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Facial Asymmetry Correction by Simultaneous Upper and Lower Jaw Distraction

5/1/2021

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This lady has had long standing facial asymmetry with deviation of the mandible to the left side due to vertical shortening of the ramus on the left and an occlusal cant with resultant malocclusion. She presented to our hospital for correction of her deformity.

She underwent mandibular distractor placement along with a Le Fort I surgery. She subsequently underwent a mandibular distraction of 2 cm after a latency period of seven days. The distractor was removed after consolidation of bone at the distracted site in six months.
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There was establishment of facial symmetry along with correction of the occlusal cant. She was very happy with the results of the surgery.
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Facial asymmetry correction in hemifacial microsomia patient using simultaneous internal maxillomandibular distraction osteogenesis

12/3/2017

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A 22 year old girl reported to our hospital for the surgical correction of asymmetry over the left side of the face. Facial asymmetry may be present in cases of hemifacial microsomia, TMJ ankylosis or may have resulted following condylar fractures. This patient had a mandibular deficiency at the ramus level and deficiency measured almost 14 mm with a resultant occlusal cant.
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After thorough clinical and radiological examination Maxillofacial Surgeon Dr. S. M. Balaji planned to correct the facial asymmetry using internal distraction osteogenesis with maxillomandibular distractor. Paragingival incision was placed over the left angle region along the anterior border of ramus. Full thickness mucoperiostal flap was reflected buccally and bone exposed. The direction of the osteotomy cut and positioning of the distractor is the most important as it determines the vector of distraction and this determines the direction of the bone growth. The distractor device was positioned and fixed using screws. Osteotomy is then completed along the medial cortex. Distractor device was checked and wound closure done. Le Fort I osteotomy was completed in maxilla. After a latency period of 5 days, distraction at the rate of 1 mm per day was accomplished and facial asymmetry was successfully corrected. Patient feels very happy to have the facial asymmetry correction without any scars on the face.
Preoperative facial view showing reduced height of the face on the left side - hemifacial microsomia
Preoperative bite showing severe occlusal cant towards left side
3DCT view showing reduced ramus height on left side with entire mandibular shift
Reduced height of ramus of mandible on left side
Normal height of ramus of mandible
During surgical procedure, distractor device fixed to the outer surface of the ramus with correct orientation with the jaw
Lefort I osteotomy to separate the maxilla from base of the skull
After completion of distraction facial asymmetry corrected completely
3DCT showing the complete bone formation after 3 months following distraction
Corrected occlusal cant with enhanced bite
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Facial asymmetry correction without scars

1/6/2016

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​A 19-year-old boy came to our hospital seeking to correct his facial asymmetry that gave unpleasant appearance. The boy was very anxious & wanted a cosmetic correction to enhance his appearance without any scars.
Maxillofacial Surgeon Dr. S.M. Balaji diagnosed that the asymmetrical face was due to unilateral masseter hypertrophy. Masseter muscle is mainly responsible for the movements of the lower jaw & plays an important role in facial aesthetics. When the muscle becomes enlarged or thickened, it gives the lower third of the face a wide, square-shaped appearance.
Maxillofacial Surgeon Dr. S. M. Balaji surgically reduced the bulk of the enlarged Masseter muscle from within the mouth itself so there were no scars. Along with the muscle, the buccal surface of the gonial angle of the mandible was also trimmed. Immediately after surgery the lower jaw appeared more proportionate and his appearance greatly improved. The boy and his family were very happy to have a more attractive, natural look.
Preoperative view showing asymmetry due right masseter hypertrophy
Preoperative worm's eye view
Preoperative OPG depicting asymmetry
Repositioning of the muscles following removal of hypertropied mass
Debulking of the masseter muscle
Suturing done
Postoperative 3 months review
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Facial asymmetry correction using Distraction osteogenesis

