jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: coldconduit on April 13, 2023, 09:50:30 AM
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Hi all,
I would gladly welcome any opinions and advice. I've been reading up all over the internet, trying to piece knowledge together and often feeling information overload to be honest - I would value some more experienced eyes on my situation, photos and ceph, to give me a direction to go from here. I'm writing off the cuff right now but will update with more information when I remember to!
All my photos and cephs are in this google drive here: https://drive.google.com/drive/u/0/folders/1P6Uwgsvc_efnwbcMZ6qcJ5pmlSGVYYaQ
Also in the drive is a pdf of the CephX analysis. It's free with a 7 day trial and then in theory you can just cancel before they charge you, but there's no button to cancel and they haven't responded to my request to cancel ::) There's a lot of pages to it, perhaps it would be useful also for others considering using that service (and perhaps those who know could comment on how accurate/useful it actually is).
Backstory:
- I'm in my early 30's. From the UK
- I had orthodontic treatment on the NHS which finished up when I was around 16. 2 upper premolars were extracted as part of the treatment.
- I have what I think are symptoms of UARS, if not OSA. I often get restricted nose breathing when lying down and wake up feeling out breath early mornings. I don't feel refreshed often after sleep. My partner tells me I make wierd noises and clicking sounds in my sleep ;D . I have been pursuing this on the NHS but it's very slow, and since the treatment on the NHS seems to be CPAP it's not so appealing to me to be wearing a machine at night for the rest of my life anyway.
- I have been a habitual mouth breather until the last couple of years where I now try to keep good tongue posture and breath through my nose during the day.
- I have tension in my jaws, and often tension and pain at the back of my skull where it meets the spine. I have a lot of neck tension/strain also. I have a tendency towards forward head posture which over the years I have been treating myself with exercises to counter this and improve my posture, which does help a lot. I find this frustrating - I have been in active (non-desk) work most of my working life, I am otherwise fit and healthy, but without constant work I feel like my body wants to push my head forward. I think this may be my body's unconscious attempts to get into a position where my airways are bigger at the expense of my posture?
My thoughts on needed treatment:- I have a narrow palate, my tongue doesn't fit on the roof of my mouth. I think this is at least in part due to my orthodontic treatment as a teenager with extractions. I believe that my narrow palate = resistance to my nasal breathing and so I have been investigating MSE treatment to widen the palate and improve this area. The teeth of my lower arch are tipped inwards to meet the smaller upper arch, so with braces + MSE I was told I could get at least ~10mm of palate expansion without any surgery done to lower jaw.
- Up until recently the MSE was the only treatment I was planning to get. I went to a consultation with an orthodontist in Europe who offered MSE, and he mentioned in passing that I may benefit from jaw surgery. That led me to investigate my side profile (not something you ever really get to look at in everyday life!) and starting reasearch around this.
- From looking at my own photographs and ceph, and from the research I've done so far, I'm in need of advancement of both the maxilla and the mandible? Like I said above, there's so much information out there that it gets a bit overwhelming, but I relate to a lot of the symptoms listed on this Pocket Dentistry article (http://pocketdentistry.com/23-short-face-growth-patterns-maxillomandibular-deficiency/) under Short Face Syndrome.
- I am concerned about aesthetics. Perhaps it's a result of studying my face and side profile so much recently that it's impossible to think about all the above and not become anxious about it. I do see really great improvements to how patients look on the instagram pages of some of the more popular surgeons and it's hard not to want that for myself also (especially if I'm going to be forking out all this money anyway!).
- Yes, also I'm missing a front incisor! I need to get this replaced with an implant at some point, I've not been dealing with it yet as it seems having implants will intefere with orthodontic treatment.
Where I'm at with procuring treatment:
- The orthodontist I consulted with earlier this year to was relatively expensive, and not as thorough as I would have liked. I'm booked in to consult with another orthodontist who is airway focussed and experienced with MSE, and I plan to ask them for recommendations on surgeons in their country - this might be unnecessary but I feel it would be better if both orthodontist and surgeon were in the same country and perhaps had worked together before.
- I have made a list of surgeons to potentially consult with. I haven't yet wanted to consult with any of them yet before I made this post here - I'd like to know what I should be asking for before seeing anyone. I'm also wary of paying between 200 and 500 euros for a consultation to not learn much/be given a price out of my range - I can't afford to pay upwards of 25000 euros for a surgery (or don't want to if there are experienced skilled surgeons who can do the same for half that price).
