Large Dentigerous Cyst, Multiple times operated Resurgery, Reconstruction with Rib Graft
The patient is a 28-year-old male from Gurdaspur in Punjab, India. He began noticing the development of…
Hemifacial Microsomia total Absence of Ramus and Condyle Reconstruction with costochondral graft
Patient born with hemifacial microsomia The patient is a 7-year-old female from Gorakhpur in Uttar Pradesh, India. She had been born with the absence of a left ramus and condyle of the mandible. The patient also had microtia along with absence of a left orbital globe. The asymmetry of her face worsened as she grew up. She was getting more and more depressed with the passage of time and was facing a lot of bullying at school. This worsened to the point where she refused to go to school. She had already undergone placement of an eye prosthesis to replace her missing left orbit. Her worried parents met with a local oral surgeon to seek advice regarding correction of her condition. The surgeon explained the complexity of treatment involved in the correction of hemifacial microsomia to the parents. He said that hemifacial microsomia surgery was performed only in a few specialty hospitals in India. The surgeon then referred them to our hospital for facial asymmetry correction surgery. Our hospital is one of the premier centers for facial cosmetic surgery in India. We are also one of the leading oral and maxillofacial surgery hospitals in India. Dr SM Balaji, our director, is a top cosmetic surgeon in India. Board certified oral and maxillofacial surgeons perform this surgery in the developed countries. A brief introduction into hemifacial microsomia Hemifacial microsomia (HFM) is a congenital disorder that predominantly affects the development of the lower half of the face. It most commonly affects the ears, the mouth, and the mandible. It usually occurs on one side of the face through it may rarely involve both sides. If severe, it may result in breathing difficulties due to obstruction of the trachea—sometimes even requiring a tracheotomy. It is the second most common birth defect of the face after cleft lip and cleft palate. Hemifacial microsomia shares many similarities with Treacher Collins syndrome, Franceschetti syndrome etc. Patients with hemifacial microsomia exhibit varying degrees of facial asymmetry. It can range from very mild to very severe. Correction of the facial asymmetry is very important for patients to gain self confidence to become productive members of society. One of the aims of this surgery is to establish as much facial symmetry as possible. Once correction of the ramus and body has been completed, soft tissue molding leads to better symmetry of the face. Plastic surgery in India has become a highly evolved field now. Reconstructive surgery performed by plastic surgeons deal with a wide variety of surgical procedures. Facial implants are also used to help in establishing better symmetry. Initial examination upon presentation at our hospital Dr SM Balaji, hemifacial microsomia surgeon, examined the patient thoroughly following which he then ordered comprehensive imaging studies including a 3D CT. Imaging studies revealed that there was absence of condyle and coronoid on the left side along with the presence of a hypoplastic ramus. This had resulted in the development of a considerable occlusal cant. The patient also had microtia on the left side. Correction of this defect was advised to be carried out at around the age of 14 years old. It was explained to the patient that she would need to undergo a ramus distraction osteogenesis for correction of her facial asymmetry. However, there was insufficient bone present to perform a successful distraction osteogenesis. Therefore, a costochondral rib graft would be harvested to create a condyle and reinforce the ramus, thus creating sufficient bone for distraction surgery Surgical augmentation of hypoplastic left mandible for distraction surgery Under general anesthesia, a right inframammary incision was first made and a costochondral rib graft was harvested through the opening. A Valsalva maneuver was then performed to ensure that there was no perforation into the thoracic cavity. The wound was then closed in layers. Following this, a left submandibular incision was placed and dissection was performed up to the condyle. The coronoid process was then created and the ramus augmented using a costochondral rib graft, which was fixed in place using titanium screws. Closure was then done using resorbable sutures. Happy patient after successful outcome of the surgery The surgery was a complete success. The coronoid was successfully created and ramus was augmented. A follow up OPG taken three months postoperatively revealed that there was sufficient bony consolidation in the area of the surgery. The patient also had a more symmetrical face. Distraction osteogenesis surgery will be performed after a period of about six months followed by ear reconstruction after attaining sufficient growth. Surgery Video
Fixed Zirconia Bridge for Broken Teeth
