CBCT 4 months after DJS - questions

[InvisalignOnly]

So I had double jaw surgery with genioplasty about 4 months ago. Overall I am happy with my results and do not have any problems except some mild nerve damage on one side of my lower jaw. I got the surgery done in Europe and am now back in the country where I usually live - this is a small place and only one local hospital offers full face CBCT. I had been to this hospital to get a CBCT done before my surgery, and consulted the maxillofacial surgeon who works there since I needed his referral to get the scan done. At the time he offered to do my surgery but I decided to get it done elsewhere as he did not seem to have enough experience and specializes in facial trauma etc. Anyway, I decided to go back to the same doctor to ask him to get a new CBCT done and review it to make sure everything is healing properly.

We got the CBCT and he said everything looks fine and as expected, the bones haven't completely healed yet but they're getting there (he said it will take 6-12 months). He did, however, say a few things that are concerning me so I thought I post here to ask for advice. First of all, there are screws in my mandible and he was very critical of that saying it is an outdated technique and said he would have used 'Arnett plates' instead. He also stated that these screws were inserted into my mandible from the outside, like, from my face (?!). I did not want to start an argument so did not question him, but I find this impossible to believe. I have very fair skin that bruises very easily, and never had any scars or bruising etc. on my face after surgery, so how would this be possible? Also, why would these 'Arnett plates' be better than screws - am I at a higher risk of relapse because they did not use plates? My advancement was not large, 7mm.

He also pointed out that two other screws, one near my nose and another one in my chin, are close to nerves. However, both are on the 'good' side of my face where I have no nerve damage and full feeling. I do not know anything about biology - is there any possibility that the altered sensation on the other side of my face has anything to do with these screws touching my nerves?

Thanks in advance for your replies! I should add that the doctor seemed unhappy about the fact that I got the surgery done elsewhere (even though I lied and told him it was for insurance purposes), so that might be a factor in him being critical of my surgeon's work, or maybe he's just being objective, I really have no idea.

[GJ]

I haven't looked into this in ages, but from memory, he's correct that plates are the standard these days. I think there's less slipping with them. I'd guess it's due to more surface area/more resistance to force compared to just a screw. I'm not positive so don't freak out. We have some surgeons who post here, and maybe one of them can chime in.

Someone told me they come in from the cheek when doing surgery, and I also didn't think that could be possible. I see no scarring, etc. Maybe something got lost in translation with us both when we were told that...

Sorry, can't be much more help.

[InvisalignOnly]

I haven't looked into this in ages, but from memory, he's correct that plates are the standard these days. I think there's less slipping with them. I'd guess it's due to more surface area/more resistance to force compared to just a screw. I'm not positive so don't freak out. We have some surgeons who post here, and maybe one of them can chime in.

Someone told me they come in from the cheek when doing surgery, and I also didn't think that could be possible. I see no scarring, etc. Maybe something got lost in translation with us both when we were told that...

Sorry, can't be much more help.

No that's actually helpful, thanks! It's good to hear someone was told the same thing about the screws being inserted from the outside. My skin gets scarred and bruised super easily, so it is very difficult to believe that they could have done that - there is nothing showing on my skin whatsoever. But who knows.

I'm not going to freak out about the lack of plates unless my mandible relapses over time - I really like the way it is now so would be really upset if there was any relapse. To be honest, I am happy I do not have huge metal plates there if I do not need them - the less metal the better, as far as I am concerned.

[InvisalignOnly]

I forgot to add one thing: my surgeon applied HA paste during surgery and to my surprise, this isn't visible at all on the CBCT scan. I cannot see anything 'unusual' in the scan in that area, and did not mention it to the doctor who reviewed the scan and he never noticed it. I find that strange as I assumed it would be visible on the CBCT, especially so soon after surgery, but nothing.

[Gadwins]

If they inserted screws from outside your face, shouldn't be there a scar? I think they shoulded cut a hole into your skin and suturing the wound.

[ArtVandelay]

I saw that mandible screw technique in this book on page 71 and was shocked at one point this was acceptable. I'd be even more shocked if someone is still doing this in 2020.

https://www.amazon.com/Aesthetic-Perspectives-Surgery-Harvey-Rosen/dp/1461274303

For sure you would see a scar at least 5mm wide if it was in fact from the outside.

[PloskoPlus]

I saw that mandible screw technique in this book on page 71 and was shocked at one point this was acceptable. I'd be even more shocked if someone is still doing this in 2020.

https://www.amazon.com/Aesthetic-Perspectives-Surgery-Harvey-Rosen/dp/1461274303

For sure you would see a scar at least 5mm wide if it was in fact from the outside.

