jawsurgeryforums.com
General Category => Aesthetics => Topic started by: Dogmatix on January 02, 2018, 03:40:06 PM
-
I'm trying to wrap my head around whats actually going on with my face and try to pin-point exactly what I'm not happy about.
It's hard for me to be very precise on my description of what I'm not happy with, it just feels off when I look at it. I'll try to explain what I see atleast.
I feel that I have "feminine" features, small/narrow jaws, bad jaw line and lack of contours in the face.
I've made a cepth scan in profile (attached), where these things kind of can be seen. I've marked out some of the things with the lower jaw. On the upper face I can feel similair things with the cheek bones not being very visible. Even though I'm not overweight at all, it's like the face is round and small however I look at it, and not the sharp well defined face one would like.
There are of course dental problems as well, but I was thinking about having focus on the aesthetical in this post, but sure it needs to be possible to wrap up with the teeth as well.
When looking at my face and I pull my entire face forward, then atleast I think it looks much better, the jawline gets enhanced etc.
So to me there are 2 approaches to the pure aesthetic problem. Either you can perform a bimax surgery and move both lower and upper jaw forward, maybe do some rotation etc to get good facial structure. I dont understand all the proportions that needs to be considered, but is there room for a procedure like this. To me it seems like if the upper jaw is advanced, it might come out of proportion with my forehead?
Or maybe it's more of a soft tissue problem. Maybe the area marked in red still will have the same problem if the jaws are advanced? How far would a plastic proceducedure that only focus on the soft tissue bring me?
What I'm trying to understand is what part of the aesthetic features that are connected to skeletal problems, and what parts that are more soft tissue problems. How will the face change with different procedures?
(https://i.imgur.com/W2mc646.jpg)
-
It looks like you have class2 Div2 deep bite with short chin.
Your maxilla (ANS-PNS) is rotated counter clockwise to a significant degree.
You would probably need a down graft and alteration of the anterior nasal spine in order to push maxilla forward if that were needed to 'match' advancement of lower jaw. If not your nasial labial ange would get excessively obtuse which it is already. Your upper front teeth would need to pushed forward for an angled out overjet and your lower teeth pushed backwards in braces to accommodate a bi-max surgery.
The line of the anterior cranial base is 11 deg away from the horizont and the norm is 7 degrees away.
Can't elaborate on everything. But it looks to be a case for a good maxfax surgeon who would be able to compensate of the excess inclination both the anterior cranial base and the maxilla has and also do rhinoplasty techniques so the nasial labial angle gets more CLOSED than more OPEN during the bi max surgery.
-
It looks like you have class2 Div2 deep bite with short chin.
Your maxilla (ANS-PNS) is rotated counter clockwise to a significant degree.
You would probably need a down graft and alteration of the anterior nasal spine in order to push maxilla forward if that were needed to 'match' advancement of lower jaw. If not your nasial labial ange would get excessively obtuse which it is already. Your upper front teeth would need to pushed forward for an angled out overjet and your lower teeth pushed backwards in braces to accommodate a bi-max surgery.
The line of the anterior cranial base is 11 deg away from the horizont and the norm is 7 degrees away.
Can't elaborate on everything. But it looks to be a case for a good maxfax surgeon who would be able to compensate of the excess inclination both the anterior cranial base and the maxilla has and also do rhinoplasty techniques so the nasial labial angle gets more CLOSED than more OPEN during the bi max surgery.
Wouldn't a rotation this way make the jaw line even less defined? Or do you mean that this is handled later with advancement forward?
-
Well, there is somewhat of a mechanical conundrum because counter clockwise rotation is often needed to get a good advancement to the lower jaw but you already have excessive CCW to the ANS-PNS (maxilla). So, more CCW or even linear advancement along the inherent incline of your maxilla would tend towards making the overly obtuse nasial labial angle more obtuse. So, maybe some clockwise rotation with the bi-max advancement. Either way, the orientation of the anterior nasal spine is not a good one and it would probabably have to be cut down/reduced to close the excessive nasial labial angle with any kind of advancement.
As to soft tissue, well the part we see from the ceph, expecially the nasial labial angle is clearly a function of the bone structure underneath.
Now, IF what 'bothers' you is the upwardly angled nose along with the long lip (labial ledge) and you can isolate THAT as the problem when looking in the mirror, that could be addressed by a type of rhino that cuts down the anterior nasal spine to kind of collapse in on the overly wide nasial labial angle. If the 'long lip' after doing that bothers you, then a lip lift decreases the longness there.
For other 'soft tissue' issues, that is assessed via a face photo and not a ceph.
-
Well, there is somewhat of a mechanical conundrum because counter clockwise rotation is often needed to get a good advancement to the lower jaw but you already have excessive CCW to the ANS-PNS (maxilla). So, more CCW or even linear advancement along the inherent incline of your maxilla would tend towards making the overly obtuse nasial labial angle more obtuse. So, maybe some clockwise rotation with the bi-max advancement. Either way, the orientation of the anterior nasal spine is not a good one and it would probabably have to be cut down/reduced to close the excessive nasial labial angle with any kind of advancement.
As to soft tissue, well the part we see from the ceph, expecially the nasial labial angle is clearly a function of the bone structure underneath.
Now, IF what 'bothers' you is the upwardly angled nose along with the long lip (labial ledge) and you can isolate THAT as the problem when looking in the mirror, that could be addressed by a type of rhino that cuts down the anterior nasal spine to kind of collapse in on the overly wide nasial labial angle. If the 'long lip' after doing that bothers you, then a lip lift decreases the longness there.
For other 'soft tissue' issues, that is assessed via a face photo and not a ceph.
The nose doesn't bother me and an isolated nose job is not gonna happen. There may be angles etc that can be drawn, but it has never been an issue for me and it would rather be taking a step backwards for me starting focusing on this as well. Of course it have to be considered if the structure of the face is going to be remodelled however.
Whats actually bothering me is what I marked in the picture. You can see that the skin on the throat is not "attached" to the jaw, hiding the entire jaw line.
