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General Category => Functional Surgery Questions => Topic started by: Matt on September 21, 2016, 03:20:06 PM

Title: Matt's CCW MMA Thread
Post by: Matt on September 21, 2016, 03:20:06 PM
Hello,

I'm having some difficulty understanding how my pre-surgical orthodontic decompensation will work (or if I even need it?). Some back story on my case:

- 22 year old male

- 4+ years of orthodontic treatment (as a child/teenager) to fix a class II overbite

- Herbst appliance used to "bring forward" my recessed mandible (which I believe led to my maxilla being pulled backwards instead)

- Result was a class I bite, but with both a recessed upper and lower jaw

- Today I am left with vertical maxillary excess, long face, gummy smile, lip incompetence, slight open bite (not too severe), a very small airway (due to recessed maxilla/mandible), tongue thrust habit (again, due to recessed maxilla/mandible - feels like I'm choking on my own tongue when mouth is closed), and just overall discomfort with my bite (requires constant mental attention to keep closed, and after a period of time the discomfort turns to pain)

I have already been approved by my insurance provider for a BSSO + LeFort I with CCW rotation (genioplasty and pre-surgical braces not included). Today I had my braces put on for the pre-surgical treatment (the third time in my life now! Haha)...but I'm unsure of how my class I bite will be decompensated for surgery. Due to the fact that I am returning to college next semester (currently on a leave of absence) my orthodontist and surgeon are working together on a fairly tight timeline. Ideally my surgeon would like the surgery to be in early December (so that I have enough time to heal before returning to school in late January). Of course, that means that my orthodontist will be trying to complete the pre-surgical treatment within 3 months (and he feels hopeful that this is possible). So now for my confusion...

How can my class I bite be decompensated back to a class II overbite (to maximize surgical movements), when the original compensation was due to the Herbst appliance recessing my maxilla? That isn't a typical case of reversable camoflauge orthodontics! So what now... do I just move forward with bimaxillary advancememt from a class I occlusion (and not receive the maximized movements of a decompensated class II bite?). A few last details to note...

As a child I never suffered from crowding, my wisdom teeth had more than enough room to fully erupt, and all four were recently removed in preperation for surgery. The only reversable compensation that I'm aware of would be my slightly retroclined teeth to camoflauge the overbite (and this is what my orthodontist is working to decompensate over the next 11 weeks). I suppose I'm just skeptical that a decompensation that small would create enough of an overbite to maximize the surgical movements.

Thank you in advance to those that take the time to read/respond to me. I would love to hear any input or feedback on my situation - it's much appreciated!

All the best,
Matt
Title: Re: Class I Decompensation for CCW MMA
Post by: mynameis on September 21, 2016, 04:32:00 PM
If the bites already good can they not just do the surgery?

I might not be understanding something... Sorry for not satisfactorily answering your question, maybe you could get them to explain what exactly the 'decompensation' part is for. Perhaps its just preparation for the after surgery bite?
Title: Re: Class I Decompensation for CCW MMA
Post by: ascolta on September 21, 2016, 07:16:35 PM
Yep I understand what you mean. I am also having a CCW rotation, though in my case it's through a posterior downgraft of my maxilla because I don't have a gummy smile. My original surgeon wasn't well versed with rotations so he recommended first premolar extractions in the lower arch and lower incisor retraction. I also had a dental class I bite though both my jaws are very recessed. Dr Gunson sort of thought the extractions were a mistake as he could've done the surgery without it -- there would've been more than enough room to advance the lower jaw relative to the upper jaw by doing CCW. That is to say, your surgery plan is what Dr Gunson would have recommended for me, but I saw him after the extractions had already been done. So now my lower incisors are too upright, when in fact they're supposed to be flared, as long as it's not excessive. On the other hand I can now have a greater mandible advancement (something crazy like 20 mm). But the large genioplasty (7 or 8 mm) I had done 5 years ago as camouflage will have to be partially reversed so I don't become prognathic.

If they can achieve orthognathic jaws without retracting your lower incisors, then you've been decompensated enough, in my opinion. Also what a coincidence -- I'm also 22, had 4 years of braces, and used a Herbst appliance. Those things should be taken off the market.
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on September 21, 2016, 10:12:30 PM
If the bites already good can they not just do the surgery?

I might not be understanding something... Sorry for not satisfactorily answering your question, maybe you could get them to explain what exactly the 'decompensation' part is for. Perhaps its just preparation for the after surgery bite?

From my understanding, decompensating the bite allows for the surgical movements to be maximized. Check out the last 3 posts in this thread (from Picollo30, kjohnt, and Tezcatli): http://jawsurgeryforums.com/index.php?topic=5246.0;nowap

My concern is that my bite may not have much to decompensate, since the camoflauge orthodntic compensation to begin with was my maxilla recessing to meet my mandible (Herbst appliance). So do I need to recreate an overbite now during this decompensation phase (to maximize surgical movements)? And if so, how could I even do that considering the only decompensation currently available to me is straightening out my retroclined upper teeth. Sure, this might create a slight gap, but my teeth aren't severely retroclined to begin with so I doubt it will be much.

Yep I understand what you mean. I am also having a CCW rotation, though in my case it's through a posterior downgraft of my maxilla because I don't have a gummy smile. My original surgeon wasn't well versed with rotations so he recommended first premolar extractions in the lower arch and lower incisor retraction. I also had a dental class I bite though both my jaws are very recessed. Dr Gunson sort of thought the extractions were a mistake as he could've done the surgery without it -- there would've been more than enough room to advance the lower jaw relative to the upper jaw by doing CCW. That is to say, your surgery plan is what Dr Gunson would have recommended for me, but I saw him after the extractions had already been done. So now my lower incisors are too upright, when in fact they're supposed to be flared, as long as it's not excessive. On the other hand I can now have a greater mandible advancement (something crazy like 20 mm). But the large genioplasty (7 or 8 mm) I had done 5 years ago as camouflage will have to be partially reversed so I don't become prognathic.

If they can achieve orthognathic jaws without retracting your lower incisors, then you've been decompensated enough, in my opinion. Also what a coincidence -- I'm also 22, had 4 years of braces, and used a Herbst appliance. Those things should be taken off the market.

