Opinion of my surgeons plan

[mediumdrinkofwater]

Hey guys,

My history: I’m a class 2 patient, 4mm overbite, deep bite, had chin wing 3 years ago. Mandible plane was decreased and chin was advanced about 5-6mm. Chin was rotated ccwr, making the whole face shorter and giving me that classic short face look. 

Horrible results, protruding mandible border, high chin fold. Now I have to reverse the damage.

I'm pretty sure I'm not a classic short face patient, since already have a light gummy smile, when I smile or laugh. Does this indicate that i do not suffer from vertical maxillary deficiency? For this reason, a surgeon told me that downgrafting of the maxilla or clockwise rotation of both jaws is not possible, since it would increase the gummy smile.

My occlusional plane is already quite flat, which is a reason why my surgeon didn't want to add any ccw-rotation. The consulted surgeon routinely does ccwr movements for sleep apnea cases, so this recommendation was not due to his personal limitations in surgery.

My mandible plane was made flatter during the chin wing surgery, since a bone graft was added in between the cut.

As of now there are two options:


Option 1:

1. Bimax ( see the plan at the end) and mandible shaving, due to the protruding mandible border.
- linear advancement (maxilla 5mm, the plan states 2-3mm, but it will probably end up being 5-6mm after revision of the plan, in order to correct overjet.

2. 1 year later revision genio: 2-3mm horizontal reduction, downgraft or deprojection of the pog


Option 2:

Would be to combine those two steps in one surgery. Which might be detrimental to the aesthetic result, since planning cant be as exact.

My questions:

1. Is linear advancement really the only option? My surgeon said no rotation possible, because of flat OP. No downgraft possible because of light gummy smile. Is there anything else in my case, that indicates a linear advancement?

2. Is there any way to down graft the maxilla without worsening the gummy smile?

3. Based on my recession, are 5mm linear maxillary advancement adequate? I'm afraid it might be to too much. Please don't base this question on the convexity of my current nose, since i had a rhinoplasty years ago as well. For this reason, I included an image of my face before all the surgeries in the link. I'm well aware that I will probably require another rhino after maxillary advancement. So please do not base your judgements of the maxillary advance length on my current nose, but rather on the original one, which was very convex and large.


Pictures, Scans and Surgery Plan:
https://imgur.com/a/aegcDPc

Greatly appreciate any piece of advice

[mediumdrinkofwater]

3. Based on my recession, are 5mm linear maxillary advancement adequate? I'm afraid it might be to too much. Please don't base this question on the convexity of my current nose, since i had a rhinoplasty years ago as well. For this reason, I included an image of my face before all the surgeries in the link. I'm well aware that I will probably require another rhino after maxillary advancement. So please do not base your judgements of the maxillary advance length on my current nose, but rather on the original one, which was very convex and large.

I guess my biggest fear with linear advancement, is getting a chimp-face. Please let me know if this worry is uncalled for in my case.


After the genio revision, I would like the chin to look like this: https://imgur.com/a/1uKnkGO
What kind of genio cut would be necessary for this type of change?

[mediumdrinkofwater]

Option 1:

1. Bimax ( see the plan at the end) and mandible shaving, due to the protruding mandible border.
- linear advancement (maxilla 5mm, the plan states 2-3mm, but it will probably end up being 5-6mm after revision of the plan, in order to correct overjet.

I actually meant to say: the plan is linear advancement of both jaws.
- 5mm in the maxilla,
- 2-3mm in the mandible according to the current plan. But I have spoken to the surgeon and told him to correct my 4mm overbite as well. For this reason the mandible will be advanced around 6-7mm in the end. 

[kavan]

Hey guys,

My history: I’m a class 2 patient, 4mm overbite, deep bite, had chin wing 3 years ago. Mandible plane was decreased and chin was advanced about 5-6mm. Chin was rotated ccwr, making the whole face shorter and giving me that classic short face look. 

Horrible results, protruding mandible border, high chin fold. Now I have to reverse the damage.

I'm pretty sure I'm not a classic short face patient, since already have a light gummy smile, when I smile or laugh. Does this indicate that i do not suffer from vertical maxillary deficiency? For this reason, a surgeon told me that downgrafting of the maxilla or clockwise rotation of both jaws is not possible, since it would increase the gummy smile.

My occlusional plane is already quite flat, which is a reason why my surgeon didn't want to add any ccw-rotation. The consulted surgeon routinely does ccwr movements for sleep apnea cases, so this recommendation was not due to his personal limitations in surgery.

My mandible plane was made flatter during the chin wing surgery, since a bone graft was added in between the cut.

