Dental caries result from the demineralization of teeth structure by acids that are formed through the degradation of food in the mouth. This leads to the breakdown of the hard structure of the tooth ultimately leading to the loss of the tooth. Teeth are attached to the bony socket with the aid of periodontal ligaments. Periodontal disease or gum disease leads to the loss of periodontal ligaments and supporting bone. This leads to the tooth becoming mobile due to loss of bony support. This also ultimately leads to the tooth falling out.
Neglect of a carious tooth with consequent abscess formation
Dental caries is treated through restorations. When dental caries perforates into the pulp chamber within the tooth, it leads to infection of the pulp tissue. When this is not treated appropriately with root canal treatment, it will ultimately lead to necrosis of the pulp and abscess formation. When a tooth abscess is not attended to and becomes a chronic problem, it will ultimately lead to a sinus tract formation to enable pus drainage.
Chronic draining sinus on the left cheek
The patient had a carious left lower first molar filled a few years ago. Filling was improperly done with progression of the caries deeper into the tooth structure. The caries ultimately reached the pulp chamber leading to infection of the pulp. An abscess soon developed in relation to that tooth. The patient neglected the tooth for a long time. Symptomatic relief through the use of antibiotics and pain killers ensured that he never underwent any proper treatment.
The pain and swelling kept recurring on and off in relation to the lower-left permanent first molar. A draining sinus to his left cheek with granulomatous tissue soon formed at the site with chronic pus drainage. He presented to our hospital for surgical excision of the sinus through the utilization of facial cosmetic surgery techniques. This would ensure that no unsightly scar tissue would be left behind at the site of the sinus opening. Results for facial cosmetic surgery in India are on par with the best in the world. A facial cosmetic surgeon in India undergoes years of rigorous training.
Initial examination of the patient at our hospital
Dr SM Balaji, facial cosmetic surgeon, is vastly experienced in cosmetic surgeries. He examined the patient and ordered a 3D CT scan of the left jaw. It revealed a sinus tracking from the distal root of the left lower first molar and opening onto the left cheek. He explained the surgical procedure to the patient who consented to surgery. He said surgical removal of the sinus was very important as it can lead to the formation of unsightly hypertrophic scars if not excised. Plastic surgery with the utilization of skin flaps would be required for the excision of such scar tissues.
Categorization of scar tissue for scar revision surgery
Different types of scars require different types of scar revision. One such cosmetic procedure would be tissue expansion. Tissue expansion is most commonly utilized for breast augmentation. Excision of extensive scar tissue requires reconstructive surgery by a plastic surgeon. These surgery procedures come under the category of facial plastic surgery. Each layer of skin is carefully sutured to avoid unsightly scar formation. This is the principle behind face lifts. The ideal approach would be to avoid extensive scar tissue formation by meticulously closing the wound through layered suturing using resorbable sutures for the deeper layers and nonresorbable suture material for closure of the skin.
Surgical excision of draining sinus tract
Under general anesthesia, a mucogingivoperiosteal incision was first made mesial to the molar. This would help expose the site of abscess formation at the distal root of the molar tooth. A flap was next raised to expose the sinus tract. The tooth was then extracted. All granulation tissue at the apical region was debrided thoroughly. This was followed by tunneling an artery forceps through the sinus tract until it reached the facial surface. Care was then taken to fully excise the sinus tract and the incisions were sutured. Adoption of facial cosmetic surgery techniques resulted in no scar formation for the patient. The patient tolerated the procedure well and recovered well from general anesthesia.
Postoperative instructions were given to the patient. The patient was instructed to keep the area clean and dry and to not pull at the scab formed at the area. It was explained that this was necessary to avoid any scar formation at the site of the sinus opening on the left cheek.
The patient presented a few weeks after surgery for a checkup. There was no visible scar formation from the surgery. This ensured that there would be no necessity for scar revision surgery in the future.
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.
This young man is from Chennai, Tamil Nadu. He had a bike accident a week ago. Direct impact to his mandible resulted in a fracture of the mandible. He sustained facial injury as a result of this accident. This resulted in inability to close his mouth with an open bite. There were no soft tissues injuries from this accident. The patient never lost consciousness. He remained lucid during the immediate period after the fracture. Examination by a neurologist revealed no signs of head injury in the patient.
