Review of surgery-first with Dr. Federico Hernández Alfaro in Barcelona 2020

[jawjawz]

Background
I had underbite since childhood. When I was 12-15 I used braces to correct the bite/teeth by inclining the superior teeth in a way that it would fit "correctly". The bones were still in the wrong position though, because the only way of fixing them was by doing a jaw surgery, but it wasn't recommended for me at that age because I was still growing. A few years later, at age 22, I decided to go ahead and do the jaw surgery.

Pre-Surgery
In October/2019, I did my first consultation with Dr. Alfaro in Barcelona to discuss the surgery. My main concerns were some snap/cracks that I had when opening my mouth, the difficult to see my teeth when I tried to smile, and also I wished to revert my teeth inclination (and I explicitly mentioned that to the doctor several times). I've communicated to him that the treatment duration was not a problem for me, even if it were to take years, because I wanted the best result possible. I went back only once for a couple of X-Ray exams and he then recommended me to do a double jaw surgery-first with the possibility of using braces later. The 3rd visit was already the surgery.

Surgery and review
In December/2019 I had the surgery. Right after the surgery when I first saw the immediate result the first thing I asked Dr. Alfaro was about my teeth inclination, he answered that I'd need to wait because that would be "later" in the "braces phase". After the "full" recovery (6 months) and in the final consultation I asked Dr. Alfaro about it again and he said that I wouldn't need braces, so I asked about the inclination, and this time he answered differently saying that they had to stay that way because otherwise, my upper lips would go down—which doesn't make much sense for me because I wasn't born with them like this and as I stated at the beginning of this post (and for him in the consultations) fixing that was one of the reasons I was wanting to go with the surgery. I feel that them being inclined is the reason I have to do a lot of effort to make them appear when I smile (lifting my nose up too much).

I also have a feeling that my lower bite could have been moved slightly more backward because my lower lips kind of look to have a very tiny underbite viewed from the side.

Regarding the installations, hospitalization, post-treatment, everything was on point. However, if I had to rate the result of my surgery compared to the expectations I had it is a 6/10 maximum, driven that low mainly by the inclined teeth aesthetics, which is honestly a pretty low review for the premium price I paid for the surgery (without any insurance support) that wasn't low.

Although I've done some research before and after the surgery I'm by no means a connoisseur of what can be done or not in the jaw surgery to tell if what Dr. Alfaro did was the best (or close to) that could have been done or not, so I was hoping I could get some opinions here with my before/after photos. My original plan was to do a porcelain veneers after recovering from jaw surgery, but I'm now doubtful if what I should really do is to go after another surgeon and go through a second surgery.

Photos
https://imgur.com/a/nTaNGgs

I also have a few more photos that I'm happy to share if you find it necessary.

[kavan]

Although Google Drive is allowed here, it isn't the best venue to show photos. I'd be happy to give you some tips on photo organization if you like. IMGUR seems to be a good place to do that.

1:Before of ONE procedure should be NEXT to the after of same procedure. This will allow a side by side comparison for viewers. Before photos, always to the LEFT and After, always to the right. On IMGUR, they let you write an explanation describing the photos (or issues).

For example if you wanted to show a side by side comparison of a before and after, but the hosting site only arranges one on top and the other below, what to do is to is put them side by side in a photo editor so they become ONE photo file.

Also, IMGUR allows for many photos on the SAME link and a SCROLL DOWN option to view.

Of course, there is no rule against Google drive or any other type of photo presentation. Just that good photo organization makes it easier for people to see immediate comparison.

From what you say as to INCLINE or inclination, aside from no inclination at all, there are 2 types; RETRO-inclination and PRO-clination. Retroclined and Proclined, retro meaning backwards and pro meaning forwards. Proclination helps support the upper lip and kind of gets it to diagonally 'stick out' more. Sometimes that's wanted. Sometimes not. For example someone who doesn't have prominent lips could get more 'ooph' with proclined teeth. On the other side of the coin, a person with very prominent lips might not want them to stick out more. However, I don't know IF there is actually a choice as to tooth inclination and TBH, I'm not the best as to ortho issues other than to convey I've seen a lot of cases where they get the 'bite right' with both retroclination and proclination and of course straight down no inclination.

There are some members on board who are very conversant in ortho issues so I will ask this for you and maybe they will chime in: 

Can a patient getting jaw surgery CHOOSE how they want the teeth inclined?
Again, I don't know if one can or can't and this sounds to be part of your issue; a choice of inclination not being accommodated.

