How to properly plan jaw surgery (DJS, trimax, orthogonatic)

[Usurper]

So I have started orthodontics about 6 months ago. Initially I had no surgery in mind, didn't know much in general and ortho said I shouldn't. I have Class I and dentally biggest issue is lower jaw crowding and a bunch on compensation in the maxila.

But about 2 months after starting ortho, I consulted with a surgeon initially with the idea of considering a genioplasty only, but after discussing a bit, seeing my CTs, etc. I realized that I was very recessed. For reference my SNA is 75 degrees. So we talked about doing a trimax, which I was clearly a candidate for, although surgeon said that I should consider if it was worth it to me since this would be a purely cosmetic case. After I agreed he talked with ortho to ensure that the new plan moved to a pre-op de-compensation ortho.

Fast forward to now and I am continuing with ortho but have no idea about any specifics of the plan.

So I messaged the surgeon to see if it would make sense to discuss now, with special consideration to if ortho is moving in a direction which would limit possible options in the future. I hope not, otherwise I would very very much not happy with him not taking initiative.

But anyway. I know proper execution of a trimax involves:
- Adequate forward movement, no under-advance, no over-advance.
- Adequate ccw rotation.
- Factors like perioral area (chimp lips), upper third convexity, E line, ghonial angle can limit max forward movement and influence ccw rotation. Biggest risk of these is perioral.
- Technique influences areas of risk: custom has relapse issues due to improper condyle positioning and increased perioral risk. Non-custom has precission issue.
- Possible future enhacements with rhinoplasty and midface implants may influence some movement decisions.
- Can L cut in BSSO be performed to gain a little flare or not?

So my question is, what is the proper due-diligence on my end to reduce these risks as much as possible? Should I get multiple opinions?

 

[Gittes]

Yes, definitely get a few extra opinions to make sure you're making the right decision or, at the very least, help clarify/inform your decision-making with alternative surgical plans.

All of the points you've raised about what constitutes a good bimax should be raised with prospective surgeons. Literally ask them to walk you through each point. That's your best way to mitigate risk. Comparing plans and bouncing points off of different surgeons is the best course of action.

 

[Usurper]

Scan with some of my basic understanding on top. I will need rhino afterwards that's pretty obvious. And I don't think my manual draft of soft tissue is realistic, I think it will be more but.

 

[czechpsl]

Can L cut in BSSO be performed to gain a little flare or not?

Is your jaw narrow? Don’t forget that condylar torque adds width to the entire ramus, so it can make you look bloated.

 

[Usurper]

Is your jaw narrow? Don’t forget that condylar torque adds width to the entire ramus, so it can make you look bloated.

Not really, no, and I have pretty ideal bizygomatic width to bighonial. Maybe not a good idea then. I would prefer having taller ramus and a bit of flare, but without any of this personally I am happy.

I put those lines into a photo of me and simulated the movements. And as long surgeon can get the lip and ANS right, which means little movements there to prevent chimp lip. I would be very happy.

 

[czechpsl]

Not really, no, and I have pretty ideal bizygomatic width to bighonial. Maybe not a good idea then. I would prefer having taller ramus and a bit of flare, but without any of this personally I am happy.

I put those lines into a photo of me and simulated the movements. And as long surgeon can get the lip and ANS right, which means little movements there to prevent chimp lip. I would be very happy.

If you want a taller ramus, consider a post-gonial cut BSSO

 

[Prøphet]

Brutal how we need to achieve a doctoral understandin of the maxillofacial complex just to try and avoid getting botched

 

[gravlek]

Brutal how we need to achieve a doctoral understandin of the maxillofacial complex just to try and avoid getting botched

I remember reading a thread which mentioned Ramieri saying ‘many men are harder to please then women, they’re very picky and perfectionistic’, this perfectly captures the bluepilled women and blackpilled men complex

 

[gravlek]

If you want a taller ramus, consider a post-gonial cut BSSO

Do any of the reputable surgeons offer this to non-syndromic patients? Feel like they will deem it too unnecessary risk (higher instability) and would rather throw in implants

