Long Lower Jaw BSSO – Bilateral Sagittal Split Osteotomy with Set Back Surgery

Long Lower Jaw BSSO – Bilateral Sagittal Split Osteotomy with Set Back Surgery

Etiology behind the occurrence of mandibular prognathism

Mandibular prognathism is the excessive protrusion of the mandible in relation to the rest of the skull. It is considered to be a pathological condition when it compromises both the functional and esthetic aspects of the lower jaw. An extended chin and an anterior crossbite renders both eating and speech difficult for the patient.

There can be a genetic element to the occurrence of mandibular prognathism. The house of Hapsburg, which was the royal lineage of Austria had an extreme manifestation of mandibular prognathism because of severe inbreeding that was done to maintain the royal bloodline. There were certain members of the family whose mandibular prognathism was so severe that it made it impossible for them to eat a normal diet.

The functional problems caused by mandibular prognathism can lead to severe limitations in jaw function. Corrective jaw surgery is performed to set right the functional problems. This is also a cosmetic surgery as it leads to an improvement in facial esthetics for the patient. The open bite and the cross bite are also corrected by this surgery.

Bilateral sagittal split osteotomy, which is the surgery performed for correction of mandibular prognathism is performed by oral and maxillofacial surgeons. Other surgical procedures performed by them include TMJ surgery.

Problems arising from a long lower jaw

The patient is a 25-year-old female from Indore in Madhya Pradesh, India who had always had a long lower jaw in relation to her upper jaw. She also had a degree of facial asymmetry arising from this condition. There were also issues with difficulty with speech and eating. She was also unable to close her lips fully. This was resulting in dry chapped lips. Her parents had decided to seek medical attention to correct this problem. They had approached a local orthopedic surgeon who had examined the patient. He explained to the patient and her parents that she needed to be operated on by an Oral and Maxillofacial Surgeon. He had referred them to our hospital as we are one of the premier centers for jaw reduction surgery in India.

Our hospital addresses every cosmetic surgical need that arises from the facial region including rhinoplasty surgery, microtia surgery, ptosis surgery, facial reanimation surgery, facial reconstruction surgery and all varieties of jaw surgeries including cyst removal surgery, TMJ joint surgery, and jaw reconstruction surgery.

Incidence rates of facial asymmetry in the general population

Among the overall population, facial asymmetry can either be noted clinically or subclinically. It not only causes esthetic compromise, but also affects functionality. Facial asymmetry can due to many etiological factors. These can broadly be divided into congenital or acquired. The treatment plan for facial asymmetry depends on age, severity and etiology. Treatment planning is arrived at by carefully assessing the results of the intraoral, extraoral and radiological examinations.

Initial presentation and treatment planning at our hospital

Dr SM Balaji, jaw reconstruction surgeon, examined the patient thoroughly and ordered radiological studies. The patient had an anterior crossbite with class III malocclusion. Various model studies were performed following which Dr SM Balaji advised them that she best undergo lower jaw reduction followed by fixed orthodontic therapy for management of her malocclusion. The patient and her parents were in agreement with the treatment plan and signed the consent form.

 Successful surgical reduction of her increased mandibular length

Under general anesthesia, incisions were placed in the mandibular retromolar regions bilaterally following which flaps were elevated. This was followed by bone cuts being made and bilateral sagittal split osteotomy performed. Extreme care was taken at this stage to ensure that there was no iatrogenic damage to the inferior alveolar nerve. It was mobilized with the distal segment so that the proximal segment could be adequately mobilized for the bilateral sagittal split osteotomy. The mandible was then pushed backward, checked for occlusion and fixed using Titanium plates and screws. This was followed by closure using resorbable sutures.

Total patient satisfaction at the results of the surgery

The patient was very happy with the outcome of the surgery. Her occlusion was completely normal and her maxillary teeth and mandibular teeth were in good alignment with a normal occlusion. Her facial profile was also corrected. She will still need to undergo fixed orthodontic treatment to correct the individual malalignment in each tooth. The patient was advised to return for this in a few months.

Surgery Video


Corrective surgery for protruding upper jaw

Corrective surgery for protruding upper jaw

A 25-year-old girl from Mumbai reported to our hospital with complaints of forwardly placed upper and lower jaw. The patient also complained about her gummy smile. She had difficulty in closing her mouth and was very self-conscious of her looks.

