Cleft Maxillary Advancement Surgery (Le Fort I) with Dental Implant
Patient born with a cleft lip and palate The patient is a 15-year-old boy from Warangal in Telangana, India. He had been born with a unilateral left sided cleft lip and palate at a local hospital. Cleft lip is incomplete fusion of the two halves of the upper lip. A palatal cleft is incomplete fusion of the roof of the mouth. These deformities are the most common congenital deformities. A doctor at the hospital had referred the patient to our hospital. Our hospital is renowned for facial deformity surgery in India. Dr SM Balaji examined the patient and treatment was commenced for the patient. The patient had undergone cleft lip surgery at 3 months of age and cleft palate surgery at 9 months of age. Cleft alveolar reconstruction surgery had been done at 4 years of age with BMP. An anterior crossbite developed as the patient grew up and there was backward positioning of the maxilla. There was also a congenitally missing left upper lateral incisor due to the cleft defect. He had a great deal of difficulty eating because of these defects. His parents brought him back to our hospital for correction of these deformities. The patient became very self conscious of his facial deformity as he grew up and became socially withdrawn. There was a lot of bullying at school and he had very few friends. Bullying by peers is commonly faced by children with cleft lip and palate deformity. This is because they are perceived as being different by other children. Parents of children born with cleft lip and palate are extensively counseled at the time of birth of the children. The first reaction at the birth of a baby with cleft deformities is shock followed by denial. They have to be counseled that full surgical rehabilitation will result in normal development of these children. Initial presentation at our hospital Dr SM Balaji, facial deformity correction surgeon, examined the patient and ordered comprehensive imaging studies. The patient had an increased crossbite in the anterior region. The maxilla was also in a retruded position in relation to the rest of the facial skeleton. There was also a congenitally missing lateral incisor on the left side due to unilateral cleft lip and palate. Treatment planning for addressing the patient’s concerns Presurgical orthodontics was planned to bring the individual teeth in correct alignment before the surgery. Surgical correction would be followed by postsurgical orthodontics for final alignment of the teeth. A Le Fort I surgery was planned to bring out the retrognathic maxilla into correct position. It was also planned to give the patient a dental implant for replacement of the missing maxillary left lateral incisor. Dental implants are the most effective way of replacing missing teeth. Artificial teeth are fixed on the dental implant once osseointegration of the implant is complete. This patient would require an artificial tooth to replace his missing left lateral incisor. Rehabilitation of this patient would be complete at the end of these procedures. The treatment planning was explained in detail to the patient’s parents who agreed to the plan. Presurgical orthodontics was initiated and the patient’s individual teeth were brought into correct alignment. The patient was next scheduled for surgical correction. Surgical correction of the patient’s problems Under general anesthesia, a sulcular incision was made in the maxilla. A mucoperiosteal flap was then elevated to expose the maxillary bone. A Nobel Biocare dental implant was placed in relation to the missing left maxillary lateral incisor. Dental implant surgery was thus completed. This was then followed by Le Fort I bone cuts, which facilitated separation of the maxillary bone. The maxillary segment was then pulled outwards and placed in correct occlusion. This was then stabilized and fixed using titanium plates and screws. The incision was then closed using resorbable sutures. Successful outcome of the surgical procedure The patient and his parents were extremely happy with the results of the surgery. The maxilla was now in correct alignment with the rest of the facial skeleton. Facial esthetics were also very pleasing now. Postsurgical orthodontic alignment would be performed once there was complete consolidation of the bone at the site of surgery. A ceramic prosthesis will be given at the implant after a period of three months once osseointegration of the implant is complete. Surgery Video
Lower Jaw Protrusion ( Prognathism ) Bilateral Sagittal Split Osteotomy (BSSO) Surgery
