BSSO or Bimax? (Cephs and Pics)

[Reoreyh]

I am currently slated to have a mandibular advancement surgery in the coming months. I am in a very fortunate position because of a family connection, so I am not going to be paying for my surgery. However, this has put me into a weird situation where I haven't really gotten more than about a half hour of face time with my surgeon or his staff since getting my pre-surgery orthodontics three years ago. My last consultation (last summer) was about 10 minutes long and I did not get to ask any questions. He's a busy guy and does a lot of work on children with deformities and other reconstructive stuff. Because I'm getting this done for free, and because of the nature of his work, I feel horribly guilty and I'm not sure if and how to ask about my aesthetic concerns. Beggars can't be choosers, to sum it up. I am almost ready to consult another surgeon so that I can get a procedure more in line with what I want.

My issue is that I've been told by others that I need bimax. I have very little incisor show and a droopy, humped nose. Almost every case I've seen similar to my own (Class II Division 1) calls for at least some maxillary downgraft.

Is anyone able to comment on what I need for both proper occlusion and an aesthetic upgrade? Am I correct to think I need a Lefort?


https://imgur.com/a/39LT5dU

[GJ]

Your occlusial plane is super flat. Pretty ideal. You also have an overjet, and it looks like about 6mm or so, maybe a little more. So you could probably get away with a linear advancement of the mandible only.

This would be ideal, imo, because you could get a nice lower jaw while avoiding all the hazards (mostly nose changes) of messing with the upper.

You could then fine tune the outcome by messing with the chin. Probably out and down (slight CW) since your face is compact and your nasolabial fold is very deep.

That's what I'd shoot for. What is the surgeon recommending? Agree that is an awkward position, but you could just be upfront and say something like, "I'm super grateful yada yada, but I am also nervous about the procedure, so I just need to know xyz (and ask your questions)."

[Reoreyh]

Your occlusial plane is super flat. Pretty ideal. You also have an overjet, and it looks like about 6mm or so, maybe a little more. So you could probably get away with a linear advancement of the mandible only.

This would be ideal, imo, because you could get a nice lower jaw while avoiding all the hazards (mostly nose changes) of messing with the upper.

You could then fine tune the outcome by messing with the chin. Probably out and down (slight CW) since your face is compact and your nasolabial fold is very deep.

That's what I'd shoot for. What is the surgeon recommending? Agree that is an awkward position, but you could just be upfront and say something like, "I'm super grateful yada yada, but I am also nervous about the procedure, so I just need to know xyz (and ask your questions)."

I updated the link with an image of my intraoral photos, showing my bite.

If I do not get a maxillary advancement, does this not limit the amount of length I can add to my mandible? My ortho mentioned a clockwise movement of my jaw in passing. Not sure how accurate that eval is. From my own research as a layperson, I have to guess that they're going to give me a clockwise rotation and advancement of the lower jaw to fix my overjet and overbite.

I honestly have no idea what he's recommending. I've barely been able to speak with the guy. My mother is the head of his staff and so she interfaces with him here and there (very briefly) about my case. I believe he's recommending a BSSO for advancement - not sure what cut. He received my models recently and suggested veneers. He says I have small teeth.

A genio/my chin has not been discussed or mentioned ever. I'm willing to entertain suggestions and ideas if that can improve my face. My biggest fear is that I'm getting the bare minimum of functional surgery and that I won't be able to get it changed or improved after.

Do you personally see any maxillary retrusion in my case? Are my chips and small teeth the cause of my lack of incisor show? Maybe I should consider a rhino instead of upper jaw fixing my nose?

[GJ]

Your incisor show looks fine to me in the photo where you're smiling.

To me, your maxilla looks to be in a good position, which is why I was thinking if you can get away with lower only then that's a good thing. And to avoid the nose changes.

If I do not get a maxillary advancement, does this not limit the amount of length I can add to my mandible?

