CCW rotation and stability

[Benjaminh]

Hey guys, so I went to my consultation with my surgeon and he said he doesn't do CCW because it's unstable and would be bad for my joints because of TMJ. He wants my ortho to remove two bottom teeth and push them back if possible so he can advance my lower jaw as well without ruining my lips. Thing is I feel like CCW will fit me the best and I've found a surgeon who has very good reviews but its all been for tooth extraction. I emailed him and he said CCW is a more unstable movement but he is willing to do it and it'll take more work. The one who doesn't do CCW has alot of good surgery rep. In this scenario what would you guys do? Keep in my mind I'm in Canada and tied to gov healthcare lol. Here's a pic of me

http://imgur.com/wi9QH6H

Thanks!

[CCW]

CCW hasn't been unstable since at least the early 90s when surgeons started to use bone grafts and fixed plates. Surgeons who say it is are either lazy or unskilled. Have you seen Dr Tocchio in Toronto? He's good and does CCW, AFAIK.

[XXRyanXXL]

Any Oral Surgeon would agree that the most stable operation for CCW rotation is to impact the maxilla, there is absolutely no relapse overtime with this. However the bone grafts used by Dr. Wolford, who actually published a study using porous HA blocks, show there was very little relapse overtime, and actually, bone tended to grow through the substrate over an extended period of time, thus strengthening the underlining structure. The initial healing time is critical though, no hard foods for 6 months, soft diet.   

These are some red flags that are being raised, and I would encourage you to seek an alternate surgeon, sounds like he's being lazy or he's incompetent.

[Benjaminh]

Any Oral Surgeon would agree that the most stable operation for CCW rotation is to impact the maxilla, there is absolutely no relapse overtime with this. However the bone grafts used by Dr. Wolford, who actually published a study using porous HA blocks, show there was very little relapse overtime, and actually, bone tended to grow through the substrate over an extended period of time, thus strengthening the underlining structure. The initial healing time is critical though, no hard foods for 6 months, soft diet.   

These are some red flags that are being raised, and I would encourage you to seek an alternate surgeon, sounds like he's being lazy or he's incompetent.

The problem with mine's is I'm not showing too much gum so I cannot be impacted according to my first surgeon. Only posterior downgraft is possible.

This is the email I received from the second surgeon I just booked a consultation with

"Thanks for the inquiry.  CCW does allow more mandibular advancement.  However, this is usually done in combination of a maxillary surgery.  Give that the it's a counter clockwise rotation.  The mandibular movement is less stable as the traditional movement.  It has its advantages and disadvantages.  I do perform this type of surgery.  But it's more surgery and less stable."

The first surgeon I saw has been in the business forever which is why he might not believe in CCW. I actually did email a surgeon in another province who gave me the best reply but sadly he's retired

I have been retired from orthognathic surgery for about 2 years now, so am unable to help you at this time.

In 2012, I did attend a course by Bill Arnett and Mike Gunson in which I learned the counterclockwise movement with advancement of both jaws. I treated a handful of patients with this approach for obstructive sleep apnea while in Winnipeg, so I can provide some commentary on this. In short, you and your surgeon both have good points.

There are certainly some aesthetic and airway benefits to this approach, however it is not without risk. Most of the patients they are treating in the US in this manner with pre-existing temporomandibular joint disorders are placed on Enbrel (an immunosuppressant medication) in order to reduce the risk of condylar necrosis.

It is a mistake to think that jaw surgery will correct a temporomandibular disorder. It most often does not. There is a significant risk of worsening of a person's pain symptoms after jaw surgery. Have you had any imaging of your jaw such as a bone scan which could rule out active degenerative changes within your jaw joint?

Have you met Graham Cobb? He is an excellent orthognathic surgeon here in Calgary and may be able to help.

I hope that helps.

There's a third surgeon I emailed who specializes in sleep apnea and said he does CCW as well but he couldn't talk about anything specific until I came for consultation. I'm hoping he'll be good. I'm located in Vancouver btw.