Correction of lower jaw protrusion Excessive protrusion of lower jaw causes both esthetic as well as functional compromises. It falls under the ambit of facial plastic surgery because of the cosmetic correction. Fixed orthodontic treatment will also be needed to move teeth into correct alignment before the surgery. This tooth movement will lead to optimal results after the surgery. This protocol is followed by the American Association of Oral and Maxillofacial Surgeons. The orthodontic appliances used for this treatment is fixed appliances. Both lower and upper jaw tooth correction is done through this treatment. Metal wires were employed back in the day for this, but modern technology has completely transformed this. Transparent or tooth colored wires are employed nowadays for this treatment. The position of the lower front teeth is most often brought to a vertical orientation for this surgery. The rationale behind this becomes clear after completion of the surgical procedures. Surgery includes backward positioning of the lower jaw in case of mandibular prognathism. The upper jaw position is not altered if the problem is associated only with the lower jaw. Patient with a disproportionately large lower jaw The patient is a 25-year-old male from Palayamkottai in Tamil Nadu, India who has always had problems because of a large lower jaw. This had led to eating and speaking difficulties ever since he can remember. He has difficulty closing his mouth and has had chronic pain in his jaw joints because of this. The patient mentioned that he had a long lower jaw from a very early age. He had gone through depression at multiple stages of life due to his elongated lower jaw. He felt lonely and led a solitary life. His parents had taken him to an oral surgeon at his hometown who had examined him. Realizing the complexity of the problem, the oral surgeon had referred the patient to our hospital for surgical correction of his oversized lower jaw. Our hospital is a renowned center for orthognathic surgery in India. Jaw reconstruction surgery as well as other facial cosmetic surgery procedures are commonly performed in our hospital. What is mandibular prognathism? Prognathism in humans can be due to normal variations among phenotypes. In human populations, prognathism may be a malformation, the result of injury, a disease state or a hereditary condition. This is considered a disorder only if it affects mastication, speech or social function as a byproduct of severely affected aesthetics of the face. Mandibular prognathism is a protrusion of the mandible, affecting the lower third of the face. Pathologic mandibular prognathism is a potentially disfiguring genetic disorder where the lower jaw outgrows the upper, resulting in an extended chin and a crossbite. It is sometimes a result of acromegaly. This condition is sometimes colloquially known as lantern jaw or the Hapsburg jaw. Initial presentation at our hospital for examination Dr SM Balaji, facial cosmetic surgeon, examined the patient and obtained a detailed history. He ordered comprehensive imaging studies for the patient. The patient had an anterior crossbite with class III malocclusion. Treatment planning was presented to the patient and his parents. The patient was advised to undergo corrective lower jaw surgery. This was to be followed by fixed orthodontic treatment for management of his dental malocclusion. Successful surgical correction of the patient’s mandibular prognathism Under general anesthesia, an incision was placed in mandibular retromolar region bilaterally. Flaps were then elevated in the region to expose the mandibular bone. Bone cuts were made and a bilateral sagittal split osteotomy was performed using the Obwegeser technique. The mandible was pushed backwards, occlusion was checked and the mandible was then fixed using Titanium plates and screws. Extreme care was taken to ensure the safety of the inferior alveolar nerve. The nerve in the proximal and distal segments was protected during this part of the procedure. Closure was then done using resorbable sutures. Total patient satisfaction at the outcome of the surgery The patient expressed total satisfaction at the results of the surgery. His facial esthetics was very pleasing and he now had a normal occlusion. His facial profile was also to his liking. He would have to return in a few months to undergo orthodontic treatment. This is for correction of his malaligned teeth. Surgery Video
Cleft Rhinoplasty Alar web Removal and Dorsal Augmentation Surgery
Patient born with unilateral cleft lip and palate The patient is a 19-year-old female from Firozpur in Punjab, India, born with a left-sided unilateral cleft lip and palate. A cleft palate is an incompletely fused roof of the mouth. She had undergone cleft lip repair at 4 months of age and cleft palate repair at 9 months of age. This had been followed by cleft alveolus reconstruction at 4 years of age. All these surgeries had been performed at a local hospital by an oral and maxillofacial surgeon. Surgical correction of these deformities is through oral and maxillofacial surgery. Experienced plastic surgeons also perform this surgery. Perfect alignment of many layers of skin and tissue are involved in this surgery. Surgery for removal of hypertrophic scar tissue might be needed at a later date. Bone grafts will be needed in case of bone deficiency in the alveolar region of the cleft. Speech therapy will be needed for normal development of speech. Normal speech development is very important for proper integration into society. The patient had developed a retruded maxilla as she grew up as well as a nasal deformity. This had made her feel very self conscious and she had always kept to herself with very few friends. She had also faced a lot of bullying at school. Bullying by peers can cause a lot of psychological scars in children with congenital deformity. This is more so in the case of cleft lip and palate as it is on the face. Her worried parents had consulted again with the