Should I have gotten CCW rotation? (Pictures and CEPHs)

[kavan]

Does CCW affect occlusion? I understand Kavan’s point that posterior downgraft is the opposite of posterior impaction (which is used for AOB), but I’m pretty sure I’ve seen CCW of the whole MM complex where occlusion remains the same. In that case, it seems like a setback with CCW would improve aesthetics while maintaining the functional result.

Not that I can afford that kind of aesthetic surgery.

If you wanted to actually do that with primary objective to reduce the convex lip, the MM complex set back would include setting back the mandible too. Seems to be contrary thing to do if the airway would be reduced in the process and since you say you LIKE the longer mandible and WISH you had MORE projection.

[Post bimax]

If you wanted to actually do that with primary objective to reduce the convex lip, the MM complex set back would include setting back the mandible too. Seems to be contrary thing to do if the airway would be reduced in the process and since you say you LIKE the longer mandible and WISH you had MORE projection.

From my understanding, CCW rotation of the mm complex allows a greater mandibular projection per unit of maxillary advancement due to the flattening of the jaw angle. For example, I’d be able to achieve the same amount of mandibular projection with (say) 7mm maxilla advancement and CCW of the complex as with 10mm of straight advancement. Whether it would be enough to change lip convexity, I don’t know.  I could be wrong about all this because I’m very new here.

This is all theoretical at this point because a full revision is not in the cards for me.

[kavan]

From my understanding, CCW rotation of the mm complex allows a greater mandibular projection per unit of maxillary advancement due to the flattening of the jaw angle. For example, I’d be able to achieve the same amount of mandibular projection with (say) 7mm maxilla advancement and CCW of the complex as with 10mm of straight advancement. Whether it would be enough to change lip convexity, I don’t know.  I could be wrong about all this because I’m very new here.

This is all theoretical at this point because a full revision is not in the cards for me.

Hi,
I understand why the doctor gave the displacements he did given what you started with and why he didn't offer CCW for the anterior open bite and tried my best to explain that. But I can't go through everyone's 'understanding' of every possible thing in this process about everything having to do with CCW.

You started out with an almost straight labial ledge (area from base of nose to top of upper lip), so even if you got 5mm advancement via CCW, I can't say it would have PRELCUDED a convexity of the lip. But I can say, it would have run counter to correcting AOB.

It's hard for me to hold Posnick's feet to the fire for not giving you CCW when you had AOB. But you can ask him why he didn't if you like.

You're right. A lot of these spin off questions are theoretical at this point and my perspective here has been what is practical at this point in time.

[Dogmatix]

From my understanding, CCW rotation of the mm complex allows a greater mandibular projection per unit of maxillary advancement due to the flattening of the jaw angle. For example, I’d be able to achieve the same amount of mandibular projection with (say) 7mm maxilla advancement and CCW of the complex as with 10mm of straight advancement. Whether it would be enough to change lip convexity, I don’t know.  I could be wrong about all this because I’m very new here.

This is all theoretical at this point because a full revision is not in the cards for me.

This is my line of thought as well. If there was anything that could be done with your concern, it would be to pull ANS back a bit, and rotate the MM complex to project the chin, maybe even further than where it's now. It would most probable not be reversing the entire advancement, but as you say, trade some of the linear advancement you got for a CCW. Also uncertain how much it would actually do on the lip, a surgeon would have to evaluate that. Even a CCW projects the lip, but in a different way. Probably less convexity than a linear advancement if I understand correctly.

I understand that a ccw rotation contradicts to direct treating an anterior open bite, but bimax have 2 degrees of freedom, both maxilla and mandible. So I think it's a legit question if ccw rotation could've been done. First the maxilla to increase the open bite, and then further rotation of the mandible to close it. If ccw seems possible from the point you're at now, I don't see that it couldn't be possible from beginning.

