Upcoming CCW Procedure - Aesthetic Concerns

[Lytric]

Hi all,

I have my DJS scheduled for next month, and I'm looking for some advice regarding the potential aesthetic outcomes based on my discussions with the surgeon. I will get the final surgical plan only a week before the surgery, and I'm not sure this will give me enough time to process it, so I'm trying to learn as much as I can now in order to know what questions I need to ask the surgeon and to determine if the plan aligns with both my functional and aesthetic goals.

A bit of background. I had braces when I was 12, all premolars were removed to push my teeth back as my mouth was protruding a lot.
When I was 27 I started experiencing sleep apnea episodes and I was diagnosed with moderate sleep apnea. Also, I didn't like my profile, my jaw was recessed and I had no chin so I went to a maxillofacial surgeon and he said I could either have a genioplasty or a DJS with CCW rotation. I opted for the genioplasty as it sounded less scary, and the doctor said it might alleviate my sleep apnea symptoms. The symptoms did not improve, but I experienced a noticeable improvement in my appearance. My face is now slightly longer and even if my profile is still very recessed, I felt much better about how I looked.

I'm now 38 and I'm mainly worried about my sleep apnea and still slightly unhappy about my appearance. I went to another surgeon and he said I need CCW, but first I need my teeth to be pushed back. So I started the orthodontic treatment a year ago, and now my surgeon says I'm ready. But I think my teeth are not in the position where they should be. They are still proclined (or the roots of the teeth are), and my nasolabial angle is too convex. To maximize the advancements of both my maxilla (to enhance my midface) and mandible, I think achieving a 'flatter,' less prominent mouth position is essential.

While my main concern revolves around curing sleep apnea, which would require significant advancement, I am also concerned about the potential changes to my facial appearance.

I uploaded some photos and CT scans:

Before Invisalign (a year ago):
https://imgur.com/LkEpmZ2 (front)
https://imgur.com/Jgu5Yrr (front, head slightly tilted upwards)
https://imgur.com/RkPJyUx (profile)
https://imgur.com/vw0aBwI (3/4)
https://imgur.com/v1LJJqo (smiling)
https://imgur.com/w6x4itk (occlusion)

After Invisalign (a week ago):
https://imgur.com/ndMyuTy (profile)

Scans:
https://imgur.com/nuBm1zw (I think my head is tilted here)
https://imgur.com/niRznQL
https://imgur.com/NTa0bH4 (CT with airways tagged)


Questions:

1) I heard CCW can shorten your face and I think I already have a short face. Can a CCW with downgraft make it slightly longer?
2) One of the things I don't like about my face is the sunken appearance of my nose in relation to my mouth. Is there any way to bring my subnasale point forward with CCW?
3) Do you think the chin should be brought further forward with the revision genioplasty?
4) I think my mouth is still protruding. Shouldn't my teeth be pushed further back before the surgery? I really don't want my mouth to protrude even more!

Thanks in advance!

[kavan]

Some points:

Your nasio labial angle would not be described as 'convex'. When talking about

ANGLES, the term would be ACUTE; less than 90 degrees.

The lower part of your central upper incisor is along a vertical and I would not

call that 'proclined'.

Some people have mouth protrusion due to overly thick soft tissue. Others have what

is called 'bimax protrusion' which is addressed by a type of surgery that is

usually not done in much of the US but is more common in places like Korea.

Basically a whole track of BONE accross the hard palate of maxilla connecting the

pre-molars from side to side is REMOVED and then the area is pushed back. Somewhat

similar with lower teeth bearing part of jaw. Not to belabor any more descriptions

of this, other than to say that if the mouth protrusion is from bimax protrusion,

pushing backwards your teeth anymore is not going to address that.

CCW posterior down graft will maximize the extent the lower jaw can go forward and

minimize the amount the maxilla goes forward. That is to say, it is good for sleep

apnea surgery because it's a surgery where the maxilla would not need to be as

advanced as much as the lower jaw where as other types of sleep apnea surgery

called 'linear advancement' advance both jaws about the same distance and with that

type, the upper jaw can be advanced 'too much' for good aesthetic and that is what

can yield an overly CONVEX upper lip area.

It is possible for the entirety of the maxilla to be down grafted to elongate the

lower 1/3rd of the face where the NET rotation is CCW but such is indicated when

the person has very little upper tooth show whereas if they have adequate upper

tooth show an overall down graft along the entire maxilla could result in gummy

smile.

So, it's looking like the surgery will address the sleep apnea, improve your

appearance but most likely will not accommodate a request for a vertically longer

lower jaw area or total correction of mouth protrusion.

Feel free to cross reference what I said here with your doctor.

ETA: excuse the double spacing. I single spaced in 'note pad' but copying and pasting in here resulted in some corruption of the formatting.

[Lytric]

Thanks kavan, that was the exact type of answer I was looking for. It was very helpful and will really assist me in explaining my concerns to my surgeon.

