Authors: Fayez Saleh (BDS Honors, MSc, PhD, Dip Med Ed.,)a & Rami Farmaui (BDS, Cert Ortho)
The purpose of this study was to present a case report of severe facial asymmetry and the orthosurgical protocol adopted to correct that deformity.
Materials and Methods: A 31-year old female patient complaining of her apparent facial asymmetry with severe mandibular and chin deviation. Data collection and analysis confirmed the necessity for combined Orthosurgical treatment which was easily accepted by the patient, LeFort 1 Osteotomy, BSSO and left mandibular body ostectomy of the bulging bone together allowed the reconstruction of the facial bones and restored facial symmetry.
Results: Satisfaction in the treatment outcome in terms of esthetics and function as perceived by patient and family was achieved.
Conclusion: Collaboration between clinicians and surgeon is essential throughout the different phases of treatment. Diagnosis, structured treatment planning, as well as knowledge of the patient’s chief complaint and expectations are important factors to achieve successful treatment outcome.
Keywords: Facial asymmetry. Combined Orthosurgery, Patients’ Satisfaction.
Condylar hyperplasia is a developmental anomaly that results in enlargement and deformity of the condylar head. Unilateral hyperplasia may lead to facial asymmetry, mandibular and chin deviation, malocclusion, and sometimes articular dysfunction. Since the majority of cases develop during childhood and puberty, the correction of deformities should be postponed until growth ceases completely and the patient is fully matured.
Peterson and Topazian (1974)(7) have emphasized the importance of patients’ perception in the success of treatment, and considered that an important objective of dentofacial surgery is to have a patient who is happy with the results of treatment. Dissatisfaction may result from failure of communication between the clinicians and the patients.
The selection of an appropriate plan of treatment is based not only upon the clinicians’ estimation of the final outcome with regard to esthetics, function, and stability but also upon patients’ desire, expectations and perception of facial profile. In accordance with this, Bell et al., (1985) (1) revealed that individuals perceive their own profiles differently than clinicians, and this strongly influences their decision to undergo orthognathic surgery.
a Professor of Orthodontics and Medical Education, former chairperson, Department of Orthodontics, Lebanese University 1995-1999; Beirut Arab University 1999-2013
b Private Orthodontic Practice
The etiology of facial asymmetry may be due to congenital, environmental, functional or local factors. The need for thorough analysis is mandatory using the most recent diagnostic tools. According to Bishara et al. (1994) (2), the lower part of the face is mostly affected and is presented in many forms and severities.
Legan (1998) (6) confirmed that the primary goal of surgical orthodontics is to eliminate the dental compensation for the skeletal deformity in all three planes of space. The collaboration between expert orthodontists and maxillofacial surgeons is therefore, essential to diagnose facial asymmetries properly and formulate a realistic and rewarding treatment planning.
Cousley et al., (2003) (4) pointed out to the importance of assessing the treatment’s feasibility and computerized prediction of treatment outcome prior to taking decision and signing the informed consent. The orthodontic and surgical changes must be described accurately to the patients in order to achieve realistic and acceptable objectives.
Silva et al. (2013) (8) developed a visual perception threshold at which most lay persons recognize a negative impact of facial structures asymmetry on the esthetics and beautiful smile. The parameters established were: 2mm dental midline shift, 4mm for nose deviation, 5 degrees of occlusal plane cant, and 3 degrees for a frontal view/ incisal plane cant.
Christou et al. (2013)(3) emphasized that, 3D imaging and analysis techniques in addition to new software packages that capture the 3D facial form, facilitated the accurate assessment of both soft and hard facial tissues abnormalities and the prediction of treatment outcome. Clinicians are therefore, encouraged to utilize these tools to properly diagnose facial asymmetries and precisely monitor the changes due to surgical procedures.
Singh et al. (2014) (9) presented two clinical cases with condylar hyperplasia and facial asymmetry, case 1 was due to overgrowth and increase in the size of the condyle that was surgically corrected by condylectomy; in case 2 the condylar neck was elongated and was treated by unilateral Sagittal split osteotomy on the side of the deformity. Both cases were successfully corrected and restored normal facial symmetry and normal occlusion.
