Dr SM Balaji invited as chief guest at the 3rd Graduation day celebrations at Tagore Dental College
Dr SM Balaji, Hon’ble Member, Dental Council of India, was the chief guest for the 3rd Graduation day at Tagore Dental College. Upon arrival at the college, he was warmly received by Prof Chitraa R Chandran, Principal, Prof S Balagopal, Vice Principal-Academics and Prof CJ Venkatakrishnan, Vice Principal-Administration. Prof Mala, Correspondent of Tagore Dental College also honored him with a bouquet. The convocation was a grand affair and all the graduands had assembled at the auditorium of the college. Prof SM Balaji addressed the students with his usual mix of brevity and humor. He emphasized to them the need to adopt a holistic approach towards their chosen profession as they embarked upon their career in dentistry. His speech reiterated to them the importance of teamwork as they stepped out into the world from the protective cocoon of their college lives. Teamwork is what elevates the individual to higher levels was a recurring theme in his address to them. He spoke about his career as a researcher and the urgent need for continued research in all specialties of dentistry. The students listened in rapt attention as he narrated snippets from his life about interactions with patients who left their mark on him and how he attained such great heights in his career as an oral and maxillofacial surgeon. He spoke about the passion and dedication he has towards attaining even greater heights and provided valuable tips to the students on how to build a successful career. Another important aspect he spoke about was about developing skills that would help in alleviating the sufferings of patients. He spoke about his various cleft surgical missions to the lesser developed regions of the world and how this acted as a spur to make him pursue this with a zeal and passion that has remained unabated over the years. “Never be discouraged by circumstances, but learn to master them” he extolled them at the conclusion of his speech. Following this, Dr SM Balaji presented Certificates of Excellence to meritorious students for their academic excellence throughout their period of study in the college.
Upper jaw Sinus Lift Surgery for immediate dental implant placement
An introduction to dental implants Most scientific advances are made through accidental discoveries. For example, Dr Alexander Flemming had left a few bacterial culture dishes unattended over a period of time and had observed a fungal growth in the dishes that had inhibited bacterial growth. This had led to the discovery of penicillin, which had directly led to the birth of modern medicine as we know it. The same way, Dr Per Ingvar Branemark had been conducting experiments with placement of titanium inserts into the bones of rabbits. Upon completion of the experiments, he had tried to retrieve the inserts as they were expensive. It was then that he discovered that the titanium inserts had completely fused with the bone. This is the phenomenon of osseointegration where the titanium and bone become one without any distinguishable joint. Later research by Dr Branemark had led to dental implants and he founded Nobel Biocare for the manufacture of implants. Constantly evolving research has led to the development of various types of dental implants. The first dental implants were single tooth units, which were used to replace a single missing tooth. We now had special dental implants such as All-on-4 dental implants and zygoma implants. These implant systems utilize a minimal number of implants to rehabilitate an entire edentulous arch. Dental implants come closest to natural teeth when it comes to its ability to bear biting forces and esthetics. Just like natural teeth require a lot of care to last a lifetime, dental implants too require a lot of care to last a lifetime. This involves the maintenance of scrupulous oral hygiene through not only tooth brushing, but also through the use of dental floss and mouth washes. Implant failure rate is also very low when all the instructions are followed for their upkeep by the patients. Patient with missing right maxillary molar teeth The patient is a young man who had prematurely lost the right molars in his upper jaw due to dental decay. This partially edentulous state had led to a lot of difficulty with chewing food along with entrapment of the tongue during chewing and speech. He had started chewing mainly with the left side of his jaw. He had visited a local dental clinic for information regarding dental implant surgery in India. He had felt apprehensive as this is a surgical procedure. The local dentist had also advised him to go for dental implants considering his young age. He had also informed the patient that sinus augmentation might be required due to the length of time the patient had been edentulous. It was also explained to the patient that he needed to go to a specialty treatment center for dental implants. The patient was then referred to our hospital for dental implant surgery. India is a major hub for medical tourism from all parts of the world. Many patients come to India because of the high quality of care allied with the low cost of treatment here. Our country boasts of a very well developed infrastructure for the delivery of quality healthcare. Chennai is considered to be the healthcare capital of India. Patients seeking the services of a quality dental implant surgeon in India form a major part of medical tourism to our country. There has been a profusion of dental implant clinics lately because of this. Edentulous mandibles are more often encountered than edentulous maxillae. Reasons for this can be varied and can depend upon food habits and diet. Initial examination and treatment planning Dr SM Balaji, director, Balaji Dental and Craniofacial Hospital, examined the patient. He ordered CBCT for treatment planning. Our hospital was the first in South India to acquire the CBCT imaging system. CBCT enables the best treatment planning for placement of maxillary dental implants and mandibular dental implants. Soft tissue contour and the maxillary sinuses are well visualized in CBCT images. The patient was informed that bone height was inadequate in the maxilla for implant placement. It was explained that the sinus lift surgery would enable building up the bone height in the maxilla for implant placement. Bio-Oss would be used to enable the sinus lift procedure. This is close to being the ideal bone graft material for maxillary bone augmentation. Bone grafts from the ribs would be required