Different Docs different movements? Side by side comparison

[Lani]

Two docs (A and B) recommended different treatment programs. I have a link to the side by side comparison (simulation by dolphine software w/ movements)

I need Bimax sugery for airway expansion/bite. My airway is very low percentile (19mm2) on a scale of 0-400 mm2.
CCW for both

 obviously, these are SUPER rough predictions and CAN change.... but which one is better? A combo of both?

OTHER Differences....
A also suggest 2-3 cuts into my maxilla for my cant on right side (lefort 1, 2- or 3 piece), B isn't sure yet and needs to run it in their software more, but most likely not....

As movements (4 mm top/ 10 mm bottom) provide for maximum airway expansion BUT there is some chimp lip going on....I heard that these dolphin visual soft tissue simulations aren't very accurate though...opinions?
BS is less movment (4 mm top, 7-8 bottom)

Both include genioplasty setback (recut a wedge out).

HX:
recessed maxilla, very recessed mandible, mandible pushes soft tissue back in sleep and i breathe poorly at night. I constantly jut lower jaw forward subconsciously during daytime to breathe better.

-all 4 bicuspids pulled
- When I smile I have "dark corners" b/c my top+bottom arch is super narrow.
--Went from a class II to a slightly better class II. one side (R) has a 2 mm cant (can't close that side, or can partially touch/close both sides jaggedly)  and bottom jaw only meets top jaw when i horizontally jut out bottom jaw to meet top jaw.


Prior surgical history 8 years ago : genioplasty (5 mm forward, 2 mm down), then had 2-3 mm of fat graft on the chin (like old school horizontally projecting chin implants). The genio was designed at 5 mm to have enough projection, but the fat graft doc without permission went and loaded my chin up with fat graft blobs... (communication error between the two surgeons....) didn't reabsorb, 80% stayed...




some other questions:

Every US surgeon consult has done an analysis (software or by hand) treating the chin fat blob like bone. When I brought it up, most acted confused and hesitant to treat that as an issue. others said they will just move my mandible forward less during the BSSO (like 7 MM instead of the planned 10-11 mm) so that my chin won't look like a witch. But that's LESS airway expansion!  And depending on the fat blob for chin aesthetics is risky...fat fades with age and less movements comromises airway expansion.

 what would you guys do about the fat blob in the chin? it's 3.5 mm of projection from chin bone (pogonion to b point) and I don't know which part is fat/muscle/the submental angle is VERY ACUTE. Also don't know what layer it's at. I went to 1 fat graft specialist and he didn't know what layer the fat was in...seem confused on removal Some do, though.


btw, does anybody know anything about  the difficulties of redraping the soft tissue after a revision genio? Some docs simply won't redo genios for that reason, saying that the muscles/soft tissues that are streched in a genio are different from those streched in a BSSO and that a genio revision (reduction of first genio w/ a wedge) would leave sagging that's not compensated by the BSSO.


thanks!!!

[GJ]

Notes:

- Your upper central incisors have short roots. Is this from prior orthodontic movement? If so you might be limited in what you can do. The angle of those teeth do look good so hopefully minimal movement. Your teeth look nice and healthy otherwise.

- Chin looks good in terms of current placement. Makes you look class I. I'm not sure about the fat grafts. Both docs seem to want setback. Just defer to them on this because nobody here will know how to treat a "fat blob", and have them remove the fat at that time.

- I don't see the need to fix that minor cant.

- You have enough overjet to get a lot of the movement there; looks like at least 3mm.

- Therefore, I'd go with the plan that has less rotation. Your facial height looks good as-is, so I think moving the jaw linearly to close that overjet, and then rotating for the rest that you need to open the airway, makes the most sense. Adjust the chin as needed. If you want a more masculine jaw go for the plan with heavier rotation. This will make the face appear shorter, wider, etc. Both should improve apnea.

[Lani]

Yes, I had an accident that resulted in shortened roots on the top two front upper incisors, due to trauma. Also, my ortho did everything every fast.

Just a quick 2 clarification questions if you're able, GJ:

-Is an anterior maxilla impaction something that you'd recommend? A wants to do an anterior impaction and a posterior downgraft (Thus CCW) that would result in the 4 maxilla/10 mm mandible movement really being anterior maxilla looking like 3 mm forward motion from the anterior point and 4 mm forward motion from the posterior point.  The rough plan/ sketch is below:
the top facial third is 34 mm, midface third is 36 mm, bottom is 33 mm, and I'm female, so wondering if maxilla impation will shorten the midface? My smile is kind of horizontally scrunched anyways. B says that is prob not necessary. They seem to be more conservative than A in this case.

--When you say plan with least rotation, I take it the rationale is the shortened teeth roots allowing for minimal orthodontics and also not wanting to affect facial height? Does CCW decrease or increase midfacial height?

Thanks so much.

[GJ]

Sorry, I didn't know you were female.

The reason I said to go with the least rotation is that your profile looks pretty balanced right now, and I'm not seeing a very steep mandible angle. So you might wind up with a short/boxy face if you do a lot of rotation. This can look good on people naturally born with that facial pattern, but if they go overboard, not so good on people who were born with longer faces or even average length faces. Reason being you can't shorten the midface or upper face. So you wind up with all the same feature relationships there, but in the lower face things change/shorten. I'm not sure which plan would result in more orthodontic movement, but given your roots, you might want to consider that, too.

If you're female, you run into the problem of rotation generally resulting in a more masculine look, too.

