Discovery of osseointegration of titanium with living bone
Dr Per Ingvar Branemark, a Swedish medical researcher, had placed titanium implants in the bones of rabbits for an experiment; however, when he tried to remove the titanium implant from the bone, he found that it had become as one with complete fusion of the bone with the implant. There was no distinguishable border between the two and he realized that he had stumbled onto something that could truly revolutionize surgeries related to bone. He later developed dental implants after extensive research and established Nobel Biocare as a manufacturer of dental implants. Constant research has helped in diversifying the type of implants available today, each one of which has specific uses. The two implants used in the case described below are the zygoma implants and conventional implants.
Patient suffering from chronic gum disease and teeth problems
The patient is a 58-year-old native of Hyderabad in Telangana. He has suffered from dental problems for a long time as he had not taken proper care of his oral hygiene and oral health. He has also had swollen and bleeding gums along with bad breath for many years now. Of late, he noticed that most of his teeth were mobile. This had made it difficult for him to eat and he had gradually reduced his food intake. His weight had gradually reduced because of this.
Finally, he decided to seek a permanent solution for his problems. He decided to seek the advice of a dental specialist and stated that he had visited multiple dental hospitals and dental clinics elsewhere in search of a solution for his dental problems. They had recommended that he undergo total extraction followed by replacement with a removable complete denture, but he felt that it would be very inconvenient. Complete removable dentures can often become dislodged during speech and chewing if there is inadequate bony support. However artificial tooth manufacturing technology has come a long way from this dated treatment modality. One dentist he had visited had recommended dental implants as a solution for his problems. It was explained to the patient that long term benefits and the convenience factor was highest with dental implants. He then referred the patient to Balaji Dental and Craniofacial Hospital as it is renowned for dental implant surgery in Chennai. Our hospital is a specialty center for zygoma implant surgery in Chennai.
Initial presentation at our hospital for consultation
Dr SM Balaji, dental implant surgeon examined the patient. Dental implant placement is a treatment modality best performed by oral and maxillofacial surgeons. This revealed that the patient had generalized gum recession and bleeding along with bad breath. He also had a bridge in his upper jaw, which had become mobile. Most of the patient’s teeth were extremely mobile. He then ordered comprehensive imaging studies for evaluating the bone level in the patient’s jaws. This revealed severe generalized bone loss.
Comprehensive treatment planning was done and explained to the patient in detail. He was made to understand the various surgical procedures that were involved in the extraction of teeth followed by placement of the implants. The patient was advised to undergo extraction of his remaining teeth followed by replacement with implants. Zygoma implants or zygomatic implants were advised for the patient as he lacked sufficient bone for conventional implants in the maxillary posterior region. The bone substitute with rh-BMP2 would to be used for sinus lift and also to augment the posterior maxillary ridge. This treatment plan was adopted as the patient was not ready for any major bone grafting procedures. He wished to undergo the whole procedure under local anesthesia if possible. The patient agreed to this treatment plan and gave his consent.
About zygoma implants and rh-BMP2 bone replacement material
Zygoma implants are different from conventional dental implants in that they anchor into the zygomatic bone rather than the maxilla. They may be used when maxillary bone quality or quantity is inadequate for the placement of regular dental implants. A bone substitute along with rh-BMP2 was used to help stimulate progenitor cells at the site into osteoblasts for formation of new bone. Rh-BMP2 is the result of biomedical engineering research that has many applications in oral and maxillofacial surgery.
Patient undergoes total extraction followed by placement of implants
The first step of treatment was removal of the mobile bridge. This was then followed by extraction of all the mandibular teeth. An incision was then made along the center of the mandibular alveolar ridge and a flap was elevated. This was followed by placement of the mandibular implants. The flap was then sutured close after placement of the implants. Extraction of the remaining maxillary teeth was performed next. A midcrestal incision was made and flap reflected. Bilateral sinus lift surgery was next performed through the lateral window technique. The Schneiderian membrane was then separated from the bone. The next step was placement of the zygoma implants bilaterally. Following this, a bone substitute mixed with rh-BMP2 was densely packed into the gap between the Schneiderian membrane and the bone. The entire maxillary ridge was also augmented using the bone substitute mix following which conventional Nobel Biocare dental implants were placed in the upper arch.