As to Alfaro, you are not the first one and by no means the only one who has reported post op dissatisfaction with the ortho aspect of it. With surgery first doctors, they put a lot of the responsibility on the ortho. With Alfaro, he seems to concern himself more with the PROFILE, you know advancing all of that out and giving a slightly MORE prominent chin wher the BSSO advancement does a lot of thrusting it out. So, no surprise if your lower lip is slightly out more than upper as that goes along with 'the ride' as to lower jaw advancement that takes the chin along with it or even a genio aimed at a 'DRAMATIC' look to the lower jaw.

I don't know but he may assume that people flocking to him are those who want a very dramatic projection to the lower jaw area which seems to be his draw as are people who actually WANT surgery first. Also, I have no reason to believe (from past posters) that Alfaro 'shines' in the COMMUNICATION department. It is more of a matter of his being able to do surgery FAST and kick up dramatic profile advancement changes.

All that said, I'd say the salient thing to establish here before considering revision surgery is to find out the question that I don't know myself which is whether or not patients have a choice as to how they want their teeth inclined when getting maxfax surgery

[PloskoPlus]

You should've probably had clockwise rotation. Your upper jaw should've been downgrafted at the front for more tooth show.

[jawjawz]

@kavan I appreciate the detailed response. I've changed the photos to IMGUR and using the before/after format you suggested in the same picture to ease the comparison.

Rethinking again on what I said, honestly, I'm more concerned with the fact that I still have some difficulties (although better than before) to show my teeth while smiling than the fact that it's inclined—I just thought that those are directly correlated so that's why I stated the inclination as my main concern.

Do you think by any chance that adding porcelain veneers would improve my issue? I was afraid that they could make the inclination even more apparent and I could get into a worse state.

@PloskoPlus I may be wrong, but if I recall correctly I remember he mentioning this, so I might have had it but maybe not sufficiently enough?

[kavan]

Well, based on the photos (which you did arrange very well!), I don't think you would would actually want any PROCLINATION of the teeth given you have an acute nose to lip angle and diagonally outward lips to begin with even though you asked him to reverse the inclination (from one of retroclination to proclination). It looks like your aesthetic boost was to the lower jaw being advanced. The smile has not changed much. It's still your smile. I mention that because there was an Alfaro patient on here a few years back crying and crying that even though Alfaro made him look OBJECTIVELY better in the eyes of on lookers and made his smile better, the guy was traumatized because the improved smile he got was no longer 'his (identity) smile. Anyway, I don't think veneers are the solution. Because longer front teeth for more tooth show would make your smile look like 'deep bite' where upper teeth cover the lower teeth too much.

I'm inclined (no pun intended) to go with Plosko's feedback tha CW rotation could have yielded more upper tooth show. But since more upper tooth show is your goal after what ever you got, it might not be worth a possibly complex revision surgery. I would suggest exploring the possibility of a lip lift to provide more upper tooth show if indeed it's more upper tooth show that's now your goal.

From the photos, I don't see anything inherently 'wrong' with the surgery to suggest a revision for more tooth show. I see that he improved your lower jaw area and kept you with the smile consistent with 'identity' smile.

[Lazlo]

Background
I had underbite since childhood. When I was 12-15 I used braces to correct the bite/teeth by inclining the superior teeth in a way that it would fit "correctly". The bones were still in the wrong position though, because the only way of fixing them was by doing a jaw surgery, but it wasn't recommended for me at that age because I was still growing. A few years later, at age 22, I decided to go ahead and do the jaw surgery.

Pre-Surgery
In October/2019, I did my first consultation with Dr. Alfaro in Barcelona to discuss the surgery. My main concerns were some snap/cracks that I had when opening my mouth, the difficult to see my teeth when I tried to smile, and also I wished to revert my teeth inclination (and I explicitly mentioned that to the doctor several times). I've communicated to him that the treatment duration was not a problem for me, even if it were to take years, because I wanted the best result possible. I went back only once for a couple of X-Ray exams and he then recommended me to do a double jaw surgery-first with the possibility of using braces later. The 3rd visit was already the surgery.

Surgery and review
In December/2019 I had the surgery. Right after the surgery when I first saw the immediate result the first thing I asked Dr. Alfaro was about my teeth inclination, he answered that I'd need to wait because that would be "later" in the "braces phase". After the "full" recovery (6 months) and in the final consultation I asked Dr. Alfaro about it again and he said that I wouldn't need braces, so I asked about the inclination, and this time he answered differently saying that they had to stay that way because otherwise, my upper lips would go down—which doesn't make much sense for me because I wasn't born with them like this and as I stated at the beginning of this post (and for him in the consultations) fixing that was one of the reasons I was wanting to go with the surgery. I feel that them being inclined is the reason I have to do a lot of effort to make them appear when I smile (lifting my nose up too much).