 

[Animepilled]

I remember reading a thread which mentioned Ramieri saying ‘many men are harder to please then women, they’re very picky and perfectionistic’, this perfectly captures the bluepilled women and blackpilled men complex

Women are blackpilled as hell. They just dont go that deep into things. Their brain doesnt work that way

 

[gravlek]

Women are blackpilled as hell. They just dont go that deep into things. Their brain doesnt work that way

You know what I mean tho bro, I’m talking about their approach to surgery. They think simply getting a procedure will ascend them, whereas men recognise the need to actually dissect the whole thing and make sure the outcome/result is optimised through an optimal surgical plan

 

[Prøphet]

I remember reading a thread which mentioned Ramieri saying ‘many men are harder to please then women, they’re very picky and perfectionistic’, this perfectly captures the bluepilled women and blackpilled men complex

“My philosophy is that”

 

[Animepilled]

You know what I mean tho bro, I’m talking about their approach to surgery. They think simply getting a procedure will ascend them, whereas men recognise the need to actually dissect the whole thing and make sure the outcome/result is optimised through an optimal surgical plan

Yeah it doesnt make them bluepilled tho.

 

[gravlek]

Yeah it doesnt make them bluepilled tho.

Bluepilled in surgery to be blackpilled on tinder

 

[Prøphet]

You know what I mean tho bro, I’m talking about their approach to surgery. They think simply getting a procedure will ascend them, whereas men recognise the need to actually dissect the whole thing and make sure the outcome/result is optimised through an optimal surgical plan

Bitches be getting a rhino just to still have the facial convexity of a waning crescent

 

[gravlek]

Bitches be getting a rhino just to still have the facial convexity of a waning crescent

This is what I see too often, girls who need a djs for their huge overbite but think a rhino will save them jfl. And even after the surgery still not able to tell what’s wrong with their side profile

 

[Prøphet]

This is what I see too often, girls who need a djs for their huge overbite but think a rhino will save them jfl. And even after the surgery still not able to tell what’s wrong with their side profile

“I need a rhino revision it’s off by 2.4 nanometers that’s why I still look like a Simpsons character”

 

[gravlek]

“I need a rhino revision it’s off by 2.4 nanometers that’s why I still look like a Simpsons character”

rhino is the most abused surgery in the book, I honestly think most normies would be better off getting a genioplasty. The rhino surgeons created millions of piggy nose revision normies

‘My dorsal hump is finally gone’

 

[Usurper]

Bitches be getting a rhino just to still have the facial convexity of a waning crescent

Very real bro, I remember being at the consultation waiting room for rhino, and I kid you not 2 out of 3 foids I saw needed DJS or at least genio.

 

[Usurper]

So based on my measurements I'll probably be looking at 6 to 7mm for incisor position, little or no vertical component, ANS and A advanced around 2mm, 7 degree or so counterclockwise. The CT drawing I did the incisor position in red isn't correct and is too forward, and will result in a lot more soft tissue changes. It seems that ortho is decompensating and removing reducing a bit incisor rotation which is good for maxillary rotation. But will confirm.

Another question I have is wether any possible ANS refinement (I saw some surgeon saying he did it sometimes) should be left to rhino surgeon or should be consider and wether I am a candidate or not. I know these parts are hard to predict so maybe it's better to just leave it to a subsequent op.

 

[czechpsl]

Do any of the reputable surgeons offer this to non-syndromic patients? Feel like they will deem it too unnecessary risk (higher instability) and would rather throw in implants

I know Ramieri does that, as well as Raffaini and Alfaro. But I haven't done much research on that, so probably way more surgeons offer it

 

[Usurper]

I know Ramieri does that, as well as Raffaini and Alfaro. But I haven't done much research on that, so probably way more surgeons offer it

Aside from stability, is there issues with masseter dehiscence? And that is the biggest problem with ghonial angle implants.

