Matt's CCW MMA Thread

[Lazlo]

Lucky bastard you'll look like a model after this surgery.

[Lazlo]

MAKE SURE YOU GET AT LEAST 1cm forward genio

[Matt]

MAKE SURE YOU GET AT LEAST 1cm forward genio

Hey, Lazlo! Thanks for the feedback. One of my concerns has actually been regarding the genioplasty. Do you think a large forward movement like that would result in a deep labiomental fold? That's something I'd really like to avoid, if possible (...is that prevented by vertically lengthening the chin, in addition to the forward advancement, so that the labiomental angle isn't overly acute?). I'm not as educated on SG movements, so I could definitely be misunderstanding this / worrying too much.

Also, what's your opinion on what was mentioned earlier in this thread (regarding the potential for needing posterior downgrafting of the maxilla, in addition to the anterior intrusion?). I know my occlusal plane is steep, but my oral surgeon has only mentioned anterior intrusion so far... do you think that will be enough for a sufficient CCW rotation?

[kjohnt]

I think your impaction should be about 3mm. 

I really do believe you need a bit of posterior downgraft to get the occlusal plane where you want it.  The downside of this would be the gum show on the sides when smiling.  I wonder if you can get some of the gum tissue over your upper molars taken off.  I have the same thing but my ortho says I just have short molars (not a gum overgrowth issue) so that's not an option and he is concerned of a posterior downgraft on me.  My occlusal plane isn't as steep as yours though. 

Your real issue I think is short ramus in conjunction with the vertical anterior excess, and ramus lengthening isn't an option so far as I know. 

Anyway, the upside is better chin projection via CCW rotation.  Honestly, I get the SG argument, but your chin would need no augmentation if your occlusal plane was corrected.  Depending on how much CCW rotation you can achieve, I personally wouldn't get genioplasty at all.  I think you instead need a large BSSO advancement as part of a large CCW rotation.  The question is is that large of a rotation feasible and would it be aesthetically better than leaving some occlusal tilt and compromising with sliding genio to get your chin where you want it to be. 

This is just my opinion based on what I currently know... and this is the exact same thing I'm trying to figure out with my own face but just to a lesser degree.

[PloskoPlus]

Agree with kjohnt. I'm afraid many surgeons simply can't do posterior down grafting and just do as much (often too much!) Anterior impaction and a big ugly genioplasty to compensate. The excuse for lack of skill is "down grafts are not stable", which is bulls**t.

[Matt]

I think your impaction should be about 3mm. 

I really do believe you need a bit of posterior downgraft to get the occlusal plane where you want it.   

Anyway, the upside is better chin projection via CCW rotation.  Honestly, I get the SG argument, but your chin would need no augmentation if your occlusal plane was corrected.  Depending on how much CCW rotation you can achieve, I personally wouldn't get genioplasty at all.  I think you instead need a large BSSO advancement as part of a large CCW rotation.  The question is is that large of a rotation feasible and would it be aesthetically better than leaving some occlusal tilt and compromising with sliding genio to get your chin where you want it to be. 

Agree with kjohnt. I'm afraid many surgeons simply can't do posterior down grafting and just do as much (often too much!) Anterior impaction and a big ugly genioplasty to compensate. The excuse for lack of skill is "down grafts are not stable", which is bulls**t.

I appreciate the feedback, guys. I'd really like to achieve the proper amount of CCW rotation, instead of compensating with a larger than needed genioplasty. Since my surgeon has yet to mention posterior downgrafting, I'm worried he may not be planning for it at all. Of course, I'll make sure that I ask him about it at our next appointment... but what if he wants to stick with anterior intrusion only? I'd hate to be left in a position where I should have had more CCW rotation and it never happened.

Is it common for surgeons in the US to perform both anterior intrusion and posterior downgrafting? I live in Florida and am unable to afford an out of network surgeon, so I did my best to find an experienced surgeon that was in network. Originally I had called Dr. Richard Joseph's office (since he was so highly regarded), however he only works with patients inside of a small local radius (and he's out of network). My current surgeon however, came recommended directly from Dr. Joseph himself. For that reason, I'd like to think that I'm in good hands and he may be able to perform a posterior downgraft. If not though, I don't know what more I can do (given my short timeline and the fact that insurance has already approved me with this current surgeon for a December 5th operation).

If anterior intrusion is the only form of CCW rotation on the table, what do you guys recommend I do?

[PloskoPlus]

I appreciate the feedback, guys. I'd really like to achieve the proper amount of CCW rotation, instead of compensating with a larger than needed genioplasty. Since my surgeon has yet to mention posterior downgrafting, I'm worried he may not be planning for it at all. Of course, I'll make sure that I ask him about it at our next appointment... but what if he wants to stick with anterior intrusion only? I'd hate to be left in a position where I should have had more CCW rotation and it never happened.