Yes, since your mandible teeth will hit your maxillary teeth after that overjet distance is closed. That's the limiting factor. So really you have whatever distance that overjet is + chin to get your jaw out further. If you do double jaw, you can move things more than that, but you're not a CCW case given your flat plane, and moving it CW could look pretty good, but it's unusual for a class 2 case to do that, and it wouldn't be a 1:1 ratio given the rotation angle. That's why personally I'd rather do that CW movement with the chin than the jaws.

I think what I gave is the ideal movement. But let others chime in. Can't hurt to ask another surgeon as well, so maybe do go on a second consult.

[Reoreyh]

Your incisor show looks fine to me in the photo where you're smiling.

To me, your maxilla looks to be in a good position, which is why I was thinking if you can get away with lower only then that's a good thing. And to avoid the nose changes.

Yes, since your mandible teeth will hit your maxillary teeth after that overjet distance is closed. That's the limiting factor. So really you have whatever distance that overjet is + chin to get your jaw out further. If you do double jaw, you can move things more than that, but you're not a CCW case given your flat plane, and moving it CW could look pretty good, but it's unusual for a class 2 case to do that, and it wouldn't be a 1:1 ratio given the rotation angle. That's why personally I'd rather do that CW movement with the chin than the jaws.

I think what I gave is the ideal movement. But let others chime in. Can't hurt to ask another surgeon as well, so maybe do go on a second consult.

I appreciate the response. You're probably right, but this is very disappointing. I don't think the movement he's going to do is going to have any affect on my appearance at all. I was hoping maybe I was missing something and that what he does will help fix my soft features like my nasolabial folds or my neck. I have deep nasolabial folds, like you said, and a double chin even at 10% body fat. Maybe I need a small implant? When I smile, I look horrible. The "smile" in that photo isn't a smile. It's just me jutting my teeth forward to touch and opening up a little. The tissues in my face and the stress needed to actually show teeth turn me into a goblin. Especially with my prominent nose.

It's funny. I was hoping for there to be much more wrong with my face than there is, so that the room for improvement would be greater.

My other question is, if he isn't going to rotate my jaw, how is he going to get my molars to touch? I cannot touch together my back teeth. Not now, or when I slide my jaw forward to where my overjet is gone.

[GJ]

When your lower jaw is out more, it will balance your nose. Everything is relative. Nose looks bigger than it is because jaw is smaller than it should be.

You actually have a good nose. Called an "aquiline" nose, and it's a sign of power and fertile masculinity. Trust me, I have that nose, and women like it. If you are having issues with women and those are the reason you're calling yourself a "goblin", I can tell you it's not the nose but something else (e.g. attitude, confidence, etc).

Also, some of the best cases I've ever seen have been Class 2 people who moved the lower jaw only. I actually think you have an ideal setup for a great result. See my sig. MM are miles on the face. If that overjet is 6 to 8mm as it appears, then it will be a big improvement.

My other question is, if he isn't going to rotate my jaw, how is he going to get my molars to touch? I cannot touch together my back teeth. Not now, or when I slide my jaw forward to where my overjet is gone.

That I don't know because they have to put the models on an articulator and see how they mesh. Hopefully it doesn't result in less advancement in order to make the teeth touch. If that's the case, then that's a bummer, and it could produce a mundane result. I'd definitely ask how many mm you can get closing that overjet. It's the key. If it limits the movement to under 6mm I'd change my mind about what I wrote above.

[kavan]

Hello. I  have only time to comment on your cephs and photos but not to address all your questions or confusion you may have accumulated by others suggesting bimax. So, I'm just going to give you my OWN 'take' based on your cephs/photos and won't be addressing what other people elsewhere told you.

You look like a very clear cut case for SINGLE JAW surgery; BSSO to mandible. That's because your upper jaw (and teeth) is/are forward to your lower jaw. So moving your lower jaw only would work for you and it looks like the bite will 'mesh' with that too (because your lower jaw teeth are 'behind' where they should be relative to the upper jaw teeth.

