jawsurgeryforums.com
General Category => Aesthetics => Topic started by: Breakingbad on December 04, 2021, 03:22:46 AM
-
Hello,
I'm really trying to get jaw surgery done as soon as possible, but feel stuck right now.
During the past couple of years I’ve seen 5 jaw surgeons. I’ve seen Dr. Wittenberg, Prof. Alfaro, Prof. Raffaini, Dr. Walline and Dr. Gunson. I've also seen a few orthodontists: Dr. Richard Ting, Dr. Rebecca Bockow, and Dr. Trista Felty.
Everything seemed to be going well at first and I was just going to pick the surgeon I felt most comfortable with. However, after my last couple of consultations, concerning discrepancies started coming up between these doctors’ opinions. Now, I’m unsure of what to do because I don’t want to embark on this journey only to make things worse or fix one problem only to cause a different problem.
I’ve been using this forum for years and it’s been an amazing resource, so I would really appreciate any input you could provide. If you could share any reading material or links, that would be great as well, as I’m eager to expand my knowledge.
My Goals
Functionally, better breathing. Here's a GIF I made which shows the aesthetic change I am aiming for: https://imgur.com/32eeAzT (https://imgur.com/32eeAzT)
By the way, in the morph I deliberately moved my nasal base forward because Dr. Gunson wrote in his report that I was missing 4 mm of nasal support. I also deliberately pushed my lips in very slightly because it seems to look better.
Structurally, I'd love to see similar changes to the ones in this B&A from Dr. Gunson's site, and I think my face looks a lot like her's in the before photos: https://imgur.com/dtLiV3k (https://imgur.com/dtLiV3k)
Surgeon Consultations
Dr. Wittenberg - He suggested medpor implants and refused to do jaw surgery on me, saying my case was not "severe" enough.
Prof. Raffaini - He initially suggested a CCW rotation with no retraction of my teeth prior to jaw surgery, and then minor orthodontic work afterward. However, as soon as I showed him photos of what I wanted to achieve, he said that 4 premolar extractions (2 upper & 2 lower) and retraction of the anterior incisors were the only way to achieve this, because I wanted my mouth to protrude from my face LESS, and not MORE after surgery. He said he would do CCW rotation, linear advancement and a small genioplasty.
Prof. Alfaro - Essentially the same as Prof. Raffaini: first he suggested the "surgery-first" protocol with no extractions and CCW rotation, but as soon as I showed him what I wanted, he said extractions would be needed before CCW, linear advancement and genioplasty.
Dr. Walline - Again, essentially the same as Prof. Raffaini. He suggested CCW rotation with no extractions, then when I showed him what I wanted, he said extractions would be needed before CCW, linear advancement and genioplasty. What was different is that he noted that my maxilla was a bit on the narrow side, and that it would be beneficial to do MSE in addition to extractions before jaw surgery.
Dr. Gunson: This consult really confused me. Gunson said he really wished I had a steep occlusal plane so that I could have CCW rotation, but that my occlusal plane was too flat already, and that if I was rotated I would end up with a "reverse smile" and a risk of functional issues. He concluded that I wasn't a good candidate for jaw surgery and that I should do genioplasty of maximum 6 mm. He said if, and only if I provided a positive sleep study, it might be an option to do MSE, extract 4 premolars and then do a linear advancement. He said if I extracted 4 premolars without MSE I would end up with a visibly narrow maxilla.
ALL of these surgeons, aside from Dr. Gunson, said that genioplasty alone wouldn't achieve the effect I wanted. I didn't get a chance to show Dr. Gunson photos of what I wanted, though.
Orthodontic Consultations
Dr. Richard Ting - He said I had a narrow upper palate and that MSE was highly recommended. He didn't think that CCW rotation would cause any of the problems that Dr. Gunson mentioned but said that linear advancement would be better for my case.
Dr. Trista Felty - She said my maxilla was almost the ideal width because my "black triangles" were very small, and that I wouldn't benefit much from MSE.
Dr. Rebecca Bockow - She said MSE + SFOT was an option but that I could probably "get by" with just correcting the shape of my dental arches and IPR (sanding down between the teeth) to make a bit of space to retract my anterior teeth with braces, before doing jaw surgery. She thought CCW rotation was an option for me.
Some Points I'm Worried About
1. Dr. Gunson said that I wasn't a candidate for CCW rotation, while all the other doctors said I was.
2. Some said I really needed MSE because my maxilla was narrow, and others said it was unnecessary.
3. Dr. Gunson said doing jaw surgery could lead to a "full" appearance around my mouth. I don't know what he meant by this, but I'm wondering if the result in the photos above is achievable with jaw surgery.
4. Since a few doctors expressed concern about extractions exacerbating the width issue, I was thinking I could do MSE + SFOT to widen my maxillary and mandibular dental arches to create the space needed to retract my anterior teeth, instead of doing the premolar extractions. I don't know if this is an option and how I can get a surgeon to go along with this idea.
5. Since Dr. Gunson doesn't seem to want to work with me, it's hard to ask him about this, but he wrote in his report that I had 4mm of nasal support missing. If I'm understanding this correctly, I would need my teeth retracted and then an advancement of my maxilla to bring my anterior nasal spine forward to get the support that's missing. I don't know if this is correct or if I should expect to need to do a separate procedure later to fix this issue.
6. I don't know if the changes in the GIF I made are what I should be aiming for or if something else would look better.
Can anyone please make any suggestions or provide any input on this?
I would be very grateful.
Photos of my face: https://imgur.com/a/rZAworb (https://imgur.com/a/rZAworb)
Ceph and snapshot of CBCT: https://imgur.com/a/2neyFcx (https://imgur.com/a/2neyFcx)
-
This looks like a pretty clear case of CCW, so I'm not sure why Dr. Gunson would say that. Unless he sensed red flags in your personality that made him not want to work with you. Did you bring in photos of models or say anything strange on the consult?
Your bite plane doesn't look steep or flat. It looks somewhere in between.
Regarding maxillary expansion, I don't think that's really known until they put the models on an articulator and see how they fit. I met Walline once, and he was a nice guy, and I think he might do that process digitally, so maybe he could make a recommendation there before getting models.
But yeah, I see CCW rotation as the best path. Your tissue appears to be thick, so maybe that's what Gunson was talking about when he said full around the mouth. In general, every 3mm of bony movement equals 1mm of soft tissue movement. So when you get your final movements, you can somewhat estimate the change to expect. I'm not sure on the 4mm of ANS issue. Your ANS area does look a bit collapsed on that scan, but I'm not sure the best way to address that, or if that's why Gunson felt you'd get full, etc. You could always go to the other surgeons with Gunson's finding on that and ask them.
-
This looks like a pretty clear case of CCW, so I'm not sure why Dr. Gunson would say that. Unless he sensed red flags in your personality that made him not want to work with you. Did you bring in photos of models or say anything strange on the consult?
No, I actually didn't show him any photos at all because we didn't have time. He did give me a short speech about how I have a heightened ability to perceive things in the face before telling me CCW wouldn't work for me. That was after I mentioned to him that I had a slight yaw, but to be honest I never noticed that myself--I was just repeating it after hearing it from another surgeon. I was trying to seem informed but I guess I overdid it.
It crossed my mind that maybe he just didn't want to work with me, but I just don't understand why he wouldn't use another excuse, like saying he'd only operate on me if I had sleep apnea. After I pressed him further about genioplasty not being a good solution, he said that he might do jaw surgery on me but only if I gave him a positive in-hospital sleep apnea test (I had told him by then that I had a negative at-home sleep study result) and that it would be a linear advancement in that case. He also pushed me to consult with other surgeons.
What's weird though is that when I pressed him on the CCW rotation he explained that it's to do with the natural position of my head. I grilled him more and he said that he uses "natural head position" rather than the Frankfurt Horizontal and that I could barely be rotated 1 or 2 degrees before causing a reverse smile. Do you have an opinion on that? I will definitely be talking to some other surgeons about it, but it helps to hear answers here because I feel they're less biased.
Your tissue appears to be thick, so maybe that's what Gunson was talking about when he said full around the mouth.
I was at 29% BF when those photos were taken according to a DEXA scan. Losing about 6 kg seems to have helped a lot with that, and I still need to lose 5 kg more to get to a healthy range. I'm hoping it'll help but I don't know.
Thank you very much for replying. Even your validation of my ANS area looking collapsed is very helpful, because I thought so too, but I never feel qualified enough to be sure about these things.
-
Surgeons can look at a patient's morph but don't necessarily accommodate based on it because the surgery has to balance bite with displacement of the jaws and soft tissue profile. In your situation accommodation would require all of those premolar extractions.
Lips are forward to a TVL (true vertical line). So advancing the jaws would only make that WORSE. They would have to extract 4 pre-molars and push the teeth backwards inorder to advance the jaws and not make the lips MORE protrusive. So, accommodation of your morph pretty much would be a '0 sum relationship'. Basically, needing to push the front of your face BACKWARDS inorder to move the jaw/s forward is a 0 sum relationship.
