~1 year post-op - Over-impaction nightmare w/ 2nd surgery

[kavan]

Thanks for your input kavan, it's much appreciated.

I can understand the trade-off you're talking about, but I would say that my issue with what happened is that there was no communication to me at all that this outcome could be remotely possible.  I left the consultation conveying my objective of moving my profile further out (which I never listed a goal distance btw, it was my OS that figured he could move the bottom jaw 10 mm and top 6 mm to achieve a more desirable profile) AND that I wished 1-2 mm of gum show when I smiled (which, as mentioned, was more tooth/gum show than I was showing pre-surgery).  That is how things were left and so that is what I believed the main objectives to be.  If he didn't believe that was possible because of the trade-off you speak of, I would think it's his absolute duty to communicate that to me, and not have me wake up to a drastically different result (seemingly off by 4-5 mm of tooth/gum show).

In any event, do you have any insight or input as to the risk of said anterior downgraft as a revision surgery, assuming I'm okay with a "weakened" profile? Is this surgery still considered quite risky, with regards to relapse?  My OS seemed to bring it up in our last visit as something relatively straightforward ("you wouldn't even need braces again, because we would just need to move one jaw vertically") - but I would also add, he traditionally omits talking about any risks or obstacles as if every surgery is a breeze, and yet here we are unsatisfied, aesthetically, after two surgeries.

Bonus question/topic: Are there many additional risks of going under the knife for a 3rd time, despite the first time being all the way in 2011?

I can't answer questions about surgical risks specific to what yours would be in 3rd surgery.
However, I'll convey what I think is an intuitively obvious way to evaluate, for yourself, the information YOU, YOURSELF, already have, in particular, INPUT vs. OUTPUT as it relates to your requests to your OS vs. your OUTCOMES. Basically, if your question is in regard to having a 3rd surgery with the same OS, all you need to do is REFLECT BACK on how 2 prior tries worked out for you WHAT EVER the communication was prior. Although he might be a 'renowned' OS in YOUR CITY, consider, you're on a board where people look for REVISION surgeons OUTSIDE of the ones they've prior CONFINED themselves to.

The bottom line here is what every communication you had with your ('renowned in your city) OS has not worked out. So, consider finding a surgeon (perhaps outside of your geographic area) who does revisions of other surgeon's work, even if it's just to advise you on potential surgical risks. That is my insight on the matter.

[ImpactedMood]

I can't answer questions about surgical risks specific to what yours would be in 3rd surgery.
However, I'll convey what I think is an intuitively obvious way to evaluate, for yourself, the information YOU, YOURSELF, already have, in particular, INPUT vs. OUTPUT as it relates to your requests to your OS vs. your OUTCOMES. Basically, if your question is in regard to having a 3rd surgery with the same OS, all you need to do is REFLECT BACK on how 2 prior tries worked out for you WHAT EVER the communication was prior. Although he might be a 'renowned' OS in YOUR CITY, consider, you're on a board where people look for REVISION surgeons OUTSIDE of the ones they've prior CONFINED themselves to.

The bottom line here is what every communication you had with your ('renowned in your city) OS has not worked out. So, consider finding a surgeon (perhaps outside of your geographic area) who does revisions of other surgeon's work, even if it's just to advise you on potential surgical risks. That is my insight on the matter.

Sorry, I probably didn't phrase my question so well and made it seem like I was considering the risks with the same OS - I completely understand your point here.  Fool me once type of thing with that - I was probably naïve to go back to him even for a 2nd surgery but it was most convenient and I suppose I gave him the benefit of the doubt that the first surgery was simply miscommunication or a matter of preferences (ie. an ideal profile can be subjective, as already seen in this thread alone).

I was merely stating that this OS made the risks of an anterior downgraft seem ordinary, which also can't really be trusted, for the same reasons as discussed.  I was seeking any additional insight or opinion on that particular surgery in general, but I understand there are probably so many variables to give a useful answer.