- This is another area where I'm a bit stuck - how do I choose a surgeon? Very few even have websites and if they do, no before/afters etc. And the famous ones seem to have as many horror stories as they do great results that they post online.
Thanks in advance to anyone who looks and replies.
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Re-reading my initial post I realise there is a lot of rambling on and it's not clear what I'm asking for help with. Sorry about that! I couldn't find how to edit the post to remove the unneccesary info... anyway to cut to the chase, and help people avoid having to read all of the above...
From the photos/cephs in the OP (Here also (https://drive.google.com/drive/u/0/folders/1P6Uwgsvc_efnwbcMZ6qcJ5pmlSGVYYaQ)):
Primary questions:
- Would I benefit from jaw surgery from a structural/aesthetic perspective?
- If so, what general movements would you recommend?
Secondary question:
- I want to get MSE before any surgery - afaik this can have a much greater effect on nasal airway size than a lefort 1 surgery. Is my assumption correct that this shouldn't change a surgical plan too much (as it is a lateral expansion only).
I'm gonna try to analyse the ceph myself using some of the resources from the education section here. will post updates here ..
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I have been looking through the Cephx analysis and learning as best I can how to read them. I found these links very useful as primers on some of the analyses, and as reference too as nothing is explained in the cephx pdf download, lots of abbreviations:
- Slideshow presentation on Ricketts analysis. (https://www.slideshare.net/MohammedElnaggar/ricketts-analysis-36754180) This one was good to refer to while looking at the cephx, can find an explanation for every measurement in here
- Slideshow presentation on McNamara analysis (https://www.slideshare.net/stanlystan/mc-namara-analysis-79980271) Similar to above, quite useful for reference.
- Journal by Dr. McNamara himself presenting his analysis method. (https://media.dent.umich.edu/labs/mcnamara/files/A%20method%20of%20cephalometric%20evaluation.pdf) Lots of easy to understand pictures in this one, great for someone like me ;D
So far, the one thing I can be sure of looking at the analyses is that my incisors are "too upright" ... I'd never even considered this before, but I read that can lead to excessive wear of the incisors. That must be why my remaining front tooth is so blunted off, heh. The orthodontist I last saw didn't mention anything about this to me, but the conversation was really mostly around MSE.
I've been concerned with the accuracy of the positions from the ai tracing. I thought the position of the Porion was off and the condyle curve also and tried to amend it myself. I found it difficult to find a good reference for where the Porion should be placed on the ceph, seemed to vary a lot in the examples I found. I found this (https://jawsurgeryforums.com/index.php/topic,8070.msg74759.html#msg74759) post by Kavan after doing all that which at least confirmed that it's bloody hard to find the Po point on the ceph.
I will upload the amended trace and updated cephx PDF from that to the google drive for comparison.
The trouble is, even though the old and new position are only a couple mm apart, that translates into a big difference on the analyses - e.g on McNamara analysis (page 8 of the pdf), distance A to NA Perp is -0.3mm with the old positions, and -3.86mm with the new trace positions (normal is 1.0mm, SD 2.0mm) See the attached images for my drawover to illustrate. With the old positions (from AI tracing) I would be quite close to normal maxilla position in relation to nasion vertical, but with the new positions I would be considered to have a retruded maxilla.
Also attached is the trace, and the Frankfurt/Nasion perpendicular lines, with ceph underlaid (amended Po and condyle positions). Maybe somebody can tell me if they're in the right place...
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The ceph (trace you did, ceph trace FH to N perp) has the ceph stat is in there to see the vertical. Now, if you passed another vertical that went right through the base of the nose where the upper lip meets it and also through the nose bone (does not have to be a specfic point on the nose bone as long as it is a vertical line parallel to the ceph stat that passes through where the base of nose and upper lip meet), that would be pretty similar to what some surgeons use in reference to where the soft tissue should be relative to that line. In the case of the ceph tracing, the lips should just about 'kiss' (a tad ahead of) that line and for them to do so, the upper jaw would come a little bit forward and lower jaw more forward than upper.
In your case, a vertical in the direction to the line of gravity (which the ceph stat shows) reveals that a perpendicular to it passes through the porion point and the point found on the lower orbit (Frankfort horizont). So, if a surgeon told you he wanted to advance your upper jaw a little and your lower jaw somewhat more, that would be the salient info relative to the vertical I referred to drawing into your ceph.
