Class II molar, overjet 15mm, openbite of 3mm, deficient chin, vertical growth pattern.
Considering the large overjet..mandibular distraction osteogenesis would be needed preferably with a 3d distractor which would close the open bite too...this is assuming that the maxilla is nornally positioned..even aftr distraction the patient might require genioplasty..and orthodontic treatment fr d more complicated malocclusion that would follow aftr distraction
I think we should consider TMJ condition on this case. How about TMJ? Is there no pathologic changes?
I believe, if TMJ is gud and maxilla is normal, distraction is the only answer to ur problem...
If distraction is not possible due to logistic problems..a bilateral inverted L osteotomy with illiac bone grafting would be required to correct it..
Overjet is considerably high in your case. A sajittal split advancement alone will cause a significant relapse.If the maxilla is protruded ( depend on the SNA) maxilla may be setback at Le Fort 1 level ( difficult procedure) to reduce the relapse This way the overjet can be distributed in themandible and maxilla.If SNA is within normal limits, a mandibular distraction pre operative will help to reduce the overjet. Open bite can be addressed with a posterior impaction of the maxilla.
Assymmetry has to be addtessed with BSSO/VSS combination.
If micrigenia is a problem an advancing genioplasy will be necessary (or an Implant). These are only for guidance in the surgical planning.Final plan will depend on the cephalometric findings and profile analysis.
Sever asymmetric mandibular deficiency seldom occurs in only anteroposterior direction but usually it occurs in vertical dimension as well. for proper evaluation of the patient it is important to check occlusal canting, upper incisors,s inclination to cranial base, gummyness of the smile, maxillary base to cranial base relationship.
cosidering all the parameters DO is a good option and in case of mandibular advancement by BSSO , suprahyoid myotomy may reduce the risk or relapas after surgery.
today's it is accepted that DO is the best option as the first step for sever maxillary or mandibular deficiency .so it depends on the Ramus height and body length of the mandible you can choose a proper Distraction device. after reducing the discrepancy to the minimum size then conventional Bi maxillary surgery needs to correct the open bite and asymmetry as well.usally advancement genioplasty also operated in the same surgery.
it might be needed to do the double osteotomy on chin or using chin prosthesis to get the optimal in profile based on the soft tissue quality and quantity.
thank you all for your valuable suggestions..I will check for any occlusal cant, upper incisor inclination, amount of gingival display and consider mandibular distraction with/without Lefort I to reduce the openbite. A genioplasty at the end of distraction if chin is still deficient..
Great treatment option put forth by the above scholars. I shall leave the orthodontics part to the experienced specialists who deal with it the best. With my limited experience with surgical correction of mandibular asymmetry, i would like to put forth a treatment option known as orthomorphic surgery introduced by professor Paul C. Salins. Asymmetry in this case can be attributed to the condylar hypo/hyperplasia. Clinical features and growth pattern would be similar to that of TMJ ankylosis if not the same (especially in case of condylar Hypoplasia). occlusal cant is a norm in such cases as the hypo/hyperplastic condlye would result in disturbed growth of maxillary alveolus (ipsilateral in case of hypoplastic condyle and contralateral in case of hyperplastic). [note-occlusal cant could be camoflouged or absent due to supraeruption of teeth].
multivector distractor with differential distraction is an attractive option which can correct both asymmetry and overjet. But control over distraction osteogenesis is always questionable with its own demerits.
If in the above mentioned case, overjet and open bite were not an issue, orthomorphic surgery would be an excellent treatment option for correction of mandibular asymmetry.
Orthomorphic surgery involves esthetic correction of the deviated mandible with no correction or alteration in the occlusion. the advantages includes swift treatment (compared to distraction), minimal invasiveness and no postoperative changes in the condylar positioning.
we have done quite a few cases with severe mandibular asymmetry. this treatment6 option works best for patients with post ankylotic mandibular asymmetry, but can work equally well in any mandibular asymmetry cases.
This treatment option may not be the best in the current case, but may be an alternative consideration if asymmetry needs to be corrected.
ref- Morphometyric basis for orthomorphic correction of mandibular asymmetry., Salins PC, Bhat V, Kavarody M., JOMS 66:1523-1531, 2008
You may Consider
the simultaneous Bi max Distraction osteogenesis Suggested by Mollina.
The cross bite can be corrected at almost any age if the patient changes their posture appropriately. They may need prior correction of occlusal contacts but the condylar heads remain responsive to oral posture into late age. Read chapter 4 available free from www.orthotropics.com. Prof John Mew.
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