Warning: Constant WP_CACHE already defined in /home/smbalnoi/backup.drsmbalaji.com/wp-config.php on line 86 Surgery – Page 8 – Balaji Dental and Craniofacial Hospital, Chennai, India
Patient involved in a two wheeler accident on the way to work
The patient is a 32-year-old woman from Bengaluru in Karnataka, India. Around three years ago, she had been on her way to work as usual on her motor scooter. A car had swiped her scooter from the side and she had lost her balance.
She ended up impacting her midfacial region on the edge of a culvert. The patient had passed out following the accident and an ambulance had been summoned.
Emergency treatment had been administered and imaging studies obtained of the facial region. This had revealed that there was a left zygomatic complex fracture with orbital floor blowout fracture. The patient had been presented with a treatment plan and had been operated on the day following the accident.
Residual facial defects from improper positioning of fracture fragments
Soon after recovering from the surgery, the patient realized that she had developed double vision. There was also an esthetic deformity from the surgical correction. Her left eye was smaller and eye level was depressed. Even though this was disconcerting, it did not hinder her activities of daily living. She had learnt to live with it due to other important commitments.
Around a month ago, a friend who met her after many years expressed shock at her appearance. She said that the patient should not compromise on something as major as her health. Realization hit her with her friend’s insistence that she get this treated.
Her family too had been admonishing her for neglecting this. They then began making enquiries regarding the best treatment center to get her deformities addressed. They were referred to our hospital for management of her condition. Our hospital is a premier center for corrective facial surgery for failed surgeries performed at other centers.
Patient and her family present at our hospital for resurgery of facial fracture
Dr SM Balaji, facial resurgery specialist, examined the patient and obtained imaging studies including a 3D CT scan. Examination revealed that the left eye was smaller than the right as stated by the patient. Imaging studies revealed that the entire fractured segment was rotated medially and downwards. This was the result of poor reduction of fracture segments.
The muscles of the floor of the orbit were also abnormally positioned as a result of the orbital floor blowout fracture. This also needed to be addressed and corrected for the patient to regain completely normal 20/20 vision. Detailed treatment planning was formulated and explained to the patient. She expressed approval of the treatment plan and consented to undergo surgery.
There would be no necessity for bone grafts with this surgery. When there is the necessity for a bone graft for a large defect, it is usually harvested from the iliac crest or the ribs.
Successful surgical correction of surgical deformities resulting from previous surgery
Under general anesthesia, attention was first turned towards correction of the malunited zygomatic complex fracture. The plates from the previous surgery had been placed through a laceration that had resulted from the accident.
Dr SM Balaji accessed the malunited fracture site through an intraoral approach. This was to avoid scar formation. An angled screwdriver was utilized to remove the old plates and screws.
Correct repositioning of the malunited fracture segments for good facial symmetry
The malunited fracture segments were disjointed and the entire segment was upwardly and laterally rotated. This corrected the downwardly placed deformity of the left eye. This was then stabilized using titanium plates and screws.
Attention was then turned to repairing the blowout fracture of the orbital floor. A lateral canthal incision was made followed by a transconjunctival incision. The floor of the orbit was explored and all abnormal connective tissue and extraocular muscle attachments were released. The orbital contents were back in their normal anatomic position now.
Following this, a titanium mesh coated with Medpor was used to reconstruct the orbital blowout fracture. This was stabilized with screws to the inferior orbital border. All incisions were then closed with sutures. The patient was then extubated and taken to recovery in stable condition.
Complete normalization of the residual facial deformities from previous surgery
There was complete resolution of the patient’s facial deformities. Her eyes were symmetrical and there was complete resolution of her double vision. There were also no visible scars as the fracture had been approached intraorally. The patient and her family expressed their thankfulness to the surgical team before final discharge from the hospital.
Patient with excessive mandibular protrusion since an early age
The patient is a 22-year-old woman from Manimala in Kerala, India. She states that she always remembers having a large lower jaw. Her chin bone too was extremely prominent. This had always detracted from her overall facial appearance. She remembers being bullied at school because of this.
Eating too had always been difficult because of this. She states that certain consonants were also distorted due to the protrusion of her mandible. Teachers had always complained that she needed to speak clearly in order to be understood. All these factors had resulted in the patient being quiet and withdrawn during her growing years.
