Which treatment plan should I choose?

[internetguy]

Hi everyone.

I am having double jaw surgery done for a mild case of sleep apnea. I am now taking the aesthetic outcome into consideration because I have been given more than one option. It has been suggested that I either have an advancement of both maxillary and mandible AND a genioplasty for a recessed chin or I have two bottom premolars extracted to push my front teeth back closer to my chin; giving me a considerable overbite, at which point I have just the maxillary and mandibular advancement without the genioplasty. The mandibular advancement in the latter surgery will be greater. I am leaning towards getting the premolars extracted because I am assuming that I won't have to worry about an increase in my mentolabial fold, giving my chin a more natural(flat) prominence, I also won't have to worry about any associated nerve damage outside of the already inherent risks of the jaw advancement. And lastly my insurance will not cover the genioplasty. But with all this said, I have heard rumors of negative consequences of tooth extraction for mandibular advancement. Any feedback/advice would be greatly appreciated.

[internetguy]

Why is this not getting any responses?

[buzzhead]

In my opinion you have outlined a very good argument in favor of 2 lower molar removal.  Any retraction resulting from removal will be more than made up for with mandibular advancement, which will be done anyway.  No additional complications from genioplasty and less money spent.  Seems to make sense to me given your overall situation.

[buzzhead]

"Bicuspid" not "molar"

[notrain]

i am on the same treatment plan (premolar removal followed by decomp followed by surgery) and this is the correct of doing things for the reasons you stated (positions bottom lip over chin). you can still do a genioplasty with this treatment plan (increase forward projection and / or height) and it will yield better results because the labiomentalfold will be more normal.

there is one caveat: closeing the premolar gaps takes 1 year of ortho minimum.

[internetguy]

Thanks for responding. Does anyone else have any feedback? I am going back to the doctor tomorrow.

[PloskoPlus]

I wouldn't extract any teeth/tooth.  If it were me, I'd go with the a,b and c option and just cough up for the extra.  Extracting permanent teeth will only flatten and make your jaw "smaller/narrow".  Plus, it'll only make your chin smaller too so, you'll end up needing a chin implant or genio(?)
I wouldn't risk it-just get the surgery to fix all your issues rather than skimping and having more issues down the line.

Definitely look up teeth extractions and the adverse results people have gotten with it.

I think this applies more to extractions of upper teeth.

[internetguy]

The following is an email from my surgeon. What do you guys think?

I think the best treatment plan, given the OSA, functionally and aesthetically would be:

1.     Removal of lower first bicuspids and possibly upper second bicuspids, followed by orthodontics.

2.     Le Fort I osteotomy of the maxilla with advancement and impaction for breathing and profile and smile aesthetics. I agree the smile is “gummy” but not excessively.  Therefore I would recommend further posterior impaction than anterior impaction (overall clockwise rotation), but with some anterior impaction.  The differential would be in millimeters.

3.     Sagittal split ramus osteotomies of the mandible with advancement for breathing and to address the occlusion, profile and smile aesthetics

4.     Genioplasty with advancement for breathing and profile aesthetics.

 
Counterclockwise rotation can help to bring the mandible/chin further forward, but would give you a reverse smile from a frontal view point, and I think this would be a negative in your case.
 
If you do not have teeth removed, given your current bite, you would definitely require Maxillary and mandibular advancement with genioplasty.
 
If you do have teeth removed, if the smile aesthetics are not a significant concern for you, you could possibly get away with a mandibular and chin advancement only.
 
It is possible with a diagnosis of obstructive sleep apnea, that the insurance would consider covering genioplasty, but there is no guarantee.
 

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I am leaning toward bottom bicuspid extraction.

[PloskoPlus]

i am on the same treatment plan (premolar removal followed by decomp followed by surgery) and this is the correct of doing things for the reasons you stated (positions bottom lip over chin). you can still do a genioplasty with this treatment plan (increase forward projection and / or height) and it will yield better results because the labiomentalfold will be more normal.

there is one caveat: closeing the premolar gaps takes 1 year of ortho minimum.

Why not just advance the maxilla as well?

[terry947]

I thought CCW rotation is the best for sleep apnea. Also if you have sleep apnea, you'd need advancement of the upper and lower jaws.

get some second opinions before choosing a surgeon.

[internetguy]

I thought CCW rotation is the best for sleep apnea. Also if you have sleep apnea, you'd need advancement of the upper and lower jaws.

get some second opinions before choosing a surgeon.

you can see in his treatment plan for optimum aesthetics that he does propose both upper and lower advancements.

[internetguy]

Why not just advance the maxilla as well?

If I understand correctly the teeth of my mandible are more forward than the actual jaw, if the teeth were pushed back to where they should be I would have a considerable overbite. this would allow for more room to move the mandible forward and the maxilla would have to be moved less, resulting in a more normal looking face.

If I were to "just advance the maxilla as well" the maxilla would have to be moved farther forward to provide the space for the mandible with the recessed jaw to be moved forward enough to open the airwary to stop OSA while still having a decent occlusion. This option seems like it has the potential to result in a monkey face. But hey i don't really know for sure. That is why I'm here, to share ideas and get feedback.

[notrain]

internetguy, can you PM me your ceph? we have the same treatment plan, is your occlusal plane flat? brachycephalic growth pattern?

if so, i think your surgeon knows what he is doing and you should follow his advice and have the lower premolar extractions.

[internetguy]

internetguy, can you PM me your ceph? we have the same treatment plan, is your occlusal plane flat? brachycephalic growth pattern?

if so, i think your surgeon knows what he is doing and you should follow his advice and have the lower premolar extractions.

Sorry but I don't have access to that at the moment. I could ask them to send it to me, but it never crossed my mind to have it until now.

[internetguy]

internetguy, can you PM me your ceph? we have the same treatment plan, is your occlusal plane flat? brachycephalic growth pattern?

if so, i think your surgeon knows what he is doing and you should follow his advice and have the lower premolar extractions.

I have the ceph now. I don't think I'm brachycephalic?