solutions to a short ramus, and high mandibular plane angle?

[XXRyanXXL]

I've posted many times on this forum and haven't had many responses to a solution to my deformed lower jaw.
I have a short ramus, and a mandibular plane angle of 42 degrees. This gives me the appearance of a longer lower face. Also my occlusional angle is 12 degrees. I went through a recent BiMax procedure where the surgeon couldn't even finish 20% of the operation because he doesn't know how to fix my condition. Apparently one learns after you go through state funded insurance, you get newbie surgeons just coming out of there residency program who are "willing to learn from there mistakes". I was there mistake.
Booked an appointment with A&G, and I want suggestions so I can bring these up at the consult.
A Few solutions I found was to perform an inverted L osteo, with posterior downgraft and anterior impaction. Second is a brand new technique called "vertical ramus elongation and mandibular advancement by endobuccal approach". The inverted L osteo, to my belief, will not give me a perfect 23 degree (normal for my age) sharp jaw angle. The second, may. 

Any other solutions?

[XXRyanXXL]

Bump.

Does anyone know any alternatives to an Inverted-L osteo with bone grafting to remedy a high mandibular plane angle (42 deg.) to possibly around 25 degrees? Is there any complications if I choose to go with the inverted L and I need significant bone grafting to fill in the void? Of course you'd want rotation so I proposed having anterior impaction with CCW rotation with posterior downgrafting.

[Post bimax]

How did your consult with Gunson go?

Here's a paper on the inverted L osteotomy, including some of the benefits and drawbacks as well as info on grafting: https://www.sciencedirect.com/science/article/pii/S221454191600002X

Any time you have significant movements/grafting, you're going to have a greater risk of relapse.  I don't know of any alternatives to the inverted L cut for increasing ramus length.

For what it's worth, Gunson's proposal for me seems to slightly increase ramus length in addition to lessening the MPA.  I'm not sure what cut he uses: https://imgur.com/a/WmaQgi5

[kavan]

For what it's worth, Gunson's proposal for me seems to slightly increase ramus length in addition to lessening the MPA.  I'm not sure what cut he uses: https://imgur.com/a/WmaQgi5

[/b]

The ramus doesn't get physically longer as you've probably surmised already. It's rotational orientation changes as a function of the (LARGE in your case) posteriorly downward rotation of the maxilla which in turn decreases the 'steepness' of the MPA. The cut for the BSSO is seen on the displacement diagram in back of the black lower molar. To the best of my knowledge, he can perform a type of independant rotational 'twisting' to the mandible with the BSSO cut. Alfaro does that too.  I don't know the technical name of what they call it. But it's the move that gives more overall CCW and sometimes the trade-off of it is a little triangle sticking out that can be seen (or felt) anterior to the posterior jaw angle and posterior to the chin. So, somewhere in between the back jaw angle and chin.

[Movebone]

why not do the BSSO followed by a chinwing? I thought that was a pretty standard strategy around here and if one time isn't enough, do it again.

[Post bimax]

The ramus doesn't get physically longer as you've probably surmised already. It's rotational orientation changes as a function of the (LARGE in your case) posteriorly downward rotation of the maxilla which in turn decreases the 'steepness' of the MPA. The cut for the BSSO is seen on the displacement diagram in back of the black lower molar. To the best of my knowledge, he can perform a type of independant rotational 'twisting' to the mandible with the BSSO cut. Alfaro does that too.  I don't know the technical name of what they call it. But it's the move that gives more overall CCW and sometimes the trade-off of it is a little triangle sticking out that can be seen (or felt) anterior to the posterior jaw angle and posterior to the chin. So, somewhere in between the back jaw angle and chin.

Yes- my meaning was that the CCW movement results in a flattened MPA that extends to the ramus on the tracing.  In reality the mandibular border might not be so smooth given the new angles the rotation creates near the cut.

why not do the BSSO followed by a chinwing? I thought that was a pretty standard strategy around here and if one time isn't enough, do it again.

Some BSSO cuts preclude CW.  Your mandible can also only take so much damage.  Multiple procedures on the same area increase risk.

[kavan]

How did your consult with Gunson go?

Here's a paper on the inverted L osteotomy, including some of the benefits and drawbacks as well as info on grafting: https://www.sciencedirect.com/science/article/pii/S221454191600002X

Nice paper. They say they are introducing a NOVEL approach. Might not be a bad idea for the OP to consult with the authors of the paper. Not sure if Gunson does the same thing.

[Post bimax]

Nice paper. They say they are introducing a NOVEL approach. Might not be a bad idea for the OP to consult with the authors of the paper. Not sure if Gunson does the same thing.

The aesthetic result in the case study presented was excellent as well, although figure H in the post-op images shows that a slight open bite remains on that lateral incisor.  I don't know enough about ortho to assess the bite in general.  I also wish there was a pre-op frontal photo.

[kavan]

The aesthetic result in the case study presented was excellent as well, although figure H in the post-op images shows that a slight open bite remains on that lateral incisor.  I don't know enough about ortho to assess the bite in general.  I also wish there was a pre-op frontal photo.

Small trade-off.