Patient referred to our hospital by a visiting dentist in her hometown
Around six months ago, a visiting neighbor who was an Ernakulam-based dentist had advised her to get this surgically corrected. He had spoken about the benefits of undergoing surgical correction of her mandibular prognathism. Explaining further, he had said that it would greatly improve both her esthetics and functioning.
The visiting dentist explained that the surgical technique used for mandibular prognathism reduction surgery required an experienced surgeon. This would ensure that there was no damage to the inferior alveolar nerves bilaterally. The patient had then been referred to our hospital for lower jaw reduction surgery.
Our hospital is a specialty oral and maxillofacial surgery center for Orthognathic surgery. Jaw reconstruction surgery, jaw advancement surgery, mandibular reconstruction surgery, jaw joint reconstruction surgery and various other surgeries are performed here.
Cosmetic surgical procedures like chin augmentation surgery, chin reduction surgery and mandibular angle reduction surgery are also performed at our hospital.
This surgery cannot be performed in pediatric patients with mixed dentitions. Growth has to be completed before undertaking this surgical correction. This rarely results in temporomandibular disorders.
Initial presentation for mandibular reduction surgery at our hospital
Dr SM Balaji, jaw surgery specialist, examined the patient and obtained imaging studies including a 3D CT scan. The patient had a skeletal anterior cross bite. There was a mandibular overjet of around 8 mm.
Molars were in a class III relationship. This was causing a great deal of inconvenience to the patient’s activities of daily living.
Meticulous treatment planning was performed for the patient. It was then decided to perform Obwegeser’s bilateral sagittal split osteotomy with a setback of 8 mm of the mandible. This would result in perfect occlusion of the teeth along with establishment of a pleasing facial profile.
Treatment planning was explained in detail to the patient and her parents. The following doubts were cleared for them. Mandibular nerves would be carefully protected from injury during surgery. The temporomandibular joint was not a factor in this surgery. They were in complete agreement with the proposed treatment plan and consented to surgery.
Successful completion of the mandibular setback surgery for prognathism correction
Under general anesthesia, incisions were made and flaps were raised down to the body of the mandible. Obwegeser’s bilateral sagittal split osteotomy was then performed. An osteotome and oscillating saw were used to perform this portion of the procedure.
Care was taken to ensure that the inferior alveolar nerve was in the distal segment. This would ensure that there was no damage to the nerve during the entire surgical procedure. The mandible was then set back with removal of 8 mm of excess bone.
Occlusion was checked and temporary intermaxillary fixation was done. The mandibular segments were then stabilized with titanium plates and screws.
The intermaxillary fixation was released and incisions were closed with sutures. The mandible was now in a class I molar relationship with the maxilla.
Total patient satisfaction with the results of the surgery
The patient and her parents were very happy with the results of the surgery. There was an immediate improvement in the patient’s esthetics and function. Her speech was also normal now and easily understood. Facial features were also very esthetic in appearance. They expressed their thankfulness to the surgical team before final discharge from the hospital.
Rehabilitation of patient born with bilateral cleft lip and palate deformity
The patient is an 18-year-old male from Warangal in Telangana, India. He had been born with a bilateral cleft lip, palate and alveolus deformity. His distressed parents had been counseled extensively at his birth by a dental professional. It was explained to them that there was no reason for them to worry. They were informed that surgical intervention would completely normalize the baby’s deformities.
A local oral surgeon who examined the baby had referred the parents to our hospital. The parents had presented with the baby to our hospital. They had been counseled that he needed cleft lip surgery at 3 months and cleft palate surgery at 8 months. This would be followed by cleft alveolus repair with premaxillary setback and bone grafting at 7 years.
Successful surgical repair of his cleft lip, palate and alveolus on schedule
Parents had rigorously followed our advice regarding surgical intervention for his cleft defects. All the surgeries had been successful and the patient had met all his developmental milestones appropriately. The patient also underwent a pharyngoplasty at 3-1/2 years of age. He therefore had normal development of speech.
The parents were counseled that the patient needed to be routinely followed up by an orthodontist. His first orthodontic consultation was around the age of 9. He underwent palatal expansion at the age of 12. Palatal expansion is usually undertaken for correction of posterior crossbite. Skeletal anterior cross bite requires orthognathic surgery.
