This document discusses a case study of using unilateral sagittal split ramus osteotomy (SSRO) with an interpositional iliac bone graft to correct facial asymmetry in a 27-year old female patient. The patient presented with flatness on the right side of her face and mandible. Clinical and radiographic examinations revealed a decrease in the mediolateral distance of the right mandibular ramus compared to the left. Unilateral SSRO was performed on the right side, and a cancellous iliac bone graft was interpositioned between the proximal and distal segments to restore symmetry. Rigid fixation with a bent plate was used to stabilize the graft and maintain thickness. At follow-up, the procedure had

1. © 2020 Journal of Cleft Lip Palate and Craniofacial Anomalies | Published by Wolters Kluwer ‑ Medknow64
Unilateral sagittal split ramus osteotomy for
facial asymmetry by IIG
Philip Mathew, Rahul V. C. Tiwari1
, Paul Mathai, Jisha David, Heena Tiwari2
,
Neeraj Bansal3
INTRODUCTION
Face is an index of the mind. Esthetics affect social
and psychological determinants of well‑being. Minor
deformities of the face are also noticed prominently by
the society. Hence, when it comes to facial asymmetry,
it is deliberated as major esthetic deformity. It is
a common encountered problem in craniofacial
surgery. Asymmetry in the lower jaw is more often
encountered compared to the upper jaw.[1]
Facial
asymmetry is classified on various grounds based on
etiology, time of onset, and structures involved. Walford
has classified it as pseudoasymmetry, normal facial
asymmetry, unilateral overdevelopment and unilateral
underdevelopment, or degeneration. Bishara has
Department of Oral and Maxillofacial Surgery and Dentistry, Jubilee
Mission Medical College Hospital and Research Institute, Thrissur,
Kerala, 1
Department of Oral and Maxillofacial Surgery, Sri Sai College
of Dental Surgery, Vikarabad, Telangana, 2
Community Health Centre,
Kondagaon, Chhattisgarh, 3
Consultant Oral and Maxillofacial Surgeon,
B-16, Molarband Badarpur, New Delhi, India
Address for correspondence: Dr. Philip Mathew,
Department of Oral and Maxillofacial Surgery and Dentistry,
Jubilee Mission Medical College Hospital and Research Institute,
Thrissur ‑ 680 005, Kerala, India.
E‑mail: philip2mathew@gmail.com
ABSTRACT
Treating cases of facial asymmetry is always
a challenge for oral and maxillofacial surgeons
especially when the face has minor deformities and
patients expectations are very high. Various non
surgical and surgical techniques including orthognathic
and orthomorphic surgeries with graftings have
kept their milestones for treating such cases. This
report presents a similar case of achieving fullness
on unilateral side of face to accomplish symmetry
which was treated using an interpoistional iliac graft
in unilateral saggital split osteotomy to correct the
disharmony of face.
Key words: Facial asymmetry, iliac graft,
interpositional graft, sagittal split ramus osteotomy
Case Report
Access this article online
Website:
www.jclpca.org
DOI:
10.4103/jclpca.
jclpca_16_19
Quick Response Code:
Cite this article as: Mathew P, Tiwari RV, Mathai P, David J, Tiwari H, Bansal N.
Unilateral sagittal split ramus osteotomy for facial asymmetry by IIG. J Cleft
Lip Palate Craniofac Anomal 2020;7:64-6.
Submission: 09.07.2019 Revision: 10.09.2019
Acceptance: 08.10.2019 Web Publication: 20.01.2020
This is an open access journal, and articles are distributed under the
termsoftheCreativeCommonsAttribution‑NonCommercial‑ShareAlike
4.0 License, which allows others to remix, tweak, and build upon the
work non‑commercially, as long as appropriate credit is given and
the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
classified it on the basis of dental, skeletal, muscular,
and functional abnormalities.[2]
Clinical, photographic,
and radiographic assessments help to achieve a proper
diagnosis for prompt management. Management of
facial asymmetry is still a challenging scenario, as it
is not only important to evaluate what we determine
as defect, but also the patient expectations needs to be
fulfilled. It is always preferred to restore the same kind
of tissue which is in deficiency, but even camouflage
helps in correcting such deformities in some cases.
CASE REPORT
A 27‑year‑old female presented to us for the first time
with a chief complaint of flatness on the right side
of face and mandible. She needs the same fullness
which is present of the other half of face to improve
the esthetics. Eliciting her history, she was operated
before for maxillary retrognathism and recessive chin.
