Functional and aesthethic evaluation

[Greenlit]

Hey guys,

Hopefully you can help with my jaw on some issues (two parts: functional and aesthetic).

Some backstory: 28 yo western european  male with a background in medicine, I (sadly) did not learn max-fac seriously enough…

First off, I had braces from 13 to 16, only on the upper teeth. All my wisdom teeth were removed as well. My molars have not had the room to come out and are still half-buried. My left TMJ would crack when I chew hard stuff (meat++) and rarely would I experience pain.

Since my teenage years, I have been snoring like crazy. My father took me to an ENT whom found nothing wrong with me (well I guess he stuck to ENT related stuff….). Since then, I have been experiencing nycturia, diurnal sleepiness, and would sometimes wake up during the night choking. All symptoms pointing toward sleep apnea, but no time to dig into this before long.
My BMI is 19, and no family history of sleep apnea.
My last semester was a rotation in a pulmonology service, and I asked for a basic sleep study (only oximeter, heart rate and airflow from the nose) that I could do at home. Keep in mind I do this on my own, no one is helping me.

Results: moderate sleep apnea: 16 AHI (undervalued by sympathetic activation, so could be more, but I don’t think it would reach toward severe).
I met an ENT with the results (nothing wrong in my nose, tonsils, tongue…), he only described my moderate retrognathia. He sent me to a pulmonologist in July, to program a complete sleep study (with the brain waves and stuff….).

I did not want to wait and do nothing until then, so on my own, I did a ceph, and some research. These are my conclusions:
-   I obviously am skeletal class 2 [the (ugly) overbite]. This have been bothering me since my teenage years; I hate my profile and I have no jaw. But having functional consequences + aesthetic, I want to tackle this the hard way.
-   I believe I have a prominant anterior nasal spine: this + the overbite make for a terrible combination aesthetically.
-   My bite is fine (but cracks and pain on the left TMJ, not that fine I guess….)
-   I reached the conclusions that bimax would make for a quick and efficient cure: no orthodontics needed, ANS shaved, and CCW to avoid the drop of the tip of the nose. Moving the two maxillas would give me the best projection aesthetically (adding a genioplasty), whereas BSSO would be limited by the upper maxilla.

I met a known maxfac yesterday, here are his conclusions:
Class II skeletal malocclusion: indication of BSSO after 12-18 months of orthodontics. He wouldn’t do bimax on me because the sleep apnea is not severe enough (I don’t understand this reasoning). Told me I would gain 5 mm of projection (but on the letter to the ortho, added that I would probably need a genio as well, I don't know if the 5mm included the genio or not).
He sent me to an ortho that will do the diagnosis (next month...).

I am not hyped by his program: two years of braces is expensive (but I would do it nonetheless if it’s necessary); BSSO only limit the projections, whereas I want to maximize aesthetics (without looking like a chimp: if I undergo surgery, I want to look the best I could). At least my sleep apnea would be solved…

I intend to go soo other maxfac.

What do you think?
Thanks !

ceph: https://imgur.com/a/vFrualm

[GJ]

For a class 2 patient, your face is on the shorter side, and your bite plane is also somewhat flat. IMO this rules out any CCW rotation. You might be best off with a linear movement, but you need some way to make up the difference in the lower jaw. This could be a case where bimax + 2 lower molar extractions make sense. Then a genio, too, though you are somewhat limited by your already deep fold. If you advance the chin forward and down, and put in some grafting in the groove, it might work.

I would get at least three opinions from top surgeons in your area. Don't tell them your idea of what you need, and don't tell them what the other surgeons said.

[Post bimax]

BSSO + genio + rhinoplasty doesn't seem like a bad plan to me.

Looks to me like you should get a 'forward and downward' genioplasty rather than sliding genio.  SG will shorten your chin further.

[kavan]

Your ceph is kind of wonkey. Perhaps because it's a photo of ceph and not the digital file of the ceph. But, of course, it still yields some information to inspect. Just not enough to be precise as to angles of inclination. For example, I measured about a 27 degree angle of inclination of the border of your mandible with the edge of the photo. That is to say, I looked at the MPA relative to the 'absolute' horizont of the picture plane. I also did a Steiner measure where your sella point to 'N' point were aligned with the horizont to get same/similar MPA angle of about 27. Thing is a photo of a ceph is going to warp things.

For the purpose of the concepts and only the concepts, for now, let's just assume it isn't warped and let's use a horizontal plane that is parallel to the horizontal edge of WHOLE photo as reference which I've elected to do because on your ceph (even though it might be warped), I can draw a straight horizont from your 's' point to your 'N' point.

