Jaw surgery: is it worth it without the esthetic component?

[InvisalignOnly]

Ruling out untoward events (getting one of the risks/complications) and whether or not the patient likes the result, with GOOD PLANNING and software (by the surgeon), aesthetic improvement IS predictable as are some deviations from it in situations where there are to be some trade-offs.

I was told by more than one experienced surgeons that results aren't predictable, especially because the soft tissue response is impossible to predict. Worldwide, only a minority of surgeons use planning softwares, for example in the country where I currently live, nobody does (which is why I'm trying to get the surgery elsewhere). I recently spoke to a very reputable and experienced British maxfac surgeon and he told me he only started using 3D planning last year, and only uses it for certain cases. So this type of planning is still far from the norm (maybe it's different in certain countries like the USA), which might contribute to the 'unpredictability' factor.

[PloskoPlus]

I was told by more than one experienced surgeons that results aren't predictable, especially because the soft tissue response is impossible to predict. Worldwide, only a minority of surgeons use planning softwares, for example in the country where I currently live, nobody does (which is why I'm trying to get the surgery elsewhere). I recently spoke to a very reputable and experienced British maxfac surgeon and he told me he only started using 3D planning last year, and only uses it for certain cases. So this type of planning is still far from the norm (maybe it's different in certain countries like the USA), which might contribute to the 'unpredictability' factor.

Yep, the vast majority just eyeball things and make it up as they go along. As long as the occlusal splint fits - job done.

[biterelapse]

Yep, the vast majority just eyeball things and make it up as they go along. As long as the occlusal splint fits - job done.

thats so messed up

[kavan]

I was told by more than one experienced surgeons that results aren't predictable, especially because the soft tissue response is impossible to predict. Worldwide, only a minority of surgeons use planning softwares, for example in the country where I currently live, nobody does (which is why I'm trying to get the surgery elsewhere). I recently spoke to a very reputable and experienced British maxfac surgeon and he told me he only started using 3D planning last year, and only uses it for certain cases. So this type of planning is still far from the norm (maybe it's different in certain countries like the USA), which might contribute to the 'unpredictability' factor.

Well, I attributed predictability to both aesthetic improvement AND high tech 3D planning software. So, the fact that a LOT of surgeons aren't with the program and DON'T use this kind of planning software doesn't negate my statement.

As to soft tissue responses, not being predictable, I've seen situations where they are predictable BUT the doctors WITHHOLD the information. For example the 'chimp lip' look from a lot of linear advancement for SLEEP APNEA cases on the part of doctors who not only lack good planning software but also don't do CCW posterior downgrafts.

We can get into SEMANTICS as to what exactly is predictability and say 'not predictable' because the doctor can't show the patient 'exactly' what they will look like after surgery. Yes that is true. But that doesn't negate a good aesthetic outcome being predictable with the high tech software via a surgeon who has good planning capabilities.

[Bowie]

thats so messed up

Not really, I'm pretty sure most surgeries are conducted like that, if not, then it would be more easy for machines to replace surgeons than it currently is.

[InvisalignOnly]

Not really, I'm pretty sure most surgeries are conducted like that, if not, then it would be more easy for machines to replace surgeons than it currently is.

That's right, until recently there were no computers and doctors still performed surgeries, mostly successfully. Of course for jaw surgery they used to draw plans and use dental casts etc. (which are still used). This doesn't mean that softwares aren't extremely useful, but surgery is quite possible without them of course.

[InvisalignOnly]

As to soft tissue responses, not being predictable, I've seen situations where they are predictable BUT the doctors WITHHOLD the information. For example the 'chimp lip' look from a lot of linear advancement for SLEEP APNEA cases on the part of doctors who not only lack good planning software but also don't do CCW posterior downgrafts.

We can get into SEMANTICS as to what exactly is predictability and say 'not predictable' because the doctor can't show the patient 'exactly' what they will look like after surgery. Yes that is true. But that doesn't negate a good aesthetic outcome being predictable with the high tech software via a surgeon who has good planning capabilities.

I think you're right re: doctors withholding information. Regarding the planning software issue - of course, ideally, one will have a surgeon who is very experienced, talented and uses high tech software, but so far I find this combination is very rare and of course very expensive (Gunson, Alfaro category). I have spoken to younger doctors with less experience that use the latest software, and older, more experienced doctors, some of whom are high profile and well regarded, that do not really use it. I wonder which one is actually more important, the high tech planning or the experience?

[kavan]

I think you're right re: doctors withholding information. Regarding the planning software issue - of course, ideally, one will have a surgeon who is very experienced, talented and uses high tech software, but so far I find this combination is very rare and of course very expensive (Gunson, Alfaro category). I have spoken to younger doctors with less experience that use the latest software, and older, more experienced doctors, some of whom are high profile and well regarded, that do not really use it. I wonder which one is actually more important, the high tech planning or the experience?

Some cases are straight forward and/or achievable enough where they can be done without high tech planning software. Doctors with a lot of experience (older ones usually) do the tracings and displacement plan by hand and also the casting models.

The high tech software allows them to 'play with it' many times (on the computer) as to try different combinations of displacements and accommodates more complex cases. There also seems to be somewhat of a relationship between doctors who do the significant posterior CCW downgrafts and the high tech software, particularly the 'NEMO FAB' where the headquarters are in Spain and incorporates the Arnett analysis.

I'd say it is important for young doc who uses high tech software to ALSO know how to do the tracings and displacement proposals by hand too in addition to having experience under belt using the high tech software. The not so young, eg. Gunsun and Alfaro  also know how to do by hand too.

