jawsurgeryforums.com
Surgeon Information => Surgeon Reviews and Leads => Topic started by: strongjawman on August 01, 2018, 07:54:30 AM
-
Hi,
Yesterday I had my first consultation with Dr. Birbe. I will outline some of my questions briefly below.
He was personable and easy to talk to. He welcomed every question I had and answered each of them in an honest an in-depth manner (I had quite a few). He was also candid regarding the limitations of surgeons but regarded himself as a perfectionist and chatting with him I got the impression that he is passionate about his profession.
Overall I would recommend a consultation with him.
"Do you regularly perform CCW of the maxillo-mandibular complex for patients with relatively steep occlusal planes?"
He does perform this procedure regularly.
"How many of these procedures have you performed? How many have you performed in the last year?"
He performs a couple of these every week.
"How many millimetres of advancement during a lefort i can cause nose widening? Do you perform an alar stitch in this case?"
He cited research that showed nose widening wasn't a foregone conclusion of a lefort i osteotomy, but rather was dependent on the specific patient's anatomy. For instance it might happen to some people but not all, and in those cases intra-operative procedures can be done to attenuate this problem.
How prevalent is nerve damage in the upper and lower jaw region following surgery?
Paresthesia is common as I'm sure everyone here already knows, but he reports that majority of his patients recover within about 6 weeks, another 30% or so within 6 months, and then the long term - that he regarded as taking a year or more or that had persistent partial numbness - was about 5%.
What are the risks of tooth death and tissue necrosis?
Can happen if the tooth is cut during a lefort i, but has never happened with his patients. He said he has only had 1 patient who was 65 years old that had one tooth problem to date.
I read on your website that you do orthodontic treatment after jaw surgery; what is the logic behind this?
He clarified that his preferred method is actually to do orthodontic treatment first as it provides a superior occlusal outcome. Then surgery and then some tweaking of the bite afterwards. Orthodontics afterwards can be done if the patient is looking for jaw surgery for primarily aesthetic reasons but has a good bite already.
I like my current amount of gum show in the upper jaw; if a lefort i and CCW is needed, what actions are taken to ensure the tooth show remains consistent following impaction and advancement of the maxilla?
I wish I asked this in a different way as I actually have more questions about this, so will ask him in my second consultation. I was pretty sleep deprived after my flight to Spain.
He explained that he measures from the medial canthus of both eyes to the upper incisors during the lefort i osteotomy to ensure tooth show is consistent. My follow up question will be "how does advancement and impaction of the maxilla affect tooth show and to what degrees in mm".
Other questions I will ask him are the effects of the nose turning up following maxillary advancement.
He showed me how he produces a surgical plan on his computer using one of his patients as an example. 3D imaging of CT scan is employed to provide precise measurements of osteotomy lines. He aims to be within 1mm of this during surgery.
The other thing I will ask him next time is to see more before and afters of his previous clients. (Can't believe I forgot to ask this!)
Lastly, I will be talking to an orthodontist in his office in September to see if orthodontics alone can fix my bite. However if they can't, he would provide a treatment plan if I decided to move forward with surgery following presurgical orthodontics. His reasoning here was that the orthodontics will change my bite which in turn will alter any plan he could have given me previously.
I will need to talk to him about this again, as I am can't see myself committing to braces before I even see what he has in store for my jaws. Will clarify when I see the orthodontist and update.
He knows Arnett and Gunson, Wolford and Schendal - personally and from reading their work, in addition to Alfaro, Mommaerts and Raffini.
Think that is everything. Just got back and am tired so I might have missed some things. Going to consult with a couple of other surgeons in the mean time and hopefully come up with a good game plan.
If you have any questions feel free to fire away.
-
In general, (anterior) impaction (one form of CCW) can reduce (upper) tooth show for the simple reason it's often done to reduce gum show (gummy smile). When maxilla also advanced there would be some gain of show. As you probably know, the most obvious cases of (anterior) inpaction CCW are where the person is actually RELIEVED of a significant gummy smile where the more relief needed from that is proportional to maximizing the CCW. In situations where someone has no gummy smile to reduce or relieve from anterior impaction, they get posterior downgraft for the CCW.
As to your EXACT mm question, it would involve a surgical displacement proposal on which an analysis of the displacement changes were done in which the measures would be on the chart. So, IF he has DONE the displacement proposal, he can give you close to an 'exact' prediction within a mm or so or what ever is the error factor of such a prediction. So,it sounds like he showed you HOW he comes up with predictions and number measures. But it doesn't sound like he did them at this point in time to answer your very exacting question.
Some surgeons, ie Gunson will provide you with a displacement plan before you commit to a surgery but they CHARGE for the WORK UP needed to generate it.
You could have a situation where ortho ALONE would fix your bite. I note that your bone structure looked great on your bone model but I did see an opening between your top front and bottom teeth--but so what--. But you need to differentiate why you are wanting the surgery. If for aesthetic PREFERENCE alone in the absence of any aesthetic 'problem' associated with those common to people getting maxfax, then any ortho would be in DIRECT DEFERENCE to what the maxfax needed to do/displace during the surgery. So, the ortho needed would be that to screw up your bite in anticipation for it to be corrected with the maxfax surgery. Basically, any ortho plan is either going to be contingent your committing to surgery OR your being committed to fix your bite with ortho ALONE. So, basically, I'm just saying in my own words what you were told by the ortho.
-
Hey Kavan, I appreciate the reply.
Thanks for clarifying the two CCW options; I didn't go into this (posterior downgrafting vs anterior impaction) with Dr. Birbe but I definitely will ask this next time. As I said I like my amount of gum/tooth show, so in this case you are saying the only option for CCW is posterior downgrafting? I presume there will also be some amount of maxillary advancement too in addition to this which will affect the overall movement.
"A surgical displacement model"; gotcha, thanks, will bring this up too. I still have a lot to learn, so again I appreciate any and all input/advice from people that have been through all this jazz before. He didn't bring this up though when I asked about the methodology behind assessing displacement though..
The main issue with the edge to edge bite at the front (it isn't as open in real life, the mandible is detachable from the maxilla in that model so it was just the way it was sitting) is that I cannot bite through certain foods, especially things like bacon, sometimes lettuce in a sandwich or I will just tear all the toppings off of a pizza without being able to bite through it. I am also cusp to cusp on the left so my teeth are wearing slowly over time.
He did explain this to me; that the orthodontics for surgery will be different than purely correcting by bite without surgery. The thing I was unsure about - and please advise me here if you are aware - is that he advised doing the surgical plan AFTER I had received the orthodontic treatment, as to do otherwise before hand would have to be changed at a later date following the orthodontics due to the teeth being in a different position. It seems like a catch-22; I need to know at least to some level of accuracy what surgery would entail before I commit to orthodontics.. right?
My only aesthetic issue is the asymmetry of the right and left mandible and chin deviation to the left of a few mm. However I have soft tissue asymmetry which is exacerbating this. The other aesthetic reason was my convex profile. He said there is room for advancement with a CCW. But the bite is the main issue; improving my profile would just be a big added benefit.
-
Hey Kavan, I appreciate the reply.
Thanks for clarifying the two CCW options; I didn't go into this (posterior downgrafting vs anterior impaction) with Dr. Birbe but I definitely will ask this next time. As I said I like my amount of gum/tooth show, so in this case you are saying the only option for CCW is posterior downgrafting? I presume there will also be some amount of maxillary advancement too in addition to this which will affect the overall movement.
"A surgical displacement model"; gotcha, thanks, will bring this up too. I still have a lot to learn, so again I appreciate any and all input/advice from people that have been through all this jazz before. He didn't bring this up though when I asked about the methodology behind assessing displacement though..
