jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: TWGOAT on December 08, 2021, 03:49:45 PM
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Hi everyone,
Seeking your opinions on my case.
Main concern is sleep apnea prevention and general health + aesthetics. I was initially concerned with condylar resorption but the surgeon i saw says condyles look fine and big enough and doesn't recommend replacement
Some pictures of smile and resting mouth posture, palate : https://imgur.com/a/9zbehcN
Side profile with tongue up holding my breath: https://i.imgur.com/e2KsoKW.png
Ceph and panoramic: https://imgur.com/a/AIJFMF6
I'm located in Canada.
I recently had a first consultation with a surgeon and here is the proposed plan i got on his report:
Diagnosis : Long face, class 2 div 1, anterior open bite
Gum show measured at 5mm when maximum smile, incisor show 10mm
Treatment plan:
Lefort 1 (1 piece)
Maxillary advancement (not specified how much)
Differential impaction : 5mm anterior, 3mm posterior
CCW rotation
BSSO 10mm advancement
Lateral deviation 1.5mm on the left
Genioplasty - 8mm advancement - 3 to 4mm reduction
Just wondering after reading a lot about CCWr, impaction, posterior downgraft.
What do you think of the plan ?
I know i need a lot of CCWr and would like to know if you guys think i need impaction, or downgraft, or both, and what should i ask the next surgeon.
I also saw all the stories about overimpaction on here.
I read that no surgeons do posterior downgrafts in Canada but not sure if i even need it.
I plan to probably do MSE first to maximize transverse expansion first since palate is narrow.
Thanks in advance for your time.
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Sounds like you have both excess posterior and anterior maxilla length resulting in excess gum show and anterior open bite. Hence the differential impaction. The anterior impaction is CCW and posterior impaction is CW. The NET rotation is CCW. So you have excess maxilla both front and back. Also, anterior open bite is consistent with posterior impaction in the plan. The BSSO and genio will give improvement to very recessive lower jaw. The gummy smile and AOB will be addressed by the 2 types of impactions.
Posterior downgraft is not indicated for someone with AOB and/or with excess posterior gum show.
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Thank you for your answer kavan !
Since the differential impaction is 5 front / 3 back, does this mean there is a limit to the maximum amount of rotation achievable with this differential ?
Which is why the genio is 8mm ?
For example if the differential impaction was 5 front / 1 back, the net rotation effect would be bigger so less genio ?
And last question, do you think 5mm impaction seems too much given the amount of gum I show ?
Thank you for your time,
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net ccw rotation is 2. combo will help you. you are very recessed which is why the 8mm add on. 5mm impaction not too much
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Reduction genioplasties make me nervous. It seems like the area you are reducing is the exact spot the tongue muscle attaches to the chin. I would think shaving that might jeopardize that attachment and possibly result in very bad sleep apnea. I could be wrong. Maybe someone knows more about it. I’ve often wondered if my sleep apnea was exacerbated by a chin implant the doctor placed unusually low that ate away a lot of the bone in the same spot I imagine it’s taken out with a reduction genioplasty.
So I’d think about whether that is really necessary as CCW will reduce chin height on its own and as a man having a chin that is too long really isn’t a big deal and many would find that in fact desirable. And why even bother for 3-4mm? That’s nothing. Especially on a man. That just makes no sense to me that you’d do a dangerous procedure for little gain that is counterproductive to the goal you are trying to achieve. That your doctor would do that makes me question his competency to be honest so make sure you get a few opinions and really trust this guy.
Other thoughts make sure you really need/want 5mm impaction as that’s a lot and if you’re doing the surgery for sleep apnea consider advancing upper jaw 8-10mm which seems like the minimum you need to do for a meaningful improvement. Between the impaction which makes apnea worse and the chin reduction which will make apnea worse you might not see much sleep improvement with your plan. You’re subtracting almost as much as you are adding here.
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You need quite a bit of CCW rotation, so I'd ask if when he says "CCW rotation" he's talking just that 2mm net movement (5mm anterior - 3mm posterior =2mm net) from impaction, or if he's actually planning to rotate the entire complex. You need the latter.
Also, I'd be a bit concerned about 5mm anterior impaction. To me looks more like 3mm is appropriate, because when you're showing the most gum (photo 2) you're also in an unnatural smile. The cut itself results in a loss of 1mm. So if he doesn't compensate for that, you're at 6mm. I always think go under 1 or 2mm from any recommendation for these reasons. Better to be a little excess there than over impacted.
8mm genio likely leaves a large step.
I think the ideal plan would look something like this:
3mm anterior impaction
15mm mandible via ccwr after posterior impaction
4mm genio
That's just a guess looking at you in the flesh, but I think that makes the most sense. Maybe you can clarify with the surgeon how they plan to get the CCW. If it's just the small 2mm net impaction movement, then your mandible will be forced to move linearly, which won't be good. I think this is his plan since it says maxillary advancement (ccwr wouldn't really advance that point) and he lists ccw separate from that.
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Reduction genioplasties make me nervous. It seems like the area you are reducing is the exact spot the tongue muscle attaches to the chin. I would think shaving that might jeopardize that attachment and possibly result in very bad sleep apnea. I could be wrong. Maybe someone knows more about it. I’ve often wondered if my sleep apnea was exacerbated by a chin implant the doctor placed unusually low that ate away a lot of the bone in the same spot I imagine it’s taken out with a reduction genioplasty.
