Should I have gotten CCW rotation? (Pictures and CEPHs)

[Post bimax]

A good maxfax, and Posnik is one, will advance out the mandible enough so that the chin augmentation with the sliding genio is modest. The more the chin goes OUTWARD horizontally, the more it has to slide UP vertically which can give a 'step off'.  SG is over a diagonal cut and movement over a diagonal has both a horizontal and vertical component. Ask for a more 'bold' chin advancement and you're asking for more of a step off.

This is a good point. If I were to do any chin augmentation going forward, it would probably be an implant (although I have reservations about those too).  I’ll likely get a rhinoplasty eventually as the nostril flare and tilt are quite severe so I’d do it then if it all. I want to give my face at least a year though to make sure everything is settled.

[kavan]

This is a good point. If I were to do any chin augmentation going forward, it would probably be an implant (although I have reservations about those too).  I’ll likely get a rhinoplasty eventually as the nostril flare and tilt are quite severe so I’d do it then if it all. I want to give my face at least a year though to make sure everything is settled.

Smart thinking. A year is good time to let things settle and re-evaluate. Perhaps also to look for isolated solution to the convexity of lip that does not include revision of the surgery you got which corrected everything else.

[Post bimax]

Smart thinking. A year is good time to let things settle and re-evaluate. Perhaps also to look for isolated solution to the convexity of lip that does not include revision of the surgery you got which corrected everything else.

As an aside-what is the general opinion on the long-term viability of chin-implants here? I'm mainly thinking of materials like porex, but I am aware of the increased infection rate and difficulty of removal with porous implants.

[kavan]

As an aside-what is the general opinion on the long-term viability of chin-implants here? I'm mainly thinking of materials like porex, but I am aware of the increased infection rate and difficulty of removal with porous implants.

Perhaps start a separate thread for general opinions.

[PloskoPlus]

OP,

Posnick is an old-school surgeon who does not do CCW.  AFAIK, he doesn't even do VY plasty and alar cinches.  Although there is some evidence that aesthetically the latter 2 are placebo, CCW does produce undoubtedly superior aesthetic results.  The only excuse surgeons have for not performing CCW is stability concerns - relapse and possibly increased joint stress.   Don't make the matters worse by trying to camouflage the issue.  A full revision with a surgeon who does CCW is your best bet.

All this "wait till the swelling come down" is bulls**t.  If you don't like your result within a couple of weeks after surgery, you never will.  You might learn to grudgingly accept it, but "liking" and "accepting" are not one and the same.

FWIW, I had only a 5 mm LF1 advancement and immediately thought it was crap, but because all of a sudden I looked younger, I kept telling myself "once the swelling is off", bla, bla.  My surgeon laughed off my concerns.  6 weeks post op my ortho, unprompted, told me that that the upper lip convexity improves greatly and that he can see a difference in photos taken 1 and 2 year post op.  But an extremely regarded surgeon told me in no uncertain terms that I had a typical lazy single jaw surgery and was over-advanced.   I did see some improvement in my case over a couple of years, but not nearly enough for me to "like the result".  TBH, I don't even accept it and cover it up with facial hair. BTW, if you don't wish to go through the ordeal again, facial hair is your best camouflage option. 

[kavan]

OP,

Posnick is an old-school surgeon who does not do CCW.  AFAIK, he doesn't even do VY plasty and alar cinches.  Although there is some evidence that aesthetically the latter 2 are placebo, CCW does produce undoubtedly superior aesthetic results.  The only excuse surgeons have for not performing CCW is stability concerns - relapse and possibly increased joint stress.   Don't make the matters worse by trying to camouflage the issue.  A full revision with a surgeon who does CCW is your best bet.

All this "wait till the swelling come down" is bulls**t.  If you don't like your result within a couple of weeks after surgery, you never will.  You might learn to grudgingly accept it, but "liking" and "accepting" are not one and the same.

FWIW, I had only a 5 mm LF1 advancement and immediately thought it was crap, but because all of a sudden I looked younger, I kept telling myself "once the swelling is off", bla, bla.  My surgeon laughed off my concerns.  6 weeks post op my ortho, unprompted, told me that that the upper lip convexity improves greatly and that he can see a difference in photos taken 1 and 2 year post op.  But an extremely regarded surgeon told me in no uncertain terms that I had a typical lazy single jaw surgery and was over-advanced.   I did see some improvement in my case over a couple of years, but not nearly enough for me to "like the result".  TBH, I don't even accept it and cover it up with facial hair. BTW, if you don't wish to go through the ordeal again, facial hair is your best camouflage option.

