FACIAL ASYMMETRY
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• Various facial patterns lend a unique identity to a the person .It is the harmony and symmetry of each segment ,which contributes to the total beauty of the face. • Any deviation from the normal facial development definitely brings out an unpleasant facial appearance www.indiandentalacademy.com
ANY CLASSIFICATION:?
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• Classification is helpful as a basis for treatment planning but it is not the necessarily the final guide to treatment. • Consider each patient individually and the problems peculiar to that Individual treated or accepted. • When considering asymmetries in upper,middle and lower third of face ,the concept of deficient and excessive growth in all three dimension allows for further subdivision www.indiandentalacademy.com
• Facial asymmetry is considered as a separate group and may involve the upper,middle and lower thirds of face, and the changes may be those of atrophy ,hypertrophy or just a simple discrepancy in growth between two sides
• Orbital or cranio-orbital deformity is considered as a separate group under which are placed Hypertelorism, micro orbitism ,mandibulo facial dysostosis etc. www.indiandentalacademy.com
CONDITIONS WITH FACIAL ASYMMETRY
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1.Asymmetrical mandibular prognathism a.With anterior open bit b. With out anterior open bite 2. Unilateral condylar hyperplasia a. Hemimandibular elongation b. Hemimandibular hyperplasia 3. Hemifacial hypertrophy 1. Asymmetrical mandibular prognathism with anterior open bite. Clinical features: Severe facial asymmetry Eccentric bilateral mandibular protrusion Deviation of the chin
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High gonial angle Anterior open bite ( anterior and posterior cross bite seen unilaterally)
Midline of the mandibular arch is shifted www.indiandentalacademy.com
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WITH OUT ANTERIOR OPEN BITE: C/F : Eccentric bilateral mandibular protrusion Deviation of the chin Class III dental malocclusion Associated maxillary hypoplasia No anterior openbite. Unilateral condylar hyperplasia Is further subdivided into Hemimandibular Elongation: www.indiandentalacademy.com
• c/f : – Horizontal Displacement of the mandible and chin toward the unaffected side – On unaffected side there may be a lateral cross bite – Secondary overeruption of maxillary teeth on the affected side to maintain the functional occlusion. – OPG/PA view show elongation of condular neck with increased ramal height on the affected .
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Hemimandibular hyperplasia: It is characterized by a three dimensional enlargement of one side of the mandible ,thus there is enlargement of condyle ,condylar neck and ascending ramus and the body. The abnormal growth terminates at symphysis giving raise to a sharp STEP in the mandible at that site thus justifying the term HEMIMANDIBULAR HYPERPLASIA. C/F: One side of face appears to be enlarged Unilateral bowing of the inferior border of the mandible is seen on the effected side Sloping of the lipline on the affected side. Gross occlusal discrepancies like www.indiandentalacademy.com
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Lateral open bite on the affected side Over eruption of the posterior teeth in maxilla Increased vertical maxillary height on the affected side. Radiography: Shows Entire hemimandible on the affected side is enlarged and the inferior dental canal is displaced downward OPG demonstrates a pathognomic appearance : Ellongation of ascending ramus (unilateral ) Elongation and thichning if condylar neck ( unilateral ) The angle is characteristically rounded
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• There are multiple causes of facial asymmetrty ,but the differential can be separated into three classes: • CONGENITAL • DEVELOPMENTAL • ACQUIRED
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• A. CONGENITAL : • Are conditions acquired during the in utero development. • Further subdivided in to : • Malformation • Deformities • Disruptions www.indiandentalacademy.com
• Malformation : As a result of Intrinsicall abnormal developmental process in embryogenesis. • Ex : Unilateral cleft lip. • Deformations: Are an abnormal form or position of a part of the body caused by nondisruptive mechanical force during fetal period. • Ex: Mandibular deformation may result from prolonged sharply laterally flexed position of head with the shoulder pressed against the mandible during the late intrauterine growth. • Disruptions : Are the morphologic defects resulting from the breakdown of an otherwise normal developmental process. • EX: Rare facial clefting and limb amputation from an amniotic band are good example. • www.indiandentalacademy.com
• B. DEVELOPMENTAL : • • Arise during post uterine growth through childhood. • C. ACQUIRED: Anomalies are conditions arising from either trauma/pathology.