[Post bimax]

This is my line of thought as well. If there was anything that could be done with your concern, it would be to pull ANS back a bit, and rotate the MM complex to project the chin, maybe even further than where it's now. It would most probable not be reversing the entire advancement, but as you say, trade some of the linear advancement you got for a CCW. Also uncertain how much it would actually do on the lip, a surgeon would have to evaluate that. Even a CCW projects the lip, but in a different way. Probably less convexity than a linear advancement if I understand correctly.

I understand that a ccw rotation contradicts to direct treating an anterior open bite, but bimax have 2 degrees of freedom, both maxilla and mandible. So I think it's a legit question if ccw rotation could've been done. First the maxilla to increase the open bite, and then further rotation of the mandible to close it. If ccw seems possible from the point you're at now, I don't see that it couldn't be possible from beginning.

I agree, but there must be some reason Posnick preferred the linear advancement. If anything, as Kavan notes, what he did was the most straightforward solution to what I presented with and CCW is technically less stable. Maybe  someone like Gunson would have included CCW but I did not consult with him. I may ask Posnick himself in a year or so if I decide on a rhino and chin enhancement as he does plastic surgery as well.

I really do wish he had warned about nostril tilt, flare and convex lip. I would have probably gone through with it anyway but that is a knock against him in my book considering how predictable those outcomes are.

[april]

This is my line of thought as well. If there was anything that could be done with your concern, it would be to pull ANS back a bit, and rotate the MM complex to project the chin, maybe even further than where it's now. It would most probable not be reversing the entire advancement, but as you say, trade some of the linear advancement you got for a CCW. Also uncertain how much it would actually do on the lip, a surgeon would have to evaluate that. Even a CCW projects the lip, but in a different way. Probably less convexity than a linear advancement if I understand correctly.

Yeah agreed, there are different points of rotation that could be used so that the mandible doesn't go back.

If you look at this triangle, they can use the incisor tip as a point of CCW rotation, which would set back ANS, bring down PNS, keep the incisors in their current position, and bring forward the chin. There might need to be additional adjustments afterwards, but I think there would be revision options of ANS set back without setting back the whole thing.

[april]

I agree, but there must be some reason Posnick preferred the linear advancement. If anything, as Kavan notes, what he did was the most straightforward solution to what I presented with and CCW is technically less stable. Maybe  someone like Gunson would have included CCW but I did not consult with him. I may ask Posnick himself in a year or so if I decide on a rhino and chin enhancement as he does plastic surgery as well.

I heard on another site that Posnick is retiring.

[GJ]

This is how an open bite is corrected: https://www.youtube.com/watch?v=2_xpiAr2L78

It's a simple movement. You can see the natural tendency of it is CW rotation, though.
Based on the photos and the convex lip, my guess is he made the cut on the upper jaw, then moved the entire complex (both jaws) forward linearly. Since the plane of the upper jaw actually steepens, this results in mild CW rotation. Surgeons don't seem to understand that if the MMC's plane is steep and you move it forward linearly you actually are creating mild CW rotation, or if they do understand it, they don't seem to care that the result is unaesthetic.

To do the surgery "properly" he should have downgrafted (filled with bone) the posterior maxilla . This would allow the complex to rotate CCW.

This is an unstable movement because the graft can reabsorb. Maybe this is why he didn't do it. I know an Arnett patient suffering from this very problem. His open bite is back five years later. Maybe Posnick made this compromise for that reason. To me, you look better before. I'm sorry. I hope you at least get better function out of this. As to whether you should have gotten CCW rotation -- if you were willing to take the risk of resorption, yes. It would have been more aesthetic. If you weren't willing to take that risk, you got the proper surgery. It sounds like the surgeon made the decision for you, though.

[PloskoPlus]

The twats don't care. We're just a profit opportunity for them at best, and fodder for their residents at worst.

