jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: mazilla on January 01, 2018, 04:10:52 PM
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I had bimax surgery for sleep apnea 2 years ago. Ever since I felt something was off. I felt I was advanced too much, and that I was left with bimax protrusion. I have now studied my pre and post op cephs on cephx.com and discovered that my occlusal plane was flat preop, but I had 10 degrees of CCW rotation anyways. Now I feel that is what makes me feel I look off, the unnecessary rotation. I was left class III and with a very small nasolabial angle due to the rotation.
I feel like my case was a simple case of straight advancement, but my surgeon gave me both anterior and posterior downgrafts although I did not want more tooth show and my occlusal plane was already flat.
Please help and advise.
Pre: https://imgur.com/a/S8vzX
Post: https://imgur.com/a/HVb0w
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I told you in the other thread, your jaws were rotated too much CCW and your occlusal plane is unjustifiably tilted CCW now relative to all the rest of your facial planes which are in really good alignment.
You do not need the jaws moved forward or backwards at this point, as they are in great alignment from that perspective.
You need to decide if you need anterior impaction at this point. This is determined primarily by how much of your upper front teeth are visible when you part your lips at rest. For a man, you want at most 1-2 mm ideally. Women is more like 4 mm (rough estimate here). If you have more than 1-2 mm of teeth showing with your lips apart at rest or your smile has become gummy, you might benefit from some anterior maxillary impaction. But I don't think you need anterior maxillary impaction despite that you mentioned you believe you do. At most you could impact the anterior aspect 1-2 mm if needed.
Otherwise what you need is posterior impaction of the maxilla by at least 3-4 degrees to get your occlusal plane back closer to the normal range. This requires revision BSSO and LF1, as you can't reorient the maxilla without reorienting the mandible as well.
The rotation will help to retrude your lower jaw a bit which has become a bit overprominent from the prior surgery as well.
Sucks doesn't it? Hard enough going through these surgeries once. Let alone twice. I feel your pain. At least yours is a relatively simple case at this stage.
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I told you in the other thread, your jaws were rotated too much CCW and your occlusal plane is unjustifiably tilted CCW now relative to all the rest of your facial planes which are in really good alignment.
You do not need the jaws moved forward or backwards at this point, as they are in great alignment from that perspective.
You need to decide if you need anterior impaction at this point. This is determined primarily by how much of your upper front teeth are visible when you part your lips at rest. For a man, you want at most 1-2 mm ideally. Women is more like 4 mm (rough estimate here). If you have more than 1-2 mm of teeth showing with your lips apart at rest or your smile has become gummy, you might benefit from some anterior maxillary impaction. But I don't think you need anterior maxillary impaction despite that you mentioned you believe you do. At most you could impact the anterior aspect 1-2 mm if needed.
Otherwise what you need is posterior impaction of the maxilla by at least 3-4 degrees to get your occlusal plane back closer to the normal range. This requires revision BSSO and LF1, as you can't reorient the maxilla without reorienting the mandible as well.
The rotation will help to retrude your lower jaw a bit which has become a bit overprominent from the prior surgery as well.
Sucks doesn't it? Hard enough going through these surgeries once. Let alone twice. I feel your pain. At least yours is a relatively simple case at this stage.
I'm more eyeballing the hypothetical changes then doing the definitive geometry on a ceph, but pretty sure any anterior impaction creates additional CCW, which you'd have to counterbalance with even more posterior impaction. Also keep in mind that some people have complications with anterior impaction, reducing support of their malar/submalar soft tissue and causing them to droop post op, making them appear older. Also, upper tooth show naturally reduces with age. I just don't see much upside with anterior impaction unless you really value poor upper tooth show over all this. IMO that's a compromise you should just accept as an objective improvement if you were to partially reverse the bimax. Research whether bringing back the maxilla a tad would be less risky than an anterior impaction. I don't know myself but removing bone, from the front, sounds more risky than removing some of whatever they use to push the maxilla forward.
Posterior impaction sounds correct to me, but to clarify 2xaround, pretty sure that does require redoing the BSSO such that the lower jaw/teeth are moved backward. If he doesn't do a multi-peice lefort, then the upper incisors will flare out less, due to the posterior impaction, essentially reversing some of prominence in the upper lip and philthrum/that whole region (w/e it's called).
