General Category > Functional Surgery Questions
My surgical plan. Thoughts?
Class2:
Hi everyone,
New here. Another stranger's story incoming.
Link with chronological scans: https://docs.google.com/presentation/d/1JWgKXtqSWXIOfA5ymbC2LvcAATQgnsXA
Information
· 34 year old male in Canada, and only choosing a Canadian surgeon due to cost
· Wisdom teeth removed, no other extractions
· 11-13 years old - braces with elastics
· Have VME – currently 5mm anterior gingival display, appearance has reduced due to aging, as seen in the photos
· 5mm lip incompetence
· Currently, 5mm overjet (it is unstable due to my post DNA bite)
· Very vaulted palate
· Minor anterior open bite ~0.5mm
· Daily nasal congestion (not from allergies). Been mouth taping and using nasal dilators for 3 years. Septum is only minimally deviated, probably not clinically significant.
· 31-33 years old DNA treatment; results – bucally tipped molars (mostly upper), potentially stretched alveolar bone, and repositioned mandible within TMJ, as seen in the pre and post cbct
· Had a posterior tongue tie release and myofunctional therapy
· 31 years old - OSA diagnosis, REM RDI of 30/hr, overall 10 RDI/hr. Use CPAP.
Goals
· Treat OSA
· Lip seal/no mentalis strain
· Improve aesthetics (gum show, retrognathia)
Tentative plan
· MARPE with piezo cuts along the MPS to gain stable transverse expansion and improve nasal breathing. Molars will be upright from DNA damage with aligners or braces. Lower arch will need SFOT to align upper and lower teeth (I only have a thin layer of buccal bone). For reasons too long to list on a jaw surgery forum, I prefer the MARPE with piezo over segmental lefort 1 or SARPE/DOME.
Surgery thoughts
Based off my research, my high occlusal and mandibular planes, desire to avoid extractions to maintain arches, and maximize BSSO advancement, CCWr seems optimal. I do think impaction would be beneficial for autorotation and gum show, however I am looking for a conservative number due to aging/reduced teeth show, and nasal cavity volume reduction. Given this limitation, CCWr via posterior downgrafting would allow for improved OP/MPA beyond that of an impaction alone, while also avoiding lower teeth extractions necessary for linear movements. I do believe my gum show is mostly anterior, so I feel I am not contraindicated for posterior downgrafting (which can exacerbate posterior gum show). I am aware that for many class 2's, a large maxillary advancement with impaction can have undesirable nose aesthetics (even with alar suture), along with that "monkey" look, so for that reason I would be conservative with this advancement. I do not have a chin, so I do think a sliding genioplasty would help with lip competency and aesthetics. Since I do have some excessive overjet in my current position, I can afford some linear advancement too.
Given my thoughts above, I was thinking (I know the numbers would vary, but just want to illustrate my plan):
· 3mm anterior impaction; 1-2mm differential impaction, depending on margin of error with custom guides
· 3-4mm maxillary advancement
· 4-6mm sliding genioplasty
· X degree downgraft
· X mm BSSO advancement. I don't know what this number would be after all the other movements. Hopefully 10-14mm at B point.
Questions
· Since rotation doesn't change the bite relationship, how is the degree of decompensation decided pre-op? My incisors are still proclined as per the photos. I of course want to maintain a dental class 1 post-op.
· What would be the ideal fixed point for the CCWr in my case, if there was one? If it wasn't for the impaction I would assume it's the ANS, but I am not sure.
· Is there a preferable material to be used for the downgraft? Autograft seems more favorable over synthetic, but I would love more opinions on this.
· Is there a certain order that makes more sense in which jaw is operated on first when impaction and downgrafting is involved?
· Any downsides to downgrafting? As far as I know, it is as stable as impaction which has been well researched.
· Does this all make sense? Any glaring deficits in my knowledge? I would love to fill in those gaps!
I have 2 consults upcoming in May, and will book more if needed. I just want to be as prepared as possible going in. If I can't find a surgeon locally to do these movements, a compromised plan would be a standard linear advancement after decompensation with a small impaction and genio. Downside is potential extractions, smaller bsso/less flattening of the OP, leading to underwhelming aesthetic outcomes and possibly unaddressed SDB.
Thanks for reading!
