Reconstruction of Upper Jaw After Resection for Fungal Infection with Associated Osteomyelitis
Patient with deficient maxilla presents for augmentation surgery The patient is a middle aged man from Waltair. He had undergone an endoscopic surgery for clearance of maxillary sinus rhinosporidiosis. A complete maxillary resection was performed previously at our hospital to remove all affected bone and bone affected by osteomyelitis. A reconstruction was done using the remaining bone. This resection however led to a maxillary bone deficiency, causing problems with nutrition and speech. He was then sent for a course of medical treatment of his rhinosporidiosis with complete resolution of his infection. He then presented to our hospital for definitive management of his problems. Rhinosporidiosis treated with full resolution Dr SM Balaji, facial reconstruction specialist, examined the patient. A biopsy was first obtained from the mucosa. Once it was confirmed that there was complete resolution of his fungal infection, the patient was then scheduled for surgery. Maxillary augmentation surgery performed with bone grafts Under general anesthesia, a rib graft was first harvested from the patient. A Valsalva maneuver was then performed to confirm patency of the thoracic cavity. The incision was then closed in layers. Successful completion of maxillary augmentation surgery Attention was next turned to the maxilla. A mucoperiosteal flap was then raised and plates from the previous surgery removed. Pieces of rib graft were then fixed at the deficient regions. This aided in augmenting the deficient maxillary bone. Once adequate augmentation was performed, the flap was then closed using sutures. Implants at a later date will complete oral rehabilitation of the patient. The patient expressed his happiness at the progress of his treatment. He expressed his gratitude at the successful completion of the first phase of treatment.
Long standing lower motor neuron facial paralysis correction by static suspension with fascia lata
The various causes that lead to partial or complete facial paralysis Facial paralysis means loss of facial movements due to nerve damage. It usually affects only one side of the face. The muscles on that side weaken and appear to droop. Causes of facial paralysis include infection, injury, tumor or stroke. Patient presents to the hospital for treatment of long standing facial paralysis This lady from Kurnool has had drooping of the left side of the mouth for a long time now. This caused problems with both eating and speech. There has also been constant drooling of saliva on that side. Her family’s search for the best facial reanimation surgeon led them to our hospital. The patient examined thoroughly and treatment planning explained Dr SM Balaji examined the patient. Diagnosis was lower motor neuron facial paralysis of the left face. Treatment planning was then explained to the patient. This would involve static reanimation using fascia lata sling graft. The patient agreed to the treatment plan and was then scheduled for surgery. A fascia lata sling operation is a static procedure done to improve the symmetry of the mouth. It is the most preferred material for sling because it is tough enough to support the mouth. More than one strip can be also taken for creation of different vectors to aid in suspension. Surgical procedure of static suspension with fascia lata strip for facial reanimation Under general anesthesia, a fascia lata strip was first harvested from the thigh. The incisions were then closed with sutures. An elliptical incision was then made in the right nasolabial fold. Another small incision was then made on the right zygomatic arch. A tunnel was then created below the skin. The fascia lata strip was then tunneled through to the zygomatic arch. It was then sutured to the atrophic orbicularis oris to act like a sling for the modiolus. Lateral tarsorrhaphy also performed to establish good facial symmetry This procedure created symmetry of the lips, corners of the mouth and laugh lines. Lateral tarsorrhaphy was then done to for partial closure of the eyelids. This would ensure that the patient was able to close her eyelids. Good facial symmetry resulted from these procedures. The patient expressed her happiness at the results before final discharge from the hospital.
