Can you get BSSO and then chin wing/side wing?

[Dex1816]

Hi,

I've been looking at way of correcting the inward inclination of my jaws. Unfortunately I don't have access to my x-rays yet, but I have seen them and they confirmed what I suspected; along with both of my jaws being moderately recessed with the downward growth associated with sleep apnoea patients, my rami and gonions tilt inwards.

I understand that I'll certainly need Lefort and BSSO to correct the first issue, but regarding the width and length of my mandible (along with the width of my chin) I still have some research to do.

For the mandible dimensions, it's basically chin wing/side wing or implants. I'd rather get chin wing if possible over implants (though apparently some small implants may be advantageous to shaping the gonion after chin wing), but I'm unclear as to whether or not its possible to have both the chin wing and BSSO.

I spoke to Dr. Brusco recently via email, and he suggested this was not possible/not advised, and that if I want this sort of three dimensional result, I should be going with DJS and then titanium implants.

But then, having read a few old posts here, it seems that it is possible, but dependant on the height of the cut performed for BSSO. Can anyone shed any light here? As those posts didn't really seem to conclude one way or the other.

Thanks!

[kavan]

One can't get the 'standard' BSSO (cut behind the back lower molar) with a chin wing or later a chin wing. When chin wing doctors do a BSSO and chin wing (at later time) they make a HIGH CUT which is a cut that will be out of the way of the chin wing cut they make. Standard BSSO cut would cause the chin wing cut to 'cross' it
and increase chance of breaking.

For what you describe; 'inward tilting' of the mandible, that is usually corrected via custom implants which don't have to be titanium. If you need DJS, the implants are put in later down the line after bone healing has taken place.

For those who DON'T 'need' DJS, in particular displacement of the maxilla, a chin wing done during ONE operation can move the border of the mandible forward and also down. A graft from the pelvic spine is needed for the border lowering. The first operation will displace the back angles forward as they go along 'for the ride' with the forward advancement of the entire lower border of the mandible. It is in a SECOND operation where they go through the SAME cut they made prior, push the displaced mandible angle segment backwards and also 'pry' it outwards. For that, another bone graft is needed to fill the space left behind.

Candidacy for chin wing depends on the mandibular nerve not being close to the cutting field and the STEEPER and SHORTER one's mandible is, the less likely one is an 'ideal' candidate.

DISCLOSURE: This is generally applicable information. It is not meant to advise on what one should specifically do or pursue.

[Dex1816]

Thanks for the detailed post.

One can't get the 'standard' BSSO (cut behind the back lower molar) with a chin wing or later a chin wing. When chin wing doctors do a BSSO and chin wing (at later time) they make a HIGH CUT which is a cut that will be out of the way of the chin wing cut they make. Standard BSSO cut would cause the chin wing cut to 'cross' it
and increase chance of breaking.

That's good to know. Is there any disadvantage to getting this type of higher cut? Such as limitations in the extent of advancement compared to the standard one?

For what you describe; 'inward tilting' of the mandible, that is usually corrected via custom implants which don't have to be titanium. If you need DJS, the implants are put in later down the line after bone healing has taken place.

For those who DON'T 'need' DJS, in particular displacement of the maxilla, a chin wing done during ONE operation can move the border of the mandible forward and also down. A graft from the pelvic spine is needed for the border lowering. The first operation will displace the back angles forward as they go along 'for the ride' with the forward advancement of the entire lower border of the mandible. It is in a SECOND operation where they go through the SAME cut they made prior, push the displaced mandible angle segment backwards and also 'pry' it outwards. For that, another bone graft is needed to fill the space left behind.

Good explanation. my gut feeling would be that this multidimensional reshaping and reangling of the mandible that you describe with the chin wing would produce a more natural result than an implant would. This is perhaps an ignorant idea, but I would worry that the implant required to lengthen the rami, slightly widen the bi-gonial width, and introduce a flaring effect to the angles, would cause a lot of thickening to the area. I'm concerned that this would cause the result to look somewhat bloated, due to both the need for the implant to extend beyond the area that needs to be augmented so that it can be fixated, and the combination of both the thickness of the implant and the natural angle of my jaw.

I have seen several jaw implant results where the person just ends up looking bloated, though I have seen some really good results as well.

For this reason, I would have thought having the higher cut BSSO and then the chin wing would provide a more natural elegant look; is there a reason implants are generally considered a better choice for my problem? -- other than the issues with not having the aforementioned problem of the height of the BSSO.

[kavan]

Thanks for the detailed post.

That's good to know. Is there any disadvantage to getting this type of higher cut? Such as limitations in the extent of advancement compared to the standard one?

Good explanation. my gut feeling would be that this multidimensional reshaping and reangling of the mandible that you describe with the chin wing would produce a more natural result than an implant would. This is perhaps an ignorant idea, but I would worry that the implant required to lengthen the rami, slightly widen the bi-gonial width, and introduce a flaring effect to the angles, would cause a lot of thickening to the area. I'm concerned that this would cause the result to look somewhat bloated, due to both the need for the implant to extend beyond the area that needs to be augmented so that it can be fixated, and the combination of both the thickness of the implant and the natural angle of my jaw.

I have seen several jaw implant results where the person just ends up looking bloated, though I have seen some really good results as well.

For this reason, I would have thought having the higher cut BSSO and then the chin wing would provide a more natural elegant look; is there a reason implants are generally considered a better choice for my problem? -- other than the issues with not having the aforementioned problem of the height of the BSSO.

The high cut is an older style cut. Its main advantage is being able to get a chin wing where the chin wing is used to advance the lower border of mandible. Like if you have no plans to get a chin wing, then the standard BSSO cut (behind the second back molar) is used.

A custom implant is sculpted to specifications of 'right size and shape'. A chin wing is working around what you have to be worked with and moved around and some of the outward prying is going to depend on the bone ELASTICITY. A 'bloated' look with jaw implants can happen if the person has too much soft tissue thickness and is expecting a super sharp chisel out of it. But for the most part, I would say the custom implant is better for people who would NOT need a lot of outward prying of their inward angled jaw. Outward prying has to be somewhat limited with chinwing because too much of it can make a break if the bone is not elastic enough to pry out that much. I'd say, the main appeal of the chin wing is for people who want to avoid implants and/or BSSOs. What the implant can NOT substitute for is advancement of anterior-posterior direction the BSSO (with standard cut) can achieve. But there is no substitute for it if angling out the mandible is the goal.

[Dex1816]

The high cut is an older style cut. Its main advantage is being able to get a chin wing where the chin wing is used to advance the lower border of mandible. Like if you have no plans to get a chin wing, then the standard BSSO cut (behind the second back molar) is used.

A custom implant is sculpted to specifications of 'right size and shape'. A chin wing is working around what you have to be worked with and moved around and some of the outward prying is going to depend on the bone ELASTICITY. A 'bloated' look with jaw implants can happen if the person has too much soft tissue thickness and is expecting a super sharp chisel out of it. But for the most part, I would say the custom implant is better for people who would NOT need a lot of outward prying of their inward angled jaw. Outward prying has to be somewhat limited with chinwing because too much of it can make a break if the bone is not elastic enough to pry out that much. I'd say, the main appeal of the chin wing is for people who want to avoid implants and/or BSSOs. What the implant can NOT substitute for is advancement of anterior-posterior direction the BSSO (with standard cut) can achieve. But there is no substitute for it if angling out the mandible is the goal.

Very informative, thank you.