Frankly though I don't get the issue with a divergent occlusal plane alone as the impetus for a revision, unless your open mouth smile looks off and is bothering you in the way it looks past your front incisors. Michael Phelps has a similar occlusal plane, I think.
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What bothers me is not the occlusal plane itself, which I had not noticed until now, what bothers me is protruding mouth, protruding teeth (with I already had preop, but the CCW made much worse), mandible too far forward, and too small nasolabial angle.
I was downgrafted anteriorly and posteriorly in my 1st surgery, so if they remove the whole HA whatever they put in both my anterior and posterior maxilla, that would derotate my jaws by 10 degrees, and leave my occlusal plane as it was pre-op, and solve the things I dont like about my result. So the impaction would not be removing my own bone, but whatever they put in there to downgraft my maxilla.
I still dont get why I would need BSSO, my lower teeth would not need to move backwards, just my mandible being rotated with the maxillary rotation, but I might be missing something here.
Should be obvious that since your mandible was advanced about 2cm and a BSSO cut was part of that and since you don't like your 'over advanced' lower jaw, a BSSO cut would be needed to push it backwards.
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What bothers me is not the occlusal plane itself, which I had not noticed until now, what bothers me is protruding mouth, protruding teeth (with I already had preop, but the CCW made much worse), mandible too far forward, and too small nasolabial angle.
I was downgrafted anteriorly and posteriorly in my 1st surgery, so if they remove the whole HA whatever they put in both my anterior and posterior maxilla, that would derotate my jaws by 10 degrees, and leave my occlusal plane as it was pre-op, and solve the things I dont like about my result. So the impaction would not be removing my own bone, but whatever they put in there to downgraft my maxilla.
I still dont get why I would need BSSO, my lower teeth would not need to move backwards, just my mandible being rotated with the maxillary rotation, but I might be missing something here.
Soft tissue is unpredictable is the point, particularly when you remove support of any kind, new or old. Just identifying risks.
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It's just basic mechanics.
1) If you rotate the upper jaw 10 degrees clockwise, you're going to have an abnormally clockwise tilted maxillary plane after that.
2) If you don't do a BSSO as well, your back teeth won't meet.
Here's a 10 degree clockwise posterior impaction of the maxilla without BBSO:
(https://s5.postimg.org/5lruozj13/mazilla_example.png)
Back teeth don't remotely meet and the maxillary plane is absurdly rotated.
Here's 4 degrees clockwise of both jaws which gives a more reasonable compromise among the planes:
(https://s5.postimg.org/ax6r9q7on/mzilla_4_degrees.png)
One other interesting thing to observe is how dramatically your mandibular plane (line along the bottom of your jaw) changed and went clockwise from preop. Again for reference, your preop angle was almost flat:
(https://s5.postimg.org/ybeqlr52f/mazilla_pre.png)
An incredible and enviably square jaw!
I don't know how it went so CW inclined just from a BSSO advancement. That BSSO destroyed your square mandibular angles and looks like they're not coming back. If you want that back, you'd need mandibular angle implants. But that's a more minor issue potentially.
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I just found something incredible. I was trying to figure out how your mandibular plane seemed to have been turned so clockwise in the post op relative to your occlusal angle (I edited my post while you were replying - might want to re-read it), so I did an overlay of your before and after cephs.
It looks like a mess, but the before is the red and the after is black/blue/green. I lined them up based on the S and N points, as those were not changed by surgery (unless you had brain surgery as well):
(https://s5.postimg.org/o5aqgn7iv/mazilla_distortion.png)
What we see is there is an INCREDIBLE amount of distortion from one ceph to the next.
How is this possible? Aren't cephs supposed to be standardized?
If this is the case, maybe we shouldn't trust our cephs very much at all.
This is absurd.
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As Kavan said - if his entire maxilla was dropped down - not just rotated, then the jaw naturally has less upward rotation to do before it meets the upper teeth. So his mandibular plane angle is bigger, as a result. You haven't shown how bad your gum show is when smiling, but pretty surprised it's not sort of on the severe end of tooth show after so much maxilla advancement and downward maxilla grafting.
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I just found something incredible. I was trying to figure out how your mandibular plane got obliterated and turned so clockwise in the post op (I edited my post while you were replying - might want to re-read it), so I did an overlay of your before and after cephs.
