Difficulties in and indications for the treatment of facial asymmetry

Int. J. Oral Surg. 1974: 3:234-238 (Key words: [ace, axymmetry; surgery, orel)

Difficulties in and indications for the treatment of facial asymmetry J. HOVINGA, E. R. KRAAL A N D L. A . M. ROORDA

Department of Oral Surgery, St. Elisabeth Hospital, Haarlem, The Netherlands

ABSTRACT -- Facial asymmetry can be acquired or congenital. The nature and extent of the anomaly can determine the indication for surgical correction, but the patient's psychologic condition is an even more decisive factor in this respect. Complaints about tcmporomandibular articulation, masticatory function, stomach, and speech can be additional indications. Surgical correction of laterognathia is often more complicated than that of prognathism and retrognathia. This is illustrated with reference to nine patients treated in the course of a year by several different combinations of maxillary and/or mandibular procedures. The results obtained are described and discussed.

F a c i a l a s y m m e t r y c a n be congenital or acquired. T h e a c q u i r e d asymmetries can be due to t r a u m a t i c injury, t u m o r growth, infection o r surgical treatment. As the literature indicates, the changes often b e c o m e m a n i f e s t p r i m a r i l y in the mandible. Reviews a n d classifications a c c o r d i n g to type and etiology h a v e been presented in several publicationsL-",~,L 8. T h e asynnmetry becomes clinically m a n i f e s t as a b n o r m a l condylar growth, unilateral p r o g n a t h i s m or hypoplasia, o p e n bite, d e v i a t i o n of the chinpoint, c o m p e n s a t o r y m a x i l l a r y growth, and e x e u r v a t i o n o f the contralateral collum mandibulae. T h e n a t u r e and extent of the abnormality can be an indication for surgical correction. T h e p a t i e n t ' s psychologic condition is an e v e n m o r e i m p o r t a n t factor in determining surgical indications. Ignorance of the possibilities a m o n g patients and dentists

or physicians can cause the f o r m e r to live through years of frustration.

Material and methods Surgical correction of facial asymmetries is often more complicated than that of prognathism or retrognathia. This is illustrated by nine patients whom we treated in the course of a year and by the results obtained in these cases. The patients were three men and six women ranging in age from 17 to 27 years (mean age 21). One patient had been edentulous for 5 years, and was wearing full maxillary and mandibular dentures. The other eight patients still had their own teeth. Three patients had received orthodontic treatment years ago. One had been treated by rapid palatal expansion :1. month before the osteotomy in the mandible. In six patients, the psychologic disturbances were the principal motivation to consult us. The other three had difficulties in eating, manifested mostly as problems of mandibular

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235

T a b l e 1. Data for the 9 operated patients Operation Patient

Age

Sex

Lateral deviation

Mandible Maxilla Ramus

A* B C D E F G t-.{ J

25 20 18 19 17 27 19 20 26

M F F F F F F M M

L L L R R R R R L

L L R

Le Fort I

L+ R L+R L + R L

Body R R R L K61e

R

Slice lower rim

chin chin chin (autograft)

R corpus f r o m angle

* Only Patient A was edentulous and had worn full dentures for 5 years. articulation; one of these was a professional diver, and he was inconvenienced by equipment not fitting snugly to his face. Four patients had preoperative complaints about mandibular articulation, specifically crepitation and pain. Only the edentulous patient was treated by a unilateral m a n d i b u l a r operation; all other operations were bilateral. One of the latter eight patients was treated by a maxillary operation along a line resembling a L e Fort I fracture before the m a n d i b u l a r osteotomy was performed. In seven of the eight cases a sagittal split operation on the ascending ramus was performed according to TRAUNER & OBWEGESER (1955), as modified by PONT (1961). In three of these patients this operation was bilateral, while in the o t h e r four it was unilateral, on the side of the chin deviation. In these four cases bone was removed from the contraIateral mandibular body; in three of these four cases, part of the lower rim of the mandible on this side was removed also, twice in the gonial area and in one case from the angle of the jaw in the ventral direction. One patient underwent a KSle osteotomy combined with genioplasty, using bone from the chin as antograft (Table 1). T h e various operations will b e explained with reference to a number of these patients. Patient E was a 17-year-old girl with deviation of the chin-point to the right and an open bite of about 0.5 cm. The orthodontist was unable to correct the anomaly. The patient wanted to become a shopgirl but had

speech difficulties. T w o years before we saw her she had taken speech lessons with little result (which was to b e expected in view of the anomaly). The patient shunned public appearances and dared not take dancing lessons. She maintained that the jaw had always deviated. After consultation t h e orthodontist (J. MEtmSINOE REYNDERS) first performed rapid palatal

Fig,. 1. A, Patient E: deviation to right and open bite, B, occlusion 6 months after operation.