Thank you for sharing your situation with me - there are definitely some similarities there, haha! I agree about the Herbst appliance (wish I never had it, and instead just had surgery to begin with). Right now my lower teeth are pretty upright (or at least I can't spot any proclination/retroclination). My uppers are slightly retroclined, and my orthodontist is working to bring them forward over the next 11 weeks... but like I said, I can't see it decompensating my bite any further than a slight gap. So where does that leave me? As Tezcatli mentioned in the thread I linked above, advancing both jaws without first decompensating the bite leads to subpar results / doesn't address the skeletal discrepancy. I just don't know how my bite could be further decompensated (especially in 3 months).
Title: Re: Class I Decompensation for CCW MMA
Post by: ascolta on September 21, 2016, 11:40:00 PM
I don't think you should worry about this. You're already getting the "discrepancy" through the CCW rotation. That is, the CCW will allow your lower jaw to be advanced x mm more than your upper jaw. If you were having a straight MMA done, then it would make sense to extract first premolars and retract the lower incisors to maximize the overjet. As it stands your lower incisors are not super flared like you said so you don't have a lot of compensations going on.
You should peruse this page (http://www.arnettgunson.com/fab-treatment-planning/airway/sleep-apnea-treatment/ccw-mma-osa-cure), it really helped me understand it. It seems that poor OSA results are due to surgeons performing straight MMA where CCW is called for, so you're good on that front. Best of luck!
Title: Re: Class I Decompensation for CCW MMA
Post by: kjohnt on September 22, 2016, 12:18:06 AM
Your ortho should decompensate to the extent that your incisors (and all other teeth for that matter) sit properly within their respective arches, regardless of how the upper teeth and lower teeth contact. This means slightly proclined for uppers and upright for lowers.  Amount of ovejet or whatever shouldn't be taken into consideration.  You don't want to "maximize amount of mandibular advancement" by creating a gap and retroclining the lower incisors because you are then bringing the mandible too far forward relative to maxilla.

So again, teeth are positioned ideally within respective arches regardless of occlusion.  The surgery takes care of everything else.  In your case, it sounds like minimal decompensation is necessary since maxilla is also recessive. Maxilla just gets moved forward as well.  If you need more mandibular movement relative to maxilla, you need ccw rotation, and your lateral ceph will show this as your occlusal plane will be steeper than ideal.
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on September 22, 2016, 09:54:11 AM
I don't think you should worry about this. You're already getting the "discrepancy" through the CCW rotation. That is, the CCW will allow your lower jaw to be advanced x mm more than your upper jaw. If you were having a straight MMA done, then it would make sense to extract first premolars and retract the lower incisors to maximize the overjet. As it stands your lower incisors are not super flared like you said so you don't have a lot of compensations going on.
You should peruse this page (http://www.arnettgunson.com/fab-treatment-planning/airway/sleep-apnea-treatment/ccw-mma-osa-cure), it really helped me understand it. It seems that poor OSA results are due to surgeons performing straight MMA where CCW is called for, so you're good on that front. Best of luck!

Your ortho should decompensate to the extent that your incisors (and all other teeth for that matter) sit properly within their respective arches, regardless of how the upper teeth and lower teeth contact. This means slightly proclined for uppers and upright for lowers.  Amount of ovejet or whatever shouldn't be taken into consideration.  You don't want to "maximize amount of mandibular advancement" by creating a gap and retroclining the lower incisors because you are then bringing the mandible too far forward relative to maxilla.

So again, teeth are positioned ideally within respective arches regardless of occlusion.  The surgery takes care of everything else.  In your case, it sounds like minimal decompensation is necessary since maxilla is also recessive. Maxilla just gets moved forward as well.  If you need more mandibular movement relative to maxilla, you need ccw rotation, and your lateral ceph will show this as your occlusal plane will be steeper than ideal.

Thank you both for the responses! I definitely have a better understanding of this now (optimizing each respective arch > maximizing malocclusion)... got it.

kjohnt, you said slightly proclined for uppers and upright for lowers. My lowers are already pretty upright, and my orthodontist is currently bringing my uppers towards that slightly proclined position - but now I have a new question: After the CCW rotation of the maxilla, wouldn't the proclined incisors flare out even more? I want to be cautious of too much proclination, as a result of both the orthodontics and surgical rotation.
Title: Re: Class I Decompensation for CCW MMA
Post by: kjohnt on September 22, 2016, 01:51:31 PM

...but now I have a new question: After the CCW rotation of the maxilla, wouldn't the proclined incisors flare out even more? I want to be cautious of too much proclination, as a result of both the orthodontics and surgical rotation.

Yes they would, but relative to your other features.  The positioning within the arch would not change because you are rotating the entire structure.  So in theory, you could have proclined upper incisors but if your jaw was cw enough prior to surgery the incisors would appear retroclined when looking at your profile.

You won't end up with overly-proclined incisors unless your ortho does bad work pre-op or camouflages your surgeon's bad work post-op. 
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on September 22, 2016, 04:53:23 PM
Yes they would, but relative to your other features.  The positioning within the arch would not change because you are rotating the entire structure.  So in theory, you could have proclined upper incisors but if your jaw was cw enough prior to surgery the incisors would appear retroclined when looking at your profile.

You won't end up with overly-proclined incisors unless your ortho does bad work pre-op or camouflages your surgeon's bad work post-op.

Makes sense - thanks so much for your help! I'm hoping that my orthodontist can get all of this done within the timeline. It's pretty tight on both ends of the surgery date, with less than 3 months pre-op and only 7 weeks post-op.

My mother's biggest concern right now is that by the time my surgery happens, it will have only been 5 months since my wisdom teeth were removed (none were impacted and the extractions went well - but my surgeon did mention that I had very long roots, and afterwards I developed a dry socket)... so for those two reasons she feels like I need to be on the latter end of that 6-9 month estimate they give for bone healing. Should this be any cause for concern?
Title: Re: Class I Decompensation for CCW MMA
Post by: kjohnt on September 22, 2016, 07:32:40 PM
Your bone is now healed from the wisdom tooth operation.  Approximately six weeks to heal bones.

FWIW, this surgery and supporting orthodontics are not things I'd want to rush.  I'd reevaluate and see if I could make it all work out on the surgeon's and ortho's timeframes while you are at school or whatever.  I imagine you risk root resorption, not truly being ready for surgery when the time comes which may potentially lead to poor positioning of jaws during surgery, and poor final result.  Keep honest and continuous communication with your ortho.
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on September 22, 2016, 08:12:46 PM
Your bone is now healed from the wisdom tooth operation.  Approximately six weeks to heal bones.

FWIW, this surgery and supporting orthodontics are not things I'd want to rush.  I'd reevaluate and see if I could make it all work out on the surgeon's and ortho's timeframes while you are at school or whatever.  I imagine you risk root resorption, not truly being ready for surgery when the time comes which may potentially lead to poor positioning of jaws during surgery, and poor final result.  Keep honest and continuous communication with your ortho.