in cases where there is bone loss in the mandible. The patient readily agreed to the procedure. A presurgical systematic review was conducted after obtaining consent from the patient. Importance of adequate maxillary bone height Adequate bony height of the maxilla is very essential for long term success of the implant. The Schneiderian membrane, which lines the maxillary sinus should not be perforated during implant fixation. Perforation of this membrane would lead to long term sinus problems with maxillary sinusitis and chronic maxillary sinus infection. Sinus lift procedure increases the height of the bone of the maxilla, thus making is possible for implant fixation in the maxilla. Bone height begins to reduce within six months of extraction of maxillary teeth. This is more pronounced in the case of loss of maxillary molars. The use of Bio-Oss provides quick formation of new bone by means of consolidation of the Bio-Oss placed through the lateral window created in the maxilla. Implant placement and Maxillary sinus lift procedure Under general anesthesia, a mucogingivoperiosteal flap was first raised in the right posterior maxillary region. Following this, a lateral window was then made in the maxillary bone using a surgical bur. The Schneiderian membrane was then gently separated from the floor of the maxillary sinus. A space was soon created between the floor of the maxillary sinus and the membrane. Extreme care was taken during to procedure to ensure that there was no tearing of the membrane. The ensuing space between the Schneiderian membrane and maxillary bone was then densely packed with Bio-Oss. This Bio-Oss would soon consolidate into new bone and this would serve as bony support for the implant. A dental implant was then placed in the
Mandibular prognathism Correction (Long Lower jaw) Surgery BSSO Bilateral Sagittal Split Osteotomy
Mandibular prognathism arising from an excessively large mandible When the lower jaw is disproportionately larger than the upper jaw in size, this condition is known as mandibular prognathism. When the upper jaw is normal in size and the lower jaw is disproportionately larger than normal, it is called true mandibular prognathism. Correction of this condition involves reduction in the size of the mandible. This is achieved through surgical correction. Benefits from the development of modern medicine and dentistry to humanity Modern dentistry has come to the aid of many conditions that caused great suffering in the past. There was a time when even the most minor of dental ailments could even turn life threatening. Alveolar abscesses that are so easily controlled today through the use of antibiotics and root canal treatment could lead to the death of the individual 150 years ago. Mandibular prognathism during olden days would have caused an extreme degree of distress to the individual with regards to eating and speech. Anterior crossbite is present in mandibular prognathism. Difficulty with chewing food would have caused intake of insufficient nutrition that could lead to malnutrition. Historical occurrence of mandibular prognathism Mandibular prognathism was a feature that was common among the von Habsburgs of Austria. The Habsburgs were the dynasty that ruled the Austro-Hungarian empire before World War I. Most of the male members of this dynasty demonstrated a marked mandibular prognathism. A prognathic mandible is also called a Habsburg jaw or lantern jaw. The Habsburg jaw was an extreme manifestation of mandibular prognathism because of many generations of inbreeding. What must have been present as mild mandibular prognathism in the first generation had become accentuated to an extreme degree through the inbreeding. It was so extreme in some of them that they were unable to chew food because of the prognathism. There was no treatment to correct jaw prognathism prior to the advent of modern dentistry. Jaw deformities are a common occurrence in case of extensive inbreeding. Many breeds of dogs that are inbred to retain the bloodline exhibit severe jaw deformities. This is because inbreeding is against the laws of nature and is something that is unique to human beings. Surgical technique used for correction of mandibular prognathism A bilateral sagittal split osteotomy is performed to reduce the size of the mandible and bring it into correct alignment with the maxilla. An illusion of mandibular prognathism can occur when there is a retruded maxilla and a normal mandible. Correction of this condition is through forward movement of the maxilla through distraction osteogenesis. This corrects the relationship between the maxilla and mandible and brings the two jaws into correct alignment. Surgeons advice diagnosis or treatment planning in several steps using various diagnostic protocols. They look for excessive wear of the teeth in the molar region. This surgery is contraindicated in patients who have undergone treatment for oral cancer as per the American Association of Oral and Maxillofacial Surgeons. Patient with mandibular prognathism referred to our hospital for surgical correction The patient is a young woman from Kurnool, Andhra Pradesh. She has had long standing problems with anterior crossbite due to mandibular prognathism. This had led to her feeling very self conscious because of the cosmetic aspect of her prognathism. She had always desired to undergo corrective jaw surgery for her problem. Parents and patient referred to our hospital for surgical management Her parents decided to seek the upper and lower jaws and teeth correction treatment advice from an oral surgeon in their hometown. She and her parents approached a local oral surgeon to seek the advice regarding the details about surgery. He said to them that this was not conducive for maintaining good oral health and referred them to Balaji Dental and Craniofacial Hospital for corrective orthognathic surgery. He explained to them that this is a specialty maxillofacial surgery center for jaw reduction surgery in India. Jaw reduction surgery requires extreme precision in measurements to achieve the best results. Mandibular prognathism is a condition that is present in 0.35% of the Indian population. This condition completely alters the jaw line. Correction of this condition is done by jaw reconstruction surgeon in India. A bilateral sagittal split osteotomy is performed to reduce the size of the lower jaw and make it proportionate with the upper jaw. Benefits of undergoing surgical correction of mandibular prognathism It is common to see many people with mandibular prognathism who