jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: Benjaminh on November 28, 2017, 09:13:01 AM
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Hey guys Im tired of all the surgeons who keep saying CCW is unstable. Im. Looking for someone who will do it and has alot of experience. Willing to fly out as long as its in canada. Anyone know whats the top?
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See my reply to you in your other thread.
CCW is NOT a 'mantra' everyone can chant and insist the maxfax do. It only applies to people with STEEP occlusal planes.
You are confusing the 'MANTRA' of 'CCW' with the true OBJECTIVE of it. The objective of CCW is to REDUCE a HIGH OP angle. If your OP angle is already LOW and close to 'flat' or would be flat or too flat with it, you might be hard pressed to find a maxfax in US who's willing to make it even MORE LESS than the norm.
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Kavan is correct. Canadian maxfacs are not as good as EU maxfacs. If you must stay in Canada I would consult fialkov, antonysyn and caminetti in that order
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Lefortitude, I remember you mentioning Fialkov and Antonyshyn in the previous thread on Canadian surgeons and you have me very interested in them. Is there any reason why you feel they're better than Caminiti?
Also, why not Tocchio? At this point, any discussion without Tocchio being mentioned seems unusual (not because I particularly like him, but just because he is always suggested).
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consult them all and see what you think. i dont think any of them do alot of ccw.
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I had my first procedure done by Dr. Claudio Tocchio which went poorly. I had no complications of the surgery itself. It was just the surgical plan was completely inadequate for my degree of malocclusion and I am still in very bad shape. I had an open bite, cross bite, underbite, and facial asymmetry. He barely touched my asymmetry, they tried to manage my crossbite through orthodontics alone, leading to relapse. I now still have all the same issues, just reduced by at most 50%.
I have consulted with Dr. Marco Caminiti in the past year about doing a revision. Caminiti seemed to grasp the issues very well and was very happy to try to help me. He was surprised by how my case was handled in the first place. He offered me a SARPE and revision BSSO/LF1. In my case, he said as I need 1.1 cm upper jaw widening, even a multipiece LF1 will not suffice, so it must be SARPE. I will probably go with Caminiti for this as I had a good feeling for him. Also helpful is that he worked with Tocchio when he was training himself, so he recognizes and is familiar with all of Tocchio's hardware (which is now in my face).
I got his name by calling around jaw surgeons and asking who would be willing to do a revision. One female jaw surgeon I spoke to said "If anyone can handle it, it's Dr. Caminiti". He teaches at U of T also for what it's worth.
Good to see his name mentioned above.
I looked at the other two names - Dr. Jeff Fialkov is a plastic surgeon not a jaw surgeon. Dr. Oleh Antonyshyn looks interesting. He's known to be good? If so, I think I will go see him as well for another opinion. Can't hurt to get more opinions.
The only negative I had from my consult with Caminiti is he wanted to "pin" my right TMJ intraoperatively to make it more stable for the procedure. I am very much against this as my TMJs are in the best shape they've been in for my adult life and I really don't want to f**k with them. When I see him again in ~5 months for getting the surgical process started, I plan to explain this to him, and if he's adamant about the pinning I'll have to go to someone else. He seems very nice and flexible though.
I also didn't discuss with him virtual surgical planning so I'm not sure to what extent he does this.
As for the subject of "CCW", I'm not sure why anyone would think a surgeon "wouldn't do CCW" if it was appropriate for the case. We are not talking about v-line surgery or some other regionally specific surgery. LF1 is part of the standard training for all maxillofacial surgeons. I can't think of any reason they wouldn't be able to do a rotation in either direction if needed.
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Regarding CCW, you're wrong. In Australia you will not find a single surgeon who does CCW with posterior down grafting... Not a single one.
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camenetti is a good surgeon. if he says he wants to stabilize your tmj, maybe he knows something you dont.
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camenetti is a good surgeon. if he says he wants to stabilize your tmj, maybe he knows something you dont.
Yeah I know what his concern is. He wants to guarantee the most stable surgical outcome. And if your TMJ has the slightest bit of laxity or mobility, then pinning it into place and fixating it is the most guaranteed way of maintaining stability intraoperatively and postoperatively.
The problem is TMJ discs are meant to be mobile for natural use of the jaw and as I have said, I have the best TMJ function at the present that I have had in my entire adult life. I would rather not get the surgery and just live with my misalignments than risk returning to a life of bad TMJ problems.