It looks like a mess, but the before is the red and the after is black. I lined them up based on the S and N points, as those were not changed by surgery (unless you had brain surgery as well):
(https://s5.postimg.org/o5aqgn7iv/mazilla_distortion.png)
What we see is there is an INCREDIBLE amount of distortion from one ceph to the next.
How is this possible? Aren't cephs supposed to be standardized?
If this is the case, maybe we shouldn't trust our cephs very much at all.
This is absurd.
I've seen distortion on after cephs even when I calibrated a linear measure.
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I've seen distortion on after cephs even when I calibrated a linear measure.
These things are f**king useless then if this degree of distortion is possible from one ceph to another.
OP, did you get your before and after cephs at the same location? Can you recall any differences in how they were taken?
You can't compare these with this degree of distortion. It makes no sense.
Even a CT is just a few hundred xrays. I HOPE they're not subject to the same distortion effects... (?)
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These things are f**king useless then if this degree of distortion is possible from one ceph to another.
OP, did you get your before and after cephs at the same location? Can you recall any differences in how they were taken?
You can't compare these with this degree of distortion. It makes no sense.
Even a CT is just a few hundred xrays. I HOPE they're not subject to the same distortion effects... (?)
Well, they are not to useful for overlaying the before with the after. They are used to make a displacement diagram on the same one for charting out a surgery.
ETA: You would have to try to scale them down to be same 'size' and then orient so the the Sella turica of both fit into each other. Tedious task. But that would have to be done to even see extent of distortion.
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Well, they are not to useful for overlaying the before with the after. They are used to make a displacement diagram on the same one for charting out a surgery.
Yeah but that is nonsense when there is this level of distortion. How can you judge that the planes are accurate or that the angles are accurate when one part (the SN line) is so contracted compared to another part (the jawline) in one ceph but not the other?
We are debating millimeters and just a few degrees of angling of components, and the whole picture we're basing this on is cartoonishly distorted.
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Yeah but that is nonsense when there is this level of distortion. How can you judge that the planes are accurate or that the angles are accurate when one part (the SN line) is so contracted compared to another part (the jawline) in one ceph but not the other?
We are debating millimeters and just a few degrees of angling of components, and the whole picture we're basing this on is cartoonishly distorted.
I see what you mean. His S-N line differs in both. You should double check with mazilla that these cephs, both of them, are DIRECT ceph files from his doctor. When he prior posted his cephs, they were actually PHOTOS he took from the doctor's computer screen and not to scale and showed they were photoed at different angles. I distinctly remember making fun of that. Like I asked him 'what was that piece of hardware the doctor put in your nose?' (I knew it was a photo shot) and his answer was it was the CURSER on the computer screen he photoed. The problem was that he requested removal of his cephs after I pointed out the crappy presentation and later insisted I remove from my files. So, now I have no way to cross reference if the cephs he sent to ceph X were his photo shots of them on the screen.
IF in fact these cephs were made from his crappy photo shots of his cephs on his doctor's computer screen, DISREGARD them.
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I see what you mean. His S-N line differs in both. You should double check with mazilla that these cephs, both of them, are DIRECT ceph files from his doctor. When he prior posted his cephs, they were actually PHOTOS he took from the doctor's computer screen and not to scale and showed they were photoed at different angles. I distinctly remember making fun of that. Like I asked him 'what was that piece of hardware the doctor put in your nose?' (I knew it was a photo shot) and his answer was it was the CURSER on the computer screen he photoed. The problem was that he requested removal of his cephs after I pointed out the crappy presentation and later insisted I remove from my files. So, now I have no way to cross reference if the cephs he sent to ceph X were his photo shots of them on the screen.
IF in fact these cephs were made from his crappy photo shots of his cephs on his doctor's computer screen, DISREGARD them.
That makes sense and is actually reassuring because I would hate to think my cephs or anyone's cephs could be that ridiculously distorted. What would we be accomplishing by analyzing them if they are?
OP you need to request a digital copy of your original cephs if you want to compare properly.
Either way the same advice applies though. If you want your jaws to be more like they were, get ~4 degrees of CW rotation with revision LF1/BSSO. There's not much else to be said than that. As we've all stated, you don't need retrusion of your jaws which will just give you back your sleep apnea and put you into a retruded profile.
If the rotation is done with referencing your upper front incisor as if it is in a "fixed" position, the lower jaw will come back a bit on its own from the rotation reducing its prominence a bit.