Now there is nothing 'wrong' with your lips being forward to the TVL. Infact, THAT'S pretty much where they WANT the lips to be in soft tissue profile. But since your lips are where they want them to be relative to the TVL, there is really NO WAY to accommodate your morph request WITHOUT also having to REMOVE all those pre-molars. CCW is not a 'savior' here.
They are looking at the TVL and seeing your lip protrusion would be made WORSE with no extractions. As to CCW not being the 'savior', CCW is something they do to AVOID extractions. But here, if you avoid extractions, it would result in more lip protrusion in a situation where you are asking for LESS lip protrusion.
So, just about all of the doctors are bascially seeing the same (lips already ahead of the TVL) situation where there is not much they can do in the absence of extractions.
I tend to AGREE with Gunson but I tend NOT to think that Gunson actually told you chin advancement would mimic what you did in your morph. It's like I said in the first sentence; surgeons can look at a morph but don't necessarily accommodate based on it (other than to tell you accommodation might reqire doing something you're not asking for as in extracting teeth). So NO SURPRISE to me that genio alone would not mimic your morph. However, chin advancement as Gunson suggested WOULD improve your profile because your chin is BEHIND the white line TVL and that's why I agree with Gunson's suggestion.
Illustration included in this post.
-
......By the way, in the morph I deliberately moved my nasal base forward because Dr. Gunson wrote in his report that I was missing 4 mm of nasal support. I also deliberately pushed my lips in very slightly because it seems to look better.
Structurally, I'd love to see similar changes to the ones in this B&A from Dr. Gunson's site, and I think my face looks a lot like her's in the before photos: https://imgur.com/dtLiV3k (https://imgur.com/dtLiV3k)......
This is PRIME EXAMPLE of WHY maxfax surgeons can't accommodate (goals) of morphs. In many cases, (and here you're the prime example of this), the morpher doesn't understand the relationships of the area he's moving. So, here, you move the ANS and the maxilla FORWARD in your morph WITHOUT also moving the upper lip area forward. Instead you moved the upper lip area backwards. So, your morph SELF NEGATES on those grounds because the lips DON'T move backwards with ANS advancement of the maxilla. They move forward. Likewise with morphing forward advancement of the lower jaw. The lips don't move backwards with mandible advancement. They move forward.
Somebody else's, outcome isn't the best communication tool either because everyone's dentition in addition to a variety of points, angles and planes are DIFFERENT
UNLESS you were actually WANTING to communicate to them that you were REQUESTING to have those 4 pre-molars extracted to even come close to your morph goal,the morph is basically useless as a communication tool. Assuming you weren't actually REQUESTING them to remove all 4 molars to push your face backwards in order to move it forwards, all the morph communicates is that you didn't understand the relationships to the areas you were moving. Hence, the morph resolved to a SELF NEGATING request that couldn't be accommodated. So, if you didn't understand that you can't move one part forward and NOT the other part that would go forward WITH it (jaw/s forward, lips go forward with it) but instead wanted the lips to go BACKWARDS, that told them everything they needed to know about a request that couldn't be accommodated.
-
Surgeons can look at a patient's morph but don't necessarily accommodate based on it because the surgery has to balance bite with displacement of the jaws and soft tissue profile. In your situation accommodation would require all of those premolar extractions.
Lips are forward to a TVL (true vertical line). So advancing the jaws would only make that WORSE. They would have to extract 4 pre-molars and push the teeth backwards inorder to advance the jaws and not make the lips MORE protrusive. So, accommodation of your morph pretty much would be a '0 sum relationship'. Basically, needing to push the front of your face BACKWARDS inorder to move the jaw/s forward is a 0 sum relationship.
Now there is nothing 'wrong' with your lips being forward to the TVL. Infact, THAT'S pretty much where they WANT the lips to be in soft tissue profile. But since your lips are where they want them to be relative to the TVL, there is really NO WAY to accommodate your morph request WITHOUT also having to REMOVE all those pre-molars. CCW is not a 'savior' here.
They are looking at the TVL and seeing your lip protrusion would be made WORSE with no extractions. As to CCW not being the 'savior', CCW is something they do to AVOID extractions. But here, if you avoid extractions, it would result in more lip protrusion in a situation where you are asking for LESS lip protrusion.
So, just about all of the doctors are bascially seeing the same (lips already ahead of the TVL) situation where there is not much they can do in the absence of extractions.
Thank you very much for your reply.
I appreciate hearing from you about the necessity of the extractions in order to accomodate my morph. To clarify, this is something that made perfect sense to me, thanks to the tremendously useful information posted on this forum by you and other users, which I’ve been reading for years.
To be clear, Raffaini, Alfaro, and Walline all initially suggested CCW rotation without extractions, but that was BEFORE I told them very clearly that I was serious about the lips not protruding even more than they are currently, and that I didn’t understand how that was possible without extractions.
Only after I told them that did they agree with me that if that was something that bothered me, extractions would be necessary.
I thought at that point that it was settled and was basically ready to proceed with that plan.
Then, I had my consultations with Gunson and Walline.
Here’s what came up and stopped me from going forward:
CCW - Even with 4 premolar extractions, Walline, Raffaini, and Alfaro all wanted to do CCW. Then, unexpectedly, Gunson told me that CCW rotation (with or without extractions) would cause a “reverse smile” and that basically any surgical plan involving CCW was a bad idea for me.
Extractions vs Width Problem - I’d be fine with extracting the 4 premolars to achieve what I want, but Gunson, Walline, and Dr. Ting, all expressed concerns about the width of my maxilla, and how 4 premolar extractions would make it worse. That’s why both Walline and Gunson suggested MSE. I was wondering if I could use MSE and SFOT to widen my upper and lower jaw to create the space needed to retract my anterior teeth. Like I said, I wouldn’t mind extracting the pre-molars, but I don’t want to cause a bigger width issue and that’s why I’m wondering if MSE and SFOT could come to the rescue as an alternative way to make the space I need for retraction.
I tend to AGREE with Gunson but I tend NOT to think that Gunson actually told you chin advancement would mimic what you did in your morph. It's like I said in the first sentence; surgeons can look at a morph but don't necessarily accommodate based on it (other than to tell you accommodation might reqire doing something you're not asking for as in extracting teeth). So NO SURPRISE to me that genio alone would not mimic your morph. However, chin advancement as Gunson suggested WOULD improve your profile because your chin is BEHIND the white line TVL and that's why I agree with Gunson's suggestion.
You’re right—there wasn’t enough time to show Gunson photos. And yes, I know that Gunson is right that genioplasty would bring an improvement, but most of the surgeons thought that it wouldn’t be enough for my case especially with what I’m aiming for.
-
UNLESS you were actually WANTING to communicate to them that you were REQUESTING to have those 4 pre-molars extracted to even come close to your morph goal,the morph is basically useless as a communication tool. Assuming you weren't actually REQUESTING them to remove all 4 molars to push your face backwards in order to move it forwards, all the morph communicates is that you didn't understand the relationships to the areas you were moving. Hence, the morph resolved to a SELF NEGATING request that couldn't be accommodated. So, if you didn't understand that you can't move one part forward and NOT the other part that would go forward WITH it (jaw/s forward, lips go forward with it) but instead wanted the lips to go BACKWARDS, that told them everything they needed to know about a request that couldn't be accommodated.
Bingo. That’s basically what I did. I tried to make that clear in my OP, sorry it wasn’t clear. I do understand that, like I said, thanks to this forum. It’s basic geometry, but it did take me years of educating myself here and elsewhere to understand. I’m sure my understanding is still lacking, though. I’m definitely having trouble figuring the rest of this stuff out.
-
Thank you very much for your reply.
I appreciate hearing from you about the necessity of the extractions in order to accomodate my morph. To clarify, this is something that made perfect sense to me, thanks to the tremendously useful information posted on this forum by you and other users, which I’ve been reading for years.
To be clear, Raffaini, Alfaro, and Walline all initially suggested CCW rotation without extractions, but that was BEFORE I told them very clearly that I was serious about the lips not protruding even more than they are currently, and that I didn’t understand how that was possible without extractions.
Only after I told them that did they agree with me that if that was something that bothered me, extractions would be necessary.
I thought at that point that it was settled and was basically ready to proceed with that plan.
Then, I had my consultations with Gunson and Walline.
Here’s what came up and stopped me from going forward:
CCW - Even with 4 premolar extractions, Walline, Raffaini, and Alfaro all wanted to do CCW. Then, unexpectedly, Gunson told me that CCW rotation (with or without extractions) would cause a “reverse smile” and that basically any surgical plan involving CCW was a bad idea for me.
