Matt's CCW MMA Thread

[Matt]

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

[mynameis]

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?

[ascolta]

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.

[Matt]

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).

[ascolta]

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!

[kjohnt]

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.

[Matt]

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.

[kjohnt]

...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. 

[Matt]

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?

[kjohnt]

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.

[Matt]

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...

[kjohnt]

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."

[Matt]

...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?

[kjohnt]

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.

[PloskoPlus]

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?