Going to have double jaw surgery

[mick9876]

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[mick9876]

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[mick9876]

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[GJ]

Probably a linear/down movement since you have a short lower third. I don't think CCW is a good option for this case. You'd need good ortho treatment to get the teeth in a position to let the lower come forward as much as possible. There is a surgeon currently answering questions here, so maybe you can ask him.

[notrain]

Unless you have a severe cant to your upper jaw, I'd advise you only get single jaw surgery.

[GJ]

Unless you have a severe cant to your upper jaw, I'd advise you only get single jaw surgery.

Lower only with extractions?
I don't see how he'd get enough space without extracting the lower premolars.
That is a valid option in cases with a short lower third and flat occlusion. I can see it working for this case.

[notrain]

Lower only with extractions?
I don't see how he'd get enough space without extracting the lower premolars.
That is a valid option in cases with a short lower third and flat occlusion. I can see it working for this case.

He is Angle Class II div 2. These cases present usually with too steeply inclined (retroclined) maxillary incisors which can be decompensated into a more natural proclined state. I'm not in the mood to download his ceph and trace everything out manually, but I figure he can get 7-8mm space for a combined (rotation and translation) movement of his lower jaw. The ortho will need to decompensate the curve of spee in the upper jaw (but not the lower!) as well to give a proper occlusal plane for the surgeon to work with. This allows him to adress the vertical deficiency without having to operate on the upper jaw as well.

See here: https://www.zmk-aktuell.de/fachgebiete/kfo/story/ein-integriertes-therapiekonzept-zur-korrektur-der-klasse-ii-dysgnathien-__5622.html

for some explanatory illustrations. Ctrl + F and enter "Chirurgische Rotation" to jump to the relevant piece or use google translator to read the entire thing if you are in the mood.

[kavan]

Hello,

been lurking on  this forum for a while and dedicated to make a thread to see if someone wants to give their general opinion comment my case in some way.

I have deep bite, short lower and upper jaw with zero teeth show, i think that aesthetically thinking the most important goal of the surgery is bringing both jaws forward since i feel like my face is pretty flat and recessed, also getting some tooth show would be nice too.

Two surgeons i have seen have suggested doing double jaw with cw rotation, one also talked about sarpe.

Btw, i am currently doing orthodontics and i have seen three surgeons, one from Belgium, one from Spain (you might guess who these are since they are pretty popular on these forums) and one from my home country, not 100% sure yet who i am choosing.

Thanks for taking the time to read this

You relay you're in ortho. Just tells me you are in ortho for something. The something to be in ortho for is ideally a pre-selected surgeon. Plans among surgeons differ and so does the ortho prep as it needs to be in reference to a plan and the 2 planners; maxfax and ortho should be in communication with each other. Posters who run around town (and this might include the world) seeking differnt opinions, who are in ortho (for who knows what) will be in perpetual uncertainty and in ortho longer than those who can pre-pick a surgeon.


Here is a quote of mine from another thread (on the educational section):

...

 ' Absence of treatment plan, when orthodontist and surgeon do not communicate....'

I think that is often the case when patients are in braces (or invasaline) for 'something' and then they go around on multi consults in pursuit of the maxfax part of various treatment proposals where the situation is inherently one where there is no communication between which ever otho they have and the doctors they are consulting with. They are in braces for 'something' and the more consults they go on, the more they get confused and linger longer in indecision. Any treatment plan via braces should be that of the CHOSEN doctor such there is direct communication via him/her and ortho. All treatment plans from any doctor are always contingent on the braces doing what they want them to do.

You relay you have short upper and lower jaw with 0 teeth show. That part is consistent with with a DOWN GRAFT to the maxilla which would yield more teeth show and elongation to the lower '1/3rd' of face. You relay the suggestion of CW rotation (clockwise). CW rotation is consistent with 'short face' and LOW ANGLE mandibular plane. CW rotation is consistent with the maxilla moving  forward and chin point moving down and back and also increasing the angle of inclination the mandibular plane has with a horizontal plane. You have 'short' lower 1/3rd and low angle mandibular plane.

Now, that's JUST the ROTATION part of it. For rotations, they are best understood by people with a basis in GEOMETRY because rotation of the maxilla/mandible complex relates to rotating a TRIANGLE around a selected rotation point and that's what is happening in maxfax. On the educational section of this board, I've included a few diagrams about rotations. The diagrams show where the TRIANGLES are constructed.

