Soft or hard tissue problem?

[Dogmatix]

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?

[Dogmatix]

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.

[kavan]

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.

[Dogmatix]

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.

[kavan]

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.'

[Dogmatix]

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?

[Dogmatix]

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.

[kavan]

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.

[Dogmatix]

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.

[kavan]

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.

[april]

-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.

[Dogmatix]

-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

[april]

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
(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.

[kavan]

Removed link to plastic surgery outfit in Beverly Hills.

[Dogmatix]

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.