Extractions vs Width Problem - I’d be fine with extracting the 4 premolars to achieve what I want, but Gunson, Walline, and Dr. Ting, all expressed concerns about the width of my maxilla, and how 4 premolar extractions would make it worse. That’s why both Walline and Gunson suggested MSE. I was wondering if I could use MSE and SFOT to widen my upper and lower jaw to create the space needed to retract my anterior teeth. Like I said, I wouldn’t mind extracting the pre-molars, but I don’t want to cause a bigger width issue and that’s why I’m wondering if MSE and SFOT could come to the rescue as an alternative way to make the space I need for retraction.
You’re right—there wasn’t enough time to show Gunson photos. And yes, I know that Gunson is right that genioplasty would bring an improvement, but most of the surgeons thought that it wouldn’t be enough for my case especially with what I’m aiming for.
I think you would be well served to just get the genio with Gunson. It will improve your profile where the chin is recessive and it won't preclude you from maxfax further down the line. I think the surgeons should disregard what you were aiming for in the morph and ADMIT that your lips are in a GOOD position relative to the TVL and the salient imbalance to the profile is the chin rather than any significant jaw to jaw imbalance.
-
I think you would be well served to just get the genio with Gunson. It will improve your profile where the chin is recessive and it won't preclude you from maxfax further down the line.
But wouldn’t that just be kicking the can down the road considering I already have a rough idea of what I want? Even if I did genioplasty first, it seems like I’ll still have to deal with the question of CCW and extractions vs the width issue eventually.
I think the surgeons should disregard what you were aiming for in the morph and ADMIT that your lips are in a GOOD position relative to the TVL and the salient imbalance to the profile is the chin rather than any significant jaw to jaw imbalance.
It was actually ME that thought my lips should be about 1 or 2 mm back from where they are, but since you’re so confident about them already being in the right position relative to the TVL, let me note that I am fine with them staying in the same place if that’s how they should be. Walline, Raffaini, and Alfaro are ALL fine with this as well. BUT, I still need the pogonion point to go forward more than a 6mm genioplasty would allow. The lack of nasal support of 4 mm that Gunson noted is also something I’d like to address if possible. SO, even if I’m okay with my lips ending up right where they currently are, I still need to deal with these issues to do jaw surgery and get the result I’m looking for.
-
This looks like a pretty clear case of CCW, so I'm not sure why Dr. Gunson would say that.
Writing without looking at my past notes, Gunson orients your head looking up more compared to Alfaro. Due to differences in how they orient your profile you get different recommendations when you're at the margin.
-
But wouldn’t that just be kicking the can down the road considering I already have a rough idea of what I want? Even if I did genioplasty first, it seems like I’ll still have to deal with the question of CCW and extractions vs the width issue eventually.
It was actually ME that thought my lips should be about 1 or 2 mm back from where they are, but since you’re so confident about them already being in the right position relative to the TVL, let me note that I am fine with them staying in the same place if that’s how they should be. Walline, Raffaini, and Alfaro are ALL fine with this as well. BUT, I still need the pogonion point to go forward more than a 6mm genioplasty would allow. The lack of nasal support of 4 mm that Gunson noted is also something I’d like to address if possible. SO, even if I’m okay with my lips ending up right where they currently are, I still need to deal with these issues to do jaw surgery and get the result I’m looking for.
Your morph could also be seen as something close to just a genio and a rhinoplasty.
-
Your morph could also be seen as something close to just a genio and a rhinoplasty.
Thanks, but the subjectivity of what "close" means worries me.
In the photo of this Gunson patient here, https://imgur.com/dtLiV3k (https://imgur.com/dtLiV3k), you can see that as a result of some (presumed)
advancement at the ANS, even in the FRONTAL VIEW, her whole paranasal area has filled out, where it previously looked visibly sunken in with respect to her mouth area. In the SIDE VIEW, her nasolabial angle has gotten slightly larger.
Can a rhinoplasty approximate even ONE of these effects?
-
Writing without looking at my past notes, Gunson orients your head looking up more compared to Alfaro. Due to differences in how they orient your profile you get different recommendations when you're at the margin.
Thank you for adding this information. It's a good point, but I'm left confused in terms of what that says about my risk of getting a "reverse smile."
-
Thanks, but the subjectivity of what "close" means worries me.
In the photo of this Gunson patient here, https://imgur.com/dtLiV3k (https://imgur.com/dtLiV3k), you can see that as a result of some (presumed)
advancement at the ANS, even in the FRONTAL VIEW, her whole paranasal area has filled out, where it previously looked visibly sunken in with respect to her mouth area. In the SIDE VIEW, her nasolabial angle has gotten slightly larger.
Can a rhinoplasty approximate even ONE of these effects?
As I said prior: 'Somebody else's, outcome isn't the best communication tool either because everyone's dentition in addition to a variety of points, angles and planes are DIFFERENT.' Your morph is a MOVING gif. and I'm not offering to separate it into 2 different still photos and then analyze it for you for exactitude objectivity with mm measures and all. So, yes, that's my subjective assessment that it's close to chin advancement and rhino. Also, don't expect the doctors to reproduce it in real time on your face.
-
As I said prior: 'Somebody else's, outcome isn't the best communication tool either because everyone's dentition in addition to a variety of points, angles and planes are DIFFERENT.'
That's A-OK, but that patient's result aside, I'm simply asking whether a rhinoplasty could make my paranasal area fill out in a similar manner? I'm genuinely wondering. I just don't know how to edit that type of change in frontal appearance into a photo of my face, but I hope that you get what I mean by making the paranasal area "fill out" now.
I'm not offering to separate it into 2 different still photos and then analyze it for you for exactitude objectivity with mm measures and all. So, yes, that's my subjective assessment that it's close to chin advancement and rhino.
I wouldn't expect you to and I appreciate your help so far. I'm not arguing with you. I KNOW that many people would say it's close. I wasn't implying that they're wrong--it's just subjective. But look at the STILL photo overlay I made below (photo attached). For reference, the measured thickness of my lower lip is about 13 mm. To my eye, that makes the difference at the pogonion point in my morph around 10 mm of SOFT TISSUE change. To me, that says that even though genioplasty could be described as close to this, there would still be a difference, as the maximum for a genioplasty would be 6 mm of BONY CHANGE for me if not less.
I don't know if you agree with me, but I don't see anything wrong with going for the marginally better option if I have the finances, time and patience for the extra aesthetic and functional benefits. That's why I'm trying to figure out how to deal with those questions about CCW and width/extractions.
-
That's A-OK, but that patient's result aside, I'm simply asking whether a rhinoplasty could make my paranasal area fill out in a similar manner? I'm genuinely wondering. I just don't know how to edit that type of change in frontal appearance into a photo of my face, but I hope that you get what I mean by making the paranasal area "fill out" now.
I wouldn't expect you to and I appreciate your help so far. I'm not arguing with you. I KNOW that many people would say it's close. I wasn't implying that they're wrong--it's just subjective. But look at the STILL photo overlay I made below (photo attached). For reference, the measured thickness of my lower lip is about 13 mm. To my eye, that makes the difference at the pogonion point in my morph around 10 mm of SOFT TISSUE change. To me, that says that even though genioplasty could be described as close to this, there would still be a difference, as the maximum for a genioplasty would be 6 mm of BONY CHANGE for me if not less.
I don't know if you agree with me, but I don't see anything wrong with going for the marginally better option if I have the finances, time and patience for the extra aesthetic and functional benefits. That's why I'm trying to figure out how to deal with those questions about CCW and width/extractions.
In the ABSENCE of referring to someone ELSE'S outcome, I convey that a (good) rhino surgeon can perform surgery to the anterior nasal spine area to better support the base of the nose. Of course, selective alteration of the ANS with aim of better support to the base of the nose does not involve advancing the entire Lefort 1 area of the maxilla forward, nor is it a procedure aimed at filling out the paranasal areas.
Your problem here is that you are STUCK on requiring communication based on your morph which is absent of the type of rigor in presentation which is needed for the viewer (here a scientifically inclined one if communication is with me) to cross reference what ever measurements you have 'exacted' or approximated. From my POV, communicative morph presentations involve 2 sets of SIDE BY SIDE presentations (present vs. desired goal). First set= 'mute' morphs which only show the visual changes. Second set shows RELATIVE LINES through landmarks which direct the viewers eye towards the displacements made. As to approximating mm measures of displacements, there needs to be reference on the diagrammed set as to the SCALE of the photo based on 'real life' measures of the distance between 2 distinct landmarks of the face in which lines are drawn between those 2 landmarks. For example, if you took a caliper to measure the distance between the ROOT of the nose and the BASE of the nose and found that distance was 'X'mm, then 'X' would substantiate other measures on the morph photo as to scale given that photos can appear as different sizes on different computer screens. Hence 'X' could be used for SCALE. So, the diagrammed morph would need to show the landmark lines passing through the point known as ROOT of nose to the point known as BASE of nose where the 'real life' distance of 'X' was noted on the diagrammed morph. In that way, 'X' can be used to adjust for the scale of the photo and also to substantiate other measures of displacement distances. Now, such a presentation is not hard to do. But it does resolve to a venue of a straight forward type of geometric proof to demonstrate to the viewer that what ever measures you approximated or 'exacted' are reliable.