So I’d think about whether that is really necessary as CCW will reduce chin height on its own and as a man having a chin that is too long really isn’t a big deal and many would find that in fact desirable. And why even bother for 3-4mm? That’s nothing. Especially on a man. That just makes no sense to me that you’d do a dangerous procedure for little gain that is counterproductive to the goal you are trying to achieve. That your doctor would do that makes me question his competency to be honest so make sure you get a few opinions and really trust this guy.
Other thoughts make sure you really need/want 5mm impaction as that’s a lot and if you’re doing the surgery for sleep apnea consider advancing upper jaw 8-10mm which seems like the minimum you need to do for a meaningful improvement. Between the impaction which makes apnea worse and the chin reduction which will make apnea worse you might not see much sleep improvement with your plan. You’re subtracting almost as much as you are adding here.
Thank you for your thoughts.
When you say chin reduction would make apnea worse, you take into account the 8mm advancement of the chin also ?
And from what he showed me, the CCW rotation will quadruple my airway width (which is currently like 3mm based on the CBCT) so i don't think sleep apnea would be a concern anymore.
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You need quite a bit of CCW rotation, so I'd ask if when he says "CCW rotation" he's talking just that 2mm net movement (5mm anterior - 3mm posterior =2mm net) from impaction, or if he's actually planning to rotate the entire complex. You need the latter.
Also, I'd be a bit concerned about 5mm anterior impaction. To me looks more like 3mm is appropriate, because when you're showing the most gum (photo 2) you're also in an unnatural smile. The cut itself results in a loss of 1mm. So if he doesn't compensate for that, you're at 6mm. I always think go under 1 or 2mm from any recommendation for these reasons. Better to be a little excess there than over impacted.
8mm genio likely leaves a large step.
I think the ideal plan would look something like this:
3mm anterior impaction
15mm mandible via ccwr
4mm genio
That's just a guess looking at you in the flesh, but I think that makes the most sense. Maybe you can clarify with the surgeon how they plan to get the CCW. If it's just the small 2mm net impaction movement, then your mandible will be forced to move linearly, which won't be good. I think this is his plan since it says maxillary advancement (ccwr wouldn't really advance that point) and he lists ccw separate from that.
Thanks for your thoughts.
When we spoke about the rotation he said everything will rotate and advance, but yes like you say i'm wondering how to rotate that much with a net 2mm movement, which was my question doesnt that limit the rotation movement compared to a 5/1 ratio for example ?
If the 5/3 ratio allows to rotate 20 degrees but i need a 30 degrees rotation, how can you gain the other 10 degrees ? I have trouble picturing that
And when you say 3mm would probably be ideal, wouldn't reducing the impaction also reduce the CCWr ?
I wasn't planning to go with him anyway, just wanted his advice on if i needed joint replacement.
I'll see what the next surgeon says.
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And when you say 3mm would probably be ideal, wouldn't reducing the impaction also reduce the CCWr ?
No, only if he planned to get his CCW-r from the impaction only.
Ideally fix a point and rotate both jaws along that point. The entire complex needs to rotate in your case. Not just a little upswing of the lower jaw via impaction, which is my interpretation of the plan you shared. This would allow the lower jaw to get out much further than the upper. The upper jaw angle would flatten (posterior comes down) and this allows the lower to swing out without having to move the upper forward.
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No, only if he planned to get his CCW-r from the impaction only.
Ideally fix a point and rotate both jaws along that point. The entire complex needs to rotate in your case. Not just a little upswing of the lower jaw via impaction, which is my interpretation of the plan you shared. This would allow the lower jaw to get out much further than the upper. The upper jaw angle would flatten (posterior comes down) and this allows the lower to swing out without having to move the upper forward.
Yes i understand this principle of rotation, but how is it supposed to be done if not only with the impaction and without posterior downgraft ?
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Yes i understand this principle of rotation, but how is it supposed to be done if not only with the impaction and without posterior downgraft ?
Posterior downgraft would be good. That's what I'm describing. But if he plans to get rotation from a few mm of anterior impaction, that's not going to allow the lower jaw to swing up enough for your case.
There are two different things here:
You can shorten the anterior maxilla (impact) and let the lower jaw swing up, and technically that is CCW. My interpretation of the plan you shared is that that is what this surgeon plans to do. It would result in an inadequate 2mm net rotation and take on much risk (premature aging, nasal base issues, lack of tooth show, etc).
The other option to get CCW-r is rotate both jaws along a fixed point. The entire complex. You can call this a posterior downgraft if you want, because yes, the posterior comes down. This is the type of CCW-r you need. It's the type that allows large movements to the lower jaw without deleterious effects to the upper jaw.
You can also combine the two, and what I said in my original post is that's the best here (imo). Limit the impaction to 3mm or so to reduce negative aesthetic risks, then rotate the entire complex some large amount (probably > than 10mm and closer to 15mm). Then be less aggressive on the chin since the jaws were properly rotated.
The one negative of that is it's generally considered less stable, but it's a proper treatment plan for recession that severe.
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Yes i understand what you mean.
I asked this surgeon and he says he doesnt do posterior downgrafting.
From what kavan said i thought it wasnt needed since i have an open bite.
Ill ask the next surgeon if he can rotate the complex enough without downgraft
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From what kavan said i thought it wasnt needed since i have an open bite.
I don't see an open bite on your ceph. I see lip incompetence.
An open bite looks like this: https://media.oralhealthgroup.com/uploads/2018/09/Razavi-Figure-2c.jpg
Maybe your bite is starting to slightly open...hard to tell, but it definitely doesn't look extreme if it's open at all. Ortho can probably fix that, especially once the jaws are in proper position.
