No human face is truly symmetric. A mild degree of facial asymmetry is always present, but not easily spotted by the naked eye. Only when this asymmetry is easily noticeable does it require surgical correction. Distraction devices are commonly employed in the correction of facial asymmetry. The distraction devices are first fitted. This is followed by distraction. Consolidation of the distracted bone segment is allowed before removal of the distraction device. The bones heal and soft tissue remodeling occurs during this period of consolidation.
Correction of hemifacial microsomia and temporomandibular joint surgery also come under corrective jaw surgery. There are many surgical techniques that are employed for correction of facial asymmetry. All these are technique sensitive and are best performed by experienced surgeons.
Guidelines for surgical correction of orofacial deformities
The American Association of Oral and Maxillofacial Surgeons has laid down guidelines for all surgical procedures of the oral and facial regions. Bone grafts are advised in certain cases where distraction is contraindicated. Distraction osteogenesis and orthognathic surgery are two arms of facial asymmetry correction. Mandibular distraction osteogenesis is more common as mandibular asymmetry occurs more commonly than maxillary asymmetry.
Patient with a history of surgery for ameloblastoma
The patient is a 24-year-old male from Vandavasi in Tamil Nadu, India. He had developed a left lower jaw swelling around two years ago and visited a local hospital. Tests had been performed by an oral surgeon at the hospital. The patient had then been diagnosed with ameloblastoma of the left mandible. A left partial mandibulectomy had been performed followed by reconstruction with a rib graft and reconstruction plate. The patient had been left with a severe facial asymmetry with the right side of the mandible being longer than the left. This had depressed the patient to a degree that he refused to go outside. His career had suffered as a result and this alarmed his worried parents.
They had consulted with the oral surgeon again who realized the severity of the problem. The parents and the patient were informed that this could be addressed only at a specialist oral and maxillofacial surgery hospital. He had then referred them to our hospital for management of the patient’s facial asymmetry.
Our hospital is renowned for facial asymmetry surgery. Jaw reconstruction surgery is performed routinely at our hospital. Facial asymmetry resulting from trauma to congenital deformities of the jaws is addressed at our hospital.
Initial presentation at our hospital
Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained a detailed history. The patient’s old medical records pertaining to the ameloblastoma surgery were studied in detail. He then ordered comprehensive imaging studies for the patient including a 3D CT scan. The patient was noted to have a deficient left mandibular body. Right side of the mandible was longer than the left. Mandibular ramus was also found to be defective.
Treatment planning presented to the patient and his parents
It was advised that the patient undergo mandibular ramus distraction osteogenesis on the left side. Removal of the reconstruction plate would be followed by mandibular ramus distractor fixation on the left side. The patient and his parents expressed understanding of the surgical procedure and consented to surgery.
Successful surgical correction of facial asymmetry
Under general anesthesia, an incision was first made through the previous surgical scar in the left submandibular region. Dissection was done down to the mandibular reconstruction plate and screws. These were then removed. An incision was then made in the left mandibular retromolar region. A flap was elevated following which bone cuts were made. Mandibular ramus distractor was then fixed on the left side using titanium screws. The activating arm of the distractor was brought out through the left submandibular incision.
Following the fixation of the distractor in the mandible, a sulcular incision was made in the maxilla. Le Fort I bone cuts were then made and the maxilla was mobilized. The posterior end of the left maxilla was fixed using transosseous wires. Hemostasis was ensured following which closure was done using sutures.
Distraction osteogenesis of the mandible to establish facial symmetry
Interarch wiring was done following the surgery. A latency period of about 6-7 days was allowed for stabilization of the surgical site following which the distractor was activated. Two clockwise turns of the distractor were performed everyday for a resultant distraction of about 1 mm. A total of 18 mm distraction of the mandibular bone was achieved at the end of the treatment. A plate was then fixed to the left posterior maxilla to prevent further downward movement. The distractor will be removed after a period of about 3-4 months once adequate consolidation of the bone in the distracted segment is seen.
Complete patient satisfaction at the results
The patient started noticing the change during the distraction phase itself. Result was obvious at the completion of 18 mm of distraction. The patient was very happy with the outcome of surgery. He expressed his satisfaction at the final outcome of the surgery. The patient also added that he would be able to start leading a normal life again
The patient is a 21-year-old male from Bhopal in Madhya Pradesh, India. His lower jaw has been very small ever since he can remember. He said that he has always had trouble with speech and eating. Snoring has also been a chronic problem for him. He stated that this had made his facial profile appear concave and he hated it.
