by smbalaji | Feb 25, 2020 | Surgery
Patient develops lower jaw swelling about a year ago
The patient is a 24-year-old male from Hoskote in Karnataka, India. He developed a swelling in the region of the left lower jaw around a year ago. This was especially alarming since he has always had asymmetry of the face with deviation of the mandible to the left side. The swelling was also associated with pain and subsequent tooth mobility in the involved region.
This had been followed by a visit to a local dental clinic where radiographic imaging had been obtained. A provisional diagnosis of odontogenic keratocyst had been made by the specialist there. It was explained to the patient that he needed to undergo left-sided partial mandibulectomy to resect the lesion. This would need to be followed by reconstruction of the jaw.
He had subsequently undergone surgery at a nearby city. The lesion had been resected, but unfortunately the condyle had been displaced superiorly into the region of the lateral pterygoid. This had resulted in worsening asymmetry of his face. The patient had become extremely distressed by this turn of events.
His parents had presented to the operating surgeon for a solution to his problem. Realizing the enormity of the condylar surgical correction and reconstruction required by the patient, the patient had been referred to our hospital for treatment.
What is an odontogenic keratocyst and how is it managed?
An odontogenic keratocyst is benign developmental cyst that is locally aggressive. Peak incidence is mostly during the second or third decades of life. At least 50% of odontogenic keratocysts are found in the posterior body and lower ramus of the mandible. Segmental mandibulectomy is performed, but results in gross residual deformities of the face.
Swelling is the most common presenting complaint. They may also be asymptomatic and found incidentally on dental radiographs. Plastic reconstructive surgery is necessary to full rehabilitate the patient. Usage of distraction devices helps restore facial symmetry. Implant treatment enables replacement of lost teeth.
Initial presentation at our hospital for treatment of his odontogenic keratocyst
Dr SM Balaji, jaw reconstruction surgeon, had examined the patient and obtained comprehensive imaging studies including a 3D CT scan. The 3D CT confirmed that the condyle had been superiorly displaced into the region of the lateral pterygoid muscle. He explained to the patient that he needed reconstruction of his resected jaw through bone grafts harvested from the patient.
He further explained that the patient’s idiopathic facial asymmetry could also be corrected through mandibular internal distractor surgery. A detailed explanation of the treatment process was given to the patient. Realizing that corrective jaw surgery would result in complete resolution of his facial asymmetry, the patient happily consented to undergo this surgery.
Successful mandibulectomy and internal distractor placement surgery
Under general anesthesia, the condyle was first brought back into correct anatomical position. This was followed by reconstruction of the resected mandible using the bone grafts. The bone grafts were fixed in position using titanium screws.
He also underwent placement of a left mandibular ramus distractor. A latency period of one week was allowed following placement of distractor. The distractor was subsequently activated by 1 mm each day for 18 days. This achieved an increase of 18 mm of mandibular distraction on the left side.
The time frame was explained to the family before surgery. It was explained that six months would be required for full consolidation of the new bone. He was instructed to return in six months. Distractor device would be removed and implants would be placed at that point. The patient expressed understanding of the instructions.
Patient returns for distractor removal surgery and dental implant surgery
A 3D CT scan was obtained at the site of distraction to check for bone consolidation. There was also good consolidation of the bone grafts at the site of the jaw reconstruction surgery. This was explained to the patient and he was scheduled for distractor removal and implant placement.
Removal of mandibular distractor and placement of dental implants
Under general anesthesia, an incision was placed in the left posterior region at the region of the distractor. A flap was then raised followed by removal of the left mandibular ramus distractor. Nobel Biocare dental implants were then placed in relation to the left mandibular second premolar and second molar. Hemostasis was achieved and wound closure was done using resorbable sutures.
Successful outcome of surgery with complete patient satisfaction
Complete symmetry of the patient’s face had been established through the distraction. The patient was extremely happy that he now had good facial harmony. He expressed how this would result in greatly increased social acceptance amongst peers. It was explained to him that he needed to return in three to four months for placement of ceramic crowns on the dental implants.
The patient expressed complete understanding of the instructions and expressed his happiness before discharge from the hospital.