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yes it's slightly open only, it's been like that since i stopped ortho as a teen and reopened due to a tongue thrust, but it's stable i would say for the last 10 years at least.
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yes it's slightly open only, it's been like that since i stopped ortho as a teen and reopened due to a tongue thrust, but it's stable i would say for the last 10 years at least.
Gotcha. You should work on fixing that tongue thrust before any surgery to avoid relapse, opening of the bite, etc. There are even videos on YouTube showing how to do this.
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Gotcha. You should work on fixing that tongue thrust before any surgery to avoid relapse, opening of the bite, etc. There are even videos on YouTube showing how to do this.
Yes its fixed now for the most part, which is why my bite is stable, but it wont be completely fixed until i get more tongue space, since swallowing is hindered by my recessed jaws.
Thanks !
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Yes i understand what you mean.
I asked this surgeon and he says he doesnt do posterior downgrafting.
From what kavan said i thought it wasnt needed since i have an open bite.
Ill ask the next surgeon if he can rotate the complex enough without downgraft
Posterior downgraft is not 'needed' for someone with anterior open bite AND excess gum show to the posterior smile. When AOB results from the back teeth closing FIRST, the front teeth (top and bottom) don't meet. The lower jaw can't swing up to close the front of the bite. When EXCESS to the posterior maxilla contributes to EXCESS of GUM SHOW to the back of the smile, a posterior downgraft would INCREASE the unwanted excess. Posterior downgrafting is based on the rotation of a triangle around a FIXED point. I included such an illustration to the post I made to GJ. A lot of things done in maxfax have basis in elementary geometrical principles which are needed to be underbelt (already learned) to relate them back to concepts in maxfax surgery proposals.
Also, look at a clock. Divide it in half vertically. Both a swing between 6 to 12 in either a clockwise direction or a counter clockwise direction are UPWARD swings. So, if the back part of the maxilla needs an upward swing to decrease both excess gum show and AOB, that's what posterior impaction relates to; clockwise rotation between 6 o'clock and 12 o'clock (left side of the clock). If the front of the maxilla also needs an upward swing between 6 o'clock and 12 o'clock, that's what anterior impaction relates to; counter clockwise rotation (right side of the clock).
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i understand the geometry principles that you explain kavan, it's just that i'm trying to imagine how much rotation is achievable with a 2mm differential, like GJ mentions seems it maybe wouldn't be enough ?
I know the goal is basically to get the maxilla / teeth almost parallel to the ground, then the mandible will follow, it's just i'm wondering if the wedge removed will be big enough to do that.
GJ, not sure what you mean when you say the entire complex, i thought that was implied that we are talking about the whole complex rotating. For example in my case if the front and back is impacted, then why would i need a downgraft after an impaction ?
would be easier to visualize on the 3D planning, i'll make sure to ask the next surgeon since he does that lol
like in this portion of the vid when Alfaro rotates the whole complex, you can see the gap created at the back of the maxilla (in this case when he does it there's no impaction). Since i need more rotation than that, i think that's where GJ is thinking about the posterior downgraft
https://youtu.be/TJUK6WZ07fM?t=1796
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why would i need a downgraft after an impaction ?
Because you're going to be recessed unless you get large CCW.
Kavan and your surgeon are banking on 2mm net to close that much recession? It's impossible.
We don't know what he means by "CCW rotation" in the plan. Could mean the small anterior impaction, or it could be he wants to rotate the complex.
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Actually, NM. I don't have the time or desire to argue, and that's where Kavan decided to take this with the condescending tone.
But what you need OP, is to figure out when he writes "CCW rotation" in the plan, is that from rotating the entire complex along a point, or is it from the anterior impaction. Because if it's the latter, you will be very recessed after. Might be a good idea to close the posterior bite surgically, too, because when they cut that wedge out you basically solve the posterior gummy smile issue. You can then rotate the entire complex, which is what you need.
I'm not going to argue because I don't have the time, energy, or desire, and I'm not going to stand a moderator being condescending.
Well that is what i am trying to understand, from what i read on here, you achieve rotation through impaction or posterior downgraft.
Not sure what you mean when you say cut a wedge and then rotate, i thought cutting a wedge is also resulting in the rotation at the same time.
From what we discussed yes he will rotate everything to bring it where we need but i'm trying to understand if the differential impaction is enough, i just don't see how a couple mm could bring a 20 degree rotation.
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Because you're going to be recessed unless you get large CCW.
Kavan and your surgeon are banking on 2mm net to close that much recession? It's impossible.
We don't know what he means by "CCW rotation" in the plan. Could mean the small anterior impaction, or it could be he wants to rotate the complex.
it means the whole complex, but i thought it was with the 2mm only. As you say i don't see how 2mm could bring that much rotation lol.
I thought impacting 5 in front and 0 in the back would bring more rotation and be a better result but what do i know about the numbers ahah
Look at this case, she has a before really similar to mine, i'm awaiting an answer whether she had impaction / downgraft or both, but that is approx how much rotation i need, maybe more.
If she says she had just a couple mm impaction and no downgraft we'll have our answer lol
https://imgur.com/a/AggY9UN
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Not sure what you mean when you say cut a wedge and then rotate
https://www.youtube.com/watch?v=VzUmMOCyBTA
The open bite is so small I was thinking ortho to fix it, but fixing it surgically might kill two birds with one stone (you fix the posterior gummy smile and close the anterior open bite). Maybe when he says he is going to impact the back 3mm he's talking about something like this. Something would have to be done to the anterior as well. A few mm of impaction.
