jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: Baguettejaws on September 06, 2020, 12:22:40 PM
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Hello Guys ! :D
First post there. 35y old, Sleep Apena (25 per hour).
I had consultations with several doctors, including DeFrancq in Belgium and finally decided to go to a french maxilofacial surgeon near Paris. My bite was class 1 so they decided they can operate without ortho.
I underwent a Bimax two weeks ago, and during my time off, I tried to better understand what all sort of movements when performing a bimax. Here is my pics preop
1) Given the ceph and pictures, what would have been the best movements to perform ? I got straightforward MMA (10mm) with standard zygo or infraorbital implants. When I asked the surgeron about a possible rotation, he told me "you don't have a gummy smile"
I told myself that maybe he did'nt think it was a geat idea as my occlusal plane were not so steep but I am not sure about that
2) In all the beautiful outcomes I see on the forum, it seems that there is a vertical line passing by the maxila and the mandibule. In my case, pre-op, the line is "tilted". How comes moving both maxilia the same amount of mm is going to create that straight line ?
I am currently wondering if I did the best choice regarding the surgeon/procedure in order to achieve facial harmony, as I see a lot of surgeries involve CCW to minimize the advancement of the upper/maximize lower advancement. I am afraid the 10 mm advancement may have been to much regarding the cephs.
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Are the records you posted all pre-op?
That second one is useless. The angle is not correct, and drawings like that are old school and not good, modern records of any value. The x-ray shows a good dental relationship, so his idea of no ortho is probably correct, but how is your bite after surgery?
If your final photo is pre-op, then I think you could have gone the route of linear movement or CCW movement. I think either would work, though I think 10mm is too much for a linear movement. If he wanted to do linear only I'd cap that at 5mm before you risk the chimp look. Linear is more old school, and that fits with what I'm seeing with that drawing. Was your surgeon and old guy? Given how flat and long your philtrum is, I'd think CCW would give a better result. If you have better records please post them.
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Thank for your fast reply.
The drawing come from a first surgeon I consulted that I did not move forward with, I brought it to the surgeon that did the bimax and he did not seemed to be interested with this document, Ceph and other X rays were more appealing to him/
Regarding the bite, I still have elastic bands but it seems to be ok from what I see.
All the records are pre-op. I can share a post-op simulation and then a post-op picture, 2 weeks after to see whether or not the result seems promising.
edit : surgeon is 45 I think, but the exams he asked before surgery were just ceph, dental panoramic, I also gave him MRI but he did not asked more exams.
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I don't know if it's just my monitor but that ceph appears useless; I can't see anything.
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Hello Guys ! :D
First post there. 35y old, Sleep Apena (25 per hour).
I had consultations with several doctors, including DeFrancq in Belgium and finally decided to go to a french maxilofacial surgeon near Paris. My bite was class 1 so they decided they can operate without ortho.
I underwent a Bimax two weeks ago, and during my time off, I tried to better understand what all sort of movements when performing a bimax. Here is my pics preop
1) Given the ceph and pictures, what would have been the best movements to perform ? I got straightforward MMA (10mm) with standard zygo or infraorbital implants. When I asked the surgeron about a possible rotation, he told me "you don't have a gummy smile"
I told myself that maybe he did'nt think it was a geat idea as my occlusal plane were not so steep but I am not sure about that
2) In all the beautiful outcomes I see on the forum, it seems that there is a vertical line passing by the maxila and the mandibule. In my case, pre-op, the line is "tilted". How comes moving both maxilia the same amount of mm is going to create that straight line ?
I am currently wondering if I did the best choice regarding the surgeon/procedure in order to achieve facial harmony, as I see a lot of surgeries involve CCW to minimize the advancement of the upper/maximize lower advancement. I am afraid the 10 mm advancement may have been to much regarding the cephs.
Elementary Geometry. A straight line, by definition, is a line made by connecting 2 points.
A diagonal line is just as 'straight' as a vertical one. So, not something where only a vertical line is straight.
When 2 lines are perpendicular to each other, they intersect at a 90 degree angle. So, 2 diagonal lines can also be perpendicular to each other when they intersect at a 90 degree angle. THAT'S what your ceph diagram is showing.