As to the hard to find Porion (po) point, an artifical intelligence program can find it. It's somewhat above the where you see the ear piece of the ceph (circled area with dot). So, a horizontal (perpendicular to gravity vertical) that passes the orbital point could be drawn to represent the Frankfort horizont.
In other cases, they might elect to rotate the ceph clockwise a number of degrees to vertical of the ceph stat and posit what they might call a 'true' vertical (even though how they call a 'true' one is not actually parallel to the true line of gravity which the ceph stat shows). In that case, a ceph rotated a number of degrees clockwise will have it that the maxilla/mandible complex relative to the new 'true vertical' they draw (to pass through the point where the base of nose meets upper lip area) will be more posterior to their proposed 'true vertical than those areas would be if they didn't rotate the ceph. In some cases, they remove the ceph stat from the ceph tracing they make from the ceph so you don't see they rotated it. For example, not all people hold their head such that the line drawn from porion point to sub orbital point is parallel to the floor horizont and who knows (well I don't) if every person has a Frankfort horizont that is parallel to the floor and perpendicular to the line of gravity. So, sometimes they will rotate the ceph as to propose a vertical where the person's soft tissue profile would look visually better in their eyes and also to onlookers
In your case the vertical line you drew that passes through the root of the nose and the ANS point is parallel to the line of gravity and also parallel to plane of the diagram and your Frankfort line (po to orbital) is perpendicular to that. So what to do next would be to draw a parallel line to your green vertical so it passes to where the base of nose meets the upper lip and that would show you the vertical that a lot of the aesthetically minded surgeons use to evaluate displacement of the soft tissue profile. The pog point of chin would be a little posterior to that line. So relative to the other vertical I referred to (Arnett vertical), in that regard your pog point (on the chin) is more posterior than that and your lips don't 'kiss' (a tad beyond) that line. So, less upper jaw advancement than lower jaw.
There are many different ways in which a ceph analysis is done but the landmarks (points) will be the same. Also, there are 'norms' as to the angular relationships drawn through the points found in the skull/face. But sometimes going beyond the norms of the angular relationships can kick up a more aesthetically pleasing profile to the soft tissue profile. For example, SNA and SNB angle can be within the norm. But increasing those angles above the norm might kick up a more aesthetically pleasing soft tissue profile. Although those are important angle relationships to look at as to relationship the upper and lower jaw have to each other and how those angles deviate from the norm, they are not always the be-it and end-all to a more 'ideal' soft tissue profile. So, there are some surgeons who will POSIT a soft tissue vertical that could look better on some people's face whether or not the SNA/SNB angles changes deviate from the norm.
Personally, I think the more straight forward method of analysis that incorporates a lot of relationships found in many types of ceph analysis is the one in the following link. https://www.sciencedirect.com/science/article/pii/S2395921516300575
In figure A of the link, it uses the Arnett soft tissue vertical for the soft tissue profile (which is the one I often refer to). Also, it demonstrates the salient points and their relation to each other as to make things 'geometrically intuitive' (relative to aesthetics). In that way, you don't have to fret about finding all the points found on a ceph. Ideally, a ceph tracing done professionally (where you are not the one finding all the points) can be used. But not every point in there is needed to do a straight forward evaluation.
So, if you like studying ceph analysis but might not want to be bogged down by the many many different methods of doing it, check out that link. It's an easier way to think about it than what you are struggling with.
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Amended assessment:
On further observation, the protrusive ANS did not appear in the ceph tracing; 'cephx trace FH-NPerp'(file attachments within his post) and the OP elected some other photo format for this ceph. That is to say, the original ceph, itself would not make that area invisible. I checked the photo storage link. The actual ceph just showed 1/2 of it--strange.
Anyway, whether or not the OP correctly charted all the points in his ceph tracing, the facial profile alone falls within the venue of type of correction that would tend to include:
1.An overall graft to the maxilla with net clockwise rotation to vertically elongate the shortness of the lower 3rd of the face and will allow for a vertically downward directional path for the advancement to take place.
2. The retrusion to the maxilla contributes to the nose looking overly prominent. It is exaggerated by the overly obtuse nose to lip angle. Trimming of the excess to the ANS will allow for maxillary advancement so it doesn't make the overly obtuse nose to lip angle (from excess to the ANS) look worse. The changes brought about this way would tend towards making the nose look better on the face.
3. Although the chin, itself, isn't overly retruded, its orientation along with the maxillary retrusion and overly prominent nose, contributes to to the mouth area looking 'caved in'. The clockwise rotation affected on the maxilla also acts to position the chin counter clockwise which would be a more favorable orientation for it such that it would not contribute to making the mouth area look more caved in when the lower jaw is brought forward.
