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 Table of Contents  
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 177-182

Orthosurgical management of a case of facial asymmetry secondary to temporomandibular joint ankylosis

Department of Orthodontics, ITS Dental College, Ghaziabad, Uttar Pradesh, India

Date of Web Publication13-Jun-2019

Correspondence Address:
Dr. Payal Sharma
Department of Orthodontics, ITS Dental College, Muradnagar, Ghaziabad, Uttar Pradesh
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DOI: 10.4103/ams.ams_128_17

PMID: 31293949

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This case report describes the successful treatment of a patient with facial asymmetry secondary to temporomandibular joint ankylosis with a combined orthodontic–surgical approach. Presurgical orthodontics involved surgically assisted rapid maxillary expansion followed by a bilateral sagittal split osteotomy and LeFort I osteotomy to reposition the mandible and correct the canting of the maxilla. The total active treatment period was 24 months. A significant improvement in occlusion and facial esthetics was achieved with treatment.

Keywords: Facial asymmetry, orthosurgical treatment, temporomandibular joint ankylosis

How to cite this article:
Sharma P, Kumar S, Kapoor P, Verma A. Orthosurgical management of a case of facial asymmetry secondary to temporomandibular joint ankylosis. Ann Maxillofac Surg 2019;9:177-82

How to cite this URL:
Sharma P, Kumar S, Kapoor P, Verma A. Orthosurgical management of a case of facial asymmetry secondary to temporomandibular joint ankylosis. Ann Maxillofac Surg [serial online] 2019 [cited 2021 Sep 28];9:177-82. Available from: https://www.amsjournal.com/text.asp?2019/9/1/177/260322

  Introduction Top

Facial asymmetry is a difficult and challenging problem in orthodontics. Facial esthetics and function is significantly affected by asymmetry.[1] Skeletal asymmetry is commonly observed in the mandible which forms the skeletal support for soft tissues of the lower face; however, most maxillary asymmetry usually develops secondary to asymmetric mandibular growth. According to Cheong and Lo,[1] etiology factors for facial asymmetry include congenital disorders, acquired factors resulting from injury or disease, and developmental deformities. Several authors have classified facial asymmetry based on different factors such as etiology – genetic or nongenetic according to Lundström;[2] structures involved – dental, skeletal, muscular, or functional according to Bishara et al.;[3] and mandibular changes – hemimandibular elongation or hyperplasia according to Obwegeser and Makek.[4] Diagnosis involves a thorough history to elicit the complaint of the patient and episodes of infection or trauma, clinical examination, and facial analysis and effects on the dentition. Supplemental diagnostic tools such as posteroanterior cephalometric radiographs, cone-beam computed tomography (CBCT), and bone scintigraphy may be required to quantify the structures involved and rule out progressive development of asymmetry.[5]

Temporomandibular joint (TMJ) ankylosis is a pathological condition, in which the mandible fuses to the fossa. It may result from a number of factors such as arthritis, infection, trauma, congenital deformities, or idiopathic factors.[6] It not only results in impairment of normal function but also causes considerable facial deformity.[7] The management of this condition is aimed at restoring mandibular movement, correction of the facial deformity, and prevention of reankylosis. It usually involves surgery to release the ankylosis, placement of a graft, and surgical repositioning of the jaws. The surgeries may be done in one or two stages depending on the skill and preference of the surgeon.[6]

This case report presents the treatment of a patient with facial asymmetry secondary to TMJ ankylosis treated with combined surgical–orthodontic treatment.

  Case Report Top

Diagnosis and etiology

A 21-year-old male was referred to the department of orthodontics and dentofacial orthopedics with a chief complaint of asymmetry of the face [Figure 1] and forwardly placed upper front teeth. He gave a history of restricted mouth opening due to ankylosis on the left side 10 years back, for which he had undergone surgery at the age of 11 years. His left central incisor was sensitive and tender on percussion.
Figure 1: Pretreatment extraoral photographs

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He had facial asymmetry with a deviation of the mandible toward the left side and a severe canting of the occlusal plane. The profile was convex with a retrognathic mandible. On smiling, gingival exposure on the right side was increased, indicating an increased posterior vertical growth of the maxilla in compensation to the mandibular deviation. Intraoral examination [Figure 2]a and [Figure 2]b revealed an Angle's Class II division I subdivision malocclusion with lower anterior crowding. Both the arches were asymmetric. The maxillary midline was deviated to the left of the facial midline by 1 mm, and the lower midline was shifted to the left by an incisor width. There was an increased overjet of 14 mm. The molar relationship was Class I on the right and Class II on the left.
Figure 2: Pretreatment intraoral photographs

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The patient underwent a CBCT scan [Figure 3]. The panoramic view [Figure 4] revealed condylectomy of the left side as reported in the history. It also showed impacted third molars on the right side. Two metal screws were visible at the left angle of the mandible, which had probably been placed at the earlier surgery to stabilize a graft. Cephalometric analysis [Figure 5] and [Table 1] revealed skeletal class II bases and a horizontal growth pattern. The upper and lower incisors were proclined on their bases. The posteroanterior cephalometric radiograph [Figure 6] showed a mandibular deviation to the left side.
Figure 3: Pretreatment cone-beam computed tomography images

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Figure 4: Pretreatment panoramic view

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Figure 5: Pretreatment lateral cephalogram

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Table 1: Cephalometric measurements

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Figure 6: Pretreatment posteroanterior cephalogram

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The mandible deviated to the left on opening. The maximum interincisal opening was 39 mm. Based on the history and clinical and radiographic examination, the patient was diagnosed with skeletal Class II malocclusion and severe facial asymmetry secondary to unilateral TMJ ankylosis.