NONE THE LESS, not even a more rigorous demonstration as stated above would duplicate the type of predicted outcome that specialized surgery design programs can do. In fact specialized surgery design (morph) programs (and the surgeons who use them) can come out SHORT of the desired soft tissue projection of the pogonian point as in short of the projected outcome you've defined for yourself (10mm) via your morph request. That's simply because desired soft tissue projection (here at pog point) is only PART of a complex MULTI-FACTORIAL EQUATION where other points, angles and planes need to be taken into consideration. Consider DISBANDING using your morph as a primary means of communication and consider INSTEAD having the doctors propose a plan for you (a VISUAL one that you can look at) and later compare to your own morph goal.
So, here, you've made what I call a 'mute' morph that resolves to EYEBALLING it where I see it as coming close to the look of a rhino and chin advancement. As to your 10mm figure, I'll accept that based on your word for it, like in the absence of my confirming or denying it's on the money. I also remind you that at NO TIME did I convey or imply to convey that the genio proposed to you by Gunson would replicate your morph. I told you that it would IMPROVE your profile; bring your chin CLOSER to the the TVL. So MOOT point (not to be confused with 'mute' morph) to point out that your 10mm measure is more than 6mm genio Gunson suggested. Although I don't deny that approx 10 mm advance to pog point would look better than a 6mm advance (based on your morph and your assessment of 10mm), I can't confirm that 10mm advance at pog point is going to be part of the MULTI-FACTORIAL equation (algorithm) where all the points, angles and planes, occlusion etc. play a role regarding where one can set the pog point WITHOUT OTHER things being shifted out of balance and function. Also, from my POV, (in your case) having to extract teeth to push the front of the face backwards, just so they can later push it forwards in a bimax surgery isn't the best reason to pursue bimax surgery for aesthetics. Instead, it's something to do if FUNCTION was the main issue and you were willing to accept FORM as playing second fiddle to that.
If improvement via Gunson's suggested genio is not enough for you, than there really isn't much to 'figure out' here because the preponderance of communication you got from the experts is that bimax surgery will involve 4 EXTRACTIONS and quite possibly some maxillary expansion to compensate for some 'shrinkage' that could arise from the extractions. Just don't expect that option to be on target with your morph goal, especially so if no doctor promised you such duplication.
As to CCW, CCW around the ANS will leave the ANS where it is but 'buck out' the incisors and PUSH the soft tissue of the lip FORWARDS. CCW around the incisor point won't move the incisors but will bring the ANS BACKWARDS. The former is on target for a patient who would benefit by the soft tissue of the lip being projected more forwards. The latter is on target for a patient who would benefit from having the ANS pushed BACKWARDS . So, I'll leave it up to you to cross reference those relationships for a person NOT needing their upper lip to move more forward and NOT needing their ANS to go more BACKWARDS.
As for self generated morphs, they are of LIMITED use as to 'talking turkey' with a surgeon. The main exception to that is when they look at them and tell you something like; 'That's quite like what I had in mind for you.' But that didn't happen here.
-
Kavan, thank you very much for putting this explanation together. I have gone over it very carefully. Your explanation is exactly of the type that I feel can help me make useful conclusions and further my understanding. I make every effort to keep up with other members here and communicate in a way that is conducive to productive discussion. Your advice with respect to communication is well noted.
I'd like to ask you a number of questions to help me fully understand and appreciate what you've said. I will try to ask only a few questions for now.
From my POV, communicative morph presentations involve 2 sets of SIDE BY SIDE presentations (present vs. desired goal). First set= 'mute' morphs which only show the visual changes. Second set shows RELATIVE LINES through landmarks which direct the viewers eye towards the displacements made. As to approximating mm measures of displacements, there needs to be reference on the diagrammed set as to the SCALE of the photo based on 'real life' measures of the distance between 2 distinct landmarks of the face in which lines are drawn between those 2 landmarks. For example, if you took a caliper to measure the distance between the ROOT of the nose and the BASE of the nose and found that distance was 'X'mm, then 'X' would substantiate other measures on the morph photo as to scale given that photos can appear as different sizes on different computer screens. Hence 'X' could be used for SCALE.
Firstly, although I'm not sure that they are of use at this moment in time, could you please confirm whether the attached photos, which I've tried to make to your instructions, better facilitate communication? Note that I do recognize your point regarding the limited utility of these photos when communicating with surgeons. Also note that for the scaling reference, I measured my lip with a caliper, and got a measurement of 16mm. My earlier measurement of 13mm (measured by ruler) was incorrect. I know you suggested I measure from the root of my nose to the base, but I thought I would be able to pull this off with my lip with a lower error considering my inexperience.
Also, from my POV, (in your case) having to extract teeth to push the front of the face backwards, just so they can later push it forwards in a bimax surgery isn't the best reason to pursue bimax surgery for aesthetics. Instead, it's something to do if FUNCTION was the main issue and you were willing to accept FORM as playing second fiddle to that.
I highly value your POV, so I'm wondering what it is about my case that makes doing this a negative for aesthetics? I ask because I have seen many academic articles where extractions followed by bimax surgery are used as treatment for BIMAXILLARY PROTRUSION to excellent aesthetic effect. I have been diagnosed with bimaxillary protrusion by several experts, including Dr. Rebecca Bockow.
I convey that a (good) rhino surgeon can perform surgery to the anterior nasal spine area to better support the base of the nose. Of course, selective alteration of the ANS with aim of better support to the base of the nose does not involve advancing the entire Lefort 1 area of the maxilla forward, nor is it a procedure aimed at filling out the paranasal areas.
Could you please, if you are able to with the pictures/xrays provided, comment on whether it seems like I am missing ONLY support of the base of the nose, or in the wider Lefort 1/paranasal area? I realize that fixing a lack of support in the wider paranasal/Lefort 1 area may not be a walk in the park, but I'm trying to get an understanding of the problem as a first step.
-
You can use your 16mm scale to estimate the distance the pog point is advanced in the morph.
IMO, bimax protrusion is better treated via anterior segmental osteotomies (often done in Korea) because the maintain the outward inclination of the teeth so that lip stays on a diagonal incline whereas retroclining the teeth in a push back can make nose to lip angle more obtuse which has the effect of the the upper lip looking visually longer via aligning it vertically.
You're the one who would have to demonstrate any paranasal problem.
-
You can use your 16mm scale to estimate the distance the pog point is advanced in the morph.
I'm getting 10.7 mm using an online tool.
retroclining the teeth in a push back can make nose to lip angle more obtuse which has the effect of the the upper lip looking visually longer via aligning it vertically.
Is this why you said the following?
"(in your case) having to extract teeth to push the front of the face backwards, just so they can later push it forwards in a bimax surgery isn't the best reason to pursue bimax surgery for aesthetics. Instead, it's something to do if FUNCTION was the main issue and you were willing to accept FORM as playing second fiddle to that."
-
if you think that's the best reason, than go with it.
-
if you think that's the best reason, than go with it.
I don't think we're understanding each other.
When you said:
"instead, it's something to do if FUNCTION was the main issue and you were willing to accept FORM as playing second fiddle to that,"
it seemed to me that you were saying that extracting teeth, retracting, and then doing jaw surgery to bring everything forward, would bring NEGATIVE aesthetic effects, and that there's no benefit to doing it for aesthetics in my case, hence it only makes sense if I'm forced to for functional reasons.
Isn't that what you were saying? If yes, I'm just asking why you think it would worsen my appearance. I'm not doubting you, just trying to understand why you said what you said.
-
I don't think we're understanding each other.
When you said:
"instead, it's something to do if FUNCTION was the main issue and you were willing to accept FORM as playing second fiddle to that,"
it seemed to me that you were saying that extracting teeth, retracting, and then doing jaw surgery to bring everything forward, would bring NEGATIVE aesthetic effects, and that there's no benefit to doing it for aesthetics in my case, hence it only makes sense if I'm forced to for functional reasons.
Isn't that what you were saying? If yes, I'm just asking why you think it would worsen my appearance. I'm not doubting you, just trying to understand why you said what you said.
Yes. But in reference to just pulling the teeth and pushing them backwards to RETROCLINE; what they offered you.
Sub apical osteos differ (and are more complex) but for most part they maintain the angulation of the teeth. For example for the maxilla, a cross section of bone is removed with the pre-molars. From there, when they move the free segment of frontal maxilla backwards, the front teeth maintain their angulation which is basically what supports the lip so it's not on vertical plane.
SAO's can be done to the lower jaw area too. So, SAO's can basically maintain the angulation of the front teeth and hence the angulation of the UPPER LIP and of course, also DECREASE the 'stick out' prominence of the lips. Asian countries, especially Korea, commonly do that type of surgery but for the most part, US doctors don't. They do what was offered to you which is something that most likely involves either retroclining your teeth or aligning with the vertical. Like HOW could it NOT be?
