The Transoral Chin Correction

Historical Background
Retrogenia

Chin Anomaly

Hypergenia

Hypogenia

Historical Background
Retrogenia Cases A bone graft was onlayed via a submental approach.
Often enough the bone graft was just placed around the cortical surface with some cancellous bone on the contact area

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Temporarily produce quite a pleasing chin prominence

Risk for possible infection Submental Scar Second operation at donor site for the bone graft Resorption of the bone graft within a year

Cortical bone shrinks like a mushroom in the sun, and cancellous bone melts away like ice cream when used as an onlay graft for contour correction. (Principle Nr.18)

Historical Background
Selections of Material Used
Autogenous bone Autogenous rib cartilage Alloplastic material :
Titanium mesh (K.H. Thoma 1948) Acrylic Prefabricated silastic chin implants
High incidence of problems. It could erode into the bone and come to rest against the roots of the patients front teeth due to the pressure from the advanced soft tissues. High incidence of infection. Secondary displacement. Dehiscence of the suture line. The need for a second operation. The graft quietly disappeared.

Historical Background
H.Obwegeser (1957)
Hyper and/or hyporetrogenia : Slide the lower border of the chin forwards and upwards, leaving it pedicled on the digastric and geniohyoid muscles. H. Obwegeser also did chin advancement transorally, using J.M. Converses degloving technique.

Historical Background
Steps on doing the chin advancement (H. Obwegeser, 1957)
Cut off lower border of chin with a Lindemann bur. The osteotomy line is from low posteriorly to higher anteriorly. Pull the bone forwards by 10 mm, pedicled on geniohyoid muscles. Fix the advanced chin horseshoe with a strong perimandibular Supramid thread on each side over an acrylic dental splint, so as to permit removal of the thread after three weeks.

Historical Background
O. Hofer (1942)
Sliding the inferior border of the chin forwards, from extraoral approach leaving it muscle pedicled on the platysma, digastric, and the geniohyoid muscles. The operation is performed on cadaver using a rather large bone saw.

Historical Background
O. Neuner (1965)
Double step advancement technique.
But, in follow up investigations, 50% resorption occured, however some of it was transformed into soft tissues, decreasing the amount of loss of contour. Later, H. Obwegeser always left the advanced inferior border musclepedicled again. Follow up study shows on average 10% resorption and even that amount often found to be transformed into soft tissue, thus producing the planned amount of prominence advancement.

H. Obwegeser (1974)
In appropriate cases, one can even perform triplestep advancement. Steps :
Free all the musculature Trim and shape to the requirements Fix it with direct wires

Material used :
Deep frozen cancellous cadaver bank bone. (But even without it he usually found new bone formation in the step area)

H. Obwegeser Final Method

The vestibular incision is made approximately 5-8 mm labial to the depth of vestibulum at a right angle at mucosal surface only, and then directed horizontally to the alveolar process.

The periosteum is incised from underneath the mental foramen as far back as necessary, from one side to another.

The direction of the bone cut has to be determined preoperatively on a tracing of the lateral cephalogram, on which the desired profile line has been drawn. According to that planning, the lower border chin has to be moved : Forwards : for correction of retrogenia Upwards and if necessary by excision of a strip of bone below the teeth : for correction of severe hypergenia or in cranially convex curvature for the correction of hypo- and retrogenia.

H. Obwegeser Final Method

The tracing with the desired profile line permits the use of transparent foil which is cut according to the existing shape of the bony chin to simulate the osteotomy necessary to achieve the planned result. If >8 mm advancement is necessary a double-step advancement should be planned. (On rather larger steps, soft tissue line will show and may be fixed into that step). The more the chin has to be advanced, the further back the bone cut will be, in particular when performing doule or triple-step advancement. The mental nerve must be well protected, The more soft tissues are left attached to the piece of bone which is to be moved, the less resorption of the moved segment will take place.

H. Obwegeser Final Method

H. Obwegeser personally like to use a reciprocating saw with thin disposable blades.
A. Triaca usually use rather use short, hard steel bur normally used in dental laboratory work (Maillefer No. 540). A.Triaca does not free the prominence of the chin from the investing soft tissues completely. He leaves the inferior part of the mentalis muscle attached to it. He only frees the lower border in the area where the osteotomy reaches it. He resects the lingual rim of the detached chin prominence with the detached musculature using the same bur in order to reduce its backwards pull when the chin is moved anteriorly. This seems much better than dissecting the insertion of the musculature.

H. Obwegeser Final Method

The technique for enlarging or reducing the width of horse-shoe shaped lower border remains the same as published in 1958. When there is need to correct hypogenia, again the desired profile line tracing is used to ascertain whether an upwardlycurved, almost semicircular bone cut will achieve the planned result or whether the sandwich technique (J.M. Converse 1964) has to be used to achieve the necessary height increase.

Final Method
H.Sailer (1985)
The asymmetric chin prominence, not only present in case of hemifacial microsomia but also in condylar hyperactivity cases, deserves special consideration. H. Sailer (1985) has suggested his socalled chin propeller technique.

Another simple way is to cut the detached lower border into two unequal segments, using the symphysis as the site of the cut. Then the longer part is shortened so that from medial to lateral both are equal in length. Both segments are fixed together and to the chin.

Final Method
Chin reduction is less often necessary than the correction of lack of its vertical height or horizontal length. The type of correction of surplus of the bony chin depends on its existing and the desired shape. To correct a horizontal surplus by trimming it off with a bur seems the easiest way. In my hand that very rarely produced a pleasing result. Almost always the prominence became too rounded. A much more pleasing result is achieved by a rather vertical strip excision. If the chin is too high (deep) in its vertical dimension preferably a wedge shaped piece will have to be excised, as shown in the illustration (H. Kole 1970).

Final Method
Smith (1985)
The soft tissue surplus in the chin region is more difficult to correct than are the bony abnormalities. A certain amount of contour reduction can be achieved by reducing the underlying bony chin. But there are cases which definitely need soft tissue excision, skin as well as subcutaneous tissues and musculature.

Fixation
Lag screws with 1,5 mm Designed plates Wires **Nowadays varies from surgeon to surgeon

Fixation

How to prevent Suture Dehiscence

The knife must cut the mucosa at a right angle to the mucosal surface permits good adaption of the wound edges With the subsegment vertical cut to the chin area, quite a bit of musculature remains on the chin Method of managing and closing incision line When closing the wound, this permits a better bite with the needle than when mucosal edges only are approximated The handling of the edges of the mucosa Better not to use toothed forceps to hold the edges. Fine single hooks do less harm. The types of material used No hydrophilic thread is any good. It absorbs saliva and conducts infection into and underneath the approximated edges.

Suturing Method
Suture Material Used
Supramid. A suture material which is not as stiff as a monofilic thread as it consists of a great number of very fine filaments which are covered by a layer of nonhygroscopic material. Submucosal catgut sutures too difficult too insert. H. Subwegeser prefers Continuous sutures, changing between a vertical mattress type to an ocassionally ordinary continuous sutures. Compress the soft tissues towards the chin, particularly above the advances part, with some slightly elastic strips.

Types of Suturing

Post-Operative Care

Principal Complications, How to Deal with Them and Avoid Them

Problems during surgery
Bleeding The Mental Nerve Wrong directions of the bone cut Problems with fixation Losing a piece of bur or a saw blade

Problems after surgery

Infection with slight pus discharge Suture dehiscence Relapse Resorption Unaesthetic chin-neck contour

Unsightly upward retraction of the skin behind the advanced prominence.