The bottom line is: if you want a more correct profile, you're going to have to have a large CCW rotation of both jaws. Impaction (which you do need) is not going to cut it, and trying to make that up with an absurdly large genio isn't a good solution. The main reason I don't like his plan is it doesn't seem to include large CCW. It implies as written linear movement after impaction, and any CCW you get is going to be small from the impaction only. That's why I said clarify with him on what that "ccw rotation" line means. Is it just impaction, or is he rotating the complex after impaction to get the 10mm of lower jaw advancement? The former will rotate your jaw a very small amount and leave you unimpressed with your profile.
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I'm including the geometric gist of the tutorial I entered last night which was removed.
I shall assume you have some basic geometric familiarity underbelt as to relate to my explanations. That's because CCW-r, how it works, is based on a very fundamental geometric principle which is the ROTATION OF A TRIANGLE.
Although the Triangle is 'ABC', when we let A=ANS, B=PNS and C=pog point (outer most point on chin), it becomes the facial triangle that maxfax surgeons use to look at how applicable CCW-r posterior downgrafting is going to be depending on the patient because each person has pretty much a unique triangle constructed from points ANS, PNS and pog point.
Included is a diagram of a triangle; ABC rotated x degrees around fixed point A. The green triangle is a tracing of the blue triangle subsequent to a CCW rotation of x degrees.
The illustrations shows how the points B and C displace subsequent to the rotation. B drops down to B' and C goes outward to C'. So, how much C goes outward to C' is going to be directly proportional to how much B drops to B' via a CCW-r of X degrees. The obvious thing to note here is that the triangle does NOT change. It's the SAME triangle with the vertexes (and all the points on its lines (or 'legs') displaced by the rotation alone. The green triangle is the SAME triangle as the blue one. The blue one just shows where the green triangle would be after a CCW r of x degrees.
When we relate the displacements of the points (vertexes) of the triangle to a posterior downgraft, we can conceptualize something 'wedging down' to rotate the triangle by x degrees. So, the downgraft could be conceptualized as wedge ABB' where vertical linear distance between B and B'is the longest distance measure of the downgraft. (Surgeons give that mm meaure but usually don't relay the degree measure of the rotation). B going to B' via the rotation the downgraft affects causes C to go outward to C' (pog point to be advanced). So, how much C goes outward to C' is a function of the linear distance of BB'which in turn, is a function of the rotation the downgraft gives. Again, the obvious thing to observe is the triangle does NOT change in SHAPE. It only changes in POSITION when rotated. Hence, it is the rotation ALONE that shifts C outward to position C'. Since C=pog point, C'= pog point going outward via rotation of the trangle when we rename it; Triangle ANS PNS pog. (Keeping in mind that everyone has a DIFFERENT triangle.
OK. So, I thing you probably get the concept that the LARGER the posterior downgraft, the MORE outward distance the pog point will shift out via the rotation alone and how the basic concept of that is related to the fundamental geometric principle that describes the rotation of a triangle; ABC around a fixed point. (in this example I chose A). So, the principle is pretty straight forward (assuming again you have some geometry underbelt to ID with the principle). But surgeons look at the unique geometry of someone's FACE; in particular the CONSTRUCT of each person's unique triangle formed by ANS, PNS and pog.
How much the pog point can be brought outward is a direct function of how much they can shift the posterior maxilla DOWNWARD with the rotation. The larger the degree measure of the rotation, the more posterior maxilla shifts downward and the more the pog point goes outward.
So a limitation of how much to get the pog point to shift outward will be how much they can shift the posterior maxilla downward for that not to negatively affect the aesthetics of the smile or the function of the bite. In your case, excess posterior gummy smile and AOB are also part of your problem set in addition to the recessive mandible (and chin). Hence a large CCW-r via posterior downgraft with aim to maximize outward advancement at the pog point via the rotation of your triangle would tend towards shifting your excess posterior gum show MORE downward and contributing MORE to AOB. Whether or not the surgeon you consulted with does posterior downgraft, the limitations I mentioned are ones that surgeons who DO do the pdg (and significant ones at that) LIMIT the extent of them. So, 2 other things in your problem set LIMIT the 'solution' being that of a significant posterior downgraft solving the extend of all the recession to the mandible. That's why the BSSO and chin augment together are relied on to IMPROVE much of the recession.
As to combined impaction with a net CCW, THAT is a rotation but differs from that of rotating a triangle on which CCW posterior downgraft is based because unlike a triangle not being changed or altered, your triangle would be altered. For example AC (ans to pog) and BC (pns to pog) are made shorter by the impaction. I mention that just to point out that although you are getting a net rotation, the model on which posterior downgrafting is based on is that of a triangle that changes ONLY in position via the rotation but not it's shape.
As to rotation of the 'whole maxilla mandible complex', well, that's what basically happens with any rotation of the maxilla even when done with no posterior downgraft. A rotation of the mandible is effected via what ever rotation is done to the maxilla. In your case, both a posterior impaction and an anterior impaction will allow the mandible to rotate upwards and decrease it's angle of inclination. That, in turn, allows the BSSO to move 'forward' along less of a steep mandibular plane angle. Even posterior impactions alone gets the mandible to swing upwards when you consider it's the excess to the posterior maxilla thrusting the mandible downwards because it can't rotate up to close the bite.
As to pursuing posterior downgrafting, I don't mean to discourage about doing so given it's a good idea to get differing opinions. So, you would need to consult with doctors who do it. They will look at the entirety of your problem set in relation to what ever limitations it would have to maximizing the downgraft to maximize outshifting of the pog point.