Surgery Video
by smbalaji | Feb 23, 2020 | Surgery
Patient dissatisfied with results of previous jaw reconstruction surgery
The patient is a 33-year-old patient from Indore in Madhya Pradesh, India. He had been diagnosed with ameloblastoma around four years ago. Surgery had been advised for him and he had then undergone ameloblastoma mandibular resection.
This had been followed by mandibular reconstruction with a titanium plate and screws. The surgery had been performed at a nearby city. Bone grafts had been used to rebuild the mandibular bone.
The patient however was not happy with the results of the surgery. He mentioned that his jaw bone seemed to be very deficient and implants could not be placed. Eating and speech have been difficult since this surgery. This had caused a compromise in the quality of daily living and he had wanted to get this addressed.
Patient referred to our hospital for surgery by many specialists
The patient had made enquiries regarding the best hospital to undergo jaw reconstructive surgery. He had been referred to our hospital by multiple sources. Our hospital is a renowned center for jaw reconstruction and other complex surgeries. We also perform dentigerous cyst surgery, odontogenic keratocyst surgery, hemifacial microsomia surgery, etc.
Large cysts are enucleated followed by jaw reconstruction at our hospital. Ear reconstruction for microtia is a specialty surgery performed in our hospital. Orthognathic surgery for jaw size discrepancies has rehabilitated scores of patients. Dental implant surgery followed by placement of artificial teeth is done using Nobel Biocare implants and Zirconium/ceramic crowns.
Remodeling of gum tissue through laser gum surgery offers good esthetic and functional results at our hospital. All this is enabled through the application of the latest state of art technology.
He presented with a complaint of a mandibular defect. The patient mentioned that his jaw was very thin and that he was unable to bite or chew on foods properly. He wanted to correct his jaw and replace his teeth as soon as possible.
Initial presentation at our hospital for mandibular reconstructive surgery
Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained a detailed history. He then ordered for radiological studies including a 3D CT scan. This revealed that the patient had deficient bone at the site of the mandibular reconstruction plate. The anterior mandibular bone was very thin and insufficient to support placement of implants.
Occurrence of ameloblastoma and treatment modalities
Ameloblastoma is a rare, benign or cancerous tumor of the odontogenic epithelium, which are more common in the mandible. This was initially known as adamantinoma and was renamed in 1930 by Ivey and Churchill. They are rarely malignant or metastatic, but can lead to severe disfigurement due to gradual growth.
Surrounding healthy bone is also destroyed by this lesion. Hence, a wide surgical excision of surrounding tissues is required to treat this disorder. If left untreated, it could potentially obstruct nasal and oral airways making it impossible to breathe without oropharyngeal intervention.
Formulation of treatment and jaw reconstructive surgery
It was explained to the patient that rib grafts needed to be harvested to reconstruct the bony defect in his mandible. Dental implant surgery would be performed after consolidation of the grafts with the mandibular bone. The patient was in complete agreement with this treatment plan and consented to surgery.
Under general anesthesia, a right inframammary incision was made and a costochondral rib graft was harvested. This was followed by a midcrestal incision placed in the anterior mandible. A flap was then elevated and dissection was made down to the site of mandibular resection. The previously placed mandibular reconstruction plate and screws were removed.
Segments of the bone graft were then crafted to recreate good mandibular form. The mandible was then reconstructed using the shaped rib graft and titanium screws. Hemostasis was then achieved and closure of the incision was done with sutures.
Successful reconstruction of the deficient mandibular bone
There was good recreation of mandibular form after surgery. The mandible had been reconstructed to its previous dimensions. The surgery was successful with no complications. Patient recovered completely following surgery.
It was explained to the patient that implants would be placed after consolidation of the grafts. He was instructed to return in 3-4 months for placement of dental implants.
Surgery Video
by smbalaji | Feb 20, 2020 | Surgery
Patient with air escaping through nose during speech
The patient is a 13-year-old female from Kallakurichi in Tamil Nadu, India. She was born with a bilateral cleft lip and palate deformity. Her parents had been counseled extensively regarding the correct surgical schedule for corrective surgery. They had meticulously followed the instructions provided at the time of her birth.
