Advice needed on ceph / impaction / surgery plan

[TWGOAT]

Hi everyone,

Seeking your opinions on my case.

Main concern is sleep apnea prevention and general health + aesthetics. I was initially concerned with condylar resorption but the surgeon i saw says condyles look fine and big enough and doesn't recommend replacement

Some pictures of smile and resting mouth posture, palate : https://imgur.com/a/9zbehcN

Side profile with tongue up holding my breath: https://i.imgur.com/e2KsoKW.png

Ceph and panoramic: https://imgur.com/a/AIJFMF6

I'm located in Canada.

I recently had a first consultation with a surgeon and here is the proposed plan i got on his report:

Diagnosis : Long face, class 2 div 1, anterior open bite

Gum show measured at 5mm when maximum smile, incisor show 10mm

Treatment plan:

Lefort 1 (1 piece)
Maxillary advancement (not specified how much)
Differential impaction : 5mm anterior, 3mm posterior
CCW rotation
BSSO 10mm advancement
Lateral deviation 1.5mm on the left
Genioplasty - 8mm advancement - 3 to 4mm reduction




Just wondering after reading a lot about CCWr, impaction, posterior downgraft.

What do you think of the plan ?

I know i need a lot of CCWr and would like to know if you guys think i need impaction, or downgraft, or both, and what should i ask the next surgeon.

I also saw all the stories about overimpaction on here.

I read that no surgeons do posterior downgrafts in Canada but not sure if i even need it.

I plan to probably do MSE first to maximize transverse expansion first since palate is narrow.

Thanks in advance for your time.

[kavan]

Sounds like you have both excess posterior and anterior maxilla length resulting in excess gum show and anterior open bite.  Hence the differential impaction. The anterior impaction is CCW and posterior impaction is CW. The NET rotation is CCW. So you have excess maxilla both front and back. Also, anterior open bite is consistent with posterior impaction in the plan. The BSSO and genio will give improvement to very recessive lower jaw. The gummy smile and AOB will be addressed by the 2 types of impactions.

Posterior downgraft is not indicated for someone with AOB and/or with excess posterior gum show.

[TWGOAT]

Thank you for your answer kavan !

Since the differential impaction is 5 front / 3 back, does this mean there is a limit to the maximum amount of rotation achievable with this differential ?

Which is why the genio is 8mm ?

For example if the differential impaction was 5 front / 1 back, the net rotation effect would be bigger so less genio ?

And last question, do you think 5mm impaction seems too much given the amount of gum I show ?

Thank you for your time,

[kavan]

net ccw rotation is 2. combo will help you. you are very recessed which is why the 8mm add on. 5mm impaction not too much

[thedude]

Reduction genioplasties make me nervous. It seems like the area you are reducing is the exact spot the tongue muscle attaches to the chin. I would think shaving that might jeopardize that attachment and possibly result in very bad sleep apnea. I could be wrong. Maybe someone knows more about it. I’ve often wondered if my sleep apnea was exacerbated by a chin implant the doctor placed unusually low that ate away a lot of the bone in the same spot I imagine it’s taken out with a reduction genioplasty.

So I’d think about whether that is really necessary as CCW will reduce chin height on its own and as a man having a chin that is too long really isn’t a big deal and many would find that in fact desirable. And why even bother for 3-4mm? That’s nothing. Especially on a man. That just makes no sense to me that you’d do a dangerous procedure for little gain that is counterproductive to the goal you are trying to achieve. That your doctor would do that makes me question his competency to be honest so make sure you get a few opinions and really trust this guy.

Other thoughts make sure you really need/want 5mm impaction as that’s a lot and if you’re doing the surgery for sleep apnea consider advancing upper jaw 8-10mm which seems like the minimum you need to do for a meaningful improvement. Between the impaction which makes apnea worse and the chin reduction which will make apnea worse you might not see much sleep improvement with your plan. You’re subtracting almost as much as you are adding here.

