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General Category => Functional Surgery Questions => Topic started by: april on August 12, 2018, 11:36:12 PM

Title: My cephs
Post by: april on August 12, 2018, 11:36:12 PM

I’d really appreciate your insights and evaluations of my cephs. The cephs after 2015 are my progression through decompensation. All of these were taken with a relaxed lip posture & biting down.

Cephs - https://imgur.com/a/iUa68

I started this round of ortho as class 2 with a 9mm overjet, overbite, some gaps, & flared upper teeth. My ortho was leaning more towards braces only, but surgeon consensus was 5-6mm BSSO.

My history
As a teen I had 4 premolar extractions and braces. A few years later at 21, TMJ pain and dislocations. Scans at the time showed advanced-stage TMJ osteoarthritis and I’ve had some degree of associated condylar resorption over the years.

Throughout my 20’s I started noticing dental changes - and I actually liked the initial changes (with the upper teeth starting to angle and come forward I had fuller lips, and a better, more effortless smile). At 28, I had all wisdom teeth removed. Around the same time, my profile became unbalanced and more class 2-like, with the top teeth flaring more extremely and my lower jaw looking recessive.

My joints seem to be stable now. I hear crunching noises but I'm used to it by now. Functionally though, I'm constantly needing to slide and hold my jaw forward and I know longterm it isn't going to be ideal.

After decompensation
My overjet is now 5mm when I measure it myself, and 7mm according to my ortho’s assistant.

My upper teeth are quite far back in my face now and as a result my upper lip is thinner and my philtrum appears somewhat longer. I think I have more of an open nasolabial angle (which is more obvious when closing my lips fully). I'm now aware that lip retraction follows incisor retraction, and a degree of retraction was going to happen in my case given how flared my upper teeth were. However, I'm worried the upper incisor retraction has gone too far and honestly I don't like the look of it. I really preferred my smile and amount of tooth show before it was all brought back and before the arch flattened at the front. (I know pics are needed to comment on cases, so I'll gather some up in the next few days).

I’ve been told I’m now only looking at a 4mm BSSO. Do people even do surgery for just a 4mm BSSO?

I’m unsure what it's coming down to: if maybe my lower jaw isn't as retrusive as I originally thought/was told, or if the dental decompensation has gone too far in their effort to close up spaces.

I've always heard of others' orthodontists maximizing whatever overjet they had in order to get the most advancement, but in my case it seems to have decreased as much as possible first (I was once wearing DOUBLE powerchains on those front upper teeth to close everything as tightly as possible).

To complicate matters, I’ve recently found out via a report that I have some root resorption of those four upper teeth. The severity has not been made clear to me and I've been getting mixed professional opinions. So I need to figure out what I'm doing with surgery quickly, or debrace and leave as is and do something like submental lipo. I'll be consulting with a new surgeon this week.

I've been told by some members that CCW may be more aesthetically ideal.

I'll add more info & have some questions, but I just wanted to get your initial thoughts on my cephs first. Thanks.

Title: Re: My cephs
Post by: kavan on August 13, 2018, 09:24:31 AM

From looking at the cephs alone:

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1:It is the FIRST one where your soft tissue profile was in much better balance. I do not think that was due to youth alone. But rather a classic case where a bite that is 'not right' doesn't significantly contribute to any negative profile imbalance.

2: The second ceph, 2015 looks to be one in preparation for surgery, perhaps BSSO given the upper teeth are flared out and the soft tissue profile has been made MORE UNBALANCED than in the first ceph.

3: The 3rd ceph, 2017, in prep for surgery has the soft tissue profile looking worse than the former #2 as the nose to lip angle (or curve if you like) is more open.

4: The 4th ceph, 2018, in prep for a surgery, demonstrates even MORE negative soft tissue sequellae than #3.

So from just looking at the cephs ALONE, I would deduce you were 'classic case' where you got one of those AWFUL orthos, the kind the Mews take a pro-active stance AGAINST, in particular the kind who pluck pre-molars and push the face backwards in order to get the 'bite right' where the negative aesthetic outcome directly related to getting the 'bite right' is is comes with the cost of getting the profile WRONG.

Also, from just looking at the cephs alone, #2,#3, and #4 show progressive detriment to the soft tissue profile. YET they are all in preparation for surgery BUT we see NO post surgery cephs.

The presentation ALONE is baffling because ceph #2 appears to be one where prior braces were with AIM of HAVING a surgery that would include a BSSO. But in #3 and #4, we see the OVERJET going  PROGRESSIVELY backwards where it almost looks to be in preparation of getting the bite right to AVOID surgery because we don't see any signs of surgery in the series.