The line passing through the maxilla from points; ANS-PNS is about parallel to the Frankfurt Horizontal. The ceph is conveying that because the more vertically oriented line passes through the 'Or' point. So, a line parallel to the one passing through the maxilla would be perpendicular to the more vertically oriented line and most likely passes through the 'po' point of the Frankfurt Horizonatal which is Po-Or.
So, if one wanted to reproduce the 'vertical' line you might see in other cephs, it would be drawn PARALLEL to the more vertically oriented (longer) line on yours so that it passed through where the base of the nose meets the upper lip area.
If I ROTATED your CEPH about 16 degrees CCW, the short line going through your maxilla would be HORIZONTAL and the longer line PERPENDICULAR to it would be VERTICAL (in direction of line of gravity). A line PARALLEL to the vertical that PASSED THROUGH where the base of the nose meets the upper lip area would be what they call the 'TVL' or 'true vertical line which would show that your chin point (pog) is BEHIND the line and so are your lips.
The ceph tracing also shows the bite is right which is an indication in favor of linear advancement, especially for a sleep apnea case. So, that coupled with the other thing the ceph shows; the line through the maxilla being parallel to the Frankfurt Horizont is an also an indication in favor of an overall linear advancement parallel to the Franfurt Horizont.
I wouldn't say the ceph tracing was 'useless'. Was useful enough for me to know what it was conveying.
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he did not seemed to be interested with this document
Okay good. It's nothing more than glorified art class.
I'd be curious to see some post-op records, yes.
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@Kavan, @GJ, thank you for your replies.
As promised, you'll find below two ost-op picture, +15 and +16 days after the bimax. The +16 picture show my head that is slightly tilted.
Well, I do not really know what to think. I don't really like what I see and I am wondering if this is because of the swelling that is more pronounced on the areas that have been directly affected by the surgery, or if we can already say that something is odd.
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Well, I'd ask if the surgery resulted in better breathing. It's common for one to see swelling right under the nose. Perhaps the conVEXity to it will flatten out somewhat with time. The surgeon/s saw an indication for the MMA linear advancement which is when the bite is right for them to move things equally.
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16 days after surgery is waaaay too early to judge the aesthetic outcome. I could not even see the outlines of my 'new face' at that stage, it was just one big swollen potato head. You have to wait several more weeks to get an idea of what the final result will look like. As Kavan says, the more important thing at this stage is, is your functional result good, from what you can tell so far?
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You look very different, but I don't think it's worse or better. Just a different look. Before you looked more nerdy and boyish, and now you look like a man. I'd imagine that's very dramatic for you to deal with since it's so drastic. Give it time to heal and to adjust, and also to realize you had to do this surgery for your health.
Can you seal your lips without strain after?
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Is it even possible to judge the after pictures? The only thing what is obvious is the philtrum area, but the rest is hidden under the beard. Even my surgeon wanted me to shave before the surgery, so he could see the real me.
Besides, it is not even the same side of the face.
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Is it even possible to judge the after pictures?
Yes.
But not 100% apples to apples. We get the general idea.
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Hello Guys,
Thank you for your qualitative replies.
I come back with some news. As usual, feel free to ask me to clarify my wording as I am not an english native speaker.
Regarding the sleep anpea/snoring
I stopped using the CPAP machine the day after surgery.
I used to monitor my snoring with an app "Ironfle" which means "I snore". My score went from 70 (without CPAP) to 3 after surgery. The recording shows absolutely no snoring, which is nice. For the sleep apnea, as I did not had polysomnography yet, I am still guessing but here is what I can feel
I no longer need 11 hours sleep, 7 hours works fine
I wake up with a slight headeache, which is usually a sign of sleep apnea. However, I force myself to sleep with a closed mouth, and I still feel a swelling inside my nose. If my mouth is opened, no headache at all, which was not the case before surgery
My partner says that she does not see any apnea at all (she stayed awake 2 hours when I was sleeping)
I no longer feel tired during the day
@GJ I can seal my lips without strain right now
Regarding the aesthetical outcome
The swelling is still here, I am going to post a picture the 24th, one month after the surgery. I'll be shaving the beard.
