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Treatment of facial asymmetries by one-stage maxillary and mandibular bilateral osteotomies
Int. J. Oral Surg. 1974: 3 : 2 3 9 - 2 4 2 (Key words: facial asymmetry; osteotomy)
Treatment of facial asymmetries by one-stage maxillary and mandibular bilateral osteotomies S. BRAMI, J. P. LAMARCHE AND F. SOUYRIS Service de Chirurgie Maxillo-Faciale et Stomatologie, C.H.U. Saint-Charles, Montpellier, France
ABSTRACT--Very often facial asymmetry is confused with laterognathia, but a careful study of facial asymmetries shows that the malformation does not involve the lower part of the face only but rather the middle part as well. Many surgeons correct the mandibular abnormality first and the affected maxilla at a later operation. This preliminary report of four cases shows that both procedures can be accomplished in a single operation. The surgical procedure was a bilateral osteotomy of the mandible together with supraalveolar osteotomy to allow a tilting and rotating movement of the bone fragments, accomplished by balancing the resection for shortening the bone against the bone grafting for lengthening. Good occlusal adjustment is obtained and the facial outlines are restored esthetically.
Usually, when we speak of facial asymmetry we think of overgrowth or undergrowth of the ascending ramus of the mandible and the treatment differs according to the type. The purpose of this paper is to describe a surgical procedure applicable to all situations, whatever the etielogy. But this procedure should be used only for major facial asymmetries as multiracial osteotomies are not without danger. Lesser asymmetries do not at all justify a complex osteotomy. Therefore it is important to determine precisely the degree of the facial asymmetry. The timing of treatment depends on the severity of the deformity and its effect on the functional and psychologic status of the patient.
Material and methods CLINICAL M A T E R I A L Four cases have been investigated and treated by our methods. Case 1 - A 15-year-old girl with right-sided atrophy. The various investigations showed complete aplasia of the masseter muscle with atrophy of the right ascending ramus. Case 2 - A 17-year-old boy with ankylosis of the temporomandibular joint, operated in early childhood, presented a consequent facial asymmetry. Case 3 - A 22-year-old woman with a first branchial arch syndrome presented a facial asymmetry accompanied by malformation of the ear and pinna, seventh nerve paresis and macrostomia (already operated). In addition,
240
B R A M I , L A M A R C H E A N D SOUYRIS
/
J
\
I according to radiograph, shows on composite tracing: site ofosteotomy; o n shaded areas: site af bony resection. Arrows show movement of the bone.
Fig. 2. Postoperative diagram with shaded
a n a t r o p h y of the m a l a r bone with absence of the zygomatic arch was f o u n d in the radiographic examination.
ed. Bone graft is inserted so as to reposition the mandibular angle. (2) A supraalveolar osteotomy is performed on the maxilla, and a bone graft is placed into the gap thus created. This procedure was modified in the first branchial arch syndrome (Figs. 1-2). The osteotomy o n the hypotrophic maxilla is performed in two parts: first ascending vertically oft the m a l a r bone up to the middle of its body. T h e n the direction changes to horizontal, and under the orbital rim the osteotomy is directed towards the piriform aperture. This procedure gives better bone fragment stability. The bone graft was L-shaped.
Fig. 1. Drawing,
Case 4 - A 27-year-old w o m a n presented a facial asymmetry of unknown origin with laterognathia and crossbite. Radiographic e x a m i n a t i o n showed, on the right side, a shortened ascending r a m u s and a decrease in height of the maxilla.
SURGICAL PROCEDURE This operative technique may be carried out o n any kind of major asymmetry because it is performed on the maxilla and mandible on both sides. O n the hypotrophie side (or normal side): (1) T h r o u g h an external subangular mandibular skin incision. A reverse L-shaped osteotomy of the ascending ramus is perform-
areas showing bone grafting.
On the hypertrophic side (or normal side): by intraoral approach: (1) W e perform a sagittal splitting of the ramus according to Trauner. (2) To insure a decrease in height of the maxilla we performed an inframalar osteotomy.