have not even considered the option of surgical correction. They have to be educated regarding the benefits of undergoing surgical correction of their condition. This would include improvement in speech and eating habits along with the improvement in esthetics. It is mostly those with pronounced functional disruption who voluntarily seek help for their condition. Tooth extraction is never a part of this surgery as it is performed posterior to the tooth bearing section of the mandible. This can also be considered a cosmetic surgery or plastic surgery as it results in dramatic improvement in facial appearance of the patient. Soft tissues automatically mold themselves once this surgery is complete and there is no need to do any soft tissue correction as part of this surgery. Initial examination and treatment planning explained to the patient and her parents Dr SM Balaji, oral and maxillofacial surgeon, examined the patient and ordered radiographic studies. The patient had anterior and right-sided posterior crossbite. Presurgical planning was meticulously carried out on the patient. He explained that orthognathic surgery is performed for correction of this condition. The patient was in agreement with the treatment plan and consented to surgery. Surgical correction of mandibular prognathism with very good results Under general anesthesia, bilateral sagittal split osteotomy was performed. The anterior segment of the mandible was then positioned posteriorly to align correctly with the maxilla. Great care was taken to protect the exposed inferior alveolar nerve during this segment of the surgery. Intermaxillary fixation was then applied. This was followed by removal of a 5 mm wide piece of bone from
Successful cleft lip repair for unilateral cleft lip
Baby girl from Mathura This little baby girl from Mathura was born with a cleft. She is now 3 months of age. Mathura accounts for a higher than average number of babies born with a cleft. Her upper lip was split into two. This is known as a cleft lip. She also had a hole in the roof of her mouth which affected her feeding. The patient’s mother was also operated for a cleft lip and palate as an infant. An ultrasound test during pregnancy revealed the baby’s cleft. There was also a familial history of clefts running through the generations. Unilateral cleft lip Cleft lip is a congenital split in the upper lip on one side often associated with cleft palate. The cleft palate usually involves the soft palate and hard palate. Babies with cleft lip usually have difficulty in feeding. Cleft babies may develop various problems as they continue to grow. They have dental problems which require corrective treatments. The dental problems require surgical and non-surgical intervention. They have an increased risk of middle ear infections which may lead to hearing problems. Babies born with clefts may have speech problems. Thereby requiring a speech therapist opinion. Cleft lip surgeon in India Though aware of the condition the parents were very depressed. They were very concerned about her future. They were searching far and wide for the best cleft lip surgeon in India. A local physician referred them to our hospital. Dr.S.M.Balaji one of the leading cleft lip and palate surgeon in India examined the patient. He planned to correct the cleft lip at 3 months of age. Primary cleft lip repair Corrective surgery to repair the lip is required. Cleft lip and palate surgeon Dr. S.M. Balaji planned to perform primary lip repair at 3 months of age. Unilateral cleft lip repair is done using Modified Millard’s technique. The upper lip musculature is also corrected during the surgery. Surgery outcome The result of the surgery was as expected. She looked like any other baby girl of her age with minimal to no scar. The parents were very pleased with the results. Future surgical corrections Cleft palate repair will be done at about 9 months of age. Bone grafting is to be done at 3 and a half to 4 months of age. Speech correction / Pharyngoplasty may be necessary at 3-4 years of age. Further surgical corrections will be carried out at later date. The mouth palate must be repaired within 10 months of age.
TMJ reconstruction surgery with costochondral graft for hemifacial microsomia
Hemifacial microsomia and the manifestations of the condition Hemifacial microsomia is a congenital condition where one side of the face is underdeveloped with the eyes, ears, cheekbone and mandible being affected. The lower half of the face is affected the most by this condition. Underdevelopment of the mandible includes underdevelopment of the TM joint. Hemifacial microsomia always results in TMJ disorders. This can result in serious structural and functional disorders of the TMJ. One manifestation of this condition is extreme facial asymmetry. Normal alignment between the upper and lower jaws is also lost. Other symptoms of hemifacial microsomia include an extremely wide mouth, skin flap present over an underdeveloped external ear and growths around the eye on the affected side. Normal and abnormal relationship between the upper and lower jaws Normal alignment of the teeth is called normal occlusion. Normal occlusion of the teeth signifies normal alignment of the maxilla and the mandible. Normal alignment of the jaws can also be present in cases of abnormal relationship between the teeth of the upper and lower jaws. This is called dental malocclusion and correction of this is through fixed orthodontic treatment. Dental malocclusion can also result when there is abnormal alignment between the two jaws. This is known as skeletal malocclusion. Skeletal malocclusion can only be corrected through surgery. Surgery that is performed to correct the relationship between the two jaws is known as orthognathic surgery. Manifestations and etiology of hemifacial microsomia TMJ symptoms begin to manifest early in life for these patients. There is also a lot of TMJ pain. Most cases of hemifacial microsomia occur as the result of a combination of genetic and environmental factors. It causes serious problems with the patient’s general health as well as oral health. Relaxation techniques do not help with pain arising from this condition as it is caused by a structural deformity. Clinical trials are constantly being performed around the world to help alleviate the symptoms in the long term. The temporomandibular joint is the only movable joint in the skull. It is the point of contact between the mandible and the skull. The joint has a cartilaginous capsule that provides synovial articulation between the glenoid fossa