TMJ Ankylosis Surgery and Jaw Distraction Surgery
A 23-year-old girl from Guntakal with facial deformity The patient is a 23-year-old female from Guntakal in Telangana, India. She had fallen down and injured her jaw while playing with friends as a little girl. The patient had landed on her chin and had cried incessantly for a few days. Her parents had taken her to a nearby hospital where they had prescribed her analgesics. She soon returned to her normal playful ways once the patient had subsided. As the patient grew up, her parents began noticing that her lower jaw growth was lagging. It soon reached the point where she had gross deformity of her lower jaw. Her mouth opening was also very much reduced and she began to have difficulty eating and with speech. There was rigidity to the position of her lower jaw. TMJ ankylosis surgery of her jaw joint Her parents had taken her to an oral surgeon in Hyderabad for consultation. He had diagnosed the patient to have left-sided TMJ ankylosis. There was a deviation of her mandible to the left side. He had recommended surgical release of her ankylosed joint. Her parents had consented to surgery and she had undergone TMJ ankylosis surgery. She now had a degree of facial asymmetry that interferes with her activities of daily living. She has lost all self confidence and rarely leaves the house. This had worried her parents endlessly and they had presented to a local oral surgeon for consultation regarding her problem. Upon examining the patient, he had realized the degree of correction needed for the patient was extreme. Explaining this to the patient, he had explained the mechanism of distraction osteogenesis surgery to them. He had then referred them to our hospital for facial asymmetry surgery to correct her facial deformity. Our hospital is a specialist center for facial deformity correction in India. Hundreds of people with facial deformity are rehabilitated in our hospital through distraction osteogenesis and Le Fort osteotomy surgery. Many patient have provided testimony about how surgery at our hospital has completely transformed their lives. Initial presentation and examination at our hospital Dr SM Balaji, facial deformity surgeon, met with the patient and her parents and obtained a detailed history from them. This was followed by a thorough clinical examination of the patient’s lower face. He then ordered comprehensive imaging studies for the patient including a 3D CT scan. The patient was diagnosed with a mandibular asymmetry caused by the TMJ ankylosis. This had caused a shift of the mandible to the left side. There was also an obvious facial asymmetry as a result of this. The patient had minimal mouth opening with poor oral hygiene. There was also an obvious occlusal cant that had resulted from the long standing ankylosis. Imaging studies revealed that the right side of the mandible was longer than the left side. Treatment planning explained in detail to the patient The patient would need treatment on the left side even though the defect was on the right side. This correction would be achieved through mandibular distraction on the left side. A mandibular ramus distractor would be fitted on the left side of the mandible. The patient and her parents expressed understanding of the treatment and consented to surgery. Successful correction of the facial asymmetry through distraction Under general anesthesia, an incision was made in the left mandibular retromolar region with elevation of a mucoperiosteal flap. Bone cuts were then made to the outer cortex of the ramus of the mandible. This was followed by fixation of the mandibular ramus distractor using titanium screws. The inner cortex of the mandible was then cut to facilitate movement of the proximal bone segment. Extreme care was taken throughout to prevent any injury to the inferior alveolar nerve. A sulcular incision was then made in the maxilla. This was followed by Le Fort I osteotomy. The maxilla was then mobilized and the posterior end of the left maxilla was fixed using transosseous wires. Hemostasis was achieved and closure was done. Postsurgical treatment phase for the patient Interarch wiring was done to stabilize the maxillary segment. A latency period of about six to seven days was then given. Following completion of the latency period, the distractor was activated by 1 mm every day. After achieving the desired increase in length of about 23 mm, the distraction process was stopped. Two weeks after this, a straight plate was fixed to the left posterior maxilla to prevent further downward movement. There was complete correction of the occlusal cant at the end of this procedure. Radiographs were then obtained after a period of about four months. This revealed complete consolidation of bone at the distraction site in the mandible. Radiographic evaluation revealed complete bone formation with a patent nerve canal. It was then decided to remove the distractor. Removal of distractor after bony consolidation Under general anesthesia, an incision was made followed by elevation of a flap. The distractor was then exposed and successfully removed without incident. The flap was then closed using sutures and the patient recovered from general anesthesia without incident. Return of self confidence and confidence following successful surgery The patient and her parents were very happy with the outcome of the surgery. She now had a very pleasant face with symmetrical profile. Her self confidence levels had improved dramatically within a short period of time. She said that she could now face the world bravely and expressed her thankfulness for restoring normalcy back to her life. Surgery Video