The neurologist explained to the family that the helmet had saved the patient’s life. He explained through charts how the injuries would have been very severe if the patient had not been wearing his helmet.
Presentation at our hospital for management of fracture
His family wanted the best treatment for his jaw fracture. They made enquiries about the best jaw fracture surgeon in India. He was then brought to our Balaji Dental and Craniofacial Hospital for treatment. Our hospital is a premier hospital for jaw fracture surgery in India. Success rate of surgery for mandibular fractures at our center is amongst the best in India. Our hospital is a specialty maxillofacial surgery center. We deal with cases of maxillofacial trauma on a daily basis. Our center is a top referral center among city plastic surgeons.
Special training through workshops are a regular feature at our hospital. Many oral and maxillofacial surgeons undergo this training. Fractures of the bones of the face are a common feature at these workshops. Injuries to the face are a common occurrence in the city. Treating these injuries needs the utmost care.
Treatment plan presented and consent obtained from patient
Dr SM Balaji, facial trauma surgeon in India, examined the patient. He obtained imaging studies for the patient. There was no fracture involvement of the eye sockets. There was no involvement of other facial bones or soft tissue. Any dental implants along the fracture line would need removal if present. Fracture was only at the left mandible. This came under the classification of facial fractures. There had been no facial lacerations from the accident. Location of the fracture determined his treatment plan.
Rigid fixation was essential for fracture stability. Fracture treatment would be through open reduction and internal fixation. This decision was based upon his experience with jaw fractures correction. The patient consented to the treatment plan. All appropriate consents were next signed by the patient and surgery scheduled.
Open reduction versus closed reduction
Open reduction and closed reduction are two ways of setting a fractured bone. The fractured segments of the bone stay reduced when it is a favorable fracture. The anatomy of the fracture ensures this. Certain fractures can be reduced without any skin incisions. These stay in place without displacement with plaster casts alone. This is a closed reduction. The break has to be clean without comminution of the fracture.
Fractures that do not stay reduced need open reduction and internal fixation. An incision is first made to gain access to the fracture site. Titanium plates and screws are then used to fix the fragments of bone to each other. This results in stabilization of the fracture. Incisions used to access the fracture are then closed with sutures. This is then followed by a period of immobilization for consolidation of bone. A closed reduction is possible only in a favorable fracture. All other fractures need open reduction and internal fixation.
Fractures of the mandible can be favorable or unfavorable fractures. Favorable mandibular fractures stay stabilized with closed reduction and intermaxillary wiring. Care should be taken to maintain proper occlusion of the teeth. These fractures heal without any further intervention.
Unfavorable mandibular fractures can comprise of several fracture segments. These do not stay stabilized with closed reduction. They need correction through stabilization with titanium plates and screws. An incision is first made to access the fracture site. The fracture fragments are then brought together into proper anatomical alignment. Titanium plates and screws are then used to stabilize the fracture. Occlusal harmony of the teeth should be ensured before final closure. The patient needs to return for periodic checks for a prescribed period of time. Full bone consolidation at the fracture site ensures complete healing of the fracture. The number of plates used for fracture reduction would increase with fracture severity.
Successful open reduction and internal fixation of the fracture
Under general anesthesia, a left vestibular incision in the mandible exposed the fracture. The fracture segments were then brought into correct alignment and occlusion checked. The fracture was then stabilized with plates and screws. Incisions were then repaired by suturing.
The patient expressed his satisfaction at the results of the surgery before discharge. He was able bring his teeth together. The open bite had undergone complete resolution. Facial esthetics was also perfect and there was no residual asymmetry.
Patient born with craniofacial deformities and cleft lip and palate
This young man is from Ambala, Punjab. He had been born with marked craniofacial deformities and a cleft lip and palate. Cleft lip and palate repair performed as an infant were satisfactory. His marked nasal deformity had resulted in hypertelorism. There was also soft tissue scarring. His parents’ search for the best craniofacial surgeon for hypertelorism in India had led them to our hospital. Our hospital is well known for hypertelorism surgery in India. Orbital hypertelorism surgeries are a division of facial reconstructive surgery. We are one of the best for facial reconstructive surgery in India. These surgeries are also performed by plastic surgeons in EU nations.