So we'll see. I'm not ready to start the surgery again for another 5 months so I'll wait until then and then see what he has to say on re-consultation.
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I had my first procedure done by Dr. Claudio Tocchio which went poorly. I had no complications of the surgery itself. It was just the surgical plan was completely inadequate for my degree of malocclusion and I am still in very bad shape. I had an open bite, cross bite, underbite, and facial asymmetry. He barely touched my asymmetry, they tried to manage my crossbite through orthodontics alone, leading to relapse. I now still have all the same issues, just reduced by at most 50%.
I have consulted with Dr. Marco Caminiti in the past year about doing a revision. Caminiti seemed to grasp the issues very well and was very happy to try to help me. He was surprised by how my case was handled in the first place. He offered me a SARPE and revision BSSO/LF1. In my case, he said as I need 1.1 cm upper jaw widening, even a multipiece LF1 will not suffice, so it must be SARPE. I will probably go with Caminiti for this as I had a good feeling for him. Also helpful is that he worked with Tocchio when he was training himself, so he recognizes and is familiar with all of Tocchio's hardware (which is now in my face).
I got his name by calling around jaw surgeons and asking who would be willing to do a revision. One female jaw surgeon I spoke to said "If anyone can handle it, it's Dr. Caminiti". He teaches at U of T also for what it's worth.
Good to see his name mentioned above.
I looked at the other two names - Dr. Jeff Fialkov is a plastic surgeon not a jaw surgeon. Dr. Oleh Antonyshyn looks interesting. He's known to be good? If so, I think I will go see him as well for another opinion. Can't hurt to get more opinions.
The only negative I had from my consult with Caminiti is he wanted to "pin" my right TMJ intraoperatively to make it more stable for the procedure. I am very much against this as my TMJs are in the best shape they've been in for my adult life and I really don't want to f**k with them. When I see him again in ~5 months for getting the surgical process started, I plan to explain this to him, and if he's adamant about the pinning I'll have to go to someone else. He seems very nice and flexible though.
I also didn't discuss with him virtual surgical planning so I'm not sure to what extent he does this.
As for the subject of "CCW", I'm not sure why anyone would think a surgeon "wouldn't do CCW" if it was appropriate for the case. We are not talking about v-line surgery or some other regionally specific surgery. LF1 is part of the standard training for all maxillofacial surgeons. I can't think of any reason they wouldn't be able to do a rotation in either direction if needed.
you do realize SARPE will involve a surgical procedure, orthodontics and then having a f**king expander in your upper arch for close to a year, then they'll have to close the spaces (your front teeth will grow far apart) and that will take another 6 months. So that's even before you're reading for the revision bimax. How old are you? How long did Camenetti say it would take?
I have consulted with Caminetti as well but wasn't too happy with his brushing off isssues of aesthetics. Also he didn't do CCW which is really the way to go. Have you consulted with Stephen Ho? He seemed to do CCW aand have some more advanced techniques.
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you do realize SARPE will involve a surgical procedure, orthodontics and then having a f**king expander in your upper arch for close to a year, then they'll have to close the spaces (your front teeth will grow far apart) and that will take another 6 months. So that's even before you're reading for the revision bimax. How old are you? How long did Camenetti say it would take?
I have consulted with Caminetti as well but wasn't too happy with his brushing off isssues of aesthetics. Also he didn't do CCW which is really the way to go. Have you consulted with Stephen Ho? He seemed to do CCW aand have some more advanced techniques.
Oh I'm well aware of the commitment. Plan was for roughly 9-10 months for the sarpe phase followed by the final surgery. I'm 35 now. This face and bite and jaws have haunted me my whole life. Time to see what I can do for it. Goal was around 1 mm expansion per day so 110-120 days of that followed by around 6 months to close the gap.
As for aesthetics, everything Caminiti suggested was what I felt was appropriate for my aesthetics. Correct the asymmetry, expand the upper jaw, bring the upper jaw forward another 2-3 mm. There's nothing else for my case to be done.
Never heard of Stephen ho. I'll give him a try for a consult if you think he's good. What makes you suggest him? His bio suggests he is primarily interested in sleep apnea.
http://www.creditvalleyoralsurgery.com/meet-us/meet-the-doctors/dr-stephen-k-c-ho/
I'm not sure what the fixation on CCW is. Do you guys have abnormal bite planes as confirmed by cephalometrics? According to cephx.com analysis my plane is normal so I don't see a reason to mess with that or fixate on it.