Oral Rehabilitation with Dental Implants
[vc_section content_layout=”full” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_row content_layout=”boxed” equal_height=”” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_column layout=”normal” vertical_align=”top” animation_delay=””][vc_column_text]This is a case of a 65 year old male who approached us with a desire to replace his missing teeth with dental implants. He gives a history of long standing periodontal pathology 5 years ago, due to which he had to get all his lower teeth and few of his upper teeth extracted elsewhere. Since then, he has been using removable dentures to replace his missing teeth. He seemed to be a reputed politician who is in a position to constantly communicate with his fellow members. Having said that, he feels that he is not able to convey his message and commands effectively to his team due to the insecurity of wearing dentures. Hence the he wanted to go for a fixed option that can restore his confidence. Patient gives a medical history of taking medication for diabetes and hypertension for the past 10 years.[/vc_column_text][vu_heading style=”2″ heading=”EXAMINATION OF THE PATIENT” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]On clinical examination, most of his teeth were missing with only afew teeth in the upper jaw left. No pathological findings seen intra-orally. On radiological examination, OPG taken shows missing teeth in the upper and lower jaw. The bone height in the both the jaws were also sufficient enough to go for a fixed teeth replacement option. Blood investigation revealed blood glucose level slightly over the normal range. His blood pressure was within the normal range.[/vc_column_text][vc_row_inner equal_height=”” animation_delay=”” disable=”” id=”” class=””][vc_column_inner vertical_align=”top” animation_delay=”” width=”1/3″][vc_single_image image=”6247″ img_size=”full” add_caption=”yes”][/vc_column_inner][vc_column_inner vertical_align=”top” animation_delay=”” width=”1/3″][vc_single_image image=”6248″ img_size=”full” add_caption=”yes”][/vc_column_inner][vc_column_inner vertical_align=”top” animation_delay=”” width=”1/3″][vc_single_image image=”6249″ img_size=”full” add_caption=”yes”][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][/vc_section][vc_row content_layout=”boxed” equal_height=”” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_column layout=”normal” vertical_align=”top” animation_delay=””][vu_heading style=”2″ heading=”TREATMENT PLAN” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]After thorough examination and considering his need and social status, Dr.SM Balaji planned to place dental implants at the relative site under local anesthesia, later followed by fixed prosthesis onto the implants. The surgical procedure was clearly explained to him. Patient’s consent was obtained.[/vc_column_text][vu_heading style=”2″ heading=”DENTAL IMPLANT PLACEMENT” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]Under local anesthesia, Dr.SM Balaji incised and elevated the gum tissues exposing the underlying upper and lower jaw bone. After a sequence of drilling protocol, dental implants of perfect size were fixed in the jaw bone with stability. Finally, the gum tissues were approximated with absorbable suture.[/vc_column_text][/vc_column][/vc_row][vc_row content_layout=”boxed” equal_height=”” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_column layout=”normal” vertical_align=”top” animation_delay=”” width=”1/2″][vc_single_image image=”6251″ img_size=”full” add_caption=”yes”][/vc_column][vc_column layout=”normal” vertical_align=”top” animation_delay=”” width=”1/2″][vc_single_image image=”6252″ img_size=”full” add_caption=”yes”][/vc_column][/vc_row][vc_row content_layout=”boxed” equal_height=”” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_column layout=”normal” vertical_align=”top” animation_delay=””][vu_heading style=”2″ heading=”POST TREATMENT FOLLOW-UP” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]He was asked to report after 3 months for placement of the final prosthesis as the dental implants require sufficient time to osseointegrate with the jaw bone. Post oral care instructions were briefed. Meanwhile a lightweight temporary prosthesis were given to replace the missing teeth in the upper and lower jaw for the time being.[/vc_column_text][vu_heading style=”2″ heading=”TREATMENT OUTCOME” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]He came back after 5 months for the final procedure. Post-operative OPG taken shows well positioned dental implants in integration with the surrounding jaw bone. Hence final measurements were taken. After a few trial procedures, the final prosthesis was fixed onto the dental implants. He felt an immediate improvement in his speech. There was an instant boost of confidence in the patient. He was very happy and uplifted with the treatment outcome. He is on a regular follow- up.[/vc_column_text][/vc_column][/vc_row]
