Patient with inability to open mouth following depressed zygoma fracture
The patient is a middle-aged man from Hassan, Karnataka. He suffered a comminuted zygoma fracture from a road accident. Improper reduction elsewhere had left him with a depressed zygoma and trismus. The depressed zygoma led to facial asymmetry and impingement of the coronoid process. This resulted in a mouth opening of only 1 cm for the patient. The patient had complaints of inability to eat well as well as impaired speech. He was becoming withdrawn and avoiding social interaction.
This became a hindrance to normal functioning in day to day life. His friends searched for the best hospital to get his asymmetry corrected. They took him to a local oral surgeon who studied the case in depth. Findings were somewhat complicated and needed an experienced surgeon. He was then referred to our hospital for correction of his complaints.
Various aspects of correction of facial asymmetry
No human face has perfect symmetry. Perfect symmetry is impossible in biological organisms. There is always a small degree of asymmetry present in all structures. The human face is no exception to this law of nature. This facial asymmetry is imperceptible in 99.90% of the population. It is only in a small minority that there is noticeable asymmetry. This asymmetry could be congenital or acquired. Congenital facial asymmetry could be the result of birth defects or injuries. Improper use of forceps during delivery can result in facial asymmetry.
Cleft lip and palate deformities result in severe facial deformities. Correction of this requires the services of an experienced cleft surgeon. The majority of acquired facial asymmetry is through trauma. An asymmetrical face can lead to psychological problems. The patient becomes very self conscious and withdraws from social interactions.
Types of presentation of asymmetry of the face
Facial asymmetry can involve the soft tissues alone or can involve the hard tissues also. Treatment options depend upon the location and degree of asymmetry. The main aim of treatment is to restore facial symmetry. We are one of the premier hospitals for facial asymmetry correction in India. Correction of the asymmetry of his face will undergo correction here. Jaw surgery is among the most common asymmetry correction surgeries performed in India. Orthognathic surgery can also correct facial asymmetry. Both maxillofacial as well as craniofacial surgeons perform these surgeries.
Treatment planning explained to the patient in detail for correction of problems
Dr SM Balaji, a premier facial deformity correction surgeon in India, examined the patient. He specializes in all manifestations of facial asymmetry. A world renowned cleft surgeon, all types of facial asymmetry undergo correction here. Facial asymmetry due to paralysis is also corrected at our hospital. Patients undergoing rehabilitation are able to lead a completely normal life after surgery. Their ability to smile restored, they are able to face life with dignity and self confidence.
Clinical examination revealed impingement of the left coronoid process during mouth opening. The patient had a mouth opening of only 1 cm. There was a depressed left zygoma with resultant facial asymmetry. He explained the treatment planning to the patient, which included a left coronoidectomy. This would enable good mouth opening again for the patient. The patient was in agreement and consented to the facial deformity correction surgery.
Left coronoidectomy performed on the patient to enable mouth opening
The patient underwent fiberoptic bronchoscopic intubation for general anesthesia. This was due to his inability to open his mouth for oral intubation. A tracheostomy would have to be performed otherwise. Once under satisfactory general anesthesia, a left retromolar incision was first made. The coronoid process was then accessed. A coronoidectomy was next performed and the coronoid process removed. The patient’s mouth opening was then demonstrated to be about 5 cm. This falls within the parameters of normal mouth opening. The incision was then closed with sutures.
Depressed zygoma elevated and fixed with plates for facial asymmetry correction
The depressed zygoma was next addressed. It was impinging on the coronoid process during mouth opening. This was preventing full opening of the mouth. Zygomatic bone was then approached through two approaches. They were through the maxillary vestibular incision and lateral canthal incision. The zygoma was first refractured to set right the depression. It was then fixed in an elevated position with the use of plates. Both incisions were then closed with sutures. The patient expressed his total satisfaction at the results of the surgery.
Patient with failed surgery elsewhere presents for correction
The patient is a young woman with failed condylar hyperplasia surgery performed elsewhere. She presented to our hospital for correctional surgery. Dr SM Balaji examined the patient and ordered detailed studies for the patient.
Rib graft and buccal fat pad graft obtained from the patient
Under general anesthesia, a rib graft was first harvested from the patient. Valsalva maneuver demonstrated a patent thoracic cavity. The incision was then closed with sutures. This was next followed by harvesting of a buccal fat pad graft from the right cheek.
Augmentation of the mandibular body done with grafts
A left sided maxillary vestibular incision was next made. The bone grafts were then shaped and fixed with screws in this region. Attention was next turned to the mandible. A mucogingivoperiosteal flap was then raised. The bone grafts were then screwed in place in the molar region. This led to adequate augmentation of the body of the mandible.