[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=”PATIENT HISTORY” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text] A 19 year old male approached our dental hospital, seeking for correction of his broken upper front teeth. Patient gives a history of traumatic fall 10 days ago, which has broken a part of the tooth structure in the upper front teeth. Patient complained of severe sensitivity of the teeth at the relative site. Even the contact of slightest air on the teeth induced sensitivity. The patient had tried using de-sensitizing toothpaste for a week and stated that it didn’t make his condition any better. Moreover, he felt that the broken anterior teeth looked aesthetically unpleasant. He felt insecure to speak confidently and smile for photos. [/vc_column_text][vu_heading style=”2″ heading=”PATIENT EXAMINATION” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text] On clinical examination, there was no pain on palpation. There was no sign of mobility or discolouration of the broken teeth. The gum tissue surrounding the relative teeth had no abnormality. On radiological examination, it was evident that a portion of the front teeth were broken exposing the structure called Dentin (yellowish structure which lies beneath the enamel of the tooth). No crack line was seen on the root of the tooth. No pathological findings in the surrounding bone structure. “Dentin consists of a sensitive layer of tissue that communicates with the nerve of your teeth. When dentin becomes exposed, things that never hurt your teeth before may also feel very painful”. [/vc_column_text][vu_heading style=”2″ heading=”TREATMENT PLAN” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text] First choice of treatment of restoration of the broken upper anteriors with tooth coloured filling material was suggested to the patient with its pros and cons. Patient was asked not to bite anything with the front teeth after the treatment, as the restoration is more likely to chip off. This concerned the patient. As he was young and aesthetically concerned, he demanded for an alternative option. Considering the patients age and demand and in order to treat hypersensitivity, our highly skilled Endodontist ( dentist specialized in restoration and root canal treatment of the teeth), under the guidance of Dr.S.M.Balaji, planned to perform root canal treatment of the affected anterior teeth under local anesthesia followed by placement of a fixed ceramic/ Zirconia bridge. The dental procedure was clearly explained to the patient. Patient opted for Zirconia as it provides more natural appearance and durability. Consent was obtained. [/vc_column_text][vu_heading style=”2″ heading=”Root canal treatment” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text] Root canal is a treatment to repair and save a badly damaged or infected tooth instead of removing it. The procedure involves removing the nerve tissue of the affected tooth (the pulp), cleaning and disinfecting it, then filling and sealing it. [/vc_column_text][vu_heading style=”2″ heading=”DENTAL PROCEDURE” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text] In the first visit, under local anesthesia, root canal procedure was carried out for the broken upper anteriors. An access hole was drilled at the back of the teeth. The nerve tissue (pulp) of the teeth is taken out followed by cleaning and disinfecting of the root canals. Saline medium is used periodically to flush away the debris. Thorough cleaning and shaping of the root canal was achieved. The exterior hole in the tooth was sealed with a temporary material to keep out contaminants like saliva and food between appointments. The patient was asked to report after 3 days. In the second visit, temporary restoration was removed. Finally the root canals are filled with a permanent restorative material called “guttapercha” and sealed with a medicated paste. Followed by root canal treatment, crown preparation of the anterior teeth was done. Restoring teeth to good form and function requires preparation of the teeth for placement of the dental restorations (crown or bridge). The process of preparation usually involves grinding of the teeth with special dental burs, until the desired shape and size is achieved, to make space for the ceramic bridge. Then the impression of the teeth in the upper and lower jaw are taken, so the permanent crown can be made accordingly. The patient was given a new temporary dental bridge that protects the tooth until the final crown is ready to be permanently placed. [/vc_column_text][vu_heading style=”2″ heading=”THE CONFIDENT PATIENT” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text] After a couple of days, the temporary bridge was removed. Aesthetically pleasant looking fixed ceramic bridge was positioned and fixed on to the teeth with special adhesive cement. The dental bridge looked real and matched the natural colour of his teeth. Patient was very pleased with the outcome and he walked out with a dazzling smile confidently. 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Zygoma implants for Atrophic upper jaw
[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] PATIENT HISTORY A 60 year old female patient approached our dental hospital with a complaint of mobile prosthesis in her upper and lower jaw. Patient had a history of long standing mobile teeth due to debilitating periodontal pathology, following which she had undergone extraction of all her teeth. The patient said that she remained without teeth for a period of 2years. Later she had replaced her missing teeth with an implant-supported prosthesis done elsewhere. Patient stated that the prosthesis had been fixed in just a week after the implant placement. Within one month of having the prosthesis fixed, she started to experience pain and discomfort in the gum tissue surrounding the prosthesis in both upper and lower jaws. Subsequently, the prosthesis exhibited mobility. Also she grumbled upon the salty tasting liquid discharge from her gums. Due to the above reasons the patient was struggling to chew food. She was very