Posnick has written papers on CCW and does it.

CCW (posterior down graft) isn't done for anterior open bite.

The main reason for the conVEX lip is the 10mm advancement. He could get that even with CCW.

CCW is great but not every one is an automatic candidate for it just because it's an automatic 'mantra' here. Gunson doesn't even do it when it isn't the solution to correct the problem.

ETA:  I can't argue with you about your personal dissatisfaction with your surgeon/surgery. I'm sorry you had to go through what you did. But  your personal dissatisfaction with your surgery/surgeon does seems to carry into your arguments against a lot of doctors. You relay that the only way the OP can be corrected is via CCW. But you also relay you still cover up a convex lip with facial hair. So, do tell. Did CCW revision totally correct your convex lip?

ETA: If a surgeon told you that you had a 'lazy single jaw' surgery and L1 5mm was over advancement, I would conclude that you had class 3 where the lower jaw should have been brought backwards so the upper jaw advancement was not that advanced that much. Is my conclusion correct?

[PloskoPlus]

Posnick has written papers on CCW and does it.

CCW (posterior down graft) isn't done for anterior open bite.

The main reason for the conVEX lip is the 10mm advancement. He could get that even with CCW.

CCW is great but not every one is an automatic candidate for it just because it's an automatic 'mantra' here. Gunson doesn't even do it when it isn't the solution to correct the problem.

ETA:  I can't argue with you about your personal dissatisfaction with your surgeon/surgery. I'm sorry you had to go through what you did. But  your personal dissatisfaction with your surgery/surgeon does seems to carry into your arguments against a lot of doctors. You relay that the only way the OP can be corrected is via CCW. But you also relay you still cover up a convex lip with facial hair. So, do tell. Did CCW revision totally correct your convex lip?

ETA: If a surgeon told you that you had a 'lazy single jaw' surgery and L1 5mm was over advancement, I would conclude that you had class 3 where the lower jaw should have been brought backwards so the upper jaw advancement was not that advanced that much. Is my conclusion correct?

The OP's op occlusal plane is far from flat.  OSA surgery is 90% about advancing the mandible to open the airway. Relative to simple linear advancement, CCW rotation allows to achieve greater mandibular advancement with a smaller maxillary advancement. 

I've seen one of Posnick's open bite surgery results - only two teeth touched. I know a person, who got a similar aesthetic result to OP with another surgeon, who had promised CCW, but didn't do it.  When that person consulted with Posnick for a revision about his, IMO, legitimate concerns, he was simply laughed off and dismissed.

As for myself...  I have a steep mandibular plane and a mildly steep occlusal plane.  I don't think I have a great chin-throat length either.  A dumb linear set back of the lower might have left me with OSA. Splitting the movements into upper and lower... might have still left me with OSA and still have given me excessive upper lip convexity (I've seen just such results).  Gunson's solution was setback with CCW to preserve the chin-throat length... I have no balls to find out. 

Anyway WRT my negativity and skepticism, the more results I see, the more it looks like only a handful of surgeons world-wide can be trusted with jaw surgery if you care about the aesthetic outcome. What is even more depressing is how often a decent bite is not achieved.  I used to think it was pretty much guaranteed... Apparently not. In reply to my post-op aesthetic concerns my surgeon told me that I should be happy with the bite, because a good bite does not always happy, I now realise he MEANT it.  The average surgeon has really low standards for him/herself.  They rely on the ortho to properly decompensate and move the teeth into occlusion.  THAT'S IT.  And if the ortho is crap, bad luck for you.

[Dogmatix]

The main reason for the conVEX lip is the 10mm advancement. He could get that even with CCW.

It sounds like both linear and ccw advancement may give a convex lip? Is there a way to perform an advancement that promotes a concave lip? CCW sounds like the best option for that, as the advancement is smallest around ANS and then increase the further down you go, so the lower part of the lip is advanced most. Is it even possible to change how the lip will want to fold over the jaw, isn't that more a muscle and soft tissue shape of the lip itself, which ofc can get more prominent with a linear advancement?

[Post bimax]

The OP's op occlusal plane is far from flat.  OSA surgery is 90% about advancing the mandible to open the airway. Relative to simple linear advancement, CCW rotation allows to achieve greater mandibular advancement with a smaller maxillary advancement. 

I've seen one of Posnick's open bite surgery results - only two teeth touched. I know a person, who got a similar aesthetic result to OP with another surgeon, who had promised CCW, but didn't do it.  When that person consulted with Posnick for a revision about his, IMO, legitimate concerns, he was simply laughed off and dismissed.

