Asking for surgery advices

[50konsurgeryat35]

Hello everyone, I’m very close to start wearing braces to move my teeth in a good position for the surgery, but I don’t know what is the best way to go for my case. I know for sure I have a class II division II malocclusion with reclined maxillary incisors and overbite that makes my face appear short.
I also have a canted maxilla.
I had consult with 3 surgeons:
- first surgeon suggested only mandible advancement after extractions of 2 lower premolars (I don’t think this is a good plan for me)
- second surgeon suggested a double jaw surgery advancement. During the consult he said I need CCW rotation but in the post-consult paper he said I need CW rotation. Unfortunately at that time I was a newbie in this field so I didn’t ask him to be more detailed.
-with the third surgeon I had an online consult and he only saw pics I’m going to post here. He suggested something like 2.5 mm of posterior downgraft and some work on the chin to increase its height.
All of them said I need to procline my upper incisors to increase the overjet and give more support to the upper lip.
I think I need some downgraft to increase my face height but I don’t know if I need CW rotation or CCW to achieve the best best outcome.
In these pics (especially x-rays) you can see I have some paranasal hollowness and I would like to know if you think Lefort 1 advancement can improve it. Unfortunately 10 months ago I had some filler in that area so it looks more projected, but in the pic where I’m wearing the grey t-shirt I don’t have filler.
Any help or advice will be very appreciated.

[kavan]

1: Class 2 DIV 2 is 'deep bite' and sometimes referred to as 'short chin' (short lower '1/3rd) due to the deep bite. Another thing Class 2 DIV 2 people have in common is they are 'low angle' patients.That refers to the MANDIBULAR PLANE ANGLE (MPA). You have all of those commonalities.

2: CCW rotation is usually good for people who have HIGH MPAs because it helps decrease the angle of inclination the MPA has relative to a horizont whereas CW-r is usually good for people with LOW MPAs because it increases the MPA and thereby increases 'height' of a (short) lower 1/3rd.

3: Positive trade-off of having some (modest) CCW (posterior downgraft) is one gets some extra lower jaw advancement with it because it pushes the chin area forward. It can also be used to SPARE plucking of the lower pre-molars. Negative trade-off is that it can make an already short MPA shorter. Positive trade-off with CW-r is that it can give some extra height to the short face because it increases the MPA. Negative trade-off is that it pushes the chin/jaw area backwards a little.

4: Bucking out the upper teeth (proclining them) and pushing back on the lower front teeth does maximize the overjet which in turn, maximizes the lower jaw advancement.

5: Since you say that you DON'T want the single jaw surgery with the lower premolar extractions, your choice is between the Doctor #2 and Doctor #3.

All that said, I think that doctor #3 would be the better choice. The CCW posterior downgraft is small/modest, will allow for more advancement to lower jaw from the BSSO. So to compensate for the negative trade-off of decreasing an already low MPA, you WOULD INDEED need chin work to elongate the chin.

[50konsurgeryat35]

1: Class 2 DIV 2 is 'deep bite' and sometimes referred to as 'short chin' (short lower '1/3rd) due to the deep bite. Another thing Class 2 DIV 2 people have in common is they are 'low angle' patients.That refers to the MANDIBULAR PLANE ANGLE (MPA). You have all of those commonalities.

2: CCW rotation is usually good for people who have HIGH MPAs because it helps decrease the angle of inclination the MPA has relative to a horizont whereas CW-r is usually good for people with LOW MPAs because it increases the MPA and thereby increases 'height' of a (short) lower 1/3rd.

3: Positive trade-off of having some (modest) CCW (posterior downgraft) is one gets some extra lower jaw advancement with it because it pushes the chin area forward. It can also be used to SPARE plucking of the lower pre-molars. Negative trade-off is that it can make an already short MPA shorter. Positive trade-off with CW-r is that it can give some extra height to the short face because it increases the MPA. Negative trade-off is that it pushes the chin/jaw area backwards a little.

4: Bucking out the upper teeth (proclining them) and pushing back on the lower front teeth does maximize the overjet which in turn, maximizes the lower jaw advancement.

5: Since you say that you DON'T want the single jaw surgery with the lower premolar extractions, your choice is between the Doctor #2 and Doctor #3.

All that said, I think that doctor #3 would be the better choice. The CCW posterior downgraft is small/modest, will allow for more advancement to lower jaw from the BSSO. So to compensate for the negative trade-off of decreasing an already low MPA, you WOULD INDEED need chin work to elongate the chin.

