The patient is a 21-year-old male from Kottayam in Kerala, India. He has had lower jaw asymmetry since his childhood. This had resulted in an asymmetrical face. There is however no history of any trauma or accidents to his jaw. This has been slowly becoming progressively worse throughout his growing years. There was also a component of open bite to his occlusion.
Chewing and speech problems had also increased exponentially with the passage of time. It has now reached a point where his lower face has become grossly deformed. This had affected him a lot and he had become socially withdrawn.
Problems in a social setting due to his facial deformity
This had led to considerable bullying in school and the patient had always been socially withdrawn. He had lost his self confidence due to his facial appearance and had very few friends. The patient’s parents stated that he was very depressed and they were worried about his well being.
They had taken him to a local oral and maxillofacial surgeon who had examined the patient. Realizing the complexity of the patient’s treatment needs, he had referred the patient to our hospital for management.
Our hospital is a specialty center for distraction osteogenesis surgery in India. Distraction osteogenesis is the technique used for bone lengthening. We were one of the first hospitals in India to utilize this method for jaw correction surgery. Patients with hemifacial microsomia are routinely treated for facial asymmetry.
Mandibular lengthening is routinely performed in our hospital through mandibular distraction osteogenesis. Our hospital is a referral center for many countries from South East Asia and Europe.
Initial presentation and treatment planning at our hospital
Dr SM Balaji, facial asymmetry surgeon, examined the patient and ordered for comprehensive imaging studies including a 3D CT scan. The right side of the patient’s mandible was longer than the left side. This had resulted in his gross facial asymmetry. The left side was noted to be deficient. There was also an obvious occlusal cant present.
Even though the defect was observed to be on the right side, it was decided that the patient needed to undergo treatment on the left side to correct the facial asymmetry. It was decided to utilize distraction osteogenesis on the left mandible to increase its length. A Univector mandibular ramus distractor was planned to be fitted on the left side.
This treatment was explained to the patient in detail who consented to surgery. The patient was scheduled to undergo facial asymmetry correction with distraction osteogenesis
Surgical correction of the facial asymmetry
Under general anesthesia, an incision was made in the left mandibular retromolar region. A flap was elevated followed by bone cuts. A Univector mandibular ramus distractor was then fixed on the left side using titanium screws. Extreme care was taken throughout to ensure that the inferior alveolar nerve was not damaged during mobilization of the distal segment of the mandible.
Following successful fitting of the distractor, correction of the occlusal can was addressed next. A sulcular incision was placed in the maxilla followed by. Le Fort I bone cuts. The maxilla was then mobilized and the posterior end of the left maxilla was fixed using transosseous wires.
Hemostasis was achieved and closure was done using sutures. This was followed by Intermaxillary fixation using stainless steel wire. The patient was then taken to the recovery room in stable condition.
Postsurgical consolidation of bone before distraction
A latency period of about 6-7 days was allowed after surgery. Following the latency period, the distractor was activated with a distraction of 1 mm every day. A total of 13 mm of bone distraction was achieved over the next two weeks. There was symmetry of the two sides of the mandible at the end of this period.
A week later, a plate was fixed to the left posterior maxilla to prevent any further downward movement. The distractor was then removed after a period of about 3-4 months following bony consolidation at the site of mandibular distraction.
Successful outcome of the distraction osteogenesis procedure
The patient started noting the changes during the distraction phase itself. He was extremely happy at the end of the distraction phase of the treatment. This had resulted in good facial harmony through correction of his asymmetry. He stated that he was now ready to face life with a new found confidence.
Patient with jaw swelling diagnosed as ameloblastoma
The patient is a 35-year-old male from a rural district in Andhra Pradesh, India. He had developed a painful swelling in his lower jaw around 12-14 months ago. Alarmed over this, he had presented at a local oral surgical hospital where imaging studies followed by a biopsy had revealed an ameloblastoma. He had been advised to undergo a mandibulectomy (partial removal of lower jaw bone), which had been performed 6-8 months ago. This had been followed by reconstruction of the jaw with a titanium plate and screws.
However, a month following surgery, the patient had developed drainage of pus from the chin region of the jaw from a nonhealing wound. The titanium plate was exposed through this nonhealing wound along with loose screws. There was also gross asymmetry of the face as a result of the surgery. An illusion of an open bite was also created by the surgery. The patient was facing difficulty with speech and eating. He had then presented again to the same oral surgeon for management of his problems.