Patient expresses his satisfaction at the results of the surgery
Postoperative course was uneventful and the patient’s wounds healed well without any complications. The patient was given a removable partial denture following implant placement. Permanent fixed dentures will be placed in the patient’s mouth once complete osseointegration of the implant with the bone has been achieved in 3-4 months.
A certain proportion of the human population has always been affected by disabling facial asymmetry. This could be congenital as a result of developmental anomalies or birth injuries or acquired as a result of disease or trauma. Once of the most common causes of facial asymmetry is trauma. This trauma could either be accidental or inflicted during interpersonal conflicts.
Human history is strewn with wars. Most major wars lead to landmark changes in the course of history. However, war has also extracted a horrific price from many soldiers. For example, trench warfare during World War I had an unnatural number of soldiers suffering serious facial injuries followed by lifelong facial deformities. A special unit was in operation in France during the war that crafted lifelike masks for soldiers with horrific facial deformities.
Importance of facial symmetry
No human face is truly symmetrical. Perfect symmetry is unnatural. There is an imperceptible degree of facial asymmetry present in each face. This small degree of facial asymmetry is what adds to the beauty of the face. When facial symmetry is 100%, it will look unnatural and unreal. However, this asymmetry should be imperceptible and not noticeable on first glance. When this facial asymmetry becomes too obvious, it becomes a social handicap leading to the person withdrawing from social contact. Surgery is needed to correct facial asymmetry. Surgical correction of facial asymmetry requires an artistic touch in addition to surgical skills. This is a requisite for good plastic surgery results.
Surgical specialties that deal with facial asymmetry correction
The services of a plastic surgeon or an oral and maxillofacial surgeon would be required for correction of facial asymmetry. They would be the equivalent of system administrator in the team that performs this surgery. Facial asymmetry commonly is a result of road traffic accidents. Horizontal osteotomy surgery is one of the treatments available for correction of mandibular asymmetry. Facial asymmetry correction surgery is performed by board certified surgeons who are well versed in their craft. There are various degrees of facial asymmetry, ranging from the very mild to extreme asymmetry.
Functional difficulties caused by facial asymmetry
Jaw discrepancies can lead to functional problems. These are corrected through orthognathic surgery. The degree of asymmetry determines the approach that is taken to correct it. Reconstructive surgery frequently uses bone grafting for correction of defects that cause facial asymmetry.
Kashmiri man with facial asymmetry referred to our hospital
The patient is a 26-year-old Kashmiri man with facial asymmetry. He has a distant history of trauma to the chin. Wishing to have his facial asymmetry corrected, he visited a local oral surgeon who explained to him that he needed reduction of the right side of the mandible and maxilla to correct his asymmetry. It was further explained to him that facial asymmetry correction surgery in India was performed only at a few specialty surgical centers. He was then referred to Balaji Dental and Craniofacial Hospital for surgical management of his facial asymmetry.
Treatment planning explained in detail to the patient
Dr SM Balaji, facial asymmetry correction surgeon, examined the patient and ordered 3D CT scan and other imaging studies. This revealed that the patient had a hyperplastic right mandibular condyle. As a result, the right side of his mandible was bigger than the left and he has a downward left to right occlusal cant. Using facial biometrics to study the skull, he explained the treatment planning in detail to the patient and the patient consented to surgery.