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What needs to be answered is whether after impaction, if the entire complex can be rotated. Nobody has been able to answer that, but if I were you I'd focus my research on that question. Find some academic papers on the topic or ask your surgeons.
It's not the same as rotating the jaws before impaction (i.e. it wouldn't "undo" the impaction) where you'd necessarily be left with a posterior gummy smile, and this is because the starting point for the posterior (and the entire maxilla) would be higher after impaction. So, hopefully this is possible.
If it's not, you're stuck with a severely recessed profile after the 2mm net CCW via impaction.
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What needs to be answered is whether after impaction, if the entire complex can be rotated. Nobody has been able to answer that, but if I were you I'd focus my research on that question. Find some academic papers on the topic or ask your surgeons.
It's not the same as rotating the jaws before impaction (i.e. it wouldn't "undo" the impaction) where you'd necessarily be left with a posterior gummy smile, and this is because the starting point for the posterior (and the entire maxilla) would be higher after impaction. So, hopefully this is possible.
If it's not, you're stuck with a severely recessed profile after the 2mm net CCW via impaction.
Well, haven't you asserted that's what he should have; combined impaction followed by a massive posterior downgraft?
Are you saying that it would be unfair to assume you had the answer/explanation as to how that's done?
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i'll ask again GJ (my last 2 posts were deleted, can you not do that please?), i thought like kavan says that you mean impacting to reduce maxilla length then downgrafting, what are the other ways to rotate if not these 2 ?
To me if the posterior maxilla is impacted it doesn't make any sense to downgraft it after since you're basically adding bone where you just removed it, so not sure what you mean when you say rotate the entire complex after the impaction, when the impaction is what makes the rotation from what i gather
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I'm including the geometric gist of the tutorial I entered last night which was removed.
I shall assume you have some basic geometric familiarity underbelt as to relate to my explanations. That's because CCW-r, how it works, is based on a very fundamental geometric principle which is the ROTATION OF A TRIANGLE.
Although the Triangle is 'ABC', when we let A=ANS, B=PNS and C=pog point (outer most point on chin), it becomes the facial triangle that maxfax surgeons use to look at how applicable CCW-r posterior downgrafting is going to be depending on the patient because each person has pretty much a unique triangle constructed from points ANS, PNS and pog point.
Included is a diagram of a triangle; ABC rotated x degrees around fixed point A. The green triangle is a tracing of the blue triangle subsequent to a CCW rotation of x degrees.
The illustrations shows how the points B and C displace subsequent to the rotation. B drops down to B' and C goes outward to C'. So, how much C goes outward to C' is going to be directly proportional to how much B drops to B' via a CCW-r of X degrees. The obvious thing to note here is that the triangle does NOT change. It's the SAME triangle with the vertexes (and all the points on its lines (or 'legs') displaced by the rotation alone. The green triangle is the SAME triangle as the blue one. The blue one just shows where the green triangle would be after a CCW r of x degrees.
When we relate the displacements of the points (vertexes) of the triangle to a posterior downgraft, we can conceptualize something 'wedging down' to rotate the triangle by x degrees. So, the downgraft could be conceptualized as wedge ABB' where vertical linear distance between B and B'is the longest distance measure of the downgraft. (Surgeons give that mm meaure but usually don't relay the degree measure of the rotation). B going to B' via the rotation the downgraft affects causes C to go outward to C' (pog point to be advanced). So, how much C goes outward to C' is a function of the linear distance of BB'which in turn, is a function of the rotation the downgraft gives. Again, the obvious thing to observe is the triangle does NOT change in SHAPE. It only changes in POSITION when rotated. Hence, it is the rotation ALONE that shifts C outward to position C'. Since C=pog point, C'= pog point going outward via rotation of the trangle when we rename it; Triangle ANS PNS pog. (Keeping in mind that everyone has a DIFFERENT triangle.
OK. So, I thing you probably get the concept that the LARGER the posterior downgraft, the MORE outward distance the pog point will shift out via the rotation alone and how the basic concept of that is related to the fundamental geometric principle that describes the rotation of a triangle; ABC around a fixed point. (in this example I chose A). So, the principle is pretty straight forward (assuming again you have some geometry underbelt to ID with the principle). But surgeons look at the unique geometry of someone's FACE; in particular the CONSTRUCT of each person's unique triangle formed by ANS, PNS and pog.
How much the pog point can be brought outward is a direct function of how much they can shift the posterior maxilla DOWNWARD with the rotation. The larger the degree measure of the rotation, the more posterior maxilla shifts downward and the more the pog point goes outward.
So a limitation of how much to get the pog point to shift outward will be how much they can shift the posterior maxilla downward for that not to negatively affect the aesthetics of the smile or the function of the bite. In your case, excess posterior gummy smile and AOB are also part of your problem set in addition to the recessive mandible (and chin). Hence a large CCW-r via posterior downgraft with aim to maximize outward advancement at the pog point via the rotation of your triangle would tend towards shifting your excess posterior gum show MORE downward and contributing MORE to AOB. Whether or not the surgeon you consulted with does posterior downgraft, the limitations I mentioned are ones that surgeons who DO do the pdg (and significant ones at that) LIMIT the extent of them. So, 2 other things in your problem set LIMIT the 'solution' being that of a significant posterior downgraft solving the extend of all the recession to the mandible. That's why the BSSO and chin augment together are relied on to IMPROVE much of the recession.
