Revision double jaw surgery - advice

[Brachy]

Local croatian oral surgeon.. I have consulted another doc and he suggested removing screws and plates 6-7 months after surgery, while revision should take place 12 months after surgery.. should I ask him again on doing both things at the same time.. what is your opinion.. thank you very much

[Brachy]

Guys, I would appreciate if You could take a look at my

[Brachy]

Guys, I would appreciate if You could take a look at my cephalometrics from last week.. appreciate Your comments, thanks in advance

[attachment deleted by admin]

[kavan]

The ceph is just a TRACING of your profile and dental/jaw relationships to the cranial base. It isn't a displacement analysis where any displacement proposals are shown overlayed to the tracing.

The analysis of the ceph tracing give the measurements and angles along with the standard deviations and how much you deviate from the norm. 1* asterisk is one standard deviation, 2** and 3** asterisks  are two and three deviations respectively.

It reveals that although your S-N line DISTANCE, which is the anterior cranial base, is within the NORM, the ceph tracing SHOWS that your S-N LINE is parallel to the HORIZONT. Although it might not give the norm angle the S-N line is inclined away from the horizont, (or it's in a language I can't read the whole thing), 'normal' SNA, SNB and ANB measures USUALLY are in reference to the S-N line being angled about 7 degrees or more away from the horizont. I don't know the exact cut off point for the range of angled away from the horizont to be 'norm'. But I don't think being flush with the horizont is normative. (But pursue that question further with the maxfax who sees LOTS of ranges and can give you insight into norms for the range of how the normative S-N lines are angled AWAY from a pure horizont).

The S-N line being basically a 'pure HORIZONT' and it ALSO being the measure and angle inclination of the CRANIAL BASE from which other measures are RELATIVE TO is what is kicking up a number of DEVIATIONS from the norm to your measures. For example your SNA and SNB angles are NOT normative (3 standard deviations= 3 * asterisks) BECAUSE the horizontal S-N line is what is INCREASING the angle measures from the norm. Basically IF the S-N line were 'SLOPED' (positive slope line) AWAY from the pure horizont, both the SNA AND SNB angles woud DECREASE more towards the norm. (Just basic geometry concept). So, you will find other deviations with distance or angle measures that have S-N in them.

It MUST be NOTED that the S-N line, it's DISTANCE and it's angle INCLINATION away from a horizont CAN NOT BE CHANGED. It is CONSTANT. It is the line that a lot of maxfax measurements are related to when you consider that maxfax surgery and displacements they do is going to be RELATIVE to the anterior CRANIAL BASE which is what that S-N line is. So, one has to be AWARE of that before they start thinking; 'Oh, my SNA and SNB angles are "too protrusive" and therefore I need both my jaws pushed backwards.' The HIGH SNA AND SNB angles arise from the S-N line being flush with a PURE horizont which DIFFERS from when the 'A' and 'B' points of those angles are 'too protrusive'. So, it's MORE about the S-N line being HORIZONTAL than it is about the A and B points being 'too protrusive' or absolutely 'needing' both jaws to be pushed backwards.

Now the ANB angle (SNA-SNB=ANB) you have is normative for Class 1 skeletal pattern from the surgery. The ANB (and also the S-N line) is used in STEINER analysis. He didn't use the 'Frankfurt plane' because there was a point in there that was HARD TO SEE on a lot of X rays. Incidentally, your Frankfort line or plane is NOT horizontal (dashed angled line you see cutting through the nose on your ceph).

In situations where someone has Class1 skeletal pattern according to STEINER analysis and or when the SNA and SNB angles are still 'off' from the norm, it's cross referenced with the WITS. Here the WITS tells you there is Class 3 skeletal pattern. The Wits is done by drawing a line through the occusial plane. Then lines from BOTH the 'A' and 'B' points are drawn TO the OP so that the lines; 'AO' and 'BO' are PERPENDICULAR to the OP which I have APPROXIMATED on your ceph tracing in RED. When line 'BO' is anterior to (ahead of) line 'AO', which is the case with YOU, the WITS reveals a Class 3 skeletal pattern. That is WHY the (Steiner) ANB angle you have is associated with the Class 1 skeletal on your SUMMARY ANALYSIS but the WITS says Class 3 skeletal.