Treatment objectives

The primary objective of the treatment was to address the chief complaint of the patient, that is, the facial asymmetry, and correct the mandibular retrognathism. Dentally, the objectives were to correct the proclination of the upper incisors, resolve crowding of the lower incisors, achieve a normal overjet and Class I molar and canine relation, and correct the midline.

Treatment plan

The marked facial asymmetry necessitated a surgical treatment plan. Bijaw surgery was planned to correct the severe occlusal cant and mandibular deviation. Presurgical orthodontics was aimed at aligning the arches and removing the dental compensations. A surgically assisted rapid maxillary expansion was performed to expand the maxillary arch and normalize the arch form. A single incisor extraction was done in the lower arch to relieve crowding.

Treatment progress

Before orthodontic treatment, the patient underwent endodontic therapy in the upper left central incisor. Presurgical orthodontics was commenced with surgically assisted rapid maxillary expansion. A hyrax screw soldered to the bands on the maxillaryfirst premolars and molars was used for the expansion [Figure 7]. The screw was activated one-quarter turn twice a day till overexpansion of 2–3 mm was achieved. The hyrax screw was then blocked and retained for 3 months to stabilize the expansion. The second phase of the treatment was started with the preadjusted edgewise appliance (MBT 0.022" × 0.028" prescription) to level, align, and decompensate the arches. The wire sequence was 0.016" heat-activated nickel titanium (HANT) and 0.018" stainless steel followed by 0.019" × 0.025" HANT. Presurgical records were obtained 1 month after the placement of final stabilizing archwires (0.019" × 0.025" SS). The presurgical phase took 12 months. Arbitrary facebow mounting was done on a Hanau articulator. Model surgery was performed on articulator-mounted casts in centric relation [Figure 8]. Two surgical splints were constructed for the bijaw surgery:first after maxillary repositioning and the final after mandibular surgery, in consultation with the oral surgeon. A bijaw surgery was performed according to the values obtained from the model surgery [Figure 9]. Healing after surgery was uneventful. The final splint was tied to the maxillary arch, and the patient was asked to wear guiding elastics to bite into the splint. Postsurgical orthodontic treatment was commenced 6 weeks after surgery when the patient had attained full range of movements and had returned to a normal diet. The stabilizing archwires were removed, and the breakages in the fixed appliance were repaired. A 0.017" × 0.025" titanium molybdenum alloy (TMA) wire was placed in the upper arch and 0.016" NiTi in the lower arch. The patient was asked to wear light elastics (3/8") for settling the posterior occlusion. At the next visit, buccal root torque was placed in the TMA wire to control the upper posterior segments. The final settling of occlusion was carried out on 0.016" S.S wires.
Figure 7: Upper occlusal radiograph showing hyrax expansion screw

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Figure 8: Model surgery and splint fabrication

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Figure 9: Intraoperative photographs

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Treatment result

The combined orthodontic–surgical treatment resulted in a good occlusal and esthetic result. A marked correction of facial asymmetry and occlusal cant was achieved after surgery, resulting in a significant improvement of facial esthetics [Figure 10] and [Figure 11]. The profile also improved considerably with mandibular advancement. Lip competence was achieved with a normal overjet and overbite.
Figure 10: Posttreatment extraoral photographs

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Figure 11: Posttreatment intraoral photographs

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Posttreatment panoramic radiograph [Figure 12] revealed acceptable root paralleling without any significant root resorption. Cephalometric analysis and superimposition [Figure 13] and [Figure 14] showed correction of the skeletal Class II pattern with a slight increase in the mandibular plane angle. The incisor inclinations and the position of the lower lip to esthetic plane also improved. The posteroanterior cephalogram [Figure 15] showed a significant improvement in facial symmetry with the mandible nearly in line with the facial midline.
Figure 12: Posttreatment panoramic radiograph

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Figure 13: Posttreatment cephalometric radiograph

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Figure 14: Cephalometric superimposition

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Figure 15: Posttreatment posteroanterior cephalogram

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A clear overlay retainer was delivered for the maxillary arch, and the patient was instructed to wear it full time for thefirst 6 months and only at night thereafter. A fixed retainer was bonded on all the mandibular incisors. Instructions were provided for oral hygiene and maintenance of the retainers.