Rotations take place to the maxilla and in reference to the TRIANGLE being rotated from a selected fixed rotation point and also the direction of the rotation, how the mandible displaces with the rotation is going to be 'self evident' to those who have no problem with the concept of rotating a triangle (elementary geometry).

In addition to the rotation, there are other movements or 'translations' where the jaw(s) are displaced along the CHANGE of PLANE the rotation has created. For example a CW rotation increases the angle of inclination of both the maxillary and mandibular planes; makes the planes steeper. (Works with flat planes.) A 'forward' movement/displacement is a translation along that plane. Hence advancing the maxilla; translating it 'forward' along the plane the rotation created can be added to address maxillary retrusion. Likewise, translating the mandible 'forward' (BSSO) along the steeper plane the rotation created can also be added.

Downward drops; a downgraft of the maxilla can also be added. For example, a downgraft to the WHOLE maxilla that was vertically longer in front than in back, would be in CW direction and one that was vertically longer in the back than the front would be in CCW direction.


All in all, I think your case looks consistent with a CW rotation via an overall downgraft that is more in front than in back. It would give more tooth show and elongate the short lower '1/3rd' of face. It will also make all of your overly 'FLAT' planes steeper (making them steeper contributes to the elongation) and from there, advancement to both upper and lower jaw follow along steeper planes. All that together would address your aesthetic issue.

The only other thing that could be added to this mix would be a genio if the BSSO does not compensate enough for the chin going backwards with the CW rotation.

I would suggest looking for similarities in what I explained here to the surgical suggestions.

To synopsize further, From your ceph, it looks like you could have a CW (overall downgraft) to the maxilla coupled with bimax advancement and quite possibly genio.

NOTES:

I will not direct in which doctor to choose. Nor will I engage in 'piecemeal' LATCHING onto an isolated mm measure.


Direction of rotations is always in reference to a profile facing the RIGHT.

[kavan]

He is Angle Class II div 2. These cases present usually with too steeply inclined (retroclined) maxillary incisors which can be decompensated into a more natural proclined state. I'm not in the mood to download his ceph and trace everything out manually, but I figure he can get 7-8mm space for a combined (rotation and translation) movement of his lower jaw. The ortho will need to decompensate the curve of spee in the upper jaw (but not the lower!) as well to give a proper occlusal plane for the surgeon to work with. This allows him to adress the vertical deficiency without having to operate on the upper jaw as well.

See here: https://www.zmk-aktuell.de/fachgebiete/kfo/story/ein-integriertes-therapiekonzept-zur-korrektur-der-klasse-ii-dysgnathien-__5622.html

for some explanatory illustrations. Ctrl + F and enter "Chirurgische Rotation" to jump to the relevant piece or use google translator to read the entire thing if you are in the mood.

Except for the fact that no tooth show is part of the problem of the vertical deficiency and he has retrusion to the maxilla. I've seen that study or technique somewhere before and the selected candidates were those with NO issues to the maxilla.

He seems pretty intuitive or self aware of what's going on with his face. eg. little to no tooth show can be seen in his ceph. Although his ceph blacks out a lot of the soft tissue profile, his downward rotated nose tip and short upper lip with overly acute nose to lip angle is suggestive of maxillary retrusion. An isolated BSSO; the type in the link that does a selective CW rotation to the mandible only (which is a great maneuver for those needing nothing done to the maxilla) won't address what he has good cause to want to also address, lack of tooth show and retrusion to the maxilla.

He's got 'short chin' which is a term for short lower 1/3rd or just 'short face', the type consistent with low or 'flat' angles to the maxillary plane and mandibular plane, Class2 div2. (Toss in the occlusal plane too if you like.) Vertical shortness of the lower 1/3rd via CW (clockwise rotation) could be addressed with an overall downgraft that's longer to front of maxilla than it is to the back of it. From there, both the translations of maxilla and mandible (forward displacements) along the planes that are made less flat by the max rotation can be done to increase his lower 1/3rd. Hence, isolated CW BSSO only technique is a limited 'fix' when no tooth show and visage of retrusive maxilla are present.

[april]

He is Angle Class II div 2. These cases present usually with too steeply inclined (retroclined) maxillary incisors which can be decompensated into a more natural proclined state. I'm not in the mood to download his ceph and trace everything out manually, but I figure he can get 7-8mm space for a combined (rotation and translation) movement of his lower jaw. The ortho will need to decompensate the curve of spee in the upper jaw (but not the lower!) as well to give a proper occlusal plane for the surgeon to work with. This allows him to adress the vertical deficiency without having to operate on the upper jaw as well.