[Benjaminh]

CCW hasn't been unstable since at least the early 90s when surgeons started to use bone grafts and fixed plates. Surgeons who say it is are either lazy or unskilled. Have you seen Dr Tocchio in Toronto? He's good and does CCW, AFAIK.

I would love an out of province recommendation but it seems like Dr.Tocchio's rating is quite below average online? Kinda scares me lol

[PloskoPlus]

You don't appear to have a steep occlusal plane from the photo you posted. I'm not sure if CCW rotation will make much of a difference in your case.

Fwiw, what that surgeon said to you is Wolford's position as well and he basically invented CCW rotation: many people who need CCW rotation, also have joint issues. He gets pilloried for doing TJRs, but he thinks that doing CCW without treating the joints will make the joint issues worse.

[XXRyanXXL]

An alternate way to approach maxillary impaction, as was noted in my case, since I have a long upper lip, I was evaluated by multiple OMS who stipulated for me to get an upper lip lift, so they would be doing a butterfly cut beneath the nose, removing tissue, then pulling up the lip, increasing vermillion show, and allowing for more maxillary impaction. In your case, I dont think you need one, but it can be an option, and you show more front teeth. But also, moving out the maxilla, for every 3mm forward, you get 1mm more tooth show, due to the elastic nature of the lip.

My best advice would be to get as many consultations as you possibly can, and share the feedback you get from the other oral surgeons, and so it makes sense to you, and your treatment objectives are met.

[Benjaminh]

Ok what my next my next surgeon suggested feels in like with what I want with I'm going to have 2MM Impaction and upper jaw moved 6mm forward plus some geniplasty possibly

[Benjaminh]

Do you guys think that 6mm advancement with 2mm impaction will make my eyes more hollow?

[Benjaminh]

https://www.ncbi.nlm.nih.gov/pubmed/27889535

People think it's the graft that is unstable in CCW but that's probably not right as there are tons of studies out there showing that HA grafts are stable long term. What causes the instability is the drastic change in the TMJ from the rotation. It's not guaranteed that you'll relapse but there may more risk with CCW when you have TMJ issues beforehand. There are other studies by Gunson that go into depth in how they reduce the stress on the joints that CCW causes.

The problem is I do have TMJ issues already and I'm looking for most of symptoms to go away as well as get rid of my sleep apnea. I do want more CCW rotation but I think a 2mm impaction will be good as it'll atleast give some more support to my cheeks which I was worried about.

[XXRyanXXL]

There was a post on here recently by member CCW who indicated that CCW rotation alone creates more airway room around the base of the tongue. But the Surgeon can always advance the whole MMC forward to create that space. Not sure about the tmj though, get an opinion through Wolford.

I'm getting CCW rotation in my next operation (my MP angle is 40 degrees, OP is 10) and I was advised my cheek pads look descended, and was suggested to get midface soft tissue suspensions. Maybe that's an option for you? These are interesting questions you are asking, I don't believe anyone on here can predict soft tissue changes and immediate bone structural issues you are inquiring about.

[Lazlo]

Hey guys, so I went to my consultation with my surgeon and he said he doesn't do CCW because it's unstable and would be bad for my joints because of TMJ. He wants my ortho to remove two bottom teeth and push them back if possible so he can advance my lower jaw as well without ruining my lips. Thing is I feel like CCW will fit me the best and I've found a surgeon who has very good reviews but its all been for tooth extraction. I emailed him and he said CCW is a more unstable movement but he is willing to do it and it'll take more work. The one who doesn't do CCW has alot of good surgery rep. In this scenario what would you guys do? Keep in my mind I'm in Canada and tied to gov healthcare lol. Here's a pic of me

http://imgur.com/wi9QH6H

Thanks!

Dr. Stephen Ho in Mississauga Ontario specializes in CCW