Taking the first picture I found on google shows similair. On the picture to the right you can see that the jaw line is fully visible from the ear to the chin, opposite to what you see on the left. This is obviously before and after pictures of a surgery case, and it seems like there's some weight loss as well. But what I wonder, is the visibility of the jaw line actually a result of the surgery, or is it more weight loss, and bringing the head forward and maybe other procedures? When I'm evaluating my face in the mirror I think it looks resonable if I throw my head forward like an osterich, then I get the jaw line as in the after picture below, and I'm thinking if this is what's bothering me aesthetical, will I be disapointed by the result of a jaw surgery and maybe can address this by liposuction of the jaw line, stretching the skin or similair? I'm not overweight at all, so it's not as you can see in the picture where one might suspect that general weight loss solves some of the problem.
I'm trying to understand if jaw surgery is like throwing my head forward (literally)?
(https://i.ytimg.com/vi/1pyCoen6Ruc/maxresdefault.jpg)
-
The person in the photo most likely had bi-max surgery and chin advancement.
-
The person in the photo most likely had bi-max surgery and chin advancement.
I'm sure he did, but is that actually whats enhancing these lines of the jaw bone? I mean, the bone is there before as well, just at another angle and position. Does the bi-max actually stretch the skin and make it "attach" more to the these lines this much?
[attachment deleted by admin]
-
I'm sure he did, but is that actually whats enhancing these lines of the jaw bone? I mean, the bone is there before as well, just at another angle and position. Does the bi-max actually stretch the skin and make it "attach" more to the these lines this much?
It does what you see in the photo of THAT patient.
-
Your maxilla (ANS-PNS) is rotated counter clockwise to a significant degree.
Would you be able to elaborate further on this? I've recently had a consultation and got a suggestion on a bi-max surgery. But the suggestion I got was to rotate the maxilla counter clockwise to open the bite further and would also close the nose angle and he didn't see any problem with the nose and was rather working in a direction where both the maxilla and mandible is rotated counter clokwise and the mandible advanced forward. The maxilla will probably be rotated further than the mandible to accomodate the curve of the lover jaw. But then it worries me when it seems like you suggest the opposite and point out that the maxilla is is already excessively rotated and that doesn't make me feel good about rotating it further.
-
Would you be able to elaborate further on this? I've recently had a consultation and got a suggestion on a bi-max surgery. But the suggestion I got was to rotate the maxilla counter clockwise to open the bite further and would also close the nose angle and he didn't see any problem with the nose and was rather working in a direction where both the maxilla and mandible is rotated counter clokwise and the mandible advanced forward. The maxilla will probably be rotated further than the mandible to accomodate the curve of the lover jaw. But then it worries me when it seems like you suggest the opposite and point out that the maxilla is is already excessively rotated and that doesn't make me feel good about rotating it further.
Yes, rotating CCW will open the bite, angle out the lip which, in turn closes in on the nose angle and also allow the mandible to come forward more even if the maxilla is already rotated in same direction he wants to rotate it more.
-
Yes, rotating CCW will open the bite, angle out the lip which, in turn closes in on the nose angle and also allow the mandible to come forward more even if the maxilla is already rotated in same direction he wants to rotate it more.
Yes, I understand this perfectly and it makes sense to me. Rotating this way would decrease the 11 degree angle you marked out at the maxilla and also have the effects you mentioned above. Wouldn't it be impossible to handle this in any other way, as rotating the maxilla clockwise would only increase this angle further, and the corresponding angle at eye level cannot be reached anyway(?), or is there any other way to think about this?
What I'm trying to understand is if this is considered a compromise from what is considered normal skeletal and kraniofacial relation. When I read your previous comment that it's rotated counter clockwise to a significant degree already, it makes me think that the suggested approach to normalize this would be to rotate the maxilla clockwise.
I mean, apart from the academic discussion, I'm just hoping for a "normal" look and want to understand the relations and figure out if there are different approaches and if they differ to a degree that it can be "correct" to both rotate clockwise and counter clockwise.
-
OK, my prior statements said 'maybe' some clockwise rotation and pointed out you had CCW inclination already. Your CONSULT with the maxfax cross referenced that 'maybe' and resolved to getting CCW as part of the correction and I confirmed that made sense to me.
Now the 11 degree angle I marked out is one where the GREEN line is an absolute horizont where the BLUE line is a basic line from anterior to posterior nasal spine (ANS-PNS)--maxillary--showing you have CCW orientation already. So, if the blue line is rotated in a ccw direction, there would be more CCW orientation than you already have and since the green line is a constant relative horizont, the angle would INCREASE with more CCW.
So, your docs findings (at least to me), convey that more CCW than you already have is needed to open the bite so the deep bite is not 'IN THE WAY' of advancing the mandible. So, that RULES OUT the 'maybe' clockwise. So, he's saying he's got to angle UP the ANS-PNS MORE to get the DEPTH of teeth overlap OUT OF THE WAY in order to advance the mandible. If not, the mandible can't be advanced as the deep bite makes too much of an overlap that gets in the way of lower jaw advancement.
Hence, based on your doc's findings that basically tells us he HAS to rotate CCW to OPEN the deep bite INORDER TO move the mandible forward, we have to RULE out the 'maybe' of clockwise rotation.
Although the CCW rotation (along with braces to angle out the front teeth) will help close in on the overly obtuse nasial labial angle, the nose also can rotate upward with that. But still, there would be a net decrease in the NLA.
[I remember, over 11 years ago, when I first consulted with a maxfax about getting my jaw advanced where at the time, I didn't know I had a deep bite, he asked me what did I like best about my face and I told him' 'my NOSE'. He told me the rotation he would have to do to advance out my lower jaw would be rotating my nose upward and it seemed at the time, his implicit assumption was that I would NOT like that look because my nose was great which is probably why he asked me what I liked best about my face. That said, I KEPT my maxfax deformity because I did not want to alter my nose.]
I tend to think that Class 2 division 2 which is the deep bite with the retroclined front insisors along with recessive mandible is the most problematic to fix. Consider that to make it look better in the MIRROR one has to lower their jaw in order to advance it out so the upper teeth meet the lower teeth where when doing that, you find that the back teeth are not meeting and there is a big GAP between them and what one is doing is in direction of clockwise rotation of lower jaw. But IF the surgery just advanced out the lower jaw with clockwise rotation of the lower jaw, (as done in the mirror to make face look better) then you would have posterior open bite.