GJ:
In general, the lower jaw is put in position first. That's based on models (on an articulator) to know where to put it. Then the upper is moved to match that. Basically a mock surgery. Some surgeons do the opposite, but it's not the modern standard of care. Natural bone is best for the down graft. I'm not sure on decompensation. An ortho should be able to answer that. Your teeth look to be in a pretty good place to me. I'd imagine it'll be minimal.
I think you're on the right track with CCWr and impaction, and to take it light on the impaction. Better to do to little than to much.
kavan:
Age 22 photo reveals excess gummy smile which is corrected by impaction. Excess length to the frontal aspect of the maxilla can force lower jaw backwards and downwards. Excess length to the back part of the maxilla can do some of that too as in anterior open bite. Your smile in age 33 (doesn't matter if it's pre or post some 'DNA' method) shows you have maxillary excess to both anterior aspect of maxilla and posterior. So, impaction would most likely be to over all maxilla to shorten excess length which would be a combo of anterior and posterior impaction. A combo of both anterior and posterior impaction yields a NET rotation. If more removed from anterior than posterior then net would be CCW-r. Conversely, if more is removed from posterior than anterior then net would be CW-r. Anyway, with an overall impaction, that is NOT a 'downgraft'
Impaction removes the excess length and often that allows the mandible to swing up and outward for a better profile. Age 23 of mentalis strain stands to be corrected in the process of correcting the gummy smile via impaction given that the surgery allows the jaw to swing upward and outward to reduce the strain. Genioplasty would also assist in that.
With the combined impaction, maxillary and mandible advancement would follow. Although the maxillary impaction alone would not advance the upper jaw, it allows the advancement of the upper jaw along a more favorable orientation. Some of advancement of lower jaw can result from an 'automatic' swinging up and out from the impaction. The other, of course from BSSO advancement.
DISCLOSURE: I have made these general observations solely by looking at some of your photos.When there are photos to observe, I observe in the absence of a posters self assessments and/or questions in the event my observations SOLELY on the photos help the poster adapt what ever questions they have to the observations I've made.
TWGOAT:
--- Quote from: kavan on April 11, 2023, 10:27:44 AM ---Age 22 photo reveals excess gummy smile which is corrected by impaction. Excess length to the frontal aspect of the maxilla can force lower jaw backwards and downwards. Excess length to the back part of the maxilla can do some of that too as in anterior open bite. Your smile in age 33 (doesn't matter if it's pre or post some 'DNA' method) shows you have maxillary excess to both anterior aspect of maxilla and posterior. So, impaction would most likely be to over all maxilla to shorten excess length which would be a combo of anterior and posterior impaction. A combo of both anterior and posterior impaction yields a NET rotation. If more removed from anterior than posterior then net would be CCW-r. Conversely, if more is removed from posterior than anterior then net would be CW-r. Anyway, with an overall impaction, that is NOT a 'downgraft'
Impaction removes the excess length and often that allows the mandible to swing up and outward for a better profile. Age 23 of mentalis strain stands to be corrected in the process of correcting the gummy smile via impaction given that the surgery allows the jaw to swing upward and outward to reduce the strain. Genioplasty would also assist in that.
With the combined impaction, maxillary and mandible advancement would follow. Although the maxillary impaction alone would not advance the upper jaw, it allows the advancement of the upper jaw along a more favorable orientation. Some of advancement of lower jaw can result from an 'automatic' swinging up and out from the impaction. The other, of course from BSSO advancement.
DISCLOSURE: I have made these general observations solely by looking at some of your photos.When there are photos to observe, I observe in the absence of a posters self assessments and/or questions in the event my observations SOLELY on the photos help the poster adapt what ever questions they have to the observations I've made.
--- End quote ---
If it can help OPs case since we have similar profile/smile, I had a consult with a reknowned surgeon last week and i discussed the CCWr rotation aspect with impaction only vs impaction/downgraft vs effect on posterior gummy smile.
He said to achieve enough rotation it's ok to compromise on some posterior gumshow and have a combination of posterior downgraft / anterior impaction.
Anterior impaction only normally can't rotate much unless you impact a lot which reduces nasal cavity volume and soft tissue support.
