I feel uncomfortable contradicting you because I am aware of the huge gaps in my knowledge at this point.
I do think you could be right - for the best - aesthetic outcome I should be looking into double jaw surgery. The reason being - lack of tooth show, strained smile.
Regarding the shortness - you know it and you're saying it - downgrafting the maxilla is not the only procedure that vertical height could come from. It can also come from the vertical genioplasty you yourself mentioned. I am aware that that could just be me trying to mask the problem and possibly failing - putting chin on an angry looking short face. But still, there is a slight possibility that I can recognize looking at my face that is allowing me to assume BSSO plus that type of genioplasty could be enough for me to be satisfied.
My opinion is that BSSO could address 80 percent of the aesthetic concerns I've got and if I'm right I won't be getting double jaw surgery just because of my lack of tooth show or my strained smile. At least I think so at the moment. If I could somehow get 3 mm of lower facial height by advancing my mandible + orthodontic work and another 3/4 with genio/fillers that would be enough for me.
You keep telling me what is the best procedure I should be looking into - and thank you for that, I asked for it and I truly appreciate your help but I am also here so you all could give me some insight into why exactly (X-rays and numbers) is my face short/er. Because it would really help me understand everything better. If you could comment on my angles and cause of me lacking in lower facial height, I would appreciate.
I attached the link - they mention two approaches for handling short faces - I have no idea what they are trying to do in the first one but the alternative (first sentence, page 133) seems to be exactly what I'm suggesting here.
Second link is about what I think I need - did she have double jaw surgery?
And sorry for asking you this but when you say 'posterior downgraft' you're talking about a segmental Lefort I, so no anterior advancement?
https://pdfs.semanticscholar.org/44b1/8fe9e7b481e51647115d31678970c6147ff7.pdf
https://www.semanticscholar.org/paper/Esthetic-Aspects-of-Orthodontic-Surgical-Treatment-Watted-Bartsch/ef74c9568c7d541aff846d0796aed40cf5f7c66b#citing-papers
You asked for advice. I gave mine and the reasoning behind it. Although I knew my advice was against a backdrop of AVOIDANCE of any surgery to the maxilla, your query was on the AESTHETIC section of the board AND your case was one that also included NO upper teeth show at rest. So, right there, it became one that didn't justify AVOIDING surgery to the maxilla. Not in terms of aesthetics and not in terms of where some shortness to the face comes from.
I also mentioned that of the cases/displacement proposals I've seen (Class2 Div2), they included CCW downgrafting. Some with just posterior downgrafting, others with an element of anterior downgrafting with the net rotation was CCW. To clarify further, those cases came from docs who would do CCW for Class2 div 2 and also would add a lengthening genio to that. The CCW aspect of it is the part that basically gives a 'free ride' to the mandible advancement (where the chin point rotates forward in this ride) and that's BEFORE, the recessive mandible, itself, is advanced further via the BSSO. Given the cases were class2 div2; cases with low angle mandibular planes where CCW does NOT make them steeper, they involved the type of genio that had an element of lengthening to it (as opposed to type that slid upward having a shortening element to it). Those cases ALL had RECESSIVE mandibles.
Now, in the process of looking for cases that involved CW rotation for short face, they had LACK of upper tooth show as you do but NOT as much recession to both the mandible chin as you do.
If you want to take a look at some of those cases, here they are:
https://pocketdentistry.com/23-short-face-growth-patterns-maxillomandibular-deficiency/https://pocketdentistry.com/9-case-reports/Now, with reference to the ROTATION at the maxilla, there are indeed, 2 approaches; CCW and CW but I just resolved your case to the CCW because despite the CW working for short face cases, the short faces shown in the papers did not ALSO have the extent of the retrusion to the mandible and chin as you do. Hence my suggesting the CCW approach that gives a 'free ride' or extra push out to the whole mandible and chin even before the BSSO is done along with it.
So, here, I'm just giving my REASONING behind the suggestion I made. But either way, CCW as would do some doctors and CW as would do others, what they BOTH have in common is SURGERY to the MAXILLA.