As of now there are two options:


Option 1:

1. Bimax ( see the plan at the end) and mandible shaving, due to the protruding mandible border.
- linear advancement (maxilla 5mm, the plan states 2-3mm, but it will probably end up being 5-6mm after revision of the plan, in order to correct overjet.

2. 1 year later revision genio: 2-3mm horizontal reduction, downgraft or deprojection of the pog


Option 2:

Would be to combine those two steps in one surgery. Which might be detrimental to the aesthetic result, since planning cant be as exact.

My questions:

1. Is linear advancement really the only option? My surgeon said no rotation possible, because of flat OP. No downgraft possible because of light gummy smile. Is there anything else in my case, that indicates a linear advancement?

2. Is there any way to down graft the maxilla without worsening the gummy smile?

3. Based on my recession, are 5mm linear maxillary advancement adequate? I'm afraid it might be to too much. Please don't base this question on the convexity of my current nose, since i had a rhinoplasty years ago as well. For this reason, I included an image of my face before all the surgeries in the link. I'm well aware that I will probably require another rhino after maxillary advancement. So please do not base your judgements of the maxillary advance length on my current nose, but rather on the original one, which was very convex and large.


Pictures, Scans and Surgery Plan:
https://imgur.com/a/aegcDPc

Greatly appreciate any piece of advice

Some basic info:

Option 1 gives you the option to choose at a LATER time whether or not you want to do anything more with the chin. So, it should be intuitively obvious that Option 1 is the better option.

'Short face' patient: There are 2 terms in maxfax concerning this; 'short FACE' and 'short CHIN'. They are not both the same. Because your maxilla is not short, the term to describe what you have is 'short CHIN'. Also, the term 'short CHIN' is associated with having the DEEP BITE, low mandibular plane angle and somewhat flat OP. So, correct, you are not a classic 'short FACE' patient and hence don't suffer from a short maxilla. Instead, you are a short chin patient. Not a short maxilla patient=no need to LENGTHEN the maxilla anywhere.

You are told your maxilla is NOT short. Your surgeon expects you to understand that making the maxilla longer ANYWHERE isn't going to solve anything. If he makes it longer in front (anterior downgraft) via a clockwise rotation, that will increase your gummy smile. If he makes is longer at the back (posterior downgraft), that is ccw-r which will just make your short chin appearance look even SHORTER.

Clockwise rotation of maxilla will increase your gum show. Counterclockwise rotation (posterior downgraft) will will make your short chin look even shorter. So, what is so hard for you to understand that the option of increasing the maxilla anywhere is NOT going to work for you? There are 3 options clockwise rotation, counterclockwise rotation and linear advancement. The rotations have been RULED OUT. So, what is so hard to understand that the only option left is linear advancement?

The plan proposal gives you sufficient VISUAL information to determine for yourself whether or not you like the profile CONTOUR CHANGES that are shown on the BLUE diagram they have provided to you. The easy to visualize- whether you like it or not- contour change proposal encompasses all of the various millimeter displacements within it. So, there is no need to discuss specific mm measures when the contour diagram lets you LOOK AT the proposed contour changes.

What I am getting at here is that you have enough info to answer your own questions. The doctor gave you ample information/explanation to CONCLUDE the only option is linear advancement and the contour diagram gives you ample VISUAL information to CONCLUDE whether or not it is to your liking.

[GJ]

Yeah, I think linear is your best option. You definitely do not want CCWr given your short face and bite plane. CWr should be an option. It's okay to have a OP that is not perfectly flat. The thing is, I don't think it would do much for you given you're already recessed. So linear would be the best option. Your chin will probably look stronger after that and might not need any revision. My concern would be chimp lip and the psychology/mental shock of it - your face will probably appear longer even if the movement is just linear. Your nose will also widen a bit. I'm not sure any of this is worth it. You look like a totally normal person right now.

[mediumdrinkofwater]

i received a new plan by my surgeon. im curious what you thinks of it?:
https://www.dropbox.com/scl/fi/qtross9ussq2ogti2mu1v/plan_neu.pdf?rlkey=snjfedko6mux1sqql3ktzxt55&st=2cr456gv&dl=0

planned movements are:
upper jaw : 6mm advancement, very slight posterior dropdown (1.2mm)
lower jaw: 9mm advancement

chin: prior chin wing will be shaved back by 70%, i think the movements in the first surgery were 5-6mm

I have two issues with this plan:

upper jaw advacement: i fear that i cant handle the 6mm advancement in the upper jaw. it seems like a lot.

chin shaving : i feel like the shin is being overly shaved back. its basically a vertical line post-op. im afraid I will be left with no chin projection.

Thinking about, letting my surgeon know that i want 1-2mm less jaw advancmeent and maybe 1-2mm more chin left


What are youre guys opinion on this new plan?