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These diagrams were made with the actual cephs sent from my doctor, not with the pictures I took with my phone.
I dont understand the distortion.
OK. I needed clarification of that due to the past cephs you put up. There is distortion.
As I said in a prior post to secondtimearound, I've seen distortion in other people's b/a cephs too when trying to scale them so each fits onto the unchanged landmarks of the other.
As I said, I've seen that type of distortion in other b/a cephs. The only explanation I can think of is a change in head posture (even if it's a small angle change). I've noticed it because there is a distinctive landmark (S ; Sella turcica) that looks like a cross between Ancient Persian script (xa) and the saddle of an invading Ottoman. The orientation/shape of that landmark changes and as if it is photoed at an angle. Steiner used that landmark because it was easy to see on an X ray and because the CENTER of it (where the dot is placed to make the S point) does not change where as the landmark for the Frankfort horizont was harder to spot. But when there is a shape change to that very distinctive landmark where it looks like it was shot at a different angle and when scaling down both cephs does not make an exact overlay to this landmark, it would reveal the head orientation for the ceph has changed.
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If the maxilla is rotated 4 degrees CW, I would need a mandibular setback if I understood correctly, right?
You said that the lower jaw would come back a bit from the rotation, but it would also need to be cut and setback, right?
I still dont understand why my occ plane got so tilted up (10 degrees) if my maxilla was CCW rotated approx 4 degrees.
If the maxillary plane was brought back to a straight plane, would that close much my airway? Im concerned about that.
Yes the lower jaw has to be cut as well. I can't really comment any further until you figure out why your ceph is so distorted and get a proper one. It's impossible to judge anything with these images.
Talk to your surgeons office and show them the overlay I made of the ditortion.
See what they have to say.
You need at least slightly comparable cephs to work with here.
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I think the problem is head position. It looks completely different in pre and post op cephs.
Yeah which makes it worthless. Cephs are supposed to be standardized position.
Also, I submitted a new image to cephx and they're saying they won't trace it because I'm not a orthodontist or surgeon. Wtf? How did you get yours done?
They did mine previously.
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Yeah which makes it worthless. Cephs are supposed to be standardized position.
Also, I submitted a new image to cephx and they're saying they won't trace it because I'm not a orthodontist or surgeon. Wtf? How did you get yours done?
They did mine previously.
To the best of my knowledge, exact head orientation is a very common issue in taking the cephs. Consider that even when they line up with the 'Frankfort horizont' or try to, the FHL is NOT actually horizontal in some people. IMO, they would need some kind of technology to actually SEE the actual bony landmarks to make a consistent line up as in seeing the X ray BEFORE the final shot of it was taken. But that would involve too much exposure to X ray radiation.
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I think the problem is head position. It looks completely different in pre and post op cephs.
Yes. See my post on this string to that regard.
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To the best of my knowledge, exact head orientation is a very common issue in taking the cephs. Consider that even when they line up with the 'Frankfort horizont' or try to, the FHL is NOT actually horizontal in some people. IMO, they would need some kind of technology to actually SEE the actual bony landmarks to make a consistent line up as in seeing the X ray BEFORE the final shot of it was taken. But that would involve too much exposure to X ray radiation.
So basically ceph surgical planning is a crapshoot, and we need CT planning if we want to be sure it is going to be remotely accurate.
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Cephx.com just did both my diagrams, I didn't do anything special.
So are my diagrams not valid? Or is it just difficult to compare both diagrams because of the different head position, but they are both valid separately?
At least one of them is not valid. Cephs must be taken from a standard position and angle for the analysis to be valid. One of these at a minimum is worthless and cannot be analyzed correctly.
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Post actual pictures of your face. The profile looks good and went from convex to normal.
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Well both of them make sense to me. Everything that is said on both analysis seems to be true.
Why does the head position matter, it the analysis is made taking into account points that are just there no matter the head position?
I understand that over positioning the diagrams would not work if the head position is different, but dont understand why each are not not valid separately.
You can say they both 'make sense' independently which they do independently. But you can't use them for an exact INTERdependent differential which is what you seem to be doing such as subtracting one angle from the other for a differential angle change. Last I checked the SN line relative to a horizont was 15 degrees away in one but 12 degrees away from the horizont in the other which could be a matter of the 'exact' head position was not consistent in both which by the way, is a common thing any time 2 different cephs are made.
