later time.

If this consideration were important to you, did you discuss it with the doctors you consulted with?


Here is a link regarding aesthetic proportions of the teeth.

http://www.cosmetic-dentistry-and-porcelain-veneers.com/files/2010/10/short_normal_long.jpg

ref: http://www.cosmetic-dentistry-and-porcelain-veneers.com/smile-design/tooth-length-porcelain-veneers-porcelain-crowns