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Augmentation bone graft for correction of mandibular asymmetry
Augmentation bone graft for correction of mandibular asymmetry Philip D. Marano, Lieutenant Colonel, USAF (DC),” Stanley C. Kolodny, Colonel, USAF (DC),** and Elliott A. Smart, Lieutenant Colonel, USAF (DC)*** WILFORD
HALL
USAF
MEDICAL
CENTER,
LACKLAND
AIR
FORCE
BASE,
TEXAS
I
n an excellent article in which they report seventeen cases, Hinds and associate@ state that mandibular asymmetry may involve either increased or decreased growth or development. Since these conditions basically can have only two causes (genetic or acquired), they suggested the following classification : I. Inherent (genetic) A. Deviation prognathism B. Condylar recession or absence (hypoplasia) II. Acquired A. Developmental 1. Hyperplasia (osteochondroma) 2. Hypoplasia a. Infection b. Trauma B. Mechanical 1. Tumor (unilateral protrusion) 2. Trauma (unilateral recession) 3. Surgery (unilateral recession) A study of newborn infants discloses that there is a 20 per cent incidence of jaw deviation. This was thought to be due to intrauterine pressure. In all cases these discrepancies were resolved within several weeks.2 Most cases of mandibular asymmetry reported in the literature are described as mandibular hyperplasia. Unless there is a history of trauma, infection, or Va.
*Chief, Oral Surgery Service, Langley USAF Regional Hospital, Formerly Senior Resident in Oral Surgery, Wilford Hall USAF **Chairman, Department of Oral Surgery. ***Assistant Chairman, Department of Oral Surgery.
Langley Medical
Air Force Center.
Base,
759
Oral December,
Surg. 1970
A
Pig. 1. cephalometric
A, Preoperative
photograph
of
hemimandibular
hypoplnsia.
B, Posteroanterior
radiograph.
A
Fig. e. A, Left lateral preoperative photograph. Note B, Lateral cephalometric radiograph showing difference in
lack right
of well-shaped gonial angle. and left inferior borders.
previous surgery, there is a tendency for the clinician to consider the larger side of an asymmetry as the abnormal one. Although the surgical procedure for reducing one side of the mandible may be technically more simple than that for augmenting the deficient side, it is imperative that all diagnostic tools available be used to determine the proper diagnosis. When the correct diagnosis has been ascertained, the proper treatment can be instituted. The following case report introduces the use of the composite photograph as an aid to the clinician in diagnosis and treatment planning. CASE
REPORT
A Center
21-year-old in February,
white woman 1970. She
was was
originally desirous
of
seen at surgical
the Wilford correction
Hall USAF Medical of a mandibular de-
Volume Number
30 6
Mawlibular
Fig.
Fig.
4. Normal
J. Slight
mandibular
occlusion
with
a marked
asymmetry
tilting
asymmetry
761
at age 7.
of the occlusal
plane.
formity (Figs. 1 and 2). The past history and physical examination mere negative except for a mandibular asymmetry which was present at birth. Photographs taken at an early age revealed a mandibular asymmetry, which had become more obvious with growth (Fig. 3). Mandibular function and occlusion were normal except for a marked tilting of the occlusal plane on the involved side (Fig. 4). The patient gave a detailed history and denied having had any injuries or infections of the jaws. Complete studies were carried out to determine whether the right mandible was hyperplastic or the left mandible was hypoplastic. Analysis of radiographs, including a facial series, Panorex, posteroanterior, and lateral cephalograms, led us to the diagnosis of left mandibular hypoplasia. Clinical evaluation strengthened this diagnosis. In order to corroborate the diagnosis, we decided to make composite photographs to determine whether reducing the right side or augmenting the left side would give a more pleasing cosmetic appearance. The full-face negative was divided vertically and each half was joined to its own mirror image (Fig. 5 and 6). The composite of the left jaw resulted in a closed vertical dimension which gave the patient the appearance of someone who had worn a tight Milwaukee brace for the treatment of scoliosis for a number of years.3
762
Mat-am,
Kolodrky,
Oral surg.
