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Table of Contents   
CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 5  |  Page : 667-671
Orthodontic-surgical management of a case of severe mandibular deficiency due to condylar ankylosis


1 Department of Orthodontics, Sri Ramachandra Dental College, Porur, Chennai, Tamil Nadu, India
2 Department of Orthodontics, Panineeya Dental College, Hyderabad, Telangana, India
3 Department of Oral and Maxillofacial Surgery, Sri Ramachandra Medical College, Porur, Chennai, Tamil Nadu, India

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Date of Submission01-May-2014
Date of Decision25-May-2014
Date of Acceptance31-Oct-2014
Date of Web Publication16-Dec-2014
 

   Abstract 

Dentofacial deformities involve deviations from the normal facial proportions and dental relationships and can range from mild to being severe enough to be severely handicapping.The term handicapping malocclusions though not a term commonly used, involves a fortunately small section (2-4%) of patients who can suffer from esthetic,psychological and functional problems. Craniofacial Orthodontics is the area of orthodontics that treats patients with congenital and acquired deformities of the integument and it's underlying musculoskeletal system within the craniofacial area and associated structures.This case report of a young woman with severe mandibular deficiency and facial asymmetry due to condylar ankylosis highlights the importance of team work in rehabilitation of such severe craniofacial deformities.

Keywords: Condylar ankylosis, dentofacial deformities, distraction oseogenesis, facial asymmetry, mandibular retrognathism

How to cite this article:
Padmanabhan S, Juvvadi S, Chithranjan AB, Ramkumar S, Kumar N N. Orthodontic-surgical management of a case of severe mandibular deficiency due to condylar ankylosis . Indian J Dent Res 2014;25:667-71

How to cite this URL:
Padmanabhan S, Juvvadi S, Chithranjan AB, Ramkumar S, Kumar N N. Orthodontic-surgical management of a case of severe mandibular deficiency due to condylar ankylosis . Indian J Dent Res [serial online] 2014 [cited 2019 Sep 15];25:667-71. Available from: http://www.ijdr.in/text.asp?2014/25/5/667/147122
Dentofacial deformities involve deviations from the normal facial proportions and dental relationships and can range from mild to being severe enough to be extremely handicapping. The term handicapping malocclusions though not a term commonly used, involves a fortunately small section (2-4%) of patients who suffer from such severe dentofacial deformities that it can cause esthetic and psychological and also functional impairment. [1] Such complex deformities require a multidisciplinary approach. Craniofacial orthodontics is the area of orthodontics that treats patients with congenital and acquired deformities of the integument and its underlying musculoskeletal system within the craniofacial area and associated structures. Treatment of such complex deformities would require team work where the orthodontist, maxillofacial surgeon and possibly other specialists would work in unison to treat such challenging deformities.


   Case report Top


A 23-year-old female patient reported to the Department of Orthodontics with a complaint of facial asymmetry, deficient chin and limited mouth opening. The patient was extremely concerned about her facial appearance and also complained of difficulty in mastication and speech.

History revealed an uneventful delivery and early childhood history. However she had suffered bilateral condylar fracture at the age of 10 years, which lead to restriction in mouth opening. She reported a history of temporomandibular joint (TMJ) ankylosis in the left joint and surgery to release the ankylosis at the age of 14 years.

Extraoral assessment

Extraoral examination revealed an asymmetric face with the asymmetry starting from the middle third of the face, but pronounced in the lower third with significant deviation of the chin to the left. Closer examination revealed that the eyes and ears were also on different levels. Profile was convex with severe retrognathia of the mandible, reduced lower facial height and deficient chin giving a "birdface" appearance. Antegonial notch was exaggerated. Nose was prominent with notching of the dorsum [Figure 1].

Intraoral assessment

Mouth opening was limited to 23 mm with deviation to the left side on opening. Intraoral examination revealed proclined upper anteriors. Overjet was around 13 mm progressively increasing on the left side because of the asymmetry. The overbite was 4 mm. Further examination revealed moderate crowding of the upper arch (arch length tooth size discrepancy of 2 mm) and severe crowding of the lower arch (7.5 mm). The molar relationship on the right side was − 2 mm (Class III) and + 5 mm (Class II) on the left. [2] The lower midline was shifted to the left by 5 mm. The upper occlusal plane exhibited a cant rolling down on the right side and superiorly on the left side [Figure 2].
Figure 1: Pretreatment extraoral view

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Figure 2: Pretreatment intraoral

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Arches were narrow, "v" shaped and asymmetrical. The lower arch was more collapsed on the right than on the left with a scissor bite on the right side [Figure 3].
Figure 3: Pretreatment occlusal views