The patient had faced significant bullying at school and in college. This had caused him to become socially withdrawn and he had few friends. He had the tendency to avoid all social gatherings and led a rather lonely life. This had greatly worried his parents and they had approached a local oral surgeon who examined the patient. Realizing the degree of deformity, the surgeon had referred them to our hospital for corrective jaw surgery.
Specialty center for Oral and Maxillofacial Surgery
Our hospital is a referral center for complicated cases requiring oral and maxillofacial surgery. All the protocols laid down by the American Association of Oral and Maxillofacial Surgeons are rigorously followed by us. We are renowned for orthognathic surgery and facial cosmetic surgery. Surgery costs are also economical when compared with developed Western countries. Open bite correction is a routine part of orthognathic surgery.
Follow up of cases is done long term after surgery with excellent results. Documentation of cases helps in the process of long term follow up of cases. The latest technology is used for the maintenance of up to date patient records.
The patient had always wished to have a masculine appearing prominent lower jaw. He felt that surgical correction of his jaw along with the resultant profile correction would solve all his problems. Our hospital is a premier center for jaw deformity surgery in India. We perform all jaw surgeries ranging from cosmetic jaw surgery to jaw surgery for pathological conditions such as cysts, tumors, etc.
What is micrognathia?
Micrognathia is a condition where the jaw is undersized. It is also sometimes called “mandibular hypoplasia”. This condition is common during infancy. It however is usually self correcting during growth with a gradual increase in the size of the mandible to normal size. Since the jaw size discrepancy will be pronounced during infancy, it can lead to abnormal alignment of teeth. When this is severe, it can even lead to disruption in the feeding patterns of the infant.
A surgical implication of micrognathia in both children and adults is that it can made intubation difficult. Anesthesia is induced through awake bronchoscopic intubation in the presence of micrognathia. Micrognathism, which is true hypoplasia of the mandible is different from retrognathism, which is a backwardly positioned mandible.
Initial presentation at our hospital for management of his problem
Dr SM Balaji, jaw deformity surgeon, examined the patient and obtained a detailed history. Comprehensive imaging studies were obtained for the patient. The patient had an anterior deep bite with class II malocclusion. His lower jaw was retruded and his face had a concave profile. Treatment planning was performed for the patient and he was advised to undergo lower jaw advancement surgery by about 10 mm. It was also explained to him that he would need postsurgical orthodontic treatment for correction of his dental malocclusion. The patient and his parents were in agreement with the jaw osteotomy and consented to surgery. All incisions will be made intraorally to avoid external scarring.
Successful correction of the patient’s micrognathia
Under general anesthesia, incisions were made in mandibular retromolar region bilaterally. Following this, flaps were elevated and bone cuts were made in the mandible. Bilateral sagittal split osteotomy was performed using Obwegeser’s technique. Extreme care was taken to protect the inferior alveolar nerve throughout mobilization of the proximal and distal segments of the mandible. The distal segment of the mandible was advanced by about 10mm. Occlusion was checked, bone was stabilized and fixed using titanium plates and screws. Closure was then done using resorbable sutures.
Complete patient satisfaction at the outcome of the surgery
The patient and his parents were very happy with the surgical outcome as the cosmetic improvement was immediate. His occlusion had become normal and he now had a prominent jaw line and masculine facial profile. He also said that his speech had improved to a great extent following the surgery.
The patient was instructed to return in a few months time for fixed orthodontic treatment. This would help in correction of his malaligned teeth. It was explained that completion of orthodontic treatment would complete rehabilitation of his dentofacial problems.
Patient born with a bilateral cleft lip and palate
The patient is a 14-year-old boy from Vadodara in Gujarat, India who was born with a bilateral cleft lip and palate. This is amongst the most common birth defects. Children born with these deformities need to be operated early. He had undergone cleft lip surgery at 3 months of age and cleft palate repair at 9 months of age. Delayed cleft palate repair would lead to improper speech development. This had been followed by a nose correction surgery at 5 years of age and an Abbe flap and lip revision at 7 years of age. The nose correction had been redone at 8 years of age. All these surgeries had been performed at a local hospital.
Patient extremely unhappy with surgical results
The patient had been left with a depressed nose and a completely closed right naris. There was both bone and cartilage insufficiency. He had extreme difficulty breathing. Even a minor nasal infection like a common cold caused him a great deal of distress. Added to this, he had an extremely unsightly scar at the region of the surgery. His nose was also asymmetrical and flat. The patient and his parents were therefore highly dissatisfied with the results of the previous rhinoplasty. He desired a nose job that would raise his nose and make it in harmony with the rest of his face.
