jawsurgeryforums.com
General Category => Aesthetics => Topic started by: Post bimax on February 07, 2019, 08:58:23 AM
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I'm 3 months post-op (Posnick)
Surgery was to treat:
Open bite (1-3mm)
Mild OSA
Teeth grinding, lisp and some chewing problems
And of course aesthetic concerns
Surgircal plan was:
10mm maxillary advancement with Lefort 1
Similar mandibular advancement with BSSO
Slight sliding genioplasty
As of 3 months, my functional concerns have basically all been taken care of. I no longer have OSA problems, no lisp, no teeth grinding (or at least much less) and i can chew/tear food normally.
My main question is regarding aesthetics. I believe my advancement was straight without any rotation, and I didn't even know what CCW rotation was until finding this forum. I currently have what looks like "chimp lip" which I know can occur with large maxillary advancements. It doesn't look so bad in the picture but it's definitely noticeable. Yesterday my ortho asked me about the "swelling" in my upper lip and a few others have commented on it. While it could still be swelling, I'm beginning to think my maxilla was simply advanced too far without any compensating rotation.
My question is: Based on my CEPHs, should I have gotten CCW as part of the surgery? It looks to me like my occlusal plane is definitely off horizontal which is a bad sign for large advancements without CCW according to this forum.
Pics and CEPHS: https://imgur.com/a/88rq7HP
Thanks
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Well, the more the Lefort 1 area is moved outward, the more the nose to lip curve* is going to change. It can go from conCAVE nose to lip curve* to STRAIGHT and then to conVEX nose to lip curve*. (*The med terminology for this nose to lip CURVE is 'Naso-labial ANGLE'. But I like to use more intuitively obvious descriptions because afterall, we are looking at a CURVE and not really an 'angle'.) So, here you see your nose to lip curve went from conCAVE to conVEX.
You relay you got 10mm L1 advance with similar BSSO which could be 'linear' advancement and that extent of it at the maxilla is usually consistent with 'chimp lip' (convex nose to lip curve). IF it wasn't linear advancement (an advancement with NO rotation to the maxilla) and you did have some kind of rotation, the rotation would have been a CLOCKWISE one. Your teeth photos show ANTERIOR open bite. The surgical correction (when needed to close anterior open bite) is a posterior impaction, a section removed from back of maxilla. Posterior impaction is CLOCKWISE rotation.
Hard to tell for sure within a 2 degree error but based on your cephs, ANS-PNS (palatal plane angle) and OP (occlusal angle) are measuring same. Either linear advancement or posterior impaction of 1-3 degrees along with the large advancement you got. Either way, an advancement of that extent is consistent with veering towards the conVEX nose to lip curve.
As to your question: ' Should I have gotten CCW rotation?', I don't think it's something you can/could pick and choose to have if you already have/had anterior open bite and there's no indication for CCW with anterior impaction. The other type of CCW rotation is the posterior downgraft. But people with anterior open bite get basically a segment REMOVED as would be added in a posterior downgraft in a person who did NOT have anterior open bite. So, that's why I don't think you had that choice in the first place.
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Kavan
That seems like a pretty comprehensive answer. My lip is definitely convex and my nostrils are substantially wider and nose is upturned, all of which I know (now) is expected with maxillary advancement.
I think overall there has been an aesthetic improvement and the nose can possibly be managed by a rhinoplasty if I choose to. The lip.. well, we'll see.
My main concern was whether it *could* have been otherwise, as irrational as that seems.
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As to your question: ' Should I have gotten CCW rotation?', I don't think it's something you can/could pick and choose to have if you already have/had anterior open bite and there's no indication for CCW with anterior impaction. The other type of CCW rotation is the posterior downgraft. But people with anterior open bite get basically a segment REMOVED as would be added in a posterior downgraft in a person who did NOT have anterior open bite. So, that's why I don't think you had that choice in the first place.
I understand your reasonening that the open bite needs to be closed, and rotating the maxilla ccw will open it further. But looking at the result where the bite is fixed, couldn't it be possible to rotate the bimaxillary complex ccw from this point, which I think is what he is looking for. Given the result, if the bimaxillary complex could've been displaced more CCW than the surgeon did, maybe by posterior downgrafting from where the result landed.
Post bimax. First of all I think you're a bit hard on your self, you have an aesthetic improvement, and you don't look like a chimp. A reasonable question is, was your surgeon even qualified to offer advanced movements as CCW rotation? Not all surgeons are trained to perform such procedure. And also as Kavan explained, maybe it wasn't even an option. It seems like the genio was a bit of ccw rotation of the chin to compensate.
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Dogmatix
I'm probably overly-critical, but I do think the chimp-ish look is apparent IRL (although I agree not so much in that picture). My surgeon was Posnick and he seems to be the most well regarded and most qualified besides maybe A/G. I had a good experience overall, I'm just curious about this one aspect.
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I understand your reasonening that the open bite needs to be closed, and rotating the maxilla ccw will open it further. But looking at the result where the bite is fixed, couldn't it be possible to rotate the bimaxillary complex ccw from this point, which I think is what he is looking for. Given the result, if the bimaxillary complex could've been displaced more CCW than the surgeon did, maybe by posterior downgrafting from where the result landed.
Post bimax. First of all I think you're a bit hard on your self, you have an aesthetic improvement, and you don't look like a chimp. A reasonable question is, was your surgeon even qualified to offer advanced movements as CCW rotation? Not all surgeons are trained to perform such procedure. And also as Kavan explained, maybe it wasn't even an option. It seems like the genio was a bit of ccw rotation of the chin to compensate.
The thing to understand (in this situation) is that correction of AOB is basically the REVERSE of posterior downgraft CCW. What's added in PDG CCW (in someone who doesn't have AOB) is removed when correcting AOB.
I'm not sure what you're asking by the way you ask it. Are you asking whether or not if AFTER correcting AOB by the REVERSE of a CCW posterior down graft, he can then get the CCW posterior downgraft?
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I'm not sure what you're asking by the way you ask it. Are you asking whether or not if AFTER correcting AOB by the REVERSE of a CCW posterior down graft, he can then get the CCW posterior downgraft?
I don't know what displacement there is done to close the anterior open bite. You mentioned a few ways it maybe was handled.