upset with her oral health. She worried that the mobility would progress more if left untreated. She was desperate to get rid of the shaking prosthesis. Patient had no history of diabetes mellitus or any other adverse habits. EXAMINATION On clinical examination, the gums surrounding the implant prosthesis were swollen and tender on palpation. There was evident pus discharge and bleeding on examination. The implants in the upper and lower jaw exhibited mild mobility depicting a condition called ‘peri-implantitis’. “Peri-implantitis is an infection of the soft and hard tissues surrounding an osseointegrated implant, leading to the loss of supporting bone.” Pre-operative x-ray taken shows diffuse radiolucency around the implants in the upper and lower jaws indicating severe bone loss, owing to the mobility of the implants. TREATMENT PLAN On view of the patient’s condition and insistence of the patient, Dr. SM Balaji planned to remove the failed dental implants along with the prosthesis under local anesthesia, to relieve the patient from suffering further. Followed by replacement of missing teeth with removable denture. TREATMENT STAGE I Under local anesthesia the prosthesis in the upper and lower jaws were removed along with the infected dental implants. Patient was put on antibiotics to decrease the infection and to aid the healing of the gum tissues. Later Impression was taken and removable upper and lower dentures were delivered to the patient to replace her missing teeth temporarily. STAGE I REVIEW The patient returned after 4 months for review. The patient stated that she was not able to relish her meals, as the upper denture covered the palate. Although patient was managing with the removable dentures, she was insisting for a fixed option by which we could replace her missing teeth. OPG taken shows insufficient bone height in the upper posterior region, to support the conventional dental implant. With regard to the patient’s oral condition and need, Dr.S.M.Balaji decided to perform a graft less technique under general anesthesia, by anchoring the upper posterior dental implants in the zygomatic bone (cheek bone) and with additional conventional dental implants where there is sufficient bone, under general anesthesia thereby providing a brilliant alternative for teeth replacement. ZYGOMA IMPLANT For severe bone resorption, zygomatic implants are excellent treatment of choice, as it would shorten time and lengthy treatment procedure involved in bone grafting techniques. Zygoma bone provides great stability and retention for the dental implant. It aids in high primary stability for immediate function. The surgical procedure was clearly explained to the patient and consent was obtained. STAGE II TREATMENT Under general anesthesia, the gum tissue is cut and elevated in the upper and lower jaw bone exposing the underlying bone. Followed by this a small oval window is cut open in the right upper lateral wall of the sinus close to the zygomatic bone (cheek bone). A membrane is exposed on the other side of the bone which acts as a barrier between the sinus and the jaw. This membrane is then gently lifted away from the area creating a space through which the zygoma implant is placed. The zygoma implant is drilled with precision, ensuring not to penetrate the membrane. Similarly, the zygoma implant was fixed in the left upper posterior region. In addition to this, conventional implants of varying height and depth were placed in the anterior region of the upper jaw and lower jaw. POST-SURGICAL PROTOCOL The patient was put on medication for 5 days to cope up with the mild pain and discomfort. Home care instructions were given. Patient was asked to report after 6 months for final prosthesis. This duration is for the dental implants to completely osseointegrate with the jaw bone. Meanwhile, patient was given a light weight provisional prosthesis. THE HAPPY PATIENT Patient reported after 6 months. Post-operative OPG taken shows zygomatic implants and conventional implants, well integrated and positioned in the jaw bone. Final impression was taken. After a couple of bite trials ensuring no traumatic bite, natural looking fixed hybrid prosthesis was fixed onto the dental implants. There was an immediate remarkable change in the patient’s speech and appearance which boosted her confidence. The patient and her family members were very happy with the outcome. Patient is on a regular follow up. 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Square Face, Masseter Muscle Excision failed – Resurgery with Gonial Angle Reduction
Facial cosmetic surgery and the reasons people opt for it Every one of us desires to have a face that is esthetically appealing and attractive to others. Just like every man would desire to have a prominent jaw with a masculine jawline, every woman desires to have a dainty feminine jaw shape. Masseter muscle hypertrophy is a condition where the masseter muscle becomes greatly increased in size. The masseter muscle is the muscle at the angle of the jaw and is one of the most important muscles of mastication. When this muscle becomes hypertrophied, it leads to the creation of a strong masculine jaw line and profile. Women who manifest this condition opt for plastic surgery to get this corrected. This is one of the many facial feminization procedures available today. Patient safety is fully assured from this surgery and there are no undesirable side effects when performed by a competent oral and maxillofacial surgeon or a board certified plastic surgeon. The facial features are softened