There is also the factor of the doc being able to make adjustments when the SN line deviates MORE than 7 degrees away from a horizont which seems he did a good job at doing.
At this point, I really think you need to disclose to people you ask for feedback that your salient issue is that you are upset because you don't look like the yourself that you were USED TO seeing and you don't care that OTHER people (on here) who have seen these changes are like WOW impressed at the dramatic difference and ultimately you are just wanting validation that you 'should be' upset due to the doc 'doing you wrong'.
I mean there are people on this board, your's truly, is one such who can explain in terms of geometry or mechanics but that goes NO WHERE because ultimately your question resolves to an EMOTIONAL one of 'Why did he DO THIS TO ME?' So any analytical explanation is just going to elicit a BLOCK of 'Why did he do this to me?' and can become an exercise in futility for the mathematically or mechanically minded people to answer. Add to this that even when you show your pics the people who say 'Wow! That looks great.' are saying what you DON'T want to hear and that just ends up inflaming your emotions because you need them to understand how he 'did you wrong' by removing you too much from the 'identity' you 'identified' with even WHEN the change was one most people on here would be ELATED if they got. 10 to 1 if you showed your photos to CCW (who has asked for them on this thread) and also 'secondtimearound', the response would be WTF.
Just your question of 'Why does the head position matter?' is an irrational and emotional one resolving to the 'Why did he do this to me' meta program in your head. Reason being is that you already YOURSELF noted that the lines being askew were due to HEAD POSITION. So on a LOGICAL level, you KNOW why it matters. But the EMOTIONAL level elicits the irrational question of 'Why does the head position matter?
Now I understand you are emotionally upset due to 'identity issues' and I understand those things exist with some patients. I also understand that doctors KNOWN for kicking up the most dramatic changes in accordance to an aesthetic that a LOT of people specifically seek out those doctors for are the docs who, here and there, get the totally unhappy patient who's grounds for discontent is that they are upset being modeled in accordance to an 'aesthetic ideal' of the doctor and 'miss' the look they IDed with. But I think you need to clarify more to others you are seeking feedback from that this is the salient issue and not one of the doctor having poor judgement in terms of aesthetics.
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I actually think it went from concave to convex. It was rotated too much for my liking and my nasolabial angle was closed. I look better post up, but too different and prognathic in my opinion. Dont eant to post my pics here though.
Your terminology is off. Rounded upper lip - convex. Sunken - concave.
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I know I look better, but I did not want such a dramatic change. On top of that it is true that I was left class III, and I don't like that. I feel that I would have looked better and not have these ID issues if I had a linear advancement instead of CCW considering that my occlusal plane was flat. I no longer think my surgeon did something 'wrong', he just gave me a too dramatic change without me knowing it, and I don't like it, although you think that I look good. I dont think my doctor has poor aesthetic judgement. I just don't like my result because I went from retrognathic to prognathic, although I look good. Is that irrational? As well as some people have said that I look much better, others have said that I do look prognathic and they understand that I dont like it nor identify with it.
As for the head position on my cephs. I emailed Cephx.com about it. Here is their answer (seems I wasn't being emotional about it ;):
Our program adjusts the ceph so that it is straight.
I have just checked both cases in your account and they are straight.
This should not effect the results of the analyses in any way.
Let me know if you need anything else.
I sent them secondtimearound's overlay of the diagrams and asked about the distortion. Will post their answer.
Plosko, sorry I meant concave, but I was actually referring to my profile, not my upper lip
What it affects is doing a comparative DIFFERENTIAL where you can't use to claim an 'absolute' angle change based on subtracting one number from the other in both read outs.
For example, the SN line in the before is 15 degrees away from a horizont and the SN line in the after is 12 degrees away from the horizont. The Frankfort horizont is about 3 degrees away from a true horizont in the before and about 8 degrees away from a true horizont in the after
ALso, if you look at BOTH the cephs, you see that the Ottoman saddle shaped figure (Sella Turica, where they put the 'S' point) has a totally different orientation. So, if those things are not CONSTANT in the poses/head postures for the cephs, you can't go around assuming you can use both to come up with an absolute differential as to how many degrees he rotated your OP or how many degrees the nasial labial angle was changed.
