The reason that I ask is that I'm in a situation, having a very wide mandible (IMW at first molars of 50mm) and a not-so-wide lower maxilla, in the process of considering a 2-piece lefort I expansion / advancement. During my last maxillofacial consult, they said that they can do a 2-piece segmented lefort but said there is a limit to how wide they can expand laterally, limited by the width of my skull at the zygomaticotemporal / upper maxillary level, remarking that reaching 50mm for my upper IMW would probably not be possible. I kind of let that sink in at the consult and haven't thought about it much until very recently.
I could be wrong, but after thinking about this in depth, the maxillofacial doctor's remarks regarding skull width don't make any sense. My mandible is very wide top to bottom. Wide at the arch level, wide at the gonion level, wide at the ramus (rami) level (and my rami do not "tilt inward" toward the top). The mandible attaches to the skull at the temporal bone, which attaches to the zygomaticotemporal complex (i.e. the posterior part of the zygomatic arch), so it's impossible for that area of my skull to be narrow or even medium-width, even though my upper arch is relatively narrow, being at the lower maxillary level.
Am I right that the doctor's comments regarding not allowing my upper arch to be expanded enough to match the lower arch make no sense? Am I missing something, skeletally speaking, in my analysis?
I should add that my lower molars do not tip outward; they actually tip inward, meaning that skeletally, my mandible is even wider than a 50mm IMW would suggest.
Ok, after much searching on this topic, I came across this video, featuring Dr. Marianna Evans:
https://www.pathlms.com/pcso/events/1648/video_presentations/143837
At roughly the 1hr 5min mark, she talks about how she is asked, "what is the limit?", and her answer is simply the ramus/ramii. She's specifically talking about implant-assisted expansion (such as MSE).
This gives me hope, since the distance between one ramus and the other in my case is quite wide, and my palate is _relatively_ narrow (though it would be considered average on a person with an average mandible).
In fact, this may be the solution to my difficult case (as I posted at the end of this thread):
/community/community/main-forum/what-are-the-pros-and-cons-of-bimax-surgery/#post-37865
I am now considering consulting with her, even though she is more than 3 hours away from me.
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