Thank you for your answer. Do you think my teeth show is good enough? Also what do you think about my paranasal hollowness causing me nasolabial folds?

[kavan]

Thank you for your answer. Do you think my teeth show is good enough? Also what do you think about my paranasal hollowness causing me nasolabial folds?

Well the vertical amount you can see them is good enough BUT they need to be proclined and possibly brought forward a bit for better orientation with the L1 rotation (mixed with a little advancement). I really don't see paranasal hollowness. But I can tell you that if some maxillary advancement goes along with your surgery, which it can in addition to the rotation, it can make less what you are perceiving as paranasal hollowness, assuming you mean the area beside your NOSTRIL area. However, if you are referring to an area above the L1 cut, like area/s beside upper areas of the nose that are above the general nostril area (eg. beside bridge of nose area), the surgery doesn't change that area.

[50konsurgeryat35]

Well the vertical amount you can see them is good enough BUT they need to be proclined and possibly brought forward a bit for better orientation with the L1 rotation (mixed with a little advancement). I really don't see paranasal hollowness. But I can tell you that if some maxillary advancement goes along with your surgery, which it can in addition to the rotation, it can make less what you are perceiving as paranasal hollowness, assuming you mean the area beside your NOSTRIL area. However, if you are referring to an area above the L1 cut, like area/s beside upper areas of the nose that are above the general nostril area (eg. beside bridge of nose area), the surgery doesn't change that area.

Yes I’m talking about the area close to the nostril, but I agree with you in these pics the problem is barely visible. I have one last question: do you think my nasal spine projection will be a problem with lefort 1 advancement? I saw you were talking, in another thread ,about a prominent nasal spine that can cause an unaesthetic outcome if it is move too much forward

[kavan]

Yes I’m talking about the area close to the nostril, but I agree with you in these pics the problem is barely visible. I have one last question: do you think my nasal spine projection will be a problem with lefort 1 advancement? I saw you were talking, in another thread ,about a prominent nasal spine that can cause an unaesthetic outcome if it is move too much forward

No.

[50konsurgeryat35]

No.

Thank you for your time

[GJ]

Paranasal hollowness can be fixed with CW rotation. CCW might actually make it worse. I don't think you need CCW at all. Your jaw is already projecting, face is on the shorter side, etc. Agree you need some proclination. I'm not sure this is a surgery case. Everything looks pretty good other than tooth position.

What is the goal of surgery?

If you go the surgery route, your maxilla should be addressed, likely by shortening the right side since that would be more stable. Then bring the entire thing down. Maybe that's what surgeon 3 was getting at. I don't like any of those plans because they aren't clear of (a) the problem and (b) how they're addressing the problem. I don't see a clear problem other than the paranasal looks slightly recessed and the maxilla is canted, and that might not even be a problem for you, and it's also possible ortho can address it to some degree. So, I'd go through the ortho treatment and then reassess.

If I were to do a surgery on you, I'd level the maxilla and then do a very very slight CW rotation. This would address the only two problems I see (paranasal and the cant).

[50konsurgeryat35]

Paranasal hollowness can be fixed with CW rotation. CCW might actually make it worse. I don't think you need CCW at all. Your jaw is already projecting, face is on the shorter side, etc. Agree you need some proclination. I'm not sure this is a surgery case. Everything looks pretty good other than tooth position.

What is the goal of surgery?

If you go the surgery route, your maxilla should be addressed, likely by shortening the right side since that would be more stable. Then bring the entire thing down. Maybe that's what surgeon 3 was getting at. I don't like any of those plans because they aren't clear of (a) the problem and (b) how they're addressing the problem. I don't see a clear problem other than the paranasal looks slightly recessed and the maxilla is canted, and that might not even be a problem for you, and it's also possible ortho can address it to some degree. So, I'd go through the ortho treatment and then reassess.

If I were to do a surgery on you, I'd level the maxilla and then do a very very slight CW rotation. This would address the only two problems I see (paranasal and the cant).

Thank you for your answer.
 The goal of the surgery is to improve my face attractiveness as much as possible, especially the lower third that appears narrow and feminine.
I want to fix my paranasal hollowness, it’s really a bad feature and I think I can fix it only moving my maxilla forward. I just completed a maxillary skeletal expansion (MSE ) but it didn’t help with the hollowness and it increased malar prominence making the face appear even more short. I also want to increase my chin/mandible projection by 5 mm at least, and obviously fix the canted maxilla.
I know CW rotation will help more than CCW rotation on the paranasal area, but I’m scared it will give me excessive gum show and it will reduce the lip support.

