Download Soft tissue genioplasty

Soft tissue genioplasty
Corresponding Authors
Dr.Emtenan Al Majid, BDS, SB , OMFS
Senior Registrar in Oral and Maxillofacial Surgery Department in Riyadh
Military Hospital
Academic instructor for Dental assistant Diploma 412 in Riyadh military
Hospital
Peer-Reviewer in Saudi Medical Journal
E mail: [email protected]
Tel: 00966-503438268
Dr .Abdullah AlAtel, BDS, MSc, FRADS
Consultant and head of OMFS Department in Riyadh Military Hospital
Head of training activities in Saudi Board in Oral and Maxillofacial Surgical
Department.
E mail: [email protected]
Tel: 00966-503020274
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Soft tissue genioplasty
ABSTRACT
OBJECTIVE: to introduce a new non invasive surgical technique of genioplasty where the
mentalis muscle is advanced surgically for some selected indicated patients.
METHODS: the technique was carried out in the Department of Oral and Maxillofacial
Surgery in Riyadh Military Hospital, Riyadh city, Kingdom of Saudi Arabia 2005. Twenty
patients were enrolled and treated with soft tissue genioplasty (intramuscular tightening).preand post operative lateral cephalometric tracing were recorded with 6 years follow up .
RESULTS: In all patients, soft tissue analysis of the lower lip and chin in lateral cephalogram
were increased in horizontal and vertical dimensions demonstrating a good post operative
improvement and patient satisfaction within 6 years follow up.
CONCLUSIONS: Soft tissue genioplasty provides superior versatility in surgical alteration of
the chin morphology in horizontal and vertical dimensions utilizing mentalis muscle only
without any hardware. It is a time saving procedure obtained under local anesthesia. It
preserves mentalis muscle attachment without dissection of mental nerve.
KEYWORDS: mentalis muscle, genioplasty, intramuscular tightening.
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INTRODUCTION
Osseous genioplasty is an important technique in the surgical alteration of the chin123,
although the procedure is stable still it carries some risks of complications4567. In
somehow, osseous genioplasty has been overshadowed by the availability and
versatility of multiple techniques of chin surgery8910.
One of the new methods is introduced by the author, called soft tissue genioplasty
where the mentalis muscle is advanced surgically for some selected indicated patients
who indicate minor chin advancement with acceptable facial profile. The distinct
advantages of this technique include time saving, procedure obtained under local
anesthesia , preserving mentalis muscle attachment with favorable cervicomental
angle , dissection of mental nerve is prohibited , hardewares are not in need .The fact
that the procedure is less technicality demanding when compared to osseous
genioplasty and it can be utilized with other surgical procedure as osseous genioplasty
or submental liposuction as with all esthetic surgical procedures , the designed results
, wishes of the patient and associated risks of the procedure will drive the surgical
treatment plan .
MATERIALS AND METHODS
Pre operative consideration and treatment planning
The most critical consideration in the surgical alteration of the chin is the pre
operative assessment of the patient11. The wide variance of anatomical configuration
provides fertile ground for less than optimal post operative results without
understanding of the anatomy and esthetic of this region. The treatment plan of soft
tissue genioplasty should include full clinical assessment of patient expectation and
objectives, pre operative photographs including frontal, profile and submental
perspectives as well as appropriate imaging studies with lateral cephalometric
evaluation. Starting from January 2005 till October 2010, twenty female patients
medically fit with age ranging from 18-25 years were selected who indicate minimum
chin advancement with acceptable facial profile. This procedure is a modification of
an original one where all the patients were consented, therefore no need for ethical
approval letter. All the patients had post operative follow up for one year.
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Clinical and radiological examinations
Alteration of the profile to achieve appropriate esthetic balance is generally a major
objective of the genioplasty procedure and usually offers the largest magnitude of
contributions to facial balance clinical and radiological assessment (lateral
cephalometric tracing). Particularly the lower facial hight in proportion to the face, as
well as the width, shape and orientation of the chin in the frontal view. When
measuring the vertical height of the chin and lower lip should be appropriately two
third the height of upper lips (subnasalis to stomion) 12. The esthetic zone of the
labiomental fold and the consequences of altering this anatomical relationship should
be considered when performing genioplasty procedure. The depth of labiomental fold
dictated by the projection of the chin as well as lower incisor angulation in
relationship to the plane of inferior border of mandible as measured on lateral
cephalogram.
