Le Fort I for Hypoplastic Maxilla and Dental Implant Surgery
Young man with maxillary retrognathism from cleft lip and palate deformity The patient is a 16-year-old male from Ankleshwar in Gujarat, India. He had been born with facial deformity comprising of bilateral cleft lip, palate and alveolus. This had resulted in him having a split maxilla. There was a communication to the nasal cavity at the roof of the mouth. The gynecologist had referred them to the dental wing of the hospital. She counseled the parents that a baby with cleft deformities would grow up to be a normal adult. The parents had presented to the dental surgeon at the hospital. He had advised them to follow the predetermined surgical schedule for cleft repair. They had then been referred to us by the dental surgeon. Our hospital is renowned for cleft lip and palate surgery in India. We are recognized as a regional affiliate of the International Cleft Lip and Palate Foundation (ICPF) of Japan. This surgery is mainly performed by Oral and Maxillofacial Surgeons in India. Plastic surgeons also perform this in countries like the US and European countries. The patient had undergone cleft lip surgery at 3 months and cleft palate surgery at 9 months in our hospital. This had been followed by cleft alveolus repair at 3-1/2 years of age. Both cosmetic and functional results from the three surgeries had been optimal. He had been referred to a speech pathologist for speech training and had developed good speech patterns. Gradually worsening maxillary deficiency with resultant facial deformity The patient had met all his developmental milestones appropriately. He was able to feed well and his speech development was also normal. However, as her grew older, his maxillary growth was deficient with resulting backwardly placed upper jaw. This made it very difficult for him to eat and he felt that it was compromising the esthetics of his face. He had an anterior skeletal crossbite. This had caused significant esthetic compromise to his facial appearance. His parents had presented back to our hospital for correction of this problem. He also had a hypoplastic maxillary left central incisor and missing lateral incisor. He had undergone bone grafting at 11 years of age. This was to create adequate bony support for placement of an implant at the site of the missing tooth. Patient presents at our hospital with his parents Dr SM Balaji, facial reconstruction surgeon, examined the patient and ordered comprehensive radiological studies for the patient including a 3D CT. Clinical examination revealed an anterior maxillary crossbite. The maxilla was also backwardly placed and with a narrow arch. His 3D CT revealed a split maxilla with maxillary hypoplasia. Common causes for maxillary hypoplasia Maxillary hypoplasia is caused by underdevelopment of the maxillary bones, which produces midfacial retrusion and creates the illusion of mandibular prognathism. It is associated with Crouzon syndrome and Angelman syndrome as well as fetal alcohol syndrome. This is also a feature of many patients with repaired cleft lip and palate deformity. A rarer etiology for this deformity is traumatic maxillary dental extractions. Treatment planning and surgical correction of maxillary retrusion It was explained to the patient that his retrognathic maxilla would be advanced through a Le Fort I procedure. The maxillary segment would be stabilized using titanium plates and screws. His split maxilla would be brought together. This would be followed by extraction of the malformed central incisor and placement of dental implants for the two incisors. The patient was in agreement with the proposed treatment plan and consented to surgery. Under general anesthesia, a crevicular incision was made in maxilla followed by elevation of a mucoperiosteal flap. Extraction of the left central and lateral incisors was then performed followed by implant placement at the extraction site. This was followed by Le Fort 1 bone cuts to the maxilla and the maxilla was downfractured. The maxillary segment was then pulled outwards and checked for occlusion. Once occlusion was deemed to be adequate, the maxillary segment was fixed using titanium plates and screws. Closure of the incision was then done using resorbable sutures. Outcome of the surgery was as planned and the maxilla was now normally positioned in relation to the mandible. Patient expresses his satisfaction at the results of the surgery The patient was very happy with the outcome of the surgery and thanked the surgical team. He expressed that his facial appearance had been transformed by the surgery with good esthetic results. His parents stated that there has been a perceptible increase in his levels of self confidence. They were also very happy with the outcome of the surgery. The patient and his parents will return in three months for placement of ceramic prostheses on the implants. They expressed their thankfulness before discharge from the hospital. Surgery Video