What I want to determine is whether you are a candidate for CCW downgrafting of the maxilla; BIMAX surgery where both maxilla and mandible are displaced. This is because CCW downgrafting allows for more significant mandibular advancements (and lower airway opening) than single BSSO in a case LIKE YOURS.

Concept #1. You can have CCW downgrafting (along with BSSO, of course) IF you are not a 'low angle' patient. This refers to the mandibular plane angle; MPA and a patient who COULD have their MPA made LESS steep and be within norms.

Approx. norms for MPA (relative to the horizont) 17-28 degrees

What I measured on YOUR ceph: 27 deg

Concept #2. You can have CCW downgrafting (along with BSSO of course) if your Occlusal Plane (OP) COULD be made less steep.

Approx. norms for OP The normal value for adults is 8 ± 4°.  So from 4 deg to 12 deg.

What I measured on YOUR ceph: About 10 deg.

BOTH plane angles; MPA and OP can already be WITHIN the norms. We just want to know IF it can be made LESS steep (even though neither is steep or too steep) and still be within the norms of those plane angles.

So, from those measures AGAINST the question of: 'Could you have CCW downgrafting?', the answer is veering toward; 'Yes' in this APPROXIMATION. For example a CCW down graft decreasing the OP by 6 deg would leave you with an OP of 4 deg which is within the norm and the approx. 6 deg CCW rotation of mandible in response would leave you with an MPA of about 21 deg which is within the norm.

As to the surgeon who told you he CAN'T do BIMAX (or won't): That is because your ANS is too protrusive where your upper lip is TETHERED to the base of your nose and pushing it forward along a horizontal vector (by aligning the maxilla via the DG so it can be move in a horizontal vector). The nose to lip angle would look BAD with any forward advancement of maxilla (where you would want SOME to get a more significant BSSO). If the surgeon just cut off your ANS (which is TOO prominent), your downwardly rotated nose tip would be 'kissing' your upper lip and that would look BAD. The surgeon does NOT want to tell you that he CAN'T DO a good rhinoplasty which would HAVE TO BE DONE in order to cut down your ANS.

The GENERAL 'rule' is to get rhino AFTER a maxfax/bimax. But EXCEPTION to this rule is when someone has a really protrusive ANS like you have. In which case you get the rhino first and have the rhino doc either keep the tip in a slight downward rotation or at least neutral. Because later maxfax advancement would tend toward the tip going a little upward. Hence, you would not want the rhino to give an upward tip. Otherwise, who ever does the bimax surgery ALSO needs to be very conversant in RHINOPLASTY or they need to work in conjunction with a rhino doc. If so, the ANS can be reduced during the bimax.

Your case is very challenging, not only because of the ANS issue but also because the BODY of the mandible is vertically very short which is not same thing as being a 'low angle' MPA. The body of the mandible is short because the distance between the roots of the lower teeth and the cortical bone is short. Between the roots of teeth and cortical bone is the mandibular nerve. So, I don't think you would be a good candidate for a chin wing to lower the border of the body of the mandible for more vertical height. Looks to be too close for confort to cut and  totally avoid the mandibular nerve.

If you could get an OVERALL downgraft to entire maxilla to increase your facial height that would be good. But that would depend on whether you had LACK of tooth show. IF you also have LACK of tooth show, an overall downgraft could be more in the back and less in the front and still be a CCW rotation.

Chin: downward diagonal direction with bone butress between the cut segment.

All that said, you would need to consult with a doc who does overall downgrafting to the maxilla. Doctors who can't do overall downgrafts to the entire maxilla, won't be able to do CCW posterior downgrafting either. Ideally, the doctor should have a good RHINO GUY on STAFF to work WITH HIM.

OTHER: You do need braces for a long period of time to prepare for bimax surgery, whether your 'bite is right' presently or not. They often need to make it 'wrong' so they can make it right for the NEW jaw BALANCE that is planned. (decompensation).

The surgery, even if you turn out to be a candidate for an over all downgraft to increase your facial height would not tend to entirely compensate for the short body of the mandible. You would be looking at a jaw implant LATER DOWN THE LINE.

[Greenlit]

A LOT of food for thought thanks to your responses, thanks.

My impression about maxfac in the area is that they are fairly conservatives in their approach. I am not sure wether the others would try a bimax on a complicated case.
 
If that's the case, my two options are
1) go with the flow (ortho + BSSO + genio + rhino as said before)
2) go abroad: doing heavy surgery (ortho + rhino + downgraft for CCW) in another country, with stuff that could go wrong a million way is not something I want to try right now...
(if you have any names in europe that are good enough to manage this, I will still take them !)

