I had a facial analysis done -- can anyone help me interpret my results?

[tjarrr]

Hi all,

I recently had a consultation with maxfac surgeon Dr. Steinbacher at Yale and had cephalometric / facial analyses done at my visit.

To be honest, I found him pretty awkward and reticent: he let me do all the talking and didn't really say much by way of responding to my concerns about my recessed midface and recessed mandible masking each other -- at first he didn't even mention orthognathic surgery as an option to me (until I prodded him on it) and went straight to suggesting cheek and jaw implants! I also didn't see any of his before/after shots so I don't think I would want him to perform any surgery without those.

I got the results back from my facial analysis today (attached, ceph. image in the imgur link at the bottom) and I'm a bit perplexed by how to interpret the results and the summary. I'm doubly unsure of how to interpret these results given how recessed my forehead is which is probably throwing off all the other measurements. I'm not even going to worry about my forehead though for now because I use my hair to camouflage it.

Anyway, I'm assuming all the values in black are within normal ranges. My dentition was normal but this is expected because I was told that I have perfect or near-perfect occlusion. Questions: How can I have two skeletal relationships at the same time? I'm Skeletal Class I (A-Po) and also Skeletal Class III (ANB)? I assume that must mean that the nasion landmark is set back from where it's supposed to be. Is this indicative of a retruded maxilla? Most of the discrepancies in the region titled "Mandible to Maxilla" seem to be measurements that include the nasion region including ANS (anterior nasal spine). Does that mean that the maxilla is the root cause of all the discrepancies? Or would there still be discrepancies in the "Mandible to Maxilla" region even after this value is corrected, meaning that there are discrepancies in the mandible as well? I'm really shocked by how wildly divergent all of the values here are!! How is my mandible length 20 standard deviations below the norm?? 

Dr. Steinbacher is waiting on the results from my sleep study before he suggests surgery routes. However, I don't think I have sleep apnea and my dentition is normal -- should I bother with orthognathic surgery (it obviously wouldn't be covered by my insurance), or are facial implants a better route? I gather some people here have strong opinions against implants though. However what other option to improve my facial aesthetics would I have, if I'm functionally normal? What do people recommend I need, given these pictures of me? http://imgur.com/a/OJdaF From the analysis the entire midface is deficient so what about Lefort I (though the consequences to the nose from this surgery are concerning)? Cheek implants and jaw implants?

I also think my infraorbital region is deficient but that area isn't addressed by this analysis.

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[Trader]

Your upper and lower jaws are both recessed, and you have a steep occlusal plane. Your low SNB and SNA angles confirm the retrusion of your lower face relative to your cranial base. Your low ANB angle suggests that your maxilla and mandible are in a class III relationship to each other. Did you have orthodontics at some point in your life?

The reason this may not be obvious to you is that you have forward head posture with neck extension. You likely do this to increase the size of your airway, but it also serves to mask your maxillomandibular retrusion. Your retrusion becomes more obvious if you put your head in a more natural posture: http://i.imgur.com/RLON4m7.png

If you want to get jaw surgery, you would need maxillomandibular advancement with counterclockwise rotation.

[tjarrr]

Your upper and lower jaws are both recessed, and you have a steep occlusal plane. Your low SNB and SNA angles confirm the retrusion of your lower face relative to your cranial base. Your low ANB angle suggests that your maxilla and mandible are in a class III relationship to each other. Did you have orthodontics at some point in your life?

The reason this may not be obvious to you is that you have forward head posture with neck extension. You likely do this to increase the size of your airway, but it also serves to mask your maxillomandibular retrusion. Your retrusion becomes more obvious if you put your head in a more natural posture: http://i.imgur.com/RLON4m7.png

If you want to get jaw surgery, you would need maxillomandibular advancement with counterclockwise rotation.

I actually never had orthodontist work done and I have received compliments on my teeth my whole life.

What I'm wondering is if it's the case that I have a recessed mandible (which the steep occlusal plane suggests), how much could an MMA + CCW rotation fix how small my mandibular length is? That measurement would be the same regardless of the position of the mandible, wouldn't it? If so, how on earth is my mandibular plane 84 mm smaller than normal? That's just absurd. Could these results be botched?

[PloskoPlus]

Your jaws are fine.

[tjarrr]

Is your goal to become more handsome? If so I would focus your resources on improving your lazy looking eyes first and then your nose (sorry to be blunt, trying to help). A godly jaw would improve you maybe 1 point max. Better eyes and nose would raise you 2/3 points.