So, that is the difference. SAOs are something you could look into if you needed more info. I'm just telling you a type of surgery exists that yes, 'pushes back' the teeth BUT in a different way. Now after an SAO or even during, I think they have the option of then bring the jaws forward. The option arises because the SAO addresses the bimax protrusion. When bimax protrusion is addressed by the SAO, the patient basically keeps his outward angulation of the teeth and when they bring forward with the bimax, it's a situation where the patient no longer has the bimax protrusion to preclude double jaw advancement.
So, what I said was in reference to what the doctors are offering; removing the premolars so they can push back the teeth, which is to either retrocline them or align with a vertical. So, when they push back outward in bimax surgery, your philtral area could look longer (because the nose to lip angle will most likely increase). Now that is not a prediction for you personally, I'm just telling you how things work. Soft tissue of the lip when aligned on a VERTICAL plane can cast vertical and look longer. Soft tissue of lip aligned on a diagonal plane can cast diagonal and look shorter. I can't explain that any further because it is one of those things that has to do with basic geometrical principles to be able to identify with and also a little perspective in artistic concepts.
But ALAS! Maybe you don't need to even fret about the SAO option. That would be great providing you were poised to accept the possibility of your upper lip looking LONGER in frontal view and/or your nose to lip angle increasing. That is to say, if you actually didn't like your short philtral area and wanted a longer looking philtrum (most people don't), extractions with the BRACES pushing the teeth backwards has a good potential of making the upper lip look longer. It won't physically increase it's length. It does so VISUALLY by changing the angle of inclination the soft tissue of the lip is supported on.
-
I'm getting 10.7 mm using an online tool.
I got close to that; 10.64... with no online tool---only grammar school math, my physical transparent ruler and a calculator.
Now, before we go any further, I would like you to tell me HOW I did that with no online tool. Like what STEPS did I go through. It doesn't matter if you come up with a different figure than me because we are talking in the range of 10mm. I'm wanting to know how YOU would figure this out with NO online tool, only grammar school math, a transparent ruler and a calculator. Tell me the steps you would take.
-
I got close to that; 10.64... with no online tool---only grammar school math, my physical transparent ruler and a calculator.
Now, before we go any further, I would like you to tell me HOW I did that with no online tool. Like what STEPS did I go through. It doesn't matter if you come up with a different figure than me because we are talking in the range of 10mm. I'm wanting to know how YOU would figure this out with NO online tool, only grammar school math, a transparent ruler and a calculator. Tell me the steps you would take.
Here are the steps I would take to do that:
First, get a print out of the photo set with the 16mm reference on it OR open it up on a non-touch screen device so that it doesn't zoom in or out while I'm measuring.
Then, with that photo set:
Step 1: Using a transparent ruler, measure the 16 mm reference line and note down its physical length. With the size of the photo I printed, I got approximately 6.5 mm. Thus, the conversion factor from the lengths measured with my ruler to 'real life numbers' is 16/6.5
Step 2: Measure the distance of the pogonion point to the vertical line passing through the base of my nose in the unedited BEFORE photo. I got right around 6 mm.
Step 3: Measure the distance of the pogonion point to the vertical line passing through the base of my nose in the AFTER (morphed) photo. I got approximately 1.7 mm.
Step 4: Subtract the number obtained in 'Step 3' from that of 'Step 2,' as follows
6 mm - 1.7 mm = 4.3 mm
Step 5: Use the conversion factor obtained in 'Step 1' to convert the measurement obtained in 'Step 4' to 'real life numbers,' as follows
4.3 mm x (16/6.5) = ~10.58 mm
Do I pass? Canadian public education isn't what it used to be.
Edit: I incorrectly referred to the “base of the nose” as the “root of the nose.” Thanks Kavan for point this out.
-
Here are the steps I would take to do that:
First, get a print out of the photo set with the 16mm reference on it OR open it up on a non-touch screen device so that it doesn't zoom in or out while I'm measuring.
Then, with that photo set:
Step 1: Using a transparent ruler, measure the 16 mm reference line and note down its physical length. With the size of the photo I printed, I got approximately 6.5 mm. Thus, the conversion factor from the lengths measured with my ruler to 'real life numbers' is 16/6.5
Step 2: Measure the distance of the pogonion point to the vertical line passing through the root of my nose in the unedited BEFORE photo. I got right around 6 mm.
Step 3: Measure the distance of the pogonion point to the vertical line passing through the root of my nose in the AFTER (morphed) photo. I got approximately 1.7 mm.
Step 4: Subtract the number obtained in 'Step 3' from that of 'Step 2,' as follows
6 mm - 1.7 mm = 4.3 mm
Step 5: Use the conversion factor obtained in 'Step 1' to convert the measurement obtained in 'Step 4' to 'real life numbers,' as follows
4.3 mm x (16/6.5) = ~10.58 mm
Do I pass? Canadian public education isn't what it used to be.
YES. You passed!
Here's how I did it:
What I did was establish the SCALE factor (conversion factor as you say): Your 16mm measured about 10.5mm on my ruler. So, the scale was about 1.52 (rounded down). I can hold it directly up to my screen without the screen changing.
BEFORE photo: I used my ruler to measure the distance from pog point to the TVL. It was 10mm.
MORPH: I used my ruler to measure the distance from pog point to TVL on morph. It was 3mm.
Difference was 7mm. I multiplied that by the SCALE I established (1.52)=10.64
ETA: There's just one thing and it really doesn't matter. But the TVL runs through the base of the nose (nose to lip junction). the root of the nose is in vicinity of the glabella but below it. root of nose is basically 'top' of the nose. but perfectly logical to think the bottom of it would be called the root. You can use just about anything on the face that you can actually measure as reference measures for the scale.
-
YES. You passed!
That’s a relief! The online tool works okay but I can see how this method would be more useful in many cases.
ETA: There's just one thing and it really doesn't matter. But the TVL runs through the base of the nose (nose to lip junction). the root of the nose is in vicinity of the glabella but below it. root of nose is basically 'top' of the nose. but perfectly logical to think the bottom of it would be called the root. You can use just about anything on the face that you can actually measure as reference measures for the scale.
Yes, thank you for pointing that out. I tried to find a diagram of all these landmarks before posting but got it all mixed up in my head somehow. I’ll try to remember that.
I can't explain that any further because it is one of those things that has to do with basic geometrical principles to be able to identify with and also a little perspective in artistic concepts.
I follow you perfectly. I was not aware that retracting the teeth with braces could visually lengthen the philtrum—that’s significant, as Gunson measured mine and mentioned to me that it was on the long side as it is. I did some SERIOUS reading on this procedure (SAO) back when you posted some information about it some months ago on this forum, but I didn’t know how and if it could be fit into my treatment plan, or whether that would be of any utility.
Do you think, then, that considering I AM concerned about the philtrum, that if I did the SAO, and then had double jaw surgery with the RIGHT surgeon and surgical plan, that the result would probably be better than what a genioplasty could achieve?
-
That’s a relief! The online tool works okay but I can see how this method would be more useful in many cases.
Yes, thank you for pointing that out. I tried to find a diagram of all these landmarks before posting but got it all mixed up in my head somehow. I’ll try to remember that.
I follow you perfectly. I was not aware that retracting the teeth with braces could visually lengthen the philtrum—that’s significant, as Gunson measured mine and mentioned to me that it was on the long side as it is. I did some SERIOUS reading on this procedure (SAO) back when you posted some information about it some months ago on this forum, but I didn’t know how and if it could be fit into my treatment plan, or whether that would be of any utility.
Do you think, then, that considering I AM concerned about the philtrum, that if I did the SAO, and then had double jaw surgery with the RIGHT surgeon and surgical plan, that the result would probably be better than what a genioplasty could achieve?
The method is one where we use the 'tools' in our head.
SAO is mostly done in Asian places as bimax protrusion very common there. I don't think Gunson does it. If he said your philtrum was on the long side as it is, makes sense that he was getting at avoiding the bimax because it involved setting the philral area on a more vertical plane.
Well, I think it would be better than using braces to retract the teeth on a retroclined or vertical plane as far as getting a surgery involving extractions. The genio would IMPROVE. But now that you have a good idea that your morph measure was close to 10 mm and the genio would be 6, it comes out 4mm short of 10mm. Seems like lower risk and time and trouble (to me) relative to SAO or retroclining with braces. A modest chin implant is about 4mm which could be a later add on.
By the way, when Gunson tells you he wishes you had a steep occlusal plane, he's looking at the occlusal plane and seeing it's in approx the 7 degree range which is basically on the LOW side of OP ranges. When people on here say you are 'clear cut' for CCW, they could be looking at the mandibular plane as closer to the high side of MPA ranges. So CCW would just give you an even LOWER OP and a 7 deg rotation would give you 0. Maybe that's what he was talking about when he mentioned something called a 'reverse smile'? It's not as if you need your present MPA reduced either. So, if you got CCW, I don't think it could be as significant as to project out the chin point as would be the case of someone with a high OP and also a high MPA.