I appreciate your feedback.

[PloskoPlus]

If CCW-r with downgrafting is the litmus test of surgeon ability (whether you need that type of movement or not), then you are s**t out of luck in Canada, because AFAIK no surgeon in Canada does this.  But at least you have some great surgeons across the border.

[ImpactedMood]

If CCW-r with downgrafting is the litmus test of surgeon ability (whether you need that type of movement or not), then you are s**t out of luck in Canada, because AFAIK no surgeon in Canada does this.  But at least you have some great surgeons across the border.

Thanks for your feedback, Plosko.

Admittedly, I need to brush up on my education of everything because I had thought (incorrectly it seems) CCW-r was done in impactions, and CW-r was done in downgrafts.  Also, not that I wish to go with my OS again, but he told me that if I wasn't happy with tooth show after a year, he could move everything down to show more teeth, and that he's done this many times/is fairly straight forward.  So are you saying what I need in your opinion (CCW-r with downgrafting) is different than what he was proposing?  Or are you saying he likely can't do what he offered very well at all?

Also, I don't think getting surgery in the U.S. would be an option for me for likely 5+ years - just don't have the money to spend on this, which would be covered by OHIP here in Canada.

[kavan]

Your smile change is not just one of upper tooth show (or lack thereof) but also one LOWER tooth show, especially if it's now harder for you to move your lower lip UP when closing your lips than it was before. 'Lip incompetence' is mentalis strain (muscle moving the lower lip). For example, when the lower jaw, including the chin is too far back or even too far forward, lifting the lower lip UP gets harder to do the more the mentalis muscle is kind of stretched out over a long diagonal path. From my perspective mechanical efficiency of ease of moving the lower lip UP is a shorter path to do so. Even if there is no direct surgery on the chin itself, I think that the more it goes outward with the ride of the jaw advancement, the muscle used to lift the lower lip up can lose some mechanical efficiency where it gets harder (takes more effort) to lift it directly 'up'.

That said, your chin looks to be somewhat 'on the stretch' as in a little too far forward and I think that could factor in to the lower tooth show. I think the lower tooth show is more visible issue than is  upper tooth show being 'invisible'.

Although anterior downgraft (CW-r) would stand to reverse CCW-r of the impaction and thereby give more upper tooth show and perhaps result in some auto rotation of the lower jaw in CW-r direction to move the chin point backwards, you might need the BSSO along with it (double jaw surgery) for stability and/or more mechanically efficient lower lip 'up' movement.

When your lower jaw was too far backwards for your aesthetic liking subsequent to the first surgery, did you have the same lower tooth show and difficulty moving your lower lip upwards as you now have? What I'm getting at here is that not only do you have to think about the lack of upper tooth show but also the presence of the lower tooth show. Like you need to think in terms of a surgery that would rectify both.

[kavan]

Thanks for your feedback, Plosko.

Admittedly, I need to brush up on my education of everything because I had thought (incorrectly it seems) CCW-r was done in impactions, and CW-r was done in downgrafts.  Also, not that I wish to go with my OS again, but he told me that if I wasn't happy with tooth show after a year, he could move everything down to show more teeth, and that he's done this many times/is fairly straight forward.  So are you saying what I need in your opinion (CCW-r with downgrafting) is different than what he was proposing?  Or are you saying he likely can't do what he offered very well at all?

Also, I don't think getting surgery in the U.S. would be an option for me for likely 5+ years - just don't have the money to spend on this, which would be covered by OHIP here in Canada.

You're not incorrect. It's just there is more correctness to be had.

CCW-r is done with anterior impactions and posterior downgrafts. Plosko is referring to the latter. Not specifically for you but rather a sign that a surgeon is 'with the program' as to keeping up with advances in techniques when they can ALSO do CCW-r with posterior downgrafts and not just with anterior impactions.

CW-r is done with anterior downgrafts and posterior impactions.

