Author Topic: Anyone look into Inverted L-osteotomy?  (Read 6117 times)

molestrip

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Anyone look into Inverted L-osteotomy?
« on: September 02, 2015, 10:00:38 AM »
I've noticed some papers talking about a resurgence in interest in this procedure. Basically, BSSO have become the workhorse of the industry and while it can produce good occlusions, it's not the ideal procedure to fix the problems. Most of us have some amount of ramus hypoplasia, those with open bites tend to have more. It has less risk of paresthesia but surgeons haven't liked it because it's not as stable and harder for the surgeon to work in that area. And, it only makes a notable difference over BSSO in the most extreme cases. I am, however, one of those cases. I note that in syndrome cases surgeons are using DO or bone grafts to address stability, mostly in kids. However, seeing some cephs their deformities don't seem all that different than mine. Mandibular plane angles of 40deg+. I'm wondering if this is worth looking into further. Some guys who wrote a chapter in a textbook on this stuff happen to be located in my city. I heard the names before but dismissed it because they were plastic surgeons, not oral surgeons. What do you all think? Should I pay them a visit?

Here are the surgeons I'm looking at now. Two of them wrote the chapter on DO in Ferraro's Principles of Orthognathic surgery. They don't have a lot of publications but the group isn't too old. The hospital is brand new so I'd guess maybe 5 years? Anyway, the research areas among the surgeons are quite diverse and interesting for these types of problems and because they're handling a lot of kids, I'd bet they have quite a bit of experience in dealing with complex problems. When the deformities become significant enough, maybe a difference skillset is required to deal with them, that's all I'm saying. Of the cephs I've seen around, most people don't seem to fall into that category.
« Last Edit: September 02, 2015, 10:11:22 AM by molestrip »

Tom2

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Re: Anyone look into Inverted L-osteotomy?
« Reply #1 on: September 02, 2015, 01:17:15 PM »
Not an option for me as I needed the jaw advancement.

I think my ramus is a bit short but compounded by my face being on the longer end of the spectrum.

So. I'm leaning cosmetic jaw implants to balce things out.     

Speaking of difficult to reach - how they heck they do any of these surgeries is amazing to me.....

PloskoPlus

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Re: Anyone look into Inverted L-osteotomy?
« Reply #2 on: September 02, 2015, 01:30:25 PM »
Not an option for me as I needed the jaw advancement.

I think my ramus is a bit short but compounded by my face being on the longer end of the spectrum.

So. I'm leaning cosmetic jaw implants to balce things out.     

Speaking of difficult to reach - how they heck they do any of these surgeries is amazing to me.....
Have you considered a chin wing?

molestrip

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Re: Anyone look into Inverted L-osteotomy?
« Reply #3 on: September 02, 2015, 01:54:34 PM »
I don't care for the aesthetics that much. I already have a strong jaw and it's only going to get stronger with MMA. People will be scared of me lol. That aside, aesthetics are usually an indicator of good health. I'm more interested in the fact that lengthening the ramus fixes the problem more accurately. Chin wing doesn't solve that problem. The pressure to the joint is different, the curves to the teeth are different, etc. The key to stability and health are getting a face and bite that are as close to ideal as possible.

Tom2

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Re: Anyone look into Inverted L-osteotomy?
« Reply #4 on: September 02, 2015, 04:59:05 PM »
I think in the end it would come down to which one gives you a reliable results.    If you're telling me there are concerns about stability - more so with the ramus surgery  - I would pay close attention to that.

One thing I have learned through the healing process with the BSSO part of my surgery is that when your jaw and TMJ's get screwed with and no longer work as effortlessly and painless as before  that you will feel it nearly every waking moment.   AND....said jaw pain will meet you in the morning with awful pain and can even wake you up in the middle of the night making you wish you could escape the pain!

So, it sounds interesting but tread carefully.

Tom2

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Re: Anyone look into Inverted L-osteotomy?
« Reply #5 on: September 02, 2015, 05:01:06 PM »
Have you considered a chin wing?

Nope.    My front lower fave/jaw is good for me.   Its just the back end that could use a bit more filling out and definition.      So - just a cosmetic issue that I may in the end leave be but I'll be making an appt for a consult to check into the procedure, risks and benefits.   I;ll start a thread about it when the time comes.

Back to Moles's topic....

PloskoPlus

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Re: Anyone look into Inverted L-osteotomy?
« Reply #6 on: September 02, 2015, 05:35:15 PM »
Nope.    My front lower fave/jaw is good for me.   Its just the back end that could use a bit more filling out and definition.      So - just a cosmetic issue that I may in the end leave be but I'll be making an appt for a consult to check into the procedure, risks and benefits.   I;ll start a thread about it when the time comes.