of the temporal bone and the mandible. There are a variety of disorders that lead to disruption in the functioning of this joint. Fractures of the TMJ are very common as any blow to the chin is directly transmitted to the joint. The condylar fractures of the mandible are amongst the most common facial fractures. Only nasal bone fractures occur in greater numbers. Common causes of condylar fractures are road traffic accidents and interpersonal assaults. Classification of disorders of the TMJ There are many conditions that lead to disorders of the TMJ. They can be broadly classified into congenital, traumatic, idiopathic, degenerative and inflammatory disorders. Congenital disorders include absence of the joint at birth, smaller than normal or larger than normal joint and abnormally developed joint. Traumatic disorders include dislocation, subluxation and fracture. An idiopathic disorder of the TMJ is defined as one where there is pain and dysfunction of the joint without any identifiable cause for the symptoms. Inflammatory disorders include myositis, capsulitis and synovitis. Degenerative disorders include rheumatoid and osteoarthritis. Benefits of surgery in patients with temporomandibular joint disorders Oral and maxillofacial surgeons always recommend surgery for this condition. There is overall improvement in the patient’s health once surgery is performed. Physical therapy in the form of jaw exercises has to be performed regularly to maintain good joint health following surgery. Surgery for hemifacial microsomia however is not an orthognathic surgery or corrective jaw surgery. This can be categorized under temporomandibular disorders that require TMJ reconstruction surgery. Patient with hemifacial microsomia with worsening mandibular deviation The patient is an 8-year-old girl with right-sided hemifacial microsomia. She also has microtia of her right ear and underdevelopment of her mandible with deviation to the right side. She had first undergone right-sided jaw reconstruction surgery elsewhere when she was 3 years old. However, over the course of time, her right-sided mandibular deviation had gotten worse with development of an open bite and her parents consulted with a plastic surgeon. Referral to our hospital by a plastic surgeon in her hometown The plastic surgeon examined the patient and explained to the parents that the patient needed TMJ surgery for temporomandibular joint reconstruction, which came under Oral and Maxillofacial Surgery. He explained that the American Association of Oral and Maxillofacial Surgeons (AAOMS) had developed a protocol for surgical treatment of this condition. Only certain hospitals in India met the stringent standards prescribed by the AAOMS for TM joint surgery. The patient was thus referred by him to Balaji Dental and Craniofacial Hospital. It was explained to the parents that the cost of temporomandibular joint reconstruction surgery in India was a fraction of what it cost in other countries with an excellent infrastructure for healthcare. Examination and treatment planning at our hospital Dr SM Balaji, an experienced temporomandibular joint reconstruction surgeon, examined the patient. He then ordered a 3D CT scan and other pertinent imaging studies. This protocol is standard for determining the best treatment option for the patient. These diagnostic studies revealed that the patient had extreme resorption of the costochondral rib grafts that had been placed during the previous surgery. Detailed treatment planning was done and it was decided to reconstruct the temporomandibular joint with rib grafts. This was explained to the parents of the patient in detail and they consented to the proposed treatment plan. Dr. SM Balaji is an experienced TMJ surgeon who has published many articles on the jaw joint surgeries performed by him in many international scientific journals. Many cases of hemifacial microsomia have been surgically rehabilitated at our hospital. Postsurgical follow up of over ten years has shown excellent results with the patient leading active lives that were fully integrated into their society. Harvesting rib grafts for jaw reconstruction surgery The patient was taken to the operation theater where she was
One stage microtia ear reconstruction surgery
Microtia deformity correction surgery The congenital underdevelopment of the external ear is defined as microtia. A completely undeveloped external ear is known as anotia. Anotia is the most extreme manifestation of microtia. Microtia is one of the birth defects that can appear in isolation or in conjunction with a syndrome. Some common syndrome that present with microtia include hemifacial microsomia, Treacher-Collins syndrome, Franceschetti syndrome and Goldenhar syndrome. Prosthetic fabrication of external ears for microtia patients Unilateral microtia is more common although occurrence of bilateral microtia is also recorded. The right ear is more commonly affected than the left ear. Fabrication of prosthetic ears using latex was in vogue in the early 1900-30s though esthetic results were not as satisfactory. Silicones are used currently for fabrication of prosthetic ears now and these ears offer satisfactory esthetic results for the patient. Studies to evaluate prospects of hearing ability It is important to determine as early as possible if the patient’s hearing can be restored through surgery. A CT scan is performed at around the age of 5-6 to determine the degree of development of the external auditory canal. Placement of cochlear implants can be considered in cases of complete lack of development of the external auditory canal. This will restore normal hearing for the child. Cosmetic aspects of microtia deformity Microtia is cosmetically disfiguring for the patient and can lead to a lot of distress for the patient and his family. Such deformity correction is performed by ear deformity correction specialists. Correction of this deformity is through the use of rib cartilage grafts and is done in three stages when the deformity is severe. Preauricular skin grafting is utilized in cases of deficiency of skin cover for the rib graft Modes of sound wave propagation Sound waves are transmitted to the inner ear through two modes. One is air conduction and the other is bone conduction. What we know as normal hearing is through air conduction. This is much clearer and the sounds are much sharper. The sound waves are propagated through the external auditory canal and strike the ear drum in this case. The second mode of propagation of sound waves is through bony conduction. When we