I DISCLOSE, I don't know all the medical/technical minutia associated with ortho or maxfax. My focus is more on aesthetic geometric relationships and such things as basic mechanical displacements that relate back to some of the displacement goals inherent in maxfax surgery

Title: Re: My cephs
Post by: april on August 14, 2018, 02:58:47 AM

Thanks for taking the time to comment Kavan! My case is tricky to explain because I've had different bites/profiles over the years. I haven't had any surgery yet, which is why there are no post-surgery cephs. I really hope I didn't make my thread unnecessarily complicated. I could've just posted the latest ceph (2018), and asked surgical opinions on just that one... but I've been confused by the whole 'surgical prep' so that's why I included the series. I think context is definitely needed to make sense of it all.

I think my ortho has been trying to close all gaps tightly together and also make the upper arch flatter and squarer up front (which I don't really like). By broadening the upper arch I think I've lost arch depth/projection as a result?

In regards to the cephs... I will add some profile pictures privately soon and that might make things clearer.

Ceph #1

Quote

1:It is the FIRST one where your soft tissue profile was in much better balance. I do not think that was due to youth alone. But rather a classic case where a bite that is 'not right' doesn't significantly contribute to any negative profile imbalance

I agree, my profile looked the best here. I can see my mandible was less angled down as well.

There is no debracing ceph, nor can I find a 'proper' profile image of how I looked RIGHT AFTER that first round of ortho, but I think I looked pretty OK afterward. My lips were probably thinner and my smile wasn't amazing (from the extractions I presume), but my lower jaw wasn't recessed.

Ceph #2

Quote

The second ceph, 2015 looks to be one in preparation for surgery, perhaps BSSO given the upper teeth are flared out and the soft tissue profile has been made MORE UNBALANCED than in the first ceph.

It does look like that from the ceph , but there was no ortho or surgery prep - it all happened naturally. Across my 20's my teeth flared forward. Slightly at first (but also enough to not fit my retainer) and then eventually to the point of the 2015 ceph and intraoral pic.

At the same time, I lost some condylar height from arthritis and disc displacements, causing some jaw recession.

In 2015, when I would push my jaw forward, I actually looked significantly better. Like I knew 100% jaw surgery would be of benefit. So that's why I started ortho/surgery consults. I (naively) didn't realize that before jaw surgery the whole mouth/smile/arch would completely change and that what I had then would NOT be what I would go into surgery with.

Ceph #3

Quote

3: The 3rd ceph, 2017, in prep for surgery has the soft tissue profile looking worse than the former #2 as the nose to lip angle (or curve if you like) is more open.

Yep, the curve opened as the top teeth went back. At the same time I noticed less tooth show than I had before. I'm not sure exactly what happened but I think my upper lip began to drape lower across my top teeth. It's also possible my central incisors were intruded in the first few months as well.

Ceph #4

Quote

4: The 4th ceph, 2018, in prep for a surgery, demonstrates even MORE negative soft tissue sequellae than #3.

I'm happy you noticed because this is what I've been noticing too. There's definite decline in some areas. Some of it's due to weight gain, but as I said above I feel my upper teeth are angled too far back now, and the nasolabial angle has really opened when I close my lips fully.

Quote

The presentation ALONE is baffling because ceph #2 appears to be one where prior braces were with AIM of HAVING a surgery that would include a BSSO. But in #3 and #4, we see the OVERJET going  PROGRESSIVELY backwards where it almost looks to be in preparation of getting the bite right to AVOID surgery because we don't see any signs of surgery in the series.

My ortho was steering me away from surgery at the start, without really explaining why. I was undecided at one point because I was worried about my TMJs, but we agreed to decompensate me first and I would then find a surgeon.

I do still look slightly better when jutting my lower jaw forward. But I'm worried I look too flat around my upper lip. I don't think the maxilla itself is actually the problem, it's more the dental side of things.

Title: Re: My cephs
Post by: kavan on August 14, 2018, 05:43:05 AM

Quote from: april on August 14, 2018, 02:58:47 AM

My ortho was steering me away from surgery at the start, without really explaining why. I was undecided at one point because I was worried about my TMJs, but we agreed to decompensate me first and I would then find a surgeon.

I do still look slightly better when jutting my lower jaw forward. But I'm worried I look too flat around my upper lip. I don't think the maxilla itself is actually the problem, it's more the dental side of things.

My observations of the soft tissue profile pretty much overlap with yours. It appears that your indecision whether or not to have surgery along with having an ortho who does not seem to work directly with a surgeon (your needing to find one yourself) has lead you more in the direction of getting 'the bite right', something where ortho ALONE can do that if that's what you want BUT it's NOT in direct preparation for a surgery.

Title: Re: My cephs
Post by: april on August 14, 2018, 06:26:15 AM

You are saying my teeth do not look like they are set up for a jaw surgery? Or that it could've been done better? I'm unfortunately not surprised either way. Sigh.

If one's overjet is increased, will it enable more mandibular advancement, or does it really come down to where the molars and other teeth intercusp regardless of creating a larger overjet?

