I'm Stuck - Advice Needed

[Breakingbad]

Hello,

I'm really trying to get jaw surgery done as soon as possible, but feel stuck right now.

During the past couple of years I’ve seen 5 jaw surgeons. I’ve seen Dr. Wittenberg, Prof. Alfaro, Prof. Raffaini, Dr. Walline and Dr. Gunson. I've also seen a few orthodontists: Dr. Richard Ting, Dr. Rebecca Bockow, and Dr. Trista Felty.
Everything seemed to be going well at first and I was just going to pick the surgeon I felt most comfortable with. However, after my last couple of consultations, concerning discrepancies started coming up between these doctors’ opinions. Now, I’m unsure of what to do because I don’t want to embark on this journey only to make things worse or fix one problem only to cause a different problem.

I’ve been using this forum for years and it’s been an amazing resource, so I would really appreciate any input you could provide. If you could share any reading material or links, that would be great as well, as I’m eager to expand my knowledge.

My Goals

Functionally, better breathing. Here's a GIF I made which shows the aesthetic change I am aiming for: https://imgur.com/32eeAzT

By the way, in the morph I deliberately moved my nasal base forward because Dr. Gunson wrote in his report that I was missing 4 mm of nasal support. I also deliberately pushed my lips in very slightly because it seems to look better.

Structurally, I'd love to see similar changes to the ones in this B&A from Dr. Gunson's site, and I think my face looks a lot like her's in the before photos: https://imgur.com/dtLiV3k

Surgeon Consultations

Dr. Wittenberg - He suggested medpor implants and refused to do jaw surgery on me, saying my case was not "severe" enough.

Prof. Raffaini - He initially suggested a CCW rotation with no retraction of my teeth prior to jaw surgery, and then minor orthodontic work afterward. However, as soon as I showed him photos of what I wanted to achieve, he said that 4 premolar extractions (2 upper & 2 lower) and retraction of the anterior incisors were the only way to achieve this, because I wanted my mouth to protrude from my face LESS, and not MORE after surgery. He said he would do CCW rotation, linear advancement and a small genioplasty.

Prof. Alfaro - Essentially the same as Prof. Raffaini: first he suggested the "surgery-first" protocol with no extractions and CCW rotation, but as soon as I showed him what I wanted, he said extractions would be needed before CCW, linear advancement and genioplasty.

Dr. Walline - Again, essentially the same as Prof. Raffaini. He suggested CCW rotation with no extractions, then when I showed him what I wanted, he said extractions would be needed before CCW, linear advancement and genioplasty. What was different is that he noted that my maxilla was a bit on the narrow side, and that it would be beneficial to do MSE in addition to extractions before jaw surgery.

Dr. Gunson: This consult really confused me. Gunson said he really wished I had a steep occlusal plane so that I could have CCW rotation, but that my occlusal plane was too flat already, and that if I was rotated I would end up with a "reverse smile" and a risk of functional issues. He concluded that I wasn't a good candidate for jaw surgery and that I should do genioplasty of maximum 6 mm. He said if, and only if I provided a positive sleep study, it might be an option to do MSE, extract 4 premolars and then do a linear advancement. He said if I extracted 4 premolars without MSE I would end up with a visibly narrow maxilla.

ALL of these surgeons, aside from Dr. Gunson, said that genioplasty alone wouldn't achieve the effect I wanted. I didn't get a chance to show Dr. Gunson photos of what I wanted, though.

Orthodontic Consultations

Dr. Richard Ting - He said I had a narrow upper palate and that MSE was highly recommended. He didn't think that CCW rotation would cause any of the problems that Dr. Gunson mentioned but said that linear advancement would be better for my case.

Dr. Trista Felty - She said my maxilla was almost the ideal width because my "black triangles" were very small, and that I wouldn't benefit much from MSE.

Dr. Rebecca Bockow - She said MSE + SFOT was an option but that I could probably "get by" with just correcting the shape of my dental arches and IPR (sanding down between the teeth) to make a bit of space to retract my anterior teeth with braces, before doing jaw surgery. She thought CCW rotation was an option for me.

