Failed CCW rotation

[dailydave]

It looks like my jaw is just at steep as before, if not even more, despite ccw rotation. What’s the issue here? My jawline has actually gotten worse after surgery and I still have a class II profile. Based on measurements I got around 11-13mm advancement at lower jaw + 6mm genioplasty and then a second round of genioplasty with +4mm and it still looks bad. When the Xray was takem I was still swollen from 2nd genio so recession is not that visible.

Before: https://ibb.co/4FJHYjT
After: https://ibb.co/23PwjrD

[kavan]

With reference to the after cephs, I don't see any aesthetic 'failure' in the outcome. I see an improvement. The Mandibular plane angle (MPA) in the after from where it is measured (with reference to the horizont) has decreased and the profile line up (with reference to a vertical) has improved and is within an aesthetic norm.

With reference to what people have in their 'mind's eye' that they want to see in the mirror, that is beyond me to measure/compare with points, angles and planes, and not something I can opine on. What I can say here is that the after ceph shows an improvement that is within the aesthetic norms of aesthtic balance

The main failure I noticed here is that the before ceph is (CCW) rotated away from the horizontal and vertical planes as if a PHOTO of the before ceph was chosen for this presentation. The after ceph is aligned with the vertical and horizontal planes. That is to say, the ceph stat in the after is aligned with the vertical plane of the after photo but the ceph stat in the before is rotated in CCW direction away from the vertical plane. None the less, when this was compensated for, the MPA was REDUCED by about 4 degrees.

The after ceph seems to show that the look of CCW-r was achieved mainly via somewhat of a CCW 'twist' of the mandible itself and a sliding genio (outward horizontally and upward vertically which is a technique they can use to give more of the look of CCW especially in a case where the CCW-r is ANTERIOR IMPACTION and there is only so much anterior impaction that can be done without the upper teeth disappearing. Basically CCW-r to the maxilla, ANY KIND, will only reduce the MPA by the same amount, NOT MORE than that. So, if the MPA is excessively steep and that steepness exceeds the the CCW-r done to the maxilla, CCW-r to the maxilla won't reduce all of it. Geometrically impossible.

So, what's the issue here? You are using cephs to talk about things you see in the MIRROR that you don't like which are not seen in the cephs. The after ceph shows an improvement with reference to your starting anatomy. I would not suggest or encourage any more revisions.

[GJ]

The position does look objectively better after.

[dailydave]

With reference to the after cephs, I don't see any aesthetic 'failure' in the outcome. I see an improvement. The Mandibular plane angle (MPA) in the after from where it is measured (with reference to the horizont) has decreased and the profile line up (with reference to a vertical) has improved and is within an aesthetic norm.

With reference to what people have in their 'mind's eye' that they want to see in the mirror, that is beyond me to measure/compare with points, angles and planes, and not something I can opine on. What I can say here is that the after ceph shows an improvement that is within the aesthetic norms of aesthtic balance

The main failure I noticed here is that the before ceph is (CCW) rotated away from the horizontal and vertical planes as if a PHOTO of the before ceph was chosen for this presentation. The after ceph is aligned with the vertical and horizontal planes. That is to say, the ceph stat in the after is aligned with the vertical plane of the after photo but the ceph stat in the before is rotated in CCW direction away from the vertical plane. None the less, when this was compensated for, the MPA was REDUCED by about 4 degrees.

The after ceph seems to show that the look of CCW-r was achieved mainly via somewhat of a CCW 'twist' of the mandible itself and a sliding genio (outward horizontally and upward vertically which is a technique they can use to give more of the look of CCW especially in a case where the CCW-r is ANTERIOR IMPACTION and there is only so much anterior impaction that can be done without the upper teeth disappearing. Basically CCW-r to the maxilla, ANY KIND, will only reduce the MPA by the same amount, NOT MORE than that. So, if the MPA is excessively steep and that steepness exceeds the the CCW-r done to the maxilla, CCW-r to the maxilla won't reduce all of it. Geometrically impossible.

So, what's the issue here? You are using cephs to talk about things you see in the MIRROR that you don't like which are not seen in the cephs. The after ceph shows an improvement with reference to your starting anatomy. I would not suggest or encourage any more revisions.

Thank you for your answer!

The reason why I thought this was a failed ccw is mainly because right after surgery my ceph looked like this:

https://imgur.com/a/8F4OFVO

It seems like the lower jaw didn’t rotate entirely with the upper one.This open bite (which I never had before surgery) was resolved later with elastics, however the part of the mandible which was moved seemed to remain in that steep, open bite position.

This is how I look now 1 year post op and genio revision:

https://imgur.com/a/Tt41CVR

I think, objectively, this would be still classified as a Class II appearence.

[kavan]

Thank you for your answer!