Orthodontic care can be commenced in patients with mixed dentitions. Many permanent teeth have erupted by this age. He also had many teeth from his deciduous dentition. Routine orthodontic intervention was undertaken.
With the passage of time, he however developed anterior crossbite due to a retruded maxilla. This began interfering with his speech and chewing too became difficult due to this. He was therefore scheduled for surgical advancement of his retruded maxilla. Board certified members of the American society of plastic surgeons also perform orthognathic surgery in America.
Patient returns with his parents to our hospital for forward positioning of his maxilla
Dr SM Balaji, facial cosmetic surgeon, examined the patient and obtained imaging studies. The patient had an anterior skeletal crossbite due to his maxillary retrusion. This had been causing him problems with his eating and speech for many years now. There was also a degree of dental malocclusion with malaligned teeth.
It was explained to the patient that this was the right time for him to undergo surgical correction. Treatment planning was explained to the patient and his parents. He would first undergo treatment with fixed orthodontics to correct his malaligned teeth. This would be followed by Le Fort I osteotomy for forwarding positioning of his maxilla.
The patient and his parents expressed understanding of the treatment plan and consent to undergo surgery.
Successful alignment of patient’s jaws with orthodontics and maxillary advancement surgery
The patient first underwent fixed orthodontic treatment. His dental arch form was restored and he was scheduled for surgery. His maxillary right central incisor, which was periodontally compromised, became mobile during the course of orthodontic treatment. It was therefore decided to extract it and replace it with a Nobel Biocare dental implant during surgery.
Under general anesthesia, a vestibular incision was made in the maxilla followed by a Le Fort I osteotomy. The maxilla was disjointed and advanced anteriorly. Occlusion was checked and it was then stabilized in position using titanium plates and screws.
Attention was then turned to the mobile central incisor, which was extracted. A dental implant was fixed in the socket and all incisions were closed with sutures. The patient and his parents were very happy with the results of the surgery. The patient now had a very pleasing profile with the forward advancement of the maxilla.
It was explained to the patient that a ceramic crown would be placed after osseointegration of the dental implant.
Patient with long standing dissatisfaction over the structure of his face
The patient is a 25-year-old male from Haridwar in Uttarakhand, India. He states that he had always had a small lower half of face. Both his maxilla and his mandible were extremely retruded. The patient had always disliked his facial structure because of this. He stated that he has no history of childhood trauma or any other issues that could have caused it.
His maxillary and mandibular retrusion were not only esthetically compromising, but also compromised function. He had been troubled with breathing problems since he was a little boy. His sleep had been disturbed and he would often wake up gasping for air. He had always had daytime somnolence and this had caused a lot of trouble with his teachers in school.
These problems had persisted all through his life. It was only about two years ago that a colleague had suggested that this could be corrected through surgery. The patient and his parents immediately fixed an appointment with a facial cosmetic surgeon in a nearby city.
Sleep study with resultant diagnosis of obstructive sleep apnea
A sleep study had been obtained with the diagnosis of obstructive sleep apnea. They had been advised that he needed jaw advancement surgery. The patient and his parents had consented to the proposed treatment plan. Subsequently, the patient had undergone bijaw surgery with advancement of both his maxilla and mandible.
The patient had been sorely disappointed with the results of the surgery. He still felt that the lower third of his face was disproportionately small compared to the rest of his face. His sleep apnea problems had also not been resolved. He still woke up tired from a full night’s sleep.
Determined to get relief from the problems that had troubled him all his life, he started making enquiries regarding corrective surgery. It was at this point that he met an old friend who had got full relief from similar problems. This friend who had been plagued by sleep issues had been operated in our hospital.
Referred by his friend, the patient immediately got in touch with our hospital manager. He was asked to send his imaging studies following which an appointment was fixed for him to come for consultation.
Patient presents with comprehensive records at our hospital
Dr SM Balaji, jawline correction specialist, examined the patient and ordered imaging studies including a 3D CT scan. This revealed that the patient had very short bilateral rami. It was explained to the patient that he had reduced airway space because of this. This was causing his tongue to fall back into the throat, causing the nighttime awakening.
A sleep study was performed, which revealed very poor oxygen saturation levels. This revealed that the previous surgery had done little to relieve the patient’s obstructive sleep apnea.
Treatment planning was then explained to the patient in detail. Bilateral mandibular distraction osteogenesis would be performed for the patient. This would result in lengthening of the bilateral rami. Lower facial height would also be increased thus improving esthetics.