They do directly work with a surgeon, but I met with their preferred surgeon and was not impressed. I asked for referrals to more surgeons (of one they were willing to work with). He gave a rough plan and showed me a morph. I found the morph bad as it had the flat upper lip and my chin in front of my lower lip - even despite the plan itself showing my lower jaw still retruded. I was just very confused and was not comfortable to go ahead. I think my upper teeth are now more retracted than the original plan and I tried to have this clarified with the original surgeon and was told it was just a rough idea and it's up to the orthodontist how the teeth are set up. I think where I am, the orthodontists take the lead and surgeons work with what they're given.

This was the original BSSO plan I was given back in 2015



I was then offered DJS, to bring my maxilla down or forward for more tooth show. (No CCW involved). I do not have any more plans. Will be seeing a new surgeon soon though, and seeking Gunson's opinion too.

Title: Re: My cephs
Post by: kavan on August 14, 2018, 06:55:06 AM

Oh, that's just dandy, a plan that doesn't seem to have any CCW where your occlusal plane is left excessively high along with the mandibular plane and where there's no line up of upper and lower lip. Seek out a surgeon who does CCW and look outside of Australia for one.

Your teeth look like they are braced up for indecision rather any specific surgery proposal.

Title: Re: My cephs
Post by: GJ on August 14, 2018, 09:59:42 AM

Yeah that plan looks like the plan of a surgeon who doesn't know how to perform modern surgery (e.g. ccw, etc).

Who did the surgery?

I missed some images that were deleted so I can't comment much more than that.

Title: Re: My cephs
Post by: april on August 14, 2018, 10:12:57 AM

I haven't had surgery yet, that was just a plan given. I'll PM you the surgeon.

Quote from: kavan on August 14, 2018, 06:55:06 AM

Oh, that's just dandy, a plan that doesn't seem to have any CCW where your occlusal plane is left excessively high along with the mandibular plane and where there's no line up of upper and lower lip. Seek out a surgeon who does CCW and look outside of Australia for one.

Yep. I want to see what Gunson and others out there have to say (well I can imagine what they'll say), but whether I can afford it will be another thing.

Quote

Your teeth look like they are braced up for indecision rather any specific surgery proposal.

This is the final set up for BSSO according to this particular ortho, despite my concerns conveyed to them. The assistants only want to see me for surgical hook placement, and the orthodontist not until after surgery (which sounds absolutely insane typing that because I don't even have a surgeon!)

Title: Re: My cephs
Post by: kavan on August 14, 2018, 11:19:58 AM

IDK, getting confused with the term 'decompensation' where as it was ceph #2 that looked more like decompensation TO get surgery than #3 and #4.

The surgical plan looks like a SINGLE BSSO where the longer the braces stay on for this 'decompensation', the LESS distance they will be able to advance the lower jaw.

Title: Re: My cephs
Post by: ditterbo on August 14, 2018, 05:15:28 PM

Fortunately for you, your chin/jaw is not sooo far back that I have a feeling you could settle for a 'normal' 3-5mm posterior downgraft, from a more run of the mill surgeon than Gunson, and get close enough to the same result for the price. Just my theory. To be clear, I'm assuming bimax CCW recommendation. Unscientifically, I see your chin is ahead of your eyes if you drop a vertical line down from the right-most edge of either point.  My own frame of ref has my (preimplant) chin lined up with my eye in profile. Total swag.

Title: Re: My cephs
Post by: PloskoPlus on August 14, 2018, 05:39:12 PM

Quote from: ditterbo on August 14, 2018, 05:15:28 PM

Fortunately for you, your chin/jaw is not sooo far back that I have a feeling you could settle for a 'normal' 3-5mm posterior downgraft, from a more run of the mill surgeon than Gunson, and get close enough to the same result for the price. Just my theory. To be clear, I'm assuming bimax CCW recommendation. Unscientifically, I see your chin is ahead of your eyes if you drop a vertical line down from the right-most edge of either point.  My own frame of ref has my (preimplant) chin lined up with my eye in profile. Total swag.

Which means no surgeon in Australia.

Title: Re: My cephs
Post by: ditterbo on August 14, 2018, 08:25:34 PM

TBH though the more I look at it the less I think I'm right about a moderate posterior downgraft, as I stare more closely at Gunson's pre-implant ceph silhouette he made of me. The orbital outline isn't quite clear to me how the eyes sit irl, and it's got her cheek bones outlined in one of them, tangent to the orbital at points. The TVL line that surgeon used was also super weak, waay behind Gunson's and might have thrown me off a bit.  Yeah that was way too unscientific of me, my apologies lol. Considering the OP, MPA, and the rest of it there's no point in guessing much else than definitely needs CCW, as was already stated here...

