jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: Dutcherhatcher on August 09, 2019, 04:02:30 PM
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Hey guys! First post for me and nice to meet you all. I am a 22 years old from a small country where our selection of surgeons is pretty limited.
I suffer from sleep apnea (currently not 100% in tests, but i am almost sure of it) , severe TMJ pains, lip incompetence and snoring/sleeping with my mouth open.
My lower jaw is pretty recessed from aesthetic point and its also something i would like to address.
I am currently speaking with the best surgeon in my state, but would still love to hear what you guys think. He currently thinks our best course of action is to decompress my bite, create an overjet and move only the lower jaw 6 mm forward and add genio if needed. Its covered by insurance due to the distance between jaws.
I will add my ceph. If something else is needed be sure to tell me
http://imgur.com/a/zkwbSWa
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Are you going to have the surgery there or are you traveling/considering all options?
It's Friday so I'm having a drink. I'll look at the records in more detail later.
Just a cursory glance:
-Why are you missing a premolar? How do they plan to address that? It should probably be addressed before surgery.
-The plan doesn't look correct at all for your structure. Though I've never seen planning software this bad -- is the blue or red line the before or after? Either way it doesn't make sense.
But I can elaborate more later if you answer those questions.
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Are you going to have the surgery there or are you traveling/considering all options?
It's Friday so I'm having a drink. I'll look at the records in more detail later.
Just a cursory glance:
-Why are you missing a premolar? How do they plan to address that? It should probably be addressed before surgery.
-The plan doesn't look correct at all for your structure. Though I've never seen planning software this bad -- is the blue or red line the before or after? Either way it doesn't make sense.
But I can elaborate more later if you answer those questions.
I am open to all options. I want what is correct for my health and face.
Haha sure thing, enjoy the drink.
It was extracted years ago due to pains. I assume you mean the premolar in the upper jaw right? As part of the treatment the doctor had me extract both of second molars on the lower jaw due to being rotten, and he is pushing the premolar to take their place.
The software is simply where the surgeon sent me to get an overview, he said he does not follow it at all but takes his own measures befote the surgery. It was a simple center for oral scans.
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The software is simply where the surgeon sent me to get an overview, he said he does not follow it at all but takes his own measures befote the surgery. It was a simple center for oral scans.
Is the blue or red line supposed to be the after? It's not clear from those images.
Did they extra your lower premolars to move the teeth back, then advance the lower jaw more? This is usually not a good solution, but some doctors do it.
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Is the blue or red line supposed to be the after? It's not clear from those images.
Did they extra your lower premolars to move the teeth back, then advance the lower jaw more? This is usually not a good solution, but some doctors do it.
As far as i understand the red lines are the ideal, the blue the current.
Yes that is the plan, the molars are already out and i am in tray 17 out of 50 with my removable braces. He wants to push the lower teeth back as much as possible before the surgery.
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Yes that is the plan, the molars are already out and i am in tray 17 out of 50 with my removable braces. He wants to push the lower teeth back as much as possible before the surgery.
Usually that's a sign the surgeon doesn't know how to rotate the jaw counter clockwise, which is why you need. So instead they pull teeth and try to get their lower jaw advancement there.
I'm extremely confused by that ceph. The upper jaw is being moved down and forward. My guess is he thinks this will open the upper airway, but sleep apnea is attributed to the lower airway, and this surgery doesn't address the lower. Also, if you have a steep mandibular plane and move the jaws forward and down (as in your plan), what actually happens is you get clockwise rotation. This is due to the steep angle. Look at the red line in the lower jaw. You can see it's slightly more recessed after, especially noticeable in the posterior, which is where you need advancement. This is a very common issue with old school surgeons who don't understand CCW rotation. Also, it makes no sense the ceph has your nose moving forward.
What you actually need is about 8mm of CCW rotation. I would run from this plan.
I'm going to enjoy my drink now, but I'll see what others say and chime in more then.
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Well, ya. If he 'bucks out' your upper teeth (with just braces) and pushes your lower teeth backwards, it will allow him to do single jaw surgery (in addition to advancing out your chin).
I'm not going to go over all of everything on your ceph read out. But it looks like he's isolated the problem to RETROGNATHIC to the LOWER jaw. That's seen in the SNB angle listing where your measure is below the norm where as your SNA angle is NOT listed at retrognathic and within norms and/or not far away from norms. It's a measure where there is option not to move the upper jaw forward.
It's kind of the minimum he can do to improve the retrusion to the lower jaw and get insurance to pay for it. There are doctors who will do surgery on BOTH jaws with aim of maximizing aesthetics which often involve types of rotations many local insurance docs don't do to that extent. But often they are self pay and require travel. I think you would see some improvement to the recessive lower jaw area and better balance with the upper jaw area as it is.
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I doubt that VTO would be an actual surgery plan. Looks like something cephx just spits out among all their other analyses.
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Dutcher... How many consults have you gone on? The more you can travel (when that might be needed for multi consults) and the more consults you go on, the more options will arise.
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Well, ya. If he 'bucks out' your upper teeth (with just braces) and pushes your lower teeth backwards, it will allow him to do single jaw surgery (in addition to advancing out your chin).
I'm not going to go over all of everything on your ceph read out. But it looks like he's isolated the problem to RETROGNATHIC to the LOWER jaw. That's seen in the SNB angle listing where your measure is below the norm where as your SNA angle is NOT listed at retrognathic and within norms and/or not far away from norms. It's a measure where there is option not to move the upper jaw forward.
It's kind of the minimum he can do to improve the retrusion to the lower jaw and get insurance to pay for it. There are doctors who will do surgery on BOTH jaws with aim of maximizing aesthetics which often involve types of rotations many local insurance docs don't do to that extent. But often they are self pay and require travel. I think you would see some improvement to the recessive lower jaw area and better balance with the upper jaw area as it is.
I see, granted when I brought it up with him, he said he knows all about rotation but he thinks it is not worth it in this case. He said moving the lower jaw is enough, and touching the upper jaw will only give me “monkey” lips. He said it’s forward enough as is.
But if I understand rotation is not about moving the upper jaw forward, it’s about rotating them. So what do you think I should do? I only consulted local surgeons since it’s a very invasive surgery and my insurance pays for it as well. Do you think it’s worth it to go to a European surgeon? GJ said I should run far away from this plan. But as far as I understand you claim there is some merit in it. I assume this plan will solve about 60% of the problem? What difference would I see in rotation vs pushing the lower jaw out as far as health benefits and aesthetics?
By the way, the other local surgeons offered joke plans like maxillary impaction due to 2 mm of gum show and genioplasty with titanium plates on the middle of the jaw. He was the one with the best plan.
Usually that's a sign the surgeon doesn't know how to rotate the jaw counter clockwise, which is why you need. So instead they pull teeth and try to get their lower jaw advancement there.
I'm extremely confused by that ceph. The upper jaw is being moved down and forward. My guess is he thinks this will open the upper airway, but sleep apnea is attributed to the lower airway, and this surgery doesn't address the lower. Also, if you have a steep mandibular plane and move the jaws forward and down (as in your plan), what actually happens is you get clockwise rotation. This is due to the steep angle. Look at the red line in the lower jaw. You can see it's slightly more recessed after, especially noticeable in the posterior, which is where you need advancement. This is a very common issue with old school surgeons who don't understand CCW rotation. Also, it makes no sense the ceph has your nose moving forward.
What you actually need is about 8mm of CCW rotation. I would run from this plan.
I'm going to enjoy my drink now, but I'll see what others say and chime in more then.
He himself told me to ignore the ceph, he used it as sort of a starting point which formed the plan for the 8mm lower jaw movement. He in no one way is following the ceph recommendation. As far as I understand you think I should ditch this plan and find a surgeon that offers rotation. Is there any good source of information I can read about the difference between BSSO vs full CCW?
Thank you very much guys, hopefully I won need revisions
Edit: Kevan and GJ. I confused pre molars and wisdom teeth, sorry. I had both first molars, not premolars in my lower jaw extracted due to root infection. Part of the prices process is to advance the molars and wisdom teeth into the their position.
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I see, granted when I brought it up with him, he said he knows all about rotation but he thinks it is not worth it in this case. He said moving the lower jaw is enough, and touching the upper jaw will only give me “monkey” lips. He said it’s forward enough as is.
But if I understand rotation is not about moving the upper jaw forward, it’s about rotating them. So what do you think I should do? I only consulted local surgeons since it’s a very invasive surgery and my insurance pays for it as well. Do you think it’s worth it to go to a European surgeon? GJ said I should run far away from this plan. But as far as I understand you claim there is some merit in it. I assume this plan will solve about 60% of the problem? What difference would I see in rotation vs pushing the lower jaw out as far as health benefits and aesthetics?
By the way, the other local surgeons offered joke plans like maxillary impaction due to 2 mm of gum show and genioplasty with titanium plates on the middle of the jaw. He was the one with the best plan.
He himself told me to ignore the ceph, he used it as sort of a starting point which formed the plan for the 8mm lower jaw movement. He in no one way is following the ceph recommendation. As far as I understand you think I should ditch this plan and find a surgeon that offers rotation. Is there any good source of information I can read about the difference between BSSO vs full CCW?
Thank you very much guys, hopefully I won need revisions
Edit: Kevan and GJ. I confused pre molars and wisdom teeth, sorry. I had both first molars, not premolars in my lower jaw extracted due to root infection. Part of the prices process is to advance the molars and wisdom teeth into the their position.
I can see from the salient ceph MEASURES; sna, snb and anb why he suggested lower jaw only. The diagrams are not really ceph displacement proposals. Not the type that actually chart out the surgery movements. I disregarded the diagrams when I saw one of them that said: 'GROWTH projection.' Although I don't know what that actually means, I know it's not actually a surgery PLAN.
Rotations take place at the UPPER jaw via a CUT there. But since the numbers/angles do suggest option for lower jaw only surgery, moot point to discuss rotations that need upper jaw cuts to do them. A rotation refers to when the maxilla is ANGLED either clockwise or counterclockwise which in turn rotates mandible in same direction. Moving the maxilla 'forward' is a separate displacement.
My feedback is/was focused on looking at your ceph Xray, some of the salient measures on the ceph read outs, your mention of LOWER jaw recession, the doctors suggestion to you where I explained the the reasoning behind the doctor's suggestion to you. Again, that info alone gives indication there would be benefit/improvement from the lower jaw only proposal. Questions concerning GJs suggestions should be directed at GJ. As to 'what I think you should do', I think you should go on MORE consultations.
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I think you should ask for a ceph showing the actual movements of his plan, and then go on more consults and compare plans. Post all those here so we can see. At least 3 consults for such a major surgery and ask for the actual plan from all 3 surgeons. Also, don't tell them what any other surgeon said. You want independent, objective opinions.
It looks like your 2nd premolar is missing on the x-ray. That's what I was referring to, not the wisdom teeth. There is a black space where the 2nd premolar (bicuspid) should be.
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I see, granted when I brought it up with him, he said he knows all about rotation but he thinks it is not worth it in this case. He said moving the lower jaw is enough, and touching the upper jaw will only give me “monkey” lips. He said it’s forward enough as is.
But if I understand rotation is not about moving the upper jaw forward, it’s about rotating them. So what do you think I should do? I only consulted local surgeons since it’s a very invasive surgery and my insurance pays for it as well. Do you think it’s worth it to go to a European surgeon? GJ said I should run far away from this plan. But as far as I understand you claim there is some merit in it. I assume this plan will solve about 60% of the problem? What difference would I see in rotation vs pushing the lower jaw out as far as health benefits and aesthetics?
By the way, the other local surgeons offered joke plans like maxillary impaction due to 2 mm of gum show and genioplasty with titanium plates on the middle of the jaw. He was the one with the best plan.
He himself told me to ignore the ceph, he used it as sort of a starting point which formed the plan for the 8mm lower jaw movement. He in no one way is following the ceph recommendation. As far as I understand you think I should ditch this plan and find a surgeon that offers rotation. Is there any good source of information I can read about the difference between BSSO vs full CCW?
Thank you very much guys, hopefully I won need revisions
Edit: Kevan and GJ. I confused pre molars and wisdom teeth, sorry. I had both first molars, not premolars in my lower jaw extracted due to root infection. Part of the prices process is to advance the molars and wisdom teeth into the their position.
Although at first glance along with prior knowledge that the pre-molars are the teeth usually removed (in anticipation of making space to push the lower teeth backwards when doing such allows surgical advancement of the lower jaw) it could look like the pre molars are removed, I confirmed which ones were missing by doing a 'count down'.
I counted the teeth on frontal X ray in accordance to which number assignment they would have.
From the double root space left behind, they are molars. As to which ones, you are missing #'s 30 and 19 which--yes-- are first molars. So, even though they are not pre-molars which they often pluck out in order to MAKE SPACE to push lower teeth backwards, (in anticipation for moving it more FORWARD in a lower jaw advancement), the spaces left behind by the missing first molars are indeed spaces they can use to push the lower teeth backwards with the goal of advancing lower jaw forward. So, that space from prior removal of first molars (that's already there for him to work with!) is another reason the doctor is offering you option of lower jaw advancement only.
Also, IF a major complaint of yours is TMJ PAIN, that also is a factor in buttressing his suggestion for lower jaw only whether or not he can or can't do a more advanced type of CCW that involves a posterior downgraft.
Basically, what I do here is look at what you have vs what a doctor's suggestion and or OPTION is to you and then explain how and why his reasoning makes sense to me (when that is the case). So, here, I'm not commenting on all possible options or possibilities 'out there' as could be found on going on multi consults, JUST the ONE you are presenting here.
Again, I think the option this doc gave you for the lower jaw only is consistent with what you have, your main complaint, takes into consideration TMJ complaint of pain, and salient angle measures given in ceph read outs.
You could get more complicated, more advanced options from some 'grand wazoo' docs in Europe or USA who offer those for EXORBITANT amounts of SELF PAY and LOTS of travel for follow ups, but for ME to OPINE on them would require YOU go on such consults and present the options THEY suggest.