by this procedure and the feminine quotient of the face is increased. This enables the patient to gain more self confidence and a sense of social acceptance that will enable her to better integrate into the social structure and not feel self conscious about having a broad masculine face. The results often influence the patient’s life to such a degree that it improves the quality of life for the patient right across the board. Patient undergoes masseter muscle reduction in her hometown The patient is a 25-year-old woman from Parbhani in Maharashtra, India. She had always felt that her lower face was very broad and square shaped. She disliked this a great deal and said that this made her look very masculine. She had always wanted to change this. Her parents had approached a plastic surgeon in their hometown about a year ago who had referred them to an oral surgeon. After a thorough examination, the oral surgeon had explained to them that the increased breadth of the lower face was due to hypertrophy of the masseter muscle at the angle of the mandible and had recommended masseter muscle reduction surgery. Patient not satisfied with the results of the master muscle reduction surgery The patient had undergone masseter muscle reduction, but still was unhappy with the appearance of her face. She felt that her facial structure had not become feminine even after the surgery. They had subsequently approached the plastic surgeon again who then referred them to our hospital as we are renowned for facial cosmetic surgery in India. Jaw reduction surgery and jaw reconstruction surgery is routinely performed in our hospital. Presentation and treatment planning at our hospital The patient and her parents thus presented to our hospital for management of her complaint. Dr SM Balaji, facial cosmetic surgeon, examined the patient clinically and obtained radiological studies of the patient’s face. Though clinical examination suggested masseter muscle hypertrophy, the 3D CT scan revealed that the patient had a very broad mandibular structure as well as prominent masseter muscles bilaterally. It was explained to the patient and her parents that masseter muscle reduction alone would not be enough to correct the patient’s problem and that bony reduction of the mandibular angles also needed to be performed bilaterally. The patient and her parents were in agreement with this treatment plan and consented to the surgical procedure. Successful surgical reduction of the patient’s lower facial breadth Under general anesthesia, a modified Ward’s incision was made bilaterally in the mandibular retromolar area. This was followed by elevation of bilateral flaps in the region to expose the gonial angle of the mandible. The gonial angle of the mandible was then carefully reduced to the right size bilaterally using a round bur. This was followed by dissection of the periosteum with identification of the masseter muscle. The masseter muscle was then partially excised with reduction of bulk bilaterally. A drain was placed at the operative site postsurgically to prevent formation of any hematoma in the region. Closure of bilateral incisions was then done using resorbable sutures. Patient and her parents express their satisfaction at the results of the surgery The patient was extremely happy with the results of the surgery. She now had a very feminine mandible without the excessive bulk. Her parents were also very happy with the results of the surgery and said that this would help the patient gain more confidence in life. Surgery Video
Lower Jaw Tori Removal Surgery
Patient begins to notice bony outgrowths in his mandible The patient is a 33-year-old patient from Bagdogra in West Bengal, India who said that he had always had small bony protrusions on the inner side of his lower jaw ever since he could remember. He however said that he was never worried about it as it had never caused him pain or any sort of discomfort. It said that it was only recently that he had felt the need to get them removed and had approached a local oral surgeon in his hometown. The surgeon had examined him thoroughly and also obtained radiological studies, which revealed multiple small bony prominences on the lingual aspect of the lower jaw. The patient was then informed that he had multiple mandibular tori. When the patient expressed his desire to have them removed, the surgeon referred him to our hospital for tori removal surgery as our hospital is renowned for jaw reduction surgery in India. Our hospital rigorously follows all key surgical protocols laid out by the American Association of Oral and Maxillofacial Surgeons. Orthognathic surgery is another specialty surgery that our hospital is very famous for. Corrective jaw surgery and cosmetic surgery often overlap when it comes to correction of facial asymmetry that is caused by jaw deformities. Surgery is performed only after meticulous surgical planning has been carried out. Torus mandibularis, their occurrence and etiology behind tori formation Torus mandibularis is the formation of bony growths in the mandible along the surface nearest to the tongue. Mandibular tori are usually present near the premolars and above the location of the attachment of the mylohyoid muscle to the mandible. In more than 90% of the cases, occurrence of the torus is bilateral, making the presence of a unilateral torus a very rare finding. Dental professionals usually are the first to identify the presence of mandibular tori unless they are extremely large and interfere with functioning. As the name suggests, tori are never found