I understand your DILEMMA simply because the DEEP BITE if one had a big extent of it, IS a dilemma where the dilemma arises from their needing to open the bite via CCW in order TO advance the jaw forward, even IF you already have CCW orientation where doing that is not going to give the clockwise rotation to the jaw which one usually does in mirror to make face look better when one has the deep bite with recessive jaw. So, it's a DILEMMA where you might not get what you want out of the surgery.
-
OK, my prior statements said 'maybe' some clockwise rotation and pointed out you had CCW inclination already. Your CONSULT with the maxfax cross referenced that 'maybe' and resolved to getting CCW as part of the correction and I confirmed that made sense to me.
Now the 11 degree angle I marked out is one where the GREEN line is an absolute horizont where the BLUE line is a basic line from anterior to posterior nasal spine (ANS-PNS)--maxillary--showing you have CCW orientation already. So, if the blue line is rotated in a ccw direction, there would be more CCW orientation than you already have and since the green line is a constant relative horizont, the angle would INCREASE with more CCW.
So, your docs findings (at least to me), convey that more CCW than you already have is needed to open the bite so the deep bite is not 'IN THE WAY' of advancing the mandible. So, that RULES OUT the 'maybe' clockwise. So, he's saying he's got to angle UP the ANS-PNS MORE to get the DEPTH of teeth overlap OUT OF THE WAY in order to advance the mandible. If not, the mandible can't be advanced as the deep bite makes too much of an overlap that gets in the way of lower jaw advancement.
Hence, based on your doc's findings that basically tells us he HAS to rotate CCW to OPEN the deep bite INORDER TO move the mandible forward, we have to RULE out the 'maybe' of clockwise rotation.
Although the CCW rotation (along with braces to angle out the front teeth) will help close in on the overly obtuse nasial labial angle, the nose also can rotate upward with that. But still, there would be a net decrease in the NLA.
[I remember, over 11 years ago, when I first consulted with a maxfax about getting my jaw advanced where at the time, I didn't know I had a deep bite, he asked me what did I like best about my face and I told him' 'my NOSE'. He told me the rotation he would have to do to advance out my lower jaw would be rotating my nose upward and it seemed at the time, his implicit assumption was that I would NOT like that look because my nose was great which is probably why he asked me what I liked best about my face. That said, I KEPT my maxfax deformity because I did not want to alter my nose.]
I tend to think that Class 2 division 2 which is the deep bite with the retroclined front incisors along with recessive mandible is the most problematic to fix. Consider that to make it look better in the MIRROR one has to lower their jaw in order to advance it out so the upper teeth meet the lower teeth where when doing that, you find that the back teeth are not meeting and there is a big GAP between them and what one is doing is in direction of clockwise rotation of lower jaw. But IF the surgery just advanced out the lower jaw with clockwise rotation of the lower jaw, (as done in the mirror to make face look better) then you would have posterior open bite.
I understand your DILEMMA simply because the DEEP BITE if one had a big extent of it, IS a dilemma where the dilemma arises from their needing to open the bite via CCW in order TO advance the jaw forward, even IF you already have CCW orientation where doing that is not going to give the clockwise rotation to the jaw which one usually does in mirror to make face look better when one has the deep bite with recessive jaw. So, it's a DILEMMA where you might not get what you want out of the surgery.
Thank you very much for your extensive explanation, it really helps me understand. I was thinking that the green lines were relative lines as well and that the rotation would moves the green line in a direction to the blue line.
Just as you point out, when sliding the lower jaw forward, the teeth doesn't meet, and a rotation is needed in some way. Before my consultation I assumed that it was going to be addressed either by rotating the lower jaw clockwise, or the upper jaw counter clockwise. Now it seems like I'm looking at a counter clockwise rotation of both the lower and upper jaw, with a bigger rotation of the upper jaw to accommodate the contact of the molars.
I was also informed that part of the reason for this was to open the airways. Even though I didn't seek help for sleep apnea or have these symptoms now (that I know of), he adviced that it might come in the future with this profile and it wouldn't be correct to not address it.
I dont really understand your point that I would get an open bite if the lower jaw is advanced and rotated clockwise to make the teeth meet. Like you say, sliding the mandible forward in the mirror creates a gap, and rotating it clockwise would close the gap. This rotation of the jaws against eachother is needed in any surgical treatment, the difference in the suggested treatment I got now is that they're first rotated for molar contact, and then the entire package is rotated together ccw. The rotation for molar contact would create the same 'open bite' angle of the incisors as I see it, however the jaw bases are rotated.
Isn't there any other way to flatten out the curve of spee so that a rotation isn't needed for contact when sliding the mandible forward? I'm thinking something like a segmentation of the lower jaw where the part with the incisors are surgically moved down?
-
It seems Kavan has helped you already, though I haven't read anything and went right to ceph.
IMO you don't seem to need surgery. Bite okay? That said, if you opt for it, from the photos I'd say linear movement of both jaws and then a slight CW rotation of the chin.
-
Thank you very much for your extensive explanation, it really helps me understand. I was thinking that the green lines were relative lines as well and that the rotation would moves the green line in a direction to the blue line.
Just as you point out, when sliding the lower jaw forward, the teeth doesn't meet, and a rotation is needed in some way. Before my consultation I assumed that it was going to be addressed either by rotating the lower jaw clockwise, or the upper jaw counter clockwise. Now it seems like I'm looking at a counter clockwise rotation of both the lower and upper jaw, with a bigger rotation of the upper jaw to accommodate the contact of the molars.
I was also informed that part of the reason for this was to open the airways. Even though I didn't seek help for sleep apnea or have these symptoms now (that I know of), he adviced that it might come in the future with this profile and it wouldn't be correct to not address it.
I dont really understand your point that I would get an open bite if the lower jaw is advanced and rotated clockwise to make the teeth meet. Like you say, sliding the mandible forward in the mirror creates a gap, and rotating it clockwise would close the gap. This rotation of the jaws against eachother is needed in any surgical treatment, the difference in the suggested treatment I got now is that they're first rotated for molar contact, and then the entire package is rotated together ccw. The rotation for molar contact would create the same 'open bite' angle of the incisors as I see it, however the jaw bases are rotated.