She had first undergone cleft lip surgery at three months followed by cleft palate surgery at nine months. Cleft alveolus surgery had been performed at 3-1/2 years of age. Results from the surgery were however suboptimal. There was upper lip deformity and she had feeding and speech difficulties. She had undergone three further surgeries to correct her problem, but none of the surgeries were successful.
The patient has always had difficulty with pronunciation of certain words. This made it difficult for people to understand her speech. Teachers had always complained to her parents that it was difficult comprehending her. There had always been a nasal quality to her speech.
Difficulty with employment due to her speech impairment
The patient is from a disadvantaged background and has been facing significant bullying at school. Her peers made fun of her speech difficulties. She has always been good at her academics. However, this bullying had become very frustrating for her and her parents had taken her a local hospital regarding this.
The doctor at the hospital had examined her and diagnosed her to have velopharyngeal insufficiency. This was causing air to escape through her nose when vocalizing sounds like ‘ah.’ Her speech was getting distorted and acquiring a nasal quality because of this. He had referred her to our hospital for corrective surgery.
Initial presentation at our hospital for corrective surgery
Dr SM Balaji, speech correction surgeon and pharyngoplasty specialist, examined the patient and obtained a detailed history. The patient had a palatal fistula. There was also a gross insufficiency of the soft palate, which resulted in air escaping through the nose during speech.
He then referred the patient to a speech pathologist for a speech assessment test. This confirmed his diagnosis of velopharyngeal insufficiency. Plastic surgeons in the United States of America first formulated a surgical protocol for successful treatment of velopharyngeal insufficiency. This is rigorously followed in our hospital.
Intonation of certain sounds results in the palate rising and touching the back of the throat. This pushes air forward and out of the mouth. The soft palate does not contact the throat during speech in velopharyngeal insufficiency. This causes air to escape through their nose during speech.
Treatment planning formulated and explained to the patient and parents
The patient was advised that the palatal fistula had to be closed. It was also explained that she needed a sphincter pharyngoplasty with double layer closure. This would result in correction of velopharyngeal insufficiency. There would be no necessity for bone grafts in speech correction surgery.
It was decided to perform both procedures in a single operation to reduce the financial burden for the patient. The patient and her parents were in agreement with the treatment plan and consented to surgery. Her parents also give a history of recurrent ear infections when she was an infant.
Successful surgical correction of velopharyngeal insufficiency
Under general anesthesia, the patient underwent palatal fistula closure using the Veau-Wardill Kilner technique. This was followed by the sphincter pharyngoplasty, which was performed by taking flaps of tissue from just behind the tonsil on each side. These flaps were then connected together across the back of the throat, thus narrowing the throat opening.
A small, central opening or “dynamic sphincter” was retained in the middle for breathing through the nose. A suction test was performed at the end of the procedure. This demonstrated good movement of the soft palate thus indicating optimum results from the surgery. A positive suction test showed movement of the roof of the mouth. This is indicative of good surgical results.
Total patient satisfaction from the results of the surgery
The patient’s speech was much improved from previous to surgery. She and her parents expressed their happiness at the results of the surgery. They were however instructed that she would need to undergo speech therapy for her speech to normalize completely. The patient will be referred to a speech therapist for further management.
Surgery Video
by smbalaji | Feb 17, 2020 | Surgery
Patient sustains a facial injury from a two wheeler accident
The patient is a 36-year-old male from Madurantakam in Tamil Nadu, India. He was on his way to work on his two-wheeler when he hit a coconut lying on the road. This caused him to skid and lose balance. He fell down on the right side of his face on a grassy area by the roadside. There was direct impact on the cheek region.
Passersby immediately rushed him to a nearby hospital where x-rays were taken. The patient was diagnosed with a right zygoma fracture by the duty doctor there. He had then been referred to our hospital for surgical management of his facial fracture.
He was not wearing a helmet at the time of the accident. It was explained to the patient that wearing a full face helmet would have prevented the fracture.