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• A. CONGENITAL ANAMOLIES: – Hemifacial microsomia: I s craniofacial malformation of the first and second branchial arches presenting with asymptomatic unilateral or bilateral hypoplasia of the mandible orbit(s) ,maxilla ,ear,cranial nerves and soft tissue. www.indiandentalacademy.com
• Current evidence states it is due to defect in proliferation and migration of the embryonic neural crest cells. • Two imp. Factors to be considered during treatment : • Facial growth potential and /or restriction and its effects on surrounding structure • The degree of hypoplasia involving the glenoid fossa,mandibular condyle, and ramus unit. www.indiandentalacademy.com
The PRUANSKY HFM classification modified by Kaban and Colleagues
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HFM Type I: c/f : 1.Gen. mild hypoplastic state involving the muscles of mastication ,the glenoid fossa and the mandibular condyle and ramus unit. • 2. TMJ functions with normal rotation and restricted translation. • 3.Pt present with mild mandibular retrognathia and facial aymmetry. • Note: coz there is satisfactory TMJ occlusal function and mild dysmorphology ,surgical therapy is usually not indicated. • HFM Type II A: • c/f : • Involves hypoplastic cone shaped condylar head. • Condyle is located medial and anterior to a hypoplastic glenoid fossa. • TMJ function is often satisfactory • Surgical intervention is usually not indicated. www.indiandentalacademy.com
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HFM Type II B : c/f: Moderate to severe hypoplasia of of glenoid fossa,condyle and mandibular ramus Pts have no articulation b/w temporal bone and condyle. HFM Type III : c/f: Complete absence of mandibular ramus and condyle. www.indiandentalacademy.com
• 2. CLEFT LIP & PALATE: • The degree and location of maxillofacial growth deficiency in children with clefts is largely dependent on location and type of cleft lip/palate repair and the age of child at the time of repair. • Most studies ahow that children with a repaired cleft lip/palate have decreased vertical and horizontal maxillary growth and decreased vertical growth of the ramus and steep mandibular plane angle. www.indiandentalacademy.com
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PLAGIOCEPHALY: Is derived from Greek word PLAGIOS which refers to the twisted shape of skull when viewed cranially-caudally.
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ETIOLOGY : Is often a unilateral synostosis of the coronal or lambdoidsuture , which results in asymmetric parallelogram – shaped forehead and brow.The affected side is flattened and the contralateral side shows compensatory bulging or bossing.
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The root of nose is deviated to the involved side and chin is deviated to the side opposite to the flattened forehead.
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CONGENITAL HEMIFACIAL HYPERPLASIA: Is rare unilat. Enlargement of craniofacial soft/bony tissue. www.indiandentalacademy.com
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DEVELOPMENTAL ANAMOLIES: Intrinsic Jaw –Growth Deformities: FACIAL HEMIATROPHY: (Parry Romberg Syndrome): C/F: Progressive unilat. Facial loss of skin,soft tissue , cartilage and bony tissue Associated abnormalities includes cutaneous pigmentation, ipsilateral alopecia. Syndr. Usually starts during fir two decades of life and complets progression with in 2-15yrs. Treatment : Involves silicone injections,alloplastic implants microfat injections and microvascular free flap transfer. www.indiandentalacademy.com
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Hemimandibular hyperplasia/elongation: c/f Diffuse enlargement of condyle ,condylar neck,mand.ramus and body. Trearmenr ranges from condylectomy to orthopedic maxillary management. Secondary growth deformities: Sternomastoid torticollis is a condition thought to result from a birth-trauma induced hematoma of SCM muscle that fibroses over time and leads to muscular contraction. www.indiandentalacademy.com
ACQUIRED FACIAL ASYMMETRIES: • CONDYLAR TRAUMA: Is a frequent cause of facial asymmetry in the growing child . • FUNCTIONAL/SOFT TISSUE EXTRACAPSULAR ANKYLOSIS: • Trauma induced injury to the condyle can lead to hemarthrosis,which result in scarring and restricted translation of the mandible. • WHETHER ORIF OF THE CONDYLAR FRACTURE IS REQUIRED? • Because the condylar head in children is generated spontaneously , the necessity of ORIF of displaced condylar segment is eliminated. www.indiandentalacademy.com
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JUVENILE IDIOPATHIC ARTHRITIS: Here TMJ is most commonly involved. c/f:
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Small mandible Class II malocclusion Anterior open bite
