Does 3 piece lefort transverse widening give soft tissue support?

[Dogmatix]

My surgeon have told me that I'm not a candidate for 3 piece lefort and transverse widening, and I also asked Gunson who said about same.

I'm a bit curious about 3 piece lefort and was thinking I'm gonna ask my surgeon for a clarification how he thinks about this in my case, but was thinking to ask here first so I understand better what it's about.

Firstly I wonder, if a 3 piece lefort and transverse widening af the maxilla is performed, can this give soft tissue support around cheek and zygomatic area? Aside from that I like a wide smile, I'm thinking it may also give beneficial soft tissue support.

Secondly I wonder how a 3 piece lefort is performed and how it changes the arch. I've seen people getting SARPE, and it creates crazy gaps between the teeth that needs to be closed orthodontically. Do they do same with a 3 piece lefort, or is it more that they split the maxilla, and then keep the distal contact point of the teeth and widen like that without any actual gap being created?

I've seen that when performing a 3 piece lefort, the surgeon often want the orthdontist to create a distal gap so they get good access to split the maxilla without cutting the teeth. Do they puzzle it together so the gap is closed after, or how do they handle it?

[kavan]

Here is a diagram of a 3 piece lefort. (photo A)

Here is an article about segmenting the maxilla where other ways of segmenting it are discussed:

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2176-94512016000100110

Although a wider palate does give better soft tissue support and wider smile--I mean people who have such naturally certainly have good soft tissue support and broad smiles--I believe the risk is higher with the multi-segment lefort and they probably justify the risk IF that's needed to correct the bite or maybe to offset a large aesthetic deviation.  I just don't think one can request a 3 piece lefort for the purpose of a wider smile and/or better soft tissue support if such is not in the plan (or needed) to correct the maxfax issue as deemed by the the surgeon after they do a bunch of studies, VSP to determine what the correction will be.

Odd that the 2 doctors told you you would not be getting a 3 piece lefort. Simply because the VSP for one doctor looks like that was entertained and as for Gunson, he often does them.

If you really don't need one, I would consider that GOOD news (less risk). If you really want to know the surgical details about how they split the maxilla in a variety of ways, there are med articles to Google for this.

[Dogmatix]

Odd that the 2 doctors told you you would not be getting a 3 piece lefort. Simply because the VSP for one doctor looks like that was entertained and as for Gunson, he often does them.

There are some odd things about this. But in the VSP you refer to, the doctor actually doesn't call that a 3 piece lefort, and the segmentation you see will probably not be performed. This was a segmentation that was done in case I wanted to do surgery first, and not decompensate the bite orthodontically before surgery. When I visited him he said something like "this is similar to what we do in a 3 piece lefort, which we will not do in your case". And the purpose was to open up and angle the anterior teeth forward, so the mandible could be advanced to a class I relation (from class II). When I asked him at a later stage if I had understood it correctly that this was not needed if I had proper orthodontic preparation he said yes, and that orthodontic decompensation was prefered. So maybe it's a play with words, but the palate would not be split all the way back in this case, only the anterior segmentation would be done.

I specifically asked Gunson "will there be any transverse widening", the response was NO. But then it's odd in this case as well, because when the quotation arrived and I read the orthodontic preparation notes, it was quoted as a segmentational lefort, and that the orthodontist should prepare gaps to prepare for a segmentational lefort. Maybe they want to keep it open to decide at surgery day, but didn't see any obvious need.

Anyway. Is a segmentational lefort considered one of the most risky procedures that is only done in special cases? Because I mean, many aspects of the surgery I'm having, and many others are having does contain medically "unecessary" parts, which mostly is done for aesthetic reasons. I mean, my bite could probably be fixed with a BSSO only, and posterior downgrafting is probably unecessary complicated for any medical purpose in most cases.