Isn't there any other way to flatten out the curve of spee so that a rotation isn't needed for contact when sliding the mandible forward? I'm thinking something like a segmentation of the lower jaw where the part with the incisors are surgically moved down?
Some points:
1: What ever rotation the upper jaw gets, the lower jaw follows because part of movement of lower jaw is an auto rotation in the direction of the rotation of the upper jaw. That's why the entire rotation is either CW or CCW.
2: A person with a DEEP BITE can't slide their lower jaw forward WITHOUT the upper teeth getting in the way. They have to clockwise rotate it (move it in downward direction) FIRST until the lower teeth are edge to edge with upper teeth IN ORDER TO move it foward.
3: Given #2 above, when a person with a DEEP BITE clockwise rotates the lower jaw (move in downward direction) to the point where the upper and lower teeth meet edge to edge, there will be a GAP between the molars. So, this GAP is like posterior open bite if a surgery did what one does in the mirror which is CW of the lower jaw while keeping the upper jaw constant. Hence, you can't pick and choose to get CW for one part and NOT CW for the other.
4: The rotation that is needed to address a DEEP BITE is the rotation the mandible is going to follow.
5: Getting out of the rotation the doctor needs to correct the deep bite is something to discuss with the doctor. I don't have any suggestions to that regard.
-
Some points:
1: What ever rotation the upper jaw gets, the lower jaw follows because part of movement of lower jaw is an auto rotation in the direction of the rotation of the upper jaw. That's why the entire rotation is either CW or CCW.
2: A person with a DEEP BITE can't slide their lower jaw forward WITHOUT the upper teeth getting in the way. They have to clockwise rotate it (move it in downward direction) FIRST until the lower teeth are edge to edge with upper teeth IN ORDER TO move it foward.
3: Given #2 above, when a person with a DEEP BITE clockwise rotates the lower jaw (move in downward direction) to the point where the upper and lower teeth meet edge to edge, there will be a GAP between the molars. So, this GAP is like posterior open bite if a surgery did what one does in the mirror which is CW of the lower jaw while keeping the upper jaw constant. Hence, you can't pick and choose to get CW for one part and NOT CW for the other.
4: The rotation that is needed to address a DEEP BITE is the rotation the mandible is going to follow.
5: Getting out of the rotation the doctor needs to correct the deep bite is something to discuss with the doctor. I don't have any suggestions to that regard.
It's a very complex relation that's hard to understand. I was thinking that a bi-max surgery is like like removing the jaws in a way where you hold one jaw in each hand, and then you can place them in the mouth at whatever angle you like. Is there any way I can get an understanding of how the relation between the jaws work, and why they follow each other in the way you describe? I surely can understand it if it was the entire upper jaw that was being cut and moved, above the joint where the mandible connects with the upper jaw. But as I understand it, this is not what the procedures look like. When I've looked at videos of surgeries, it's more like the "teeth part" of the upper jaw is disconnected, or is this maybe an incorrect understanding from me?
Is it a correct understanding that the mandible can be rotated individually? Because if neither of the jaws can be rotated individually, I dont understand how the contact between the back teeth can be achieved. Say that the upper jaw is rotated ccw, and the lower jaw follows at the same pace, then I just have the same situation at another angle, at some point one of the jaws needs to be rotated more or less than the others. In this case it would seem like the procedure would be a CCW rotations of the upper jaw where the lower jaw follows, and then an advancement and a CW rotation of the lower jaw to fix the contact?
-
It seems Kavan has helped you already, though I haven't read anything and went right to ceph.
IMO you don't seem to need surgery. Bite okay? That said, if you opt for it, from the photos I'd say linear movement of both jaws and then a slight CW rotation of the chin.
Bite okay? I actually have no idea of what's considered an ok bite anymore. I've had so many thoughts and concerns about my bite so I've lost all concept of what's normal. I can say that it for sure doesn't feel ok, I feel alienated in my bite. I actually don't have contact between my back teeth at rest either, even though it's only a matter of margins. The overjet is enough to just miss contact between incissors. And when the suregon asked me about if my breathing is ok and that he suspected that if I don't already have sleap apnea, I might get it, it kind of makes sense if my bad sleep can depend on this, even if I haven't thought about it.
It also makes sense to me when I struggle with muscle tensions and neck pain, that it can be caused by a recessed jaw that blocks the breathing, which is compensated by a forward head posture, as described here:
https://www.intechopen.com/books/sleep-apnea-recent-updates/head-posture-and-upper-cervical-spine-morphology-in-patients-with-obstructive-sleep-apnea
So, I actually have no idea at what state of "need" I have for surgery. What I'm thinking is that it's atleast worth considering and might even go for it. Unfortinuately it's apparently not enough of a problem to be covered by insurance so it's a gamble I'll have to take in that case.
-
Hi,
I really don't have time to 'tutor' you in all of this. I will tell you though that a very good grounding in basic geometry is helpful simply because the displacement done in maxfax are all about points, lines, angles, planes and rotations. A lot of maxfax relationships become 'self evident to people with good grounding in basic geometry which is the study of the relationship of points, lines, angles, planes and rotations.
With a CCW rotation of the upper jaw which your doc is telling you he needs to do to open the deep bite SO he can MOVE the lower jaw, the lower jaw will follow that rotation. The mandibular plane angle will decrease (which might be unfavorable to a low mandibular plane angle patient). To compensate a CW rotation of the chin can be done.
Since you are considering doing this with aesthetics in mind, it would be prudent to request from your max fax a ceph diagram displacement plan which shows a before and after profile CONTOUR diagram of the proposed surgery. It is the most easy to understand way I can think of to assist in visualizing the profile changes in the proposed surgery.
-
Hi,
I really don't have time to 'tutor' you in all of this. I will tell you though that a very good grounding in basic geometry is helpful simply because the displacement done in maxfax are all about points, lines, angles, planes and rotations. A lot of maxfax relationships become 'self evident to people with good grounding in basic geometry which is the study of the relationship of points, lines, angles, planes and rotations.
With a CCW rotation of the upper jaw which your doc is telling you he needs to do to open the deep bite SO he can MOVE the lower jaw, the lower jaw will follow that rotation. The mandibular plane angle will decrease (which might be unfavorable to a low mandibular plane angle patient). To compensate a CW rotation of the chin can be done.
