I'm Stuck - Advice Needed

[kavan]

Would you be able to give me an idea of how many degrees I could be CCW rotated before aesthetics start to be negatively affected by the low angle? I'm just asking about the occlusal plane and smile aesthetics here, ignoring the other factors for a moment like protrusion and whatnot. I just want to try to calculate how many mm approximately I could gain at the pog point purely from the ROTATION COMPONENT of bimax surgery.

That would involve my drafting out a tedious tutorial to substantiate my angle estimate based on a triangle of points; ANS, PNS and POG. CCW or CW is based on the rotation of a triangle. I think I have something up there on the educational section about the concept of rotating a triangle. Someone wanting to use their own triangle would need to be able to find those points on their ceph, mark it out on their ceph and then construct another triangle in different color over it with the same rotation to look where the pog point goes subsequent to a rotation. That changes for each unique triangle. It's tedious to give verbal directions of how to do it. But suffice to say, someone wanting to 'figure out' will be needing some geometry and needing to look at the relationship between the angle of rotation and advancement of pog point, in particular the relationship between the vertical drop down distance from the PNS points of each triangle and the outward distance from the pog points of each triangle.   Basically, applying basic geometry just to appreciate the CONCEPT of it but not really with aim to figure out how much the doctor should rotate or to plan your own surgery.

What I can tell you now is what I said which was your OP is in the approx range of 7. So a 7 deg rotation would give you a 0 degree OP. So, CCW-r would need to be LESS than 7 deg. By the way, the norms for OP are about 8 + or - 4, so 4 to 12 is normative range depending on where you look. From that info I would GUESSTIMATE the doctors doing CCW might not want go more than 3 deg rotation. As to the extent of the rotation where your aesthetics would be wonky, I think you would need to just ask the doctors how many degrees they have in mind to rotate ccw or just get a PLAN from them. My 'thing' here is basically to point out that displacements in maxfax are RELATED to concepts in geometry. But not to provide the 'exact' number of degrees or mms for each unique case. That's the doctor's task to come up with when other factors go into things.

Included is a diagram of the rotation of a triangle; A, B C.  so you let A=ans, B=pns and C=pog where the triangle is your OWN made from those points where you rotate it X degrees (a CONSTRUCT of ABC rotated where the triangle is SAME but just rotated).

[Breakingbad]

Sounds like you have resolved NOT to elect for the genio alone which was my (and Gunson's) suggestion. Not that I expect people to follow my advice but TBH, I'm hard pressed to advocate, coach, figure out details etc when someone really wants the thing I'm not suggesting.

I RESPECT your values and your conclusion 100%. However, as is INHERENTLY the case when weighing something like this, it's based on YOUR personal values, that you concluded that weighing all the facts, genio is the better choice. Normative statements like the ones you and other members often make here are GREAT and can be very useful.  But since this all depends on PERSONAL values, I think it's not strange that I'm leaning towards further exploring the SAO + bimax surgery, which, is, by the way, also something that you explained was an option.

Not that I expect people to follow my advice but TBH, I'm hard pressed to advocate, coach, figure out details etc when someone really wants the thing I'm not suggesting. But of course, have no issues when the doctors on target with what you want figure those things out for you . . . But that's something one does WITHOUT needing someone else to figure out (other than the surgeon himself) all the details their soul impels them to do

I think it's very important to note, that I'm here to READ, ask questions, and LEARN because I believe that all patients should do so when considering surgical procedures. I think that's what this forum is for, regardless of one's personal values on what procedure is the right balance of trouble vs reward for them. I don't know of another forum like this one, and that's why I'm asking these questions here. If you really don't want to answer questions on this, that's your prerogative and I have to accept that obviously.

I could just try to rely on dealing with surgeons directly and see how it goes. I've already done that and plan to continue doing so. BUT, I'm trying, through reading and asking questions, to inform myself independently of these doctors. I also view the information and answers here as relatively unbiased, so that's another reason I'm here. Every patient improves their chance of a successful intervention by seeking help from those who know more than them, and I was hoping that was encouraged here.

I hope that clarifies things and allows you to appreciate my POV.

Sorry if I've taken too much of your time. Your help is appreciated.

