Patient with the complaint of idiopathic maxillary retrusion
The patient is a 28-year-old male from Amritsar in Punjab, India. He has always had a retruded midface of idiopathic origin ever since he can remember. This had resulted in an anterior crossbite, which had made it hard for him to eat and utter certain sounds.
Deciding to get this corrected, he had presented to an oral and maxillofacial surgeon at a nearby city. He had been advised to undergo bijaw advancement surgery. This falls under the category of oral and maxillofacial surgery.
The patient had subsequently undergone bijaw surgery. His crossbite had been corrected. He had however not been satisfied with the results.
The patient and his parents had subsequently made widespread enquiries regarding selection of the hospital to correct this condition. They had finally decided to come to our hospital for surgical correction of his hypoplastic maxilla. He also wished to undergo dental implant surgery to replace his missing upper left lateral incisor.
Conditions that lead to retruded midfacial bone structure
Crouzon’s syndrome results in midfacial hypoplasia. Alcohol consumption by the mother during pregnancy can also lead to this condition. This presentation is known as fetal alcohol syndrome.
Midfacial hypoplasia is one of the constellation of signs that accompany this condition. Others include a small head size, low body weight and a reduced vertical height.
Corrective measures employed to correct maxillary retrognathism
This condition can be corrected by conventional orthognathic surgery. Conventional orthognathic surgery for forward positioning of the maxilla is known as Le Fort I surgery.
Bone cuts are made followed by dysjunction of the maxilla. The maxilla is then positioned forwards and stabilized using titanium plates and screws. This results in esthetic forward positioning of the retruded maxilla.
Initial presentation at our hospital for surgical correction
Dr SM Balaji, jaw reconstruction surgeon, examined the case. He then ordered for comprehensive radiographic studies including a 3D CT scan. It revealed that the patient still had a retruded maxilla. It was explained to the patient that he needed to undergo presurgical orthodontics for alignment of his teeth before surgery.
It was also explained to the patient that he needed to undergo further Le Fort I jaw advancement surgery. The patient and his parents were in complete agreement with the treatment plan and signed the informed patient consent.
He subsequently underwent fixed orthodontic treatment for alignment of his teeth. Once adequate alignment had been obtained, he was scheduled for surgery.
Successful surgical advancement of retruded maxilla
Under general anesthesia, the patient first underwent placement of a Nobel Biocare implant at the site of the missing lateral incisor. A vestibular incision was then made in the maxilla and the plates from the previous surgery were exposed.
A Le Fort I osteotomy was then performed after removal of the plates. The maxillary segment was advanced by 4 mm and occlusion was checked. This was then stabilized with Titanium plates and screws. The incision was then closed with sutures.
Uneventful postoperative recovery period following surgery
The patient recovered without any complications. He and his parents expressed their delight at the new facial esthetics after surgery. The patient said that he would now be able to face life with greater confidence levels. They expressed their gratitude before final discharge from the hospital.
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.
Patient presents with odontogenic keratocyst of left lower jaw
The patient is a 28-year-old female from Tuticorin in Tamil Nadu, India. She developed a progressively enlarging growth in her posterior left lower jaw around six months ago. This was also associated with pain and caused difficulty with eating and speech.
She had presented at a local hospital where x-rays had been obtained. Her provisional diagnosis was odontogenic keratocyst and she was referred to our hospital for management of her condition.
Etiology of odontogenic keratocyst and its implications
An odontogenic keratocyst is a benign but locally aggressive developmental cyst. It most commonly occurs in the posterior region of the mandible in the third decade of life. They comprise around 19% of jaw cysts. It first manifests as a swelling with development of pain in the affected region.
Rarely asymptomatic, it can also be an incidental discovery in unrelated dental radiographs. Surgery has to be performed to remove the cyst. Teeth in the involved region are extracted. The patient later undergoes dental implant surgery with placement of zirconium crowns. Removable dentures are rarely used since the advent of dental implants.
