CCW - bone sticking out from rotation

[ArtVandelay]

It's what another thread mentions as triangle sticking out. Attached is an image to show what I mean.

Seems like it should happen to anyone with a CCW rotation and posterior downgraft. Is the bone typically shaved down?

[kavan]

Art,

Some of the CCW docs are actually able to do a SEPARATE CCW or 'extra' to the BSSO itself which is a little twist where the trade-off is a little triangle of bone sticking out. A CW separate twist in the opposite direction can also be done for patients with 'short chin' or who need MPA increased.  It's NOT the downgraft that does it. It's a technique where they are ABLE to give a separate CCW twist with the BSSO.

[ArtVandelay]

thanks for your reply, yeah I was hoping the forward advancement would kind of hide this but apparently not in my case. I'll add this to my list and ask if this is addressed in any form and report back here

[Dogmatix]

Yes, this triangle is a real step off you'll be able to feel.

[DRIVVEN]

Art,

Some of the CCW docs are actually able to do a SEPARATE CCW or 'extra' to the BSSO itself which is a little twist where the trade-off is a little triangle of bone sticking out. A CW separate twist in the opposite direction can also be done for patients with 'short chin' or who need MPA increased.  It's NOT the downgraft that does it. It's a technique where they are ABLE to give a separate CCW twist with the BSSO.

What is the benefit of this "extra"? I would not want a triangle of bone sticking out, seems like it would be more noticeable in older patients or someone with a thin face. I think I posted a picture thinking it was exposed bone, but it might have been this twist...

[Dogmatix]

What is the benefit of this "extra"? I would not want a triangle of bone sticking out, seems like it would be more noticeable in older patients or someone with a thin face. I think I posted a picture thinking it was exposed bone, but it might have been this twist...

It's a degree of freedome in the displacement of the mandible. You can increase the rotation of the entire maxilomandibular complex if you allow rotation of the mandible. If you don't want this rotation of the mandible, it will be traded for less rotation of the maxilla as well and less projection/advancement of the chin and less opening of the airways.

[Tempus]

I've also seen similar examples, although I haven't seen what the soft tissue appearance looks like. 

[DRIVVEN]

It's a degree of freedome in the displacement of the mandible. You can increase the rotation of the entire maxilomandibular complex if you allow rotation of the mandible. If you don't want this rotation of the mandible, it will be traded for less rotation of the maxilla as well and less projection/advancement of the chin and less opening of the airways.

Thank you. I think what happened in my case, is that I was given this twist and advancement as if my upper jaw were operated but then the upper surgery was abandoned supposedly because of a bone metabolism problem, so the increased rotation and over-advancment with a now severely recessed maxilla. I presented with almost no over bite and overjet at my consult, but the lower jaw was advanced 14 mm, just bad geometry I guess.  (recent testing confirms I have normal bone metabolism, no bone disease or infection)

[DRIVVEN]

I've also seen similar examples, although I haven't seen what the soft tissue appearance looks like.

If you are an older patient or have a thin face, once the swelling from the surgery goes down, the defects appear.

[kavan]

What is the benefit of this "extra"? I would not want a triangle of bone sticking out, seems like it would be more noticeable in older patients or someone with a thin face. I think I posted a picture thinking it was exposed bone, but it might have been this twist...

I would imagine that it would decrease the direct dependency on the maxillary rotation alone to achieve the desired mandibular rotation.

[ArtVandelay]

What is the benefit of this "extra"? I would not want a triangle of bone sticking out, seems like it would be more noticeable in older patients or someone with a thin face. I think I posted a picture thinking it was exposed bone, but it might have been this twist...

I'm told although I don't fully understand the specifics, CCW rotation can increase the airway more than just a linear advancement. For some patients with steep mandibular planes there are also aesthetic benefits.

[ArtVandelay]

There is another thread which claims Dr. Wolford technique minimizes the notch though I can't find any papers online about it.

http://jawsurgeryforums.com/index.php/topic,4969.msg42410.html#msg42410

[Post bimax]

I'm told although I don't fully understand the specifics, CCW rotation can increase the airway more than just a linear advancement. For some patients with steep mandibular planes there are also aesthetic benefits.

My understanding is that it’s primarily the lower jaw advancement that improves the airway. CCW is ‘superior’ in the sense that it allows for more lower jaw advancement than mere linear bimax advancement. However, it may be the case that linear bimax advancement is equal or superior for airway opening ‘millimeter for millimeter’ .

[april]

I've also seen similar examples, although I haven't seen what the soft tissue appearance looks like.

The girl in that image had clockwise rotation.

The caption was "Three-dimensional skeletal image after bimaxillary surgery in which jaws were rotated clockwise as part of surgical plan to avoid counterclockwise mandibular advancement.  Surgery resulted in Class II anterior
open bite and maximum projection of ANS, which led to nasal base fullness, upturned nasal tip, and straight
upper lip. Mandibular advancement was also diminished, requiring large genioplasty that produced deep
labiomental fold and still failed to normalize chin projection "

[april]

Looking at Aflaros instagram & there's a video of a case of his that looks like CCW (with both anterior and posterior downgrafting?)

The animation sort of shows what happens and how this bone sticking out occurs
 https://www.instagram.com/p/B5VIVKIKQy-/ (but u need to swipe across to the video)

Like they have to lower the back of the mandible too in order to lower the upper, or else the back teeth will crunch into each other, and the whole thing won't be physically possible.

ETA: 

But then there's this one, and it's CW according to the caption and she has it too in her vsp So IDK.
https://www.instagram.com/p/B34w4buokAI/