[Post bimax]

This is how an open bite is corrected: https://www.youtube.com/watch?v=2_xpiAr2L78

It's a simple movement. You can see the natural tendency of it is CW rotation, though.
Based on the photos and the convex lip, my guess is he made the cut on the upper jaw, then moved the entire complex (both jaws) forward linearly. Since the plane of the upper jaw actually steepens, this results in mild CW rotation. Surgeons don't seem to understand that if the MMC's plane is steep and you move it forward linearly you actually are creating mild CW rotation, or if they do understand it, they don't seem to care that the result is unaesthetic.

To do the surgery "properly" he should have downgrafted (filled with bone) the posterior maxilla . This would allow the complex to rotate CCW.

This is an unstable movement because the graft can reabsorb. Maybe this is why he didn't do it. I know an Arnett patient suffering from this very problem. His open bite is back five years later. Maybe Posnick made this compromise for that reason. To me, you look better before. I'm sorry. I hope you at least get better function out of this. As to whether you should have gotten CCW rotation -- if you were willing to take the risk of resorption, yes. It would have been more aesthetic. If you weren't willing to take that risk, you got the proper surgery. It sounds like the surgeon made the decision for you, though.

I think that's one way AOB can be corrected, but I think it can also be corrected via anterior downgraft which is what I think I got. Could be wrong though because I didn't know enough to ask at the time.

At this point, I also think I looked better before.  The changes to my upper lip and nose are even more apparent from the frontal view.  I was never warned about any of this and I found this community too late.  Another doctor had offered to only do a LF1 and genioplasty but I went with Posnick because I figured his approach was more complete.

The 'chimp' look is especially bad in my case because my ears already stick out a bit and my eyes are on the 'closer' set side. So I've got the ears, nose, lip and eyes all working in concert to produce a simian aesthetic.

Gunson must agree with you to some extent because he offered a consultation for revision, so I guess I'll see what happens. JS is just such a mentally, physically and financially taxing experience. I'm not looking forward to round 2 if it comes to that.

[kavan]

I think that's one way AOB can be corrected, but I think it can also be corrected via anterior downgraft which is what I think I got. Could be wrong though because I didn't know enough to ask at the time.

At this point, I also think I looked better before.  The changes to my upper lip and nose are even more apparent from the frontal view.  I was never warned about any of this and I found this community too late.  Another doctor had offered to only do a LF1 and genioplasty but I went with Posnick because I figured his approach was more complete.

The 'chimp' look is especially bad in my case because my ears already stick out a bit and my eyes are on the 'closer' set side. So I've got the ears, nose, lip and eyes all working in concert to produce a simian aesthetic.

Gunson must agree with you to some extent because he offered a consultation for revision, so I guess I'll see what happens. JS is just such a mentally, physically and financially taxing experience. I'm not looking forward to round 2 if it comes to that.

As a function of time, in retrospect, the presentation of info has been a 'moving target' where it's hard to pin down exactly what you had. I say in 'retrospect' because initially, I had to go through an 'if THIS than THAT' process due to absence of info as to how the AOB was treated (posterior impaction, anterior downgraft or just linear advancement). But later down the line you say you think you got anterior downgraft. Another later down the line 'movement' of info was that in another thread you mentioned you may have had a 3 piece L1 where initial assumption was just 1 piece. Another later down the line 'movement' of info was the removal (from your IMGUR) link the ceph with the BRACES on which was most likely the one used to plan the surgery.


I'm not faulting for that as you did your best to relay what you had done based on what the doctor told you VERBALLY and then there is the mystery of where your 'A' point is (fuzzy cephs where outline is not clear) which presents another 'IF here THAN that' situation in the explanation department of why you had what you had (or didn't have what you wanted to know if you should have had). I'm just observing a MOVING TARGET (changes in the presentation of info).

Ok, so Gunson offered a consult for revision. Other than agreeing on the obvious (which is your not liking the aesthetic outcome), which before ceph/s did you send him...the ONLY one LEFT on your IMGUR link or did you also send along the 2 other ones. One being where you were concerned your head was tilted up (ceph with NO braces) and the ceph with braces. Although I realize it wasn't needed to send him one of the cephs where your doctor rejected it because it was cut off too much. So, that one is not in question. Hope you're not 'picking and choosing' based on what you think he should be looking at.

