Analyze My Cephalometric X-ray

[kjohnt]

I recently went to my childhood ortho to ask some questions about my treatment.  He provided a current ceph and some photos.  I've attached an untouched copy of the ceph plus a version with which I did a cursory analysis.

I think it's obvious I need bimaxillary advancement.  My maxilla is horizontally recessed and I can tell because I have no upper lip support and my philtrum basically goes straight down.  My mandible is also horizontally short.

Assuming I've drawn the Frankfurt plane correctly and the picture doesn't need rotated, my occlusal plane is about 9° relative to it.  Normal is 8° +/- 4° according to Wolford's papers, so I'm there, but I don't understand then why the lack of chin projection since it seems my menton (button of chin) is projected adequately relative to my lower incisors.  Arnett's papers say 5° +/- something like 1.5° (or actually 95° but comparing to a vertical line so same difference) for occlusal plane is ideal, so I believe CCW rotation to bring my occlusal plane to that would help bring my chin forward a bit.  Though perhaps a small sliding genio in conjunction with bimaxillary advancement which includes CCW rotation.  My lower lip curls out a lot though and I don't want to end up with a huge labiomental fold.  Maybe the BSSO will help the lower lip so I wouldn't have to worry about that?

It sure would be nice if I just needed straight advancement, but I think the amount of mandibular advancement needed would bee too much for my maxilla and I'd end up with an upturned nose and "chimp lip."

My mandibular plane is near normal range from my research (read 21° from Down's analysis which was conducted about 50 years ago or so but another source said 25°).  But it is weird in that there is a significant chunk missing on either side directly in front of the gonial angles so it makes it appear steeper.  I speculate the is where my vertical maxillary growth (partially because of cervical pull headgear) pushed my mandible downward, but I could be wrong.  I suppose the "why" doesn't matter now in any case.

My ortho said I have a class I occlusion and braces would not be necessary for surgery; rather, I'd be fitted with arch bars by the surgeon.  I've done a little research but don't know the implications thereof.  I like the idea of not having to go through braces again, and I'd save some cash.  Anybody have experience with or know anything about arch bars?  Do they stay on for a long time after surgery?  Any negatives?

TLDR:
- I think I need bimaxillary advancement with CCW rotation and possibly a genio in addition to balance my chin.  Thoughts?
- Any insight regarding arch bars in lieu of braces for jaw surgery?

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[thinkingme]

I think if there is no healt issues. dont go surgery. U seem good i think.

[notrain]

Your ceph analysis is correct and you have no issues really. Both the hard and soft tissue indicate a normal orthognathic retro profile. Unless you have sleep apnea, you don't need surgery.

[PloskoPlus]

Arch bars shred gums.  Another fixation option is IMF screws.  Whatever your ortho says, the bite will most likely require fine tuning after surgery (surgical movement aren't perfect), so you may need braces anyway.

I don't think you will gain much from jaw surgery.  You will just look different, possibly worse. I think your upper lip support is fine.  You don't want your upper lip stretched over your teeth.

[strongjawman]

Not saying it's right or wrong, but I can see why people with obvious facial deformities and functional problems get frustrated when good-looking people with a good bite and no other functional issues feel they need to get surgery.

OP, you are a good-looking man with strong facial features. Sure you can go from a text book about what the perfect measurements are and apply it to everyone, but you honestly look good. Why go through the hassle of spending a tonne of money to cut your skull open for a minor subjective improvement? Especially considering the health risks. Seems like the risk/cost outweighs the reward/benefit.

Feel free to correct me if I'm missing something though.

[overbiter]

I had arch bars. They were a nightmare on my soft tissue, I was so relieved to have them taken off.

Not saying it's right or wrong, but I can see why people with obvious facial deformities and functional problems get frustrated when good-looking people with a good bite and no other functional issues feel they need to get surgery.

OP, you are a good-looking man with strong facial features. Sure you can go from a text book about what the perfect measurements are and apply it to everyone, but you honestly look good. Why go through the hassle of spending a tonne of money to cut your skull open for a minor subjective improvement? Especially considering the health risks. Seems like the risk/cost outweighs the reward/benefit.

Feel free to correct me if I'm missing something though.

^ Yeah.

[JayJaw]

Your head is slightly tilted down in the pictures. I really do believe bottom ear hole and bottom of nose is "level" for everyone. This would bring your chin in line with your forehead and wouldn't look as recessed when analyzing it in the vertical.