I am a little bit concerned by the appearance of the cheek implants. It seems that the placement is a little bit off, but again, I am going to wait and see what happens.
By the way, you'll find enclosed a proper pre-op ceph, the previous one was very dark, thanks Kavan for your analysis despite the poor material I provided.
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Hello guys
Just a little update about my surgery.
I had an appointement with the surgeron. He seems satisfied with his job.
Here were my concerns :
Cheeks implants seems to have a weird look :o
Maxila seems proeminent
Bite not perfect ( maxila seems to be more advanced that the mandible). To give you an idea, if I take a surgeon mask and bite the elastics with my front teeths, they can slip out of my months. Nice job, especially when I was class 1 before the surgery.
A little bit gummy smile
Surgeon answer "wait more, it is going to fix itself"
I had some concerns about the outcome so I decided to do some cephs post op to bring it to another surgeron
The other surgeron looked at my face and cephs and said that the maxila was probably over advanced, that the cheeks were to be removed (wrong position) and too big (werent tailor made but off the shelf) and that the bite is incorrect.
He suggest that I come back in a few months, once everything is stabilized, in order to
Remove the cheeks implants
Perform movements on the jaws (impaction/rotation in order to restore the bite and show less gum)
Conclusion : chose your surgeron wisely. Even the big names are sometime not really reliable for a surgery on a "simple case".
Enclosed : a before/after. Note : the before was a scan of my preop and the after is simply the ceph that I put on the computer screen. So the material is unusable for any analysis, I just wanted to give you a general idea as soon as possible.
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I've never seen cephs like that with someone's reflection in the background. So perfectly understandable, they can't be used for much feed back here. If you are still in braces, the objective would be towards final bite corrections which is why both are telling you to wait.
As to choosing a surgeon wisely, it would be the choice of the SECOND one that you have to be wiser about.
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Unfortunately, no more braces or wires, removed on Friday. Surgeon 1 told me that the bite is going to close with time, speaking and eating will make my jaws work and help fixing the bite.
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Unfortunately, no more braces or wires, removed on Friday. Surgeon 1 told me that the bite is going to close with time, speaking and eating will make my jaws work and help fixing the bite.
Well, you'll have to wait that time out anyway before having the other surgeon doing any work.
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Bags, it's a weird thing in that you went from looking like an accountant to looking like a track coach. Somewhat nerdy to jocky. It's very dramatic that type of change. Is this what is throwing you off so much? I don't think you look bad after. If I saw you on the street I'd just think I walked past the high school track coach. The bite issue has me more concerned than your looks.
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Well, you'll have to wait that time out anyway before having the other surgeon doing any work.
I do. I am not in a hurry to do a revision. This is just 1 month and things can still change.
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Bags, it's a weird thing in that you went from looking like an accountant to looking like a track coach. Somewhat nerdy to jocky. It's very dramatic that type of change. Is this what is throwing you off so much? I don't think you look bad after. If I saw you on the street I'd just think I walked past the high school track coach. The bite issue has me more concerned than your looks.
"it's a weird thing in that you went from looking like an accountant to looking like a track coach" :D :D
I am not against looking like a track coach, I am fine with that.
I'll post some pictures in the next days so you can have all a better idea of the result.
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One month is definitely too early to judge aesthetics plus I agree with GJ that you look fine in the after photos you posted; however the bite is a concern. It does not look right to me in that ceph and I find it super weird that your surgeon said that will get fixed magically by itself. I have never heard of anything like that before. I am 2 months post op and my bite has not changed at all since I woke up in the recovery room (and I've been doing a lot of speaking and chewing lately). It would be pretty strange if people's bites changed post surgery because of eating and speaking! I personally think you'll eventually need some orthodontic work to sort this out (hopefully not long though, maybe a few months).
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Unfortunately, no more braces or wires, removed on Friday. Surgeon 1 told me that the bite is going to close with time, speaking and eating will make my jaws work and help fixing the bite.
Assuming your bite is off because your upper jaw was overadvanced, two things can happen to make what he said true:
* the upper jaw may relapse a little.
* your teeth will start to naturally compensate the overjet - the upper teeth will incline backwards, the lower forwards. This will only increase the convexity of your upper lip.