Facial Asymmetry Surgery with Bilateral Sagittal Split Osteotomy
Patient with a severely prognathic mandible The patient is a 20-year-old female from Kottayam in Kerala, India who has a disproportionately large lower jaw. This problem manifested at an early age in the patient. She said that she has always had a very long lower jaw, which had gradually worsened with time. Her parents had sought a consultation with a local oral surgeon who had advised surgical correction after completion of her growth. Thumb sucking habit results in the exact opposite of this. It causes maxillary prognathism and a class II skeletal malocclusion. It is essential that habits like thumb sucking are broken at the earliest to avoid later problems with the jaw bones and teeth. The tongue posture is itself changed by such habits. Effects of adverse effects on future treatment needs for the patient This leads to requiring extensive treatment to obtain normally positioned permanent dentition. Such treatments could include both surgery as well as orthodontics. Treatment can be initiated during the mixed dentition phase. The patient is now 20 years old and had approached him again. Seeing the degree of correction needed for the patient, he had referred them to our hospital for correction of her problem. The patient did have an extreme degree of mandibular prognathism. Her mandibular prognathism is so extreme that she is unable to close her mouth. She also has a lot of difficulty with chewing and speech. Our hospital is a premier center for corrective jaw surgery in India. Both jaw reduction surgery and jaw advancement surgery are done at our hospital. Her mandibular plane would also be normalized by this surgery. Distraction osteogenesis is the treatment of choice for increasing jaw size. Reduction of mandibular size is through bilateral sagittal split osteotomy. Occurrence of mandibular prognathism with possible etiology Prognathism in humans can be due to normal variation among phenotypes. In humans, prognathism may be a malformation, the result of injury, a disease state or a hereditary condition. It is considered a disorder only when it affects mastication, speech or the ability to function normally in a social setting. Mandibular prognathism is a protrusion of the mandible in relation to the rest of the face. Pathologic mandibular prognathism is a potentially disfiguring genetic disorder where the lower jaw outgrows the upper jaw resulting in a protruding chin and anterior cross bite. Facial asymmetry surgery would address all of the patient’s problems. Initial presentation at our hospital for mandibular prognathism Dr SM Balaji, facial asymmetry surgeon, examined the patient and obtained comprehensive imaging studies. The patient had a skeletal class III malocclusion and an anterior open bite. He explained that the patient first needed to undergo fixed orthodontic treatment for straightening of her lower anterior teeth. This was to ensure proper alignment of the upper and lower anterior teeth following surgery. He then explained the surgical details of bilateral sagittal split osteotomy to the patient. All the aspects of the treatment plan were presented to them. The patient and her parents were in agreement with the proposed treatment plan and consented to surgery. Successful surgical correction of her mandibular prognathism Under general anesthesia, incisions were first placed in the mandibular retromolar region bilaterally. Flaps were then elevated to expose the mandibular bone. Bone cuts were then made and bilateral sagittal split osteotomy was performed using the Obwegeser’s technique. The mandible was pushed posteriorly ensuring proper occlusion of the teeth. This was then fixed in place using titanium plates and screws. Extreme care was taken throughout the procedure to ensure protection of the inferior alveolar nerve during mobilization of the proximal segment. All incisions were then closed with resorbable sutures. Complete patient satisfaction with the outcome of the surgery Results of the surgery were immediately evident to the patient and her parents. They were very happy with the outcome of the surgery. The patient’s occlusion was completely normal and she had an esthetic facial profile. She would need to undergo continued orthodontic treatment to bring her teeth into perfect alignment, thus obtaining good facial symmetry. The patient expressed her happiness and said that this would transform her life completely. Surgery Video
Reconstruction of Upper Lip with Lower Lip Abbe Flap