But you need to work with some of the limitations that ideal candidates for the type of significant CCW-r didn't start out with

That's why I asked for your opinion--I am trying to gain an appreciation for the benefits and limitations. That's why I asked about how many degrees approximately I could be rotated.

And I was hoping to use that information to calculate BY MYSELF the number of mm of advancement that this would give. I don't yet understand whether I NEED significant CCW-r. A little bit of CCW-r + linear advancement after SAO seems like it could work too.

[Breakingbad]

That would involve my drafting out a tedious tutorial to substantiate my angle estimate based on a triangle of points; ANS, PNS and POG. CCW or CW is based on the rotation of a triangle. I think I have something up there on the educational section about the concept of rotating a triangle. Someone wanting to use their own triangle would need to be able to find those points on their ceph, mark it out on their ceph and then construct another triangle in different color over it with the same rotation to look where the pog point goes subsequent to a rotation. That changes for each unique triangle. It's tedious to give verbal directions of how to do it. But suffice to say, someone wanting to 'figure out' will be needing some geometry and needing to look at the relationship between the angle of rotation and advancement of pog point, in particular the relationship between the vertical drop down distance from the PNS points of each triangle and the outward distance from the pog points of each triangle.   Basically, applying basic geometry just to appreciate the CONCEPT of it but not really with aim to figure out how much the doctor should rotate or to plan your own surgery.

What I can tell you now is what I said which was your OP is in the approx range of 7. So a 7 deg rotation would give you a 0 degree OP. So, CCW-r would need to be LESS than 7 deg. By the way, the norms for OP are about 8 + or - 4, so 4 to 12 is normative range depending on where you look. From that info I would GUESSTIMATE the doctors doing CCW might not want go more than 3 deg rotation. As to the extent of the rotation where your aesthetics would be wonky, I think you would need to just ask the doctors how many degrees they have in mind to rotate ccw or just get a PLAN from them. My 'thing' here is basically to point out that displacements in maxfax are RELATED to concepts in geometry. But not to provide the 'exact' number of degrees or mms for each unique case. That's the doctor's task to come up with when other factors go into things.

Included is a diagram of the rotation of a triangle; A, B C.  so you let A=ans, B=pns and C=pog where the triangle is your OWN made from those points where you rotate it X degrees (a CONSTRUCT of ABC rotated where the triangle is SAME but just rotated).

THANK YOU. I hadn't seen this yet when I submitted my reply a few minutes ago. Yes, I know it's tedious and that's why I didn't ask you to tell me how many mm that is at the pog point. I am familiar with the method you described and appreciate you directing me to the right place to refresh my memory so I can calculate this myself. Yes, I know I shouldn't plan my own surgery, just trying to get a better idea on this.

[kavan]

I RESPECT your values and your conclusion 100%. However, as is INHERENTLY the case when weighing something like this, it's based on YOUR personal values, that you concluded that weighing all the facts, genio is the better choice. Normative statements like the ones you and other members often make here are GREAT and can be very useful.  But since this all depends on PERSONAL values, I think it's not strange that I'm leaning towards further exploring the SAO + bimax surgery, which, is, by the way, also something that you explained was an option.

I think it's very important to note, that I'm here to READ, ask questions, and LEARN because I believe that all patients should do so when considering surgical procedures. I think that's what this forum is for, regardless of one's personal values on what procedure is the right balance of trouble vs reward for them. I don't know of another forum like this one, and that's why I'm asking these questions here. If you really don't want to answer questions on this, that's your prerogative and I have to accept that obviously.

I could just try to rely on dealing with surgeons directly and see how it goes. I've already done that and plan to continue doing so. BUT, I'm trying, through reading and asking questions, to inform myself independently of these doctors. I also view the information and answers here as relatively unbiased, so that's another reason I'm here. Every patient improves their chance of a successful intervention by seeking help from those who know more than them, and I was hoping that was encouraged here.

I hope that clarifies things and allows you to appreciate my POV.

Sorry if I've taken too much of your time. Your help is appreciated.

That's why I asked for your opinion--I am trying to gain an appreciation for the benefits and limitations. That's why I asked about how many degrees approximately I could be rotated.

And I was hoping to use that information to calculate BY MYSELF the number of mm of advancement that this would give. I don't yet understand whether I NEED significant CCW-r. A little bit of CCW-r + linear advancement after SAO seems like it could work too.