You are a LOW angle patient. This means that your MPA, mandibular plane angle is on low side, something where it's almost horizontal as is another measure; the OP (occulsal plane). Sometimes the angle relationship/s you have is referred to as 'short chin'. Now, what all that resolves to (even if you don't know what all these angle relationships mean) is this:

IF, in addition to having your mandible advanced 'forward', you ALSO wanted your chin to be BOTH a little LONGER and a little more PROJECTED, the type to opt for would be a 'diagonally downward' genio; something where the chin moves both outward and downward.

Other:

You have ample tooth show when smiling. If you seek more tooth show, then smile harder.

There is no problem with your nose that 'needs' correction via maxillary advancement or rhino. Although your tip has a downward rotation, that can be considered a GOOD thing BECAUSE it gives appearance of a short/er upper lip. Your upper lip (philtrum) would look LONGER to you if you got maxillary advancement to de-rotate the tip.

End of story.

[Reoreyh]

I believe I found a case very very close to my own. Tell me if I'm on the right track here.

https://www.youtube.com/watch?v=slQgtq6JMWY

The actual surgical movements are shown between 0:15-0:20. This is the only way that I can see him making my teeth actually line up - with a CW rotation like this. If he slid directly forward, I would have no occlusion. So when you guys say a BSSO - regardless of the cut type - it must call for this rotational movement, right?

[Reoreyh]

Your incisor show looks fine to me in the photo where you're smiling.

To me, your maxilla looks to be in a good position, which is why I was thinking if you can get away with lower only then that's a good thing. And to avoid the nose changes.

Yes, since your mandible teeth will hit your maxillary teeth after that overjet distance is closed. That's the limiting factor. So really you have whatever distance that overjet is + chin to get your jaw out further. If you do double jaw, you can move things more than that, but you're not a CCW case given your flat plane, and moving it CW could look pretty good, but it's unusual for a class 2 case to do that, and it wouldn't be a 1:1 ratio given the rotation angle. That's why personally I'd rather do that CW movement with the chin than the jaws.

I think what I gave is the ideal movement. But let others chime in. Can't hurt to ask another surgeon as well, so maybe do go on a second consult.

Hello. I  have only time to comment on your cephs and photos but not to address all your questions or confusion you may have accumulated by others suggesting bimax. So, I'm just going to give you my OWN 'take' based on your cephs/photos and won't be addressing what other people elsewhere told you.

You look like a very clear cut case for SINGLE JAW surgery; BSSO to mandible. That's because your upper jaw (and teeth) is/are forward to your lower jaw. So moving your lower jaw only would work for you and it looks like the bite will 'mesh' with that too (because your lower jaw teeth are 'behind' where they should be relative to the upper jaw teeth.

You are a LOW angle patient. This means that your MPA, mandibular plane angle is on low side, something where it's almost horizontal as is another measure; the OP (occulsal plane). Sometimes the angle relationship/s you have is referred to as 'short chin'. Now, what all that resolves to (even if you don't know what all these angle relationships mean) is this:

IF, in addition to having your mandible advanced 'forward', you ALSO wanted your chin to be BOTH a little LONGER and a little more PROJECTED, the type to opt for would be a 'diagonally downward' genio; something where the chin moves both outward and downward.

Other:

You have ample tooth show when smiling. If you seek more tooth show, then smile harder.

There is no problem with your nose that 'needs' correction via maxillary advancement or rhino. Although your tip has a downward rotation, that can be considered a GOOD thing BECAUSE it gives appearance of a short/er upper lip. Your upper lip (philtrum) would look LONGER to you if you got maxillary advancement to de-rotate the tip.

End of story.

I've seen my surgeon twice now since making this thread and I am now very, very lost. I've lost all confidence in him and I don't know what to do.

Basically he's not rotating anything. It's a straight advancement of 7mm to the mandible and that's it. I don't understand how that will even fix my occlusion. In no position am I able to close my molars and have an actual bite. I was 99% sure I was getting a CW rotation but I'm not. When I jut forward and try and simulate even a perfectly flat advancement, there is a large gap between my lower and upper teeth across all of them and I cannot close down any further.