My question was not so much to speculate in what displacement the surgeon have done or if it should've been ccw rotation from starting point. But rather looking at the result, and respecting the concern about the concave lip. Looking at the angle where the surgeon placed the OP, could the surgeon have performed the displacement in a way where it's relative rotated CCW to where it was placed, to comply better with the thread starters concerns and for best aesthetic result? If the displacement was done by posterior impaction and CW rotation to close the bite, then it could've been achieved by less impaction and less CW rotation, which would be a CCW rotation relative to the end result.
I did simplify the question to if a ccw revision could be feasible given the concerns, since if the answer would be yes, then it would also imply that it could've been put that way in the first surgery, regardless if it would've been a ccw rotation from the starting point.
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Kavan
That seems like a pretty comprehensive answer. My lip is definitely convex and my nostrils are substantially wider and nose is upturned, all of which I know (now) is expected with maxillary advancement.
I think overall there has been an aesthetic improvement and the nose can possibly be managed by a rhinoplasty if I choose to. The lip.. well, we'll see.
My main concern was whether it *could* have been otherwise, as irrational as that seems.
Well, Anterior open bite, (AOB) is from too much downgrowth of the posterior maxilla (or over extrusion of back teeth) where the back teeth meet first and there's not enough closure to the teeth in front of them. They remove a segment from the posterior maxilla to correct the AOB. Even if the bite was corrected with braces to 'intrude' the back teeth and you didn't get the posterior impaction, getting a CCW posterior down graft would put you in the same position you had corrected; an AOB. To the best of my knowledge, a propensity towards AOB is contraindication for CCW posterior downgraft.
It looks like your surgery had most of the focus on correcting functional problems and the lip contour could be considered a 'trade-off'. It's pretty much a predictable one and I think that doctors should brace the patients for it.
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Well, Anterior open bite, (AOB) is from too much downgrowth of the posterior maxilla (or over extrusion of back teeth) where the back teeth meet first and there's not enough closure to the teeth in front of them. They remove a segment from the posterior maxilla to correct the AOB. Even if the bite was corrected with braces to 'intrude' the back teeth and you didn't get the posterior impaction, getting a CCW posterior down graft would put you in the same position you had corrected; an AOB. To the best of my knowledge, a propensity towards AOB is contraindication for CCW posterior downgraft.
It looks like your surgery had most of the focus on correcting functional problems and the lip contour could be considered a 'trade-off'. It's pretty much a predictable one and I think that doctors should brace the patients for it.
I do wish he was a bit more forthcoming about the lip/nose changes. Although, I may have taken the risk anyway because I appreciate the longer mandible and more anteriorly projected face overall. If anything, he could have been a little more bold on the genioplasty. I still have braces so that may gain me a mm of projection relative to my bottom lip when they come off.
Overall I still recommend Posnick as the functional outcomes were good and I basically got what I asked for
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I don't know what displacement there is done to close the anterior open bite. You mentioned a few ways it maybe was handled.
My question was not so much to speculate in what displacement the surgeon have done or if it should've been ccw rotation from starting point. But rather looking at the result, and respecting the concern about the concave lip. Looking at the angle where the surgeon placed the OP, could the surgeon have performed the displacement in a way where it's relative rotated CCW to where it was placed, to comply better with the thread starters concerns and for best aesthetic result? If the displacement was done by posterior impaction and CW rotation to close the bite, then it could've been achieved by less impaction and less CW rotation, which would be a CCW rotation relative to the end result.
I did simplify the question to if a ccw revision could be feasible given the concerns, since if the answer would be yes, then it would also imply that it could've been put that way in the first surgery, regardless if it would've been a ccw rotation from the starting point.
I'm sorry. I don't understand the questions the way you ask them. I'll say the following:
a: A wedge section is often removed to close AOB. A wedge where the vertical height of it is more to the BACK of maxilla and min towards the FRONT. When the posterior maxilla 'wedges' down too much, the back teeth touch first and the ones in front of them don't touch which is what AOB is which is why a wedge section is removed from the back.
b: A CCW posterior down graft is basically where a similar shape wedge section is ADDED.
c: A person needing a wedge section REMOVED to close an AOB doesn't get a wedge shape section ADDED.
d: In effect, someone with AOB already has EXCESS CCW to the posterior maxilla. So, the excess kicking up the AOB is removed.
e: Although posterior impaction is CW, having it doesn't necessarily result in a NET CW if the end result on the ceph shows ANS-PNS rotated CCW away from a horizont drawn FROM PNS (in a ceph profile facing RIGHT where the horizont drawn from PNS is is constructed from there to the right of the photo.) So, possible to be left with NET CCW orientation of ANS to PNS. BUT STILL, a LARGE advancement despite what rotation someone gets can kick up a conVEX nose to lip curve.
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I do wish he was a bit more forthcoming about the lip/nose changes. Although, I may have taken the risk anyway because I appreciate the longer mandible and more anteriorly projected face overall. If anything, he could have been a little more bold on the genioplasty. I still have braces so that may gain me a mm of projection relative to my bottom lip when they come off.
Overall I still recommend Posnick as the functional outcomes were good and I basically got what I asked for
Sorry you got the dreaded trade-off. But I don't think it could have been avoided given the extent of the upper jaw advancement. As I said in my first post, the nose to lip curve changes with the extent of the advancement; from concave , less concave, straight, convex, more convex as a function of the advancement and it wasn't a thing where he could give you CCW posterior downgraft (or impact the anterior maxilla) because that would not have corrected the AOB.
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Hmm. I'll try with a shorter formulation.
Could a ccw revision be performed to adress the concerns with the convex upper lip and also asking for a more bold chin advancement.
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Hmm. I'll try with a shorter formulation.
Could a ccw revision be performed to adress the concerns with the convex upper lip and also asking for a more bold chin advancement.
This also interests me. Although the price for an aesthetic revision would be astronomical because insurance wouldn't cover any hospital costs and I'm not sure he would do it anyway.
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Hmm. I'll try with a shorter formulation.
Could a ccw revision be performed to adress the concerns with the convex upper lip and also asking for a more bold chin advancement.
Please read my responses to the OP. I try to make my feedback to be 'in tune' with what the original question was and what I feel the original person with that question will understand. I think I added some clarity to HIM as to the; 'Should I have gotten CCW rotation.' If I haven't, I give up. If HE really wants to pursue a revision and/or attributes 'more CCW' as the 'fix', he can so consult to that regard.