Is there a difference from a SARPE and the C case in your picture? Seems like it's same, just that the SARPE cases I've seen create crazy gaps between the teeth. Like this. https://drrichardjoseph.com/assets/images/sarpe2.jpg

[kavan]

OK, so sounds like the decompensation ortho is working enough so you don't need 3 piece lefort (with the surgeon who did the 3 d vsp). It's just that the initial diagrams of both of them kind of looked like they wanted to do 3 piece. But perhaps that was just prelim just in case the ortho did not prepare for 1 piece.

All those surgeries are very intricate and TBH, I'm not sure if figure 'C' is the SARPE or something just directed to expand at posterior maxilla. But with SARPE, post surgery braces close the big gap between the front teeth.

The more cuts you make to the maxilla, the higher the risks--blood loss, tooth denervation or the parts just not fitting together right or moving apart from where they put them (relapse). So, you should be happy you don't 'need' 3 piece.

Which doctor are you going with, the one who did the VSP or Gunson? I would not be fretting about multi-segment leforts if they are not something you 'need'.

[Dogmatix]

OK, so sounds like the decompensation ortho is working enough so you don't need 3 piece lefort (with the surgeon who did the 3 d vsp). It's just that the initial diagrams of both of them kind of looked like they wanted to do 3 piece. But perhaps that was just prelim just in case the ortho did not prepare for 1 piece.

All those surgeries are very intricate and TBH, I'm not sure if figure 'C' is the SARPE or something just directed to expand at posterior maxilla. But with SARPE, post surgery braces close the big gap between the front teeth.

The more cuts you make to the maxilla, the higher the risks--blood loss, tooth denervation or the parts just not fitting together right or moving apart from where they put them (relapse). So, you should be happy you don't 'need' 3 piece.

Which doctor are you going with, the one who did the VSP or Gunson? I would not be fretting about multi-segment leforts if they are not something you 'need'.

Ok, maybe I should not push for a 3 piece lefort in that case. The reason I've been thinking about it is widening of the smile, and also more bony structure and soft tissue support at mid face. I read about people discussing zygomatic osteotomy, implants etc for such, and was thinking if I'm going through with bimax, I might as well have the palate widened and get the aesthetic benefits from this in the process.

Do you think the CCW and maxilla advancement will do something for soft tissue support at mid face for me? I'm not going with the Gunson plan, and most probably going with the other. In this plan ANS is virtually stationary, but rather significant ccw rotation, and upper incisor tip comes forward about 7mm. Can it also be that the entire maxilomandibular rotation gives more soft tissue support at mid face, I mean you are pulling a significant piece of the face, and I can imagine it stretches a bit on different places.

How do you see in the Gunson diagram that he was working towards a 3 piece? What I got and have posted here is only a 2d ceph displacement.

[kavan]

Anytime you create more 'face space' which is what is being done by the downgraft along with the BSSO (and genio), there's more soft tissue support.

As to Gunson's diagram, I was just guessing given he often does 3 piece and because the other VSP colored the maxilla in segments. Also, G's diagram had that dashed line over the maxilla diagram. But maybe that's always depicted.

[april]

The cut that Gunson usually does is like photo B, where the cuts are between the canine and lateral incisors. It's technically 4 pieces. The article posted explains the benefits/disadvantages/reasons for it, but I think it basically gives them more flexibility to move the 3 outer segments in whichever way they like.

You can also see in your original surgeon VSP, that had you done surgery-first, the cuts would've been between canines and laterals. You're super lucky you don't need it.

[Dogmatix]

The cut that Gunson usually does is like photo B, where the cuts are between the canine and lateral incisors. It's technically 4 pieces. The article posted explains the benefits/disadvantages/reasons for it, but I think it basically gives them more flexibility to move the 3 outer segments in whichever way they like.

You can also see in your original surgeon VSP, that had you done surgery-first, the cuts would've been between canines and laterals. You're super lucky you don't need it.