[Luka2020]

Hey Luka, I'd prefer not to really because A. I'd have to dig a bit to find the good ones, and B. I'm not sure what benefit it would produce, even for you. What I would say is after impacting 3 mm in first surgery, and another 3 mm in this surgery, I still have a bit of lip incompetence (eg. when teeth are in bite position, I still need to force lips closed as they do not meet).  So I guess one can have lip incompetence even with a short maxilla! (ie. my present situation).  Obviously goes to show the complexity of all this and how trying to solve all concerns may not be possible.

Understood, no problem. It is really interesting that you have lip incompetence after so much impaction and a very strong lower jaw/chin . I don't think I have seen that before. It is usually on people with long gummy maxillas and/ or recessed mandibles/ chins. Also in bimax protrusion cases. Could be some kind of soft tissue memory after a lifetime of lip incompetence.

[InvisalignOnly]

It is really interesting that you have lip incompetence after so much impaction and a very strong lower jaw/chin

I still have lip incompetence after double jaw surgery, more than what OP has. Several surgeons told me when I was still in the planning stages that I would still have it after the surgery. I am happy with it though - it is less than it was before surgery and I have both upper and lower teeth show, and I am a woman so I actually prefer this look - closing my lips (which could only be be achieved with a lot more impaction) would just make me look sad and old. If you ask me, closing the lips is overrated

[ImpactedMood]

Your smile change is not just one of upper tooth show (or lack thereof) but also one LOWER tooth show, especially if it's now harder for you to move your lower lip UP when closing your lips than it was before. 'Lip incompetence' is mentalis strain (muscle moving the lower lip). For example, when the lower jaw, including the chin is too far back or even too far forward, lifting the lower lip UP gets harder to do the more the mentalis muscle is kind of stretched out over a long diagonal path. From my perspective mechanical efficiency of ease of moving the lower lip UP is a shorter path to do so. Even if there is no direct surgery on the chin itself, I think that the more it goes outward with the ride of the jaw advancement, the muscle used to lift the lower lip up can lose some mechanical efficiency where it gets harder (takes more effort) to lift it directly 'up'.

That said, your chin looks to be somewhat 'on the stretch' as in a little too far forward and I think that could factor in to the lower tooth show. I think the lower tooth show is more visible issue than is  upper tooth show being 'invisible'.

Although anterior downgraft (CW-r) would stand to reverse CCW-r of the impaction and thereby give more upper tooth show and perhaps result in some auto rotation of the lower jaw in CW-r direction to move the chin point backwards, you might need the BSSO along with it (double jaw surgery) for stability and/or more mechanically efficient lower lip 'up' movement.

When your lower jaw was too far backwards for your aesthetic liking subsequent to the first surgery, did you have the same lower tooth show and difficulty moving your lower lip upwards as you now have? What I'm getting at here is that not only do you have to think about the lack of upper tooth show but also the presence of the lower tooth show. Like you need to think in terms of a surgery that would rectify both.

Hi kavan, thanks once again for all your feedback and insight. It is very much appreciated.

So for one, my lip incompetence issue was not developed by this second surgery, I'm sorry if it seemed like I alluded to that.  I would say my lip incompetence issue was worst prior to my first surgery, and while improved after that surgery, not eliminated by it.  I would say there's not been much of a noticeable change in lip incompetence prior to and after my second surgery - maybe even improved slightly (but still present).

Secondly, my lower tooth show is definitely something I've only really noticed after this second surgery, and not prior to it.  I'm definitely still a bit confused as to what caused it - I initially thought it was rather straight-forward and because I was over impacted, thus losing upper length in my jaw, when everything was stitched back (ie. inside top lip under nose and bottom lip above chin) naturally it was stitched back in different locations on my jaw (lower on top and bottom, thereby exposing less top teeth and more bottom teeth).  So I simply assumed that my exposure of more bottom teeth was the exact same problem and went hand-in-hand (or was a byproduct) of the over impaction mistake - ie. if he didn't impact at all, things would have been stitched back higher on both jaws, yielding more top tooth show and less bottom tooth show.  I'm not sure if this makes sense, but I'm learning here that perhaps the bottom tooth show problem is a different problem/cause all together..?

