jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: beyondconfusedtbh on June 30, 2018, 04:04:53 AM
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Hi all,
I'll be getting SARPE pretty soon which is all well and good, but i'm concerned about formulating a plan for the bimax.
I'd love to get some of your opinions on this.
Up until now I thought the best thing for me would be some sort of maxillary advancement plus posterior downgrafting to achieve CCW.
Is this a good plan? I've just been reading up on a few cases on here & found some incredibly helpful material as usual, so i'll put it below just for reference. Thanks everyone :)
It could be that the steep occlusal plane is what's making your face look longish and the downgrafted posterior maxilla will actually make your face appear shorter since the CCW rotation would be achieved, because what you see is the front of your face, and the convex profile is part of what gives people "long faces." Also note that as I mentioned in my previous post, maxillary advancement will add to tooth show (gumminess) because you are stretching the soft tissues, so impaction would be performed to offset this.
If you think about a face from profile view and create three vertical sections: back, middle and front... the middle would then be lengthened but the front would be shortened... like a maxillary teeter-totter. And when you talk about a long face, you're talking about the front.
This is how I understand it anyway.
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What's going on in your x ray...are those white globs impacted teeth?
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sadly yeah. the plan is to remove one of the wisdom teeth so that there's an even amount.
I know my upper jaw is completely screwed up but I do have a somewhat steep occlusal plane right? Ignoring the fact that the teeth are lower at the back of my maxilla on the profile.
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Wow is my xray that bad, f**k
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From what I understand, if your head is not tilted up in your profile xrays, then your occlusal plane would be flat and you mandibular plane, steep. If you did CCW, your occlusal plane would be going up, which would be weird. I am not a pro tho.
Whar are your reasons to getting bimax?
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I know my upper jaw is completely screwed up but I do have a somewhat steep occlusal plane right? Ignoring the fact that the teeth are lower at the back of my maxilla on the profile.
The steepness of the occlusal plane is literally defined as how much higher (or lower) the the teeth at the back of your maxilla are than the teeth at the front. "Ignoring the fact that the teeth are lower at the back of my maxilla" would be like asking "Does my jaw lack forward growth? Please ignore how far forward my jaw is."
Also, if that x-ray is natural head posture, your occlusal plane is anything but steep. Why do you think you need CCW (other than that everyone throws around the terms like it's some godly solution to all cephalometric imbalances)? If anything, you'd need CW (assuming NHP).
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Your profile looks normal.
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Yeah my heads tilted. Thats just how they had me rest my head on the machine. I have the classic convex profile going on so I guess hopefully the angle of the occlusal plane on the x-rays is where i'll be at.
My bad, certainly should've thought about that and put it in my original post.
Now with that out of the way, anyone want to give advice on my current plan of action?
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oh yeah, about this posterior downgrafting thing.
read that its kind of like tilting your head back on another post. 'kind of' does not mean 'the same as' in this case, does it?
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What do you want to achieve? Why do you want bimax? Weren't you considering lf3? With just the xrays man, your profile seems normal to me.
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If you were that tilted in the scan, you're going to need to post a photo in your NHP... none of these members can really help you otherwise.
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What do you want to achieve? Why do you want bimax? Weren't you considering lf3? With just the xrays man, your profile seems normal to me.
I guess my main goal is to compensate for a lack of development during my teens. More specifically, a shorter midface & more forward growth. Thanks though, although like i said I'm fairly certain my head was tilted a bit. Thats just how they had me sat for the CT.
Regarding MLFIII, I have a couple threads on that but i'll sum it up real quick (TLDR):
Face grew down rather than out (to some degree at least, maybe not quite as severe as other cases) resulting in hypoplasia of mid-face. Together the lack of forward growth of my jaws coupled with the lack of development of orbital area etc look 'okay' on an x-ray I guess, but thats just because they're both lacking.
And perhaps most glaringly of all, it's still not taking into account the fact that my head is tilted (my fault but if you rotate the profile slightly you'll understand).
Thanks everyone for the help so far, sorry for causing this confusion
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Your jaw is rather robust and makes about a 20 degree angle from the horizont. So it is NOT 'too steep'. Would not be considered steep at all.
I don't see aesthetic need for double jaw advancement. Your face looks pretty forward. You don't have 'convex' profile.