Yi et al. (2014)(10) conducted an analytical Posterior-anterior radiographic study of forty five patients with different degrees of facial asymmetry after surgical orthodontic treatment. Measurements revealed that facial asymmetry was mainly manifested in the mandible (28 in the mandibular body, 15 in the ramus, and 2 cases in both the body and the ramus).
Hassani et al. (2014)(5) described the surgical treatment of hemimandibular hyperplasia and facial asymmetry. They introduced a new protocol to dissect and save inferior alveolar nerve in unilateral body ostectomy under direct visualization. The procedure was a combination of low condylectomy of the affected side, unilateral sagittal split osteotomy and LeFort I Osteotomy and intended to correct hemi-mandibular hyperplasia and facial asymmetry. The outcome was successful and the innovative technique was safe with low risk of nerve damage.
A healthy female patient, 30 years and 5 months old, presented with the chief complaint of facial asymmetry and mandibular deviation. The patient did not report any previous facial trauma, pathology or orthodontic treatment.
Figure 1 shows the face in 3Ds, clear frontal facial asymmetry and severe mandibular deviation to the right. Sagittally the lips were retruded 4 mm in relation to the E line of Ricketts developing a dished-in face. Obvious vertical discrepancy between right and left halves of the face rendered distorted facial horizontal planes that are not parallel to the inter-pupillary plane.
|Fig 1. Frontal and lateral facial views showing transverse asymmetry, Concave profile and vertical discrepancy between right and left halves,|
The occlusion is Angle’s class I malocclusion with mild crowding, dental mid line deviation and canted occlusal plane, unilateral buccal crossbite and vertically normal overbite (Fig 2.).
Fig 2. Pretreatment occlusion
Fig and Table 3. Frontal Cephalometric Analysis of Grammons by DFPlus
The frontal cephalometric analysis (Fig 3.) confirmed the clinical examination where the left ramus height was longer than that of the right one (Left= 64.1mm, Rt= 50.6mm). The left Antigonial angle was94.3⁰ and the right was 119.1⁰ due to overgrowth of the left mandibular half. The chin was 8.9mm off set to confirm the true skeletal asymmetry.
Fig and Table 4. Lateral Vertical Cephalometric Analysis (McNamara and Jarabak)
The vertical cephalometric analysis reveals a short Brachyface; this is due to counterclockwise rotation of the mandible and chin.
Table 5. Sagittal Cephalometric Analysis (McNamara and Jarabak)
The lateral cephalometric analysis presented a skeletal Class III skeletal pattern due to maxillary deficiency mainly.
|Dentoalveolar Status Jarabak Analysis||Case||Norm||Diagnosis|
|Interincisal Angle||129.6||135.0||Proclined Incisors|
|U1 / S-N||111.5||102.0||Proclined|
|Table 6. Disclosing the axial inclination of the incisors with respect to basal bone|
The lateral cephalometric dentoalveolar analysis demonstrated that the maxillary incisors were proclined to compensate for the maxillary deficiency illustrated in the skeletal sagittal analysis.
Fig 6. A panoramic view showing the overgrowth of the left mandibular half and impacted 3rd molars
The panoramic radiograph (Fig 6) revealed the left condylar hyperplasia and overgrowth of the body of the mandible at that side, a point to be considered in treatment planning. Mesioangular Impaction of third molars is another issue to be resolved presurgically.
Treatment Options and Objectives
Based on the collected data and consultation with the maxillofacial surgeon, details of the orthodontic and surgical procedures were described to the patient in order to achieve realistic and acceptable objectives. Prior to signing the consent form, a computerized prediction simulation of the possible treatment outcome was presented and easily convinced the patient.