As for myself...  I have a steep mandibular plane and a mildly steep occlusal plane.  I don't think I have a great chin-throat length either.  A dumb linear set back of the lower might have left me with OSA. Splitting the movements into upper and lower... might have still left me with OSA and still have given me excessive upper lip convexity (I've seen just such results).  Gunson's solution was setback with CCW to preserve the chin-throat length... I have no balls to find out. 

Anyway WRT my negativity and skepticism, the more results I see, the more it looks like only a handful of surgeons world-wide can be trusted with jaw surgery if you care about the aesthetic outcome. What is even more depressing is how often a decent bite is not achieved.  I used to think it was pretty much guaranteed... Apparently not. In reply to my post-op aesthetic concerns my surgeon told me that I should be happy with the bite, because a good bite does not always happy, I now realise he MEANT it.  The average surgeon has really low standards for him/herself.  They rely on the ortho to properly decompensate and move the teeth into occlusion.  THAT'S IT.  And if the ortho is crap, bad luck for you.

Does CCW affect occlusion? I understand Kavan’s point that posterior downgraft is the opposite of posterior impaction (which is used for AOB), but I’m pretty sure I’ve seen CCW of the whole MM complex where occlusion remains the same. In that case, it seems like a setback with CCW would improve aesthetics while maintaining the functional result.

Not that I can afford that kind of aesthetic surgery.

[ditterbo]

OP,

Posnick is an old-school surgeon who does not do CCW.  AFAIK, he doesn't even do VY plasty and alar cinches.  Although there is some evidence that aesthetically the latter 2 are placebo, CCW does produce undoubtedly superior aesthetic results.  The only excuse surgeons have for not performing CCW is stability concerns - relapse and possibly increased joint stress.   Don't make the matters worse by trying to camouflage the issue.  A full revision with a surgeon who does CCW is your best bet.

All this "wait till the swelling come down" is bulls**t.  If you don't like your result within a couple of weeks after surgery, you never will.  You might learn to grudgingly accept it, but "liking" and "accepting" are not one and the same.

FWIW, I had only a 5 mm LF1 advancement and immediately thought it was crap, but because all of a sudden I looked younger, I kept telling myself "once the swelling is off", bla, bla.  My surgeon laughed off my concerns.  6 weeks post op my ortho, unprompted, told me that that the upper lip convexity improves greatly and that he can see a difference in photos taken 1 and 2 year post op.  But an extremely regarded surgeon told me in no uncertain terms that I had a typical lazy single jaw surgery and was over-advanced.   I did see some improvement in my case over a couple of years, but not nearly enough for me to "like the result".  TBH, I don't even accept it and cover it up with facial hair. BTW, if you don't wish to go through the ordeal again, facial hair is your best camouflage option.

As Kavan said, Posnick does CCW but more on the scale of like Relle or other docs who somewhat factor in aesthetics without ""adding excessive risk"" to the TMJs. So like a posterior downgraft no greater than 4-6mm where Gunson goes as high as 10mm, maybe more. Having consulted both of those docs and Gunson, Gunson would have doubled my CCW (posterior downgraft), relative to that 4-6mm ceiling of other docs, while cutting my L1 advancement to less than half the amount Posnick guestimated he would do on me. (can't recall Relle's amount right now but I know he didn't post #'s anyway). Relle and Posnick would rather extract teeth than go further in the posterior downgraft. Both are craptastic options, that is if you don't like to gamble away your TMJ's or your immune system, if you ask me.

[Dogmatix]

Does CCW affect occlusion?

CCW is short for counter clock wise, so it's basically just a direction. To my knowledge it's possible to take the maxillomandibular complex and rotate it CCW with maintained occlusion. That is what's being done in aesthetic cases where braces is not needed and the patient already have good occlusion.

[kavan]

The OP's op occlusal plane is far from flat.  OSA surgery is 90% about advancing the mandible to open the airway. Relative to simple linear advancement, CCW rotation allows to achieve greater mandibular advancement with a smaller maxillary advancement. 

I've seen one of Posnick's open bite surgery results - only two teeth touched. I know a person, who got a similar aesthetic result to OP with another surgeon, who had promised CCW, but didn't do it.  When that person consulted with Posnick for a revision about his, IMO, legitimate concerns, he was simply laughed off and dismissed.

