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Mandibula wing osteotomy for correction of the mandibular plane: a case report
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British Journal of Oral and Maxillofacial Surgery 48 (2010) 182–184
Short communication
Mandibula wing osteotomy for correction of the mandibular plane: a case report Albino Triaca a,∗ , Roger Minoretti a , Nikola Saulacic b a b
Center for Maxillofacial Surgery, Pyramide Clinic, Bellerivestr. 34, CH-8034 Zurich, Switzerland Department of Cranio-Maxillofacial Surgery, University Hospital, University of Bern, Switzerland
Accepted 17 August 2009 Available online 3 October 2009
Abstract We report a new technique for vertical enlargement of the inferior border of the mandible. © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Facial asymmetry; Hemifacial microsomia; Mandibular plane
Introduction Complete restoration of facial asymmetry is always difficult to achieve. Despite correction of the occlusal plane, facial asymmetry can persist if the mandibular body differs in height. We devised a new technique for skeletal correction of the mandibular plane that avoided the disadvantages and limitations of other techniques.
Case report An 18-year-old girl with hemifacial microsomia Type I (Fig. 1) also required reoperative removal of her mandibular third molars and orthodontic treatment to align her teeth. She was listed for vertical enlargement of the mandibular right border by mandibular wing osteotomy (Fig. 2a). The occlusal plane was corrected by rotation of the bimaxillary complex with Le Fort 1 and bilateral sagittal split rotation osteotomies. The mucosa was incised from the
ascending ramus of the mandible to the opposite ramus, and the mucoperiosteum raised just to the future line of a wing osteotomy. Horizontal bicortical chin osteotomy was done with a Mayfair bur (Maillefer Instruments, Ballaigues, Switzerland). About 1 cm anterior to the mental foramen the bicortical horizontal osteotomy was turned into a monocortical vertical osteotomy. The osteotomy cut was completed below the estimated path of the inferior alveolar nerve with a bur positioned in a sloping direction from superior to inferior. The completing osteotomy, which extended to the lower border of the mandible, was accomplished with a sharpened dental enamel chisel. In the anterior region, the cut segment of bone was split into two parts. Mobilisation was with two large chisels, taking particular care to avoid the fracture around the mental foramen. An autologous iliac crest graft was then placed to fill the region of the gap and the cut fragment of bone was fixed in the correct position (Fig. 2b). Postoperatively the patient had vertical augmentation of the right mandibular border with improved facial asymmetry (Fig. 3).
Discussion ∗
Corresponding author. Tel.: +41 44 388 15 15; fax: +41 44 381 26 26. E-mail address: [email protected] (A. Triaca).
Restoration of the symmetrical facial contour is challenging, particularly in moderate to severe deformities, because of the
0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2009.08.011
A. Triaca et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 182–184
183
Fig. 3. Postoperative photograph showing improved symmetry of the face. Fig. 1. Preoperative photograph showing facial asymmetry.
necessary overcorrection of the bony deformity relative to the normal side.1 Repeat operation may ultimately fail to achieve adequate reconstructive goals because of a self-perpetuating cycle of further devascularisation, resorption, and scarring, or even non-union in the case of non-vascularised bone grafts. Vascularised free flaps were used for correction of deformed
facial contours with limited donor site morbidity, mainly for salvage.2 Particularly important is the fact that the cut segment of bone after wing osteotomy preserved its vascularisation. The repositioning of bony fragments results in correction of the intergonial angle, an important indicator of facial symmetry or asymmetry.3 Splitting in the midline allows positioning of the cut segment of bone more laterally and corrects the lack of width in the mandible angle. While the onlay technique is
Fig. 2. (a) Model of wing osteotomy. (b) Postoperative panoramic view of the mandibular wing osteotomy and interposition of autologous bone.
184
A. Triaca et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 182–184
overshadowed by a high relapse rate, conventional sandwich augmentation is virtually impossible because of the presence of the inferior alveolar nerve. Before the wing osteotomy, it is necessary to identify the position of the inferior alveolar canal meticulously on the digital tomogram. Although it is technically demanding, the monocortical sliding osteotomy is reliable. During the last 4 years we have used the wing osteotomy successfully in over 200 patients. The long-term results remain to be documented.
References 1. Longaker MT, Siebert JW. Microsurgical correction of facial contour in congenital malformations: the marriage of hard and soft tissue. Plast Reconstr Surg 1996;98:942–50. 2. Chiu ES, Sharma S, Siebert JW. Salvage of silicone-treated facial deformities using autogenous free tissue transfer. Plast Reconstr Surg 2005;166:1195–205. 3. Padwa BL, Kaiser MO, Kaban LB. Occlusal cant in the frontal plane as a reflection of facial asymmetry. J Oral Maxillofac Surg 1997;55:811–6.
