advice on clockwise rotation case

[sooq]

Hi

I am a 37 yr old woman who lives in the UK, and a newbie to the board. I have only just gotten around to looking round this board despite investigating jaw surgery for YEARS. Anyway I am massively impressed with the level of knowledge on here. I am hoping that some of your expertise might help me 

One of the issues I have had, in terms of the slowness of my research progression, is that my case is not exactly common. I have seen jaw issues of all kinds, mostly a necessity for maxilla or mandibular advancement/reduction, and occasionally counter-clockwise rotation, but I never see a need for clockwise rotation when the occlusal angle is very low, but there is no underbite.
I have a deep bite, but it is not a severe deep bite - when i bite down you can still some of the lower teeth). I don't like to close my teeth fully except when eating as it seems uncomfortable - it feels better when I separate my teeth a bit, as if the pressure in my jaw joints is less and the masseters can relax a bit (they are hypertrophic). Dentists are not bothered by my deep bite. From the front my jaw looks very square. It is shorter on the left and so kicks up (i.e. if you measure vertically from the top of the cheekbone down to the base of the jaw the measurement on the left would be less than the right). But aside from this asymmetry and the need for CW rotation (low occlusal plane) I do not think I need anything else (i.e. I don't think either of my jaws need to be advanced or reduced horizontally). It is only because of the fact that both jaws are rotated upwards that my lower jaw seems to jut out and my chin appears more projecting horizontally (though i could be wrong??). I used to think I had a prognathic lower jaw simply because in profile it looked so, but I couldn't make sense of the fact that my bite was fine, unlike the prognathic cases with their underbite. I had never heard of occlusal planes or rotation and it took a while to hunt out the correct info. I still feel very under-informed about this particular procedure. The other thing I noticed from a frontal x-ray is that I have a deviated septum, which I am guessing happened as a result of the jaws growing unevenly a long time ago?? In terms of teeth, I only ever had one wisdom tooth in my upper left jaw and that is impacted. I never had a second molar on my lower left jaw either and had the other 2nd molar removed about 15 yrs ago. So only 12 teeth in my lower jaw!

I recently found a scientific paper online and for the first time EVER saw what seemed like my issue and a result which showed exactly what I would want. My occlusal angle is actually probably lower than hers (in profile the line running along the underside of my jaw is essential a flat horizontal one) The change to her face is so dramatic from the CW rotation. You'd think she had an underbite but like me it seems ok. I have the same slightly masculine look as in her pre-op photo because of the projecting look of that lower jaw. She seems to have had a chin reduction,  but unless I am way off I don't think she had any reduction/retrusion of the lower jaw horizontally or advancement of the maxilla either, so it is mainly down to the rotation? (feel free to tell me otherwise though as you all seem to know your stuff whereas i really don't!) I nearly fell off my chair in excitement that I finally had a visual representation to show my issue and what I might need to correct it 
Link is below - it is the brunette girl not the first blonde girl.

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2176-94512012000400028

So my questions all relate to getting info about clockwise rotation and if anyone knows anyone who has the same issue and even better who has had it corrected. And surgeons who specialise in it?! I know all the big names, but I have no idea which ones have a speciality in the low occlusal plane issue. I am considering hunting down the Brazilian surgeons who wrote the paper, simply because I will know they understand the issue and can correct it with a good aesthetic outcome. Though of course this is a bit of a random way to choose a surgeon. i would research them properly of course!

Anyway, apologies for the long message! Advice/opinions on my issues and how difficult they might be to fix would be appreciated. I will be consulting with several surgeons soon.

I will include some x-rays. I will have them in a staggered way because of the file sizes. The first one below shows
the flattened curve of spee.



[attachment deleted by admin]

[sooq]

the next one shows the masculine projection of my jaws in profile. yuk!

[attachment deleted by admin]

[sooq]

these last 2 below are actually photos of physical x-rays so hope they are clear enough. Please note my teeth are not closed together in these second 2 as the lady forgot to ask me to bite down before she did them (!!) and I only saw that once it was too late to do them again (don't ask!) But at least it does show how I hold my teeth open most of the time and how it feels comfortable. It also shows the difference that closing my teeth down makes in profile when you compare with the first lateral ceph x-ray.

[attachment deleted by admin]

[sooq]

Should say that in the scientific article I posted a link for the brunette girl I am talking about being similar to is figs 6-10.

[notrain]

actually we share some similarities:

- well defined rami
- flat occlusal plane
- brachycephalic skull type

but i am class 2 and i don't think cw rotation is planned in my case. you have to realize that the midface is the deciding factor if you need any type of CW or CCW rotation (in brachycephalic patients):

- midface is compact / small -> CCW rotation to shorten lower third to bring it closer to the midface
- midface is long(ish) -> CW rotation to lengthen lower third to achieve facial harmony

Midface length is basically determined by the length of your nose. My midface is short and despite my mild deep bite (Overbite 4mm) and flat occlusal plane, the lower third of my face is already slightly longer than my midface. CW rotation in this case would actually be detrimental to my looks, although my occlusal plane is flat.

The girl in the link you posted did indeed have a short lower third, but since you haven't posted an actual picture of yourself, it's not possible to tell if you indeed have the same problem she does.

My point is: you can't look at this in isolation and say "oh, my occlusal plane is too flat, i need to rotate it clockwise".

if you are brave enough, post a pic of your face (front and profile). since your jaws are class 1, you might be better off just getting ortho work to lift the deep bite (this alone will very slightly rotate your occlusal plane clockwise and make your lower third a bit longer).

[Tiny]

- midface is compact / small -> CCW rotation to shorten lower third to bring it closer to the midface
- midface is long(ish) -> CW rotation to lengthen lower third to achieve facial harmony

Don't think it's quite that cut and dried - my upper midface is fine but the entire lower half is very short and I'm getting CCW and lengthening the face.  If you have CCW with impaction that will shorten the anterior aspect but I'm getting a downgraft to lengthen posterior and anterior.


Sooq, this is interesting, I think you're the only case we have on the boards right now with a plane that is too shallow!  And it's both jaws, too.

[notrain]

yeah, but to be fair, aren't you a case of ramus hypoplasia ?

those cases are a bit of an exception to the rule, since the short rami throw everything else off.

I think if the rami are fine, the generalisation i made should be pretty accurate.

[sooq]

my face is v similar to the girl in the pics, if anything my lower face is even shorter and occlusal angle even lower than hers (sorry but not brave enough to post pics! hate photos of myself!). I am pretty sure the clockwise rotation would be good for my midface, but I am really in the dark at the moment. Hopefully some surgeon consults will clarify things though?!!

celticcavegirl - yes, I do get the feeling I am the only one around with this problem! It certainly underlines why I have had such difficulty trying to make headway in my online research over the years! Use low angles are scarce apparently - maybe I can be the board pioneer for the issue