Counterclockwise Rotation - Maxillomandibular Advancement Jaw Surgery
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- čas přidán 15. 06. 2021
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0:36 Regular maxillomandibular advancement (MMA) cuts
1:07 Counterclockwise rotation (CCWR)
1:34 Occlusal plane angle
2:06 Steep occlusal plane angle = indicator that you may benefit from a CCWR with your MMA procedure
2:42 Stability of CCWR with maxillomandibular advancement surgery
Disclaimer - The information in this video and on this CZcams channel is not medical advice. Please discuss this information with your doctor or health professional before undertaking anything suggested on this channel
Majority of people need this now, epidemic of down swung faces that are also recessed and narrow.
Hopefully, awareness will lead to prevention!
@@allsleepashleyAshley please respond my question….
It is an epidemic, sadly.
I may sound crazy saying this. But I don’t believe it’s 100% purely a “genetic condition”. But researching what the Industrial Revolution has done to the human body and how we’ve adapted to constantly eating very soft processed foods I believe plays a big role in this.
@@poopbutterontoast You don't sound crazy. 'Specialists/experts' love to throw out the 'it's genetic' excuse. Definitely softer (and less nutrient-dense) foods contribute to this epidemic.
MMA (mixed martial artists) sometimes give each other an occlusal plane rotation during their fights.
💯😹 tony got one recently
Found this in a web search 💖 Nice job, Ashley!
Move back here!
Thank you
👍
So, what to do if you hve TMJ?
Thank you for a very clear explanation by the way!
Thank you for giving me more indepth undering of CCW rotation, now who can I talk to that would diagnose this?
I think I am a canidate, yet, my ortho believes that since my upper and lower mandables are in good relation really nothing has to do be done regardless of the slant
Thank you so much for this. I am really nervous because the orthodontist said I need surgery to truly fix my jaw. He offered that and then to do a lesser intervention, which I am still getting details of.
I am not sure I can afford the surgery, but I am going to try. I have a lot of breathing problems that have only gotten worse with age.
Insurance should cover if you really need it
Thank you for your informative video . Do you suggest a surgeon for me who is really good at doing this surgery ?
Is this primarily a cosmetic surgery or for sleep apnea? I searched online for sleep apnea surgery’s and this was one of the first to pop up. I appreciate the informative video thanks
It could be done for sleep apnea, cosmetics, and/or occlusion.
Very interesting! Thank you for this video. Does this question require removal of wisdom teeth? I had to remove one for medical purposes and another one didn't show up, I'm not keen on removing even more teeth.
i have an anterior crossbite with a steep mandibular angle which makes nasal breathing with proper tongue posture feel constrained, so if I do go in for surgery I will be sure to ask about this thank you!
hey Ashley this was a very informative and nice video. So what happens if you have wear and tear on the condylar joints? Is there any solution to ensure a positive outcome? Would there be a joint replacement of some kind?
Depending on how much wear and tear you have on the condyles, some surgeons will suggest TMJ replacements for better long-term stability of the surgery/joints. Surgeons will have varying opinions on this so it's wise to get at least 2-3 opinions before moving forward.
Good video only thing I have objection with is maxillary impaction and auto-rotation improving the airway, that's really not the case, in order to improve soft tissue support / increase tension between the soft and the hard tissue you must enlarge the face such as with downgrafting not shrink it. Years ago people said it helps the airway but it is since disproven.
Thanks for bringing this up. Can you please send me the articles disproving it? I would be very curious to read them. Thanks again!
You could send them to ashleysommerspt@gmail.com or write the article name, year, and authors here so others can read as well. Thank you!
How you doing Ashley ? Have a question and a request for you , if you don’t mind of course ! The question is how a steep occlusal plane affects the joints ? And my request is that if yo don’t mind me sending my e line ricketts test befor and after my bimaxillary advancement surgery , i just wanna know why my mandible angle became steep, my chin is not as forward and I seem
To have some sort of lip incompetence , thank you !
@@amadeomiotto4573 Reading "Management of Obstructive Sleep Apnea" (at least parts of it) published last year by Springer, may help you understand the most current research regarding the relationship between the TMJ, the e line, in regards to the MMA itself.