Le Fort I osteotomy correction of maxillary occlusal cant
Under general anesthesia, a maxillary vestibular incision was made in the sulcus and a Le Fort I osteotomy was performed. The right maxilla was disjointed and a 10-12 mm segment of bone was removed from the region. This resulted in correction of the maxillary occlusal cant and the maxilla was stabilized and fixed with titanium plates and screws. This resulted in an open bite on the corrected side. This will be corrected by the bilateral sagittal split osteotomy (BSSO) of the mandible.
Bilateral sagittal split osteotomy of the mandible for occlusal cant correction
Following this, a right sided buccal vestibular incision was made in the mandible for the bilateral sagittal split osteotomy. This was repeated on the left side. BSSO was performed with an uplift of 10-12 mm of mandibular bone on the right side. This resulted in correction of the occlusal cant with establishment of perfect occlusion. The mandible was then stabilized and fixed with titanium plates and screws.
Sliding genioplasty for restoration of full facial symmetry
However, it was noticed that the chin was still skewed after the jaw surgeries. So attention was next turned towards correction of the chin. A reciprocating saw was used to perform an osteotomy and the chin was repositioned with a sliding genioplasty and fixed with titanium plates and screws. This resulted in complete correction of the patient’s facial asymmetry. All incisions were then closed with sutures and the patient taken to the recovery room in stable condition. The patient expressed his full satisfaction with the results of surgery before final discharge from the hospital.
Hemifacial microsomia is a congenital disorder, which mostly affects the development of the face. A congenital disorder is a disease condition that exists at the time of birth. The lower half of the face including the lower jaw and the ears are affected the most. There is a small jaw and rudimentary external ears. At times, it is so severe that the external ears are just skin tags. Ear reconstruction is best performed after 10 years of age. It usually affects only one side of the face and is rarely bilateral. The rudimentary ears need ear reconstruction surgery with cartilaginous grafts from the ribs.
Rudimentary external ear or microtia correction surgery
Microtia surgery is performed by only a few experienced surgeons. It is a very difficult surgery that requires years of experience to master. It is a three step surgery. During the first surgery, the cartilaginous rib grafts are crafted and shaped according to a template that is obtained from biometric study of the patient’s face. This is a procedure that requires a great deal of artistic skill since the graft has to be crafted to be symmetrical to the patient’s normal ear.
The three steps of successful ear reconstruction surgery or cosmetic ear surgery
This graft is first placed in a skin pocket created in the region of the patient’s external ear. This is allowed to mature. The second and the third stages of the procedure involve lifting up the cartilaginous graft using skin flaps so that it perfectly mimics the patient’s normal ear in structure. Children who undergo this procedure are ecstatic at seeing the results of the procedure as they have always felt self conscious, fearing comments from other children.
Effects of hemifacial microsomia on the quality of life of the patients
Disability from hemifacial microsomia is at many levels. The facial asymmetry also results in the patient withdrawing into a shell, shying away from all social contact. Absence of an external auditory canal is one of the symptoms of hemifacial microsomia. It is also a feature of craniofacial microsomia. Hearing loss is a common presentation in this presentation. Bony conduction of hearing is however present in a majority of cases. The use of cochlear implants greatly enhances the patient’s ability to hear.
Static or dynamic smile recreation surgery through fascia lata graft
Patients suffering from hemifacial microsomia also have an asymmetrical mouth. A beautiful smile is the ornament of a vibrant personality. The asymmetrical mouth makes them very self conscious and they tend to avoid eye contact with other people. This can be rectified through judicious performance of facial reanimation surgery. A strip of fascia lata graft is first harvested from the thigh.
Transformation in the life of patients after facial reanimation surgery
This strip of fascia lata is used as a graft to connect the labial commissure of the affected side of the mouth to a dynamic muscle, which when activated results in a beautiful smile. The fascia lata graft is tunneled from the muscle to the angle of the mouth and anchored in place using sutures. This is a life changing surgery and patients undergoing this have a transformed personality due to regaining their ability to smile, which enables them to connect with others.
