jawsurgeryforums.com
Education => Educational Material => Topic started by: april on April 27, 2019, 08:08:43 PM
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" Dr. Antipov covers the steps of the procedure in his lecture. Starting from diagnosis, 2d planning, 3d planning, surgery and recovery. "
https://youtu.be/4vIrUQXvy8M
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He discusses this girl's case and planning. He seems to follow the AG style of dealing with TMJ cases
I think her tooth show got destroyed. Too much impaction/rotation?
(https://i.imgur.com/AvFqGJh.jpg?1)
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She looks great.
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She looks great.
Yeah, but the tooth show is terrible.
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There's no doubt she looks better overall.
But I'm just honing in on the tooth show, and I'm wondering if making her OP completely flat like he said he did, has resulted in more lower teeth showing and less of her upper teeth and gums.
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There's no doubt she looks better overall.
But I'm just honing in on the tooth show, and I'm wondering if making her OP completely flat like he said he did, has resulted in more lower teeth showing and less of her upper teeth and gums.
Didn't watch the whole video. Just skipped through it. But even if the lower tooth show was a function of making the OP flat, maximizing the airway and maximizing the advancement which did result in GREAT overall AESTHETIC improvement was ALSO a function of the choice to flatten the OP. So, some lower tooth show (and less upper show) could be considered a MINOR trade-off of the OVERALL improvement.
To the best of my knowledge, the VSP, (since they do PLAN all this stuff out) will show, in the read outs numerical data of the parts that will be 'on target' with desired aesthetics and things that will deviate somewhat. It will have numbers to that regard and color coding of such.
Aside from something going 'wrong' in the surgery or some unexpected unfavorable consequence (eg. a risk associated with surgery), for the most part, they look at the VSP predictions of all the things that will change as a result of their plan where they see the highly favorable ones along with what would be considered 'trade-offs'; deviations from either the norm or deviations from 'highly favorable' (and here, perhaps the tooth show). So, they probably can anticipate them. But they are considered 'trade-offs' because the data tells them they are things that can't be changed to 'highly favorable' without altering the other very SALIENT highly favorable changes.
Honing in on the tooth show:
Actually, the tooth show can be anticipated via the ceph displacement plan. If you look closely at the displacement diagrams, ( photo of ceph tracing called 2D plan) and ZERO IN on the teeth, you can see that the lower tooth does not show through the mouth in the before. Now, if you look at the 'after' plan and zero in on the lower tooth, you can see that it's going to show through the mouth and it shows kind of high. You can do the same with the upper too.
So, that does look to be something that they anticipate as happening. Afterall, even if one can't understand what the numbers and color coding of them mean, how the teeth are going to show through the mouth can be seen via the 2D plan vs the before just by LOOKING at the relative position of the TRACING of them relative to the lips. Hence, it's something that shows as PART of the PLAN and something they accept as a trade-off in exchange for the other over all improvements involved with the entire plan.
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Yeah, but the tooth show is terrible.
Trade-off for overall improvement.
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Yeah, but the tooth show is terrible.
Really? It looked excessive before, and now it looks within the realm of normal. I mean maybe another half mm, but to expect that kind of precision is unrealistic.
Unless robots do the surgery. Hopefully they will soon.
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Didn't watch the whole video. Just skipped through it. But even if the lower tooth show was a function of making the OP flat, maximizing the airway and maximizing the advancement which did result in GREAT overall AESTHETIC improvement was ALSO a function of the choice to flatten the OP. So, some lower tooth show (and less upper show) could be considered a MINOR trade-off of the OVERALL improvement.
True, it could be a minor issue for her considering everything else. She looks happy. I think I am projecting my own issues and worries about tooth show on to this case; it was the first thing that stood out to me. She might also still be recovering and have muscle weakness etc going on which makes her unable to show more of her upper teeth.
Actually, the tooth show can be anticipated via the ceph displacement plan. If you look closely at the displacement diagrams, ( photo of ceph tracing called 2D plan) and ZERO IN on the teeth, you can see that the lower tooth does not show through the mouth in the before. Now, if you look at the 'after' plan and zero in on the lower tooth, you can see that it's going to show through the mouth and it shows kind of high. You can do the same with the upper too.
So, that does look to be something that they anticipate as happening. Afterall, even if one can't understand what the numbers and color coding of them mean, how the teeth are going to show through the mouth can be seen via the 2D plan vs the before just by LOOKING at the relative position of the TRACING of them relative to the lips. Hence, it's something that shows as PART of the PLAN and something they accept as a trade-off in exchange for the other over all improvements involved with the entire plan.
