Treatment options

[ArtVandelay]

Initially I was presented 2 treatment plans L1 + BSSO versus just L1. In both I had significantly better predictions on three metrics: expected profile, shorter lower third, and less steep mandible angle. At the time I didn't need an SG, the L1 + BSSO would yield a satisfactory outcome. Can't explain why it didn't work out, but looks like it won't influence future decisions.

It would have been nice to receive an honest post surgery brief with what exactly went wrong, instead of repeated evasiveness; maybe I wouldn't be as upset as I am now.

Anyway, that's probably enough history. I'll continue gathering more SG advice as I'm leaning towards it.

[ArtVandelay]

I've sat through month long waiting lists and now, finally, have two possible ways to proceed forward:

1.) Reduction Genioplasty (not the same as sliding genioplasty). This I agree is a better way than an SG to address my problems.

2.) Full revision with now a 3 piece Lefort I (instead of what was done previously which was just a regular L1)

To give some more insight to whats wrong with my bite. For my previous surgery I had what, in my own words, I'd call orthognathic camouflage. They fixated on closing the open bite without proper consideration to other aspects. My former surgeon manged to barely cure one symptom, an open bite, without considering the underlying factors that caused it; in addition to not addressing the lip incompetence. My upper arch is narrow so in order to get my bite to close they rotated and tipped my lower molars to connect. This rotation has caused gum recession and root shortening to the point where my roots are banging up against the side of my lower jaw bone. A small upper arch led to incorrect growth patterns and my initial surgery did not address any of this,

To fix this I would have to de-compensate the lower molars by rotating them back (rotation not intrusion) into their natural angle and then widen the upper arch surgically (3 piece L1) while advancing both jaws.

I'm leaning towards number 2 for a variety of reasons, only one surgeon I'm considering for this, but will get a sleep study done before fully committing.

[kavan]

As long as you have already established that your 'reduction' genio is NOT going to be a sliding genio in the backward direction. I mention this because sometimes doctors use the term 'reduction genio' for a SG that goes BACKWARDS and also you don't specifically state whether or or not a segment of your chin is to be removed in this 'reduction' genio and make NO mention of any advancement to the chin.

If the doctor is using the term 'reduction' genio LOOSELY and it turns out to be a SG in the REVERSE (backward) direction, your chin is going to look longer and your lip incompetence will be WORSE and your aesthetics will be f*cked.

Your X rays reveal you would benefit from an ADVANCEMENT sliding genio, which, in fact, REDUCES the vertical height of the chin and perhaps with a segment of the chin removed. So, segment removal WITH SG advancement genio.

[ArtVandelay]

By reduction genio I mean a wedge will be cut and removed and the loose piece of chin will be rotated to connect the two pieces (and possibly slid  forward, I need to clarify this). The end result will both shorten the chin vertically as well as adding forward projection.

So yeah I need to clarify if in addition to rotating will the chin be slid forward too.

[kavan]

By reduction genio I mean a wedge will be cut and removed and the loose piece of chin will be rotated to connect the two pieces (and possibly slid  forward, I need to clarify this). The end result will both shorten the chin vertically as well as adding forward projection.

So yeah I need to clarify if in addition to rotating will the chin be slid forward too.

OK, then that sounds like the right kind. If segment is in shape of wedge, where max height of wedge is found at FRONT of chin (assuming a profile facing toward the RIGHT), then the loose piece of chin IS rotated CCW to meet the other piece of it (in addition to it being vertically shortened). To that the chin should be slid FORWARD so that an imaginary vertical line dropped from the lower lip has the chin slightly behind to 'almost kissing' it but not too much in advance of it.

[ArtVandelay]

OK, then that sounds like the right kind. If segment is in shape of wedge, where max height of wedge is found at FRONT of chin (assuming a profile facing toward the RIGHT), then the loose piece of chin IS rotated CCW to meet the other piece of it (in addition to it being vertically shortened). To that the chin should be slid FORWARD so that an imaginary vertical line dropped from the lower lip has the chin slightly behind to 'almost kissing' it but not too much in advance of it.

Yes the wedge is exactly how you describe, with CCW chin rotation. At this point I'm comfortable with the surgeon and will get a sleep study done before proceeding.