oral and maxillofacial surgeon who referred them to our hospital. Initial presentation at our hospital in 2018 The patient and her parents initially presented to our hospital in 2018. Dr SM Balaji, rhinoplasty surgeon, had examined the patient and obtained a detailed history. He then ordered for detailed imaging studies, which revealed the retruded maxilla. The patient also had a nose that was depressed on the left side. There was also an ungainly scar with alar webbing on her upper lip from the previous surgery. The patient and her parents wanted correction of the above defects along with creation of a symmetrical nose and scar removal. Treatment planning included Le Fort I correction of her retruded maxilla followed by scar revision surgery of her upper lip. A rhinoplasty surgery was also planned for the nasal deformity correction. She underwent Le Fort I advancement of the maxilla at the time of her initial presentation to our hospital in 2018. She now presents with her parents for rhinoplasty and scar revision surgery. Treatment planning for rhinoplasty and scar revision surgery Examination revealed that the patient had an unsightly scar from her previous cleft lip surgery. There was also a nasal deformity with a depressed left nostril, which was considerably smaller in size than the right nostril. Left nasal sill correction and nose correction with costochondral graft was planned. Alar web correction was also planned on the left side. Surgical correction of the patient’s facial deformities Under general anesthesia, an incision was made in the right inframammary region and a costochondral rib graft was harvested. A Valsalva maneuver was performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers with sutures. Following this, a sulcular incision was made in the left anterior maxilla and a flap was elevated. The previously placed titanium plate and screws were removed. Left anterior maxilla was then augmented using the rib graft, which was fixed using titanium screws. Left nasal sill correction was next performed followed by closure of the incision with sutures. A transcartilagenous incision was then placed in the right nostril with dissection up to the dorsum of the nose. The nasal dorsum was augmented using the costochondral graft. A strut graft was then placed. This was followed by closure using resorbable sutures intraorally and intranasally. Successful correction of the patient’s complaints through surgery The patient and her parents were extremely happy with the results of the surgery. There was tremendous improvement in the esthetics of her face. She now had a nose that was symmetrical and in harmony with her face. The patient expressed that she could now face the world with a renewed sense of confidence. Surgery Video
Cleft Rhinoplasty – Nasal Augmentation and Creating Symmetry
Patient born with right sided cleft lip and palate The patient is an 18-year-old female from Jhansi in Uttar Pradesh, India who was born with a right sided unilateral cleft lip and palate. Cleft lip is the presence of a gap in between the two halves of the upper lip. This is a developmental defect that happens in utero. Repair of cleft lip involves perfect integration of layers of skin and muscle tissues. A cleft palate is incomplete fusion of the roof of the mouth. Cleft palate repair would result in closure of this defect. She had undergone cleft lip surgery at 3 months of age, cleft palate surgery at 8 months of age and cleft alveolus reconstruction at 4 years of age. All these surgeries had been performed by an oral surgeon at a local hospital. Cosmetic and functional complications arising from surgery The patient had developed an asymmetrical depressed nose along with hypertrophic scar from the cleft lip repair surgery. She had faced a lot of bullying in school and had always been a socially withdrawn person with few friends. The patient had become depressed of late and had begun to isolate herself inside the house. Her worried parents visited the oral surgeon who had referred her to our hospital for surgical correction of her deformities. The patient wished to have a symmetrical nose along with removal of the scar from the upper lip. Social difficulties face by children with cleft lip and palate Children born with cleft lip and palate deformity can face a lot of social difficulties. Bullying by peers is one of them. This usually occurs in the school setting. This is a result of these children being perceived as being different by other children. Parents have to be very sensitive and understanding while addressing these issues. Improper handling at this stage can lead to lifelong psychological scarring in these children. Initial presentation at our hospital with treatment planning Dr SM Balaji, cleft rhinoplasty surgeon, examined the patient and ordered comprehensive imaging studies. The patient had a unilateral cleft lip on the right side, which had caused the right side of the nose to become depressed. The right nostril was considerably smaller in size than the left nostril. There was also a noticeable scar near the right nasal sill. Treatment planning of nasal asymmetry and scar revision Rhinoplasty surgery would be required for correction of the nasal asymmetry. A rhinoplasty is also known as the nose job. Correction of the nasal