Anyway, I'll keep going at it.
kavan, even though the ceph is wonkey, with the conservative approach (BSSO + genio), how much of projection do you think I could manage to gain ? And compared to bimax (considering it COULD be done, which is not a given) ?

[kavan]

A LOT of food for thought thanks to your responses, thanks.

My impression about maxfac in the area is that they are fairly conservatives in their approach. I am not sure wether the others would try a bimax on a complicated case.
 
If that's the case, my two options are
1) go with the flow (ortho + BSSO + genio + rhino as said before)
2) go abroad: doing heavy surgery (ortho + rhino + downgraft for CCW) in another country, with stuff that could go wrong a million way is not something I want to try right now...
(if you have any names in europe that are good enough to manage this, I will still take them !)

Anyway, I'll keep going at it.
kavan, even though the ceph is wonkey, with the conservative approach (BSSO + genio), how much of projection do you think I could manage to gain ? And compared to bimax (considering it COULD be done, which is not a given) ?

Challenging vs. complicated is matter of semantics. I don't know if it's a 'complicated' case. It's more of a matter of it being challenging and so you would be looking for doctors who are USED TO tackling these kind of challenges that indeed would be 'complicated' for a lot of the garden variety maxfax docs.

What I mean by 'challenging' refers to doctors who CAN do the overall maxillary downgrafting which can have a significant 'thickness' to it that other doctors don't usually do. An example is type of CCW downgrafting.




Notes:

1: 'Abroad' for you is not that far given you are in Europe.

2: As mod of board, I don't give recs. for doctors. However, others are free to do so given they are familiar with the ones who do the 'thick' maxillary downgrafting.

3: I don't calculate the mm gain and would not do so with that type of ceph where I don't know the distortions. I would tend to defer to what the doctor told you for a general approximation. Like I'm not going to challenge or deny his 5mm estimate other than to say, aesthetically, you would need more than that. How much you can get with individual BSSO is a function of how far they can push the lower teeth backwards which usually involves pre molar extraction and braces to push teeth backwards. You probably would not like that phase because the lower lip would go backwards with (temp) loss of support of lower teeth and you would have a more exaggerated overbite look in the interim of preparing for the surgery.

I can tell you though you could get MORE BSSO gain with CCW downgrafting than you would have with BSSO only. Also, it usually does not involve tooth extraction to make room to push the lower teeth backwards in order to displace the mandible forwards.

The concept of more advancement involved is the 'Rotation of a TRIANGLE'. I have a post on this in the educational section. Here is the link: http://jawsurgeryforums.com/index.php/topic,7883.msg72313.html#msg72313

[Greenlit]

Thanks, I will try to keep the topic alive when I have news.

[kavan]

Thanks, I will try to keep the topic alive when I have news.

Seriously, I would pursue a rhinoplasty first given the Anterior Nasal Spine of your nose and also given that one of the best maxfax guys in CCW downgrafting can't do all of the other  rhino techniques that would go along with cutting down the ANS. Going into a bimax/maxfax consult with the ANS/nose situation already CORRECTED will open up your options for bimax . 'Tension nose.' 'Tethered lip from protrusive Anterior Nasal Spine.' 'Deprojection.' 'Hypertrophy of the nasal spine'

Here are a few names of rhino docs in Europe you could consult with:

Olivier Gerbault, M.D. France

Lucian Ion, M.D.  London, England

Armando Boccieri MD Rome, Italy

[PloskoPlus]

I would not do rhinoplasty first since you will need jaw surgery regardless, and most likely bi-max.  No matter what the surgeons promise, the nose always changes after upper jaw surgery — sometimes a little, sometimes a lot. Also reducing the ANS is a standard procedure for most jaw surgeons.  You really need proper cephalometric analysis before going further with this.  SNA, SNB and occlusal plane angles will determine what the best treatment plan is in terms of advancement and rotation.  BTW, your chin bone is quite prominent.  I don't think you need genioplasty.

[kavan]

I would not do rhinoplasty first since you will need jaw surgery regardless, and most likely bi-max.  No matter what the surgeons promise, the nose always changes after upper jaw surgery — sometimes a little, sometimes a lot. Also reducing the ANS is a standard procedure for most jaw surgeons.  You really need proper cephalometric analysis before going further with this.  SNA, SNB and occlusal plane angles will determine what the best treatment plan is in terms of advancement and rotation.  BTW, your chin bone is quite prominent.  I don't think you need genioplasty.