Some Points I'm Worried About

1. Dr. Gunson said that I wasn't a candidate for CCW rotation, while all the other doctors said I was.

2. Some said I really needed MSE because my maxilla was narrow, and others said it was unnecessary.

3. Dr. Gunson said doing jaw surgery could lead to a "full" appearance around my mouth. I don't know what he meant by this, but I'm wondering if the result in the photos above is achievable with jaw surgery.

4. Since a few doctors expressed concern about extractions exacerbating the width issue, I was thinking I could do MSE + SFOT to widen my maxillary and mandibular dental arches to create the space needed to retract my anterior teeth, instead of doing the premolar extractions. I don't know if this is an option and how I can get a surgeon to go along with this idea.

5. Since Dr. Gunson doesn't seem to want to work with me, it's hard to ask him about this, but he wrote in his report that I had 4mm of nasal support missing. If I'm understanding this correctly, I would need my teeth retracted and then an advancement of my maxilla to bring my anterior nasal spine forward to get the support that's missing. I don't know if this is correct or if I should expect to need to do a separate procedure later to fix this issue.

6. I don't know if the changes in the GIF I made are what I should be aiming for or if something else would look better.

Can anyone please make any suggestions or provide any input on this?

I would be very grateful.

Photos of my face: https://imgur.com/a/rZAworb

Ceph and snapshot of CBCT: https://imgur.com/a/2neyFcx

[GJ]

This looks like a pretty clear case of CCW, so I'm not sure why Dr. Gunson would say that. Unless he sensed red flags in your personality that made him not want to work with you. Did you bring in photos of models or say anything strange on the consult?

Your bite plane doesn't look steep or flat. It looks somewhere in between.

Regarding maxillary expansion, I don't think that's really known until they put the models on an articulator and see how they fit. I met Walline once, and he was a nice guy, and I think he might do that process digitally, so maybe he could make a recommendation there before getting models.

But yeah, I see CCW rotation as the best path. Your tissue appears to be thick, so maybe that's what Gunson was talking about when he said full around the mouth. In general, every 3mm of bony movement equals 1mm of soft tissue movement. So when you get your final movements, you can somewhat estimate the change to expect. I'm not sure on the 4mm of ANS issue. Your ANS area does look a bit collapsed on that scan, but I'm not sure the best way to address that, or if that's why Gunson felt you'd get full, etc. You could always go to the other surgeons with Gunson's finding on that and ask them.

[Breakingbad]

This looks like a pretty clear case of CCW, so I'm not sure why Dr. Gunson would say that. Unless he sensed red flags in your personality that made him not want to work with you. Did you bring in photos of models or say anything strange on the consult?

No, I actually didn't show him any photos at all because we didn't have time. He did give me a short speech about how I have a heightened ability to perceive things in the face before telling me CCW wouldn't work for me. That was after I mentioned to him that I had a slight yaw, but to be honest I never noticed that myself--I was just repeating it after hearing it from another surgeon. I was trying to seem informed but I guess I overdid it.

It crossed my mind that maybe he just didn't want to work with me, but I just don't understand why he wouldn't use another excuse, like saying he'd only operate on me if I had sleep apnea. After I pressed him further about genioplasty not being a good solution, he said that he might do jaw surgery on me but only if I gave him a positive in-hospital sleep apnea test (I had told him by then that I had a negative at-home sleep study result) and that it would be a linear advancement in that case. He also pushed me to consult with other surgeons.

What's weird though is that when I pressed him on the CCW rotation he explained that it's to do with the natural position of my head. I grilled him more and he said that he uses "natural head position" rather than the Frankfurt Horizontal and that I could barely be rotated 1 or 2 degrees before causing a reverse smile. Do you have an opinion on that? I will definitely be talking to some other surgeons about it, but it helps to hear answers here because I feel they're less biased.

Your tissue appears to be thick, so maybe that's what Gunson was talking about when he said full around the mouth.

I was at 29% BF when those photos were taken according to a DEXA scan. Losing about 6 kg seems to have helped a lot with that, and I still need to lose 5 kg more to get to a healthy range. I'm hoping it'll help but I don't know.

