Author Topic: Advice for recessed maxilla surgical plan  (Read 2728 times)

ultralightbeam

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Advice for recessed maxilla surgical plan
« on: September 06, 2021, 01:54:05 AM »
Hi, I'm an early 20s male in orthodontic preop for surgery and I wanted to get some feedback on my surgical plan.

Issues/symtoms
My maxilla is recessed and vertically deficient, I can't bite properly as I am edge to edge, and I have a slight lisp. I had a cross bite and corresponding nasal breathing issues as well, but I underwent maxillary expansion last year to correct that - my symptoms are much better now and a recent PSG showed no evidence of apnea. Aesthetically, I have sunken eyes/scleral show, a flat midface, and my tooth show while smiling is less than half of what it should be.

I consulted with two well known surgeons and both suggested an upper jaw advancement and anterior maxillary downgraft. The surgeon I chose wants to move my maxilla forward 3.9mm and down 2.9mm, measured at the ANS (see Surgical plan below). The main difference between their plans is that the other surgeon also suggested cheek implants and a genioplasty to shorten the lower third of my face, as it is a bit long. However, my surgeon recommended not to do either of those because he said I would look unnatural.

Questions:
  • Is the proposed jaw movement enough, both forward and down, based on my ceph?
  • How much, if at all, of an airway improvement would be noticed by a 4mm maxilla advancement? Does an anterior downgraft affect the airway as well?
  • Is my lower jaw projected forward enough?
  • My lower jaw is off-center by 1-2mm - would it be noticeable if the surgeon has to shift my maxilla or if I have to undergo ortho post op to correct the misalignment? And is it commonly done in jaw surgeries? Ideally my lower jaw would be centered but I don't think it's worth paying for and going through the risk and recovery of lower jaw surgery just to slightly shift it.
  • Will this movement make my midface more or less prominent? I've seen some people online say that it helps and some say that it makes it flatter. The surgeon said he can do a high LeFort I but I'm not sure if that helps.
  • Would cheek implants/genioplasty be something to consider or would it look unnatural as my surgeon said? If I did want implants, my surgeon would use HA grafts.

I've attached images below. Thanks in advance - I've read a lot of the information on this site for over a year and it helped me greatly in learning all about jaw surgery, so I'm looking forward to getting some advice from you guys here!

Front skeletal - https://imgur.com/4zrgppd
Lateral skeletal + soft tissue - https://imgur.com/0986WtP
Lateral Xray - https://imgur.com/ayZzNkU
Front face - https://imgur.com/rBuVnzm
Side face - https://imgur.com/ANqYu1N
Side face 2 - https://imgur.com/woLp0x9
Diagonal face - https://imgur.com/pi7yU6h
Ceph tracing - https://imgur.com/LsjZvWZ
Surgical plan - https://imgur.com/wyzh50K

Lazlo

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Re: Advice for recessed maxilla surgical plan
« Reply #1 on: September 06, 2021, 10:29:31 AM »
yeah just get the maxilla shifted forward, would be a massive improvement. don't worry about lower jaw surgery at all, your chin and lower jaw are perfect --everyone has a bit of asymmetry, not worth addressing given the risks.

kavan

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Re: Advice for recessed maxilla surgical plan
« Reply #2 on: September 06, 2021, 01:29:12 PM »
You really should put your photos together all on ONE IMGUR link. Absent of that, I will just look at ONE link which is the surgical displacement plan. Thanx though for naming the links so I knew which one to choose.

It looks like a good plan that focuses on addressing some maxillary deficiency and basically allowing your mandible to AUTO-ROTATE (a little) to close the new bite. Lucky you, it's basically a single jaw surgery aimed at addressing maxillary recession.

The plan conveys that the directional displacement vectors of the maxilla are approx 4mm horizontal and approx 3mm downward which is the displacement needed for your mandible to stay ALMOST where it is already but auto rotate just enough to close the new bite.

The proposed movement is a good one. No one on here can get any more accurate that the high tech program used by this doctor to balance the jaws and the bite.

Airway opening is a MOOT point since you probably don't have a problem to the lower airway because your lower jaw is in a GOOD position. It's NOT recessed. Also, you relay your upper air way has been addressed prior.

Sometimes the lower jaw is off centered due to the maxilla. If that's the case, they often do a 3 piece lefort to make adjustments. However, everyone has SOME asymmetry and yours might be within the norm

Movement is to correct maxillary recession so your maxilla will go horizontally outward and down. The 'lefort 1' area is where the movement is. So that is approximately LOWER midface becomes more prominent. Parts of the maxilla above the L1 area are NOT moved; areas under eyes and cheek areas STAY where they are. If they are already recessed and could look RELATIVELY more recessed via the L1 area movement, that can be addressed with some HA paste material so they don't look more recessed.