awd Smart
Ihxemher,
1970
Fig. predicts
5. Composite photograph appearance of face if right
demonstrating mirror image mandible had been reduced.
of
small
side
of
mandible
5 Pig. predicts
6. Composite photograph appearance of face if right
demonstrating mirror image mandible had been augmented.
of
large
side
of
mandible
The treatment plan elected was an augmentation iliac crest bone graft to the deficient left mandible. Comparative measurements disclosed a maximum deficiency of 2 cm. at the angle of the mandible, tapering to 0.5 cm. at the symphysis region. A metallic template was designed which accurately simulated the contour and size of bone required to restore mandibular symmetry. The template was made slightly larger to compensate for anticipated loss due to resorption and remodeling. On March 17, 1970, the left mandible was exposed via a curved submandibular incision extending from the left angle to the symphysis. The facial artery and vein were ligated, and the marginal mandibular branch of the facial nerve wss retracted superiorly. The exposed left body of the mandible was obviously underdeveloped (Fig. 7). The metallic template was applied to the mandible in order to determine the proper contour of the graft. The surgical site was covered with sterile towels while the graft was obtained. The right iliac crest was exposed in the usual manner. The contoured template was used to locate the most ideally shaped portion of the crest from which to take the graft and to ensure removal of a proper-sized segment of bone (Fig. 8). Next, 1 cm. of the inferior border of the mandible was deoorticated (Fig. 9). Similarly, a 1 cm. decortication was per-
Volume Number
30 6
Mandibular
asymmetry
763
Fig .8
Pig.
F
10
F
Fig. Fig. Fig. Fig. Fig.
7. Left mandibular body is underdeveloped. 8. Template (arrow) adapted to iliac crest. 9. Decortication of mandible exposing bleeding cancellous 20. Decortication of iliac crest autogenous bone graft. II. Bone graft secured to mandible.
bone.
formed on that portion of the graft which would be in contact with the recipient site (Fig. 10). Because of the decreased size of the left mandible, the inferior alveolar neurovascular bundle approximated the inferior border, Five evenly spaced bur holes were made through the body of the mandible superior to the canal. Similar bur holes were made 1 cm. below the superior margin of the graft. Transosseous stainIess steel wires secured the graft in good apposition to the mandible (Fig. 11). The soft tissues were widely undermined to prevent undue tension. The postoperative course was uneventful. Radiographs revealed the graft to be in good position (Fig. 12). The patient’s appearance has been greatly improved (Figs. 13 and 14), although a still more satidactory result is anticipated after the expected resorption and recontouring of the graft have occurred.
11
764
Pig.
Fig.
Oral December,
Marano,
13. Postoperative
radiograph
showing
graft
to mandible
(arrows).
1‘3
Fig. 13. Appearance of profile 2 months postoperatively. Fig. 24. Two months postoperatively. Note slight fullness allow for resorption and reeontouring of bone graft.
Surg. 1970
of
left
mandibular
Fig.
14
rtrgiou
to
DlSCUSSloN to arrive at a correct Every diagnostic method available must bc used diagnks. Although radiographic analysis is an excellent aid in differentiating the normal from the abnormal, one’s critical clinical judgment, may be the deciding factor. The composite photograph is another valuccl tool in the dingnostie armamcnta~ium. Not only docks it 11~11)tliRcrcnt i;ttc the normal from the abnormal, but it gives the sturgeon :I pt’evicw of the results of altc~ni\tc surgical procedures.
Volume Number
30 6
Mandibular
asymmetry
765
SUMMARY The methods of determining which side is abnormal in a case of mandibular asymmetry have been presented, and the use of composite photographs in diagnosis has been introduced. The augmentation of a hypoplastic left mandible with an autogenous iliac crest bone graft has been described. REFERENCES
1. Hinds, E. C., Reid, L. C., and Burch, R. J.: Classification Asymmetry, Amer. J. Surg. 100: 826, 1960. 2. Gerry, R. G., and Sang&on, R. E.: Congenital Mandibular fants, Amer. J. Orthodont. 32: 439, 3946. 3. Gruber, H.: Oro-facial Changes Incidental to Milwaukee thesis.)