Occurrence of zygomatic fracture and associated symptomatology
Zygoma fracture is a form of facial fracture caused by a fracture to the zygomatic bone. This often results from facial trauma such as violence, falls or automobile accidents. Symptoms include flattening of the face, trismus (reduced opening of the jaw) and subconjunctival hemorrhage.
It has been scientifically proven through the use of crash test dummies that helmets prevent facial and head injuries. Statistics prove that 99% of head injuries occur in riders without helmets. It is a laudable initiative by the government to educate the public towards road safety awareness through the use of helmets.
There is scientific evidence that the chances of the pillion rider suffering fatal injuries are very high. It is therefore imperative that the pillion rider too wears a helmet.
Initial presentation at our hospital for treatment
Dr SM Balaji, facial trauma surgeon, examined the patient and obtained a detailed history. The patient complained of a depression on the right side of the face along with pain, swelling and limitation of function. He stated that he was very upset by the facial asymmetry that had been caused by the accident.
A complete clinical and radiological evaluation was done. Clinical examination revealed a depressed right zygoma. Radiographic examination revealed depressed right zygoma, zygomatic arch and frontozygomatic fracture. This is the classical fracture pattern caused by impact in the zygomatic region from road traffic accidents.
The findings were explained to the patient in detail. He was advised to undergo zygoma fracture reduction and fixation through an intraoral approach. This would avoid any unsightly extraoral scarring. The patient was also advised to take liquid diet for about 1-2 weeks followed by a semi-solid diet.
Successful rehabilitation of the fracture and return to normalcy
Under general anesthesia, a sulcular incision was made in the right maxillary vestibular region and a flap was raised. Dissection was made to the region of the zygomatic fracture. The depressed right zygoma fracture segment was identified, reduced and stabilized using titanium plates and screws. The closure was done using resorbable sutures intraorally.
Surgery was successful with no postoperative complications. Results were immediate. The patient was greatly satisfied with the outcome of the surgery.
There was no residual facial depression and his face was now symmetrical on both sides. He expressed his happiness to the surgical team.
Surgery Video
by smbalaji | Feb 13, 2020 | Surgery
Patient born with cleft lip and palate deformity
The patient is a 29-year-old male from Theni in Tamil Nadu, India. He is a known case of cleft lip and palate deformity who had been born in Madurai. His parents had been counseled regarding what to expect with an infant with cleft lip and palate deformity.
Surgery performed as per correct surgical protocol for cleft deformity
He had undergone cleft lip surgery at three months of age and cleft palate surgery at nine months of age at a hospital in Madurai. This had been followed by cleft alveolus surgery at the age of 3-1/2 years. These surgeries had resulted in good restoration of function and esthetics for the patient.
He had not faced any feeding problems after his surgery. All his growth parameters had been met on schedule and the patient had thrived well. He had always been good at academics and is now well settled in life.
Persistent difficulty with speech for forming certain sounds
He has however had persistent difficulty with speech. There had always been a hypernasal speech quality with difficulty associated with pronouncing certain sounds. Some of his colleagues at work had found it difficult to understand his speech. This is due to velopharyngeal dysfunction.
His difficulty with speech had been diagnosed to be due to a palatal fistula. This fistula was causing air to escape into the nose during speech. His parents stated that his voice was not clear while pronouncing certain words. There was a clear nasal quality to his voice.
His parents mentioned that they were also looking for a bride to get him married and wanted to correct his speech problem as soon as possible. The patient wanted to undergo speech correction surgery.
Initial presentation at our hospital for correction of his speech problems
Dr SM Balaji, pharyngoplasty specialist, examined the patient and ordered for radiological studies. He further referred the patient for a speech assessment, which stated that the patient’s nasal twang was caused by velopharyngeal insufficiency (VPI).
Velopharyngeal insufficiency and its implications on daily life
Velo refers to the velum or soft palate. It is the part of the roof of the mouth that moves with sounds like “ah.” Pharyngeal refers to the throat. During normal speech with the creation of certain sounds, the palate rises to touch the back of the throat and sends the air out of the mouth.
