Author Topic: Best Aesthetic  (Read 3678 times)

jawsurgery029184

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Best Aesthetic
« on: November 28, 2018, 02:55:37 AM »
Hi everyone,

I was wondering if you guys can offer any advice as to which procedures for the upper jaw would give the best aesthetic outcome. My lower jaw is recessed and I know I will have to get a BSSO, but it seems that the surgeon I have consulted is not sure whether or not the upper jaw should be moved. I will be looking into further consultations, but would like to hear your thoughts.

https://imgur.com/a/LVLmqI5

Thanks

PloskoPlus

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Re: Best Aesthetic
« Reply #1 on: November 28, 2018, 03:04:55 AM »
You have a steep occlusal plane, so DJS.

jawsurgery029184

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Re: Best Aesthetic
« Reply #2 on: November 28, 2018, 04:25:17 AM »
I just did some googling and yes it does look like I have a steep occlusal plane. Now I'm wondering why my orthodontist thought that this is a clear case of BSSO-only and why the OMS seemed to think so too. I will bring the occlusal plane steepness up during a next meeting/consultation, thanks

PloskoPlus

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Re: Best Aesthetic
« Reply #3 on: November 28, 2018, 07:41:46 AM »
I just did some googling and yes it does look like I have a steep occlusal plane. Now I'm wondering why my orthodontist thought that this is a clear case of BSSO-only and why the OMS seemed to think so too. I will bring the occlusal plane steepness up during a next meeting/consultation, thanks
Orthodontists think about the tooth-to-tooth relationship and little else.  Truth be told most surgeons are bite-only as well.  The fact that your surgeon brought it up means that at least he is mindful of aesthetics.  This still does not mean he's a good surgeon.  BSSO only will probably give you a longer face and you will still look recessed. A lazy surgeon would then try to camouflage this with a genioplasty..

jawsurgery029184

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Re: Best Aesthetic
« Reply #4 on: November 28, 2018, 05:54:54 PM »
Do you know how it is determined whether someone needs impaction, CCW, a segmented lefort, etc?

ghiggson90

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Re: Best Aesthetic
« Reply #5 on: November 28, 2018, 08:12:30 PM »
I agree the steep occlusal plane suggests CCW, which requires DJS. Only with a clinical evaluation can the appropriate movement to improve facial balance be planned. Impaction is determined with reference to the upper lip to maxillary incisor tip relationship. I would consult with Wolford’s paper on occlusal plane alteration for more on CCW.

kavan

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Re: Best Aesthetic
« Reply #6 on: November 30, 2018, 08:48:01 PM »
You have a 'complicated' facial geometry in the sense there are some distance relationships that can't be changed but are a significant number of deviations from the norm. For example the S-N line distance is very short compared to the norm. So, they are kind of limited in how much they can 'balance' so that all is within the norms. Also, the teeth are kind of 'bucked out' which will limit the extent of CCW they can do because the CCW (posterior down graft) would tend to buck them out more as the teeth also get rotated in that process.


With reference to a horizont;

your occlusal plane angle is about 16 degrees

your Mandibular plane angle is approx 36 degrees

your OP is about 4 degrees in excess of the norm range of about 12 deg

your MP is about is about 9 degrees in excess of the norm range of about 27 deg

Sure, you could say "steep" but when ever you can MEASURE something relative to a line that could be used in a ceph analysis, you can compare HOW steep with reference to which line one is using to take the angle and then look up the norms.


Here, I'm using a 'true' horizont because your Frankfort line is pretty close to a horizont (a few degrees off but close enough).