Treatment: methotrexate therapy. DEGENERATIVE JOINT DISEASE: The wear and tear of DJD on TMJ results in condylar –glenoid erosion and decreased consylar ramus height. Clinically : Pts shows increasing preauricular crepitus, a limited mandibular range of motion ,pain and anterior open bite. www.indiandentalacademy.com
JAW DEFORMATIES IN THE FACIAL SYNDROMES
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MANDIBULAR DEFICIENCY: Pierre robin Treacher –collins Hemifacial microsomia MANDIBULAR EXCESS Basal cell naevus syndrome (gorlin Hemihypertrophy MIDFACE DEFICIENCY Achondroplasia Apert Cleidocranial dysostosis Crouzan Hemifacial microsomia Cleft lip and palate www.indiandentalacademy.com
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FACIAL ASYMMETRY Hemihypertrophy Hemifacial microsomia Orbital and cranio-orbital deformities Apert Orofacial digital Treacher Collins
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• PIERRE ROBIN : • C/F: • Skull : Hydrocephaly and microcephaly occasionally • Oral: cleft palate; micrognathia are common • EYES: Cataract;glaucoma;retinal detachment • EARS: Low set and dysplastic;occasional DEAFNESS • Problem areas: Feeding and airway problems at birth. www.indiandentalacademy.com
• TREACHER-COLLINS:Autosomal dominant condition • FACE: Tongue of hair from temple o cheek,antimongoloid slant of palpebral fissures • Large narrow nose • Hypoplastic or missing Zygoma • Often high ot cleft palate • Coloboma of outer third of lower eyelids • Problem areas: Deafness,maxillary,malar and mandibular deformity www.indiandentalacademy.com
• HEMIFACIAL MICROSOMIA: ( INCLUDING GOLDENHAR SYNDOCCULOAURICULOVERTEBRAL DYSPLASIA) • Face: Three dimensional asymmetric hypoplasia • Unilateral mandibular hypoplasia • Zygomatic arch hypoplasia • High arched palate • Crowding of the teeth • Antimongoloid slant of palpebral fissure • Malformed pinna • Problem areas: normal life span,normal intellect,deafness,unilateral deformity causing asymmetry;cardiac and renal problems www.indiandentalacademy.com
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• APERT SYNDROME: Autosomal dominant condition. • Skull: premature closure of cranial sutures giving a variable appearance of turribrachycephaly. • Exopthalmus • Hypertelorism • Retrusion and vertical shortning of whole midface;narrow and high arched palate
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• Class III occlusion and anterior open bite • Parrot beak nose • Hyperseborrhoea • Syndactyle of the fingers and toes • Problem areas: mental retardation,optic atrophy causing blindness;short life span and skull deformity. www.indiandentalacademy.com
• ACHONDROPLASIA: AUTOSOMAL DONIMAMT • Brachycephaly,frontal bossing • Depressed nasal bridge • Dwarfism with short limbs • Waddling gait • Lumbar lordosisbowlegs • Midface deficiency www.indiandentalacademy.com
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• CROUZAN SYNDROME: (CRANIOFACIAL DYSOSTOSIS) • Premature closure of cranial sutures particularly coronal suture often causing raised intracranial pressure • Proptosis caused by shallow orbits • Retrusion snd vertical shortening of whole midface • Relatively prominent nose;short upper lip www.indiandentalacademy.com
• Class III malocclusion • Problem areas: progressive blindness,mental retardation,midface deformity;dislocation of globes
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• OROFACIAL DIGITAL : Is a sex linked dominant condition occurring virtually always in female patients. • Frontal bossing,patchy hair loss,midline cleft of upper lip • Division of hard palate by frenulae in canine region • Missing lower lateral incisors • Hypoplastic malarsyndactyle • Problem areas: mental retardation,facial and oral deformity,digital deformity. www.indiandentalacademy.com
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ASSESSMENT OF THE PATIENT AND TREATMENT PLANNING
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EXAMINATION
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• POSITION OF HEAD : • Attain natural head position • Obtain rest position by asking the pt to moisten the lips. Or to say the letter M. • With pt. at rest position ,face is examined from above and below and in both left and right hand profiles. • Thus face is considered in anteroposterior,transverse and vertical dimensions. www.indiandentalacademy.com
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SYMMETRY OF THE FACE: Asymmetry occurs in all three dimensions. TRANSVERSE DIMENSION: It should be possible to draw a vertical mid-line passing through the middle of the fore head and the bridge of the nose ,midway b/w the orbits,through the columella,b/w both philtral folds,through the centre of the cupids bow of the upper lip,b/w the upper central incisors,lower central incisors,the middle of the lower lip and the exact midpoint of the www.indiandentalacademy.com