I'm not a doctor, so I can't recommend anything. But with regard to impaction, that's impossible to say without seeing the records that made them recommend impaction. In general, if you have 3mm or more of gum showing when smiling, that level of impaction is about right. But how long are your teeth? Will they get hidden at rest by the lips? Etc. You might have to compromise. I'd go for showing teeth at rest (youthful) over worrying about gum show on big smiles if I had to make a choice between the two.

[PloskoPlus]

Not a radical plan by Wolford's standards.

[SMSOMS]

With the 1 mm impaction of the maxilla that Wolford proposed you will get some autorotation of the mandible forward and that is some of the difference in the amount of pogonion change of 10mm vs 8mm.  Segmenting the maxilla also gives you total control of the 3D changes in the maxilla and gives you better coupling of the occlusion, allows for some minor incisor re-angulating if desired and is something I routinely do.  I feel it is so beneficial that I may do 3-5 single piece LeForts a year and the other 130-145 per year are segmented.  None of the soft tissue simulations are really that accurate so do not make a decision based on that.  I agree the chin needs setback

[PloskoPlus]

With the 1 mm impaction of the maxilla that Wolford proposed you will get some autorotation of the mandible forward and that is some of the difference in the amount of pogonion change of 10mm vs 8mm.  Segmenting the maxilla also gives you total control of the 3D changes in the maxilla and gives you better coupling of the occlusion, allows for some minor incisor re-angulating if desired and is something I routinely do.  I feel it is so beneficial that I may do 3-5 single piece LeForts a year and the other 130-145 per year are segmented.  None of the soft tissue simulations are really that accurate so do not make a decision based on that.  I agree the chin needs setback

Isn't every lefort an automatic 1mm impaction due to the osteotomy?

[SMSOMS]

No...Most put an external reference Steinman pin at Nasion and you measure pre surgically and then before you plate the maxilla such that you can keep it the same or change it

[PloskoPlus]

No...Most put an external reference Steinman pin at Nasion and you measure pre surgically and then before you plate the maxilla such that you can keep it the same or change it

It's just that I see so many cases where supposedly nothing was done to the maxilla vertically, yet the tooth show is clearly worse after surgery.

[SMSOMS]

They may be using internal measurements which are notoriously inaccurate or guessing.  There are lots of dabblers doing jaw surgery.  I see that in my community.  Guys are doing 3-5 cases a year and on their website they are "doing all the time".  Unless someone is doing 50 or more DJS a year they are a dabbler in my view.  Sounds harsh but true

[Lani]

SMSCOMS, (or anybody else with insights of course)

wanted to ask you a question-- when you mentioned a multi-piece segmental lefort, in my case, would that be beneficial or extra risk due to my shortened tooth roots (you can see how short on my xray in the original posts link above)?

Asking b/c i have a mildly crappy bite (cant on right side) and 4 bicuspids pulled sadly. Due to sleep apnea induced teeth grinding, I have shortened roots (as seen on my cbct/xray) on all. the front two incisors have ultra short roots due to an accident `18 years ago. I"m early thirties in good health, and female...

Some (non segmental lefort 1 maxilla 1 piece guy) have said to just to invisilign after jaw surgery to make it "good enough" and some (more aggressive/more experienced guy, 2 or 3 piece maxilla  lefort 1 guy) have said to do braces before, jaw surgery, then after. All have said they'll have to be careful due to my short roots, moving the teeth the minimal amount (to within mm's).

you said a multi piece lefort 1 can allow my maxilla pieces after the cut to allow for a better bite afterwards--does this mean less orthodontic movement to teeth with braces? I imagine if you are manipulating the maxilla pieces in different angles/vectors (?) that's less movement for teeth to make? Or does it not matter b/c the teeth will have to be in line with each other since they are neighbors even if not on the same piece of bone.

asking b/c 1 doc (non-segmental lefort guy says just to do invisiline after, and the more aggressive (multi segmental lefort 1 guy)  says to do braces before and after. I may be wrong, but sense that just maybe, the non-segmental lefort guy is saying that b/c he wants to reduce risk or doesn't have enough experiance in doing that jigsaw with the different segments/braces..the 2nd guy is known for being aggressive.

Are my teeth roots really short such that one is better other the other? I'd love to be able to fix the cant while not damaging my teeth roots more, the right side can't close it's a few mm off and that side is also where I exclusivity grind all the time (chewed through multiple night guards). would like to fix that as well as better breathing.

thanks for any insights and have a great holidays!!! 

[ArtVandelay]

you said a multi piece lefort 1 can allow my maxilla pieces after the cut to allow for a better bite afterwards--does this mean less orthodontic movement to teeth with braces? I imagine if you are manipulating the maxilla pieces in different angles/vectors (?) that's less movement for teeth to make? Or does it not matter b/c the teeth will have to be in line with each other since they are neighbors even if not on the same piece of bone.

I'll take a stab at this part. The answer is not necessarily, I'm in a similar position where a one piece L1 solves airway problems but a segmental would do a lot to improve the bite. For a one piece L1 I'm essentially a surgery first and possibly only case. But to go the segmental route I need heavy braces for pre-surgery orthodontic de-compensation to rotate my lower molars upright . If you're being recommended a segemental I would imagine you have either 1.) a cross bite and regular upright molars (unlikely if segmental isn't a unanimous suggestion) 2.) also have tipped lower molars to some extent which needs an orthodontic rotation

See post #26 here for what I mean by tipped lower molars:
http://jawsurgeryforums.com/index.php/topic,7383.msg71403.html#msg71403