Although we CAN measure those angles on BOTH and most of my angle measures with a hand held protractor and some geometry were basically consistent with each read out, the numbers and angle measures in the read out can't be subtracted from each other in an attempt to say with 'absoluteness' the number of degrees he changed the planes.
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You should have gotten a CD from the place that took your cbct.
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Well, a CEPH usually shows the cephalostat at the root of the nose/cranial base on the ceph. On it is a 'true vertical' (and sometimes linear measures on it too) such that REFERENCE lines can be assessed. https://en.wikipedia.org/wiki/Cephalometric_analysis
It sounds like one of your 'cephs' was not a true ceph but rather a slice from a 3-d type program used to simulate a surgery and they had to estimate where the Sella Turcica was which is a landmark that is highly visible in a CEPH but might not be in a sagittal cross section coming from a 3-d program.
AS to these DICOM files and other SOFTWARE to 'extract' things, that sort of computer stuff is beyond me. However, ditterbo is a computer genius for programs and software and perhaps could shed some light on that.
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Thanks secondtimearound. I had little tooth show preop, and now I show some gum, which I dont like. My smile was not ideal preop, but I didnt want to change it. I would like to remove the whole downgraft altogether, anterior and posterior, and leave my occlusal plane as it was. Also, my maxilla was advanced 10 mm, so that would have been enough to give me a little more tooth show.
What I do not understand is why can't I rotate the maxilla CW without BSSO? Doesnt the mandible just rotate WITH the maxilla? Maybe im missing something here. You mean I would need a mandibular setback to match the maxillary rotation?
Also, why are you saying I now need only 3-4 degrees of rotation? I was rotated 10 degrees and my occlusal plane was already flat. Wouldn't I need to derotate 10 degrees?
It really sucks my friend. Horrible to have to think about the surgery again. The agony before the surgery not knowing if everything will go well, the horrible recovery...
Where did you come up with the assessment that your OP was rotated 10 degrees? Your after ceph read out (even if it was for a non ceph but rather a CT cross section) said it was about 5.9 degrees. Even if you thought both were correct read outs in their own right and knew your OP was 'flat' in the before and your read out said it was 5.9 in the after. How did you conclude a rotation of 10 degrees?
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According to Steiner analysis, my occlusal plane to SN was 15,98 pre-op and 5,67 post-op. Thats why I said 10 degrees.
So, you made this conclusion by subtracting the after number the ceph read out gave you from the before number.
Do you still think the NET change in OP angle was 10 degrees?
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I have no idea to be honest. But I suspect it is not. I don't know how to get the change in OP.
Anyways the after ceph is not valid, right? Ill get a proper ceph done on Monday.
I used 6th grade geometry to cross reference your ceph read outs.
First thing I did was measure an angle that they DON'T give which is the angle the SN line makes with a 'pure' horizont.
Since the before showed the SN line was angled about 16 degrees away from a horizont and the OP line was 'flat' (about 0 degrees from a horizont) it was self evident that the Steiner 'op plane angle' (SN-OP angle) said 16 degrees away on the before.
In the after, it was also self evident to me that the SN-OP angle was 6. (Done by taking a line segment from the OP line and transferring it to the SN line to where the 2 meet form the apex of an angle and measuring the angle.)
So, what ever both ceph read outs said for the SN-OP angles were self evident to me. However, I knew NOT to subtract the after reading from the before reading (numbers in ceph read out). There was a reason I knew not to subtract the reading from one ceph read out from the other
Instead, to get the approximate NET angle change for the OP, I drew HORIZONTS. OP of before was 'flat' (0 degrees from horizont). OP of after was 6 degrees away from a horizont. Therefore NET angle change of OP was 6 degrees. So, and got 6 degree change. NOT '10'.
That is REAL (simple) 'analysis' using only elementary geometry concepts and a protractor to measure angles.
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Ok got it. Thanks a lot.
I guess my surgeon rotated CCW to open even more my airway, but given that my occlusal plane was flat preop, it gave a worse bite and aesthetic result than linear advancement would have given in my opinion. Linear advancement would not have changed my appearence as much in my opinion too.
If I got a revision, I guess I would just want the rotation undone.
Sorry to say, but the moral of the story is that your opinion isn't based on accurate observation or assessment of the angle changes but rather on the fact that you DON'T LIKE the result. I understand you don't like the result. But that can be expressed without trying to buttress it with statements that imply you know what linear advancement or this or that angle of rotation would have done.