BILATERAL OSTEOTOMIES
Fig. 3. Significant facial asymmetry associated with a total aplasia of masseter muscle,
Discussion The management of facial asymmetry requires preliminary investigation in order to determine to what extent the middle part of the face is involved and to eliminate the possibility that the deformity is due to laterognathia alone. Because of the spatial concept it imposes we rely chiefly on tridimensional cephalography, which is indispensable for the understanding of complicated asymmetries. It is composed of three radiographs (one frontal view, one lateral view and one vertical view). Clinical examination enables us to distinguish the bony malformation from disturbances of the soft tissues. Intraoral examination shows the abnormal dental relationships (such as a cross bite or a lateral open bite). T h e malformation is clearly seen on plaster dental casts which assist in
24t
Fig. 4. Postoperative photograph of same patient.
choosing the best site for osteotomy. These casts have been set on Chateau's articulator in order to study the preexisting occlusal malformations or those which might occur after osteotomy. Bilateral osteotomies on the maxilla a n d mandible were an adaptive procedure, using adequate osteotomy on one side a n d sufficient bone grafting on the other. This procedure considerably improves the oeclusal malformations by giving finer adjustment than can be obtained by using o l d e r techniques. By performing osteotomy on the healthy side we are able to ensure a smaller and more balanced removal. T h e vertical section through the ascending ramus facilitates the rotation of the m a n dibular body without really disturbing the temporomandibular joint. Still many surgeons think the one-stage operation is out of proportion to its g o a l
242
BRAMI, LAMARCHE AND SOUYRIS
Fig. 5. Left: l~reoperative radiograph. Right: postoperative radiograph with internal fixations.
because of the greater blood loss and postoperative discomfort, but we consider that, thanks to improved anesthetic procedures, this is no problem. Also, patients prefer a one-stage operation as the postoperative discomfort increases their anxiety when they know they must undergo a second one. Often it is very difficult to get a true opinion as to the respective parts played by soft tissues and bony frame in the asymAddress: S. Brami "Le St Jaumes" 53, rue du Fattbourg St. Jaumes 34000 Montpellier France
metry, especially in hypoplasia with a congenital origin. In these cases it was necessary to do secondary bone grafting or silicone implantation. Yet inlay bone grafts have been placed over the defective side of the mandible at the same operative stage. Any slight asymmetry which still persists can be reduced by a muscular functional re-educatio~, Fixation is effected by means of steel wiring, plates and screws, Postoperative relapse is minimized by immobilization for 7-10 weeks, with intermaxillary fixation. Therefore, in facial asymmetries, a surgical bilateral correction must be considered when the whole facial skeleton is injured. The appropriate technique must be sufficient to permit the best fitting of bony fragments and give an esthetic and functional result with very little removal. These conditions are realized by maxillary and mandibular bilateral osteotomies of jaws. These osteotomies must be carried out together and at the sarne time (Figs. 3-5).
Treatment of facial asymmetries by one-stage maxillary and mandibular bilateral osteotomies S. BRAMI, J. P. LAMARCHE AND F. SOUYRIS Service de Chirurgie Maxillo-Faciale et Stomatologie, C.H.U. Saint-Charles, Montpellier, France
ABSTRACT--Very often facial asymmetry is confused with laterognathia, but a careful study of facial asymmetries shows that the malformation does not involve the lower part of the face only but rather the middle part as well. Many surgeons correct the mandibular abnormality first and the affected maxilla at a later operation. This preliminary report of four cases shows that both procedures can be accomplished in a single operation. The surgical procedure was a bilateral osteotomy of the mandible together with supraalveolar osteotomy to allow a tilting and rotating movement of the bone fragments, accomplished by balancing the resection for shortening the bone against the bone grafting for lengthening. Good occlusal adjustment is obtained and the facial outlines are restored esthetically.
Usually, when we speak of facial asymmetry we think of overgrowth or undergrowth of the ascending ramus of the mandible and the treatment differs according to the type. The purpose of this paper is to describe a surgical procedure applicable to all situations, whatever the etielogy. But this procedure should be used only for major facial asymmetries as multiracial osteotomies are not without danger. Lesser asymmetries do not at all justify a complex osteotomy. Therefore it is important to determine precisely the degree of the facial asymmetry. The timing of treatment depends on the severity of the deformity and its effect on the functional and psychologic status of the patient.
Material and methods CLINICAL M A T E R I A L Four cases have been investigated and treated by our methods. Case 1 - A 15-year-old girl with right-sided atrophy. The various investigations showed complete aplasia of the masseter muscle with atrophy of the right ascending ramus. Case 2 - A 17-year-old boy with ankylosis of the temporomandibular joint, operated in early childhood, presented a consequent facial asymmetry. Case 3 - A 22-year-old woman with a first branchial arch syndrome presented a facial asymmetry accompanied by malformation of the ear and pinna, seventh nerve paresis and macrostomia (already operated). In addition,
240
B R A M I , L A M A R C H E A N D SOUYRIS
/
J
\
I according to radiograph, shows on composite tracing: site ofosteotomy; o n shaded areas: site af bony resection. Arrows show movement of the bone.
