Advice needed on ceph / impaction / surgery plan

[TWGOAT]

Well, it's hard for them to be precise until an actual pre-surgical plan is charted out. With combined CCW anterior impaction + CW posterior impaction, anterior impaction , the rotation is net CCW if there is more anterior impaction than posterior impaction. If your maxilla was uniformly long both anteriorly and posteriorly and they removed a uniform segment from it, net rotation would be zero.

If the surgery is DJS where the maxilla is advanced after the combined impaction, there will be some gain in tooth show which was 'lost' from the anterior impaction. For example, if tooth show after anterior impaction was reduced by 5mm but the excess was 8mm, you wouldn't be left with 3, you would gain more than 3 as a function of the maxillary advancement. For every X mm of maxillary advancement, you gain Y mm of tooth show. There is no specific Y with each X because it's a function of the inclination of the maxilla (or Occlusal Plane) which is being advanced.

From my calculations, since i want at least to reach Soft Tissue Plane (STP), i need around 15mm maxillary advancement (with current retroclined incisors so i guess maybe 12-13mm in reality ?).

If i currently have  around 8-10mm tooth show at rest, and the 2nd surgeon says he wants to impact around 6mm in front, i wonder if he advances maxilla 12-13mm, how much tooth show i would have after. I know you say there is no specific Y with X but i guess i will see at the simulation. I know 2-4mm tooth show is considered ideal

Here is the pic i put with the STP and 15mm line at the maxilla, and 25mm line at the chin:

https://imgur.com/a/3rnGMya

[kavan]

From my calculations, since i want at least to reach Soft Tissue Plane (STP), i need around 15mm maxillary advancement (with current retroclined incisors so i guess maybe 12-13mm in reality ?).

If i currently have  around 8-10mm tooth show at rest, and the 2nd surgeon says he wants to impact around 6mm in front, i wonder if he advances maxilla 12-13mm, how much tooth show i would have after. I know you say there is no specific Y with X but i guess i will see at the simulation. I know 2-4mm tooth show is considered ideal

Here is the pic i put with the STP and 15mm line at the maxilla, and 25mm line at the chin:

https://imgur.com/a/3rnGMya

No confirmation of calculations and no idea if your surgeon is giving 15mm of advancement to maxilla. 4mm range of tooth show is good.

[TWGOAT]

No confirmation of calculations and no idea if your surgeon is giving 15mm of advancement to maxilla. 4mm range of tooth show is good.

I know, i hope he gives me over 10 ahah

[ArtVandelay]

You definitely need a modern surgeon who does large CCW with down-grafting.

[TWGOAT]

You definitely need a modern surgeon who does large CCW with down-grafting.

Both i saw yet have told me i'm not a case for downgraft due to the vertical maxillary excess.

My before profile is similar to this patient with the vertical excess, who achieved the maxillary CCW with impaction only. Difference is patient needed TJR.

So it seems possible to achieve enough rotation with the impaction only but why do you think i need downgraft absolutely ?

[ArtVandelay]

So it seems possible to achieve enough rotation with the impaction only but why do you think i need downgraft absolutely ?

I misspoke, you definitely need Counter-clockwise rotation since your occlusal angle allows it and your upper incisors are retroclined.

I'm not an expert so can't tell if you need posterior downgrafting or anterior impaction or a combination. Regardless see a modern surgeon anyway, because some don't perform downgrafting and they might recommend what they're comfortable with. So see someone who can perform any movement and will recommend what's best without skill limitations.

[kavan]

Both i saw yet have told me i'm not a case for downgraft due to the vertical maxillary excess.

My before profile is similar to this patient with the vertical excess, who achieved the maxillary CCW with impaction only. Difference is patient needed TJR.

So it seems possible to achieve enough rotation with the impaction only but why do you think i need downgraft absolutely ?

I told you similar. You have both anterior and posterior vertical excess whereas the latter negates CCW via posterior downgrafting. Also, I think, but not exactly sure, that another thing that might negate the CCW via PDG is a short ramus which you also have.  As to folks on here being 'absolutely sure' you 'need CCW' via PDG, we've been through that before. IMO, it's an 'auto-pilot' thing where people just see a lower jaw that needs to come forward a lot and automatically 'equate' that with CCW PDG whereas that is not always the case due to some factors that negate the PDG (eg. excess posterior maxilla in addition to excess anterior maxilla).

Where did you get the photo/s that look JUST LIKE you? Anyway, what to notice is that the ramus was made LONGER. But I don't know how to ID a TJR from an X ray which is why I'm asking where you got the photo of someone who had similar start point as you. Like WHICH doctor's website, if any, can this be found?

[TWGOAT]

I told you similar. You have both anterior and posterior vertical excess whereas the latter negates CCW via posterior downgrafting. Also, I think, but not exactly sure, that another thing that might negate the CCW via PDG is a short ramus which you also have.  As to folks on here being 'absolutely sure' you 'need CCW' via PDG, we've been through that before. IMO, it's an 'auto-pilot' thing where people just see a lower jaw that needs to come forward a lot and automatically 'equate' that with CCW PDG whereas that is not always the case due to some factors that negate the PDG (eg. excess posterior maxilla in addition to excess anterior maxilla).