Since you are considering doing this with aesthetics in mind, it would be prudent to request from your max fax a ceph diagram displacement plan which shows a before and after profile CONTOUR diagram of the proposed surgery. It is the most easy to understand way I can think of to assist in visualizing the profile changes in the proposed surgery.
I do have a Msc in physics and would assume that I have a better understanding of geometry than most surgeons. So if the relations explained can be derived to pure geometry, then I should have no problems understanding the relations. I do understand that if a bite is correct and one wish to rotate one jaw, then the other need to be moved a corresponding amount by the surgeon. What they don't teach you in the mathematical cources however is the pure medical relations of the jaws, joints and tissue, and how rotating one jaw, implicitly will rotate the other in a non optional way. To understand that one need to know where the cuts are made and understand what tissue and bones are connected to the part beeing moved.
I dont wish to force you to participate in any discussion, but of course appreciate all feedback and response.
-
That's great that you have the background. A LOT of maxfax just relates back to elementary geometry concepts. Just a matter of keeping that in mind and 'connecting' to it.
What you have is a DEEP BITE; Class2 Division 2. I remind again because when GJ asked about your bite, you told him you had 'no idea of what's considered an OK bite anymore.'
-
Would anyone be able to comment on the airways. This was one of the main concerns from the surgeon and he wondered if I had sleep apnea. From looking at the picture I'm not sure whats shadows and where the actual airways is. It seems like it could be 4mm, but also more on the most narrow point.
What's considered narrow in this context?
-
That's great that you have the background. A LOT of maxfax just relates back to elementary geometry concepts. Just a matter of keeping that in mind and 'connecting' to it.
What you have is a DEEP BITE; Class2 Division 2. I remind again because when GJ asked about your bite, you told him you had 'no idea of what's considered an OK bite anymore.'
Do you think I should have any concerns regarding the occlusal plane with a ccw rotation? From what I can understand the occlusal plane is already almost horizontal, and will point up with a rotation. Is that really a good and desirable situation? Thinking both functional and aesthetic.
-
Do you think I should have any concerns regarding the occlusal plane with a ccw rotation? From what I can understand the occlusal plane is already almost horizontal, and will point up with a rotation. Is that really a good and desirable situation? Thinking both functional and aesthetic.
For sleep apnea/narrow airway, (if insurance pays for it) they probably would want to do a linear advancement which is along the CCW plane you already have. But they would probably also angle your front upper teeth outward so the overly obtuse nasial labial angle does not get much worse.
Concerns for deep bite is that it is hardest one to give all aesthetics when done to increase airway via maxilla/mandible advancement MMA. So, you would probably have to be braced to have a rhino later down the line and other procedures to maximize aesthetics.
Moral of story: Don't count on MMA for airway opening to maximize aesthetics if you have deep bite UNLESS it is NOT insurance pay for it but instead it is private expen$ive with someone like Gunson.
-
For sleep apnea/narrow airway, (if insurance pays for it) they probably would want to do a linear advancement which is along the CCW plane you already have. But they would probably also angle your front upper teeth outward so the overly obtuse nasial labial angle does not get much worse.
Concerns for deep bite is that it is hardest one to give all aesthetics when done to increase airway via maxilla/mandible advancement MMA. So, you would probably have to be braced to have a rhino later down the line and other procedures to maximize aesthetics.
Moral of story: Don't count on MMA for airway opening to maximize aesthetics if you have deep bite UNLESS it is NOT insurance pay for it but instead it is private expen$ive with someone like Gunson.
The private suggestion I've got is a bimax surgery with a ccw rotation. I have'nt been able to get a displacement diagram, but a computer morph. On this it looks like the maxilla is rotated ccw by posterior downgrafting and the maxilla is not really advanced, but rather just rotated. The mandible is rotated and advanced, and a genioplasty if needed. The reply I've got from the surgeon is that the nose is fine, doesn't need any adjustment and that the nose it self wont change with the surgery, but that the nasial lab angle will decrease with the rotation, which will benefit me. I was a bit concerned about that answear as I've read from other posts that the nose change with a procedure like this, but my surgeon says no.
In my opinion the computer morph looks good and the obtusness of the nose is not in the focus when looking at the full context on a profile picture, but rather the retruded lower jaw.
However, what does worry me at the moment is as described, the change of the occlusal plane with such procedure. I look at the computer morph and conlude that it looks good, but then I try to relate it to how it's going to change my bite and as I asked in previous post. Is it really a good situation to put myself in with an inclination of the occlusal plane that with any rotation from where it is now, looks like it will have an upward inclination?
Is it correct that there's a private part of this forum? Thinking maybe it would make sense for me to post more detailed photos there.
-
The private suggestion I've got is a bimax surgery with a ccw rotation. I have'nt been able to get a displacement diagram, but a computer morph. On this it looks like the maxilla is rotated ccw by posterior downgrafting and the maxilla is not really advanced, but rather just rotated. The mandible is rotated and advanced, and a genioplasty if needed. The reply I've got from the surgeon is that the nose is fine, doesn't need any adjustment and that the nose it self wont change with the surgery, but that the nasial lab angle will decrease with the rotation, which will benefit me. I was a bit concerned about that answear as I've read from other posts that the nose change with a procedure like this, but my surgeon says no.
In my opinion the computer morph looks good and the obtusness of the nose is not in the focus when looking at the full context on a profile picture, but rather the retruded lower jaw.
However, what does worry me at the moment is as described, the change of the occlusal plane with such procedure. I look at the computer morph and conlude that it looks good, but then I try to relate it to how it's going to change my bite and as I asked in previous post. Is it really a good situation to put myself in with an inclination of the occlusal plane that with any rotation from where it is now, looks like it will have an upward inclination?
Is it correct that there's a private part of this forum? Thinking maybe it would make sense for me to post more detailed photos there.