defect was planned through the use of a costochondral graft harvested from the patient. The nasal bridge was to be elevated using the costochondral graft. A strut graft would be used to correct the depressed right nostril. Revision of the scar from the cleft lip repair surgery was also planned for the patient. This was explained to the patient and her parents who consented to surgery. Successful surgical correction of the patient’s complaints Under general anesthesia, an incision was made in the right inframammary region 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. Scar revision surgery was next performed with the scar near the right nasal sill being excised. A transcartilagenous incision was next placed in the left nostril and dissection done up to the dorsum of the nose. The nasal dorsum was augmented using the costochondral graft. A strut graft was then utilized to elevate the depressed right nostril. Closure was then done using resorbable sutures both intranasally and extraorally. Complete patient satisfaction at the outcome of the surgery The surgery was a success with a resultant symmetrical nose along with excision of the scar from the sill of the nose. Esthetic improvement of the patient’s face was immediate. The patient and her parents expressed complete satisfaction at the outcome of the surgery. The patient now had a more symmetrical nose, which was in harmony with the rest of her face. She expressed her joy and sincere gratitude to the surgeon. She was no longer afraid of fellow students teasing her. She will now be able to lead a normal life with more self-confidence. Surgery Video
Square Face, Masseter Muscle Excision failed – Resurgery with Gonial Angle Reduction
Patient with complaints of a broad lower face due to masseter hypertrophy The patient is a 25-year-old boy from Ranchi in Jharkhand, India. He had always felt very self conscious about his face as he felt that the lower half of his face was very broad. This had made him very self conscious and socially withdrawn over a period of time. He said that he had faced a lot of bullying in school and in college. The patient had presented to a local oral surgeon who had diagnosed him to have hypertrophy of the masseter muscles. The face plays a huge part in day to day interactions. Nobody is truly satisfied with the face that they have, but this does not prevent them from carrying out their activities of daily living. It is only when this dissatisfaction with one’s face crosses a threshold point that it starts to interfere with carrying out one’s daily duties. Plastic surgery initially evolved from general surgery to deal with gross disfigurements of the face. It is only later that it evolved to even correct minor blemishes of the face. Plastic surgery in India has become a highly evolved specialty today. Facial plastic surgeons in India perform a wide variety of cosmetic surgery procedures that range from face lifts to tummy tucks. Reduction of a broad lower face comes under the category of corrective jaw surgery as it involves reduction of the bony excess at the gonial angles of the mandible. Patient not satisfied with results of masseter muscle reduction surgery It had been advised that he undergo masseter muscle reduction surgery (square face surgery) and he had consented for the same. He had undergone masseter reduction surgery through an extraoral approach. This had however failed to remove the masseter muscle and he was not satisfied with the results. There had been an unsightly residual scar. He said that his face still had a square appearance and he felt that it was still esthetically unappealing. His facial profile was not to his satisfaction and he still remained unhappy. He had spoken about his problem with a friend from another city and expressed his lack of self confidence due to this. The friend mentioned that his problem could be easily solved at our hospital. We are a renowned hospital for facial cosmetic surgery in India as well as jaw reconstruction surgery in India. Initial evaluation and treatment planning at our hospital Dr SM Balaji, facial cosmetic surgeon, examined the patient in detail and obtained biometric readings of the patient’s face. He ordered imaging studies including a 3D CT scan of the patient’s facial architecture. The 3D CT scan revealed that the patient had a very broad mandible with prominent gonial angles. This revealed that the patient needed both masseter muscle bulk reduction surgery and trimming and shaping of the gonial angles of his mandible. The findings were discussed in detail with the patient who was in full agreement with the surgical plan and signed the informed consent. Surgical reduction of the gonial angles and masseter bulk Under general anesthesia, modified Wards incisions were placed in the mandibular retromolar regions bilaterally following which flaps were elevated. Dissection was carried down to the gonial angle of the mandible. The gonial angles of the mandible were then reduced bilaterally. This was followed by dissection of the periosteum following which the masseter muscle was identified. The masseter muscle was completely excised bilaterally. Drains were also placed postsurgically in order to ensure that there would be no hematoma formation at the operative site. The wound was checked for hemostasis following which closure was then done using resorbable sutures. Patient very satisfied with the results of the surgery The patient was happy with the outcome of the surgery. He now had a narrower appearing mandible. His facial bulk had also been reduced giving him a more chiseled and sophisticated look. He said that he was very happy with the appearance of his face now. The patient was even more pleased during his subsequent postsurgical follow up visits once the swelling from the surgery had considerably subsided. Surgery Video