I want a wider smile and enhanced cheek bones goddammit

Just joking, I hear what you're saying. It is a bit strange though, if it's really as bad as you're saying, why does Gunson seem to do it always, even in cases like mine where it can be avoided.
April, am I right that you have also done more than one consultation, and got proposals both with and without segmentation of the maxilla?

I've been drafting a mail with some questions and had this as a question and almost formulated it as I want it. Maybe I should remove this and just let it be. I mean, I don't want to get in a situation where he agrees because I really seem to want it, when that's not how I mean it. More like I want to be informed and explore what it means and pros and cons. As I reasoned earlier, I see many of these procedures as not medical necesarry, some of the movements are more advanced and performed just for aesthetic reasons, and it's hard to know where to stop. No one here seems to tell me I should avoid bimax and posterior downgrafting because bite probably can be corrected any way e.g.

[kavan]

I want a wider smile and enhanced cheek bones goddammit

Just joking, I hear what you're saying. It is a bit strange though, if it's really as bad as you're saying, why does Gunson seem to do it always, even in cases like mine where it can be avoided.
April, am I right that you have also done more than one consultation, and got proposals both with and without segmentation of the maxilla?

I've been drafting a mail with some questions and had this as a question and almost formulated it as I want it. Maybe I should remove this and just let it be. I mean, I don't want to get in a situation where he agrees because I really seem to want it, when that's not how I mean it. More like I want to be informed and explore what it means and pros and cons. As I reasoned earlier, I see many of these procedures as not medical necesarry, some of the movements are more advanced and performed just for aesthetic reasons, and it's hard to know where to stop. No one here seems to tell me I should avoid bimax and posterior downgrafting because bite probably can be corrected any way e.g.

If you want to be informed then Google and READ more med journal articles about associated risks with making requests for extra maxilla cuts when the docs tell you you don't need them OR explore other ways to build out the teeth with CAPS or OVERLAYS which they do to build out the face. Otherwise, docs are not going to 'inform' you about things they don't suggest you undergo with them to correct your salient problem. Also, be informed that there are situations where when a doc informs a patient about the surgery they are proposing and the patient keeps on asking and asking questions about stuff they don't suggest or appears to be perpetually indecisive about the surgery proposed to them and needs much more time than the average patient, just to keep asking the doctor questions, the doc can DECLINE surgery.

[april]

Just joking, I hear what you're saying. It is a bit strange though, if it's really as bad as you're saying, why does Gunson seem to do it always, even in cases like mine where it can be avoided.

The article Kavan posted lists some of the arch and teeth angle issues multisegment can solve. He doesn't always do multisegment btw- this guy didn't have it.

If you really need to know why Gunson wanted to do it, you could ask them why they wanted your ortho to create spaces and they might explain why. Maybe it's precautionary to move the roots, just in case you needed it once they do 3d planning. Or maybe he needs the separate segments for some other reason and nothing to do with widening.

But the surgeon you're actually going with seems pretty skilled enough to make the call.

April, am I right that you have also done more than one consultation, and got proposals both with and without segmentation of the maxilla?

Yeah that's right. But the differences in opinions in my case come down to what procedures these different surgeons are comfortable with, what arch issues they are trained to address surgically or just let slide, and what they are experienced enough to do. I only consulted with 1 "world class" surgeon (Gunson), so yeah. I think your surgeon is obviously capable enough to do it if he thought you actually needed it.

[Dogmatix]

The article Kavan posted lists some of the arch and teeth angle issues multisegment can solve. He doesn't always do multisegment btw- this guy didn't have it.

If you really need to know why Gunson wanted to do it, you could ask them why they wanted your ortho to create spaces and they might explain why. Maybe it's precautionary to move the roots, just in case you needed it once they do 3d planning. Or maybe he needs the separate segments for some other reason and nothing to do with widening.

But the surgeon you're actually going with seems pretty skilled enough to make the call.