She underwent Le Fort I advancement and advancement
genioplasty. Pre‑ and post‑orthodontic correction was
performed. On clinical examination, her profile was
normal and a good occlusion with overjet and overbite.
Flatness was present on the ramus and body area on
the right side. To evaluate the deformity in detail, a
posterior‑anterior skull view was taken which showed
a decrease in the mediolateral distance of ramus of
mandible on the right side as compared to the left
tissue [Figure 1]. There was no soft‑tissue deficiency
present. This clinical scenario comes under the
skeletal defect of Bishara classification. Accordingly,
[Downloaded free from http://www.jclpca.org on Friday, January 24, 2020, IP: 123.201.170.234]

2. Mathew, et al.: Unilateral SSRO by IIG
65Volume 7 / Issue 1 / January‑June 2020Journal of Cleft Lip Palate and Craniofacial Anomalies
a unilateral sagittal split ramus osteotomy (SSRO)
was performed on the right side, and a single chunk
of cancellous iliac bone graft was harvested and was
interpositioned between proximal and distal segments.
The superoinferior dimension of mandible was
measured in orthopantomogram. The cancellous graft
was reshaped into correct form to prevent impingement
of the graft on soft tissue, which can cause esthetic
compromise. The width of graft was of only 3 mm, so
as not to cause any deformity in the condylar deviation
due to the flaring achieved in the proximal segment
after placing the cancellous inlay graft [Figure 2]. For
stabilizing the graft, rigid fixation technique was used.
A six‑hole plate with gap was selected, and it was
given two bends of 90° in the gap area when the plate
traverse from proximal to distal segment to adapt it
in desired position in the sound bone [Figure 3]. This
bend is designed in such a way that the thickness of
graft and bend are equal to maintain the thickness
and prevents compression of graft between segments.
The other benefit of this bend is it will help the graft
to stay in position and prevent the graft from moving
anteriorly between the segments and maintain the
desired position. Placing a cancellous bone or inlay
graft rather than cortical or onlay graft will increase
the chances of take up and reduce resorption. After
reduction of swelling in the postoperative week, we
have achieved patient’s expectations too.
DISCUSSION
Facial asymmetry as a diagnosis implies esthetic
imbalance which deeply affects the psychological
status of patients. Fulfilling patient’s expectations
is the prime consideration for prompt management.
Hence, it is a matter of utmost importance to diagnose
the correct classification of deformity and replace
it with the same kind of tissue. History, clinical
examinations, sagittal, coronal, and axial section
are certain helpful diagnostic aids which add up
for the betterment of treatment plan.[3]
Frontal view
photographic examination and posteroanterior view
of skull as radiographic examination carries crucial
and significant evaluation criteria.[4]
A hyperextended
45° superior submental view is useful in measuring
projection and symmetry of anterior cranial vault,
orbit, and cheeks. The study models elicit occlusal
cants.[5]
Computed tomography (CT), cone‑beam
CT, three‑dimensional (3D) CT, magnetic resonance
imaging, and skeletal scintigraphy are also used for
better precision and reproducibility.[6]
Not every
mandibular asymmetry is a rotational asymmetry. There
may be a lateralization of the entire mandible which
requires bodily movement of the distal mandible away
from the original side. Malformations, deformations,
and disruptions can be interrelated for producing
asymmetries. Management of facial asymmetry has
a vast extension. The reason for this is its extensive
etiology. In spite of acquired defects, developmental
Figure 2: Iliac interpositional graft placed
Figure 1: Posterior-anterior skull showing mediolateral ramal distance
Figure 3: Rigid fixation and plate adaptation
[Downloaded free from http://www.jclpca.org on Friday, January 24, 2020, IP: 123.201.170.234]

3. Mathew, et al.: Unilateral SSRO by IIG
Journal of Cleft Lip Palate and Craniofacial Anomalies66 Volume 7 / Issue 1 / January‑June 2020
defects also are its cause. Hemifacial microsomia,
Treacher Collins syndrome, and Goldenhar syndrome
are the genetic‑related defects causing orofacial clefts
which lead to facial asymmetry. Hard‑ and soft‑tissue
procedures, autogenous or synthetic graft materials as
well as Botox and fillers are preferred choices. Botox
and derma fillers are not very reliable techniques for
such deformities due to their poor substantiation on the
anatomical site. Orthognathic surgery and distraction
osteogenesis are dynamic processes to facilitate 3D
correction of facial asymmetry. In addition, various
modified surgical techniques have been documented in
the literature.[7]
Other options include grafting through
patient‑specific implant, onlay bone graft, Medpor
implant, or major corrections through orthomorphic
surgery. Although several articles have been written
for correction of facial asymmetry by unilateral
sagittal split osteotomy, the published data on bone
grafting to correct deformity is scarce.[8,9]
Correction
of midline deviations of 2 mm or smaller has little
effect on the condylar/proximal segment position,
and modifications of the sagittal split osteotomy do
not seem necessary.[9]
Bone shim placed between
segments is a reliable technique with a pitfall of delayed
healing in the bone shim area. In our procedure, we
used a chunk of cancellous iliac graft which has been
interpositioned between the split segments. The reason
is that interpositional graft due to cancellous contact
has an immense better take up when compared to an
onlay graft. Other benefits are blood supply, rate of
resorption, and contour with exteroception is unaltered.