Where did you get the photo/s that look JUST LIKE you? Anyway, what to notice is that the ramus was made LONGER. But I don't know how to ID a TJR from an X ray which is why I'm asking where you got the photo of someone who had similar start point as you. Like WHICH doctor's website, if any, can this be found?

Yes i know we discussed it before, i'll ask the next surgeon the same question anyway to see how much rotation can be achieved with the impaction.

As for the photos, it's from a patient on a jaw surgery facebook group. You can see the TJR / prosthetic on the picture in white

But yes the ramus was made longer with the prosthetic, it's just that her before profile and ceph look really similar to mine so i found it interesting to compare

I brought this pic to the surgeons and they said my condyles are big enough and not resorbing so i don't need replacement.

[kavan]

I wonder if you could get the TJR for aesthetic purposes.

[TWGOAT]

Well, technically with AOB there are 2 occlusal planes. I'm getting in the approx range of about 13 degrees for the singular maxillary OP. So, it would be the maxillary OP being reduced by about 3 deg. But consider, that's done for the lower jaw to go on the upswing to close the AOB.

in Webceph it says my occlusal plane is 20 degrees, you think that's calculated with the open bite ?

Can you show me how you got 13 of maxillary OP ?

13 to 10 sounds better than 20 to 17 ahah, since i think optimal is around 7-8 ?

Second surgeon said he would probably impact more than 5mm but didn't give me any specific numbers, so should reduce OP even more.

I'll ask the third surgeon to be more precise

[kavan]

in Webceph it says my occlusal plane is 20 degrees, you think that's calculated with the open bite ?

Can you show me how you got 13 of maxillary OP ?

13 to 10 sounds better than 20 to 17 ahah, since i think optimal is around 7-8 ?

Second surgeon said he would probably impact more than 5mm but didn't give me any specific numbers, so should reduce OP even more.

I'll ask the third surgeon to be more precise

My entry as to the OP was made on Dec 11 when I looked at the OP to approximate via hand held protractor. So, not up to the task of going back to your cephs, measuring with hand held protractor to show you how I arrived at my approximation. It would involve me doing it all over again. Not to mention you are asking for such regarding the same DAY a lot of stuff on this string was deleted. So, no issue if  Webceph kicked up something different if you want to resolve to that.

[TWGOAT]

My entry as to the OP was made on Dec 11 when I looked at the OP to approximate via hand held protractor. So, not up to the task of going back to your cephs, measuring with hand held protractor to show you how I arrived at my approximation. It would involve me doing it all over again. Not to mention you are asking for such regarding the same DAY a lot of stuff on this string was deleted. So, no issue if  Webceph kicked up something different if you want to resolve to that.

No worries ahah, i think like you said the webceph OP is probably higher due to the open bite and mandible OP being bigger, but not the maxillary OP which is more relevant given the open bite.

[TWGOAT]

My entry as to the OP was made on Dec 11 when I looked at the OP to approximate via hand held protractor. So, not up to the task of going back to your cephs, measuring with hand held protractor to show you how I arrived at my approximation. It would involve me doing it all over again. Not to mention you are asking for such regarding the same DAY a lot of stuff on this string was deleted. So, no issue if  Webceph kicked up something different if you want to resolve to that.

Hey Kavan,

Discussed with a user on reddit who has been researching surgery for a long time, and he says he doesn't see why i wouldn't get posterior downgraft.

He compared the CCWr movement to this procedure in terms of degrees : https://www.youtube.com/watch?v=Eb2jSQLWnGY&list=PL41DE318030DD6523&index=59

He says i would have suboptimal result with impaction. I know you said normally with maxillary excess impaction is the way to go like the 2 consults i had already, but the guy says since in Canada nobody does downgraft, they necessarily won't offer to do it.

Do you think i should get an online consult with Alfaro to be sure ?

[kavan]

Hey Kavan,

Discussed with a user on reddit who has been researching surgery for a long time, and he says he doesn't see why i wouldn't get posterior downgraft.

He compared the CCWr movement to this procedure in terms of degrees : https://www.youtube.com/watch?v=Eb2jSQLWnGY&list=PL41DE318030DD6523&index=59

He says i would have suboptimal result with impaction. I know you said normally with maxillary excess impaction is the way to go like the 2 consults i had already, but the guy says since in Canada nobody does downgraft, they necessarily won't offer to do it.

Do you think i should get an online consult with Alfaro to be sure ?

Sure, you can consult with Alfaro. Be sure to establish from him HOW the case in the YT video, where the guy got a MASSIVE posterior downgraft and also somewhat of a downgraft to anterior maxilla RELATES to YOURS. I would be most curious if he offered someone (like you) who starts with excess anterior gum show and excess front tooth show in addition to excess POSTERIOR GUM SHOW, a similar surgery as shown on the YT video....and by the way...this will be the last time I engage in a 'cross pollination' question based on stuff kicked up on another board.

[TWGOAT]

Saw the ortho yesterday, he took pictures and made a quick analysis / treatment / morph on his program (similar to webceph), minimum movements for optimal results were 5mm maxillary advancement and 20mm chin advancement. That was with a 7.8 degree CCWr