The only questions I can address via your WORDS alone are:
a: The text I have emphasized in your post (posterior down graft) is a good sign because it's akin to something Gunson would do. Hence, that's better than some 'insurance pay' for sleep apnea when they just do the linear advancement to open the airway. As to changing your bite, the objective is to get a GOOD bite from the displacements.
b: Yes, there is a private forum. You have my approval to join. All you need is GJ's approval WITH mine. A DONATION is needed for the private forum. It is for SHY people who don't want to post their photos on PUBLIC section of the board. But it does not guarantee any more 'special attention' that one would get on the public section. Also, I disclose that if I spend time addressing a person's posts and DON'T get an 'applaud' ever from them, I take it as feedback that my posts were NOT helpful to them and hence can elect not to keep on addressing each question they have.
-
-not an expert- But I've seen deep bites treated in two ways - opened during ortho decompensation (pretty much the first day of orthodontics with bite blocks on molars), or kept deep until surgery. It depends on the aesthetic goals needing to be achieved. Your surgeon and ortho need to agree.
-
-not an expert- But I've seen deep bites treated in two ways - opened during ortho decompensation (pretty much the first day of orthodontics with bite blocks on molars), or kept deep until surgery. It depends on the aesthetic goals needing to be achieved. Your surgeon and ortho need to agree.
Thanks. Could you please elaborate on the terms so I can follow better? When you say open, you mean angle out?
How does biteblocks on molars help, doesn't that work in the opposite direction than what would be desireable? Don't you rather need bite ramps on upper incissors to help the intrusion of incissors and extrusion of molars to level the curve of spee?
When you say keep deep until surgery, do you mean that the situation is accepted and that the surgeon makes the bite work with it? Or that something will happen later?
You don't mention vertical displacement of the incissors, which seems to be what the surgeon asks for, but my orthodontist say is a bit optimistic.
Is what's happening on the video below even possible?
https://youtu.be/1uYiifr7W6s
-
Thanks. Could you please elaborate on the terms so I can follow better? When you say open, you mean angle out?
How does biteblocks on molars help, doesn't that work in the opposite direction than what would be desireable? Don't you rather need bite ramps on upper incissors to help the intrusion of incissors and extrusion of molars to level the curve of spee?
Well when I said I'm not an expert I actually mean it :) you probably know more than me. I know some who had deep bites (myself included, somewhat deep) whose bite was leveled during ortho. Leveling (in this case opening up the deep bite) is generally part of pre-surgical ortho decompensation. However, often in some cases, it should be kept deep before surgery.
When you say keep deep until surgery, do you mean that the situation is accepted and that the surgeon makes the bite work with it? Or that something will happen later?
Keeping it deep pre-surgery, allows the mandible to rotate CW during surgery, which ensures the chin doesn't become too prominent.
https://academic.oup.com/ejo/article/32/3/342/433527 (https://academic.oup.com/ejo/article/32/3/342/433527)
(This may not apply for double jaw surgery, or your chin at all.)
Whats actually bothering me is what I marked in the picture. You can see that the skin on the throat is not "attached" to the jaw, hiding the entire jaw line.Taking the first picture I found on google shows similair. On the picture to the right you can see that the jaw line is fully visible from the ear to the chin, opposite to what you see on the left. This is obviously before and after pictures of a surgery case, and it seems like there's some weight loss as well. But what I wonder, is the visibility of the jaw line actually a result of the surgery, or is it more weight loss, and bringing the head forward and maybe other procedures? When I'm evaluating my face in the mirror I think it looks resonable if I throw my head forward like an osterich, then I get the jaw line as in the after picture below, and I'm thinking if this is what's bothering me aesthetical, will I be disapointed by the result of a jaw surgery and maybe can address this by liposuction of the jaw line, stretching the skin or similair? I'm not overweight at all, so it's not as you can see in the picture where one might suspect that general weight loss solves some of the problem.
If what's ACTUALLY bothering you is the submental area, you should see some form of improvement from advancement, as the skin becomes more tented up/taut. But you could also try liposuction too - before surgery (it might even be all you need, if this jaw/dental/convex lip stuff really isn't that much of an issue to you?) Or you can do it after jaw surgery, if you still don't get the required definition.
-
Removed link to plastic surgery outfit in Beverly Hills.
-
Your maxilla (ANS-PNS) is rotated counter clockwise to a significant degree.
The line of the anterior cranial base is 11 deg away from the horizont and the norm is 7 degrees away.
I'm getting a bit confused regarding what the horizon actually is here. It seems like the meassurements you made, assume the absolute horizon in the ceph, but isn't that a bit ambigious reference to meassure with? As I remember the situation when taking the ceph, it was more like "put your head here", and maybe not my natural head posture. Wouldn't it make more sense to meassure the ANS-PNS rotation against horizon with the FH-Horizon, which is not ambigious, compared to the relative horizon which may change depending on how the head is positioned when taking the ceph. I'm thinking, if the green line would be FH-Horizon, then the angle would be lower than 11.
-
I'm getting a bit confused regarding what the horizon actually is here. It seems like the meassurements you made, assume the absolute horizon in the ceph, but isn't that a bit ambigious reference to meassure with? As I remember the situation when taking the ceph, it was more like "put your head here", and maybe not my natural head posture. Wouldn't it make more sense to meassure the ANS-PNS rotation against horizon with the FH-Horizon, which is not ambigious, compared to the relative horizon which may change depending on how the head is positioned when taking the ceph. I'm thinking, if the green line would be FH-Horizon, then the angle would be lower than 11.
It's not ambiguous when I make clear I measured relative to an absolute horizon of the photo which is perpendicular to the vertical of the cephalostat. However, if you can find the Frankfurt Horizont in the ceph, you can measure relative to that.
'Po' point (needed for FH) is sometimes difficult to see on a ceph. For that reason the Steiner analysis uses the 'S' point.
Not all people have a FH that is 'horizontal' and based on my eyeballing your ceph, but just approximating where the 'Po' point would be (but not being able to exactly find it), it looks like your FH is not 'horizontal'.
-
It's not ambiguous when I make clear I measured relative to an absolute horizon of the photo which is perpendicular to the vertical of the cephalostat. However, if you can find the Frankfurt Horizont in the ceph, you can measure relative to that.
'Po' point (needed for FH) is sometimes difficult to see on a ceph. For that reason the Steiner analysis uses the 'S' point.
Not all people have a FH that is 'horizontal' and based on my eyeballing your ceph, but just approximating where the 'Po' point would be (but not being able to exactly find it), it looks like your FH is not 'horizontal'.