Pre-Surgical phase of Treatment
Leveling and alignment stage was associated with a quadhelix installed to expand the maxillary arch and level the occlusal plane. Decompensation of the proclined incisors was performed. The patient was then referred to the oral surgeon to extract the lower wisdom teeth. No attempt was initiated to correct midline deviation by using intermaxillary elastics which is left to the maxillofacial surgeon. Prefinishing check list confirmed the parallelism of the roots and leveled occlusal plane. Heavy rectangular stainless steel archwires were then inserted and surgical hooks were tied firmly.
Impressions to construct working and duplicate casts were taken. Model surgery was then jointly performed to simulate the bimaxillary surgical movements and make any final corrections if needed.
The planned Le Fort I osteotomy with 4mm impaction of the affected side was performed to horizontally stabilize the occlusal plane in an esthetic zone and achieve normal efficient functional occlusion. Bilateral sagittal split ramus osteotomy (BSSO) then allowed the rotation of the mandible and the dentition to interdigitate with the maxillary counterparts. Ostectomy of the enlarged left body of the mandible was also carried out to harmonize the right and left halves of the mandible. The inferior alveolar nerve was saved by cutting 4 mm below the canal from mental foramen backward, the radiographs in Figs 7 & 8 show the steps of surgical intervention and improvement of the facial symmetry.
Fig 9. Pre & Post Treatment Front Cephalometric Analysis Showing Changes in the Harmony & Balance of the Face
Fig 10. Pre & Post Lateral Cephametric Analysis showing the changes in the sagittal direction
One month after surgery, orthodontic detailing of occlusion began and the heavy overlay arch wire with surgical hooks was removed. Minor corrections allowed settling of occlusion and a routine check list was applied before debonding and detachment of appliances. Postoperative instructions were fully given to the patient in terms of hygiene, retainers and periodic office visits.
Fig 11. Post-Surgical Phase Focusing on the Role of Inter-maxillary Elastics in Stabilizing the Occlusion
Fig 13. Retention Phase
The combined orthosurgical correction of the presented severe facial asymmetry case resulted in satisfactory outcome with pleasant smile, facial esthetics in three dimensions, and normal functional occlusion. The key to successful treatment was the sympathy and mutual understanding of biologic limitations between patients and clinicians. However, patient’s perception and expectations were fully respected.
- Bell R, Kiyak HA, Joondeph DR, McNeil RW, and Wallen TR (1985): Perception of facial profile and their influence on the decision to undergo orthognathic surgery. Am J Orthod., 88: 323-332
- Bishara S, Burkey P, and Kharouf J (1994). Dental and Fcaial Assymmetries: A Review. Angle Orthod; 64: 89-98
- Christou T, Kau CH, Waite PD, Abou Kheir N, and Mouristen D (2013). Modified method of analysis for surgical correction of facial asymmetry. Annals of Maxillofacial Surgery, 3(2): 185-191. .
- Cousley RRJ, Grant E, and Kindelan JD (2003): The validity of computerized orthognathic predictions. J Orthod., 30: 149-154
- Hassani A., Malekpor Z, Sohrabi M, Afsar N, Karizmeh M, and Aghdam H., (2014). Surgical Treatment of Hemimandibular Hyperplasia Leading to Unilateral Overdevelopment of the Face. Thrita: J Med Science; 3 (2): 1-4
- Legan H. (1998): Surgical correction of patients with asymmetries. Semin Orthod.; 4(3):189-198.
- Peterson LJ, Topazian RG. The preoperative interview and psychological evaluation of the orthognathic surgery patient. J Oral Surg. 1974; 32:583–588.
- Silva BP, Castellanos EJ, Martinez-de-Fuentes, Greenberg JR, and Chu S (2013). Laypersons’ Perception of Facial and Dental Asymmetries. Int J Period Restor Dent; 33: e162-e171
- Singh V, Verma A, Attresh G, and Batra J (2014). Orthosurgical management of condylar hyperplasia: Rare case reports. National Journal of Maxillofacial Surgery, 5 (1): 54-59.
- Yi L, Yan C, and Yang B (2014) Asymmetric index analysis on the orthodontic-orthognathic treatment of facial asymmetry patients in skull positioning posterior-anterior radiographs. West China Journal of Stomatology, 32(2):138-144.