What exactly makes CCW rotation with posterior down grafting harder for docs?

[FranAK]

So ive read on here that ccw rotation is something that not a lot of docs do, and that its an "advanced movement", why tho? The doc I consulted with said I dont need it, I disagree, but I think he said it in a way as in he doesn't even know how to do it, so what if I just hopped on his computer while hes on the virtual 3D planning, then I rotate my jaws, and then say "Can you just do this?" Like how hard is it to literally just rotate the jaws while they are literally or metaphorically in your hands?

Like to play devil's advocate, maybe you need specialized splints or something idk.

I feel like I need something like this idk https://imgur.com/a/lhumP1d

Well... i dont feel.. i see.. when I jut my lower jaw and stick a ruler in my mouth its about 6mm, it looks good, yet the doc said my maxilla needs like 4mm of movement.. granted, he just eyeballed the xray.. so... right there is a conflict. Idk it seems rotating 6 degrees (the edit) makes it so I can get that 6mm on my lower. And assuming maybe he eyeballed wrong and will say I need 6mm on my maxilla, the problem is that at least my lower teeth push my bottom lip out too much and are too in front of the chin due to the steepness of the mandibular plane and i know ccw can help that.

[GJ]

So ive read on here that ccw rotation is something that not a lot of docs do, and that its an "advanced movement", why tho?

Posterior downgraft requires bone or other material to fill the space. Those grafts aren't stable for various reasons (bone tends to absorb, large gaps/not enough bone to fill, etc).

[FranAK]

Posterior downgraft requires bone or other material to fill the space. Those grafts aren't stable for various reasons (bone tends to absorb, large gaps/not enough bone to fill, etc).

Wait i think he said he wants to bring my maxilla down to help my smile.. so I imagine the whole maxilla. Doesnt that require grafting too? So if he can do that doesnt that mean he can also do it for ccw rotation?

[GJ]

He wants to move the entire maxilla down and then rotate it CCW? On what fixed point? Without a fixed point/fulcrum to rotate on that seems extremely unstable. Normally the posterior would come down, be filled with grafting, and the anterior would move up -- the fulcrum point and anterior points fusing to create some stability with the posterior being unstable. What you are describing is essentially a floating maxilla. Maybe get a ceph of the exact plan.

[FranAK]

He wants to move the entire maxilla down and then rotate it CCW? On what fixed point? Without a fixed point/fulcrum to rotate on that seems extremely unstable. Normally the posterior would come down, be filled with grafting, and the anterior would move up -- the fulcrum point and anterior points fusing to create some stability with the posterior being unstable. What you are describing is essentially a floating maxilla. Maybe get a ceph of the exact plan.

No sorry, im being miss understood, im trying to figure out if he even does ccw rotation. He said he would bring my maxilla down... WITH NO CCW. But you said that ccw requires bone grafting... if he said hes bringing the whole maxilla down then doesnt that also require bone grafting? So doesnt that mean he has the ability to do CCW in general?

But anyways, i found this picture on his website, does it look like the patient got ccw rotation? No way braces changed her occlusal plane, right?

https://imgur.com/a/tR8jHdt

[GJ]

That ceph sure looks like CCW. Why not just ask him if he does it?
I'm sure he can lower the maxilla without rotating it, but that seems super unstable to just have it floating by plates. Do you have no tooth show at rest? I'm trying to understand why he'd want to do that movement.

[Post bimax]

No sorry, im being miss understood, im trying to figure out if he even does ccw rotation. He said he would bring my maxilla down... WITH NO CCW. But you said that ccw requires bone grafting... if he said hes bringing the whole maxilla down then doesnt that also require bone grafting? So doesnt that mean he has the ability to do CCW in general?

But anyways, i found this picture on his website, does it look like the patient got ccw rotation? No way braces changed her occlusal plane, right?

https://imgur.com/a/tR8jHdt

The head position is different in the b/a so be careful about eyeballing it.  Look at the difference in spinal curvature.  It's possible this person just has better head posture plus the genio in the 'after'. If the doc is saying he won't do CCW don't just assume he's actually going to do it.