Is it common for surgeons in the US to perform both anterior intrusion and posterior downgrafting? I live in Florida and am unable to afford an out of network surgeon, so I did my best to find an experienced surgeon that was in network. Originally I had called Dr. Richard Joseph's office (since he was so highly regarded), however he only works with patients inside of a small local radius (and he's out of network). My current surgeon however, came recommended directly from Dr. Joseph himself. For that reason, I'd like to think that I'm in good hands and he may be able to perform a posterior downgraft. If not though, I don't know what more I can do (given my short timeline and the fact that insurance has already approved me with this current surgeon for a December 5th operation).

If anterior intrusion is the only form of CCW rotation on the table, what do you guys recommend I do?

IANAD.  You may not need any posterior down grafting after all - you do have a very gummy smile, and your retrusion is not that severe.  So you may achieve everything with just anterior impaction.  But you cannot really know this until you get advice from a doctor who does posterior down grafts routinely.
Even with all the gum that you show, I would be weary of impacting too much (even Gunson has done this in the past).  It is a) ageing if overdone and b) large vertical facial changes have the biggest psychological effect for good or bad.
Unless that is your one and only opportunity for surgery, I would take a chill pill and get other opinions.  I sure as hell wish I did.

[kjohnt]

Yeah basically same answer as above.  I'd just talk to your surgeon and explain your desired outcome and your concerns.  I too think you should get multiple opinions, because they will vary, unfortunately.  These would be my questions/concerns in order:

1) ANTERIOR IMPACTION - How much?  You don't want it overdone.  Should have 0-1mm gum show above upper incisors when fully smiling and that will limit the amount that should be done.  Given this, would that amount of anterior impaction alone be enough to flatten your occlusal plane to the extent that your chin lines up nicely in profile?  If yes, skip ahead to #3.  If not...

2a) POSTERIOR DOWNGRAFT - Can posterior downgraft be performed to further flatten your occlusal plane and bring your mandible (and therefore chin) further forward relative to your maxilla?  Is the surgeon comfortable with doing this?  What are the downsides to doing this?

2b) SLIDING GENIOPLASTY - If downgraft isn't suitable/feasible/whatever, you'll want horizontal chin advancement via sliding genioplasty to line up your profile.

3) BIMAX ADVANCEMENT - Amount of horizontal advancement of maxilla and mandible.

[mike888miller]

i second the above.

it is funny, our side profiles are very similar, yet my occlusal plane is basically horizontal, which sadly means that i cannot have any Rotation, as it would mess up the curve of spee and thereby my smile. plus, my mandible lacks projection and is too deep so i in Need max sagital horizontal advancement of man and max, and gne in order to reduce the mandible height, and in order to achieve the projection.

http://jawsurgeryforums.com/index.php?topic=6074.0

you have a great Combo of steep plane plus a good, normally shaped mandible. therefore you Need to maximise the projection achieved via ccm, as projection achieved via Rotation of the jaw in the ideal inclication will provide a superior result to that of the gne.

the further back the Point around which you rotate is the more Rotation you achieve.

[Matt]

IANAD.  You may not need any posterior down grafting after all - you do have a very gummy smile, and your retrusion is not that severe.  So you may achieve everything with just anterior impaction.  But you cannot really know this until you get advice from a doctor who does posterior down grafts routinely.
Even with all the gum that you show, I would be weary of impacting too much (even Gunson has done this in the past).  It is a) ageing if overdone and b) large vertical facial changes have the biggest psychological effect for good or bad.
Unless that is your one and only opportunity for surgery, I would take a chill pill and get other opinions.  I sure as hell wish I did.

Yeah basically same answer as above.  I'd just talk to your surgeon and explain your desired outcome and your concerns.  I too think you should get multiple opinions, because they will vary, unfortunately.  These would be my questions/concerns in order:

1) ANTERIOR IMPACTION - How much?  You don't want it overdone.  Should have 0-1mm gum show above upper incisors when fully smiling and that will limit the amount that should be done.  Given this, would that amount of anterior impaction alone be enough to flatten your occlusal plane to the extent that your chin lines up nicely in profile?  If yes, skip ahead to #3.  If not...

2a) POSTERIOR DOWNGRAFT - Can posterior downgraft be performed to further flatten your occlusal plane and bring your mandible (and therefore chin) further forward relative to your maxilla?  Is the surgeon comfortable with doing this?  What are the downsides to doing this?