Can you guys please help me understand what this guy is doing? I tried to get an explanation out of him why he isn't doing a CW rotation but he seemed to think that post operative orthodontics would fix this gap/bite? That can't possible be the case. Is this normal? If the orthodontic fixation is going to cause the occlusive solution, wouldn't that basically negate the entirety of my advancement by having the elastics just relapse my jaw back into it's original position?

I am devastated and panicking. I don't think I'm going to get any noticeable aesthetic or occlusal improvement. Am I missing something here?

Edit: Because you both mentioned that I have a flat occlusal plane, and that this determines what is possible/desireable for a surgery, I should mention that THEY made my occlusal plane like this with orthodontics. This was their plan. I was not born with or already had an occlusal plane like this. This was three years of braces to prepare me for this surgery. I have added a larger image of my smile taken at my orthodontist's clinic. For this photo they had me jut my lower jaw all the way forward to bring my teeth to touch - which I think is ridiculous and makes the photo inaccurate. It is NOT what my smile looks like. And I do not understand how this is ample tooth show. It's forced and stretched and you can barely see 2mm of incisor.

[kavan]

I gave you my take. You look like a very clear cut case for SINGLE jaw surgery. Rotation takes place at the maxilla. So since it's single jaw; BSSO, that's why there's no rotation.

[Reoreyh]

I gave you my take. You look like a very clear cut case for SINGLE jaw surgery. Rotation takes place at the maxilla. So since it's single jaw; BSSO, that's why there's no rotation.

And I accept and understand your take. I'm not questioning you. I'm questioning my surgeon. Why is he not going to AT LEAST rotate my lower jaw down so I can actually bite? Forget the maxilla. I don't understand how he can even align my bite with a purely horizontal movement. Am I missing something? I thought the purpose of the standard saggital split was to allow for both linear movement and rotations to fix occlusion.

[kavan]

And I accept and understand your take. I'm not questioning you. I'm questioning my surgeon. Why is he not going to AT LEAST rotate my lower jaw down so I can actually bite? Forget the maxilla. I don't understand how he can even align my bite with a purely horizontal movement. Am I missing something? I thought the purpose of the standard saggital split was to allow for both linear movement and rotations to fix occlusion.

Ya. Elementary math. He's not moving in a pure horizont. The movement is along the INCLINE of your lower jaw. So there is a combined horizontal  outward displacement AND a vertically downward displacement; outwards and downwards.

[Reoreyh]

Ya. Elementary math. He's not moving in a pure horizont. The movement is along the INCLINE of your lower jaw. So there is a combined horizontal  outward displacement AND a vertically downward displacement; outwards and downwards.

Okay for the sake of the example let's assume horizontal means straight along the occlusal plane. He moves my jaw straight across the occlusal plane - but my canines come into contact with the top canines before my teeth have reached a place where they can even bite. I can fit my tongue between my top and bottom teeth with this movement. He should be rotating the back part of my lower jaw up - CW - to get it to where I can actually bite.

[kavan]

Okay for the sake of the example let's assume horizontal means straight along the occlusal plane. He moves my jaw straight across the occlusal plane - but my canines come into contact with the top canines before my teeth have reached a place where they can even bite. I can fit my tongue between my top and bottom teeth with this movement. He should be rotating the back part of my lower jaw up - CW - to get it to where I can actually bite.

There's no 'assuming' of what horizontal means. It means horizontal and the movement is NOT pure horizontal and the movement of the BSSO is parallel to the MANDIBULAR plane.
END of story. END of dialog.

[Reoreyh]

There's no 'assuming' of what horizontal means. It means horizontal and the movement is NOT pure horizontal and the movement of the BSSO is parallel to the MANDIBULAR plane.
END of story. END of dialog.

All of your responses are inappropriately snarky, sarcastic,  unhelpful, and cringeworthy. "END of discussion." "END of dialog."

Who talks like this? You moderate a forum of jaw surgery patients who are often anxious or in pain, and this is your demeanor? Is this your sad little stomping ground where you feel big?

You obviously have nothing to offer anyway, if you think "rotation happens at the maxilla" only.