@@allsleepashley Bit late to the party but I'll send you a few. The sources alone may not prove anything one way or the other to empirical certainty, but I think also looking at the physiological side of things explains it quite well. Even if we don't know everything empirically I believe best practices should suffice.
Two important ones I'll list are these two:
* Effects of maxillary advancement and impaction on nasal airway function
* A one-arm surgical trial of obstructive sleep apnea (OSA) patients before and 12 months after Bilateral Internal Ramus Distraction of the mandible (BIRD)
When it comes to auto-rotation, it's quite simple and can be explained physiologically, you want to splint the mandible. Think of a oral appliance, a MAD, this type of tool keeps the mandible in a forward position during sleep so the tongue base is more forward so it won't fall back as far and, hopefully increase negative pressure (though they usually don't work but that's an argument for another day). The issue with auto-rotation is that whilst it changes the position of the mandible during sleep however it can fall back to the original position. Alternatively when the mandible is lengthened (for example with CCWr w/ posterior downgraft), the isn't possible, it is splinted, there is now no need for an oral appliance.
Also with impaction, I mean why would you want to shrink the nasal airway, you know that just opposes everything we know about nasal airway surgeries reducing AHI. Turbinate reduction, nasomaxillary expansion, etc. If the nasal aperture were a non factor then these surgeries especially nasomaxillary expansion which expands the nasal aperture, exactly what we're talking about here except in the vertical dimension as opposed to transverse, wouldn't be so effective.
* Endoscopically-assisted surgical expansion (EASE) for the treatment of obstructive sleep apnea
The other thing is that as you probably know, these two typically go together, and so not only are you now simultaneously not splinting the mandible but you are also shrinking the nasal aperture (and thus the nasal cavity volume and releasing tension to the muscles).
If you would like to hear additional information on nasomaxillary expansion / EASE, and also MMAs which required revisions from Stanley Liu due to auto-rotation, impaction, and GGA, this video from KKL is a great watch. ~ Maxillary Expansion with Dr. Kasey Li | Not All Are Created Equal | EASE
For someone who has excessive vertical growth, does this limit how much ccw can be performed by the surgeon?
Hey there,
I am being referred to an oral surgeon regarding double jaw surgery. I also have some cranial distortions regarding a jamming / misalignment in my sphenoid bone. Do you know that when surgery takes place in bringing the maxilla forward, if the sphenoid moves forward too along with the maxilla?
hi! i think i need this type of surgery except my condyles are already worn :( are there any alternatives for the same results? could i get this surgery with a tmj replacement?
as i have a overbite at 21 with recession in both jaws from mouth breathing growing up(i have long midface and narrow skull because of it) i guess i need trimax CCW and probably undereye implants as i have zero support, it is what it is. good luck everybody !
Someone with a week steep lower jaw has to do DJS for OSA. The bite is good, and can’t tolerate orthodontics as a result of past ortho lost front bone, also has done 9 MM genio few years back, being advised to revising the genio at the time of DJS. Is revision necessarily for surgeon to maximize the counterclockwise rotation? Or an aesthetic choice?
Does the comment about the wear on condyles impacting the stability of the procedure apply only to CCW or to all jaw surgery (including, say, just a mandibular advancement)
This is very helpful. Thank you. I’m getting Lefort 1 & BSSO with CCW
I hope all goes smoothly for you! It's a big surgery. Good luck!
Could u suggest name of doctor
to get bimax cw rotation with best result under 6k dollar
@@parasjoshi1062 I don't think you're going to find this. All the best orthognathic surgeons that I am aware of are out-of-network and charge between $30-70k for the procedure. Where are you located?
@@allsleepashley Would you suggest a surgeon in CA? Preferably located in LA or SF
@@allsleepashley Hi Ashley. I'm from Chicago, IL. Do you know of any good surgeons in my area?
can you explain auto rotation mma surgery…
Can i achieve some counterclockwise rotation with marpe+facemask?
You can only impact the front aspect which is not basil bone. That’s more for a front aesthetic and not the actual maxilla
Yes, a CCW rotation is often used for aesthetics as well. The maxilla is cut side to side horizontally, intersecting with the walls of the nasal cavity. The palatine portion of the maxilla is rotated counterclockwise. You are correct, not the entire maxilla is rotated in this procedure. It is the same portion of the maxilla that is moved forward in a traditional (non-segmental) MMA.