have a severe respiratory illness or an ear infection, the external auditory canal gets blocked. Though we are still able to hear sounds, it sounds muffled and has a vibratory quality. This is because the sounds we hear are reaching the eardrum through the bone. This is known as bony conduction. Grades of microtia deformity There are four grades of microtia. Grade I microtia features a less than complete development of the external ear. This external ear has a shape and form of a near normal external ear. A fully functional external auditory canal is also present. Grade II microtia features a partially developed ear where the top of the external ear is affected. This is informally known as a lop ear. It has a closed external auditory canal but the ability to hear is retained in these patients and it is through bony conduction of sound waves. Grade III microtia features a tiny remnant of the external ear that resembles an ear tag. This is the most common form of microtia. Grade IV microtia features the complete absence of an external ear. Severe microtia is also accompanied by complete lack of an external auditory canal. This causes severe hearing impairment. It is very rare that a patient without an external auditory canal has the ability to ear through bony conduction. It is very important that good blood supply is maintained when surgical reconstruction of microtia defect is performed. Gradual loss of blood supply to the cartilage graft over a period of time was the main reason for the failure of other microtia surgery technique. Loss of blood supply can lead to gradual withering of the reconstructed external ear. Alternative techniques of microtia reconstruction A few other reconstructive techniques were utilized for microtia reconstruction in the past although they have been discontinued to lack of good long term results. Treating microtia is also a form of plastic surgery. Cosmetic ear surgery requires the surgeon to have an artistic vision of the final surgical outcome. When the reconstruction is unilateral, the surgeon should be able to visualize the process through which symmetry of the ears will be achieved. An ear framework template or cartilage framework is first constructed and the cartilaginous rib grafts that are harvested from the patient are crafted to suitable size and shape. The reconstructed ear should be symmetrical to the normal ear. This surgery can also be done in a single stage when the deformity is not extreme as illustrated in the case described below. Young boy with microtia desires to undergo surgery This is a young boy with microtia in the form of a congenitally deformed right external ear. He is now 8 years of age. Teasing at school by other children was causing great distress to him. His concerned parents consulted a local surgeon to enquire about ear reconstruction surgery in India. He explained to them that a good ear reconstruction surgeon would be able to correct his ear deformity. Cost of microtia surgery in India Cost of ear reconstruction surgery in India is only a fraction of what it costs in developed countries. The results are however as good as in any western country. He made extensive enquiries and referred them to Balaji Dental and Craniofacial Hospital. The patient and her parents subsequently presented at our hospital. Patient presents at our hospital for microtia surgery Dr SM Balaji, ear deformity correction surgeon, examined the patient. He ordered facial biometrics for both the deformed ear and the normal left ear.This would ensure that the reconstructed right ear was symmetrical to the normal ear. Biometric studies revealed this to be a constricted ear. Detailed planning for the surgery was done. Usual microtia ear reconstruction surgery is normally performed in three stages.He decided to do a single stage deformity correction
Revision Rhinoplasty Surgery with Scar Removal in the Chest
Increasing numbers of revision rhinoplasty surgery in India A revision rhinoplasty is performed when a patient is not satisfied with the results obtained from the original rhinoplasty surgery. It is also performed when there is a functional compromise from the original rhinoplasty. This could be worsening difficulty with breathing or snoring from a deviated nasal septum. A revision rhinoplasty is more difficult that a rhinoplasty as it has to offset the damage arising from the previous rhinoplasty. An inexperienced rhinoplasty surgeon might remove more bone or cartilage than necessary thus causing serious damage to the nasal structures. The initial surgery is known as primary rhinoplasty and the revision rhinoplasty is known as secondary or corrective rhinoplasty. Indications for rhinoplasty surgery or nose surgery A rhinoplasty procedure or nose job is advised when a patient has breathing difficulties or excessive snoring during sleep. This can be due to a deviated nasal septum. A nasal septum deviation could be congenital or could be caused by trauma to the nasal bone. This results in a deviation in the nasal passage, thus obstructing the clear passage of air during breathing. A rhinoplasty procedure needs to be performed to rectify this. Rhinoplasty surgery restores the function of the nose back to optimal levels. Principal qualities of a good rhinoplasty surgeon An experienced rhinoplasty surgeon instinctively diagnoses the cause for the problem and the degree of correction required in each case. There is no unnecessary excision of tissue or removal of bone. This ensures that optimal results are obtained with maximum cosmetic as well as functional benefit to the patient from the surgery. It always results in an improvement in facial features. Rhinoplasty surgery is not just purely a cosmetic surgery. It also results in relieving a person’s breathing difficulties. Facial plastic surgeons as well as oral and maxillofacial surgeons perform rhinoplasty procedures. Different categories of nasal deformity corrected by rhinoplasty surgery Rhinoplasty surgery is a form of facial plastic surgery. There are many kinds of nasal deformities that are addressed by a rhinoplasty. These include parrot beak deformity, flat nose deformity, hooked nose deformity, dorsal nasal hump, saddle nose deformity, broad nose deformity, crooked nose deformity and asymmetrical nose deformity. A rib cartilage is often used as a graft to enhance the bridge of the nose in case of a flattened nose. The protocol followed for rhinoplasty is the same as for other surgery procedures. Cleft rhinoplasty is a highly specialized field. Only the most experienced of surgeons excel in this