If things such as looking better with a less short face, less over-dominating nose and less caved in looking mouth area can be visualized then it would be easy during a consult, to listen for those types of suggestions from a surgeon.
The ceph (trace you did, ceph trace FH to N perp) has the ceph stat is in there to see the vertical. Now, if you passed another vertical that went right through the base of the nose where the upper lip meets it and also through the nose bone (does not have to be a specfic point on the nose bone as long as it is a vertical line parallel to the ceph stat that passes through where the base of nose and upper lip meet), that would be pretty similar to what some surgeons use in reference to where the soft tissue should be relative to that line. In the case of the ceph tracing, the lips should just about 'kiss' (a tad ahead of) that line and for them to do so, the upper jaw would come a little bit forward and lower jaw more forward than upper.
In your case, a vertical in the direction to the line of gravity (which the ceph stat shows) reveals that a perpendicular to it passes through the porion point and the point found on the lower orbit (Frankfort horizont). So, if a surgeon told you he wanted to advance your upper jaw a little and your lower jaw somewhat more, that would be the salient info relative to the vertical I referred to drawing into your ceph.
As to the hard to find Porion (po) point, an artifical intelligence program can find it. It's somewhat above the where you see the ear piece of the ceph (circled area with dot). So, a horizontal (perpendicular to gravity vertical) that passes the orbital point could be drawn to represent the Frankfort horizont.
In other cases, they might elect to rotate the ceph clockwise a number of degrees to vertical of the ceph stat and posit what they might call a 'true' vertical (even though how they call a 'true' one is not actually parallel to the true line of gravity which the ceph stat shows). In that case, a ceph rotated a number of degrees clockwise will have it that the maxilla/mandible complex relative to the new 'true vertical' they draw (to pass through the point where the base of nose meets upper lip area) will be more posterior to their proposed 'true vertical than those areas would be if they didn't rotate the ceph. In some cases, they remove the ceph stat from the ceph tracing they make from the ceph so you don't see they rotated it. For example, not all people hold their head such that the line drawn from porion point to sub orbital point is parallel to the floor horizont and who knows (well I don't) if every person has a Frankfort horizont that is parallel to the floor and perpendicular to the line of gravity. So, sometimes they will rotate the ceph as to propose a vertical where the person's soft tissue profile would look visually better in their eyes and also to onlookers
In your case the vertical line you drew that passes through the root of the nose and the ANS point is parallel to the line of gravity and also parallel to plane of the diagram and your Frankfort line (po to orbital) is perpendicular to that. So what to do next would be to draw a parallel line to your green vertical so it passes to where the base of nose meets the upper lip and that would show you the vertical that a lot of the aesthetically minded surgeons use to evaluate displacement of the soft tissue profile. The pog point of chin would be a little posterior to that line. So relative to the other vertical I referred to (Arnett vertical), in that regard your pog point (on the chin) is more posterior than that and your lips don't 'kiss' (a tad beyond) that line. So, less upper jaw advancement than lower jaw.
There are many different ways in which a ceph analysis is done but the landmarks (points) will be the same. Also, there are 'norms' as to the angular relationships drawn through the points found in the skull/face. But sometimes going beyond the norms of the angular relationships can kick up a more aesthetically pleasing profile to the soft tissue profile. For example, SNA and SNB angle can be within the norm. But increasing those angles above the norm might kick up a more aesthetically pleasing soft tissue profile. Although those are important angle relationships to look at as to relationship the upper and lower jaw have to each other and how those angles deviate from the norm, they are not always the be-it and end-all to a more 'ideal' soft tissue profile. So, there are some surgeons who will POSIT a soft tissue vertical that could look better on some people's face whether or not the SNA/SNB angles changes deviate from the norm.
Personally, I think the more straight forward method of analysis that incorporates a lot of relationships found in many types of ceph analysis is the one in the following link. https://www.sciencedirect.com/science/article/pii/S2395921516300575
In figure A of the link, it uses the Arnett soft tissue vertical for the soft tissue profile (which is the one I often refer to). Also, it demonstrates the salient points and their relation to each other as to make things 'geometrically intuitive' (relative to aesthetics). In that way, you don't have to fret about finding all the points found on a ceph. Ideally, a ceph tracing done professionally (where you are not the one finding all the points) can be used. But not every point in there is needed to do a straight forward evaluation.