Long Lower Jaw BSSO – Bilateral Sagittal Split Osteotomy with Set Back Surgery
Etiology behind the occurrence of mandibular prognathism Mandibular prognathism is the excessive protrusion of the mandible in relation to the rest of the skull. It is considered to be a pathological condition when it compromises both the functional and esthetic aspects of the lower jaw. An extended chin and an anterior crossbite renders both eating and speech difficult for the patient. There can be a genetic element to the occurrence of mandibular prognathism. The house of Hapsburg, which was the royal lineage of Austria had an extreme manifestation of mandibular prognathism because of severe inbreeding that was done to maintain the royal bloodline. There were certain members of the family whose mandibular prognathism was so severe that it made it impossible for them to eat a normal diet. The functional problems caused by mandibular prognathism can lead to severe limitations in jaw function. Corrective jaw surgery is performed to set right the functional problems. This is also a cosmetic surgery as it leads to an improvement in facial esthetics for the patient. The open bite and the cross bite are also corrected by this surgery. Bilateral sagittal split osteotomy, which is the surgery performed for correction of mandibular prognathism is performed by oral and maxillofacial surgeons. Other surgical procedures performed by them include TMJ surgery. Problems arising from a long lower jaw The patient is a 25-year-old female from Indore in Madhya Pradesh, India who had always had a long lower jaw in relation to her upper jaw. She also had a degree of facial asymmetry arising from this condition. There were also issues with difficulty with speech and eating. She was also unable to close her lips fully. This was resulting in dry chapped lips. Her parents had decided to seek medical attention to correct this problem. They had approached a local orthopedic surgeon who had examined the patient. He explained to the patient and her parents that she needed to be operated on by an Oral and Maxillofacial Surgeon. He had referred them to our hospital as we are one of the premier centers for jaw reduction surgery in India. Our hospital addresses every cosmetic surgical need that arises from the facial region including rhinoplasty surgery, microtia surgery, ptosis surgery, facial reanimation surgery, facial reconstruction surgery and all varieties of jaw surgeries including cyst removal surgery, TMJ joint surgery, and jaw reconstruction surgery. Incidence rates of facial asymmetry in the general population Among the overall population, facial asymmetry can either be noted clinically or subclinically. It not only causes esthetic compromise, but also affects functionality. Facial asymmetry can due to many etiological factors. These can broadly be divided into congenital or acquired. The treatment plan for facial asymmetry depends on age, severity and etiology. Treatment planning is arrived at by carefully assessing the results of the intraoral, extraoral and radiological examinations. Initial presentation and treatment planning at our hospital Dr SM Balaji, jaw reconstruction surgeon, examined the patient thoroughly and ordered radiological studies. The patient had an anterior crossbite with class III malocclusion. Various model studies were performed following which Dr SM Balaji advised them that she best undergo lower jaw reduction followed by fixed orthodontic therapy for management of her malocclusion. The patient and her parents were in agreement with the treatment plan and signed the consent form. Successful surgical reduction of her increased mandibular length Under general anesthesia, incisions were placed in the mandibular retromolar regions bilaterally following which flaps were elevated. This was followed by bone cuts being made and bilateral sagittal split osteotomy performed. Extreme care was taken at this stage to ensure that there was no iatrogenic damage to the inferior alveolar nerve. It was mobilized with the distal segment so that the proximal segment could be adequately mobilized for the bilateral sagittal split osteotomy. The mandible was then pushed backward, checked for occlusion and fixed using Titanium plates and screws. This was followed by closure using resorbable sutures. Total patient satisfaction at the results of the surgery The patient was very happy with the outcome of the surgery. Her occlusion was completely normal and her maxillary teeth and mandibular teeth were in good alignment with a normal occlusion. Her facial profile was also corrected. She will still need to undergo fixed orthodontic treatment to correct the individual malalignment in each tooth. The patient was advised to return for this in a few months. Surgery Video