I had heard from many sources (including my surgeon) that bone heal after wisdom teeth extractions can take around 6 months. If it only takes approximately 6 weeks, then why do most surgeons request a 6 month break between extractions and surgery? Thank you so much for all of your helpful responses... but now I'm very confused! Why would I be at risk of all these things if I'm only having very minor changes to my bite pre-op? Once the orthodontist and surgeon feel my teeth are in the correct pre-surgical position, wouldn't I be good to go (or do I need time to let the orthodntic work settle)? I'm able to take as long as I'd need for the post-op orthodntics - it's just the pre-surgical movements that my orthodontist is trying to finish in 3 months (and in his words: "it's optimistic, but we can do it"). Thanks again for all of the feedback. I of course don't want to risk what you mentioned in your last post...
Title: Re: Class I Decompensation for CCW MMA
Post by: kjohnt on September 23, 2016, 01:15:55 AM
I misread your previous post and thought you meant you had to have braces off by 6 to 9 months.  NM that.  But pre-op it sounds like minimal movement is needed but you said he's expediting, so be careful.  I have some root resorption due to overly-aggressive orthodontics in the past and have heard a few stories of dental implants being necessary for the same reason.

I've always heard it takes six weeks for bone to heal.  I believe that is the standard timeframe for casts on brooen limbs as well as splints for jaw surgery when used.  I just read that it could be more like twelve for the tissues to fully harden, but six months seems like overkill to me.  I am not a doctor though.  All that said, just as with the braces, no need to rush anything.

In any case, it sounds like your ortho and surgeon have a plan and are on the same page, so everything will probably go well.  I don't mean to worry you.  But it is good you are learning and being your own advocate.  I've read of bad outcomes here and on Facebook and when I ask what movements were planned and what went wrong, half the time the people have no idea what they were having done in the first place aside from "moving jaws forward."
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on September 23, 2016, 09:00:24 AM
...pre-op it sounds like minimal movement is needed but you said he's expediting, so be careful.  I have some root resorption due to overly-aggressive orthodontics in the past and have heard a few stories of dental implants being necessary for the same reason.

Thanks for the heads up! Next time I meet with my orthodontist I'll mention that and see what he says. Expediting the pre-surgical movements isn't worth any long term damage...

...it is good you are learning and being your own advocate.  I've read of bad outcomes here and on Facebook and when I ask what movements were planned and what went wrong, half the time the people have no idea what they were having done in the first place aside from "moving jaws forward."

Yeah, I'm doing my best to educate myself and stay involved where I can! As far as surgical movements go, the only part I'm still unsure of is how far forward my surgeon plans to move me. I know I'm having CCW impaction/rotation to fix the long face and gummy smile, and I know both jaws will be advanced, but I still don't know by how much. Are there methods to determine how much projection would be ideal? My surgeon joked to my mother: "I can pull him all the way out to here if I wanted! But that would make him look ridiculous!"... so he didn't really offer any specifics, haha. Thankfully, the CCW rotation will allow for more natural movements (especially with larger advancements)... but is there any way to calculate an ideal?
Title: Re: Class I Decompensation for CCW MMA
Post by: kjohnt on September 27, 2016, 01:24:30 AM
I've personally come to the conclusion that I need about 10mm lower advancement and 6mm upper just based on imaging my ceph over others', getting analyses done by different people, soft tissue morphs I've done, and skeletal morphs with my ortho using Dolphin imaging software.  There is no ideal as this is somewhat subjective.  I'd recommend seeing a few surgeons and maybe online analysis.  You'll get different opinions but you'll have a good ballpark once you hear enough opinions.
Title: Re: Class I Decompensation for CCW MMA
Post by: PloskoPlus on September 27, 2016, 02:37:40 AM
I've personally come to the conclusion that I need about 10mm lower advancement and 6mm upper just based on imaging my ceph over others', getting analyses done by different people, soft tissue morphs I've done, and skeletal morphs with my ortho using Dolphin imaging software.  There is no ideal as this is somewhat subjective.  I'd recommend seeing a few surgeons and maybe online analysis.  You'll get different opinions but you'll have a good ballpark once you hear enough opinions.
What did gunson suggest?
Title: Re: Class I Decompensation for CCW MMA
Post by: mike888miller on September 27, 2016, 05:30:11 AM
how much movement of the maxila is targetted, and how much impaction?

around which point is the rotation?

is it one or three piece le fort?

Title: Re: Class I Decompensation for CCW MMA
Post by: kjohnt on September 27, 2016, 06:14:42 PM
What did gunson suggest?

IDK what's going on with that.  I've been waiting months now and haven't heard from Kim since 8/18 I believe.
Title: Re: Class I Decompensation for CCW MMA
Post by: PloskoPlus on September 27, 2016, 06:33:19 PM
IDK what's going on with that.  I've been waiting months now and haven't heard from Kim since 8/18 I believe.
They took over 3 months to reply. I'll speak to gunson over the phone in a couple of weeks.
Title: Re: Class I Decompensation for CCW MMA
Post by: Lazlo on September 27, 2016, 10:22:39 PM
They took over 3 months to reply. I'll speak to gunson over the phone in a couple of weeks.

 so the easiest thing to do is call them speak to someone, ask that you be put on a waiting list for the next available appointment. Within a couple weeks someone will cancel and they'll call you. This is only if you're flexible. Otherwise it'll take a couple of months to get the appointment to see them . Its the best way for them to fully examine you and give you a full surgical plan. It's worth it. That said, I'm very happy on a scale of 1-10 I'm like 8 having had surgery with Dr. Sinn. The reason I'd recommend him is that he's so experienced, and this surgery is such a piece of cake for him that he'll give you a great result without mistakes and downtime. Honestly while I made the foolish mistake of leaving way too early and thus ran into pain issues. It was only for a few weeks. And the two points i'm docking is cause my lower jaw could have been advanced farther, and indeed I may have that done in the future. But other than that, what Dr. Sinn was able to achieve was pretty flawless. He did a complicated downgraft that gave me my smile and my teeth back that had disappeared to the back of my mouth from the crappy ortho i had received.
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on September 27, 2016, 10:47:01 PM
I've personally come to the conclusion that I need about 10mm lower advancement and 6mm upper just based on imaging my ceph over others', getting analyses done by different people, soft tissue morphs I've done, and skeletal morphs with my ortho using Dolphin imaging software.  There is no ideal as this is somewhat subjective.  I'd recommend seeing a few surgeons and maybe online analysis.  You'll get different opinions but you'll have a good ballpark once you hear enough opinions.

I attached my lateral ceph below. I wish I was able to post a better quality image, but unfortunately I only had a paper copy on hand and thus had to scan it to the computer. Any opinions? Thank you again!

how much movement of the maxila is targetted, and how much impaction?

around which point is the rotation?

is it one or three piece le fort?