The SUMMARY ANALYSIS also says you are BRACHY (cephalic), hence, I guess your selected screen name where you probably know you are brachiocephalic which means you have a high ratio of WIDTH to head vs LENGTH of the entire cranial base (anterior to posterior). This is OFTEN associated with a 'SHORT' lower 1/3rd of the face or 'short chin'. A lot of ethnic groups in Eastern Europe are brachiocephalic and not doliocephalic. So having a shorter lower 1/3rd of the face can be considered normative for many groups of people such that they don't have the 'equal 1/3rds'. So 'Facial Pattern: Brachy-facial' on your chart could just be an assessment that you are brachiocephalic (skull measures) and have facial pattern associated with that. It could also reveal (I'm guessing here) that you started off with SHORT lower 1/3rd (or short chin) and PERHAPS you wanted an INCREASE in that dimension and perhaps the doctor felt the surgery justified if he found also that your UPPER JAW was also short (lack of upper teeth show). Your ceph certainly shows (and also your initial statement) your upper jaw was dropped down (made longer). Also that CLOCKWISE rotation was used in ADDITION to making the CHIN longer which would be the case of someone wanting a LONGER lower 1/3rd and/or chin who wanted to look LESS brachy-facial.

[Brachy]

Dear Kavan,

thank You very much. I appreciate Your comments on sella-nasion inclination and its impact on overall analysis..

[kavan]

Dear Kavan,

thank You very much. I appreciate Your comments on sella-nasion inclination and its impact on overall analysis..

Thanx for the thanx. Another way to thank is to give an upvote for a post which means to hit the 'applaud' option below a person's screen name. That is what gives me the right feedback as to whether or not a post was helpful.

[Brachy]

I have consulted dr. Z and dr. B. and I can say only high words about them.. they care very much about their patients, are pleasant to talk and discuss all the issues.. since I bite only on two teeth and am very unhappy with my face, I have decided to revise my first surgery to:
Fix maxilla and mandibula asymmetry
Counterclockwise rotation of the occlusal plane
Small backward setback to reduce protrusive profile
Genioplasty revision to solve lip incompetence

In general, I feel like I was overcorrected and liked my face before. My jaws are so big and wide for the small face I have.. I hope that some "middle" solution could work for me.. thanks in advance

[Dogmatix]

I have consulted dr. Z and dr. B. and I can say only high words about them.. they care very much about their patients, are pleasant to talk and discuss all the issues.. since I bite only on two teeth and am very unhappy with my face, I have decided to revise my first surgery to:
Fix maxilla and mandibula asymmetry
Counterclockwise rotation of the occlusal plane
Small backward setback to reduce protrusive profile
Genioplasty revision to solve lip incompetence

In general, I feel like I was overcorrected and liked my face before. My jaws are so big and wide for the small face I have.. I hope that some "middle" solution could work for me.. thanks in advance

Please spell out the names.

[Brachy]

I have consulted dr. Brusco, dr. Zarrinbal, dr. Iannetti, dr. Malek

[kavan]

I have consulted dr. Z and dr. B. and I can say only high words about them.. they care very much about their patients, are pleasant to talk and discuss all the issues.. since I bite only on two teeth and am very unhappy with my face, I have decided to revise my first surgery to:
Fix maxilla and mandibula asymmetry
Counterclockwise rotation of the occlusal plane
Small backward setback to reduce protrusive profile
Genioplasty revision to solve lip incompetence

In general, I feel like I was overcorrected and liked my face before. My jaws are so big and wide for the small face I have.. I hope that some "middle" solution could work for me.. thanks in advance

OK. Sounds like Dr. Z and B are nice guys. Now, let's RELATE your EXTRAPOLATION/conclusion of what you have decided to do to THEIR suggestions for you:

[Fix maxilla and mandibular asymmetry
Counterclockwise rotation of the occlusal plane
Small backward setback to reduce protrusive profile
Genioplasty revision to solve lip incompetence]

Here, I'm wanting to know if both Dr. Z and B AGREE with YOUR conclusion that you need the first 3 things listed on your 'to do list'.

The first 3 things on your 'to do' list appear to OVERLAP with what your FIRST surgeon (who you say did not give you the right surgery in the first place; "Unfortunately, plan was not correct" which you said in your opening post) wants to do.

Is that correct? Are the first 3 things on your list ALSO the things your FIRST surgeon wants to do for you?