on the roof of the mouth. They never involve the upper jaw and are always found on the inner aspect of the mandible. The bone of the tori can often be harvested to be used for bone grafting. This makes for an ideal bone grafts material as it is harvested from the patient’s own body thus completely negating any chances of graft reduction. The rate of occurrence of mandibular tori ranges from 5-40% of the population. They are usually very small and do not cause any inconvenience to the patient. The formation of mandibular tori could be due to several factors. They are more common in early adult life and are frequently found in patients with bruxism. The size of the tori may fluctuate throughout life. In rare instances, the tori can be large enough to touch each other in the midline of the mouth. Consequently, it is believed that the development of mandibular tori can also result from local factors and are not solely due to genetic influences. Initial presentation at our hospital for management of his tori Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained radiological studies. He explained to the patient that he had mandibular tori as diagnosed by the oral surgeon in his hometown. It was further explained to the patient that removal was not mandatory if they were not causing any problems. The patient however was insistent that he wanted them removed. The surgical procedure was explained to the procedure who consented to surgery and signed the surgical consent to undergo removal of mandibular tori. Successful surgical removal of the patient’s mandibular tori Following successful induction of general anesthesia, a crevicular incision was placed in the lingual aspect of the mandible, which was followed by elevation of a mucoperiosteal flap. The mandibular tori were then exposed and subsequently reduced with the help of a round bur. The bony prominences were made flush with the surrounding bone. Closure of the incision was then done using resorbable sutures. Patient expresses satisfaction at the results of the surgery The patient was extremely happy with the results of the surgery and said that he would now return to his hometown in a peaceful state of mind.
Crouzon Syndrome Le Fort III Advancement with Kawamoto’s Distraction
Genetic transmission of disorders in human beings Genes are a form of code used by living cells to guide developmental pathways in living organisms. The sequence of the code in the DNA is very important for the normal development of all forms of life. They are transferred from one generation to another and contain information that is vital for the normal development of the organisms. Mutations are changes in the sequence of the code contained in genes. Mutations can either be beneficial or harmful. Evolution of living organisms through the ages has been enabled by beneficial mutations. These help species adapt to their changing environment. An example of this adaptation is the quality of air millions of years ago and the quality of the air we breathe now. Oxygen content in the air millions of years ago was much higher than what it is now. If this air was to be breathed by organisms living today, it would prove lethal to all forms of life. The gradual adaptation of life to lowered oxygen levels has been enabled by beneficial genetic mutations down the ages. Harmful mutations can cause abnormalities in living organisms and are responsible for the various syndromes and disorders found in living organisms. They also cause the disorders to be transmitted from one generation to another. Crouzon syndrome is one such disorder that is transmitted through genes from one generation to another. Patient born with Crouzon syndrome: This is a 15-year-old boy from Patna in Bihar, India who was born with Crouzon syndrome. He has retrusion of his maxillary bone and facial asymmetry. One of his main complaints was a pointed nose. This had been progressively getting worse as he grew up and he had become very socially withdrawn and depressed because of this developing facial deformity. His parents had been very distressed by this and had approached a local surgeon for treatment. Referral to our hospital for surgical management The surgeon examined the patient and explained to the parents that the patient needed to be operated on by an oral and maxillofacial surgeon. He then referred them to our hospital as our hospital is renowned for facial reconstruction surgery in India. Our hospital is one of the few specialty centres for distraction osteogenesis surgery in India. Initial presentation at our hospital for consultation and treatment Dr SM Balaji, facial cosmetic surgeon, examined the patient and formulated a detailed treatment plan for the patient. This included distraction osteogenesis of his maxilla using Kawamoto distractors followed by rhinoplasty surgery at the time of removal of the distractors. He is one of the few surgeons in India who has extensive experience with distraction osteogenesis. The parents of the boy were in total agreement with the proposed treatment plan and signed the informed surgical consent. This surgery will correct the cosmetic congenital defects arising from Crouzon syndrome. It is one of the cosmetic procedures performed on patients with this syndrome. Surgery is performed to help the patient lead a normal life. Plastic surgeons rarely perform this procedure though this can be categorized under facial plastic surgery. Kawamoto distractors are manufactured by KLS Martin, one of the leading manufacturers of cutting edge surgical equipment in the world. Constant