Initial presentation at our hospital for management of her lesion
Dr SM Balaji, cyst removal surgeon, examined the patient and obtained radiographs of the region. He also ordered for a biopsy, which confirmed the diagnosis of odontogenic keratocyst. The patient subsequently underwent left mandibular marginal resection along with removal of teeth in the affected region.
The patient also underwent reconstruction of the region utilizing rib grafts that were harvested from the patient. These rib grafts were crafted into the right shape and fixed in place using titanium screws. The patient was advised to return in six months for dental implant surgery. This would complete rehabilitation of the patient with restoration of lost teeth structures with the implants and crowns.
Patient presents after six months for dental implant surgery
The patient presents now for her dental implant surgery. Radiographs including OPG and 3D CT scan were obtained at this time to evaluate the healing of her bone grafts. Radiographs revealed good consolidation of the bone grafts with the residual jaw bone. The patient was advised that it was the optimum time for her to undergo placement of Nobel Biocare dental implants as previously planned.
Successful placement of dental implants at the site of bone graft
Under general anesthesia, an incision was made in the left posterior mandibular region at the site of the previously placed bone grafts. A flap was elevated and the titanium screws holding the bone grafts were removed. There was good integration of the bone grafts with the mandibular bone.
Attention was next turned to placement of the Nobel Biocare dental implants. Dental implant surgery was performed with three dental implants. These were placed in the bone corresponding to the sites of the left lower second premolar and first and second molars. Once optimal placement of dental implants had been confirmed, hemostasis was achieved and the flap was sutured using resorbable sutures.
Total patient satisfaction with the results of the surgery
The patient expressed her happiness at the successful completion of the surgery. She said that she had been very depressed following the diagnosis of odontogenic keratocyst. Her greatest fear had been about residual facial deformity following surgery. She said that all her fears had been laid to rest and she was confident that her quality of life would not be diminished by this.
The patient further expressed that she was looking forward to returning in three months for Zirconium/ceramic crowns on the dental implants. She conveyed her thankfulness to the surgical team before discharge from the hospital.
The patient is a 56-year-old male from Alwar in Rajasthan, India. He had been diagnosed with right mandibular carcinoma and had undergone a hemimandibulectomy at a nearby city. The missing section of his mandible had been reconstructed with a fibular graft and reconstruction plate with condylar head. This had been approximately two years ago.
He had subsequently undergone chemotherapy and radiotherapy with complete resolution of his cancer. The patient had had difficulty with eating and speech following surgery. There was also facial asymmetry following surgery. The reconstruction plate however became exposed around six months following the resection.
Gradually worsening over time, this had become an exposed wound with drainage of pus. The patient was greatly distressed by this. This had reached the point where it had become intolerable to the patient. He had been in constant pain because of this.
His family had made widespread enquiries regarding the best hospital for jaw surgery in India. They had subsequently been referred to our hospital for management.
Initial presentation at our hospital for removal of his infected plate
Dr SM Balaji, jaw reconstruction surgeon, examined the patient and ordered for radiological studies. Clinical examination revealed that the patient had an exposed plate in relation to the right mandible. There was also drainage of pus from the site.
The patient also had associated inflammation at the site of the exposed plate. There was also trismus with inability to fully open the mouth.
The 3D CT scan revealed significant signs of infection at the site of the plate and screws. A PET scan was also obtained and was completely negative for metastasis. The patient stated that he wanted immediate removal of the plate because of the extreme level of discomfort associated with it. Decision was therefore made to remove the infected plate as per the patient’s request.
Jaw reconstruction would be the next step in the rehabilitation of the patient. This would be performed utilizing reconstruction plate and bone grafts harvested from the patient. Good consolidation of the bone grafts would take a few months after surgery. This would be followed by dental implant surgery to complete rehabilitation of the patient.