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This also interests me. Although the price for an aesthetic revision would be astronomical because insurance wouldn't cover any hospital costs and I'm not sure he would do it anyway.
A good maxfax, and Posnik is one, will advance out the mandible enough so that the chin augmentation with the sliding genio is modest. The more the chin goes OUTWARD horizontally, the more it has to slide UP vertically which can give a 'step off'. SG is over a diagonal cut and movement over a diagonal has both a horizontal and vertical component. Ask for a more 'bold' chin advancement and you're asking for more of a step off.
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A good maxfax, and Posnik is one, will advance out the mandible enough so that the chin augmentation with the sliding genio is modest. The more the chin goes OUTWARD horizontally, the more it has to slide UP vertically which can give a 'step off'. SG is over a diagonal cut and movement over a diagonal has both a horizontal and vertical component. Ask for a more 'bold' chin advancement and you're asking for more of a step off.
This is a good point. If I were to do any chin augmentation going forward, it would probably be an implant (although I have reservations about those too). I’ll likely get a rhinoplasty eventually as the nostril flare and tilt are quite severe so I’d do it then if it all. I want to give my face at least a year though to make sure everything is settled.
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This is a good point. If I were to do any chin augmentation going forward, it would probably be an implant (although I have reservations about those too). I’ll likely get a rhinoplasty eventually as the nostril flare and tilt are quite severe so I’d do it then if it all. I want to give my face at least a year though to make sure everything is settled.
Smart thinking. A year is good time to let things settle and re-evaluate. Perhaps also to look for isolated solution to the convexity of lip that does not include revision of the surgery you got which corrected everything else.
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Smart thinking. A year is good time to let things settle and re-evaluate. Perhaps also to look for isolated solution to the convexity of lip that does not include revision of the surgery you got which corrected everything else.
As an aside-what is the general opinion on the long-term viability of chin-implants here? I'm mainly thinking of materials like porex, but I am aware of the increased infection rate and difficulty of removal with porous implants.
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As an aside-what is the general opinion on the long-term viability of chin-implants here? I'm mainly thinking of materials like porex, but I am aware of the increased infection rate and difficulty of removal with porous implants.
Perhaps start a separate thread for general opinions.
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OP,
Posnick is an old-school surgeon who does not do CCW. AFAIK, he doesn't even do VY plasty and alar cinches. Although there is some evidence that aesthetically the latter 2 are placebo, CCW does produce undoubtedly superior aesthetic results. The only excuse surgeons have for not performing CCW is stability concerns - relapse and possibly increased joint stress. Don't make the matters worse by trying to camouflage the issue. A full revision with a surgeon who does CCW is your best bet.
All this "wait till the swelling come down" is bulls**t. If you don't like your result within a couple of weeks after surgery, you never will. You might learn to grudgingly accept it, but "liking" and "accepting" are not one and the same.
FWIW, I had only a 5 mm LF1 advancement and immediately thought it was crap, but because all of a sudden I looked younger, I kept telling myself "once the swelling is off", bla, bla. My surgeon laughed off my concerns. 6 weeks post op my ortho, unprompted, told me that that the upper lip convexity improves greatly and that he can see a difference in photos taken 1 and 2 year post op. But an extremely regarded surgeon told me in no uncertain terms that I had a typical lazy single jaw surgery and was over-advanced. I did see some improvement in my case over a couple of years, but not nearly enough for me to "like the result". TBH, I don't even accept it and cover it up with facial hair. BTW, if you don't wish to go through the ordeal again, facial hair is your best camouflage option.
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OP,
Posnick is an old-school surgeon who does not do CCW. AFAIK, he doesn't even do VY plasty and alar cinches. Although there is some evidence that aesthetically the latter 2 are placebo, CCW does produce undoubtedly superior aesthetic results. The only excuse surgeons have for not performing CCW is stability concerns - relapse and possibly increased joint stress. Don't make the matters worse by trying to camouflage the issue. A full revision with a surgeon who does CCW is your best bet.
All this "wait till the swelling come down" is bulls**t. If you don't like your result within a couple of weeks after surgery, you never will. You might learn to grudgingly accept it, but "liking" and "accepting" are not one and the same.
FWIW, I had only a 5 mm LF1 advancement and immediately thought it was crap, but because all of a sudden I looked younger, I kept telling myself "once the swelling is off", bla, bla. My surgeon laughed off my concerns. 6 weeks post op my ortho, unprompted, told me that that the upper lip convexity improves greatly and that he can see a difference in photos taken 1 and 2 year post op. But an extremely regarded surgeon told me in no uncertain terms that I had a typical lazy single jaw surgery and was over-advanced. I did see some improvement in my case over a couple of years, but not nearly enough for me to "like the result". TBH, I don't even accept it and cover it up with facial hair. BTW, if you don't wish to go through the ordeal again, facial hair is your best camouflage option.
Posnick has written papers on CCW and does it.
CCW (posterior down graft) isn't done for anterior open bite.
The main reason for the conVEX lip is the 10mm advancement. He could get that even with CCW.
CCW is great but not every one is an automatic candidate for it just because it's an automatic 'mantra' here. Gunson doesn't even do it when it isn't the solution to correct the problem.
ETA: I can't argue with you about your personal dissatisfaction with your surgeon/surgery. I'm sorry you had to go through what you did. But your personal dissatisfaction with your surgery/surgeon does seems to carry into your arguments against a lot of doctors. You relay that the only way the OP can be corrected is via CCW. But you also relay you still cover up a convex lip with facial hair. So, do tell. Did CCW revision totally correct your convex lip?
ETA: If a surgeon told you that you had a 'lazy single jaw' surgery and L1 5mm was over advancement, I would conclude that you had class 3 where the lower jaw should have been brought backwards so the upper jaw advancement was not that advanced that much. Is my conclusion correct?
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Posnick has written papers on CCW and does it.
CCW (posterior down graft) isn't done for anterior open bite.
The main reason for the conVEX lip is the 10mm advancement. He could get that even with CCW.
CCW is great but not every one is an automatic candidate for it just because it's an automatic 'mantra' here. Gunson doesn't even do it when it isn't the solution to correct the problem.