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Gj: As both you and Kevan suggested, that is what i am going to do. I will consult with top european doctors (R,Z and B) and also with G in the US to hear what they have to say without telling them about the other plan. As for the teeth, the first molars were moved, not the premolars. They both had root infection and failure. The doctor told me my options were to either extract them in preperation for the jaw surgery or try to save them in a half a year long treatment and than just remove the wisdom teeth.
Kevan: Just a note, the first molars were removed by his direction, not before i saw him. They were both heavily infected and required a year long process to save which even than was not sure. We decided simply to remove them and move the rest of the molars into place instead of saving them and than extracting the wisdom teeth, which would have given us the same solution.
So i agree with this move. As for the rest, you said it yourself, the decision to move only the lower jaw is one which makes sense due to the whole situation. Its a much more simple solution that a fancy rotation by top European doctors. And is very worth to take into account. I am happy you agree with his plan, even if its not the "best of the best" or even the most optimal one, it means he knows what to do. As you said, we can play around all day about diffrent surgical ideas, but the best plan right is now to consult with some of those top doctors to just get a sense of what other options are out there, they may as well agree that lower jaw is enough in my case, or that the difference between DJ and lower jaw is minimal.
I have to say, the prices i saw that some of those doctors take is not that far away from what my doctors takes here, the only thing that worries me is such a major operation in a different country.
I will contact Gunson, Raffiani, zarrinbal and a doctor in Belgium to get just more options. I will make sure to update
Although I ID-ed them (as first molars) in the 'Teeth Countdown' document, which is seen only when you look at the whole thread, it doesn't make much of a difference that they are not pre-molars because as long as there is a SPACE for them to move the lower teeth backwards. So, he gave you good advice on that one in the sense that extractions that could be used for SPACE were the BAD teeth.
He's probably a doctor unknown on this board but you could put out a feeler on him by naming him on small chance someone on here has any familiarity with him. As I said, the Grand Wazoo doctors are often SELF PAY where yours is getting insurance to pay for it (free for you). There can be multi follow ups (travel expenses) depending on which ones want that. So, if finances are a consideration, that's going to factor into a decision. Your guy might not be a Grand Wazoo. But as long as he isn't a hack.
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Although I ID-ed them (as first molars) in the 'Teeth Countdown' document, which is seen only when you look at the whole thread, it doesn't make much of a difference that they are not pre-molars because as long as there is a SPACE for them to move the lower teeth backwards. So, he gave you good advice on that one in the sense that extractions that could be used for SPACE were the BAD teeth.
He's probably a doctor unknown on this board but you could put out a feeler on him by naming him on small chance someone on here has any familiarity with him. As I said, the Grand Wazoo doctors are often SELF PAY where yours is getting insurance to pay for it (free for you). There can be multi follow ups (travel expenses) depending on which ones want that. So, if finances are a consideration, that's going to factor into a decision. Your guy might not be a Grand Wazoo. But as long as he isn't a hack.
He keeps a group chat with over 300 of his patients and he encourages us to speak to other patients and review photos. As I said, my main worry is the limit of his surgical skill, because that is what he does and learned here. If he only knows how to advance jaws, so he recommends what he think is best and will probably do a very good job with it, but’s it’s also not the best option out there possibly. He is definitely the best in my country, but what is being the best in my country VS being good in Europe.
He worked with the university of Texas and also in Italy, so I am sure he is well aware of the concept of CCW.
The question I feel will come down to how much I care about the best possible result vs price and convenience.
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Sure. The name is Dr. Dror Allon.
He keeps a group chat with over 300 of his patients and he encourages us to speak to other patients and review photos. As I said, my main worry is the limit of his surgical skill, because that is what he does and learned here. If he only knows how to advance jaws, so he recommends what he think is best and will probably do a very good job with it, but’s it’s also not the best option out there possibly. He is definitely the best in my country, but what is being the best in my country VS being good in Europe.
He worked with the university of Texas and also in Italy, so I am sure he is well aware of the concept of CCW.
The question I feel will come down to how much I care about the best possible result vs price and convenience.
Never heard of him. I looked him up. I think he can do what he told you he would do. If he has a group of patients you can speak to and review photos, well that should be sufficient to eyeball his outcomes. But do explore options you mentioned in prior post.
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I will contact Gunson, Raffiani, zarrinbal and a doctor in Belgium to get just more options. I will make sure to update.
Nah, Zarrinbal is not the right doc for you because he's a chin wing guy. Your issues are both functional and aesthetic, so you need a surgeon who takes both of them into account. I'd recommend Raffaini and Alfaro in Europe and Gunson and Relle in the US.
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Okay guys, i had my first consultation with a big name doctor as recommended here.
I wont name him as i have no idea if any doctors check this forum, but i can pm him if you want.
He said the following.
On the surgical plan, what he said was identical to my doctor. Move the lower jaw by 8-10 mm forward, if i suffer from severe sleep apnea advance the upper jaw around 3 mm. Really against touching the upper jaw if there is no medical need since 3 mm will barley make any difference on the face and it is a very difficult cut (le fort 1). So far so good, so he pretty much confirmed the plan my doctor proposed was ideal and the correct route.
However he was shocked that the first molars were removed. He said that he is not sure that the gap can be covered by moving the teeth alone and i might need implant. Once i explained to him that one the teeth was heavily infected and the other was also post root treatment he agreed with me that there was no easy choice here. He recommended to continue with the braces (invisalign) and see if i need a dental implant and to contact him in 6 months for a new evaluation.
I had a few questions @kevan. i hope you can help me clear a few things.
1)Do you think in the grand scheme of things it was a mistake to remove the first molars? there was a 50/50 chance one of them was going to go anyway, so my doctor convinced me it was needed. However i keep reading in this forum that extracting any teeth beside the wisdom will lead to collapse of the face. Will this happen to me? Is there anything i can do to prevent it? What would be the correct course of action in your opinion?
2) I keep running into the SNA and SNB angles. Is there any ideal figure for them?
I am going to update in the next 2-3 weeks as i am going to see 3 more highly rated doctors in Europe.
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That's why I asked on page 1 "why you're missing premolars?"
You said they were back molars (wisdom teeth), but clearly there is a black spot where your premolars should be.
To answer your question: yes it's a mistake to remove those. The proper fix if the teeth won't fix is a 3 piece to widen the arch. If the bottom teeth don't 't fit as well, it gets more complex as you can't widen the arch; but, if anything they should have tried IPR or removed the 2nd premolar rather than the 1st (more root structure compared to the 2nd and thus more bone loss when pulled).
Whether it will cause the face to sag depends on many things. I've seen it do that, and I've seen it cause no issues. I had four 1st premolars pulled, so I can tell you in my case the face didn't sag. But I have great skin, and I had advancement that offset it a bit. You can also accept some space between the premolar and molars so as to not retract the teeth as much -- this is an option, too, but if the surgeon is Gunson he won't allow that and will want spaces closed. If the spaces are still wide enough, you can put implants in them as well. This is difficult but possible.
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That's why I asked on page 1 "why you're missing premolars?"
You said they were back molars (wisdom teeth), but clearly there is a black spot where your premolars should be.
To answer your question: yes it's a mistake to remove those. The proper fix if the teeth won't fix is a 3 piece to widen the arch. If the bottom teeth don't 't fit as well, it gets more complex as you can't widen the arch; but, if anything they should have tried IPR or removed the 2nd premolar rather than the 1st (more root structure compared to the 2nd and thus more bone loss when pulled).
Whether it will cause the face to sag depends on many things. I've seen it do that, and I've seen it cause no issues. I had four 1st premolars pulled, so I can tell you in my case the face didn't sag. But I have great skin, and I had advancement that offset it a bit. You can also accept some space between the premolar and molars so as to not retract the teeth as much -- this is an option, too, but if the surgeon is Gunson he won't allow that and will want spaces closed. If the spaces are still wide enough, you can put implants in them as well. This is difficult but possible.
Sorry, i was sure i had it cleared up. He removed the first molars instead of the wisdom teeth simply because they were heavily eroded. One of them was far gone and was going to be removed anyway, the other one was hanging there. So he offered to either try to save them, do a half a year treatment and best case scenario remove 2 wisdom teeth and stay with 2 rotten teeth (that might be removed anyway) or simply remove the molars. Of course that in an ideal situation i would have extracted the wisdom, but that was not in the cards.
So what do you recommend i do now to "Save" it? the extraction happened in late march, so i dont think too much damage was done. What can i do now? Or is it too late? Implants i assume wont covered the root of the bone that was loss?
I assumed that there was no difference between extracting molars and third molars since the end situation is the same, you stay with 2 molars. If you extract the wisdom thats it, but if you extract the first molars the second take their place and third take the second place.
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Sorry, i was sure i had it cleared up. He removed the first molars instead of the wisdom teeth simply because they were heavily eroded. One of them was far gone and was going to be removed anyway, the other one was hanging there. So he offered to either try to save them, do a half a year treatment and best case scenario remove 2 wisdom teeth and stay with 2 rotten teeth (that might be removed anyway) or simply remove the molars. Of course that in an ideal situation i would have extracted the wisdom, but that was not in the cards.
So what do you recommend i do now to "Save" it? the extraction happened in late march, so i dont think too much damage was done. What can i do now? Or is it too late? Implants i assume wont covered the root of the bone that was loss?
I assumed that there was no difference between extracting molars and third molars since the end situation is the same, you stay with 2 molars. If you extract the wisdom thats it, but if you extract the first molars the second take their place and third take the second place.
I see. Well he should have removed the wisdom teeth rather than the first molars (though, I'd have to see what you mean by "rotten teeth"). If they truly were rotten, how did they get that bad? Do you brush, floss, etc? If they needed to be extracted (dubious), then so be it, but likely you could have filled any cavity or put a crown on them if they were chipped. Unless the roots were destroyed there's no reason to extract them, and roots rarely get destroyed from routine wear but rather usually from orthodontics (root resorption).
In terms of what you can do, have someone measure the space and see if an implant will fit. They can be implanted with bone grafts attached if there isn't enough bone at the site. The screw in the implant simulates a root. Usually the bone reabsorbs within 3 months, so you might be low on bone there. What keeps the bone from reabsorbing is the biting force itself on the tooth, so if you lack a tooth there is no force to keep regenerating bone. This is the main reason extractions lead to sagging face. The bone reabsorbs without that biting force to keep it regenerating. The body basically assumes it doesn't need to keep producing bone since there is no force at that spot.
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So what do you recommend i do now to "Save" it? the extraction happened in late march, so i dont think too much damage was done. What can i do now? Or is it too late? Implants i assume wont covered the root of the bone that was loss?
Is it better to have implants done before surgery or after surgery? I feel like after-surgery makes more sense because there's often a lot of bite adjusting by the ortho that happens post-surgery too. And I'm assuming when an implant is in, it can't be moved?
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Okay guys, i had my first consultation with a big name doctor as recommended here.
I wont name him as i have no idea if any doctors check this forum, but i can pm him if you want.
He said the following.
On the surgical plan, what he said was identical to my doctor. Move the lower jaw by 8-10 mm forward, if i suffer from severe sleep apnea advance the upper jaw around 3 mm. Really against touching the upper jaw if there is no medical need since 3 mm will barley make any difference on the face and it is a very difficult cut (le fort 1). So far so good, so he pretty much confirmed the plan my doctor proposed was ideal and the correct route.
However he was shocked that the first molars were removed. He said that he is not sure that the gap can be covered by moving the teeth alone and i might need implant. Once i explained to him that one the teeth was heavily infected and the other was also post root treatment he agreed with me that there was no easy choice here. He recommended to continue with the braces (invisalign) and see if i need a dental implant and to contact him in 6 months for a new evaluation.
I had a few questions @kevan. i hope you can help me clear a few things.
1)Do you think in the grand scheme of things it was a mistake to remove the first molars? there was a 50/50 chance one of them was going to go anyway, so my doctor convinced me it was needed. However i keep reading in this forum that extracting any teeth beside the wisdom will lead to collapse of the face. Will this happen to me? Is there anything i can do to prevent it? What would be the correct course of action in your opinion?
2) I keep running into the SNA and SNB angles. Is there any ideal figure for them?
I am going to update in the next 2-3 weeks as i am going to see 3 more highly rated doctors in Europe.
1: No 'mistake' to remove infected teeth when one still got infected even after trying to 'save' with root canal. So, what if people say extracting teeth will lead to collapse of face. Were they referring to HEALTHY teeth or INFECTED teeth? Sure tooth loss can lead to some loss of bone support. But the risk of keeping infected teeth in is Ludwig's Angina. (See photo below)
(http://www.jmgims.co.in/articles/2018/23/2/images/JMahatmaGandhiInstMedSci_2018_23_2_89_243125_f1.jpg)
I'm not sure if tooth implants are to be put in before or after the BSSO. I would imagine afterwards. If the other doctor mentioned he wanted to do a tooth implant, cross reference that with the first doctor in your country. Sailent course of action, IMO, would be to use other consults as cross reference of what your other doctor wants to do. Here you got a cross reference that what your doctor's plan was a good one. Personally, I think the doctor in your own local is offering the most straight forward low risk option with biggest bang for the buck.
2: There are NORMS for SNA and SNB angles. No single measurement of anything is 'ideal' in it's own right.
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ETA: Trying to 'save' the INFECTED teeth and removing other teeth instead could have lead to the ones prone to infection being removed later down the line anyway. So, those would be gone in addition to the other ones moved 'instead'. I guess if you really wanted to 'hold onto' the teeth that got infected, the waiting period could have involved another root canal and further infection and/or just RISKING a very BAD systemic infection. Basically, there's a RISK involved with a 'wait and see' process of removing other teeth INSTEAD that aren't infected and trying to save the infected ones. Wait and see process could just lead to finding out for sure they are can't be salvaged or a serious infection that goes BEYOND the teeth. Like sometimes, the tooth can be cracked and the crack extends to the roots. But cracks are hard to see in an X ray. So, if you kept on trying to save a tooth that had that, the wait and see process would lead to just finding out it could not be salvaged and would need to be extracted and/or infections entering through the crack could lead to much worse things.
