Update on jaw surgery consultations(including with Dr Alfaro) and questions

[SmallJaw12]

Link to my previous post- https://jawsurgeryforums.com/index.php/topic,8264.0.html

Link with some updated photos I sent for the consultation with Alfaro- https://imgur.com/a/yOJQhOB

So I had 3 consultations before having an online consult with Dr. A. I'll try to summarize them below-

• Surgeon 1 & 2 recommended just a BSSO + Genioplasty. Movements suggested by surgeon 2 were surgery first 6mm BSSO advancement and 5mm Genio advancment.
• Surgeon 3 trained under Dr. S and also performs the 'rotation advancement surgery' which Dr. S does. This surgeon's recommendations- DJS with CCW and advancement at chin amounting to around 2cm

Since surgeon 3's recommendation was totally different from the other surgeons and @Kavan's in my previous post, I decided to have an online consultation with Dr Alfaro.
Dr. Alfaro's recommendation was for a BSSO advancement of 4mm and Genio advancement of 8mm. He said that my upper incisor is already located at the vertical reference line through soft tissue which he uses. So minimal or no maxillary advancement will be needed. This matched with Kavan's advice in the previous post. Which goes to show how knowledgeable people on this forum are. Should have listened to his advice, would have saved the money I used on the online consultation

So now coming to my questions(I'll try to actually ask only a few this time)-

• Does anything need to be done with the vertical height of my chin along with advancing it? @Kavan, you had mentioned in my last post that the genio should be outwards and upwards. Does this mean my chin height should be reduced?
• How does the recovery for just LJS compare with DJS? I would assume that breathing should be easier at least in the case of just LJS.

Anyways, thanks in advance for the advice and help! 

[kavan]

chin advancement is rarely in a 'pure' horizontal direction.  It's in diagonal direction with 2 directional displacement vectors; horizontal and vertical. Assuming the horizontal displacement vector is horizontally outward to advance, the vertical displacement vector is upward to shorten when shortening of the chin is needed and the VDV is downward when more length is needed to the chin. So, outwards and upwards would be to shorten.

[SmallJaw12]

Hi Kavan, thanks for the reply. Here are some frontal view pictures of my face- https://ibb.co/k4LP8Rx  https://ibb.co/hYtnTp8

How much of an upward movement do you feel would be suitable? A tiny one or larger? Am concerned with overshortening of my chin.

Also, what happens to the lower lip when the chin height is reduced?

[GJ]

I didn't read the previous post or anything in this post, so apologies if I'm repeating or ignoring anything, but just going off the records you provided, you appear to be a CCW double jaw case. This is due to your very high mandible angle and recessed mandible - only way to correct both issues is CCW.

You need ortho work to flatten that exaggerated curve of spee as well. You have a mild anterior open bite that will need addressing, too, either via ortho or during the surgery.

[kavan]

Hi.

After reviewing the link   https://jawsurgeryforums.com/index.php/topic,8264.0.html
where I addressed your situation, I feel I gave adequate explanation, especially so in regard to    WHY I did NOT suggest CCW in your case. It is all there for review for you (and anyone else) wanting to know the reasoning behind my suggesting lower jaw and chin but no upper jaw.

Your MPA is on the upper range close to high or 'steep'. So, the more the mandible is brought 'forward' along its (higher) angle of inclination (MPA), your chin will cast downward in addition to outward with the BSSO displacement. That is because 'forward' movement along a DOWNWARD DIAGONAL (inclination your mandible has with the horizontal) will have 2 displacement vectors; horizontally outward and vertically downward. (Reflect back on elementary concepts learned in geometry and high school to identify with the very elementary concept that moving 'forward' along a DIAGONAL plane will always have 2 displacement vectors; horizonal and vertical because the movement is a combination of both.)

So, 'how much' your chin would/should be advanced will be a FUNCTION of whether or not he moves 'forward' with the BSSO along your steep dowward diagonal MPA or if he makes an isolated (CCW) 'twist' to the BSSO cut to decrease the MPA as to move 'forward' along less of a steep incline. The DISPLACEMENT VECTORS of the isolated chin movement will be a FUNCTION of the ANGLE OF INCLINATION the mandible is moved along during the BSSO.

The OBJECTIVE of the surgeon (here alfaro) would be to 'put' the chin point (pogonian) in the most favorable aesthetic position. So, if he sees that the chin point will be 'too low' (as in too long for the face) as a FUNCTION of the angle of inclination the mandible is moved 'forward' via the BSSO, adjusting for that would involve a genio that has a vertically upward displacement vector (in addition to a horizontally outward one). Outward and up with the chin (point) gives appearance of CCW.

The lower lip will get less 'floppy' due to better support from both the bsso and genio

[kavan]

I didn't read the previous post or anything in this post, so apologies if I'm repeating or ignoring anything, but just going off the records you provided, you appear to be a CCW double jaw case. This is due to your very high mandible angle and recessed mandible - only way to correct both issues is CCW.

You need ortho work to flatten that exaggerated curve of spee as well. You have a mild anterior open bite that will need addressing, too, either via ortho or during the surgery.

His history and cephs reflect he has relationships that are antagonistic to CCW (posterior downgraft) including but not limited to such things as pre-existing excess posterior gum show (which would increase) and his front teeth are NOT his natural teeth (some of roots of teeth are not there to move with braces to prepare for a surgery). But you are right to observe the anterior bite relationship.