 

[czechpsl]

I remember reading a thread which mentioned Ramieri saying ‘many men are harder to please then women, they’re very picky and perfectionistic’, this perfectly captures the bluepilled women and blackpilled men complex

I ain't leaving the operating room without an ideal gonial angle and forward growth. TF is Ramieri thinking?

 

[Gittes]

So based on my measurements I'll probably be looking at 6 to 7mm for incisor position, little or no vertical component, ANS and A advanced around 2mm, 7 degree or so counterclockwise. The CT drawing I did the incisor position in red isn't correct and is too forward, and will result in a lot more soft tissue changes.

What benchmark are you using to ensure optimal bite correction/jaw movements (SNA angle, A to Nasion etc...)?

It seems that ortho is decompensating and removing reducing a bit incisor rotation which is good for maxillary rotation. But will confirm.

I'm pretty sure the whole purpose of decompensation is to give the surgeon as much latitude as possible for jaw movements, including rotation as well as any linear advancements.

Another question I have is wether any possible ANS refinement (I saw some surgeon saying he did it sometimes) should be left to rhino surgeon or should be consider and wether I am a candidate or not. I know these parts are hard to predict so maybe it's better to just leave it to a subsequent op.

Due to the unpredictability of soft tissue changes, I'd wait until after the surgery personally.

 

[czechpsl]

Aside from stability, is there issues with masseter dehiscence? And that is the biggest problem with ghonial angle implants.

There might be a problem—that's the thing I want to ask the surgeons about soon, but I'm sure it'll be way less than with implants, maybe not at all. Below is an example of the result, doesn't seem like dehiscence at first glance

 

[Gittes]

I remember reading a thread which mentioned Ramieri saying ‘many men are harder to please then women, they’re very picky and perfectionistic’, this perfectly captures the bluepilled women and blackpilled men complex

No, I just think Ramieri's male patients, especially foreign ones, are self-selecting since they're far more likely to have heard of him from looksmaxxing forums. Your average bimax patient - male or female - will defer almost completely to the surgeon.

 

[Usurper]

There might be a problem—that's the thing I want to ask the surgeons about soon, but I'm sure it'll be way less than with implants, maybe not at all. Below is an example of the result, doesn't seem like dehiscence at first glance

Ok, I'll do some research on this as well.

 

[czechpsl]

Your average bimax patient will defer almost completely to the surgeon.

Yeah, and then they wonder why they look worse than before (got chimp lip, inferior border notching, and a terrible ramus-to-mandible ratio).

 

[Gittes]

Yeah, and then they wonder why they look worse than before (got chin lip, inferior border notching, and a terrible ramus-to-mandible ratio).

No, many won't notice and will just be pleased with some degree of improvement while overlooking any shortcomings.

Funny that you mention Alfaro before because thanks to his infamous "Barcelona line", he's been guilty of a lot of over-advancement as well,

 

[czechpsl]

Ok, I'll do some research on this as well.

How much do you think is safe for the maxilla so you don't get chimp lip? I asked Ramieri and he said like 5mm is max (probably meant 5mm linear advancement, no rotation). but that’s upper limit so I would guess 3mm would be ideal?

 

[czechpsl]

No, many won't notice and will just be pleased with some degree of improvement while overlooking any shortcomings.

Funny that you mention Alfaro before because thanks to his infamous "Barcelona line", he's been guilty of a lot of over-advancement as well,

Yeah, his infamous Barcelona line. I wonder if patients can tell him that they want less maxilla movement. Would be funny if he said, 'No, you gotta get that chimp lip, otherwise I won't operate on you

 

[czechpsl]

No, many won't notice and will just be pleased with some degree of improvement while overlooking any shortcomings.

Funny that you mention Alfaro before because thanks to his infamous "Barcelona line", he's been guilty of a lot of over-advancement as well,

Btw, what do you think about the height of the LeFort cut? Everyone swears by high cut, high cut, but to me, it seems like a massive gimmick at best

 

[Usurper]

How much do you think is safe for the maxilla so you don't get chimp lip? I asked Ramieri and he said like 5mm is max (probably meant 5mm linear advancement, no rotation). but that’s upper limit so I would guess 3mm would be ideal?

