BRIEF CLINICAL STUDIES
Mandibular Symphyseal L-Inverted Midline Osteotomy to Correct Mild Laterognathia and Malocclusion Carlos Collantes, DDS,y Nicola´s Solano, DDS,z§jjô Luis Romero, DDS,y# Ce´sar Molina, DDS,yy and Andre´s Go´mez-Delgado, DDSzz§§ Objective: The aim of this study was to present the authors’ experience with a new surgical technique to correct mild laterognathia and malocclusion by means of an L-inverted midline osteotomy. Patient and Methods: The patient was a 26-year-old woman diagnosed with left laterognathia and ipsilateral posterior crossbite. She was operated by using this novel technique in November 2009 at Hogar Clı´nica San Rafael, Maracaibo, Venezuela. Bicortical midline symphyseal vertical osteotomy was executed, followed by block removal of the central right inferior incisor and its surrounding alveolar bone. The mandibular segmentation was completed by means of a right hemimentoplasty. After this, a 4-mm right mandibular rotation was made, and titanium plates and monocortical screws of the 2.0 system were used to achieve the rigid fixation. Results: The patient showed outstanding aesthetic and functional results after 5 years. Conclusions: This technique provides a new treatment option for the correction of mild laterognathia cases associated with dental malocclusion. Key Words: Dentofacial anomaly correction, L-inverted osteotomy, midline mandibular osteotomy
S
everal osteotomies have been described to correct mandibular deformities, such as vertical ramus, L-inverted, and C osteotomies among others. The sagittal ramus osteotomy, described by Obwegeser, is probably the most popular procedure used for the From the Department of Oral and Maxillofacial Surgery, Hogar Clı´nica San Rafael, Maracaibo; yOral Surgery Program, Universidad del Zulia; zDepartment of Oral and Maxillofacial Surgery, Hospital Manuel Noriega Trigo, San Francisco; §Department of Oral and Maxillofacial; jjDepartment of Plastic, Maxillofacial and Reconstructive Surgery Department Hospital Universitario de Maracaibo; ôDepartment of Oncology Surgery, Hospital Universitario de Maracaibo; #Department of Oral and Maxillofacial, Hospital General Dr. Adolfo D’Empaire, Cabimas; Oral Surgery Program, Universidad del Zulia; yyDepartment of Oral and Maxillofacial Surgery, Hogar Clı´nica San Rafael, Maracaibo, Venezuela; zzDepartment of Oral and Maxillofacial Surgery; and §§Publications Committee, Universidad El Bosque, Bogota´, Colombia. Received September 17, 2014. Accepted for publication March 5, 2015. Address correspondence and reprint requests to Dr Andre´s Go´mezDelgado, DDS, Universidad El Bosque, Departmento de Cirugı´a Oral y Maxilofacial, Carrera 9B No. 134 B-85, Co´digo Postal 110121, Bogota´, Colombia; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001842
The Journal of Craniofacial Surgery
FIGURE 1. A, C, Presurgical clinical photographs of the patient showing evident left laterognathia and B, a straight face profile.
treatment of patients with retrognathia, prognathia, or laterognathia.1 Osteotomies performed at the anterior mandibular region are usually the result of combined techniques to correct transverse anomalies of the jaws, and most part of the time, they are considered as supplementary to other more complex mandibular procedures, reason why they are poorly mentioned in literature.2 Together with the mentoplasty, the midline osteotomy is one of the most popular techniques performed on the mandibular symphysis, and it can also be combined with a bilateral sagittal ramus osteotomy. The indication of this osteotomy, first described by Bell3 in 1976, is to narrow the mandible while correcting its anterioposterior excess. Alexander et al4 reported the stability of the procedure, safety to periodontal tissues, and absence of temporomandibular joint disorders. The aim of this study was to describe a new surgical technique to correct patients with mild laterognathia, which provides outstanding aesthetic and functional results, without the need to execute additional invasive procedures, or significant postorthodontic treatment.