@@allsleepashley yea
Would the outcomes of this surgery be similar to an upper jaw advancement with impaction
On top of the functional results, can Counter Clockwise movement with MMA improve gonial and mandibular plane angles (decrease angle and make jaw more square/masculine)? And can the movement be done without shortening the face from the front view?
So if you have consuls flattening but a steep mandibular angle/bite plane, the counterclockwise rotation isn’t wise?
Could u suggest name of doctor doing bimax CW rotation under 6k dollar
Thanks for your video and the explanation. I have one question which is; Does the Clockwise rotation of the mandible cause the airways to be tighter?
possibly
How is this a ccw rotation? In the video, according to the demonstration, the movement was clockwise.
Question about the TMJ part of what you said.
Couldn't one stabilize the tm joint after the counterclockwise surgery? Would it matter too much to stabilize before or after as long as it gets done? Also if it is moved forward would it not become more stable since it's not grinding anymore?
I have unstable left tm joint causing the jaw to be tilted and worn down on one side. I am potentially getting MSE expander with Dr Ting and then was going to bring upper and lower jaw forward with counter clockwise rotation. Apparently the surgery is supposed to fix the TMD.....Idk know anymore though because I feel like what you said makes sense.
The instability of the TMJ after surgery means that the bone on the condyle could resorb, shifting the mandible into a less predictable position, which would also then influence your dental occlusion in a negative way.
When you say "not grinding anymore", what exactly do you mean? Do you mean the condyle grinding on the temporal fossa? This is not necessarily what is going on when you have TMJ issues (but it could be in your case if you've confirmed this with imaging).
When you say "unstable left tmj" what do you mean? Is the disc stuck off of the condyle? Are you experiencing condylar resorption?
There is no guarantee in any surgery. It is always a risk. It depends on your own goals and your analysis of whether the potential risk is worth the potential benefit.
I am currently in an MSE.
Is Dr. Ting planning to do cortipuncture with your MSE?
I got the CCW rotation. I wish I had seen this video before my surgery though
Why is that? Are you pleased with your outcome?
@@allsleepashley Tough to say. I just had it April 26th.
@@jeffreylylemason Only 4 weeks out! I hope recovery is going smoothly. Please let me know if you gain any strong insights from this process. Wishing you the best in regards to your results and meeting your health goals.
@@allsleepashley Sleep is improving. Process has been painfully slow. Sensation in my face is about 95% back (from what I lost).
@@jeffreylylemason you had surgery with Dr Coceancig?
Don't they rotate just the upper jaw?
Hey Ashley! Are you planning on having MMA?
Hi Ashley, thanks for the video. Is *clockwise* rotation common during MMA procedure? Or is it mostly CCW? Why would someone undergo CW vs CCW?
sometimes CW is done for people with very short midfaces (for aesthetic reasons). I dont think it’s common. I had MMA surgery for sleep apnea but we did not do any CCW because my occlusal plane angle is already -2 (yes negative lol), so we did linear advancement since there is no room to do any CCW. and I don’t have a super short midface. CCW is always better for airway, if your anatomy is a candidate.
CW rotation is not common among the surgeons who work with my patients or who I have consulted with. CCW is more common. I agree with John down there. The occlusal plane angle that a person is starting with will largely determine if they can tolerate any CCW. There are also surgeons who are not trained in/don't have experience with CCW, so do not do it at all. I have seen less appealing aesthetic results when the mandible and maxilla are moved forward without CCW rotation. This is not always true and obviously depends on the starting position of the face... but it is certainly a pattern I have seen.
@@allsleepashley the risk of less appealing aesthetic result of doing too much linear advancement (without CCW) was the reason we decided to do a conservative 6mm advancement of the maxilla with my surgeon, thinking more than this could create a bad aesthetic result even if it benefits the airway more. I’m very happy with the aesthetic results of 6mm linear advancement, no complaints.
I think the risk of bad aesthetic outcome in linear advancement also depends on the occlusal plane angle. if the person has a steep occlusal plane angle and is a good candidate for CCW, but instead they do a large linear advancement, the outcome is more likely to be not very good.
