Revision double jaw surgery - advice

[kavan]

Thanks. 
To begin with, besides jaw (bite) issues I have learnt that I have midface deformity which was not explained to me. Hope with your and other members help, maybe in 5-10 years I could try solve it.
I am almost certain that frontal pictures looked better before - it seems that vertically short (but wide) maxilla was playing the role of zygomas, making impression of wide and square face. At rest it worked, however tooth show was minimal. My occlusal plane was oriented up above horizontal line of 0° Also, retruded mandible "blend in" on somewhat retrussive and short profile.
As for the treatment plan, I am very happy with the tooth show, however, profile is to protrusive in my opinion due to too much maxiliary clockwise rotation which was then accomodated with more mandibular advancement than initially needed. Also, plan included vertically elongation (and backward movement) of the chin
to compensate mentolabial relationship after 6mm bone graft was placed in maxilla. After seeing video one lecture from Mr. Triaca, it seems that only chin wing gives good lip competence for chin reduction (of cource if properly done).
So my thaughts: backward movement of both jaws (and I will definitely ask dr. Z. and B. on reducing tooth size since upper lip is incompetent too - don't know whether small maxiliary backward movement will lengthen upper lip) and vertical shortening of the chin will help lip incompetence. Other possibility, if still feasible, chin wing to decrease visible border of mandible (like in class 3) and bring up tissue around lower lip.

All this could improve profile, but due to short sella nasion line I will still be below average. But hope that lips will have their own function again.. I will post before pictures tommorrow. Thanks in advance.

C-  on the HOMEWORK assignment.  You did not use photos of cephs and before to explain your surgical proposal.

[Brachy]

I apologise, will upload tommorrow with superimposition.. my incisors are 10mm long, is it too much, especially if your midface is so underdeveloped?

[kavan]

I apologise, will upload tommorrow with superimposition.. my incisors are 10mm long, is it too much, especially if your midface is so underdeveloped?

i told you to put midface issues on back burner for LATER time.

[Brachy]

I apologise in advance, this is superimposition of my first surgery.. I think that too much clockwise rotation was performed, also, chin is vertically too big.. Protrussive profile is, I believe, due to midface deformity (SNA & SNB > 90, short anterior cranial length).. tomorrow I am consulting one austrian surgeon.. also I have started communication with one Italian surgeon on distraction osteogenosis and LeFort 3 and he promised to reply after he analyzes CBCT.. I believe that my speech problems and facial expressions can't be solved without LeFort 3 osteotomy.. however, even if I find a surgeon to perform it, I think I would rather go and revise my first surgery - counterclockwise rotation, less teeth visible, genioplasty up.. I would appreciate your comments

[kavan]

OK. Looks like you have some 'beliefs' where you think you got too much clockwise rotation and your protrusive profile is due to midface deformity and you 'need' LeFort3. Since those are not 'beliefs' I have, YOU will need to be the one to validate that your 'beliefs' result in the right decision.

Sorry, but your entry does not do what I asked. Beliefs don't demonstrate an understanding with regard to what you would be asking a surgeon to do for you.

I've given you my take on the salient problem associated with the look of protrusion and it's isolated to the CHIN. In fact, the most obvious change in your overlay is the CHIN.

Best of luck with your beliefs with regard to their working out in terms what ever surgery you choose based on them.

[Brachy]

Kavan, I apologise.. main reason why I wanted ro get surgery is to improve my speech.. my speech did not improve at all, even got worse due to lip incompetence.. I appreciate Your comments and will definitely ask surgeons for their treatment plan, not suggesting my since I am newbie and do not have any knowledge.. I am drivibg to Austria and will keep posting.. tnx

[kavan]

Kavan, I apologise.. main reason why I wanted ro get surgery is to improve my speech.. my speech did not improve at all, even got worse due to lip incompetence.. I appreciate Your comments and will definitely ask surgeons for their treatment plan, not suggesting my since I am newbie and do not have any knowledge.. I am drivibg to Austria and will keep posting.. tnx

Well, I have NO IDEA how L3 or any of the other things you 'believe' you need which you mention for aesthetic reasons is going to improve your speech. Nor did you mention the initial surgery was to improve your speech.  As to lip incompetence, it's usually associated with chin imbalance.