With regard to a lot of back and forths as to your choice of what to do, I'm just saying, I'm going to be in a time crunch real soon as to extent of time and there are some thing you should just ASK the doctors such as:

a: will you be retroclining my teeth or aligning straight down and if so, what's your estimate of the new nasial labial angle.
(measure your present one first--it's in the 90 deg. range). Better yet, just ask if your NLA will INCREASE

b: if my NLA increases too much due to new orientation of front teeth, is is possible to later get braces for a lips to rest on diagonal plane?

c: can you give me an idea of an approximate number of degrees of the CCW or approximate mm length of posterior downgraft used in the CCW

a and b  (if they tell you) will allow you to be poised for an increase in NLA and be poised to accept that as a trade off

c will give you an idea of what you could expect with the pog point projection as a function of degrees of ccw-r

[Breakingbad]

With regard to a lot of back and forths as to your choice of what to do, I'm just saying, I'm going to be in a time crunch real soon as to extent of time and there are some thing you should just ASK the doctors such as:

a: will you be retroclining my teeth or aligning straight down and if so, what's your estimate of the new nasial labial angle.
(measure your present one first--it's in the 90 deg. range). Better yet, just ask if your NLA will INCREASE

b: if my NLA increases too much due to new orientation of front teeth, is is possible to later get braces for a lips to rest on diagonal plane?

c: can you give me an idea of an approximate number of degrees of the CCW or approximate mm length of posterior downgraft used in the CCW

a and b  (if they tell you) will allow you to be poised for an increase in NLA and be poised to accept that as a trade off

c will give you an idea of what you could expect with the pog point projection as a function of degrees of ccw-r

Okay, thank you. I'll do that. About this sentence though:

"will you be retroclining my teeth or aligning straight down"

I am familiar with the term "retroclination," and will be sure to ask this as you've written it, but, for my own comprehension, does this question basically mean: "will you be pushing in my teeth in a LITTLE (i.e. retroclining a little) or pushing my teeth in a LOT (ie. retroclining them so far as to align them straight down)?

I'm fairly certain I understand you but want to be sure.

You're the one who would have to demonstrate any paranasal problem.

Do you have any guess as to why Gunson wrote "Nasal base is soft and needs 4 mm of support" in his report? I would think this refers to solely ANS deficiency, rather than wider paranasal retrusion. To me I see a bit of a collapsed area all around the lower half of my nose, and that's why I said I suspected a paranasal problem. I don't know if my eyes are to be trusted on this, though.

I want to understand this while we're on the nasolabial angle as we're talking about the same general area so this is all interrelated.

[kavan]

Okay, thank you. I'll do that. About this sentence though:

"will you be retroclining my teeth or aligning straight down"

I am familiar with the term "retroclination," and will be sure to ask this as you've written it, but, for my own comprehension, does this question basically mean: "will you be pushing in my teeth in a LITTLE (i.e. retroclining a little) or pushing my teeth in a LOT (ie. retroclining them so far as to align them straight down)?

I'm fairly certain I understand you but want to be sure.

Do you have any guess as to why Gunson wrote "Nasal base is soft and needs 4 mm of support" in his report? I would think this refers to solely ANS deficiency, rather than wider paranasal retrusion. To me I see a bit of a collapsed area all around the lower half of my nose, and that's why I said I suspected a paranasal problem. I don't know if my eyes are to be trusted on this, though.

I want to understand this while we're on the nasolabial angle as we're talking about the same general area so this is all interrelated.

Retroclining refers to pushing them back BEYOND straight vertical; diagonally inward. Perhaps semantics but I DON'T mean it as pushing diagonally outward teeth 'a little'.

Not sure what Gunson meant my GUESS is that it could mean he wants to put bone 'paste' to the area. He did not use word 'paranasal' and he doesn't do rhinos. But he does put bone paste to the paranasal area (beside lower part of nose, beside nostril area.) The nose base is where it sounds like it is at the nose bottom the ANS helps support the nose base. I know they have implants that go under the entire nose base. So, maybe he wanted to put bone paste there.