Jaw reconstruction surgery for correction of asymmetrical mandible
Jaw correction is achieved through mandibular distraction osteogenesis by the use of distraction devices on the affected side. Plastic reconstructive surgery (plast reconstr surg) is the surgery of choice for correction of the facial asymmetry that results from hemifacial microsomia. Correction of soft tissue defects is through the use of fat grafts. Le Fort I osteotomy is performed when there is involvement of the maxilla in craniofacial microsomia. Use of bone graft in deficient bone segments is used to correct any residual facial asymmetry after completion of the osteotomy.
Patient with long standing facial asymmetry due to hemifacial microsomia
The patient is a young man from Solapur, Maharashtra. He had begun noticing a facial asymmetry a few years ago that had developed gradually. He had also progressively developed difficulty with chewing and speech. This problem was slowly turning debilitating and his quality of life had significantly declined. He had habitually started tilting his head to the left side to conceal his facial asymmetry from other people. This had resulted in severe spasms of his neck muscles. The spasms were very painful and had begun to affect his sleeping cycle. This chronic lack of sleep had begun to affect all walks of his life including his work life.
Patient and parents seek medical help to help the patient
He and his parents approached a local oral surgeon for diagnosis and treatment due to the severe neck pain. It was explained to them that the patient had a high degree of facial asymmetry with a skewed occlusal cant. He diagnosed the patient as having hemifacial microsomia. The patient required facial asymmetry correction surgery. It was explained to them that facial asymmetry surgery in India was performed only in a few specialty centers. The patient and his parents were then referred by him to Balaji Dental and Craniofacial Hospital in Chennai, India.
Treatment planning explained and consent obtained for distraction osteogenesis
Dr SM Balaji examined the patient and ordered detailed imaging studies including a 3D CT scan. Biometrics were then obtained, which revealed a 10 cm shortening of the ramus on the left side when compared to the right. It was decided to proceed with simultaneous maxillary and mandibular distraction for the patient. The treatment planning was explained in detail to the patient and his parents who consented to the surgery.
Bilateral sagittal split osteotomy of the mandible
Under general anesthesia, a sagittal split osteotomy was performed on the left mandibular ramus. A Univector ramus distractor was then fixed with screws to the distracted segments of the mandible. Functioning of the distractor was checked before the incision was closed with sutures.
Attention was next turned to the maxillary distraction. A vestibular incision was performed followed by a Le Fort I maxillary osteotomy. Dysjunction of the maxilla was then performed on the left side followed by stabilization of the distracted segments.
Establishment of facial symmetry through distraction osteogenesis
Distraction osteogenesis of the mandible would be performed after a latency period of seven days to allow for stabilization of the distracted site. This will be followed by a distraction of 1 mm everyday for a total of 10 mm of distraction in ten days. The distractors would be left in place for a period of three months for the new bone to consolidate at the distracted site. Consolidation of the new bone is confirmed by establishment of normal trabecular pattern at the site of new bone formation. The distractors are removed once the trabecular pattern of the new bone and old bone become indistinguishable.
This would result in establishment of facial symmetry for the patient. The patient and his parents expressed their satisfaction at the results of the surgery before final discharge from the hospital. Parents of the patient said that they could already see that the patient was very excited about facing the future after undergoing this life changing surgery.
Mankind has always been prone to violence with a history strewn with small battles and major wars. Back in the olden days, fighting was invariably close contact before the invention of weapons whose destructive capabilities could wipe out entire sections of an army with one single shot. This close quarter fighting with swords and knives invariably resulted in horrific hard and soft tissue damage. Even though the soldiers wore protective armor, this was rarely adequate to avoid injuries. Jaw fractures were common and debilitating for those surviving them.