British Journal of Oral and Maxillofacial Surgery 48 (2010) 182–184
Short communication
Mandibula wing osteotomy for correction of the mandibular plane: a case report Albino Triaca a,∗ , Roger Minoretti a , Nikola Saulacic b a b
Center for Maxillofacial Surgery, Pyramide Clinic, Bellerivestr. 34, CH-8034 Zurich, Switzerland Department of Cranio-Maxillofacial Surgery, University Hospital, University of Bern, Switzerland
Accepted 17 August 2009 Available online 3 October 2009
Abstract We report a new technique for vertical enlargement of the inferior border of the mandible. © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Facial asymmetry; Hemifacial microsomia; Mandibular plane
Introduction Complete restoration of facial asymmetry is always difficult to achieve. Despite correction of the occlusal plane, facial asymmetry can persist if the mandibular body differs in height. We devised a new technique for skeletal correction of the mandibular plane that avoided the disadvantages and limitations of other techniques.
Case report An 18-year-old girl with hemifacial microsomia Type I (Fig. 1) also required reoperative removal of her mandibular third molars and orthodontic treatment to align her teeth. She was listed for vertical enlargement of the mandibular right border by mandibular wing osteotomy (Fig. 2a). The occlusal plane was corrected by rotation of the bimaxillary complex with Le Fort 1 and bilateral sagittal split rotation osteotomies. The mucosa was incised from the
ascending ramus of the mandible to the opposite ramus, and the mucoperiosteum raised just to the future line of a wing osteotomy. Horizontal bicortical chin osteotomy was done with a Mayfair bur (Maillefer Instruments, Ballaigues, Switzerland). About 1 cm anterior to the mental foramen the bicortical horizontal osteotomy was turned into a monocortical vertical osteotomy. The osteotomy cut was completed below the estimated path of the inferior alveolar nerve with a bur positioned in a sloping direction from superior to inferior. The completing osteotomy, which extended to the lower border of the mandible, was accomplished with a sharpened dental enamel chisel. In the anterior region, the cut segment of bone was split into two parts. Mobilisation was with two large chisels, taking particular care to avoid the fracture around the mental foramen. An autologous iliac crest graft was then placed to fill the region of the gap and the cut fragment of bone was fixed in the correct position (Fig. 2b). Postoperatively the patient had vertical augmentation of the right mandibular border with improved facial asymmetry (Fig. 3).
Discussion ∗
Corresponding author. Tel.: +41 44 388 15 15; fax: +41 44 381 26 26. E-mail address: [email protected] (A. Triaca).
Restoration of the symmetrical facial contour is challenging, particularly in moderate to severe deformities, because of the
0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2009.08.011
A. Triaca et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 182–184
183
Fig. 3. Postoperative photograph showing improved symmetry of the face. Fig. 1. Preoperative photograph showing facial asymmetry.
necessary overcorrection of the bony deformity relative to the normal side.1 Repeat operation may ultimately fail to achieve adequate reconstructive goals because of a self-perpetuating cycle of further devascularisation, resorption, and scarring, or even non-union in the case of non-vascularised bone grafts. Vascularised free flaps were used for correction of deformed
facial contours with limited donor site morbidity, mainly for salvage.2 Particularly important is the fact that the cut segment of bone after wing osteotomy preserved its vascularisation. The repositioning of bony fragments results in correction of the intergonial angle, an important indicator of facial symmetry or asymmetry.3 Splitting in the midline allows positioning of the cut segment of bone more laterally and corrects the lack of width in the mandible angle. While the onlay technique is
Fig. 2. (a) Model of wing osteotomy. (b) Postoperative panoramic view of the mandibular wing osteotomy and interposition of autologous bone.
184
A. Triaca et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 182–184
overshadowed by a high relapse rate, conventional sandwich augmentation is virtually impossible because of the presence of the inferior alveolar nerve. Before the wing osteotomy, it is necessary to identify the position of the inferior alveolar canal meticulously on the digital tomogram. Although it is technically demanding, the monocortical sliding osteotomy is reliable. During the last 4 years we have used the wing osteotomy successfully in over 200 patients. The long-term results remain to be documented.
References 1. Longaker MT, Siebert JW. Microsurgical correction of facial contour in congenital malformations: the marriage of hard and soft tissue. Plast Reconstr Surg 1996;98:942–50. 2. Chiu ES, Sharma S, Siebert JW. Salvage of silicone-treated facial deformities using autogenous free tissue transfer. Plast Reconstr Surg 2005;166:1195–205. 3. Padwa BL, Kaiser MO, Kaban LB. Occlusal cant in the frontal plane as a reflection of facial asymmetry. J Oral Maxillofac Surg 1997;55:811–6.