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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 64-66

Unilateral sagittal split ramus osteotomy for facial asymmetry by IIG


1 Department of Oral and Maxillofacial Surgery and Dentistry, Jubilee Mission Medical College Hospital and Research Institute, Thrissur, Kerala, India
2 Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
3 Community Health Centre, Kondagaon, Chhattisgarh, India
4 Consultant Oral and Maxillofacial Surgeon, B-16, Molarband Badarpur, New Delhi, India

Date of Submission09-Jul-2019
Date of Acceptance08-Oct-2019
Date of Web Publication20-Jan-2020

Correspondence Address:
Dr. Philip Mathew
Department of Oral and Maxillofacial Surgery and Dentistry, Jubilee Mission Medical College Hospital and Research Institute, Thrissur - 680 005, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_16_19

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  Abstract 


Treating cases of facial asymmetry is always a challenge for oral and maxillofacial surgeons especially when the face has minor deformities and patients expectations are very high. Various non surgical and surgical techniques including orthognathic and orthomorphic surgeries with graftings have kept their milestones for treating such cases. This report presents a similar case of achieving fullness on unilateral side of face to accomplish symmetry which was treated using an interpoistional iliac graft in unilateral saggital split osteotomy to correct the disharmony of face.

Keywords: Facial asymmetry, iliac graft, interpositional graft, sagittal split ramus osteotomy


How to cite this article:
Mathew P, Tiwari RV, Mathai P, David J, Tiwari H, Bansal N. Unilateral sagittal split ramus osteotomy for facial asymmetry by IIG. J Cleft Lip Palate Craniofac Anomal 2020;7:64-6

How to cite this URL:
Mathew P, Tiwari RV, Mathai P, David J, Tiwari H, Bansal N. Unilateral sagittal split ramus osteotomy for facial asymmetry by IIG. J Cleft Lip Palate Craniofac Anomal [serial online] 2020 [cited 2020 Feb 22];7:64-6. Available from: http://www.jclpca.org/text.asp?2020/7/1/64/276194




  Introduction Top


Face is an index of the mind. Esthetics affect social and psychological determinants of well-being. Minor deformities of the face are also noticed prominently by the society. Hence, when it comes to facial asymmetry, it is deliberated as major esthetic deformity. It is a common encountered problem in craniofacial surgery. Asymmetry in the lower jaw is more often encountered compared to the upper jaw.[1] Facial asymmetry is classified on various grounds based on etiology, time of onset, and structures involved. Walford has classified it as pseudoasymmetry, normal facial asymmetry, unilateral overdevelopment and unilateral underdevelopment, or degeneration. Bishara has classified it on the basis of dental, skeletal, muscular, and functional abnormalities.[2] Clinical, photographic, and radiographic assessments help to achieve a proper diagnosis for prompt management. Management of facial asymmetry is still a challenging scenario, as it is not only important to evaluate what we determine as defect, but also the patient expectations needs to be fulfilled. It is always preferred to restore the same kind of tissue which is in deficiency, but even camouflage helps in correcting such deformities in some cases.


  Case Report Top


A 27-year-old female presented to us for the first time with a chief complaint of flatness on the right side of face and mandible. She needs the same fullness which is present of the other half of face to improve the esthetics. Eliciting her history, she was operated before for maxillary retrognathism and recessive chin. She underwent Le Fort I advancement and advancement genioplasty. Pre- and post-orthodontic correction was performed. On clinical examination, her profile was normal and a good occlusion with overjet and overbite. Flatness was present on the ramus and body area on the right side. To evaluate the deformity in detail, a posterior-anterior skull view was taken which showed a decrease in the mediolateral distance of ramus of mandible on the right side as compared to the left tissue [Figure 1]. There was no soft-tissue deficiency present. This clinical scenario comes under the skeletal defect of Bishara classification. Accordingly, a unilateral sagittal split ramus osteotomy (SSRO) was performed on the right side, and a single chunk of cancellous iliac bone graft was harvested and was interpositioned between proximal and distal segments. The superoinferior dimension of mandible was measured in orthopantomogram. The cancellous graft was reshaped into correct form to prevent impingement of the graft on soft tissue, which can cause esthetic compromise. The width of graft was of only 3 mm, so as not to cause any deformity in the condylar deviation due to the flaring achieved in the proximal segment after placing the cancellous inlay graft [Figure 2]. For stabilizing the graft, rigid fixation technique was used. A six-hole plate with gap was selected, and it was given two bends of 90° in the gap area when the plate traverse from proximal to distal segment to adapt it in desired position in the sound bone [Figure 3]. This bend is designed in such a way that the thickness of graft and bend are equal to maintain the thickness and prevents compression of graft between segments. The other benefit of this bend is it will help the graft to stay in position and prevent the graft from moving anteriorly between the segments and maintain the desired position. Placing a cancellous bone or inlay graft rather than cortical or onlay graft will increase the chances of take up and reduce resorption. After reduction of swelling in the postoperative week, we have achieved patient's expectations too.
Figure 1: Posterior-anterior skull showing mediolateral ramal distance

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Figure 2: Iliac interpositional graft placed

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Figure 3: Rigid fixation and plate adaptation