Initial steps towards formulating a protocol for jaw reconstruction
Dental specialists and surgeons tried their best to restore enough esthetics and function for the patient to integrate back into society after the wars, but this was prevented by serious infections caused by poor oral hygiene, which left the survivors with severely disfigured faces and bodies. Using artificial teeth through the utilization of removable dentures to bring a semblance of normalcy to shattered jaws proved to be grossly inadequate. Jaw reconstruction proved to be a task that was well beyond the capabilities of mankind at that point in time. Cosmetic surgery and artificial tooth fabrication technology was still in its infancy with poor esthetics.
Development of jaw reconstruction surgery
Jaw reconstruction surgery is a relatively modern surgical procedure. It made its first appearance in the most rudimentary of forms in the year 1846 when Dr Simon Hullihen performed the first orthognathic surgery involving mandibular osteotomy with setback for a patient. An improvement in the understanding of the growth and development of the jaws including the genesis of the dental lamina, rete ridges and epithelial lining along with the development of general and local anesthesia led to improvement in jaw surgery techniques.
Patient with pain and swelling in her jaws presents to a local dentist
The patient is a young woman who presented with a slight swelling and pain in the premolar region of the left mandible. There was also displacement of the teeth in that region. She and her parents had presented to an oral surgeon in her hometown who had obtained radiographs of the region.
Two failed cyst enucleation surgeries in her hometown
He diagnosed the patient to have a cystic lesion in that region. The patient was informed that she would require enucleation of the cyst followed by reconstruction of the jaw at a later date. She and her parents consented to surgery, but unfortunately, the cyst recurred a few months after surgery. She had approached the same surgeon again who had performed another enucleation, which again was followed by recurrence of the cyst a few months later.
Referral to our hospital for single sitting enucleation and jaw reconstruction surgery
Feeling very frustrated, she and her parents had sought a second opinion from a plastic surgeon in their home town who had explained to the parents and the patient that a single sitting cyst enucleation followed by jaw reconstruction surgery in India was performed in only a few specialty centers. He then referred the patient to Balaji Dental and Craniofacial Hospital in Chennai, India for surgical management of her cystic lesion.
Diagnosis and treatment planning presented to the patient
The patient was examined by Dr SM Balaji, jaw reconstruction surgeon who then proceeded to order imaging studies for the patient including a 3D CT scan and also a biopsy, which revealed an odontogenic keratocyst. Odontogenic keratocysts (OKCS) always have to be removed completely in order to prevent relapse like the patient had experienced earlier. This is one of the common odontogenic tumors. He explained the treatment planning including the bone grafting with rib grafts to the patient and her parents who consented to surgery. The implant surgery would give perfect lifelike replacements for the natural teeth. Any impacted wisdom teeth if present are extracted during the time of this surgery.
Cyst removal followed by jaw reconstruction surgery
Under general anesthesia, two rib grafts were harvested from the patient. A Valsalva maneuver was then performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers. Attention was then turned to the cyst enucleation and jaw reconstruction portion of the surgery.
The gingiva overlying the region of the cyst was retracted to expose the cyst. Contents of the cystic cavity were completely enucleated. The teeth overlying the cyst were also extracted and removed. The two rib grafts were then crafted and shaped to fit snugly into the bony defect left behind by the cyst. These were then fixed with screws and the flap closed with sutures.
Dental implant surgery to complete full oral rehabilitation
The patient returned after three months for dental implant surgery. Radiographic studies demonstrated that the grafts had fused with the jaw bone and there was full correction of the bony defect from the cyst removal surgery. A dentoalveolar flap was raised and the screws used to fix the grafts were removed. This was followed by placement of four dental implants in the region. The flaps were then closed with sutures.
The patient will return in six months after the healing process is complete and there is full osseointegration of the implants with the jaw bone. Crowns will be placed over the implants at that time to complete total oral rehabilitation for the patient.
Patient with long standing facial asymmetry due to hemifacial microsomia
The patient is a young man from Thrissur, Kerala with hemifacial microsomia. His parents had slowly begun noticing a facial asymmetry as he grew up. The left side of the jaw was shorter than the right side as the corpus of the mandible was not growing normally and there was also a deformity of the left maxilla. He had also progressively developed difficulty chewing and with his speech.