Thank you very much for replying. Even your validation of my ANS area looking collapsed is very helpful, because I thought so too, but I never feel qualified enough to be sure about these things.

[kavan]

Surgeons can look at a patient's morph but don't necessarily accommodate based on  it because the surgery has to balance bite with displacement of the jaws and soft tissue profile. In your situation accommodation would require all of those premolar extractions.

Lips are forward to a TVL (true vertical line). So advancing the jaws would only make that WORSE. They would have to extract 4 pre-molars and push the teeth backwards inorder to advance the jaws and not make the lips MORE protrusive. So, accommodation of your morph pretty much would be a '0 sum relationship'. Basically, needing to push the front of your face BACKWARDS inorder to move the jaw/s forward is a 0 sum relationship.

Now there is nothing 'wrong' with your lips being forward to the TVL. Infact, THAT'S pretty much where they WANT the lips to be in soft tissue profile. But since your lips are where they want them to be relative to the TVL, there is really NO WAY to accommodate your morph request WITHOUT also having to REMOVE all those pre-molars. CCW is not a 'savior' here.

They are looking at the TVL and seeing your lip protrusion would be made WORSE with no extractions. As to CCW not being the 'savior', CCW is something they do to AVOID extractions. But here, if you avoid extractions, it would result in more lip protrusion in a situation where you are asking for LESS lip protrusion.

So, just about all of the doctors are bascially seeing the same (lips already ahead of the TVL) situation where there is not much they can do in the absence of extractions.

I tend to AGREE with Gunson but I tend NOT to think that Gunson actually told you chin advancement would mimic what you did in your morph. It's like I said in the first sentence; surgeons can look at a morph but don't necessarily accommodate based on it (other than to tell you accommodation might reqire doing something you're not asking for as in extracting teeth). So NO SURPRISE to me that genio alone would not mimic your morph. However, chin advancement as Gunson suggested WOULD improve your profile because your chin is BEHIND the white line TVL and that's why I agree with Gunson's suggestion.

Illustration included in this post.

[kavan]

......By the way, in the morph I deliberately moved my nasal base forward because Dr. Gunson wrote in his report that I was missing 4 mm of nasal support. I also deliberately pushed my lips in very slightly because it seems to look better.

Structurally, I'd love to see similar changes to the ones in this B&A from Dr. Gunson's site, and I think my face looks a lot like her's in the before photos: https://imgur.com/dtLiV3k......

This is PRIME EXAMPLE of WHY maxfax surgeons can't accommodate (goals) of morphs. In many cases, (and here you're the prime example of this), the morpher doesn't understand the relationships of the area he's moving. So, here, you move the ANS and the maxilla FORWARD in your morph WITHOUT also moving the upper lip area forward. Instead you moved the upper lip area backwards. So, your morph SELF NEGATES on those grounds because the lips DON'T move backwards with ANS advancement of the maxilla. They move forward. Likewise with morphing forward advancement of the lower jaw. The lips don't move backwards with mandible advancement. They move forward.

Somebody else's, outcome isn't the best communication tool either because everyone's dentition in addition to a variety of points, angles and planes are DIFFERENT

UNLESS you were actually WANTING to communicate to them that you were REQUESTING to have those 4 pre-molars extracted to even come close to your morph goal,the morph is basically useless as a communication tool. Assuming you weren't actually REQUESTING them to remove all 4 molars to push your face backwards in order to move it forwards, all the morph communicates is that you didn't understand the relationships to the areas you were moving. Hence, the morph resolved to a SELF NEGATING request that couldn't be accommodated. So, if you didn't understand that you can't move one part forward and NOT the other part that would go forward WITH it (jaw/s forward, lips go forward with it) but instead wanted the lips to go BACKWARDS, that told them everything they needed to know about a request that couldn't be accommodated.

[Breakingbad]

Surgeons can look at a patient's morph but don't necessarily accommodate based on  it because the surgery has to balance bite with displacement of the jaws and soft tissue profile. In your situation accommodation would require all of those premolar extractions.