My surgeon listed the movements as:
- "LeFort I osteotomy with advancement with anterior intrustion"
- "Bilateral mandibular ramus osteotomy with advancement"
- "Advancement genioplasty"

My insurance approval letter listed the LeFort I as "single piece". So, my interpretation of all this was that I'd be having a BSSO + one piece LeFort I with CCW rotation (and genioplasty). Does that seem correct? I'm not sure how much impaction he is planning on... he did note my "maxillary incisor-to-upper lip being 7 mm". I've attached my lateral ceph below if that can be of any help. Thanks so much!
Title: Re: Class I Decompensation for CCW MMA
Post by: PloskoPlus on September 27, 2016, 11:25:26 PM
Your jaws look steep. CCW will allow the lower to be advanced more than yourr current overjet allows. Rotation can be achieved by impacting the front of the maxilla and/or down grafting the back of the maxilla.
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on September 28, 2016, 12:08:35 AM
Your jaws look steep. CCW will allow the lower to be advanced more than yourr current overjet allows. Rotation can be achieved by impacting the front of the maxilla and/or down grafting the back of the maxilla.

When my surgeon writes "anterior intrusion" that's implying CCW rotation, correct? I'm still not sure how much impaction / advancement would be needed for a nice rotation.
Title: Re: Class I Decompensation for CCW MMA
Post by: mike888miller on September 28, 2016, 08:09:42 AM
re the gunson phone consult - is the the 175 or the 500 one? does it inclube a call with him?
Title: Re: Class I Decompensation for CCW MMA
Post by: mike888miller on October 06, 2016, 10:13:37 AM
can you post your x rays, and also mark in into which position the doctor wants to move them? is it rotation mostly or sagital movement?
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on October 06, 2016, 09:13:23 PM
can you post your x rays, and also mark in into which position the doctor wants to move them? is it rotation mostly or sagital movement?

Unfortunately the three photos attached below are all I really have right now (FYI, they were taken before decompensation orthodontics began). Like I mentioned previously, the information that I have from my surgeon, in writing, is as follows:

"PROBLEM LIST:

- Sleep apnea.
- Mallampati severe Class IV.
- Anterior open bite from teeth #s 5 to 12.
- Vertical maxillary excess with his maxillary incisor-to-upper lip being 7 mm.
- He has polyps in his maxillary sinus.
- He is a mouth breather.
- He has a tongue thrust habit.
- This patient postures his mandible forward to help with his breathing difficulties. He also has residual tonsillar tissue and a very small oropharyngeal opening.


PRELIMINARY SURGICAL DIAGNOSES:

- Sleep apnea.
- Anterior open bite.
- Vertical maxillary excess.
- Tongue thrust habit.


PRESURGICAL ORTHODONTIC CONSIDERATIONS:

- Presurgical orthodontics is essentially completed. This patient presents with significant Mallampati Class IV relationship of his soft palate drape and an extremely small oropharyngeal airway. He also complains of jaw joint pain, secondary to protruding his mandible forward to help him with his posterior airway.


PRELIMINARY SURGICAL PLAN:

- LeFort I osteotomy with advancement with anterior intrusion.
- Bilateral mandibular ramus osteotomy with advancement.
- Advancement genioplasty."
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on October 16, 2016, 04:12:14 PM
My surgery date has been tentatively set for December 5th, and I'll have the final meeting with my oral surgeon to approve everything on November 9th. In the meantime, I'd be super grateful for any feedback pertaining to the information / photos in my last post. Thanks in advance!
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on October 24, 2016, 08:49:40 PM
Hey guys,

I just wanted to give this a quick bump to see if anyone might be kind enough to offer feedback regarding the scans and write up from my surgeon. As I mentioned, my next appointment is approaching on November 9th (with the surgical date shortly after on December 5th) and I'd love to receive as many opinions on the surgical plan as possible, before talking with my surgeon again.

Anything I should be aware of as it pertains to the scans I attached two posts up, and what my surgeon has written so far? My own personal concerns / things I really want to avoid are of course the typical ones: upturned nose / convex philtrum after LeFort I advancement with anterior intrusion ("chimp look"), a deep labiomental fold after advancement genioplasty, etc... Do any of these seem like a probability for me, when looking at my scans?

Thanks again for any help!
Title: Re: Class I Decompensation for CCW MMA
Post by: Trader on October 24, 2016, 10:24:07 PM
You have a very steep occlusal plane. You also don't appear to have a significant dental overbite.

The upshot is that you'll need a large degree of counterclockwise rotation to achieve a desirable advancement of your mandible. Unless you have a very large gummy smile, I'm not sure that an anterior impaction of your maxilla will achieve enough rotation -- I think you'll likely need posterior lengthening of your maxilla as well.

Can you post some pictures of your smile and your resting mouth posture?
Title: Re: Class I Decompensation for CCW MMA
Post by: kjohnt on October 25, 2016, 11:57:41 AM
You have a very steep occlusal plane. You also don't appear to have a significant dental overbite.

The upshot is that you'll need a large degree of counterclockwise rotation to achieve a desirable advancement of your mandible. Unless you have a very large gummy smile, I'm not sure that an anterior impaction of your maxilla will achieve enough rotation -- I think you'll likely need posterior lengthening of your maxilla as well.

Can you post some pictures of your smile and your resting mouth posture?

Agreed.

Incisor inclinations look good and perhaps even very slightly overly-retroclined in both arches.  Mandibular advancement will be achieved by way of CCW rotation and then to "catch up" with the amount the maxilla is being advanced.  Anterior up as much as possible so there is about 1mm gum show... 7mm tooth to upper lip is large but my concern is I'm not seeing that much in the ceph...  does the surgeon mean when smiling?  So I agree with above that perhaps posterior downgraft may be necessary.  Without pictures of your smile this is only speculation, but the one question I'd ask is if the surgeon plans to downgraft the posterior maxilla at all or if CCW rotation is being achieved fully with anterior impaction.  Ask why.
Title: Re: Class I Decompensation for CCW MMA
Post by: Matt on October 26, 2016, 08:00:27 PM
You have a very steep occlusal plane. You also don't appear to have a significant dental overbite.

The upshot is that you'll need a large degree of counterclockwise rotation to achieve a desirable advancement of your mandible. Unless you have a very large gummy smile, I'm not sure that an anterior impaction of your maxilla will achieve enough rotation -- I think you'll likely need posterior lengthening of your maxilla as well.

Can you post some pictures of your smile and your resting mouth posture?

Agreed.

Incisor inclinations look good and perhaps even very slightly overly-retroclined in both arches.  Mandibular advancement will be achieved by way of CCW rotation and then to "catch up" with the amount the maxilla is being advanced.  Anterior up as much as possible so there is about 1mm gum show... 7mm tooth to upper lip is large but my concern is I'm not seeing that much in the ceph...  does the surgeon mean when smiling?  So I agree with above that perhaps posterior downgraft may be necessary.  Without pictures of your smile this is only speculation, but the one question I'd ask is if the surgeon plans to downgraft the posterior maxilla at all or if CCW rotation is being achieved fully with anterior impaction.  Ask why.

