Weak and recessed lower jaw-health problems.

[Dutcherhatcher]

Hey guys! First post for me and nice to meet you all. I am a 22 years old from a small country where our selection of surgeons is pretty limited.

I suffer from sleep apnea (currently not 100% in tests, but i am almost sure of it) , severe TMJ pains, lip incompetence and snoring/sleeping with my mouth open.

My lower jaw is pretty recessed from aesthetic point and its also something i would like to address.

I am currently speaking with the best surgeon in my state, but would still love to hear what you guys think. He currently thinks our best course of action is to decompress my bite, create an overjet and move only the lower jaw 6 mm forward and add genio if needed. Its covered by insurance due to the distance between jaws.

I will add my ceph. If something else is needed be sure to tell me

http://imgur.com/a/zkwbSWa

[GJ]

Are you going to have the surgery there or are you traveling/considering all options?

It's Friday so I'm having a drink. I'll look at the records in more detail later.

Just a cursory glance:

-Why are you missing a premolar? How do they plan to address that? It should probably be addressed before surgery.

-The plan doesn't look correct at all for your structure. Though I've never seen planning software this bad -- is the blue or red line the before or after? Either way it doesn't make sense.

But I can elaborate more later if you answer those questions.

[Dutcherhatcher]

Are you going to have the surgery there or are you traveling/considering all options?

It's Friday so I'm having a drink. I'll look at the records in more detail later.

Just a cursory glance:

-Why are you missing a premolar? How do they plan to address that? It should probably be addressed before surgery.

-The plan doesn't look correct at all for your structure. Though I've never seen planning software this bad -- is the blue or red line the before or after? Either way it doesn't make sense.

But I can elaborate more later if you answer those questions.

I am open to all options. I want what is correct for my health and face.

Haha sure thing, enjoy the drink.

It was extracted years ago due to pains. I assume you mean the premolar in the upper jaw right? As part of the treatment the doctor had me extract both of second molars on the lower jaw due to being rotten, and he is pushing the premolar to take their place.

The software is simply where the surgeon sent me to get an overview, he said he does not follow it at all but takes his own measures befote the surgery. It was a simple center for oral scans.

[GJ]

The software is simply where the surgeon sent me to get an overview, he said he does not follow it at all but takes his own measures befote the surgery. It was a simple center for oral scans.

Is the blue or red line supposed to be the after? It's not clear from those images.

Did they extra your lower premolars to move the teeth back, then advance the lower jaw more? This is usually not a good solution, but some doctors do it.

[Dutcherhatcher]

Is the blue or red line supposed to be the after? It's not clear from those images.

Did they extra your lower premolars to move the teeth back, then advance the lower jaw more? This is usually not a good solution, but some doctors do it.

As far as i understand the red lines are the ideal, the blue the current.

Yes that is the plan, the molars are already out and i am in tray 17 out of 50 with my removable braces. He wants to push the lower teeth back as much as possible before the surgery.

[GJ]

Yes that is the plan, the molars are already out and i am in tray 17 out of 50 with my removable braces. He wants to push the lower teeth back as much as possible before the surgery.

Usually that's a sign the surgeon doesn't know how to rotate the jaw counter clockwise, which is why you need. So instead they pull teeth and try to get their lower jaw advancement there.

I'm extremely confused by that ceph. The upper jaw is being moved down and forward. My guess is he thinks this will open the upper airway, but sleep apnea is attributed to the lower airway, and this surgery doesn't address the lower. Also, if you have a steep mandibular plane and move the jaws forward and down (as in your plan), what actually happens is you get clockwise rotation. This is due to the steep angle. Look at the red line in the lower jaw. You can see it's slightly more recessed after, especially noticeable in the posterior, which is where you need advancement. This is a very common issue with old school surgeons who don't understand CCW rotation. Also, it makes no sense the ceph has your nose moving forward.

What you actually need is about 8mm of CCW rotation. I would run from this plan.

I'm going to enjoy my drink now, but I'll see what others say and chime in more then.

[kavan]

Well, ya. If he 'bucks out' your upper teeth (with just braces) and pushes your lower teeth backwards, it will allow him to do single jaw surgery (in addition to advancing out your chin).

I'm not going to go over all of everything on your ceph read out. But it looks like he's isolated the problem to RETROGNATHIC to the LOWER jaw. That's seen in the SNB angle listing where your measure is below the norm where as your SNA angle is NOT listed at retrognathic and within norms and/or not far away from norms. It's a measure where there is option not to move the upper jaw forward.