I'm not sure if what I'm pointing at got through completely. There's no ambiguity in what is meassured, it's completely clear.
What I'm confused about is how to interpret the 11 deg angle. If we agree that this angle is based on how I hold my head when taking the ceph, in a way where if I tilt my head either up or down, it will change. If so, this also implies that it's hard to evaluate if there's an abnormal rotation of ANS-PNS, as I could go back, take another ceph and get a different result.
If the angle would be meassured with FH-plane, I couldn't go back and take another ceph to get another result, it would be a fixed relation. I'm not in any way qualified to make an absolute mark where the FH-plane is, but I think it's safe to say that the ceph would be rotated CW, and when I do some guessing it seems atleast 5 degrees. If the ceph is rotated 5 degrees, the 11 degree angle would be decresed to 6, which would put the analysis in a different context, saying that ANS-PNS is rotated CW compared to norm.
When saying that the norm is 7 deg, what is the definition of this norm. Is it defined as a meassurement of ANS-PNS to the absolute horizon? It seems like there must be a strict definition of how this angle is meassured when there's a norm attached to it. "if you can find the Frankfurt Horizont in the ceph, you can measure relative to that." This sounds like I can meassure relative to anything I like, and maybe even find a horizon that will make it follow the norm.
I'm not sure how you mean when you say that everyone doesn't have a FH-plane, and that mine is not horizontal. It's surely not horizontal with the ceph, which is basically what this question is all about, where I mean that I don't remember anyone pointing out for me to hold my head in a "natural" position when doing the x-ray.
In some sense, the goal of such surgery is to get a balanced facial profile, and it seems like meassurement with FH-plane would be a more strict definition and put the jaws in a relation with the skull, while meassurement with the ceph horizon or posture horizon is more fuzzy, and I'm trying to understand how this is normally handled.
-
I'm not sure if what I'm pointing at got through completely. There's no ambiguity in what is meassured, it's completely clear.
What I'm confused about is how to interpret the 11 deg angle. If we agree that this angle is based on how I hold my head when taking the ceph, in a way where if I tilt my head either up or down, it will change. If so, this also implies that it's hard to evaluate if there's an abnormal rotation of ANS-PNS, as I could go back, take another ceph and get a different result.
If the angle would be meassured with FH-plane, I couldn't go back and take another ceph to get another result, it would be a fixed relation. I'm not in any way qualified to make an absolute mark where the FH-plane is, but I think it's safe to say that the ceph would be rotated CW, and when I do some guessing it seems atleast 5 degrees. If the ceph is rotated 5 degrees, the 11 degree angle would be decresed to 6, which would put the analysis in a different context, saying that ANS-PNS is rotated CW compared to norm.
When saying that the norm is 7 deg, what is the definition of this norm. Is it defined as a meassurement of ANS-PNS to the absolute horizon? It seems like there must be a strict definition of how this angle is meassured when there's a norm attached to it. "if you can find the Frankfurt Horizont in the ceph, you can measure relative to that." This sounds like I can meassure relative to anything I like, and maybe even find a horizon that will make it follow the norm.
I'm not sure how you mean when you say that everyone doesn't have a FH-plane, and that mine is not horizontal. It's surely not horizontal with the ceph, which is basically what this question is all about, where I mean that I don't remember anyone pointing out for me to hold my head in a "natural" position when doing the x-ray.
In some sense, the goal of such surgery is to get a balanced facial profile, and it seems like meassurement with FH-plane would be a more strict definition and put the jaws in a relation with the skull, while meassurement with the ceph horizon or posture horizon is more fuzzy, and I'm trying to understand how this is normally handled.
You're a bit too confused for me to unconfuse. If you want to use the Frankfurt H then you need to find exactly where point 'Po' is and also point 'Or' where Po is not that easy to find on a ceph. I've approximated both on your ceph to demonstrate that your FH is not a 'pure' horizont and is approx. 11 degrees from a pure horizont.
A 'pure' horizont would be one that is perpendicular to the vertical of the cepholastat. Not everyone's FH is a pure horizont. I can't fathom what is so hard to understand about that.
If you are concerned about your head position, which looks right to me, then have your doc mark out the POINTS, especially the FH and measure the angles yourself OR find some ceph analysis place on the net that will mark out the points on your ceph.
The easiest ones to find are 'S' and 'N' which the line connecting those points are rarely pure horizonts either but as used as 'horizontal' planes in Steiner analysis.
-
You're a bit too confused for me to unconfuse.
Lol. Never had someone sum up my life in one sentence with such accuracy :)
I've approximated both on your ceph to demonstrate that your FH is not a 'pure' horizont and is approx. 11 degrees from a pure horizont.
A 'pure' horizont would be one that is perpendicular to the vertical of the cepholastat. Not everyone's FH is a pure horizont. I can't fathom what is so hard to understand about that.
If the definition of a pure horizon is that it's "perpendicular to the vertical of the cepholastat", then there's nothing hard to understand about the terminology. What I'm trying to figure out is if such meassurement can be used with confidence when taking a decission, or comparing to a norm, since it can be altered by the patient and the instructions of the nurse when taking the x-ray.
I may walk around with my head horizontal to the FH-plane, or maybe not, who knows. Putting my head in a machine to take an x-ray while sitting down doesn't seem to be an accurate way to evaluate if my FH is a pure horizon in my normal life. If I would put my head in the x-ray and orient the FH-plane with the horizon of the cepholastat, we would have a result telling me that my ANS-PNS is significantly rotated CW.
The easiest ones to find are 'S' and 'N' which the line connecting those points are rarely pure horizonts either but as used as 'horizontal' planes in Steiner analysis.
This seems as good as the FH-plane to me. Wouldn't using this horizon tell me that ANS-PNS is significantly rotated CW, if the norm is 7 degrees with steiner analysis as well?
-
Your question/confusion is predicated on the assumption that you are NOT aligned properly with what is meant to be measured. So all your confusing pondering is a moot point unless you can demonstrate that you are NOT aligned properly.
Let me put it this way, if your ANS-PNS were not overly rotated CCW in orientation (disregard the # of degrees with the pure horizont I made!), do you think you would have the DEEP BITE your you have or the low angle mandibular plane?
-
.
