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

[Post bimax]

I'm 3 months post-op (Posnick)

Surgery was to treat:
Open bite (1-3mm)
Mild OSA
Teeth grinding, lisp and some chewing problems
And of course aesthetic concerns

Surgircal plan was:
10mm maxillary advancement with Lefort 1
Similar mandibular advancement with BSSO
Slight sliding genioplasty

As of 3 months, my functional concerns have basically all been taken care of. I no longer have OSA problems, no lisp, no teeth grinding (or at least much less) and i can chew/tear food normally.

My main question is regarding aesthetics.  I believe my advancement was straight without any rotation, and I didn't even know what CCW rotation was until finding this forum.  I currently have what looks like "chimp lip" which I know can occur with large maxillary advancements. It doesn't look so bad in the picture but it's definitely noticeable.  Yesterday my ortho asked me about the "swelling" in my upper lip and a few others have commented on it.  While it could still be swelling, I'm beginning to think my maxilla was simply advanced too far without any compensating rotation.

My question is: Based on my CEPHs, should I have gotten CCW as part of the surgery? It looks to me like my occlusal plane is definitely off horizontal which is a bad sign for large advancements without CCW according to this forum.

Pics and CEPHS: https://imgur.com/a/88rq7HP

Thanks

[kavan]

Well, the more the Lefort 1 area is moved outward, the more the nose to lip curve* is going to change. It can go from conCAVE nose to lip curve* to STRAIGHT and then to conVEX nose to lip curve*. (*The med terminology for this nose to lip CURVE is 'Naso-labial ANGLE'. But I like to use more intuitively obvious descriptions because afterall, we are looking at a CURVE and not really an 'angle'.) So, here you see your nose to lip curve went from conCAVE to conVEX.

You relay you got 10mm L1 advance with similar BSSO which could be 'linear' advancement and that extent of it at the maxilla is usually consistent with 'chimp lip' (convex nose to lip curve). IF it wasn't linear advancement (an advancement with NO rotation to the maxilla) and you did have some kind of rotation, the rotation would have been a CLOCKWISE one. Your teeth photos show ANTERIOR open bite. The surgical correction (when needed to close anterior open bite) is a posterior impaction, a section removed from back of maxilla. Posterior impaction is CLOCKWISE rotation.

Hard to tell for sure within a 2 degree error but based on your cephs, ANS-PNS (palatal plane angle) and OP (occlusal angle) are measuring same. Either linear advancement or posterior impaction of 1-3 degrees along with the large advancement you got. Either way, an advancement of that extent is consistent with veering towards the conVEX nose to lip curve.

As to your question: ' Should I have gotten CCW rotation?', I don't think it's something you can/could pick and choose to have if you already have/had anterior open bite and there's no indication for CCW with anterior impaction. The other type of CCW rotation is the posterior downgraft. But people with anterior open bite get basically a segment REMOVED as would be added in a posterior downgraft in a person who did NOT have anterior open bite. So, that's why I don't think you had that choice in the first place.

[Post bimax]

Kavan

That seems like a pretty comprehensive answer. My lip is definitely convex and my nostrils are substantially wider and nose is upturned, all of which I know (now) is expected with maxillary advancement.

I think overall there has been an aesthetic improvement and the nose can possibly be managed by a rhinoplasty if I choose to.  The lip.. well, we'll see.

My main concern was whether it *could* have been otherwise, as irrational as that seems.

[Dogmatix]

As to your question: ' Should I have gotten CCW rotation?', I don't think it's something you can/could pick and choose to have if you already have/had anterior open bite and there's no indication for CCW with anterior impaction. The other type of CCW rotation is the posterior downgraft. But people with anterior open bite get basically a segment REMOVED as would be added in a posterior downgraft in a person who did NOT have anterior open bite. So, that's why I don't think you had that choice in the first place.

I understand your reasonening that the open bite needs to be closed, and rotating the maxilla  ccw will open it further. But looking at the result where the bite is fixed, couldn't it be possible to rotate the bimaxillary complex ccw from this point, which I think is what he is looking for. Given the result, if the bimaxillary complex could've been displaced more CCW than the surgeon did, maybe by posterior downgrafting from where the result landed.

