Surgery First Protocol

[Dopesaint]

Well, I don't know if surgeon A was conveying to you that WITH pre-molar extraction and with braces before surgery you get 'more' advancement that way than you would get if you just got pre-surgery braces but with no pre molar extraction. So, I don't know what 'more' is in reference to when you asked 'A'. In reference to not including extraction in PRE-SURGICAL PREP or in reference to more advancement with pre surgical preparation than with surgery first.

I can't say if Surgeon B was 'wrong'. It could be that surgeon A might not have been clear on what question you were asking him.

Good point, to clarify I asked surgeon A if I will get more projection with decompensation in pre-orthodontics compared to surgery first approach.

I also mentioned this to him because I read his book in preparation for my consultation with him and in his book he did mention decompensation would worsen the appearance in pre-orthodontics but helps allow for greater jaw movement (I can cite this for you if needed)

Like many people mentioned in this thread, it seems I will sacrifice that greater movement of my jaws by going with surgery first approach.

[kavan]

Good point, to clarify I asked surgeon A if I will get more projection with decompensation in pre-orthodontics compared to surgery first approach.

I also mentioned this to him because I read his book in preparation for my consultation with him and in his book he did mention decompensation would worsen the appearance in pre-orthodontics but helps allow for greater jaw movement (I can cite this for you if needed)

Like many people mentioned in this thread, it seems I will sacrifice that greater movement of my jaws by going with surgery first approach.

Well,TBH, I can't be a 'truth meter' for who's right and who's wrong concerning A and B when it comes to choosing one over the other. Because it could be an matter of CONTEXT where they are both being honest with you and neither is 'wrong' given the context in which THEY answered your question.

If surgeon B  uses larger posterior down grafts than A, then that would allow him to get the same horizontal displacement in the BSSO as A gets without surgery first (but with pre-molar extraction). That's an example of a context where they are both being honest, a context they know they are operating from where you don't (and nor do I).

[InvisalignOnly]

I think my case has similarities with yours: I have class 2 jaws but had orthodontic 'camouflage' treatment previously so my bite was almost class 1 with no crowding when I started consulting with surgeons. I was told that surgery first was an option in principle but I would end up with an underbite which, according to the surgeon I spoke to, would look so bad that he refused to even offer me that option even though it could have been fixed with braces afterwards. Another surgeon also said surgery first was an option and he would remove lower premolars during the surgery, which would increase the risk (and the cost) of the surgery significantly (more cuts, less accuracy). So I opted for lower premolar extractions and braces to close the gaps prior to surgery.

I was also told that it would take 6 months but in hindsight I don't think that's realistic, it is more likely to take at least 8 months or so to close the gaps. I have a really good orthodontist that I see every 3 weeks (!) to get my braces tightened and he also uses powerchains and I wear elastics and the braces are self-ligating etc. and it will still take around 8 months to have a large enough overbite to perform the operation (and the extraction space will probably only be fully closed afterwards). Obviously wearing braces isn't fun and now the gaps are closing I definitely look worse than before because the overbite is more noticeable, but hopefully this is only for the next few months and then things will improve after the surgery.

So to answer your original question: I would not trust a surgeon that told you it is a good idea to perform surgery first if it will mean you will have an underbite after surgery and tried to downplay it like that's not a big deal.

[notrain]

There are a couple of requirements that need to be met for a patient to be a "surgery first approach" candidate. Among them are:

- no or at the most mild crowding
- no excessive curve of spee
- correct axial inclination of the incisors
- no transverse discrepancies (i.e. narrow maxilla which would yield a crossbite postop)

Now here's the thing why both of your surgeons sound like idiots: A patient where lower jaw premolar extractions for the purpose of decompensation is an option, then the surgery first option cannot be at the same time applicable to that patient because one or more of the above requirements are violated (most of the time there is too much crowding, tilted incisors and a too deep curve of spee).

So if you have gotten proposed premolar extractions for decompensation, then you should consult more surgeons about surgery first because I doubt that you are a candidate for that. If you still go ahead and do the surgery first approach, the results will be most likely disappointing.

[Post bimax]

There are a couple of requirements that need to be met for a patient to be a "surgery first approach" candidate. Among them are:

- no or at the most mild crowding
- no excessive curve of spee
- correct axial inclination of the incisors
- no transverse discrepancies (i.e. narrow maxilla which would yield a crossbite postop)

Now here's the thing why both of your surgeons sound like idiots: A patient where lower jaw premolar extractions for the purpose of decompensation is an option, then the surgery first option cannot be at the same time applicable to that patient because one or more of the above requirements are violated (most of the time there is too much crowding, tilted incisors and a too deep curve of spee).

So if you have gotten proposed premolar extractions for decompensation, then you should consult more surgeons about surgery first because I doubt that you are a candidate for that. If you still go ahead and do the surgery first approach, the results will be most likely disappointing.

I think I know who "surgeon B" is and I can't understand why he is so confident in proposing surgery-first in every case.  From a paper of his (in support of SF effectiveness), two excerpts from the abstract:

"Selected cases presented symmetrical skeletal malocclusions with no need for extractions or surgically assisted rapid palatal expansion. Periodontal or temporomandibular joint problems and management by an orthodontist without experience in orthognathic surgery were considered exclusion criteria."

and

"Nevertheless, careful patient selection, precise treatment planning, and fluent bidirectional feedback between the surgeon and the orthodontist are mandatory."

Assuming I'm correct in guessing who "surgeon B" is, this seems totally at odds with my own experience with him and that of other forum users who have sought him out for consultation.

[Dopesaint]

There are a couple of requirements that need to be met for a patient to be a "surgery first approach" candidate. Among them are:

- no or at the most mild crowding
- no excessive curve of spee
- correct axial inclination of the incisors
- no transverse discrepancies (i.e. narrow maxilla which would yield a crossbite postop)

Now here's the thing why both of your surgeons sound like idiots: A patient where lower jaw premolar extractions for the purpose of decompensation is an option, then the surgery first option cannot be at the same time applicable to that patient because one or more of the above requirements are violated (most of the time there is too much crowding, tilted incisors and a too deep curve of spee).

So if you have gotten proposed premolar extractions for decompensation, then you should consult more surgeons about surgery first because I doubt that you are a candidate for that. If you still go ahead and do the surgery first approach, the results will be most likely disappointing.

I would have to disagree with your last statement, I've seen some phenomenal surgery first approach results.

Also, I did not request surgery first approach with either doctor in my consultation. At the end of my consultations, both offered me SFA.  (I am surprised because I did have a consultation with Gunson and he stated pre orthodontics is a requirement in all his jaw surgery cases)

[Post bimax]

I would have to disagree with your last statement, I've seen some phenomenal surgery first approach results.

Also, I did not request surgery first approach with either doctor in my consultation. At the end of my consultations, both offered me SFA.  (I am surprised because I did have a consultation Gunson and he stated pre orthodontics is a requirement in all his jaw surgery cases)

He's saying SF would be disappointing in YOUR case given your ortho situation presently violates some of the pre-requisites for optimal SF result.

Gunson actually does SF in a very limited number of cases.

[Dopesaint]

He's saying SF would be disappointing in YOUR case given your ortho situation presently violates some of the pre-requisites for optimal SF result.

Gunson actually does SF in a very limited number of cases.

Oh, I see, thank you for the clarification.