The main issue with the edge to edge bite at the front (it isn't as open in real life, the mandible is detachable from the maxilla in that model so it was just the way it was sitting) is that I cannot bite through certain foods, especially things like bacon, sometimes lettuce in a sandwich or I will just tear all the toppings off of a pizza without being able to bite through it. I am also cusp to cusp on the left so my teeth are wearing slowly over time.
He did explain this to me; that the orthodontics for surgery will be different than purely correcting by bite without surgery. The thing I was unsure about - and please advise me here if you are aware - is that he advised doing the surgical plan AFTER I had received the orthodontic treatment, as to do otherwise before hand would have to be changed at a later date following the orthodontics due to the teeth being in a different position. It seems like a catch-22; I need to know at least to some level of accuracy what surgery would entail before I commit to orthodontics.. right?
My only aesthetic issue is the asymmetry of the right and left mandible and chin deviation to the left of a few mm. However I have soft tissue asymmetry which is exacerbating this. The other aesthetic reason was my convex profile. He said there is room for advancement with a CCW. But the bite is the main issue; improving my profile would just be a big added benefit.
You might have 2 options of CCW. So ask about both. Anterior impaction with advancement can have a gain of tooth/gum show close to the loss of it (zero sum thing) via the impaction if it were only impaction. So ask about that.
In order for him to answer very specific MM measures, a displacement proposal and analysis thereof needs to be done first and that might cost you extra for him to perform.
As to the ortho treatment, you would need to RESOLVE to having surgery and with that committment, your ortho (braces) would be to prepare you for the objectives of the surgery. So, yes, the doc would need you already IN BRACES to give a surgical proposal and answer exact mm questions.
As to least amount he could tell you in absence of what presents after you get the braces to prepare for surgery, is basic information about the type of surgery which he already covered in general terms.
-
You might have 2 options of CCW. So ask about both. Anterior impaction with advancement can have a gain of tooth/gum show close to the loss of it (zero sum thing) via the impaction if it were only impaction. So ask about that.
In order for him to answer very specific MM measures, a displacement proposal and analysis thereof needs to be done first and that might cost you extra for him to perform.
As to the ortho treatment, you would need to RESOLVE to having surgery and with that committment, your ortho (braces) would be to prepare you for the objectives of the surgery. So, yes, the doc would need you already IN BRACES to give a surgical proposal and answer exact mm questions.
As to least amount he could tell you in absence of what presents after you get the braces to prepare for surgery, is basic information about the type of surgery which he already covered in general terms.
Okay less posterior downgrafting sounds like it wouldn't change the shape of the mandible itself as much, but rather facilitate more of a CCW rotation into place if I can imagine it correctly.
I suppose my issue is that if choosing a surgeon is so important based on the actual plan they decide to give you, surely I should have even some idea before I commit to them? I didn't receive a ceph analysis or x ray; is this something the ortho typically does? I keep reading threads here where people come back from their first consultation with at least suggestions of advancements and a ceph analysis/occlusal/mandibular plane analysis..(I know that the actual surgical plan may differ but at least they had an in-depth analysis of their anatomy). Mine was more of an im depth discussion, so to speak.
-
Okay less posterior downgrafting sounds like it wouldn't change the shape of the mandible itself as much, but rather facilitate more of a CCW rotation into place if I can imagine it correctly.
I suppose my issue is that if choosing a surgeon is so important based on the actual plan they decide to give you, surely I should have even some idea before I commit to them? I didn't receive a ceph analysis or x ray; is this something the ortho typically does? I keep reading threads here where people come back from their first consultation with at least suggestions of advancements and a ceph analysis/occlusal/mandibular plane analysis..(I know that the actual surgical plan may differ but at least they had an in-depth analysis of their anatomy). Mine was more of an im depth discussion, so to speak.
Very few people (on here) would actually understand much about a surgery plan as there are LOTS of numbers with the WHOLE 'gestalt' of the plan. So there is no sense in asking for specific mm displacements unless you know how to read what all those measures mean in a displacement plan.
-
Regarding BSSO advancement of the mandible, we really don't speak in terms of 'shape' or change of shape of it. That's because advancement is really an elongation from where they make the cut to advance (near back of 2ncd molar) to a point to the chin. In effect, there has been a DISTANCE INCREASE to lets say; 'ALONG THE JAW LINE'. Rotation to the maxilla done with the BSSO changes the ORIENTATION of the mandible. So, basically, they are working with what ever mandible 'SHAPE' you start with and 'displacing' its position.
So, what you need to get an IDEA ABOUT are the basic concepts associated with the type of surgery you are requesting, eg. here, language/terms to use to demonstrate you understand the difference between changes of SHAPE of the mandible from changes in ORIENTATION.
Basically, if you want to 'talk turkey' with a SURGEON with reference to mm exactitude, he/she most likely would not engage in the absence of your reflecting conceptual understanding of the WHOLE thing and how the part you are asking about relates to it. I mean the discussion about the change of ONE thing, is relative to a surgery that can change MANY OTHER things than the one thing you are asking about.
The ortho could give a 'ceph analysis'. BUt it is the SURGEON who does a ceph DISPLACEMENT proposal (based on the ceph analysis) which is basically the PLAN of the surgery to be done.
So, in terms of getting ideas about things, there is a difference between a ceph analysis and ceph displacement proposal which uses the ceph analysis as the BASE LINE for the displacement proposal.
In essence, it looks like your surgeon is holding contingent that you present with a KNOWN baseline (as to the position of your teeth after braces are used to move them) before he comes up with a SURGICAL PLAN. That's because a surgical plan is contingent on where the teeth actually are. So, in effect contingent on getting the ortho first when the GOAL of the ortho is to HAVE the surgery.
With regard to other patients getting the displacement proposal aka surgical plan, they are usually committed to GETTING the surgery where as in your case, you seem to be wanting to decide whether you should get surgery OR just get ortho to fix your bite.
So, your goal of having surgery is not really clear to the guy, especially so if you are consulting to decide whether or not you should have the surgery OR to just fix your bite in ABSENCE of any surgery.
IDK...see if you can clarify your GOALS to YOURSELF so you can articulate those goals to the surgeon in the absence of discussing mm displacements with exactitude. For example:
'I would like both my jaws advanced forward for better aesthetics'
'I would like my gum show to remain the same'.
'I would like more symmetry to my jaw'
I'm not going to go through every possible request that can be factored into a goal. Just saying you would need to, in which case, the surgeon can see if there were any conflicting goals or if they are compatible with the surgery they do.
My PRACTICAL advice is this:
IF you want to know if your bite can be fixed WITHOUT surgery, find that out from an ortho NOT associated with this surgeon (or a few orthos if you like). The answer is probably; 'yes'.
That information alone will allow you to then decide whether to have surgery to move the jaws for 'aesthetic reasons'. In which case, you would need to forgo the option of ortho ONLY to fix your bite and instead commit to having what ever ortho needed to have FOR the surgery you want when the surgeon NEEDS to KNOW where the teeth actually ARE inorder to do a displacement proposal surgical plan.
-
Regarding BSSO advancement of the mandible, we really don't speak in terms of 'shape' or change of shape of it. That's because advancement is really an elongation from where they make the cut to advance (near back of 2ncd molar) to a point to the chin. In effect, there has been a DISTANCE INCREASE to lets say; 'ALONG THE JAW LINE'. Rotation to the maxilla done with the BSSO changes the ORIENTATION of the mandible. So, basically, they are working with what ever mandible 'SHAPE' you start with and 'displacing' its position.
So, what you need to get an IDEA ABOUT are the basic concepts associated with the type of surgery you are requesting, eg. here, language/terms to use to demonstrate you understand the difference between changes of SHAPE of the mandible from changes in ORIENTATION.