[Breakingbad]

Retroclining refers to pushing them back BEYOND straight vertical; diagonally inward. Perhaps semantics but I DON'T mean it as pushing diagonally outward teeth 'a little'.

Sorry, I’m still not totally sure I understand. I’ve attached a diagram with 2 illustrations labelled A and B.

You’re saying “retroclining” would be A, where the incisors are pushed in so far they start to angle inward.

And “aligning straight down” would be B, where the incisors are pushed in to the point where they’re totally vertical.

Did I understand correctly?

Thanks for offering your guess regarding the nasal issue.

[kavan]

Sorry, I’m still not totally sure I understand. I’ve attached a diagram with 2 illustrations labelled A and B.

You’re saying “retroclining” would be A, where the incisors are pushed in so far they start to angle inward.

And “aligning straight down” would be B, where the incisors are pushed in to the point where they’re totally vertical.

Did I understand correctly?

Thanks for offering your guess regarding the nasal issue.

In the OPPOSITE direction in which your teeth are presently inclined.  Look at your OWN teeth and note the diagonally outward direction of them. So the OPPOSITE direction is what I mean. You don't need that diagram to refer to your OWN teeth and figure out what's the opposite direction of their present orientation.

ETA: Proclined incisors – The front teeth are excessively tipped outwards

Retroclined incisors – The front teeth are excessively tipped back

[Breakingbad]

In the OPPOSITE direction in which your teeth are presently inclined.  Look at your OWN teeth and note the diagonally outward direction of them. So the OPPOSITE direction is what I mean. You don't need that diagram to refer to your OWN teeth and figure out what's the opposite direction of their present orientation.

Makes good sense that that’s what “retroclining” would mean. But then, what would “aligning straight down” be in relation to that?

[kavan]

Makes good sense that that’s what “retroclining” would mean. But then, what would “aligning straight down” be in relation to that?

answer DECLINED. Figure it out.

[Breakingbad]

answer DECLINED. Figure it out.

Okay, I’ll try. Thanks for trying to explain.

[varbrah]

Occlusal plane is normal and your ANS is vertically aligned with your maxillary incisive edge (ideal). Soft tissue of the upper lip and nose are in balance. -4mm of nasal support isn't a huge deal. Gunson's genioplasty plan is perfectly sound, and he is absolutely correct that advancing the maxilla (as is) would look bad.

Have you gotten a sleep study done? Your airways look quite open based on your ceph, so you may not need DJS for OSA purposes. You should make sure.

If your goal is to maximize aesthetics, that's fine too. You currently don't have the necessary base for achieving your morph, so you will need extensive orthodontic preparation - expansion, extractions, braces, etc. - as the other surgeons laid out. Their plans are also sound.

IMO your choices are perfectly clear. What you need to decide is whether the incremental aesthetic benefits of DJS are going to be worth all of the extra trouble vs. genioplasty only.

[Breakingbad]

Thanks for replying varbrah.

Occlusal plane is normal and your ANS is vertically aligned with your maxillary incisive edge (ideal). Soft tissue of the upper lip and nose are in balance.

Hm. Good to know. That makes me wonder, though: If my ANS is in ideal vertical alignment with my maxillary incisive edge, then what the heck does the -4mm nasal support refer to? I was under the impression that this had a direct relation to the ANS, so this is new to me.

Gunson's genioplasty plan is perfectly sound, and he is absolutely correct that advancing the maxilla (as is) would look bad.

What's crazy is that I knew that from the beginning, yet all these top surgeons except for Gunson initially encouraged me to do jaw surgery without any orthodontic preparation. They all eventually admitted that doing orthodontics would deliver a better result, but only because I was persistent in explaining my concerns with doing that.

Have you gotten a sleep study done? Your airways look quite open based on your ceph, so you may not need DJS for OSA purposes.

I’ve had an at home one done, which came back negative, but I was told I should do an in-clinic study for a more accurate picture. I have an in-clinic study scheduled for next week. I'm set on doing jaw surgery for various reasons regardless of the result, though.

You currently don't have the necessary base for achieving your morph, so you will need extensive orthodontic preparation - expansion, extractions, braces, etc. - as the other surgeons laid out. Their plans are also sound.