corrective procedure. It is a highly complex procedure and complete mastery over all the basic sciences of medicine is a prerequisite to master this. Rhinoplasty surgery used to be confined to the rich and the famous in the past, but the number of rhinoplasty procedures has drastically increased leading to the increase in the number of hospitals offering this service to patients. A rhinoplasty surgery requires extreme finesse and precision to give the best esthetic results. It takes years of training under an experienced surgeon to master this. When an inexperienced surgeon performs this surgery, chances of patient dissatisfaction with the results is high and this automatically leads to an increase in the number of revision surgeries being performed. Patient dissatisfied with previous rhinoplasty surgery The patient is a young girl who had undergone rhinoplasty elsewhere with placement of a rib graft to augment the bridge of her nose. She had also had placement of a graft to the tip of the nose. Over a period of time, she felt that the bridge of her nose was too broad and the tip of the nose was very pronounced. She desired to have a narrower bridge of the nose and a less pointy tip of the nose. She had presented to a plastic surgeon in her hometown to enquire about surgeons performing rhinoplasty surgery in India and also scar revision surgery in India. He referred her to our hospital. She therefore presented to our hospital requesting corrective surgery as it was a failed rhinoplasty and revision was advised. Patient presents at our hospital for revision rhinoplasty Dr SM Balaji, a well known rhinoplasty surgeon in India, examined the patient and ordered imaging studies. As the outcome of the initial rhinoplasty was not satisfactory to the patient, she was a little apprehensive and enquired about the revision rhinoplasty swelling timeline. It was explained to the patient that the recovery period would be for a period of one to two weeks and that she would need to stay home for the first ten days following surgery. The splint that would be placed on her nose after the procedure would be removed at this point. He explained that the graft to the bridge of the nose would need to be shaped to a finer form during the revision rhinoplasty surgery. The patient also complained of an unsightly scar at the site of the bone graft harvest from the previous surgery. It was decided to perform a scar revision surgery at that site during this surgery. The scar revision procedure would involve closure of the wound in several layers for minimal residual scar formation. Harvesting of bone graft for nasal bridge rhinoplasty augmentation Under general anesthesia, a rhinoplasty incision was placed in the columella and the bone graft was taken out. It was then reshaped to form a finer bridge of the nose. It was placed again at the bridge of the nose. The tip of the nose was also shaped to be less pronounced. Incision was then closed with sutures. Scar revision surgery performed with optimal results Attention was then turned to scar removal from the chest wall. An incision was made at the old chest incision scar site. The unsightly scar tissue was excised completely. A Valsalva maneuver was then performed to ensure that there was no accidental perforation into the thoracic cavity. The incision was then closed in layers. The patient’s revision nose surgery was meticulously documented in her medical records. Surgery Video
Facial Reconstruction Surgery of Upper Jaw after Treatment of Fungal Infection Followed By Dental Implant Surgery
History of maxillary rhinosporidiosis with pain and drainage This patient had been having undiagnosed pain and swelling for two years when he first came to our hospital. He had been referred here by a surgeon in his hometown after several doctors in various dental clinics had been unable to diagnose his condition. He even visited a few oral surgery implants clinics without any solution. He was examined by Dr SM Balaji, oral and maxillofacial surgeon, who ordered a 3D CT scan and biopsy. Cultures of the biopsy specimen were done and revealed rhinosporidiosis infection of the maxillary sinus. Surgery was performed and all infected bone had been removed. This had lead to a maxillary bone deficiency. A jaw reconstruction surgery was indicated for the patient. Jaw reconstruction surgery in India is very affordable compared to western countries. A jaw reconstruction surgeon in India undergoes years of rigorous training. The patient had lost most of his natural teeth in the maxilla and was partially edentulous. The jaw joint was however not compromised by this. There were no retained tooth roots and the health of the soft tissues were not compromised. Only two wisdom teeth were present in his mouth, his left mandibular third molar, which was impacted, and his right maxillary third molar. Dental work following surgery would be the placement of implants followed by dental rehabilitation with crowns. The patient complained of excessive daytime sleepiness, but there was no suspicion of sleep apnea. The patient was advised to come back to the hospital after adequate healing of the maxillary surgical site. Bony rehabilitation of the lower and upper jaws is also treated by plastic surgeons. Principles of orthognathic surgery are not used in these cases although this is also corrective jaw surgery. Surgery for maxillary augmentation with bone grafts The patient presented after the surgical wounds had healed completely. A biopsy obtained from the maxilla revealed complete resolution of his maxillary rhinosporidiosis. Augmentation of his maxillary bone had been performed with bone grafting for placement of dental implants at a later date. The patient presents now for placement of dental implants. Nobel Biocare implants are very commonly used for dental implant surgery in India. Almost every implant surgeon in India uses this. Implant surgery is a component of maxillofacial surgery. History of modern dental implants It was Dr Per-Ingvar Branemark who first discovered osseointegration of titanium with bone. During the course of his research into factors that influence bone healing, he inserted titanium rods into rabbit leg bones. When he later tried to retrieve it, he discovered that the titanium rod had completely fused with the bone and the two had become indistinguishable. The structure of the bone was not affected in any way and bony strength to withstand stresses was also normal. This later led to the development of dental implants by Dr. Branemark. He is considered to be the father of dental