Of the links you gave:
They helped clarify what I mentioned to April where I said I was not familiar with a type of BSSO only where the BSSO rotated without rotation of the maxilla. Looks like there is a type of BSSO that rotates (CW) independently of any rotation to the maxilla. So, that answered my question aimed to her in this thread.
I also looked at the photos of patients on them. They had AMPLE tooth show and a LESSER extent of the type of mandibular and chin retrusion you do. No downgrafts to the maxilla were needed to increase tooth show. Nor was any CW rotation to the maxilla needed to do it.
So, from those links, I would conclude that the BSSO only technique with CW to the BSSO look to work well for patients who already have AMPLE upper tooth show and DON'T have the extent of mandibular retrusion you do.
Admittedly, I looked at them in terms of whether or not I gave the 'wrong' advice. For example, if I found that the cases had the extent of both the mandibular and chin retrusion you do AND the patients in them ALSO had NO upper tooth show at rest as you do, I would have seen the 'err' of reasoning process behind the advice I gave. But I didn't.
ETA: I can't call it exactly because your case could also fit into a type of downgraft that would involve CW rotation where the downgrafting is more in front than in the back. But that is often one where the mandible is recessive BUT the chin itself is not. Yet still something where a downgraft is done and not something that avoids surgery to the maxilla.
What I also looked at is your opinion which is STRONGLY rooted in AVOIDANCE of any possible surgery to the maxilla. Your FILTERING process is one in favor of AVOIDANCE of any surgery to the maxilla. Now, April's mention of this '3 point landing' BSSO technique, was very well received by you and was exactly the type of information you were looking for because it went through your filter of wanting to AVOID any surgery to the maxilla.
Now, I'm not the one who gave you 'exactly the type of information' you were looking for (information that filtered through and appealed to your desire to avoid any surgery to the maxilla). April did. So, you should direct your questions to HER as to WHY you should move TOWARD the type of surgery she mentioned that doesn't include surgery to the maxilla. Thing is, I'm NOT going to give advice or fill in any info gaps of understanding just because the advice I already gave and the reasoning behind it didn't go through your avoidance filter.
IMO, GAPS of understanding can arise from avoidance filters. Case in point is that you don't seem to understand that someone with a short face who ALSO has NO upper tooth show at rest would also have SOME of the shortness to it attributable to the maxilla in which case moving the maxilla downward would be included into a surgery. You don't understand that because a strong avoidance filter is a MENTAL BLOCK.
What you need--or WANT--is someone to ACCOMMODATE your opinion/desire to AVOID surgery to the maxilla and to do so DESPITE some of the shortness (lack of upper tooth show) coming from the maxilla. You GOT that. April gave you info that involved 'BSSO only' (3 point landing). You even seemed to filter out the parts where she said it wouldn't address issues to the maxilla related to lack of tooth show where she said DJS is usually better to address everything. Also, April commented on your angles. So, direct your question to her as to how your angles apply to avoiding any surgery to the maxilla and/or directly relate to your opinion about BSSO only doing what you want or think it will do.
I'm not going to do a ceph analysis for you, measure all your angles and distances and from there, tutor you just because I gave advice that included something you had a MENTAL BLOCK against entertaining (ANY surgery to the maxilla). Ball is in your court to address your mental block. Not for me to UNBLOCK it for you.
Again, I looked at the links to the type of surgery you wanted. Although it looked very successful for the patients in them, the patients in them didn't start with LACK of UPPER TOOTH SHOW (short maxilla) and their chin and jaw recession was not as extensive as yours. I think it's great April gave you the name of a surgery which you could find a LINK to an article about. So, look at the names on the article and maybe consult with some of the authors based on your strong opinion you are a candidate for JUST THAT and with NO surgery to the maxilla. They should be in the capacity to either confirm or deny you candidacy for it or accommodate your desire to maintain what ever extent of shortness your maxilla with its lack of upper tooth show is contributing to the total shortness you have.