Children with cleft lip and palate deformity face difficulties during interaction with peers. They are perceived as being different and may face bullying. Parents of children both with these deformities have to be very supportive. They should take care not to express any negative emotions towards children with cleft lip and palate. At the same time, they should ensure that the children are brought up in a normal atmosphere. Care should be taken to not spoil these children.
The patient had been feeling very depressed about this and his parents consulted a local cosmetic surgeon to address this problem. He had examined the patient and obtained imaging studies. Realizing the complexity of the problem, he had referred them to Balaji Dental and Craniofacial Hospital for surgical correction. Our hospital is a premier centre for rhinoplasty surgery in India. We also deal with all other facial cosmetic surgery procedures.
Initial presentation at our hospital for consultation
Dr SM Balaji, cosmetic rhinoplasty surgeon, examined the patient and obtained a detailed history. He then ordered comprehensive imaging studies for the patient. This had revealed that the patient did not have a right nostril. He also had a depressed nasal bridge and the columella was also absent.
Treatment planning for correction of the patient’s problems
The aim of the surgery was primarily to create a new hole for his right naris. Detailed treatment planning was done for the patient. Skin from the right nasolabial region would be utilized to create the nasal floor. A vestibular mucosal flap would be utilized for columellar reconstruction. It was also decided to elevate the dorsum of the nose using a double deckered costochondral rib graft. Bone grafts would not need to be harvested. The nose tip was to be elevated using a strut graft. This was explained to the parents who were in agreement and consented to surgery.
Surgical correction of the patient’s facial deformities
Under general anesthesia, an incision was made in the right inframammary region and costochondral graft was harvested. A Valsalva maneuver was then performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers using sutures.
Following this, using the open rhinoplasty technique, the depressed nasal bridge was augmented to recreate perfect nasal form using the costochondral graft. The strut graft was next placed to elevate the tip of the nose. Right nostril was then created using a triangular flap of tissue from the nasolabial region. This was followed by creation of the columella using a flap of tissue from the upper lip. Once complete hemostasis had been achieved, closure was done using both resorbable and nonresorbable sutures.
Successful outcome to the surgery
The patient and his parents were very happy with the results of the surgery. They said that the patient’s face was in harmony now. His facial esthetics had been restored by the surgery and he would now be able to face the world confidently.
The patient is an 8-year-old boy from Meerut in Uttar Pradesh, India. His parents had begun noticing a developing facial asymmetry as he grew up. It has now reached the point where it is very visible and this has greatly distressed his parents. The patient too has been facing a lot of bully at school and does not have many friends. They had approached a local doctor who had explained to them that their son had hemifacial microsomia. He had further explained the treatment protocol for hemifacial microsomia and had referred them to our hospital for treatment.
Our hospital is a premier center for hemifacial microsomia surgery in India. Facial reanimation surgery is performed on a regular basis in our hospital. Patients from all over the world are referred to our hospital for hemifacial microsomia treatment.
What is hemifacial microsomia?
Hemifacial microsomia is a congenital disorder that affects the development of the lower half of the face. It most commonly affects the ears, the mouth, and the lower jaw. It mainly manifests on only one side of the face, but may rarely involve both sides. When hemifacial microsomia is severe, it may cause breathing difficulties from tracheal obstruction. This may even require a tracheotomy. It is the second most common birth defect of the face after cleft lip and palate. Incidence rate is one out of every 3500 to 4500 live births.
Children born with hemifacial microsomia could face difficulties at school and at social settings. Their facial features are perceived as being different. This could lead to a sense of isolation and loneliness in these children. Parents too need counseling to overcome feelings of despair and depression. Improper handling of these children during the growing years could lead to permanent psychological scarring.
Common features seen in this condition
The affected side has the appearance of facial paralysis. However, there is no involvement of the facial nerve. Soft tissue disfigurement is a prominent feature of this condition. The lower areas of the face are mainly affected. Microtia too is a common feature. Cleft lip and cleft palate are not associated with this condition. Orthognathic surgery could be required to correct the jaw deformity. Craniofacial centers specializing in reconstructive surgery are well equipped to handle these cases. Correction of drooping corner of the mouth is performed by reanimation surgery using fascia lata grafts.