ETA: I can't argue with you about your personal dissatisfaction with your surgeon/surgery. I'm sorry you had to go through what you did. But your personal dissatisfaction with your surgery/surgeon does seems to carry into your arguments against a lot of doctors. You relay that the only way the OP can be corrected is via CCW. But you also relay you still cover up a convex lip with facial hair. So, do tell. Did CCW revision totally correct your convex lip?
ETA: If a surgeon told you that you had a 'lazy single jaw' surgery and L1 5mm was over advancement, I would conclude that you had class 3 where the lower jaw should have been brought backwards so the upper jaw advancement was not that advanced that much. Is my conclusion correct?
The OP's op occlusal plane is far from flat. OSA surgery is 90% about advancing the mandible to open the airway. Relative to simple linear advancement, CCW rotation allows to achieve greater mandibular advancement with a smaller maxillary advancement.
I've seen one of Posnick's open bite surgery results - only two teeth touched. I know a person, who got a similar aesthetic result to OP with another surgeon, who had promised CCW, but didn't do it. When that person consulted with Posnick for a revision about his, IMO, legitimate concerns, he was simply laughed off and dismissed.
As for myself... I have a steep mandibular plane and a mildly steep occlusal plane. I don't think I have a great chin-throat length either. A dumb linear set back of the lower might have left me with OSA. Splitting the movements into upper and lower... might have still left me with OSA and still have given me excessive upper lip convexity (I've seen just such results). Gunson's solution was setback with CCW to preserve the chin-throat length... I have no balls to find out.
Anyway WRT my negativity and skepticism, the more results I see, the more it looks like only a handful of surgeons world-wide can be trusted with jaw surgery if you care about the aesthetic outcome. What is even more depressing is how often a decent bite is not achieved. I used to think it was pretty much guaranteed... Apparently not. In reply to my post-op aesthetic concerns my surgeon told me that I should be happy with the bite, because a good bite does not always happy, I now realise he MEANT it. The average surgeon has really low standards for him/herself. They rely on the ortho to properly decompensate and move the teeth into occlusion. THAT'S IT. And if the ortho is crap, bad luck for you.
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The main reason for the conVEX lip is the 10mm advancement. He could get that even with CCW.
It sounds like both linear and ccw advancement may give a convex lip? Is there a way to perform an advancement that promotes a concave lip? CCW sounds like the best option for that, as the advancement is smallest around ANS and then increase the further down you go, so the lower part of the lip is advanced most. Is it even possible to change how the lip will want to fold over the jaw, isn't that more a muscle and soft tissue shape of the lip itself, which ofc can get more prominent with a linear advancement?
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The OP's op occlusal plane is far from flat. OSA surgery is 90% about advancing the mandible to open the airway. Relative to simple linear advancement, CCW rotation allows to achieve greater mandibular advancement with a smaller maxillary advancement.
I've seen one of Posnick's open bite surgery results - only two teeth touched. I know a person, who got a similar aesthetic result to OP with another surgeon, who had promised CCW, but didn't do it. When that person consulted with Posnick for a revision about his, IMO, legitimate concerns, he was simply laughed off and dismissed.
As for myself... I have a steep mandibular plane and a mildly steep occlusal plane. I don't think I have a great chin-throat length either. A dumb linear set back of the lower might have left me with OSA. Splitting the movements into upper and lower... might have still left me with OSA and still have given me excessive upper lip convexity (I've seen just such results). Gunson's solution was setback with CCW to preserve the chin-throat length... I have no balls to find out.
Anyway WRT my negativity and skepticism, the more results I see, the more it looks like only a handful of surgeons world-wide can be trusted with jaw surgery if you care about the aesthetic outcome. What is even more depressing is how often a decent bite is not achieved. I used to think it was pretty much guaranteed... Apparently not. In reply to my post-op aesthetic concerns my surgeon told me that I should be happy with the bite, because a good bite does not always happy, I now realise he MEANT it. The average surgeon has really low standards for him/herself. They rely on the ortho to properly decompensate and move the teeth into occlusion. THAT'S IT. And if the ortho is crap, bad luck for you.
Does CCW affect occlusion? I understand Kavan’s point that posterior downgraft is the opposite of posterior impaction (which is used for AOB), but I’m pretty sure I’ve seen CCW of the whole MM complex where occlusion remains the same. In that case, it seems like a setback with CCW would improve aesthetics while maintaining the functional result.
Not that I can afford that kind of aesthetic surgery.
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OP,
Posnick is an old-school surgeon who does not do CCW. AFAIK, he doesn't even do VY plasty and alar cinches. Although there is some evidence that aesthetically the latter 2 are placebo, CCW does produce undoubtedly superior aesthetic results. The only excuse surgeons have for not performing CCW is stability concerns - relapse and possibly increased joint stress. Don't make the matters worse by trying to camouflage the issue. A full revision with a surgeon who does CCW is your best bet.
All this "wait till the swelling come down" is bulls**t. If you don't like your result within a couple of weeks after surgery, you never will. You might learn to grudgingly accept it, but "liking" and "accepting" are not one and the same.
FWIW, I had only a 5 mm LF1 advancement and immediately thought it was crap, but because all of a sudden I looked younger, I kept telling myself "once the swelling is off", bla, bla. My surgeon laughed off my concerns. 6 weeks post op my ortho, unprompted, told me that that the upper lip convexity improves greatly and that he can see a difference in photos taken 1 and 2 year post op. But an extremely regarded surgeon told me in no uncertain terms that I had a typical lazy single jaw surgery and was over-advanced. I did see some improvement in my case over a couple of years, but not nearly enough for me to "like the result". TBH, I don't even accept it and cover it up with facial hair. BTW, if you don't wish to go through the ordeal again, facial hair is your best camouflage option.
As Kavan said, Posnick does CCW but more on the scale of like Relle or other docs who somewhat factor in aesthetics without ""adding excessive risk"" to the TMJs. So like a posterior downgraft no greater than 4-6mm where Gunson goes as high as 10mm, maybe more. Having consulted both of those docs and Gunson, Gunson would have doubled my CCW (posterior downgraft), relative to that 4-6mm ceiling of other docs, while cutting my L1 advancement to less than half the amount Posnick guestimated he would do on me. (can't recall Relle's amount right now but I know he didn't post #'s anyway). Relle and Posnick would rather extract teeth than go further in the posterior downgraft. Both are craptastic options, that is if you don't like to gamble away your TMJ's or your immune system, if you ask me.
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Does CCW affect occlusion?