Large Salivary Stone (Calculi) Removal Surgery
Patient with painful lumps under his tongue presents for treatment The patient is a middle aged male from Cuttack. He stated that he had felt two hard lumps under his tongue. This has been causing pain for around two years now that increases while eating. He presented to our hospital for definitive management and treatment. A diagnosis of sublingual salivary calculi confirmed through studies Dr SM Balaji examined the patient and ordered diagnostic studies. A 3D sialogram and OPG demonstrated presence of two sublingual salivary duct calculi. Palpation of the region revealed two hard masses in the left sublingual duct. Treatment planning was then explained to the patient who agreed to the surgery. Successful removal of salivary calculi with uneventful healing Under adequate general anesthesia, the opening to the Wharton’s duct was first identified. Gentian violet was then injected into the duct to fix the position of the calculi. The calculi were first palpated to confirm their location. A small incision was then made at the orifice of the salivary duct. The two calculi were then manipulated and teased out of the duct. This would ensure uninterrupted flow of saliva after healing. The patient recovered from general anesthesia. Postoperative healing was uneventful and salivary flow was normal and at optimal level. The patient expressed his gratitude before final discharge from the hospital. Surgery Video:
Double Chin Correction Surgery- Advancement Genioplasty for snoring and sleep apnea and Neck fat Removal
Patient with extreme double chin presents for surgical correction This middle aged man is from Latur in Maharashtra. He is a chronic snorer and has suffered from disturbed sleep for a long time. He has retrognathia and excessive neck fat. This had combined to give him an extreme double chin. His dissatisfaction with his appearance had led him to become withdrawn. He had searched far and wide for the best cosmetic surgeon to correct this. Word of mouth references from local dentists had led him straight to our hospital. The patient examined and treatment plan explained in detail Dr SM Balaji examined the patient and ordered lab and radiologic studies. Radiographic studies revealed impaction of left second and third molars. The patient also had a retrognathic mandible. Treatment planning included advancement genioplasty and neck fat removal. This surgery would result in increased pharyngeal airspace. It would also result in tauter musculature. This would relieve his snoring and sleep difficulties. The patient was in agreement with the proposed treatment planning. Advancement genioplasty and impactions performed Under adequate general anesthesia, markings were first made on the chin for reference. Advancement genioplasty was first performed. A vestibular incision was first made in the anterior mandible. The chin was then exposed and osteotomy performed. Chin was then brought forward and stabilized with two four-holed L-shaped plates. Attention was then turned to the two molar impactions. These were then extracted without event. The incision was then closed with sutures. Neck fat removal surgery with good results Attention was next turned to the neck fat removal surgery. An incision was then made below the chin and dissected to the region of fat deposits. Adipose tissue was then dissected in a meticulous manner. After adequate removal of fat tissue, the incision was then closed with sutures. The patient was very satisfied with the results of the surgery. He expressed his happiness before discharge from the hospital.
Total Calvarial Reconstruction (for Craniosynostosis) for 10 Month old baby with Crouzon Syndrome
Crouzon syndrome Crouzon syndrome is an autosomal dominant genetic disorder. The first brachial arch is the affected arch. The brachial arches are also known as pharyngeal arches. This syndrome results from a mutation in chromosome 10. The name of this syndrome is derived from Octave Crouzon. He is the one who first described this condition. This syndrome is always manifested by premature closure of the cranial sutures. A 10 month old boy presents for Crouzon syndrome surgical correction The patient is a 10-month-old boy with premature closure of cranial sutures. He had the typical presentation of bulging eyes (exophthalmos). His parents brought him to our hospital for definitive treatment. Dr SM Balaji and the neurosurgical team examined the patient. Extensive investigative studies were then ordered for the patient. A 3D CT revealed premature fusion of the bilateral occipitoparietal sutures. The exophthalmos in his case arose from shallow orbital cavities. Parents were then counseled about his condition. The premature closure of the sutures would cause increased intracranial pressure. This would result in impaired brain development. Complications that could arise from this were also explained to the parents. The parents agreed to the surgery. A 3-D stereolithographic model was then obtained for performing mock surgery. Intricate interdisciplinary surgery performed with great success The entire neurosurgical team was present for the surgery. This surgery would be a multidisciplinary undertaking. Under general anesthesia, markings were first made on the scalp for the incisions. A bicoronal incision was then made and scalp reflected. A craniotome was then used to make the bone cuts. The craniotome utilizes a clutch that stops it after penetration through the bone. The meninges are thus protected from damage. Our hospital was one of the first in India to get a craniotome. This was way back in the early 2000s. The different sections of the skull bones were then removed and barrel stave cuts made in them. This was to accommodate the growth of the brain. Bone segments fixed with resorbable Sonic Weld It was planned to fix the bony segments with sonic weld. It is used with resorbable plates. A galvanic current passes through the screwdriver that is utilized to fix the sonic weld. This melts the screws thus making it flow into the trabeculae. The screws and plates hold the bones together for a period of three months. They resorb after three months thus allowing for normal bone development. Adequate barrel stave relief cuts were then made in the sections of the skull bones. The frontal bone was then fixed back again using resorbable plates with sonic weld. Each bone section was then sutured to the duramater using resorbable Vicryl sutures. This was for added stability of the bone. These sutures and the sonic weld will completely dissolve on their own. This would make it unnecessary to perform a second surgery to remove them. The bones were then checked to ensure correct placement. Sonic weld was perfect. The bicoronal flap was then placed back into anatomic position. Closure was then done using surgical staples. The patient recovered well from general anesthesia without event. Successful surgical result for boy with Crouzon syndrome The patient was playful and happy a few days after surgery. He was interacting in his usual friendly way with the staff in the hospital. His parents expressed their gratitude to the whole surgical team. Their son would develop as a normal boy.