Have you considered just getting a hold of your actual SURGICAL RECORDS where WHICH cephs were used and Which EXACT movements you actually got are given? What to do will be based on what you actually had. Not on what you think you had.

[Post bimax]

As a function of time, in retrospect, the presentation of info has been a 'moving target' where it's hard to pin down exactly what you had. I say in 'retrospect' because initially, I had to go through an 'if THIS than THAT' process due to absence of info as to how the AOB was treated (posterior impaction, anterior downgraft or just linear advancement). But later down the line you say you think you got anterior downgraft. Another later down the line 'movement' of info was that in another thread you mentioned you may have had a 3 piece L1 where initial assumption was just 1 piece. Another later down the line 'movement' of info was the removal (from your IMGUR) link the ceph with the BRACES on which was most likely the one used to plan the surgery.


I'm not faulting for that as you did your best to relay what you had done based on what the doctor told you VERBALLY and then there is the mystery of where your 'A' point is (fuzzy cephs where outline is not clear) which presents another 'IF here THAN that' situation in the explanation department of why you had what you had (or didn't have what you wanted to know if you should have had). I'm just observing a MOVING TARGET (changes in the presentation of info).

Ok, so Gunson offered a consult for revision. Other than agreeing on the obvious (which is your not liking the aesthetic outcome), which before ceph/s did you send him...the ONLY one LEFT on your IMGUR link or did you also send along the 2 other ones. One being where you were concerned your head was tilted up (ceph with NO braces) and the ceph with braces. Although I realize it wasn't needed to send him one of the cephs where your doctor rejected it because it was cut off too much. So, that one is not in question. Hope you're not 'picking and choosing' based on what you think he should be looking at.

Have you considered just getting a hold of your actual SURGICAL RECORDS where WHICH cephs were used and Which EXACT movements you actually got are given? What to do will be based on what you actually had. Not on what you think you had.

Yeah, sorry about this. Joining this board has been a learning process for me as I had very little knowledge of JS before posting, so my understanding of what constitutes salient information has been a 'moving target' for me as well.  I believe I got an anterior downgraft based on Plosko's comment and then looking at the x-ray again myself. Posnick never specified either way in this regard. He did, however, tell me my LF1 was 3 piece.

The CEPHs I sent Gunson were the 2011 (at or close to NHP), 2018 pre-op (head possibly tilted up, this is the one that was ACCEPTED by Posnick), and the 2018 post-op xray.  I did NOT send him the CEPH with my chin cut off when I was looking down that was rejected by Posnick. If I were 'picking and choosing', I'd probably have just sent this one to give the impression that my OP is steep.  I labeled my CEPHs by date.  I also sent him the PAN xrays that were taken at the same time as each CEPH.

I'll email Posnick and try to get a hold of the actual surgical records.

[kavan]

Yeah, sorry about this. Joining this board has been a learning process for me as I had very little knowledge of JS before posting, so my understanding of what constitutes salient information has been a 'moving target' for me as well.  I believe I got an anterior downgraft based on Plosko's comment and then looking at the x-ray again myself. Posnick never specified either way in this regard. He did, however, tell me my LF1 was 3 piece.

The CEPHs I sent Gunson were the 2011 (at or close to NHP), 2018 pre-op (head possibly tilted up, this is the one that was ACCEPTED by Posnick), and the 2018 post-op xray.  I did NOT send him the CEPH with my chin cut off when I was looking down that was rejected by Posnick. If I were 'picking and choosing', I'd probably have just sent this one to give the impression that my OP is steep.  I labeled my CEPHs by date.  I also sent him the PAN xrays that were taken at the same time as each CEPH.

I'll email Posnick and try to get a hold of the actual surgical records.