Next question:

Are those ALSO the SAME 3 things both Dr. B and Dr. Z who are 'chin wing' docs (but of course also do max fax) want to do for you? Both of those doctors also want to give you more COUNTER clockwise rotation and move both your jaws backwards?

In particular, please relay what BOTH Dr. B and Dr. Z suggested to you. Their both being 'nice guys' tells me NOTHING about HOW what they suggested to you RELATES to your conclusion that you need the first 3 things you listed.

So:

1: Do both Z and B AGREE you need to do what your FIRST doctor is willing to do for you?

2: Are they willing to do that FOR you in ADDITION to revising your chin OR do they want you to get that done by the first doctor before they revise the chin for you?

Just answer the questions. No other self assessments of what you think you need to do.

What I'm trying to establish here is whether or not both Dr. Z and B ALSO AGREE with the first 3 things that YOU think you need to do which are same things your FIRST surgeon has agreed to do for you.


ETA: I'm a bit confused. Does your original doctor want to do clockwise rotation (more of it with his double jaw set back) or counterclockwise with his double jaw set back?

[Brachy]

Here, I'm wanting to know if both Dr. Z and B AGREE with YOUR conclusion that you need the first 3 things listed on your 'to do list'.


[I have significant asymmetry and my teeth do not meet properly. All 3 doctors agree it can't be fixed with elastics. Maxilla is very much rotated to the right and even chin is asymmetric. As for the protrusivness, both dr. Z. and dr. B. are of opinion that I was overcorrected and my occlusal plane is to steep. So too much teeth show, too much clockwise rotation. ]

Is that correct? Are the first 3 things on your list ALSO the things your FIRST surgeon wants to do for you?

[From the last visit, I would say yes. I am seeing doc on Wednesday again.]

Are those ALSO the SAME 3 things both Dr. B and Dr. Z who are 'chin wing' docs (but of course also do max fax) want to do for you? Both of those doctors also want to give you more COUNTER clockwise rotation and move both your jaws backwards?



[Jaw setback would be minimal 1-2mm, but too much teeth show and clockwise rotation is common opinion.]

1: Do both Z and B AGREE you need to do what your FIRST doctor is willing to do for you?

[In general yes, all 3 doctors say I was overcorrected. ]

2: Are they willing to do that FOR you in ADDITION to revising your chin OR do they want you to get that done by the first doctor before they revise the chin for you?

[They both told me I need ortodontic preparation for revision surgery, especially dr. B. was unhappy about my teeth preparation. As of today, I do not have formal document (letter), but they were positive
about the surgery (in approximately next 6-9 months, not before)]

Last question - counterclockwise

[uj]

If several surgeons have suggested similar plans, this is probably reasonable.

Hi, I had undergone double jaw surgery and genioplasty 4 months ago.. I had maxiliary downgrafting, clockwise rotation and mandible brought forward to correct class 2 bite.. Unfortunately, plan was not correct and I would appreciate your help what needs/can be done to correct:

- lip incompetence - I can't close my lips without straining, it so much affects my speech
- protrusive profile - perhaps slight backward movement of both jaws (I have very high SNA/SNB values)

Jaw setback would be minimal 1-2mm, but too much teeth show and clockwise rotation is common opinion.

There is some unpredictability/variabilty to the soft-tissue response, but I have been told that 1 mm bony movement presents as 0.5 mm at the soft-tissue level.

Did your first surgeon give you a copy of the plan prior to surgery? Were you shown the soft-tissue simulation? If so, how does this compare with how you look now?

Do you have any numbness?

[Brachy]

I appreciate your comment. I wish I had never undergone jaw surgery process and would wish to come back to my old situation (no teeth show, short face). I hate my big, protrusive jaws and even consider going back to the old situation.
However, surgeons would probably consider "middle" version as solution. I have very much regreted the operation and the worst thing is that I often notice smile on people's faces while I talk.
I have been shown simulation prior to surgery, but then again it is not realistic I would say. I know approximate movements (like do not know the amount of clockwise rotation), but will ask on Wednesday.

Numbmess is present, I would say chin area 50%, lower lip 10%. Upper lip - no problem. 6 months post op. I have noticed much more muscular tention after increasing lower third.

Please do not hesitate to ask in case of further questions.

[CCW]

Who was your surgeon?

[Brachy]

Local croatian oral surgeon, why do You ask?