CCW is short for counter clock wise, so it's basically just a direction. To my knowledge it's possible to take the maxillomandibular complex and rotate it CCW with maintained occlusion. That is what's being done in aesthetic cases where braces is not needed and the patient already have good occlusion.
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The OP's op occlusal plane is far from flat. OSA surgery is 90% about advancing the mandible to open the airway. Relative to simple linear advancement, CCW rotation allows to achieve greater mandibular advancement with a smaller maxillary advancement.
I've seen one of Posnick's open bite surgery results - only two teeth touched. I know a person, who got a similar aesthetic result to OP with another surgeon, who had promised CCW, but didn't do it. When that person consulted with Posnick for a revision about his, IMO, legitimate concerns, he was simply laughed off and dismissed.
As for myself... I have a steep mandibular plane and a mildly steep occlusal plane. I don't think I have a great chin-throat length either. A dumb linear set back of the lower might have left me with OSA. Splitting the movements into upper and lower... might have still left me with OSA and still have given me excessive upper lip convexity (I've seen just such results). Gunson's solution was setback with CCW to preserve the chin-throat length... I have no balls to find out.
Anyway WRT my negativity and skepticism, the more results I see, the more it looks like only a handful of surgeons world-wide can be trusted with jaw surgery if you care about the aesthetic outcome. What is even more depressing is how often a decent bite is not achieved. I used to think it was pretty much guaranteed... Apparently not. In reply to my post-op aesthetic concerns my surgeon told me that I should be happy with the bite, because a good bite does not always happy, I now realise he MEANT it. The average surgeon has really low standards for him/herself. They rely on the ortho to properly decompensate and move the teeth into occlusion. THAT'S IT. And if the ortho is crap, bad luck for you.
I didn't say his OP was flat. Nor was his OP steep. Nor was his MP steep. I said he had anterior open bite which is NOT corrected with CCW. It's perfectly understandable to me he didn't get CCW because I'm not 'reacting' out a negative emotional response. I'm just looking at what goes with what. His case is DIFFERENT from yours.
Gunson's solution for you via CCW would have most likely done what a double jaw surgery would have done for class 3 so the upper jaw DID NOT have to be advanced more forward than needed where the correction not only would be CCW but also a lower jaw SET BACK. Lower jaw set back IN ORDER TO also set back the maxilla might not be the right thing to do for this guy with OSA and as you say, it might very well (in your case) NOT been enough to eradicate the convex lip which is why I'm perplexed you are saying with such conviction (conviction being an emotive respose) that the OP should do that.
As to this handful of surgeons, Gunson included, I've seen critiques of him on the private board and for a patient he did a GREAT job on. The patient started off with CLOSE SET eyes, got some cheek enhancement and a multi segment lefort in addition to max/man advancement for SLEEP APNEA and people were making fun of his (Gunson's) results and failed to see it was the close set eyes of the patient that resulted in his not having 'maximum aesthetics', basically something the doctor can't change. Not to mention, there's another for whom the correction is NOT CCW but the proposed correction with some CW (posterior impaction) looks great.
So, I do see some of these reactions as coming from an unhappy experience where the facts and circumstances of the person having them DON'T EVEN APPLY to the OP.
That's why I asked you IF 'the surgeon' telling you that you got a lazy single advancement actually rectified the convex lip. Seems like you didn't go through with it due to some possible trade offs. But should the OP, as you suggest he do, really go through with it where a risk could be he could find out FOR SURE if it really doesn't eradicate the convex lip.
I guess I'll leave it at IF the OP really wants to find out for SURE whether or not correction via CCW will reverse his convex lip, he can try it. I'm just not going to encourage him to. But you can if you like.
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Honestly, mild lip convexivity is not really devastating and there is still potential for it to decrease. Plosko, I think I saw you mention somewhere else that yours is actually slightly concave now. If anything I think the relative weakness of my lower 1/3 is more impactful aesthetically and there are options to fix that short of a revision.
What I’m gathering from this thread is that CCW of the mm complex was *possible*, but not necessarily indicated in my case for the reasons Kavan mentioned. My guess is Posnick was not willing to add risk to a case for slight aesthetic benefit where CCW was in fact counter to functional priorities (AOB). It’s hard to disagree with that IMO.
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CCW (posterior down graft) isn't done for anterior open bite.
I'm going to guess each anterior open bite is treated differently depending on the cause and the surgeon. I say this because I've seen a ceph treatment plan from Gunson where a large AOB is closed with CCW (PNS coming down 6mm) and multisegment surgery.
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I'm going to guess each anterior open bite is treated differently depending on the cause and the surgeon. I say this because I've seen a ceph treatment plan from Gunson where a large AOB is closed with CCW (PNS coming down 6mm) and multisegment surgery.
Yes. Each AOB is treated differently depending on the cause and the surgeon, much like any bite if the reference is all (number of) specific measures and/or other problems the person has with it. Like someone can have anterior open bite for example, WITH transverse upper jaw too narrow where multi-segment is needed to treat that. So, AOB can come with a variety of other things where correction of them can involve CCW.
My statement was in context of the OP's situation and counter to assertion that only revision with CCW would address/correct his upper lip convexity. So, here my focus was directly on the OP and not a multitude of other situations which I had no reason to believe were directly applicable to his.
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Does CCW affect occlusion? I understand Kavan’s point that posterior downgraft is the opposite of posterior impaction (which is used for AOB), but I’m pretty sure I’ve seen CCW of the whole MM complex where occlusion remains the same. In that case, it seems like a setback with CCW would improve aesthetics while maintaining the functional result.
Not that I can afford that kind of aesthetic surgery.
If you wanted to actually do that with primary objective to reduce the convex lip, the MM complex set back would include setting back the mandible too. Seems to be contrary thing to do if the airway would be reduced in the process and since you say you LIKE the longer mandible and WISH you had MORE projection.
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If you wanted to actually do that with primary objective to reduce the convex lip, the MM complex set back would include setting back the mandible too. Seems to be contrary thing to do if the airway would be reduced in the process and since you say you LIKE the longer mandible and WISH you had MORE projection.
From my understanding, CCW rotation of the mm complex allows a greater mandibular projection per unit of maxillary advancement due to the flattening of the jaw angle. For example, I’d be able to achieve the same amount of mandibular projection with (say) 7mm maxilla advancement and CCW of the complex as with 10mm of straight advancement. Whether it would be enough to change lip convexity, I don’t know. I could be wrong about all this because I’m very new here.