PATIENT AND METHODS A 26-year-old female patient was admitted to the Department of Oral and Maxillofacial Surgery at Hogar Clı´nica San Rafael, Maracaibo Venezuela, with the chief complaint of facial asymmetry. Clinical examination showed balance of the facial thirds, straight face profile, and marked left laterognathia (Fig. 1). Intraorally, the most relevant finding was left crossbite, dental class I at the right side, and a left 4-mm deviation of the inferior dental midline (Fig. 2). The cause of the asymmetry was inheritance. No evidence of condylar hyperplasia or hypoplasia was recorded. No syndromes were related to the patient.
Surgical Technique Under general anesthesia with nasotracheal intubation, surgical field preparation, and local anesthetic infiltration, an incision through the mucosa in the vestibule, similar to the usual chin osteotomy transoral approach, was performed. A single marginal vestibular and lingual incision around the tooth related to the vertical osteotomy was executed, followed by cephalocaudal tunneling dissection. After this, a bicortical symphyseal vertical osteotomy was made, by using an electric saw and chisels. The cut included the right central incisor and its surrounding alveolar bone. The right hemimentoplasty osteotomy was made (Fig. 3A), and the block was removed. The osteotomies allowed a 4-mm displacement of the left mandibular segment toward the right side. Titanium plates and monocortical screws (2.0 system) were used for
FIGURE 2. Presurgical intraoral photograph that shows midline left deviation and ipsilateral crossbite.
Volume 26, Number 5, July 2015
1709
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Brief Clinical Studies
FIGURE 3. A, L-inverted midline osteotomy, B, internal rigid fixation with 2.0 system plates and screws.
Volume 26, Number 5, July 2015
FIGURE 5. Intraoral image showing the correction of the left crossbite and occlusal stability.
rigid fixation. The screws were placed carefully to avoid perforation of the dental roots (Fig. 3B). After this, suturing was performed by using 4–0 Coated VICRYL (polyglactin 910) Suture. This research complies with the World Medical Association Declaration of Helsinki on medical protocols and ethics.
RESULTS Postoperatively, acceptable facial symmetry and balance were observed, with inferior facial third slimming and reduction of the intercommissural distance (Fig. 4). Intraorally, bilateral class I occlusion and acceptable dental occlusion was achieved (Fig. 5). Five-year follow-up computed tomography shows complete bone healing, harmonic articular relation, and condylar shape (Fig. 6). To present, there are no signs or symptoms of articular dysfunction.
DISCUSSION One of the first studies of mandibular segmental osteotomies was made by Hullihen5 in 1849, being the first symphyseal osteotomy reported in 1952 by Trauner.6 In 1967, Plumpton7 published a study describing symphyseal osteotomy to correct asymmetric prognathism. Sowray and Haskell8 and O’Driscoll9 described the use of alveolar and symphyseal combined osteotomies, including patients with tooth extraction, to allow the bone cut to pass through the alveolus, in cases of transverse mandibular overgrowth. Obwegeser10 published several studies reporting the combination of osteotomies and ostectomies of the mandibular symphysis to correct malocclusion. Later, MacDonald et al11 described a modification of the Plumpton technique, by extracting a central incisor and performing a midline mandibular osteotomy. The mandibular midline osteotomy is probably one of the safest procedures because of the low risk of vascular and nerve injuries during surgery, adequate perfusion of the tissues, and the possibility of combining it with other osteotomies or ostectomies. Common indications for this technique are presence of interdental spaces caused by prognathism, in which mandible is wider than the maxilla, and dental crowding because of tooth size-dental arch dimension discrepancy. The combination of this osteotomy with the removal of a single incisive tooth can help to establish a maxillomandibular transverse correction. The central incisor needs to be removed with a block of surrounding alveolar bone, to collapse transversally the mandible, because of the altered maxillomandibular relation, in which the mandible has larger transverse diameter in relation to the maxillary transverse diameter. This permits to eliminate the unilateral crossbite and laterognathia at the same time. As the mandibular transverse diameter collapse is