The reason why I thought this was a failed ccw is mainly because right after surgery my ceph looked like this:

https://imgur.com/a/8F4OFVO

It seems like the lower jaw didn’t rotate entirely with the upper one.This open bite (which I never had before surgery) was resolved later with elastics, however the part of the mandible which was moved seemed to remain in that steep, open bite position.

This is how I look now 1 year post op and genio revision:

https://imgur.com/a/Tt41CVR

I think, objectively, this would be still classified as a Class II appearence.

I think your result looks well within normative and/or good aesthetics. The BSSO advancement on the scan looks significant and the chin is vertically up and horizontally outward for CCW look. Although larger BSSO advancements are possible with the posterior downgraft CCW and the the more rotation, the more they can decrease the Mandibular plane angle (MPA). But when the CCW-r is via impaction only, the MPA decrease can only be proportional to the extent of the impaction. When I looked, you got in venue of about 4 degrees decrease in MPA.

So, ya, 4 degrees is less than reduction of MPA and less advancement than a 15 degree posterior downgraft. But not everyone is a candidate for that just because it's mentioned a lot on here. The fact that you got somewhat of an anterior open bite (AOB) afterwards tells me that you would have much MORE of one if you got a large rotation via CCW-r posterior downgraft which would mean the doctor worked within the LIMITATIONS of what could be done and you were not a candidate for a large CCW-r posterior downgraft. So, not being a candidate for a large rotation via CCW-posterior downgraft does not make it a 'failed CCW'.

Class 2 appearance is overly convex profile. You don't have that. Your appearance is ORTHOGNATIC as in jaws in good balance. 'Orthognatic' does not always mean prominent lower jaw or low side of spectrum of MPA.

[dailydave]

I think your result looks well within normative and/or good aesthetics. The BSSO advancement on the scan looks significant and the chin is vertically up and horizontally outward for CCW look. Although larger BSSO advancements are possible with the posterior downgraft CCW and the the more rotation, the more they can decrease the Mandibular plane angle (MPA). But when the CCW-r is via impaction only, the MPA decrease can only be proportional to the extent of the impaction. When I looked, you got in venue of about 4 degrees decrease in MPA.

So, ya, 4 degrees is less than reduction of MPA and less advancement than a 15 degree posterior downgraft. But not everyone is a candidate for that just because it's mentioned a lot on here. The fact that you got somewhat of an anterior open bite (AOB) afterwards tells me that you would have much MORE of one if you got a large rotation via CCW-r posterior downgraft which would mean the doctor worked within the LIMITATIONS of what could be done and you were not a candidate for a large CCW-r posterior downgraft. So, not being a candidate for a large rotation via CCW-posterior downgraft does not make it a 'failed CCW'.

Class 2 appearance is overly convex profile. You don't have that. Your appearance is ORTHOGNATIC as in jaws in good balance. 'Orthognatic' does not always mean prominent lower jaw or low side of spectrum of MPA.

Thank you kavan!

Please let me ask one more question.
This was me after DJS but before my 2nd genio. Why the area within the circle is so steep?:

https://ibb.co/j6Hrry3

This is the before surgery pic:

https://ibb.co/X3VCgy9

It was obviously less steep before the surgery. How is that possible, ccw shoudl have done the exact opposite. I just don’t get it.

Thsi was the plan but I’m sure the final results is not the same:

Plan: https://ibb.co/41k4dTm
Final result: https://ibb.co/BV474rc

I believe that MPA decreased because of the upward genio movement but it looks like the opposite for the part of the mandible that was moved.

[kavan]

Thank you kavan!

Please let me ask one more question.
This was me after DJS but before my 2nd genio. Why the area within the circle is so steep?:

https://ibb.co/j6Hrry3

This is the before surgery pic:

https://ibb.co/X3VCgy9

It was obviously less steep before the surgery. How is that possible, ccw shoudl have done the exact opposite. I just don’t get it.

Thsi was the plan but I’m sure the final results is not the same:

Plan: https://ibb.co/41k4dTm
Final result: https://ibb.co/BV474rc

I believe that MPA decreased because of the upward genio movement but it looks like the opposite for the part of the mandible that was moved.

The MPA (mandibular plane angle) is measured from a line drawn from a point in the chin  to a point in back of jaw relative to a horizontal plane. The term 'steepness' is in reference to the MPA. It isn't used to describe the type of indent you have between the points of the jaw line the MPA is measured.

Your before photo shows a SIMILAR INDENT. So, if you start with an indented area between the back angle of the jaw and the part of the chin the MPA is measured, a BSSO is NOT going to make that go away. Nor is a revision genio.

The reason you 'don't get it' most likely is because you didn't observe you started with an indented area between your gonial angle and your chin.

You probably could try some soft tissue filler to the area to stream line the lower border of the mandible.

Again, you started with a minor indent to the lower border of the mandible. Look again on your before photo.

ETA: The word for what you started with is an 'antegonial notch' (an indent in front of the gonial angle). So, BSSO jaw advancement whether or not it's CCW, is not going to fill that notch in or make it go away. It can make it more visible.

