CASE PRESENTATION

Presented by :-
Dr Govind
29-Apr-19 JRII
Patient details

• Patient Name - Mahesh Kumar

• OPD no. - 378565
• Age- 24yrs
• Gender- Male
• Address- Gomti nagar, lucknow
• Phone number 9874273865.

29-Apr-19
• C/C- patient C/O facial disfigurement and reduce
mouth opening since last 14 yrs.
• HOPI revealed that he was suffering from mild
deformity of face since birth but it aggravated
after he met with an accident around the age 4
yr. when he was hit by a two wheeler and got hit
on the chin region. According to his guardian the
lower jaw growth was hampered and mouth
opening was also reduced after the incident.

29-Apr-19
• In the year 2004 he was diagnosed with TMJ
ankylosis in KGMC. He was treated with extraoral
distractor on the right side to increase the
vertical height. After two months it was removed
and he was advised for second surgery of Left
side after few.
• In 2015 he reported back to KGMC for the surgery
of other side but he was diagnosed with HCV +ve.
• The treatment was not done and he was advised
for treatment of HCV which was continued for 7
months. Then he came to our department in
2017 for the treatment facial assymetrey.
• In 2018 he was treated in our department, for the
correction of disfigurement by using distraction
device on both the side of mandible.
29-Apr-19
• Medical History- Epileptic since 4 years, last
attack 4months back,
• On medication (oxycarbazepine 300mg
morning and 450mg at night)
• No known allergies

29-Apr-19
 Personal history
• Marital status: Unmarried
• Diet: Veg.
• Religion: Hindu
• Social status: Middle class
• Normal sleeping pattern
• Normal appetite
• Normal bowel and bladder functions.
• Patient cleans his teeth with tooth paste and
toothbrush once daily for 2-3 mins.
• Patient has no parafunctional /deleterious oral
habits.

29-Apr-19
 General examination
• Patient is lean and thin
• Conscious. Cooperative, well oriented to
time/place/person.
• Vital data at the time of examination
• Temperature: 98.4⁰F
• Pulse: 76/min
• Respiratory rate: 18/min
• Blood pressure: 124/78mm Hg
• Weight: 45kgs
• No signs of pallor, icterus, clubbing, cyanosis,
lymphadenopathy.
• CVS: No abnormality detected.

29-Apr-19
 • RESPIRATORY: Bilaterally symmetric chest
expansion seen.
• ABDOMEN: Bowel movements are normal

29-Apr-19
 Before After

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 Before After

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 Before After

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• Extraoral examination

• Gross facial asymmetry.

• Retrognathic mandible.
• Midline shifted to right.
• Side profile: Retrognathic mandible
• Rt side facial height is more than left side

29-Apr-19
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• INTRA-ORAL EXAMINATION:-
• Moderate stains
• Mild calculus
• Missing tooth 11,12,21,22,23,24
• Accentuated curve of spee
• Occlusal canting on left
• Midline shift to right
• Antegonial notch prominent on both sides
• Grating sound on left TMJ lateral movement
• Mouth opening 15 mm
• Eyelet wires present

29-Apr-19
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 Blood Investigation.

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 Blood examination

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 Radiographic examination chest

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 Advancement of mandible by
distractor.

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 Tmj ankylosis

29-Apr-19
 Cephalometric analysis

• GRUMMANS
The PA cephalogram offers an effective tool in
evaluating the craniofacial structures in
transverse and vertical dimensions.
• It allows us to look at the facial skeleton in
relative view of the right-left face and upper-
lower face.

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 Horizontal planes

FZ suture

Zygomatic arch

Juglar process

Menton

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 Mandibular morphology analysis
• Leftsided and rightsided triangles are
formed between the head of the
condyle (Co) to the antegonial notch
(Ag) and menton (Me).

• A vertical line from ANS to Me

visualizes the midsaggital plane in the
lower face.

PARAMETER RIGHT LEFT

Co-Ag 50mm 52mm
Ag-ME 35mm 48mm
29-Apr-19 Co-Me 70mm 82mm
 Volumetric comparision
• Four connected points determine
an area, and here a connection is
made between the points:
– condylion (Co);
– antegonial notch (Ag);
– menton (Me)
– the intersection with a
perpendicular from Co to MSR

• The two polygons (leftsided and

rightsided) that are defined by
these points can be superimposed
parameters Right left with the aid of a computer
Ag-MSR 45mm 34mm program, and a percentile value of
Co-MSR 45mm 44mm symmetry can be obtained
J-MSR 30mm 25mm 29-Apr-19
 Maxillomandibular comparision of
assymetry
• Four lines are constructed,
perpendicular to MSR, from Ag and
from J, bilaterally.