I could also use the Steiner S-N line to measure the OP and MP. Your S-N line is about 8 degrees away from a horizont. With that system:

your OP is about 24 deg

your MP is about 44 deg

your OP is about 10 deg in excess of a 14 deg mean in Steiner

your MP is about 12 deg in excess of a 32 deg mean in Steiner


So you could say BOTH are 'steep'. But you can't really conclude that CCW to the maxilla (hence double jaw) is the 'answer'. If you think it is, calculate the amount of OP rotation that would be needed to offset (make less) the excess angle of inclination of the MP. Or just think intuitively in terms of knowing that CCW to the maxilla (here posterior downgraft) will be proportional to the rotation of the mandible. So, to make it easier, let's say rotate maxilla 4 degrees to get about a 4 degree auto-rotation of mandible. Make it 5, 6, 7...and still you won't be enough to offset the excess of the MP. But wait...there's an easier way to think about this. NOTE the PURPLE LINE I drew on your ceph. That's basically the line that would be rotated CCW. Note that the more that's rotated, the more your teeth are going to be 'bucked out' closer to a horizontal axis. In essence, you have some angle relationships that LIMIT how much benefit you would get from CCW.

Now your maxfax probably saw that kind of relationship and hence just suggested single jaw only.  They could also look at the angle relationship between the MP and OP which are BOTH 'steep'. It's about 20 deg which is about within the norm for an OP-MP angle even though both are steep.

What they are looking at is DATA that would justify BSSO only. They can also see that although your S-N line is short and with a number of deviations from the norm length (something that can't be changed), your SNA is within the norm (that refers to maxilla angle relationship) and it's only your SNB (that refers to the mandible) that is LESS than norm for that angle and hence can be isolated for single jaw advancement.

So, I've found what they most likely would be looking at and how they would look at some of these relationships.

Now, it isn't easy for me to EXPLAIN this stuff. Like I never know if people getting this stuff are even 'in tune' with some fundamental geometric relationships which I'm using to explain things. If not, not my task to fill in too many gaps.

So, here, I'm just conveying the most likely HOW and WHY the doc who suggested BSSO only is looking at it and conveying such in the event you would like to think more about the conclusion of: 'You need bimax CCW because you have a steep OP'. A steep OP is not the only thing a max fax looks at. If that were the case, there would not be all those lines and angle measure relationships made from them which you can see on the ceph and measures of them on the ceph analysis.



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ditterbo

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Re: Best Aesthetic
« Reply #7 on: December 01, 2018, 05:39:51 PM »
Very cool (explanation)... I just spent the past half hour looking into the sella-nasion line but couldn't find anything on the 'normal' length. This is the area I've been insecure about too, being too short in length, but never knew for sure. My head circumference isn't abnormally short (measured 57.9cm - in the market for a full face helmet..). Does anyone know where more information lies on the average length of the SN line? Much appreciated!  Puts things into better perspective, if that's indeed the case for me too.

ETA: Well FWIW, the "Bjork-Jarabak Analysis" thinks the average "N-S" measurement is 71mm. Mines 70.67, so maybe I'm imagining things...
« Last Edit: December 01, 2018, 05:50:59 PM by ditterbo »

kavan

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Re: Best Aesthetic
« Reply #8 on: December 01, 2018, 06:30:01 PM »
Very cool (explanation)... I just spent the past half hour looking into the sella-nasion line but couldn't find anything on the 'normal' length. This is the area I've been insecure about too, being too short in length, but never knew for sure. My head circumference isn't abnormally short (measured 57.9cm - in the market for a full face helmet..). Does anyone know where more information lies on the average length of the SN line? Much appreciated!  Puts things into better perspective, if that's indeed the case for me too.

ETA: Well FWIW, the "Bjork-Jarabak Analysis" thinks the average "N-S" measurement is 71mm. Mines 70.67, so maybe I'm imagining things...

Thanks pal. A lot of analysis systems don't give the value measure of N-S. But sometimes you can ferret out that it's small by the other linear measures given on other types of analysis (eg McNamara), like mandible or maxilla 'length' where these lengths are diagonal ones which are listed as small which would be small if the SN was small. Small face is also consistent with it.  I think the person who posted this string once had the ceph read outs up. But then took them down. I recall seeing the N-S listed on it. So maybe he/she can put that back up for the number. But I know it's difficult to look up.
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jawsurgery029184

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Re: Best Aesthetic
« Reply #9 on: December 07, 2018, 08:27:54 PM »
Late response, but I re-uploaded my the measurements in case anyone would be helped by it. Also, thank you for your diagram and explanation, Kavan. There is definitely some content that I still need to look up and that’s not easily digestible to me, but I see why the current flaring of my upper teeth poses issues for CCW.