-
Seems like lower risk and time and trouble (to me) relative to SAO or retroclining with braces.
You know, I do recognize your points and I appreciate you reminding me of that. It is a lot more trouble and risk, and many would probably consider it not worth it. But I've been weighing this for years and have been firmly resolved to doing jaw surgery for a long time. I'm still heavily leaning towards jaw surgery, and that's because:
-I truly want the greater functional benefits that jaw surgery can bring.
-6 mm would be bony displacement which doesn't equal soft tissue displacement as you know. My 10 mm is 10 mm of soft tissue displacement.
-Even 6 mm of bony displacement seems like too much for the genioplasty-Walline and Alfaro both told me that genioplasties look best when they're less than 4 mm max.
-Looking at surgery results for many years, I don't think I've ever seen a genioplasty result improve a face similar to MY face to a satisfactory extent.
-Comparing genioplasty to jaw surgery results, genioplasty results seem to be SUBTLY unnatural looking far more often where the person started off with a face like mine. Don't get me started on chin implants.
I won't go on but there are more reasons...
I know this isn't a choice that everyone would make, but it seems like the right one for me. Prof. Raffaini told me to "listen to my soul" when making a choice between a simpler and a more tedious treatment plan and I think that's what I need to do.
-
By the way, when Gunson tells you he wishes you had a steep occlusal plane, he's looking at the occlusal plane and seeing it's in approx the 7 degree range which is basically on the LOW side of OP ranges. When people on here say you are 'clear cut' for CCW, they could be looking at the mandibular plane as closer to the high side of MPA ranges. So CCW would just give you an even LOWER OP and a 7 deg rotation would give you 0. Maybe that's what he was talking about when he mentioned something called a 'reverse smile'? It's not as if you need your present MPA reduced either. So, if you got CCW, I don't think it could be as significant as to project out the chin point as would be the case of someone with a high OP and also a high MPA.
Would you be able to give me an idea of how many degrees I could be CCW rotated before aesthetics start to be negatively affected by the low angle? I'm just asking about the occlusal plane and smile aesthetics here, ignoring the other factors for a moment like protrusion and whatnot. I just want to try to calculate how many mm approximately I could gain at the pog point purely from the ROTATION COMPONENT of bimax surgery.
-
You know, I do recognize your points and I appreciate you reminding me of that. It is a lot more trouble and risk, and many would probably consider it not worth it. But I've been weighing this for years and have been firmly resolved to doing jaw surgery for a long time. I'm still heavily leaning towards jaw surgery, and that's because:
-I truly want the greater functional benefits that jaw surgery can bring.
-6 mm would be bony displacement which doesn't equal soft tissue displacement as you know. My 10 mm is 10 mm of soft tissue displacement.
-Even 6 mm of bony displacement seems like too much for the genioplasty-Walline and Alfaro both told me that genioplasties look best when they're less than 4 mm max.
-Looking at surgery results for many years, I don't think I've ever seen a genioplasty result improve a face similar to MY face to a satisfactory extent.
-Comparing genioplasty to jaw surgery results, genioplasty results seem to be SUBTLY unnatural looking far more often where the person started off with a face like mine. Don't get me started on chin implants.
I won't go on but there are more reasons...
I know this isn't a choice that everyone would make, but it seems like the right one for me. Prof. Raffaini told me to "listen to my soul" when making a choice between a simpler and a more tedious treatment plan and I think that's what I need to do.
I don't know where the ratio of bone movement to soft tissue projection came from; the one that I hear almost echoed here where for every Xmm of bone projection there is Y mm of soft tissue projection where for every 2-3mm of bone projection there is 1mm of soft tissue--something like that. I FORGOT what that ratio was BECAUSE I DISREGARDED it. No idea how reliable that is for each person to apply to themselves. So, if you're operating on that factor, no way for me to validate it for you in any prediction of how many 'exact' mm you personally need.
All those doctors agree that genios look best when they are in 4mm range or less. THAT'S because they are able to bring out the pog point via a significant ccw-r and don't have to rely on the genio. To the best of my knowledge, they would not have to give the patient a 0 to NEGATIVE value for the OP to do that because in many situations the ideal patient for a significant ccw-r (posterior downgraft) is one with a STEEP OP, one with a steeper one than you have.
Sure, if one compares genio results to jaw surgery results, the jaw surgery results would look better, especially so if the person STARTED OFF as a good candidate for the jaw surgery instead. But you need to work with some of the limitations that ideal candidates for the type of significant CCW-r didn't start out with such as the bimax protrusion and an OP that's not on the steep side.
Sounds like you have resolved NOT to elect for the genio alone which was my (and Gunson's) suggestion. Not that I expect people to follow my advice but TBH, I'm hard pressed to advocate, coach, figure out details etc when someone really wants the thing I'm not suggesting. But of course, have no issues when the doctors on target with what you want figure those things out for you.
I have no issue with Raffaini telling you to 'go with your soul'. But that's something one does WITHOUT needing someone else to figure out (other than the surgeon himself) all the details their soul impels them to do
-
Would you be able to give me an idea of how many degrees I could be CCW rotated before aesthetics start to be negatively affected by the low angle? I'm just asking about the occlusal plane and smile aesthetics here, ignoring the other factors for a moment like protrusion and whatnot. I just want to try to calculate how many mm approximately I could gain at the pog point purely from the ROTATION COMPONENT of bimax surgery.
That would involve my drafting out a tedious tutorial to substantiate my angle estimate based on a triangle of points; ANS, PNS and POG. CCW or CW is based on the rotation of a triangle. I think I have something up there on the educational section about the concept of rotating a triangle. Someone wanting to use their own triangle would need to be able to find those points on their ceph, mark it out on their ceph and then construct another triangle in different color over it with the same rotation to look where the pog point goes subsequent to a rotation. That changes for each unique triangle. It's tedious to give verbal directions of how to do it. But suffice to say, someone wanting to 'figure out' will be needing some geometry and needing to look at the relationship between the angle of rotation and advancement of pog point, in particular the relationship between the vertical drop down distance from the PNS points of each triangle and the outward distance from the pog points of each triangle. Basically, applying basic geometry just to appreciate the CONCEPT of it but not really with aim to figure out how much the doctor should rotate or to plan your own surgery.
What I can tell you now is what I said which was your OP is in the approx range of 7. So a 7 deg rotation would give you a 0 degree OP. So, CCW-r would need to be LESS than 7 deg. By the way, the norms for OP are about 8 + or - 4, so 4 to 12 is normative range depending on where you look. From that info I would GUESSTIMATE the doctors doing CCW might not want go more than 3 deg rotation. As to the extent of the rotation where your aesthetics would be wonky, I think you would need to just ask the doctors how many degrees they have in mind to rotate ccw or just get a PLAN from them. My 'thing' here is basically to point out that displacements in maxfax are RELATED to concepts in geometry. But not to provide the 'exact' number of degrees or mms for each unique case. That's the doctor's task to come up with when other factors go into things.
Included is a diagram of the rotation of a triangle; A, B C. so you let A=ans, B=pns and C=pog where the triangle is your OWN made from those points where you rotate it X degrees (a CONSTRUCT of ABC rotated where the triangle is SAME but just rotated).
-
Sounds like you have resolved NOT to elect for the genio alone which was my (and Gunson's) suggestion. Not that I expect people to follow my advice but TBH, I'm hard pressed to advocate, coach, figure out details etc when someone really wants the thing I'm not suggesting.
I RESPECT your values and your conclusion 100%. However, as is INHERENTLY the case when weighing something like this, it's based on YOUR personal values, that you concluded that weighing all the facts, genio is the better choice. Normative statements like the ones you and other members often make here are GREAT and can be very useful. But since this all depends on PERSONAL values, I think it's not strange that I'm leaning towards further exploring the SAO + bimax surgery, which, is, by the way, also something that you explained was an option.
Not that I expect people to follow my advice but TBH, I'm hard pressed to advocate, coach, figure out details etc when someone really wants the thing I'm not suggesting. But of course, have no issues when the doctors on target with what you want figure those things out for you . . . But that's something one does WITHOUT needing someone else to figure out (other than the surgeon himself) all the details their soul impels them to do
I think it's very important to note, that I'm here to READ, ask questions, and LEARN because I believe that all patients should do so when considering surgical procedures. I think that's what this forum is for, regardless of one's personal values on what procedure is the right balance of trouble vs reward for them. I don't know of another forum like this one, and that's why I'm asking these questions here. If you really don't want to answer questions on this, that's your prerogative and I have to accept that obviously.
I could just try to rely on dealing with surgeons directly and see how it goes. I've already done that and plan to continue doing so. BUT, I'm trying, through reading and asking questions, to inform myself independently of these doctors. I also view the information and answers here as relatively unbiased, so that's another reason I'm here. Every patient improves their chance of a successful intervention by seeking help from those who know more than them, and I was hoping that was encouraged here.
I hope that clarifies things and allows you to appreciate my POV.
