Patient dissatisfied with results of previous jaw reconstruction surgery
The patient is a 33-year-old patient from Indore in Madhya Pradesh, India. He had been diagnosed with ameloblastoma around four years ago. Surgery had been advised for him and he had then undergone ameloblastoma mandibular resection.
This had been followed by mandibular reconstruction with a titanium plate and screws. The surgery had been performed at a nearby city. Bone grafts had been used to rebuild the mandibular bone.
The patient however was not happy with the results of the surgery. He mentioned that his jaw bone seemed to be very deficient and implants could not be placed. Eating and speech have been difficult since this surgery. This had caused a compromise in the quality of daily living and he had wanted to get this addressed.
Patient referred to our hospital for surgery by many specialists
The patient had made enquiries regarding the best hospital to undergo jaw reconstructive surgery. He had been referred to our hospital by multiple sources. Our hospital is a renowned center for jaw reconstruction and other complex surgeries. We also perform dentigerous cyst surgery, odontogenic keratocyst surgery, hemifacial microsomia surgery, etc.
Large cysts are enucleated followed by jaw reconstruction at our hospital. Ear reconstruction for microtia is a specialty surgery performed in our hospital. Orthognathic surgery for jaw size discrepancies has rehabilitated scores of patients. Dental implant surgery followed by placement of artificial teeth is done using Nobel Biocare implants and Zirconium/ceramic crowns.
Remodeling of gum tissue through laser gum surgery offers good esthetic and functional results at our hospital. All this is enabled through the application of the latest state of art technology.
He presented with a complaint of a mandibular defect. The patient mentioned that his jaw was very thin and that he was unable to bite or chew on foods properly. He wanted to correct his jaw and replace his teeth as soon as possible.
Initial presentation at our hospital for mandibular reconstructive surgery
Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained a detailed history. He then ordered for radiological studies including a 3D CT scan. This revealed that the patient had deficient bone at the site of the mandibular reconstruction plate. The anterior mandibular bone was very thin and insufficient to support placement of implants.
Occurrence of ameloblastoma and treatment modalities
Ameloblastoma is a rare, benign or cancerous tumor of the odontogenic epithelium, which are more common in the mandible. This was initially known as adamantinoma and was renamed in 1930 by Ivey and Churchill. They are rarely malignant or metastatic, but can lead to severe disfigurement due to gradual growth.
Surrounding healthy bone is also destroyed by this lesion. Hence, a wide surgical excision of surrounding tissues is required to treat this disorder. If left untreated, it could potentially obstruct nasal and oral airways making it impossible to breathe without oropharyngeal intervention.
Formulation of treatment and jaw reconstructive surgery
It was explained to the patient that rib grafts needed to be harvested to reconstruct the bony defect in his mandible. Dental implant surgery would be performed after consolidation of the grafts with the mandibular bone. The patient was in complete agreement with this treatment plan and consented to surgery.
Under general anesthesia, a right inframammary incision was made and a costochondral rib graft was harvested. This was followed by a midcrestal incision placed in the anterior mandible. A flap was then elevated and dissection was made down to the site of mandibular resection. The previously placed mandibular reconstruction plate and screws were removed.
Segments of the bone graft were then crafted to recreate good mandibular form. The mandible was then reconstructed using the shaped rib graft and titanium screws. Hemostasis was then achieved and closure of the incision was done with sutures.
Successful reconstruction of the deficient mandibular bone
There was good recreation of mandibular form after surgery. The mandible had been reconstructed to its previous dimensions. The surgery was successful with no complications. Patient recovered completely following surgery.
It was explained to the patient that implants would be placed after consolidation of the grafts. He was instructed to return in 3-4 months for placement of dental implants.
Patient with pain in her right mandibular first molar
The patient is a 21-year-old girl from Kottayam in Kerala, India. She had started noticing a swelling on the left side of her mandible over the last few months. Pain had also developed along with the swelling. This had rendered her unable to chew anything. Her taste sensation had also become altered along with the other presenting symptoms.
Her parents had become very alarmed by this development. Upon consultation with their family doctor, he had referred them to come to our hospital. He explained to them that our hospital was the premier center in India for treatment of jaw cysts.
Initial presentation at our hospital for diagnosis and treatment
Dr SM Balaji, jaw reconstruction surgeon, examined the patient. He then ordered comprehensive imaging studies including an OPG and a 3D CT scan. This revealed a cystic lesion in the left posterior mandibular region, which extended well into the ramus region. A biopsy was obtained from the cystic lesion, which revealed it to be a dentigerous cyst.
Treatment planning explained to the patient in detail
It was explained to the patient that the cystic lesion needed to be enucleated in toto. The patient was also informed that the bony defect that would result from the surgery would have to be reconstructed. It was further explained that rib grafts harvested from the patient would be used for the jaw reconstruction surgery.
Dental implants would then be placed after complete bony consolidation of the bone grafts with the mandibular bone. This would be followed by placement of crowns after osseointegration of the dental implants with the surrounding bone. The patient discussed this with her parents and signed the informed consent for the surgery.
What is a dentigerous cyst?