They approached a local oral surgeon for diagnosis and treatment. It was explained to them that the patient had a high degree of facial asymmetry with a skewed occlusal cant. The surgeon had then informed them that facial asymmetry surgery in India was performed only in a few specialty centers. The patient and his parents were then referred by him to Balaji Dental and Craniofacial Hospital in Chennai.
Treatment planning explained and consent obtained for distraction osteogenesis
Dr SM Balaji examined the patient and ordered detailed imaging studies including a 3D CT scan. Facial biometrics were then obtained, which revealed a 10 cm shortening of the ramus on the left side when compared to the right. It was decided to proceed with simultaneous maxillary and mandibular distraction for the patient. The treatment planning was explained in detail to the patient and his parents who consented to the surgery.
Sagittal split osteotomy of the mandible
Under general anesthesia, a sagittal split osteotomy was performed on the left mandibular ramus. A Univector ramus distractor was then fixed with screws to the distracted segments of the mandible. Functioning of the distractor was checked before the incision was closed with sutures.
Attention was next turned to the maxillary distraction. A vestibular incision was performed followed by a Le Fort I maxillary osteotomy. Dysjunction of the maxilla was then performed on the left side followed by stabilization of the distracted segments.
Establishment of facial symmetry through distraction osteogenesis
Distraction osteogenesis of the mandible would be performed after a latency period of seven days to allow for stabilization of the distracted site. This will be followed by a distraction of 1 mm everyday for a total of 10 mm of distraction in ten days. The distractors would be left in place for a period of three months for new bone to consolidate at the distracted site.
This would result in establishment of facial symmetry for the patient. The patient and his parents expressed their satisfaction at the results of the surgery before final discharge from the hospital.
Genesis and characteristics of an odontogenic keratocyst
A cyst is essentially a sac of membranous tissue that can occur anywhere in the body. They normally contain fluid, but other substances can also be found inside them on occasion. Cysts are benign and not cancerous growth. There are many kinds of cysts. They include epidermoid cyst, sebaceous cyst, pilonidal cyst, ovarian cyst, chalazion of the eyes, popliteal cyst and pilar cyst amongst others.
Varieties of common cystic lesions
Treatment of cysts includes excision and careful enucleation of the cystic lesion including the membranous lining of the cyst. Any remnants left behind during enucleation can lead to recurrence of the cyst. Care has to thus be taken to ensure complete removal of the contents of the cystic cavity. Some of the more common cysts include the sebaceous cyst, the chalazion, and the epidermoid cyst. Cysts can turn painful when they occur in a confined space or get infected.
Epidermoid cysts are slow growing cysts that are the result of keratin buildup under the skin. They can get infected easily as they are very close to the surface of the skin. Sebaceous cysts occur when sebum glands get clogged leading to a buildup of sebum. This too can get infected easily. Surgical excision is the treatment of choice for both these cysts.
A pilonidal cyst occurs at a hair follicle and is said to occur due to a combination of hormonal changes, friction or prolonged pressure to that region. It can be quite painful and there is a foul smelling discharge from the cyst. A hair follicle is also present in association with the cyst. Treatment is curettage and enucleation along with removal of the associated hair follicle.
Etiology and pathogenesis of odontogenic keratocyst
An odontogenic keratocyst is a very rare benign developmental cyst that is very aggressive. It results in extensive destruction of the bone. It is most commonly seen in the posterior mandibular region in the third decade of life. The PTCH1 gene, which leads to the occurrence of odontogenic keratocyst has also been linked to the occurrence of ovarian cysts and ovarian cancer. Differential diagnoses for odontogenic keratocysts can include epidermoid cysts though these are completely different in their origin.