I see it, yes, thanks. You often hear upset patients who've been over-impacted by various surgeons, and had no warning it would happen. So it's at least good this was visible on her tracings.
I've sort of learned how to read these 2D plans. I'm over-analyzing, but the number that I am pretty sure represents upper tooth show actually look a bit off when you compare it to the tracing of the teeth under the lip. Like the number does not correspond with the position of the teeth.
https://i.imgur.com/q0uN90T.jpg
She started with 5mm of upper mx incisor show at rest (as seen by the green 5), and the projected plan says 3 (in black). But it really doesn't look like 3mm of her upper teeth are sitting below her upper lip in the drawing, more like 1mm or 2mm.
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Really? It looked excessive before, and now it looks within the realm of normal. I mean maybe another half mm, but to expect that kind of precision is unrealistic.
Unless robots do the surgery. Hopefully they will soon.
I always thought you were supposed to show about 1mm of gum at full smile. Even more important if you're young like she is, as it gets worse with age. But I might be overreacting and she may still be recovering her lip mobility after surgery. Or it might just be the agreed trade-off.
Anyway, I didn't mean my observation to take away from the vid itself. There's some good info in there.
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I'd have to see more photos of her, but plenty of people show less than 1mm of gum and look normal/great.
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True, it could be a minor issue for her considering everything else. She looks happy. I think I am projecting my own issues and worries about tooth show on to this case; it was the first thing that stood out to me. She might also still be recovering and have muscle weakness etc going on which makes her unable to show more of her upper teeth.
I see it, yes, thanks. You often hear upset patients who've been over-impacted by various surgeons, and had no warning it would happen. So it's at least good this was visible on her tracings.
I've sort of learned how to read these 2D plans. I'm over-analyzing, but the number that I am pretty sure represents upper tooth show actually look a bit off when you compare it to the tracing of the teeth under the lip. Like the number does not correspond with the position of the teeth.
https://i.imgur.com/q0uN90T.jpg
She started with 5mm of upper mx incisor show at rest (as seen by the green 5), and the projected plan says 3 (in black). But it really doesn't look like 3mm of her upper teeth are sitting below her upper lip in the drawing, more like 1mm or 2mm.
Well, she's got a RED 19 for the lower tooth on the before and a green 9(?) on the after and a black -11 for the upper tooth show on the before and green 7 for upper tooth show in the after. So, the colors green and numbers with them seem to indicate within norms.
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It's all basically a multi-variable/factorial optimization equation where they 'balance' the numbers/factors to fit into a desired visual paradigm. But they can't make each and every one of the displacements associated with the numbers 'perfect'. One would have to be extremely lucky to have NO deviations from the ideal visual paradigm.
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It's all basically a multi-variable/factorial optimization equation where they 'balance' the numbers/factors to fit into a desired visual paradigm. But they can't make each and every one of the displacements associated with the numbers 'perfect'. One would have to be extremely lucky to have NO deviations from the ideal visual paradigm.
Just wait until someone starts doing multipiece lefort III :).
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Just wait until someone starts doing multipiece lefort III :).
Indeed.
(https://upload.wikimedia.org/wikipedia/en/thumb/a/a7/National_Gallery_of_Victoria_Weeping_Woman.jpg/200px-National_Gallery_of_Victoria_Weeping_Woman.jpg)
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It's all basically a multi-variable/factorial optimization equation where they 'balance' the numbers/factors to fit into a desired visual paradigm. But they can't make each and every one of the displacements associated with the numbers 'perfect'. One would have to be extremely lucky to have NO deviations from the ideal visual paradigm.
Yep none of us will ever have a perfect surgical plan. I think you're doing pretty good if you have black and green and not too much red or blue.
There is usually a method to the madness though. These surgeons who follow Arnett's analysis normally start with setting the upper incisor position first and plan from that. He says in the video the incisor is key to facial planning.
BUT I also re-watched parts further into the video and he said in her case he made the OP completely flat with aggressive CCW to help her joints and airway. Not sure how that helps her joints, but yes what you said is true, it was a trade-off. I never pick up on stuff from the first watch, so that'll be my lesson to re-watch. He said he will even do a negative OP in some cases, but that's when it really affects the smile.
Well, she's got a RED 19 for the lower tooth on the before and a green 9(?) on the after and a black -11 for the upper tooth show on the before and green 7 for upper tooth show in the after. So, the colors green and numbers with them seem to indicate within norms.
Those numbers on her teeth represent how far away horizontally the tips of her teeth are from the TVL.