Hemifacial microsomia shares many similarities with Treacher Collins syndrome, Franceschetti syndrome, Goldenhar syndrome and Parry-Romberg syndrome.
Initial presentation at our hospital for hemifacial microsomia treatment
Dr SM Balaji, hemifacial microsomia surgeon, examined the patient and obtained a detailed history. He then ordered for comprehensive imaging studies including a 3D CT for the patient. The patient had facial asymmetry on the right side. His 3D CT scan revealed the absence of the condyle and coronoid on the right side along with a hypoplastic ramus. The patient also had microtia on the right side. There was also the presence of a noticeable occlusal cant.
Treatment planning explained to the parents
A right sided ramus distraction osteogenesis was planned for correction of the patient’s facial asymmetry. Bone was however not sufficient for performing the distraction osteogenesis. Plan was to create a condyle using a costochondral graft with a growth centre and reinforce the mandibular ramus. This would enable the presence of sufficient bone for performing distraction osteogenesis later.
Successful surgical creation of condyle on the right side
Under general anesthesia, a right inframammary incision was made and a costochondral rib graft was harvested. A Valsalva maneuver was then performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers with sutures. Next, a right submandibular incision was made and dissection was done up to the condyle. The coronoid was created and the ramus was augmented using the costochondral rib graft, which was fixed using titanium screws. Closure of the wound was then done using resorbable sutures.
Optimal anatomical coronoid, condyle and ramus structures
The surgery was a complete success. Coronoid was successfully created and ramus was augmented. A postoperative OPG taken after 3 months revealed sufficient bone consolidation. The patient now had a more symmetrical face. It was explained that the patient needed to return in six months for distraction osteogenesis. That would then be followed by reconstruction of the patient’s ear after sufficient growth has occurred. Correction of facial deformity greatly benefits patients suffering from hemifacial microsomia.
The patient is a 15-year-old boy from Warangal in Telangana, India. He had been born with a unilateral left sided cleft lip and palate at a local hospital. Cleft lip is incomplete fusion of the two halves of the upper lip. A palatal cleft is incomplete fusion of the roof of the mouth. These deformities are the most common congenital deformities. A doctor at the hospital had referred the patient to our hospital. Our hospital is renowned for facial deformity surgery in India.
Dr SM Balaji examined the patient and treatment was commenced for the patient. The patient had undergone cleft lip surgery at 3 months of age and cleft palate surgery at 9 months of age. Cleft alveolar reconstruction surgery had been done at 4 years of age with BMP. An anterior crossbite developed as the patient grew up and there was backward positioning of the maxilla. There was also a congenitally missing left upper lateral incisor due to the cleft defect. He had a great deal of difficulty eating because of these defects. His parents brought him back to our hospital for correction of these deformities.
The patient became very self conscious of his facial deformity as he grew up and became socially withdrawn. There was a lot of bullying at school and he had very few friends. Bullying by peers is commonly faced by children with cleft lip and palate deformity. This is because they are perceived as being different by other children.
Parents of children born with cleft lip and palate are extensively counseled at the time of birth of the children. The first reaction at the birth of a baby with cleft deformities is shock followed by denial. They have to be counseled that full surgical rehabilitation will result in normal development of these children.
Initial presentation at our hospital
Dr SM Balaji, facial deformity correction surgeon, examined the patient and ordered comprehensive imaging studies. The patient had an increased crossbite in the anterior region. The maxilla was also in a retruded position in relation to the rest of the facial skeleton. There was also a congenitally missing lateral incisor on the left side due to unilateral cleft lip and palate.
Treatment planning for addressing the patient’s concerns
Presurgical orthodontics was planned to bring the individual teeth in correct alignment before the surgery. Surgical correction would be followed by postsurgical orthodontics for final alignment of the teeth. A Le Fort I surgery was planned to bring out the retrognathic maxilla into correct position. It was also planned to give the patient a dental implant for replacement of the missing maxillary left lateral incisor.
Dental implants are the most effective way of replacing missing teeth. Artificial teeth are fixed on the dental implant once osseointegration of the implant is complete. This patient would require an artificial tooth to replace his missing left lateral incisor. Rehabilitation of this patient would be complete at the end of these procedures.
The treatment planning was explained in detail to the patient’s parents who agreed to the plan. Presurgical orthodontics was initiated and the patient’s individual teeth were brought into correct alignment. The patient was next scheduled for surgical correction.