Artificial teeth or replacement teeth would be placed on the dental implants. Removable dentures are never opted for by patients nowadays. Meticulous planning of the surgery is done to avoid complications like open bite.
Successful surgical removal of reconstruction plate and debridement of infected tissue
General anesthesia was induced through bronchoscopic intubation due to difficulty opening his mouth. Once the patient was anesthetized, a linear incision was placed over the exposed plate extraorally. Dissection was done up to the condylar prosthesis. The infected mandibular reconstruction plate and screws were removed along with the condylar head.
Infected bone was then thoroughly debrided until healthy bone was exposed. The soft tissues surrounding the region were also cleared of infected tissue. The wound edges were then approximated and closed with sutures.
Successful resolution of symptoms caused by infected reconstruction plate
The surgery was successful and there were no postoperative complications. The patient was very happy with the outcome of the surgery. He and his family expressed understanding that this was the first step towards total rehabilitation of his oral tissues. They said that they would return in three to four months for jaw reconstruction.
Young man with retruded mandible and sleep problems
The patient is a 26-year-old male from Kashmir in India. He had always felt that he had a weak chin since his childhood days. This had made him feel that he had a feminine profile. The patient desired to have a prominent masculine jawline.
He had also been plagued with breathing difficulties since very young. The quality of his sleep had always been poor with frequent awakening in the middle of the night. This could be caused by a sleep disorder, but he had however never had an open bite.
Coming from a pastoral background, this had been neglected by his parents. He had been plagued by this all through his student days. The patient had always been good at academics and had secured a good job in a metropolitan city.
Patient seeks medical attention for correction of his complaints
He decided to seek medical help a few years ago to address these issues. Full investigations had been performed on the patient based upon his complaints.
A sleep study had also been ordered for the patient. This had revealed that the patient had obstructive sleep apnea. There was no upper airway obstruction from enlarged tonsils and adenoids. He had been counseled that this was caused by his retruded mandible.
Need for internal distraction for mandibular advancement
The patient had been referred to an Oral and Maxillofacial surgeon. He had informed the patient that he needed to undergo surgical treatment through distraction osteogenesis using Kawamoto internal distractors.
This would result in advancement of his mandible with correction of his mandibular retrognathism. His sleep apnea would also be corrected through this surgery.
The patient had subsequently been referred to our hospital for mandibular distraction surgery. Our hospital is a specialist referral center for jaw reconstructive surgery. Patients plagued with obstructive sleep apnea have undergone complete relief after mandibular advancement surgery.
Initial assessment upon presentation at our hospital
Dr SM Balaji, jaw advancement surgeon, examined the patient and obtained a detailed history. The patient stated that he hated his retruded mandible and weak chin. He stated that he wanted a more masculine profile with a prominent chin button. The patient also complained of always feeling tired despite regular bedtime schedules.
Pertinent radiographic imaging was obtained including a 3D CT scan. This revealed a retruded mandible. It was explained to the patient that he needed an advancement of his mandible by 16 mm through internal distraction.
Presurgical fixed orthodontic treatment would be needed for correct alignment of his teeth. Jawline correction surgery was explained in detail.
The patient was in agreement with the treatment plan and orthodontic treatment was initiated. Once the teeth had been brought into alignment, the patient underwent surgery. Under general anesthesia, he underwent advancement genioplasty and bilateral mandibular internal distractor fixation. A latency period of ten days was allowed after placement of the distractors.
The distractors were then activated by 1 mm each day for a total distraction of 16 mm. It was explained to the patient that the distractors needed to be in place for approximately six months. This was to ensure adequate bony consolidation at the site of distraction. He was instructed to return to the hospital for distractor removal in six months.
Patient reports to the hospital for removal of Kawamoto distractors
The patient now reports for removal of bilateral mandibular distractors. Radiographic studies were obtained and demonstrated adequate bony consolidation at the site of distraction. A sleep study was ordered and demonstrated good oxygen perfusion. The distractors were then removed under general anesthesia.