1: No 'mistake' to remove infected teeth when one still got infected even after trying to 'save' with root canal. So, what if people say extracting teeth will lead to collapse of face. Were they referring to HEALTHY teeth or INFECTED teeth? Sure tooth loss can lead to some loss of bone support. But the risk of keeping infected teeth in is Ludwig's Angina. (See photo below)
I'm not sure if tooth implants are to be put in before or after the BSSO. I would imagine afterwards. If the other doctor mentioned he wanted to do a tooth implant, cross reference that with the first doctor in your country. Sailent course of action, IMO, would be to use other consults as cross reference of what your other doctor wants to do. Here you got a cross reference that what your doctor's plan was a good one. Personally, I think the doctor in your own local is offering the most straight forward low risk option with biggest bang for the buck.
2: There are NORMS for SNA and SNB angles. No single measurement of anything is 'ideal' in it's own right.
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Sorry, i was sure i had it cleared up. He removed the first molars instead of the wisdom teeth simply because they were heavily eroded. One of them was far gone and was going to be removed anyway, the other one was hanging there. So he offered to either try to save them, do a half a year treatment and best case scenario remove 2 wisdom teeth and stay with 2 rotten teeth (that might be removed anyway) or simply remove the molars. Of course that in an ideal situation i would have extracted the wisdom, but that was not in the cards.
So what do you recommend i do now to "Save" it? the extraction happened in late march, so i dont think too much damage was done. What can i do now? Or is it too late? Implants i assume wont covered the root of the bone that was loss?
I assumed that there was no difference between extracting molars and third molars since the end situation is the same, you stay with 2 molars. If you extract the wisdom thats it, but if you extract the first molars the second take their place and third take the second place.
I also validated that the teeth removed were the first molars. See Reply #12 where I did a count down of the teeth to show ones removed were first pre molars.
As to getting an implant in the space where the 1rst molars are gone WHY would you even want to do that given THAT'S the space to be used to push the lower teeth backwards in order to push the lower jaw forwards. One tooth has to be GONE to push some other teeth backwards for the BSSO. Getting an implant in that space would involve THEN having to have the pre molar removed to make space.
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Is it better to have implants done before surgery or after surgery? I feel like after-surgery makes more sense because there's often a lot of bite adjusting by the ortho that happens post-surgery too. And I'm assuming when an implant is in, it can't be moved?
I wasn't sure either at the time I wrote one of my posts saying I wasn't sure. Just looked into it. An implant can't be moved with braces. So, would not be wise to put one in before ortho, in preparation for a surgery, was completed. Also, in his case, the missing tooth is being used as a space so they can push the other teeth backwards to move jaw forward. So,if he gets an implant to fill that space, it could result in having the pre molar removed to make a space and possibly throw a wrench in the gears for ortho prep.
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Agree, which is why I said we need to see these "infected" teeth (did he see infected or "rotten"? I think he said rotten, whatever that means). If they were simply cavities or chipped or something like this and the doctor just wanted to pull teeth that's different than an actual infection. Also, how/why did they become infected? If you have poor dental care you're not going to do well in any circumstance.
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Agree, which is why I said we need to see these "infected" teeth (did he see infected or "rotten"? I think he said rotten, whatever that means). If they were simply cavities or chipped or something like this and the doctor just wanted to pull teeth that's different than an actual infection. Also, how/why did they become infected? If you have poor dental care you're not going to do well in any circumstance.
Rotten usually means teaming with putrefactive bacteria. So, I took his term of that to imply infection.
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Hopefully he'll give more info on what was wrong with these teeth. I took rotten to mean cavities. Rotten isn't really a proper diagnosis. Lol
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Here is the picture.
I had 2 root canal treatments+crown in on them and one of them failed.
https://imgur.com/a/QcPOmrJ
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Gj post 21
But he claimed the roots were destroyed and i am looking at an extraction anyway. it was 75/25. And it was after both crowns and root treatment.
3 Months? so as far as i understand any damage that was suppose to be done was already done? If that is the case i didnt notice any change, i guess that is good. Would you say that post surgery with implants the damage (if it is there) is 100% fixable?
Kevan post #23
1.Ye no thanks. The doctor was really insisted on removing them and said any option to save them was very hopeful at this point. I guess i could have them removed and replaced with implants and then removed the wisdom, but it seems like too much of a hassle for something with a much simpler solution.
That is great to hear and i am already very geared towards the plan he suggested. I see that going into upper jaw surgery when you only need to advance only 3 mm is moot unless there is a pressing health issue.
Kevan post 24# I understand, another good reason to extract the damaged infected teeth and try and keep the normal healthy one. As the other doctor said, there was no easy solution here, Both option had downsides and upsides.
Kevan 25# i got kinda scared to be honest for a moment that i made a mistake that would lead to a collapse of the face. Maybe the other option that was to put implants where the teeth were, remove the wisdom and than push the jaw was better since it would lead to a better structural integrity but after reading your posts i understand it was not the correct course of action.
There is one thing i am still confused about and its the point i raised in the other post, wont the final outcome will be the same, since the place of the first molars are taken by the second and the second by the third? Wont the outcome be exactly the same as simply removing the wisdom? I mean sure we are talking about a longer process of braces but the end position of the teeth is the same.
Kevan+Gj final posts. I have the picture up. As you can see i am already post canal and crown on them. And of the roots failed. So it was much much worse than a cavity
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Gj post 21
But he claimed the roots were destroyed and i am looking at an extraction anyway. it was 75/25. And it was after both crowns and root treatment.
3 Months? so as far as i understand any damage that was suppose to be done was already done? If that is the case i didnt notice any change, i guess that is good. Would you say that post surgery with implants the damage (if it is there) is 100% fixable?
Kevan post #23
1.Ye no thanks. The doctor was really insisted on removing them and said any option to save them was very hopeful at this point. I guess i could have them removed and replaced with implants and then removed the wisdom, but it seems like too much of a hassle for something with a much simpler solution.
That is great to hear and i am already very geared towards the plan he suggested. I see that going into upper jaw surgery when you only need to advance only 3 mm is moot unless there is a pressing health issue.
Kevan post 24# I understand, another good reason to extract the damaged infected teeth and try and keep the normal healthy one. As the other doctor said, there was no easy solution here, Both option had downsides and upsides.
Kevan 25# i got kinda scared to be honest for a moment that i made a mistake that would lead to a collapse of the face. Maybe the other option that was to put implants where the teeth were, remove the wisdom and than push the jaw was better since it would lead to a better structural integrity but after reading your posts i understand it was not the correct course of action.
There is one thing i am still confused about and its the point i raised in the other post, wont the final outcome will be the same, since the place of the first molars are taken by the second and the second by the third? Wont the outcome be exactly the same as simply removing the wisdom? I mean sure we are talking about a longer process of braces but the end position of the teeth is the same.
Kevan+Gj final posts. I have the picture up. As you can see i am already post canal and crown on them. And of the roots failed. So it was much much worse than a cavity
Sorry, I'm confused by the way you ask your question you're confused about. Bottom line is to keep the spaces of the removed first molars so they can push the other teeth backwards. The remaining molars wisdom and second molar leave you with 2 molars. Put an implant in there now INDEPENDENT of your final selection of surgeon and screw up plans involving ortho preparation to prepare for surgery with 'at home' doctor if you decide on him and/or need a pre-molar extraction to replace the space you filled with an implant.
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Sorry, I'm confused by the way you ask your question you're confused about. Bottom line is to keep the spaces of the removed first molars so they can push the other teeth backwards. The remaining molars wisdom and second molar leave you with 2 molars. Put an implant in there now INDEPENDENT of your final selection of surgeon and screw up plans involving ortho preparation to prepare for surgery with 'at home' doctor if you decide on him and/or need a pre-molar extraction to replace the space you filled with an implant.
I am sorry Kevan, here is a picture to better ilustare my point.
https://imgur.com/a/Li7aCGf
As you can see, there is now a hole were the first molars were removed, i assumed that the braces move (as the arrow goes) the other molars into the place the first molars was, and the final cut is made were the wisdom teeth were. Am i wrong?
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I am sorry Kevan, here is a picture to better ilustare my point.
https://imgur.com/a/Li7aCGf
As you can see, there is now a hole were the first molars were removed, i assumed that the braces move (as the arrow goes) the other molars into the place the first molars was, and the final cut is made were the wisdom teeth were. Am i wrong?
The space is there for the teeth anterior to it to be retroclined backwards and maybe for the teeth posterior to it to be pushed forwards. I don't think it's a thing where one tooth jumps into the other slot. TBH, I don't feel like thinking about or describing the displacements. All you need to know is to keep the space there in preparation for the teeth to be moved so they can do the surgery.
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The space is there for the teeth anterior to it to be retroclined backwards and maybe for the teeth posterior to it to be pushed forwards. I don't think it's a thing where one tooth jumps into the other slot. TBH, I don't feel like thinking about or describing the displacements. All you need to know is to keep the space there in preparation for the teeth to be moved so they can do the surgery.
I see now! Thank you! I will update once i get the rest of the consultation done. Thank you so much guys
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Ok guys, huge update.
First of all, the consultation was awsome, he took his time to answer every question i had, explain everything in layman terms and generaly was very down to earth.
As far as the consultation itself.
He said my lower jaw was defenitly recessive and needed to be brought forward by about 8-10mm
He was surprised however and noted that was the only thing he recommened.
The suprising thing was that he said that he has done 5000 cases, and only in around 10% he would recommend only doing a lower jaw, saying that usually if one jaw grew wrong the other would too. However he said that my upper jaw grew correct in every dimension be it width, vertical or saggital. He said i should be very thankful.
So he gave my 2 options.
The first to only move the lower if the braces will allow it. Which he said is ideal and what i should strive for.
The second is to do a CCW if there wont be enough space. He made sure to comment that the CCW will only be used if there is not enough space for my lower jaw to come forward and ideally i would avoid from the upper jaw. Since less is better.
He said he saw nothing wrong with removing the first molars and using the wisdom teeth to take their place and he dismissed any concern i raised about bone absorption.
Also talked about surgery first, he said only 15% are fit for it, and it requires either you to be very very not pretty or suffer from a major health issue. Idealy a surgery later is better and i am not fit because of it.
Beside that we talked a bit more about surgery and prices, which i would avoid out saying out of respect.
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Kind of resolves to what I told you in the first place which is that the surgical suggestion of your surgeon in your country was a good one. So, it does look like you are getting some cross reference validation for that.
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Kind of resolves to what I told you in the first place which is that the surgical suggestion of your surgeon in your country was a good one. So, it does look like you are getting some cross reference validation for that.
Yes you are correct. I have to admit that a big part of it is psychological. Knowing my plan is the correct one and having several high profile surgeons review it. I would be very happy to do one jaw surgery and be done with it.
If we are talking about a simple lower jaw moment, is there any difference in skill between my local surgeon and high profile surgeon from Europe?
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Yes you are correct. I have to admit that a big part of it is psychological. Knowing my plan is the correct one and having several high profile surgeons review it. I would be very happy to do one jaw surgery and be done with it.
If we are talking about a simple lower jaw moment, is there any difference in skill between my local surgeon and high profile surgeon from Europe?
No idea.
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No idea.
Sorry, i will phrase the question again. Do you think the extra money is worth it to go to a high profile surgeon when a simple jaw movement as compared to a complex plan? Or in other words will the more skillful surgeon produce better results if the movement is the same?
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Sorry, i will phrase the question again. Do you think the extra money is worth it to go to a high profile surgeon when a simple jaw movement as compared to a complex plan? Or in other words will the more skillful surgeon produce better results if the movement is the same?
Im of the school in which its not worth cutting corners when it comes to jaw surgery.
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Im of the school in which its not worth cutting corners when it comes to jaw surgery.
Hmm even when its such a simple thing? In my country it ia almost free but in Europe i have to pay full premium price
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Hmm even when its such a simple thing? In my country it ia almost free but in Europe i have to pay full premium price
It's definitely not only top surgeons who can be great. Sometimes it's like selling bottled water, with a nice enough bottle you can sell same thing much more expensive. What you get with a well known surgeon is just that he/she is well known and you can easily look up results and patient stories, compared to at your local surgeon where the patients hardly know or care who the surgeon is. As in all professions, there are both good and bad professionals and with a well known name you know who it is. At least if it's a "simple" surgery with no rotations or multipiece, it's a good chance that more than the big names can give a great result. But sure, if you have the money, why not go with the best.
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Sorry, i will phrase the question again. Do you think the extra money is worth it to go to a high profile surgeon when a simple jaw movement as compared to a complex plan? Or in other words will the more skillful surgeon produce better results if the movement is the same?
I'm not thinking in the terms you are asking me to think in. I don't think in terms of 'high profile doctor = best and worth it'. With the high profile docs, I think in PRAGMATIC terms of things they can do that others don't, in particular, significant DOWN GRAFTING and WHEN such looks to be applicable to someone. Recognition of them, by me, is usually based on capacity to do a significant down graft because that's a key factor in setting them apart from the others.
AS to 'skill', I think in terms of TIME needed to produce SAME outcome. The doctor who could produce the same outcome FASTER than the other one would be considered more 'skilled'. But so what.
It depends on whether or not you have money burning a hole in your pocket. People who think in terms of high price = 'the best' can afford to go to a high profile doctor for a straight forward thing other doctors could do whether or not a lesser know doctor could produce same/similar. If that's the case, I don't need to think for them.
I've already thought about this and I think the doctor who advised you (your local one) is on target for your case based on his assessment. I don't need to think about the high profile doctors for your case. If you do, there are plenty of others who think in terms of high profile, high $$$= best to engage.
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Guys thank you again for taking the time. And huge thanks for Kavan. I had a few more questions.
My surgeon offered me to give some feedback so i had a few questions.
Is there an ideal saggital projections of the jaw/chin?
An ideal vertical and width of the chin?