The surgeon had tried to set right this problem by tightening the screws and debriding and suturing the wound. This had however only worsened the situation for the patient. Realizing this, the patient sought a second opinion at a different hospital locally. Upon examining the patient, the surgeon had realized the complexity of the presenting problem. He had referred him to our hospital for surgical management and correction of his problems.
Our hospital is a premier center for jaw reconstruction surgery in India. Complicated angle to angle mandibulectomy for ameloblastoma surgery is also routinely performed in our hospital followed by jaw reconstruction.
Clinical presentation of an ameloblastoma
Ameloblastoma is a rare, benign or cancerous tumor arising from the odontogenic epithelium. It occurs more commonly in the lower jaw than the upper jaw. Left unattended, they can cause severe disfigurement and destruction of the involved jaw. They are however rarely malignant or metastatic and progress slowly.
Initial examination and treatment planning at our hospital
Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained a detailed history. He then ordered comprehensive imaging studies including a 3D CT scan. Clinical examination revealed multiple open wounds in the chin region with significant extraoral pus discharge. Radiographic evaluation showed significant signs of infected plates and screws.
A comprehensive treatment plan was formulated for the patient. It was explained to the patient that the plates and screws needed to be removed because of the infection. The region of the jaw that had been resected would then be reconstructed. This would be through utilization of another mandibular titanium reconstruction plate and screws along with rib grafts.
This would be followed by placement of dental implants in the bone grafts after sufficient integration of the graft with the jaw bone. The open draining chin wound would also be closed. All this was explained to the patient in detail. The patient expressed agreement with the treatment plan and consented for surgery.
Successful surgical reconstruction of the jaw
Under general anesthesia, a midcrestal incision was made in the left mandible followed by elevation of a mucoperiosteal flap. This exposed the infected mandibular reconstruction plate and screws. These were then removed along with an infected mandibular right second molar. Necrotic soft bone surrounding the infected tooth root and plate screws was also removed. Mandibular reconstruction was then performed using the titanium reconstruction plate and screws.
Following this, an inframammary incision was made to harvest the rib grafts. A Valsalva maneuver was then performed to ensure that there was no perforation into the thoracic cavity. The wound was then closed in layers with sutures.
Bone grafts were then fixed to the titanium reconstruction plates with screws to reconstruct the bony defect in the mandible. This resulted in reestablishment of mandibular contour and symmetry. Also, the necrotic skin and soft tissue in the extraoral wound in the chin that had been draining pus was excised. This was followed by approximation and closure of healthy tissue using sutures.
A period of 4-6 months would be allowed for complete integration of the rib grafts with the mandibular bone. The patient was instructed to return at that time for dental implant surgery. Artificial teeth would be fitted to the dental implants following osseointegration of the implants. An abutment is attached from the implant to each artificial tooth. This would complete total rehabilitation of the patient. The patient was counseled that meticulous gum tissue and oral dental care was needed for long term success of the implants.
Patient expresses complete satisfaction with the surgery
Healing of the surgical wounds was uneventful and the patient recovered completely from the surgery. He was very happy with the outcome of the surgery. Facial symmetry had been reestablished and he was completely pain free.
The patient is a 12-year-old female from Hubli in Karnataka, India. She was born with a left-sided cleft lip, palate and alveolus defect. A cleft lip defect usually involves the lip and nose. Postsurgical scar formation usually involves the philtral column. The patient and her parents had been referred to our hospital at that time for surgical correction.
This is the most common birth defect found in newborn babies. Plastic surgeons also address this problem in most countries along with oral and maxillofacial surgeons.
She had undergone initial cleft lip repair at our hospital at the age of three months. This was followed by cleft palate repair at the age of nine months. The optimum age for cleft lip surgery and cleft palate surgery is three and nine months respectively. The hole in the roof of the mouth had been successfully closed at this time. Speech therapy will be necessary at a later date for correction of any speech abnormalities.
The parents of the patient were extensively counseled at that time regarding raising a child with cleft lip and palate deformity. They were educated regarding what to expect and how to deal with situations unique to these children. Parents were also advised to return at the age of 12 for cleft alveolus surgery.