[GJ]

You need quite a bit of CCW rotation, so I'd ask if when he says "CCW rotation" he's talking just that 2mm net movement (5mm anterior - 3mm posterior =2mm net) from impaction, or if he's actually planning to rotate the entire complex. You need the latter.

Also, I'd be a bit concerned about 5mm anterior impaction. To me looks more like 3mm is appropriate, because when you're showing the most gum (photo 2) you're also in an unnatural smile. The cut itself results in a loss of 1mm. So if he doesn't compensate for that, you're at 6mm. I always think go under 1 or 2mm from any recommendation for these reasons. Better to be a little excess there than over impacted.

8mm genio likely leaves a large step.

I think the ideal plan would look something like this:

3mm anterior impaction
15mm mandible via ccwr after posterior impaction
4mm genio

That's just a guess looking at you in the flesh, but I think that makes the most sense. Maybe you can clarify with the surgeon how they plan to get the CCW. If it's just the small 2mm net impaction movement, then your mandible will be forced to move linearly, which won't be good. I think this is his plan since it says maxillary advancement (ccwr wouldn't really advance that point) and he lists ccw separate from that.

[TWGOAT]

Reduction genioplasties make me nervous. It seems like the area you are reducing is the exact spot the tongue muscle attaches to the chin. I would think shaving that might jeopardize that attachment and possibly result in very bad sleep apnea. I could be wrong. Maybe someone knows more about it. I’ve often wondered if my sleep apnea was exacerbated by a chin implant the doctor placed unusually low that ate away a lot of the bone in the same spot I imagine it’s taken out with a reduction genioplasty.

So I’d think about whether that is really necessary as CCW will reduce chin height on its own and as a man having a chin that is too long really isn’t a big deal and many would find that in fact desirable. And why even bother for 3-4mm? That’s nothing. Especially on a man. That just makes no sense to me that you’d do a dangerous procedure for little gain that is counterproductive to the goal you are trying to achieve. That your doctor would do that makes me question his competency to be honest so make sure you get a few opinions and really trust this guy.

Other thoughts make sure you really need/want 5mm impaction as that’s a lot and if you’re doing the surgery for sleep apnea consider advancing upper jaw 8-10mm which seems like the minimum you need to do for a meaningful improvement. Between the impaction which makes apnea worse and the chin reduction which will make apnea worse you might not see much sleep improvement with your plan. You’re subtracting almost as much as you are adding here.

Thank you for your thoughts.

When you say chin reduction would make apnea worse, you take into account the 8mm advancement of the chin also ?

And from what he showed me, the CCW rotation will quadruple my airway width (which is currently like 3mm based on the CBCT) so i don't think sleep apnea would be a concern anymore.

[TWGOAT]

You need quite a bit of CCW rotation, so I'd ask if when he says "CCW rotation" he's talking just that 2mm net movement (5mm anterior - 3mm posterior =2mm net) from impaction, or if he's actually planning to rotate the entire complex. You need the latter.

Also, I'd be a bit concerned about 5mm anterior impaction. To me looks more like 3mm is appropriate, because when you're showing the most gum (photo 2) you're also in an unnatural smile. The cut itself results in a loss of 1mm. So if he doesn't compensate for that, you're at 6mm. I always think go under 1 or 2mm from any recommendation for these reasons. Better to be a little excess there than over impacted.

8mm genio likely leaves a large step.

I think the ideal plan would look something like this:

3mm anterior impaction
15mm mandible via ccwr
4mm genio

That's just a guess looking at you in the flesh, but I think that makes the most sense. Maybe you can clarify with the surgeon how they plan to get the CCW. If it's just the small 2mm net impaction movement, then your mandible will be forced to move linearly, which won't be good. I think this is his plan since it says maxillary advancement (ccwr wouldn't really advance that point) and he lists ccw separate from that.

Thanks for your thoughts.

