What should be done during my revision surgery? Thoughts? Ideas?

[secondtimearound]

I had LF1/BSSO/genio for class 3 growth (underbite, openbite, crossbite, excess chin height) in the early 2000s. Unfortunately, this was not an adequate approach, and I have considerable remaining problems. I am therefore planning for revision.

I am looking for opinions to see if I'm on the right track with identifying the remaining issues and the best ways to fix them. I have had one consult with a good jaw surgeon who said he would be happy to take on my case and his feedback has played into this as well. Before I get more consults, I want to understand my condition the best way I can.

Possible Problems:
- 8 mm transverse upper jaw deficiency (crossbite)
- 2-3 mm open bite
- Excess chin length
- 5-6 mm lip incompetence
- High mandibular angle and short ramus
- Retruded maxilla (4 mm by Wits and Sassouni, although SNA is normal)
- Cant and facial asymmetry
- Upper incisor proclined forward, lower incisor tilted back (too upright).

Possible Solutions:
- SARPE (proposed by my surgeon to expand 1-1.1 cm to "overshoot" a bit in case of dental relapse)
- Allow upper incisor to retrude in angle slightly if it can during SARPE.
- Maxillary advancement by 2-4 mm based on whatever position is reached after SARPE for good occlusion.
- Facial asymmetry/cant correction during LF1/BSSO.
- V-line surgery done conservatively in Korea to shorten the chin another 5-6 mm, provide a straighter jaw line, and hopefully close the lip incompetence.
- Lastly, if all goes well, mandibular angle implants to lengthen the ramus and further flatten my mandibular plane.

Things I'm Really Not Sure Of:
- Should anything be intentionally done with my occlusal plane? It is slightly clockwise based on FH and SN but this was measured by cephx directly through the middle of my open bite. I am unsure what will happen during SARPE. If the SARPE keeps my maxillary plane as it is, then my mandible can perhaps be rotated a few degrees CCW to close the open bite. My maxillary plane is already a bit CCW oriented (despite the bite being CW).
- Does my "narrow saddle angle" (under Biodynamic) somehow explain why my SNA is normal but Sassouni finds me to have a retruded maxilla?

Here are my images and some excerpts from my cephx assessment. Thanks for any help.

PA ceph:


Lateral Ceph:


Overlay:


Biodynamic:


Clark:


Down's:


Mid Continent:


Sassouni:


SLU:

[secondtimearound]

I just noticed something with my occlusal plane. Figured I'd post the summary here for my reference as well.

SN to OP
By SLU analysis, my SN to Occ Plane is 16.26 (normal 16).
By Steiner analysis, my Occ Plane to SN Deg is 16.26 (normal 14.0 +/-3.0).

FH to OP
By Clark analysis, my Occ Plane to FH Deg is 10.48 (normal 8.0 +/- 2.0).
By Downs analysis, my Occ Plane to FH Deg is 10.48 (normal 9.3 +/- 3..

So out of the 4 analyses, all rate me as slightly clockwise but within the normal distribution (0.26 by SLU, 2.26 by Steiner, 2.48 by Clark, and 1.13 by Downs).

If we split the difference and say 2 degrees, and the distance from my front top incisor to the end of my back molar is about 4.8 cm, this would represent only a 1.6 mm distraction at the back upper molar to "correct this".

The reality is I think most surgery is simply not this precise. Especially when you are fixing asymmetry as well.

And there remains the uncertainty of how the maxillary bite plane will shift during SARPE. Probably I will have to wait until after SARPE to see if this will be a significant issue. Probably it will not be. The issue is if you commit to a surgeon who doesn't do CCW than you're stuck either way.

But nothing with these surgeries is really precise to the exact mm I don't think. I'm pretty sure everything will be within 1-2 mm error at best just due to the difficulty of cutting, sawing, and plating with any greater precision.

[secondtimearound]

After reading from CCW that Gunson and Wolford don't do much SARPE, I looked into it and found this fascinating article:

http://www.toportho.org/think-pieces/sarpe-a-frequently-misunderstood-surgical-procedure

I posted this in another thread, but wanted to post it here as well because it's so important to me personally.

Here's what they say relevant to me:

Misconception: SARPE is needed as the first phase of surgical technique when skeletal transverse and a-p / vertical change are desired.
Why would you do that? In theory, so that in a second surgical phase the maxilla can be repositioned in one piece and the transverse expansion will be more stable.
               
The problem with that concept is that results with one-phase segmental osteotomy for transverse changes and a-p / vertical repositioning at the same time are remarkably similar to the results with two-phase surgery. At present, there is a divide between surgeons in the northeastern US and eastern Canada, many of whom advocate two-phase treatment for three-dimensional problems, and those in the rest of the US and Canada, who usually manage problems in all three dimensions with a single surgery. The two-phase treatment has greater morbidity, cost, and difficulty in a repeat of the bone cuts that were done in the first procedure. It is hard to justify that if you can get the same results with a single surgery, and orthodontists should be sensitive to this point (3,4).
               
The bottom line: at present, SARPE offers a slight advantage to the patient in stability and surgical morbidity when only transverse changes from maxillary surgery are needed, and a significant disadvantage when three-dimensional changes are needed. It is indicated only when transverse expansion is all the patient needs.

So in my case, getting it all done as a multipiece LF1 makes much more sense, and this is a regional jaw surgeon preference that must be worked around.

I am so surprised by how regional jaw surgery skills are. For example, the only place I am aware of in the world you can get a competent v-line surgery is Korea and its neighboring countries. And now I am learning that multipiece LF1 vs. SARPE is also a regional skill/preference.

It would save me so much pain, torment, and possibly prevent more gum recession if I can avoid SARPE.

[PhoenixHiker]

Hi secondtimearound, I'm following your case. If you don't mind could you share a 3D CT surface model here (both PA and Lateral) so that we can see a better skeleton pic. There's a free software called 3DimViewer that can generate your CT files (a series of .dcm file) to a pretty nice 3D rotatable model. Or your original file may already have the 3D model.