Mandibular Symphyseal L-Inverted Midline Osteotomy to Correct Mild Laterognathia and Malocclusion Carlos Collantes, DDS,y Nicola´s Solano, DDS,z§jjô Luis Romero, DDS,y# Ce´sar Molina, DDS,yy and Andre´s Go´mez-Delgado, DDSzz§§ Objective: The aim of this study was to present the authors’ experience with a new surgical technique to correct mild laterognathia and malocclusion by means of an L-inverted midline osteotomy. Patient and Methods: The patient was a 26-year-old woman diagnosed with left laterognathia and ipsilateral posterior crossbite. She was operated by using this novel technique in November 2009 at Hogar Clı´nica San Rafael, Maracaibo, Venezuela. Bicortical midline symphyseal vertical osteotomy was executed, followed by block removal of the central right inferior incisor and its surrounding alveolar bone. The mandibular segmentation was completed by means of a right hemimentoplasty. After this, a 4-mm right mandibular rotation was made, and titanium plates and monocortical screws of the 2.0 system were used to achieve the rigid fixation. Results: The patient showed outstanding aesthetic and functional results after 5 years. Conclusions: This technique provides a new treatment option for the correction of mild laterognathia cases associated with dental malocclusion. Key Words: Dentofacial anomaly correction, L-inverted osteotomy, midline mandibular osteotomy
S
everal osteotomies have been described to correct mandibular deformities, such as vertical ramus, L-inverted, and C osteotomies among others. The sagittal ramus osteotomy, described by Obwegeser, is probably the most popular procedure used for the From the Department of Oral and Maxillofacial Surgery, Hogar Clı´nica San Rafael, Maracaibo; yOral Surgery Program, Universidad del Zulia; zDepartment of Oral and Maxillofacial Surgery, Hospital Manuel Noriega Trigo, San Francisco; §Department of Oral and Maxillofacial; jjDepartment of Plastic, Maxillofacial and Reconstructive Surgery Department Hospital Universitario de Maracaibo; ôDepartment of Oncology Surgery, Hospital Universitario de Maracaibo; #Department of Oral and Maxillofacial, Hospital General Dr. Adolfo D’Empaire, Cabimas; Oral Surgery Program, Universidad del Zulia; yyDepartment of Oral and Maxillofacial Surgery, Hogar Clı´nica San Rafael, Maracaibo, Venezuela; zzDepartment of Oral and Maxillofacial Surgery; and §§Publications Committee, Universidad El Bosque, Bogota´, Colombia. Received September 17, 2014. Accepted for publication March 5, 2015. Address correspondence and reprint requests to Dr Andre´s Go´mezDelgado, DDS, Universidad El Bosque, Departmento de Cirugı´a Oral y Maxilofacial, Carrera 9B No. 134 B-85, Co´digo Postal 110121, Bogota´, Colombia; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001842
The Journal of Craniofacial Surgery
FIGURE 1. A, C, Presurgical clinical photographs of the patient showing evident left laterognathia and B, a straight face profile.
treatment of patients with retrognathia, prognathia, or laterognathia.1 Osteotomies performed at the anterior mandibular region are usually the result of combined techniques to correct transverse anomalies of the jaws, and most part of the time, they are considered as supplementary to other more complex mandibular procedures, reason why they are poorly mentioned in literature.2 Together with the mentoplasty, the midline osteotomy is one of the most popular techniques performed on the mandibular symphysis, and it can also be combined with a bilateral sagittal ramus osteotomy. The indication of this osteotomy, first described by Bell3 in 1976, is to narrow the mandible while correcting its anterioposterior excess. Alexander et al4 reported the stability of the procedure, safety to periodontal tissues, and absence of temporomandibular joint disorders. The aim of this study was to describe a new surgical technique to correct patients with mild laterognathia, which provides outstanding aesthetic and functional results, without the need to execute additional invasive procedures, or significant postorthodontic treatment.