@@borz55 agreed.
can you do Clockwise Bimax surgery? i have an online consultation just a few days ago. i was telling my surgeon that i did some research that by doing counterclockwise bimax surgery, not only it will open more airway but will give forward grown face so called "ante-face" profile.
but according to my surgeon, because im Asian, and my concern is maxillary hollow, doing CCW will only worsen my maxillary hollow, clockwise is preferable in my case
but he will do virtual surgical planning for both CW and CCW and let me see it.
but i cant really get the idea.
hope u can make video about clockwise rotation bimax? pleaseeee
Great question! Sorry for the delay. I will put this on my list of videos to do in the future. I am not as familiar with the discrepancy in MMA procedure for Asian faces as I would like to be but I intend to learn more about it this year. Hopefully, our timelines will align.
Name of surgeon
Can i have this surgery at 14 years old? Help
Can you do a video on clockwise rotation?
I can't promise this any time soon, but I'll add it to my list for future videos!
Can you plz explain why is counterclockwise rotation important from a physical therapy and from a sleeping/breathing perspective?
From a breathing perspective- a CCW rotation of the maxillaromandibular complex can further increase the anterior to posterior dimensions of the airway behind the midface (in addition to what maxillomandibular advancement can provide). CCW rotation can be done in various ways with axes of rotation as anterior as the anterior nasal spine and as posterior as the posterior nasal spine. If a person is having trouble breathing at night, this could help them reach a better outcome if they are having surgery with the goal of making their airway (behind their midface) bigger. From a physical therapy perspective, many patients I see have sleep breathing issues. With sleep breathing issues can come postural changes, muscle stiffness, increased pain, poor motor learning, etc. This is always worth addressing.
I'm having TJR for ICR and a segmented lefort to close my open bite. By doing counterclockwise rotation, will I show less teeth? As I don't really want to lose tooth show
This is a good question for your surgeon (and other surgeons so you have a few opinions) as it will depend on other details of your surgery as well. I know that if they do an impaction of the maxilla or, conversely, downgrafting of the maxilla in addition to CCWR it will more dramatically influence how much your teeth show. I would think only doing CCWR would not impact tooth exposure as much, but this will likely depend on if they are bringing your maxilla and mandible forward and how much they are doing so as this will impact how the soft tissue of your midface settles.
Can you explain how this opens up your airways? I'm confused by this. I was a mouth breather my whole life and I'm now considering getting this surgery done
Watch Dr. CG Portrait on YT. He explains it quite well. Dr. CG coined OSA and created AHI.
When you rotate the mid-face into counterclockwise rotation, the airway behind the lower part of the mid-face will get wider front to back because the airway sits behind the midface.
Hi, I need quick analysis about my jaw. I’ve done CBCT but appointment with my doctor is scheduled for may 18. Can I send my scans of my skull on your email ?
Thanks for the video Ashley :)
I have doubts, can you please help me.
I am looking forward to getting this surgery, however If the hollow under eye area that I have, that makes my eyes look tired.
my face is similar to my dads except, his face is developed, he is a nose breather, strong jaw good under eye support due to cheekbones.
in my case, I have cranofacila dystrophy, so could you please tell
1, if this surgery can fix my under eye area, asking because I am confused, as I see in all the surgery animated videos where no matter what changes they make the under eye area is intact, I would appreciate if you could educate me regarding that.
2. If this surgery will actually make my face what it was always supposed to be ( if I had been a nose breather from childhood)
if not, how much percent approx will it change my face to what It should have always looked like.
3. will I ever be able to eat hard food again, (ofc after the recovery, ) but can this permanently change my jaw force or make it fragile even after its healed?
once again thanks for the video, really happy to see this topic covered, as I coulndt find much videos talking about counterclockwise type surgery :)
1. No this surgery won't change the area immediately under your eyes (the lower part of the bony orbit). There are several things (consistent exercises) you can do leading up to your surgery, though, to expand the upper maxilla (lower part of the orbit) forward prior to the surgery so when you fixate the lower part of the maxilla more forward, the upper part of the maxilla will be sitting more forward at that time and won't be fixed as far backward as it would have been otherwise. I did this prior to my surgery and made a huge change in my midface/cheekbone area.
2. There is no way to know the answer to this question. My opinion is no it won't make your face into what it "should be". You are manipulating one small portion of the body and fixing it into a position that a few modern humans have agreed upon (with much variation to this "agreement").