Title: Re: My cephs
Post by: april on August 18, 2018, 01:01:58 PM

Guys were you thinking CCW based on my latest ceph as well? Or just that surgical plan tracing above?

The thing with that tracing is I think the surgeon rotated the original ceph and made me look more retrusive and higher angled than I actually ever was (as they all seem to do). But I guess that tracing is irrelevant now anyway since I've had all this weird ortho work.  I'm hoping those teeth can be moved forward again without causing further resorption. Or that their current vertical-ness can work with a 'normal' CCW.

Quote from: ditterbo on August 14, 2018, 05:15:28 PM

Fortunately for you, your chin/jaw is not sooo far back that I have a feeling you could settle for a 'normal' 3-5mm posterior downgraft, from a more run of the mill surgeon than Gunson, and get close enough to the same result for the price. Just my theory. To be clear, I'm assuming bimax CCW recommendation. Unscientifically, I see your chin is ahead of your eyes if you drop a vertical line down from the right-most edge of either point.  My own frame of ref has my (preimplant) chin lined up with my eye in profile. Total swag.

well I'm liking the idea of 'normal' p. downgraft much better, as I may actually be able to get that. So even though you changed your mind I'm hoping you're still right. With your chin position are you talking about the bone or soft tissue?

Title: Re: My cephs
Post by: kavan on August 18, 2018, 01:25:04 PM

Quote from: april on August 18, 2018, 01:01:58 PM

Guys were you thinking CCW based on my latest ceph (https://i.imgur.com/zWJv7um.jpg?4) as well? Or just that surgical plan tracing above?

The thing with that tracing is I think the surgeon rotated the original ceph and made me look more retrusive and higher angled than I actually ever was (as they all seem to do). But I guess that tracing is irrelevant now anyway since I've had all this weird ortho work.  I'm hoping those teeth can be moved forward again without causing further resorption. Or that their current vertical-ness can work with a 'normal' CCW.
 well I'm liking the idea of 'normal' p. downgraft much better, as I may actually be able to get that. So even though you changed your mind I'm hoping you're still right. With your chin position are you talking about the bone or soft tissue?

YES, if your goal is to get more of an advancement with the BSSO and to cut down on the possibility of the nose to lip curve getting even flatter if all you got was linear advancement of both the maxilla and mandible.

Title: Re: My cephs
Post by: XXRyanXXL on August 21, 2018, 01:54:24 PM

You'll definitely look good with CCW rotation. The rotation alone will give you a pronounced jaw line and get rid of any gullet.

Title: Re: My cephs
Post by: april on August 25, 2018, 09:27:28 AM

Thank you both. I don't think I can justify doing jaw surgery for only 4mm mandibular advancement. So it'd have to be DJS or nothing.
I've now had CCW suggested to me by an actual surgeon (crazy right? :P) But I don't know the movements & there are a lot more variables I now need to consider.

As for doing nothing, well now that everything has been pushed back, my lips are actually more in alignment - so from an outsiders perspective I don't actually look that recessed (besides the double chin). People in my life wonder why I would even consider jaw surgery. Well, I FEEL recessed; there's not much room for my tongue and I need to hold my jaw forward. But I could technically just keep jutting forward...

Out of curiosity, I tried to figure out the ANB (but I might have done it wrong) and I'm getting 8-9.
(Before extractions, it looks like it was 5-ish. Then it increased to around 7 after extractions, wisdom teeth removal and condylar resorption.)
My upper jaw position seems close to the norm. So I'm guessing (as you've said to others Kavan) that's why I was only really offered LJS in the past.

Title: Re: My cephs
Post by: kavan on August 25, 2018, 11:51:41 AM

With reference to your LAST ceph and the 'S', 'N', 'A' and 'B' points where angle ANB=SNA-SNB
an 8 for ANB sounds about right via my approximation of SNA about 80 and SNB about 72.

Quote from: april on August 25, 2018, 09:27:28 AM

Thank you both. I don't think I can justify doing jaw surgery for only 4mm mandibular advancement. So it'd have to be DJS or nothing.
I've now had CCW suggested to me by an actual surgeon (crazy right? :P) But I don't know the movements & there are a lot more variables I now need to consider.

As for doing nothing, well now that everything has been pushed back, my lips are actually more in alignment - so from an outsiders perspective I don't actually look that recessed (besides the double chin). People in my life wonder why I would even consider jaw surgery. Well, I FEEL recessed; there's not much room for my tongue and I need to hold my jaw forward. But I could technically just keep jutting forward...

Out of curiosity, I tried to figure out the ANB (but I might have done it wrong) and I'm getting 8-9.
(Before extractions, it looks like it was 5-ish. Then it increased to around 7 after extractions, wisdom teeth removal and condylar resorption.)
My upper jaw position seems close to the norm. So I'm guessing (as you've said to others Kavan) that's why I was only really offered LJS in the past.