2b) SLIDING GENIOPLASTY - If downgraft isn't suitable/feasible/whatever, you'll want horizontal chin advancement via sliding genioplasty to line up your profile.

3) BIMAX ADVANCEMENT - Amount of horizontal advancement of maxilla and mandible.

i second the above.

it is funny, our side profiles are very similar, yet my occlusal plane is basically horizontal, which sadly means that i cannot have any Rotation, as it would mess up the curve of spee and thereby my smile. plus, my mandible lacks projection and is too deep so i in Need max sagital horizontal advancement of man and max, and gne in order to reduce the mandible height, and in order to achieve the projection.

http://jawsurgeryforums.com/index.php?topic=6074.0

you have a great Combo of steep plane plus a good, normally shaped mandible. therefore you Need to maximise the projection achieved via ccm, as projection achieved via Rotation of the jaw in the ideal inclication will provide a superior result to that of the gne.

the further back the Point around which you rotate is the more Rotation you achieve.

Guys, thanks so much for all of the responses. They were incredibly helpful. I actually ended up speaking with molestrip privately via e-mail and he had some great insight to offer as well. On November 9th I'm going to be seeing my surgeon again, so I'll ask him about how much rotation is needed here and what he thinks about the posterior downgrafting.

Today I saw my orthodontist and he mentioned a 3-piece LeFort to me, out of nowhere. The insurance approval letter I have mentions a single piece LeFort I, and my surgeon never mentioned 3-piece to me - so I'm not quite sure that is the current plan, but my orthodontist seemed to think it was something to consider. It's ironic, because molestrip took a look at everything and immediately said he thinks I would benefit from a 3-piece and should consider it, being that I'm young enough to heal well. This hadn't ever crossed my mind, and to be honest, 3-piece vs single piece isn't a topic I'm very educated on. What do you guys think?

I feel like my surgeon is going to think I'm crazy, asking to change things from single piece with anterior intrusion only, to a 3-piece with posterior downgrafting as well. Oh boy, haha...

[kjohnt]

Well you don't necessarily need to ask him to change his plan; rather, just ask him about these things and see what he thinks.  At the time of final planning, if you don't agree, then you'll need to be more assertive and may risk losing the surgeon.  Assuming your ortho and surgeon are communicating to any degree, your ortho will likely bring it up as well since he mentioned it to you.

It's funny because I'm wondering about the three piece for myself since my lower premolars seem to have some lingual tipping and if uprighted then my upper arch would be too narrow, as my uppers are good right now and are going to be slightly tipped buccally to accomodate my mandible being moved forward relative to my maxilla.  I really don't want three piece because that means more time under anesthetic, more boney surface area prone to non-union, higher chance of root damage, higher chance of bad placement by surgeon, etc.

[Matt]

I really don't want three piece because that means more time under anesthetic, more boney surface area prone to non-union, higher chance of root damage, higher chance of bad placement by surgeon, etc.

Well now I'm questioning if I should even want this! I just feel too ignorant in this area to understand whether my case would benefit from a 3-piece or not. Of course I'll see what my surgeon says about it all, but I don't really know what I should want to hear.

[Matt]

Hey guys,

I just wanted to post a quick update along with some new scans / drawings from my surgeon. Since my last post, I met with my orthodontist and surgeon each one more time, and unfortunately surgery had to be postponed from the original December 5th date. Apparently my orthodontist needs some more time pre-op. My surgeon did a test surgery on some updated impressions of mine, and he too said I needed some more time in braces. Apparently I'll be ready in another month or two, but now I'm uncertain if I'll do the surgery in Jan/Feb/March or just wait until the summer time because of college/university, etc.

At my last appointment, my surgeon informed me that I would not be having a 3 piece LeFort I. Even though my orthodontist had mentioned it to me, he looked at me like I was crazy when I brought it up, and said that he only does 3 pieces when he absolutely needs to, otherwise he likes to avoid it. Unfortunately, after we discussed that, he left the office quite quickly and I was left having to discuss some of my questions/concerns with his nurse. When I asked her about posterior downgrafting of the maxilla, she again looked at me like I was crazy. I tried to politely explain to her why I felt I needed more CCW rotation instead of just compensating with straight advancement, but it seems like they're only planning on doing the anterior intrusion. When I asked about that, she said that I'd be impacted to help rotate, but that the impaction would leave my upper lip at about where my brackets are (around half way down my teeth she said). That seems like too much! I told her I was hoping to still have 0-1mm of gum show after the impaction, but she seemed to think that wouldn't be the case (she made it seem like impaction half way down my upper teeth wasn't abnormal??). I know these things should have been discussed with my surgeon and not his nurse, so I'll be sure to ask him as well the next time I see him.