I would be more concerned about increasing the risk of a fracture when getting the wisdom (impacted lower) teeth removed during the same surgery as a BSSO.
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Your jaw is rather robust and makes about a 20 degree angle from the horizont. So it is NOT 'too steep'. Would not be considered steep at all.
Heads tilted back :/
It's possible I walk around like this but I have forward head posture or whatever its called, been working on bad posture habits from years of sitting etc I have all the usual bad habits.
Don't worry about the impacted lowers, I think the Dr. was considering removing them during the SARPE surgery.
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Heads tilted back :/
It's possible I walk around like this but I have forward head posture or whatever its called, been working on bad posture habits from years of sitting etc I have all the usual bad habits.
Don't worry about the impacted lowers, I think the Dr. was considering removing them during the SARPE surgery.
Head tilt here is not significant. Salient point is your mandibular plane angle is NOT steep.
I understand that you are confused about things. But when speaking of a 'plan' in the same mention where you are getting surgery, what precludes you from clarifying what is actually PLANNED for the surgery you are getting?
If the doctor will be removing the impacted lower wisdom teeth during a SARPE surgery (which is fine), why did you toss a BSSO and everything else into the mix?
Establish WHAT the surgical plan actually is for the surgery you are booked for.
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Well first off I think my surgeon agreed my head was tilted in the xray, and he examined my face again there itself. This probably influenced the following.
For the bi-max we agreed on rotation done through anterior impaction & posterior downgrafting + advancement (of maxilla mainly) but I was told it'd be easier to focus on it after the SARPE :/
I'm really confused right now. I have such a long & narrow midface, can this just not be treated in my case?
How on earth could i have such a disproportionately long midface and a perfectly fine occlusal plane?
If this is of any valuable information I had some s**tty orthodontic treatment when I was younger (braces).
Also, I'm struggling to understand the whole tilt thing kavan. See attached
PS: surgeon in question also recommended ZSO (obviously must take it with a grain of salt) But after seeing the bone cuts I'm not sure if it'd produce a good effect. Should I consider it in conjuction with HA paste? Anyone got any experience?
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I've been reading up + trying to figure this stuff out but idk if im getting anywhere.
Can I still get impaction & shorten my midface? Someone clue me in because I feel like an idiot right now.
Thanks everyone who's helped so far, its greatly appreciated.
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Most of "midface length" is the nose, which cannot be shortened.
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I'm aware of that, but as others have stated a good fix to 'long face' is through the means i stated.
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Can I private message one of you some pictures? I understand you’re all busy but perhaps it’d be easier to explain for both parties.
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Well first off I think my surgeon agreed my head was tilted in the xray, and he examined my face again there itself. This probably influenced the following.
For the bi-max we agreed on rotation done through anterior impaction & posterior downgrafting + advancement (of maxilla mainly) but I was told it'd be easier to focus on it after the SARPE :/
I'm really confused right now. I have such a long & narrow midface, can this just not be treated in my case?
How on earth could i have such a disproportionately long midface and a perfectly fine occlusal plane?
If this is of any valuable information I had some s**tty orthodontic treatment when I was younger (braces).
Also, I'm struggling to understand the whole tilt thing kavan. See attached
PS: surgeon in question also recommended ZSO (obviously must take it with a grain of salt) But after seeing the bone cuts I'm not sure if it'd produce a good effect. Should I consider it in conjuction with HA paste? Anyone got any experience?
Yes, INDEED, it would be EASIER for you to focus on the bimax AFTER the SARPE.
In fact because you are indeed 'beyond confused', you need to focus on ONLY the surgery you are planning on getting FIRST and not be throwing wrenches into the gears regarding multiple surgery possibilities.
If you are FIRST getting SARPE, that should address SOME narrowness to the face. Your (potential) satisfaction with some improvement from THAT should engender some confidence in the surgeon doing more things later down the line. This ASSUMES it would be the SAME surgeon.
IF other things are to be done with different surgeons, it's just tossing MORE wrenches into the gears of your understanding to start pondering them now.
For now, just focus on what you are BOOKED for sugery.
There is a fine line between 'beyond confused' to 'beyond help' if you keep TOSSING IN more complex things with 'who knows who' doctors and in the absence of photos in the FLESH and other typle information as to which doctors. Such photos should be posted on the boards or ask GJ if you can get access to private section of board if you are SHY about open postings of your photos.