Thanks a lot for the feedback, guys. I was originally feeling hesitant about posting my photos on here... but I've realized that I only want to go through this surgery once, so receiving as much feedback as possible is in my best interest. I'm going to attach quite a long string of photos, but I've taken the time to caption each one with some text that I hope everyone will read (side note: #8 is the most realistic picture of what's actually going on here. The first few are when things appear "normal").

Anyways, I do hope that these photos can be somewhat helpful. After seeing them, does it look like I'll need posterior downgrafting of the maxilla in addition to the anterior intrusion? Thanks again for all of the generous feedback, everyone - it's much appreciated!
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: Lazlo on October 26, 2016, 10:12:52 PM
Lucky bastard you'll look like a model after this surgery.
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: Lazlo on October 26, 2016, 10:13:54 PM
MAKE SURE YOU GET AT LEAST 1cm forward genio
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: Matt on October 27, 2016, 01:36:29 PM
MAKE SURE YOU GET AT LEAST 1cm forward genio

Hey, Lazlo! Thanks for the feedback. One of my concerns has actually been regarding the genioplasty. Do you think a large forward movement like that would result in a deep labiomental fold? That's something I'd really like to avoid, if possible (...is that prevented by vertically lengthening the chin, in addition to the forward advancement, so that the labiomental angle isn't overly acute?). I'm not as educated on SG movements, so I could definitely be misunderstanding this / worrying too much.

Also, what's your opinion on what was mentioned earlier in this thread (regarding the potential for needing posterior downgrafting of the maxilla, in addition to the anterior intrusion?). I know my occlusal plane is steep, but my oral surgeon has only mentioned anterior intrusion so far... do you think that will be enough for a sufficient CCW rotation?
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: kjohnt on October 27, 2016, 02:01:37 PM
I think your impaction should be about 3mm. 

I really do believe you need a bit of posterior downgraft to get the occlusal plane where you want it.  The downside of this would be the gum show on the sides when smiling.  I wonder if you can get some of the gum tissue over your upper molars taken off.  I have the same thing but my ortho says I just have short molars (not a gum overgrowth issue) so that's not an option and he is concerned of a posterior downgraft on me.  My occlusal plane isn't as steep as yours though. 

Your real issue I think is short ramus in conjunction with the vertical anterior excess, and ramus lengthening isn't an option so far as I know. 

Anyway, the upside is better chin projection via CCW rotation.  Honestly, I get the SG argument, but your chin would need no augmentation if your occlusal plane was corrected.  Depending on how much CCW rotation you can achieve, I personally wouldn't get genioplasty at all.  I think you instead need a large BSSO advancement as part of a large CCW rotation.  The question is is that large of a rotation feasible and would it be aesthetically better than leaving some occlusal tilt and compromising with sliding genio to get your chin where you want it to be. 

This is just my opinion based on what I currently know... and this is the exact same thing I'm trying to figure out with my own face but just to a lesser degree.
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: PloskoPlus on October 27, 2016, 03:09:30 PM
Agree with kjohnt. I'm afraid many surgeons simply can't do posterior down grafting and just do as much (often too much!) Anterior impaction and a big ugly genioplasty to compensate. The excuse for lack of skill is "down grafts are not stable", which is bulls**t.
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: Matt on October 27, 2016, 11:10:24 PM
I think your impaction should be about 3mm. 

I really do believe you need a bit of posterior downgraft to get the occlusal plane where you want it.   

Anyway, the upside is better chin projection via CCW rotation.  Honestly, I get the SG argument, but your chin would need no augmentation if your occlusal plane was corrected.  Depending on how much CCW rotation you can achieve, I personally wouldn't get genioplasty at all.  I think you instead need a large BSSO advancement as part of a large CCW rotation.  The question is is that large of a rotation feasible and would it be aesthetically better than leaving some occlusal tilt and compromising with sliding genio to get your chin where you want it to be. 

Agree with kjohnt. I'm afraid many surgeons simply can't do posterior down grafting and just do as much (often too much!) Anterior impaction and a big ugly genioplasty to compensate. The excuse for lack of skill is "down grafts are not stable", which is bulls**t.

I appreciate the feedback, guys. I'd really like to achieve the proper amount of CCW rotation, instead of compensating with a larger than needed genioplasty. Since my surgeon has yet to mention posterior downgrafting, I'm worried he may not be planning for it at all. Of course, I'll make sure that I ask him about it at our next appointment... but what if he wants to stick with anterior intrusion only? I'd hate to be left in a position where I should have had more CCW rotation and it never happened.

Is it common for surgeons in the US to perform both anterior intrusion and posterior downgrafting? I live in Florida and am unable to afford an out of network surgeon, so I did my best to find an experienced surgeon that was in network. Originally I had called Dr. Richard Joseph's office (since he was so highly regarded), however he only works with patients inside of a small local radius (and he's out of network). My current surgeon however, came recommended directly from Dr. Joseph himself. For that reason, I'd like to think that I'm in good hands and he may be able to perform a posterior downgraft. If not though, I don't know what more I can do (given my short timeline and the fact that insurance has already approved me with this current surgeon for a December 5th operation).

If anterior intrusion is the only form of CCW rotation on the table, what do you guys recommend I do?
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: PloskoPlus on October 28, 2016, 02:00:11 AM
I appreciate the feedback, guys. I'd really like to achieve the proper amount of CCW rotation, instead of compensating with a larger than needed genioplasty. Since my surgeon has yet to mention posterior downgrafting, I'm worried he may not be planning for it at all. Of course, I'll make sure that I ask him about it at our next appointment... but what if he wants to stick with anterior intrusion only? I'd hate to be left in a position where I should have had more CCW rotation and it never happened.

Is it common for surgeons in the US to perform both anterior intrusion and posterior downgrafting? I live in Florida and am unable to afford an out of network surgeon, so I did my best to find an experienced surgeon that was in network. Originally I had called Dr. Richard Joseph's office (since he was so highly regarded), however he only works with patients inside of a small local radius (and he's out of network). My current surgeon however, came recommended directly from Dr. Joseph himself. For that reason, I'd like to think that I'm in good hands and he may be able to perform a posterior downgraft. If not though, I don't know what more I can do (given my short timeline and the fact that insurance has already approved me with this current surgeon for a December 5th operation).

If anterior intrusion is the only form of CCW rotation on the table, what do you guys recommend I do?