My goal is just the normalization of as many of my features as possible. Normal = attractive, at least when compared with dysmorphic. Statistically averaged faces are the most attractive overall, and that's what cephalometrics are based on - averages.
Are you guys having problems because you are trying to "correct" things that are already within the normal range?
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Oh I'm well aware of the commitment. Plan was for roughly 9-10 months for the sarpe phase followed by the final surgery. I'm 35 now. This face and bite and jaws have haunted me my whole life. Time to see what I can do for it. Goal was around 1 mm expansion per day so 110-120 days of that followed by around 6 months to close the gap.
As for aesthetics, everything Caminiti suggested was what I felt was appropriate for my aesthetics. Correct the asymmetry, expand the upper jaw, bring the upper jaw forward another 2-3 mm. There's nothing else for my case to be done.
Never heard of Stephen ho. I'll give him a try for a consult if you think he's good. What makes you suggest him? His bio suggests he is primarily interested in sleep apnea.
http://www.creditvalleyoralsurgery.com/meet-us/meet-the-doctors/dr-stephen-k-c-ho/
I'm not sure what the fixation on CCW is. Do you guys have abnormal bite planes as confirmed by cephalometrics? According to cephx.com analysis my plane is normal so I don't see a reason to mess with that or fixate on it.
My goal is just the normalization of as many of my features as possible. Normal = attractive, at least when compared with dysmorphic. Statistically averaged faces are the most attractive overall, and that's what cephalometrics are based on - averages.
Are you guys having problems because you are trying to "correct" things that are already within the normal range?
Okay so I have to update on this. I looked through my analysis from cephx.com in more detail and looks like I could benefit from a bit of ccw. f**k. Also will need downgrafting if so since my front maxilla was already impacted a bit in the prior surgery and I can't afford any more unless I want to stop showing my upper teeth.
According to Clark analysis my occlusional plane is 10.48 and it should be 8 +/-2. Not far off, but I do think ccw does a good job of masculinizing the face which I could benefit from. It would also help lengthen my ramus which is 5 mm too short.
Probably this would only need 2-3 mm of posterior downgrafting. Guessing I won't be able to convince Caminiti to do this from what people are saying here. I'll be doing all my consults in 4 months so I'll let you know what he says. If he agrees to do it id prefer to go with him, but we'll see.
I'll meet dr. Ho too. I don't know if ho could handle the complex revision and sarpe as well though. Otherwise I'm stuck with Americans like gunson and wolford which will cost me 5-10x more.
Tough.
For reference I need:
- Sarpe 1.2 cm expansion
- 2-3 degrees ccw
- teeth realigned and then maxilla advanced another 3 mm.
- a few degrees of cant correction and midline shift
Ideally without any overall impaction or distraction if the maxilla at the front incisor.
Tough job I think especially given that its a revision.
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Don't trust any of those cephx analyses for your occlusal plane angle.
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Don't trust any of those cephx analyses for your occlusal plane angle.
Is there a common problem with them I should be aware of?
I can tweak the landmarks myself for a different result as needed. I notice the alignment through the molars might not be exact. I am only on my phone so I will go do that in a few days when I'm home.
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Go to a max fac to confirm your occlusal plane and any other number for that matter. Clarks was off 3 degrees compared to what my max facs consult surgeon measured.
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Go to a max fac to confirm your occlusal plane and any other number for that matter. Clarks was off 3 degrees compared to what my max facs consult surgeon measured.
Clark's is used for an ortho device that clark designed. So, ya, it might not be consistent with other methods.
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Clark's is used for an ortho device that clark designed. So, ya, it might not be consistent with other methods.
Useful to know. There's so many analyses it's hard to know what's what.
Downs analysis provided an occlusal plane angle of 10.48. Normal is 9.3 +/- 3.8.
Those are the only two places the cephx stats provide an occlusal plane angle, and in general while it also suggests I am somewhat clockwise oriented it's not dramatic. Maybe it's not worth going to a different surgeon over regardless of what Caminiti says he's willing to do.
But if there's anything I've learned about jaw surgery it's that every mm counts. I hate being a perfectionist. But it was by neglecting the details the first time that I'm in this position now...