and
Management Deformities
Brace
Treatment.
of Mandibular in
Newborn (Unpublished
In-
HALL
USAF
MEDICAL
CENTER,
LACKLAND
AIR
FORCE
BASE,
TEXAS
I
n an excellent article in which they report seventeen cases, Hinds and associate@ state that mandibular asymmetry may involve either increased or decreased growth or development. Since these conditions basically can have only two causes (genetic or acquired), they suggested the following classification : I. Inherent (genetic) A. Deviation prognathism B. Condylar recession or absence (hypoplasia) II. Acquired A. Developmental 1. Hyperplasia (osteochondroma) 2. Hypoplasia a. Infection b. Trauma B. Mechanical 1. Tumor (unilateral protrusion) 2. Trauma (unilateral recession) 3. Surgery (unilateral recession) A study of newborn infants discloses that there is a 20 per cent incidence of jaw deviation. This was thought to be due to intrauterine pressure. In all cases these discrepancies were resolved within several weeks.2 Most cases of mandibular asymmetry reported in the literature are described as mandibular hyperplasia. Unless there is a history of trauma, infection, or Va.
*Chief, Oral Surgery Service, Langley USAF Regional Hospital, Formerly Senior Resident in Oral Surgery, Wilford Hall USAF **Chairman, Department of Oral Surgery. ***Assistant Chairman, Department of Oral Surgery.
Langley Medical
Air Force Center.
Base,
759
Oral December,
Surg. 1970
A
Pig. 1. cephalometric
A, Preoperative
photograph
of
hemimandibular
hypoplnsia.
B, Posteroanterior
radiograph.
A
Fig. e. A, Left lateral preoperative photograph. Note B, Lateral cephalometric radiograph showing difference in
lack right
of well-shaped gonial angle. and left inferior borders.
previous surgery, there is a tendency for the clinician to consider the larger side of an asymmetry as the abnormal one. Although the surgical procedure for reducing one side of the mandible may be technically more simple than that for augmenting the deficient side, it is imperative that all diagnostic tools available be used to determine the proper diagnosis. When the correct diagnosis has been ascertained, the proper treatment can be instituted. The following case report introduces the use of the composite photograph as an aid to the clinician in diagnosis and treatment planning. CASE
REPORT
A Center
21-year-old in February,
white woman 1970. She
was was
originally desirous
of
seen at surgical
the Wilford correction
Hall USAF Medical of a mandibular de-
Volume Number
30 6
Mawlibular
Fig.
Fig.
4. Normal
J. Slight
mandibular
occlusion
with
a marked
asymmetry
tilting
asymmetry
761
at age 7.
of the occlusal
plane.
formity (Figs. 1 and 2). The past history and physical examination mere negative except for a mandibular asymmetry which was present at birth. Photographs taken at an early age revealed a mandibular asymmetry, which had become more obvious with growth (Fig. 3). Mandibular function and occlusion were normal except for a marked tilting of the occlusal plane on the involved side (Fig. 4). The patient gave a detailed history and denied having had any injuries or infections of the jaws. Complete studies were carried out to determine whether the right mandible was hyperplastic or the left mandible was hypoplastic. Analysis of radiographs, including a facial series, Panorex, posteroanterior, and lateral cephalograms, led us to the diagnosis of left mandibular hypoplasia. Clinical evaluation strengthened this diagnosis. In order to corroborate the diagnosis, we decided to make composite photographs to determine whether reducing the right side or augmenting the left side would give a more pleasing cosmetic appearance. The full-face negative was divided vertically and each half was joined to its own mirror image (Fig. 5 and 6). The composite of the left jaw resulted in a closed vertical dimension which gave the patient the appearance of someone who had worn a tight Milwaukee brace for the treatment of scoliosis for a number of years.3
762
Mat-am,
Kolodrky,
Oral surg.
awd Smart
Ihxemher,
1970
Fig. predicts
5. Composite photograph appearance of face if right
demonstrating mirror image mandible had been reduced.