IANAD.  You may not need any posterior down grafting after all - you do have a very gummy smile, and your retrusion is not that severe.  So you may achieve everything with just anterior impaction.  But you cannot really know this until you get advice from a doctor who does posterior down grafts routinely.
Even with all the gum that you show, I would be weary of impacting too much (even Gunson has done this in the past).  It is a) ageing if overdone and b) large vertical facial changes have the biggest psychological effect for good or bad.
Unless that is your one and only opportunity for surgery, I would take a chill pill and get other opinions.  I sure as hell wish I did.
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: kjohnt on October 28, 2016, 10:25:19 AM
Yeah basically same answer as above.  I'd just talk to your surgeon and explain your desired outcome and your concerns.  I too think you should get multiple opinions, because they will vary, unfortunately.  These would be my questions/concerns in order:

1) ANTERIOR IMPACTION - How much?  You don't want it overdone.  Should have 0-1mm gum show above upper incisors when fully smiling and that will limit the amount that should be done.  Given this, would that amount of anterior impaction alone be enough to flatten your occlusal plane to the extent that your chin lines up nicely in profile?  If yes, skip ahead to #3.  If not...

2a) POSTERIOR DOWNGRAFT - Can posterior downgraft be performed to further flatten your occlusal plane and bring your mandible (and therefore chin) further forward relative to your maxilla?  Is the surgeon comfortable with doing this?  What are the downsides to doing this?

2b) SLIDING GENIOPLASTY - If downgraft isn't suitable/feasible/whatever, you'll want horizontal chin advancement via sliding genioplasty to line up your profile.

3) BIMAX ADVANCEMENT - Amount of horizontal advancement of maxilla and mandible.
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: mike888miller on November 02, 2016, 11:02:41 AM
i second the above.

it is funny, our side profiles are very similar, yet my occlusal plane is basically horizontal, which sadly means that i cannot have any Rotation, as it would mess up the curve of spee and thereby my smile. plus, my mandible lacks projection and is too deep so i in Need max sagital horizontal advancement of man and max, and gne in order to reduce the mandible height, and in order to achieve the projection.

http://jawsurgeryforums.com/index.php?topic=6074.0

you have a great Combo of steep plane plus a good, normally shaped mandible. therefore you Need to maximise the projection achieved via ccm, as projection achieved via Rotation of the jaw in the ideal inclication will provide a superior result to that of the gne.

the further back the Point around which you rotate is the more Rotation you achieve.
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: Matt on November 03, 2016, 11:27:29 AM
IANAD.  You may not need any posterior down grafting after all - you do have a very gummy smile, and your retrusion is not that severe.  So you may achieve everything with just anterior impaction.  But you cannot really know this until you get advice from a doctor who does posterior down grafts routinely.
Even with all the gum that you show, I would be weary of impacting too much (even Gunson has done this in the past).  It is a) ageing if overdone and b) large vertical facial changes have the biggest psychological effect for good or bad.
Unless that is your one and only opportunity for surgery, I would take a chill pill and get other opinions.  I sure as hell wish I did.

Yeah basically same answer as above.  I'd just talk to your surgeon and explain your desired outcome and your concerns.  I too think you should get multiple opinions, because they will vary, unfortunately.  These would be my questions/concerns in order:

1) ANTERIOR IMPACTION - How much?  You don't want it overdone.  Should have 0-1mm gum show above upper incisors when fully smiling and that will limit the amount that should be done.  Given this, would that amount of anterior impaction alone be enough to flatten your occlusal plane to the extent that your chin lines up nicely in profile?  If yes, skip ahead to #3.  If not...

2a) POSTERIOR DOWNGRAFT - Can posterior downgraft be performed to further flatten your occlusal plane and bring your mandible (and therefore chin) further forward relative to your maxilla?  Is the surgeon comfortable with doing this?  What are the downsides to doing this?

2b) SLIDING GENIOPLASTY - If downgraft isn't suitable/feasible/whatever, you'll want horizontal chin advancement via sliding genioplasty to line up your profile.

3) BIMAX ADVANCEMENT - Amount of horizontal advancement of maxilla and mandible.

i second the above.

it is funny, our side profiles are very similar, yet my occlusal plane is basically horizontal, which sadly means that i cannot have any Rotation, as it would mess up the curve of spee and thereby my smile. plus, my mandible lacks projection and is too deep so i in Need max sagital horizontal advancement of man and max, and gne in order to reduce the mandible height, and in order to achieve the projection.

http://jawsurgeryforums.com/index.php?topic=6074.0

you have a great Combo of steep plane plus a good, normally shaped mandible. therefore you Need to maximise the projection achieved via ccm, as projection achieved via Rotation of the jaw in the ideal inclication will provide a superior result to that of the gne.

the further back the Point around which you rotate is the more Rotation you achieve.

Guys, thanks so much for all of the responses. They were incredibly helpful. I actually ended up speaking with molestrip privately via e-mail and he had some great insight to offer as well. On November 9th I'm going to be seeing my surgeon again, so I'll ask him about how much rotation is needed here and what he thinks about the posterior downgrafting.

Today I saw my orthodontist and he mentioned a 3-piece LeFort to me, out of nowhere. The insurance approval letter I have mentions a single piece LeFort I, and my surgeon never mentioned 3-piece to me - so I'm not quite sure that is the current plan, but my orthodontist seemed to think it was something to consider. It's ironic, because molestrip took a look at everything and immediately said he thinks I would benefit from a 3-piece and should consider it, being that I'm young enough to heal well. This hadn't ever crossed my mind, and to be honest, 3-piece vs single piece isn't a topic I'm very educated on. What do you guys think?

I feel like my surgeon is going to think I'm crazy, asking to change things from single piece with anterior intrusion only, to a 3-piece with posterior downgrafting as well. Oh boy, haha...
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: kjohnt on November 03, 2016, 01:10:00 PM
Well you don't necessarily need to ask him to change his plan; rather, just ask him about these things and see what he thinks.  At the time of final planning, if you don't agree, then you'll need to be more assertive and may risk losing the surgeon.  Assuming your ortho and surgeon are communicating to any degree, your ortho will likely bring it up as well since he mentioned it to you.

It's funny because I'm wondering about the three piece for myself since my lower premolars seem to have some lingual tipping and if uprighted then my upper arch would be too narrow, as my uppers are good right now and are going to be slightly tipped buccally to accomodate my mandible being moved forward relative to my maxilla.  I really don't want three piece because that means more time under anesthetic, more boney surface area prone to non-union, higher chance of root damage, higher chance of bad placement by surgeon, etc.
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: Matt on November 07, 2016, 12:26:40 PM
I really don't want three piece because that means more time under anesthetic, more boney surface area prone to non-union, higher chance of root damage, higher chance of bad placement by surgeon, etc.