Thanks, this is useful. I didn't actually bring any of this up with him but I most certainly will in September when I fly back. You are correct, I meant that with CCW the orientation of the body of the mandible will change slightly with respect to the ramus, but to a lesser degree with less posterior downgrafting of the maxilla. He also mentioned that with BSSO the width of the mandible at the back will appear wider due to it being slightly thicker at the back than the front.
Basically, if you want to 'talk turkey' with a SURGEON with reference to mm exactitude, he/she most likely would not engage in the absence of your reflecting conceptual understanding of the WHOLE thing and how the part you are asking about relates to it. I mean the discussion about the change of ONE thing, is relative to a surgery that can change MANY OTHER things than the one thing you are asking about.
I understand this. He was actually enthusiastic during the consultation in explaining the science/technical aspects of the movements I did ask about. But I will try to remain as specific as possible in future to avoid any miscommunications.
The ortho could give a 'ceph analysis'. BUt it is the SURGEON who does a ceph DISPLACEMENT proposal (based on the ceph analysis) which is basically the PLAN of the surgery to be done.
So, in terms of getting ideas about things, there is a difference between a ceph analysis and ceph displacement proposal which uses the ceph analysis as the BASE LINE for the displacement proposal.
Understood.
In essence, it looks like your surgeon is holding contingent that you present with a KNOWN baseline (as to the position of your teeth after braces are used to move them) before he comes up with a SURGICAL PLAN. That's because a surgical plan is contingent on where the teeth actually are. So, in effect contingent on getting the ortho first when the GOAL of the ortho is to HAVE the surgery.
With regard to other patients getting the displacement proposal aka surgical plan, they are usually committed to GETTING the surgery where as in your case, you seem to be wanting to decide whether you should get surgery OR just get ortho to fix your bite.
If the ortho cannot correct my bite, then I will certainly move forward with surgery. I just want some idea of what osteotomies/movements of my jaws and chin will be likely before I commit to an ortho in another country, in case decide to have surgery done elsewhere by someone else.
So, your goal of having surgery is not really clear to the guy, especially so if you are consulting to decide whether or not you should have the surgery OR to just fix your bite in ABSENCE of any surgery.
My first surgeon in 2012 concluded that "The study models are not true orthodontic models but it is not possible to get a good class 1 occlusion on the left even after moving the models so that the upper and lower midlines are coincident. If he wishes to correct the occlusion and appearance he would need a combination of orthodontics and surgery".
I entered this consultation with the assumption that I needed jaw surgery based on my previous surgeons findings. Dr. Birbe recommended that I consult with one of his orthodontists first to see if orthodonics can be employed. I suppose my surgery would be primarily functional. The aesthetic improvements I want are improved left-right symmetry and an improvement in my profile (I have a convex profile).
Are you implying that the importance of the consultation is essentially finding out the competency of the surgeon and that they can perform the specific kinds of osteotomies you wish?
For example, hypothetically, if someone had zero knowledge of jaw surgery consulted with a surgeon and agreed to get braces to fix a severe underbite, but then when the time came to provide a surgical plan, the surgeon's plan included ONLY advancing the maxilla forward and not setting the mandible back. If the patient didn't agree with such a plan, could they get another surgical plan/suggestion/ceph analysis done elsewhere by another surgeon? Is this not something that should be discussed as a likelihood prior to the orthodontics? I guess my point is, I've seen people suggest getting surgical plans from some of the big names, and then asking more affordable local surgeons to carry out the procedure; but this seems like it wouldn't be possible in the case where you only get even a semblance of a plan after you commit to months of orthodontics with your surgeon.
I apologise if this seems obvious to you and don't expect you to take time out of your day to walk anyone through any of this, I just want to fully understand this process.
Even though I have been on these forums since 2012 I am still relatively new to the whole consultation process and just want to ensure I understand everything correctly.
My PRACTICAL advice is this:
IF you want to know if your bite can be fixed WITHOUT surgery, find that out from an ortho NOT associated with this surgeon (or a few orthos if you like). The answer is probably; 'yes'.
See above advice from previous surgeon.
That information alone will allow you to then decide whether to have surgery to move the jaws for 'aesthetic reasons'. In which case, you would need to forgo the option of ortho ONLY to fix your bite and instead commit to having what ever ortho needed to have FOR the surgery you want when the surgeon NEEDS to KNOW where the teeth actually ARE inorder to do a displacement proposal surgical plan.
Thanks man.
-
Here's what to keep in mind. With regard to wanting to know a very specific mm displacement as to how much gum and/or tooth show you get from the surgery (will it be 'same' as what you now have and already like?)--well THAT particular question, in order for the doctor to answer it for you is contingent on KNOWING exactly where your teeth will be AFTER you get braces in preparation for the surgery.
Your surgeon CAN'T answer that question because the answer is contingent on something he does not know YET.
Even IF he did a preliminary displacement analysis/surgical proposal based on where your teeth are NOW but MIGHT BE in the FUTURE after the braces to prepare for surgery, that alone does not PREDICT 'exactly' where your teeth will actually be in the future--not enough to answer a highly specific question as to whether or not you will have the same amount of gum show you want as a result of getting the surgery.
What he knows NOW is what direction the braces should move the teeth in reference to the main objectives of the surgery. But he doesn't know exactly what position they will be in at a future time.
So, your question is contingent on something he does NOT know YET and could only know after the amount of time needed to see exactly how the braces have moved the teeth.
Your question/CONSTRAINT is TOO specific to answer/predict with the type of certainty needed to give you an 'exact' answer.
Basically, you are asking a question that can't be known at the time you want the highly specific answer to it.
-
Understood.
Will consult with a couple of others as well and go from there. Looking forward to figuring this out.
Thanks again for taking the time to offer your thoughts.
-
Apologies for interrupting your thread, Strongjawman.
Anterior impaction with advancement can have a gain of tooth/gum show close to the loss of it (zero sum thing) via the impaction if it were only impaction. So ask about that.
That's news to me. Thank you for that snippet of info. Is there anyway to prevent the result of an anterior impaction being negated during maxilla advancement?
-
Apologies for interrupting your thread, Strongjawman.
That's news to me. Thank you for that snippet of info. Is there anyway to prevent the result of an anterior impaction being negated during maxilla advancement?
It's not something to really be concerned about if the impaction is to be done to address a gummy smile and also to affect a CCW of the mandible. The amount of optimal tooth show--and there is some wiggle room for that-- is factored into impaction advancement combination.
-
IF you want to know if your bite can be fixed WITHOUT surgery, find that out from an ortho NOT associated with this surgeon (or a few orthos if you like). The answer is probably; 'yes'.
That information alone will allow you to then decide whether to have surgery to move the jaws for 'aesthetic reasons'. In which case, you would need to forgo the option of ortho ONLY to fix your bite and instead commit to having what ever ortho needed to have FOR the surgery you want when the surgeon NEEDS to KNOW where the teeth actually ARE inorder to do a displacement proposal surgical plan.
What is the normal protocol when planning a surgical procedure? I also experience the catch 22 problem when trying to communicate with orthodontists and surgeons. When I meet an orthodontist, they ask "so, have you decided for surgery?" -Uhm no, I was thinking you could explain the orthodontic movements and how this will work. "Nop, can't do that, you need to discuss what the surgeon will do".
Ok, so I go to the surgeon and experience that they tell me that in order to do a planning, I need to go to my orhtodontist to get a decompensation before they can tell me exact, but the orthodontist won't do that if I'm not comitted. So it seems like it's about comitting before knowing what you're comitting to.
It would make sense if someone is the boss in this situation, directing the entire procedure. It seems like the surgeon would be in the best position for this, as it's their work to change the underlying structure and decide where the jaws can be displaced, and know how the teeth will be angled after the procedure in case of e.g rotation. Say you're doing a ccw rotation e.g, it may make more sense to not angle teeth out prior to surgery, if it's going to be rotated out anyway, but it seems like there needs to be a concensus on this prior to starting the treatment.