The patient now has the masculine profile he desired with a strong chin. He expressed his happiness and total satisfaction with the results before final discharge from the hospital.
Patient suffers injuries from a two wheeler road traffic accident
The patient is a 23-year-old male from Cuttack in Odisha, India, who rides a two-wheeler to work. It was on the way to work that he was involved in a multiple vehicle road traffic accident. He had fallen down with his chin directly impacting on the asphalt surface. There was also a skin laceration with bleeding at the point of impact on his chin.
He had immediately developed excruciating pain to his jaw region along with inability to open his mouth. An ambulance had been summoned to the accident spot and the patient had been rushed to a nearby hospital. First aid had been administered to his wounds and the chin and lip lacerations had been sutured. His wounds had also been thoroughly debrided.
Diagnosis of multiple fractures to the lower jaw from the accident
The patient had been informed that there were multiple fractures to his lower jaw. Upon hearing this, the patient had requested that he wanted to get this treated at our hospital and had been discharged. The patient and his parents then emergently flew down to Chennai to get this treated at our hospital.
Our hospital is renowned for facial fracture surgery in India. Patients with multiple fractures to the face resulting from road traffic accidents have been successfully rehabilitated at our hospital. Successful facial reconstruction surgery arising from shattered facial bones is a specialty feature at our hospital.
Initial presentation at our hospital for treatment of his fractures
Dr SM Balaji, facial trauma surgeon, examined the patient and obtained a detailed history from his parents. They reported that the patient complained of extreme pain when opening and closing the mouth. Eating and speech had also been very difficult since the accident. He also had an open bite following the accident.
Radiological studies including an OPG and a 3D CT scan were then ordered. These revealed that the patient had a displaced symphysis fracture. There were also displaced right and left condylar fractures and a left coronoid fracture. The bilateral condyle fractures were displaced medially.
There was no damage to the stylomastoid foramen. The internal acoustic meatus was also intact with no compromise in hearing. Only complicated presentation of the fractures was the medial displacement of the condyles.
Treatment planning formulated and explained to the patient in detail
The severity of the fractures was explained to the patient and his parents in detail. They were advised that he needed immediate symphysis and left condylar fracture reduction and fixation. It was explained to them that intermaxillary fixation would also be necessary to promote healing.
The patient was also advised to stay on a liquid diet for about two to three weeks following surgery. This would need to be followed by another ten days on a semisolid diet. The patient and his parents expressed understanding of the treatment plan and consented to surgery.
Successful surgical reduction of the multiple mandibular fractures
Under general anesthesia, the previously placed sutures in the chin and lip were removed. This was followed by a sulcular incision in the mandible. A mucoperiosteal flap was then elevated. The symphysis fracture identified, reduced and then fixed using two four-holed titanium plates and screws.
Attention was next turned to the condylar fractures. An open bite is always a presentation in cases of bilateral condylar fractures. It is necessary at times to perform open reduction and internal fixation of both condyles to correct the open bite. However, in this case, it was deemed that unilateral left-sided reduction would rectify the patient’s open bite.
A modified Alkayat Bramley incision was placed on the left side of the face. A flap was then elevated to expose the site of the condylar fracture. The condylar fracture was reduced and adequate correction was demonstrated through movement of the mandible. Once occlusion had been confirmed to be normal, the fracture segments were then fixed using titanium plates and screws.
Extreme care was taken throughout the surgery to ensure that there was no damage to the facial nerve. This was followed by sutures to the chin and lip lacerations.
Total restoration of normalcy with normal facial nerve function
There was complete restoration of normal occlusion following surgery. Postsurgical facial nerve testing revealed normal facial nerve function. The patient was very happy following successful completion of surgery. He related that there was full restoration of facial esthetics following surgery.
It was explained to him that he had to carefully follow all postoperative instructions. He said that he would follow the dietary restrictions that had been previously explained to him.