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H O V I N G A , K R A A L AND R O O R D A

expansion, w h i c h gave about 1 cm more width in the maxillary dental arch. One month later we p e r f o r m e d a mandibular osteotomy according to KgLE (1963). T h e continuity of the mandible was thus maintained by a piece of bone with a height of 0.5 cm. The space between this bone and tlle mobilized dentulous part of the jaw was filled with the dissected chin fragment, which served as autograft; this was fixed with two steel ligatures. After removal of the splint, the mandibular teeth and 4 still showed marked lingual kipping, but 3 months later there was substantial spontaneous i m p r o v e m e n t in this respect. T h e patient is now p l a n n i n g to take speech lessons again. She is very happy with the result and has taken a job as a shopgirl. Patient H was a 20-year-old mart with maxillary a n d m a n d i b u l a r asymmetry but good occlusion - as if the entire dentition were placed askew in the head. T h e chin-point showed a 15 m m deviation to the right. T h e patient was severely disturbed by his appearance and dared hardly l a u g h because the anomaly became more obvious when h e did. For 3 years this patient urged us to operate because he thought that everybody was looking at him. We decided to operate in two phases. The first operation was an osteotomy of the maxilla, following the line of a Le F o r t I fracture. On the left side,

bone was removed over a width of i cm from the piriform aperture to the dorsal aspect. The maxitia was then rotated and mobilized to the left, to be suspended from the zygomatous arches by means of steel ligatures. The excised bone was used as autograft and applied left and right to the cut. The open bite resulting from the operation was filled up by means of an acrylic bite-plate. The postoperative course was uneventful and the patient in fact gained 2 kg body weight so that osteotomy of the mandible followed 3 weeks later. T h e left and right rami were submitted to a sagittal split operation according to TRAUNBR ~; OBWEGESER as modified by PONT. The bone fragments on the left side were then shortened 1 cm, allowing upward displacement of the mandible on this side. Fixation was effected with the aid of splints on the dentition and intermaxil[ary ligatures, in addition to the ligatures previously placed around Ne zygomatieus arches. The anteroposterior cranial radiograph revealed a symmetric mandible. The patient is now very satisfied with the result, although there is still some soft tissue asymmetry; we are contemplating correction of this asymmetry by means of a silicone implant. Patient J was a m a n aged 26 with marked deviation of the mandible to the left. The right t a m e s was unmistakably longer than the left.

Fig. 2. A, oblique position of plane of occlusion is clearly demonstrated with the aid of a spatula between c l a m p e d jaws. B, after maxillary osteotomy according to a Le Fort I line and bilateral sagittal splitting o~ the mandible.

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237

Fig. 3. A, Patient J: preoperative condition. Right ramus about 1.5 cm longer than t h e left. Left mandibular premolars and molars outside corresponding maxillary teeth in occlusion. B, after sagittal split of left ramus and ostectomy of right mandibular body. Intraoral examination showed the mandibular dental arch to be larger than the maxillary arch. There was frontal cross-bite, and on the left side the mandibular premolars and molars bit outside the maxillary teeth. The patient occasionally had gastric symptoms and pain in the t e m p o r o m a n d i b u l a r joint, particularly on the right. He was employed in a fire brigade, and in this service h e doubled as a professional diver. In this work h e had difficulties with his equipment which did not fit snugly enough to his face due to the mandibular asymmetry. Radiographs revealed hypertrophy of the right collum mandibulae. The first and second right mandibular molars were absent. Work on a study model suggested an osteotomy at this site because when material was removed over a distance of 12 mm, bilateral contact in the premolar-molar region could be achieved on the model. Measurements showed that the left mandibular body had to b e lowered about 8 ram; this decided us in favor of a sagittal split osteotomy on the left ascending ramus. The operation was started by the above mentioned sagittal split cut in the left ascending ramus. Next, an incision was made in the alveolar process of the right mandible, through which bone was removed from this process over a