• Lines connecting Cg and J, and

lines from Cg to Ag, are also drawn.

• Two pairs of triangles are formed in

this way, and each pair is bisected
by MSR. If symmetry is present, the
constructed lines also form the two
triangles, namely J-Cg-J and Ag-Cg-
29-Apr-19 Ag.
 Linear assymetry

• The linear distance to MSR and

the difference in the vertical
dimension of the perpendicular
projections of bilateral landmarks
to MSR are calculated for the
landmarks Co, NC, J, Ag, and Me.

• With the use of a computer, left

and right values and the vertical
discrepancies between bilateral
landmarks can be listed

29-Apr-19 Me-MSR Rt side 9mm

shifted
 Frontal Vertical
Proportional Analysis

Upper facial ratio Cg-ANS: Cg-Me

Middle facial ratio ANS –Me : Cg-
Me
Lower facial ratio ANS-A1: ANS-
Me
Total maxillary ratio ANS-AI:Cg-Me
Mandibular ratio BI-Me :ANS-Me
Total mandibular ratio BI-Me:Cg-
Me
Maxillomandibular Ratio ANS- FZ-OP 67mm 75mm
AI:BI-Me (Rt) (Lt)

29-Apr-19 Maxillary cant is 8mm upward on rt side.

 COGS analysis
• Charles J. Burstone et al (1978) developed an
analysis specially designed for patients
requiring Orthognathic surgery.
• They used the landmarks and the
measurements that can be altered by
common surgical procedures.
• This analysis is also called as Cephalometrics
for Orthognathic Surgery (COGS)

29-Apr-19
• COGS system describes the horizontal and
vertical positions of the facial bones by the
use of constant coordinate systems as follows:
• Size of the bone are represented by direct
linear measurements.
• Shape of the bones are represented by the
angular measurements.

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 Skeletal And Dental Analysis
• ☺Landmarks
• Sella (S) - The center of Pituitary Fossa
• Nasion (N) – The most anterior point of
the nasofrontal suture in the
midsagittal plane
• Anterior Nasal Spine (ANS) – The
anterior most midsagittal point on the
tip of sharp bony process of maxilla
• Subspinale (A) – The deepest
midsagittal point on the concavity
between Anterior Nasal Spine and
Prosthion
• Supramentale (B) – The deepest point
in mid sagittal plane on the concavity
between infradentale and pogonion
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• Pogonion (Pg) – Most anterior
mid sagittal point on the contour
of the chin
• Gnathion (Gn) – Constructed by
bisecting the Facial plane and
tangent to lower border of
mandible
• Menton (Me) – Most inferior
point on the inferior contour of
the chin
• Pterygomaxillary fissure (Ptm) –
The most posterior point on the
anterior contour of the maxillary
tuberosity
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• Posterior Nasal Spine (PNS) – The
most posterior point on the contour
of the palate.
• Articulare (Ar) – The intersection of
sphenoid and the posterior border
of the condyle
• Gonion (Go) – constructed by
bisecting the posterior ramal plane
and mandibular plane.
• Mandibular Plane (MP) – It is the
line joining Gonion and Gnathion
• Nasal Floor (NF) – A plane
constructed by joining ANS and PNS

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☺Two measurements are
considered in Cranial Base
length – Ar-Ptm and Ptm-N
☺Ar-Ptm is the distance
between Ar and Ptm which is
measured parallel to HP
☺Standard Value
☺MALES 37.1 ± 2.8 mm
☺FEMALES 32.8 ± 1.9 mm
☺Ar-Ptm indicates the position
of mandible in relation to
posterior surface of maxilla
Patient value 25mm
A/D 27mm
29-Apr-19
• ☺Ptm-N is the distance between Ptm
and N which is measured parallel to
HP
☺Standard Value
☺MALES 52.8 ± 4.1 mm
☺FEMALES 50.9 ± 3 mm
☺Ptm-N indicates the position of
posterior border of maxilla in relation
to Nasion
☺If this value increases it indicates
more posterior position of maxilla in
relation to N and if it decreases it
indicates anterior position of maxilla
in relation to N
Patient Value 56mm
A/D 48mm
29-Apr-19
 Horizontal Skeletal Profile Analysis
☺A few simple measurements should be made
on the skeletal profile to assess the amount of
discrepancy in anteroposterior direction.
☺It is called as Horizontal Skeletal Profile
analysis because all the measurements in this
set of analysis are made parallel to HP