Post bimax. First of all I think you're a bit hard on your self, you have an aesthetic improvement, and you don't look like a chimp. A reasonable question is, was your surgeon even qualified to offer advanced movements as CCW rotation? Not all surgeons are trained to perform such procedure. And also as Kavan explained, maybe it wasn't even an option. It seems like the genio was a bit of ccw rotation of the chin to compensate.

[Post bimax]

Dogmatix

I'm probably overly-critical, but I do think the chimp-ish look is apparent IRL (although I agree not so much in that picture).  My surgeon was Posnick and he seems to be the most well regarded and most qualified besides maybe A/G.  I had a good experience overall, I'm just curious about this one aspect.

[kavan]

I understand your reasonening that the open bite needs to be closed, and rotating the maxilla  ccw will open it further. But looking at the result where the bite is fixed, couldn't it be possible to rotate the bimaxillary complex ccw from this point, which I think is what he is looking for. Given the result, if the bimaxillary complex could've been displaced more CCW than the surgeon did, maybe by posterior downgrafting from where the result landed.

Post bimax. First of all I think you're a bit hard on your self, you have an aesthetic improvement, and you don't look like a chimp. A reasonable question is, was your surgeon even qualified to offer advanced movements as CCW rotation? Not all surgeons are trained to perform such procedure. And also as Kavan explained, maybe it wasn't even an option. It seems like the genio was a bit of ccw rotation of the chin to compensate.

The thing to understand (in this situation) is that correction of AOB is basically the REVERSE of posterior downgraft CCW. What's added in PDG CCW (in someone who doesn't have AOB) is removed when correcting AOB.

I'm not sure what you're asking by the way you ask it. Are you asking whether or not if AFTER correcting AOB by the REVERSE of a CCW posterior down graft, he can then get the CCW posterior downgraft?

[Dogmatix]

I'm not sure what you're asking by the way you ask it. Are you asking whether or not if AFTER correcting AOB by the REVERSE of a CCW posterior down graft, he can then get the CCW posterior downgraft?

I don't know what displacement there is done to close the anterior open bite. You mentioned a few ways it maybe was handled.

My question was not so much to speculate in what displacement the surgeon have done or if it should've been ccw rotation from starting point. But rather looking at the result, and respecting the concern about the concave lip. Looking at the angle where the surgeon placed the OP, could the surgeon have performed the displacement in a way where it's relative rotated CCW to where it was placed, to comply better with the thread starters concerns and for best aesthetic result? If the displacement was done by posterior impaction and CW rotation to close the bite, then it could've been achieved by less impaction and less CW rotation, which would be a CCW rotation relative to the end result.

I did simplify the question to if a ccw revision could be feasible given the concerns, since if the answer would be yes, then it would also imply that it could've been put that way in the first surgery, regardless if it would've been a ccw rotation from the starting point.

[kavan]

Kavan

That seems like a pretty comprehensive answer. My lip is definitely convex and my nostrils are substantially wider and nose is upturned, all of which I know (now) is expected with maxillary advancement.

I think overall there has been an aesthetic improvement and the nose can possibly be managed by a rhinoplasty if I choose to.  The lip.. well, we'll see.

My main concern was whether it *could* have been otherwise, as irrational as that seems.

Well, Anterior open bite, (AOB) is from too much downgrowth of the posterior maxilla (or over extrusion of back teeth) where the back teeth meet first and there's not enough closure to the teeth in front of them. They remove a segment from the posterior maxilla to correct the AOB. Even if the bite was corrected with braces to 'intrude' the back teeth and you didn't get the posterior impaction, getting a CCW posterior down graft would put you in the same position you had corrected; an AOB. To the best of my knowledge, a propensity towards AOB is contraindication for CCW posterior downgraft.

It looks like your surgery had most of the focus on correcting functional problems and the lip contour could be considered a 'trade-off'. It's pretty much a predictable one and I think that doctors should brace the patients for it.

[Post bimax]

Well, Anterior open bite, (AOB) is from too much downgrowth of the posterior maxilla (or over extrusion of back teeth) where the back teeth meet first and there's not enough closure to the teeth in front of them. They remove a segment from the posterior maxilla to correct the AOB. Even if the bite was corrected with braces to 'intrude' the back teeth and you didn't get the posterior impaction, getting a CCW posterior down graft would put you in the same position you had corrected; an AOB. To the best of my knowledge, a propensity towards AOB is contraindication for CCW posterior downgraft.

It looks like your surgery had most of the focus on correcting functional problems and the lip contour could be considered a 'trade-off'. It's pretty much a predictable one and I think that doctors should brace the patients for it.