implantology. This led to the formation of Nobel Biocare and he continued to research ways to improve dental implants. Advantages of dental implants over other dental prostheses Titanium is very light and completely fuses with the bone. The joint between the bone and the titanium implant is virtually indistinguishable and very strong. It can withstand occlusal loads comparable to that of natural teeth. Constant research into dental implants has led to different implant designs to cater to individual patient needs. The most common type of implant is the single tooth dental implant. The crown fixed to this type of implant can either be a single crown or a crown that is a part of a bridge. The number of implants used to fix a bridge depends upon various factors. Factors such as the amount of occlusal load the implant will have to bear determine this. Different types of dental implants systems in use today All on 4 implants utilize the placement of tilted dental implants for the rehabilitation of an entire arch. Placement of the teeth prosthesis, typically a bridge, can be done within 24 hours. It is very convenient for the patient and the postoperative recovery phase is the shortest for this implant. Patients thus rehabilitated are able to eat all varieties of food and the occlusal loads borne by these implants are equal to that of natural teeth. Long-standing edentulous condition of the maxilla can lead to severe resorption of the maxillary bone. This can be to a degree that cannot support most implant systems. This lead to the development of zygoma implants. Dental implants are directly fixed to the zygomatic bone. The zygomatic bone is a very strong bone and serves as an ideal foundation to soak up occlusal forces that are exerted upon these implants. Factors behind the long term success of dental implant surgery The success rate of dental implants is very high. It ranges from 98% to 99.5%; however, it needs to be reiterated that the patient needs to take good care of the implants to enable long-term success of the implants. The habit of smoking greatly reduces the success of implant placement. The patient also needs to maintain meticulous oral hygiene with the use of aids such as dental floss and special mouthwashes that will be prescribed to the patient. Maintenance of poor oral hygiene will definitely lead to failure of the implant system. The dental implant surgeon will have to ascertain the patient’s levels of motivation before going ahead with the placement of dental implants. Periodic checkup of dental implants needs to be done by the surgeon to ensure that the right conditions are being maintained in the oral cavity to ensure long term success of the dental implant treatment. Placement of maxillary dental implants A mucogingivoperiosteal flap was raised in the maxilla to expose the augmented maxillary bone. Screws used to fix the bone grafts to the maxilla during the previous surgery were removed. The bone grafts were seen to be fully integrated with the maxillary bone. Implants were then fixed in the maxilla. A total
Cosmetic Eye Surgery for Bilateral Antimongoloid Slant Correction
Occurrence of antimongoloid slant of the eyes The shape of the eye and the eyelids is heavily influenced by genes. Each race is characterized by a particular eye and eyelid form. When the nasal corner of the palpebral fissure is higher than the temporal corner, it gives rise to an antimongoloid slant to the eyes. This is a genetic feature and is heavily influenced by hereditary factors. It is manifested by a slight downward slant to the lateral upper eyelids. This gives the eyes the typically narrow appearance. Mongoloid slant to the eyes explained in detail It is the opposite of the mongoloid slanting of the eyes where the temporal corner of the palpebral fissure is at a higher level than the nasal corner. This is a racial characteristic that is found amongst the Chinese, Japanese, Malay and other similar races. Mongoloid slant to the eyes is a prominent finding in Down’s syndrome. Down’s syndrome is also known by the term mongolism. The other features of Down’s syndrome include short stature, flat face and mental retardation. Down’s syndrome is not a genetic disorder, but occurs due to a random mutation during the cell division phase of fetal development. Certain syndromes that have a presentation of antimongoloid slant to the eyes also feature mental retardation amongst the constellation of symptoms associated with it. Syndromes associated with antimongoloid slant to the eyes Certain syndromes give rise to an antimongoloid slant of the eyes. These include Tarsal Tunnel, Cri Du Chat, gigantism, Curry Hall, Weaver, Waisman, Pallister, Noonan, Charge and Treacher-Collins syndromes. Antimongoloid slant of bilateral eyes appears as one amongst a constellation of features in these syndromes. However, this patient did not display any syndromic presentation. His antimongoloid slant of the bilateral eyes occurred in complete isolation. This could be due to an isolated genetic mutation or could be the result of hereditary transference from a distant ancestor. Patient with the complaint of antimongoloid slant to the eyes This patient had an antimongoloid slant due to the downward slant of his bilateral lateral eyelids. This led to a myopic or drooping appearance to his eyes. He felt uncomfortable with his appearance because of this. A friend recommended that he undergo cosmetic eye surgery to correct this. The patient presented to a local board certified plastic surgeon who referred him to our hospital. Presentation at our hospital for cosmetic eye surgery for antimongoloid slant correction Our hospital is a well known center for facial reconstructive surgery in Chennai. Dr SM Balaji examined the patient and explained that the patient needed plastic surgery similar to a brow lift procedure. He explained that the principle was the same as breast augmentation surgery. The technique used would be the same that was used to make sagging skin taut. The difference was that the tautening the skin involved removing excess skin. This however was not a case of excess eyelid skin. This was an anatomical variation that presented in approximately 0.5% of the population. He said that droopy eyelids involved both upper and lower eyelids. It was illustrated to the patient that a downward tilt of the lateral upper lids of the eyes gave the antimongoloid appearance. This is a purely cosmetic procedure and has no functional aspect to it. Principles of cosmetic eye surgery explained to the patient The principle behind face lifts