Removing the hardware so early is bizarre. There is a thing called "regional accelleratory phenomenon" - after the bones are cut and moved, teeth start to move really fast. It is used to sell surgery first because the total time in braces is in theory less (for those that need teeth to move... never mind that it makes the surgery itself less accurate). But even if your bite is perfect after surgery, retention is required to prevent the teeth from moving.
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Thank you for your feedback. The hardware was not braces, but a metal wire in my gum with little hooks. I assume it was used during the surgery to handle the maxila/mandible, and after to put the elastics.
So, removing the hardware makes me unable tu use the elastics.
The relapse of the upper jaw would be perfect as it would close the bite AND make me looks like less chimpy.
Anyway, I am going to see another surgeron, in Italy, so I can have one more medical feedback.
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Removing the hardware so early is bizarre. There is a thing called "regional accelleratory phenomenon" - after the bones are cut and moved, teeth start to move really fast. It is used to sell surgery first because the total time in braces is in theory less (for those that need teeth to move... never mind that it makes the surgery itself less accurate). But even if your bite is perfect after surgery, retention is required to prevent the teeth from moving.
I only needed braces for my bottom teeth to close extraction gaps and they put brackets on top just for the surgery. Those were removed 6 weeks after surgery and they gave me a retainer to wear at night (still need the lower ones to close remaining gaps etc.). My ortho has a lot of experience with surgical cases and he told me that in his personal experience, teeth don't typically move faster after surgery than before. Still, OP should probably get a retainer or something just in case.
Having said that, if he gets a retainer, his bite can't magically correct itself unlike the surgeon suggested...
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Thank you for your feedback. The hardware was not braces, but a metal wire in my gum with little hooks. I assume it was used during the surgery to handle the maxila/mandible, and after to put the elastics.
So, removing the hardware makes me unable tu use the elastics.
The relapse of the upper jaw would be perfect as it would close the bite AND make me looks like less chimpy.
Anyway, I am going to see another surgeron, in Italy, so I can have one more medical feedback.
If you have arch bars, then the faster they're out, the better. They shred gums.
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I only needed braces for my bottom teeth to close extraction gaps and they put brackets on top just for the surgery. Those were removed 6 weeks after surgery and they gave me a retainer to wear at night (still need the lower ones to close remaining gaps etc.). My ortho has a lot of experience with surgical cases and he told me that in his personal experience, teeth don't typically move faster after surgery than before. Still, OP should probably get a retainer or something just in case.
Having said that, if he gets a retainer, his bite can't magically correct itself unlike the surgeon suggested...
Can't predict whether or not his bite will correct itself. But just to say, that IS the theory behind eventual self correction via COMPENSATION where the teeth will kind of move into place on their own without the braces still in there.
The retainer comes in AFTER the teeth compensate to fit into place. It is to keep them in place. So, if they are out of place for a good bite, a retainer would tend to keep them out of place before they could compensate on their own.
The teeth moving faster after surgery that Plosko referred to; 'regional accelleratory phenomenon' is indeed an observed phenomenon the surgery first doctors rely on. It has something to do with the blood supply that's there after a fresh cut to the jaw bones. Although I don't know the exact bio-dynamic particulars. The observation of that being the case (faster teeth movement) is something that orthos working with surgery first cases would most likely see more of than those not. However, even though faster teeth movement after surgery first happens, some people DO need to stay in the braces longer because no matter how fast they move, the surgical plan itself is one where the surgeon just ASSUMES the ortho will make the bite right after his surgery and that's not often the case when the surgeon is actually not doing things based on PRE-ORTHO accuracy for him to do it.
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Can't predict whether or not his bite will correct itself. But just to say, that IS the theory behind eventual self correction via COMPENSATION where the teeth will kind of move into place on their own without the braces still in there.
I see! Thanks for the info, never heard of that before. Must be a bit scary for OP seeing he had a class 1 bite before surgery - hope it will work out for him.
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Hi guys,
Just saw an ortho yesterday to make a dental cast. Impossible to do it because opening my mouth enough was not possible.
When we speak about the occlusion, she said that "teeths move and naturally search contact". So she is confident that the teeths are going to get in place soon.