I might be wrong. I sometimes am. But if you really think you have a good grasp of what all these planes are and how they should be manipulated, than I invite you to do a geometrical ceph displacement on the after to SHOW how linear displacement or any other displacement he should have done would look like.
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I have no idea to be honest. But I suspect it is not. I don't know how to get the change in OP.
Anyways the after ceph is not valid, right? Ill get a proper ceph done on Monday.
What's not valid is the act (yours) of subtracting the after SN-OP angle (of 6) from the before SN-OP angle (of 16) to claim a 10 degree CCW in the absence of observing the angle of inclination the S-N line had with the horizont differed by 4 degrees. It was 16 degrees away in the before and and 12 degrees away in the after. That is to say, the angle the S-N line makes with a horizont should not change that much at all and that needed to be observed before just taking the numbers from the ceph read out and subtracting them from each other.
Ceph analysis read outs like that are only as helpful as one's familiarity with geometry and what those points and lines are and one must be familiar enough with that and also be able to just measure the angles directly so the read outs are self evident such that discrepancies are easily spotted. I think that's one of the reasons the company does not like to send out if they know you are not actually an ortho. They expect a type of familiarity with what the measures are how they are measured and relative to what.
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Ok I apologize for my ignorance.
So I was not rotated 10 degrees. I was rotated 6 degrees.
The problem is that an occlusal plane that is flat does not need ANY CCW rotation. If any it would need CW rotation. In my case (since I had OSA) it just had to be left alone and just perform LINEAR advancement.
So my statement that I was over rotated unnecessarily is still valid. Even if the rotation was 1 degree, but it happens to be 6 degrees, leading to an unfavorable result. I emailed Gunson with my cephs and pictures and he AGREED.
It's 'valid' mostly in subjective terms of YOU DON'T LIKE IT. That subjective assessment is uber valid to you despite the subjective response of others who see your result and say a favorably impressed; 'WOW'. However in OBJECTIVE terms, relative to rotations in a surgery needed to open the airway (sleep apnea), CCW maximizes the extent the mandible can be advanced to open the air way (plenty of room). So, you can't just patently take the perspective that 'because' your ANS-PNS line and OP line was 'flat', he 'should not' have done the CCW and instead 'should have' done CW or just linear advancement.
You went to a doctor, world KNOWN and flocked to for giving DRAMATIC results, especially for the lower jaw advancements which are had via CCW.
As to Gunson 'agreeing' with you, no doubt he agreed with possibly being able to revise some things based on what you DON'T LIKE. But, did he 'agree' with your assessments that your ANS was 'cut off' or that you need to be counter rotated so your ANS-PNS and OP line are 'flat' again?
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I didn't know he was world known for dramatic results, he was just referred to me as 'the best' in Europe so I went with him. Never could I have imagined such a dramatic change in appearance.
I know that I look much better post op and that people think that, but is it so difficult to understand that I believe I would have looked better with linear advancement and would not have had such a dramatic change and ID issues. I should have done better research, AND he should have warned me about the dramatic change he was going to give me, which is WAY bigger than the ones he has on his website.
As for Gunson, I told him that I feel I was overotated leaving me with a class III relationship, poor nasolabial angle, bad bite, and grinding TMJ. After examining my photos and cephs he agreed with that. I dont think he would be open to revise my case if he though I had a good outcome on the first one.
You are only basing your opinion on 'you look better post op and other people agree with that'. I AGREE I look better Kavan. BUT, again, the rotation I got left me with a class III relationship, poor nasolabial angle, bad bite, and grinding TMJ.
So, you can't just patently take the perspective that 'because' your ANS-PNS line and OP line was 'flat', he 'should not' have done the CCW and instead 'should have' done CW or just linear advancement. I think I can. I feel I would have been cured just with linear advancement, the same way many people on this forum have been cured with linear advancement. I wanted my sleep apnea cured, but not at the expense of 'losing' my ID. If I knew that was the price needed to pay to cure it, I would have stuck to the CRAP machine.
Anyways, I understood that I am not going to convince you. My occlusal plane was left OUT OF THE NORM, leading to things that are objectively bad (bad bite, TMJ, poor nasolabial angle, protruding mouth, class III relationship), as well as subjective things (ID issues), BUT I agree with you that I still look much better post op. I dont want to convince you anymore, I think I kind of needed to convince you for some reason (I guess in order to feel that it was not all in my head). But well, now that Gunson agreed I feel much better.