Condylar displacement is one of the most common
complications after SSRO and can induce relapse and
temporomandibular joint dysfunction symptoms. The
study shows that there is the presence of condylar
movement after SSRO and grafting. The condylar
displacement had no relationship to the rotation of the
mandible.[10]
Kang et al. have proven that the amount
of mandibular rotation <4 mm did not influence the
position of the condyle significantly which was studied
by various section of 3D computed tomography.[10]
It
is important to keep the intersegmental space intact
for postoperative surgical stability by the use of an
autogenous bone graft with ease and simplicity. In our
case, we have followed the same. Moreover, we have
also performed a rigid fixation by bending the plate and
adapting it to the required and desired position on the
sound cortical bone which helped our interpositional
graft to sustain its from function to position.
CONCLUSION
The fundamental cognition of facial asymmetry is a
substantive requisite to critically analyze the feature
involved in deformity and correctly measure the
magnitude of disparity. This facilitates to articulate
satisfying treatment plan to achieve maximum esthetics
and function deliberating patient’s perception and
expectations. In summary, we demonstrate an authentic
and dependable technique to use single chunk of
interpositional iliac cancellous bone graft to align the
proximal and distal segment, maintaining the baseline
position of condyles for correction of unilateral facial
asymmetry by unilateral SSRO.
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient(s) has/have given his/her/their consent for his/
her/their images and other clinical information to be
reported in the journal. The patients understand that
their names and initials will not be published and
due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Srivastava D, Singh H, Mishra S, Sharma P, Kapoor P, Chandra L,
et al. Facial asymmetry revisited: Part I‑ diagnosis and treatment
planning. J Oral Biol Craniofac Res 2018;8:7‑14.
2. Srivastava D, Singh H, Mishra S, Sharma P, Kapoor P, Chandra L,
et al. Facial asymmetry revisited: Part II‑conceptualizing the
management. J Oral Biol Craniofac Res 2018;8:15‑9.
3. Cheong YW, Lo LJ. Facial asymmetry: Etiology, evaluation, and
management. Chang Gung Med J 2011;34:341‑51.
4. Legan HL. Surgical correction of patients with asymmetries. Semin
Orthod 1998;4:189‑98.
5. Wolford LM. Facial asymmetry: Diagnosis and treatment
considerations. In: Turvey TA, editor. Oral and Maxillofacial Surgery.
2nd
ed., Vol. 3. St. Louis, MO: Saunders; 2009.
6. Epker BN, Stella JP, Fish LC. Diagnosis and treatment planning for
correction of asymmetric dentofacial deformities. In: Epker BN,
Stella JP, Fish Dentofacial LC, editors. Deformities‑Integrated
Orthodontic and Surgical Correction. 2nd
ed. Vol. 4. St. Louis, MO:
Mosby; 1958.
7. Choi JY, Choi JP, Lee YK, Baek SH. Simultaneous correction of
hard‑and soft‑tissue facial asymmetry: Combination of orthognathic
surgery and face lift using a resorbable fixation device. J Craniofac
Surg 2010;21:363‑70.
8. Zhu SS, Feng G, Li JH, Luo E, Hu J. Correction of mandibular
deficiency by inverted‑L osteotomy of ramus and iliac crest bone
grafting. Int J Oral Sci 2012;4:214‑7.
9. Peacock ZS, Lee JS. Modification of the bilateral sagittal split
osteotomy for the asymmetric mandible. J Oral Maxillofac Surg
2011;69:2437‑41.
10. Kang MG, Yun KI, Kim CH, Park JU. Postoperative condylar position
by sagittal split ramus osteotomy with and without bone graft. J Oral
Maxillofac Surg 2010;68:2058‑64.
[Downloaded free from http://www.jclpca.org on Friday, January 24, 2020, IP: 123.201.170.234]