Successful bilateral internal mandibular distractor fixation surgery performed
Under general anesthesia, bilateral mandibular vestibular incisions were made with dissection down to the ramus. Old plates were then unscrewed and removed from the body of the mandible. Bone cuts were made to the ramus followed by fixation of the internal mandibular distractors. Distraction function was checked and found to be optimal. Incisions were then closed with sutures.
A maxillary vestibular incision was then made followed by removal of all the plates fixed at the previous surgery. The maxilla was then disjointed followed by intermaxillary fixation. This would ensure that the patient had perfect occlusion.
A latency period of five days was allowed following placement of distractors. Bilateral ramus distraction of 1 mm was performed per day after completion of the latency period. A total of 18 mm of distraction was done over a period of 18 days.
Resolution of obstructive sleep apnea with resultant increased oxygen saturation
There was dramatic improvement in the quality of the patient’s sleep after completion of the distraction. He also expressed his happiness with his facial esthetics. It was explained to the patient that the distractors will remain in place for a period of four months. This would allow for consolidation of new bone formed at the site of distraction.
The patient was instructed to return after four months for distractor removal surgery. He expressed understanding of the instructions and expressed his satisfaction at the results of the surgery.
Patient with lower facial asymmetry manifesting at birth
The patient is a 7-year-old female from Hastinapur in Uttar Pradesh, India. She had a minor degree of facial asymmetry at birth. This gradually worsened with age. It soon became apparent to her parents that there was an abnormality underlying her condition.
Worried over the turn of events, when she was around three years old, they had taken her to a local hospital.
Suspecting this to be the result of a genetic abnormality, they had been advised gene testing. Gene testing had revealed that the patient had the genetic abnormality linked to hemifacial microsomia.
Hemifacial microsomia explained to allay fears of the parents
The process causing hemifacial microsomia usually begins by the first trimester. It is still unclear as to the exact cause behind this condition. One probable cause could be disruption of vascularity to the face of the developing fetus. Though it usually manifests unilaterally, it can also occur bilaterally.
No external causes have been identified that lead to hemifacial microsomia. These include mother’s diet, metabolic conditions like diabetes or other such factors.
Parents were extensively counseled regarding the condition. It was explained to them that she had unilateral hemifacial microsomia, which involved her left lower face. There was also a minor deformity to the pinna of the left ear. They were informed that this would require cosmetic ear surgery at a later date.
Patients with hemifacial microsomia do not have prominent ears. Plastic surgeons perform ear reconstruction in most western countries.
The parents were advised that surgical correction of the deformities would be required for the patient at the appropriate ages. This would also include reconstruction of the affected side of the mandible.
Parents decide to seek consultation for correction of facial deformity
Deciding to get her condition corrected surgically, parents made widespread enquiries regarding the best surgeon to address this problem. They finally decided to come to our hospital for surgical management. Our hospital is a specialist craniofacial center with a dedicated craniofacial team.
Our hospital is a renowned center for facial asymmetry correction. Facial asymmetry arising from varied causes such as cancer, trauma and congenital causes are corrected surgically in our hospital. Facial reconstructive surgery is a specialty feature that has won accolades through our craniofacial program.
Initial presentation at our hospital for treatment of hemifacial microsomia
Dr SM Balaji, hemifacial microsomia surgery specialist, examined the patient and obtained comprehensive imaging studies including a 3D CT scan. This revealed that ramus and condyle were missing on the left side. There was no TMJ structure present. The patient had deviation of the mandible to the left side.
A comprehensive treatment plan was formulated and explained to the patient’s parents. It was explained that distraction osteogenesis cannot be performed due to insufficient bone. A costochondral rib graft with perichondrium would be harvested from the patient.
Harvesting with the perichondrium would enable lengthening of the ramus through growth as the patient grows up. In case growth of the ramus does not occur, ramus lengthening surgery through distraction osteogenesis would be performed.
The patient would also need TMJ reconstruction surgery at a later date. Parents expressed understanding of the treatment plan and consented to surgery.
Successful surgical placement of rib graft to posterior ramus
Under general anesthesia, an inframammary incision was made and a costochondral rib graft was harvested. This was followed by a Valsalva maneuver to ensure that there was no perforation of the thoracic cavity. The incision was then closed in layers with sutures.