It's kind of the minimum he can do to improve the retrusion to the lower jaw and get insurance to pay for it. There are doctors who will do surgery on BOTH jaws with aim of maximizing aesthetics which often involve types of rotations many local insurance docs don't do to that extent. But often they are self pay and require travel. I think you would see some improvement to the recessive lower jaw area and better balance with the upper jaw area as it is.

[april]

 I doubt that VTO would be an actual surgery plan. Looks like something cephx just spits out among all their other analyses.

[kavan]

Dutcher... How many consults have you gone on? The more you can travel (when that might be needed for multi consults) and the more consults you go on, the more options will arise.

[Dutcherhatcher]

Well, ya. If he 'bucks out' your upper teeth (with just braces) and pushes your lower teeth backwards, it will allow him to do single jaw surgery (in addition to advancing out your chin).

I'm not going to go over all of everything on your ceph read out. But it looks like he's isolated the problem to RETROGNATHIC to the LOWER jaw. That's seen in the SNB angle listing where your measure is below the norm where as your SNA angle is NOT listed at retrognathic and within norms and/or not far away from norms. It's a measure where there is option not to move the upper jaw forward.

It's kind of the minimum he can do to improve the retrusion to the lower jaw and get insurance to pay for it. There are doctors who will do surgery on BOTH jaws with aim of maximizing aesthetics which often involve types of rotations many local insurance docs don't do to that extent. But often they are self pay and require travel. I think you would see some improvement to the recessive lower jaw area and better balance with the upper jaw area as it is.

I see, granted when I brought it up with him, he said he knows all about rotation but he thinks it is not worth it in this case. He said moving the lower jaw is enough, and touching the upper jaw will only give me “monkey” lips. He said it’s forward enough as is.

But if I understand rotation is not about moving the upper jaw forward, it’s about rotating them. So what do you think I should do? I only consulted local surgeons since it’s a very invasive surgery and my insurance pays for it as well. Do you think it’s worth it to go to a European surgeon? GJ said I should run far away from this plan. But as far as I understand you claim there is some merit in it. I assume this plan will solve about 60% of the problem? What difference would I see in rotation vs pushing the lower jaw out as far as health benefits and aesthetics?

By the way, the other local surgeons offered joke plans like maxillary impaction due to 2 mm of gum show and genioplasty with titanium plates on the middle of the jaw. He was the one with the best plan.

Usually that's a sign the surgeon doesn't know how to rotate the jaw counter clockwise, which is why you need. So instead they pull teeth and try to get their lower jaw advancement there.

I'm extremely confused by that ceph. The upper jaw is being moved down and forward. My guess is he thinks this will open the upper airway, but sleep apnea is attributed to the lower airway, and this surgery doesn't address the lower. Also, if you have a steep mandibular plane and move the jaws forward and down (as in your plan), what actually happens is you get clockwise rotation. This is due to the steep angle. Look at the red line in the lower jaw. You can see it's slightly more recessed after, especially noticeable in the posterior, which is where you need advancement. This is a very common issue with old school surgeons who don't understand CCW rotation. Also, it makes no sense the ceph has your nose moving forward.

What you actually need is about 8mm of CCW rotation. I would run from this plan.

I'm going to enjoy my drink now, but I'll see what others say and chime in more then.

He himself told me to ignore the ceph, he used it as sort of a starting point which formed the plan for the 8mm lower jaw movement. He in no one way is following the ceph recommendation. As far as I understand you think I should ditch this plan and find a surgeon that offers rotation. Is there any good source of information I can read about the difference between BSSO vs  full CCW?

Thank you very much guys, hopefully I won need revisions

Edit: Kevan and GJ. I confused pre molars and wisdom teeth, sorry. I had both first molars, not premolars in my lower jaw extracted due to root infection. Part of the prices process is to advance the molars and wisdom teeth into the their position.

[kavan]

I see, granted when I brought it up with him, he said he knows all about rotation but he thinks it is not worth it in this case. He said moving the lower jaw is enough, and touching the upper jaw will only give me “monkey” lips. He said it’s forward enough as is.

But if I understand rotation is not about moving the upper jaw forward, it’s about rotating them. So what do you think I should do? I only consulted local surgeons since it’s a very invasive surgery and my insurance pays for it as well. Do you think it’s worth it to go to a European surgeon? GJ said I should run far away from this plan. But as far as I understand you claim there is some merit in it. I assume this plan will solve about 60% of the problem? What difference would I see in rotation vs pushing the lower jaw out as far as health benefits and aesthetics?