Dr SM Balaji attends the convocation of the Latin American chapter of the Academy of Dentistry International held at Buenos Aires
History of the Academy of Dentistry International The Academy of Dentistry International (ADI) is an honorific academy that was founded to promote dentistry as both an art as well as a science through research and continuing education programs. It was founded by Dr. Albert Wasserman in 1974. The ADI has chapters in every country around the world. Dr Gerhard Seeberger is the current president of the ADI Dr SM Balaji attends the convocation of the Latin American chapter of the ADI The ADI confers fellowships to its members on the basis of their consistent contribution towards the betterment of society through dentistry and other health related fields. This year’s convocation was held in Buenos Aires, Argentina. This Latin American chapter ADI convocation was organized by Dr. Javier Fontelo and Dr. Santiago of ADI, Argentina. Dr SM Balaji introduced at the newly appointed Editor in Chief of the JADI Dr SM Balaji who is a Fellow of the Academy of Dentistry International (ADI) was present at this year’s convocation. Fellowships were awarded this year by the President of the ADI, Dr Gerhard Konrad Seeberger. Dr Seeberger presented Dr SM Balaji to the members of the Academy of Dentistry International as the newly appointed editor of the Journal of the Academy of Dentistry International (JADI) and made a special mention about his contributions towards the advancement of the goals of the ADI. Dr Balaji also met with Dr Robert Ramus, Executive Director, ADI, and held discussions with him about implementation of plans formulated for the ADI in the upcoming years.
Parry Romberg’s Nose Lip and Chin Asymmetry Correction with Reduction Rhinoplasty
Mechanism of Parry Romberg syndrome explained Parry Romberg syndrome is a rare neurocutaneous syndrome of unknown origin. It causes progressive hemifacial atrophy. This is often sporadic in its course. It leads to shrinkage of tissues underneath the skin. Only one side of the face is often affected. It also rarely extends to other parts of the body. Females are most commonly affected by this disease. Onset is often between 5 to 15 years of age. Other associated morbidities include those of a neurological, ocular and oral nature. Severity of this condition varies between patients. Patient with Parry Romberg syndrome referred to our hospital This middle aged male from Tirupati presented to our hospital for management. He has undergone previous surgeries elsewhere. The patient presented with nose, lip and chin asymmetry. He desired establishment of symmetry to the face. Treatment planning and surgery explained to the patient Dr SM Balaji examined the patient and ordered diagnostic studies. He explained that fascia lata graft from his thigh needed to be harvested for this surgery. The patient agreed to the treatment planning and consented to surgery. Successful surgical correction of the patient’s facial asymmetry Under general anesthesia, an S shaped incision was first made on his lateral thigh. The incision was then closed after harvesting a fascia lata graft. Attention was next turned to the chin asymmetry. A vestibular incision first made in the anterior mandibular region. Dissection was then carried down to the chin and an osteotomy done. The osteotomized piece of chin bone was then repositioned and screwed in place. This resulted in establishment of chin symmetry. The incision was then closed with sutures. Attention was next turned to the upper lip. A midline incision was then made on the inner aspect of the lip. The fascia lata strip was then tunneled from the corner of the lip on the left to the midline incision. This was then sutured and secured. This resulted in establishment of lip symmetry. Attention was then turned to the nasal asymmetry. Intranasal incisions ensured absence of any visible scars. Lateral osteotomies were then performed of the nasal bone. The medial cartilage was then partially excised from the nasal septum. This resulted in good nasal symmetry. The patient recovered from general anesthesia without event. He expressed his happiness at the results before final discharge from the hospital. Surgery Video
The Hon’ble Justice MY Eqbal witnesses Dr SM Balaji performing distraction osteogenesis on a Crouzon syndrome patient