No definitive answer as to which more important; high tech planning or experience. In GENERAL, the less complex the case and/or the less significant CCW posterior downgrafts come into play, the more likely the case will resolve to types of doctors other than types like Alfaro and Gunson... as in doctors with a lot of experience but who don't use the high tech software.

[InvisalignOnly]

Thanks for this, a lot of food for thought... I think you're right, it ultimately comes down to what you say at the end:

In GENERAL, the less complex the case and/or the less significant CCW posterior downgrafts come into play, the more likely the case will resolve to types of doctors other than types like Alfaro and Gunson...

[kavan]

Thanks for this, a lot of food for thought... I think you're right, it ultimately comes down to what you say at the end:

 

[april]

As to soft tissue responses, not being predictable, I've seen situations where they are predictable BUT the doctors WITHHOLD the information. For example the 'chimp lip' look from a lot of linear advancement for SLEEP APNEA cases on the part of doctors who not only lack good planning software but also don't do CCW posterior downgrafts.

There was a post on the facebook group where someone wrote how her surgeon warned her she might look like a 'monkey', and everyone in the group was completely outraged, like how dare this surgeon say she will look like a monkey! He was unapologetically honest though. Obviously he couldn't do CCW to avoid it, lol but at least he warned her.

Do you think a 3d/VSP soft tissue mask would show a chimp lip, if it were going to happen?
I really want to avoid that at all costs. I don't trust 2d plans to show it.

[biterelapse]

Some cases are straight forward and/or achievable enough where they can be done without high tech planning software. Doctors with a lot of experience (older ones usually) do the tracings and displacement plan by hand and also the casting models.

The high tech software allows them to 'play with it' many times (on the computer) as to try different combinations of displacements and accommodates more complex cases. There also seems to be somewhat of a relationship between doctors who do the significant posterior CCW downgrafts and the high tech software, particularly the 'NEMO FAB' where the headquarters are in Spain and incorporates the Arnett analysis.

I'd say it is important for young doc who uses high tech software to ALSO know how to do the tracings and displacement proposals by hand too in addition to having experience under belt using the high tech software. The not so young, eg. Gunsun and Alfaro  also know how to do by hand too.

No definitive answer as to which more important; high tech planning or experience. In GENERAL, the less complex the case and/or the less significant CCW posterior downgrafts come into play, the more likely the case will resolve to types of doctors other than types like Alfaro and Gunson... as in doctors with a lot of experience but who don't use the high tech software.

What’re your thoughts on the use of custom-made osteosynthesis material by CAD-CAM, where the software is not only used to move bones, but also to design osteotomy guides, brocade and plates? meaning software is not only used to print an occlusal splint to guide the bite, but also to print bone cutting guides, plates and screws and print it in a way specifically customized for the patient’s biologic needs. In addition the use of a map during surgery, that includes the length and thickness used for each screw. I wonder what constitutes a patients "biologic needs" and if this only refers to size (width &length of the materials) or if there are other more important qualities of the materials that can be better fitted, to any given patients particular biology?    Also, I wonder if this strategy tends to increase the chances of achieving a more stable outcome, thus reducing the chance of complications or relapse or if it only streamlines the procedure and makes it easier for the surgeon.

[kavan]

What’re your thoughts on the use of custom-made osteosynthesis material by CAD-CAM, where the software is not only used to move bones, but also to design osteotomy guides, brocade and plates? meaning software is not only used to print an occlusal splint to guide the bite, but also to print bone cutting guides, plates and screws and print it in a way specifically customized for the patient’s biologic needs. In addition the use of a map during surgery, that includes the length and thickness used for each screw. I wonder what constitutes a patients "biologic needs" and if this only refers to size (width &length of the materials) or if there are other more important qualities of the materials that can be better fitted, to any given patients particular biology?    Also, I wonder if this strategy tends to increase the chances of achieving a more stable outcome, thus reducing the chance of complications or relapse or if it only streamlines the procedure and makes it easier for the surgeon.

It's in the high tech venue and an extension of the 3-d planning software. First the help with planning and next the help with doing.

[Dogmatix]

Do you think a 3d/VSP soft tissue mask would show a chimp lip, if it were going to happen?
I really want to avoid that at all costs. I don't trust 2d plans to show it.

At least I don't think a software would be designed to not show 'chimp' lips. Anything else than making the best prediction they can would not make sense, why even do a prediction then. It's a well known consequence of jaw advancement, so I don't see any reason to believe this predicition would be any different in accuracy than any else.

But also, chimps look like chimps and humans look like humans. It kind of resolves to that you should have a big enough issue with current situation that you figure that it's not an option to not proceed. Of course want a doctor who can do it in the best way and if you're a candidate for ccw, that will be the best displacement to minimize this effect. The doctors can't do magic. If you get a plan where ANS is advanced in a way that protrude the upper lip, then the option may be to move it back, but then you start saying you want the chin to stay where it is and you have to chose, or probably the doctor will chose for you.

[InvisalignOnly]

There was a post on the facebook group where someone wrote how her surgeon warned her she might look like a 'monkey', and everyone in the group was completely outraged, like how dare this surgeon say she will look like a monkey! He was unapologetically honest though.

That's the thing with the Facebook groups, at least the one I'm in. It's full of these women that seem to have no idea what is the surgeon planning to do to their faces but they are all so convinced jaw surgery will make them look great and keep trying to convince each other of the same. If anybody questions anything or mentions anything that went wrong or could go wrong, they get upset and dismissive. That's my experience with the group anyway.