I realize I need extractions and braces to push my anterior teeth back, but do you personally see a reason I would need expansion? Since I last posted to this thread, I saw Alfaro and Walline for a follow up consult, and I saw Dr. Sullivan in Oklahoma for an initial consult. All 3 of them said I didn't need expansion, so that leaves only Gunson that said I needed it. I guess Walline only went along with the idea initially because I questioned him so much on my maxillary width.

[Breakingbad]

Update:

I've had follow up consultations with Alfaro and Walline. I also saw a new doctor, Dr. Sullivan in Oklahoma.

Gums
My gum recession at my lower anterior teeth keeps coming up during consults. My understanding is that braces and jaw surgery (and maybe SFOT) are the solution. It's certainly not related to my oral hygiene--I brush and floss properly and thoroughly, and I always have very little plaque built up between cleanings. Attached are photos showing the current state of my gum recession.

Expansion
Alfaro, Sullivan, and Walline are all of the opinion that I don't need maxillary expansion. It seems that Walline initially went along with the idea only because I questioned him so much on my maxillary width. That leaves Gunson and Dr. Ting as the only ones who thought I needed expansion.

Orthodontics
Alfaro and Sullivan have added two new ideas.

Both of their ideas involve increasing my overjet.

Here's where they differ:

-Alfaro's idea is to extract all my wisdom teeth and then use that space to do "en masse" retraction of both my maxillary and mandibular teeth. He would retract the mandibular teeth more than the maxillary teeth though, to increase my overjet. No pre-molar extractions at all, just the wisdom teeth. Corticotomy might be used to speed up the process.

-Sullivan's idea is to leave my maxillary wisdom teeth intact, but extract lower premolars, and then retract my mandibular anterior teeth. He would leave my maxillary pre-molars intact though.

a: will you be retroclining my teeth or aligning straight down and if so, what's your estimate of the new nasial labial angle.
(measure your present one first--it's in the 90 deg. range). Better yet, just ask if your NLA will INCREASE

b: if my NLA increases too much due to new orientation of front teeth, is is possible to later get braces for a lips to rest on diagonal plane?

c: can you give me an idea of an approximate number of degrees of the CCW or approximate mm length of posterior downgraft used in the CCW

a and b  (if they tell you) will allow you to be poised for an increase in NLA and be poised to accept that as a trade off

c will give you an idea of what you could expect with the pog point projection as a function of degrees of ccw-r

I asked Alfaro and Sullivan these questions. Here's what they said:

Question A:
Alfaro - Both.
Sullivan - Both

I still am not confident I understand the difference between retroclining and aligning straight down, though. I've tried to understand, but again, I am not confident.

Question B:
Alfaro - Yes, but that won't happen so there won't be a need, as CCW-r will return the nasolabial angle to what it is now after the initial increase due to extractions/retraction.
Sullivan - Same as Alfaro

Question C:
Alfaro - Maybe 5, maybe 8, maybe 10. He doesn't know. It depends on how much I need based on the orthodontic result achieved. He disagrees that there is a "normal range" for the occlusal plane.
Sullivan - 4 degrees, subject to change post-orthodontics.


I would be grateful for any thoughts. I'm still trying to learn as much as I can about this.

[kavan]

......
 

I asked Alfaro and Sullivan these questions. Here's what they said:

Question A:
Alfaro - Both.
Sullivan - Both

I still am not confident I understand the difference between retroclining and aligning straight down, though. I've tried to understand, but again, I am not confident.

Question B:
Alfaro - Yes, but that won't happen so there won't be a need, as CCW-r will return the nasolabial angle to what it is now after the initial increase due to extractions/retraction.
Sullivan - Same as Alfaro

Question C:
Alfaro - Maybe 5, maybe 8, maybe 10. He doesn't know. It depends on how much I need based on the orthodontic result achieved. He disagrees that there is a "normal range" for the occlusal plane.
Sullivan - 4 degrees, subject to change post-orthodontics.


I would be grateful for any thoughts. I'm still trying to learn as much as I can about this.

When I say 'retrocline', I'm meaning the opposite of procline. Proclined teeth (gums too) are tilted diagonally outward (toward the lips) relative to a straight line vertical. The opposite of that; retroclined teeth (and gums too) are tilted diagonally inward (toward the roof of mouth).

Glad to hear they answered the proposed questions.