Surgical correction of the patient’s problems
Under general anesthesia, a sulcular incision was made in the maxilla. A mucoperiosteal flap was then elevated to expose the maxillary bone. A Nobel Biocare dental implant was placed in relation to the missing left maxillary lateral incisor. Dental implant surgery was thus completed. This was then followed by Le Fort I bone cuts, which facilitated separation of the maxillary bone. The maxillary segment was then pulled outwards and placed in correct occlusion. This was then stabilized and fixed using titanium plates and screws. The incision was then closed using resorbable sutures.
Successful outcome of the surgical procedure
The patient and his parents were extremely happy with the results of the surgery. The maxilla was now in correct alignment with the rest of the facial skeleton. Facial esthetics were also very pleasing now. Postsurgical orthodontic alignment would be performed once there was complete consolidation of the bone at the site of surgery.
A ceramic prosthesis will be given at the implant after a period of three months once osseointegration of the implant is complete.
Excessive protrusion of lower jaw causes both esthetic as well as functional compromises. It falls under the ambit of facial plastic surgery because of the cosmetic correction. Fixed orthodontic treatment will also be needed to move teeth into correct alignment before the surgery. This tooth movement will lead to optimal results after the surgery. This protocol is followed by the American Association of Oral and Maxillofacial Surgeons. The orthodontic appliances used for this treatment is fixed appliances.
Both lower and upper jaw tooth correction is done through this treatment. Metal wires were employed back in the day for this, but modern technology has completely transformed this. Transparent or tooth colored wires are employed nowadays for this treatment. The position of the lower front teeth is most often brought to a vertical orientation for this surgery. The rationale behind this becomes clear after completion of the surgical procedures. Surgery includes backward positioning of the lower jaw in case of mandibular prognathism. The upper jaw position is not altered if the problem is associated only with the lower jaw.
Patient with a disproportionately large lower jaw
The patient is a 25-year-old male from Palayamkottai in Tamil Nadu, India who has always had problems because of a large lower jaw. This had led to eating and speaking difficulties ever since he can remember. He has difficulty closing his mouth and has had chronic pain in his jaw joints because of this. The patient mentioned that he had a long lower jaw from a very early age. He had gone through depression at multiple stages of life due to his elongated lower jaw. He felt lonely and led a solitary life.
His parents had taken him to an oral surgeon at his hometown who had examined him. Realizing the complexity of the problem, the oral surgeon had referred the patient to our hospital for surgical correction of his oversized lower jaw. Our hospital is a renowned center for orthognathic surgery in India. Jaw reconstruction surgery as well as other facial cosmetic surgery procedures are commonly performed in our hospital.
What is mandibular prognathism?
Prognathism in humans can be due to normal variations among phenotypes. In human populations, prognathism may be a malformation, the result of injury, a disease state or a hereditary condition. This is considered a disorder only if it affects mastication, speech or social function as a byproduct of severely affected aesthetics of the face.
Mandibular prognathism is a protrusion of the mandible, affecting the lower third of the face. Pathologic mandibular prognathism is a potentially disfiguring genetic disorder where the lower jaw outgrows the upper, resulting in an extended chin and a crossbite. It is sometimes a result of acromegaly. This condition is sometimes colloquially known as lantern jaw or the Hapsburg jaw.
Initial presentation at our hospital for examination
Dr SM Balaji, facial cosmetic surgeon, examined the patient and obtained a detailed history. He ordered comprehensive imaging studies for the patient. The patient had an anterior crossbite with class III malocclusion. Treatment planning was presented to the patient and his parents. The patient was advised to undergo corrective lower jaw surgery. This was to be followed by fixed orthodontic treatment for management of his dental malocclusion.
Successful surgical correction of the patient’s mandibular prognathism
Under general anesthesia, an incision was placed in mandibular retromolar region bilaterally. Flaps were then elevated in the region to expose the mandibular bone. Bone cuts were made and a bilateral sagittal split osteotomy was performed using the Obwegeser technique. The mandible was pushed backwards, occlusion was checked and the mandible was then fixed using Titanium plates and screws. Extreme care was taken to ensure the safety of the inferior alveolar nerve. The nerve in the proximal and distal segments was protected during this part of the procedure. Closure was then done using resorbable sutures.
Total patient satisfaction at the outcome of the surgery
The patient expressed total satisfaction at the results of the surgery. His facial esthetics was very pleasing and he now had a normal occlusion. His facial profile was also to his liking. He would have to return in a few months to undergo orthodontic treatment. This is for correction of his malaligned teeth.