Baby girl born with cleft lip and palate The patient is a 12-year-old girl from Guwahati in Assam, India. She was born with a cleft lip and palate along with a cleft alveolus. Cleft lip surgery had been performed at 3 months of age. This was followed by cleft palate surgery at 9 months of age and cleft alveolus surgery at 4 years of age. Progressive development of facial deformity with growth As the patient grew up, her nose began to get progressively deformed and flat. There was also a hypertrophic scar from the cleft lip repair. This detracted from the appearance of her face and she felt self-conscious because of this. Her nasal tip was also flattened. She said that the left side of the face appeared different from the right side of the face. Cleft lip deformities are considered to be facial deformities and not craniofacial deformities. Facial palsy is never present in cleft lip and palate patients. Bell’s palsy is a variant of facial palsy. She began to get constantly bullied at school. This led to a lot of social problems with the patient isolating herself and withdrawing from everyone. She had very few friends in school and rarely went out of the house. The bullying reached the point where the patient refused to go to school. Her alarmed parents decided to get her condition corrected and approached a local plastic surgeon. Following a detailed examination, the surgeon realized the complexity of the patient’s presentation. He referred the patient to our hospital for correction for facial deformity correction. Premier centre for facial cosmetic surgery in India Our hospital is a premier centre for facial deformity surgery in India. Facial cosmetic surgery is performed for correction of all deformities. Our hospital is one of the few to perform facial reanimation surgery in India. Extensive deformity correction with reestablishment of facial asymmetry is a specialty at our hospital. Initial presentation at our hospital for treatment planning Dr SM Balaji, cleft rhinoplasty surgeon, examined the patient and studied all her old case records. She had an obtuse nose with a short prolabium and nearly no columella, which is a typical presentation of bilateral cleft lip and palate patients. The patient desired to have a normal nose and upper lip. It was advised for her to undergo nose correction through open rhinoplasty through rearrangement of nasal cartilage and lip correction using lower lip Abbe flap technique. Reconstruction of the columella of the nose and the prolabium will also be done using this technique. The two stages of the surgical procedure The surgery is usually done in two stages. In the first stage, an incision is placed in the upper lip and the tissue is mobilized to create a new columella. This stage is a columella reconstruction surgery. Nose correction is also done at this stage. Following this initial procedure, a portion of tissue from the lower lip is transferred to the upper lip with its base still attached to maintain vascularity. This will be used to create the prolabium. A period of about three weeks is allowed for new blood supply to establish from the upper lip to the tissue transferred from the lower lip. Once adequate vascular supply has been established, the pedicle will be separated from the lower lip. The donor and recipient sites are then sutured. This will enable restoration of normal lip anatomy. Successful completion of the first stage of surgery Under general anaesthesia, the first stage of the aforementioned surgical technique was successfully performed. The columella of the nose was successfully created along with the prolabium. Patient will be on a liquid diet for a period of 21 days until division of the flap is done. It was explained to the parents that scrupulous hygiene is very essential during this 21 day period. Division of the pedicle flap and separation from the lower lip was performed after 21 days. The patient and her parents were very happy with the results of the surgery. They expressed that she will gain more self-confidence from the normal appearance of her lips after the surgery. Surgery Video
Microtia Second Stage Ear Reconstruction Surgery
Girl born with deformed right external ear The patient is a now 24-year-old girl from Ranchi in Jharkhand, India who was born with near total absence of her external right ear. She had just a peanut like wedge instead. There was also absence of an external ear canal and eardrum. Her marriage had been fixed three years ago and they had approached a local plastic surgeon. Upon examining the patient, he had realized that she needed to get it addressed at a specialty center. He had then referred them to our hospital for treatment. Our hospital is a premier surgical center for microtia surgery in India. Many patients have been rehabilitated here and are leading completely normal lives today. Our hospital is a premier center for facial plastic surgery in India. Initial presentation and consultation at our hospital Dr SM Balaji, ear reconstruction surgeon, examined the patient and conducted a detailed evaluation. He explained to the patient the processes involved in ear reconstruction surgery. Microtia surgery is performed in three stages. The first stage involves reconstruction of the ear using rib cartilage. A skin pocket is first created at the site of the missing external ear. The cartilage is then banked in the skin pocket created at this location. The