Well now I'm questioning if I should even want this! I just feel too ignorant in this area to understand whether my case would benefit from a 3-piece or not. Of course I'll see what my surgeon says about it all, but I don't really know what I should want to hear.
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: Matt on December 07, 2016, 06:02:47 PM
Hey guys,

I just wanted to post a quick update along with some new scans / drawings from my surgeon. Since my last post, I met with my orthodontist and surgeon each one more time, and unfortunately surgery had to be postponed from the original December 5th date. Apparently my orthodontist needs some more time pre-op. My surgeon did a test surgery on some updated impressions of mine, and he too said I needed some more time in braces. Apparently I'll be ready in another month or two, but now I'm uncertain if I'll do the surgery in Jan/Feb/March or just wait until the summer time because of college/university, etc.

At my last appointment, my surgeon informed me that I would not be having a 3 piece LeFort I. Even though my orthodontist had mentioned it to me, he looked at me like I was crazy when I brought it up, and said that he only does 3 pieces when he absolutely needs to, otherwise he likes to avoid it. Unfortunately, after we discussed that, he left the office quite quickly and I was left having to discuss some of my questions/concerns with his nurse. When I asked her about posterior downgrafting of the maxilla, she again looked at me like I was crazy. I tried to politely explain to her why I felt I needed more CCW rotation instead of just compensating with straight advancement, but it seems like they're only planning on doing the anterior intrusion. When I asked about that, she said that I'd be impacted to help rotate, but that the impaction would leave my upper lip at about where my brackets are (around half way down my teeth she said). That seems like too much! I told her I was hoping to still have 0-1mm of gum show after the impaction, but she seemed to think that wouldn't be the case (she made it seem like impaction half way down my upper teeth wasn't abnormal??). I know these things should have been discussed with my surgeon and not his nurse, so I'll be sure to ask him as well the next time I see him.

Now that I have more time before the surgery though, I've decided to get a second opinion from an out-of-network surgeon that my orthodontist had originally recommended to me. I can't really afford an out-of-network surgeon to be honest, but at the same time I don't want to let price pressure me into a less than optimal surgical plan. I'm going to attach some updated scans below, as well as the work-up / drawing that my current surgeon did. What do guys think of all this? I really want to make sure I'm getting enough rotation, and I definitely don't want to be over-impacted...
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: ditterbo on December 07, 2016, 06:55:26 PM
As I'm learning about bimax, it gets relatively simple as to how your mouth can be tweaked one way or another to bring everything forward for your particular case.  The tricky as hell part for us both right now is sort of the cost/benefit ratio to various amounts of posterior downgrafting in a class 2.  Maybe some doctors can do a posterior downgraft, with some compromises, for way less than like Gunson, in exchange for maybe .5 points in the looks department.  I just don't know how to figure out the 'best' compromise yet. 

Good for you for second guessing that surgical plan.  A half an upper tooth show when smiling sounds quite off. Maybe ask for before/after's of similar cases?

In other news, damn my retrusive jaw looks rotated forward compared to yours!  You also maybe have a lot of potential with that squared ramus, just need a way to make that pop more.  Getting down to it, this rotation business is really done to avoid a straight forward advancement it seems like, with the presumption that most people don't have deficient maxilla's on the scale of their jaws.  So if you must move the jaw forward a hell of a lot compared to the maxilla, rotation is required to minimize the maxilla's advancement.  Then you can consider posterior downgrafts superior if you don't have a gummy smile.  I think that's all there is to this CCW thing?
Title: Re: Class I Decompensation for CCW MMA (UPDATED WITH PHOTOS)
Post by: Matt on December 08, 2016, 04:26:13 PM
Good idea mate. You should really take your time approaching jaw surgery because it can almost break or make your life. Good luck, you will look really good once you get your jaw upgraded.

As I'm learning about bimax, it gets relatively simple as to how your mouth can be tweaked one way or another to bring everything forward for your particular case.  The tricky as hell part for us both right now is sort of the cost/benefit ratio to various amounts of posterior downgrafting in a class 2.  Maybe some doctors can do a posterior downgraft, with some compromises, for way less than like Gunson, in exchange for maybe .5 points in the looks department.  I just don't know how to figure out the 'best' compromise yet. 

Good for you for second guessing that surgical plan.  A half an upper tooth show when smiling sounds quite off. Maybe ask for their 'brag book' of similar cases?

In other news, damn my retrusive jaw looks rotated forward compared to yours!  You also maybe have a lot of potential with that squared ramus, just need a way to make that pop more.  Getting down to it, this rotation business is really done to avoid a straight forward advancement it seems like, with the presumption that most people don't have deficient maxilla's on the scale of their jaws.  So if you must move the jaw forward a hell of a lot compared to the maxilla, rotation is required to minimize the maxilla's advancement.  Then you can consider posterior downgrafts superior if you don't have a gummy smile.  I think that's all there is to this CCW thing?

Thanks, guys. Yeah, I agree that at this point I should really just get another opinion - it can't hurt and maybe I'll find out that I do need the extra CCW rotation (combination downgrafting / impaction rather than impaction only). I can't really tell if the drawing from my surgeon is enough rotation for my steep jaws. It's impaction only of course, and I can't help but feel like it's not enough. I'd like to maximize the rotation first and then finish off with the proper amount of straight advancement / genio (really dislike the idea of compensating for poor rotation with extra advancement).

Now comes the question of which surgeons will be right for my case. I'm sure many can do the anterior intrusion considering I have a gummy smile that needs impacting... but what about any further rotation / posterior downgrafting? Originally I planned to stay in-network since insurance will pay for everything after my $4,000 out of pocket maximum. Now I'm starting to reconsider, though. I'll just take out the extra student loans if I have to, because I'd rather bite the bullet on cost to make sure I'm getting the right movements with the right surgeon. Obviously names like Arnett, Gunson, Wolford, Sinn, Posnick, etc. are thrown around these forums often. Any recommendation on where to go next? My insurance will only pay their 60% of the out of network costs if they consider the surgeon's rates to be "reasonable / typical". From some online insurance calculators I've found, I'm guessing that means $20-25K for bimax/genio and not the $50K+ range. So what surgeons am I left with then?

I know Dr. Richard Joseph in Jacksonville, FL is about $23-26K for bimax / genio. However, he only works with patients inside of his "radius" - and despite us both being in Florida, I'm too far south for him to consider working with me. I don't know... maybe the drawing from my current surgeon is good enough for my case? Maybe it isn't, and I'll just never know until I speak with a surgeon that does the extra CCW rotation I seem to need. Ahh, I just feel so lost right now :-[
Title: Re: Combination Downgrafting / Impaction for CCW MMA? (UPDATED WITH PHOTOS)
Post by: Matt on December 09, 2016, 08:54:13 PM
Hey, guys. Sorry for another post, but I'm hoping for some surgeon advice, if anyone can help.

As I mentioned in my last post, I may try going to an out-of-network surgeon now, but if I do their rates must be around the ballpark of what my insurance provider considers "customary / reasonable". Upon further research, that's looking like the $20,000 - $30,000 range.