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Yeah you're right, I'll forget about bimax for now & focus on the surgery at hand. Thanks kavan :)
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Yes. Do things gradually that CAN be done gradually in SEPARATE surgeries.
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Thanks, I still have one question though. How is it that SARPE has an effect ‘externally’ on the face?
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Thanks, I still have one question though. How is it that SARPE has an effect ‘externally’ on the face?
Time to put on your thinking cap to answer this question for yourself. Think about it. You can do it.
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Time to put on your thinking cap to answer this question for yourself. Think about it. You can do it.
From my understanding these are the (potential, as some may not be noticeable) changes:
Smaller buccal corridors meaning i'll have a fuller smile.
Will fill out upper part of my cheeks a bit
Widen the base of nose & cheekbones*
Slight CW rotation of the maxilla*
The first two are fairly obvious but the last two I'm not entirely sure about, it would make sense that there would perhaps be a slight change to the nose & cheekbones but I can't see it being even SLIGHTLY noticeable. Maybe it just depends on the extent of the expansion.
Anyway, feel free to correct me if I'm mistaken.
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From my understanding these are the (potential, as some may not be noticeable) changes:
Smaller buccal corridors meaning i'll have a fuller smile.
Will fill out upper part of my cheeks a bit
Widen the base of nose & cheekbones*
Slight CW rotation of the maxilla*
The first two are fairly obvious but the last two I'm not entirely sure about, it would make sense that there would perhaps be a slight change to the nose & cheekbones but I can't see it being even SLIGHTLY noticeable. Maybe it just depends on the extent of the expansion.
Anyway, feel free to correct me if I'm mistaken.
Let's start with WHY you are getting the surgery and what your surgeon told you this would do.
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Widen the base of nose & cheekbones*
...
The first two are fairly obvious but the last two I'm not entirely sure about, it would make sense that there would perhaps be a slight change to the nose & cheekbones but I can't see it being even SLIGHTLY noticeable. Maybe it just depends on the extent of the expansion.
Anyway, feel free to correct me if I'm mistaken.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5655960/
The widening of the nose could definitely be noticeable.
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Let's start with WHY you are getting the surgery and what your surgeon told you this would do.
I currently have a pretty narrow palate, can't fit my tongue of the roof of my mouth & have a cross bite on the left side + some malocclusion (due to prior orthodontic treatment.)
I asked Dr. Z if these problems could be addressed while I was explaining my reasons for Bi-max. He told me that these issues should be solved PRIOR to bi-max, and then recommended SARPE + orthodontic treatment post op.
Obviously the impacted wisdom tooth on the upper jaw would be addressed further down the line (if that's even relevant at all)
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If I was to just summarise I guess the SARPE would be in the interest of creating more room in my mouth (smaller buccal corridors) & setting the teeth up to be aligned later on down the line.
This is why I was asking about the other aesthetic implications, as they're more than welcome (well maybe not the nose thing but there's preventions/ solutions) but they were not the focal point during my consultation & so I did not ask about them.
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If I was to just summarise I guess the SARPE would be in the interest of creating more room in my mouth (smaller buccal corridors) & setting the teeth up to be aligned later on down the line.
This is why I was asking about the other aesthetic implications, as they're more than welcome (well maybe not the nose thing but there's preventions/ solutions) but they were not the focal point during my consultation & so I did not ask about them.
Yes.
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okay so lets call these
Will fill out upper part of my cheeks a bit
Widen the base of nose & cheekbones*
Slight CW rotation of the maxilla*
side effects
Is there any way of pushing FOR the CW rotation? What bit of SARPE even causes this tbh
Also, while almost completely irrelevant to me I was curious about this procedure:
https://www.youtube.com/watch?v=S8TQa4c1D9g (https://www.youtube.com/watch?v=S8TQa4c1D9g)
Is this like a more dated sarpe? wtf are those things they insert in between the gaps?
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okay so lets call these
side effects
Is there any way of pushing FOR the CW rotation? What bit of SARPE even causes this tbh
Also, while almost completely irrelevant to me I was curious about this procedure:
https://www.youtube.com/watch?v=S8TQa4c1D9g (https://www.youtube.com/watch?v=S8TQa4c1D9g)
Is this like a more dated sarpe? wtf are those things they insert in between the gaps?