Refracturing the malunited jaw, correcting the occlusion and upper jaw augmentation surgery
Evolution of Facial Fracture Treatment down the ages We live in the golden age of mankind where wars are minimal and the frontiers of medical science are being expanded on a daily basis. The fields of oral surgery and orthognathic surgery have become highly advanced, both in the form of techniques and the materials used. Medical treatment was very primitive in the ancient days. Mankind too led far more violent lives and the occurrence of facial fractures was quite common. This left behind debilitating deformities of the face. There was also partial loss of dentition when the fractures involved the bones of the jaws. This led to a great drop in the quality of life of the person. Functional problems directly contributed to a reduction in the lifespan of the individual. Common sites of occurrence of facial fractures Common fractures that occurred included orbital fractures, fractures of the sides of the face, nasal fractures and broken bones involving the eye sockets. This led to an asymmetrical face with soft tissue distortion. Facial features became distorted leading to social problems. The advent of reconstructive surgery and corrective jaw surgery in modern times greatly helped in the treatment of facial fractures. Modern surgical practices utilize titanium screws and plates to correctly align and stabilize the fractured segments in normal anatomical alignment. Implants are used to replace any lost teeth. An implant mimics a tooth root. Artificial teeth are fixed on top of these implants to rehabilitate the patient. Straightforward implant surgery is a simple procedure and can be performed under local anesthesia. This not only results in improved oral health but also improved general health. Bone grafting is utilized when there is loss of bony support for fixing implants. Care should be taken during the healing process to ensure best long term viability of the implants. Patient with a history of multiple fractures from a road traffic accident The patient is a 32-year-old female from Kurnool in Andhra Pradesh, India who had been involved in a horrific road traffic accident around five years ago. This had resulted in panfacial fractures for the patient. She had been admitted at a local hospital for fracture reduction and plate fixation. However, she had never been happy with the outcome of the facial fracture surgery as it had resulted in a facial asymmetry. The fractured segments of her mandible had collapsed inwards and there was also a deficit of 8-10 mm of bone at the fracture site. In fact, this had slowly developed into a depression with her avoiding all social contact. She also had functional jaw problems, which made it difficult for her to eat well. A family friend from Chennai had visited her in Kurnool and had come to know about her problems. She had then referred the patient to Balaji Dental and Craniofacial Hospital in Chennai. The patient and her husband thus presented to our hospital for surgical correction of her malunited fracture. Our hospital is a renowned center for jaw deformity surgery in India. Initial examination and treatment planning in our hospital Dr SM Balaji, facial asymmetry surgeon, examined the patient and ordered radiographic studies. Clinical examination revealed that the patient had partially edentulous maxilla and mandible. The right maxillary and mandibular ridges were not in alignment and were also not suitable for teeth replacement. There was notable facial asymmetry in the lower part of the face. A 3DCT scan revealed malunited mandible. The patient also did not have sufficient bone in the right maxilla for replacement of her missing teeth. The treatment plan was to refractured the mandible and fix it in proper alignment using plates and screws. The right maxillary alveolar ridge was to be reconstructed using the rib graft. Surgical correction of the malunited fracture through refractured of the jaw Under general anesthesia, rib grafts were first harvested from the patient. Following this, a Valsalva maneuver was performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers with sutures. Next, a crevicular incision was placed in mandible and a mucoperiosteal flap was elevated. Dissection was then done down to the previously placed titanium plates and screws, which were then removed. Following this, the mandible was refractured along the midline, checked and separated by about 8-10 mm at the midline. This gap was closed using pieces of rib graft. The segments were then stabilized and fixed in the new position using titanium plates and screws. A midcrestal incision was next placed in right maxilla and a mucoperiosteal flap was elevated. The previously placed plates and screws removed. The right maxillary alveolar ridge was augmented using rib graft and fixed with screws. Hemostasis was achieved and closure was done using resorbable sutures. Successful outcome of the surgery The patient was very happy with the outcome of the surgery. Her facial asymmetry was completely corrected and the right maxillary and mandibular alveolar ridges were in perfect alignment. The patient can undergo dental implant surgery after about 3-4 months following complete bone formation. She expressed her total satisfaction at the outcome of the surgery. Surgery Video