Or should i just tell him to do what he thinks.
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I'm not thinking in the terms you are asking me to think in. I don't think in terms of 'high profile doctor = best and worth it'. With the high profile docs, I think in PRAGMATIC terms of things they can do that others don't, in particular, significant DOWN GRAFTING and WHEN such looks to be applicable to someone. Recognition of them, by me, is usually based on capacity to do a significant down graft because that's a key factor in setting them apart from the others.
AS to 'skill', I think in terms of TIME needed to produce SAME outcome. The doctor who could produce the same outcome FASTER than the other one would be considered more 'skilled'. But so what.
It depends on whether or not you have money burning a hole in your pocket. People who think in terms of high price = 'the best' can afford to go to a high profile doctor for a straight forward thing other doctors could do whether or not a lesser know doctor could produce same/similar. If that's the case, I don't need to think for them.
I've already thought about this and I think the doctor who advised you (your local one) is on target for your case based on his assessment. I don't need to think about the high profile doctors for your case. If you do, there are plenty of others who think in terms of high profile, high $$$= best to engage.
Okay, got it. I think i am going to stick with my local guy. I wish i did not have to go with this suegery at all. It is such time consuming and anxiety inducing. I hopw my children wont get my jaws
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Guys thank you again for taking the time. And huge thanks for Kavan. I had a few more questions.
My surgeon offered me to give some feedback so i had a few questions.
Is there an ideal saggital projections of the jaw/chin?
An ideal vertical and width of the chin?
Or should i just tell him to do what he thinks.
Not a good idea to be a 'back seat driver'.
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Ok, this will be my last consultation. Pretty confused now. I knew i should have stopped at 3.
Says i need CCW. My lower jaw needs to come forward by at least 12mm. 8 not enough.
Impossible to create overjet larger than 5 mm with orthodentics, he laughed very hard when i showed him my program. Said i will lose all my teeth. "Good luck".
Agreed with extracting the first molars.
Says the rotation will be minimal, will bring my upper jaw forard by 2 mm
Also found my nose septum to be deviated, said i need a nose surgery, said my breathing is almost at a "critical state"
Sorry Kevan, should have stopped at time :-\
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Ok, this will be my last consultation. Pretty confused now. I knew i should have stopped at 3.
Says i need CCW. My lower jaw needs to come forward by at least 12mm. 8 not enough.
Impossible to create overjet larger than 5 mm with orthodentics, he laughed very hard when i showed him my program. Said i will lose all my teeth. "Good luck".
Agreed with extracting the first molars.
Says the rotation will be minimal, will bring my upper jaw forard by 2 mm
Also found my nose septum to be deviated, said i need a nose surgery, said my breathing is almost at a "critical state"
Sorry Kevan, should have stopped at time :-\
Sounds like he's looking for employment opportunities in your mouth.
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Sounds like he's looking for employment opportunities in your mouth.
I thought someone like prof who is very thought of in this forum will be above looking to make a quick buck.
Edit: He showed me on the ct scan where is the nose deviated. I am going to confirm it with a local doctor as well
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I thought someone like prof R who is very thought of in this forum will be above looking to make a quick buck.
That's what I used to think, but changed my mind very quickly as soon as I started consulting with some of these 'big name' doctors! Will not say more here, beyond that you should be careful and use common sense and don't believe everything they say, particularly if they start telling you you 'need' more work on your face (nose, cheeks etc.). As Kavan suggested, you can get that stuff done after jaw surgery if you really 'need' it.
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I think it's common during bimaxs to get septoplasty done at the same time.
Yes it is if someone needs it - it's very questionable though that OP is one of those if he never noticed there was anything wrong with his septum. For example, for me it is very clear that I have a deviated septum, I can feel it and have been aware for some time that I can breath through one nostril much better than the other. I got a scan done recently and the ENT said it's not nearly serious enough for me to get surgery for it, even though I have symptoms, and it seems that OP has no symptoms. In any case, he's getting his lower jaw moved forward which should help with his breathing problems (I am hoping for the same for myself).
My understanding is that even though it's a relatively common practice, not everyone thinks that nose surgery combined with jaw surgery is a good idea, not least because recovery will be even much more difficult than after just jaw surgery on it's own. Also, personally, if I wanted to get septoplasty, and wasn't a millionaire, I would probably not get it from an expensive 'star' plastic surgeon but just someone that specializes in that procedure, preferably with ENT background.
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To the OP:
1rst 'big name' doctor.
Was HONEST with you. Told you to move upper jaw forward aprox 3mm ONLY IF you had severe sleep apnea. BUT was AGAINST it IF NO medical need. There is also NO aesthetic need to advance your upper jaw either. He CONFIRMED what your local doctor said. You did not name him. But I think he deserves credit for being forthright with you.
2ncd 'big name' doctor, which I think might be Alfaro. Also CONFIRMED that 'less is better' for you as far doing any surgery to the maxilla is concerned. Basically CONFIRMED that your local doctor had a good plan and gave you good advice.
3rd 'big name' which I think would be Raffiani.
Said you 'need' CCW but the rotation would be MINIMAL and advancement of 2mm to upper jaw would also be MINIMAL. Yes, 'minimal' indeed. Perhaps 'just enough' to give you 4mm in EXCESS to the lower jaw and 'just enough' to find ANOTHER EMPLOYMENT OPPORTUNITY when he does the maxilla, ie. a RHINOPLASTY. Then you have him telling you that you would 'lose all your teeth' and your breathing was in 'critical state'. That sounds like SCARE TACTICS.
As to his laughing at your local doctor's plan, given that 2 other 'big name' doctors who IMO, were HONEST with you as in were not OPPORTUNISTS who laughed at your local doctor's plans but instead CONFIRMED them, and in this process suggested extra surgery, in a situation where you can avoid the RISK involved with extra surgery, that RESOLVES to what I told you in a prior post, which is that IF YOU HAVE MONEY BURNING A HOLE IN YOUR POCKET, then by all means, disregard everyone else who was HONEST with you as to want to spare you the extra risk of the maxilla surgery and go to R.
That's all I say about him and since he CONFUSED you as to UNDO the info and reasoning given to you prior, not only by me but also the other doctors, you can ask HIM to 'un-confuse' you.
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Yes it is if someone needs it - it's very questionable though that OP is one of those if he never noticed there was anything wrong with his septum. For example, for me it is very clear that I have a deviated septum, I can feel it and have been aware for some time that I can breath through one nostril much better than the other. I got a scan done recently and the ENT said it's not nearly serious enough for me to get surgery for it, even though I have symptoms, and it seems that OP has no symptoms. In any case, he's getting his lower jaw moved forward which should help with his breathing problems (I am hoping for the same for myself).
My understanding is that even though it's a relatively common practice, not everyone thinks that nose surgery combined with jaw surgery is a good idea, not least because recovery will be even much more difficult than after just jaw surgery on it's own. Also, personally, if I wanted to get septoplasty, and wasn't a millionaire, I would probably not get it from an expensive 'star' plastic surgeon but just someone that specializes in that procedure, preferably with ENT background.
There's NO DOUBT that a rhino can be done at same time during bimax, ie, when one is ALSO getting the lefort 1.
The DOUBT comes in--in my mind-- as to whether or not the Lefort 1 was suggested was OPPORTUNISTIC 'shoe in' to do a rhino (Dr. finding employment opportunities). Also, this doctor cast DOUBT on all the OTHER suggestions given to the patient who CONFIRMED that his local doctor's plan was a good one. Hence, my doubt about some of the tactics of this #3 'big name' doctor.
I think it's common during bimaxs to get septoplasty done at the same time. But if he wants you to do a cosmetic rhino though, that's a bit different. Seems he does a lot of those https://www.ncbi.nlm.nih.gov/pubmed/29560545
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That's what I used to think, but changed my mind very quickly as soon as I started consulting with some of these 'big name' doctors! Will not say more here, beyond that you should be careful and use common sense and don't believe everything they say, particularly if they start telling you you 'need' more work on your face (nose, cheeks etc.). As Kavan suggested, you can get that stuff done after jaw surgery if you really 'need' it.
He didnt say i need another surgery, he said i need a septoplasty which is included in the original Bimax. The main difference is the 14 mm vs the 8-10 everyone else agreed on and the braces.
Why would you lose your teeth?
So you have 3 opinions
Local guy - BSSO only
Dr A - BSSO only / or CCW if can't make enough space
Dr R - CCW
Dr A seems to sit in the middle, so based just on that, he could be a good pick
I think it's common during bimaxs to get septoplasty done at the same time. But if he wants you to do a cosmetic rhino though, that's a bit different. Seems he does a lot of those https://www.ncbi.nlm.nih.gov/pubmed/29560545
He wants me to get a septoplasty, he is afraid of my losing the root of teeth because he said that creating an overjet of 8mm is insane.
Yes it is if someone needs it - it's very questionable though that OP is one of those if he never noticed there was anything wrong with his septum. For example, for me it is very clear that I have a deviated septum, I can feel it and have been aware for some time that I can breath through one nostril much better than the other. I got a scan done recently and the ENT said it's not nearly serious enough for me to get surgery for it, even though I have symptoms, and it seems that OP has no symptoms. In any case, he's getting his lower jaw moved forward which should help with his breathing problems (I am hoping for the same for myself).
My understanding is that even though it's a relatively common practice, not everyone thinks that nose surgery combined with jaw surgery is a good idea, not least because recovery will be even much more difficult than after just jaw surgery on it's own. Also, personally, if I wanted to get septoplasty, and wasn't a millionaire, I would probably not get it from an expensive 'star' plastic surgeon but just someone that specializes in that procedure, preferably with ENT background.
Never noticed anything about my nose. I have a ct scan on me i am going to take to a local ENT soon to get his opinon.
To the OP:
1rst 'big name' doctor.
Was HONEST with you. Told you to move upper jaw forward aprox 3mm ONLY IF you had severe sleep apnea. BUT was AGAINST it IF NO medical need. There is also NO aesthetic need to advance your upper jaw either. He CONFIRMED what your local doctor said. You did not name him. But I think he deserves credit for being forthright with you.
2ncd 'big name' doctor, which I think might be Alfaro. Also CONFIRMED that 'less is better' for you as far doing any surgery to the maxilla is concerned. Basically CONFIRMED that your local doctor had a good plan and gave you good advice.
3rd 'big name' which I think would be Raffiani.
Said you 'need' CCW but the rotation would be MINIMAL and advancement of 2mm to upper jaw would also be MINIMAL. Yes, 'minimal' indeed. Perhaps 'just enough' to give you 4mm in EXCESS to the lower jaw and 'just enough' to find ANOTHER EMPLOYMENT OPPORTUNITY when he does the maxilla, ie. a RHINOPLASTY. Then you have him telling you that you would 'lose all your teeth' and your breathing was in 'critical state'. That sounds like SCARE TACTICS.
As to his laughing at your local doctor's plan, given that 2 other 'big name' doctors who IMO, were HONEST with you as in were not OPPORTUNISTS who laughed at your local doctor's plans but instead CONFIRMED them, and in this process suggested extra surgery, in a situation where you can avoid the RISK involved with extra surgery, that RESOLVES to what I told you in a prior post, which is that IF YOU HAVE MONEY BURNING A HOLE IN YOUR POCKET, then by all means, disregard everyone else who was HONEST with you as to want to spare you the extra risk of the maxilla surgery and go to R.
That's all I say about him and since he CONFUSED you as to UNDO the info and reasoning given to you prior, not only by me but also the other doctors, you can ask HIM to 'un-confuse' you.
Ok, thank you Kevan. I wont press for more info.
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In general what confuses me is that there are 2 medical opinions today which i also noticed in my country.
Creating an overjet of 8-10mm is possible if young
VS
its never possible.
Which is why it is weird how some of those top doctors contradict each other.
They all agreed i dont need any upper jaw movement at all.
However R decided i need 12mm instead of 8mm. How can they be of such different opinions? He also decided braces will never get me to the needed Overjet, and i need CCW because of it. I have no idea what to think now, since he is one of the top "guns" recommended here and is suppose to be the best of the best in the market compared to my local guy. I have a lot to think about and a decision to make, and it is a decision you only make once, so i hope i will get it right.
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Being confused is normal in this case. I think most of us that were told we 'need' jaw surgery and then started doing some research / getting more opinions from doctors ended up getting confused and got at least a couple of opinions that directly contradicted each other etc., it just seems to be the way this stuff works. I reckon the only people that don't feel confused are the ones that went to one doctor, were told they need 'the' surgery, never asked any questions, never tried to understand what was happening to them and just accepted everything and let the doctor do their 'thing'. I honestly wish I was one of those, I should have just let my local NHS doctors in England 'do their thing' when I was 20 or so. Anyway, whatever you do, I wish you well and hope it works out for you.
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The over jet is approx = to mm amount the upper teeth can be angled out + mm amount the lower teeth can be angled in.
Let mm amount upper teeth can be angled out be 'X'.
Let mm amount lower teeth can be angled in be 'Y'.
Let mm total amount= OJ
X + Y = OJ.
The question is CAN [X+Y=OJ=8] be possible or is is really 'impossible' for [X+Y =8]
For example, is it really 'impossible' for X+Y to = 8
I've certainly not come across any info that it's 'impossible' to achieve an 8mm overjet (in preparation for surgery) by a combination of angling the lower teeth backwards and the upper teeth outwards. Have you cross referenced that 'impossibility' with some ORTHOS who prepare the brace work for surgery?
Have you asked around--even on this board-- what is the LIMIT the upper teeth can be angled out and what is the LIMIT the lower teeth can be angled in such that it would be 'impossible' for [x+Y=8]?
We can assume that [X+Y=12] is NOT possible given that the:
a: 'need' for 12 on the part of R was chosen resolved to HIS 'need' to do MORE surgery than you actually needed
b: Other doctors did not determine any 'need' for 12 mm advancement of mandible nor told you 12 mm over jet was possible.