[FranAK]

That ceph sure looks like CCW. Why not just ask him if he does it?
I'm sure he can lower the maxilla without rotating it, but that seems super unstable to just have it floating by plates. Do you have no tooth show at rest? I'm trying to understand why he'd want to do that movement.

When i talk/open my mouth  u cant really see my top teeth.. but his reasoning is that he was looking at me smile and he said it would improve my smile. When I smile you cant see any gums, so i think i could use like 1-2mm of gum show. Idk

Well, i cant really contact him to ask, ive only seen him for the consultation and i "ghosted" him for 2 months and didnt have an orthodontist contact him because I didnt want to see him if he didnt do ccw but now that it seems like he does it, im going to have an orthodontist contact him.

[FranAK]

The head position is different in the b/a so be careful about eyeballing it.  Look at the difference in spinal curvature.  It's possible this person just has better head posture plus the genio in the 'after'. If the doc is saying he won't do CCW don't just assume he's actually going to do it.

Oh true, i was being conscious of it and at first I thought it was the same exact head position, but looking at it now, its slightly different but when I rotate a picture to match it still kind of looks like they got ccw.

[PloskoPlus]

If you have any doubts, defer the surgery (especially with the whole pandemic thing). No surgery is better than a bad surgery. Realistically you have only one shot to get it right. It’s not a hair cut. Revisions are rare and most surgeons shirk them.

[FranAK]

If you have any doubts, defer the surgery (especially with the whole pandemic thing). No surgery is better than a bad surgery. Realistically you have only one shot to get it right. It’s not a hair cut. Revisions are rare and most surgeons shirk them.

Yeah exactly, im not even close to the surgery part because ive been holding off on having the orthodontist contact him because i wasnt sure id want him. And yeah i was like day dreaming me talking to him and saying that exact thing "hey i really think i need ccw rotation and i really only have 1 chance to get it right so can u plz do it" lol

[ODog]

No sorry, im being miss understood, im trying to figure out if he even does ccw rotation. He said he would bring my maxilla down... WITH NO CCW. But you said that ccw requires bone grafting... if he said hes bringing the whole maxilla down then doesnt that also require bone grafting? So doesnt that mean he has the ability to do CCW in general?

But anyways, i found this picture on his website, does it look like the patient got ccw rotation? No way braces changed her occlusal plane, right?

https://imgur.com/a/tR8jHdt

Who’s the surgeon that’s recommending this? I was a similar case to you, occlusal plane was flat and tooth show/ smile wasnt good but my mandible was steep. I got CW rotation which did help my smile but it does make the jaw steeper, although the change isn’t really noticeable tbh.

Ideally if I had know better at the time, I would have gone abroad for downgrafting of the maxilla so that CCW-r could be achieved. The US surgeons who do downgrafting are too expensive for me so I ruled that out as an option. Little did I know there are many competent surgeons in Europe that use this method as well.

If you want an ideal surgery, I’d find someone who can downgrafting to your posterior and anterior maxilla so you can both improve your tooth show while achieving CCW rotation.

[ODog]

No sorry, im being miss understood, im trying to figure out if he even does ccw rotation. He said he would bring my maxilla down... WITH NO CCW. But you said that ccw requires bone grafting... if he said hes bringing the whole maxilla down then doesnt that also require bone grafting? So doesnt that mean he has the ability to do CCW in general?

But anyways, i found this picture on his website, does it look like the patient got ccw rotation? No way braces changed her occlusal plane, right?

https://imgur.com/a/tR8jHdt

CW rotation to bring the maxilla downward doesn’t require bone grafting, they tilt the back upward and the front downward.

[ODog]

Could someone explain to me why the occlusal plane should match the mandibular plane ? Does this cause TMJ issues?

I have TMJ post-op and am wondering if CCW-r would have eased that a bit.