Oral Submucous Fibrosis – partial Trismus Mouth Opening Surgery With Nasolabial Flap Surgery
The growth of aesthetic surgery in India Cosmetic surgery or plastic surgery in India has become highly sought after since the advent of globalization. Some of the common procedures performed include brow lift eyelid surgery, face lifts, correction of congenital defects, reconstructive surgery for trauma victims etc. There has been a mushrooming of plastic surgery hospitals in India of late. Patients who wish to opt for cosmetic procedures have to be very cautious in choosing the right hospital. There have been many instances where the results of the surgery have been catastrophic for the patient. This necessitates corrective surgery at the hands of an experienced surgeon. Therefore, patients have to be very cautious in the selection of the surgeon as well as the hospital. Young man with progressively worsening mouth opening The patient is a 19-year-old male from Kashipur in Manipur, India who began noticing a tightness while opening his mouth from around two years ago. This was slowly getting worse with the passage of time. It has now reached a point where he is able to opening his mouth by only around 7 mm. This has made eating very difficult and he noticed that his cheeks had also started hardening. The patient has been chewing khaini, a mixture of tobacco, lime and betel nut since he was 12 years old. He however does not smoke cigarettes or drink alcohol. Patient decides to seek medical attention for his mouth opening problems It ultimately reached the point that the patient decided to seek medical attention for his problem. An oral and maxillofacial surgeon in his hometown examined him and informed him that he had submucous fibrosis. He also informed the patient that this had been brought about by his tobacco habit and advised the patient to quit his habit immediately. The patient was also informed that treatment for submucous fibrosis was mainly surgical and that only a few specialty hospitals in India performed this surgery. He then referred the patient to our hospital for management of his submucous fibrosis as our hospital is renowned for oral submucous fibrosis surgery. Our hospital is also renowned for a variety of facial cosmetic surgery in India. What is oral submucous fibrosis? Oral submucous fibrosis is a chronic, complex, premalignant (1% transformation risk) condition of the oral cavity, characterized by progressive fibrosis of the submucosal tissues. As the disease progresses, the jaws become rigid to the point that the person is unable to open the mouth. The condition is remotely linked to oral cancers and is associated with areca nut or betel quid chewing. This is a habit that is practiced predominantly in SouthEast Asia and India and is similar to tobacco chewing. Once oral submucosal fibrosis has set in, it cannot be reversed and treatment mainly consists of management with steroids and surgery. Initial presentation at our hospital for management of oral submucous fibrosis Dr SM Balaji, oral submucous fibrosis surgeon, examined the patient. Various measurements were obtained from the patient’s mouth. The patient had a mouth opening of about 7mm. Clinical examination revealed thick fibrous bands on the buccal mucosa bilaterally. He was diagnosed with oral submucous fibrosis. The patient’s condition was explained to him in detail. Surgical planning to for excising the fibrous bands followed by covering the raw area with nasolabial flap was also discussed with the patient. The patient was in agreement with the treatment plan and signed the consent form. Surgical treatment of the patient’s oral submucous fibrosis The patient underwent awake bronchoscopic intubation as the patient was not able to open his mouth adequately for normal intubation. Following successful intubation, the incisions were marked out on the skin along natural skin creases to minimize visible scar formation. Following this, a linear horizontal incision was made in the buccal mucosa bilaterally and the fibrous bands were excised. This was followed by placement of an elliptical incision in the nasolabial region bilaterally and an inferiorly based nasolabial flap was elevated. Blood supply to the flap was through the facial artery. Care was taken at all times to ensure that blood supply was not compromised. Tunneling was then done and the flap was rotated Intraorally and sutured to the buccal mucosa using resorbable sutures. A mouth opening of about 3.2 cm was achieved through this procedure. Successful outcome to the surgical intervention The outcome of the surgery was as planned. Adequate mouth opening was achieved postsurgically. The patient was advised to do mouth opening exercises to further improve his mouth opening. There was hardly any noticeable scar on the nasolabial region at the patient’s one month follow up appointment. Surgery Video
Facial Asymmetry Correction by BSSO Bilateral Sagittal Split Osteotomy and total shift of Mandible (Lower Jaw) Surgery
The patient is a 22-year-old female patient from Gwalior in Madhya Pradesh, India who has always had the complaint of facial asymmetry. She had an anterior crossbite with jaw deviation to the left upon mouth opening.
