Comparison of two bimax simulations

[VincentGT]

So here I am again.

Attached you find the pictures of my face.

A few months ago I cancelled a surgery because my surgeon would only do a BSSO and not bimax, although it was always explaind as a bimax. His reasoning: bimax would mean the mandible needs to be advanced (even) more and this would result in flaring mandible corners, which you don't want. The original simulation you find here.

A few weeks after the cancelled appointment, he agreed to make a simulation of bimax ("just to show how little of a difference there is"). So I'm not even sure he would be willing to perform this plan. This bimax simulation you find here.

And although compared like that the difference doesn't seem that great, it actually is if you draw a straight line, like so.

In the meantime I've seen another surgeon who simulated bimax. He understood my wished for a slightly advanced maxilla. You find his simulation right here.

What do we think of these simulations? Any suggestions or opinions?
I think the last one contains some CCW, which would probably be benefifical. But although I have more than enough teeth show, I don't really have a gummy smile today. So I hope this CCW wouldn't change my teeth show drastically.
I don't think I necessarily need genio as there is quite a bit of chin bone. It's always possible afterwards too.

[GJ]

Tough call. You appear to have a large enough overjet where I'd only do the lower jaw. Moving the upper jaw is where all the problems happen (nose, chimp look, too long/short, etc)...you're in a grey zone. I'd do lower jaw and maybe a small genio.

[VincentGT]

The thing is: my upper jaw IS a few mm recessed; every surgeon confirmed this. It’s hard to pass on it then. Here you see a picture of my facewhere I jut my lower jaw forward. I think the maxilla recession is obvious this way. On the right side you a morph with upper jaw advancement.. way better I think.

[GJ]

To me that's a lot of risk for that slight improvement (if it even is one). The left looks good, and you won't have a wider nose or other risks that come with moving the upper jaw, which will more than offset any gain in the profile. Also, jutting the jaw forward isn't how the surgery will actually look. Most of the problems of jaw surgery come from moving the upper jaw.

If you think the risk it worth it then do it, though.

[kavan]

I think you would be OK with the double jaw surgery. Although the upper jaw looks RELATIVELY more advanced than the lower jaw, the upper jaw might not be 'over advanced' in its own right. A bit more advancement would tend to give more support to the base of the nose and give a straighter nose (dorsal) profile and with less downward tip rotation. Also, to get a good advancement to the lower jaw via CCW, they have to cut into the maxilla to affect a rotation. So, it's not as if cutting into the maxilla to provide a CCW-r and with a small amount of advancement is going to risk a bad base of the nose. I mean, a lower jaw advancement can be effected with just the CCW-r and no maxilla advancement. But again, to get a good lower jaw advancement via CCW-r, one does need a Lefort 1 cut to the maxilla to initiate the rotation even if there is no maxillary advancement. From those photos (front), I don't think the prospect of the gonial angles flaring out is going to be any aesthetic detriment either given that you have wide prominent cheek bones.

Basically, I don't see this as an AESTHETIC 'risk' for you to get the double jaw surgery. Looks more to me in the venue of an aesthetic 'pay-off' if you get a little upper jaw advancement and of course the CCW-r for which the maxilla needs to be cut into whether or not you get any advancement. No aesthetic risk either for getting more outward flare to gonial angles. Might even be possible to get a good advancement of the chin point with the BSSO because it can be taken out further with the CCW-r, in which case, you might not need a chin cut for a genio.

Feel free to cross reference what I told you here with the doctor/s who WANT to provide the double jaw surgery given you don't want the guy who just wants to do ONLY the lower jaw.

[GJ]

I think you would be OK with the double jaw surgery. Although the upper jaw looks RELATIVELY more advanced than the lower jaw, the upper jaw might not be 'over advanced' in its own right. A bit more advancement would tend to give more support to the base of the nose and give a straighter nose (dorsal) profile and with less downward tip rotation. Also, to get a good advancement to the lower jaw via CCW, they have to cut into the maxilla to affect a rotation. So, it's not as if cutting into the maxilla to provide a CCW-r and with a small amount of advancement is going to risk a bad base of the nose. I mean, a lower jaw advancement can be effected with just the CCW-r and no maxilla advancement. But again, to get a good lower jaw advancement via CCW-r, one does need a Lefort 1 cut to the maxilla to initiate the rotation even if there is no maxillary advancement. From those photos (front), I don't think the prospect of the gonial angles flaring out is going to be any aesthetic detriment either given that you have wide prominent cheek bones.

Basically, I don't see this as an AESTHETIC 'risk' for you to get the double jaw surgery. Looks more to me in the venue of an aesthetic 'pay-off' if you get a little upper jaw advancement and of course the CCW-r for which the maxilla needs to be cut into whether or not you get any advancement. No aesthetic risk either for getting more outward flare to gonial angles. Might even be possible to get a good advancement of the chin point with the BSSO because it can be taken out further with the CCW-r, in which case, you might not need a chin cut for a genio.

Feel free to cross reference what I told you here with the doctor/s who WANT to provide the double jaw surgery given you don't want the guy who just wants to do ONLY the lower jaw.