So, if you like studying ceph analysis but might not want to be bogged down by the many many different methods of doing it, check out that link. It's an easier way to think about it than what you are struggling with.
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Amended assessment:
On further observation, the protrusive ANS did not appear in the ceph tracing; 'cephx trace FH-NPerp'(file attachments within his post) and the OP elected some other photo format for this ceph. That is to say, the original ceph, itself would not make that area invisible. I checked the photo storage link. The actual ceph just showed 1/2 of it--strange.
Anyway, whether or not the OP correctly charted all the points in his ceph tracing, the facial profile alone falls within the venue of type of correction that would tend to include:
1.An overall graft to the maxilla with net clockwise rotation to vertically elongate the shortness of the lower 3rd of the face and will allow for a vertically downward directional path for the advancement to take place.
2. The retrusion to the maxilla contributes to the nose looking overly prominent. It is exaggerated by the overly obtuse nose to lip angle. Trimming of the excess to the ANS will allow for maxillary advancement so it doesn't make the overly obtuse nose to lip angle (from excess to the ANS) look worse. The changes brought about this way would tend towards making the nose look better on the face.
3. Although the chin, itself, isn't overly retruded, its orientation along with the maxillary retrusion and overly prominent nose, contributes to to the mouth area looking 'caved in'. The clockwise rotation affected on the maxilla also acts to position the chin counter clockwise which would be a more favorable orientation for it such that it would not contribute to making the mouth area look more caved in when the lower jaw is brought forward.
If things such as looking better with a less short face, less over-dominating nose and less caved in looking mouth area can be visualized then it would be easy during a consult, to listen for those types of suggestions from a surgeon.
Thanks kavan, I really appreciate all the feedback you've provided so far. I'd actually seen recently a post of yours replying to another member of this forum regarding a longer ANS and there was a very useful link included which was written by a surgeon specialising in rhinoplasty, I was planning to ask about it actually as yes I could see that the ceph tracing from Cephx doesn't include that at all! Perhaps the AI tracing is designed not to go past certain boundaries that it would consider to be outliers, so that the majority of tracings are close to correct, and perhaps those with unusual features (I don't know how uncommon a protrusive ANS is) would be already something that the person doing the analysis is aware of and looking out for to correct manually afterwards.
I've been busy with work since my last post, but planned to give a proper update/reply sometime this week - will do so hopefully later tonight or tomorrow night.
EDIT: Found the link from the other other post (I actually couldn't find the original post which was frustrating, but this is the same link): FaceSurgery.com - The Anterior Nasal Spine (http://www.facialsurgery.com/ClkoffTPgt3_2011_09_01bh.html)
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Thanks kavan, I really appreciate all the feedback you've provided so far. I'd actually seen recently a post of yours replying to another member of this forum regarding a longer ANS and there was a very useful link included which was written by a surgeon specialising in rhinoplasty, I was planning to ask about it actually as yes I could see that the ceph tracing from Cephx doesn't include that at all! Perhaps the AI tracing is designed not to go past certain boundaries that it would consider to be outliers, so that the majority of tracings are close to correct, and perhaps those with unusual features (I don't know how uncommon a protrusive ANS is) would be already something that the person doing the analysis is aware of and looking out for to correct manually afterwards.
I've been busy with work since my last post, but planned to give a proper update/reply sometime this week - will do so hopefully later tonight or tomorrow night.
EDIT: Found the link from the other other post (I actually couldn't find the original post which was frustrating, but this is the same link): FaceSurgery.com - The Anterior Nasal Spine (http://www.facialsurgery.com/ClkoffTPgt3_2011_09_01bh.html)
The link you found on the ANS is the one I gave in my prior posts regarding someone having a prominent ANS. I probably gave it to a number of posters. Hence, same link given by ME on this board, would resolve to the one you cited here.
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I followed the ceph analysis method kavan linked above as best I could. My findings:
- Subnasal vertical (blue vertical line) is significantly forward of lips and chin also. Chin and lower lip is a little behind upper lip, suggesting, as kavan said above, both jaws could be advanced, lower jaw a little more than upper jaw.
- Looking at the relationship between A vertical and upper incisor vertical (yellow vertical line. Both of these seem to be on the same vertical) - Upper insisor is significantly retroclined. To be honest this isn't a surprise to me as my incisor sits a little back behind my canines.