Recommended treatment protocol for odontogenic keratocysts
Treatment of the odontogenic keratocyst involves meticulous resection to completely remove the lesion followed by reconstruction of the jaw with bone grafting. Implant surgery for the placement of dental implants is performed after full bony consolidation of the bone grafts to complete full oral rehabilitation for the patient. This is the treatment protocol that is recommended by the American Association of Oral and Maxillofacial Surgeons. The patients thus properly cared for can go on to lead a completely normal life.
Use of dental implants for oral rehabilitation from destructive jaw lesions
The advent of dental implant treatment has enabled complete rehabilitation patients with odontogenic keratocyst. Implants enable replacing missing teeth. Success rates are extremely high for patients rehabilitated with dental implants. This is because dental implants mimic tooth roots and are able to bear occlusal loads that are borne by natural teeth.
Before dental implant treatment became a part of routine surgical protocol, postsurgical dental rehabilitation was through the use of removable dentures. This was highly unsatisfactory for the patient. The patient faced a lot of difficulty with both chewing and speech.
Dental implants have enabled the complete rehabilitation of both the upper and lower jaws. Proper maintenance of dental implants aided by following instructions of the implant surgeon meticulously is essential for the success of dental implant treatment.
Patient develops pain and swelling in the left posterior mandibular region
The patient is an 18-year-old female who had slowly developed a soft tissue swelling of the left posterior mandible with pain for the last six months. She had consulted a local dentist who noticed that the patient’s left third molar was missing from the oral cavity. Suspecting the swelling to be a dentigerous cyst, he had referred the patient to our hospital for management. Our hospital is a renowned center for jaw reconstruction surgery. Implants will need to be placed to complete oral rehabilitation after jaw reconstruction surgery.
Examination of the patient at our hospital with subsequent investigations
The patient presented at our hospital for management of the pain and swelling in her left posterior mandibular region. Dr SM Balaji, an oral and maxillofacial surgeon and jaw reconstruction surgeon in Chennai, examined the patient and ordered imaging studies and a biopsy of the lesion. The biopsy results returned as odontogenic keratocyst.
Imaging studies revealed a radiolucent lesion in relation to the left mandibular molars and a horizontally impacted third molar. Treatment planning for the management of the odontogenic keratocyst was explained to the patient in detail. She was advised to undergo cyst removal surgery and was in total agreement with surgical management of the lesion.
Bone graft harvested from the patient for jaw reconstruction
Under general anesthesia, rib grafts were first harvested from the patient. The rib grafts will be used to reconstruct the jaw after resection of the odontogenic keratocyst. A Valsalva maneuver was then performed to ensure that there was no perforation into the thoracic cavity. Following this, the incision was then closed in layers with sutures.
Resection of the odontogenic keratocyst from the left posterior mandible.
A mucogingivoperiosteal flap was raised in the left posterior mandibular region. This exposed the area of the odontogenic keratocyst. The cystic lesion was exposed and then completely resected. Great care was taken to ensure that there were no cystic remnants left behind in the bony cavity. The rib grafts were then carefully shaped to fit into the bony defect left behind by the lesion.
Titanium screws were used to fix the rib grafts into the bony defect in the jaw to reconstruct the jaw. Once adequate jaw reconstruction had been achieved with the rib grafts, the flap was then closed with sutures. The healing process along with bone remodeling of the grafts to merge in with the mandibular bone takes up to 6-8 months. Implants should only be placed after this is complete to ensure good long term results.
Placement of dental implants for complete oral rehabilitation for the patient
Once adequate consolidation of the bone grafts has been achieved, the patient will return to our hospital again for placement of dental implants. A period of six months will be given following dental implant surgery to allow for complete osseointegration of the dental implants with the mandibular bone. Complete oral rehabilitation of the patient would then be done with placement of tooth coloured crowns to the dental implants. Zirconium crowns or ceramic crowns offer great functional and esthetic results to complete the patient’s rehabilitation.
