Matt's CCW MMA Thread

[mike888miller]

how much movement of the maxila is targetted, and how much impaction?

around which point is the rotation?

is it one or three piece le fort?

[kjohnt]

What did gunson suggest?

IDK what's going on with that.  I've been waiting months now and haven't heard from Kim since 8/18 I believe.

[PloskoPlus]

IDK what's going on with that.  I've been waiting months now and haven't heard from Kim since 8/18 I believe.

They took over 3 months to reply. I'll speak to gunson over the phone in a couple of weeks.

[Lazlo]

They took over 3 months to reply. I'll speak to gunson over the phone in a couple of weeks.

 so the easiest thing to do is call them speak to someone, ask that you be put on a waiting list for the next available appointment. Within a couple weeks someone will cancel and they'll call you. This is only if you're flexible. Otherwise it'll take a couple of months to get the appointment to see them . Its the best way for them to fully examine you and give you a full surgical plan. It's worth it. That said, I'm very happy on a scale of 1-10 I'm like 8 having had surgery with Dr. Sinn. The reason I'd recommend him is that he's so experienced, and this surgery is such a piece of cake for him that he'll give you a great result without mistakes and downtime. Honestly while I made the foolish mistake of leaving way too early and thus ran into pain issues. It was only for a few weeks. And the two points i'm docking is cause my lower jaw could have been advanced farther, and indeed I may have that done in the future. But other than that, what Dr. Sinn was able to achieve was pretty flawless. He did a complicated downgraft that gave me my smile and my teeth back that had disappeared to the back of my mouth from the crappy ortho i had received.

[Matt]

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.

I attached my lateral ceph below. I wish I was able to post a better quality image, but unfortunately I only had a paper copy on hand and thus had to scan it to the computer. Any opinions? Thank you again!

how much movement of the maxila is targetted, and how much impaction?

around which point is the rotation?

is it one or three piece le fort?

My surgeon listed the movements as:
- "LeFort I osteotomy with advancement with anterior intrustion"
- "Bilateral mandibular ramus osteotomy with advancement"
- "Advancement genioplasty"

My insurance approval letter listed the LeFort I as "single piece". So, my interpretation of all this was that I'd be having a BSSO + one piece LeFort I with CCW rotation (and genioplasty). Does that seem correct? I'm not sure how much impaction he is planning on... he did note my "maxillary incisor-to-upper lip being 7 mm". I've attached my lateral ceph below if that can be of any help. Thanks so much!

[PloskoPlus]

Your jaws look steep. CCW will allow the lower to be advanced more than yourr current overjet allows. Rotation can be achieved by impacting the front of the maxilla and/or down grafting the back of the maxilla.

[Matt]

Your jaws look steep. CCW will allow the lower to be advanced more than yourr current overjet allows. Rotation can be achieved by impacting the front of the maxilla and/or down grafting the back of the maxilla.

When my surgeon writes "anterior intrusion" that's implying CCW rotation, correct? I'm still not sure how much impaction / advancement would be needed for a nice rotation.

[mike888miller]

re the gunson phone consult - is the the 175 or the 500 one? does it inclube a call with him?

[mike888miller]

can you post your x rays, and also mark in into which position the doctor wants to move them? is it rotation mostly or sagital movement?

[Matt]

can you post your x rays, and also mark in into which position the doctor wants to move them? is it rotation mostly or sagital movement?

Unfortunately the three photos attached below are all I really have right now (FYI, they were taken before decompensation orthodontics began). Like I mentioned previously, the information that I have from my surgeon, in writing, is as follows:

"PROBLEM LIST:

- Sleep apnea.
- Mallampati severe Class IV.
- Anterior open bite from teeth #s 5 to 12.
- Vertical maxillary excess with his maxillary incisor-to-upper lip being 7 mm.
- He has polyps in his maxillary sinus.
- He is a mouth breather.
- He has a tongue thrust habit.
- This patient postures his mandible forward to help with his breathing difficulties. He also has residual tonsillar tissue and a very small oropharyngeal opening.


PRELIMINARY SURGICAL DIAGNOSES:

- Sleep apnea.
- Anterior open bite.
- Vertical maxillary excess.
- Tongue thrust habit.


PRESURGICAL ORTHODONTIC CONSIDERATIONS:

- Presurgical orthodontics is essentially completed. This patient presents with significant Mallampati Class IV relationship of his soft palate drape and an extremely small oropharyngeal airway. He also complains of jaw joint pain, secondary to protruding his mandible forward to help him with his posterior airway.