I agree that YOU DON'T LIKE IT and also, it is likely that some of the things you don't like can be revised by Gunson.
What annoys me is blanket assessments of yours as to such things as the QUANTITATIVE extent of of CCW you 'should' or 'should not' have had when you're not even conversant in what those points, lines, planes and angles formed from them are. For example, somewhere on one of these strings, you had to ask what 'S', 'N' was (S-N line) was. Then you didn't observe it's angle of inclination was changed in both ceph tracings. IMO, that's an example of not being conversant or familiar enough with the QUANTITATIVE subject matter and not enough to content what the QUANTATIVE angle rotations--what ever-- 'should have' been.
So, ultimately you are buttressing your QUALTATIVE assessment of 'you don't like it' with quantitative measures where I end up taking a closer look at those quantitative measures and find they are off.
Don't tell me my opinion is based (soley) on the aspect that you look better when CLEARLY I showed you a GEOMETRIC demonstration of why my 'opinion' differed from your 10 degree angle assessment and also gave you a CLUE that the S-N differed too much and due to this CLUE you were able to find out you did not even KNOW you submitted a CT slice as your 'ceph'. Your assessment of my 'opinion' disregards I'm familar with geometrical angle relationships, points, lines, planes etc used in these ceph relationships.
Perhaps, it's particularly annoying to ME because I'm an MIT grad and it's just frustrating to me to discuss angle relationships against the back drop of 'I don't like it'.
That said, I AGREE that you don't like it. But you are on your own to make what ever quantitative assessments you like as far as angle rotations that you 'should' have. If I think you are off on those, I'm not going to frustrate myself anymore cross referencing or taking a closer look at those assessments. I've reached the limit of my annoyance with this and especially so with your statement that my opinion is based 'ONLY' on your looking better. Screw that.
Reminder to myself: Poke eyes with hot steel rods before giving feedback in the realm of logic or geometrical relationships to mazilla. Leave mazilla to his own opinion. Do not interfere.
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I apologize for saying that you base your opinion on my looks. Should not have said that.
Its true that I have no idea about those angles, points and planes used on cephs.
Its true that you demonstrated with logic that I made a mistake with the 10 degrees measurement. Thus you assume that I am OVERALL wrong. I was wrong about the quantitative assessment, not the qualitative one. I don't mind if it was 6 degrees or 10 degrees Kavan. The point im trying to make is that my occlusal plane was fine as it was. Flat occlusal planes do not need CCW rotation, even if you have OSA. It does open the airway, but it can lead to unwanted consequences such as the ones I had: class III relationship, closed nasolabial angle, protruding mouth, open bite... DESPITE this, I ended looking better than preop, but I believe all these could have been avoided.
So IN MY OPINION (I might be wrong, let's see what Gunson will say), and based on the results I got, I think that I should have had no rotation.
Not 10 degrees, not 6 degrees, not 1 degree. NONE, NADA.
I didn't assume that you were OVERALL wrong. I agreed that you did NOT LIKE your result (on qualitative grounds).
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Well that is a subjective statement, which cannot be refused. If you tell me you don't like spaghetti meatballs, I cannot say you are wrong Kavan, spaghetti meatballs is a delicious meal. But im sure you know that and you are just playing with me.
Well, I could not find any other case of a flat occlusal plane being rotated CCW any degrees, let alone 6 degrees. OSA or non OSA. Could not find it. In cases of flat occlusal planes I just found linear advancements.
Is it wrong? Well it does open more the airway so it is not technically wrong. Does it lead to an optimal aesthetic and functional outcome? I don't think so, definitely not in my case. Was it necessary? I don't think so either.
Can you agree with those? Or you can just agree with me not liking my result? Well it does not really matter if you agree or not. Well see what Gunson says, but lets imagine for a second that he does agree with me: CCW was not necessary to cure your OSA as you OP was flat, and it lead to unwanted aesthetic and functional outcomes. What would you say in that case? Spaghetti meatballs as well?
I agree you have the opinions you have and you are entitled to have them without my input.
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I had a proper CT scan and study done.
It does say I have mandibular prognathism and that I am severe brachiocephalic. I am an outlier in several measures.
Secondtimearound, if you want any measures or diagrams I can post them.
I am still considering revision.