This is all theoretical at this point because a full revision is not in the cards for me.
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From my understanding, CCW rotation of the mm complex allows a greater mandibular projection per unit of maxillary advancement due to the flattening of the jaw angle. For example, I’d be able to achieve the same amount of mandibular projection with (say) 7mm maxilla advancement and CCW of the complex as with 10mm of straight advancement. Whether it would be enough to change lip convexity, I don’t know. I could be wrong about all this because I’m very new here.
This is all theoretical at this point because a full revision is not in the cards for me.
Hi,
I understand why the doctor gave the displacements he did given what you started with and why he didn't offer CCW for the anterior open bite and tried my best to explain that. But I can't go through everyone's 'understanding' of every possible thing in this process about everything having to do with CCW.
You started out with an almost straight labial ledge (area from base of nose to top of upper lip), so even if you got 5mm advancement via CCW, I can't say it would have PRELCUDED a convexity of the lip. But I can say, it would have run counter to correcting AOB.
It's hard for me to hold Posnick's feet to the fire for not giving you CCW when you had AOB. But you can ask him why he didn't if you like.
You're right. A lot of these spin off questions are theoretical at this point and my perspective here has been what is practical at this point in time.
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From my understanding, CCW rotation of the mm complex allows a greater mandibular projection per unit of maxillary advancement due to the flattening of the jaw angle. For example, I’d be able to achieve the same amount of mandibular projection with (say) 7mm maxilla advancement and CCW of the complex as with 10mm of straight advancement. Whether it would be enough to change lip convexity, I don’t know. I could be wrong about all this because I’m very new here.
This is all theoretical at this point because a full revision is not in the cards for me.
This is my line of thought as well. If there was anything that could be done with your concern, it would be to pull ANS back a bit, and rotate the MM complex to project the chin, maybe even further than where it's now. It would most probable not be reversing the entire advancement, but as you say, trade some of the linear advancement you got for a CCW. Also uncertain how much it would actually do on the lip, a surgeon would have to evaluate that. Even a CCW projects the lip, but in a different way. Probably less convexity than a linear advancement if I understand correctly.
I understand that a ccw rotation contradicts to direct treating an anterior open bite, but bimax have 2 degrees of freedom, both maxilla and mandible. So I think it's a legit question if ccw rotation could've been done. First the maxilla to increase the open bite, and then further rotation of the mandible to close it. If ccw seems possible from the point you're at now, I don't see that it couldn't be possible from beginning.
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This is my line of thought as well. If there was anything that could be done with your concern, it would be to pull ANS back a bit, and rotate the MM complex to project the chin, maybe even further than where it's now. It would most probable not be reversing the entire advancement, but as you say, trade some of the linear advancement you got for a CCW. Also uncertain how much it would actually do on the lip, a surgeon would have to evaluate that. Even a CCW projects the lip, but in a different way. Probably less convexity than a linear advancement if I understand correctly.
I understand that a ccw rotation contradicts to direct treating an anterior open bite, but bimax have 2 degrees of freedom, both maxilla and mandible. So I think it's a legit question if ccw rotation could've been done. First the maxilla to increase the open bite, and then further rotation of the mandible to close it. If ccw seems possible from the point you're at now, I don't see that it couldn't be possible from beginning.
I agree, but there must be some reason Posnick preferred the linear advancement. If anything, as Kavan notes, what he did was the most straightforward solution to what I presented with and CCW is technically less stable. Maybe someone like Gunson would have included CCW but I did not consult with him. I may ask Posnick himself in a year or so if I decide on a rhino and chin enhancement as he does plastic surgery as well.
I really do wish he had warned about nostril tilt, flare and convex lip. I would have probably gone through with it anyway but that is a knock against him in my book considering how predictable those outcomes are.
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This is my line of thought as well. If there was anything that could be done with your concern, it would be to pull ANS back a bit, and rotate the MM complex to project the chin, maybe even further than where it's now. It would most probable not be reversing the entire advancement, but as you say, trade some of the linear advancement you got for a CCW. Also uncertain how much it would actually do on the lip, a surgeon would have to evaluate that. Even a CCW projects the lip, but in a different way. Probably less convexity than a linear advancement if I understand correctly.
Yeah agreed, there are different points of rotation that could be used so that the mandible doesn't go back.
If you look at this triangle, they can use the incisor tip as a point of CCW rotation, which would set back ANS, bring down PNS, keep the incisors in their current position, and bring forward the chin. There might need to be additional adjustments afterwards, but I think there would be revision options of ANS set back without setting back the whole thing.
(https://i.imgur.com/0Ou0dGv.jpg?1)
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I agree, but there must be some reason Posnick preferred the linear advancement. If anything, as Kavan notes, what he did was the most straightforward solution to what I presented with and CCW is technically less stable. Maybe someone like Gunson would have included CCW but I did not consult with him. I may ask Posnick himself in a year or so if I decide on a rhino and chin enhancement as he does plastic surgery as well.
I heard on another site that Posnick is retiring.
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This is how an open bite is corrected: https://www.youtube.com/watch?v=2_xpiAr2L78
It's a simple movement. You can see the natural tendency of it is CW rotation, though.
Based on the photos and the convex lip, my guess is he made the cut on the upper jaw, then moved the entire complex (both jaws) forward linearly. Since the plane of the upper jaw actually steepens, this results in mild CW rotation. Surgeons don't seem to understand that if the MMC's plane is steep and you move it forward linearly you actually are creating mild CW rotation, or if they do understand it, they don't seem to care that the result is unaesthetic.
To do the surgery "properly" he should have downgrafted (filled with bone) the posterior maxilla . This would allow the complex to rotate CCW.
This is an unstable movement because the graft can reabsorb. Maybe this is why he didn't do it. I know an Arnett patient suffering from this very problem. His open bite is back five years later. Maybe Posnick made this compromise for that reason. To me, you look better before. I'm sorry. I hope you at least get better function out of this. As to whether you should have gotten CCW rotation -- if you were willing to take the risk of resorption, yes. It would have been more aesthetic. If you weren't willing to take that risk, you got the proper surgery. It sounds like the surgeon made the decision for you, though.
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The twats don't care. We're just a profit opportunity for them at best, and fodder for their residents at worst.