patient has already undergone this stage of the surgery two years ago at our hospital. Lobule shifting had also been completed. She now presents for the second stage microtia surgery. Presentation and classification of microtia ear deformity Microtia is a congenital deformity where the external ear is underdeveloped. Complete absence of the external ear is referred to as anotia. Microtia can be unilateral or bilateral and occurs in around 1 out of about 8,000–10,000 births. The right ear is more commonly affected than the left ear. Unilateral microtia is more common than bilateral microtia. Microtia is graded according to its severity. In grade I microtia, there is a less than complete development of the external ear with identifiable structures and a small but present external ear canal. Grade II microtia manifests a partially developed ear with an underdeveloped upper half. The external ear canal is closed leading to conductive hearing loss. Grade III microtia is more severe with near complete absence of the external ear with just a small peanut-like structure along with the absence of the external ear canal and ear drum. This is also the most common form of microtia. Grade IV microtia denotes the complete absence of the external ear. Second stage microtia surgery for ear reconstruction After a clinical evaluation, the second stage surgery for ear elevation was scheduled for the patient. Under general anesthesia, the banked cartilage was first removed. This was followed by excision of the scar in the inframammary region where the graft for the first stage had been harvested. A full thickness skin graft was then obtained from the hip region and right ear elevation was done using the banked graft and the full thickness skin graft. Successful completion of the second stage microtia repair The ear was successfully elevated, but constant monitoring was needed to ensure that the site of the graft did not develop an infection. Routine check-up was performed for a period of about one month. The patient and his parents were very happy with the results of the surgery. Surgery Video
Upper lip reconstruction with lower lip Abbe Flap surgery
Child born with cleft lip and palate deformity The patient is a 12-year-old boy from Vizag in Andhra Pradesh, India who was born with bilateral cleft lip and palate. Parents were counselled extensively regarding their child’s condition. The roof of the mouth had a hole in it. As per the recommendations made, he underwent cleft lip surgery first at 3 months of age. This was followed by cleft palate surgery at 9 months of age and cleft alveolus surgery at 4 years of age. These are as per the guidelines followed by the American Association of Oral and Maxillofacial Surgeons in the United States of America. As the patient grew up, he gradually developed a flat nose deformity. There was also a prominent scar in his upper lip from the cleft lip repair. This had led to considerable bullying at school. The patient was becoming combative and rebellious because of all these factors. There was also flattening of the nasal tip from the surgery. His worried parents had consulted a facial cosmetic surgeon who had suggested getting these deformities corrected. Due to the nature of these defects, he had referred them to our hospital for surgical management of his problem. The lip and nasal deformities will be addressed by the surgical repair. Initial presentation and treatment planning at our hospital Dr SM Balaji, cleft rhinoplasty surgeon, examined the patient and reviewed all his old surgical records. He observed that the patient had an obtuse nose, a short prolabium and a near absent columella, which is typical of bilateral cleft lip and palate deformity. A treatment plan was then formulated for the patient. It was advised that the patient undergo nose correction through open rhinoplasty and philtral reconstruction using an Abbe flap technique from the lower lip. The columella of the nose will be reconstructed using the philtrum of the nose. Description of the surgical procedure This surgery is done in two stages. In the first stage, an incision is placed in the upper lip and prolabium is mobilized. This is then utilised to create the columella. Nose correction is also done at this stage. The next step involves mobilization of a portion of the lower lip that is then transferred to the upper lip with its base still attached to maintain vascularity. This is used to create the philtrum. Following a period of approximately 21 days, the second stage of the surgery will be performed. This period is given to allow the flap to establish vascular supply from the surrounding tissues in the upper lip. Once this has been established, the pedicle will be divided and the donor and recipient sites sutured. The lip anatomy will thus be completely restored. Successful surgical reconstruction of the upper lip deformity Under general anesthesia, the columella of the nose was successfully created along with the prolabium. The patient will have to be on a liquid diet for a period of 21 days until division of the flap is done. Maintaining hygiene is very essential during this period. The parents and the patients were extremely pleased after division of the pedicle after the 21-day waiting period. The cosmetic results were excellent and there was also an improvement in lip function. Normalcy was restored to the appearance of the nose and lip of the patient. Parents stated that the child would now be able to face life with self-confidence and hope. Surgery Video