If the nose widening wasn't a near 100% guarantee I'd agree with this, but I don't think it's worth it given he will most certainly get that. His nose is already on the large side and flares when he smiles. I think this will be bad, but...we shall see.

[kavan]

If the nose widening wasn't a near 100% guarantee I'd agree with this, but I don't think it's worth it given he will most certainly get that. His nose is already on the large side and flares when he smiles. I think this will be bad, but...we shall see.

He would not need that much maxillary advancement at all, not to the extent associated with linear advancement when they advance both jaws equally and the upper jaw gets over advanced in the process of getting a good lower jaw advancement (often done in some sleep apnea surgeries). A modest amount would tend to support the base of his nose better and straighten out somewhat the dorsum. Besides to get CCW-r, the maxilla needs to be cut into to effect a rotation and in turn allow for a greater lower jaw advancement.

I've said that before in my post to him and you've said what you've said before. So, both of us have said our say 2X. So, now he has 2 perspectives repeated twice and he can choose between the 2.

[VincentGT]

Thanks for both of your opinions. Your views are definitely interesting and a genuine help.

@kavan: can I conclude that you prefer the second simulation (with the CCW-r and without the genio)?

The only things I really worry about with this plan (= the second simulation)?are these:

• Won’t the CCW change my teeth show too much? According to most surgeons, my teeth show is perfect now (although I would never want any more teeth show — personally, I think I’m flirting with a gummy smile at times).
• Will the upper lip look thinner and the philtrum longer? Or can this mostly be mitigated through a V-Y suture? Would you assume this V-Y suture is necessary?
• The nose concerns of GJ are legit, but according to the plan, the maxilla will only be advanced 3 mm. They could also use an alar cinch? I need the septum fixed too, so this will be done at the same time. Also, my nose is quite large in profile, but not that wide — look at the current alar base.

[kavan]

Thanks for both of your opinions. Your views are definitely interesting and a genuine help.

@kavan: can I conclude that you prefer the second simulation (with the CCW-r and without the genio)?

The only things I really worry about with this plan (= the second simulation)?are these:

• Won’t the CCW change my teeth show too much? According to most surgeons, my teeth show is perfect now (although I would never want any more teeth show — personally, I think I’m flirting with a gummy smile at times).
• Will the upper lip look thinner and the philtrum longer? Or can this mostly be mitigated through a V-Y suture? Would you assume this V-Y suture is necessary?
• The nose concerns of GJ are legit, but according to the plan, the maxilla will only be advanced 3 mm. They could also use an alar cinch? I need the septum fixed too, so this will be done at the same time. Also, my nose is quite large in profile, but not that wide — look at the current alar base.

Sorry, I can't keep track of which plan is which when plans are not all together on the same page and described.

I'm just saying that I think your nose would also benefit by some modest maxillary advancement. You have a slightly convex (slightly) and slightly downward rotation of the tip and the dorsum of the nose stands to get somewhat straightened out and the tip somewhat de-rotated with maxillary advancement. That is to say, in PROFILE perspective, your nose contour is consistent with what you say you have and what other doctors said you had which was somewhat of a recessive maxilla. Also, since you now say that your nose is NOT wide at the alar base, all that is CONSISTANT  with my saying I think your nose would veer in direction of benefit vs detriment--and YES, an alar cinch can be used to mitigate excess unwanted width. If you had a conCAVE nose (a dip in the dorsum) and a turned up tip, that's the type of nose that can experience un aesthetic sequella with maxillary advancement. OK.

CCW-r is associated with getting a larger lower jaw advancement than you would otherwise get without CCW-r assuming the CCW-r in question is a posterior downgraft. If the rotation point is at the ANS, that type of rotation doesn't affect the upper tooth show. The type of CCW-r that can affect the upper tooth show in the sense that it REDUCES a gummy smile is anterior impaction; a slice removed from the anterior maxilla. However, what can increase the tooth show (or gum show) is the maxillary advancement. So, if you want more of a lower jaw advancement than you would get WITHOUT CCW-r posterior downgraft than you would have to weight that in with the possible trade-off of more gum show with the maxillary advancement. So, I would say, the maxillary advancement would benefit your nose profile contour and the cut to do it would allow for CCW rotation to get a good lower jaw advancement. So, you would have to decide if the 2 possible 'pay offs' are worth the 1 possible 'trade-off'.

The upper lip can go 'both ways'. For example if someone gets a LARGE maxillary advancement, the philtral upper lip area can kind of get 'squeezed on' and could look thinner or it could get pushed out too much along an unfavorable native orientation of the ANS-PNS plane (maxillary plane) and start looking conVEX. The other way is that since the upper lip is being brought more forward in the FORGROUND of the picture plane (or the mirror), the upper lip can look more prominent. But to the best of my knowledge, we are talking about a MODEST maxillary advancement that doesn't come with the same boat load of worries that some LARGE ones can come with. So, you would need to ask your surgeon as to any 'need' for V-Y sutures.