Hon’ble Justice MY Eqbal is a former Chief Justice of the Madras High Court and Justice of the Supreme Court. He is well known for his humanitarianism. Upon a recent visit to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai, he witnessed Dr SM Balaji activating the Kawamoto internal distractor fixed to the cranium of a young boy with Crouzon syndrome. Dr SM Balaji demonstrates the mechanisms of distraction osteogenesis to the Hon’ble Justice MY Eqbal Wishing to know more about the procedure being performed, he approached Dr SM Balaji with a few queries. Dr SM Balaji explained that the patient was born with Crouzon syndrome. He was diagnosed with premature multisutural synostosis at about the age of one year following which he underwent craniosynostosis surgery. He further explained to the Hon’ble Justice Eqbal how this surgery would prevent permanent brain damage. Dr SM Balaji then explained to the Hon’ble Judge Eqbal that the patient has now been operated for midface advancement. He explained that the patient’s sister had also undergone the same Le Fort III distraction surgery at our hospital. Dr SM Balaji explained how this bone distraction would lead to formation of new bone growth for the patient, leading to esthetic and functional improvements. The Hon’ble Justice My Eqbal speaks with the patient and his parents and blesses them He explained the mechanism of the Kawamoto internal distractor device and the intricacies involved in the surgery to attach it. Dr SM Balaji shared some of the preoperative photographs with the Hon’ble Justice. The Hon’ble Justice spoke to the patient and his parents about the patient’s care and blessed them wholeheartedly. Dr SM Balaji explained to the Hon’ble justice that the patient would need another surgery to remove the distractors after completion of the distraction. This surgery would be performed three months after completion of the distraction treatment to allow for consolidation of newly distracted bone.
Dr SM Balaji visits the Hospital Aleman in Buenos Aires at the invitation of Dr Victoria Pezza
Prof SM Balaji meets Dr Victoria Pezza at the Hospital Aleman in Buenos Aires Prof SM Balaji met with Dr Victoria Pezza of the Department of Oral and Maxillofacial Surgery at the Hospital Aleman in Buenos Aires. He observed a few oral and maxillofacial surgeries. Prof Balaji then attended rounds at the Hospital Aleman’s Department of Oral and Maxillofacial Surgery with the residents and met with patients at the hospital. Prof SM Balaji invites staff members of the hospital to his hospital in Chennai Prof SM Balaji bid farewell to the doctors at the end of his visit and extended warm invitations to them to visit Balaji Dental and Craniofacial Hospital in Chennai, India as observers when they visit India.
Crouzon Syndrome – Le Fort III Advancement Surgery by Internal Distraction Osteogenesis
Physical characteristics of Crouzon syndrome Crouzon syndrome is a rare genetic disorder with premature fusion of a few skull bones. This fusion prevents the skull from growing in all three dimensions. The shape of the head and face is most affected by this along with the mid-facial structures. This leads to wide-set, bulging eyes due to shallow eye sockets. The retruded middle part of the face results in an abnormal appearance. Surgery is the only treatment modality for adult patients. Patient with retruded midface presents for surgery This is a 15-year-old from Ajmer, India. He had undergone surgery for craniosynostosis elsewhere at 10 years of age. He presented to our hospital for facial reconstruction. His midface retrusion was causing him breathing and eating difficulties. Dr SM Balaji examined the patient and ordered diagnostic studies. He explained his proposed treatment plan to the patient. This would involved a Le Fort III advancement. The patient and his parents agreed to the treatment plan. Midface advancement from skull for Le Fort III Under general anesthesia, an incision was first made over the old scar. A bicoronal flap was then raised. The scalp was then dissected till the glabella and supra-orbital notch. Plates from the previous surgery were first removed. Careful bony cuts were next placed in four regions. These were the zygomatic arch, frontozygomatic sutures, floor of orbit and nasion. In the midline, the vomer and the ethmoid bone were then separated from the cranial base. Pterygomaxilary dysjunction was first done through the intraoral approach. His entire midface was now detached from the skull. Kawamoto distractors placed for midface advancement Attention was next turned towards placement of the Kawamoto distractors. First, the right temporalis muscle was dissected to gain access to the area. The distractor was then fixed with the help of screws to the skull and to the orbital border. Distraction was next tested and found to be perfect. The same procedure was next performed on the left side. After surgery, a latency period of six days was then given for bone stabilization. Distraction of 1 mm each day will be performed until adequate advancement of the midface. A total of 18 mm distraction was planned for this patient to be performed over a period of 18 days. The patient recovered from general anesthesia without event. The distractor will be kept in place for three months for bony consolidation. It will then be removed to be followed by orthodontic treatment. Postsurgical results were very satisfying for the patient and his family. He and his family expressed their gratitude before discharge from the hospital. Surgery Video