Pediatric Mandibular Distraction for Sleep Apnea
History of a fall on her chin as a little girl The patient is an 18-year-old young girl from Guntur in Andhra Pradesh, India. She has a history of a fall at the age of two when she fell off the bed and landed on her chin. This had resulted in pain and difficulty with chewing for a few days. She soon became pain free and her parents did not follow up with the doctor. As she grew up, it became evident that her lower jaw was not growing normally. There was also difficulty with chewing and mouth opening. They had taken her to a local oral surgeon who had obtained imaging studies of her mandible. He explained to them that she had ankylosis of bilateral TMJ and had advised release of her ankylosis. She had subsequently undergone TMJ ankylosis surgery for release of her jaw joints. However, her parents soon realized that her mandibular deformity was getting progressively worse as she grew up. Her mandible was extremely retruded in relation to the rest of her face. She was having problems with both chewing and speech and had minimal mouth opening. History of breathing problems leading to chronic tiredness The patient has also had breathing problems for a long time and complained of feeling tired all the time. Her parents said that she woke up regularly in the middle of the night with a loud gasp. She was also constantly drowsy throughout the day. Her parents took her to an oral surgeon in Hyderabad for a consultation. He realized that the patient had micrognathia and needed distraction osteogenesis with internal devices for lengthening of her mandible. Explaining the situation to them, he informed them that there were only a few specialty hospitals that performed this surgery in India. He then referred them to our hospital for management of her problem. Initial presentation at our hospital for consultation and treatment planning Dr. SM Balaji, Distraction Osteogenesis Surgeon, examined the patient and observed that she appeared pale. Her skin was cyanotic and he ordered sleep studies. Pulse oximetry revealed decreased oxygen saturation levels in her red blood cells due to sleep apnea. He explained the condition in detail to the parents and advised them of the proposed treatment plan. It was explained that the patient needed to undergo a tracheostomy before distraction osteogenesis surgery for her micrognathia correction. This was also because of the patient’s restricted mouth opening. The parents expressed understanding and consented to surgery. Successful surgical correction of micrognathia Under general anesthesia, the patient first underwent a tracheostomy. This was followed by bilateral incisions in the mandible with elevation of mucoperiosteal flaps. Vertical bone cuts were first made on the outer cortex of the mandibular body bilaterally. Univector mandibular body distractors were then fixed with the activating arms exiting outwards. The inner cortex was broken following fixation of the distractors. Total duration of the distraction osteogenesis treatment The tracheostomy would remain in place throughout the entire distraction treatment phase. Activation of the distractors would begin after a latency period of five days following surgery. Distraction of 1 mm would be performed every day until a total distraction of 25 mm had been achieved. After sufficient increase in length of the mandible has been achieved, the distraction would be stopped. The distraction devices would however remain in place for a further period of four months. Once sufficient consolidation of bone is demonstrated at the site of distraction, this would be followed by another surgery for removal of the distractors. The patient would have full function of the lower lip including sensation due to reformation of the nerve canal. There would be an increase in the parapharyngeal space following completion of the treatment. This would enable the patient to breathe normally. Blood oxygen levels would return to normal. Her facial appearance would also be greatly improved with the increase in the size of the lower jaw. The parents expressed their gratitude to Dr. Balaji following surgery. Surgery Video
Bilateral Mandibular Distraction Osteogenesis