Radiographic analysis of the facial bones showed that she had a prognathic maxilla and mandible. Maxillofacial surgeon Dr. S.M. Balaji planned to perform Lefort I osteotomy followed by subapical osteotomy. The excess bone from the upper jaw was removed & the jaw was set backwards and upwards in proper alignment with the lower jaw. The anterior portion of the lower jaw was setback using Kole’s technique. The results were spontaneous and she was overjoyed with her new look.


Profile enhancement by correction of upper jaw using AMO

Profile enhancement by correction of upper jaw using AMO

A 25-year-old male from Raipur reported to our hospital wanting to correct his gummy smile. He also stated that his protruding upper jaw affected his appearance. He had low self-esteem and complained of inability to close his mouth. He also wanted to enhance his looks. His parents too were anxious to correct his smile and enhance his facial appearance.

Maxillofacial Surgeon Dr. SM. Balaji planned for removal of the maxillary bone. The gummy smile was corrected by Anterior Maxillary Osteotomy. Post surgery his appearance improved greatly and his parents were happy with the immediate results. He was overjoyed with the outcome as he was able to close his mouth without any difficulty.


Unilateral Cleft Maxillary (Upper jaw) advancement. LeFort I Osteotomy with Dental Implant Surgery

Unilateral Cleft Maxillary (Upper jaw) advancement. LeFort I Osteotomy with Dental Implant Surgery

The patient is a young woman who had been born with a unilateral right sided cleft lip and palate. She had undergone cleft lip repair as a 2-month infant at Balaji Dental and Craniofacial Hospital. Second surgery was for repair of cleft palate. Stage 3 surgery involved the placement of a bone graft for closure of her alveolar bone cleft. The patient now presents for a LeFort I osteotomy for advancement of her retruded maxilla and for placement of implants for replacement of her missing maxillary teeth. An implant was first placed for replacement of her right maxillary canine. This was then followed by placement of an implant for replacement of her missing first molar.

Attention was next turned towards the LeFort I osteotomy of her maxilla. A gingival mucoperiosteal flap was first raised up to the buccal sulcus. A LeFort I osteotomy was then performed. The entire maxilla was then advanced by 2-3 mm. This resulted in establishment of a Class I occlusion along with correction of her anterior crossbite. The maxillary segment was then stabilized in position with the use of three plates with four screws to each plate. This would aid in stability of her plates during the healing period. Her occlusion was then checked and the teeth were found to be in perfect alignment. The flap was then sutured in place. She recovered well from general anesthesia and was in stable condition.

The patient was very happy with the results of the surgery and expressed the same to Dr SM Balaji.
Surgery Video


Fibrous dysplasia reduction Osteotomy

Fibrous dysplasia reduction Osteotomy

This lady had been aware for some time now that the left side of her lower jaw was slowly, but surely increasing in size. Since the lesion was painless, she had ignored it for a while. Her family decided that she needed medical intervention and took her to a dentist in their hometown. She was referred by that dentist to Balaji Dental and Craniofacial Hospital, Teynampet, Chennai, for management of her problem.

Dr. S. M. Balaji, Maxillo-Craniofacial Surgeon, examined the patient and ordered a 3D axial CT scan, which revealed a dense overgrowth in the region, which is characteristic of fibrous dysplasia. This is a disorder of the bone where normal bone is replaced by a scar-like fibrous tissue that leads to weakening of the bone structure. Dr. Balaji explained to the patient and her family that a reduction osteotomy was necessary to restore symmetry to the patient’s face. They were in agreement with this and she was scheduled for surgery.

Under satisfactory general anesthesia, a mucogingival flap was raised distal to the left lower canine and extended to the vestibule to expose the entire fibrous dysplasia lesion. The fibrous bone was then trimmed with high speed drills until perfect facial asymmetry was reestablished. Care was taken to ensure that the mental nerve was protected throughout the surgery. The flaps were then closed with sutures and the patient recovered uneventfully from general anesthesia.

The patient expressed her deep gratitude to Dr. Balaji for restoring symmetry back to her face before being discharged from the hospital.