3. If all goes, well, yes, you will be able to eat hard foods again. Yes, the forces on the joint will be different than they were originally. This is part of the risk of the surgery long-term.
@@allsleepashley Thank you so much for response.
Alright so I get the 2nd and the 3rd point .what Im confused about is the line - " ...you can do leading up to your surgery, though, to expand the upper maxilla (lower part of the orbit) forward prior to the surgery so when you fixate the lower part of the maxilla more forward, the upper part of the maxilla will be sitting more forward at that time and won't be fixed as far backward as it would have been otherwise. "
so does this mean, the Lower orbit that I am talking about ( the bone under my eye) can be fixed by doing Maxillary expansion and then CCW surgery? So when you initially said "No this surgery wont change, do you mean this CCW surgery specifically or like any Jaw surgery including the maxillary expansion. Thanks once again.
@@shivgaming007 Bone is malleable and can bend in response to stress. There are certain exercises you can do with your body to bring the maxilla (including the areas under your eyes) forward over several months. I'm saying that doing a Le Fort I with maxillary advancement will not bring the lower part of your eye sockets (lower orbits) forward and if this is something you're worried about, you can do these exercises before you have your MMA surgery. I'm not familiar with any COMMONLY done jaw surgeries that bring the upper part of the maxilla (all the way to the lower orbit) forward.
@@allsleepashley oh I see :( sure enough gotta work on those exercises now. do you happen to know any if so can you list like a couple atleast so i can get a gist of what further exercises and videos i should watch
Will counterclockwise MMA for sleep apnea lengthen or shorten your face?
yes
I need CCW of my maxilla. My oral surgeon said it can be done orthodontically to correct. Will this orthodontic correction of jaw rotation improve my breathing/airway? Or will surgical CCW be the only way for that?
I am not aware of how orthodontics can create a CCW rotation of the mandible and the maxilla. Can you please explain how this is done?
@@allsleepashley Not sure, I actually didn't ask how. The surgeon just said it can be done orthodontically, since we are not doing MMA and only SARPE.
I think it's only rotating the Maxilla and not the mandible (so my posterior open bite will close). I assume maybe they would probably attach TADs on my dentalaveolar bone?
@@Mechthild42 I recommend asking the specifics of this. I'm guessing they are going to extrude some teeth and impact others but probably not move the maxilla? Ask specifics so you know what the plan is.
hi Ashley! I am considering getting double jaw surgery with CCW rotation. However, my surgeon has cautioned on the post-surgical stability of this procedure regarding a relapse in the form of a clockwise movement of the lower jaw resulting in a possible open bite. Have you had experience with this?
I been a member of the jaw surgery forums for ages and have contacted a lot of OMS surgeons who perform CCW rotations. About a decade ago there was inherit stability issues due to the bone grafting procedures, the CCW rotations and the procedure itself. Nowaways they use this porous bone material, not sure what it's called, HA paste, there is some regression in the following months after the procedure,
@@Daniel456324 Even for people with existing TMJ pathology?
@@joedimaggio3146 Yes absolutely. The health of your TMJ joints directly impacts if you can get jaw surgery. If you experience popping, clicking, your joints have worn down and need to be replaced, otherwise the proejction of the jaw and stability is compromised.. Dr. Larry Wolford is very experienced in replacing your joints.
@@Daniel456324 I have bilateral anterior disc displacement with reduction and some pain. No clicking or popping and no limited mouth opening. Do you think I can still have MMA? I am going to consult with several surgeons but I also want opinions from people who don't have a vested interest to perform surgery
@@Daniel456324 so if a 21 year old is experiencing some clicking in their TMJ they need to have it replaced prior to DJS? every DJS surgeon i talked to never even looked at my tmj or cared for it.. whaaat
Hello! I have this procedure to be done pretty soon however I believe I haven't reached facial skeletal maturity yet, would there be any complications with that?
May I ask how old you are and where you will be having the procedure done?
@@allsleepashley I'm 20 currently but my father was a late bloomer, I'm getting this done at the Instituto Maxillofacial in Barcelona
@@johnnyzain2072 I suggest getting at least 2-3 surgical opinions in regards to your case. Ask all of them about your age concerns. Will your surgeon be Dr. Hernandez-Alfaro? When is your surgical date?