As to being 'highly esteemed' on this board, in the event you think that I, myself gave you that impression, RULE ME OUT. Not saying I hold him in low regard, rather that he's just one of the doctors I recognize as being able to do a LARGE CCW. But most certainly not a doc I would suggest to specifically seek out for someone who I thought didn't need a large CCW yet alone someone who could still come out ahead with NO surgery to the maxilla at all and was candidate for single lower jaw surgery only.
Better check to see if your confusion is coming from your conclusion that [X+Y=8] is 'impossible' 'because' R set the 'need' for it to be 12.
Also keep in mind that if the whole mandible, INCLUDING the CHIN is what would look good as coming forward at 12, the BSSO, itself can be 8 and the genio advance can be 4. This is especially so if the chin ITSELF is ALSO retruded.
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The over jet is approx = to mm amount the upper teeth can be angled out + mm amount the lower teeth can be angled in.
Let mm amount upper teeth can be angled out be 'X'.
Let mm amount lower teeth can be angled in be 'Y'.
Let mm total amount= OJ
X + Y = OJ.
The question is CAN [X+Y=OJ=8] be possible or is is really 'impossible' for [X+Y =8]
For example, is it really 'impossible' for X+Y to = 8
I've certainly not come across any info that it's 'impossible' to achieve an 8mm overjet (in preparation for surgery) by a combination of angling the lower teeth backwards and the upper teeth outwards. Have you cross referenced that 'impossibility' with some ORTHOS who prepare the brace work for surgery?
Have you asked around--even on this board-- what is the LIMIT the upper teeth can be angled out and what is the LIMIT the lower teeth can be angled in such that it would be 'impossible' for [x+Y=8]?
We can assume that [X+Y=12] is NOT possible given that the:
a: 'need' for 12 on the part of R was chosen resolved to HIS 'need' to do MORE surgery than you actually needed
b: Other doctors did not determine any 'need' for 12 mm advancement of mandible nor told you 12 mm over jet was possible.
As to being 'highly esteemed' on this board, in the event you think that I, myself gave you that impression, RULE ME OUT. Not saying I hold him in low regard, rather that he's just one of the doctors I recognize as being able to do a LARGE CCW. But most certainly not a doc I would suggest to specifically seek out for someone who I thought didn't need a large CCW yet alone someone who could still come out ahead with NO surgery to the maxilla at all and was candidate for single lower jaw surgery only.
Better check to see if your confusion is coming from your conclusion that [X+Y=8] is 'impossible' 'because' R set the 'need' for it to be 12.
Also keep in mind that if the whole mandible, INCLUDING the CHIN is what would look good as coming forward at 12, the BSSO, itself can be 8 and the genio advance can be 4. This is especially so if the chin ITSELF is ALSO retruded.
When i went to the original ortho as recommended by my surgeon, she refused to treat me and citing the same reasons as, that my roots will "escape".
Now my surgeons said it is more the old traditional thoughts and that the now it is much more believed that you can move such distances. So i heard his verison once before. I am going to check it with more orthos though.
Is there any differnce healthwise 12 vs 8+4
Any difference visualy?
If not, the logical train of thought is to go with the local guy first.
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When i went to the original ortho as recommended by my surgeon, she refused to treat me and citing the same reasons as, that my roots will "escape".
Now my surgeons said it is more the old traditional thoughts and that the now it is much more believed that you can move such distances. So i heard his verison once before. I am going to check it with more orthos though.
Is there any differnce healthwise 12 vs 8+4
Any difference visualy?
If not, the logical train of thought is to go with the local guy first.
I'm saying a BSSO of 8 (contingent on X+Y=8; an over jet of 8mm) with a genio of 4, still gives an overall advancement of 12 and resolves to SINGLE jaw surgery. Your chin is also somewhat recessive and chin advancement also helps with apnea. Also, your maxilla is NOT recessive. Your SNA angle is somewhat higher than normal. Hence, I'm NOT finding much to justify R's surgery proposal to do the lefort as to advance SO HE can make the BSSO as 12.
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It sounds like A was touching on smth slightly similar about the overjet, no? Altho he was working to a 8-10 advancement, not 12mm.
(bolding my own)
The first to only move the lower if the braces will allow it. Which he said is ideal and what i should strive for.
The second is to do a CCW if there wont be enough space. He made sure to comment that the CCW will only be used if there is not enough space for my lower jaw to come forward and ideally i would avoid from the upper jaw. Since less is better.
You don't want to be edge-to-edge. At a very minimum you need to end up with a 1-2mm overjet afterwards (although 3mm is the ideal post surg overjet according to Arnett/Gunson).
So you will need close to 9-10mm overjet, in order to get a 8mm bsso and be left with a 1-2mm overjet post surg. What is your overjet now?
Its true they can't just procline teeth in/out as much as they want. There are limits. I think the point is to have the teeth in a healthy position in the bone, so the results are stable long term. I think they do some sort of angle measurements of the incisors to figure some of this out.
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Just saw in your cephx reports your overjet is around 4mm now.
Sorry if you already mentioned it, but what's happening with that extraction space according to these docs? Are they retracting the front teeth back, or protracting the back teeth forward?
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retract the lower teeth backwards. He's got the space from the missing molar to do that.
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I just saw in the first post he said his local guy only wants to move his jaw forward 6mm. Then in other posts says 8mm forward. Which one, dutcherhatcher?
For 6mm advancement you will need 7-8mm overjet, which would be more attainable than a 9-10mm overjet needed for an 8mm advancement.
Dutcher, can you clarify if all these advancement numbers from these surgeons are including or not including genio?
He currently thinks our best course of action is to decompress my bite, create an overjet and move only the lower jaw 6 mm forward and add genio if needed
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I'm saying a BSSO of 8 (contingent on X+Y=8; an over jet of 8mm) with a genio of 4, still gives an overall advancement of 12 and resolves to SINGLE jaw surgery. Your chin is also somewhat recessive and chin advancement also helps with apnea. Also, your maxilla is NOT recessive. Your SNA angle is somewhat higher than normal. Hence, I'm NOT finding much to justify R's surgery proposal to do the lefort as to advance SO HE can make the BSSO as 12.
Ok. gotcha.
It sounds like A was touching on smth slightly similar about the overjet, no? Altho he was working to a 8-10 advancement, not 12mm.
(bolding my own)
You don't want to be edge-to-edge. At a very minimum you need to end up with a 1-2mm overjet afterwards (although 3mm is the ideal post surg overjet according to Arnett/Gunson).
So you will need close to 9-10mm overjet, in order to get a 8mm bsso and be left with a 1-2mm overjet post surg. What is your overjet now?
Its true they can't just procline teeth in/out as much as they want. There are limits. I think the point is to have the teeth in a healthy position in the bone, so the results are stable long term. I think they do some sort of angle measurements of the incisors to figure some of this out.
We are talking about going from normal perfect class 1 occlusion to an overjet that needs 8mm correction to go back to being perfect. Perfect is a 3mm overjet as you said.
I just saw in the first post he said his local guy only wants to move his jaw forward 6mm. Then in other posts says 8mm forward. Which one, dutcherhatcher?
For 6mm advancement you will need 7-8mm overjet, which would be more attainable than a 9-10mm overjet needed for an 8mm advancement.
Dutcher, can you clarify if all these advancement numbers from these surgeons are including or not including genio?
We are suppose to advance it at 8, sorry it was a typo. And Kavan already answered to your other question.
And they dont include genio
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Lower incisors are proclined forward (protruded). They are using the empty space from the missing tooth to push them backwards. That would create most of the over jet. How much exactly, I don't know. If the empty tooth space were totally or mostly closed up, that part of the over jet would be close to the mm measure of the empty tooth space.
Elsewhere, April mentioned the size of a pre-molar was about 7mm-8mm wide. A molar (as you have lost) would tend to be wider.
Ref=http://jawsurgeryforums.com/index.php/topic,7831.msg71158.html#msg71158 (reply #6)
I don't know all the minutia--not within 2mm--of such things as your molar width SPACE or whether or not it gets closed completely by pushing back the lower front teeth. But IF let's say, they got a push back (part of overjet) of 6, the PUSH OUT to the front UPPER teeth would need to be 3-4 for total overjet of 9 to 10. That could allow the 8mm BSSO with a 1 to 2mm 'clearance' overjet. Your front uppers look to be straight down or maybe a tad retroclined (Class 2 is common for retroclined). So, I don't know why some (R and some other recent doctor) are telling you close to 'impossible' to get the OJ needed for an 8mm BSSO. I mean I've seen cases of class2 in brace prep for surgery where they create a significant overjet by bucking out front uppers and pushing backwards the front lowers (after a space is made by extraction to lower jaw).
I don't think anyone can predict 'exactly' within 1 or 2mm if they can get 8-9mm for the overjet. It just looks pretty LIKELY to me, you would get close enough to the 8mm BSSO from the single jaw proposal. Would still be improvement if 7 or 6 and then just ADD the genio given you chin is recessed anyway.
The only way to know for sure how much 'exactly' your overjet is going to be is to be in the braces. If it's the amount needed for it to be for your local guy to do the single 8mm BSSO (have him do the chin also), then go with him (providing he also does the chin). If it's less than that and/or he won't do the chin, then choose one of the other docs.
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I do get a bit too stuck in the minutia of things! But this sounds like good advice! You won't know until they attempt it.
The only way to know for sure how much 'exactly' your overjet is going to be is to be in the braces. If it's the amount needed for it to be for your local guy to do the single 8mm BSSO (have him do the chin also), then go with him (providing he also does the chin). If it's less than that and/or he won't do the chin, then choose one of the other docs.
It's just weird R didn't think you could even get more than 5mm overjet safely.
All I can think is that he wasn't thinking of retracting the front bottom teeth back all the way to close that extraction space :o IDK.
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I do get a bit too stuck in the minutia of things! But this sounds like good advice! You won't know until they attempt it.
It's just weird R didn't think you could even get more than 5mm overjet safely.
All I can think is that he wasn't thinking of retracting the front bottom teeth back all the way to close that extraction space :o IDK.
Hi April,
I must have missed this post. Anyway, minutia is OK and true what you mentioned about approx 2mm clearance space (residual over jet) being needed. It's just that I go with the main concept. So, easy enough to factor in the 2mm with it.
I too found it very weird--let's say 'off'or even 'suspect'-- R said the OJ needed (for his 8mm BSSO) could not be had safely. Not to mention the selection of a 12mm BSSO, which to me harked of a number where one would HAVE TO DO a Lefort1 to get the BSSO for 12mm BSSO. Add suggestion of septo/rhino and breathing scare.
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Hi April,
I must have missed this post. Anyway, minutia is OK and true what you mentioned about approx 2mm clearance space (residual over jet) being needed. It's just that I go with the main concept. So, easy enough to factor in the 2mm with it.
I too found it very weird--let's say 'off'or even 'suspect'-- said the OJ needed (for his 8mm BSSO) could not be had safely. Not to mention the selection of a 12mm BSSO, which to me harked of a number where one would HAVE TO DO a Lefort1 to get the BSSO for 12mm BSSO. Add suggestion of septo/rhino and breathing scare.
Hey Kevan; the last couple of days I thought about the subject non stop and here are my thoughts.
Currently I suffer from health problems and aesthetic problems. Of course I want to max both solutions.
On the one hand, we have my local doctor, who is considered a no name compared to some of the guys here. I already managed to confirm my self he does not do CCW and is more newer in the scene.
On the other hand, we have someone who trained with Gunson and Wolford, is one of the best in the world and who have written huge books about aesthetic. If he say something should be done, should I not listen to him? Why should I trust my local guy who is only a decade or 2 in the business? I mean trained under the guy who invented jaw surgery! I just find it hard to believe he would try to oversell something or be a sellman. I fear that but the time I finish my local surgery I will regret not going with him.
What if the overjet soultion is the more simple one, but would not max the best outcome since the upperjaw is not touched? What if prof saw that solution first and is why he does not want to touch my upper jaw? When i asked him he directly on advancing the upper jaw, he had one clear answer NO
I am confused since I feel my upper jaw can be better, and got even more confused when I read threads here about Ante face vs monkey lips. Some say it’s bad, some say it’s good. I mean my SNA is slightly under average, my mind is telling me slightly above average is the best measurement, but then how do you avoid the monkey mouth?
I feel like I have a 50/50 chance here to make the right call and I only have one time, and if i will make the wrong call I will live with it for the rest of my life. Currently I have no idea who to choose. The world famous surgeon who might try to oversell me or the local surgeon with 5% of the expirence
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I'm not Kavan, but I just want to say that I don't think you need to worry about getting a 'monkey mouth' from ANY of these surgeons :D Some will just do lower jaw surgery, so there's no risk at all there because your upper jaw won't be touched.
I also think the 'ante face' and monkey mouth/chimp lip are two different things.
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Hey Kevan; the last couple of days I thought about the subject non stop and here are my thoughts.
Currently I suffer from health problems and aesthetic problems. Of course I want to max both solutions.
On the one hand, we have my local doctor, who is considered a no name compared to some of the guys here. I already managed to confirm my self he does not do CCW and is more newer in the scene.
On the other hand, we have someone like who trained with Gunson and Wolford, is one of the best in the world and who have written huge books about aesthetic. If he say something should be done, should I not listen to him? Why should I trust my local guy who is only a decade or 2 in the business? I mean trained under the guy who invented jaw surgery! I just find it hard to believe he would try to oversell something or be a sellman. I fear that but the time I finish my local surgery I will regret not going with him.
What if the overjet soultion is the more simple one, but would not max the best outcome since the upperjaw is not touched? What if prof saw that solution first and is why he does not want to touch my upper jaw? When i asked him he directly on advancing the upper jaw, he had one clear answer NO
I am confused since I feel my upper jaw can be better, and got even more confused when I read threads here about Ante face vs monkey lips. Some say it’s bad, some say it’s good. I mean my SNA is slightly under average, my mind is telling me slightly above average is the best measurement, but then how do you avoid the monkey mouth?