[dailydave]

Thank you kavan! I understand this. What I don’t understand is why after a ccw rotation with impaction + posterior downgrafting my whole face appears longer and why the border of the lower jaw got steeper. I thought the exact opposite was expected to happen. I attached two pics to show what I mean:

Before: https://ibb.co/0Q8Cwvn
After: https://ibb.co/y8Jq3Qm

I can clearly see that the upper jaw was rotated.Remember that I had an anterior open bite right after surgery which was only fixed with elastics so technically, skeletally my jaw is still in that open bite position. My theory is that the surgeon did everything according to plan but condylar sagging or muscular relapse happened as soon as I woke up, so it pulled my lower jaw and I think that should have been fixed as soon as I woke up from surgery.

[kavan]

Thank you kavan! I understand this. What I don’t understand is why after a ccw rotation with impaction + posterior downgrafting my whole face appears longer and why the border of the lower jaw got steeper. I thought the exact opposite was expected to happen. I attached two pics to show what I mean:

Before: https://ibb.co/0Q8Cwvn
After: https://ibb.co/y8Jq3Qm

I can clearly see that the upper jaw was rotated.Remember that I had an anterior open bite right after surgery which was only fixed with elastics so technically, skeletally my jaw is still in that open bite position. My theory is that the surgeon did everything according to plan but condylar sagging or muscular relapse happened as soon as I woke up, so it pulled my lower jaw and I think that should have been fixed as soon as I woke up from surgery.

I gave you my explanation and reasoning. I did not measure it as steeper. When I measured via the CORRECT landmark points, your MPA was LESS steep than start. Your measures don't use the correct points to measure the MPA and I 'm not up to giving a tutorial on how to measure. I shall leave you with your own assesments.

[dailydave]

I gave you my explanation and reasoning. I did not measure it as steeper. When I measured via the CORRECT landmark points, your MPA was LESS steep than start. Your measures don't use the correct points to measure the MPA and I 'm not up to giving a tutorial on how to measure. I shall leave you with your own assesments.

“ Anterior open-bite is the most common undesirable dental outcome post-operatively and may be due to (1) Central condylar sag, (2) Improper positioning of the maxilla intraoperatively or (3) Excessive muscular forces.”

I immediately developed an anterior open bite after surgery which I never had before, so I guess this means that even if I had proper lower rotation during surgery, it rotated back CW as soon I woke up.

I understand and agree with you that the MPA improved. But it looks like it was solely achieved by the genioplasty only and not the ccw, as that part of the mandible which was moved (not the chin part) is just as steep (or eves steeper) as before, which I think is not ideal.

[GJ]

“ Anterior open-bite is the most common undesirable dental outcome post-operatively and may be due to (1) Central condylar sag, (2) Improper positioning of the maxilla intraoperatively or (3) Excessive muscular forces.”

See another surgeon (or two) and ask which of these caused it. It looks to me a problem with the lower jaw position, either (2) or (1).

[kavan]

“ Anterior open-bite is the most common undesirable dental outcome post-operatively and may be due to (1) Central condylar sag, (2) Improper positioning of the maxilla intraoperatively or (3) Excessive muscular forces.”

I immediately developed an anterior open bite after surgery which I never had before, so I guess this means that even if I had proper lower rotation during surgery, it rotated back CW as soon I woke up.

I understand and agree with you that the MPA improved. But it looks like it was solely achieved by the genioplasty only and not the ccw, as that part of the mandible which was moved (not the chin part) is just as steep (or eves steeper) as before, which I think is not ideal.

As I said in my prior comments, the fact that you had AOB after the surgery (however, it was corrected with ortho) conveys that you were not a good candidate for any more CCW than you already had. The CCW you got which was not a whole lot (because you had a limitation) allowed for more of a BSSO advance than normal if you had not had any CCW and when one measures the MPA using the correct points, your MPA was made about 4 degrees less. with help of the type of genio you got. Your soft tissue profile after photos look much BETTER. This could be from unrealistic expectations from the term 'CCW'.

[dailydave]

One more question just popped into my mind. If there was truly a proper rotation of the lower jaw (without immediate relapse after surgery) then how is that possible that my chin, now after DJS + genio + another genio, is still at the same height like before jaw surgery. I put a ruler there to demonstrate. .

However in may case the rotation is invisible. My jawline is even steeper than before and they tried to camouflage it with the upward chin movement. It looks like all the minimal improvement in my case comes from the genioplasty:

https://ibb.co/Kw33s7Y
https://ibb.co/tB313mT

When I say rotation, I think of something like this: https://ibb.co/JpngHZY

There you can see that the whole mandible rotated properly not just camouflaged the non existing rotation with upward genio movement.

[kavan]

I've spent time on this, said what I had to say. It's not getting anywhere with this. I'll leave you to your own assessments.