RTA – Malunited Very old Fracture of Maxilla (Upper Jaw) and Zygoma (Cheekbone) with Enophthalmos Correction Surgery
Young man with residual facial deformities from motor vehicle accident This young man from Indore, Madhya Pradesh, was riding his bike when he collided with a car 1.5 years back. He suffered facial fractures involving the maxilla, zygoma and orbital region. The patient underwent surgical correction at a local hospital after the accident. This surgery left him with residual deformities. These included an anterior crossbite and a sunken right zygoma with enophthalmos. The patient presents to our hospital for specialized facial deformity correction Dr SM Balaji, facial deformity correction specialist, examined the patient. He ordered 3D CT scan and other imaging studies. There were many plates seen from the previous surgery. The maxilla was in a retruded position. He recommended advancing the maxilla forward with a Le Fort I osteotomy for crossbite correction. Other recommended surgeries were refracture of the zygoma with plate fixation. Release of herniated fat trapped in the right eye with Titanium mesh placement was also recommended for enophthalmos. The patient consented to surgery. Patient undergoes correction of anterior crossbite with Le Fort I maxillary advancement osteotomy Under general anesthesia, a buccal vestibular incision exposed the old maxillary plates. These were then removed and the maxilla advanced forward with a Le Fort I advancement osteotomy. This resulted in correction of the anterior crossbite. Four L-shaped four holed plates were utilized to achieve this. Enophthalmos and zygomatic depression correction done for the patient The enophthalmos and depression in the zygoma were then addressed. A right lateral canthal incision was first made. This was then followed by a right transconjunctival incision. Dissection down into the floor of the orbit exposed the herniated fat under the eye, which was freed. An old plate from the previous surgery was then removed through the lateral canthal incision. The zygoma was then refractured and repositioned with new plates. This resulted in correction of the depressed zygoma. The enophthalmos was then addressed. A Titanium mesh with Medpor was used to correct it. The Titanium mesh was then fixed with screws to the lower orbital rim. All incisions were then closed with sutures and the patient extubated. The patient expressed complete satisfaction at the results of the surgery before final discharge. Surgery Video
Vertical augmentation genioplasty, LeFort I advancement, malar augmentation, BSSO by Distraction Osteogenesis Surgery for Double Chin Correction
Patient who hated his small jaw presents to our hospital This young man from Australia never liked his retruded chin. It caused him to have a double chin. He had always wished to have a more prominent mandible. His quality of life was also affected by this. The patient had enquired all over Europe, but the costs there were prohibitive. Being a medical doctor himself, he researched the Internet for a quality oral surgeon. His Internet search led him straight to our hospital. He got in contact with our hospital manager who arranged for his travel to India. Treatment plan explained to the patient The patient met with Dr SM Balaji who obtained a detailed history from him. He was very particular that he wanted advancement through distractors. This was because he wanted to monitor for himself the changes as the distractors were activated each day. A treatment plan was then formulated and explained to the patient. His double chin would be corrected. He was then scheduled for surgery. Surgical jaw correction for treatment of double chin A rib graft was first harvested from the patient. A Valsalva maneuver demonstrated absence of any perforation into the thoracic cavity. The incision was then closed with sutures. Attention was next turned to the retrognathic mandible. A vestibular incision exposed the anterior mandibular bone. The chin was then placed forwards with a vertical augmentation genioplasty. Two L-shaped four holed plates were then used to fix the bones of the chin. The posterior mandible was then osteotomized for placement of the distractors. Mandibular distractors were then fixed with screws and tested. There was adequate function of the distractors. Bilateral inferior alveolar nerves were carefully protected during the entire procedure. Attention was then turned to the maxilla. Maxillary osteotomy with placement of bone grafts aided distractor placement. Similar distractors were also utilized here. The incisions were then closed with sutures. The distractors were in stable position. 1 mm distraction per day will be next performed until adequate advancement of jaws. The patient recovered from general anesthesia without any complications. The patient expressed his complete satisfaction with the results before discharge.