What the correct and normal way to invoke such procedure, is it to go to the surgeon and get a plan that directs the orthodontist before surgery. Or is the orthodontic movements out of the competence area of the surgeon, so it's just for the patient to put on the blind fold and see where the ride lands?
-
What is the normal protocol when planning a surgical procedure? I also experience the catch 22 problem when trying to communicate with orthodontists and surgeons. When I meet an orthodontist, they ask "so, have you decided for surgery?" -Uhm no, I was thinking you could explain the orthodontic movements and how this will work. "Nop, can't do that, you need to discuss what the surgeon will do".
Ok, so I go to the surgeon and experience that they tell me that in order to do a planning, I need to go to my orhtodontist to get a decompensation before they can tell me exact, but the orthodontist won't do that if I'm not comitted. So it seems like it's about comitting before knowing what you're comitting to.
It would make sense if someone is the boss in this situation, directing the entire procedure. It seems like the surgeon would be in the best position for this, as it's their work to change the underlying structure and decide where the jaws can be displaced, and know how the teeth will be angled after the procedure in case of e.g rotation. Say you're doing a ccw rotation e.g, it may make more sense to not angle teeth out prior to surgery, if it's going to be rotated out anyway, but it seems like there needs to be a concensus on this prior to starting the treatment.
What the correct and normal way to invoke such procedure, is it to go to the surgeon and get a plan that directs the orthodontist before surgery. Or is the orthodontic movements out of the competence area of the surgeon, so it's just for the patient to put on the blind fold and see where the ride lands?
Thanks for posting. I share the same uncertainty with all of this.
I'm sure there is an obvious answer that we just have not figured out or received yet. How does the orthodontist know what position to put the teeth in the absence of a surgical plan?.. I do not know the answer. Perhaps they line them up with orthodontic models and then the surgery slides the jaw into position? Sounding extremely green about this aspect here lol
Secondly. If I have a problem with asymmetry of the left-right mandible and chin deviation, how can I be certain that committing to one surgeon is the right answer when they haven't described the types of cuts that are likely to fix the problem. Not even looking for specific mm displacements here, just how the surgeon would go about correcting the problem..
-
Thanks for posting. I share the same uncertainty with all of this.
I'm sure there is an obvious answer that we just have not figured out or received yet. How does the orthodontist know what position to put the teeth in the absence of a surgical plan?.. I do not know the answer. Perhaps they line them up with orthodontic models and then the surgery slides the jaw into position? Sounding extremely green about this aspect here lol
Secondly. If I have a problem with asymmetry of the left-right mandible and chin deviation, how can I be certain that committing to one surgeon is the right answer when they haven't described the types of cuts that are likely to fix the problem. Not even looking for specific mm displacements here, just how the surgeon would go about correcting the problem..
It's presumed that the ortho would be in the capacity to understand a preliminary surgical plan/objective as it would relate to WHERE the teeth SHOULD be (where the surgeon wants them to be)--like what direction he needs to displace the teeth-- for the goal of surgery to be achieved. It's understood by BOTH of them that relaying such a plan/obective to the ortho is not a promise or prediction that the teeth will be 'exactly' where the surgeon wants them at any 'exact' point in time. Hence the final surgical plan as it relates to giving it to the patient will be given when it's determined the teeth ACTUALLY ARE close enough to where they are needed to be for the basic goals of the surgery to be met.
As to how you can be CERTAIN. You can't. Instead, approach from the perspective of how UNCERTAIN it is that the surgeon can deliver exactly what you want/expect whether or not it be wanting to know if your smile/tooth/gum show will remain exactly the same or want to know ALL the input going into the surgery. So, learn to deal with uncertainty or resolve NOT to have surgery if it's CERTAINTY you want.
I mean even IF a surgeon gave you a surgical plan, ask yourself if YOU would be certain that you would understand everything in it to make a decision for or against the surgery. If it would be something where you would have to 'crowd source' (like on here) asking people what the plan MEANS, how would you be certain you were getting the right answers? You can't. So, why would it be contingent for you to have one if you could not be certain you would understand it all in it's entirety or be certain that info from 'crowd sourcing'would be precise or correct enough for you to be certain?
-
It's presumed that the ortho would be in the capacity to understand a preliminary surgical plan/objective as it would relate to WHERE the teeth SHOULD be (where the surgeon wants them to be)--like what direction he needs to displace the teeth-- for the goal of surgery to be achieved. It's understood by BOTH of them that relaying such a plan/obective to the ortho is not a promise or prediction that the teeth will be 'exactly' where the surgeon wants them at any 'exact' point in time. Hence the final surgical plan as it relates to giving it to the patient will be given when it's determined the teeth ACTUALLY ARE close enough to where they are needed to be for the basic goals of the surgery to be met.
As to how you can be CERTAIN. You can't. Instead, approach from the perspective of how UNCERTAIN it is that the surgeon can deliver exactly what you want/expect whether or not it be wanting to know if your smile/tooth/gum show will remain exactly the same or want to know ALL the input going into the surgery. So, learn to deal with uncertainty or resolve NOT to have surgery if it's CERTAINTY you want.
I mean even IF a surgeon gave you a surgical plan, ask yourself if YOU would be certain that you would understand everything in it to make a decision for or against the surgery. If it would be something where you would have to 'crowd source' (like on here) asking people what the plan MEANS, how would you be certain you were getting the right answers? You can't. So, why would it be contingent for you to have one if you could not be certain you would understand it all in it's entirety or be certain that info from 'crowd sourcing'would be precise or correct enough for you to be certain?
True. So in the absence of having personally read all the research pertaining to orthognathic jaw surgery (and possessing the ability to interpret said research with a high level of competency) - my choice of surgeon will be limited to seeing their before/afters, the "vibe" I get from my consultations and their experience/track record so to speak.. in a nut shell.
I can see this being a case where - if I get a good vibe off of all of the surgeons I consult with, and all of their before afters are satisfactory to me and they can answer my questions to a degree I am comfortable with - then the only differentiating factor would be price, so I will elect to go with the most affordable surgeon.
-
Firstly, I'm an advocate of the 'abnormal' protocol which is gathering enough KNOWLEDGE on one's own and enough to either be close to certain as to what you want and why OR to REDUCE confusion and uncertainty enough so one does not go into a consult knowing little to nothing about what they are consulting about, in which case the DEPENDANCY on the doctor to explain every little thing will exceed his/her time to do so. Nor do they have any obligation to do so.
For example, a lot of, if not most of maxfax relationships are GEOMETRICAL; points, angles, planes, rotations. So a good grounding in that will allow a person to relate back those concepts. Of course, not enough to figure out everything but enough so that a remedial course in geometry is not required for the doctor to give in order for one to understand the relationship that maxfax ALSO has to points, angles and planes, rotations and displacements thereof.
Not to belabor this but just to say that a lot of BASIC stuff having to do with maxfax becomes self evident just like concepts in geometry and logic become self evident to those who have studied it.
Background in logic or anything that enhances reasoning abilities so they become more rational than irrational is also important to have. For example the ability to understand the concepts of one 'knowing what they don't know' and 'not knowing what they don't know'.
For example, the surgeon understands the basic concept of he/she KNOWS what he does NOT know. He knows that he can't plan out a surgery with precision and relay 'NOW' knowledge to you about precise plans when such precise plans are contingent on information that will present itself at a FUTURE time. So, requests for surgical plans with any expectation they be PRECISE predictions of what is TO BE done or commitments to do so, resolves to an irrational request, one where you need to know NOW a precise surgical plan whereas the precision you want is contingent on a piece of information that is NOT known NOW and requires a FUTURE time to know it.
As to the 'catch 22', the ortho and the maxfax BOTH want you to know what you COULD know and could know on YOUR OWN.
