Dr. Joan Birbe - Spain - First consultation

[strongjawman]

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.

[kavan]

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.

[strongjawman]

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.

[kavan]

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.

[strongjawman]

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.

[kavan]

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.

[kavan]

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.

[strongjawman]

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.

[kavan]

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.

[strongjawman]

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.

[JourneyToSerenity]

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?

[kavan]

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.

[Dogmatix]

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?

[strongjawman]

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..

[kavan]

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?