By the way, the other local surgeons offered joke plans like maxillary impaction due to 2 mm of gum show and genioplasty with titanium plates on the middle of the jaw. He was the one with the best plan.

He himself told me to ignore the ceph, he used it as sort of a starting point which formed the plan for the 8mm lower jaw movement. He in no one way is following the ceph recommendation. As far as I understand you think I should ditch this plan and find a surgeon that offers rotation. Is there any good source of information I can read about the difference between BSSO vs  full CCW?

Thank you very much guys, hopefully I won need revisions

Edit: Kevan and GJ. I confused pre molars and wisdom teeth, sorry. I had both first molars, not premolars in my lower jaw extracted due to root infection. Part of the prices process is to advance the molars and wisdom teeth into the their position.

I can see from the salient ceph MEASURES; sna, snb and anb why he suggested lower jaw only. The diagrams are not really ceph displacement proposals. Not the type that actually chart out the surgery movements. I disregarded the diagrams when I saw one of them that said: 'GROWTH projection.' Although I don't know what that actually means, I know it's not actually a surgery PLAN.

Rotations take place at the UPPER jaw via a CUT there. But since the numbers/angles do suggest option for lower jaw only surgery, moot point to discuss rotations that need upper jaw cuts to do them. A rotation refers to when the maxilla is ANGLED either clockwise or counterclockwise which in turn rotates mandible in same direction. Moving the maxilla 'forward' is a separate displacement.

My feedback is/was focused on looking at your ceph Xray, some of the salient measures on the ceph read outs, your mention of LOWER jaw recession, the doctors suggestion to you where I explained the the reasoning behind the doctor's suggestion to you. Again, that info alone gives indication there would be benefit/improvement from the lower jaw only proposal. Questions concerning GJs suggestions should be directed at GJ. As to 'what I think you should do', I think you should go on MORE consultations.

[GJ]

I think you should ask for a ceph showing the actual movements of his plan, and then go on more consults and compare plans. Post all those here so we can see. At least 3 consults for such a major surgery and ask for the actual plan from all 3 surgeons. Also, don't tell them what any other surgeon said. You want independent, objective opinions.

It looks like your 2nd premolar is missing on the x-ray. That's what I was referring to, not the wisdom teeth. There is a black space where the 2nd premolar (bicuspid) should be.

[kavan]

I see, granted when I brought it up with him, he said he knows all about rotation but he thinks it is not worth it in this case. He said moving the lower jaw is enough, and touching the upper jaw will only give me “monkey” lips. He said it’s forward enough as is.

But if I understand rotation is not about moving the upper jaw forward, it’s about rotating them. So what do you think I should do? I only consulted local surgeons since it’s a very invasive surgery and my insurance pays for it as well. Do you think it’s worth it to go to a European surgeon? GJ said I should run far away from this plan. But as far as I understand you claim there is some merit in it. I assume this plan will solve about 60% of the problem? What difference would I see in rotation vs pushing the lower jaw out as far as health benefits and aesthetics?

By the way, the other local surgeons offered joke plans like maxillary impaction due to 2 mm of gum show and genioplasty with titanium plates on the middle of the jaw. He was the one with the best plan.

He himself told me to ignore the ceph, he used it as sort of a starting point which formed the plan for the 8mm lower jaw movement. He in no one way is following the ceph recommendation. As far as I understand you think I should ditch this plan and find a surgeon that offers rotation. Is there any good source of information I can read about the difference between BSSO vs  full CCW?

Thank you very much guys, hopefully I won need revisions

Edit: Kevan and GJ. I confused pre molars and wisdom teeth, sorry. I had both first molars, not premolars in my lower jaw extracted due to root infection. Part of the prices process is to advance the molars and wisdom teeth into the their position.

Although at first glance along with prior knowledge that the pre-molars are the teeth usually removed (in anticipation of making space to push the lower teeth backwards when doing such allows surgical advancement of the lower jaw) it could look like the pre molars are removed, I confirmed which ones were missing by doing a 'count down'.

I counted the teeth on frontal X ray in accordance to which number assignment they would have.

From the double root space left behind, they are molars. As to which ones, you are missing #'s 30 and 19 which--yes-- are first molars. So, even though they are not pre-molars which they often pluck out in order to MAKE SPACE to push lower teeth backwards, (in anticipation for moving it more FORWARD in a lower jaw advancement), the spaces left behind by the missing first molars are indeed spaces they can use to push the lower teeth backwards with the goal of advancing lower jaw forward. So, that space from prior removal of first molars (that's already there for him to work with!) is another reason the doctor is offering you option of lower jaw advancement only.