You mentioned that CCW with maxilar downgraft might lead to more upper teeth show, even gummy smile. Is there any way to compensate for this by rotating the jaws a bit more? If the surgeon rotates the jaws (so teeth move up) and brings them down a bit (teeth move down), wouldn't that allow him to lengthen the face without compromising tooth show?

Also, what do you think about my midface? I think it's recessed, but my bimax protrusion 'masks' the recession. However, the base of my nose is too far back. Wouldn't a CCW without moving my maxilla much make it look even more recessed (since the mandible would now be proportionally more forward)?

Lastly, I believe my bimax protrusion is caused not only by thick tissue, as you mentioned, but also by exostosis along the dental arch, often caused by bruxism. I found this article:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4441241/

Have you ever heard of this? Is it easy or recommended to remove?

Thanks again

[kavan]

Thanks kavan, that was the exact type of answer I was looking for. It was very helpful and will really assist me in explaining my concerns to my surgeon.

You mentioned that CCW with maxilar downgraft might lead to more upper teeth show, even gummy smile. Is there any way to compensate for this by rotating the jaws a bit more? If the surgeon rotates the jaws (so teeth move up) and brings them down a bit (teeth move down), wouldn't that allow him to lengthen the face without compromising tooth show?

Also, what do you think about my midface? I think it's recessed, but my bimax protrusion 'masks' the recession. However, the base of my nose is too far back. Wouldn't a CCW without moving my maxilla much make it look even more recessed (since the mandible would now be proportionally more forward)?

Lastly, I believe my bimax protrusion is caused not only by thick tissue, as you mentioned, but also by exostosis along the dental arch, often caused by bruxism. I found this article:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4441241/

Have you ever heard of this? Is it easy or recommended to remove?

Thanks again

Exostoses are excess bone growth as to make a boney part thicker than it would be normally. Your surgeon would be able to tell you IF you had that by looking at your X ray. I doubt you have that. But check with the doctor who's conversant in interpreting such things from X rays.

I mentioned that if someone got an OVERALL downgraft of the ENTIRE maxilla and the NET rotation was CCW, that would elongate the lower 1/3rd if the face but that only works for people with very little upper tooth show. You see the downgraft part to the anterior maxilla is actually CW (clockwise) and the downgraft to the posterior maxilla is the CCW part. So in an overall downgraft, if the downgraft is MORE to the posterior part of maxilla, then the NET rotation is CCW. Thing is, it is the isolated POSTERIOR downgraft which maximizes lower jaw advancement. CCW for the ANTERIOR maxilla involves IMPACTION  means cutting out part of the frontal maxilla and THAT would shorten the face. So, no, your surgeon can't compensate via the way you are asking if that is so.

CCW via posterior down graft is a ROTATION. Moving the anterior spine of the nose (base of the nose) is a TRANSLATION and a different movement (for example an advancement). A rotation of an object is a different movement than an advancement of an object along a line or a plane. Anyway, if the plan calls for CCW to maximize the advancement of the lower jaw, it probably will call for some advancement of the maxilla also. No assumption can be made that ONLY rotation of the upper jaw will transpire in the absence of also moving it forward for both jaws to align and for the teeth to mesh.

[Lytric]

That's a very good explanation, thanks. This diagram you posted a while ago has also been quite helpful: https://jawsurgeryforums.com/index.php?action=dlattach;topic=8410.0;attach=8285;image


So it looks like in addition to the to the CCW with posterior downgraft, I probably should get some maxillar forward linear movement in order to provide more support to the base of the nose and to prevent my profile from looking too unbalanced between my 2/3 and my 1/3. I'm still slightly worried that lips will end up protruding too much, but I've heard that thicker lips tend to absorb movements more effectively than thinner ones, so hopefully that will help.

Regarding the exostosis, an oral surgeon has confirmed its presence (see picture below). However, both my orthodontist and surgeon have mentioned that keeping the extra bone in that area is preferable because we lose bone as we age. I just hope it won't affect the analysis and planning.

https://imgur.com/a/ma1N9Ec (exostosis)
https://imgur.com/a/dLsXeFA (just found this saggital scan taken before orthodontics, the exostosis is also visible here)

Thanks again! I will try to keep you updated, in case my situation proves helpful to others.

[GJ]

The proposed CCW makes sense to me, and I think your genio might look more pronounced (and maybe even give length given the angle of it looks more vertical) once your jaw is out more. I'm not positive, but I think so. I'd not mess with genio during the jaw surgery. See where things sit after, and if you need to revise the chin after DJS then do it later.

Do address any sunken in areas, if doing a CCW movement, I think you'd have to have bone or HA grafting in those areas. I think it's hard to predict how that area will react, but if the upper jaw is rotating back, it seems to me they would actually get worse if the upper isn't also advanced.