Attention was next turned to the left ramus region of the mandible. An incision was made to expose the underdeveloped left ramus. The mandible was then pulled down and the costochondral graft with perichondrium affixed to the posterior ramus using titanium screws.
This resulted in improvement in facial symmetry for the patient. The wound was then closed with sutures.
It was explained to the parents that the patient would require further surgeries for complete rehabilitation of her facial deformity. Parents expressed understanding of the information and expressed their thankfulness before final discharge from the hospital.
Patient involved in a minor road traffic accident as a child in her hometown
The patient is a 23-year-old female from Mallapuram in Kerala, India. She had been involved in a minor road traffic accident when she was a little girl. Her father had been riding his motorcycle with her seated in front of him. A cyclist had abruptly cut across their path, which had resulted in them skidding and falling down.
There were only minor bruises and scrapes resulting from the accident. She had complained of a mild pain on the left side of her face upon opening her mouth. This had however soon resolved. The patient and parents had completely forgotten about it and had got on with their lives.
Her parents gradually began noticing the development of a mild deviation of her lower jaw to the left. This progressively worsened until it became evident to even a casual observer. Worried about this development, her parents fixed an appointment with an oral and maxillofacial surgeon in a nearby city.
Failed temporomandibular ankylosis release with damage to facial nerve
The surgeon examined the patient and obtained imaging studies of her temporomandibular joint. This revealed that there was ankylosis of the patient’s left jaw joint. He explained to them that this was most probably caused by an injury to the joint at the time of the accident.
The parents were counseled that the patient needed temporomandibular joint ankylosis surgery. They consented to the treatment plan and the patient underwent surgery. This surgery was however a failure and the patient began complaining of an altered taste sensation following surgery.
Feeling despondent over these developments, they sought the advice of a family friend who was a medical professional. She made thorough enquiries regarding hospitals where the patient’s condition would be adequately treated. Deciding that our hospital met all the criteria listed by her, she referred them to us for surgical management.
Facial plastic or cosmetic surgery is routinely performed in our hospital. Distraction devices are used for gradually lengthening the bone through osteogenesis of the mandible. Mouth opening is enhanced through this procedure. Upper airway obstruction due to small lower jaw is also relieved through distraction. Cleft palate surgery is a superspecialty feature of our hospital.
Initial presentation at Balaji Dental and Craniofacial Hospital for consultation
Dr SM Balaji, temporomandibular joint ankylosis surgeon, examined the patient. He then obtained imaging studies including a 3D CT scan. The patient also demonstrated a significantly skewed occlusal cant.
The patient was informed her altered taste sensation was from facial nerve damage. This had been caused by her previous surgery. He advised that the patient undergo left TMJ gap arthroplasty with interpositioning of temporalis muscle.
This would be followed six months later by unilateral mandibular distraction and Le Fort I surgery. He also advised advancement genioplasty for overall good cosmetic results. The patient and her parents consented to the treatment plan and the patient had successful release of her joint ankylosis. They now present for the second stage of surgery.
Patient and her parents present for second stage of surgical correction
Dr SM Balaji, facial asymmetry correction surgeon, examined the patient and there was good movement of her previously ankylosed left temporomandibular joint. It was then decided to proceed with the next step of surgery. There would be correction of the mandibular asymmetry and the skewed occlusal cant following this surgery.
A left mandibular vestibular incision was first made following which a bone cut was made to the ramus. Mandibular distraction osteogenesis was then made with good demonstration of distraction upon activation of the device.
Interdigitation of the occlusal plane with good facial asymmetry
Attention was next turned to the Le Fort I osteotomy of the maxilla. The maxillary segment was disjointed. This was followed by advancement genioplasty, which gave the patient an esthetically pleasing chin. Transosseous wiring was then performed to fix the maxilla on the right side.
This was followed by intermaxillary fixation of the jaws. A latency period of five days will be allowed following which distraction will be initiated. It was planned to perform a total of 12 mm of mandibular distraction over a period of 12 days. The distractor will be left in place for four months for good bony consolidation at the site of distraction.
Complete patient and parental satisfaction at the results of the surgery
There was good establishment of facial asymmetry after completion of the distraction. The patient and her parents expressed their complete satisfaction with the results of the surgery. They expressed understanding of the instructions and will return in four months for distractor removal surgery.