Also, IF a major complaint of yours is TMJ PAIN, that also is a factor in buttressing his suggestion for lower jaw only whether or not he can or can't do a more advanced type of CCW that involves a posterior downgraft.

Basically, what I do here is look at what you have vs what a doctor's suggestion and or OPTION is to you and then explain how and why his reasoning makes sense to me (when that is the case). So, here, I'm not commenting on all possible options or possibilities 'out there' as could be found on going on multi consults, JUST the ONE you are presenting here.

Again, I think the option this doc gave you for the lower jaw only is consistent with what you have, your main complaint, takes into consideration TMJ complaint of pain, and salient angle measures given in ceph read outs.

You could get more complicated, more advanced options from some 'grand wazoo' docs in Europe or USA who offer those for EXORBITANT amounts of SELF PAY and LOTS of travel for follow ups, but for ME to OPINE on them would require YOU go on such consults and present the options THEY suggest.

[kavan]

Gj: As both you and Kevan suggested, that is what i am going to do. I will consult with top european doctors (R,Z and B) and also with G in the US to hear what they have to say without telling them about the other plan. As for the teeth, the first molars were moved, not the premolars. They both had root infection and failure. The doctor told me my options were to either extract them in preperation for the jaw surgery or try to save them in a half a year long treatment and than just remove the wisdom teeth.

Kevan: Just a note, the first molars were removed by his direction, not before i saw him. They were both heavily infected and required a year long process to save which even than was not sure. We decided simply to remove them and move the rest of the molars into place instead of saving them and than extracting the wisdom teeth, which would have given us the same solution.

So i agree with this move. As for the rest, you said it yourself, the decision to move only the lower jaw is one which makes sense due to the whole situation. Its a much more simple solution that a fancy rotation by top European doctors. And is very worth to take into account. I am happy you agree with his plan, even if its not the "best of the best" or even the most optimal one, it means he knows what to do. As you said, we can play around all day about diffrent surgical ideas, but the best plan right is now to consult with some of those top doctors to just get a sense of what other options are out there, they may as well agree that lower jaw is enough in my case, or that the difference between DJ and lower jaw is minimal.

I have to say, the prices i saw that some of those doctors take is not that far away from what my doctors takes here, the only thing that worries me is such a major operation in a different country.

I will contact Gunson, Raffiani, zarrinbal and a doctor in Belgium to get just more options. I will make sure to update

Although I ID-ed them (as first molars) in the 'Teeth Countdown' document, which is seen only when you look at the whole thread, it doesn't make much of a difference that they are not pre-molars because as long as there is a SPACE for them to move the lower teeth backwards. So, he gave you good advice on that one in the sense that extractions that could be used for SPACE were the BAD teeth.

He's probably a doctor unknown on this board but you could put out a feeler on him by naming him on small chance someone on here has any familiarity with him. As I said, the Grand Wazoo doctors are often SELF PAY where yours is getting insurance to pay for it (free for you).  There can be multi follow ups (travel expenses) depending on which ones want that. So, if finances are a consideration, that's going to factor into a decision. Your guy might not be a Grand Wazoo. But as long as he isn't a hack.

[Dutcherhatcher]

Although I ID-ed them (as first molars) in the 'Teeth Countdown' document, which is seen only when you look at the whole thread, it doesn't make much of a difference that they are not pre-molars because as long as there is a SPACE for them to move the lower teeth backwards. So, he gave you good advice on that one in the sense that extractions that could be used for SPACE were the BAD teeth.

He's probably a doctor unknown on this board but you could put out a feeler on him by naming him on small chance someone on here has any familiarity with him. As I said, the Grand Wazoo doctors are often SELF PAY where yours is getting insurance to pay for it (free for you).  There can be multi follow ups (travel expenses) depending on which ones want that. So, if finances are a consideration, that's going to factor into a decision. Your guy might not be a Grand Wazoo. But as long as he isn't a hack.

He keeps a group chat with over 300 of his patients and he encourages us to speak to other patients and review photos. As I said, my main worry is the limit of his surgical skill, because that is what he does and learned here. If he only knows how to advance jaws, so he recommends what he think is best and will probably do a very good job with it, but’s it’s also not the best option out there possibly. He is definitely the best in my country, but what is being the best in my country VS being good in Europe.
He worked with the university of Texas and also in Italy, so I am sure he is well aware of the concept of CCW.

The question I feel will come down to how much I care about the best possible result vs price and convenience.