Back to Moles's topic....
Chin wing is done across the whole mandibular plane and goes all the way back to the ramus. Look at the before and afters on triaca's site.

healer

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Re: Anyone look into Inverted L-osteotomy?
« Reply #7 on: September 02, 2015, 07:13:00 PM »
IVSRO can be used for mandibular advancement up to 6mm

here a modified version of IVSRO can be seen:

http://clinmedjournals.org/articles/ijsrp/clinmed-international-library-ijsrp-2-023.pdf

molestrip

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Re: Anyone look into Inverted L-osteotomy?
« Reply #8 on: September 03, 2015, 01:36:40 AM »
I don't need advancement. My mandible body is long enough. I need a longer ramus and rotation and a small genio to be ideal. Rotation would add forward movement. I think I got the cut wrong. I need an HSSO. I've read these movements aren't considered stable, haven't been done in deades. Massetter is too strong and will overpower the plates, not to mention difficulty operating back there. But, no risk of nerve damage and lack of bony overlap partly mitigated by BMP and/or grafts. DO should work too.

Did I mention you can keep your wisdom teeth with this cut too? There's other cuts that too without lengthening the ramus.
« Last Edit: September 03, 2015, 01:47:31 AM by molestrip »

terry947

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Re: Anyone look into Inverted L-osteotomy?
« Reply #9 on: September 03, 2015, 10:09:51 AM »
How would a longer ramus cure your sleep apnea? Thinking about it logically it wouldn't do much.

molestrip

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Re: Anyone look into Inverted L-osteotomy?
« Reply #10 on: September 03, 2015, 10:25:41 AM »
By itself, it wouldn't. I have an open bite already. Lengthening the ramus and then rotating it up would because the distance from the throat to the chin would increase since it'd be further away on the curve. The ramus is also not perfectly vertical so the increase would add a little horizontal projection. Between the two, I'd get a few mm of advancement. Considering I'm starting from 9mm, if it's only even 3mm that'd make me grossly normal. Maxilla would still have to advance to meet it but it's slightly deficient too of course.

terry947

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Re: Anyone look into Inverted L-osteotomy?
« Reply #11 on: September 03, 2015, 10:38:21 AM »
Well if you're increasing the ramus length and have a sleep occlusion you'd also need a CCW rotation plus they'd probably have rotate the mandible  to meet this. Lengthening the ramus would probably provide some nice aesthetic outcome. Also you'd have a nice side profile.

I hope this makes sense but I always wonder if surgeons look at the relationship of the ramus to your over all bite. for example say that your cranial vault is level on the Frankfort plane and yet your ramus is rotated  vertically behind vs being level. (I guess the tmj would be anteriorly rotated but the bottom of your ramus would be facing towards your neck )

 When they'd do an advancement would they change the angle of the ramus to be less jammed back? Or do they simply advance the lower jaw and hope for the best. I've just noticed that some class II patients have ramus's that look too far back.


molestrip

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Re: Anyone look into Inverted L-osteotomy?
« Reply #12 on: September 03, 2015, 10:45:14 AM »
Yes I need CCW rotation. Serious rotation. That's an additional benefit of doing this surgery because my occlusal plane is 19deg and it needs to be 8deg to be normal and they can't get me there with BSSO. I haven't worked out the math but I'd guess it's gonna be something like 10-12deg and to make up for it, they're advancing the mandible a little further. All things considered, it's not the end of the world. The body is adaptable and it's probably close enough, just not ideal. It seems that extending the ramus may also cause TMJ problems. I dunno, the guys in Japan seemed to have good outcomes with 20 surgeries followed over a few years. Makes me jealous. Would avoid that molar to molar incision and all the blood supply and paresthesia problems that come with it. Would have been able to keep my wisdom teeth. Avoids risks to IAN. I mean, this stuff is great all around. Again, surgery is going to be so much better in a decade. And it'll probably be so much better a decade after that lol. Still, it makes me wonder whether I should have just held out for another 5 years :( Not an option now that the wisdom teeth are out. Of course, not much has changed in the last decade. We have BMP now and planning tools come to mind but good surgeons did about the same back then.

terry947

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Re: Anyone look into Inverted L-osteotomy?
« Reply #13 on: September 03, 2015, 10:48:47 AM »
Lol ya sucks. Are they only going to downgraph the posterior maxilla for the CCW? Can't they also impact the front as well to achieve a greater rotation?

molestrip

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Re: Anyone look into Inverted L-osteotomy?
« Reply #14 on: September 03, 2015, 10:50:42 AM »
That's correct. In my case impaction isn't an option. In fact, it drops like 1-2mm. Haven't had joint problems yet, hopefully it'll stay that way.