A dentigerous cyst is an odontogenic cyst, which is associated with the crown of an unerupted or partially erupted tooth. Based on radiological presentation, dentigerous cysts can be classified into central type, lateral type and the circumferential type.
The most common dentigerous cysts are those that are associated with mandibular third molars followed by maxillary canines. They are rarely found in association with deciduous teeth and occasionally with odontomas. Treatment of dentigerous cyst is through enucleation of the cyst followed by extraction of the associated tooth.
Surgical enucleation of the dentigerous cyst
Under general anesthesia, a right inframammary incision was made and costochondral rib grafts were harvested. This was followed by a Valsalva maneuver to ensure that there was no perforation into the thoracic cavity. The incision was then closed in sutures.
A crevicular incision was next made in the left mandible followed by elevation of a mucoperiosteal flap. This was followed by extraction of the three left lower molars. Complete cyst enucleation was then performed and electrocautery was applied followed by antibiotic flushing.
The resultant bony defect was then packed with rib grafts, which were contoured to fit into the defect. These were then fixed with titanium screws and the flap was closed with sutures.
Results:
The patient and her parents were extremely relieved after the successful completion of the surgery. They were very happy that the dentigerous cyst had been treated with such good results. It was explained to them that they would need to return in a three months for dental implant surgery.
Artificial teeth would be fixed to the dental implants. This would offer complete rehabilitation after the surgery. This would be in the form of a fixed ceramic bridge. Removable dentures are normally not advised for patients. Maintenance of gum tissue health is imperative for success of dental implants.
The patient is a 27-year-old female from Chengam in Tamil Nadu, India. She began noticing the development of a swelling in her lower jaw around a year ago. This was on the left side. The swelling was not painful, but there was loosening of teeth in the affected region. This also began interfering with her eating and speech.
Alarmed at the turn of events, she visited a local dental surgeon who examined her. He also obtained imaging studies for the patient. Realizing that the problem was too complex and needed surgical intervention, he referred the patient to our hospital for further management.
Our hospital is a well-known center for jaw deformity surgery in India. All problems relating to jaw correction surgery are addressed at our hospital. Jaw lengthening surgery, jaw reduction surgery and jaw cyst surgery are specialty procedures performed at our hospital.
Initial consultation and treatment planning
Dr SM Balaji, jaw reconstruction surgeon, examined the patient and obtained a detailed history. He ordered for comprehensive imaging studies including a 3D CT scan. Imaging studies revealed that there was a cystic lesion extending from the left lower canine to the third molar. There was also perforation of the lingual cortex of the mandible.
Biopsy of the lesion confirmed the diagnosis of odontogenic keratocyst. He explained to the patient that total removal of affected portion of the mandible would be performed. Involved teeth in the region would also be extracted to prevent recurrence of the lesion.
Hemimandibulectomy would be followed by reconstruction of the bony defect with grafts harvested from the patient’s ribs. Rehabilitation of the patient would then be completed with placement of implants through dental implant surgery. This is the treatment protocol recommended by the American Association of Oral and Maxillofacial Surgeons.
It was explained that artificial crowns will be placed on the dental implants later. The artificial teeth would enable the patient to eat a normal diet. Normal speech would also be enabled by this treatment plan. The patient and her parents were in complete agreement with the treatment plan and consented to surgery. Removable dentures were not recommended to the patient. It was explained to them that meticulous dental care needed to be performed for good long term results.
Characteristics of an odontogenic keratocyst
An odontogenic keratocyst is a rare and benign but locally aggressive developmental cyst. It most often affects the posterior mandible and commonly presents in the third decade of life. Odontogenic keratocysts make up around 19% of jaw cysts. Radiographically, these lesions are unilocular when presented at the periapex and can be mistaken for radicular or lateral periodontal cysts.
Successful surgical excision of the odontogenic keratocyst
Under general anesthesia, a right inframammary incision was made and dissection was carried down to the ribs. Costochondral rib grafts were then harvested for reconstruction of the jaw. A Valsalva maneuver was performed to ensure that there was no perforation into the thoracic cavity. The incision was then closed in layers with sutures.
Attention was next turned to the odontogenic keratocyst. A crevicular incision was made in the mandible followed by elevation of a mucoperiosteal flap. The area of the cystic defect was identified followed by extraction of the teeth in the involved area. These included the canine, first premolar, second premolar and the three molars.
Hemimandibulectomy was then performed followed by application of diathermy to control bleeding. Antibiotic flushing was also done in the region of the bony defect. The mandible was reconstructed using a mandibular reconstruction plate. Rib grafts were also fixed using titanium screws. Wound was then closed with sutures following adequate hemostasis.
Follow up treatment after surgery
It was explained to the patient that dental implant would be fixed on the rib grafts after consolidation with the surrounding bone. This would be followed by fixation of crowns to the dental implants after adequate osseointegration has been demonstrated with the surrounding bones. The patient and her parents expressed understanding of the treatment plan.
The patient is a 41-year-old male from Chikkaballapur in Karnataka, India. He noticed the development of a swelling in his right lower jaw around 9-10 months ago. Thinking it would subside on its own, he had ignored it for a couple of months. It was the development of pain, which made him approach a dentist for consultation.