would be utilized to correct the antimongoloid slant. He said that the patient needed a facial cosmetic surgeon and referred him to our hospital. The cost of facial cosmetic surgery in India is very economical compared to the developed countries in the west. Facial plastic surgery in India is highly developed and very advanced due to the high demand. These surgery procedures are very commonly performed nowadays. It is a combination of these factors that had led to the explosion in medical tourism to India. Cosmetic surgical procedures feature at the top of the list for medical tourism to India. Highly skilled medical professionals allied with excellent infrastructure provide very good results for the patients. Patient presents for facial cosmetic surgery Dr SM Balaji, a well known facial cosmetic surgeon in India, next ordered a series of biometric studies as these surgical procedures demand a high degree of precision. Decision was made to perform cosmetic eye surgery. He made detailed measurements of the needed corrections. The surgery was then explained in detail to the patient. Patient agreed to the surgery and provided his consent. Surgical correction of antimongoloid slant of the eyes Under conscious sedation, a right lateral upper eyelid crease incision was first made. A fine Prolene suture was then used to suture the underlying tissues of the eyelid to the periosteum of the lateral orbital bone. Elevation of the lateral eyelid resulted in correction of the antimongoloid slant of the eye. Same procedure was then repeated on the left eye with similar results. The patient expressed total satisfaction at the results of the surgery. Surgery Video
Facial cosmetic surgery for abscess sinus tract removal and extraction of abscessed tooth
Dental caries and periodontal disease Dental caries result from the demineralization of teeth structure by acids that are formed through the degradation of food in the mouth. This leads to the breakdown of the hard structure of the tooth ultimately leading to the loss of the tooth. Teeth are attached to the bony socket with the aid of periodontal ligaments. Periodontal disease or gum disease leads to the loss of periodontal ligaments and supporting bone. This leads to the tooth becoming mobile due to loss of bony support. This also ultimately leads to the tooth falling out. Neglect of a carious tooth with consequent abscess formation Dental caries is treated through restorations. When dental caries perforates into the pulp chamber within the tooth, it leads to infection of the pulp tissue. When this is not treated appropriately with root canal treatment, it will ultimately lead to necrosis of the pulp and abscess formation. When a tooth abscess is not attended to and becomes a chronic problem, it will ultimately lead to a sinus tract formation to enable pus drainage. Chronic draining sinus on the left cheek The patient had a carious left lower first molar filled a few years ago. Filling was improperly done with progression of the caries deeper into the tooth structure. The caries ultimately reached the pulp chamber leading to infection of the pulp. An abscess soon developed in relation to that tooth. The patient neglected the tooth for a long time. Symptomatic relief through the use of antibiotics and pain killers ensured that he never underwent any proper treatment. The pain and swelling kept recurring on and off in relation to the lower-left permanent first molar. A draining sinus to his left cheek with granulomatous tissue soon formed at the site with chronic pus drainage. He presented to our hospital for surgical excision of the sinus through the utilization of facial cosmetic surgery techniques. This would ensure that no unsightly scar tissue would be left behind at the site of the sinus opening. Results for facial cosmetic surgery in India are on par with the best in the world. A facial cosmetic surgeon in India undergoes years of rigorous training. Initial examination of the patient at our hospital Dr SM Balaji, facial cosmetic surgeon, is vastly experienced in cosmetic surgeries. He examined the patient and ordered a 3D CT scan of the left jaw. It revealed a sinus tracking from the distal root of the left lower first molar and opening onto the left cheek. He explained the surgical procedure to the patient who consented to surgery. He said surgical removal of the sinus was very important as it can lead to the formation of unsightly hypertrophic scars if not excised. Plastic surgery with the utilization of skin flaps would be required for the excision of such scar tissues. Categorization of scar tissue for scar revision surgery Different types of scars require different types of scar revision. One such cosmetic procedure would be tissue expansion. Tissue expansion is most commonly utilized for breast augmentation. Excision of extensive scar tissue requires reconstructive surgery by a plastic surgeon. These surgery procedures come under the category of facial plastic surgery. Each layer of skin is carefully sutured to avoid unsightly scar formation. This is the principle behind face lifts. The ideal approach would be to avoid extensive scar tissue formation by meticulously closing the wound through layered suturing using resorbable sutures for the deeper layers and nonresorbable suture material for closure of the skin. Surgical excision of draining sinus tract Under general anesthesia, a mucogingivoperiosteal incision was first made mesial to the molar. This would help expose the site of abscess formation at the distal root of the molar tooth. A flap was next raised to expose the sinus tract. The tooth was then extracted. All granulation tissue at the apical region was debrided thoroughly. This was followed by tunneling an artery forceps through the sinus tract until it reached the facial surface. Care was then taken to fully excise the sinus tract and the incisions were sutured. Adoption of facial cosmetic surgery techniques resulted in no scar formation for the patient. The patient tolerated the procedure well and recovered well from general anesthesia. Postoperative instructions were given to the patient. The patient was instructed to keep the area clean and dry and to not pull at the scab formed at the area. It was explained that this was necessary to avoid any scar formation at the site of the sinus opening on the left cheek. The patient presented a few weeks after surgery for a checkup. There was no visible scar formation from the surgery. This ensured that there would be no necessity for scar revision surgery in the future. Surgery Video