For example COULD one know that one WANTS surgery INSTEAD of ortho alone to fix the bite and ALSO advance out the jaw/jaws? The answer is 'YES'. One COULD know that they WANT one thing over the other and in the absence of knowing if what they want can be done, in which case the pursuit of information becomes one to 'find out' if what they want can be accommodated via surgery.
For example Patient A has an overbite and recessive jaw and knows he WANTS surgery to correct BOTH. He's also has enough background knowledge underbelt to know what he wants is reasonable to inquire about having. So, reasonable to want a normative balance to the jaws and a bite to go with it. If he goes to an ortho, he will be able to answer the question: 'Have you decided whether or not you want surgery or ortho alone to correct your bite?'
The other example is patient B who does NOT know what he wants. He doesn't know whether he wants surgery aimed at BALANCING the JAWS with the bite or if he wants ortho alone just to 'get the bite right'. He can't expect the ortho to give him a comparative analysis of both so he can decide on which one he wants. The ortho does NOT plan out surgery FOR the maxfax. Nor can he expect the maxfax to predict the OUTCOMES of ortho before the outcomes present themselves and 'because' he 'needs' this plan to decide whether he wants ortho alone or maxfax.
What's the DIFFERENCE? Patient A, KNOWING that he WANTS surgery will be offered more information (or validation) towards that goal than will patient B. Why? Because patient B doesn't know even IF he wants one over the other.
What do the ortho and the maxfax both have in common? They both want the patient to demonstrate some kind of RESOLVE, DESIRE or WANT of one thing over the other. NEITHER will predict FOR the other with any exactitude when your GOAL actually IS for EITHER of them to do that because you DON'T know whether or not you want one or the other.
That said, the 'normal protocol' is what is basically ABNORMAL for a LOT of people on this board which is to have enough background conceptual info underbelt as to use it as basis to understand and/or gather more info about maxfax and enough so to at LEAST know whether or not they want surgery or ortho alone. Again, from my POV, it's quite possible to gather and process enough information on ONE'S OWN to know whether or not you want surgery. I'm not talking about 'need' because need for it (information thereof) can be gathered after one KNOWS they WANT it. I'm talking about information processing abilities that allow one to make decisions under uncertainty.
It is NORMAL to have UNCERTAINTY about the surgery you are considering. But it is also possible to LOWER uncertainty or become more certain that you WANT surgery and enough to RESOLVE to having it in the absence of precise predictions of it's outcomes and also in the presence of what ever the inherent risks are involved with the surgery (which the surgeon/s you are consulting with should be able to convey). You just need to be in the capacity to know what you want and have a good idea why. Even if you are way off target as to why you want a type of surgery, as long as you can communicate WHY you want it is enough for the doc to tell you if that's a good or unrealistic expectation to make a decision on.
It's NOT so hard to understand that a surgeon KNOWS what he does not know, tells you what he does not know (where your teeth will be EXACTLY at some time in the FUTURE) and why you would not expect him to draft out a PREDICTIVE and PRECISE PLAN based on knowledge he does not have NOW when you want it when knowledge of such is contingent on some time in the FUTURE.
It's NOT hard to understand the reasoning why some surgeons would be reluctant to give a precise plan when the patient appears to need it to be a 'certain' PREDICTION of the OUTCOMES of the surgery. They would be concerned that the patient would misconstrue it as an absolute promise against the outcome. They can pick up on a patient 'needing' it for CERTAINTY and withhold giving one for that reason.
Some docs will give a surgical displacement analysis to SHOW you what their AIM is which will allow you to see if you are on 'same page' as to the aesthetic objective. They might charge extra for that. As to the ortho aspect of it, it would show where they plan the teeth to be/oriented (seen on the after contour diagram). But it doesn't convey with CERTAINTY that the ortho needed prior will be exactly on target with the surgeon's plan.
Suffice to say if you want a plan/proposal, seek out surgeons who give one. But realize, it's NOT an 'absolute' prediction of the OUTCOME. It's better used/requested to compare aesthetic PREFERENCES between doctors.
When the question is; 'How do I know what I want?', your f**ked. Because the answer is KNOW that you DON'T KNOW what you want. Don't expect others to know FOR you what you want if you don't know yourself. Wait for a time when you can express what you want, in which case it will be easier for you to gather (and understand) information as to what you want is possible or not.
-
True. So in the absence of having personally read all the research pertaining to orthognathic jaw surgery (and possessing the ability to interpret said research with a high level of competency) - my choice of surgeon will be limited to seeing their before/afters, the "vibe" I get from my consultations and their experience/track record so to speak.. in a nut shell.
I can see this being a case where - if I get a good vibe off of all of the surgeons I consult with, and all of their before afters are satisfactory to me and they can answer my questions to a degree I am comfortable with - then the only differentiating factor would be price, so I will elect to go with the most affordable surgeon.
You don't have to read all the research papers pertaining to jaw surgery. But you should have some grounding in some basic studies (geometry for example) that would allow you to understand some basic things you don't understand in terms of concepts you do understand.
For example a lot of maxfax has to do with points, lines, angles, planes, rotations, displacements (extrapolations). When that stuff is totally 'foriegn' to someone, they wouldn't get much of anything by reading research papers because they are written with presumption that the readership has background in those things.
I suppose you could go by 'vibes' if you had to. It would depend on how good your intuition was. Like how decisions based on vibes worked out for you in the past.
In essence, what ever knowledge you have that you feel you can depend on to gather more knowledge and make a decision.
-
I can't thank you enough for taking the time to reply, Kavan.
Okay, you have clarified this to me a lot more.
I am a very logical and methodical person (I debate a lot) and have more knowledge on my own facial anatomy (I went out of my way to get a skeletal model done, MRI and soft tissue scans to determine the extent of my boney asymmetry vs soft tissue) and of jaw surgery than someone who has done zero research. But obviously I am not an expert.
With regards to your example of patient B; if they had an overbite and a recessive bite; I would assume that - in the absence of any of their own knowledge of which was the better solution (orthodontics vs surgery) - this is the kind of basic info I was referring to that the surgeon/ortho might be able could offer them. For instance in a situation where both could technically be options, surgery might be a more fitting solution as orthodontics only might require extractions or have a less than ideal tooth inclination afterwards.
I suppose I was more looking for some basic suggestions of the TYPES of movements that would be involved in my case. But there is also the possibility that my case is a lot simpler in terms of types of osteotomies needed (bimax with high chance of CCW and genio were essentially what I was quoted for).
For instance perhaps if I had extreme mandibular hyperplasia the surgeon could have suggested distraction osteogenesis as a POSSIBILITY (not promise) or an osteotomy of the ramus on the affected side.
To be honest, I think the real crux of what I wanted to know - and you have explained that it isn't possible to know this ahead of time - was that: if the degree of change in orientation/advancement of my jaws in order to achieve a perfect bite was such that it would drastically alter how I look, then I might not want to go ahead with surgery. However if the degree of displacement was such that my bite could be improved through surgery but with lesser drastic appearance changes, I would be more likely to go ahead with surgery.
Even I had to come up with an elevator pitch of sorts, it would be this:
- I wish to correct my bite.
- I would like an improvement in my profile (it is convex)
- I would like my chin deviation to be corrected if possible.
- I don't want to add further length onto my face and would like CCW to mitigate this.
- If the amount of advancement/displacement of the upper and lower jaws needed to correct my bite is going to push my jaws outside of the aesthetic boundaries I have asked for (for example if it increased left-right asymmetry and/or is TOO much advancement), then I would not get the surgery.
Does this seem reasonable? Do you think this is an obvious answer? I don't have a severe underbite or overbite, so am I worrying over nothing? It's not like huge movements would be needed to bring the teeth together as they are already essentially together, right?
I get what you are saying, it is not the surgeons job to educate me on every single type of osteotomy available unless I have specific preferences or questions about them.