Anyhow, I will certainly be mindful of this lower tooth show problem when I start back seeing OS' for consultations (hopefully within the next couple months).

[ImpactedMood]

You're not incorrect. It's just there is more correctness to be had.

CCW-r is done with anterior impactions and posterior downgrafts. Plosko is referring to the latter. Not specifically for you but rather a sign that a surgeon is 'with the program' as to keeping up with advances in techniques when they can ALSO do CCW-r with posterior downgrafts and not just with anterior impactions.

CW-r is done with anterior downgrafts and posterior impactions.

I see.  So does that mean that someone with my concerns (limited top tooth show) can have either type of CCW-r performed to correct this?  I would have thought that only CW-r would correct a lack of top tooth show problem?

If there are any good websites that explain all of these movements in more detail and what each is best used to treat, I would be happy to educate myself!  I will continue searching in hopes of better understanding everything.

[ImpactedMood]

Understood, no problem. It is really interesting that you have lip incompetence after so much impaction and a very strong lower jaw/chin . I don't think I have seen that before. It is usually on people with long gummy maxillas and/ or recessed mandibles/ chins. Also in bimax protrusion cases. Could be some kind of soft tissue memory after a lifetime of lip incompetence.

Wow, despite the consensus in this thread seemingly thinking my lower jaw was advanced too much, it still feels sort of nice to hear someone refer to my lower jaw or chin as 'very strong' haha.  For most of my life of course, I was always subconscious with it lagging behind and being recessed, so much so I'd ALWAYS protrude it forward, even after my first jaw surgery.  This became habitual, but still mentally taxing.  So I will take the imperfections in the opposite direction for once! lol.  I do think, though, that my beard in the pictures really accentuates my bottom jaw and it's more in line with normal than it's being perceived in here.

I'll try to PM you a picture or two pre first surgery if it can be helpful for your situation.

Edit: there didn't seem to be an option to add attachments in the PM so I'll just post a couple shots here.  I would say probably not your worst case of long jaw/mouth-breather/recession type of profile.  Not much of a gummy smile (even though maybe slightly more than in this photo)

[kavan]

Hi kavan, thanks once again for all your feedback and insight. It is very much appreciated.

So for one, my lip incompetence issue was not developed by this second surgery, I'm sorry if it seemed like I alluded to that.  I would say my lip incompetence issue was worst prior to my first surgery, and while improved after that surgery, not eliminated by it.  I would say there's not been much of a noticeable change in lip incompetence prior to and after my second surgery - maybe even improved slightly (but still present).

Secondly, my lower tooth show is definitely something I've only really noticed after this second surgery, and not prior to it.  I'm definitely still a bit confused as to what caused it - I initially thought it was rather straight-forward and because I was over impacted, thus losing upper length in my jaw, when everything was stitched back (ie. inside top lip under nose and bottom lip above chin) naturally it was stitched back in different locations on my jaw (lower on top and bottom, thereby exposing less top teeth and more bottom teeth).  So I simply assumed that my exposure of more bottom teeth was the exact same problem and went hand-in-hand (or was a byproduct) of the over impaction mistake - ie. if he didn't impact at all, things would have been stitched back higher on both jaws, yielding more top tooth show and less bottom tooth show.  I'm not sure if this makes sense, but I'm learning here that perhaps the bottom tooth show problem is a different problem/cause all together..?

Anyhow, I will certainly be mindful of this lower tooth show problem when I start back seeing OS' for consultations (hopefully within the next couple months).

There are muscles on the chin that can move the lower lip up and out (mentalis) and those that can depress it. So, maybe the orientation change to the lower jaw had an unfavorable effect. Either a lower lip elevator getting weaker or lower lip depressor getting stronger. Muscles move with bone.