In the case of a child with velopharyngeal insufficiency, there is deficiency in the posterior extent of the soft palate. This results in the soft palate not contacting the throat during the creation of sounds like “ah.” This results in air escaping through the nose during speech instead of exiting through the oral cavity, thus rendering a nasal quality to the speech.
Treatment planning formulated for the patient
It was decided to perform a Veau-Wardill Kilner sphincter pharyngoplasty for the patient. This would involve taking flaps of tissue from just behind the tonsil from each side. These flaps of tissue are then connected across the back of the throat.
This results in narrowing down of the throat opening. A small central opening or “port” is left in the middle for breathing through the nose.
Successful surgical correction of velopharyngeal insufficiency
Under general anesthesia, the patient underwent a sphincter pharyngoplasty with creation of the small central “port” to facilitate proper nasal breathing. A suction test performed at the end of the surgery resulted in proper action of the soft palate. This indicated complete correction of the velopharyngeal insufficiency.
There was improvement in the tone of voice after surgery. The patient and his family were very happy with the results of the surgery. It was explained to them that he would need speech therapy to completely normalize the quality of his voice.
They expressed understanding of the instructions and said that this would definitely lead to an improvement in the quality of life for the patient.
Surgery Video
by smbalaji | Feb 10, 2020 | Surgery
Patient with increasing lip deformity over the last ten years
The patient is a 33-year-old female from Hubli in Karnataka, India. She stated that she had been fine up until about 10 years ago. It was around that time that her lower lip began to gradually increase in size. This continued to grow in size until it became large enough to prevent closure of her mouth with loss of lip seal. Eating and speech also became difficult due to this. There was also significant facial cosmetic deformity because of her lower lip deformity.
She approached a local cosmetic surgeon around six years ago. He had examined her and had diagnosed it as a vascular lesion (hemangioma). His recommendation was for lip reduction surgery to reduce the lip back to its original anatomical dimensions. Surgery had been performed with reduction in the size of the lip. The lip however continued to grow and was back to its increased size within two years after surgery.
She had undergone another surgery at that point, which also proved to be of no avail in providing her with a permanent solution. In addition, she felt that the second surgery had caused a deformity to the shape of her lip. The patient began to feel hopeless and depressed by the situation.
Feeling very frustrated, she and her husband had made enquiries regarding the best hospital to undergo cosmetic lip surgery. They had subsequently been referred to our hospital. Our hospital is a leading center for various facial reconstructive surgeries.
Initial presentation at our hospital for surgical correction of her lip deformity
Dr SM Balaji, cheiloplasty specialist, examined the patient and obtained a detailed oral history. Suspecting it to be a hemangioma of the lower lip, he then ordered an angiogram to confirm his diagnosis. The angiogram confirmed his initial diagnosis of hemangioma.
He explained to the patient and her husband that he planned to perform lip reduction surgery along with cauterization of the feeder vessels. Diathermy would be used to perform this. This would result in permanent resolution of the patient’s problems. They were in agreement with the treatment plan and consented to undergo surgery.
What is hemangioma and how is it treated?
Hemangioma is a benign vascular tumor derived from blood vessel cell types. The most common form is the congenital infantile hemangioma, commonly referred to as a strawberry mark. This is most commonly seen on the skin at birth or in the first few weeks of life. A hemangioma can occur anywhere on the body, but most commonly appears on the face, scalp, chest or back.
Treatment of hemangioma is usually unnecessary unless it interferes with vision or breathing, or in rare cases, internal hemangioma causes or contributes to other medical problems. It is also addressed when it leads to a cosmetic disfigurement for the patient. Hemangioma is usually treated by surgery or by injecting sclerosing agents into its feeder vessels.
Successful surgical reduction and contouring of enlarged lower lip
Under general anesthesia, the lip hemangioma was excised in its entirety. Diathermy was used to make the incision and cauterize the feeder vessels to the hemangioma. Once proper lip form and contour had been established, hemostasis was achieved and the incision was sutured with resorbable sutures.
The patient was very happy with the outcome of the surgery. She was now able to close her mouth with ease and had a symmetrical lower lip. The size and form of her lip was now in complete harmony with the rest of her face. She was also very happy that there was no visible scarring from the surgery.
Surgery Video