Maxillary movement in maxfax surgery does NOT change the cheeks nor area below eyes. So, if those are recessed, they might look a little more relatively recessed after the surgery. BUT where the part of the maxilla they actually MOVE is now recessed, THAT PART of the maxilla make your lower midface more prominent.

It is best to wait AFTER the type of surgery you are getting, to get upper face implants LATER on OR the surgeon can use some HA grafts to enhance those areas. Cheek implants could be too much of a 'surprise', perhaps an unpleasant one which is why it is best to evaluate AFTER surgery to put in those things. HA paste, however, is more subtle and can be done so areas above Lefort 1 area don't look relatively more recessed. So, fine IF your surgeon wants to put in the HA paste during the surgery. But NOT fine for what ever one/s wanted to put in cheek implants during the surgery.

Chin can be shortened at LATER time too. BUT it is FINE where it is NOW and will be FINE after this particular proposed surgery. So, the surgeon is CORRECT not to change chin during this surgery which gives you OPTION to 'wait and see' at a LATER time whether or not you want to shorten it.

I AGREE with which ever surgeon gave you THIS plan and advised you NOT to get CHEEK IMPLANTS and chin shortening during the same surgery. But I do agree he could enhance cheek/upper midface area with HA paste/bone paste during same surgery which would help address any RELATIVE recession you might see to upper midface after your lower midface is displaced 'forward'.
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ultralightbeam

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Re: Advice for recessed maxilla surgical plan
« Reply #3 on: September 06, 2021, 09:01:22 PM »
Thanks for both your responses! And sorry about the separate links - here is a link with them all: https://imgur.com/a/HHEwPss

Quote
It looks like a good plan that focuses on addressing some maxillary deficiency and basically allowing your mandible to AUTO-ROTATE (a little) to close the new bite.

Where do you see the autorotation in the plan? Is it the -8 figure for Lower 1? If so, does that mean my lower jaw will swing up 8 degrees? And does that translate to a noticeable visual difference or is it almost imperceptible?


Quote
Sometimes the lower jaw is off centered due to the maxilla. If that's the case, they often do a 3 piece lefort to make adjustments.

My surgery will be a one piece LeFort so that's why I don't completely understand how the jaws will be aligned. And all of the surgeons I've consulted have said my maxilla is symmetrical, so it is just my lower jaw that is slightly off center. You can see in this Invisalign model the degree of asymmetry in my lower jaw: https://imgur.com/Qo91fbi (also in the album link above).


Quote
I AGREE with which ever surgeon gave you THIS plan and advised you NOT to get CHEEK IMPLANTS and chin shortening during the same surgery. But I do agree he could enhance cheek/upper midface area with HA paste/bone paste during same surgery which would help address any RELATIVE recession you might see to upper midface after your lower midface is displaced 'forward'.

Sorry I should've been more clear - both surgeons offered HA paste for cheek augmentation, but the surgeon I chose didn't recommend it. I'm a little wary because from what I've read on here, cheek augmentation on males does not look good/natural, so unless that doesn't also apply to HA paste, I am not too confident about going forward with it.

Thanks again for the helpful advice!

kavan

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Re: Advice for recessed maxilla surgical plan
« Reply #4 on: September 06, 2021, 11:34:18 PM »
Thanks for both your responses! And sorry about the separate links - here is a link with them all: https://imgur.com/a/HHEwPss

Where do you see the autorotation in the plan? Is it the -8 figure for Lower 1? If so, does that mean my lower jaw will swing up 8 degrees? And does that translate to a noticeable visual difference or is it almost imperceptible?


My surgery will be a one piece LeFort so that's why I don't completely understand how the jaws will be aligned. And all of the surgeons I've consulted have said my maxilla is symmetrical, so it is just my lower jaw that is slightly off center. You can see in this Invisalign model the degree of asymmetry in my lower jaw: https://imgur.com/Qo91fbi (also in the album link above).


Sorry I should've been more clear - both surgeons offered HA paste for cheek augmentation, but the surgeon I chose didn't recommend it. I'm a little wary because from what I've read on here, cheek augmentation on males does not look good/natural, so unless that doesn't also apply to HA paste, I am not too confident about going forward with it.

Thanks again for the helpful advice!

The plan has hardly any displacement to the mandible at the B point and Pog point. So it's basically a single jaw surgery to upper jaw. Imperceptible movement at lower jaw.

If one piece Lefort and you're not getting a BSSO, than maybe the asymmetry is minor or braces can help.

You don't have to go through with any cheek augmentation if you don't want to. You can do that LATER if you so decide.
Please. No PMs for private advice. Board issues only.