Sorry if I've taken too much of your time. Your help is appreciated.
But you need to work with some of the limitations that ideal candidates for the type of significant CCW-r didn't start out with
That's why I asked for your opinion--I am trying to gain an appreciation for the benefits and limitations. That's why I asked about how many degrees approximately I could be rotated.
And I was hoping to use that information to calculate BY MYSELF the number of mm of advancement that this would give. I don't yet understand whether I NEED significant CCW-r. A little bit of CCW-r + linear advancement after SAO seems like it could work too.
-
That would involve my drafting out a tedious tutorial to substantiate my angle estimate based on a triangle of points; ANS, PNS and POG. CCW or CW is based on the rotation of a triangle. I think I have something up there on the educational section about the concept of rotating a triangle. Someone wanting to use their own triangle would need to be able to find those points on their ceph, mark it out on their ceph and then construct another triangle in different color over it with the same rotation to look where the pog point goes subsequent to a rotation. That changes for each unique triangle. It's tedious to give verbal directions of how to do it. But suffice to say, someone wanting to 'figure out' will be needing some geometry and needing to look at the relationship between the angle of rotation and advancement of pog point, in particular the relationship between the vertical drop down distance from the PNS points of each triangle and the outward distance from the pog points of each triangle. Basically, applying basic geometry just to appreciate the CONCEPT of it but not really with aim to figure out how much the doctor should rotate or to plan your own surgery.
What I can tell you now is what I said which was your OP is in the approx range of 7. So a 7 deg rotation would give you a 0 degree OP. So, CCW-r would need to be LESS than 7 deg. By the way, the norms for OP are about 8 + or - 4, so 4 to 12 is normative range depending on where you look. From that info I would GUESSTIMATE the doctors doing CCW might not want go more than 3 deg rotation. As to the extent of the rotation where your aesthetics would be wonky, I think you would need to just ask the doctors how many degrees they have in mind to rotate ccw or just get a PLAN from them. My 'thing' here is basically to point out that displacements in maxfax are RELATED to concepts in geometry. But not to provide the 'exact' number of degrees or mms for each unique case. That's the doctor's task to come up with when other factors go into things.
Included is a diagram of the rotation of a triangle; A, B C. so you let A=ans, B=pns and C=pog where the triangle is your OWN made from those points where you rotate it X degrees (a CONSTRUCT of ABC rotated where the triangle is SAME but just rotated).
THANK YOU. I hadn't seen this yet when I submitted my reply a few minutes ago. Yes, I know it's tedious and that's why I didn't ask you to tell me how many mm that is at the pog point. I am familiar with the method you described and appreciate you directing me to the right place to refresh my memory so I can calculate this myself. Yes, I know I shouldn't plan my own surgery, just trying to get a better idea on this.
-
I RESPECT your values and your conclusion 100%. However, as is INHERENTLY the case when weighing something like this, it's based on YOUR personal values, that you concluded that weighing all the facts, genio is the better choice. Normative statements like the ones you and other members often make here are GREAT and can be very useful. But since this all depends on PERSONAL values, I think it's not strange that I'm leaning towards further exploring the SAO + bimax surgery, which, is, by the way, also something that you explained was an option.
I think it's very important to note, that I'm here to READ, ask questions, and LEARN because I believe that all patients should do so when considering surgical procedures. I think that's what this forum is for, regardless of one's personal values on what procedure is the right balance of trouble vs reward for them. I don't know of another forum like this one, and that's why I'm asking these questions here. If you really don't want to answer questions on this, that's your prerogative and I have to accept that obviously.
I could just try to rely on dealing with surgeons directly and see how it goes. I've already done that and plan to continue doing so. BUT, I'm trying, through reading and asking questions, to inform myself independently of these doctors. I also view the information and answers here as relatively unbiased, so that's another reason I'm here. Every patient improves their chance of a successful intervention by seeking help from those who know more than them, and I was hoping that was encouraged here.
I hope that clarifies things and allows you to appreciate my POV.
Sorry if I've taken too much of your time. Your help is appreciated.
That's why I asked for your opinion--I am trying to gain an appreciation for the benefits and limitations. That's why I asked about how many degrees approximately I could be rotated.
And I was hoping to use that information to calculate BY MYSELF the number of mm of advancement that this would give. I don't yet understand whether I NEED significant CCW-r. A little bit of CCW-r + linear advancement after SAO seems like it could work too.
With regard to a lot of back and forths as to your choice of what to do, I'm just saying, I'm going to be in a time crunch real soon as to extent of time and there are some thing you should just ASK the doctors such as:
a: will you be retroclining my teeth or aligning straight down and if so, what's your estimate of the new nasial labial angle.
(measure your present one first--it's in the 90 deg. range). Better yet, just ask if your NLA will INCREASE
b: if my NLA increases too much due to new orientation of front teeth, is is possible to later get braces for a lips to rest on diagonal plane?
c: can you give me an idea of an approximate number of degrees of the CCW or approximate mm length of posterior downgraft used in the CCW
a and b (if they tell you) will allow you to be poised for an increase in NLA and be poised to accept that as a trade off
c will give you an idea of what you could expect with the pog point projection as a function of degrees of ccw-r
-
With regard to a lot of back and forths as to your choice of what to do, I'm just saying, I'm going to be in a time crunch real soon as to extent of time and there are some thing you should just ASK the doctors such as:
a: will you be retroclining my teeth or aligning straight down and if so, what's your estimate of the new nasial labial angle.
(measure your present one first--it's in the 90 deg. range). Better yet, just ask if your NLA will INCREASE
b: if my NLA increases too much due to new orientation of front teeth, is is possible to later get braces for a lips to rest on diagonal plane?
c: can you give me an idea of an approximate number of degrees of the CCW or approximate mm length of posterior downgraft used in the CCW
a and b (if they tell you) will allow you to be poised for an increase in NLA and be poised to accept that as a trade off
c will give you an idea of what you could expect with the pog point projection as a function of degrees of ccw-r
Okay, thank you. I'll do that. About this sentence though:
"will you be retroclining my teeth or aligning straight down"
I am familiar with the term "retroclination," and will be sure to ask this as you've written it, but, for my own comprehension, does this question basically mean: "will you be pushing in my teeth in a LITTLE (i.e. retroclining a little) or pushing my teeth in a LOT (ie. retroclining them so far as to align them straight down)?
I'm fairly certain I understand you but want to be sure.
You're the one who would have to demonstrate any paranasal problem.
Do you have any guess as to why Gunson wrote "Nasal base is soft and needs 4 mm of support" in his report? I would think this refers to solely ANS deficiency, rather than wider paranasal retrusion. To me I see a bit of a collapsed area all around the lower half of my nose, and that's why I said I suspected a paranasal problem. I don't know if my eyes are to be trusted on this, though.
I want to understand this while we're on the nasolabial angle as we're talking about the same general area so this is all interrelated.
-
Okay, thank you. I'll do that. About this sentence though:
"will you be retroclining my teeth or aligning straight down"
I am familiar with the term "retroclination," and will be sure to ask this as you've written it, but, for my own comprehension, does this question basically mean: "will you be pushing in my teeth in a LITTLE (i.e. retroclining a little) or pushing my teeth in a LOT (ie. retroclining them so far as to align them straight down)?
I'm fairly certain I understand you but want to be sure.
Do you have any guess as to why Gunson wrote "Nasal base is soft and needs 4 mm of support" in his report? I would think this refers to solely ANS deficiency, rather than wider paranasal retrusion. To me I see a bit of a collapsed area all around the lower half of my nose, and that's why I said I suspected a paranasal problem. I don't know if my eyes are to be trusted on this, though.
I want to understand this while we're on the nasolabial angle as we're talking about the same general area so this is all interrelated.
Retroclining refers to pushing them back BEYOND straight vertical; diagonally inward. Perhaps semantics but I DON'T mean it as pushing diagonally outward teeth 'a little'.
Not sure what Gunson meant my GUESS is that it could mean he wants to put bone 'paste' to the area. He did not use word 'paranasal' and he doesn't do rhinos. But he does put bone paste to the paranasal area (beside lower part of nose, beside nostril area.) The nose base is where it sounds like it is at the nose bottom the ANS helps support the nose base. I know they have implants that go under the entire nose base. So, maybe he wanted to put bone paste there.
-
Retroclining refers to pushing them back BEYOND straight vertical; diagonally inward. Perhaps semantics but I DON'T mean it as pushing diagonally outward teeth 'a little'.
Sorry, I’m still not totally sure I understand. I’ve attached a diagram with 2 illustrations labelled A and B.
You’re saying “retroclining” would be A, where the incisors are pushed in so far they start to angle inward.
And “aligning straight down” would be B, where the incisors are pushed in to the point where they’re totally vertical.
Did I understand correctly?
Thanks for offering your guess regarding the nasal issue.
-
Sorry, I’m still not totally sure I understand. I’ve attached a diagram with 2 illustrations labelled A and B.