I was previously quoted 5mm anterior impaction with 3mm posterior impaction by a local surgeon which nets a maximum of 2-3 degree CCW rotation
Here is the drawing based on my ceph, disregard the TJR, it would be BSSO in this case - with approx 4mm impaction, and 3mm downgraft for around 13 deg CCW rotation, around 14mm BSSO, and he said maxillary incisor advancement of around 9mm : https://imgur.com/a/N8O15zm
Here is my previous thread for reference : https://jawsurgeryforums.com/index.php/topic,8442.0.html
I'm also in Canada by the way, will have a follow up consult next week with a local surgeon to show him this plan.
Class2:
--- Quote from: kavan on April 11, 2023, 10:27:44 AM ---Age 22 photo reveals excess gummy smile which is corrected by impaction. Excess length to the frontal aspect of the maxilla can force lower jaw backwards and downwards. Excess length to the back part of the maxilla can do some of that too as in anterior open bite. Your smile in age 33 (doesn't matter if it's pre or post some 'DNA' method) shows you have maxillary excess to both anterior aspect of maxilla and posterior. So, impaction would most likely be to over all maxilla to shorten excess length which would be a combo of anterior and posterior impaction. A combo of both anterior and posterior impaction yields a NET rotation. If more removed from anterior than posterior then net would be CCW-r. Conversely, if more is removed from posterior than anterior then net would be CW-r. Anyway, with an overall impaction, that is NOT a 'downgraft'
Impaction removes the excess length and often that allows the mandible to swing up and outward for a better profile. Age 23 of mentalis strain stands to be corrected in the process of correcting the gummy smile via impaction given that the surgery allows the jaw to swing upward and outward to reduce the strain. Genioplasty would also assist in that.
With the combined impaction, maxillary and mandible advancement would follow. Although the maxillary impaction alone would not advance the upper jaw, it allows the advancement of the upper jaw along a more favorable orientation. Some of advancement of lower jaw can result from an 'automatic' swinging up and out from the impaction. The other, of course from BSSO advancement.
DISCLOSURE: I have made these general observations solely by looking at some of your photos.When there are photos to observe, I observe in the absence of a posters self assessments and/or questions in the event my observations SOLELY on the photos help the poster adapt what ever questions they have to the observations I've made.
--- End quote ---
--- Quote from: GJ on April 10, 2023, 09:52:53 PM ---In general, the lower jaw is put in position first. That's based on models (on an articulator) to know where to put it. Then the upper is moved to match that. Basically a mock surgery. Some surgeons do the opposite, but it's not the modern standard of care. Natural bone is best for the down graft. I'm not sure on decompensation. An ortho should be able to answer that. Your teeth look to be in a pretty good place to me. I'd imagine it'll be minimal.
I think you're on the right track with CCWr and impaction, and to take it light on the impaction. Better to do to little than to much.
--- End quote ---
Thank you for your responses. I just got back from seeing my first surgeon and I wanted to know what you two or anybody else on the forum thinks.
He explained that for my case, he doesn't feel my mandible is particularly steep/high and that an anterior differential impaction of 3-4mm would result in poor nasal aesthetic outcomes and a flat appearance. We couldn't do a VSP on the spot as it is out sourced, but he did give some preliminary numbers to work with. He feels that a 3mm level impaction with maybe 1mm anterior differential and then bsso and small max adv + 4-6mm sliding genio to follow would be sufficient. Because of my plane he feels downgrafting is also unnecessary (but he is trained to do this).
He explained that when you make the standard lefort 1 cuts at the ANS, because the cut is not horizontal bur rather diagonal, maxillary advancement alone will cause superior movement of the maxilla, and when you add impaction on top of that it can be too much in some cases, especially for the nasal region. He also said that anterior impaction doesn't autorotate the mandible as much as posterior impaction does. I didn't fully comprehend the explanation on this reasoning though.
I asked him about my 5mm lip incompetency and he said the level impaction and if I wanted a V–Y closure (this part I might've confused with something else, there was a lot of information) would help. I have a large beard so hopefully he's not being influenced by that when looking at aesthetics in person lol (it hides most of my recession). Very passionate and friendly surgeon!
This was surprising news as I thought I for sure had a steep mandibular plane, albeit not as bad as others on this forum. I booked an appointment with him and a VSP tech/engineer(?) to go over numbers in more detail. Thoughts? Red flags? Underwhelming numbers? I'm seeing another surgeon in 2 weeks.
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