As to combined impaction with a net CCW, THAT is a rotation but differs from that of rotating a triangle on which CCW posterior downgraft is based because unlike a triangle not being changed or altered, your triangle would be altered. For example AC (ans to pog) and BC (pns to pog) are made shorter by the impaction. I mention that just to point out that although you are getting a net rotation, the model on which posterior downgrafting is based on is that of a triangle that changes ONLY in position via the rotation but not it's shape.
As to rotation of the 'whole maxilla mandible complex', well, that's what basically happens with any rotation of the maxilla even when done with no posterior downgraft. A rotation of the mandible is effected via what ever rotation is done to the maxilla. In your case, both a posterior impaction and an anterior impaction will allow the mandible to rotate upwards and decrease it's angle of inclination. That, in turn, allows the BSSO to move 'forward' along less of a steep mandibular plane angle. Even posterior impactions alone gets the mandible to swing upwards when you consider it's the excess to the posterior maxilla thrusting the mandible downwards because it can't rotate up to close the bite.
As to pursuing posterior downgrafting, I don't mean to discourage about doing so given it's a good idea to get differing opinions. So, you would need to consult with doctors who do it. They will look at the entirety of your problem set in relation to what ever limitations it would have to maximizing the downgraft to maximize outshifting of the pog point.
so do you think i can gain enough rotation in degrees with the differential impaction ?
i found this case online just for numbers comparison, 6mm anterior impaction / 5mm posterior impaction, 2 deg CCW rotation occlusal plane:
https://imgur.com/a/rbw56b3
She was way less recessed than me
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so do you think i can gain enough rotation in degrees with the differential impaction ?
i found this case online just for numbers comparison, 6mm anterior impaction / 5mm posterior impaction, 2 deg CCW rotation occlusal plane:
https://imgur.com/a/rbw56b3
She was way less recessed than me
Well, TBH, my explanation as to the basic concept posterior downgrafting is based on (rotation of a triange) wasn't really an invitation to analyze someone elses unique situation and apply to yours.
The objective of it was to explain in terms of the rotation of a triange that your case has limitations with reference to the concept of posterior downgrafting as it relates to the rotation of a triangle where the shape of it is not at all changed.
So, in effect, I'm concluding your advancement would be less than it would be compared to someone who didn't start with the same things that would limit getting an extensive posterior downgraft to maximize the outward projection of the pog point. So, I think you can expect IMPROVEMENT but not total correction.
As to net CCW-r, well, yes, that's an angle measure based on subtraction of angles where as the mm differential is a linear measure. But the calculation is going to differ depending on the shape of the entire 'cut out' from the maxilla and the linear measure of line ANS-PNS.
On a side note, the more PRAGMATICAL thing to do would be to ask, on your consults, for a contour displacement diagram which basically is a tracing of your present profile with ceph landmarks on it with an overlay of a tracing of the proposed changes to it.
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Thank you, yes i understand the geometric principles discussed.
I will ask the next surgeon since he offers 3D planning so will be easier to visualize.
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Are you saying that it would be unfair to assume you had the answer/explanation as to how that's done?
I don't know how it's done, but since the jaw can move in any dimension, I'd imagine it's possible.
Maybe baking it into the posterior wedge cut/impaction so when it's reattached there's margin to swing it down. It's not up to me to answer that, though. He needs to ask the surgeon. I'm just saying what he needs. And if he doesn't get that, he'll be disappointed.
To me if the posterior maxilla is impacted it doesn't make any sense to downgraft it after since you're basically adding bone where you just removed
Take it to the extreme with a thought experiment and say they impact your maxilla so its height is only 1mm total. Then they CCW rotate it. You really think that would result in a posterior gummy smile? The starting point when it begins rotation matters. The impaction moves it up, and then it can be rotated it from a higher starting point.
Maybe I'm wrong or missing something that can't be done, but that's how I imagine it working out and getting the best of both worlds.
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Thank you, yes i understand the geometric principles discussed.
I will ask the next surgeon since he offers 3D planning so will be easier to visualize.
Indeed, it's much easier when you can see the 'geometry' of the output vs. the input. You are doing your due diligence.
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I don't know how it's done, but since the jaw can move in any dimension, I'd imagine it's possible.
Maybe baking it into the posterior wedge cut/impaction so when it's reattached there's margin to swing it down. It's not up to me to answer that, though. He needs to ask the surgeon. I'm just saying what he needs. And if he doesn't get that, he'll be disappointed.
Take it to the extreme with a thought experiment and say they impact your maxilla so its height is only 1mm total. Then they CCW rotate it. You really think that would result in a posterior gummy smile? The starting point when it begins rotation matters. The impaction moves it up, and then it can be rotated it from a higher starting point.
Maybe I'm wrong or missing something that can't be done, but that's how I imagine it working out and getting the best of both worlds.
I don't think it would necessarily result in a posterior gummy smile. It's just that why would they reduce the maxilla height let's say to 1mm, if at the end once the rotation is done, it needs to be 10mm height to have the bone connect, and i guess fill the gap with posterior downgraft, or it's just gonna be hanging loose.
Since i have an occlusal plane of around 20 degrees and optimal is 8, there needs to be big amount of rotation as you know.
I'll see with the 3D planning and update you on what the next surgeon says about what happens to the posterior maxilla if he doesn't downgraft and how to achieve the rotation needed.