With better eyes and nose you would look rather handsome imo and wouldn't need jaw enhancement.

Yep, that's my goal. I mention orthognathic surgery as an option because recessed mandibles/maxilla can lead to sleep apnea surgery later in life so if I didn't get it now I would need it later anyway.

You mention improving my nose. In what way, exactly? You know, I thought for the longest time that the issue was my nose, but looking into facial aesthetics made me realize, couldn't the issue not be with my nose but rather with a recessed maxilla which gives the illusion of the nose looking bigger? For instance, people who get MMAs who had a dorsal hump in their nose prior to surgery find that it becomes much less pronounced after the maxilla is advanced.

And yep, totally agree about the eyes, and I think infraorbital implants would give me great results. Ideally I could just get a Lefort III but obviously those are hard to come by and I'm probably not the ideal candidate anyway.

How much do you think this 2/3 point increase in aesthetics would come from the eyes vs the nose? (Ah, nevermind, I realize you implicitly answered this by saying fixing my eyes first lol.)

[PloskoPlus]

The nose is fine. The eyes are 80℅ of looks.

[Lazlo]

YOUR JAWS ARE PERFECT GET OFF THIS FORUM AND STOP BOTHERING DOCTORS FOR SOME PSCYHOLOGICAL ISSUE YOU OBVIOUSLY HAVE> END OF STORY.

[Trader]

I actually never had orthodontist work done and I have received compliments on my teeth my whole life.

What I'm wondering is if it's the case that I have a recessed mandible (which the steep occlusal plane suggests), how much could an MMA + CCW rotation fix how small my mandibular length is? That measurement would be the same regardless of the position of the mandible, wouldn't it? If so, how on earth is my mandibular plane 84 mm smaller than normal? That's just absurd. Could these results be botched?

I think you're overthinking things.

Your SNB and SNA values show that you have a very retrusive maxilla and mandible. These are by far the most important numbers for a facial analysis.

Since you have a steep occlusal plane and no overjet, you would need counterclockwise rotation to achieve a desirable projection of your mandible relative to your maxilla.

I think if the OP shaved off all of his facial hair, his jaw problem would be a lot more apparent. I suspect he needs around 15mm of mandibular advancement at the pogonion to achieve a balanced facial profile and a healthy airway.

[PloskoPlus]

He doesn't have a steep occlusal plane.

[Trader]

He doesn't have a steep occlusal plane.

Are you making that conclusion by comparing his occlusal plane to the Frankfurt horizontal?

Arnett and Gunson state that occlusal plane analysis should not be done according to the Frankfurt horizontal. Rather, the occlusal plane should be analyzed relative to the patient's natural head posture. http://www.arnettgunson.com/files/2015/02/9-2010-JCO-1-Interview-Esthetic-Treatment-Planning-for-Orthognathic-Surgery.pdf

I think the OP's head position that results in a horizontal Frankfurt plane (http://i.imgur.com/lciDOKy.png) is very different from his natural head position. His natural head position would have a lot less neck extension and therefore a steeper occlusal plane. His profile and occlusion (convex face with no overjet) also suggest a steep occlusal plane.

[ditterbo]

Yeah if we go by his SNA and SNB deviation from the mean (very helpful info Trader, btw!), than he's got it even worse than me by 5 degrees on average.  Everyone told me I needed bimax, so tada! You must therefore be a candidate as well.  Interesting your maxilla is weaker than mine by 10 degrees (SNA measurement) and mandible also slightly worse but your face looks much more balanced than mine was pre chin implant and nose job. Eerily similar eyes... coincidence?

I also think Trader is spot on... the lack of forehead reference is making it hard to see the recession.

EDIT: Or could his measurements be completely off if it was based on a grossly unnatural head posture?

[slidinggenio]

Are you making that conclusion by comparing his occlusal plane to the Frankfurt horizontal?

Arnett and Gunson state that occlusal plane analysis should not be done according to the Frankfurt horizontal. Rather, the occlusal plane should be analyzed relative to the patient's natural head posture. http://www.arnettgunson.com/files/2015/02/9-2010-JCO-1-Interview-Esthetic-Treatment-Planning-for-Orthognathic-Surgery.pdf

I think the OP's head position that results in a horizontal Frankfurt plane (http://i.imgur.com/lciDOKy.png) is very different from his natural head position. His natural head position would have a lot less neck extension and therefore a steeper occlusal plane. His profile and occlusion (convex face with no overjet) also suggest a steep occlusal plane.