Thanks for clearing this up, I feel I understand the whole process a lot more and will come increasingly prepared for future consultations.
Have a great weekend man.
-
By the way, Strongjawman.
Your initial questions you asked of Birbe were all GREAT. Try not to get 'stuck' on requiring that your smile stay exactly the same or within 1mm of same, like not to the extent you give the impression you're asking to see a surgical proposal in order to be 'CERTAIN' nothing about it's orientation will change.
IMO, you're better off asking to see before and after photos, noting that in them the smile changes (even if slightly) and saying something like: 'His smile looks so much better'. Even if you don't mean it, it can elicit a response like; 'Oh yes, smiles change too for the better.' That will give you some information that your smile could change. Another way is to say something like: 'Why didn't his smile change?' Even if you observed it did change, the question would also elicit a response of; 'Oh yes it did change and for the better.' Getting the doc to CONFIRM a change relative to that type of way of asking the question will give you the info you want which is basically; 'Will a change to the smile occur?'
-
I can't thank you enough for taking the time to reply, Kavan.
Okay, you have clarified this to me a lot more.
I am a very logical and methodical person (I debate a lot) and have more knowledge on my own facial anatomy (I went out of my way to get a skeletal model done, MRI and soft tissue scans to determine the extent of my boney asymmetry vs soft tissue) and of jaw surgery than someone who has done zero research. But obviously I am not an expert.
With regards to your example of patient B; if they had an overbite and a recessive bite; I would assume that - in the absence of any of their own knowledge of which was the better solution (orthodontics vs surgery) - this is the kind of basic info I was referring to that the surgeon/ortho might be able could offer them. For instance in a situation where both could technically be options, surgery might be a more fitting solution as orthodontics only might require extractions or have a less than ideal tooth inclination afterwards.
I suppose I was more looking for some basic suggestions of the TYPES of movements that would be involved in my case. But there is also the possibility that my case is a lot simpler in terms of types of osteotomies needed (bimax with high chance of CCW and genio were essentially what I was quoted for).
For instance perhaps if I had extreme mandibular hyperplasia the surgeon could have suggested distraction osteogenesis as a POSSIBILITY (not promise) or an osteotomy of the ramus on the affected side.
To be honest, I think the real crux of what I wanted to know - and you have explained that it isn't possible to know this ahead of time - was that: if the degree of change in orientation/advancement of my jaws in order to achieve a perfect bite was such that it would drastically alter how I look, then I might not want to go ahead with surgery. However if the degree of displacement was such that my bite could be improved through surgery but with lesser drastic appearance changes, I would be more likely to go ahead with surgery.
Even I had to come up with an elevator pitch of sorts, it would be this:
- I wish to correct my bite.
- I would like an improvement in my profile (it is convex)
- I would like my chin deviation to be corrected if possible.
- I don't want to add further length onto my face and would like CCW to mitigate this.
- If the amount of advancement/displacement of the upper and lower jaws needed to correct my bite is going to push my jaws outside of the aesthetic boundaries I have asked for (for example if it increased left-right asymmetry and/or is TOO much advancement), then I would not get the surgery.
Does this seem reasonable? Do you think this is an obvious answer? I don't have a severe underbite or overbite, so am I worrying over nothing? It's not like huge movements would be needed to bring the teeth together as they are already essentially together, right?
I get what you are saying, it is not the surgeons job to educate me on every single type of osteotomy available unless I have specific preferences or questions about them.
Thanks for clearing this up, I feel I understand the whole process a lot more and will come increasingly prepared for future consultations.
Have a great weekend man.
Well, yes, it's because I pick up that you are logical that you would be receptive to my responses.
Now with regard to patient B, there are a LOT of patient B's (over bite with recessive jaw) out there (some even on this board) who relay and REGRET depending on the ortho's advice which amounted to COMPENSATING for the skeletal imbalance by PUSHING their face more INWARD just to get the 'bite right'.
That's why people with some knowledge and enough to know that they want surgery are in a better position then those who have no idea they are candidates for surgery and instead depend on the ortho to volunteer that info in the event the ortho could make the bite right without it. So, there are a lot of patient B's out there who have found out the hard way that the 'right bite' can look WRONG on the face.
That's the sort of thing Mew and his father openly critique; the types of orthos limiting their advice to just getting the bite right and thereby making the patients skeletal imbalance WORSE. Those that wouldn't tell them they would be better off with the surgery.
Your elevator pitch sounds good to me.
-
Strongjawman, how did you come across Dr.Birbe? Is he well respected in the field, and how does he compare to Dr.Raffaini & Alfaro?
It's not something to really be concerned about if the impaction is to be done to address a gummy smile and also to affect a CCW of the mandible. The amount of optimal tooth show--and there is some wiggle room for that-- is factored into impaction advancement combination.
Many thanks for the response. Also, I show a lot of gum tissue on my frontal side, is there a limit on how much impaction can be done to the posterior side of the gums?
Also, I've heard conflicting reports on where the impaction is done, is it done above the nasal cavity or on the gums, itself?
-
Strongjawman, how did you come across Dr.Birbe? Is he well respected in the field, and how does he compare to Dr.Raffaini & Alfaro?
Many thanks for the response. Also, I show a lot of gum tissue on my frontal side, is there a limit on how much impaction can be done to the posterior side of the gums?
Also, I've heard conflicting reports on where the impaction is done, is it done above the nasal cavity or on the gums, itself?
They have to balance multi relationships to optimize better balance.
Impaction is the result of removing a SECTION, can be a bone wedge from front or back or can be an 'even' section and closing in on the space left by the removal of what ever section, shape thereof was removed. One cut for this is though the base of nose at nasal spine level.
-
In the process of booking a consultation with, Dr.Birbe's sec, don't know how he compares to the other prominent surgeons given the limited information available, but he seems to be highly regarded on here. Also, it'll be nice to have another professional opinion that I can use in order to help me make an informed decision.
They have to balance multi relationships to optimize better balance.
Impaction is the result of removing a SECTION, can be a bone wedge from front or back or can be an 'even' section and closing in on the space left by the removal of what ever section, shape thereof was removed. One cut for this is though the base of nose at nasal spine level.
I'll make sure to ask the doctor on how he'll plan to do the impaction on the maxilla. Thanks for the reply, Kavan.
-
Strongjawman, how did you come across Dr.Birbe? Is he well respected in the field, and how does he compare to Dr.Raffaini & Alfaro?
I came across him through this forum! He posted here a few times in the past. Not sure how he compares to be honest; he isn't as well known but he has been recommended as among the best in Spain.
-
I came across him through this forum! He posted here a few times in the past. Not sure how he compares to be honest; he isn't as well known but he has been recommended as among the best in Spain.
Thanks. Yeah, that's why I initially asked the question because I got nothing back from doing a background search on him [apart from a poster listing him as one of the more experienced surgeons]. At least doing a background search on this forum with names like, Dr.Alfaro, Dr.Zarrinbal, you hear of posters who have undergone treatment, are satisfied, and can vouch for those surgeons.
The only problem I have with being among the best in Spain, is who's making that comment, and how good are the rest of the surgeons in Spain barring Alfaro. This whole selection process is a hit and miss.
I'm going to book with Dr.Alfaro while I'm out there, too, so I'll be killing two birds with one stone.
-
Birbe seems like a nice guy. He reads this forum, and we've talked via email.
I have no idea how he is as a surgeon.
-
Birbe seems like a nice guy. He reads this forum, and we've talked via email.
I have no idea how he is as a surgeon.
Agree. I mailed the clinic and got ridiculous fast responses to my mails and had a video consultation the same day and got a quotation fast etc. Very good service, the best I've come across and directly thought this is the guy for me. Fast and easy to talk to.