Lips are forward to a TVL (true vertical line). So advancing the jaws would only make that WORSE. They would have to extract 4 pre-molars and push the teeth backwards inorder to advance the jaws and not make the lips MORE protrusive. So, accommodation of your morph pretty much would be a '0 sum relationship'. Basically, needing to push the front of your face BACKWARDS inorder to move the jaw/s forward is a 0 sum relationship.

Now there is nothing 'wrong' with your lips being forward to the TVL. Infact, THAT'S pretty much where they WANT the lips to be in soft tissue profile. But since your lips are where they want them to be relative to the TVL, there is really NO WAY to accommodate your morph request WITHOUT also having to REMOVE all those pre-molars. CCW is not a 'savior' here.

They are looking at the TVL and seeing your lip protrusion would be made WORSE with no extractions. As to CCW not being the 'savior', CCW is something they do to AVOID extractions. But here, if you avoid extractions, it would result in more lip protrusion in a situation where you are asking for LESS lip protrusion.

So, just about all of the doctors are bascially seeing the same (lips already ahead of the TVL) situation where there is not much they can do in the absence of extractions.

Thank you very much for your reply.

I appreciate hearing from you about the necessity of the extractions in order to accomodate my morph. To clarify, this is something that made perfect sense to me, thanks to the tremendously useful information posted on this forum by you and other users, which I’ve been reading for years.

To be clear, Raffaini, Alfaro, and Walline all initially suggested CCW rotation without extractions, but that was BEFORE I told them very clearly that I was serious about the lips not protruding even more than they are currently, and that I didn’t understand how that was possible without extractions.

Only after I told them that did they agree with me that if that was something that bothered me, extractions would be necessary.

I thought at that point that it was settled and was basically ready to proceed with that plan.

Then, I had my consultations with Gunson and Walline.

Here’s what came up and stopped me from going forward:

CCW - Even with 4 premolar extractions, Walline, Raffaini, and Alfaro all wanted to do CCW. Then, unexpectedly, Gunson told me that CCW rotation (with or without extractions) would cause a “reverse smile” and that basically any surgical plan involving CCW was a bad idea for me.

Extractions vs Width Problem - I’d be fine with extracting the 4 premolars to achieve what I want, but Gunson, Walline, and Dr. Ting, all expressed concerns about the width of my maxilla, and how 4 premolar extractions would make it worse. That’s why both Walline and Gunson suggested MSE. I was wondering if I could use MSE and SFOT to widen my upper and lower jaw to create the space needed to retract my anterior teeth. Like I said, I wouldn’t mind extracting the pre-molars, but I don’t want to cause a bigger width issue and that’s why I’m wondering if MSE and SFOT could come to the rescue as an alternative way to make the space I need for retraction.

I tend to AGREE with Gunson but I tend NOT to think that Gunson actually told you chin advancement would mimic what you did in your morph. It's like I said in the first sentence; surgeons can look at a morph but don't necessarily accommodate based on it (other than to tell you accommodation might reqire doing something you're not asking for as in extracting teeth). So NO SURPRISE to me that genio alone would not mimic your morph. However, chin advancement as Gunson suggested WOULD improve your profile because your chin is BEHIND the white line TVL and that's why I agree with Gunson's suggestion.

You’re right—there wasn’t enough time to show Gunson photos. And yes, I know that Gunson is right that genioplasty would bring an improvement, but most of the surgeons thought that it wouldn’t be enough for my case especially with what I’m aiming for.

[Breakingbad]

UNLESS you were actually WANTING to communicate to them that you were REQUESTING to have those 4 pre-molars extracted to even come close to your morph goal,the morph is basically useless as a communication tool. Assuming you weren't actually REQUESTING them to remove all 4 molars to push your face backwards in order to move it forwards, all the morph communicates is that you didn't understand the relationships to the areas you were moving. Hence, the morph resolved to a SELF NEGATING request that couldn't be accommodated. So, if you didn't understand that you can't move one part forward and NOT the other part that would go forward WITH it (jaw/s forward, lips go forward with it) but instead wanted the lips to go BACKWARDS, that told them everything they needed to know about a request that couldn't be accommodated.