research is conducted to advance surgical frontiers to provide better results for patients. Advancements in the field of craniofacial surgical instrumentation is made possible by inputs from leading craniofacial surgeons from around the world like Dr SM Balaji. Our hospital is a leading hospital in India that provides such invaluable feedback to instrument manufacturers around the world. The patient then underwent Le Fort III with distraction osteogenesis using bilateral Kawamoto distractors at our hospital. After about 10 days of consolidation for stabilization of the Kawamoto distractors, distraction of about 1 mm was performed every day bilaterally until a total distraction of 18 mm was achieved bilaterally. Following completion of the distraction, a period of three months was allowed for complete consolidation and stabilization of the distracted maxillary bone. A brief introduction to Crouzon syndrome This is a genetic disorder where there is premature fusion of skull bones. A mutation in chromosome 10 results in Crouzon syndrome. The first branchial arch is affected by this. This results in abnormal development of the bones of the face and the skull. Fusion of the metopic suture results in frontal bossing and trigonocephaly, fusion of the coronal suture results in brachycephaly and fusion of the sagittal suture results in dolichocephaly. Patient presents for removal of distractor The patient now presents three months after successful distraction osteogenesis for removal of the Kawamoto distractors. A rhinoplasty procedure will also be performed at the same time for correction of his nasal deformity. A 3D CT scan was first taken to check for new bone formation. The amount of new bone formation was found to be sufficient. Successful removal of bilateral Kawamoto distractors and rhinoplasty Under general anaesthesia, bilateral incisions were placed through the previous surgical scars, bicoronal flaps were raised, and the temporalis muscle was reflected. The Kawamoto distractors were exposed bilaterally and removed. Closure of the incisions was done using resorbable sutures. Once this had been achieved, the rhinoplasty was then performed. Broad nose correction after distractor removal Through an intranasal approach, intercartilaginous incision was placed and the nasal mucosa was dissected. The medial nasal cartilage was trimmed and medial osteotomies were performed followed by lateral osteotomies bilaterally. Closure was then done using resorbable sutures. Patient and parents express their happiness at surgical result The patient and his parents were very happy with the results of the surgery. His face was symmetrical now and his nose also had a normal contour now without being pointy. They said that he would now be able to lead a normal life as he was very happy with the cosmetic results of the surgery. Surgery Video
Large Periapical Dental Cyst Removal and Reconstruction of Upper Jaw with Rib Graft
What is a cyst and what are the problems arising from cysts? A cyst is a sac with a membranous lining that separates the contents of the sac from the surrounding tissues. This lining is comprised of cells that are abnormal when compared to the surrounding cells. The contents of the cystic sac can comprise of many materials. These include air, fluids, solids or even semisolids. A cyst does rarely resolve on its own at times through it has to be surgically removed when it persists. A cyst that occurs within a bone can lead to resorption of the bone due to pressure and can weaken the bone. This can lead to serious complications when it is present in long bones like the femur, tibia or fibula. Examples of cysts include epidermoid cyst, ganglion cyst, chalazion cyst, hydatid cyst, glial cyst, dentigerous cyst and dermoid cyst. All these cysts need to be addressed surgically to excise them. Complete excision of the cyst lining is mandatory as any remnants left behind could lead to recurrence of the cyst. Bone grafting is necessary to fill in the defect when removal of the cyst results in a large bony defect. Patient presents with a complaint of a swelling in the anterior maxilla The patient is a 22-year-old male from Varanasi, India who presented with the complaint of a swelling in the anterior maxilla with a mobile tooth in the upper front teeth region. He stated that the tooth was hit by a ball while playing cricket in his childhood. This was followed by a pain and a mild swelling in that region, which subsided spontaneously a few days later. The patient’s parents did not seek any medical help for the patient. He said that he first noticed a swelling in that region around a year ago with gradual loosening of his right upper central incisor. This swelling had gradually grown in size along with increasing mobility of the tooth. He had approached a local dental surgeon in his hometown who had obtained radiographic studies. The radiographic studies revealed a large area of radiolucency in the region, which was diagnosed as a cyst. As the cyst was very large, there was loss of a considerable amount of bone in that region. The dentist explained to the patient that this needed surgical intervention and referred him to our hospital for cyst removal surgery. Our hospital is a specialty center for jaw reconstruction surgery in India. Alveolar bone graft surgery is a specialty feature of our hospital. Initial presentation at our hospital for treatment of his swelling Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained a detailed oral history. He also ordered comprehensive radiographic studies for the