If I were to want CCW anyway, would the main option to go about this is to get extractions to decrease the flaring and then ask for bimax with CCW?  Does anyone know if there is any substantial evidence of a steep occlusal plane and high mandibular plane angle being detrimental to one’s health? Most insurances don’t seem to have anything on the necessity of CCW or anything on occlusal planes on their websites (I know insurances obviously vary in what they choose to provide and aren’t the best resource, but I am still surprised that there is no mention of anything other than standard malocclusions).

kavan

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Re: Best Aesthetic
« Reply #10 on: December 07, 2018, 08:43:36 PM »
Late response, but I re-uploaded my the measurements in case anyone would be helped by it. Also, thank you for your diagram and explanation, Kavan. There is definitely some content that I still need to look up and that’s not easily digestible to me, but I see why the current flaring of my upper teeth poses issues for CCW.

If I were to want CCW anyway, would the main option to go about this is to get extractions to decrease the flaring and then ask for bimax with CCW?  Does anyone know if there is any substantial evidence of a steep occlusal plane and high mandibular plane angle being detrimental to one’s health? Most insurances don’t seem to have anything on the necessity of CCW or anything on occlusal planes on their websites (I know insurances obviously vary in what they choose to provide and aren’t the best resource, but I am still surprised that there is no mention of anything other than standard malocclusions).

Your option is to consult with a doc who does CCW.
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kavan

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Re: Best Aesthetic
« Reply #11 on: December 08, 2018, 11:57:46 AM »
Late response, but I re-uploaded my the measurements in case anyone would be helped by it. Also, thank you for your diagram and explanation, Kavan. There is definitely some content that I still need to look up and that’s not easily digestible to me, but I see why the current flaring of my upper teeth poses issues for CCW.

If I were to want CCW anyway, would the main option to go about this is to get extractions to decrease the flaring and then ask for bimax with CCW?  Does anyone know if there is any substantial evidence of a steep occlusal plane and high mandibular plane angle being detrimental to one’s health? Most insurances don’t seem to have anything on the necessity of CCW or anything on occlusal planes on their websites (I know insurances obviously vary in what they choose to provide and aren’t the best resource, but I am still surprised that there is no mention of anything other than standard malocclusions).

Insurance just covers surgery where there is what they consider a 'medical indication' for it. Something where the jaw to jaw relationship impinges on one's health such as sleep apnea or a type of bite problem--malocclusion-- that can be associated with with some 'medical indication' for the insurance company to pay for the surgery.

The claim is submitted in terms of alleviating what ever med condition it would alleviate. Although aesthetic improvement can be had by a surgery where there is 'medical indication' for it and that is so because some very salient aesthetic deviations as to jaw imbalance are associated with health issues, NEED for the surgery is NOT evaluated in terms rotations. Because which rotation to do (or not to do) is a FUNCTION of which one will 'fix' the malocclusion (assuming malocclusion is the problem). Hence malocclusion already takes into consideration the occlusal plane. So NO SURPRISE different types of rotations to the maxilla (or no rotations at all) will depend on which one fixes the malocclusion.

Insurance agencies are pretty circumspect about patients perusing maxfax solely for 'aesthetics' and/or the doc being compensated might not be so inclined to do something that will maximize aesthetics IF the malocclusion can be addressed by lets say, BSSO only AND there will be an aesthetic IMPROVEMENT. So, if the aesthetics could be maximized, for example by a CCW via posterior downgraft, the doc might  elect to GO THE EXTRA MILE to do that but insurance might not pay out for that extra mile if they feel the doctor is billing them extra for 'cosmetics'.

If you want to pick and choose among maxfax docs known to maximize aesthetics, options are more open with self pay. That or look for a doc who has a lot of private pay patients but also takes insurance.
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