You’re saying “retroclining” would be A, where the incisors are pushed in so far they start to angle inward.
And “aligning straight down” would be B, where the incisors are pushed in to the point where they’re totally vertical.
Did I understand correctly?
Thanks for offering your guess regarding the nasal issue.
In the OPPOSITE direction in which your teeth are presently inclined. Look at your OWN teeth and note the diagonally outward direction of them. So the OPPOSITE direction is what I mean. You don't need that diagram to refer to your OWN teeth and figure out what's the opposite direction of their present orientation.
ETA: Proclined incisors – The front teeth are excessively tipped outwards
Retroclined incisors – The front teeth are excessively tipped back
-
In the OPPOSITE direction in which your teeth are presently inclined. Look at your OWN teeth and note the diagonally outward direction of them. So the OPPOSITE direction is what I mean. You don't need that diagram to refer to your OWN teeth and figure out what's the opposite direction of their present orientation.
Makes good sense that that’s what “retroclining” would mean. But then, what would “aligning straight down” be in relation to that?
-
Makes good sense that that’s what “retroclining” would mean. But then, what would “aligning straight down” be in relation to that?
answer DECLINED. Figure it out.
-
answer DECLINED. Figure it out.
Okay, I’ll try. Thanks for trying to explain.
-
Occlusal plane is normal and your ANS is vertically aligned with your maxillary incisive edge (ideal). Soft tissue of the upper lip and nose are in balance. -4mm of nasal support isn't a huge deal. Gunson's genioplasty plan is perfectly sound, and he is absolutely correct that advancing the maxilla (as is) would look bad.
Have you gotten a sleep study done? Your airways look quite open based on your ceph, so you may not need DJS for OSA purposes. You should make sure.
If your goal is to maximize aesthetics, that's fine too. You currently don't have the necessary base for achieving your morph, so you will need extensive orthodontic preparation - expansion, extractions, braces, etc. - as the other surgeons laid out. Their plans are also sound.
IMO your choices are perfectly clear. What you need to decide is whether the incremental aesthetic benefits of DJS are going to be worth all of the extra trouble vs. genioplasty only.
-
Thanks for replying varbrah.
Occlusal plane is normal and your ANS is vertically aligned with your maxillary incisive edge (ideal). Soft tissue of the upper lip and nose are in balance.
Hm. Good to know. That makes me wonder, though: If my ANS is in ideal vertical alignment with my maxillary incisive edge, then what the heck does the -4mm nasal support refer to? I was under the impression that this had a direct relation to the ANS, so this is new to me.
Gunson's genioplasty plan is perfectly sound, and he is absolutely correct that advancing the maxilla (as is) would look bad.
What's crazy is that I knew that from the beginning, yet all these top surgeons except for Gunson initially encouraged me to do jaw surgery without any orthodontic preparation. They all eventually admitted that doing orthodontics would deliver a better result, but only because I was persistent in explaining my concerns with doing that.
Have you gotten a sleep study done? Your airways look quite open based on your ceph, so you may not need DJS for OSA purposes.
I’ve had an at home one done, which came back negative, but I was told I should do an in-clinic study for a more accurate picture. I have an in-clinic study scheduled for next week. I'm set on doing jaw surgery for various reasons regardless of the result, though.
You currently don't have the necessary base for achieving your morph, so you will need extensive orthodontic preparation - expansion, extractions, braces, etc. - as the other surgeons laid out. Their plans are also sound.
I realize I need extractions and braces to push my anterior teeth back, but do you personally see a reason I would need expansion? Since I last posted to this thread, I saw Alfaro and Walline for a follow up consult, and I saw Dr. Sullivan in Oklahoma for an initial consult. All 3 of them said I didn't need expansion, so that leaves only Gunson that said I needed it. I guess Walline only went along with the idea initially because I questioned him so much on my maxillary width.
-
Update:
I've had follow up consultations with Alfaro and Walline. I also saw a new doctor, Dr. Sullivan in Oklahoma.
Gums
My gum recession at my lower anterior teeth keeps coming up during consults. My understanding is that braces and jaw surgery (and maybe SFOT) are the solution. It's certainly not related to my oral hygiene--I brush and floss properly and thoroughly, and I always have very little plaque built up between cleanings. Attached are photos showing the current state of my gum recession.
Expansion
Alfaro, Sullivan, and Walline are all of the opinion that I don't need maxillary expansion. It seems that Walline initially went along with the idea only because I questioned him so much on my maxillary width. That leaves Gunson and Dr. Ting as the only ones who thought I needed expansion.
Orthodontics
Alfaro and Sullivan have added two new ideas.
Both of their ideas involve increasing my overjet.
Here's where they differ:
-Alfaro's idea is to extract all my wisdom teeth and then use that space to do "en masse" retraction of both my maxillary and mandibular teeth. He would retract the mandibular teeth more than the maxillary teeth though, to increase my overjet. No pre-molar extractions at all, just the wisdom teeth. Corticotomy might be used to speed up the process.
-Sullivan's idea is to leave my maxillary wisdom teeth intact, but extract lower premolars, and then retract my mandibular anterior teeth. He would leave my maxillary pre-molars intact though.
a: will you be retroclining my teeth or aligning straight down and if so, what's your estimate of the new nasial labial angle.
(measure your present one first--it's in the 90 deg. range). Better yet, just ask if your NLA will INCREASE
b: if my NLA increases too much due to new orientation of front teeth, is is possible to later get braces for a lips to rest on diagonal plane?
c: can you give me an idea of an approximate number of degrees of the CCW or approximate mm length of posterior downgraft used in the CCW
a and b (if they tell you) will allow you to be poised for an increase in NLA and be poised to accept that as a trade off
c will give you an idea of what you could expect with the pog point projection as a function of degrees of ccw-r
I asked Alfaro and Sullivan these questions. Here's what they said:
Question A:
Alfaro - Both.
Sullivan - Both
I still am not confident I understand the difference between retroclining and aligning straight down, though. I've tried to understand, but again, I am not confident.
Question B:
Alfaro - Yes, but that won't happen so there won't be a need, as CCW-r will return the nasolabial angle to what it is now after the initial increase due to extractions/retraction.
Sullivan - Same as Alfaro
Question C:
Alfaro - Maybe 5, maybe 8, maybe 10. He doesn't know. It depends on how much I need based on the orthodontic result achieved. He disagrees that there is a "normal range" for the occlusal plane.
Sullivan - 4 degrees, subject to change post-orthodontics.
I would be grateful for any thoughts. I'm still trying to learn as much as I can about this.
-
......
I asked Alfaro and Sullivan these questions. Here's what they said:
Question A:
Alfaro - Both.
Sullivan - Both
I still am not confident I understand the difference between retroclining and aligning straight down, though. I've tried to understand, but again, I am not confident.
Question B:
Alfaro - Yes, but that won't happen so there won't be a need, as CCW-r will return the nasolabial angle to what it is now after the initial increase due to extractions/retraction.
Sullivan - Same as Alfaro
Question C:
Alfaro - Maybe 5, maybe 8, maybe 10. He doesn't know. It depends on how much I need based on the orthodontic result achieved. He disagrees that there is a "normal range" for the occlusal plane.
Sullivan - 4 degrees, subject to change post-orthodontics.
I would be grateful for any thoughts. I'm still trying to learn as much as I can about this.
When I say 'retrocline', I'm meaning the opposite of procline. Proclined teeth (gums too) are tilted diagonally outward (toward the lips) relative to a straight line vertical. The opposite of that; retroclined teeth (and gums too) are tilted diagonally inward (toward the roof of mouth).
Glad to hear they answered the proposed questions.
-
When I say 'retrocline', I'm meaning the opposite of procline. Proclined teeth (gums too) are tilted diagonally outward (toward the lips) relative to a straight line vertical. The opposite of that; retroclined teeth (and gums too) are tilted diagonally inward (toward the roof of mouth).
Glad to hear they answered the proposed questions.
The distinction between proclining and retroclining is clear to me. What I’ve had trouble understanding from the start is how “aligning straight down” differs from either of these.
Does “aligning straight down” just mean retracting the teeth while taking care to neither procline or retrocline them in the process, that is, taking care to not change the inclination of the teeth themselves in the process of retroclining?
Would you please confirm?
I’m not certain this distinction is important at this particular moment, but I’m sure it will be at some point.
-
The distinction between proclining and retroclining is clear to me. What I’ve had trouble understanding from the start is how “aligning straight down” differs from either of these.
Does “aligning straight down” just mean retracting the teeth while taking care to neither procline or retrocline them in the process, that is, taking care to not change the inclination of the teeth themselves in the process of retroclining?
Would you please confirm?
I’m not certain this distinction is important at this particular moment, but I’m sure it will be at some point.
I would describe aligning straight down as parallel to the vertical vector of gravity.
-
Update: After an in-clinic sleep study, I've been diagnosed with moderate sleep apnea. Just goes to show how unreliable at-home sleep studies are. Anyway, this development doesn't shock me in the slightest.