distance of 12 mm. T h e osteotomy was completed through an extraoral incision, leaving the mandibular nerve intact. Since the original difference in length between the two ascending rami was about 16 ram, the remaining difference after restoration of occlusion was 1 6 - 8 = 8 ram. This is why through the extraoral incision already made, more b o n e was removed from t h e right mandibular body, from the posterior r i m as far as the cuspid region. The dorsal height of this slice was about 8 ram, and it tapered down in ventral direction. After osteosynthesis, the soft tissues were closed in layers and further fixation was ensured by intraoral splints and intermaxillary ligatures. The mandibular frontal teeth originally showed lingual tilting but, at follow-up 4 months after abolition of the intermaxillary fixation, they had come so far upright that frontal contact was m a d e in occlusion. A t follow-up :14 months after the operation the patient was no longer troubled by the temporomandibular articulation. The gastric symptoms had disappeared and the hypesthesia of the lower lip was virtually gone. T h e patient is now extremely satisfied and can use his diving equipment without any difficulty. All patients were given antibiotics (penicillin

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HOVINGA, K R A A L AND ROORDA

and streptomycin or oxytetracycline) for a few days, and all also received benzydamine hydrochloride (Tantum| Intermaxillary fixation was maintained for an average of 8 weeks; in patients submitted to an ostectomy in the mandibular body, the mandibular splints remained in situ a few weeks longer.

Results and discussion Of the nine patients with facial asymmetry, one (Patient H) showed unmistakable localization of the asymmetry in maxilla as well as mandible. Of the patients discussed, only Patient J showed marked hypertrophy of one collum mandibulae. Three patients (B, C and F) had had orthodontic treatment at art early age, and patients B and C had had one tooth extracted each. These two patients may originally have shown prognathism. The etiology of the anomaly remained largely unexplained in these nine patients. In Patients E and H, bone obtained by the osteotomy was subsequently used as autograft. Bone regeneration followed. Six of the patients described had psychologic problems of greater (A, C, E and H) or lesser severity (B and J); this was an important (if not the only) indication for operation. I n all cases the postoperative reaction to the result obtained was obviously positive. I n objective terms, too, the improvement in appearance was evident. W e wish to point out that, in principle, we do not perform an osteotomy unless the patient himself (or herself) is obviously well-motivated. In addition to the psychologic problems, mention must be made of complaints about the temporomandibular articulation (Patients A, B, G and J), the difficulties of mastication which inconvenienced Patients A, ]3, E and F in particular, and speech difficulties (Patients B, E and F) as factors indicating osteotomy. Rapid postoperative improvement was

observed not only in eating and speech but also in the complaints about the temporomandibular articulation. Two patients who had had gastric symptoms prior to the operation were no longer bothered b y these symptoms afterwards. N o n e of the patients experienced the hypesthesia of the lower lip as a grave inconvenience. Sensibility returned in all cases.

References 1. BRUCE, R. A. & ~'L.~YWARD,J. R,: Condylar hyperplasia and mandibular asymmetry: a review. J. Oral Surg. 1968: 26: 281-290. 2, HATZtFOTIADIS,D. ~ TSIVITSARIS, P.: Ober einige F~ille yon Unterkieferverschiebung verschiedener Xtiologie. Zahnaerztl. Welt 1972: 81: 856-862. 3. K6L~, H.: Probleme zur operativen Behandlung der Progenie. Dtsch. Zahn-, Mund-, Kieferheilkd. 1963: 40: 177. 4. PONT, G.d.: Die retromolare Osteotomie zur Korrektur der Progenie, der Retrogenie und Mordex apertus. Oeslerr. Z. Stomatol. 1961: 5: 8-11. 5. TxRsrrANO, I. I. & WOOTEN, J. W.: The asymmetrical mandible: report of six cases. ]. Oral Sltrg. 1970: 28:832-840 6. TRAUN~R, R. & OBWEOESE~, H.: Zur Operationstechnik bei der Progenie und anderen Unterkieferanomalien. Dtsch. Zahn-, Mttnd-, Kieferheilkd. 1955: 23: 1-26. 7. WHITE, D. E.: Mandibular asymmetry. In: KA.Y, L. W. (ed.): Trans. 4th Conf. Oral Surg. Munksgaard, Copenhagen 1973, p. 246-251. 8. WAL~g, R. V.: Condylar abnormalities. In: HUSTED, E. & HJORTINO-HANSEN, ]'. (ed.): Trans. 2nd Conf. Oral Surg. Munksgaard, Copenhagen 1967, p. 81,-96, Address: J. Hovlnga Department of Oral Surgery St. Elisabeth's Gasthuis Postbus 417 Haarlem The Netherlands