You need to look at linear advancement at ANS and A. And more than 3mm I would start to be cautious. So what Ramieri said makes sense.

The specific form on the maxilla and the soft tissue impacts the result. For example if there is some pre-existing gap between the A point and the soft tissue, then you can move the amount of that gap with zero predicted movement of soft tissue. For me I estimate this to be around 1 or 1.5mm. Rotation of the ANS in itself also changes how lip drapes. More rotation will push tissue in a way that results in better convexity and thus less chimp lip (while also risking lifting the lip too much btw, but that's another topic).

I've seen Dr. Steven Sullivan that all of this was hard to predict in planning and I take his word on it. He specifically said to do OR final adjustments just because of these predictability problems, so something to keep in mind.

 

[Usurper]

Btw, what do you think about the height of the LeFort cut? Everyone swears by high cut, high cut, but to me, it seems like a massive gimmick at best

I am interested in this as well, I have no opinion on it.

 

[Gittes]

Btw, what do you think about the height of the LeFort cut? Everyone swears by high cut, high cut, but to me, it seems like a massive gimmick at best

Honestly, I don't think it makes too much of a difference. It's probably still better to go for a slightly higher cut to try and address any paranasal deficiency since most people with a retruded upper jaw also have recession extending across the entire maxilla as well.

So my answer would probably be to opt for something like type B and augment the upper maxilla with implants.

Another issue with higher cuts is that it's not always aesthetically desirable to bring everything forward, especially in male cases. Several surgeons I've spoken to told me that you really want infraorbital, anterior malar projection + jaws.

 

[Usurper]

What benchmark are you using to ensure optimal bite correction/jaw movements (SNA angle, A to Nasion etc...)?

As for how. I followed basic planning from this surgeon and some common sense. I dont have bite correction to do I don't think. It's all about incisor position.

 

[gravlek]

I ain't leaving the operating room without an ideal gonial angle and forward growth. TF is Ramieri thinking?

What’s you current gonial angle?

 

[Usurper]

Honestly, I don't think it makes too much of a difference. It's probably still better to go for a slightly higher cut to try and address any paranasal deficiency since most people with a retruded upper jaw also have recession extending across the entire maxilla as well.

So my answer would probably be to opt for something like type B and augment the upper maxilla with implants.

Another issue with higher cuts is that it's not always aesthetically desirable to bring everything forward, especially in male cases. Several surgeons I've spoken to told me that you really want infraorbital, anterior malar projection + jaws.


View attachment 5531363

Just initial impressions on this. Higher cut will result in higher forward movements in A and ANS with ccw rotation. And thus chimp lip. There will be a huge difference in fact, from A to B. That's several mms in height on the cut. Which can easily result in that same ccw rotation, double the forward movement on A point. So definetly very important.

Another topic to research then. And whether to use implants or higher cut.

 

[czechpsl]

I've seen Dr. Steven Sullivan

Yeah, I've seen it too, but to me, he was way too against custom plates. I get it, in the US they're extremely overpriced, but in Europe they aren't. Most people can get away without custom plates and benefit from lower OR charges, but for some, custom plates are a godsend—especially in cases of moderate to severe asymmetry in either the maxilla or mandible. I know that with custom plates you can't predict gum show and a few other things, but at least you can control symmetry and condylar torque if necessary. And I know you risk condylar sag, but I don't think that's a big deal

 

[czechpsl]

What’s you current gonial angle?

That was a joke. But 129—I had 127 when I was 13. No clue what happened. What's yours?

 

[Usurper]

Yeah, I've seen it too, but to me, he was way too against custom plates. I get it, in the US they're extremely overpriced, but in Europe they aren't. Most people can get away without custom plates and benefit from lower OR charges, but for some, custom plates are a godsend—especially in cases of moderate to severe asymmetry in either the maxilla or mandible. I know that with custom plates you can't predict gum show and a few other things, but at least you can control symmetry and condylar torque if necessary. And I know you risk condylar sag, but I don't think that's a big deal

He has a point though. Custom or non-custom have different advantages/disadvantages. If he is good controlling the precision problem with non-custom, then it's fine.