Sorry. Can't advise you on how to push for something (clockwise rotation) where it's not clear to me you know what you are requesting and why. All I can suggest to that regard is that you confirm you want Clockwise rotation and demonstrate your reasoning for wanting it. When you know what you want and why, it becomes easier to discuss different displacement possibilities with the attending surgeon.
As to the VIDEO. SARPE and SARME are the same thing. In SARPE, the 'P' stands for Palate and in SARME, the 'M' stands for Maxilla. 'P'= 'M' as in different words for same thing.
HOWEVER, as to the video it is showing a 3 piece Lefort 1 to a recessed and narrow maxilla/palate. The things between the gaps are BONE BUTTRESS material so the openings made don't close.
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Once again I've been thinking about this in completely the wrong way.
So I want CW rotation (as another user pointed out) because my occlusal plane is a little too flat. I have NO IDEA why I didn't think to just ASK my surgeon about this as if it were some random uncontrollable outcome.
Sorry lol
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You need to ascertain WHAT displacement(s) you are getting and not confuse yourself more with videos of what you might not be getting in your surgery such as the prior video. This video, is probably what you are getting. But only YOU can ascertain FROM your doctor what will be done in terms of displacements. https://www.youtube.com/watch?v=aNngGPuA4ho
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Thanks for your concern, yet again I probably mislead you by posting that video but rest assured I'm aware that I'm getting SARPE with a distraction device that I'll turn myself follower by braces --> power rails etc etc
My only concern came from the fact that I thought I MIGHT as a SIDE EFFECT get some CW ROTATION (although desirable), but as you pointed out my worry stemmed from me not asking my surgeon to fully explain his plan for the surgery.
tldr: I was focusing on the SARPE and not looking into what the proposed SARPE actually entailed
thanks again :)
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Thanks for your concern, yet again I probably mislead you by posting that video but rest assured I'm aware that I'm getting SARPE with a distraction device that I'll turn myself follower by braces --> power rails etc etc
My only concern came from the fact that I thought I MIGHT as a SIDE EFFECT get some CW ROTATION (although desirable), but as you pointed out my worry stemmed from me not asking my surgeon to fully explain his plan for the surgery.
tldr: I was focusing on the SARPE and not looking into what the proposed SARPE actually entailed
thanks again :)
Glad I was helpful. thanx
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Reviving this.
Since head tilt doesn't effect the actual shape of the skull I tried calculating the SNA angle (pic attached)
The mean value of this angle is 82+-2 degrees, I got ~68 degrees. So I have retrognathia of my maxilla and by extension my mandible also needs advancing. AKA my profile is not fine & there IS reason to have an advancement.
Please let me know if there's any gaps in my knowledge/ a flaw in my conclusion (especially if the S point I've used is accurate, had a hard time finding the sella.)
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To me it looks like my sella is strangely positioned when compared to the anatomical 'norm' & that could be skewing the results. That's just my analysis though. Regardless, I assume this positioning signals that there is something not exactly correct about my skeletal development.
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Yes. There would be gaps if you did not know:
a: The A point is about 4 degees ahead of where you put it. So, SNA approx 72
b: Where the B point would be. SNA= SNB=72 (approx), therefore ANB=0
c: That when ANB=0, the 'Wits analysis' number would also be 0
d: That a Wits number of 0 is class 1 class= balance between both jaws
e: That your SN line being 20 degrees away from a horizont is in EXCESS of the norm.
Although I don't know exactly what the norm for SN line relative to horizont is, it could be around 10 degrees. So, an approx 10 degree deviation of the SN norm would account for SNA being 72 when the SNA norm is about 82.
In essence the deviation from the norm inclination of the SN line relative to a horizont would account for the deviation your SNA has from the norm.
Factoring the deviation and the Wit's # in, this would be considered class 1 skeletal BALANCE and NOT an indication to advance either the maxilla or mandible or both.
Outside of that the salient observation to make which is 'intuitively obvious' to a lot of people and in the absence of knowing anything about these points IS there is GOOD BALANCE to the jaws and harmony to the profile.
That is a sufficient # of gaps for me to fill in.