13/5/2016

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Hemifacial microsomia is a condition in which there is an under-development of one side of the face resulting in facial asymmetry. The affected side of the face appears disproportionately smaller than the other. Characteristically, the lower jaw (mandible), facial soft tissues & musculature, cheek and ear on one side of the face is poorly developed. Sometimes, structural defects in the eye may also be seen. A 28-year-old boy afflicted with Hemifacial Microsomia reported to our Hospital. His lower jaw and ear was under-developed on the right side. He had a slanting bite and an obvious asymmetry of the face. A radiographic examination showed a grossly under-developed lower jaw (mandible) on the right side. There was found to be a bone deformity of about 20 mm.
The goal of the treatment is to elongate the deficient jaw bone to restore facial symmetry and correct the slanting bite (occlusion). To achieve this, an advanced and effective treatment technique is distraction osteogenesis. This is a new technique for regenerating new bone by slow, progressive stretching of the bone, without requiring a bone graft.
Eminent Craniofacial Surgeon Dr. S.M. Balaji is a pioneer in introducing this revolutionary technique and has successfully rehabilitated the maximum number of patients afflicted with facial disfigurements in the country.
In distraction osteogenesis, the jaw bone on the deficient side is cut. A sophisticated device called distractor is placed such that the two arms of the device are fixed to the two segments of jaw bone. After a few days, a screw attached to the distractor is turned gradually, ideally at a rate of 1 mm per day. When this is done, the two cut segments move apart and new bone is formed in the resultant gap. After the required length is achieved and new bone is stabilized, the distractor device is removed subsequently correcting the asymmetry of the face.
This is a powerful tissue engineering technique for generating bone for the desired volume. The overlying soft tissues that are deficient also are expanded, therefore along with the underlying bone deformity, the overlying skin and soft tissue defect is also corrected.
This is the only procedure to increase the size of the jaw bones after the cessation of actual bone growth. For this patient, Dr. Balaji adopted a stage-by-stage rehabilitation. To correct the jaw deformity, he applied the innovative simultaneous maxillary and mandibular distraction procedure wherein new bone is formed in both the upper and lower jaws simultaneously to restore facial symmetry.
Preoperative facial view showing asymmetrical face ( short face on left side)
Slanting bite (occlusal cant) due to retarded development of facial bones on left side
Preoperative 3DCT showing retarded development of maxilla and mandible on left side
After distraction showing symmetrical appearance and elongated genium highlighted in 3DCT scan image
Immediately after fixing the distractor device in position
After completion of distraction and formation of callus at the end of consolidation before distractor removal
3DCT scan showing good new bone formation
Enhanced bone formation following distraction osteogenesis
During distractor removal the genial excess was alos corrected
Excess bone was highlighted
Excess bone was removed
Excess bone removed was used to augment the symphysis on other side
Postoperative facial view showing symmetrical face without any scars on the face
Postoperative occlusal view showing corrected bite
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Facial asymmetry correction using simultaneous internal maxillomandibular distraction osteogenesis

4/11/2014

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A 22 year old male reported to our hospital for the surgical correction of asymmetry over the left side of the face. Facial asymmetry may be present in cases of hemifacial microsomia, TMJ ankylosis or may have resulted following condylar fractures. This patient had a mandibular deficiency at the ramus level due to condylar fracture and deficiency measured almost 17 mm with a resultant occlusal cant.

After thorough clinical and radiological examination Maxillofacial Surgeon Dr. S. M. Balaji planned to correct the facial asymmetry using internal distraction osteogenesis with maxillomandibular distractor. Paragingival incision was placed over the left angle region along the anterior border of ramus. Full thickness mucoperiostal flap was reflected buccally and bone exposed. The direction of the osteotomy cut and positioning of the distractor is the most important as it determines the vector of distraction and this determines the direction of the bone growth. The distractor device was positioned and fixed using screws. Osteotomy is then completed along the medial cortex. Distractor device was checked and wound closure done. Le Fort I osteotomy was completed in maxilla. After a latency period of 5 days, distraction at the rate of 1 mm per day was accomplished and facial asymmetry was successfully corrected.
Preoperative facial view showing asymmetrical appearance of the face due to reduced height on the left side
Preoperative bite showing occlusal cant due to reduced mandible height on the left side
Preoperative 3D CT scan showing altered height of the ramus of the mandible on the left side leading to asymmetry
During surgical procedure, distractor device fixed to the outer surface of the ramus with correct orientation with the jaw
Trial activation done to check the movement of the mandible
Lefort I osteotomy cut was placed in the maxilla and fixed to the mandible by IMF for simultaneous distraction
Postoperative view showing corrected occlusal cant by lengthening the lower half of the face using distraction osteohistogenesis
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Facial asymmetry correction with advanced distraction osteogenesis technique

16/6/2014

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A 20 year old girl reported to our hospital with a complaint of asymmetrical face giving her an unpleasant appearance and she was not able to chew foods due to slanting bite. Her parents were also worried & wanted the correction done without any scars on the face. The girl was too anxious due to her asymmetrical face which affected her self-esteem considerably.

After thorough clinical and radiological examination, it was diagnosed that she had hemifacial microsomia in which the ramul height of the mandible on right side was considerably less which led to asymmetry. Maxillofacial Surgeon    Dr. S. M. Balaji skillfully planned to correct her face as well as her bite with the innovative “Distraction Osteogenesis” technique. Intraorally Le Fort I osteotomy was done, lower jaw bone on the right side was cut and distractor device was fixed to the mandible at the ramus region. The screw attached to the distractor was turned gradually everyday that pushed the cut bone segments apart. New bone was formed in the resultant gap and the jaw bone was ultimately lengthened. After the face became symmetrical, the distractor was removed.

Thus entire surgery was done inside the mouth with no scars on the face.  The girl and her parents were very happy with the results.
Preoperative view showing facial asymmetry due to reduced height of the lower jaw on right side
Preoperative view showing slanting bite towards right side due to hemifacial defect
Distractor fixed in the right side of the mandible to increase the height of the jaw
Postoperative view showing enhanced appearance of the face with symmetrical appearance
Postoperative view showing corected bite with symmetrically aligned upper and lower jaw without any scars on the face
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