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Radiographic assessment

Computed tomography reconstructions showed the obvious facial asymmetry with the mandible deviated to the left. The deformed joints were evident with signs of prior surgery. The profile views showed severe mandibular deficiency and steepness of the mandibular plane. The antegonial notching was more severe on the right than on the left side [Figure 4]. Panaromic view showed impaction of 18 and 38 [Figure 5].
Figure 4: Pretreatment computed tomography images

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Figure 5: Pretreatment panaromic view

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Cephalometric examination confirmed the magnitude of the severe skeletal dysplasia and associated upper anterior proclination [Table 1].
Table 1: Pretreatment and posttreatment cephalometric parametres


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Aims of treatment

The treatment objective was to address the mandibular hypoplasia caused by TMJ ankylosis in order to improve the profile and create a more normal maxillomandibular relationship, to achieve acceptable facial symmetry and improve frontal facial esthetics.

Orthodontic objectives were to align the lower anteriors, expand the upper arch and create adequate overjet to facilitate mandibular advancement and establish a functional and stable occlusion.

Treatment plan and rationale

Since the mandibular deficiency was severe, it was decided to treat a patient with distraction osteogenesis (DO). [3],[4] Presurgical orthodontics was planned to alleviate the severe crowding and co-ordinate upper and lower arches to facilitate distraction.

It was initially decided to treat the upper arch nonextraction to prevent over retraction of upper anteriors and maintain enough overjet to facilitate maximum advancement of the mandible. Consideration was also taken of the nose size, projection and the obtuse nasolabial angle in the nonextraction decision. Thus it was decided to expand the narrow upper arch to alleviate the minimal crowding and also accomadate the advanced mandible.

The impacted molars (18 and 38) were extracted. The lower first premolars were also extracted to create space to alleviate the crowding, level the teeth and maintain/increase the overjet to facilitate maximum advancement of the mandible.

Treatment progress

The patient was treated with a pre-adjusted edge-wise appliance, MBT (Ormco Mini 2000) .022 slot size. The course of presurgical orthodontics was 14 months. The upper and lower arches were levelled and aligned and the upper arch was expanded with a progression of widened archwires. Starting from 0.016 nickel-titanium to 0.019-025 stainless steel. The transverse compensations in the upper and lower arches due to the skeletal asymmetry were also eliminated.

Similar arch wire progression was also used in the lower arch. After alleviation of crowding the remaining space, was used to effect maximum retraction of lower anteriors to increase the overjet to facilitate maximum mandibular advancement.

When all the above objectives were achieved the surgical phase of treatment was planned. Surgery was delayed because the patient failed to report for nearly 8 months. Finally, stereolithographic models were used to plan the surgery [Figure 6].
Figure 6: Presurgical stereolithographic models

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Under general anesthesia, the angle of the mandible was approached via submandibular incision. Inverted L osteotomy on the left side and oblique osteotomy on the right side were placed to facilitate asymmetric traction. Intraoral distractors were placed and after a 7 day latency period, distraction was performed at a rate of 0.5 mm twice daily. After achieving an edge to edge incisal relationship, distraction on the right side was stopped and only the left side was activated. A bite block was given on the right side to prevent extrusion of the posteriors and maintain the vertical dimension. Intermaxillary elastics were used for optimal molding of the callus [Figure 7]. After the distraction phase of almost 3 weeks adequate time of 12 weeks was given for consolidation and remodeling. [5] The status of the callus was evaluated during this period with ultrasound. The distraction achieved was about 13 mm on the right side and 15 mm on the left side. The mandibular position appeared stable postsurgery and since there wasn't sufficient overjet to allow retractions of the upper anteriors, the upper arch was finished without extractions. Postsurgical orthodontics was continued for 9 months to settle the occlusion.
Figure 7: Molding of the regenerate

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   Discussion and conclusion Top


Craniofacial orthodontics is the area of orthodontics that treats patients with congenital and acquired deformities of the integument and its underlying musculoskeletal system within the craniofacial area and associated structures. Mandibular deficiency is the most prevalent of the dentofacial deformies either genetic, congenital or trauma induced. [6]

Distraction Osteogenesis (DO) is a process where new bone formation is induced by gradual separation of bony segments by incremental traction after an osteotomy. [3] DO was first introduced by Codivilla at the beginning of twentieth century and the studies of Ilizarov made a contribution in the development of this technique by elucidating the biological and mechanical prinicipals in the formation of new bone. [7],[8] In dentistry it was popularized by McCarthy who used the procedure to lengthen hypoplastic mandibles. [9]

Maxillofacial distraction as compared to long bones involves three dimensional movements and the shape of the bone, complex muscle attachments, and occlusal goals make the procedure more complex and less predictable than routine orthognathic procedures. The distraction devices used in this case were internal distractors. Because the limited mouth opening made their placement difficult, they were placed via an extraoral approach. Internal distractors have the advantage of being less visible than external distractors.