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  Discussion Top


Facial asymmetry as a diagnosis implies esthetic imbalance which deeply affects the psychological status of patients. Fulfilling patient's expectations is the prime consideration for prompt management. Hence, it is a matter of utmost importance to diagnose the correct classification of deformity and replace it with the same kind of tissue. History, clinical examinations, sagittal, coronal, and axial section are certain helpful diagnostic aids which add up for the betterment of treatment plan.[3] Frontal view photographic examination and posteroanterior view of skull as radiographic examination carries crucial and significant evaluation criteria.[4] A hyperextended 45° superior submental view is useful in measuring projection and symmetry of anterior cranial vault, orbit, and cheeks. The study models elicit occlusal cants.[5] Computed tomography (CT), cone-beam CT, three-dimensional (3D) CT, magnetic resonance imaging, and skeletal scintigraphy are also used for better precision and reproducibility.[6] Not every mandibular asymmetry is a rotational asymmetry. There may be a lateralization of the entire mandible which requires bodily movement of the distal mandible away from the original side. Malformations, deformations, and disruptions can be interrelated for producing asymmetries. Management of facial asymmetry has a vast extension. The reason for this is its extensive etiology. In spite of acquired defects, developmental defects also are its cause. Hemifacial microsomia,  Treacher Collins syndrome More Details, and Goldenhar syndrome are the genetic-related defects causing orofacial clefts which lead to facial asymmetry. Hard- and soft-tissue procedures, autogenous or synthetic graft materials as well as Botox and fillers are preferred choices. Botox and derma fillers are not very reliable techniques for such deformities due to their poor substantiation on the anatomical site. Orthognathic surgery and distraction osteogenesis are dynamic processes to facilitate 3D correction of facial asymmetry. In addition, various modified surgical techniques have been documented in the literature.[7] Other options include grafting through patient-specific implant, onlay bone graft, Medpor implant, or major corrections through orthomorphic surgery. Although several articles have been written for correction of facial asymmetry by unilateral sagittal split osteotomy, the published data on bone grafting to correct deformity is scarce.[8],[9] Correction of midline deviations of 2 mm or smaller has little effect on the condylar/proximal segment position, and modifications of the sagittal split osteotomy do not seem necessary.[9] Bone shim placed between segments is a reliable technique with a pitfall of delayed healing in the bone shim area. In our procedure, we used a chunk of cancellous iliac graft which has been interpositioned between the split segments. The reason is that interpositional graft due to cancellous contact has an immense better take up when compared to an onlay graft. Other benefits are blood supply, rate of resorption, and contour with exteroception is unaltered. Condylar displacement is one of the most common complications after SSRO and can induce relapse and temporomandibular joint dysfunction symptoms. The study shows that there is the presence of condylar movement after SSRO and grafting. The condylar displacement had no relationship to the rotation of the mandible.[10] Kang et al. have proven that the amount of mandibular rotation <4 mm did not influence the position of the condyle significantly which was studied by various section of 3D computed tomography.[10] It is important to keep the intersegmental space intact for postoperative surgical stability by the use of an autogenous bone graft with ease and simplicity. In our case, we have followed the same. Moreover, we have also performed a rigid fixation by bending the plate and adapting it to the required and desired position on the sound cortical bone which helped our interpositional graft to sustain its from function to position.


  Conclusion Top


The fundamental cognition of facial asymmetry is a substantive requisite to critically analyze the feature involved in deformity and correctly measure the magnitude of disparity. This facilitates to articulate satisfying treatment plan to achieve maximum esthetics and function deliberating patient's perception and expectations. In summary, we demonstrate an authentic and dependable technique to use single chunk of interpositional iliac cancellous bone graft to align the proximal and distal segment, maintaining the baseline position of condyles for correction of unilateral facial asymmetry by unilateral SSRO.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Srivastava D, Singh H, Mishra S, Sharma P, Kapoor P, Chandra L, et al. Facial asymmetry revisited: Part I- diagnosis and treatment planning. J Oral Biol Craniofac Res 2018;8:7-14.  Back to cited text no. 1
    
2.
Srivastava D, Singh H, Mishra S, Sharma P, Kapoor P, Chandra L, et al. Facial asymmetry revisited: Part II-conceptualizing the management. J Oral Biol Craniofac Res 2018;8:15-9.  Back to cited text no. 2
    
3.
Cheong YW, Lo LJ. Facial asymmetry: Etiology, evaluation, and management. Chang Gung Med J 2011;34:341-51.  Back to cited text no. 3
    
4.
Legan HL. Surgical correction of patients with asymmetries. Semin Orthod 1998;4:189-98.  Back to cited text no. 4
    
5.
Wolford LM. Facial asymmetry: Diagnosis and treatment considerations. In: Turvey TA, editor. Oral and Maxillofacial Surgery. 2nd ed., Vol. 3. St. Louis, MO: Saunders; 2009.  Back to cited text no. 5
    
6.
Epker BN, Stella JP, Fish LC. Diagnosis and treatment planning for correction of asymmetric dentofacial deformities. In: Epker BN, Stella JP, Fish Dentofacial LC, editors. Deformities-Integrated Orthodontic and Surgical Correction. 2nd ed. Vol. 4. St. Louis, MO: Mosby; 1958.  Back to cited text no. 6
    
7.
Choi JY, Choi JP, Lee YK, Baek SH. Simultaneous correction of hard-and soft-tissue facial asymmetry: Combination of orthognathic surgery and face lift using a resorbable fixation device. J Craniofac Surg 2010;21:363-70.  Back to cited text no. 7
    
8.
Zhu SS, Feng G, Li JH, Luo E, Hu J. Correction of mandibular deficiency by inverted-L osteotomy of ramus and iliac crest bone grafting. Int J Oral Sci 2012;4:214-7.  Back to cited text no. 8
    
9.
Peacock ZS, Lee JS. Modification of the bilateral sagittal split osteotomy for the asymmetric mandible. J Oral Maxillofac Surg 2011;69:2437-41.  Back to cited text no. 9
    
10.
Kang MG, Yun KI, Kim CH, Park JU. Postoperative condylar position by sagittal split ramus osteotomy with and without bone graft. J Oral Maxillofac Surg 2010;68:2058-64.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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