Well, it looks like picking and choosing because you chose to send him a 2011 and not a later one. No idea how you know the 2011 one is 'neutral head posture' vs another one that came later (also without braces) or realize there's a difference between 'neutral' head position and 'natural' head position. I myself get those confused. One is holding the head the way one holds it and the other is holding it so the eyes look straight ahead (at mirror in distance) in a pure horizont whether or not that's how one holds one's head which is the one that lets them look at 'true' verticals vs 'true' horizonts.

It looks like there was one in your series that came after 2011 that you elected not to send which is what I meant by 'picking and choosing'. It also did NOT have braces. But unlike the 2011 one that looked to have wisdom teeth, this one did not. So, it must have been taken later than 2011.

In fact, I actually used it to take a closer look at why Plosko said your OP became steeper afterwards ('not flat anymore'). I found that your OP was about 4 degrees more in the post op. But I also found that an angle formed by 2 distinct points on on the post op was 4 degrees more than those 2 distinct points on the pre-op (the one I used).

The photo on the left is the one I chose and chose it because the 'pure' horizont passes closer through near center of eyeball than does the 2011 and also because it was a LATER photo given the wisdom teeth were not in the jaw. I then compared relative angle changes in head position based on points that DON'T change; the 'S' and 'Or' points. Hence it didn't look like the OP really got significantly 'less flat' or 'steeper' given the amount it became steeper in the post op was about the SAME 4 degrees your head tilt was MORE than that in the pre op.

[Post bimax]

Well, it looks like picking and choosing because you chose to send him a 2011 and not a later one. No idea how you know the 2011 one is 'neutral head posture' vs another one that came later (also without braces) or realize there's a difference between 'neutral' head position and 'natural' head position. I myself get those confused. One is holding the head the way one holds it and the other is holding it so the eyes look straight ahead (at mirror in distance) in a pure horizont whether or not that's how one holds one's head which is the one that lets them look at 'true' verticals vs 'true' horizonts.

It looks like there was one in your series that came after 2011 that you elected not to send which is what I meant by 'picking and choosing'. It also did NOT have braces. But unlike the 2011 one that looked to have wisdom teeth, this one did not. So, it must have been taken later than 2011.

In fact, I actually used it to take a closer look at why Plosko said your OP became steeper afterwards ('not flat anymore'). I found that your OP was about 4 degrees more in the post op. But I also found that an angle formed by 2 distinct points on on the post op was 4 degrees more than those 2 distinct points on the pre-op (the one I used).

The photo on the left is the one I chose and chose it because the 'pure' horizont passes closer through near center of eyeball than does the 2011 and also because it was a LATER photo given the wisdom teeth were not in the jaw. I then compared relative angle changes in head position based on points that DON'T change; the 'S' and 'Or' points. Hence it didn't look like the OP really got significantly 'less flat' or 'steeper' given the amount it became steeper in the post op was about the SAME 4 degrees your head tilt was MORE than that in the pre op.

Maybe you are forgetting something or misread my post. I’ve posted 4 CEPHs to this board.

2011 (what I considered NHP)
2018 pre-op (rejected)
2018 pre-op (accepted)
2018 post-op

I sent Gunson everything except the ‘rejected’ CEPH, including the PAN xrays. The photo provided in your reply is the 2018 accepted one, which was sent to gunson.

I am not trying to ‘trick’ my way into a revision jaw surgery.

 

[kavan]

Maybe you are forgetting something or misread my post. I’ve posted 4 CEPHs to this board.

2011 (what I considered NHP)
2018 pre-op (rejected)
2018 pre-op (accepted)
2018 post-op

I sent Gunson everything except the ‘rejected’ CEPH, including the PAN xrays. The photo provided in your reply is the 2018 accepted one, which was sent to gunson.

I am not trying to ‘trick’ my way into a revision jaw surgery.

Could be because your IMGUR link removed some of the cephs you had on there.