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Just make sure you see Dr. Stephen Ho, he uses some newer techniques and ask him about SARPE to confirm that will do the trick and the timeline for it. Good luck.
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Useful to know. There's so many analyses it's hard to know what's what.
Downs analysis provided an occlusal plane angle of 10.48. Normal is 9.3 +/- 3.8.
Those are the only two places the cephx stats provide an occlusal plane angle, and in general while it also suggests I am somewhat clockwise oriented it's not dramatic. Maybe it's not worth going to a different surgeon over regardless of what Caminiti says he's willing to do.
But if there's anything I've learned about jaw surgery it's that every mm counts. I hate being a perfectionist. But it was by neglecting the details the first time that I'm in this position now...
CephX just gives a LITANY of of different analysis methods. It's not as if you can look at one type of method for one measure and than the other type for another measure. Angles are relative to lines and planes and some of them use different reference lines for the angle measure. For example if the reference 'horizontal' line is S-N in one method but the Frankfurt horizontal is used in the other method, the angle cited will differ and that angle might have same name in both methods.
IMO, the BEST thing to KNOW and really know well is GEOMETRY. Afterall, all ceph analysis is based on defined POINTS and lines, planes and angles with REFERENCE to those points and actually IS a type of geometrical balance. Speaking of points, I think it is pointless to just be looking at a bunch of numbers and angle measurements outside of having underbelt the basic framework understanding of geometrical concepts.
Some points on a ceph are easier to find than others. S, N, A, B, ANS, PNS and also the 'line' of OP (points connected from one place to frontal incisor to other place in back molar) are such examples. From there, you can look at the angles they make with defined horizonts or verticals. Someone, should AT LEAST be able to do that (elementary geometry) for a more holistic understanding (how the parts relate to the whole). Otherwise, just spouting off exact mm measures a program spouts out to you isn't enough. I suggest this type of exercise applying geometry to one's own ceph even if it isn't enough to plan out your surgery. In this way, you get a better appreciation of the many or few things needing to be balanced or even if it's possible to balance all if there are many imbalances.
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Just make sure you see Dr. Stephen Ho, he uses some newer techniques and ask him about SARPE to confirm that will do the trick and the timeline for it. Good luck.
Thanks. I definitely plan to. The only worry as I said about him is if he's mostly doing sleep apnea surgery, I doubt he does much SARPE, and certainly doubt he does much revision work, while Caminiti was quite comfortable with SARPE and revision work.
I mean, I'm sure Dr. Ho is TRAINED in SARPE, but training is not the same as regular daily experience. I'll let you guys know when I see him what my impression was.
CephX just gives a LITANY of of different analysis methods. It's not as if you can look at one type of method for one measure and than the other type for another measure. Angles are relative to lines and planes and some of them use different reference lines for the angle measure. For example if the reference 'horizontal' line is S-N in one method but the Frankfurt horizontal is used in the other method, the angle cited will differ and that angle might have same name in both methods.
IMO, the BEST thing to KNOW and really know well is GEOMETRY. Afterall, all ceph analysis is based on defined POINTS and lines, planes and angles with REFERENCE to those points and actually IS a type of geometrical balance. Speaking of points, I think it is pointless to just be looking at a bunch of numbers and angle measurements outside of having underbelt the basic framework understanding of geometrical concepts.
Some points on a ceph are easier to find than others. S, N, A, B, ANS, PNS and also the 'line' of OP (points connected from one place to frontal incisor to other place in back molar) are such examples. From there, you can look at the angles they make with defined horizonts or verticals. Someone, should AT LEAST be able to do that (elementary geometry) for a more holistic understanding (how the parts relate to the whole). Otherwise, just spouting off exact mm measures a program spouts out to you isn't enough. I suggest this type of exercise applying geometry to one's own ceph even if it isn't enough to plan out your surgery. In this way, you get a better appreciation of the many or few things needing to be balanced or even if it's possible to balance all if there are many imbalances.
Thanks. That's useful as well. I am already recognizing the degree of compromise needed based on the fact that we are juggling so many variables with these surgeries. For many of us it is likely not possible to get every parameter within the normal range.