A posterior position of the chin (pog and pog' in lateral cephalogram) according to
zero Gonzales shouldn’t exceed more than 5 mm, otherwise osseous genioplasty is the
proper choice. Other orthognathic abnormalities needs to be documented such as
mandibular hypoplasia should alert the clinician to consider the necessity of
mandibular advancement procedure .camouflage type procedure are only indicated in
the events that the patient doesn’t wish to consider orthognathic surgery13. A
conservative approach regarding the magnitude of advancement should be adapted.
Operative technique
Genioplasty procedure may be performed within office based local anesthesia or
intravenous sedation technique, or with general anesthesia. In either case, the
administration of local anesthesia with vasoconstrictor is critical to provide
hemostasis as well as postoperative analgesia. Local infiltration of vestibular region
between the mental foramen as well as the attachment of the mentalis muscle will
significantly improve the surgical field during the dissection.
After administration of local anesthesia, vestibular incision is made extending from
the distal aspect of the canine tooth to the distal aspect of the contraletral canine. The
incision should be placed approximately 5-7 mm below the level of the attached
gingival, within the free gingival (which can be determined by pulling the lower lip
outward) 6. The incision should be placed perpendicular to the bony surface of the
mandible and oblique incisions are to be avoided. Sub periosteal dissection should be
performed to expose mentalis muscle, it is important to avoid transecting the belly of
the mentalis muscle as this will result in unwanted hemorrhage and will make the
dissection problematic14. Intra muscular tightening of mentalis muscle is performed
and raised superiorly for re- attachment using 1/0 dexon (figure 1). The mucosa is
then approximated with interrupted or 3/0 vicryle suture.
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All twenty patients had 6 years follow up with series of photos, lateral cephalometric
tracings and documented satisfaction questionnaires as below.
Not satisfied at all
Extremely satisfied
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Figure 1.intraoperative mentalis muscle tightening.
Results
Immediately post operatively there was no edema in the chin, floor of the mouth and
submental zone because of the limited area for dissection and short procedure (around
10 minutes). The patients have no neurosensory disturbance because the mental
bundle was not dissected in this technique.
Post operative cephalometric soft tissue tracing showed significant changes in
Vertical and sagittal parameters mostly lower facial height (around 4-6 mm) and
thickness of the chin (around 4-7 mm) summaries in Table 1.
All twenty patients had 6 years follow up with series of photos, lateral cephalometric
tracings and documented satisfaction questionnaires revealing unchanged results with
high satisfaction more than 95 %. (Figure 2)
Vertical and sagittal
parameters
Mean pre- operative
lateral cephalometric
tracing measures in
millimeters for twenty
patients
Mean post operative
lateral cephalometric
tracing measures in
millimeters for twenty
patients
Difference in millimeters
1
2/3 lower facial
height
45
49
4
Position of vermillion
border
12
13
1
Exposure of lower
incisors
0
2
2
Labiomental fold
distance
13
17
4
Lower lip thickness
13
--
--
Thickness of
labiomental fold
10
14
4
Thickness of chin
12
15
3
Angle of the fold
0
--
--
Table 1. Vertical and horizontal parameters.
Satisfaction score
Figure 2: patient’s satisfaction following soft tissue genioplasty.
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Discussion: soft tissue genioplasty is a new method introduced by the authors when
mentalis muscle advanced surgically for some selected patients who indicates minor
chin advancement with acceptable facial profile. It is a time saving procedure
obtained under local anesthesia preserving mentalis muscle attachment with favorable
cervicomental angle without any hardwares and it can be utilized with other surgical
procedures as osseous geioplasty or submental liposuction.
One of the most important advantages for this procedure is the post operative lack of
edema and neurosensory disturbance because of limited dissection of mentalis muscle
and mental nerve bundle.
In this study, post operative laeral cephalometric soft tissue tracing for the twenty
patients showed significant changes in vertical and sagittal parameters mostly lower
facial height and chin thickness sustained for up to 6 years follow up with satisfactory
results . At the end, patient’s selection, wishes of the patient, designed results and risk
of the procedure will drive surgical treatment plan.
Case#1
18 years old Saudi female medically fit complaining from small chin, she wants minor
surgical procedure under local anesthesia.
Pre operative work up
Pre-operative frontal and lateral profiles
Pre-operative lateral cephalometric tracing.
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Post operative work up
Post-operative frontal and lateral profiles
Post-operative lateral cephalometric tracing.
Post operative parameters
Case # 2
Pre operative photo
postoperative photo
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