See here: https://www.zmk-aktuell.de/fachgebiete/kfo/story/ein-integriertes-therapiekonzept-zur-korrektur-der-klasse-ii-dysgnathien-__5622.html

for some explanatory illustrations. Ctrl + F and enter "Chirurgische Rotation" to jump to the relevant piece or use google translator to read the entire thing if you are in the mood.

I think in English they call this either tripod setup or 3-point landing BSSO. Like a CW of just the lower jaw.

But it won't be addressing his tooth show, if his tooth show is his concern.

Mike9876, it seems you have a consensus between the 2 surgeons you've seen, so you're in a pretty good position in that regard. Choose from the two, and make sure your ortho is on board and not currently doing their own thing.

ETA: what Kavan said. I didn't see his reply just above as I posted.

[kavan]

i also could get bsso to fix the bite and the lower jaw for free on the national health care thing, the upper the Le Fort would be for cosmetic reasons.

Every surgeon i have consulted this far has seemed to believe that there would be good aesthetic reasons to also do the upper jaw and i would benefit from it and one of them even straight up said that i will not be happy with the bsso only results.

I certainly agree you would benefit from extra work to the Lefort 1 area. My other posts on this thread explain such.

[kavan]

I think in English they call this either tripod setup or 3-point landing BSSO. Like a CW of just the lower jaw.

But it won't be addressing his tooth show, if his tooth show is his concern.

Mike9876, it seems you have a consensus between the 2 surgeons you've seen, so you're in a pretty good position in that regard. Choose from the two, and make sure your ortho is on board and not currently doing their own thing.

Oh, ya. That's where I remember I saw a paper on same/similar. I knew i saw that somewhere before. My critique of it, as I recall, was that the patients were cherry picked and limited to those with enough tooth show and/or no issues to the maxilla.

[april]

You know, his xray actually confused me at first glance because it looks like he would show more than zero tooth show at rest as his upper teeth extend below his upper lip. But I remember jsf member Apollo saying in short-faces scans apparently aren't reliable to assess tooth show. This is because of the lip smooshing. So he probably shows even less than what the x-ray makes it look like.

"When patients have lip overclosure (often due to a deep bite), it's impossible to assess incisor show (as well as relaxed lip contour) if they bite down during the scan. For example, a patient might have -2mm of incisor exposure in repose, but when they bite down and their lips overclose, measuring the incisor tip to bottom of upper lip in a scan could be 0mm (as the upper lip is driven upwards by the lower lip when they come together)." -- Apollo

[mick9876]

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[kavan]

First of all thank you for taking the time and effort to answer everyone! This is greatly appreciated.

The reason i have not locked down a surgeon yet is that i am waiting for a transfer to other university hospital to see if they think that double jaw surgery is the best choice for me and if that happens i have an option to get the djs for free, right after that i will make the final dedication.


The thing that concerns me about cw rotation plan is the chin going backwards and limitations of the lower jaw advancement, when the aesthetic goal is having the pogonion in line with glabella or at least close to that. I have heard some surgeon say that the biggest advancement to the lower jaw he will do is like 6-8mm so even with genio i wonder that will it be enough.

The third surgeon i got consultation from talked about ccw and bringing my lower jaw out more or something like that but this was when he had just seen my face by a glance and not examined me or seen the x-rays, i should have asked for the final plan.

But yeah the next thing i will do is choosing a surgeon

I think CW is more on target with your case than is CCW. To this regard, I will show you a case from a 'Grand Wazoo' of CCW (Gunson) who has actually done a CW rotation on a patient who is pretty much similar to you.  But, of course, he avoids telling people straight out it's a CW case and not a CCW case.

Here's a Gunson case, pretty similar to yours (although no case is 'exactly' like anothers'). The red lines I drew on the model to illustrate what I meant by an overall down graft in direction of CLOCKWISE rotation for the short face. Observe it is longer in front than in back.   Gunson, doesn't seem to tell people straight out when he's doing CW. He certainly didn't announce it on the FB page I found this example. But this is an example of CW with the the type of overall downgraft I was suggesting in my posts.

As I said prior, the CW will give you the elongation to the face needed and a genio can also be added.  The Gunson case has the CW via overall downgraft to the maxilla, advancement of both maxilla and mandible and also a genio.

photo or diagram included in this post.