I feel like I have a 50/50 chance here to make the right call and I only have one time, and if i will make the wrong call I will live with it for the rest of my life. Currently I have no idea who to choose. The world famous surgeon who might try to oversell me or the local surgeon with 5% of the expirence
I gave my thoughts and reasoning on the matter via direct observation of your situation and putting into perspective what the other surgeons told you before confused you or otherwise, in your mind, invalidated the other perspectives that basically confirmed the suggestion of single jaw surgery that your home town doctor had.
His name gets bandied about here and 'recycled' by others who hear it bandied about. Your interpretation of 'being highly esteemed by the board' or 'best in the world' or that 'most people' think his results are best in Europe is your own. It's not mine. You are entitled to have that interpretation/opinion or act on the opinions of others. But I'm not obliged to remove it from you.
I did my best to add some clarity. You are confused because HE confused you. Not my task at this point to un-confuse due to that. Nor one to choose your doctor FOR you. You went on enough consults to make a choice.
CCW is moot point IF someone is candidate for single (lower) jaw surgery only.
Your SNA is within the norm.
Your very questions, statements, interpretations about him, discounting the others, belie you want what is selling you on. So, I think you're in the capacity to un-confuse yourself as to whom to choose.
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I gave my thoughts and reasoning on the matter via direct observation of your situation and putting into perspective what the other surgeons told you before confused you or otherwise, in your mind, invalidated the other perspectives that basically confirmed the suggestion of single jaw surgery that your home town doctor had.
His name gets bandied about here and 'recycled' by others who hear it bandied about. Your interpretation of 'being highly esteemed by the board' or 'best in the world' or that 'most people' think his results are best in Europe is your own. It's not mine. You are entitled to have that interpretation/opinion or act on the opinions of others. But I'm not obliged to remove it from you.
I did my best to add some clarity. You are confused because HE confused you. Not my task at this point to un-confuse due to that. Nor one to choose your doctor FOR you. You went on enough consults to make a choice.
CCW is moot point IF someone is candidate for single (lower) jaw surgery only.
Your SNA is within the norm.
Your very questions, statements, interpretations about him, discounting the others, belie you want what is selling you on. So, I think you're in the capacity to un-confuse yourself as to whom to choose.
Would it be ok, if i were to ask you who you think is "the best" in Europe, or is it 100% moot at this point as you are certain i should go with the local guy? I still think the 3d planning software is a huge advantage which my local guy does not offer. I Still think about going with A since he offers both options and i think that may be the best. But i am still not sure.
Also April, thank you very much
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Would it be ok, if i were to ask you who you think is "the best" in Europe, or is it 100% moot at this point as you are certain i should go with the local guy? I still think the 3d planning software is a huge advantage which my local guy does not offer. I Still think about going with A since he offers both options and i think that may be the best. But i am still not sure.
Also April, thank you very much
I have no answer to 'who is best in Europe?'. I'm not going to choose your doctor FOR you other than to say 'A' with both options where he's BRACED to do the CCW if it looks like single jaw can't get approx 6-8mm seems to be a reasonable option.
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Hey guys. I have a bad update.
Just left my ortho, according to her, due to new estimates we are loking at least another year in braces (good case scenario) and maximum teeth movment of 5-6 mm instead of 8.
I have no idea what to do now. 6 mm is no where near enough for me, and another year and a year and a half of braces is an insane amount. What should i do??
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All does depend on end result of the ortho. I said that in a prior post. Get second opinion. Besides, since you were wanting veering toward double jaw, you have that option and have consulted with about already.
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All does depend on end result of the ortho. I said that in a prior post. Get second opinion. Besides, since you were wanting veering toward double jaw, you have that option and have consulted with about already.
I saw 2 other orthos that refused to treat me because I already began treatment.
The end result of the ortho will be 6 mm max. It is simply not enough. Not to mention that we talking here about a year more at least. I am much much more inclined towards CCW now and already mailed about it with the new info from today.
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Can't they extract a couple of primolars from your lower jaw? It seems an obvious thing to do to be able to create distance between your upper and lower teeth. I can't understand how can they not do more than 6mm - if they really want to - but maybe I'm missing something here. Of course if you prefer bimax surgery anyway, that's another story.
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Just checked your previous posts and see you're using Invisalign or similar - can they not do IPR / file down some teeth (instead of extractions) to create more space? What I don't get is, if you have a class 2 issue like myself, so your lower jaw is too far back compared to your upper, how can they not create more distance even though two of your lower teeth are missing already. The whole 'point' of class 2 is that there's distance between the two sets of teeth / jaws, right? Or maybe your case is very different from mine.
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Although 6mm could be sufficient for improvement, maybe easier to just REJOICE! a decision dilemma was made easier by ruling out a prior option due to ortho conflicts.
It's only bad news if you really had your heart set on single jaw only which you didn't. Now that the OPTION of single jaw looks to be ruled out due to ortho not getting up to the goal, that makes the UNCERTAINTY and INDECISION (single vs. double) LESS.
Keep in mind that a maxfax needs to work with an ortho toward goal of type of plan the maxfax wants. So best to narrow down WHICH of the other bimax ones you want.
Ok. So yoy are right. My family said the same thing. Sometimes the hand of fate chooses for you. Although i was already set on the BSSO i guess life shepherds me towards a way.
Right now my PG is around 1.7 cm behind the upper lip. If i get a 6mm BSSO we are talking about a 1 cm genio.. feels to me like its a "cover up" and that is a best case scenario.
Now, the question is how much can the upper jaw movement be minimzed, and what other effects will rotataion have compared to only lower jaw. Since so far i feel no one really told me or downsized those effects on the upper jaw area.
In case i cannot find a good plan from the doctors i talked to so far, is there anyone else in Europe you think i should look into?
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Just checked your previous posts and see you're using Invisalign or similar - can they not do IPR / file down some teeth (instead of extractions) to create more space? What I don't get is, if you have a class 2 issue like myself, so your lower jaw is too far back compared to your upper, how can they not create more distance even though two of your lower teeth are missing already. The whole 'point' of class 2 is that there's distance between the two sets of teeth / jaws, right? Or maybe your case is very different from mine.
Exactly, but i have no idea as to why or how we cannot do more than 6. I really dont want to extract more teeth, escpeilly when i already removed 2 molars. What is the end result? Good jaws but no teeth? I mean that was not the promised i got at the start of my treatment. If that is the case, i just rather do the CCW. Which avoides both the long treatment time and the need to remove more teeth.
Edit: not to blame you of course, but why should i tell my ortho those options? Thats her job!
In my case my body compensated for the week skeletal jaws by jutting the teeth, creating a perfect occlusion. In a case like mine you either create an overjet or do a CCW
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Ok. So yoy are right. My family said the same thing. Sometimes the hand of fate chooses for you. Although i was already set on the BSSO i guess life shepherds me towards a way.
Right now my PG is around 1.7 cm behind the upper lip. If i get a 6mm BSSO we are talking about a 1 cm genio.. feels to me like its a "cover up" and that is a best case scenario.
Now, the question is how much can the upper jaw movement be minimzed, and what other effects will rotataion have compared to only lower jaw. Since so far i feel no one really told me or downsized those effects on the upper jaw area.
In case i cannot find a good plan from the doctors i talked to so far, is there anyone else in Europe you think i should look into?
If you got a 6mm BSSO, it could be followed by a 3-4mm genio. NOT a 1cm genio. No suggestion for other doctors since that just brings more confusion. Upper jaw displacement=0 for single jaw surgery. Would need more advancement with Italian doctor to give large BSSO and maybe less with. Both CCW. Read articles in educational section.
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If you got a 6mm BSSO, it could be followed by a 3-4mm genio. NOT a 1cm genio. No suggestion for other doctors since that just brings more confusion. Upper jaw displacement=0 for single jaw surgery. Would need more advancement with Italian doctor to give large BSSO and maybe less with. Both CCW. Read articles in educational section.
I had no idea BSSO limits the genio.
I meant the upper jaw displacment effect followed by CCW on the face and teeth.
Ok, i will read and make sure to update following my.talk with them.
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why should i tell my ortho those options? Thats her job!
You're absolutely right, but after some bad experiences, I honestly got to the point that I'll only ever get orthodontic treatment again from an orthodontist that actually listens to me and / or to a surgeon selected by me. Having had braces before and consulted several orthodontists in the past as well as recently, I got the impression many of them don't see the big picture (in terms of what's best for the patient's face, aesthetically speaking), and simply ignore the fact that wearing braces for years has serious consequences for the patient's quality of life. They do not even try to find ways to shorten the treatment, make it less visible or more convenient or faster etc. This does not apply to all of them but the majority I spoke to seemed to be like this. One says, 'xyz cannot be done' (full confidence - it's a 'fact'), then next day you go to another one and they say 'xyz should be done' (again, full confidence, it's a fact etc.). The same applies to surgeons to an extent but I find it's even much more so with orthodontists.
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You're absolutely right, but after some bad experiences, I honestly got to the point that I'll only ever get orthodontic treatment again from an orthodontist that actually listens to me and / or to a surgeon selected by me. Having had braces before and consulted several orthodontists in the past as well as recently, I got the impression many of them don't see the big picture (in terms of what's best for the patient's face, aesthetically speaking), and simply ignore the fact that wearing braces for years has serious consequences for the patient's quality of life. They do not even try to find ways to shorten the treatment, make it less visible or more convenient or faster etc. This does not apply to all of them but the majority I spoke to seemed to be like this. One says, 'xyz cannot be done' (full confidence - it's a 'fact'), then next day you go to another one and they say 'xyz should be done' (again, full confidence, it's a fact etc.). The same applies to surgeons to an extent but I find it's even much more so with orthodontists.
The good thing about my current ortho is that she said she is ready to be 100% commited tk any surgeon plan i bring her. Including working with surgeons from Europe. But i am just sad the plan failed
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I see, so what exactly happened? Did you have a plan / clincheck that showed more than 6mm overjet as the end result, and your teeth stopped tracking, or? I thought one of the advantages of Invisalign was that you can see in the beginning what result are you going to get at the end (unless teeth does not move as planned). I'm asking because I'm also planning to use Invisalign to set my teeth up for surgery.
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I had no idea BSSO limits the genio.
I meant the upper jaw displacment effect followed by CCW on the face and teeth.
Ok, i will read and make sure to update following my.talk with them.
I was meaning that a single jaw 6mm BSSO + a 4mm genio, TOGETHER are a total 10mm advance at pogonian. I had no idea where you got the movement of 1CM (10mm) for the chin.
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I was meaning that a single jaw 6mm BSSO + a 4mm genio, TOGETHER are a total 10mm advance at pogonian. I had no idea where you got the movement of 1CM (10mm) for the chin.
I meant that the 1 cm genio is what i will still need in order to bring the pog to a good position. But as far as i understand if i get the 6 mm bsso i will be limited to a 4mm genio.
Also the CCW i need is posterior downgrafting right? There is no effect other than the mandible coming forward due to the rotation effect.
Anterior impaction is for people with long faces and steep occlsuopm that need to shorten the face right?
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I meant that the 1 cm genio is what i will still need in order to bring the pog to a good position. But as far as i understand if i get the 6 mm bsso i will be limited to a 4mm genio.
Also the CCW i need is posterior downgrafting right? There is no effect other than the mandible coming forward due to the rotation effect.
Anterior impaction is for people with long faces and steep occlsuopm that need to shorten the face right?
Anterior impaction is to correct a gummy smile. If your gum and tooth show is fine, it's a bad option. The only other way to achieve CCW is posterior downgraft, which does swing the mandible forward. Posterior downgraft does not preclude BSSO advancement nor a genio.
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Anterior impaction is to correct a gummy smile. If your gum and tooth show is fine, it's a bad option. The only other way to achieve CCW is posterior downgraft, which does swing the mandible forward. Posterior downgraft does not preclude BSSO advancement nor a genio.
My gum show is perfect. That means that if i go with posterior downgraft, should i expect any other effect beside the lower jaw coming forward? As far as teeth goes,nose etc
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My gum show is perfect. That means that if i go with posterior downgraft, should i expect any other effect beside the lower jaw coming forward? As far as teeth goes,nose etc
Posterior downgraft will tend to increase your posterior gum show. I'm not sure exactly what the effect would be in your case, but it could be worth the tradeoff (if it occurs).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3909438/
This is what I'm referring to
Nose changes are minimized by CCW because the maxillary advancement is minimized, but changes are still possible. CCW alone with no advancement should have virtually no impact on the nose.
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Posterior downgraft will tend to increase your posterior gum show. I'm not sure exactly what the effect would be in your case, but it could be worth the tradeoff (if it occurs).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3909438/
This is what I'm referring to
Nose changes are minimized by CCW because the maxillary advancement is minimized, but changes are still possible. CCW alone with no advancement should have virtually no impact on the nose.
Right now i think i have around 2mm. So that might put me closer to the ideal of 6mm according to the paper.
A few more questions if it is okay. Does the upper jaw have to be advanced?
As long as there is no advancment almost no changes will occur, allowing for a smooth advancment of the lower jaw?
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Right now i think i have around 2mm. So that might put me closer to the ideal of 6mm according to the paper.
A few more questions if it is okay. Does the upper jaw have to be advanced?
As long as there is no advancment almost no changes will occur, allowing for a smooth advancment of the lower jaw?
You don't have to advance the upper jaw. The jaws can be rotated CCW around the incisor tip or the ANS without physically lengthening the bone. There's a limit to the amount of pogonion differential that can be achieved via rotation alone, and that will largely depend on your starting occlusal plane. I wouldn't worry about the effects of a maxillary advancement of 3mm or less though if you really need the extra advancement to achieve your goal.
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You don't have to advance the upper jaw. The jaws can be rotated CCW around the incisor tip or the ANS without physically lengthening the bone. There's a limit to the amount of pogonion differential that can be achieved via rotation alone, and that will largely depend on your starting occlusal plane. I wouldn't worry about the effects of a maxillary advancement of 3mm or less though if you really need the extra advancement to achieve your goal.
All surgeons agreed i will need 2 mm Upper jaw advancment. Which i guess is good.