Then all of a sudden when I sent a mail with some more serious questions on how I can actually proceed if I wish to get serious about this, and get a more in-depth analysis of my specific case, no more response. It seemed very strange to me, I mean this should be the mail they would want to get, how can they else get any customer to actually get a procedure. I wonder if it could be that I asked specifically regarding posterior down grafting and if it could be handled if necessary. Maybe they figure it's a lost case if they don't do it and I specifically ask for it.
Have anyone else asked regarding this and knows if he performs ccw by posterior down grafting?
-
I have also consulted with Dr.Birbe online and found him knowledgeable and easy to talk to.
As for the CCW rotation via posterior downgrading I believe he does it as he suggested it for me.
I am planning on seeing him in September so will be able to provide more info after that.
-
Agree. I mailed the clinic and got ridiculous fast responses to my mails and had a video consultation the same day and got a quotation fast etc. Very good service, the best I've come across and directly thought this is the guy for me. Fast and easy to talk to.
Then all of a sudden when I sent a mail with some more serious questions on how I can actually proceed if I wish to get serious about this, and get a more in-depth analysis of my specific case, no more response. It seemed very strange to me, I mean this should be the mail they would want to get, how can they else get any customer to actually get a procedure. I wonder if it could be that I asked specifically regarding posterior down grafting and if it could be handled if necessary. Maybe they figure it's a lost case if they don't do it and I specifically ask for it.
Have anyone else asked regarding this and knows if he performs ccw by posterior down grafting?
Can you clarify whether or not your second e mail to him was with the expectation that he give you an indepth analysis of your case VIA E MAIL.
They certainly don't want to get e mail where there is any indication that the sender holds contingent any 'obligation' on the part of the doctor to address questions that are highly specific to the potential patient's case.
So, if he got the impression you FELT he was 'obliged' to address any specific questions which you thought were applicable to your specific case and you came off as feeling it was CONTINGENT he address such via e mail or anything else where you gave impression of '(potential) customer is king and customer deserves his specificities be addressed', that is reason enough for NO response back.
To the best of my knowledge, YES, he does do posterior downgrafting. But he probably wants to avoid e mail communications where his saying he does in any reference to your specific case which could be misconstrued as an implied promise he would do that for you or any implication that he's done an indepth analysis of your case if he answered your question.
Basically, he could have gotten the 'vibe' that you could either misconstrue or misunderstand any further in depth information whereas to properly even RENDER it usually involves an in person consult.
-
Can you clarify whether or not your second e mail to him was with the expectation that he give you an indepth analysis of your case VIA E MAIL.
Simply asking if it would be ok to come down and have a cbct done, do some kind of vsp or if he suggests me to involve an orthodontist at this stage and if so how I should go about this. Asking for some guidance what he would propose the best way forward would be for me if I feel I want to get into more details on this. I'll give it another try, maybe just got lost some where.
-
Simply asking if it would be ok to come down and have a cbct done, do some kind of vsp or if he suggests me to involve an orthodontist at this stage and if so how I should go about this. Asking for some guidance what he would propose the best way forward would be for me if I feel I want to get into more details on this. I'll give it another try, maybe just got lost some where.
Sounds OK to ask in terms of making an in person consult. I guess you would have to go through his secretary to book it.
-
Sounds OK to ask in terms of making an in person consult. I guess you would have to go through his secretary to book it.
Yep. And you know from previous discussions that I'm a bit anxious about this 'catch-22', wanting to know as much as possible. The only way I see my self moving forward is to actually meet these guys. It may be that it's just a NO when I ask if it's possible to get some kind of vsp before a decompensation is done, which in my opinion is a bit sad if I'm ok with some kind of approximation to ease my mind.
The reason I asked specifically on posterior down grafting was more to know if this is in the toolbox, regardless if it will happen to me. It's a difference if a surgeon can do it but chose not to, or if they can't and are stuck having to solve it in a different way.
-
It may be that it's just a NO when I ask if it's possible to get some kind of vsp before a decompensation is done, which in my opinion is a bit sad if I'm ok with some kind of approximation to ease my mind.
When you say some kind of VSP before decompensation, what are you referring to exactly? A 2D ceph plan showing the displacements and a morph?
-
When you say some kind of VSP before decompensation, what are you referring to exactly? A 2D ceph plan showing the displacements and a morph?
I'm very humble with regard to what can be offered, but what I understand, a cbct can be loaded into a vsp program as below. If I could pay someone to spend an hour in a program like this with me to show roughly how they think about this, I'd be very happy.
I mean, this is a big medical procedure that's being discussed, I can't be the only one feeling like this.
https://youtu.be/EyDUHdyAYQ4
-
I completely understand where you're coming from Dogmatix. But I don't think surgeons will bother to do an actual VSP session (between surgeon and engineer) on a non-decompensated bite. it may also be futile for you too because your decompensated bite might require different movements anyway.
But if you're willing to pay $$$ why not ask Antipov and see what he says? He has that option of 3D planning listed on his website here (https://www.drantipov.com/online-consultation/).
The soft tissue is also still going to be unpredictable with VSP. Something to keep in mind.
-
In that video, he is going over the surgical possibilities with someone CONVERSANT in the software he's using who will be preparing a SPLINT (or a bone buttress material shaped for what ever graft they might need) based on the surgical plan. It isn't a TUTORIAL that a patient is going to get from the doctor using the software.
If you are in any way conveying to Birbe that you expect a long sit down 'show and tell' tutorial session with the software before you decide to have the surgery, he might be thinking in terms of: 'NOT enough TIME to address all the contingencies this patient has in the decision making process.'
As to his doing the posterior down graft, you already had access to that information that was in his toolbox on another part of this forum where a patient relayed the posterior downgraft was offered to her.
ETA: If another doctor offers such, (I see that the doc in the video is asking over $600 for that sort of consult), then you have option of paying for it with doctors who offer that option. But one doctor's plan might not be the same plan of another doctor.
-
^There's actually no price listed for the 3D surgical planning which he offers upon request. The $600+ consult is for 2D planning (plan and morph) like in this video of his https://www.youtube.com/watch?v=h72Lt4hclUA
-
^There's actually no price listed for the 3D surgical planning which he offers upon request. The $600+ consult is for 2D planning (plan and morph) like in this video of his https://www.youtube.com/watch?v=h72Lt4hclUA
I bet the price quote would be HIGHER than the $600+ and maybe a function of TIME in the event the patient wanted/needed a tutorial out of the session.
-
In that video, he is going over the surgical possibilities with someone CONVERSANT in the software he's using who will be preparing a SPLINT (or a bone buttress material shaped for what ever graft they might need) based on the surgical plan. It isn't a TUTORIAL that a patient is going to get from the doctor using the software.
If you are in any way conveying to Birbe that you expect a long sit down 'show and tell' tutorial session with the software before you decide to have the surgery, he might be thinking in terms of: 'NOT enough TIME to address all the contingencies this patient has in the decision making process.'
As to his doing the posterior down graft, you already had access to that information that was in his toolbox on another part of this forum where a patient relayed the posterior downgraft was offered to her.
ETA: If another doctor offers such, (I see that the doc in the video is asking over $600 for that sort of consult), then you have option of paying for it with doctors who offer that option. But one doctor's plan might not be the same plan of another doctor.
Yes of course, there are many ways I can be interpreted. The above was not my intention with such question, just have seen how the surgeons seem to work with this and think it's a fair question, not with any intention to be tutored or educated, just see some rough simulation. Any way, let's not over analyse this.
-
Yes of course, there are many ways I can be interpreted. The above was not my intention with such question, just have seen how the surgeons seem to work with this and think it's a fair question, not with any intention to be tutored or educated, just see some rough simulation. Any way, let's not over analyse this.
I'm just trying to help with the 'mystery' of why he didn't get back to you.