Cleft alveolus and difficulties associated with the condition
An alveolar cleft is a gap between two halves of the maxilla in cases of unilateral cleft lip and palate. These two segments of the maxilla have to be fused before any further surgery of the maxilla. Fusing of these two segments is done through the use of a costochondral rib graft.
Advancing the maxilla without fusing the two segments will result in a collapse of the bone. This gap results in a communication between the mouth and the nose. This affects speech and allows fluid to enter into the nasal cavity when eating and drinking. The quality of the voice also acquires a nasal tone in patients with this defect.
Alveolar cleft grafting is the surgical procedure that is performed to repair the defect between the two segments of the maxillary bone. The defect is filled with a bone graft that has been harvested from the patient. The graft is harvested from the ribs as sufficient bone cannot be harvested from the iliac crest. This surgery ensures that any abnormal communication between the mouth and the nose is closed.
Patient returns to our hospital for cleft alveolus correction
The patient returned to our hospital at 12 years old along with her parents. Her parents had been counseled at the time of previous discharge to bring the patient in for closure of her maxillary cleft at around the age of 12 years.
Dr SM Balaji, Cleft Maxilla Surgeon, examined the patient and obtained imaging studies. The patient had a left-sided alveolar cleft. Her chief complaint upon presentation was the inability to chew food properly. She said that there was nasal regurgitation of fluids along with a nasal tone to her voice.
Detailed treatment planning explained to parents and patient
A treatment plan was formulated for correction of the patient’s cleft alveolus defect. The defect in the alveolus would be augmented and closed with a bone graft with maxillary cleft surgery. Closure of the oroantral fistula was also planned to be performed for the patient.
Successful surgical correction of the maxillary cleft through rib graft
Under general anesthesia, an incision was made in the right inframammary region. A costochondral rib graft was then harvested. A Valsalva maneuver was performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers using sutures
Surgical correction of the patient’s cleft alveolus
Attention was then turned to the cleft alveolus in the left anterior maxillary region. A sulcular incision was made followed by elevation of a flap to expose the bony cleft. A palatal layer was created in the flap and sutured.
The oroantral fistula was also closed and sutured using resorbable sutures. This was followed by closure of the defect in the left anterior maxilla using rib graft fixed using screws. Closure was then done using resorbable sutures.
Successful outcome to the surgical procedure
Improvement in the patient’s oral functions was immediate after surgery. The patient was very happy with the outcome of the surgery and could eat well now. She and her parents expressed complete satisfaction with the results of the surgery.
The patient is a 25-year-old female from Mahabalipuram in Tamil Nadu, India. She was born with a unilateral cleft lip and palate. Doctors at that hospital had explained the condition in detail to her parents. They were counseled that surgical correction needed to be done at the right time for this condition.
The patient had undergone a cleft lip surgery at 3 months and cleft palate surgery at 9 months of age. She had also undergone a cleft alveolus reconstruction at 4 years of age. All these surgeries were performed elsewhere. The roof of the mouth had been repaired adequately.
Over time, the patient slowly developed a crooked nose deformity. The tip of the nose was flattened. She also felt that the scar from the previous surgery was unsightly and her lip was very thin. This had caused her to become depressed.
She had stopped going to work or visiting with friends and relatives. Her looks distressed her and she kept to herself all the time. Her parents decided to get this corrected surgically and visited the original surgeon. They explained that she desired lip deformity surgery and nose augmentation surgery. She said that she wanted a nose job.
Referral to our hospital for surgical management
Upon examination, the surgeon realized the complexity of the correction involved and referred her to our hospital for management.. Our hospital is renowned for nose deformity surgery and lip augmentation surgery. Facial reconstruction surgery is also a specialty at our hospital. Rhinoplasty surgery is performed on hundreds of patients each year with glowing patient testimonials.
Initial presentation and treatment planning at our hospital
Dr SM Balaji, cosmetic nose surgeon, examined the patient. He ordered comprehensive imaging studies for the patient. The patient had a unilateral cleft lip on the left side. This had led to development of a facial deformity on that side.
The left side of her nose was depressed and her nose was deviated to the right side. She also had a loss of musculature on the upper lip with an unsightly scar. The depressed nose also resulted in chronic breathing difficulties for the patient. There was also a component of snoring.