Noe just making sure i understand, the bigger the rotation the more my lower jaw will come forward.
You can however add a bsso ontop of the rotation, in which case you will need to renove the wisdom teeth and a make a cut there, or avoid a BSSO and a cut at the wisdom teeth, and simply make the rotation larger.
This might be the reason why Alfaro wanted me to wait and create an overjet, so the rotation will be smaller and the BSSO larger.
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I see, so what exactly happened? Did you have a plan / clincheck that showed more than 6mm overjet as the end result, and your teeth stopped tracking, or? I thought one of the advantages of Invisalign was that you can see in the beginning what result are you going to get at the end (unless teeth does not move as planned). I'm asking because I'm also planning to use Invisalign to set my teeth up for surgery.
I think my orthodontist simply overreached
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All surgeons agreed i will need 2 mm Upper jaw advancment. Which i guess is good.
Noe just making sure i understand, the bigger the rotation the more my lower jaw will come forward.
You can however add a bsso ontop of the rotation, in which case you will need to renove the wisdom teeth and a make a cut there, or avoid a BSSO and a cut at the wisdom teeth, and simply make the rotation larger.
This might be the reason why Alfaro wanted me to wait and create an overjet, so the rotation will be smaller and the BSSO larger.
Bigger rotation = more advancement (to a point, obviously).
The BSSO osteotomy is naturally more stable than the CCW movement, so that could be a factor. The size of a movement correlates with instability.
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Bigger rotation = more advancement (to a point, obviously).
The BSSO osteotomy is naturally more stable than the CCW movement, so that could be a factor. The size of a movement correlates with instability.
Ok gotcha. Where does 12mm jaw advancement falls as far advancements go
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Ok gotcha. Where does 12mm jaw advancement falls as far advancements go
That's larger than the average advancement but well within the realm of manageability. I wouldn't be concerned about that. Especially if part of the advancement is from rotation and the other part BSSO mandibular lengthening. FWIW my own procedure was 10mm straight MMA (both jaws) and it has been perfectly stable.
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That's larger than the average advancement but well within the realm of manageability. I wouldn't be concerned about that. Especially if part of the advancement is from rotation and the other part BSSO mandibular lengthening. FWIW my own procedure was 10mm straight MMA (both jaws) and it has been perfectly stable.
It comes only from the CCW.
It was offered by Raffaini. He believes it will be stable
I have 2 options. Either wait a year+ and create an overjet of around 5 mm and complete the rest with CCW
Or do the CCW now without any BSSO at all ( if I understood everything correctly)
I understand this might get pretty technical at this point, but I would still like to hear what you think.
Of course I rather do the surgery now than wait an entire year
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It comes only from the CCW.
It was offered by Raffaini. He believes it will be stable
I have 2 options. Either wait a year+ and create an overjet of around 5 mm and complete the rest with CCW
Or do the CCW now without any BSSO at all ( if I understood everything correctly)
I understand this might get pretty technical at this point, but I would still like to hear what you think.
Of course I rather do the surgery now than wait an entire year
Sounds to me like you should get the bimax now.
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Sounds to me like you should get the bimax now.
I would like to hear your opinion as to why. The questions is how much effect the 5 mm BSSO will have.
Thank you very much for taking the time. And explaining it to me. You helped me so so much
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I would like to hear your opinion as to why. The questions is how much effect the 5 mm BSSO will have.
Thank you very much for taking the time. And explaining it to me. You helped me so so much
A few reasons:
1) Life is short and being in braces sucks. Another year+ in braces is not an exciting prospect.
2) You have personally perceived 5-6mm is not enough mandibular advancement for your case. In my opinion, CCW rotation gives a more natural and aesthetic result than a BSSO that is compensated with a genioplasty. Your best option to achieve 12mm pogonion advancement would therefore be to rotate the jaws.
3) Extreme proclination of the upper incisors can have deleterious effects on the gums. It sounds like a bimax now will mitigate the amount of incisor proclination relative to trying to create a huge overjet and then meeting the bite with a BSSO.
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A few reasons:
1) Life is short and being in braces sucks. Another year+ in braces is not an exciting prospect.
2) You have personally perceived 5-6mm is not enough mandibular advancement for your case. In my opinion, CCW rotation gives a more natural and aesthetic result than a BSSO that is compensated with a genioplasty. Your best option to achieve 12mm pogonion advancement would therefore be to rotate the jaws.
3) Extreme proclination of the upper incisors can have deleterious effects on the gums. It sounds like a bimax now will mitigate the amount of incisor proclination relative to trying to create a huge overjet and then meeting the bite with a BSSO.
The BSSO will be part of the CCW so i guess the second point is moot? But the rest are dead on and excellent.
I guess the downsides will be less stable result and maybe unwanted effects on the face due to bigger rotation.
Both options are good i guesa and offered by both Raffaini and Alfaro. But i am much much more inclined towards the CCW only like you said. I just hope i wont have a relapse horroe story
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I meant that the 1 cm genio is what i will still need in order to bring the pog to a good position. But as far as i understand if i get the 6 mm bsso i will be limited to a 4mm genio.
Also the CCW i need is posterior downgrafting right? There is no effect other than the mandible coming forward due to the rotation effect.
Anterior impaction is for people with long faces and steep occlsuopm that need to shorten the face right?
I'm sorry BUT I have no idea where your basis of 'understanding' is coming from with regard to your bringing in a genio of 10mm advancement and now my brain is being scrambled.
Let's just FORGET the option of a single jaw advancement since that was RULED OUT.
As to understanding relationships having to do with rotations of the maxilla, it relates to the construct of a TRIANGLE. You would need to ALREADY HAVE grounding in elementary geometry as a BASIS to understand how rotating the maxillary mandibular complex RELATES to the construct of a TRIANGLE and what would happen with rotation of it around a selected FIXED point. Confusion follows when people lack the that type of basis.
Enclosed is a diagram of a triangle that has been rotated x degrees CCW around a FIXED point. You would need to 'relate' to what is happening there to relate it BACK to what's happening with a rotation at the maxilla around a FIXED point.
VISIT the educational section for material. Link to diagrams on rotation: http://jawsurgeryforums.com/index.php/topic,7883.msg72313.html#msg72313
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It comes only from the CCW.
It was offered by Raffaini. He believes it will be stable
I have 2 options. Either wait a year+ and create an overjet of around 5 mm and complete the rest with CCW
Or do the CCW now without any BSSO at all ( if I understood everything correctly)
I understand this might get pretty technical at this point, but I would still like to hear what you think.
Of course I rather do the surgery now than wait an entire year
NO. You have ONE option and that is to revisit concepts in elementary geometry because if you don't understand the very fundamental relationship of rotating a TRIANGLE and how the parts of it displace as a function of the direction of the rotation and a fixed rotation point you will have NO BASIS to relate anything they do in maxfax. Nor will I address questions that reflect a a lack of that type of basis. Your questions reflect you lack this fundamental basis.
'Post bimax's' answers reflect he has good grounding in basic geometry which is what you need for things to be more self explanatory.
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I'm sorry BUT I have no idea where your basis of 'understanding' is coming from with regard to your bringing in a genio of 10mm advancement and now my brain is being scrambled.
Let's just FORGET the option of a single jaw advancement since that was RULED OUT.
As to understanding relationships having to do with rotations of the maxilla, it relates to the construct of a TRIANGLE. You would need to ALREADY HAVE grounding in elementary geometry as a BASIS to understand how rotating the maxillary mandibular complex RELATES to the construct of a TRIANGLE and what would happen with rotation of it around a selected FIXED point. Confusion follows when people lack the that type of basis.
Enclosed is a diagram of a triangle that has been rotated x degrees CCW around a FIXED point. You would need to 'relate' to what is happening there to relate it BACK to what's happening with a rotation at the maxilla around a FIXED point.
VISIT the educational section for material. Link to diagrams on rotation: http://jawsurgeryforums.com/index.php/topic,7883.msg72313.html#msg72313
Hey Kevan. The 1.5 cm advancement comes from the fact that my Pog is 1.5cm behind the lip line. Which means i need to advance it by that much. If we only get 6 mm at the jaw, the rest needs to come from somewhere else.
Regarding the rotation, let me dwell on it a bit more to make sure I have full understanding.
I also found this info guide https://pocketdentistry.com/rotation-of-the-occlusal-plane/
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NO. You have ONE option and that is to revisit concepts in elementary geometry because if you don't understand the very fundamental relationship of rotating a TRIANGLE and how the parts of it displace as a function of the direction of the rotation and a fixed rotation point you will have NO BASIS to relate anything they do in maxfax. Nor will I address questions that reflect a a lack of that type of basis. Your questions reflect you lack this fundamental basis.
'Post bimax's' answers reflect he has good grounding in basic geometry which is what you need for things to be more self explanatory.
Hey i went over the educational section. Focusing for example on Arnett FAB planning and Antipov presentation, and the occlusion plane paper you linked. i understand better how to approach my problem and how does the CCW comes into effect.
We need to have space for the mandible to come forward>we elongate the back of the maxilla(make a cut, lower it and fill it with bone) >that in turns rotate the entire structure, giving the surgeon the option to advance the mandible in the new structure> the occlusion planes flattens>the lip\upper maxila area comes a bit forward.
cavats: stability of the joints might be a problem
Too much flatting might happen.
One thing i did not find any refrence for is the "anchorage" point of the rotation, either at the incisiors or the ANS. How does that come into effect? Can you direct me to a paper that explains that point?
What do you think about doing CCW in my case where i have one sided TMJ? I understand Arnett and co believe it is stable, but it still scares me that a large body of current day surgeons believes it is unstable, not that i hace another option if i want to breathe air like a normal person.
I understand now why CCW without BSSO makes no sense and what you meant
The philtrum area advances simply because of the rotation effect
Antipov also talks about Occlusiom plane being ideal at around 8. How can i know my occlusion plane now?
Anything else you think i should be focused if i continue now with A/R, including self education etc.
In the attached picture, i think is the best way to show the rotation, but still could not find any refernce to the ANS vs incisiors refernce point. Do you mean posterior vs anterior impaction
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Refer to figure 1 of the most recent post in the Education section
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So, I think I have an even better understanding now.
Sadly in this section
(https://pocketdentistry.com/rotation-of-the-occlusal-plane/)
they only refer clockwise rotation at certain points, but I still got the gist of it.
A case like mine should have advancement at the ans point, since I do want the Ans to not go backward, as well as provide better lip support. I assume rotation around the incisor is done with bimax protrusion cases?
TABLE 12-5
Counterclockwise Rotation of the Maxillomandibular Complex around the ANS Point *
Hard-Tissue Changes Soft-Tissue Changes
OP angle Decrease Subnasale No change
Maxillary incisor tip Advance Upper lip support Increase
Pog position Advance Facial convexity (contour) Decrease
Maxillary incisor angle Increase Mandibular prominence Increase
Maxilla at ANS No change Paranasal fullness No change
MP angle Decrease Nasolabial angle Decrease
Posterior maxillary height Increase Anterior facial height No change
Chin throat length Increase
Ok after paying 50$ and getting the full page.
“Rotation of the maxillomandibular complex is considered only in cases in which an acceptable result cannot be achieved by conventional treatment planning methods. A conventional visual treatment objective should always be developed for every patient before alternative treatment designs are contemplated.”
We tried it in my case and failed, there is no option to bring the mandible forward
“ There are scant data in the literature regarding skeletal stability after clockwise and counterclockwise rotation of the jaws. Poor skeletal stability after the counterclockwise rotation of the mandible has been reported by Schendel and Epker. They relate poor stability to the increase in posterior facial height and the associated increase in length of the pterygomasseteric musculature. Proffit, Turvey, and Phillips found that surgical decrease of the anterior facial height by counterclockwise rotation of the mandible (i.e., closure of anterior open bite malocclusions) would jeopardize the stability of results. Their results, when treating patients with vertical maxillary excess and mandibular anteroposterior deficiency (with or without open bite) by means of superior repositioning of the maxilla and mandibular advancement, proved to be more stable, with 60% of cases judged to have excellent clinical results. Moreover, the use of rigid fixation in these cases further improved stability, with 90% of these cases being judged to have excellent clinical outcomes. Chemello, Wolford, and Buschang reported stable results after both clockwise and counterclockwise rotation of the maxillomandibular complex. They stipulate that this is made possible by proper preoperative orthodontic treatment, proper execution of surgery, and the presence of healthy temporomandibular joints. Rosen reported similar results and made certain surgical recommendations to improve the stability. Reports in the literature identify three factors that may influence stability after orthognathic surgical procedures.”
This is worrying, but it’s not like I have another option. I don’t think there are more people out there with better skills than A/R. I guess this is my main problem, since I do suffer from TMJ on my right side. I know Wolford like to replace the joint, but what about the rest
Anything else I am missing Kevan?
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Let's say I was testing capacity students had to recognize elementary geometric relationships based on ROTATING a triangle and I found some random photo on which I CONSTRUCTED the red triangle of ABC. But NO student was expected to know ANYTHING about maxfax. Instead, just conceptual things having to do with triangles.
Let's say that on the capacity test, ONLY the red triangle ABC was there on the photo. Not the green one.
Let's say, the green one on the photo was drawn ONLY by the students who passed the capacity test.
Here is what would be asked to determine capacity:
'Rotate Triangle ABC 10 degrees so that C is displaced forward to C' and B is displaced downward to B'. Choose A as the fixation point and use green.'
(The capacity test did not say which direction to choose; CCW or CW because part of the capacity being tested was ability to to recognize which direction to choose to answer the question.)
QUESTION: What would the people who could pass the very basic capacity test need some basis in to show the answer to the question?
a: Geometrical relationships
b: Maxillo-facial surgery.
Answer: 'a'.