patient including a 3D CT scan of the region. Clinical examination revealed that the patient had a swelling involving the upper maxilla and palate. His right upper central incisor was very mobile and was displaced buccally. The patient’s radiological studies revealed that there was a cystic lesion extending from the right lateral incisor to the left lateral incisor with extensive destruction of surrounding alveolar bone. A biopsy obtained from the area confirmed it to be a periapical cyst. Treatment plan formulated and explained to the patient It was explained to the patient and his parents that the cyst needed to be enucleated in its entirety along with extraction of the mobile right central incisor. There would be no necessity to extract any remaining teeth in the affected region as it was a periapical cyst. It was also explained that a rib graft needed to be harvested for bone grafting as there was extensive bone loss in the region of the cyst. Surgical procedure for correction cyst removal and jaw reconstruction Under general anesthesia, a right inframammary incision was made and a costochondral rib graft was harvested. A Valsalva maneuver was then performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers with sutures. Following this, a crevicular incision was then made in the maxilla over the region of cystic involvement. A mucoperiosteal flap was then elevated and the cystic defect exposed. This was followed by enucleation of the cyst taking care to ensure that the entire lining of the cyst was removed. The mobile right central incisor was also extracted. Electrocauterization was then done followed by flushing the area with an antibiotic solution. The area of bony defect was then packed with rib grafts following which the wound was closed with resorbable sutures. Successful outcome of the surgery Surgery was successful with establishment of normal alveolar bone contour following placement of the rib grafts. Healing was uneventful and the patient was very happy with the outcome of the surgery. Surgery Video
Reconstruction of Condyle (Jaw Joint) Coronoid and Ramus using rib graft for Hemifacial Microsomia
An introduction to hemifacial microsomia Hemifacial microsomia is a congenital disorder that affects the development of the lower half of the face. It most commonly affects the ears, the mouth and the mandible. It usually occurs only on one side of the face, but rarely may involve both sides of the face. If severe, it may result in breathing difficulties due to obstruction of the trachea—sometimes even requiring a tracheotomy. With an incidence in the range of 1:3500 to 1:4500, it is the second most common birth defect of the face after cleft lip and cleft palate. Hemifacial microsomia shares many similarities with Treacher Collins syndrome, Goldenhar syndrome and Franceschetti syndrome. Surgical procedures for correction of the resulting facial asymmetry is the only remedy available for patients with hemifacial microsomia. Fat grafting into areas of soft tissue deficiency is one mode of treatment. The aim of reconstructive surgery is to restore symmetry to facial structures. It involves performing both oral and maxillofacial surgery as well as plastic surgery procedures. Temporomandibular joint surgery is performed in case of involvement of the joint. Tooth extractions might be needed if there is a tooth at the site of the bony cut placed for mandibular distraction. Patient with gradually developing facial asymmetry The patient is a 23-year-old female from Varkala in Kerala, India whose parents began to notice developing facial asymmetry since her infancy. It gradually kept worsening over a period of time until it became cosmetically unappealing. A doctor in her hometown diagnosed her with hemifacial microsomia and recommended that they wait until adulthood before they sought surgical correction of her facial asymmetry. She had become socially withdrawn and quiet over the years and hardly left the house. She also kept her head tilted onto the right shoulder in an attempt to conceal the asymmetry. This had resulted in chronic neck pain for the patient. They recently met with an oral and maxillofacial surgeon near their hometown who referred them to our hospital for hemifacial microsomia surgery. Our hospital is a renowned specialist center for facial asymmetry surgery in India. Initial presentation at our hospital for consultation Dr SM Balaji, facial asymmetry correction surgeon, examined the patient and ordered comprehensive imaging studies. Complete clinical and radiological examination done. Clinical examination revealed facial asymmetry on the right side along with torticollis on the right side. Torticollis or wry neck is a form of dystonia that is defined by an abnormal, asymmetrical head or neck position, the etiology of which might be due to a variety of causes. The term torticollis is derived from the Latin words tortus, which means twisted and collum, which means neck. The patient’s 3D CT scan revealed a hypoplastic right ramus. She also had an ear tag on the right side of her face. Treatment planning formulated for the patient Dr SM Balaji planned to do ramus distraction osteogenesis for correction of her facial asymmetry, but since there was insufficient bone at that site for the distraction osteogenesis, it was decided to do the surgery in two steps. The first step would involve obtaining a costochondral rib graft and recreate a coronoid and reinforce the mandibular ramus. This surgery would result in creation of sufficient bone for distraction. Once the grafts have been