I think you look good. You have the width and enough forward growth. Do you have ante face? No. You'd need your chin/mandible to extend further forward to come more in line with your maxilla (both being ahead of forward when head properly tilts level) to have that.

Is surgery worth it for that? I don't think so... but that's up to you to decide.

[Picollo30]

sometimes a camouflage orthodontic treatment doesnt treat the underlying problems, achieving a class I dental occlusion but staying with a weak jaw, retruded chin and a small airway of 4 mm that gives me severe sleep apnea says the treatment wasnt effective. see more maxfac surgeons and listen to what they have to say.

[molestrip]

Have you had a sleep study? The airway looks a few mm too small to me. Your occlusal plane looks great. I see the antegonial notch, commonly found with vertical growth patterns and your jaw looks like [it had some](http://fx.damasgate.com/wp-content/uploads/5-15-2011-11-09-25-PM.jpg). Normal is 25-30deg I believe. I would at least keep a close eye on your sleep, get a study every 5 years. But I think everyone should get regular sleep studies at least with every colonoscopy.

[kjohnt]

Thanks for the replies.

Regarding my aesthetic motives, it really has to do with the space between my chin and my neck - there isn't much.  Add to that that my mandible is narrow at the gonial angles and it appears my neck blends right into my face in pictures and on video, and I've hated it for as long as I can remember.  This on top of being very lean.  For the longest time I thought I just had a weakly projected chin, but I now know there's more to it.

I don't think I look horrible, but I do feel there is room for improvement.

I had arch bars. They were a nightmare on my soft tissue, I was so relieved to have them taken off.

^ Yeah.

How long did you have to have them?  I'd think at least a few months in order to ensure the jaws are stabilized?  Did you have an option of IMF screws?

Your head is slightly tilted down in the pictures. I really do believe bottom ear hole and bottom of nose is "level" for everyone. This would bring your chin in line with your forehead and wouldn't look as recessed when analyzing it in the vertical.

I think you look good. You have the width and enough forward growth. Do you have ante face? No. You'd need your chin/mandible to extend further forward to come more in line with your maxilla (both being ahead of forward when head properly tilts level) to have that.

Is surgery worth it for that? I don't think so... but that's up to you to decide.

It isn't.  My ceph is exactly horizontal as I can tell and the pictures I had posted match it.  The bottom of the orbital rim to the pogonion (which can be seen only in a ceph and it is difficult even then) is horizontal.

Have you had a sleep study? The airway looks a few mm too small to me. Your occlusal plane looks great. I see the antegonial notch, commonly found with vertical growth patterns and your jaw looks like [it had some](http://fx.damasgate.com/wp-content/uploads/5-15-2011-11-09-25-PM.jpg). Normal is 25-30deg I believe. I would at least keep a close eye on your sleep, get a study every 5 years. But I think everyone should get regular sleep studies at least with every colonoscopy.

I just had an at-home study done a few days ago and will get the result in a couple of weeks.  I'm 95% sure I have sleep apnea, and it runs in my family, though both obstructive and central.  If I have it, I sure hope it's the former.

Normal airway is 10mm I've read; mine's 6.5.

[kjohnt]

I realize most feel I'm not a candidate aesthetically but I want you guys to look again at my morph and tell me if you still feel the same.

I did a morph predicting STRAIGHT MMA without genioplasty.  I first slightly CCW rotated the lower half of my nose to the bottom of my upper lip since that soft tissue should rotate CCW even with straight advancement since above the advancement will naturally rotate.  This includes desireable upper lip projection and undesireable nose upturn.  Then I advanced from the top of the lower lip on down straight horizontally.  Finally, I pulled the lower lip in a bit since I think it won't curl out so much after mandibular advancement.

This is the result.  I roughly measured 10mm advancement at the chin by sizing my cephalometric x-ray to my profile shot and using the ruler on the ceph machine to compare the space between before and after.  I've also posted the photo I used to do this.  I realize it's probably not exactly 10mm, but I think it's close, say within 1mm either way.

I'd also hope that my jawline would pop slightly more with the advancement due to tightening skin, but I didn't try to create that effect.

Further questions:
1) Is this achievable/realistic?  Did I underestimate the amount the top of my philtrum will advance (i.e. under-project "chimp lip")?
2) If it is achievable, how does my morph look?  Do you think it looks better than my current profile?
3) Is 10mm bimax considered a large advancement?  How much could I expect this much advancement to affect my airway?