- My upper incisor sits behind the Nasion vertical (orange vertical line). The analysis method assumes my incisor sits at least somewhere forward of the nasion vertical. My upper incisor (and maxilla) is retrusive.
- incisor mandibular plane Angle (lime green lines Gonion-Menton, lower incisor axis) - norm is 90 - 95 degrees. Mine is 82.8 degrees. Confirms retroclined lower incisors.
- Sn-Gn Axis, upper incisor Axis (pink lines) - should be parrallel. These lines are definitely not parrallel! Confirms retroclined upper incisor.
- ANS horizontal (cyan line, I tried to correct the position of ANS here) and PNS horizontal (pale green line) - this one confused me a little - ANS horizontal is below PNS horizontal, which is not the ideal position regardless. I understand this as being a "palatal plane with an anterior inclination" but this doesn't result in a Class III malocclusion or vertical maxillary excess as described in the method, but the opposite - I believe I have Class II malocclusion and (minor) vertical deficiency.
- Upper Stomion horizontal (brown line) - outside of norm - upper incisor sits too high on this line, and so does the lower incisor.
- Upper and lower facial halves (boxes on left) - each blue box is the height of the upper half (Nasion horizontal to horizontal line between ANS and PNS lines). Lower half (ANS-PNS horizontal to Menton horizontal) should ideally be one third longer than the upper. My lower half doesn't quite reach this (see small red boxes to illustrate).
To be honest I haven't strayed far from my initial (self) diagnosis of short face syndrome, or as kavan succintly put it, short face, over-dominating nose and caved in looking mouth area ;D haha...
@kavan Please correct me if I'm wrong, as I understand it, I have quite a flat occlusal pain in relation to true vertical, which asks/allows for some CW rotation to bring it to a more ideal angle, while increasing vertical maxilla length. Often people with short face syndrome have poor upper tooth show, so this CW rotation fixes that too.
I was a little confused before as I don't think I have poor upper tooth show, but this patient in particular of Raffaini's (link to instagram) (https://www.instagram.com/p/Ci7SiL1N5Ne/?hl=en) also has plenty upper tooth show and has a CW rotation of maxilla and mandible, with a great result in my opinion. I think this girl's before photos match my current situation and so gives guidance as to what sort of movements I should be looking for (minus the shaving down of the mandible).
Another really good result from short-face pre surgery which also preserves the masculine angle of the mandible (https://www.instagram.com/p/ClYP5jENHLQ/)
Could you clarify what you mean when you say "The clockwise rotation affected on the maxilla also acts to position the chin counter clockwise" - how would the chin be positioned counter clockwise, unless it was moved seperately/in the opposite direction to the maxilla and mandible?
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Flat occlusal plane + short face is something that often does not justify CCW-r. Hence it's in venue of of CW-r.
As to my saying: 'The clockwise rotation affected on the maxilla also acts to position the chin in CW rotation.' That is because a CW rotation on the maxilla also puts the mandible in CW rotation and the chin is connected to the mandible. However, if need be, the chin can be addressed separately despite it going along for the ride with the mandible during the BSSO part of the operation.
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However, if need be, the chin can be addressed separately despite it going along for the ride with the mandible during the BSSO part of the operation.
Thanks again kavan.
Yes that makes sense, and it's well illustrated in those infographics on the cases linked my last post (from Raffaini's insta) where the chin was cut away from the mandible and repositioned in both cases.
My main initial questions have pretty much been answered now. Yes surgery would be beneficial, and I now know the general movements that deal with a situation like mine (bimax advancement, CW rotation). Nothing more to it but to book consultations with surgeons...
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Thanks again kavan.
Yes that makes sense, and it's well illustrated in those infographics on the cases linked my last post (from Raffaini's insta) where the chin was cut away from the mandible and repositioned in both cases.
My main initial questions have pretty much been answered now. Yes surgery would be beneficial, and I now know the general movements that deal with a situation like mine (bimax advancement, CW rotation). Nothing more to it but to book consultations with surgeons...
I'm glad I was of help. A lot of the time I'm of no help but the correlation with that is the person has no working familiarity with the most elementary geometrical concepts (basic grammar or high school geometry), without which, there would be no conceptual frame work (in their heads) for me to explain much. In your case, you clearly demonstrated you could 'relate' to basic geometrical concepts. So, you were easier to help. Although it's not actually needed to know all the points angles and planes in a ceph analysis, as long as one has a basic understanding of geometrical relationships, it becomes easier to RELATE a 'what to do' suggestion back to those which you have demonstrated. Best of luck.