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• ANTEROPOSTERIOR DIMENSION: Nos easy objective of assessing asymmetry in the AP dimension and is done qualitatively by looking from above and below. • VERTICAL DIMENSION: It is considered for individual parts for instance by measuring the variations in the orbital height ,the level of ears,or angles of the mandible. • The determination of the midline of the face is purely a clinical judgement. • The upper limit of inner (medial) canthal distance for 97% of pts over age of 10yrs is 35mm (Feingold & bossert 1974) and the distance from the centre of bridge of nose to each medial canthus should be equal. www.indiandentalacademy.com
• FACIAL PROPORTIONS: • The face is divided in to the Horizontal thirds and Vertical fifths. • The three horizontal thirds are UPPER,MID AND LOWER thirds of the face. • UPPER THIRD: Lies above the soft tissue nasion and includes the supra orbital ridges . • MIDDLE THIRD: Lies b/w supra orbital ridges and the columella • LOWER THIRD: Lies b/w columella and the soft tissue menton. www.indiandentalacademy.com
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• VERTICAL FIFTHS: • Central fifths: is the Interalar distance. It is limited by the vertical line ,on each side which should pass through medial canthi and just medial to commisure of the lips. • Two fifths either side of the central fifths are bounded by the lines passing through the medial and lateral canthi; their bredth should be equal to that of the outermost two fifths.The later are bounded by the lateral canthi and the maximal width of the face. • When examining the face again is divided in to the Upper,middle and the lower face. • The most useful information obtained from the profile is the evidence of hypo/hyperplasia in one part. www.indiandentalacademy.com
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• UPPRER FACE : Includes the cranium and the supraorbital region.. • Asymmetries associated with it are mainly craniosynostosis and are often not immmedatly apparent as are masked by the hair. • In profile view both hypo-hyperplasia of the supraorbital ridges are easily seen as are recession and protrusion of the frontal bones
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• MIDDLE FACE: Contains he orbits,the nose and the cheeks.The principal biny structures being the nasal,malar bones.The surgical reference point for the midface and indeed the whole face must be the eyes as these are structures which are least capable of movement,especially in AP dimension. • EX: In craniostenotic syndromes and for example fibrous dysplasia of cranial vault ,alteration in the vertical levels of the globes and the orbit is the most common asymmetry although AP & Transverse asymmetry can also occur. • In occlular hypertelorism there may also be alteration in the vertical levels of eyes and orbits and this may be further complicated by lateral rotation . • www.indiandentalacademy.com
• NOTE: Telecanthus ,where the diatance b/w the medial canthi is altered ( adult normal 2535mm) must be differentiated from ocular hypertelorism ,where there is separation of the orbit and the interpupillary distance is increased. • NOTE: The normal intercanthal distance is the approx. twice the intermedial canthal distance. • The relation of the globe to the nasal bridge is as this is often a guide to the extent of nasal hypoplasia present www.indiandentalacademy.com
• Infull face examination , the nose should have a triangular shape and in profile the tip should project.The angle of projection must be in order of 30-35degrees.Another important relationship is the columella/lip angle which for a pleasant appearance,should be 90-110deg.
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• LOWER FACE: Includes the structures below the alar base and for conviniencd may be divided in the full face view in to three parts: – UPPER THIRD: Is the upper lip and the lower 2/3rd are from the junction of the vermillion borders to the soft tissue menton. – Marked asymmetry of the two sides of the face is uncommon ,except in conditions such as condylar hyperplasia ,hemifacial microsomia.
• Lips must be examined both in function and at rest..The position of lip is effected by mouth breathing and abnormal occlusal relationship www.indiandentalacademy.com
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Normal rest position the lips may be together or up to 3.5mm apart.where the distance is exceeded, it suggest incompetence or shortness of upper lip. When more than 2mm of upper gingiva is visible during smile ,this is an indication of either vertical maxillary exces or an absolute shotage of upper li height which is normally about 20-24mm.