Facial Asymmetry Surgery BSSO Bilateral Sagittal Split osteotomy with Total Lower Jaw Shift
Patient with lower jaw problems for a long time The patient is a 19-year-old boy from Malkajgiri in Telangana, India who has had jaw problems as long as he can remember. His lower jaw was longer than his upper jaw and had been deviated to the left side with a resultant crossbite. This had detracted not only from the esthetics of his face, but has also caused him difficulties with speech and eating. Social interactions have always been a difficult area for the patient because of this. The patient stated that he has no history of any injury to his jaw region that could have resulted in this. Of note, interestingly, the patient’s brother as well as father also had mandibular prognathism for which they underwent surgery with full resolution of the problem. Patient desires to undergo corrective jaw surgery He complained to his parents that he wanted this corrected as it was getting to be extremely difficult to handle this with the passage of years. His parents too felt that this needed to be addressed and they visited a local oral surgeon who had examined the patient thoroughly and obtained comprehensive imaging studies. He explained that the patient needed corrective jaw surgery followed by fixed orthodontic therapy to correct the malaligned teeth. The oral surgeon further advised that this surgery was a complex procedure and said that only a few specialty centers in India performed this. He therefore referred the patient to our hospital, which is a premier center for jaw correction surgery in India. We are also renowned for orthognathic surgery in India. What is the meaning of mandibular prognathism? Mandibular prognathism is a positional relationship of the mandible or maxilla to the skeletal base where the lower jaw protrudes beyond the upper jaw, thereby leading to malocclusion. The word prognathism derives from the Greek πρό (pro, meaning “forward”) and γνάθος (gnáthos, “jaw”). One or more types of prognathism can result in the common condition of malocclusion, in which an individual’s top teeth and lower teeth are not aligned properly. Correction of this condition is through both surgery as well as fixed orthodontics Initial presentation and examination at our hospital Dr SM Balaji, facial asymmetry surgeon, examined the patient and obtained comprehensive imaging studies. This revealed that the mandible was deviated to the left side with a crossbite. It was advised that the patient undergo lower jaw correction surgery for correction of his facial asymmetry. He was further advised to undergo orthodontic treatment for management of his dental malocclusion. The patient and his parents were in agreement with the proposed plan of treatment and consented to the surgery. Our hospital strictly adheres to the protocols laid by the American Association of Oral and Maxillofacial Surgeons with regards to performance of all surgical procedures. Facial asymmetry surgery is a procedure that not only requires a high degree of surgical skill, but also requires an eye for esthetics on the surgeon’s part. The two halves of the face have to be perfectly balanced in order to produce true facial harmony and ideal esthetics. Long term stability of the results can be ensured by strict adherence to these protocols. Surgical correction of the patient’s jaw deviation Under general anesthesia, eyelets were first placed in both jaws. Following this, incisions were placed in the mandibular retromolar region bilaterally. Flaps were elevated, bone cuts were made and bilateral sagittal split osteotomy done. The mandible was rotated to the right side and pushed backward so that correct occlusion was achieved along with complete correction of the facial asymmetry. It was then fixed in the new position using titanium plates and screws. Closure of the two incisions was then performed using resorbable sutures. Full patient satisfaction at the outcome of the surgery The outcome of the surgery was immediate and the patient was very happy with the results. He now had a completely normal occlusion and his facial asymmetry had also been corrected. He said that he would now have the confidence to face the outside world bravely. Orthodontic treatment would be performed at a later time for correction of his malaligned teeth. Surgery Video