Fig. 2. Postoperative diagram with shaded
a n a t r o p h y of the m a l a r bone with absence of the zygomatic arch was f o u n d in the radiographic examination.
ed. Bone graft is inserted so as to reposition the mandibular angle. (2) A supraalveolar osteotomy is performed on the maxilla, and a bone graft is placed into the gap thus created. This procedure was modified in the first branchial arch syndrome (Figs. 1-2). The osteotomy o n the hypotrophic maxilla is performed in two parts: first ascending vertically oft the m a l a r bone up to the middle of its body. T h e n the direction changes to horizontal, and under the orbital rim the osteotomy is directed towards the piriform aperture. This procedure gives better bone fragment stability. The bone graft was L-shaped.
Fig. 1. Drawing,
Case 4 - A 27-year-old w o m a n presented a facial asymmetry of unknown origin with laterognathia and crossbite. Radiographic e x a m i n a t i o n showed, on the right side, a shortened ascending r a m u s and a decrease in height of the maxilla.
SURGICAL PROCEDURE This operative technique may be carried out o n any kind of major asymmetry because it is performed on the maxilla and mandible on both sides. O n the hypotrophie side (or normal side): (1) T h r o u g h an external subangular mandibular skin incision. A reverse L-shaped osteotomy of the ascending ramus is perform-
areas showing bone grafting.
On the hypertrophic side (or normal side): by intraoral approach: (1) W e perform a sagittal splitting of the ramus according to Trauner. (2) To insure a decrease in height of the maxilla we performed an inframalar osteotomy.
BILATERAL OSTEOTOMIES
Fig. 3. Significant facial asymmetry associated with a total aplasia of masseter muscle,
Discussion The management of facial asymmetry requires preliminary investigation in order to determine to what extent the middle part of the face is involved and to eliminate the possibility that the deformity is due to laterognathia alone. Because of the spatial concept it imposes we rely chiefly on tridimensional cephalography, which is indispensable for the understanding of complicated asymmetries. It is composed of three radiographs (one frontal view, one lateral view and one vertical view). Clinical examination enables us to distinguish the bony malformation from disturbances of the soft tissues. Intraoral examination shows the abnormal dental relationships (such as a cross bite or a lateral open bite). T h e malformation is clearly seen on plaster dental casts which assist in
24t
Fig. 4. Postoperative photograph of same patient.
choosing the best site for osteotomy. These casts have been set on Chateau's articulator in order to study the preexisting occlusal malformations or those which might occur after osteotomy. Bilateral osteotomies on the maxilla a n d mandible were an adaptive procedure, using adequate osteotomy on one side a n d sufficient bone grafting on the other. This procedure considerably improves the oeclusal malformations by giving finer adjustment than can be obtained by using o l d e r techniques. By performing osteotomy on the healthy side we are able to ensure a smaller and more balanced removal. T h e vertical section through the ascending ramus facilitates the rotation of the m a n dibular body without really disturbing the temporomandibular joint. Still many surgeons think the one-stage operation is out of proportion to its g o a l
242
BRAMI, LAMARCHE AND SOUYRIS
Fig. 5. Left: l~reoperative radiograph. Right: postoperative radiograph with internal fixations.
because of the greater blood loss and postoperative discomfort, but we consider that, thanks to improved anesthetic procedures, this is no problem. Also, patients prefer a one-stage operation as the postoperative discomfort increases their anxiety when they know they must undergo a second one. Often it is very difficult to get a true opinion as to the respective parts played by soft tissues and bony frame in the asymAddress: S. Brami "Le St Jaumes" 53, rue du Fattbourg St. Jaumes 34000 Montpellier France
metry, especially in hypoplasia with a congenital origin. In these cases it was necessary to do secondary bone grafting or silicone implantation. Yet inlay bone grafts have been placed over the defective side of the mandible at the same operative stage. Any slight asymmetry which still persists can be reduced by a muscular functional re-educatio~, Fixation is effected by means of steel wiring, plates and screws, Postoperative relapse is minimized by immobilization for 7-10 weeks, with intermaxillary fixation. Therefore, in facial asymmetries, a surgical bilateral correction must be considered when the whole facial skeleton is injured. The appropriate technique must be sufficient to permit the best fitting of bony fragments and give an esthetic and functional result with very little removal. These conditions are realized by maxillary and mandibular bilateral osteotomies of jaws. These osteotomies must be carried out together and at the sarne time (Figs. 3-5).