  Discussion Top

An accurate diagnosis and assessment of facial asymmetry through clinical and radiographic evaluation is important to identify the location and extent of facial asymmetry and to understand the dentoalveolar compensations associated with the condition. Milder facial asymmetries or those having a dental component may be treated with asymmetric mechanics or extraction pattern, but skeletal asymmetry usually calls for a surgical treatment plan. Identifying the etiology of the problem and understanding the expectations of the patient from treatment are important factors to be considered before formulating a treatment plan.[1],[8]

Various methods of radiographic assessment have been used to diagnose and measure facial asymmetry. Conventionally, these methods have been limited to two-dimensional (2D) radiographic images such as the posteroanterior cephalometric radiograph and the submentovertex view. 2D imaging of 3D objects has inherent problems of distortion and projection. Overlap of anatomic structures, magnification errors, and head positioning introduce further errors making them unreliable for accurate measurements.[9] Cook [10] have shown that rotation error of 5° can result in a reversal of the side of asymmetry.

CBCT has gained popularity as a 3D imaging modality because of less radiation exposure and cost compared to a conventional CT. The technique is particularly suitable for cases of facial asymmetry as the built-in reconstruction algorithm can correct distortion due to projection errors.[11] The clinician can accurately assess skull anatomy using 2D slices or 3D surface renderings, especially in the frontal view. The multiplanar reconstructions also allow generation of conventional images such as panoramic radiographs and lateral and posteroanterior cephalometric radiographs. CBCT imaging was used for assessing asymmetry and accurate visualization of the mandibular anatomy in this patient.

The patient had a history of TMJ ankylosis and previous surgery to treat the condition at the age of 11 years. The left condyle had been resected, and two metal screws were visible at the angle of the mandible, indicating the placement of a costochondral graft which had resorbed. Although costochondral grafts are considered the "gold standard" in joint reconstruction of growing children due to their growth potential, they are prone to several problems such as graft failure, unpredictable growth, and ankylosis along with donor site morbidity.[6],[12] The failure of the graft resulted in deficient mandibular growth on the left side, resulting in the development of significant facial asymmetry. At the time of presentation, the patient exhibited a normal range of mouth opening. The magnitude of facial asymmetry present led to a surgical treatment plan which was promptly accepted by the patient because he was keen to improve his facial esthetics.

Surgically assisted rapid maxillary expansion was done to expand the arch and also to prevent the occurrence of posterior crossbite on mandibular advancement. The expansion of the maxillary arch resulted in a 5 mm increase in intercanine width, providing some space for retraction of the anterior teeth and reduction of the overjet. Extraction of a lower incisor provided space to resolve crowding and improve Bolton's ratio.

CBCT images and mock surgery on the models helped quantify the movements required to correct the asymmetry in the lower third of the face. The asymmetric overgrowth of the ipsilateral maxilla had shifted the midline and slope of the maxillary plane. LeFort I osteotomy was used to realign the maxilla with the facial midline and correct the occlusal cant of 14 mm along with an asymmetric advancement and rotation of the mandible with a bilateral sagittal split osteotomy.

  Conclusion Top

The esthetic result and occlusal outcome in the present case of facial asymmetry secondary to TMJ ankylosis were achieved by an orthosurgical approach assisted with 3D CBCT imaging.

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


Conflicts of interest

There are no conflicts of interest.

  References Top

Cheong YW, Lo LJ. Facial asymmetry: Etiology, evaluation, and management. Chang Gung Med J 2011;34:341-51.  Back to cited text no. 1
Lundström A. Some asymmetries of the dental arches, jaws, and skull, and their etiological significance. Am J Orthod 1961;47:81-106.  Back to cited text no. 2
Bishara SE, Burkey PS, Kharouf JG. Dental and facial asymmetries: A review. Angle Orthod 1994;64:89-98.  Back to cited text no. 3
Obwegeser HL, Makek MS. Hemimandibular hyperplasia – Hemimandibular elongation. J Maxillofac Surg 1986;14:183-208.  Back to cited text no. 4
Thiesen G, Gribel BF, Freitas MP. Facial asymmetry: A current review. Dental Press J Orthod 2015;20:110-25.  Back to cited text no. 5
Movahed R, Mercuri LG. Management of temporomandibular joint ankylosis. Oral Maxillofac Surg Clin North Am 2015;27:27-35.  Back to cited text no. 6
Lello GE. Surgical correction of temporomandibular joint ankylosis. J Craniomaxillofac Surg 1990;18:19-26.  Back to cited text no. 7
Singh H, Srivastava D, Kapoor P, Sharma P. Surgical orthodontic correction of mandibular laterognathism. J Orthod Sci 2016;5:74-80.  Back to cited text no. 8
Terajima M, Nakasima A, Aoki Y, Goto TK, Tokumori K, Mori N, et al. A 3-dimensional method for analyzing the morphology of patients with maxillofacial deformities. Am J Orthod Dentofacial Orthop 2009;136:857-67.  Back to cited text no. 9
Cook JT. Asymmetry of the cranio-facial skeleton. Br J Orthod 1980;7:33-8.  Back to cited text no. 10
Sievers MM, Larson BE, Gaillard PR, Wey A. Asymmetry assessment using cone beam CT. A class I and class II patient comparison. Angle Orthod 2012;82:410-7.  Back to cited text no. 11
MacIntosh RB. The use of autogenous tissues for temporomandibular joint reconstruction. J Oral Maxillofac Surg 2000;58:63-9.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]

  [Table 1]


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