A fall from bed as an infant with resultant chin injury The patient is a 4-year-old boy from Chennai in Tamil Nadu, India who rolled off his crib as an infant. He had landed on his chin and had cried a lot due to the resultant pain. His worried parents had taken him to a nearby hospital where the duty doctor had examined him and prescribed analgesics. The child soon returned to his normal playful self though he had developed difficulty chewing. Parents soon noted that his facial structure was slowly changing with his chin getting retruded progressively. He also developed progressive breathing difficulties. The parents then had taken him to an oral surgeon who diagnosed bilateral ankylosis of the TMJ. He advised release of the ankylosis, which had been done. However, the patient still had difficulty with mouth opening and his breathing difficulties were also worsening. It was then that he was referred to our hospital for management of his difficulties. Our hospital is a premier center for TMJ ankylosis surgery in India. Jaw deformity surgery is routinely performed in our hospital. Distraction osteogenesis surgery is a specialty at our hospital. We were one of the first centers in India to offer this specialized jaw treatment. Initial presentation at our hospital for consultation Dr SM Balaji, Jaw Lengthening Surgery specialist, examined the patient and obtained a detailed history from the parents. They complained that he was always feeling drowsy and tired. He was listless and had difficulty breathing, particularly during sleep. Dr SM Balaji noted that the patient looked very pale and had mild cyanosis of the skin. The patient also had a backwardly positioned lower jaw. He immediately ordered for pulse oximetry and oxygen saturation tests, which revealed extremely reduced blood oxygen levels in the red blood cells. It was decided to do an emergency tracheostomy to relieve this and the patient’s skin tone immediately returned to normal. The parents were counseled that the tracheostomy needed to be in place during the entire period of jaw lengthening through mandibular distraction osteogenesis. It was explained to them that the tracheostomy needed to be retained for about 4-5 months during the entire duration of distraction treatment. Mandibular lengthening through distraction device fixation would lead to increased airway space, thus facilitating improvement in his breathing. Parents were in agreement with the treatment plan and consented to surgery. Successful completion of mandibular distraction osteogenesis Under general anesthesia, incisions were placed in the mandible bilaterally and mucoperiosteal flaps raised. Vertical bone cuts were made in the mandibular body bilaterally following which mandibular body distractors were fixed bilaterally with the activating arms exiting outwards. After a period of about five days, distraction was started by turning the distractors clockwise. The Univector distractors were distracted bilaterally by 1 mm daily for a total of 20 mm in three weeks to compensate for deficiency in growth of the mandible. Distractors retained during the period of bony consolidation The distractors were left in place for a latency period of four months. The distractors were removed once adequate bony consolidation was seen at the site of the distraction. Oxygen saturation tests were then performed to check the patient’s oxygen levels. Once it was seen to be normal, the tracheostomy was removed with complete restoration of normalcy in the patient’s life. Lower lip function including sensation was intact with complete reformation of the nerve canal. This was documented radiographically. The patient’s facial profile was also normal with lengthening of the mandible. His breathing had returned to normal following the increase in his parapharyngeal space. He was once again a very active young boy. The parents expressed their gratitude to Dr. Balaji as their child was breathing well during sleep without any signs of obstructive sleep apnea. Surgery Video
ICD Conference 2018 & Annual Convocation and Awards Function
[vc_section content_layout=”full” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_row content_layout=”boxed” equal_height=”” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_column layout=”normal” vertical_align=”top” animation_delay=””][vu_heading style=”2″ heading=”International College of Dentists Conference in Hyderabad” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]The International College of Dentists (ICD), Section VI – India, Nepal and Sri Lanka held its Conference, Annual Convocation and Awards Function at the Marriott in Hyderabad, India. Dr Bettie McKaig, President, ICD International, Dr OP Kharbanda, President, ICD Section VI and Dr Rajiv Chugh, Secretary General, ICD Section VI were present at the conference along with fellows of ICD Section VI and other luminaries in the field of dentistry. The conference had a pre-conference workshop that was well attended by both students and practitioners alike. This was conducted by many international as well as national delegates.[/vc_column_text][vu_heading style=”2″ heading=”Honour for Dr SM Balaji” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]Dr SM Balaji, a renowned Chennai-based Cranio-Maxillofacial Surgeon and Fellow, International College of Dentists, was honored at this year’s conference for his contributions towards the rehabilitation of children afflicted with craniofacial deformities. His services to humanity were lauded by the ICD Section VI.