Bingo. That’s basically what I did. I tried to make that clear in my OP, sorry it wasn’t clear. I do understand that, like I said, thanks to this forum. It’s basic geometry, but it did take me years of educating myself here and elsewhere to understand. I’m sure my understanding is still lacking, though. I’m definitely having trouble figuring the rest of this stuff out.

[kavan]

Thank you very much for your reply.

I appreciate hearing from you about the necessity of the extractions in order to accomodate my morph. To clarify, this is something that made perfect sense to me, thanks to the tremendously useful information posted on this forum by you and other users, which I’ve been reading for years.

To be clear, Raffaini, Alfaro, and Walline all initially suggested CCW rotation without extractions, but that was BEFORE I told them very clearly that I was serious about the lips not protruding even more than they are currently, and that I didn’t understand how that was possible without extractions.

Only after I told them that did they agree with me that if that was something that bothered me, extractions would be necessary.

I thought at that point that it was settled and was basically ready to proceed with that plan.

Then, I had my consultations with Gunson and Walline.

Here’s what came up and stopped me from going forward:

CCW - Even with 4 premolar extractions, Walline, Raffaini, and Alfaro all wanted to do CCW. Then, unexpectedly, Gunson told me that CCW rotation (with or without extractions) would cause a “reverse smile” and that basically any surgical plan involving CCW was a bad idea for me.

Extractions vs Width Problem - I’d be fine with extracting the 4 premolars to achieve what I want, but Gunson, Walline, and Dr. Ting, all expressed concerns about the width of my maxilla, and how 4 premolar extractions would make it worse. That’s why both Walline and Gunson suggested MSE. I was wondering if I could use MSE and SFOT to widen my upper and lower jaw to create the space needed to retract my anterior teeth. Like I said, I wouldn’t mind extracting the pre-molars, but I don’t want to cause a bigger width issue and that’s why I’m wondering if MSE and SFOT could come to the rescue as an alternative way to make the space I need for retraction.
You’re right—there wasn’t enough time to show Gunson photos. And yes, I know that Gunson is right that genioplasty would bring an improvement, but most of the surgeons thought that it wouldn’t be enough for my case especially with what I’m aiming for.

I think you would be well served to just get the genio with Gunson. It will improve your profile where the chin is recessive and it won't preclude you from maxfax further down the line.  I think the surgeons should disregard what you were aiming for in the morph and ADMIT that your lips are in a GOOD position relative to the TVL and the salient imbalance to the profile is the chin rather than any significant jaw to jaw imbalance.

[Breakingbad]

I think you would be well served to just get the genio with Gunson. It will improve your profile where the chin is recessive and it won't preclude you from maxfax further down the line.

But wouldn’t that just be kicking the can down the road considering I already have a rough idea of what I want? Even if I did genioplasty first, it seems like I’ll still have to deal with the question of CCW and extractions vs the width issue eventually.

I think the surgeons should disregard what you were aiming for in the morph and ADMIT that your lips are in a GOOD position relative to the TVL and the salient imbalance to the profile is the chin rather than any significant jaw to jaw imbalance.

It was actually ME that thought my lips should be about 1 or 2 mm back from where they are, but since you’re so confident about them already being in the right position relative to the TVL, let me note that I am fine with them staying in the same place if that’s how they should be. Walline, Raffaini, and Alfaro are ALL fine with this as well. BUT, I still need the pogonion point to go forward more than a 6mm genioplasty would allow. The lack of nasal support of 4 mm that Gunson noted is also something I’d like to address if possible. SO, even if I’m okay with my lips ending up right where they currently are, I still need to deal with these issues to do jaw surgery and get the result I’m looking for.

[ArtVandelay]

This looks like a pretty clear case of CCW, so I'm not sure why Dr. Gunson would say that.

Writing without looking at my past notes, Gunson orients your head looking up more compared to Alfaro. Due to differences in how they orient your profile you get different recommendations when you're at the margin.