-
I'm just trying to help with the 'mystery' of why he didn't get back to you.
Yep, noted. I still have high thoughts about him and have contacted the service desk, and it seems like the clinic is closed during August. So for now I'm giving it some time.
-
Yep, noted. I still have high thoughts about him and have contacted the service desk, and it seems like the clinic is closed during August. So for now I'm giving it some time.
Yes. Good idea to give more time.
-
^There's actually no price listed for the 3D surgical planning which he offers upon request. The $600+ consult is for 2D planning (plan and morph) like in this video of his https://www.youtube.com/watch?v=h72Lt4hclUA
The base price for the initial consult with Antipov is $500 and includes a CTScan, as well as some photographs and he sits with you to go over some them using a computer program for 2D planning (the software also generates morphs). Your insurance might cover some of the cost if you have the right plan. He doesn't do 3D planning on the first consult from what I gathered so I cant comment on how much that costs.
-
Thanks; so he charges more for online consults then.
-
Seems like a steep price for what equates to be a Skype call (or whatever video service you're using). I think it's fair to say that in person consultations are the best.
-
Got back from my second consultation with Dr. Birbe last week.
I met with his orthodontist first, and then I spoke with him afterwards.
The ortho said he believes that he can correct my bite without surgery, but he wasn't very forthcoming with how he would actually achieve that.
His explanation didn't make sense to me. I have a lower incisor midline shift to the left of approx 2mm. He said he would move the bottom left teeth forward to the right 1mm and the top teeth left and back 1mm. Logically this seems like it would result in my upper midline being off by 1mm, and the same for the lower. He also suggested filing my incisors down on either side to create space so that they could be pulled back. The fact that I used to have a perfect bite suggests to me that there is no need to shave my teeth down; I really didn't like this suggestion.
His English wasn't as a good as Dr. Birbe's. They both said that surgery MAY (not certain) reduce the time in braces due to jaw movements. However their blanket statement was essentially 18 months in braces either way. My teeth are already very straight so they didn't explain to me very well when I asked how they calculated the length of time needed in braces. A year and a half seems long to me given that I have no crowding, but perhaps this is standard.
The orthodontist did an oral exam only, no impressions or models or anything like that, although I did show him models I had done from 2012, the same ones where my previous surgeon suggested that orthodontic correction was impossible without surgery.
Dr. Birbe said I need to determine my prioritites; cosmetic improvement vs functional improvement. The former requiring surgery and the latter braces only.
I was quoted for braces only (regular and invisalign) and then braces and BIMAX + Genio. The orthodontics only was honestly a lot more than I expected for Spain, in fact I know people in Ireland and the UK who get orthodontic work done for the same price and even up to 30% less; and the average salary is double there.
The requote for bimax was more than the original quote I got the first day. Their front desk staff never emailed me after the first day like they said they would, so now the second quote they did email is more + the orthodontics cost; which the front desk staff told me was included the first time.
So overall I would be paying about 30% more than I originally thought. Not to mention the fact that 18 months of orthodontics in Spain, with 18 monthly check-ins would be an additional 4 or 5 thousand EURO in flights alone.
I will email and enquire whether I can do orthodontics at home if he can work with someone abroad if I decide to go ahead.
I think I will consult with another couple of surgeons in the mean time.
He does do posterior downgrafting as someone asked.
He doesn't use custom built plates, but rather customises them himself.
I saw a few before and afters that looked okay, he was kind of scrolling through them though. A lot of the images were from lectures he has given. I waited almost an hour after my appointment date to actually see them which kind of annoyed me considering I was awake at 4am to fly to Spain. I explained that to him when I felt he might be in a rush and he seemed to understand this and became more relaxed and accommodating to answering my questions, and explained how grateful he was that people have travelled internationally to consult with him.
He said nose upturning isn't a foregone conclusion and that steps can be taken intraoperatively to mitigate this if needed.
Average surgical time is a couple of hours or less.
I explained how I had read that advancement can actually cause FURTHER asymmetry, but he didn't agree and claimed that the whole point of surgery to improve asymmetry wouldn't increase it as that would be counterproductive to the whole point of surgery.
I still like Dr. Birbe although I'm not 100% on the orthodontist. He seemed surprised that I knew much of the terminology and was aware of my own anatomy at first - he is probably used to telling patients quickly and without any inquisition. The quote was also more the second time around.
Any questions feel free to ask.
-
Got back from my second consultation with Dr. Birbe last week.
I met with his orthodontist first, and then I spoke with him afterwards.
The ortho said he believes that he can correct my bite without surgery, but he wasn't very forthcoming with how he would actually achieve that.
His explanation didn't make sense to me. I have a lower incisor midline shift to the left of approx 2mm. He said he would move the bottom left teeth forward to the right 1mm and the top teeth left and back 1mm. Logically this seems like it would result in my upper midline being off by 1mm, and the same for the lower. He also suggested filing my incisors down on either side to create space so that they could be pulled back. The fact that I used to have a perfect bite suggests to me that there is no need to shave my teeth down; I really didn't like this suggestion.
His English wasn't as a good as Dr. Birbe's. They both said that surgery MAY (not certain) reduce the time in braces due to jaw movements. However their blanket statement was essentially 18 months in braces either way. My teeth are already very straight so they didn't explain to me very well when I asked how they calculated the length of time needed in braces. A year and a half seems long to me given that I have no crowding, but perhaps this is standard.
The orthodontist did an oral exam only, no impressions or models or anything like that, although I did show him models I had done from 2012, the same ones where my previous surgeon suggested that orthodontic correction was impossible without surgery.
Dr. Birbe said I need to determine my prioritites; cosmetic improvement vs functional improvement. The former requiring surgery and the latter braces only.
I was quoted for braces only (regular and invisalign) and then braces and BIMAX + Genio. The orthodontics only was honestly a lot more than I expected for Spain, in fact I know people in Ireland and the UK who get orthodontic work done for the same price and even up to 30% less; and the average salary is double there.
The requote for bimax was more than the original quote I got the first day. Their front desk staff never emailed me after the first day like they said they would, so now the second quote they did email is more + the orthodontics cost; which the front desk staff told me was included the first time.
So overall I would be paying about 30% more than I originally thought. Not to mention the fact that 18 months of orthodontics in Spain, with 18 monthly check-ins would be an additional 4 or 5 thousand EURO in flights alone.
I will email and enquire whether I can do orthodontics at home if he can work with someone abroad if I decide to go ahead.
I think I will consult with another couple of surgeons in the mean time.
He does do posterior downgrafting as someone asked.
He doesn't use custom built plates, but rather customises them himself.
I saw a few before and afters that looked okay, he was kind of scrolling through them though. A lot of the images were from lectures he has given. I waited almost an hour after my appointment date to actually see them which kind of annoyed me considering I was awake at 4am to fly to Spain. I explained that to him when I felt he might be in a rush and he seemed to understand this and became more relaxed and accommodating to answering my questions, and explained how grateful he was that people have travelled internationally to consult with him.
He said nose upturning isn't a foregone conclusion and that steps can be taken intraoperatively to mitigate this if needed.
Average surgical time is a couple of hours or less.
I explained how I had read that advancement can actually cause FURTHER asymmetry, but he didn't agree and claimed that the whole point of surgery to improve asymmetry wouldn't increase it as that would be counterproductive to the whole point of surgery.
I still like Dr. Birbe although I'm not 100% on the orthodontist. He seemed surprised that I knew much of the terminology and was aware of my own anatomy at first - he is probably used to telling patients quickly and without any inquisition. The quote was also more the second time around.
Any questions feel free to ask.
Were there any x-rays or cbct taken on this visit, or was there anything mentioned regarding how and when the actual planning will take place. Did you get any morph or similar to give you an understanding of what will be done, or what did you actually get from traveling to see him in person instead of a video call?