Maxillary repositioning and buccal fat pad transfer performed
Attention was next turned to the anterior maxillary region. An osteotomy was then performed and the maxilla repositioned with four holed plates. This was then followed by transfer of the buccal fat pad graft to the left cheek. All incisions were then closed with sutures.
The patient expressed complete satisfaction with the results of the surgery before discharge.
This is a 33-year-old male patient from Siliguri. He met with an accident about three months ago. He underwent emergent treatment at a nearby local hospital. He realized that the accident had left him with a left sided double vision. He underwent three surgeries for his double vision, but this persisted. A depressed fracture of his left eyebrow and maxilla had left him with facial asymmetry.
None of these issues were set right by the three surgeries. The oral surgeon who operated on him referred him to our hospital. He told the patient that all his problems would be set right.
He presented for consultation. Dr SM Balaji examined him and recommended a 3D CT scan. This revealed a malunited zygomaticomaxillary complex fracture. The treatment plan was then explained to the patient. This would involve the use of a costochondral bone graft.
Pre-operative view showing depressed left maxilla, prominent left zygoma
Pre-operative view showing depressed left eyebrow and increased width of the right nasal bone
Malunited zygomaticomaxillary complex and naso-orbital bone
Costochondral rib and cartilage graft harvested
Lateral wall of orbit and orbital floor reconstruction with Titan medpor
Left eyebrow defect augmentation done with cc bone graft
Left maxillary depression augmented using cc bone graft
Lateral Osteotomy done on right side of the nose
The left side zygomatic arch was refractured intraorally and pushed back
Immediately after suturing showing corrected left eyebrow defect
A costochondral bone graft was first harvested from the sixth intercostal rib. Reconstruction of the lateral wall of orbit and orbital floor was then done with a Titan Medpor mesh. This corrected the diplopia and enophthalmos. The left zygomatic arch was then refractured and pushed inwards. Attention then turned to the left maxillary defect and depression in the left eyebrow.
This was by using a costochondral bone graft, which was then fixed using titanium screws. The deviated left nasal bridge was then corrected using lateral osteotomy. The patient was very satisfied with the results of the surgery.
Patient with masseter hypertrophy and excess lateral mandibular angle bone
The patient is a young girl from Rajasthan. She began noticing the development of an asymmetry in her face at around 14 years of age. The right side angle of the mandible region was becoming bulkier as time went by. It reached the point where the asymmetry became too obvious to ignore. She wanted to get it corrected. A local dentist advised her that surgical correction was the only way to correct it. She and her parents researched the Internet for the best oral surgeon. Their search led them to our hospital in Chennai. They got in touch with the hospital manager who asked them to send a few photos through email.
Lateral angle of mandible reduction and masseter debulking surgery
Dr SM Balaji examined the photographs in detail and instructed the patient to meet him. The patient and her parents came to our hospital in Chennai. He examined the patient in detail and explained the problem. The patient had excessive thickness to the lateral angle of mandible bone. This had to be first reduced. There was also masseter muscle hypertrophy that needed to be set right. This would be by removing excessive muscle tissue. The patient and her parents were in complete agreement with the treatment plan. The patient was then scheduled for surgery.
Surgical correction of masseter hypertrophy and angle reduction
Under general anesthesia, an incision was first made buccal to the right lower molars. The third molar was then elevated and removed. Dissection was then carried down to the lateral angle of the mandible. A hand piece was then used to trim down the excessive cortical bone on the lateral aspect of the mandible. Attention was next turned to the masseter muscle. Excessive muscle tissue was next trimmed until symmetry of both sides was achieved. The incision was then closed with sutures.
The patient expressed her happiness to Dr SM Balaji with the results of the surgery.
A 23-year-old girl reported to our hospital seeking to correct her protruding and deviated lower jaw. She was discontent with her facial appearance and mentioned about her inability to chew food.
After thorough clinical and radiological examination, Maxillofacial Surgeon Dr. S. M. Balaji planned to correct her bite both orthodontically and surgically. Presurgical orthodontic treatment was started and the teeth were aligned. Through intraoral approach, bilateral sagittal split osteotomy (Obwegesers and short lingual split technique) was done and the excessive length of the mandible was reduced. The patient was beaming with joy on seeing the results as there was no visible post-surgical scar. Her speech and ability to chew food also improved markedly.
Intraoral view showing anterior cross bite due to forwardly placed lower jaw
Intraoperative view showing sagittal split osteotomy – in right side
Improved bite following surgery giving enhanced appearance