So, with those numbers in mind, do you guys have any recommendations for surgeons that can perform large CCW rotations? I may need posterior downgrafting of my maxilla (in addition to the anterior impaction of my gummy smile) so finding a surgeon that can do this combination will be the goal.

Obviously Dr. Gunson and Dr. Wolford are not in the $20,000 - $30,000 price range. What about Dr. Posnick, though? I found one thread stating that he did double jaw, genio, septo, etc. all for $24,000 (although it seemed to be an old post) and then shortly after I found another post saying he was in the $50,000 range just like Arnett, Gunson, Wolford, etc.

How about Dr. Sinn or Dr. Kasey Li? Are they any more affordable? Molestrip sent me an e-mail recommending Dr. Terry Taylor in Houston, TX. Apparently he does 200 surgeries a year and is in-network with my insurance provider (BCBS) which would bring the cost down a lot ($4,000 total - the cost of my out of pocket maximum and that's it).

Finally, I'm still going to push for Dr. Richard Joseph here in Florida. Maybe I can get him to budge and take me on as a patient, despite living just outside of his radius. If so, I'd be looking at $9,000 - $12,000 out of pocket (which I'm happy to pay for someone like Dr. Joseph). I just want to find a surgeon who can offer the amount of rotation I need, and for a "customary / reasonable" price.
Title: Re: Matt's CCW MMA Thread (Photos, X-Rays, Work-up)
Post by: swsee on December 10, 2016, 04:43:32 AM
What surgeon's have you spoken with? I consulted with 8 different surgeons, and every single one suggested rather significant posterior downgrafting to achieve CCW rotation and flatten my occlusal plane to ~8 degrees. I don't know why everyone on this forum acts like there's only like 3 surgeons in the world that do such a thing. I know this doesn't really answer your question, but I think if ask around you will find it is not as uncommon as you may think.
Title: Re: Matt's CCW MMA Thread (Photos, X-Rays, Work-up)
Post by: Matt on December 10, 2016, 12:55:56 PM
What surgeon's have you spoken with? I consulted with 8 different surgeons, and every single one suggested rather significant posterior downgrafting to achieve CCW rotation and flatten my occlusal plane to ~8 degrees. I don't know why everyone on this forum acts like there's only like 3 surgeons in the world that do such a thing. I know this doesn't really answer your question, but I think if ask around you will find it is not as uncommon as you may think.

Thanks for the response, swsee. I don't want to post my current surgeon's name on here just yet, because as of right now I'm technically still working with him. However, I will say that he was a somewhat local option that was in-network for me (I live in Palm Beach Gardens, FL and drive two hours up to Orlando, FL to see him). Apparently he does surgeries every Monday (so I'm guessing around 50 a year?) and he seems to be one of the more senior surgeons at the practice. With that said, though... I'm not sure if his plan is right for me. He's only planning anterior intrusion (impaction) for my CCW rotation, and never mentioned posterior downgrafting to me (verbally or in his written plan). I've reattached the drawing of his surgical work-up below (what do you think of it?). To me, I feel like I need more rotational advancement than I do straight advancement - and I'm worried that the anterior intrusion alone is not enough (considering how steep my jaws are, wouldn't you think combination anterior impaction / posterior downgrafting is necessary?).

Since I'm feeling a bit uneasy about this, I'll be getting a second opinion from Dr. Stephen Rimer down in Boca Raton, FL (an out-of-network surgeon that my orthodontist had originally recommended to me). I'm hoping he'll suggest more rotation to me when we meet next week. If not, I don't know who to consult with next. Any suggestions, given my case and pricing requirements?
Title: Re: Matt's CCW MMA Thread (SURGERY IN 4 DAYS! - FINAL MEASUREMENTS??)
Post by: Matt on April 14, 2017, 12:34:43 PM
Hi, everyone. It's been a while! I wanted to update my thread one last time, as I'm actually having surgery this coming Tuesday (April 18th) with an entirely new surgeon. I was given the measurements today (all done with virtual surgical planning) and I wanted to run them by the forum one last time before heading into surgery on Tuesday. So, as of now, my movements will be:

- 2-piece upper jaw (originally he thought it'd be a 3-piece, but after virtual planning said that 2-piece was the way to go). I've actually never heard of a 2-piece, usually just single or 3, but he felt this was best for me and he'd be widening my upper jaw at the back towards the molars to better place my upper teeth over my lower teeth.

- 4mm upper jaw impaction. He said this was on the conservative side for me, but he really doesn't want to over-impact and he feels that having a little extra gum show is aesthetic and youthful.

- 6mm upper jaw advancement.

- BSSO moving my lower jaw 12mm, tip to tip.

- Occlusal plane will lower by about 8-9 degrees, from about 14/15 degrees now to 6/7 degrees after surgery.

- No genioplasty. He feels my chin is good as it is, and in his words "doing anything to your chin will... make it look like something was done to your chin". Haha. (I know this was something we spoke about previously in this thread. He seemed to plan my case with the higher level goal of trying to get enough rotation that we could avoid the genioplasty for me.)

- Septoplasty while he's in there.

That's about everything! He said he'll let me look at the virtual stuff before going into surgery, and iron out any final questions that I might still have. In his words, he felt everything was looking very "artistic" and he was happy about it.

What do you guys think of these measurements? I really trust my new surgeon, but some final opinions / reassurance (hopefully!) would be nice before surgery. I'll repost some old photos and x-rays just for reference again, in case that helps at all.
Title: Re: Matt's CCW MMA Thread (SURGERY IN 4 DAYS! - FINAL MEASUREMENTS??)
Post by: Matt on April 15, 2017, 08:35:00 PM
Bump! Any last words on the surgical plan before I head into surgery? Two days left!
Title: Re: Matt's CCW MMA Thread (SURGERY IN 2 DAYS! - FINAL MEASUREMENTS??)
Post by: kjohnt on April 18, 2017, 01:20:35 AM
Sounds like a good plan to me man, best of luck!
Title: Re: Matt's CCW MMA Thread
Post by: XXRyanXXL on August 03, 2017, 06:13:38 PM
Matt
You havn't posted your surgery results yet.
Let us know how it went!
Guys, keep bumping this thread to the top!
Title: Re: Matt's CCW MMA Thread
Post by: mike888miller on August 28, 2017, 12:59:53 PM
is there anyone that can enlighten me about the scenrios of downgrafting?

also, my doc today mentioned that he might use a higher cut line for me bsso, as it would allow him to lengthen my ramus, even thought it is less stable and he will need to get filling material out of my hip.
Title: Re: Matt's CCW MMA Thread
Post by: ditterbo on January 29, 2018, 06:30:50 PM
Aaaand he's long gone.