[/vc_column_text][vu_heading style=”2″ heading=”Dr SM Balaji meets with student delegates from Bangladesh” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]Student delegates from Bangladesh met with Dr SM Balaji and interacted with him at the conference. He answered all their queries related to career development and how to balance their social responsibilities and their dental career. The students expressed their thankfulness and appreciation to him for having provided them with sound advice.[/vc_column_text][vu_heading style=”2″ heading=”Paper Presentation at the conference by Dr Balaji” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]Dr SM Balaji delivered the keynote lecture at the conference. The topic of his lecture was Rhinoplasty Surgery – Correction of Nasal Deformities. He presented many cases from his more than 25 years experience as a rhinoplasty specialist and explained the nuances of nasal deformity correction. His lecture was widely appreciated by the audience. The lecture was followed by a lively question and answer session with the audience.[/vc_column_text][/vc_column][/vc_row][vc_row content_layout=”boxed” equal_height=”” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_column layout=”normal” vertical_align=”top” animation_delay=”” width=”1/3″][vc_single_image image=”6188″ img_size=”full”][/vc_column][vc_column layout=”normal” vertical_align=”top” animation_delay=”” width=”1/3″][vc_single_image image=”6189″ img_size=”full”][/vc_column][vc_column layout=”normal” vertical_align=”top” animation_delay=”” width=”1/3″][vc_single_image image=”6190″ img_size=”full”][/vc_column][/vc_row][/vc_section]
Unilateral Condylar Fracture Surgery | Dr SM Balaji, maxillofacial Surgeon
Young man involved in a road traffic accident The patient is a 24-year-old male from Surat in Gujarat, India. He had been involved in a road traffic accident while riding his bike. A collision with another two wheeler had resulted in his motorcycle skidding and he had landed hard on his chin. This had immediately resulted in difficulty opening his mouth and speaking. His parents had taken him to a local hospital where emergency treatment was administered. Wound debridement had been done for his superficial lacerations along with dressing. An x-ray taken at the hospital revealed a left-sided condylar fracture. The radiologist had explained to the patient that this needed to be addressed surgically at a specialty center. Due to its complicated presentation, the patient had been referred to our hospital for surgical management. Initial presentation at our hospital for treatment planning Dr SM Balaji, mandibular fracture surgeon, examined the patient and ordered an orthopantomogram and 3D CT scan to visualize the fracture. The patient was in a considerable amount of pain and had difficulty opening his mouth. He also had vertical shortening of the lower face along with a posterior open bite. There was also mild facial asymmetry with deviation of the mandible to the left side. Both the OPG as well as the 3D CT scan clearly revealed a displaced left-sided condylar fracture. It was explained to the patient that he needed condylar fracture surgery with open reduction and internal fixation along with plating to stabilize the fracture. He would also be placed in Intermaxillary fixation to promote healing of the fracture site. The area of the stylomastoid foramen in the temporal bone was not involved in the fracture. A liquid diet would be needed during the period of Intermaxillary fixation, which would be for a period of 2-3 weeks. This would be followed by a period of semi-solid diet. The patient and his parents were explained the rationale behind the treatment planning and consented to surgery. Successful surgical management of the condylar fracture Under general anesthesia, a modified Alkayat-Bramley incision was made on the left side of the face. This was just anterior and superior to the pinna of the ear. A flap was then elevated and dissection was carried out until the fracture site was identified. The displaced condylar fracture was then reduced followed by a check for normal occlusion. Once it had been determined that the fracture had been adequately reduced, it was then fixed using titanium plates and screws. Extreme care was taken to ensure that the facial nerve was adequately protected throughout the procedure. Intermaxillary fixation was applied to the jaws and the patient was instructed to follow all the postoperative instructions. The patient demonstrated full function of the facial nerve in the immediate postoperative period including furrowing of the brow and eye movements. Bite was also normal. Patient satisfaction at the results of the surgery The patient returned after a period of two weeks for removal of his Intermaxillary fixation. Facial asymmetry had been reestablished and there was no difficulty with opening his mouth. Pain was also absent and the patient demonstrated full facial nerve function without any compromise. Parotid gland function was also completely normal. There was no alteration in the taste sensation. The patient and his parents were very relieved that he had gained complete function without any sequelae from his road traffic accident. They expressed their complete satisfaction at the results of the surgery. Surgery Video