Here, I am just going with the flow of your DESIRE to have the maxillary advancement as part of the double jaw surgery and I can buttress some of the reasons behind your desire to have the maxillary advancement. But now you have all these concerns/worries about having that?

Again, I can tell you how things work and you can apply the concepts to weigh the pay offs vs. the trade-offs. I think there are more pay-offs than trade-offs (gains vs. losses) with the maxilla included in the surgery. Best I can do is what I have done via explaining why I think that is so. But I'm not going to 'sell you on' getting the maxillary aspect of the surgery, the very surgery you WANTED to have, gave reason to have which were reasonable to want soon after I validate some of the reasons to have it and then you express a lot of concerns about the very thing you wanted to have.

If you are looking for CERTAINTY, then certainly there is no chance of ANY unfavorable nose changes, no chance of ANY unfavorable changes to tooth/gum show, philtral changes etc. with NO surgery to the maxilla. But then again there's no chance of any favorable changes either with no surgery to the maxilla.

[VincentGT]

Sorry, I can't keep track of which plan is which when plans are not all together on the same page and described.

I'm just saying that I think your nose would also benefit by some modest maxillary advancement. You have a slightly convex (slightly) and slightly downward rotation of the tip and the dorsum of the nose stands to get somewhat straightened out and the tip somewhat de-rotated with maxillary advancement. That is to say, in PROFILE perspective, your nose contour is consistent with what you say you have and what other doctors said you had which was somewhat of a recessive maxilla. Also, since you now say that your nose is NOT wide at the alar base, all that is CONSISTANT  with my saying I think your nose would veer in direction of benefit vs detriment--and YES, an alar cinch can be used to mitigate excess unwanted width. If you had a conCAVE nose (a dip in the dorsum) and a turned up tip, that's the type of nose that can experience un aesthetic sequella with maxillary advancement. OK.

CCW-r is associated with getting a larger lower jaw advancement than you would otherwise get without CCW-r assuming the CCW-r in question is a posterior downgraft. If the rotation point is at the ANS, that type of rotation doesn't affect the upper tooth show. The type of CCW-r that can affect the upper tooth show in the sense that it REDUCES a gummy smile is anterior impaction; a slice removed from the anterior maxilla. However, what can increase the tooth show (or gum show) is the maxillary advancement. So, if you want more of a lower jaw advancement than you would get WITHOUT CCW-r posterior downgraft than you would have to weight that in with the possible trade-off of more gum show with the maxillary advancement. So, I would say, the maxillary advancement would benefit your nose profile contour and the cut to do it would allow for CCW rotation to get a good lower jaw advancement. So, you would have to decide if the 2 possible 'pay offs' are worth the 1 possible 'trade-off'.

The upper lip can go 'both ways'. For example if someone gets a LARGE maxillary advancement, the philtral upper lip area can kind of get 'squeezed on' and could look thinner or it could get pushed out too much along an unfavorable native orientation of the ANS-PNS plane (maxillary plane) and start looking conVEX. The other way is that since the upper lip is being brought more forward in the FORGROUND of the picture plane (or the mirror), the upper lip can look more prominent. But to the best of my knowledge, we are talking about a MODEST maxillary advancement that doesn't come with the same boat load of worries that some LARGE ones can come with. So, you would need to ask your surgeon as to any 'need' for V-Y sutures.

Here, I am just going with the flow of your DESIRE to have the maxillary advancement as part of the double jaw surgery and I can buttress some of the reasons behind your desire to have the maxillary advancement. But now you have all these concerns/worries about having that?

Again, I can tell you how things work and you can apply the concepts to weigh the pay offs vs. the trade-offs. I think there are more pay-offs than trade-offs (gains vs. losses) with the maxilla included in the surgery. Best I can do is what I have done via explaining why I think that is so. But I'm not going to 'sell you on' getting the maxillary aspect of the surgery, the very surgery you WANTED to have, gave reason to have which were reasonable to want soon after I validate some of the reasons to have it and then you express a lot of concerns about the very thing you wanted to have.

If you are looking for CERTAINTY, then certainly there is no chance of ANY unfavorable nose changes, no chance of ANY unfavorable changes to tooth/gum show, philtral changes etc. with NO surgery to the maxilla. But then again there's no chance of any favorable changes either with no surgery to the maxilla.

Thanks, Kavan.

I see what you are saying. The part marked in bold makes sense, but I'm not too sure that I draw the right conclusions from the given simulation.

In this simulation: I can tell that both jaws are advanced and given the slight rise of the mandible there should be some rotation, right? It's hard to tell though whether this is through an interior impaction or a posterior downgraft? The rotation seems modest, but this is likely desirable given that the degree of the gonial angles is already good and the fact that we are talking about only a slight maxilla movement (apparently 3mm). Teeth show doesn't need to change (much) so a modest move makes sense. I did get a few measurements of this simulation by the way: click here.

I think and hope that you are right that the impact of perceived philtrum length will be negligible because of the modest maxilla movement.

Do you think it's problematic that the upper and lower lip don't really line up in the profile view of the simulation? I know lips are notoriously difficult to simulate though.