Yeah that's right. But the differences in opinions in my case come down to what procedures these different surgeons are comfortable with, what arch issues they are trained to address surgically or just let slide, and what they are experienced enough to do. I only consulted with 1 "world class" surgeon (Gunson), so yeah. I think your surgeon is obviously capable enough to do it if he thought you actually needed it.

Thanks, I agree with your reasoning, it's probably for the best to trust that segmentation should not be performed if it's not in the plan.


Kavan. I understand that surgeons may decline a patient for those reasons. I have good intentions with all my questions and it is stressing me that I may come across as being indecesive and all over the place, when all I really want is to fully understand the procedure, what will/can be done and why. Getting a degree as a max-fac surgeon is a long education and I can't possibly know everything or even read up on everything on my own. Asking questions, and sometimes even "stupid" questions and pushing in different directions is a way to learn and understand. Honestly, I would have no problem paying a surgeon to educate me in general about these procedures, but this is not an option that is offered any where.

[Lazlo]

Surgeons will offer only procedures they are comfortable in doing, even if you clearly need a particular procedure. They will even reason with you that you don't need it.

This is just the way surgeons are. I consulted with a regular max fac recently and he concurred I had no problems and there were no procedures to help fix what I had, whereas a couple of very experienced max facs were totally okay with doing those procedures and said there was low risk. So I think its best to do your research and that way you can see what is more normative in your case.

[april]

So true. I know it's a business but I wish those sort of surgeons would just be honest and be like "look you really need xyz but I just can't do it".

But that said, in Dogmatix's case I think his surgeon is considered pretty top notch and definitely not risk-averse. He was going to do the multisegment on him if he had done surgery-first.

[kavan]

You don't understand stuff because you find ways to CONFUSE yourself. No surgeon is going to sit down with you and tutor you in this stuff so you 'understand' all of it. It's a million times quicker for them just to DO the surgery. Even when I try to explain stuff (and I'm good at explaining things), you get confused.

Although you say you 'can't possibly learn all on your own', you can't expect the doctor to sit down with you and actually TUTOR you with remedial lessons so you understand what they went YEARS in school for.

For some doctors, a patient asking incessant questions and expecting them to dote, tutor or respond to incessant questions is a TIME SINK and if they are used to just DOING the surgery, they might DECLINE it in patients who need a lot of remedial attention if they give appearance that is a CONTINGENCY. So, if you want the surgery, you will need to READ and study up ON YOUR OWN just like other well informed patients have done.

Your case is really straight forward. There is no need to OVER COMPLICATE it and CONFUSE yourself other than some desire or proclivity you have to do that and you must work on what ever that proclivity is ON YOUR OWN.

 They do a posterior downgraft to MAXIMIZE the CCW and maximize the lower jaw advancement and to MINIMIZE changes at the BASE OF NOSE which is why the first surgeon did not advance the maxilla that much. Then they elongate the chin and advance it a little because people with DEEP BITE have the 'short chin'. It's THAT SIMPLE and they made it more EASY to 'see' what they were doing (especially the first doc with the VSP) by SHOWING the bone changes.

[JourneyToSerenity]

You don't understand stuff because you find ways to CONFUSE yourself. No surgeon is going to sit down with you and tutor you in this stuff so you 'understand' all of it. It's a million times quicker for them just to DO the surgery. Even when I try to explain stuff (and I'm good at explaining things), you get confused.

For some doctors, a patient asking incessant questions and expecting them to dote, tutor or respond to incessant questions is a TIME SINK and if they are used to just DOING the surgery, they might DECLINE it in patients who need a lot of remedial attention if they give appearance that is a CONTINGENCY. So, if you want the surgery, you will need to READ and study up ON YOUR OWN just like other well informed patients have done.

Some of us don't have that luxury, Kavan. Suffering from SA[not compliant with CPAP/APAP] or those who have unbearable TMJ pain will make it extremely difficult to keep alert on here let alone scrolling through various academic papers in order to better understand our condition and ways we can go about correcting such conditions & possible complication that may arise.