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I don't think it would necessarily result in a posterior gummy smile. It's just that why would they reduce the maxilla height let's say to 1mm, if at the end once the rotation is done
To get a higher starting point, so when they rotate it's not a posterior gummy smile. Your posterior maxilla is too low to rotate right now (at first I didn't see this as a major problem, but after looking more, now I do). Impact posterior as high as possible, then rotate it. Again, I don't know if this is possible, but it's what I'd personally be trying to figure out. I would guess the limit would be enough bone to house the teeth, but I've never looked into this type of movement. You also need to factor in how to close that open bite - surgically or ortho. That could be another limiting factor.
Just to be clear: a 1mm maxilla is impossible and was just a thought experiment!
I'm done with the thread, but when you find out more info and go on more consults I'll come back and read it because it's an interesting case.
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Thank you for your thoughts.
When you say chin reduction would make apnea worse, you take into account the 8mm advancement of the chin also ?
And from what he showed me, the CCW rotation will quadruple my airway width (which is currently like 3mm based on the CBCT) so i don't think sleep apnea would be a concern anymore.
It's not an exact science. Plenty of people with bad sleep apnea have had far more aggressive surgeries than you are having and still ended up with quite a bit of sleep apnea. Airway measurements are basically meaningless. It's just something they show you to make it look like they did their job. The size of your soft tissues, size of your tongue, the size of your nasal airway, width of your palate, all matter just as much or more than the big part of your airway they measure on a CT scan. No matter what you do sleep apnea will still be a concern, it's just a matter of how much of a concern. A well done sleep apnea double jaw surgery usually results in a 50% decrease in sleep apnea. A poorly done one can make it worse.
My concern with chin reduction is that if you look at an xray you will see the muscle that is part of the tongue literally attaches to the chin very close to the part they are shaving. I would suspect if you damage that attachment it could do more damage than 8mm of advancement will compensate for. It just seems like a strange thing to do unless you want to look more like a girl and have worse sleep apnea.
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TWGOAT,
Here is how I would go about guesstimating the net rotation. But mostly, this is a demonstration of conceptual methodology rather than an exercise in mm or degree 'exactitude'.
I increased size of your ceph so that from the root of your nose to the base of it measured 60 mm on my screen (which is the average length of a nose). Although it might not be your exact nose length, I'm just showing how I would make a ballpark estimate of the net CCW. Also, 'round' numbers are just easier for me to deal with when I'm holding a transparent ruler and protractor up to the screen.
From there, I got a measure of about 50 mm of ANS-PNS (maxilla area) and marked a CUT OUT figure in red where the right side of the figure was about 5mm and left side about 3mm.
It's basically the SEGMENT being removed across the length of the maxilla.
Since the red figure is one where there is more vertical length to the right of it than the left of it, I knew I could draw 2 white lines bordering it and extrapolate them all the way back UNTIL they CONVERGED. I got about 3 degrees. Although subtracting 3mm from 5mm=2mm, the angle measure can differ.
So, the net CCW would be the bottom white line rotating about 3 degrees CCW to meet the top white line. That's the impaction.
Now, if you wanted to do it using the EXACT length of ANS-PNS, you could. I'm just showing the basic METHOD I would use from a geometric perspective.
Illustration included in this post.
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It's not an exact science. Plenty of people with bad sleep apnea have had far more aggressive surgeries than you are having and still ended up with quite a bit of sleep apnea. Airway measurements are basically meaningless. It's just something they show you to make it look like they did their job. The size of your soft tissues, size of your tongue, the size of your nasal airway, width of your palate, all matter just as much or more than the big part of your airway they measure on a CT scan. No matter what you do sleep apnea will still be a concern, it's just a matter of how much of a concern. A well done sleep apnea double jaw surgery usually results in a 50% decrease in sleep apnea. A poorly done one can make it worse.
My concern with chin reduction is that if you look at an xray you will see the muscle that is part of the tongue literally attaches to the chin very close to the part they are shaving. I would suspect if you damage that attachment it could do more damage than 8mm of advancement will compensate for. It just seems like a strange thing to do unless you want to look more like a girl and have worse sleep apnea.
Good thing i don't have sleep apnea yet, i want to do the procedure before i develop it.
But the reduction is just to reduce lower third length, correct? I have severe long face and don't think i'll look like a girl no matter what they do lmao. I don't think they damage the hyoid muscles attachments, i hope lol
I see what you mean if the tendon or ligament is damaged it could lessen muscle strength
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Good thing i don't have sleep apnea yet, i want to do the procedure before i develop it.
But the reduction is just to reduce lower third length, correct? I have severe long face and don't think i'll look like a girl no matter what they do lmao. I don't think they damage the hyoid muscles attachments, i hope lol
I see what you mean if the tendon or ligament is damaged it could lessen muscle strength
Referring back to the basic ABC triangle figure I gave prior where A=ANS and C=pog point of chin and I told you the distance between points A and C were being reduced, so correct, it's just the linear distance from ANS to pog point of chin that is being reduced by about 5mm. Anterior facial height is being reduced.
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TWGOAT,
Here is how I would go about guesstimating the net rotation. But mostly, this is a demonstration of conceptual methodology rather than an exercise in mm or degree 'exactitude'.
I increased size of your ceph so that from the root of your nose to the base of it measured 60 mm on my screen (which is the average length of a nose). Although it might not be your exact nose length, I'm just showing how I would make a ballpark estimate of the net CCW. Also, 'round' numbers are just easier for me to deal with when I'm holding a transparent ruler and protractor up to the screen.
From there, I got a measure of about 50 mm of ANS-PNS (maxilla area) and marked a CUT OUT figure in red where the right side of the figure was about 5mm and left side about 3mm.
It's basically the SEGMENT being removed across the length of the maxilla.