PATIENT AND METHODS A 26-year-old female patient was admitted to the Department of Oral and Maxillofacial Surgery at Hogar Clı´nica San Rafael, Maracaibo Venezuela, with the chief complaint of facial asymmetry. Clinical examination showed balance of the facial thirds, straight face profile, and marked left laterognathia (Fig. 1). Intraorally, the most relevant finding was left crossbite, dental class I at the right side, and a left 4-mm deviation of the inferior dental midline (Fig. 2). The cause of the asymmetry was inheritance. No evidence of condylar hyperplasia or hypoplasia was recorded. No syndromes were related to the patient.
Surgical Technique Under general anesthesia with nasotracheal intubation, surgical field preparation, and local anesthetic infiltration, an incision through the mucosa in the vestibule, similar to the usual chin osteotomy transoral approach, was performed. A single marginal vestibular and lingual incision around the tooth related to the vertical osteotomy was executed, followed by cephalocaudal tunneling dissection. After this, a bicortical symphyseal vertical osteotomy was made, by using an electric saw and chisels. The cut included the right central incisor and its surrounding alveolar bone. The right hemimentoplasty osteotomy was made (Fig. 3A), and the block was removed. The osteotomies allowed a 4-mm displacement of the left mandibular segment toward the right side. Titanium plates and monocortical screws (2.0 system) were used for
FIGURE 2. Presurgical intraoral photograph that shows midline left deviation and ipsilateral crossbite.
Volume 26, Number 5, July 2015
1709
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Brief Clinical Studies
FIGURE 3. A, L-inverted midline osteotomy, B, internal rigid fixation with 2.0 system plates and screws.
Volume 26, Number 5, July 2015
FIGURE 5. Intraoral image showing the correction of the left crossbite and occlusal stability.
rigid fixation. The screws were placed carefully to avoid perforation of the dental roots (Fig. 3B). After this, suturing was performed by using 4–0 Coated VICRYL (polyglactin 910) Suture. This research complies with the World Medical Association Declaration of Helsinki on medical protocols and ethics.
RESULTS Postoperatively, acceptable facial symmetry and balance were observed, with inferior facial third slimming and reduction of the intercommissural distance (Fig. 4). Intraorally, bilateral class I occlusion and acceptable dental occlusion was achieved (Fig. 5). Five-year follow-up computed tomography shows complete bone healing, harmonic articular relation, and condylar shape (Fig. 6). To present, there are no signs or symptoms of articular dysfunction.
DISCUSSION One of the first studies of mandibular segmental osteotomies was made by Hullihen5 in 1849, being the first symphyseal osteotomy reported in 1952 by Trauner.6 In 1967, Plumpton7 published a study describing symphyseal osteotomy to correct asymmetric prognathism. Sowray and Haskell8 and O’Driscoll9 described the use of alveolar and symphyseal combined osteotomies, including patients with tooth extraction, to allow the bone cut to pass through the alveolus, in cases of transverse mandibular overgrowth. Obwegeser10 published several studies reporting the combination of osteotomies and ostectomies of the mandibular symphysis to correct malocclusion. Later, MacDonald et al11 described a modification of the Plumpton technique, by extracting a central incisor and performing a midline mandibular osteotomy. The mandibular midline osteotomy is probably one of the safest procedures because of the low risk of vascular and nerve injuries during surgery, adequate perfusion of the tissues, and the possibility of combining it with other osteotomies or ostectomies. Common indications for this technique are presence of interdental spaces caused by prognathism, in which mandible is wider than the maxilla, and dental crowding because of tooth size-dental arch dimension discrepancy. The combination of this osteotomy with the removal of a single incisive tooth can help to establish a maxillomandibular transverse correction. The central incisor needs to be removed with a block of surrounding alveolar bone, to collapse transversally the mandible, because of the altered maxillomandibular relation, in which the mandible has larger transverse diameter in relation to the maxillary transverse diameter. This permits to eliminate the unilateral crossbite and laterognathia at the same time. As the mandibular transverse diameter collapse is