Wait and see, I have an appointement with an Italian Surgeron in Parma in a few weeks, I'll keep you updated after the consultation
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Just saw an ortho yesterday to make a dental cast. Impossible to do it because opening my mouth enough was not possible.
My mouth opening is quite limited as well after surgery but my ortho has a small sized plastic tray that he managed to get inside slowly for the impressions - maybe you can ask next time if they have that size. Good to know that teeth can move by themselves, I really had no idea (and I'll be more serious than ever about wearing my retainer from now - first time in my life I have a class 1 bite, can't afford to lose that!). Good luck with the consultation and everything else, really hope things will work out well for you.
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Hi guys,
Just saw an ortho yesterday to make a dental cast. Impossible to do it because opening my mouth enough was not possible.
When we speak about the occlusion, she said that "teeths move and naturally search contact". So she is confident that the teeths are going to get in place soon.
Wait and see, I have an appointement with an Italian Surgeron in Parma in a few weeks, I'll keep you updated after the consultation
She's sort of right.
It depends what's wrong with the bite (did you say somewhere in the thread?)...e.g. if they need to extrude, teeth naturally want to do that, to a point. If you tell me exactly what's wrong with the bite, I can probably give you the reality of whether they will fix themselves or not.
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Hi GJ,
Actually, I thought it may be useful to post some pictures.
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Any thoughts, @GJ ?
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Any thoughts, @GJ ?
Can you take photos from the side and front?
From those photos, it looks like you have the back teeth hitting first.
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Hello guys,
Just a quick update:
I tried to see a French Doctor to have another feedback. The appointment was in Neuilly. The doctor told me GTFO, go to see your original surgeron. Total time: 2 min.
I finally went to Italy to see a surgeon. Very professional and welcoming. I did not share a lot of my thoughts with him before the appointment, just said that I underwent a bimax. He did an ICAT, here is his conclusions:
• Over advanced maxilla
• Mandible not enough advanced/bite incorrect
• Swelling or infection that compress nerves on certain parts of the face
• Implants misplaced
• Nasal spine cut, he wouldn’t have did it
• Cutting of the mandible is kind of weird (not traditional)
• And the best : on the icat, you can see that there is a gap/void over the maxila. No bone here. According to him, this is because no “granules” or graft was done, making the bone formation impossible. The maxilla is just fixed with the plates and nothing else. It is not going to change unless a new surgery is done
He recommends operating again, probablysetting back the maxilla to +5mm with respect to the original position, with a CCW rotation. He can not operate before 6 to 8 months.
I knew that I had to do some research before undergoing this surgery, and I think that I did it more than most of the patients. I did not expect this surgery to fail so much.
Conclusion: Take your time, only go to the best surgeons. This mistake is going to cost me one year of my life and roughly the price of a brand new Porsche Macan. ;D
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Sending you a PM.
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Hello guys,
Just a quick update:
I tried to see a French Doctor to have another feedback. The appointment was in Neuilly. The doctor told me GTFO, go to see your original surgeron. Total time: 2 min.
I finally went to Italy to see a surgeon. Very professional and welcoming. I did not share a lot of my thoughts with him before the appointment, just said that I underwent a bimax. He did an ICAT, here is his conclusions:
• Over advanced maxilla
• Mandible not enough advanced/bite incorrect
• Swelling or infection that compress nerves on certain parts of the face
• Implants misplaced
• Nasal spine cut, he wouldn’t have did it
• Cutting of the mandible is kind of weird (not traditional)
• And the best : on the icat, you can see that there is a gap/void over the maxila. No bone here. According to him, this is because no “granules” or graft was done, making the bone formation impossible. The maxilla is just fixed with the plates and nothing else. It is not going to change unless a new surgery is done
That sounds right. Regarding the void over the maxilla, did he think there was risk keeping it like that? I believe it will fill in with tissue not remain a void if left. At least that's how non unions form. If you press on your maxilla you can actually see it move, in these cases. The nasal spine likely had to be cut because of the large advancement, so it makes sense for the surgery you got, but you probably got the wrong plan.
That French guy sounds like a piece of work. Who was it?
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Will he rebuild the nasal spine after moving your maxilla back?