QUESTION: Which people on JSF entertaining maxfax surgery will become MOST confused about a subject having to do with points, lines, angles, planes and rotations.
a: Those who have a basis of elementary geometry to 'relate to'.
b: Those who don't
Answer: 'b'
QUESTION: Given that the angles and relative distances of the 'legs' of the triangle are measured out and leg AC is LONGER than leg AB and without measuring or calculating the distance of BB' or CC', which people would 'intuitively' know that distance CC' is going to be MORE than distance BB'.
a: Those who go on multiple consults
b: Those who see the relationship that triangles; ABB' and ACC' both are 10 degrees at vertex A
and both are isosceles triangles (because AB=AB' in one and AC=AC' in the other) but since AC is LONGER than AB, the BASE of triangle ACC' will be longer than the base of triangle ABB'.
Answer: 'b'
MORAL OF STORY: The (hypothetical) student who could show the green triangle AB'C' to demonstrate a 10 degree rotation of the red triangle; ABC and would know to choose direction CCW such that B' was found vertically lower, C' was found advanced forward and A was fixation point to show that, would have NO PROBLEM relating the distance; BB' to a posterior downgraft and the also relating the horizontal displacement distance from C to C' as being a direct consequence of the vertical displacement of B to B' from the CCW rotation. They also would be able to rotate ANY triangle in either direction from any fixed point and observe the displacements to the triangle. People, who would not be able to do something like that will have a hard time understanding how some of these maxfax relationships work BECAUSE they have limited basis to relate it BACK to.
Diagram enclosed with this post.
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Let's say I was testing capacity students had to recognize elementary geometric relationships based on ROTATING a triangle and I found some random photo on which I CONSTRUCTED the red triangle of ABC. But NO student was expected to know ANYTHING about maxfax. Instead, just conceptual things having to do with triangles.
Let's say that on the capacity test, ONLY the red triangle ABC was there on the photo. Not the green one.
Let's say, the green one on the photo was drawn ONLY by the students who passed the capacity test.
Here is what would be asked to determine capacity:
'Rotate Triangle ABC 10 degrees so that C is displaced forward to C' and B is displaced downward to B'. Choose A as the fixation point and use green.'
(The capacity test did not say which direction to choose; CCW or CW because part of the capacity being tested was ability to to recognize which direction to choose to answer the question.)
QUESTION: What would the people who could pass the very basic capacity test need some basis in to show the answer to the question?
a: Geometrical relationships
b: Maxillo-facial surgery.
Answer: 'a'.
QUESTION: Which people on JSF entertaining maxfax surgery will become MOST confused about a subject having to do with points, lines, angles, planes and rotations.
a: Those who have a basis of elementary geometry to 'relate to'.
b: Those who don't
Answer: 'b'
QUESTION: Given that the angles and relative distances of the 'legs' of the triangle are measured out and leg AC is LONGER than leg AB and without measuring or calculating the distance of BB' or CC', which people would 'intuitively' know that distance CC' is going to be MORE than distance BB'.
a: Those who go on multiple consults
b: Those who see the relationship that triangles; ABB' and ACC' both are 10 degrees at vertex A
and both are isosceles triangles (because AB=AB' in one and AC=AC' in the other) but since AC is LONGER than AB, the BASE of triangle ACC' will be longer than the base of triangle ABB'.
Answer: 'b'
MORAL OF STORY: The (hypothetical) student who could show the green triangle AB'C' to demonstrate a 10 degree rotation of the red triangle; ABC and would know to choose direction CCW such that B' was found vertically lower, C' was found advanced forward and A was fixation point to show that, would have NO PROBLEM relating the distance; BB' to a posterior downgraft and the also relating the horizontal displacement distance from C to C' as being a direct consequence of the vertical displacement of B to B' from the CCW rotation. They also would be able to rotate ANY triangle in either direction from any fixed point and observe the displacements to the triangle. People, who would not be able to do something like that will have a hard time understanding how some of these maxfax relationships work BECAUSE they have limited basis to relate it BACK to.
Diagram enclosed with this post.
Thank you very much Kavan. I believe i understand it much better
You got a very nice skeletal model there. I am sure the guy is very handsome
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Thank you very much Kavan. I believe i understand it much better
You got a very nice skeletal model there. I am sure the guy is very handsome
;D Totally random photo I found on the internet.
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Hey i went over the educational section. Focusing for example on Arnett FAB planning and Antipov presentation, .....
I just wanted you to look at the link where I put the triangles.
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One thing i did not find any refrence for is the "anchorage" point of the rotation, either at the incisiors or the ANS. How does that come into effect? Can you direct me to a paper that explains that point?
I assume rotation around the incisor is done with bimax protrusion cases?
Its confusing, but when they do the practical planning, the incisor tips are often used as the point of rotation. I saw this on screen during my own consult with G (his plan for me was a very large posterior downgraft/CCW). He played around with the rotation (increasing and decreasing) and I could see the rotation was happening around the incisors, not ANS. It didn't really match with Reyneke's triangle concepts, where one would expect that a posterior downgraft would rotate around an ANS point.
I saw that in the below article it does say Arnett Gunson plan surgery with the incisor point as the point of rotation. It seems the planning/workflow seems to be to basically get everything correct horizontally and vertically, and then as a final step rotate the occlusal plane around incisor tips as needed.
Esthetic cephalometric planning for orthognathic surgery involves seven substeps:
1. Maxillary incisor angulation to the maxillary occlusal plane (orthodontic tooth movement)
2. Mandibular incisor angulation to the mandibular occlusal plane (orthodontic tooth movement)
3. Overbite correction (may be obtained with substeps 1 and 2)
4. Overjet correction (may be obtained with substeps 1 and 2)
5. Esthetic anteroposterior and vertical maxillary incisor positioning (may be obtained with substeps 1 and 2 or maxillary surgery)
6. Occlusal plane manipulation to produce esthetic anteroposterior positions of the nasal base and chin (requires two-jaw surgery)
7. Chin osteotomy when necessary (only after steps 1-6)
Substeps 1 and 2 have been described above under orthodontic incisor positioning; the normal ranges for the upper and lower incisors to the upper and lower occlusal planes are 54-60° and 61-68°, respectively. If orthodontic completion of these substeps corrects the overjet and overbite and provides acceptable facial esthetics, and if a normal airway exists, then surgery is not necessary.
If an overjet abnormality still exists after substeps 1 and 2, treatment proceeds to substeps 3 and 4. In these substeps, the occlusion is positioned in a Class I relationship, and the overbite and overjet are corrected by surgery of the lower, upper, or both jaws.
Substep 5 is utilized when the face is still imbalanced or the airway is still compromised. This maxillary surgery positions the maxillary incisors anteroposteriorly and vertically as indicated by facial needs, providing ideal anteroposterior support of the lip with 3-4mm of incisor exposed beneath the lip.
Substep 6 alters the maxillary and mandibular occlusal planes, based on esthetic and airway needs. The maxillary incisor position, as set in substep 5, acts as the center of rotation for the occlusal plane. The posterior occlusal plane is moved either superiorly or inferiorly, depending on nasal base and chin projection needs. When ideal esthetics are achieved, the maxillary occlusal plane is usually between 93° and 98° to the true vertical line, which is a line perpendicular to natural head position as described by Arnett and colleagues.3 Flattening the occlusal plane into the normal range maximizes chin projection without the need for substantial, unattractive chin augmentation (Fig. 3). Additionally, a normal occlusal plane prevents the excessive nasal base fullness that can occur when the occlusal plane is steepened with traditional posterior maxillary impaction.
From http://jawsurgeryforums.com/index.php/topic,7881.0.html
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Its confusing, but when they do the practical planning, the incisor tips are often used as the point of rotation. I saw this on screen during my own consult with G (his plan for me was a very large posterior downgraft/CCW). He played around with the rotation (increasing and decreasing) and I could see the rotation was happening around the incisors, not ANS. It didn't really match with Reyneke's triangle concepts, where one would expect that a posterior downgraft would rotate around an ANS point.
I saw that in the below article it does say Arnett Gunson plan surgery with the incisor point as the point of rotation. It seems the planning/workflow seems to be to basically get everything correct horizontally and vertically, and then as a final step rotate the occlusal plane around incisor tips as needed.
From http://jawsurgeryforums.com/index.php/topic,7881.0.html
What matters is that people wanting to know about rotations, any of them understand the fundamental geometric concepts involved with rotating triangles around a point, ANY point.
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A useful mental model for visualizing rotations IMO is to ‘stick a pin’ in the axis and then mentally rotate and think about what that means in terms of surgical procedures.
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A useful mental model for visualizing rotations IMO is to ‘stick a pin’ in the axis and then mentally rotate and think about what that means in terms of surgical procedures.
YES. But we call this the POINT of rotation when it involves a triangle. I just corralled in a friends kid, (in 4th grade) gave him a cut out of a triangle, asked him to trace it. Then ask him to hold a selected point down (a vertex like the one I gave in my example), rotate the triangle, trace that and tell me something about where the other vertices went. The KID was able to observe and answer the question correctly. Not saying that ALL kids would be able to get it right though.
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Guys a few questions i have.
How terrible would it be if my maxilla is advanced by 2 mm as compared to nothing? Is it avoidable?
My occlusal plane right now is 5 degrees. Is it not problematic?
How does the occlusal plane translate into teeth show?
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Just spoke with my original surgeon. He was shocked that the ortho said she will only be able to produce 5 mm result. As well as another year of treatment. He said he is still 100% sure he will be able to get 8-9 mm of jaw movement along with 4/5 mm of genio at a much shorter time. He will give me an update in the next few days on how to proceed.
Why am I the one who is suppose to tell him? Are they not suppose to communicate between them? What the hell did I get myself into.
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Just spoke with my original surgeon. He was shocked that the ortho said she will only be able to produce 5 mm result. As well as another year of treatment. He said he is still 100% sure he will be able to get 8-9 mm of jaw movement along with 4/5 mm of genio at a much shorter time. He will give me an update in the next few days on how to proceed.
Why am I the one who is suppose to tell him? Are they not suppose to communicate between them? What the hell did I get myself into.
Here is a quote of mine from another thread (on the educational section):
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' Absence of treatment plan, when orthodontist and surgeon do not communicate....'
I think that is often the case when patients are in braces (or invasaline) for 'something' and then they go around on multi consults in pursuit of the maxfax part of various treatment proposals where the situation is inherently one where there is no communication between which ever otho they have and the doctors they are consulting with. They are in braces for 'something' and the more consults they go on, the more they get confused and linger longer in indecision. Any treatment plan via braces should be that of the CHOSEN doctor such there is direct communication via him/her and ortho. All treatment plans from any doctor are always contingent on the braces doing what they want them to do.
Also, the operative word in your statement is 'MY', 'my surgeon'. Perhaps, just semantics, but he's not 'your' surgeon unless you've pre-selected him over the others you consulted with.
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Why am I the one who is suppose to tell him? Are they not suppose to communicate between them? What the hell did I get myself into.
You remind me of me. Things felt 'wrong' and I was getting very frustrated with the lack of communication from quite early on in the process, and how I was doing all the work for them. It was a red flag I didn't think to give enough attention to. I would advise you to be careful - if you think it's lack of communication from your ortho specifically, transfer to a new one.
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All surgeons agreed i will need 2 mm Upper jaw advancment. Which i guess is good.
'All surgeons' is inconsistent with your saying your home town surgeon suggested SINGLE JAW surgery. So, hard to make anything out of the info you relay. I give up.
You know what...you should get a job with one of those intel agencies known for scrambling the flow of information so that all is a moving target where no information can be PINNED DOWN.
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Here is a quote of mine from another thread (on the educational section):
Also, the operative word in your statement is 'MY', 'my surgeon'. Perhaps, just semantics, but he's not 'your' surgeon unless you've pre-selected him over the others you consulted with.
I agree with that you wrote and also made the connection. I had a feeling in some small part you were refearing to my case. Both the act of me running around the world with braces and consulting with surgeons when I am already in braces, with each surgeon refearing to the situation as it is now developing.
In an ideal case I would go to the surgeons w a virgin mouth. As for the commuinication between ortho and surgeon, I wrote a more detailed post for April where I show my thoughts.You are absouloutly right. For now he is "a" surgeon, not "my" surgeon.
You remind me of me. Things felt 'wrong' and I was getting very frustrated with the lack of communication from quite early on in the process, and how I was doing all the work for them. It was a red flag I didn't think to give enough attention to. I would advise you to be careful - if you think it's lack of communication from your ortho specifically, transfer to a new one.
The situation is not that good looking. So far, the usual ortho my surgeon works with refused to treat me citing me an "impossible" case. Now the second ortho that i was referrred to and agreed to work with me decided to tell me after almost a year that we need to double my time in braces and that the maximum movement of movement that is 6-5 and we agreed to it from the start.
This is a complete lie, we agreed to 8-9. That is what i think you would call a red flag
Not only that, but i was the one who had to break the news to the local surgeon. He was shocked. Another red flag
How did he not know that? Why did they not communicate for 2 months? Why is she moving the surgery goalpost by herself? What would have happened had i been a "run of the mill" patient and just went along with the flow. I am very mad right now and feel as if i am being played around.
I would like to hear what happpened to you April, via here or PM.
'All surgeons' is inconsistent with your saying your home town surgeon suggested SINGLE JAW surgery. So, hard to make anything out of the info you relay. I give up.
You know what...you should get a job with one of those intel agencies known for scrambling the flow of information so that all is a moving target where no information can be PINNED DOWN.
Haha, i am very very sorry. I was just very mad and confused for the last few days so i just scrambled everything. Let me try one more time make a much more constructed post without wasting youe time.
I finally realised why you advocated that the best patient is an educated one that can ask the proper question without wasting the surgeon time and that is also able to make the correct, educated decision. I am trying to follow that philosophy and believe i have a much better understanding now.
What i meant was that all the surgeons who raised the option of CCW, also said that i would need a 2mm upper jaw advancment as well, so that seems good.
I have a few other questions such as how those same surgeons are going to do a CCW when my mandibular plane is 22 and occlusal plane 5, but those are not question you need to answer, but rather the surgeons who made those plans, since i now feel my questions are much more appropriate.
Sorry again you had to read my rumbling.