 

[Gittes]

Just initial impressions on this. Higher cut will result in higher forward movements in A and ANS with ccw rotation. And thus chimp lip. There will be a huge difference in fact, from A to B. That's several mms in height on the cut. Which can easily result in that same ccw rotation, double the forward movement on A point. So definetly very important.

Obviously, you wouldn't do the same amount of CCW rotation for a higher cut though. Besides, one of the downsides of these higher cuts is more limited rotation since you approaching the infraorbital foramen - basically these little circular notches which are passageways for clumps of nerves and blood vessels.

My point was that the aesthetic difference of higher cuts is limited. You can look at results online. Very underwhelming.
Generally a slightly higher cut + implants is superior since you can actually augment the bone, not just bring the existing flawed structure forward.

In cases where just linear advancements are needed, if you're advancing more of the maxilla beyond upper jaw, you actually reduce the risk of chimp lip.

 

[czechpsl]

He has a point though. Custom or non-custom have different advantages/disadvantages. If he is good controlling the precision problem with non-custom, then it's fine.

Yeah, there are like two groups: one is Alfi “COS” coper , and the other is old school like Sullivan. I think the truth is somewhere in the middle, maybe a bit more towards the old school. But I don't know if I buy his claim that he does a bimax in under one hour—like, that's so fucking fast, I can't even imagine. That's the same time as moderately impacted wisdom teeth

 

[Gittes]

Yeah, there are like two groups: one is Alfi “COS” coper , and the other is old school like Sullivan. I think the truth is somewhere in the middle, maybe a bit more towards the old school. But I don't know if I buy his claim that he does a bimax in under one hour—like, that's so fucking fast, I can't even imagine. That's the same time as moderately impacted wisdom teeth

For my surgery, I had custom plates for the upper jaw since the movements were more complex - correction of cant, downgrafting. The surgeon said it would provide greater precision and control, although he said non custom would be fine.

 

[czechpsl]

For my surgery, I had custom plates for the upper jaw since the movements were more complex - correction of cant, downgrafting. The surgeon said it would provide greater precision and control, although he said non custom would be fine.

How much advancement? What's the gum show? Would you change anything, or was it ideal and you're happy with the result?

 

[Gittes]

How much advancement?

High Cut LF1 (hybrid between A and B).
About 5mm A point, 3mm downgraft, CCW 2 degrees. Not big movements. Also had BSSO so fix asymmetry but no setback.

What's the gum show?

I had a vertically deficient maxilla, so poor upper tooth show. Needed downgrafting to make my upper teeth visible + correction of cant.

Would you change anything, or was it ideal and you're happy with the result?

No, I'm pretty satisfied with the result; I really wanted to eradicate my SFS and the surgery has accomplished that. Outside of my smile, it was a subtle change but that's what I expected.

In retrospect, I probably would have gone for slightly more downgrafting to bring out a little more tooth show.

 

[czechpsl]

About 5mm A point

Don't you have a bit of a chimp lip?

 

[Gittes]

Don't you have a bit of a chimp lip?

No, not in my case. My upper jaw was pretty retruded relative to cranial base so it worked out well. I was very clear when consulting with surgeons that overadvancment was a major concern for me so it was factored into planning.

 

[gravlek]

That was a joke. But 129—I had 127 when I was 13. No clue what happened. What's yours?

About 125/126 rn. So I would definitely benefit from a gonial angle lowering bsso.

I was originally planning on getting Ramieris ramus widening cut, but knowing that he offers ramus lengthening cut is interesting too.
I wonder if he can lengthen and widen the ramus at the same time? I know he doesn’t do what he isn’t comfortable doing.

 

[czechpsl]

No, not in my case. My upper jaw was pretty retruded relative to cranial base so it worked out well. I was very clear when consulting with surgeons that overadvancment was a major concern for me so it was factored into planning.

Do you know what your SNA was before surgery?