@@allsleepashley Yes, my surgery will be early april, thank you!
@@johnnyzain2072 Good luck! I hope all goes smoothly.
How many mm can a jaw be rotated counterclockwise, what's the maximum?
That's a great question. I don't know the answer to it. I imagine the limitation is the separation distance at the posterior mandible. I know with significant CCWR there is often bone grafting performed in that area.
Have you undergone your own surgery yet?
No, but soon.
Will CCW make maxilla more sunken?
should make your face less sunkun if anything
Naha to be honest best result of jaw surgery come from CCW
U need to do r own braces update with close up’s off ur appliance
Noted
Is it possible to do a ccw rotation on your lefort 3 region ?
Really good question. I am not sure of the answer. Please report back if you find an answer.
@@allsleepashley Also does a lefort 3 make your eyes more compact ? i've seen a bunch of them all the eyes look smaller i wonder if non sydromed patients could get this 1 could essentially get the ideal eyes with surgery
@@tysolbohan6446 Because the lefort 3 transects the orbit, it would certainly influence the eyes. I imagine if you CW rotate or CCW rotate it will decompress or compress the anterior portion (visible part) of the eyes, respectively. I have not yet seen anyone with a lefort 3. I imagine there is more risk to this osteotomy based on the involvement of the orbits, more cranial nerves, etc.
@@allsleepashley It's risk heavy but reward heavy as well if your wanting to get that ''exotic'' look so lauded over this surgery is usually needed half the time people with exotic looks really just have an insanely forward grown maxilla and very compacted orbits this comes with a forward and wide upper jaw hence why i wanted it the only surgeons who preform it are sunil richardson dr sinn or professor sailer in zurich but both of those charge 6 figures each that's a lot of money sunil i think does it for 30 K but i don't know if he does it on non syndromed patients.
@@tysolbohan6446 Thanks for that background. Is this something you are planning to have done yourself?
Mam sometimes daily i keep saliva in my mouth without swallowing. By keeping spit in mouth without swallowing, will it cause mouth to droop or chin to get longer(elongate) or any other problem? Pls reply
I cannot see keeping excessive saliva in your mouth as a direct cause of causing a chin to get longer.
I have a question. The coutner clock rotation during the bimaxillary conversion osteotomy differs greatly from clinic to clinic in the size of the angle. The following is done in Berlin: Shift 1.1 cm forward, rotate 8 degrees, and additionally advance the lower jaw with a chin plastic.
In Heidelberg they rotate 18-23 degrees.
Those are massive differences. Do you know what could be the reason?
Are these movement ranges both for your individual case? Treatment plans can vary dramatically from one individual to the next depending on the person's starting facial structure and what the goal of the surgery is. One individual can consult 5 different surgeons with the same chief complaint and the surgeons can give quite a wide variety of surgical plans from that individual (with large variations in advancement and rotation, as well). There is not one way to get an outcome and which surgeon you choose can dramatically impact your aesthetic outcome.
@@allsleepashley Yes, both are the same case. In Berlin (Charite) they rotate by 8 degrees and in Heidelberg (Seegartenklinik) they rotate by 18-23 degrees. I ask myself why this difference and which surgeon I should choose now. But thanks for your answer.
@@kokoska3999 Don't be afraid to ask surgeons why they are planning to do certain movements. It will help you to ask this so you can follow their reasoning.... asking several surgeons to explain their reasoning will help you develop your own reasoning in regards to which surgeon to choose.
@@allsleepashley yeah i have to get more informations about ankles. thank you for the help
@@kokoska3999 23 degrees is A LOT
Actually cut must be really high set to avoid too upward occlusal plane.
Mam does keeping tongue on palate and breathing through nose while walking, will it make us grow taller in height? Because i have to walk 20 minutes daily to reach bus stop from my college etc(10 mins while going to college and another 10 mins reaching bus stop) total 20 minutes ill walk a day..pls reply..
There are too many confounding factors to say that doing this action will cause this outcome.
@@allsleepashley mam i cant understand what ur saying.. Are u sure about this? Some people said me that keeping tongue on palate will make us grow taller in height.. pls reply 🙏💞
@@nasreenakhuda I'm not aware of the research that exists to prove this.
Wanna contact u
You can find my contact information at sommerspt.com