You can see how far her teeth were advanced forward by comparing those ones e.g 19-9 = 10mm advancement of her lower teeth, and 11-7 = 4mm advancement of her upper teeth. That matches up with her VSP read outs.
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Yep none of us will ever have a perfect surgical plan. I think you're doing pretty good if you have black and green and not too much red or blue.
There is usually a method to the madness though. These surgeons who follow Arnett's analysis normally start with setting the upper incisor position first and plan from that. He says in the video the incisor is key to facial planning.
BUT I also re-watched parts further into the video and he said in her case he made the OP completely flat with aggressive CCW to help her joints and airway. Not sure how that helps her joints, but yes what you said is true, it was a trade-off. I never pick up on stuff from the first watch, so that'll be my lesson to re-watch. He said he will even do a negative OP in some cases, but that's when it really affects the smile.
Those numbers on her teeth represent how far away horizontally the tips of her teeth are from the TVL.
You can see how far her teeth were advanced forward by comparing those ones e.g 19-9 = 10mm advancement of her lower teeth, and 11-7 = 4mm advancement of her upper teeth. That matches up with her VSP read outs.
Well, if they need to make the OP flat, it would be to maximize both the airway and the the 'pure' horizontal displacement of the mandible and also to minimize unfavorable changes to the nose base from displacements of the maxilla. Basically, they're looking to maximize the horizontal advancement of a 'forward' displacement and minimize the vertical displacement that is also a component of moving 'forward' along a DIAGONAL line. Diagonals are inclined away from a horizont. The OP is something that has an ANGLE OF INCLINATION away from the horizont and the higher the it's angle of inclination is relative to a horizont the more (unwanted) vertical displacement there will be to achieve the 'pure' horizontal displacement needed. So, a CCW that makes the OP 'flat' allows for only the needed horizontal displacement because the angle of inclination the OP has with the horizont becomes 0 deg (or 180 which is same) in which moving 'FORWARD' becomes a 'pure' horizontal displacement where as moving 'forward' over an INCLINED PLANE (diagonal inclined away from the horizont) has ALSO a VERTICAL component of displacement to achieve the wanted horizontal displacement. So, if any vertical displacement is unwanted with the movement the angle of inclination the OP has with the horizont is minimized.
The whole concept behind CCW is basically to minimize any unwanted vertical displacement that would arise if one moved 'forward' along a diagonal inclined 'too much' away from the horizont. In that way, they can get the horizontal displacement they want and have more control over the vertical displacement that would arise as a function of the angle of inclination the OP has with the horizont.
The easiest way, at least for me, to appreciate that concept is to think in terms of a RIGHT ANGLE triangle where the hypotenuse is the diagonal line ('plane' or 'slope') one moves 'forward' on. 'Forward' movement along that line has BOTH a horizontal element and a VERTICAL. The higher the angle of inclination the diagonal/hypotenuse has with the horizont, the more vertical displacement you will have via the act of moving 'forward' on it to move a horizontal distance. So, if one wanted to totally eliminate any vertical displacement that would arise in the act of moving 'forward' along a diagonal line, 'slope' or PLANE with angle on inclination away from the horizont, one would have to reduce the angle of inclination to 0 (or 180 deg) in which all movement would be 'purely' horizontal with NO vertical component. Hence the concept of FLAT PLANE and the geometrical relationship of REDUCING the angle of inclination the OP has with the horizont. Done to minimize, mitigate or eliminate unwanted VERTICAL displacement that would arise in moving 'forward' along a diagonal line, slope or plane.
As to the numbers (and color coding), I don't get into it in detail from 'worms eye' perspective. But rather from 'birds eye' perspective where I see they relate to what the surgeon can anticipate; such things as some things getting 'bull's eye' on target with 'ideal' and other things being improved but with some deviations from the norm (or ideal). Hence trade-offs.
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To me that's a pretty bad result. She did not have excessive tooth show before surgery. It's bad now, especially for a young woman. The LF1 osteotomy line alone is an 0.5-1 mm impaction. Alar cinches and VY plasty are known to lengthen the lip. I wonder if such outcomes can be explained by doing lower jaw first like Arnett & Gunson do. I mean, once the lower is in place, one can only move the upper to only what the lower will now allow.
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Those of you who say it's a bad result, what would the correction be in terms of cephalometric displacements? Is it the plan, or the execution you think is bad?
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Oh, no......as to the comments about 'bad results' or 'mistakes', check out his location.
Oh well.....as long as he doesn't bury them.
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Oh, no......as to the comments about 'bad results' or 'mistakes', check out his location.
Oh well.....as long as he doesn't bury them.
He's just an 'all or nothing' type of doc