I also have a feeling that my lower bite could have been moved slightly more backward because my lower lips kind of look to have a very tiny underbite viewed from the side.

Regarding the installations, hospitalization, post-treatment, everything was on point. However, if I had to rate the result of my surgery compared to the expectations I had it is a 6/10 maximum, driven that low mainly by the inclined teeth aesthetics, which is honestly a pretty low review for the premium price I paid for the surgery (without any insurance support) that wasn't low.

Although I've done some research before and after the surgery I'm by no means a connoisseur of what can be done or not in the jaw surgery to tell if what Dr. Alfaro did was the best (or close to) that could have been done or not, so I was hoping I could get some opinions here with my before/after photos. My original plan was to do a porcelain veneers after recovering from jaw surgery, but I'm now doubtful if what I should really do is to go after another surgeon and go through a second surgery.

Photos
https://imgur.com/a/nTaNGgs

I also have a few more photos that I'm happy to share if you find it necessary.

Yeah so with the inclination issue, it seems the doctor just completely disregarded this issue. That said, it may only be possible to incline the teeth straight with either SARPE or extractions. Proclined teeth are preferrable to extractions any day of the week.

Honestly, you look great as far as I can tell. Your lower jaw looks strong and i don't think you really look like you have an underbite. At least not an obvious one. Your bite looks decent.

[InvisalignOnly]

Personally I think this is one of those cases where OP already looked normal / good before surgery so the improvement may not be dramatic simply because there wasn't that much to improve about an already good looking face. The thing about jaw surgery is that there will always be trade offs, it is physically impossible to 'fix' everything - surgery is not photoshop. For example, let's say they could have advanced the maxilla more in this case so there would be more tooth show but it could have resulted in a chimp look (upturned nose etc.).

The issue here seems to be a miscommunication between OP and Alfaro in that OP had a very specific concern and if Alfaro could not / did not want to address that, that should have been made clear from the start. This might be a misunderstanding between them, I am not saying Alfaro was deliberately trying to mislead OP but at the same time I can understand how the situation is disappointing for OP if he was expecting a different outcome. As for revision etc., personally I do not think I'd do that, this is an objectively good outcome and there is no guarantee that any other surgery would achieve what OP had in mind - it could just lead to further disappointment. If I was in this situation, I would consult a few orthos, cosmetic dentists or plastic surgeons to see if there is anything that could be done to get closer to the smile OP would prefer.

[InvisalignOnly]

That said, it may only be possible to incline the teeth straight with either SARPE or extractions. Proclined teeth are preferrable to extractions any day of the week.

Very true - I had an overbite, gummy smile and proclined upper teeth, and funnily enough, it was Alfaro that told me to get upper premolars extracted to get the teeth straight, followed by lower jaw surgery. I discussed that plan with a few orthos and the experienced ones said that it would have been a disaster aesthetically plus it could have relapsed even with fixed retainers (i.e. the teeth would start sticking out again anyway). Now imagine in OP's case - I think extractions would be a terrible idea, and there might not be any other way to straighten the teeth.

[simonsjaw11]

Very true - I had an overbite, gummy smile and proclined upper teeth, and funnily enough, it was Alfaro that told me to get upper premolars extracted to get the teeth straight, followed by lower jaw surgery. I discussed that plan with a few orthos and the experienced ones said that it would have been a disaster aesthetically plus it could have relapsed even with fixed retainers (i.e. the teeth would start sticking out again anyway). Now imagine in OP's case - I think extractions would be a terrible idea, and there might not be any other way to straighten the teeth.

I also have an 5mm overbite and he told me the same thing. He said I could extract 4 wisedom teeth, and use miniscrews in order to retract all of my teeth 5mm, and then I could have a lower jaw surgery plus genio.
I thought his plan makes the most sense cause without teeth extraction the movement of insicors is limited to 2mm, and I might need an extra 3mm maxilla setback to acheive 5mm.  But if it's just teeth straighten then perhaps there's no need for extraction.

[InvisalignOnly]

I also have an 5mm overbite and he told me the same thing. He said I could extract 4 wisedom teeth, and use miniscrews in order to retract all of my teeth 5mm, and then I could have a lower jaw surgery plus genio.
I thought his plan makes the most sense cause without teeth extraction the movement of insicors is limited to 2mm, and I might need an extra 3mm maxilla setback to acheive 5mm.  But if it's just teeth straighten then perhaps there's no need for extraction.

I just saw this comment and looked at your previous posts - our starting points are very different, even though we both have / had an overbite. Maybe his plan could have been a good one for your case but definitely not for mine, mostly because I had significant vertical maxillary excess in addition to the overbite.