[GJ]

I know CW rotation will help more than CCW rotation on the paranasal area, but I’m scared it will give me excessive gum show and it will reduce the lip support.

It would do both, but proclining the teeth would probably offset the lip support, and excessive gum show could be fixed with impaction at the time of surgery.

Getting the teeth proclined is needed either way, so I'd reassess how things look after you go through that.

[50konsurgeryat35]

It would do both, but proclining the teeth would probably offset the lip support, and excessive gum show could be fixed with impaction at the time of surgery.

Getting the teeth proclined is needed either way, so I'd reassess how things look after you go through that.

Can you please explain me why you think ccw in not a good option for my case? Maybe something like 4,5 mm of posterior downgraft plus 2 mm of anterior downgraft to achieve a slight ccw rotation and increase facial height at the same time and 3-4 mm of advancement to improve paranasal area

[kavan]

Can you please explain me why you think ccw in not a good option for my case? Maybe something like 4,5 mm of posterior downgraft plus 2 mm of anterior downgraft to achieve a slight ccw rotation and increase facial height at the same time and 3-4 mm of advancement to improve paranasal area

It appears you got confused by GJ's entry about paranasal hollows potentially getting worse with CCW-r. I'm including a diagram of CW and CCW for reference.

There are 2 rotation points (pivot points) for the CCW-r; incisor point and ANS. (Same 2 for CW-r) GJ must be talking about rotation around the incisor point because that's the one that brings the ANS backwards. CCW-r around the ANS doesn't move it at all. If it helps, I shall REPEAT what I told you prior in my post (reply #3) which is that it is the L1 ADVANCEMENT that pushes the base of the nose area (and paranasal area beside nostrils) forward. So, whether or not you got CCW-r around either rotation point, the addition of the maxillary advancement would help the paranasal area by moving it forward. Because your teeth are backwards to your mouth (like noticibly backwards), it's highly likely you will have L1 ADVANCEMENT with the bimax surgery. Also, since the CCW-r would need to be MODEST to small in your case, even if you got the CCW-r around incisor point which must have been the one GJ was referring to, it's more likely than not the L1 advancement, if added to your surgery (you know to move your teeth and gums CLOSER to your lips) would exceed the small amount that particular CCW-r rotation point would bring the ANS area backwards.

[50konsurgeryat35]

It appears you got confused by GJ's entry about paranasal hollows potentially getting worse with CCW-r. I'm including a diagram of CW and CCW for reference.

There are 2 rotation points (pivot points) for the CCW-r; incisor point and ANS. (Same 2 for CW-r) GJ must be talking about rotation around the incisor point because that's the one that brings the ANS backwards. CCW-r around the ANS doesn't move it at all. If it helps, I shall REPEAT what I told you prior in my post (reply #3) which is that it is the L1 ADVANCEMENT that pushes the base of the nose area (and paranasal area beside nostrils) forward. So, whether or not you got CCW-r around either rotation point, the addition of the maxillary advancement would help the paranasal area by moving it forward. Because your teeth are backwards to your mouth (like noticibly backwards), it's highly likely you will have L1 ADVANCEMENT with the bimax surgery. Also, since the CCW-r would need to be MODEST to small in your case, even if you got the CCW-r around incisor point which must have been the one GJ was referring to, it's more likely than not the L1 advancement, if added to your surgery (you know to move your teeth and gums CLOSER to your lips) would exceed the small amount that particular CCW-r rotation point would bring the ANS area backwards.

Thanks for the explanation, especially for the part where you talk about my teeth position and how they are backwards. I will have a consult with the second surgeon in real life pretty soon so he can judge my case in a proper way and give me a more detailed plan.

[kavan]

Thanks for the explanation, especially for the part where you talk about my teeth position and how they are backwards. I will have a consult with the second surgeon in real life pretty soon so he can judge my case in a proper way and give me a more detailed plan.

Is the 'second' surgeon surgeon referred to as #2 or #3 in this thread?  By the way, when a thread is active as in it's being responded to in a timely manner, it's best to keep your visuals (cephs/photos) up.

[50konsurgeryat35]

Is the 'second' surgeon surgeon referred to as #2 or #3 in this thread?  By the way, when a thread is active as in it's being responded to in a timely manner, it's best to keep your visuals (cephs/photos) up.

Sorry I meant the third surgeon, but I will get another consult even with the second one to understand why he thinks CW is a better option for me. I removed the pics because after 2 days nobody else replied to the thread, I just reposted them