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ANGLE OF SKELETAL CONVEXITY
☺It is the angle formed
between N-A and A-Pg
☺Standard Value
☺MALES 3.9⁰ ± 6.4⁰
☺FEMALES 2.6⁰ ± 5.1⁰
☺A positive angle indicates
convex profile while negative
angle indicates concave
profile
Patient value 31
A/D 20
29-Apr-19
N Perpendicular to A, parallel to HP
☺A perpendicular to HP is dropped
from N (N perpendicular) and
horizontal distance parallel to HP
is measured from point A
☺Standard Value
☺MALES 0 ± 3.7 mm
☺FEMALES -2 ±3.7 mm
☺This measurement describes the
position of apical base of maxilla
in relation to nasion
Patient value -9
A/D -9

29-Apr-19
N Perpendicular to B, parallel to HP
☺It is obtained by measuring the
distance between Point B and
Nasion perpendicular (N
perpendicular)
☺Standard Value
☺MALES -5.3 ± 6.7 mm
☺FEMALES -6.9± 4.3 mm
☺This measurement describes the
position of apical base of mandible
in relation to nasion
Patients value -40
A/D -32
29-Apr-19
N Perpendicular to Pg, parallel to
HP
☺It is obtained by measuring the
distance between Pogonion and
Nasion perpendicular (N
perpendicular to HP)
☺Standard Value
☺MALES -4.3 ± 8.5 mm
☺FEMALES -6.5 ± 5.1 mm
☺This measurement describes
the position of mandibular chin
in relation to nasion
Patients value -42
A/D -34
29-Apr-19
Lower 1 to MP
☺To obtain lower anterior dental
height, perpendicular distance
between incisal edge of lower
incisor to MP is measured
☺Standard Value
☺MALES 45 ± 2.1 mm
☺FEMALES 40.8 ± 1.8 mm
☺Any increase or decrease in this
value indicates increased or
decreased lower anterior dental
height respectively
Patients value 49
29-Apr-19
Upper 1 to platal plane
☺To obtain upper anterior dental
height, perpendicular distance
from incisal edge of upper
incisor to palatal plane is
measured
☺Standard Value
☺MALES 30.5 + 2.1 mm
☺FEMALES 27.5 + 1.7 mm
☺Any increase or decrease in
this value indicates increased
or decreased upper anterior
dental height respectively
Pateints Value 20
29-Apr-19
 Maxilla and Mandible
ANS to PNS
☺ANS and PNS are projected on
HP
☺Distance between these two
points on HP gives us total
effective maxillary length
☺Standard Value
☺MALES 57.7 + 2.5 mm
☺FEMALES 52.6 + 3.5 mm
Patients value 50
A/D 55
29-Apr-19
Ar to Go
☺Mandibular ramal length is the
linear distance between
Articulare and Gonion
☺Standard Value
☺MALES 52 ± 4.2 mm
☺FEMALES 46.8 ± 2.5 mm
☺Variation in Ramal length can be
a causative factor for skeletal
open bite or deep bite
Patients value 40(defeciency of
10mm)
A/D 36mm
29-Apr-19
Go to Pg
☺Mandibular body length is the
linear distance between Gonion
and Pogonion
☺Standard Value
☺MALES 83.7 ± 4.6 mm
☺FEMALES 74.3 ± 5.8 mm
☺increase in length denotes skeletal
class III
☺decrease in length signifies skeletal
class II
Patients value 45(defeciency of 35)
A/D 57 mm
29-Apr-19
Ar-Go-Gn Angle (Gonial angle)
☺This measurment represents
the relationship between the
ramal plane and mandibular
plane
☺Standard Value
☺MALES 119.1 ⁰ + 6.5 ⁰
☺FEMALES 112⁰ + 6.9 ⁰
☺Gonial angle also contributes
to skeletal open bite or deep
bite
Patients value 116
A/D 120
29-Apr-19
Upper 1 to NF (Angle)
☺ This angle is constructed by
intersecting a line passing
through the tip of insical edge
through the root tip of upper
incisor and NF line
☺Standard Value
☺MALES 110 ± 4.70
☺FEMALES 112.50 ± 5.30
☺This angle gives us the inclination
of upper incisors in relation to
palatal plane (NF)
Patients value 126
29-Apr-19
Lower 1 to MP (Angle)
☺ This angle is constructed by
intersecting a line joining the
incisal edge of lower incisor
passing through its root tip and
MP
☺Standard Value
☺MALES 95.9⁰ ± 5.2 ⁰
☺FEMALES 95.9⁰ ± 5.7 ⁰
☺This angle gives inclination of
lower incisors in relation to MP
Patients value 108
29-Apr-19
 Ankylosis
Def- Ankylosis (joint stiffness) is the
pathological fusion of parts of a joint
resulting in restricted movement across the
joint.
Ankylosis of the Temporomandibular joint,
an arthrogenic disorder of the TMJ, refers to
restricted mandibular movements
(hypomobility) with deviation to the affected
side on opening of the mouth.