Let me put it this way, if your ANS-PNS were not overly rotated CCW in orientation (disregard the # of degrees with the pure horizont I made!), do you think you would have the DEEP BITE your you have or the low angle mandibular plane?
The first thing I think of as a cause of the deep bite and low angle mandibular plane is the class 2 relation and overjet, allowing it to grow that way. Trying to figure out how a different rotation of the ANS-PNS would've change the development of the bite, but it only seems like it would put the jaws in a strange relation.
It's actually same confusion from my end here as well. Evaluating if the maxilla is overly rotated by using the mandible as reference, assume that the mandible is correct, when it actually could be the mandible that has "wrong" position.
I think this discussion concludes what we're already discussed. When fixing issues like this there's no clear answear what is the "correct" movement. Surgeon offers further ccw rotation even though it may be argumentet that it's already overly rotated, since it's the best he can do with the situation.
What I was pursuing was a way to measure that doesn't have a reference that is mobile and can be changed, as I'm a bit insecure about my head posture and want to exclude myself from the equation if possible, and it would also motivate further ccw rotation. FH-plane and steiner hz plane are both such planes that are attached to the skull, and you would have to be a real dare devil trying to have surgery to change those. When looking at displacement diagrams and cephalometric analyzis, it seems like surgeons often look at the cephs rotated to one of these planes and that surgeons maybe evaluate the situation with one of these rotations?
-
You have not demonstrated WHY you think your head is not oriented correctly. Do you realize that IF you tried to tip your head CW 11 degrees, the cephalostat (angled part) would preclude that? So, what is it about the ceph that makes you think that if you held your head differently, you would have the 'correct' alignment for the ceph and your FH would be parallel with the horizont?
Here is your ceph rotated (CW) 11 degrees. So that now your FH is on the horizont as pretty much your ANS-PNS. Does that make it any easier for you?
-
Just to clairfy, is NHP the correct posture/alignment for taking a ceph? Or are techs adjusting patients to a specific plane, prior to the ceph being taken?
-
Just to clairfy, is NHP the correct posture/alignment for taking a ceph? Or are techs adjusting patients to a specific plane, prior to the ceph being taken?
Great question and very succinctly expressed so it's clear (to me) what you are asking.
Assuming that NHP stands for Natural Head Position, here is a link to an article (although there are many articles on this) on the subject matter.
https://www.sciencedirect.com/science/article/pii/S2395921516301179#fig0005
When reading the article, it's important to differentiate 'Natural Head Position' from 'Natural (head) POSTURE' because both sound so similar.
Here is an excerpt from the article regarding the Frankfurt Horizont:
[The Frankfort Horizontal Plane (FHP) is one of the most used planes in cephalometry. It was adopted with the purpose of orienting the skull in a similar way to the natural head position. In cephalometric practice this plane presents two difficulties: a) Problems in locating accurately its two reference points, especially Porion, b) The operator assumes that the Frankfurt plane is parallel to the true horizontal plane which does not occur in many individuals, there have been observed differences of up to 10 degrees and even more.17 Arnett mentions:18 no one walks with the Frankfort plane parallel to the ground and we can have a patient in natural head position but with the Frankfurt Plane inclined upwards or downwards.]
And another concept from the study:
[ Concepts used in the study.
Natural head position (assisted) It is defined as an innate, physiological and reproducible position of the head. It is obtained when the patient is in a relaxed position, sitting or standing, looking into the horizon or into an external reference point (mirror, mark on the wall, etc.) at eye level2., 3., 4., 5., 6., 7., 8., 9., 10., 11., 12., 13. or at the same level as the olives
Natural head posture (orthoposition) It is the physiological position that a person shows when giving a step forward. This posture is different among individuals and may vary if the person has nasal obstruction or other physiological anomalies2,3,29]
-
Oh boy, I had no idea natural head posture and natural head position were two different things. Thanks for the reference, Kavan. I'm going through some of the other references linked too.
I think my head position looks different in about half of my cephs. This may be because I've been to 2-3 dental radiology places over the years (different machines and different operators). I can't remember if I was told to look to the horizon or not, but definetly never had an external reference point such as a mirror.
The next question I've been wondering about is if there's a significant change to the way one naturally holds their head after surgery -- in class II's correctly corrected I would assume so given increased airways and less need for self-posturing.
-
Oh boy, I had no idea natural head posture and natural head position were two different things. Thanks for the reference, Kavan. I'm going through some of the other references linked too.
I think my head position looks different in about half of my cephs. This may be because I've been to 2-3 dental radiology places over the years (different machines and different operators). I can't remember if I was told to look to the horizon or not, but definetly never had an external reference point such as a mirror.
The next question I've been wondering about is if there's a significant change to the way one naturally holds their head after surgery -- in class II's correctly corrected I would assume so given increased airways and less need for self-posturing.
Natural head posture and natural head position are so confusing. I know. Class 2's often tilt their head up so jaw does not blend into neck too much. I guess if the lower jaw is brought forward, they would have to compensate less that way.
-
Oh boy, I had no idea natural head posture and natural head position were two different things. Thanks for the reference, Kavan. I'm going through some of the other references linked too.
I think my head position looks different in about half of my cephs. This may be because I've been to 2-3 dental radiology places over the years (different machines and different operators). I can't remember if I was told to look to the horizon or not, but definetly never had an external reference point such as a mirror.
The next question I've been wondering about is if there's a significant change to the way one naturally holds their head after surgery -- in class II's correctly corrected I would assume so given increased airways and less need for self-posturing.
What is clear is that there is a relation between forward head posture and OSA
https://www.ncbi.nlm.nih.gov/pubmed/27894543
https://www.ncbi.nlm.nih.gov/pubmed/9633167
https://www.intechopen.com/books/sleep-apnea-recent-updates/head-posture-and-upper-cervical-spine-morphology-in-patients-with-obstructive-sleep-apnea
What would seem logical to me is that the forward head posture is a way for people with OSA to open their airways mechanically, by moving their head forward and tilting it up. Same movement as a maxillomandibular advancement does. To me it seems like there could be a relation that if the airways are opened with a MMA surgery, the need for a forward head posture could be relieved.
Everything below the publications are my own thoughts and not anything I've been able to get confirmed by anyone.