[kavan]

But wouldn’t that just be kicking the can down the road considering I already have a rough idea of what I want? Even if I did genioplasty first, it seems like I’ll still have to deal with the question of CCW and extractions vs the width issue eventually.

It was actually ME that thought my lips should be about 1 or 2 mm back from where they are, but since you’re so confident about them already being in the right position relative to the TVL, let me note that I am fine with them staying in the same place if that’s how they should be. Walline, Raffaini, and Alfaro are ALL fine with this as well. BUT, I still need the pogonion point to go forward more than a 6mm genioplasty would allow. The lack of nasal support of 4 mm that Gunson noted is also something I’d like to address if possible. SO, even if I’m okay with my lips ending up right where they currently are, I still need to deal with these issues to do jaw surgery and get the result I’m looking for.

Your morph could also be seen as something close to just a genio and a rhinoplasty.

[Breakingbad]

Your morph could also be seen as something close to just a genio and a rhinoplasty.

Thanks, but the subjectivity of what "close" means worries me.

In the photo of this Gunson patient here, https://imgur.com/dtLiV3k, you can see that as a result of some (presumed)
advancement at the ANS, even in the FRONTAL VIEW, her whole paranasal area has filled out, where it previously looked visibly sunken in with respect to her mouth area. In the SIDE VIEW, her nasolabial angle has gotten slightly larger.

Can a rhinoplasty approximate even ONE of these effects?

[Breakingbad]

Writing without looking at my past notes, Gunson orients your head looking up more compared to Alfaro. Due to differences in how they orient your profile you get different recommendations when you're at the margin.

Thank you for adding this information. It's a good point, but I'm left confused in terms of what that says about my risk of getting a "reverse smile."

[kavan]

Thanks, but the subjectivity of what "close" means worries me.

In the photo of this Gunson patient here, https://imgur.com/dtLiV3k, you can see that as a result of some (presumed)
advancement at the ANS, even in the FRONTAL VIEW, her whole paranasal area has filled out, where it previously looked visibly sunken in with respect to her mouth area. In the SIDE VIEW, her nasolabial angle has gotten slightly larger.

Can a rhinoplasty approximate even ONE of these effects?

As I said prior: 'Somebody else's, outcome isn't the best communication tool either because everyone's dentition in addition to a variety of points, angles and planes are DIFFERENT.' Your morph is a MOVING gif. and I'm not offering to separate it into 2 different still photos and then analyze it for you for exactitude objectivity with mm measures and all. So, yes, that's my subjective assessment that it's close to chin advancement and rhino. Also, don't expect the doctors to reproduce it in real time on your face.

[Breakingbad]

As I said prior: 'Somebody else's, outcome isn't the best communication tool either because everyone's dentition in addition to a variety of points, angles and planes are DIFFERENT.'

That's A-OK, but that patient's result aside, I'm simply asking whether a rhinoplasty could make my paranasal area fill out in a similar manner? I'm genuinely wondering. I just don't know how to edit that type of change in frontal appearance into a photo of my face, but I hope that you get what I mean by making the paranasal area "fill out" now.

I'm not offering to separate it into 2 different still photos and then analyze it for you for exactitude objectivity with mm measures and all. So, yes, that's my subjective assessment that it's close to chin advancement and rhino.

I wouldn't expect you to and I appreciate your help so far. I'm not arguing with you. I KNOW that many people would say it's close. I wasn't implying that they're wrong--it's just subjective. But look at the STILL photo overlay I made below (photo attached). For reference, the measured thickness of my lower lip is about 13 mm. To my eye, that makes the difference at the pogonion point in my morph around 10 mm of SOFT TISSUE change. To me, that says that even though genioplasty could be described as close to this, there would still be a difference, as the maximum for a genioplasty would be 6 mm of BONY CHANGE for me if not less.

I don't know if you agree with me, but I don't see anything wrong with going for the marginally better option if I have the finances, time and patience for the extra aesthetic and functional benefits. That's why I'm trying to figure out how to deal with those questions about CCW and width/extractions.