adequately consolidated in the area, the patient would then undergo the distraction osteogenesis. Successful recreation of the coronoid and mandibular ramus Under general anesthesia, a right inframammary incision was first made and costochondral rib grafts were harvested. A Valsalva maneuver was then performed to ensure absence of perforation into the thorax following which closure of the incision was then done in layers. A right submandibular incision was then made and dissection was performed up to the condyle. The bone grafts were crafted to the right size and the coronoid was recreated along with augmentation of the ramus of the mandible. These grafts were then fixed with titanium screws and the incisions closed with resorbable sutures. A postoperative OPG taken two months after the surgery showed evidence of sufficient bone consolidation at the site of the grafting. The patient’s face was also more symmetric. The patient would return in six months for her distraction osteogenesis. The patient’s parents expressed their thankfulness as the patient’s hemifacial microsomia had affected the patient to such a degree that the whole family had been affected by it. Surgery Video
Simultaneous Alveolar Bone Graft and Cleft Rhinoplasty Surgery
[et_pb_section admin_label=”section”] [et_pb_row admin_label=”row”] [et_pb_column type=”4_4″][et_pb_text admin_label=”Text”] Classification of cleft lip and palate surgery Surgery for the correction of a cleft lip and palate comes under both functional as well as cosmetic surgery. Other cosmetic procedures include face lifts, tummy tucks, removal of signs of aging such as wrinkling of skin, other forms of skin care surgery such as removal of warts and scars, brow lift and eyelid surgery. Wrinkling of skin is a sign of ageing. This is a physiological process and happens with due course of time. Premature wrinkling can lead to loss of confidence in a person. This can be corrected by tightening the skin by pulling it near the jaw line. An experienced surgeon is needed to perform this to perfection as it may lead to a mask like appearance of the face if done incorrectly. Facial lifts are performed this way. All these come under facial plastic surgery. Bilateral cleft lip and palate surgery is the most severe form of cleft. Correction of cleft lip and palate deformity is performed by an oral and maxillofacial surgeon. Board certified plastic surgeons also perform these above mentioned surgeries in the developed nations of the world. Patient with a history of unilateral cleft lip and palate The patient is a 25-year-old male from Ranchi in Jharkhand, India who was born with a unilateral cleft lip and palate deformity. He had undergone cleft lip surgery at the age of 3 months and cleft palate surgery at the age of 9 months. Pharyngoplasty had been performed at the age of 3-1/2 years to improve his speech and correct his velopharyngeal insufficiency. Alveolar cleft defect reconstruction was done at the age of 4 years. All the surgeries were done elsewhere. The patient has always had a nasal deformity due to his cleft, which has always made him feel very self conscious. He had always been a loner because of this and has few friends. His worried parents had consulted a doctor in their hometown who advised them to get this corrected surgically. He had then referred the patient to us as our hospital is renowned for cleft rhinoplasty surgery. Our hospital is a premier center for all varieties of facial cosmetic surgery in India. Initial presentation and examination at our hospital Dr SM Balaji, facial cosmetic surgeon, examined the patient and ordered comprehensive imaging studies. Imaging studies revealed a noticeable depression in the right anterior maxillary region. Since the patient is a case of unilateral cleft on the right side, the right side of the nose was depressed along with a depressed nasal bridge. The right nostril was also depressed. It was explained to the patient that the depression in the right maxilla needed to be corrected with placement of a rib graft along with a costochondral graft for nose correction. The right anterior maxillary graft would add bulk to the lip contour thus elevating the base of the nose. A lip revision and Weir excision was also planned for the patient. Successful surgical correction of the nasal deformity Under general anesthesia, an incision was first placed in the right inframammary region and a costochondral rib graft was harvested. This was followed by a Valsalva maneuver, which demonstrated a patent thoracic cavity without any perforations. The incision was then closed in layers. Following this, a sulcular incision placed in the right anterior maxilla and a flap was elevated. A rib graft was crafted to fit into the defect in the right anterior maxilla. This was then fixed in place using titanium screws. Next, a transcartilaginous incision was made in the left nostril and dissection was done up to the dorsum of the nose. Following this, the nasal bridge was then augmented using a costochondral rib graft. A strut graft was also placed to elevate the right nostril. This was then followed by lip revision surgery with Weir excision done on the left side. Full patient satisfaction at the results of the surgery The patient was very satisfied with the results of the surgery. He expressed his happiness at the cosmetic outcome of the surgery. His parents expressed their thankfulness to the surgical team, saying that this would enable the patient to lead a normal life. Surgery Video [/et_pb_text][/et_pb_column] [/et_pb_row] [/et_pb_section]