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This is how an open bite is corrected: https://www.youtube.com/watch?v=2_xpiAr2L78
It's a simple movement. You can see the natural tendency of it is CW rotation, though.
Based on the photos and the convex lip, my guess is he made the cut on the upper jaw, then moved the entire complex (both jaws) forward linearly. Since the plane of the upper jaw actually steepens, this results in mild CW rotation. Surgeons don't seem to understand that if the MMC's plane is steep and you move it forward linearly you actually are creating mild CW rotation, or if they do understand it, they don't seem to care that the result is unaesthetic.
To do the surgery "properly" he should have downgrafted (filled with bone) the posterior maxilla . This would allow the complex to rotate CCW.
This is an unstable movement because the graft can reabsorb. Maybe this is why he didn't do it. I know an Arnett patient suffering from this very problem. His open bite is back five years later. Maybe Posnick made this compromise for that reason. To me, you look better before. I'm sorry. I hope you at least get better function out of this. As to whether you should have gotten CCW rotation -- if you were willing to take the risk of resorption, yes. It would have been more aesthetic. If you weren't willing to take that risk, you got the proper surgery. It sounds like the surgeon made the decision for you, though.
I think that's one way AOB can be corrected, but I think it can also be corrected via anterior downgraft which is what I think I got. Could be wrong though because I didn't know enough to ask at the time.
At this point, I also think I looked better before. The changes to my upper lip and nose are even more apparent from the frontal view. I was never warned about any of this and I found this community too late. Another doctor had offered to only do a LF1 and genioplasty but I went with Posnick because I figured his approach was more complete.
The 'chimp' look is especially bad in my case because my ears already stick out a bit and my eyes are on the 'closer' set side. So I've got the ears, nose, lip and eyes all working in concert to produce a simian aesthetic.
Gunson must agree with you to some extent because he offered a consultation for revision, so I guess I'll see what happens. JS is just such a mentally, physically and financially taxing experience. I'm not looking forward to round 2 if it comes to that.
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I think that's one way AOB can be corrected, but I think it can also be corrected via anterior downgraft which is what I think I got. Could be wrong though because I didn't know enough to ask at the time.
At this point, I also think I looked better before. The changes to my upper lip and nose are even more apparent from the frontal view. I was never warned about any of this and I found this community too late. Another doctor had offered to only do a LF1 and genioplasty but I went with Posnick because I figured his approach was more complete.
The 'chimp' look is especially bad in my case because my ears already stick out a bit and my eyes are on the 'closer' set side. So I've got the ears, nose, lip and eyes all working in concert to produce a simian aesthetic.
Gunson must agree with you to some extent because he offered a consultation for revision, so I guess I'll see what happens. JS is just such a mentally, physically and financially taxing experience. I'm not looking forward to round 2 if it comes to that.
As a function of time, in retrospect, the presentation of info has been a 'moving target' where it's hard to pin down exactly what you had. I say in 'retrospect' because initially, I had to go through an 'if THIS than THAT' process due to absence of info as to how the AOB was treated (posterior impaction, anterior downgraft or just linear advancement). But later down the line you say you think you got anterior downgraft. Another later down the line 'movement' of info was that in another thread you mentioned you may have had a 3 piece L1 where initial assumption was just 1 piece. Another later down the line 'movement' of info was the removal (from your IMGUR) link the ceph with the BRACES on which was most likely the one used to plan the surgery.
I'm not faulting for that as you did your best to relay what you had done based on what the doctor told you VERBALLY and then there is the mystery of where your 'A' point is (fuzzy cephs where outline is not clear) which presents another 'IF here THAN that' situation in the explanation department of why you had what you had (or didn't have what you wanted to know if you should have had). I'm just observing a MOVING TARGET (changes in the presentation of info).
Ok, so Gunson offered a consult for revision. Other than agreeing on the obvious (which is your not liking the aesthetic outcome), which before ceph/s did you send him...the ONLY one LEFT on your IMGUR link or did you also send along the 2 other ones. One being where you were concerned your head was tilted up (ceph with NO braces) and the ceph with braces. Although I realize it wasn't needed to send him one of the cephs where your doctor rejected it because it was cut off too much. So, that one is not in question. Hope you're not 'picking and choosing' based on what you think he should be looking at.
Have you considered just getting a hold of your actual SURGICAL RECORDS where WHICH cephs were used and Which EXACT movements you actually got are given? What to do will be based on what you actually had. Not on what you think you had.
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As a function of time, in retrospect, the presentation of info has been a 'moving target' where it's hard to pin down exactly what you had. I say in 'retrospect' because initially, I had to go through an 'if THIS than THAT' process due to absence of info as to how the AOB was treated (posterior impaction, anterior downgraft or just linear advancement). But later down the line you say you think you got anterior downgraft. Another later down the line 'movement' of info was that in another thread you mentioned you may have had a 3 piece L1 where initial assumption was just 1 piece. Another later down the line 'movement' of info was the removal (from your IMGUR) link the ceph with the BRACES on which was most likely the one used to plan the surgery.
I'm not faulting for that as you did your best to relay what you had done based on what the doctor told you VERBALLY and then there is the mystery of where your 'A' point is (fuzzy cephs where outline is not clear) which presents another 'IF here THAN that' situation in the explanation department of why you had what you had (or didn't have what you wanted to know if you should have had). I'm just observing a MOVING TARGET (changes in the presentation of info).
Ok, so Gunson offered a consult for revision. Other than agreeing on the obvious (which is your not liking the aesthetic outcome), which before ceph/s did you send him...the ONLY one LEFT on your IMGUR link or did you also send along the 2 other ones. One being where you were concerned your head was tilted up (ceph with NO braces) and the ceph with braces. Although I realize it wasn't needed to send him one of the cephs where your doctor rejected it because it was cut off too much. So, that one is not in question. Hope you're not 'picking and choosing' based on what you think he should be looking at.
Have you considered just getting a hold of your actual SURGICAL RECORDS where WHICH cephs were used and Which EXACT movements you actually got are given? What to do will be based on what you actually had. Not on what you think you had.
Yeah, sorry about this. Joining this board has been a learning process for me as I had very little knowledge of JS before posting, so my understanding of what constitutes salient information has been a 'moving target' for me as well. I believe I got an anterior downgraft based on Plosko's comment and then looking at the x-ray again myself. Posnick never specified either way in this regard. He did, however, tell me my LF1 was 3 piece.