[Brachy]

Hi, regarding speech I was reffering to fact that while I speak, I tend to look like I smile, to be more precise, often I notice smile on my counterparty's face, althought nothing is funny to me - just want to be serious at work and not having problems at presentations.. regarding LeFort 3, I would appreciate if you could look attached picture - my main concern are emotions, I am often described as angry and unfriendly countenance, although I am nice person and would just want to show my emotions more naturally.. what is your opinion on my midface?

Thank you very much on help.

[Brachy]

As for today's consultations with austrian surgeon - I have mixed impressions.. his plan is CLOCKWISE rotation of maxillomandibular complex and he specifically said that my chin can't go up after first surgery.. I am being honest.. he sees assimetry as my main problem and would solve my concern regarind protrusive profile with clockwise rotation..
I said that I have mixed impressions, because I am very unsure about his plan for me, while on the other hand I saw 2 LeFort 3 osteotomies he performed and they were so natural.. he said that he performed > 25 of them
I would just like to look more cute, so smaller chin, less mandibular projection and more midface.. thanks on comments

[Brachy]

Hi, regarding speech I was reffering to fact that while I speak, I tend to look like I smile, to be more precise, often I notice smile on my counterparty's face, althought nothing is funny to me - just want to be serious at work and not having problems at presentations.. regarding LeFort 3, I would appreciate if you could look attached picture - my main concern are emotions, I am often described as angry and unfriendly countenance, although I am nice person and would just want to show my emotions more naturally.. what is your opinion on my midface?

Thank you very much on help.

Please, I would appreciate Your comments.. thanks

[kavan]

Your comments are self contradictory. You relay you look like you smile when you speak but in the same paragraph also relay you are often described as having an angry and unfriendly looking countenence.

That's my comment on your comment and I'm passing the torch here to OTHERS who can make heads or tails concerning your 'beliefs' of what you should do. So use the information I've given you already, try to process it so you can relate the advice to what doctors are telling you. Because nothing in your 'speech' on HERE gives me any indication you processed the info I already gave you.

[Brachy]

When my mouth is closed, I have angry, depressed look, I would say it is associated to midface problems. However, when I start talking I often see that my counterparty is not looking me into eyes, or even face

[kavan]

When my mouth is closed, I have angry, depressed look, I would say it is associated to midface problems. However, when I start talking I often see that my counterparty is not looking me into eyes, or even face

OK, so what you have as you describe it is beyond what I can help with.

[Brachy]

Tnx kavan on all your comments. I know it sounds strange, but if You look at my last photo, there is something wrong with my facial expressions, at least they are somewhat different from other people.
You are absolutely wright, I should concentate on lower third problems, i.e. lip incompetence.
I am seeing dr. Z. on Tuesday, I hope that genioplasty can be revised. I read that is better to revise it as soon as possible. Do you know whether it is true, is there any explanation behind?
 Yet, I would be interested in small backward movement of jaws since I have really hard time dealing with it. Thanks.

[kavan]

I'm sorry. Communication is not working out here. I'm unable to solve your problems based on your communication as to what they are. We've already gone through 4 pages only to find on page 4 you got the initial surgery for some 'speech problems' and later to find these 'speech problems' are how people look at you when you speak. I also can't validate what your 'beliefs' are as to Lefort 3 being the solution to these 'speech' problems

If you recall, I already asked you to put your BEFORE photos and cephs up and with explanation as to the MECHANICAL reasoning that would SUBSTANTIATE your beliefs/assessments that you 'needed' CCW and 2mm set back which you felt was the solution to your problem. What I was looking for was some demonstration of some understanding on your part. I found NO demonstration on your part. Nor did I find you even PROCESSED the request to show BEFORE and after cephs/photos as was requested. What I found was your 'beliefs' with added TOSS IN of Lefort 3. I can't validate each of your beliefs in the way you present them where it pans out during the course of the posts, your problems are a MOVING TARGET.

Then come the entries of: Such and such a surgeon told you this or that along with your beliefs  where I CAN'T evaluate EACH AND EVERY doctor's assessments against a back drop of your stated objective to solve these 'speech' problems.

So. NO. I won't be addressing each further moving target twist and turn you bring in when the pattern here is that each time I address one of your questions, a new moving twist and turn is brought in.

Again, the WAY you present your problem here is BEYOND my capacity to help with.

If you need explanation as to how going forward with any of your beliefs as they apply to surgical displacements of any to many parts of the face with the objective of however YOU define your 'speech problem' or 'expression issue', you need to cross reference all of those many things with the DOCTORS you consult with.

Sorry, I'm getting frustrated here and need to pass the torch to OTHERS who might be able to help.