As for myself...  I have a steep mandibular plane and a mildly steep occlusal plane.  I don't think I have a great chin-throat length either.  A dumb linear set back of the lower might have left me with OSA. Splitting the movements into upper and lower... might have still left me with OSA and still have given me excessive upper lip convexity (I've seen just such results).  Gunson's solution was setback with CCW to preserve the chin-throat length... I have no balls to find out. 

Anyway WRT my negativity and skepticism, the more results I see, the more it looks like only a handful of surgeons world-wide can be trusted with jaw surgery if you care about the aesthetic outcome. What is even more depressing is how often a decent bite is not achieved.  I used to think it was pretty much guaranteed... Apparently not. In reply to my post-op aesthetic concerns my surgeon told me that I should be happy with the bite, because a good bite does not always happy, I now realise he MEANT it.  The average surgeon has really low standards for him/herself.  They rely on the ortho to properly decompensate and move the teeth into occlusion.  THAT'S IT.  And if the ortho is crap, bad luck for you.

I didn't say his OP was flat. Nor was his OP steep. Nor was his MP steep.  I said he had anterior open bite which is NOT corrected with CCW. It's perfectly understandable to me he didn't get CCW because I'm not 'reacting' out a negative emotional response. I'm just looking at what goes with what. His case is DIFFERENT from yours.

Gunson's solution for you via CCW would have most likely done what a double jaw surgery would have done for class 3 so the upper jaw DID NOT have to be advanced more forward than needed where the correction not only would be CCW but also a lower jaw SET BACK. Lower jaw set back IN  ORDER TO also set back the maxilla might not be the right thing to do for this guy with OSA and as you say, it might very well (in your case) NOT been enough to eradicate the convex lip which is why I'm perplexed you are saying with such conviction (conviction being an emotive respose) that the OP should do that.

As to this handful of surgeons, Gunson included, I've seen critiques of him on the private board and for a patient he did a GREAT job on. The patient started off with CLOSE SET eyes, got some cheek enhancement and a multi segment lefort in addition to max/man advancement for SLEEP APNEA and people were making fun of his (Gunson's) results and failed to see it was the close set eyes of the patient that resulted in his not having 'maximum aesthetics', basically something the doctor can't change. Not to mention, there's another for whom the correction is NOT CCW but the proposed correction with some CW (posterior impaction) looks great.

So, I do see some of these reactions as coming from an unhappy experience where the facts and circumstances of the person having them DON'T EVEN APPLY to the OP.

That's why I asked you IF 'the surgeon' telling you that you got a lazy single advancement actually rectified the convex lip. Seems like you didn't go through with it due to some possible trade offs. But should the OP, as you suggest he do, really go through with it where a risk could be he could find out FOR SURE if it really doesn't  eradicate the convex lip.

I guess I'll leave it at IF the OP really wants to find out for SURE whether or not correction via CCW will reverse his convex lip, he can try it. I'm just not going to encourage him to. But you can if you like.

[Post bimax]

Honestly, mild lip convexivity is not really devastating and there is still potential for it to decrease. Plosko, I think I saw you mention somewhere else that yours is actually slightly concave now. If anything I think the relative weakness of my lower 1/3 is more impactful aesthetically and there are options to fix that short of a revision.

What I’m gathering from this thread is that CCW of the mm complex was *possible*,  but not necessarily indicated in my case for the reasons Kavan mentioned. My guess is Posnick was not willing to add risk to a case for slight aesthetic benefit where CCW was in fact counter to functional priorities (AOB). It’s hard to disagree with that IMO.

[april]

CCW (posterior down graft) isn't done for anterior open bite.

I'm going to guess each anterior open bite is treated differently depending on the cause and the surgeon. I say this because I've seen a ceph treatment plan from Gunson where a large AOB is closed with CCW (PNS coming down 6mm) and multisegment surgery.

[kavan]

I'm going to guess each anterior open bite is treated differently depending on the cause and the surgeon. I say this because I've seen a ceph treatment plan from Gunson where a large AOB is closed with CCW (PNS coming down 6mm) and multisegment surgery.

Yes. Each AOB is treated differently depending on the cause and the surgeon, much like any bite if the reference is all (number of) specific measures and/or other problems the person has with it. Like someone can have anterior open bite for example, WITH transverse upper jaw too narrow where multi-segment is needed to treat that. So, AOB can come with a variety of other things where correction of them can involve CCW.

My statement was in context of the OP's situation and counter to assertion that only revision with CCW would address/correct his upper lip convexity. So, here my focus was directly on the OP and not a multitude of other situations which I had no reason to believe were directly applicable to his.