I do wish he was a bit more forthcoming about the lip/nose changes. Although, I may have taken the risk anyway because I appreciate the longer mandible and more anteriorly projected face overall.  If anything, he could have been a little more bold on the genioplasty. I still have braces so that may gain me a mm of projection relative to my bottom lip when they come off.

Overall I still recommend Posnick as the functional outcomes were good and I basically got what I asked for

[kavan]

I don't know what displacement there is done to close the anterior open bite. You mentioned a few ways it maybe was handled.

My question was not so much to speculate in what displacement the surgeon have done or if it should've been ccw rotation from starting point. But rather looking at the result, and respecting the concern about the concave lip. Looking at the angle where the surgeon placed the OP, could the surgeon have performed the displacement in a way where it's relative rotated CCW to where it was placed, to comply better with the thread starters concerns and for best aesthetic result? If the displacement was done by posterior impaction and CW rotation to close the bite, then it could've been achieved by less impaction and less CW rotation, which would be a CCW rotation relative to the end result.

I did simplify the question to if a ccw revision could be feasible given the concerns, since if the answer would be yes, then it would also imply that it could've been put that way in the first surgery, regardless if it would've been a ccw rotation from the starting point.

I'm sorry. I don't understand the questions the way you ask them. I'll say the following:

a: A wedge section is often removed to close AOB. A wedge where the vertical height of it is more to the BACK of maxilla and min towards the FRONT. When the posterior maxilla 'wedges' down too much, the back teeth touch first and the ones in front of them don't touch which is what AOB is which is why a wedge section is removed from the back.

b: A CCW posterior down graft is basically where a similar shape wedge section is ADDED.

c: A person needing a wedge section REMOVED to close an AOB doesn't get a wedge shape section ADDED.

d: In effect, someone with AOB already has EXCESS CCW to the posterior maxilla. So, the excess kicking up the AOB is removed.

e: Although posterior impaction is CW, having it doesn't necessarily result in a NET CW  if the end result on the ceph shows ANS-PNS rotated CCW away from a horizont drawn FROM PNS (in a ceph profile facing RIGHT where the horizont drawn from PNS is is constructed from there to the right of the photo.) So, possible to be left with NET CCW orientation of ANS to PNS. BUT STILL, a LARGE advancement despite what rotation someone gets can kick up a conVEX nose to lip curve.

[kavan]

I do wish he was a bit more forthcoming about the lip/nose changes. Although, I may have taken the risk anyway because I appreciate the longer mandible and more anteriorly projected face overall.  If anything, he could have been a little more bold on the genioplasty. I still have braces so that may gain me a mm of projection relative to my bottom lip when they come off.

Overall I still recommend Posnick as the functional outcomes were good and I basically got what I asked for

Sorry you got the dreaded trade-off. But I don't think it could have been avoided given the extent of the upper jaw advancement. As I said in my first post, the nose to lip curve changes with the extent of the advancement; from concave , less concave, straight, convex, more convex as a function of the advancement and it wasn't a thing where he could give you CCW posterior downgraft (or impact the anterior maxilla) because that would not have corrected the AOB. 

[Dogmatix]

Hmm. I'll try with a shorter formulation.

Could a ccw revision be performed to adress the concerns with the convex upper lip and also asking for a more bold chin advancement.

[Post bimax]

Hmm. I'll try with a shorter formulation.

Could a ccw revision be performed to adress the concerns with the convex upper lip and also asking for a more bold chin advancement.

This also interests me.  Although the price for an aesthetic revision would be astronomical because insurance wouldn't cover any hospital costs and I'm not sure he would do it anyway.

[kavan]

Hmm. I'll try with a shorter formulation.

Could a ccw revision be performed to adress the concerns with the convex upper lip and also asking for a more bold chin advancement.

Please read my responses to the OP. I try to make my feedback to be 'in tune' with what the original question was and what I feel the original person with that question will understand. I think I added some clarity to HIM as to the; 'Should I have gotten CCW rotation.' If I haven't, I give up. If HE really wants to pursue a revision and/or attributes 'more CCW' as the 'fix', he can so consult to that regard.

[kavan]

This also interests me.  Although the price for an aesthetic revision would be astronomical because insurance wouldn't cover any hospital costs and I'm not sure he would do it anyway.

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.