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LOWER FACE: In profile the shape of kower face is particularly dependent on the underlying bone structure
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• Deep bite such as in classII malocclusion decreases the facial height where as an anterior open bite increases the facial height. • Function of the joint must be examined prior to the surgery , as severe restriction of opening may be present as a result of the condylar/coronoid pathology.Severe mandibular retrusion alone,particularly when associated with ankylosis, can cause considerable mechanical problems for anesthetist www.indiandentalacademy.com
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INTRAORAL EXAMINATION: INCLUDES: Check for over crowdind/spacing Interarch relation ship.detailed information must be obtained from good study models. • NOTE; It is essential to know why the patient has come for the treatment and what is expected from it. • NOTE: Surgeon should resist any temptation to compromise over treatment. www.indiandentalacademy.com
• STANDERED LANDMARKS AND THERE SIGNIFICANCE: • SNA angle –mean value : 81deg. • If < 81 : retrognathic maxilla • If > 81 : prognathic maxilla • SNB angle – mean value :79deg. • If < 79 : Retrognathic mandible • If >79 : prognathic mandible • ANB angle : mean value is 2deg. • If ANB angle is >/< it can be concluded that there is abnormal relationship of mandible to the maxilla. www.indiandentalacademy.com
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• SN-Pog angle is usually 2deg//> than SNB angle .if the difference is less than this then the chin is retrogehic and if greater it is progneic • PALATAL PLANE:(maxillary plane) is a line drawn from ANS to PNS . • Is used to determine the inclination of maxillary incisors .Its mean value is 110deg,a small angle means upright incisors ,whereas igger angle means they are proclined. is a line drawn from ANS to PNS • MANDIBULAR PLANE ANGLE: used to measure the inclination of lower incisors .Mean value is 90 deg +/-3degrees. • Larger angle – indicates protrusion • Small angle – Indicates retrocline. • An ideal angle b/w upper and lower incisor is 135degree. www.indiandentalacademy.com
â&#x20AC;˘ Measurement of anterior facial height : most commonly used method is the from Nasion to menton. The % ratio of this line is measured from the N to ANS and from ANS to Menton.It should be 45-55deg. â&#x20AC;˘ Any deviation in this ratio will suggest a change in the vertical height of the either the mandible or the lower face www.indiandentalacademy.com
â&#x20AC;˘ This measurement is usefull particularly as an indication as to whether the height of the maxilla requires to be adjusted surgically. â&#x20AC;˘ It also indicates whether the anterior mandible height should be altered at surgery,or alternativly the mandible be allowed to autorotate around its condylar axis.
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RADIOGRAPHY
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PANORAAMIC RADIOGRAPH: To find out: Relative height of condyle and ramus Degenerative change PA VEW: To find out Extent of deformity relative to cranial base LATERAL CEPH: To find out Clues of vertical deficiencies by the lack of superimposition • Computed Tomography: To find out : • Two dimensional localized views of facial skeleton www.indiandentalacademy.com
• STEREOLITHOGRAPHIC MODELA: To find out: • 3-D T can provide information to allow fabrication of an acute 3-D skeletal model. • Technetium 99m phosphate bone scans: To find out : • In pts with facial asymmetry mandibular overgrowth ,nucleotide uptake is not symmetric bilaterally;pts present wth increased uptake of nucleotide on the affected side. www.indiandentalacademy.com
SURGICAL TREATMENT
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CORRECT TREATMENT BEGINS WITH PROPER DIAGNOSIS
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• One must evaluate face in all dimensions, carefully analyzing the vertical and horizontal dimensions corresponding to the facial subunits. • Ultimatly the clinical examination is the ultimate diagnostic tool.body posture,mannerisms, and hairstyle hide the facial aymmetry and may mislead the treatment plan. • DELAYED TREATMENT: • Treatment of asymmetry in preadolescent children is extremely complex and results are often unpredictable. www.indiandentalacademy.com
• Bite block therapy can be helpful in controlling the plane of occlusion but rarely prevents surgery .It is mainly indicated as an intervention for secondary growth deformities. • • Facial aymmetry can be improved esthetically by an inferior border ostectomy, augmentation and genioplasty. • The esthetic impact of aymmetry involves both hard and soft tissue. • Surgical procedure should be selected based on etiology and a concern for stability. • Severe aymmetries with a short ramus height may require an extraorla inverted L osteotomy with bone grafting.This technique releases the mandibular sling and provides good access to hypotrophic ramus excellent bone grafting access , and accurate rigid fixation www.indiandentalacademy.com
• Vertical changes of < 6-8mm may be treated by intra oral saggital split osteotamies. • The first and perhaps most important treatment plan descion the surgeon encounters involves the upper incisor position. • The choice of maxillary incisor position is the key and essentially determines the 3-D position of everything else. • Surgeon must correct : • Maxillary incisor midlines • Proclination • Occlusal plane • Smile arch • Lip support www.indiandentalacademy.com
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NOTHING CAN REPLACE SURGICAL EXPERIENCE
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• Surgical mobalization is a key point in bimaxillary surgery.The mandible and maxilla should be free enough to be positioned passively without pulling the soft tissue.This is a significant point to be considered becoz positioning can create a tight masseteric sling and limited periosteal tissue .If segments are stretched into position,one cannot expect long term stability. • In cases of severe hypoplastic asymmetry with only rudimentary condyle ,one should consider condylar reconstruxtion or extraorla procedures of rams. • In some situations distraction osteogenesis may even be helpful in growing more bone and essentially expanding tissue. www.indiandentalacademy.com
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