The mandible is more similar to the limbs than the maxilla and DO is indicated when mandibular advancement of more than 10-15 mm is required. [4],[10] The callus formed between the separated bone segments and the molding of this regenerate is critical in achieving the required mandibular shape and occlusion. Control of the vectors of forces are critical in achieving the desired skeletal and dental changes. [11] In this case, the shift of the mandible to the left and the developing open bite was controlled with elastics and a bite plate on the right side. Although the same degree of precision might not be possible as in orthognathic surgery, DO is more effective with larger movements because of the gradual stretching and adaptation of the soft tissues leading to an expansion of the soft tissue envelope (distraction histogenesis). [12]

Post treatment results showed excellent esthetics with good facial symmetry, improvement in profile and good chin projection established [Figure 8]. The patients mouth opening was significantly improved as was her speech and other functions. Nose symmetry was established even though no rhinoplasty was performed. Patient was happy with the improvement in facial esthetics. The upper arch was treated without extraction and the nasolabial angle and upper lip position favoured this decision.
Figure 8: Posttreatment extraoral view

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Because the upper arch was treated without extraction the molar relation at the end of treatment was class III on right and left sides. The midlines were coincident, transverse co-ordination was established and reasonable functional contacts were established between upper and lower arches. Since she travelled from a distant town, her visits were infrequent and appliances were debonded when reasonable occlusion was established [Figure 9] and [Figure 10].

Superimpositions of pretreatment and post treatment cephalograms showed the remarkable improvement in skeletal and facial contours [Figure 11]. The total duration of treatment was nearly 35 months.
Figure 9: Posttreatment intraoral view

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Figure 10: Posttreatment occlusal views

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Figure 11: Pretreatment and Post-treatment superimpositions

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Distraction osteogenesis is an emerging field, which helps the surgical-orthodontic team achieve their objectives even in extremely challenging cases. The dramatic improvement in esthetics and function improves the patient's overall wellbeing and quality of life.

 
   References Top

1.
Profitt WR, Fields HW, Sarver DM. Contemporary Orthodontics. 5 th ed. St.Louis: Elsevier; 2013.  Back to cited text no. 1
    
2.
Neto AB, Nishio C, Mucha JN. Agreement evaluation of a newly proposed system for malocclusion classification. Int J Odontostomatol 2010;4:33-41.  Back to cited text no. 2
    
3.
Proffit WR, White RP, Sarver DM. Contemporary Treatment of Dentofacial Deformity. St.Louis: Mosby; 2003.  Back to cited text no. 3
    
4.
Rubio-Bueno P, Villa E, Carreno A, Diaz-Gonzales FJ. Intraoral mandibular distraction osteogenesis. Special attention to treatment planning. J Craniomaxillofac Surg 2001;29:254-62.  Back to cited text no. 4
    
5.
McCarthy JG. Distraction of the Craniofacial Skeleton. New York: Springer; 1999.  Back to cited text no. 5
    
6.
Santiago PE, Grayson BH. Introduction to craniofacial orthodontics. Semin Orthod 2009;15:219-20.  Back to cited text no. 6
    
7.
Codivilla A. The classic: On the means of lengthening, in the lower limbs, the muscles and tissues which are shortened through deformity. Clin Orthop Relat Res 2008;466:2903-09.  Back to cited text no. 7
    
8.
Ilizarov GA. The tension-stess effect on the genesis and growth of tissues: Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res 1989;238:249-81.  Back to cited text no. 8
    
9.
McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH. Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 1992;89:1-8.  Back to cited text no. 9
    
10.
Padmanabhan S, Chitharanjan AB, Ramkumar S, Nandakumar N, Ravindran C. Surgical-orthodontic management of severe sleep apnea. J Clin Orthod 2011;45:507-12.  Back to cited text no. 10
    
11.
Grayson BH, McCormick S, Santiago PE, McCarthy JG. Vector of device placement and trajectory of mandibular distraction. J Craniofac Surg 1997;8:473-80.  Back to cited text no. 11
    
12.
Rachmiel A, Levy M, Laufer D. Lengthening of the mandible by distraction osteogenesis: Report of cases. J Oral Maxillofac Surg 1995;53:838-46.  Back to cited text no. 12
    

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Correspondence Address:
Sridevi Padmanabhan
Department of Orthodontics, Sri Ramachandra Dental College, Porur, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.147122

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    Figures

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