The patient desired to have a prominent symmetrical nose that was in harmony with the rest of her face. She also wanted to have the scar on her upper lip removed along with bulking up of the thin lip. She said that the depression on the left side of her nose was making her feel dejected.
Treatment planning was formulated for the patient. It was explained to the patient that scar revision surgery would be performed on the upper lip followed by nose correction surgery. Bulking up of the lip would be through placement of a fascia lata graft harvested from the patient’s thigh. The patient was in agreement with the treatment plan and consented to surgery.
It was explained that she would need to stay indoors for a week after surgery. The patient expressed understanding that success of the surgery also depended on good postoperative wound care. The patient would be undergoing a closed rhinoplasty as an open rhinoplasty would result in a visible scar.
Successful surgical correction of the deformities
Under general anesthesia, a fascia lata was first harvested from the patient’s thigh. This was followed by the scar revision surgery through a Z plasty technique. A transcartilagenous incision was next made in the right nostril and dissection was done. The lateral nasal cartilage was excised partially.
This was followed by a medial and right lateral osteotomy to straighten the nose. Finally, the harvested fascia lata graft was tunneled into the upper lip to bulk up the thin lip. The lip was now in harmony with the rest of her facial features.
Total patient satisfaction at the surgical results
The cosmetic transformation as a result of the surgery was immediate. There was complete symmetry to the nose and no visible scar to the lip. The fullness to the lips was also in complete harmony to the rest of the face. She said that she would now be able to face the world with a new found confidence as a result of
The patient is a 25-year-old female from Ongole in Andhra Pradesh, India. She was born with a unilateral cleft lip and palate. Her parents had been advised that she needed to undergo cleft lip repair at 3 months and cleft palate surgery at 8 months of age. The hole in the roof of her mouth was successfully closed through cleft palate repair.
She had subsequently undergone both surgeries at a local hospital. A cleft alveolus reconstruction had been performed at 4 years of age. This is the correct recommended timetable to undergo surgery for these congenital defects.
Teeth can be missing in the region of the cleft in the alveolus. These are replaced through the use of artificial teeth attached to implants. Meticulous gum tissue health is necessary for success of implants.
Dissatisfaction with appearance while growing up
The patient developed a flat and bulky nose over time. She also had a very prominent scar from her cleft lip surgery. This had made her feel very self conscious. Her self confidence level was also low because of her facial deformities. She had always desired to have a sharp prominent nose. The nose consists of both bone and cartilage tissue.
The patient and her parents had visited a local cosmetic surgeon who examined her. Realizing the extent of correction required, he had referred them to our hospital. Our hospital is a premier center for cosmetic nose surgery in India. Results over the years stand testimony to the level of care at our hospital for cosmetic rhinoplasty.
Initial presentation at our hospital for management
Dr SM Balaji, facial cosmetic surgeon, examined the patient and obtained relevant diagnostic imaging studies. The patient’s chief complaint was a depressed nose and lip scar. Columellar collapse had resulted in the depressed nose.
She also complained of mobility of her upper front teeth. This was found to be retained deciduous lateral incisors. The patient stated that her nose looked bulky and this made her feel uncomfortable. She requested for a symmetrical nose with prominent tip. The patient was also found to have a depressed left anterior maxilla.
Treatment planning formulated and explained to the patient
A complete treatment plan was formulated for the patient. It was decided to extract the mobile retained deciduous lateral incisors. This would be replaced with dental implants. It was also decided to augment the left anterior maxillary defect with a rib graft. This would result in elevation of the base of the nose. Our hospital is a specialty center for cosmetic surgery procedures.
A costochondral graft would then be used to perform nose correction of the depressed bridge. This would give the patient a prominent bridge of the nose. The patient consented for cleft rhinoplasty with dental implant surgery.
Successful surgical correction of the patient’s complaints
Under general anesthesia, an incision was made in the right inframammary region. Dissection was carried down to the ribs. A costochondral rib graft was then harvested. This was followed by a Valsalva maneuver to ascertain that there was no perforation into the thoracic cavity. The wound was then closed in layers with sutures.
Attention was then turned to lip scar revision surgery. Once this had been successfully performed, the two retained deciduous teeth were extracted. Nobel Biocare dental implants were then placed at the extraction sites.
Attention was then turned to the depressed region of the left anterior maxilla. A flap was elevated and the area was augmented using the rib graft. The graft was then fixed using titanium screws. This would slowly integrate with the maxillary bone over time to form a defect free maxilla.