The CEPHs I sent Gunson were the 2011 (at or close to NHP), 2018 pre-op (head possibly tilted up, this is the one that was ACCEPTED by Posnick), and the 2018 post-op xray. I did NOT send him the CEPH with my chin cut off when I was looking down that was rejected by Posnick. If I were 'picking and choosing', I'd probably have just sent this one to give the impression that my OP is steep. I labeled my CEPHs by date. I also sent him the PAN xrays that were taken at the same time as each CEPH.
I'll email Posnick and try to get a hold of the actual surgical records.
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Yeah, sorry about this. Joining this board has been a learning process for me as I had very little knowledge of JS before posting, so my understanding of what constitutes salient information has been a 'moving target' for me as well. I believe I got an anterior downgraft based on Plosko's comment and then looking at the x-ray again myself. Posnick never specified either way in this regard. He did, however, tell me my LF1 was 3 piece.
The CEPHs I sent Gunson were the 2011 (at or close to NHP), 2018 pre-op (head possibly tilted up, this is the one that was ACCEPTED by Posnick), and the 2018 post-op xray. I did NOT send him the CEPH with my chin cut off when I was looking down that was rejected by Posnick. If I were 'picking and choosing', I'd probably have just sent this one to give the impression that my OP is steep. I labeled my CEPHs by date. I also sent him the PAN xrays that were taken at the same time as each CEPH.
I'll email Posnick and try to get a hold of the actual surgical records.
Well, it looks like picking and choosing because you chose to send him a 2011 and not a later one. No idea how you know the 2011 one is 'neutral head posture' vs another one that came later (also without braces) or realize there's a difference between 'neutral' head position and 'natural' head position. I myself get those confused. One is holding the head the way one holds it and the other is holding it so the eyes look straight ahead (at mirror in distance) in a pure horizont whether or not that's how one holds one's head which is the one that lets them look at 'true' verticals vs 'true' horizonts.
It looks like there was one in your series that came after 2011 that you elected not to send which is what I meant by 'picking and choosing'. It also did NOT have braces. But unlike the 2011 one that looked to have wisdom teeth, this one did not. So, it must have been taken later than 2011.
In fact, I actually used it to take a closer look at why Plosko said your OP became steeper afterwards ('not flat anymore'). I found that your OP was about 4 degrees more in the post op. But I also found that an angle formed by 2 distinct points on on the post op was 4 degrees more than those 2 distinct points on the pre-op (the one I used).
The photo on the left is the one I chose and chose it because the 'pure' horizont passes closer through near center of eyeball than does the 2011 and also because it was a LATER photo given the wisdom teeth were not in the jaw. I then compared relative angle changes in head position based on points that DON'T change; the 'S' and 'Or' points. Hence it didn't look like the OP really got significantly 'less flat' or 'steeper' given the amount it became steeper in the post op was about the SAME 4 degrees your head tilt was MORE than that in the pre op.
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Well, it looks like picking and choosing because you chose to send him a 2011 and not a later one. No idea how you know the 2011 one is 'neutral head posture' vs another one that came later (also without braces) or realize there's a difference between 'neutral' head position and 'natural' head position. I myself get those confused. One is holding the head the way one holds it and the other is holding it so the eyes look straight ahead (at mirror in distance) in a pure horizont whether or not that's how one holds one's head which is the one that lets them look at 'true' verticals vs 'true' horizonts.
It looks like there was one in your series that came after 2011 that you elected not to send which is what I meant by 'picking and choosing'. It also did NOT have braces. But unlike the 2011 one that looked to have wisdom teeth, this one did not. So, it must have been taken later than 2011.
In fact, I actually used it to take a closer look at why Plosko said your OP became steeper afterwards ('not flat anymore'). I found that your OP was about 4 degrees more in the post op. But I also found that an angle formed by 2 distinct points on on the post op was 4 degrees more than those 2 distinct points on the pre-op (the one I used).
The photo on the left is the one I chose and chose it because the 'pure' horizont passes closer through near center of eyeball than does the 2011 and also because it was a LATER photo given the wisdom teeth were not in the jaw. I then compared relative angle changes in head position based on points that DON'T change; the 'S' and 'Or' points. Hence it didn't look like the OP really got significantly 'less flat' or 'steeper' given the amount it became steeper in the post op was about the SAME 4 degrees your head tilt was MORE than that in the pre op.
Maybe you are forgetting something or misread my post. I’ve posted 4 CEPHs to this board.
2011 (what I considered NHP)
2018 pre-op (rejected)
2018 pre-op (accepted)
2018 post-op
I sent Gunson everything except the ‘rejected’ CEPH, including the PAN xrays. The photo provided in your reply is the 2018 accepted one, which was sent to gunson.
I am not trying to ‘trick’ my way into a revision jaw surgery.
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Maybe you are forgetting something or misread my post. I’ve posted 4 CEPHs to this board.
2011 (what I considered NHP)
2018 pre-op (rejected)
2018 pre-op (accepted)
2018 post-op
I sent Gunson everything except the ‘rejected’ CEPH, including the PAN xrays. The photo provided in your reply is the 2018 accepted one, which was sent to gunson.
I am not trying to ‘trick’ my way into a revision jaw surgery.
Could be because your IMGUR link removed some of the cephs you had on there.
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Could be because your IMGUR link removed some of the cephs you had on there.
Here is the link where I had posted all CEPHs:
https://imgur.com/a/G8mbkWC (https://imgur.com/a/G8mbkWC)
All of these were sent except the 6/1/18 rejected. I have another ceph from 2009 pre the orthodontics I had 2009-2011 but I don’t think that’s relevant.
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Here is the link where I had posted all CEPHs:
https://imgur.com/a/G8mbkWC (https://imgur.com/a/G8mbkWC)
All of these were sent except the 6/1/18 rejected. I have another ceph from 2009 pre the orthodontics I had 2009-2011 but I don’t think that’s relevant.
Oh, OK. My bad. I kept looking at the link in THIS post (first post) and knew I saw more cephs that were in there. So, it was the other link the ones i saw. Sorry about that. I did get confused.
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Now that its been longer, do you have updated pics and/or are you happier with the outcome?
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Now that its been longer, do you have updated pics and/or are you happier with the outcome?
Sent you pm