Mastering maxillomandibular complex rotation: a narrative review of clockwise and counterclockwise surgical strategies

Background Orthognathic surgery has evolved toward a dynamic approach to the maxillomandibular complex (MMC), where the modulation of the occlusal and mandibular plane angles—through either counterclockwise (CCWR) or clockwise (CWR) rotation—serves as a primary strategy to optimize facial aesthetics and functional balance. While these techniques diverge in their skeletal and soft-tissue outcomes, both represent advanced surgical tools for the precise refinement of vertical and sagittal proportions. This article reviews the rationale, technical principles, indications, and limitations of both CCWR and CWR of the MMC. Main Body The choice between these two rotations allows for the surgical customization of the lower facial third. CWR produces posterior repositioning of the chin and elongation of the lower anterior facial height, offering a tapered, slender aesthetic suitable for short-face or hypodivergent patients. Conversely, CCWR reduces occlusal and mandibular plane angles, strengthening chin projection and enhancing cervicomental definition; it is particularly indicated for hyperdivergent patterns, Class II patients with major mandibular retrusion, and is integral to maxillomandibular advancement for obstructive sleep apnea (OSA) to increase oropharyngeal volume. While CCWR is favored for its impact on airway patency, CWR provides essential solutions for managing vertical discrepancies and correcting over-advancement or excessive counterclockwise rotation. Both techniques rely on precise 3D planning and coordinated orthodontics; long-term clinical evidence demonstrates that, with appropriate fixation and TMJ management, both rotations achieve skeletal and soft-tissue stability comparable to conventional orthognathic approaches. Conclusion By synthesizing current evidence, this review highlights the distinct yet complementary roles of CCWR and CWR in modern orthognathic surgery. Rather than viewing them as isolated procedures, this framework encourages surgeons to consider the deliberate manipulation of MMC rotation as an option to be incorporated into individualized treatment planning in appropriately selected patients.