A transcartilagenous incision was next made in the right nostril. Dissection was then done down to the lateral nasal cartilages, which were excised. Following this, the nasal dorsum was augmented using the costochondral rib graft. This resulted in a prominent sharp nose for the patient.
Patient satisfaction at the results of the surgery
Cosmetic improvement from the surgery was immediate. The patient was very happy with the outcome of the surgery. She now had a symmetrical and prominent nose without the lip scar. Her parents also expressed their happiness at the results of the surgery.
Deformities of the ear are classified under microtia. The various grades of microtia manifest from the mildest to the most severe. Anotia or absence of an external ear is the most severe form. A Stahl ear is one where there is deformity of the cartilage of the ear. Rib cartilage is harvested to correct microtia deformity. Plastic surgeons normally perform this technique sensitive plastic surgery. Experienced craniofacial surgeons are also adept at performing this procedure.
A piece of cartilage is taken from the ribs and shaped to mimic the ear cartilage. These are then used to recreate the external pinna in three steps. Treatment options also include prosthetic ears, which are anchored to the skull using implant screws. Microtia surgery is performed to correct these congenital ear deformities. A variety of skin grafts are utilized to obtain the best cosmetic results. Patients might initially feel that they have prominent ears after microtia surgery. This however is just an illusion arising from having deformed ears for a long time.
Patient born with right ear deformity
The patient is a 14-year-old boy from Calicut in Kerala, India who was born with a congenitally deformed right ear. It was diagnosed as a grade III microtia with absence of an external ear. There was just a small peanut like vestige along with absence of an external ear canal and eardrum. He was diagnosed with a grade III microtia. His parents had sought advice at the hospital for treatment of his ear deformity. They were referred to Balaji Dental and Craniofacial Hospital for surgical management of his ear deformity.
Our hospital is renowned for microtia surgery in India. Ear reconstruction surgery is performed on a routine basis in our hospital. The parents presented with the patient to our hospital. It had been explained to the parents that microtia surgery required a three stage repair and that they needed to bring the patient in for the first stage repair when he was 11 years old. Ear deformity surgery is best initiated at this age.
An introduction into microtia and a classification of its severity
Microtia is a congenital deformity where the external ear is underdeveloped. When the external ear is absent, it is referred to as anotia. Because microtia and anotia have the same origin, it can be referred to as microtia-anotia. Microtia can be either unilateral or bilateral. The occurrence of microtia is about one out of 8,000–10,000 live births. When it is unilateral microtia, the right ear is most commonly affected.
There are four grades of microtia. A less than complete development of the external ear with identifiable structures and a small but present external ear canal is grade I microtia. When the external ear is partially developed with a closed stenotic ear canal and conductive hearing loss, it is known as grade II microtia. When there is just a small peanut vestige in the place of the external ear along with absence of the external ear canal and ear drum, it is grade III microtia. This is also the most common form of microtia. Anotia or complete absence of the external ear is grade IV microtia.
Initial presentation for treatment at our hospital
Dr SM Balaji, ear reconstruction surgeon, examined the patient. Examination revealed that he had grade III microtia with absence of the external ear with a small peanut-like vestige structure and an absence of the external ear canal and ear drum. The patient had undergone the first two stages of ear correction in our hospital age the ages of 10 and 12 years old. The first stage was right ear reconstruction with a costochondral graft. The ear was carved from the costochondral graft using a template and buried in the desired site. After a period of 6-8 months, the second stage of the repair, which involved elevation of the buried right ear structure was done with a full thickness flap obtained from the right iliac region.
Patient presents for third stage microtia repair
The patient now presents for the third stage of his microtia repair. This would involved reconstruction and shifting of the right ear lobe. Under general anesthesia, an incision was made and the right ear lobule was shifted to its correct anatomical position in the pinna. Closure of the incision was then done in layers using resorbable and non-resorbable sutures.
Complete patient satisfaction at the results of the surgery
The patient and his parents were very happy with the outcome of the surgery. The ear lobule had been repositioned in its correct anatomical position following the surgery. His right ear was now more symmetrical with his left ear. Parents who had been very concerned about this deformity expressed their complete satisfaction with the results of the surgery. His parents mentioned that he will now be able to face life with more self confidence as a result of the surgery.