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Well as to the prior research you relay you did and say it was 'more than most patients', your first entry to JSF reflects a question AFTER THE FACT as to what would have been best movements to perform. So, I would wonder what your prior research actually was.
Presently, you don't give the name of the surgeon who's going to correct you. What ever research, which ever way you do it, isn't one of exploring if any members here used the same surgeon or have any feedback on him. So, no idea if this un named new sugeon is recognized as one of the 'best' or just another yahoo.
Hope you researched what a columellar strut graft is or his capacity in revision rhino as to re-supporting the base of the nose area where the ANS was cut. Because it doesn't seem to be enough info to me for him to just tell you he would not have cut it and not tell you how he's going to correct that area along with his set back.
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@GJ
I am not sure about it. The fact is I do a lot of risky activities (racetrack for instance) and I would like to avoid having my maxilla get hurt in case of a light crash
French guy is Dr L.oncle.
@Plosko : we did not discuss about that, so I do not know
@kavan. Do not let the jsf average knowledge mistakes you. Other patients facebook groups for instance, which count thousands of people, show a relatively low awareness of what is going to be done on their face. Most of them have absolutely no idea on how mm millimeters their jaws are going to be moved, let alone more complex topics. Regarding the name of the surgeon who’s going to correct me, I do not have it yet as I did not made my choice. If you are looking for the name of the surgeon I saw in Parma, it is Mirco.
I am going to extract the Icat if you would like to see it
@Invisalign, replying to your PM
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@kavan. Do not let the jsf average knowledge mistakes you. Other patients facebook groups for instance, which count thousands of people, show a relatively low awareness of what is going to be done on their face. Most of them have absolutely no idea on how mm millimeters their jaws are going to be moved, let alone more complex topics. Regarding the name of the surgeon who’s going to correct me, I do not have it yet as I did not made my choice. If you are looking for the name of the surgeon I saw in Parma, it is Mirco.
I am going to extract the Icat if you would like to see it
That would be an understatement. If anything most display wilful ignorance (surgeons love these kinds of patients). And if I had a dollar for every time I read "my guy is the best in the state"...
Good luck with your revision. I hope you get a much better outcome second time around. It is criminal what we let surgeons get away with.
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@Plosko : we did not discuss about that, so I do not know
@kavan. Do not let the jsf average knowledge mistakes you. Other patients facebook groups for instance, which count thousands of people, show a relatively low awareness of what is going to be done on their face. Most of them have absolutely no idea on how mm millimeters their jaws are going to be moved, let alone more complex topics. Regarding the name of the surgeon who’s going to correct me, I do not have it yet as I did not made my choice. If you are looking for the name of the surgeon I saw in Parma, it is Mirco.
I am going to extract the Icat if you would like to see it
Are you telling me that I, myself recognize the average knowledge of people who come to jsf is above average? Quite the contrary. More often than not, I DON'T find that. The root of it is NOT just 'lack of information'. The root of it is LACK of such things as; the fundamental basis needed to RELATE to the basic concepts inherent in maxfax which happens to be simple grammar school geometry and logical thinking patterns. More often than not, the problem isn't lack of information or research. It's lack of ability to 'digest' it. That resolves to lack of a foundation to build on and to make order or put information into perspective. Your statement also seems to imply that 'awareness' of a mm measure of movement is needed to have. It's useless to a person who lacks the basic foundation to relate that to basic concepts such as displacements over a diagonal path.
I don't actually need to see the ICAT. But this 'awareness' and 'research' you speak of doesn't go far for anybody if a basis in conceptual relationships isn't the foundation one is working with. For example if one cuts down the support to the base of the nose to accommodate a large advancement, CONCEPTUALLY, one needs to be thinking in terms of 'what's going to happen when the area is pushed back where the prior base of nose support is no longer there. Hence the question Plosko asked as to what he's going to do to build up the nose support. I harked on similar. But I guess you weren't thinking in those terms.
As to Micro R. in Parma, that would be great if he panned out with a good revision result for you. His name has been bandied about here like in an echo chamber by people who see a few results on his web page who then go on to suggest others go to him. I've actually been WAITING to see one of his results on an actual JSF member.