I heard the extra oral approach is less traumatic to the nerves.

[InvisalignOnly]

For sure you would see a scar at least 5mm wide if it was in fact from the outside.

Thanks for the info - do you know where these scars would be, approximately?

[LeFort 3000]

this doesnt make sense. screws are not put in through the skin, its completely absurd. they need to cut the jaws inside the mouth anyway, why the f**k would anyone put a hole through your cheeks. also screws are screws and plates are plates. you need always both obviously. you cannot have plates without screws and screws without plates have no function. you heavily misunderstood your doctor in this consultation

[InvisalignOnly]

this doesnt make sense. screws are not put in through the skin, its completely absurd. they need to cut the jaws inside the mouth anyway, why the f**k would anyone put a hole through your cheeks. also screws are screws and plates are plates. you need always both obviously. you cannot have plates without screws and screws without plates have no function. you heavily misunderstood your doctor in this consultation

Why are you swearing and verbally attacking me? You need to chill lol. I did not misunderstand him at all, and actually have just found the place where they inserted the screws, indeed from the outside. It is not from my cheeks but from under my chin - will take a picture later if I get the time. I remembered I had tiny 'holes' there after the surgery but did not think anything of it. It never caused me any issues. And what you are saying about screws without plates is just nonsense - of course you can have screws without plates and vica versa, this is surgery and not a metal building kit for kids. If you can't be helpful, why comment at all?

[aestheticseeker]

Why are you swearing and verbally attacking me? You need to chill lol. I did not misunderstand him at all, and actually have just found the place where they inserted the screws, indeed from the outside. It is not from my cheeks but from under my chin - will take a picture later if I get the time. I remembered I had tiny 'holes' there after the surgery but did not think anything of it. It never caused me any issues. And what you are saying about screws without plates is just nonsense - of course you can have screws without plates and vica versa, this is surgery and not a metal building kit for kids. If you can't be helpful, why comment at all?

There are some cases where they put the screws through tiny holes of the skin yes

[LeFort 3000]

Why are you swearing and verbally attacking me? You need to chill lol. I did not misunderstand him at all, and actually have just found the place where they inserted the screws, indeed from the outside. It is not from my cheeks but from under my chin - will take a picture later if I get the time. I remembered I had tiny 'holes' there after the surgery but did not think anything of it. It never caused me any issues. And what you are saying about screws without plates is just nonsense - of course you can have screws without plates and vica versa, this is surgery and not a metal building kit for kids. If you can't be helpful, why comment at all?

im not swearing or attacking at all but whatever.
yea pretty sure you did not have put screws through your skin while having a djs.
okay so tell me, what function would a screw have without using it with plates? which function would a plate have when its not fixed with screws? it still doesnt make sense at all

[Gadwins]

im not swearing or attacking at all but whatever.
yea pretty sure you did not have put screws through your skin while having a djs.
okay so tell me, what function would a screw have without using it with plates? which function would a plate have when its not fixed with screws? it still doesnt make sense at all

Plates without screws does not make any sense. But by sagittal split there are still bone segments, which are overlapping. At this overlape you can just put screws to hold them together. Still I think there should be some stichtes from the outside or at least a band aid after the surgery, which couldn't be unnoticed. Stichtes should be there at least for 2 weeks.

[SMSOMS]

I will have to respectfully disagree that "Arnett Plates" are the standard.  He just likes them promotes and the has a cult like following who for no scientific reason think they are better.  I would be willing to bet that more BSSO's are done using position screws than plates and using a 3-4 mm poke in the cheek you cannot see in 10 days.  Look at the literature and stability and outcome are indiscernible. 

Arnett, and he is a friend, promotes that "if you do not use plates you get condylar resorption and relapse".  This is total BS.  I presented our research at the Arnett Forum in 2019 using 3D mapping of the condyles after a statistically significant number of Class II and Class III DJS done with position screws and guess what.....resorprtion was insignificant and less than 0.5mm which is considered adaptive.  Furthermore there was apposition in other ares, again adaptive.  No change in the occlusion as expected.  Arnett/Gunson claim that anything other than manual positioning of the proximal segment and then using two plates causes the medial pole of the condyle to resorb and cause relapse.

Again total BS.  In our study I used a specially designed BBSO segment holding clamp, which is heresy in the Arnett/Gunson camp, and guess what....not a single patient had any resorption on the medial pole.  When I presented our data and answered questions directly from Arnett the audience was stunned. 

Be very careful in what is considered "gospel" and standard of care. 

[kavan]

They can put screws through the skin even with jaw implants. Small puncture pokes that close up quick and you don't see due to the swelling. Also with fat grafting, they make the small puncture poke to introduce the cannula and they close up quickly.