If you guys think I'm crazy, well, let me know that too I guess.

edit: removed my pics.  Message if you want to see them.

[jesterofmalice]

I don't think you're crazy, and I get annoyed when other people get annoyed at someone who wants surgery mainly for aesthetic reasons.
There's nothing wrong with wanting to look better, and just because ones issues aren't a medical necessity, it doesn't make it wrong want to improve.
On the facebook jawsurgery group i've seen lots of people who look very 'normal' and would probably get told by people here that they would never find a surgeon to operate on them as they look fine, but they all do fine a surgeon and get surgery done, and most of them look better after.

I'm not gonna try to get technical with you because you clearly know a lot more about all of this stuff than me, but I'd say that morph is a fair possibility based on the various 'before and afters' i've seen from people.

In your particular case (and in my personal opinion) you look different in the after, but i'm not sure you look that much better. Maybe very slightly. But it's all about personal preference, I guess. I think you look pretty good already.

Good luck!

[Bobbit]

I realize most feel I'm not a candidate aesthetically but I want you guys to look again at my morph and tell me if you still feel the same.

I did a morph predicting STRAIGHT MMA without genioplasty.  I first slightly CCW rotated the lower half of my nose to the bottom of my upper lip since that soft tissue should rotate CCW even with straight advancement since above the advancement will naturally rotate.  This includes desireable upper lip projection and undesireable nose upturn.  Then I advanced from the top of the lower lip on down straight horizontally.  Finally, I pulled the lower lip in a bit since I think it won't curl out so much after mandibular advancement.

This is the result.  I roughly measured 10mm advancement at the chin by sizing my cephalometric x-ray to my profile shot and using the ruler on the ceph machine to compare the space between before and after.  I've also posted the photo I used to do this.  I realize it's probably not exactly 10mm, but I think it's close, say within 1mm either way.

I'd also hope that my jawline would pop slightly more with the advancement due to tightening skin, but I didn't try to create that effect.

Further questions:
1) Is this achievable/realistic?  Did I underestimate the amount the top of my philtrum will advance (i.e. under-project "chimp lip")?
2) If it is achievable, how does my morph look?  Do you think it looks better than my current profile?
3) Is 10mm bimax considered a large advancement?  How much could I expect this much advancement to affect my airway?

If you guys think I'm crazy, well, let me know that too I guess.

What software did you use to do he MORPHS - -  ?

Nicely done, BTW.  I suspect they are reasonable.

[kjohnt]

What software did you use to do he MORPHS - -  ?

Nicely done, BTW.  I suspect they are reasonable.

MS Paint, actually.  To rotate the nose and upper lip, I just Googled "rotate picture" and used one of the links.  I rotated, saved as new image, and used said pieces from it.

[strongjawman]

I don't think you're crazy, and I get annoyed when other people get annoyed at someone who wants surgery mainly for aesthetic reasons.
There's nothing wrong with wanting to look better, and just because ones issues aren't a medical necessity, it doesn't make it wrong want to improve.
On the facebook jawsurgery group i've seen lots of people who look very 'normal' and would probably get told by people here that they would never find a surgeon to operate on them as they look fine, but they all do fine a surgeon and get surgery done, and most of them look better after.

I'm not gonna try to get technical with you because you clearly know a lot more about all of this stuff than me, but I'd say that morph is a fair possibility based on the various 'before and afters' i've seen from people.

In your particular case (and in my personal opinion) you look different in the after, but i'm not sure you look that much better. Maybe very slightly. But it's all about personal preference, I guess. I think you look pretty good already.

Good luck!

There is a difference between wanting to look better when you are not very attractive to begin with and when you are attractive to begin with. Double jaw surgery is a major surgery. If you are willing to have both your jaws cut open and spend thousands of dollars to change your face when you are already good looking, I would suggest you have some underlying self-esteem issues that your confidence is hanging on.

It is a dangerous road, and many people don't stop with one surgery and end up looking much worse than when they started. In theses cases I think it is not only justified to warn people against it but morally irresponsible to encourage people to go down this path.

OP is a very good looking man, but in my opinion is blaming his appearance for other self-esteem issues.

Do you feel your appearance is holding you back anywhere in life OP?

Do you really hate your appearance that much? Ask anyone and they will tell you that you are attractive by any objective standards.

Kjohnt, again feel free to correct me if you feel I am wrong and explain your rational for this.