PRELIMINARY SURGICAL PLAN:

- LeFort I osteotomy with advancement with anterior intrusion.
- Bilateral mandibular ramus osteotomy with advancement.
- Advancement genioplasty."

[Matt]

My surgery date has been tentatively set for December 5th, and I'll have the final meeting with my oral surgeon to approve everything on November 9th. In the meantime, I'd be super grateful for any feedback pertaining to the information / photos in my last post. Thanks in advance!

[Matt]

Hey guys,

I just wanted to give this a quick bump to see if anyone might be kind enough to offer feedback regarding the scans and write up from my surgeon. As I mentioned, my next appointment is approaching on November 9th (with the surgical date shortly after on December 5th) and I'd love to receive as many opinions on the surgical plan as possible, before talking with my surgeon again.

Anything I should be aware of as it pertains to the scans I attached two posts up, and what my surgeon has written so far? My own personal concerns / things I really want to avoid are of course the typical ones: upturned nose / convex philtrum after LeFort I advancement with anterior intrusion ("chimp look"), a deep labiomental fold after advancement genioplasty, etc... Do any of these seem like a probability for me, when looking at my scans?

Thanks again for any help!

[Trader]

You have a very steep occlusal plane. You also don't appear to have a significant dental overbite.

The upshot is that you'll need a large degree of counterclockwise rotation to achieve a desirable advancement of your mandible. Unless you have a very large gummy smile, I'm not sure that an anterior impaction of your maxilla will achieve enough rotation -- I think you'll likely need posterior lengthening of your maxilla as well.

Can you post some pictures of your smile and your resting mouth posture?

[kjohnt]

You have a very steep occlusal plane. You also don't appear to have a significant dental overbite.

The upshot is that you'll need a large degree of counterclockwise rotation to achieve a desirable advancement of your mandible. Unless you have a very large gummy smile, I'm not sure that an anterior impaction of your maxilla will achieve enough rotation -- I think you'll likely need posterior lengthening of your maxilla as well.

Can you post some pictures of your smile and your resting mouth posture?

Agreed.

Incisor inclinations look good and perhaps even very slightly overly-retroclined in both arches.  Mandibular advancement will be achieved by way of CCW rotation and then to "catch up" with the amount the maxilla is being advanced.  Anterior up as much as possible so there is about 1mm gum show... 7mm tooth to upper lip is large but my concern is I'm not seeing that much in the ceph...  does the surgeon mean when smiling?  So I agree with above that perhaps posterior downgraft may be necessary.  Without pictures of your smile this is only speculation, but the one question I'd ask is if the surgeon plans to downgraft the posterior maxilla at all or if CCW rotation is being achieved fully with anterior impaction.  Ask why.

[Matt]

You have a very steep occlusal plane. You also don't appear to have a significant dental overbite.

The upshot is that you'll need a large degree of counterclockwise rotation to achieve a desirable advancement of your mandible. Unless you have a very large gummy smile, I'm not sure that an anterior impaction of your maxilla will achieve enough rotation -- I think you'll likely need posterior lengthening of your maxilla as well.

Can you post some pictures of your smile and your resting mouth posture?

Agreed.

Incisor inclinations look good and perhaps even very slightly overly-retroclined in both arches.  Mandibular advancement will be achieved by way of CCW rotation and then to "catch up" with the amount the maxilla is being advanced.  Anterior up as much as possible so there is about 1mm gum show... 7mm tooth to upper lip is large but my concern is I'm not seeing that much in the ceph...  does the surgeon mean when smiling?  So I agree with above that perhaps posterior downgraft may be necessary.  Without pictures of your smile this is only speculation, but the one question I'd ask is if the surgeon plans to downgraft the posterior maxilla at all or if CCW rotation is being achieved fully with anterior impaction.  Ask why.

Thanks a lot for the feedback, guys. I was originally feeling hesitant about posting my photos on here... but I've realized that I only want to go through this surgery once, so receiving as much feedback as possible is in my best interest. I'm going to attach quite a long string of photos, but I've taken the time to caption each one with some text that I hope everyone will read (side note: #8 is the most realistic picture of what's actually going on here. The first few are when things appear "normal").

Anyways, I do hope that these photos can be somewhat helpful. After seeing them, does it look like I'll need posterior downgrafting of the maxilla in addition to the anterior intrusion? Thanks again for all of the generous feedback, everyone - it's much appreciated!