Read my explanation as to why, in his case, it should be done first.

ETA: He took his photos down.

[Greenlit]

Yes, I got enough info for now. I took a new picture of the ceph in better conditions (on a flat surface, with light coming from behind), I believe it's more suitable for correct analysis. Anyway, I probably will have numeric pics with the ortho.

Thanks for the rhino contacts (why these one though, there are hundreds of plastic guys that do rhino ?)

[kavan]

Yes, I got enough info for now. I took a new picture of the ceph in better conditions (on a flat surface, with light coming from behind), I believe it's more suitable for correct analysis. Anyway, I probably will have numeric pics with the ortho.

Thanks for the rhino contacts (why these one though, there are hundreds of plastic guys that do rhino ?)

Indeed, there are multiples of 100's of rhino guys. Rhinoplasty is the most difficult operation (unless someone has what some call a 'Green light' nose -no relation to your screen name.- which is basically just a dorsal hump. It's called 'green light' rhino because the surgery is more straight forward than 'yellow light' or 'red light' noses and also because patients get the most satisfaction from it.)

Why these names? To decrease the probability of your going to a 'garden variety', 'who knows who', 'run of the mill' PS because NONE of the names I gave are such.

Also because they are in EUROPE and are either respected names in rhino and/or who have contributed to the advancement of rhino techniques eg. literature publications, open courses and/or have overlap with maxfax.

I would also add Wolfgang Gubisch (Germany) and Nazim Cerkes (Turkey) to this list.

Basically, I have a good grasp of 'who's who' in rhinoplasty. Basically, IMO, you don't have what they call a 'green light' nose situation which would be in venue of countless PSs out there doing rhinos. Given there are INDEED not only '100's of PSs who do rhino but also multi 100's, that situation can  INCREASE your PROBABILITY of going to a 'garden variety', 'run of the mill' one. Hence, I've tried to DECREASE the PROBABILITY of doing that by giving you some names that are NOT the run of the mill, 'who knows who' PSs doing rhino.

There are more good rhino guys in Europe. But I think giving you 5 names to consider consulting with (who have peer recognition in the field) will lower the probability of 'wasted' consults on the multi hundreds of run of the mill possible PSs who do rhinos.

[Greenlit]

Hello everyone,

Update regarding several things:
- sleep apnea was confimed with a complete sleep study (but less severe than predicted, 10 AHI)
- I consulted with an expert in rhino as kavan advised (the one who invented a recent tool, you probably know who I'm talking about kavan).... he told me that it would be unwise to touch the nose before a bimax even if the nose is "prepared", as it's difficult to anticipate soft tissue reaction to maxillary movements.
- I consulted with maxfac in my area:
-> regarding the first one I saw at the beginning of the year, it was confirmed by a second maxfac that only moving forward the mandible would not allow sufficient movement (not close AT ALL) to cure the OSA...
-> he wants to do bimax but can only do foward advancement.... with the risks implied (chimp lip, and the tethering lip+++). He seems to have an eye for aesthetics, but you can only do so much with limited techniques.
Among the other maxfac in my area, none can do or will do downgraft with CCW rotation (which is kind of amazing....).
The rhino guy advised against maxillar advancement from an aesthethic standpoint... (he talked about straightfoward I believe, probably because of the tethering; no one does posterior downgraft in my country it seems)

I did an online consult with a famous spanish maxfac, here are the conclusions of the consult (my comments)
Maxillo-mandibular retrusion
- High occlusal plane (meh, not that high IMO, the OP is more flat than steep on the ceph)
- Lack of support of perimandibular tissues and neck (yes)
- Relative rhinomegaly (yes)
- Obstructive sleep apnea (yes)
- Class II (yes)
- Dental compensations in the upper and lower arches

He is proposing
- Orthodontic decompensation with torque correction in the incisors
- Bimaxillary surgery with advancement and counterclockwise rotation by posterior downgrafting with HA blocks

Told me spontaneously that I did not need rhino (unless it was a huge aesthetic concern for me, he could do it) because the nasolabial angle would be closed by: shaving of the ANS, correcting angulation of the upper incisors with orthodontics associated with CCW rotation of the maxilla. The bimax would put everything in the same plane and decrease the "important" aspect of the nose.
Told me that I did not need genioplasty either (but I forgot to ask about the shortening of the face after rotation, I will send him a question).

The price is hefty, I have to think about it.

- What do you think about this ? I am not sure I am positive regarding the tethering of the lip corrected by ortho + CCW of the maxilla during the bimax, the litterature describes the opening of the nasolabial angle (but only when straightfoward advancement i believe)