Now that I have more time before the surgery though, I've decided to get a second opinion from an out-of-network surgeon that my orthodontist had originally recommended to me. I can't really afford an out-of-network surgeon to be honest, but at the same time I don't want to let price pressure me into a less than optimal surgical plan. I'm going to attach some updated scans below, as well as the work-up / drawing that my current surgeon did. What do guys think of all this? I really want to make sure I'm getting enough rotation, and I definitely don't want to be over-impacted...

[ditterbo]

As I'm learning about bimax, it gets relatively simple as to how your mouth can be tweaked one way or another to bring everything forward for your particular case.  The tricky as hell part for us both right now is sort of the cost/benefit ratio to various amounts of posterior downgrafting in a class 2.  Maybe some doctors can do a posterior downgraft, with some compromises, for way less than like Gunson, in exchange for maybe .5 points in the looks department.  I just don't know how to figure out the 'best' compromise yet. 

Good for you for second guessing that surgical plan.  A half an upper tooth show when smiling sounds quite off. Maybe ask for before/after's of similar cases?

In other news, damn my retrusive jaw looks rotated forward compared to yours!  You also maybe have a lot of potential with that squared ramus, just need a way to make that pop more.  Getting down to it, this rotation business is really done to avoid a straight forward advancement it seems like, with the presumption that most people don't have deficient maxilla's on the scale of their jaws.  So if you must move the jaw forward a hell of a lot compared to the maxilla, rotation is required to minimize the maxilla's advancement.  Then you can consider posterior downgrafts superior if you don't have a gummy smile.  I think that's all there is to this CCW thing?

[Matt]

Good idea mate. You should really take your time approaching jaw surgery because it can almost break or make your life. Good luck, you will look really good once you get your jaw upgraded.

As I'm learning about bimax, it gets relatively simple as to how your mouth can be tweaked one way or another to bring everything forward for your particular case.  The tricky as hell part for us both right now is sort of the cost/benefit ratio to various amounts of posterior downgrafting in a class 2.  Maybe some doctors can do a posterior downgraft, with some compromises, for way less than like Gunson, in exchange for maybe .5 points in the looks department.  I just don't know how to figure out the 'best' compromise yet. 

Good for you for second guessing that surgical plan.  A half an upper tooth show when smiling sounds quite off. Maybe ask for their 'brag book' of similar cases?

In other news, damn my retrusive jaw looks rotated forward compared to yours!  You also maybe have a lot of potential with that squared ramus, just need a way to make that pop more.  Getting down to it, this rotation business is really done to avoid a straight forward advancement it seems like, with the presumption that most people don't have deficient maxilla's on the scale of their jaws.  So if you must move the jaw forward a hell of a lot compared to the maxilla, rotation is required to minimize the maxilla's advancement.  Then you can consider posterior downgrafts superior if you don't have a gummy smile.  I think that's all there is to this CCW thing?

Thanks, guys. Yeah, I agree that at this point I should really just get another opinion - it can't hurt and maybe I'll find out that I do need the extra CCW rotation (combination downgrafting / impaction rather than impaction only). I can't really tell if the drawing from my surgeon is enough rotation for my steep jaws. It's impaction only of course, and I can't help but feel like it's not enough. I'd like to maximize the rotation first and then finish off with the proper amount of straight advancement / genio (really dislike the idea of compensating for poor rotation with extra advancement).

Now comes the question of which surgeons will be right for my case. I'm sure many can do the anterior intrusion considering I have a gummy smile that needs impacting... but what about any further rotation / posterior downgrafting? Originally I planned to stay in-network since insurance will pay for everything after my $4,000 out of pocket maximum. Now I'm starting to reconsider, though. I'll just take out the extra student loans if I have to, because I'd rather bite the bullet on cost to make sure I'm getting the right movements with the right surgeon. Obviously names like Arnett, Gunson, Wolford, Sinn, Posnick, etc. are thrown around these forums often. Any recommendation on where to go next? My insurance will only pay their 60% of the out of network costs if they consider the surgeon's rates to be "reasonable / typical". From some online insurance calculators I've found, I'm guessing that means $20-25K for bimax/genio and not the $50K+ range. So what surgeons am I left with then?

I know Dr. Richard Joseph in Jacksonville, FL is about $23-26K for bimax / genio. However, he only works with patients inside of his "radius" - and despite us both being in Florida, I'm too far south for him to consider working with me. I don't know... maybe the drawing from my current surgeon is good enough for my case? Maybe it isn't, and I'll just never know until I speak with a surgeon that does the extra CCW rotation I seem to need. Ahh, I just feel so lost right now