[kavan]

Yes the wedge is exactly how you describe, with CCW chin rotation. At this point I'm comfortable with the surgeon and will get a sleep study done before proceeding.

Not sure if you need a sleep study simply simply because it shouldn't be needed to have that done to the chin. I mean, you could have the chin work done 'in it's own right' because mechanically it will improve aesthetics, lip incompetence and should have some positive effect on breathing. Only reason to get a sleep study would be if insurance needed that in order to pay for the chin surgery.

[ArtVandelay]

Not sure if you need a sleep study simply simply because it shouldn't be needed to have that done to the chin. I mean, you could have the chin work done 'in it's own right' because mechanically it will improve aesthetics, lip incompetence and should have some positive effect on breathing. Only reason to get a sleep study would be if insurance needed that in order to pay for the chin surgery.

Sorry the purpose of the sleep study is to see if I have sleep apnea/other issues due to retrusive jaws which makes the case for double jaw surgery more compelling. It's not needed to justify any solo chin work. Obviously I snore at night but that's a function of both lip incompetence and any airway issues.

[kavan]

Sorry the purpose of the sleep study is to see if I have sleep apnea/other issues due to retrusive jaws which makes the case for double jaw surgery more compelling. It's not needed to justify any solo chin work. Obviously I snore at night but that's a function of both lip incompetence and any airway issues.

Well since your case one where the doc. moved your BSSO backwards to close (or make less) the open bite (where the open bite does look much more closed), it would add more complexity to get another bi-max given the chin work alone could help mitigate things. But then again, your airway does look more narrow in the after X ray.

[ArtVandelay]

Well since your case one where the doc. moved your BSSO backwards to close (or make less) the open bite (where the open bite does look much more closed), it would add more complexity to get another bi-max given the chin work alone could help mitigate things. But then again, your airway does look more narrow in the after X ray.

In my original surgery, the plan was that after impacting my maxilla, my lower jaw autorotates forward and it would be moved slightly back through a BSSO to fit the bite. These movements offset each other but the net movement should have been forward. That was the plan but in reality it doesn't look like that happened(to the planned extent). And again afterwards my surgeon wouldn't speak with me to discuss the results so I'm more or less giving my personal untrained opinion on this; he stayed in his office while a brand new 1st year resident spent a good while reading through my case file and afterwards being unable to answer any specific questions. Since I'm considering a revision now; knowing what went wrong would be very helpful but apparently that's too much too ask.

Regardless I'm done seeking consultations and am debating between these two options, both with the same new surgeon. Think getting the sleep study wouldn't hurt as you can schedule it very soon so it doesn't delay things.

[kavan]

wouldn't hurt

[ArtVandelay]

To clarify what I meant by bad bite earlier. Here's an image from my current CBCT. My lower molars were tipped and rotated to fit into an narrow maxilla.

This should have been addressed by my surgeon the first time around.

[ArtVandelay]

My last post on this thread to wrap it up:

My problem is that I have bimax retrusion with the consensus recommendation that I needed advancement. Surgeons differ on other points but all of the top surgeons have agreed I need at least 5mm advancement. A solo genioplasty won't address the retrusion problem although it would offer a marginal benefit.

My result looks nothing like originally planned. I haven't been able to figure out exactly why, most likely poor plan executed by a poorly skilled surgeon. Either due to compilations on surgery day or poor skill it appears I got too much clockwise rotation (from posterior impaction) or just not enough advancement. My mandible was set back but that was supposed to be more than offset by the lower jaw auto-rotating forward but again it appears the plan was wildly different from reality,

Evidently my original surgeon was unaware that airway management is a necessary component of any successful jaw surgery.

[ArtVandelay]

Last comment, I emailed Dr. David Behrman asking what went wrong with my surgery (recall he refused to speak with me in-person). His very last email response to me:

"I honestly have no idea what you are referring to"

[PloskoPlus]

Last comment, I emailed Dr. David Behrman asking what went wrong with my surgery (recall he refused to speak with me in-person). His very last email response to me:

"I honestly have no idea what you are referring to"

Psychopath.