I would have thought they would have done the opposite. Can't your occlusal plane appear normal because your posture is f**ked due partly due to your s**tty jaw?

[tjarrr]

Are you making that conclusion by comparing his occlusal plane to the Frankfurt horizontal?

Arnett and Gunson state that occlusal plane analysis should not be done according to the Frankfurt horizontal. Rather, the occlusal plane should be analyzed relative to the patient's natural head posture. http://www.arnettgunson.com/files/2015/02/9-2010-JCO-1-Interview-Esthetic-Treatment-Planning-for-Orthognathic-Surgery.pdf

I think the OP's head position that results in a horizontal Frankfurt plane (http://i.imgur.com/lciDOKy.png) is very different from his natural head position. His natural head position would have a lot less neck extension and therefore a steeper occlusal plane. His profile and occlusion (convex face with no overjet) also suggest a steep occlusal plane.

Could you compare it then to my natural head posture as seen in my pictures?

Also, I'm sorry that I'm just learning about this stuff and thank you for being so patient trying to explain this to me. I guess however I'm a bit confused by the idea that the head posture can screw up the measurements. All of the facial landmarks will stay in the same relation to one another regardless of whatever posture my head is in. None of these measurements are made against an imaginary x-y axis.

That said, shouldn't there be a way to measure the occlusal plane from the values given by the analysis, rather than resorting to guesswork by looking at my head posture in the images?

In any case, I don't know how much it would matter if my head was in an unnatural position because the imaging technique performed on me is similar to probably everyone else who's ever had this imaging done. No one would know if they had a steep occlusal plane if the head position were that unnatural when their pictures were taken. Also, I actually do remember trying to position myself very naturally when the images were being taken, and trying to make sure that the way I was positioned my chin on the chin rest didn't cause my jaw to jut out or anything like that. My head was held in place by two grips at each side so I don't think my posture changed during the imaging.

Where does the plane begin and end? I've seen some sources that limit the plane to the line dissecting the mouth but I've also seen sources with the line of the plane extending much farther back than that, almost to the center of the head.

[tjarrr]

What I would really like to understand is how the hell my mandible length is 84 cm smaller than normal??? It just baffles me beyond belief that that could even be possible. Could my prominent chin be camouflaging how small it is? Still doesn't account for an 84 cm difference... a vertical growth pattern doesn't explain it either, since the literature seems to suggest that in vertical growth the mandible plane is the same length but the angle is just steeper. According to these results in the summary section, my mandibular plane is apparently steep, although I don't know which values to look at to see this for myself.

[Trader]

Could you compare it then to my natural head posture as seen in my pictures?

Also, I'm sorry that I'm just learning about this stuff and thank you for being so patient trying to explain this to me. I guess however I'm a bit confused by the idea that the head posture can screw up the measurements. All of the facial landmarks will stay in the same relation to one another regardless of whatever posture my head is in. None of these measurements are made against an imaginary x-y axis.

That said, shouldn't there be a way to measure the occlusal plane from the values given by the analysis, rather than resorting to guesswork by looking at my head posture in the images?

In any case, I don't know how much it would matter if my head was in an unnatural position because the imaging technique performed on me is similar to probably everyone else who's ever had this imaging done. No one would know if they had a steep occlusal plane if the head position were that unnatural when their pictures were taken. Also, I actually do remember trying to position myself very naturally when the images were being taken, and trying to make sure that the way I was positioned my chin on the chin rest didn't cause my jaw to jut out or anything like that. My head was held in place by two grips at each side so I don't think my posture changed during the imaging.

Where does the plane begin and end? I've seen some sources that limit the plane to the line dissecting the mouth but I've also seen sources with the line of the plane extending much farther back than that, almost to the center of the head.

I'm talking about the occlusal plane in the way that Arnett and Gunson use it.

"When ideal esthetics are achieved, the maxillary occlusal plane is usually between 93° and 98° to the true vertical  line,  which  is  a  line  perpendicular  to natural head position as described by Arnett and colleagues."

So, yes, the occlusal plane is influenced by posture. Most people with steep occlusal planes employ a forward head, neck extended posture that makes their occlusal planes seem flatter than they actually are. They often have to be guided into their ideal head position, which may feel unnatural for them because they don't have a large enough airway to support it. Arnett and Gunson are fastidious about getting these measurements right.


Here's a morph showing maxillomandibular advancement with counterclockwise rotation. I'm convinced it's what you need if you choose to get jaw surgery: http://i.imgur.com/jC0lViw.png