For example, my Wits analysis still puts me at a -4 mm alignment (class 3) despite my teeth tips overlying each other (upper incisors tilted forward, lower tilted back, thanks ortho). During my SARPE I will be asking my ortho to try to return both to as neutral and natural a tilt as possible and then I will be having my upper jaw advanced by whatever amount needed to create a good bite.
But I notice already my SNA and SNB are slightly above the exact average. And no one would call me one of the "antefaced" types that some people jerk off over. My midface still looks retruded, but this can be all relative, as depending on the angle of the SN component, the angle will change, and we can't change the SN with surgery.
In my photoshops I definitely look better with further maxillary advancement than with mandibular retrusion, even though maxillary advancement pushes my SNA even higher. Retruding the lower jaw just makes me look like I have a weak lower jaw, which I don't want.
Currently my SNA is 83.67 (normal 82.0 +/- 2.0) and my SNB is 81.59 (79.0 +/- 2.0).
Regarding CCW and the occlusal plane, I'm pretty sure my prior surgeon did a bit of CW impaction during the prior surgery to try to close my bite a bit. I will try to take my own measurements of the occlusal plane to cross reference, and I will certainly ask the surgeons I see for reconsultation on this in advance of any decisions.
I will also make a separate thread with my cephs and cephx.com analysis another time to get feedback and opinions. No f**king around this time! There's no room for unnecessary error or poor planning again at this stage. Thanks for the feedback everyone so far. It's a fascinating subject and so important to really understand thoroughly.
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Thanks. I definitely plan to. The only worry as I said about him is if he's mostly doing sleep apnea surgery, I doubt he does much SARPE, and certainly doubt he does much revision work, while Caminiti was quite comfortable with SARPE and revision work.
I mean, I'm sure Dr. Ho is TRAINED in SARPE, but training is not the same as regular daily experience. I'll let you guys know when I see him what my impression was.
Thanks. That's useful as well. I am already recognizing the degree of compromise needed based on the fact that we are juggling so many variables with these surgeries. For many of us it is likely not possible to get every parameter within the normal range.
For example, my Wits analysis still puts me at a -4 mm alignment (class 3) despite my teeth tips overlying each other (upper incisors tilted forward, lower tilted back, thanks ortho). During my SARPE I will be asking my ortho to try to return both to as neutral and natural a tilt as possible and then I will be having my upper jaw advanced by whatever amount needed to create a good bite.
But I notice already my SNA and SNB are slightly above the exact average. And no one would call me one of the "antefaced" types that some people jerk off over. My midface still looks retruded, but this can be all relative, as depending on the angle of the SN component, the angle will change, and we can't change the SN with surgery.
In my photoshops I definitely look better with further maxillary advancement than with mandibular retrusion, even though maxillary advancement pushes my SNA even higher. Retruding the lower jaw just makes me look like I have a weak lower jaw, which I don't want.
Currently my SNA is 83.67 (normal 82.0 +/- 2.0) and my SNB is 81.59 (79.0 +/- 2.0).
Regarding CCW and the occlusal plane, I'm pretty sure my prior surgeon did a bit of CW impaction during the prior surgery to try to close my bite a bit. I will try to take my own measurements of the occlusal plane to cross reference, and I will certainly ask the surgeons I see for reconsultation on this in advance of any decisions.
I will also make a separate thread with my cephs and cephx.com analysis another time to get feedback and opinions. No f**king around this time! There's no room for unnecessary error or poor planning again at this stage. Thanks for the feedback everyone so far. It's a fascinating subject and so important to really understand thoroughly.
You need to be able to measure YOUR OWN angles via marking out the points yourself and using a protractor. Yes, it might be off by a few degrees but still being able to apply simple geometry is needed. IMO, no good can be gained by looking at a bunch of measures in a bunch of different ceph analysis read outs. Geometry is needed so it can be SELF EVIDENT to someone that ALL might not be able to be balanced and alsos self evident why certain 'trade-offs' (deviations from desired outcome or 'perfection') are so.
I have seen cases where the S-N line was 15 degrees from a horizont. Yet the 'norm' for this line is 7 degrees away. S-N is used for a 'horizont' in some analysis. But it will be OFF when you got a deviation of 15 degrees from a 'pure' horizont. That's an example of using geometry to question even measures you get in a ceph analysis. Especially so SNA, SNB and ANB measures.
ETA: even the Franfort 'horizontal' is NOT a horizont in SOME people.