This had progressively increased in size along with development of pain and loosening of teeth. Chewing and eating became progressively difficult because of the swelling. Alarmed at this, he had presented to a local oral surgeon for diagnosis and management. Radiographs had been obtained revealing the presence of a dentigerous cyst in the region.
Seeing the complicated presentation of the cyst, the surgeon referred the patient to our hospital for management. Our hospital is a renowned center for dentigerous cyst surgery in India. We are also a premier center for mandibular reconstruction in India.
Dentigerous cyst:
A dentigerous cyst is an odontogenic cyst, which is felt to be of developmental origin. This is always associated with the crown of an unerupted or a partially erupted tooth. Mandibular third molars are the teeth most commonly associated with a dentigerous cyst. These are the most commonly impacted teeth in the mouth.
Next most commonly involved teeth are the maxillary canines. They are also rarely found involving deciduous teeth and occasionally odontomas. Orthodontic treatment is employed to bring the canines into the arch if there is no pathology present in relation to the impacted tooth.
Diagnosis is through radiographic imaging of the affected region. Dentigerous cysts are classified according to their radiological position, namely central type, lateral type and circumferential type. A dentigerous cyst is often treated by excision of the cyst along with the extraction of the associated tooth.
Initial presentation at our hospital
Dr SM Balaji, jaw reconstruction surgeon, examined the patient and ordered comprehensive imaging studies including a 3D CT scan. The patient had a swelling in relation to right lower molar region. Imaging studies revealed the presence of a cystic lesion extending from the first molar up to the ramus of the mandible. This confirmed the diagnosis of dentigerous cyst.
Treatment planning explained to the patient
It was explained that the cyst needed to be enucleated completely. Associated teeth would also be extracted to ensure that the cyst did not recur. This would be followed by jaw reconstruction surgery. The residual bony defect would then be reconstructed using a costochondral graft harvested from the patient.
Final step of rehabilitation of the patient would involve dental implants. This would enable the patient to regain full masticatory function of his jaws. Abutment is attached to the implant. Artificial teeth are then attached to the implants to facilitate this. Implants mimic tooth roots. Good gum tissue health is necessary for success of implants. Single implants can be placed under local anesthesia.
Dental implants would be placed after consolidation of the grafts. This would result in complete rehabilitation of the patient’s oral cavity. Dental implants need meticulous oral hygiene and dental care for optimal results in the long run. In the case of full mouth rehabilitation with implants, removable dentures can be placed over the implants.
Successful surgical enucleation of the dentigerous cyst
Under general anesthesia, a right inframammary incision was first made. This was followed by dissection down to the ribs following which 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.
Following this, a crevicular incision was made in the mandible and a mucoperiosteal flap was elevated. The right lower first and second molars were then extracted as they contacted the cystic cavity. A transalveolar extraction of the impacted third molar was then performed followed by total cyst enucleation.
This was followed by electrocauterisation of the cystic cavity along with antibiotic flushing. The resultant bony defect was packed with rib graft. Hemostasis was check followed by closure of the incision with sutures. There was satisfactory control of postoperative bleeding at the surgical site.
Complete patient satisfaction at the surgical result
The patient expressed complete satisfaction at the surgical results. There was no external scar as all incisions were intraoral. It was explained that dental implant surgery done after consolidation of bone would result in total rehabilitation.
[vc_section content_layout=”full” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_row content_layout=”boxed” equal_height=”” animation_delay=”” disable=”” id=”” class=”” bg_type=”image” bg_image=”” color_overlay=”” enable_parallax=”” enable_pattern=””][vc_column layout=”normal” vertical_align=”top” animation_delay=””][vu_heading style=”2″ heading=”Jaw reconstruction surgery down the ages” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]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.[/vc_column_text][vu_heading style=”2″ heading=”Initial steps towards formulating a protocol for jaw reconstruction” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]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.[/vc_column_text][vu_heading style=”2″ heading=”Development of jaw reconstruction surgery” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]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.[/vc_column_text][vu_heading style=”2″ heading=”Patient with pain and swelling in her jaws presents to a local dentist” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]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.[/vc_column_text][vu_heading style=”2″ heading=”Two failed cyst enucleation surgeries in her hometown” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]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.[/vc_column_text][vu_heading style=”2″ heading=”Referral to our hospital for single sitting enucleation and jaw reconstruction surgery” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]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.[/vc_column_text][vu_heading style=”2″ heading=”Diagnosis and treatment planning presented to the patient” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]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.[/vc_column_text][vu_heading style=”2″ heading=”Cyst removal followed by jaw reconstruction surgery” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]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.[/vc_column_text][vu_heading style=”2″ heading=”Dental implant surgery to complete full oral rehabilitation” subheading=”” alignment=”left” custom_colors=”” class=””][vc_column_text]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.[/vc_column_text][vu_heading style=”2″ heading=”Surgery Video” subheading=”” alignment=”left” custom_colors=”” class=””][vc_video link=”https://www.youtube.com/embed/vGgx10VUqEA”][/vc_column][/vc_row][/vc_section]