of
small
side
of
mandible
5 Pig. predicts
6. Composite photograph appearance of face if right
demonstrating mirror image mandible had been augmented.
of
large
side
of
mandible
The treatment plan elected was an augmentation iliac crest bone graft to the deficient left mandible. Comparative measurements disclosed a maximum deficiency of 2 cm. at the angle of the mandible, tapering to 0.5 cm. at the symphysis region. A metallic template was designed which accurately simulated the contour and size of bone required to restore mandibular symmetry. The template was made slightly larger to compensate for anticipated loss due to resorption and remodeling. On March 17, 1970, the left mandible was exposed via a curved submandibular incision extending from the left angle to the symphysis. The facial artery and vein were ligated, and the marginal mandibular branch of the facial nerve wss retracted superiorly. The exposed left body of the mandible was obviously underdeveloped (Fig. 7). The metallic template was applied to the mandible in order to determine the proper contour of the graft. The surgical site was covered with sterile towels while the graft was obtained. The right iliac crest was exposed in the usual manner. The contoured template was used to locate the most ideally shaped portion of the crest from which to take the graft and to ensure removal of a proper-sized segment of bone (Fig. 8). Next, 1 cm. of the inferior border of the mandible was deoorticated (Fig. 9). Similarly, a 1 cm. decortication was per-
Volume Number
30 6
Mandibular
asymmetry
763
Fig .8
Pig.
F
10
F
Fig. Fig. Fig. Fig. Fig.
7. Left mandibular body is underdeveloped. 8. Template (arrow) adapted to iliac crest. 9. Decortication of mandible exposing bleeding cancellous 20. Decortication of iliac crest autogenous bone graft. II. Bone graft secured to mandible.
bone.
formed on that portion of the graft which would be in contact with the recipient site (Fig. 10). Because of the decreased size of the left mandible, the inferior alveolar neurovascular bundle approximated the inferior border, Five evenly spaced bur holes were made through the body of the mandible superior to the canal. Similar bur holes were made 1 cm. below the superior margin of the graft. Transosseous stainIess steel wires secured the graft in good apposition to the mandible (Fig. 11). The soft tissues were widely undermined to prevent undue tension. The postoperative course was uneventful. Radiographs revealed the graft to be in good position (Fig. 12). The patient’s appearance has been greatly improved (Figs. 13 and 14), although a still more satidactory result is anticipated after the expected resorption and recontouring of the graft have occurred.
11
764
Pig.
Fig.
Oral December,
Marano,
13. Postoperative
radiograph
showing
graft
to mandible
(arrows).
1‘3
Fig. 13. Appearance of profile 2 months postoperatively. Fig. 24. Two months postoperatively. Note slight fullness allow for resorption and reeontouring of bone graft.
Surg. 1970
of
left
mandibular
Fig.
14
rtrgiou
to
DlSCUSSloN to arrive at a correct Every diagnostic method available must bc used diagnks. Although radiographic analysis is an excellent aid in differentiating the normal from the abnormal, one’s critical clinical judgment, may be the deciding factor. The composite photograph is another valuccl tool in the dingnostie armamcnta~ium. Not only docks it 11~11)tliRcrcnt i;ttc the normal from the abnormal, but it gives the sturgeon :I pt’evicw of the results of altc~ni\tc surgical procedures.
Volume Number
30 6
Mandibular
asymmetry
765
SUMMARY The methods of determining which side is abnormal in a case of mandibular asymmetry have been presented, and the use of composite photographs in diagnosis has been introduced. The augmentation of a hypoplastic left mandible with an autogenous iliac crest bone graft has been described. REFERENCES
1. Hinds, E. C., Reid, L. C., and Burch, R. J.: Classification Asymmetry, Amer. J. Surg. 100: 826, 1960. 2. Gerry, R. G., and Sang&on, R. E.: Congenital Mandibular fants, Amer. J. Orthodont. 32: 439, 3946. 3. Gruber, H.: Oro-facial Changes Incidental to Milwaukee thesis.)
and
Management Deformities
Brace
Treatment.
of Mandibular in
Newborn (Unpublished
In-