Sidewing-Technique from DR.B

[mediumdrinkofwater]

Referenced Case:
https://www.instagram.com/p/Cf_oWZ-tUWF/

I have wondered for a while what exactly was done to this patient, since I myself am interested in a modified cw-aproach, without horizontal movement, to adress the gonial angles.
So I asked Dr.Brusco in respect to the aforementioned case, which he documented on instagram, and he wrote back the following:

DR.B:
"The movement in this case involved mainly a slight anterior shortening and centering associated with a lateral outwards flaring of the wings to achieve the best possible symmetry. The gaps were filled with an autologous bonegraft.

My thoughts now:
What does he mean by anterior shortening, how does that look like from the side-view?

Also, is it just me or has the front view not changed at all from the picture? However, the x-rays clearly display that the angles were laterally flared out extensively. Maybe the beard is covering up the change?

[Tomasjohn]

What I can see in In this case other than the obvious is that left mandible was shortened at the angle which was longer or let's say more pronounced. https://imgur.com/a/IS0G4oJ

I don't know if this is what he meant by anterior shortening since I would expect anterior to be at the chin.

[mediumdrinkofwater]

So shortening is basically bone shaving?

[Tomasjohn]

So shortening is basically bone shaving?

No i just said what I can observe. I don't think this is what he meant tough.

Shortening is making something shorter by any means.

Still not happy with your CW result?

EDIT: https://www.facebook.com/161961044428233/posts/581844712439862/?flite=scwspnss

-- This is a funny result I saw recently.

[mediumdrinkofwater]

Wow, that after-profile looks terrible.

The only thing I’m unhappy with are the somewhat blunted angles from the front view, so it’s either a side wing for me or I call it a day. Either way is fine for me at this point

[Tomasjohn]

I remember when I looked at your post op pics i thought you look good. Solid wide jaw i believe. What do friends and family say?

If you want objective feedback some pre/post pics would help.

If either way is fine then call it a day.. 

[kavan]

What I can see in In this case other than the obvious is that left mandible was shortened at the angle which was longer or let's say more pronounced. https://imgur.com/a/IS0G4oJ

I don't know if this is what he meant by anterior shortening since I would expect anterior to be at the chin.

Anterior shortening would apply to the front of face as to shorten the chin and or to adjust for symmetry at the place where they cut through the chin. They don't shorten it from the bottom or anything like that. But when they make a cut that goes right through the chin, they have option to remove some bone area at the cut if some adjustments in that regard are needed. I think they can also use the little bone fragments or 'chips' to jump start the osteogenisis process to the posterior area of the jaw.

[Tomasjohn]

Anterior shortening would apply to the front of face as to shorten the chin and or to adjust for symmetry at the place where they cut through the chin. They don't shorten it from the bottom or anything like that. But when they make a cut that goes right through the chin, they have option to remove some bone area at the cut if some adjustments in that regard are needed. I think they can also use the little bone fragments or 'chips' to jump start the osteogenisis process to the posterior area of the jaw.

Ah that makes sense, thank you.

[mediumdrinkofwater]

Anterior shortening would apply to the front of face as to shorten the chin and or to adjust for symmetry at the place where they cut through the chin.

Interesting, thx!

[GJ]

Wow, that after-profile looks terrible.

Why is it terrible? The chin looks to be in the right place, but there should have been some grafting of the groove - is that the part you think looks terrible? It could probably be fixed with a graft still if the patient wanted it.

[kavan]

Ah that makes sense, thank you.

If you look closely at the frontal bone scan, you can see the shape of the cut to the chin. The bone scar of chin cut is kind of straight horizont below the lower central incisors and it angles down to form sort of a notch below the the nerve holes. So, below the initial cut they make is where they can shorten areas of the chin and/or 'anterior mandible' to adjust for symmetry if needed. It's not uncommon for areas to the central chin and or the anterior mandible (areas beside the central chin) to be a little long or off center. So, when adjustments to symmetry and/or excess length are made to the anterior aspect of the mandible (central chin and area beside it), it avoids asymmetry from the chin being carried through the rest of the cut  below (inferior to) and beyond (towards the posterior direction) the nerve holes.
 
Now, beyond and below the nerve holes, they continue the cut to the back of the jaw and they want the areas released from the cut to be as symmetrical as possible. Basically, they have to PRY areas and PULL down to flare out and lengthen the posterior jaw angle area. Prying away and pulling down are 2 FORCES that could snap the bone if they are also coupled with the need to apply them unequally to adjust for asymmetry at the back of the jaw line. Also, if they have to pry out a LOT to get a large flare out. So, ability to apply those forces to both sides of the jaw segment, somewhat equally, is enhanced by addressing what ever adjustments needed to the anterior mandible (central chin and beside it) to cut down on asymmetry/excess length coming from that area so it does not carry through to the segments they need to pry out and pull down beyond (posterior to) the anterior mandible. In this particular case, I think that is what the doctor was dealing with and describing when he mentioned anterior shortening and centering associated with lateral outward flaring. Like not too much shortening or alteration to the anterior mandible but just what was needed to safely pry and pull at the posterior mandible.

The (frontal) increase in width is an improvement yet is subtle. But that is understandable because too much prying and pulling to effect a more dramatic flare out can be a recipe for an unwanted snap when done in an initial surgery.

[Tomasjohn]

I have read your reply.. learned something new!

[mediumdrinkofwater]

Why is it terrible? The chin looks to be in the right place, but there should have been some grafting of the groove - is that the part you think looks terrible? It could probably be fixed with a graft still if the patient wanted it.

Yes, I was referring to the strong mento-labial fold mainly. It looks very artificial, non-natural imo. I thought this kind of thing was avoided with chin wings? 

[Tomasjohn]

Yes, I was referring to the strong mento-labial fold mainly. It looks very artificial, non-natural imo. I thought this kind of thing was avoided with chin wings?

It is not avoided because of the chin wing but because the cut at the chin goes further up (like a shield) and the space behind is filled with bone graft or alloplastic material.  Other method is something that is called chin visor.

Shield: https://www.instagram.com/p/CRV1mBpJCH_/?utm_source=ig_web_copy_link

In short: Basically just add volume above the chin.
I mean could also be achieved with filler.

Unrelated but this is the best cw result i have ever seen: https://www.instagram.com/p/Ced2dXLoh8C/?utm_source=ig_web_copy_link

... I've posted a video where they show what was done to him if you want to know.

[mediumdrinkofwater]

Unrelated but this is the best cw result i have ever seen: https://www.instagram.com/p/Ced2dXLoh8C/?utm_source=ig_web_copy_link

... I've posted a video where they show what was done to him if you want to know.

Agree, very nice result! Same technique as with the other person (long cw). It’s really baffling how every result looks completely different than the next one. Can you post the link of the vid? I would like to see the X-ray (if available).