Since the red figure is one where there is more vertical length to the right of it than the left of it, I knew I could draw 2 white lines bordering it and extrapolate them all the way back UNTIL they CONVERGED. I got about 3 degrees. Although subtracting 3mm from 5mm=2mm, the angle measure can differ.
So, the net CCW would be the bottom white line rotating about 3 degrees CCW to meet the top white line. That's the impaction.
Now, if you wanted to do it using the EXACT length of ANS-PNS, you could. I'm just showing the basic METHOD I would use from a geometric perspective.
Illustration included in this post.
Yes i see, thank you for the visual.
That would mean about the same degree of change for the occlusal plane ?
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Referring back to the basic ABC triangle figure I gave prior where A=ANS and C=pog point of chin and I told you the distance between points A and C were being reduced, so correct, it's just the linear distance from ANS to pog point of chin that is being reduced by about 5mm. Anterior facial height is being reduced.
I was replying to thedude about the genioplasty, which is 8mm advancement and 3-4mm reduction, which i think the 3-4mm is height reduction of the chin ?
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Yes i see, thank you for the visual.
That would mean about the same degree of change for the occlusal plane ?
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.
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I was replying to thedude about the genioplasty, which is 8mm advancement and 3-4mm reduction, which i think the 3-4mm is height reduction of the chin ?
Oh, OK. Genioplasty - 8mm advancement - 3 to 4mm reduction. That could refer to an upward diagonal sliding genio where they make a diagonal cut which has 2 displacement vectors; horizontally outward and vertically upward where 8 would be the horizontal outward displacement and 4 would be the upward vertical displacement which is type they do as add ons for sleep apnea reduction. It isn't something where they lop off or shave down the base of your chin to make it shorter or anything like that.
ETA. By 'add ons' for sleep apnea cases, the type of genio I described is to advance the genioglossus muscle which helps with breathing. But again, the base of the chin is not being 'shaved down'.
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Oh, OK. Genioplasty - 8mm advancement - 3 to 4mm reduction. That could refer to an upward diagonal sliding genio where they make a diagonal cut which has 2 displacement vectors; horizontally outward and vertically upward where 8 would be the horizontal outward displacement and 4 would be the upward vertical displacement which is type they do as add ons for sleep apnea reduction. It isn't something where they lop off or shave down the base of your chin to make it shorter or anything like that.
ETA. By 'add ons' for sleep apnea cases, the type of genio I described is to advance the genioglossus muscle which helps with breathing. But again, the base of the chin is not being 'shaved down'.
I think if you did that and looked at impacting more like 3mm like GJ suggested you would have a nice outcome. There is no reason to go from one extreme to the other - a little maxillary excess looks normal and you’ll come out of the surgery still recognizable and won’t risk damaging sleep or nasal breathing so much either.
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I think if you did that and looked at impacting more like 3mm like GJ suggested you would have a nice outcome. There is no reason to go from one extreme to the other - a little maxillary excess looks normal and you’ll come out of the surgery still recognizable and won’t risk damaging sleep or nasal breathing so much either.
Than that would give him 0 deg CCW r as in NO net CCW because both the anterior and posterior impaction would be 3.
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Than that would give him 0 deg CCW r as in NO net CCW because both the anterior and posterior impaction would be 3.
Sorry I’m not really up on the complexities of rotation or how lowering the jaw unequally in the front and back works or looks for that matter I was just making a general observation that moving the teeth up around 3mm would be where I would see them looking nice aesthetically (however you get them there).
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Sorry I’m not really up on the complexities of rotation or how lowering the jaw unequally in the front and back works or looks for that matter I was just making a general observation that moving the teeth up around 3mm would be where I would see them looking nice aesthetically (however you get them there).
no problem
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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
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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.
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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
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You definitely need a modern surgeon who does large CCW with down-grafting.
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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 ?
(https://scontent.fymy1-1.fna.fbcdn.net/v/t1.6435-9/117346497_10216539264026360_902115683393968204_n.jpg?_nc_cat=102&ccb=1-5&_nc_sid=825194&_nc_ohc=slcxhVEz97YAX9A7eW_&tn=vaRlRVqGhW8ebNS5&_nc_ht=scontent.fymy1-1.fna&oh=00_AT_0htMjy3h6ZIHahFDDIXpPNEqbY5Php0J1j92KLcH9Xw&oe=621B8841)
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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.
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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 ?
(https://scontent.fymy1-1.fna.fbcdn.net/v/t1.6435-9/117346497_10216539264026360_902115683393968204_n.jpg?_nc_cat=102&ccb=1-5&_nc_sid=825194&_nc_ohc=slcxhVEz97YAX9A7eW_&tn=vaRlRVqGhW8ebNS5&_nc_ht=scontent.fymy1-1.fna&oh=00_AT_0htMjy3h6ZIHahFDDIXpPNEqbY5Php0J1j92KLcH9Xw&oe=621B8841)
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?
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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.
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I wonder if you could get the TJR for aesthetic purposes.
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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
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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.
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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.
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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 ?
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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.
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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
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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.
Hey Kavan, i just saw this interesting result from Dr. Pary where the before looks similar to me, with less gum and tooth show but still some anterior and posterior vertical excess
https://www.instagram.com/p/CbThY5ju9Xr/
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Hey Kavan, i just saw this interesting result from Dr. Pary where the before looks similar to me, with less gum and tooth show but still some anterior and posterior vertical excess
https://www.instagram.com/p/CbThY5ju9Xr/
turned it off due to the LOUD blaring music it came with.