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 CLASSIFICATIONS

o •Bilateral or Unilateral ankylosis

o •Fibrous ankylosis or Bony ankylosis
o KAZANZIAN
o •Intra-articular (true ankylosis)
o Extra-articular ankylosis (false ankylosis)
o ••

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Kazanzian Topazian Sawhney’s

True Stage 1 Type 1

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 Pathophysiology

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 Aetiology
Trauma Infection and Systemic disease others
inflammatory
At birth (forcep Rheumatoid Arthritis Small pox Malignancies
injury)

Blow to the chin Septic arthritis Ankylosin spondylitis Post radiology

Condylar fracture -Otitis media Syphilis Post surgery

-

-Mastoditis Typhoid fever Prolonged trismus

Parotitis Scarlet fever

-Osteoarthritis
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 Clinical Features of bilateral tmj
ankylosis

 Inability to open the mouth

 Mandible symmetrical but micrognathic
 Bird face deformity
 Antigonialnotch well defined bilaterally
 Upper incisors protrusive with ant open bite
 Multiple carious teeth with bad PDL health
 Severe malocclusion , crowding .
 Multiple Impacted teeth may be found on radiograph

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 Management
1.Condylectomy
2.Gap arthroplasty
3.Interpositional arthroplasty

Kaban’s protocol for management of TMJ ankylosis

1- Early surgical management
2- Aggressive excission of ankylotic mass
3- coronoidectomy and myotomy of affected side.
4-If step 1+2+3 does not work opposite side
coronoidectomy is done.
5- reconstruction of ramal ht with costrochondral graft.
6- early post operative mobilization and aggressive
physiotherapy for atleast 6 to 12 months.

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 Approaches to tmj
1. Preauricular incision
2. Postauricular incision
3. Hemicoronal
4. Submandibular incision
5. Post ramal
6. Endaural incision

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 Condylectomy
Indications :
• Fibrous ankylosis
• Neoplasia
• Dislocation
• Trauma
• Developmental disorders
• Non responding to non surgical therapy

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 Condylectomy

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Done in case of ankylosis where anatomic
features of the joint are not completely changed
as in case of fibrous or partial ankylosis.
• An incision is placed and the condylar region is
exposed.
• A horizontal cut is made at the region of the neck
of the condyle.
• The head of the condyle is sectioned at the level
of the neck and carefully separated

29-Apr-19
• Since the superior attachment is not firm, it
may be detached and the entire head of the
condyle is separated and removed.

• The stump of the condyle at the neck is

smoothened and thus a new joint is created here.

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 GAP ARTHROPLASTY
• Gap Arthroplasty involves creation of an anatomical
gap in the ankylosed segment to form an artificial joint
space.
• Commonly done in cases of complete ankylosis.
• A gap in the bone is created to separate the ramus
from the ankylosed mass in the glenoid fossa.
• 2 horizontal bony cuts are made in the most superior
aspect of the ramus and the wedge of the bone between
these 2 cuts is removed.
• Care should be taken while removing the bone from
the medial aspect as it is close to the maxillary artery
and carotid canal.
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A gap of about 1-1.5 cm is
created and not interposed
with any material.
• The mouth is forced open
with the help of a mouth
gag.
• The gap should be
maintained by active
physiotherapy of the
joint to prevent
reankylosis.

29-Apr-19
 Interpositional Arthroplasty
When gap arthroplasty is done to release ankylosis,
there are chances of contact between the bone ends to
form a reankylosis.
So an interpositional material is to be placed in
between them to avoid contact and minimize chances of
reankylosis.
Materials which can be used are either alloplastic or
autogenous materials.
Procedure involves creating a gap and then inserting an
interpositional material and stabilizing it.
When adequate movement cannot be brought about it
may be required to osteotomise the coronoid process
also.
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 Materials used for interpositional
arthroplasty
Alloplastic
Non metallic Metallic :
- Silastic Metallic Tantalum plate
- Acrylic Stainless Steel
- Teflon - Titanium
- Cerami
AUTOGENOUS MATERIALS:
- Costochondral graft
- Metatarsal graft
- Sternoclavicular joint
- Auricular cartilage
- Temporalis muscle or Fascia or both
- Fascia
29-Apr-19 lata
 Removal of distraction device
• Both the distractors will be removed through
submandibular incision bilaterally.