When we spoke about the rotation he said everything will rotate and advance, but yes like you say i'm wondering how to rotate that much with a net 2mm movement, which was my question doesnt that limit the rotation movement compared to a 5/1 ratio for example ?

If the 5/3 ratio allows to rotate 20 degrees but i need a 30 degrees rotation, how can you gain the other 10  degrees ? I have trouble picturing that

And when you say 3mm would probably be ideal, wouldn't reducing the impaction also reduce the CCWr ?

I wasn't planning to go with him anyway, just wanted his advice on if i needed joint replacement.

I'll see what the next surgeon says.

[GJ]

And when you say 3mm would probably be ideal, wouldn't reducing the impaction also reduce the CCWr ?

No, only if he planned to get his CCW-r from the impaction only.

Ideally fix a point and rotate both jaws along that point. The entire complex needs to rotate in your case. Not just a little upswing of the lower jaw via impaction, which is my interpretation of the plan you shared. This would allow the lower jaw to get out much further than the upper. The upper jaw angle would flatten (posterior comes down) and this allows the lower to swing out without having to move the upper forward.

[TWGOAT]

No, only if he planned to get his CCW-r from the impaction only.

Ideally fix a point and rotate both jaws along that point. The entire complex needs to rotate in your case. Not just a little upswing of the lower jaw via impaction, which is my interpretation of the plan you shared. This would allow the lower jaw to get out much further than the upper. The upper jaw angle would flatten (posterior comes down) and this allows the lower to swing out without having to move the upper forward.

Yes i understand this principle of rotation, but how is it supposed to be done if not only with the impaction and without posterior downgraft ?

[GJ]

Yes i understand this principle of rotation, but how is it supposed to be done if not only with the impaction and without posterior downgraft ?

Posterior downgraft would be good. That's what I'm describing. But if he plans to get rotation from a few mm of anterior impaction, that's not going to allow the lower jaw to swing up enough for your case.

There are two different things here:

You can shorten the anterior maxilla (impact) and let the lower jaw swing up, and technically that is CCW. My interpretation of the plan you shared is that that is what this surgeon plans to do. It would result in an inadequate 2mm net rotation and take on much risk (premature aging, nasal base issues, lack of tooth show, etc).

The other option to get CCW-r is rotate both jaws along a fixed point. The entire complex. You can call this a posterior downgraft if you want, because yes, the posterior comes down. This is the type of CCW-r you need. It's the type that allows large movements to the lower jaw without deleterious effects to the upper jaw.

You can also combine the two, and what I said in my original post is that's the best here (imo). Limit the impaction to 3mm or so to reduce negative aesthetic risks, then rotate the entire complex some large amount (probably > than 10mm and closer to 15mm). Then be less aggressive on the chin since the jaws were properly rotated.

The one negative of that is it's generally considered less stable, but it's a proper treatment plan for recession that severe.

[TWGOAT]

Yes i understand what you mean.

I asked this surgeon and he says he doesnt do posterior downgrafting.

From what kavan said i thought it wasnt needed since i have an open bite.

Ill ask the next surgeon if he can rotate the complex enough without downgraft

[GJ]

From what kavan said i thought it wasnt needed since i have an open bite.

I don't see an open bite on your ceph. I see lip incompetence.

An open bite looks like this: https://media.oralhealthgroup.com/uploads/2018/09/Razavi-Figure-2c.jpg

Maybe your bite is starting to slightly open...hard to tell, but it definitely doesn't look extreme if it's open at all. Ortho can probably fix that, especially once the jaws are in proper position.

[TWGOAT]

yes it's slightly open only, it's been like that since i  stopped ortho as a teen and reopened due to a tongue thrust, but it's stable i would say for the last 10 years at least.

[GJ]

yes it's slightly open only, it's been like that since i  stopped ortho as a teen and reopened due to a tongue thrust, but it's stable i would say for the last 10 years at least.

Gotcha. You should work on fixing that tongue thrust before any surgery to avoid relapse, opening of the bite, etc. There are even videos on YouTube showing how to do this.