Planning Bimax+CCW for open bite and overbite (pics included)

[Soccerboy]

https://imgur.com/a/3cMdYfn

I have already consulted with an orthodontist and oral surgeon. I am going with a surgeon covered by insurance (Dr. David M Morgan in D.C.), so if anyone has experience with him, I would like to hear about it. I am now 6 months into braces (so my teeth are straighter than in the pics), and I plan to have surgery in around 6 months. I trust my doctor - still, because of how important this procedure is, I'm looking for some second opinions on his plan, specifically in the aesthetics department .

I'll just dump everything I see on the diagnosis sheet here, sorry if the language is overly technical.

Important points:
Overjet: 5mm
Openbite: 3mm
Lip Incompetence: 4mm

Miscellaneous:
mandibular dental midline 1mm left of maxillary midline
Anterior open bite is noted, some tooth show with smile, but no gingival show
Mandibular retrognathic with asymmetry
Anterior apertognathia with maxillary and mandibular hypoplasia
Upper CI is exposed at rest 3mm
Upper CI exposed at smile 10mm + 0mm gingiva

Here are the symptoms I experience:
Recessed looking lower face (my primary concern)
Drooling in sleep, or as I try to sleep (I often wake up with my mouth open, though I am not mouthbreathing)
Difficulty eating (openbite)
Chin dimpling
Difficulty breathing through nose (it always feels stuffed)

He gave me a rough plan when I met with him 6 months ago, to be refined based on how I responded to the braces:
4-6 mm lower jaw advancement (I don't know if this is counting the CCW, or in addition to it). He said that advancements on the order of 10mm were not stable, though I see people on here who got that much.
A 3 piece lefort (I don't know how much, if any, upper jaw advancement is planned). He said that this would give me a fuller upper lip and make my nose look smaller.
CCW rotation (I don't know what kind, or how much)

Finally, a few specific questions (but feel free to provide other commentary outside of the scope of these questions):
We didn't discuss genioplasty when we met, because I hadn't heard of it then. Do I look like I could benefit from it? If so, how much of an advancement would you recommend?
Does 4-6 mm seem like enough lower jaw advancement?
How much of an upper jaw advancement do I look like I need?

Please tell me if there's any more info I could give to help you out! I can also post more recent pics based on how braces have affected my face if you think those would help.

[Dogmatix]

You basically want to know how many mm advancement you need. There's no way to meassure such by looking at pictures. That is decided when having a cbct and the VSP done and you can see how many mm that is needed to meet the objective. I can say that it looks like a proper diagnosis that you will benefit from advancement and probably a significant one. Your surgeon tells you that advancement in the region 10mm is not stable. That may tell that he is not capable of the techniques required to achieve this. When those advancements are done, it's usually by ccw rotation where you get leverage in the chin advancement from the rotation. So the advancement that is not possible for someone who don't do these rotations, is maybe possible for a surgeon who have this in the toolbox. And also, maybe a rotation is not even feasible with your bite situation, so it's not just to rotate anything, the entire case needs to be evaluated. An additional genio plasty allows further chin advancement and the total chin advancement that is often mentioned is the one achieved from the bimax + genio. I think more than 4-6mm chin advancement including genioplasty should be possible for any surgeon, I've seen genioplasty that have this advancement alone.

[Soccerboy]

I can say that it looks like a proper diagnosis that you will benefit from advancement and probably a significant one. Your surgeon tells you that advancement in the region 10mm is not stable. That may tell that he is not capable of the techniques required to achieve this.

Ok, thanks. I will ask him if he thinks that another surgeon would be capable of providing larger stable movements. I have a 5mm over jet, so I only need 4-6mm to line up my jaws, but that's without any forward advancement of the upper jaw. He is not a cosmetic surgeon, so perhaps his only goal is to line up the jaws relative to each other, without regard to how far forward they should be in absolute terms. I will also consult with other surgeons, though I would like to go with someone covered by my insurance.

And also, maybe a rotation is not even feasible with your bite situation, so it's not just to rotate anything, the entire case needs to be evaluated

To be clear, he has established that CCW is possible in my case; he plans to do it. I think I put too much in my info dump above, which made it unclear 

[Dogmatix]

Ok, thanks. I will ask him if he thinks that another surgeon would be capable of providing larger stable movements. I have a 5mm over jet, so I only need 4-6mm to line up my jaws, but that's without any forward advancement of the upper jaw. He is not a cosmetic surgeon, so perhaps his only goal is to line up the jaws relative to each other, without regard to how far forward they should be in absolute terms. I will also consult with other surgeons, though I would like to go with someone covered by my insurance.

To be clear, he has established that CCW is possible in my case; he plans to do it. I think I put too much in my info dump above, which made it unclear 

Ok, I looked closer now. You have an open bite, so rotating the maxilla ccw is maybe not possible as it would open the bite even further and require even more movement of the mandible to close it. So maybe your surgeon is saying he will rotate the mandible ccw to close the bite. It's really hard to comment on your plan as you don't seem sure your self. Basically you may have advancement from closing the bite, from there the surgeon can work in different ways, maybe bring both jaws forward if it looks like a good idea, or as you've discussed, only the chin by a genioplasty.

[kavan]

You have anterior open bite. The most common rotation done with that is CW; clockwise rotation. Not CCW; counter clockwise. So, double check whether or not he told you CW or CCW.

3 piece Lefort. Posterior impaction (CW) is usually done to the posterior part of maxilla because it has some excess length. This length, forces the lower jaw down a lot in CW rotation because the back teeth close before the front teeth can. For that reason, the lower jaw can't swing up and out. When the excess is removed from posterior part of jaw, DESPITE it being CW rotation, the lower jaw can swing up more because it's no longer forced backwards and down by the overgrowth at posterior maxilla. To help close the AOB, the FRONT part can be moved downward. Although that's also a CW rotation, it doesn't make a CW to lower jaw because it's just helping to close the GAP the front upper and lower teeth have. So, 3 piece, posterior impaction (CW) and downward move to front teeth (CW), gives a net CW rotation BUT in some cases (and I think yours would be one of those), where the CW rotation at upper jaw LEVELS OUT the upper jaw and helps RELIEVE the excess CW the lower jaw is forced into by the excess posterior maxilla. Counter-intuitive as it seems, although it's CW, it helps the lower jaw swing more upward and out as does CCW.

That said, I DON'T think you are getting CCW. I think you are getting CW. But it's the kind of CW that levels out the bite and relieves the EXCESS CW rotation your lower jaw is being forced into by the posterior overgrowth of posterior maxilla.

The above refers ONLY to the ROTATION of the maxilla.

The other displacements would be to move both the maxilla and mandible forward. MORE for the mandible than the maxilla. You could request a sliding genio WITH the surgery. It will give more advancement to chin and make it a little shorter and that will offset a steep mandibular plane and give more of the 'look' of CCW rotation.

I don't opine on specific mm displacements because what ever they may be has to be in accordance to everything else in the surgery 'meshing together' and that's something the surgeon determines. It's more important to understand the CONCEPTS which I've touched on above.

[Soccerboy]

Thanks for your detailed response, kavan. I will check on these matters and make an update. It may take me a while.

On whether or not it is CW or CCW - your points make sense. My diagnosis sheet doesn't say anything about the matter. I will ask about this specifically.