29-Apr-19
 Lefort 1 osteotomy
• *“Lefort I osteotomy has become the work
horse of Orthognathic surgical procedures .Its
technical ease ,its broad application to resolve
many functional and aesthetic problems and
the dependability of its results support this
evolution.

29-Apr-19
Indications
The lefort I osteotomy can be used to correct a variety of
maxillofacial problems like maxillary advancement, especially in
cleft palate and post trauma patients.
• To correct maxillary prognathism .
• Superior repositioning of the maxilla, to correct vertical
maxillary excess
• Inferior repositioning of the maxilla, to correct vertical
maxillary deficiency
• Widening of the maxilla, to correct transverse
• Discrepancies .3D repositioning of the maxilla ( segmental
• osteotomies )
• In all instances of apertognathia, lefort I osteotomy
• should be given consideration because of the stability
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• issues.
 Anatomical consideration

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• Technique
• An intraoral incision is made in the buccal vestibule of
the maxilla from the molar region of one side to the
opposite one and a mucoperiosteal flap is raised
exposing the anterior-lateral walls of the maxilla.
• The dissection is extended laterally and superiorly
towards the zygomatic buttress and the zygomatic
process of the temporal bone. The infraorbital nerve is
identified and the dissection is then extended to the
orbital floor with a curved periosteal elevator in order
to simplify the following osteotomies and to achieve
direct control of periorbital tissues.

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• The osteotomy is performed with a reciprocating saw
or a fissure bur, starting from the lateral aspect of the
piriform aperture and is extended to the medial
aspect of the inferior orbital rim. The second
osteotomy line starts from the lateral aspect of the
inferior orbital rim and is directed towards the
zygomatic buttress as far back as is possible.
• This osteotomy is completed with a chisel, which is
inclined backwards and laterally, in order to create an
enlarged mobilized segment of the malar bone. The
two osteotomies are then connected along the
anterior orbital floor with curved osteotomes specially
designed for this manoeuvre and for protection of
periorbital tissues.
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• The same procedure is performed on the opposite side.
The osteotomy of the nasal septum is performed
according to Le Fort I routine modalities, whereas the
osteotomy of the medial walls of the maxillary sinuses
are carried out in a higher position.
• Particular attention must be drawn to
pterygomaxillary osteotomy both apically and medially
in order to simplify the mobilization of the maxillo-
malar complex. Advantages of these modifications are
the following: 1. The aesthetic 'epicentre' of the
zygomatic buttress is

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Vertical Skeletal
☺N-ANS (linear) 53mm – A/D – 50 mm (54.7mm)
☺ANS-Gn (linear) 63mm- A/D – 66mm (68.6mm)
☺PNS-N (linear) 46mm –A/D -45mm (53.9mm)
☺MP-HP (linear)31 –A/D -43 (23)

29-Apr-19
 Genioplasty
• Genioplasty is the surgical procedure used to
alter the size and morphology of the bony chin
with concomitant changes in the surrounding
soft tissues. It can be used as a single
procedure or it can be used as an adjunctive
procedure along with other major
osteotomies of the jaw.

29-Apr-19
 Indication
• In facial asymmetry where the complete
correction of the assymetry can not be
achieved by appropriate jaw osteotomies.
• The horizontal osteotomy is done and
segment is shifted laterally and then
contoured to get desired result.

29-Apr-19
In our patient the mandibular body length from
gonion to pogonion is 25 mm deficient.
(83.7mm) –Normal
The N- pg value is -34mm, normal value is ( -4.3)
Deficiency of 29.7mm

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 Horizontal osteotomy with
advancement

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 Double sliding technique

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 Overlapping genioplasty

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 Antero - post reduction

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 Widening and narrowing of the chin

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 Correction of mandibular assymetry

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 Vertical reduction genioplasty

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 complication
• Prolonged neurosensory disturbance
• Avascular necrosisof mobilized segments
• Hemorrhage causing lingual hematoma
• Possibleairway compromise
• Unaesthetic soft tissue changessuchaschinptosis
• Excessivelower toothdisplay
• Bonyresorption under alloplasts
• Devitalization of teeth
• Mandibular fracture
• Creation of mucogingival problems
• Asymmetry, and
• Anunaesthetic end result

29-Apr-19