Treatment plan explained to the patient and his parents in detail
Dr SM Balaji, Craniofacial deformity surgery specialist, examined the patient. The neurosurgical team assisted throughout this process. A 3D stereolithographic model was first obtained of the patient’s skull. A detailed study was then conducted followed by a mock box osteotomy procedure. Once the treatment plan decision had been made, this was then explained to the patient. The patient and his parents consented to surgery.
The patient undergoes box osteotomy procedure for hypertelorism correction
Under general anesthesia, a lumbar puncture was first performed and CSF drain placed. This was to ensure adequate control of intracranial pressure. A bicoronal flap was then raised. Following this, a craniotomy was then performed 2 cm above the supraciliary arches. The posterior cut was anterior to the coronal sutures. The squamous part of the frontal bone then removed and preserved for later placement. The frontal lobe of the brain was then exposed and around 60 mL of CSF drained. This was to decompress the brain for better surgical access. This aided in retraction of the frontal bone from the floor of the anterior cranial fossa.
An osteotomy was then done parallel to the craniotomy cut to create the frontal bar. Temporalis muscle retraction aided in visualization of the inferior orbital fissure. This was then followed by bilateral osteotomies of the zygomatic arches. A transverse osteotomy was then done across the roof of the orbit. Final maxillary Le Fort I osteotomy through intraoral incisions resulted in complete disengagement of the midface. Bone was then removed from the lateral and medial regions of the orbit. Careful positioning of the bone resulted in correction of the hypertelorism. The repositioned bone segments were then stabilized with plates to the frontal bar. Intraoral incision was also closed with sutures.
Treatment plan for closure of frontonasal encephalocele discovered during surgery
A frontonasal encephalocele had been discovered during this stage of the surgery. There was congenital absence of duramater in this region. This could result in herniation of brain tissue at a later date. The neurosurgical team advised closure of this cavity with fat graft.
Fat graft and fibrin glue utilized for closure of frontonasal encephalocele
A fat graft was thus obtained from the patient for this purpose. This incision was then closed with staples. A layer of fat graft was first laid over the opening. The fat graft was next covered with fibrin glue followed by another layer of fat graft. This resulted in complete closure of the defect in the bone. The bony segments of the skull were then placed back into correct position. These segments were then fixed in position with four holed plates. The bicoronal flap was then stapled back into position.
Successful completion of the first stage of the patient’s rehabilitation
This completed the first stage of the patient’s surgical correction. The second stage would involve correction of the nasal deformity. The patient recovered well from surgery and was then discharged home.
Road traffic accident leaves patient with a sunken left eye
This young woman is from Tirupur, Tamil Nadu. A road traffic accident resulted in injury around the left eye. This had resulted in a blowout fracture of the left eye. Surgery elsewhere resulted in a sunken left eye and residual ptosis. This was the result of fat herniation into a medial orbital wall fracture. A local oral surgeon referred her to our hospital for surgical correction.
Treatment planning explained to patient and consent obtained
Dr SM Balaji, facial deformity correction specialist, examined the patient. He explained that the sunken eye was due to herniated fat. The patient also needed ptosis correction. He explained that levator palpabrae superioris muscle needed corrective surgery. The patient consented to surgery.
Osteomesh utilized for correction of fat herniation into medial wall fracture
After general anesthesia, the medial wall of orbit fracture was first accessed. Herniated fat was then released from the fracture site. An Osteopor-Osteomesh was then inserted to cover the fracture site. This would form a permanent film over the fracture site. Fat herniation would thus not recur at the fracture site. Fine ophthalmic sutures were then used to close the incision.
Ptosis surgery done with full correction of deformity
The levator palpabrae superioris was next addressed. An incision was first made at the old scar site. The muscle was then accessed and a suture used to attach it to the orbicularis oculi. This incision was also closed with fine sutures.
The patient’s eye function was then tested after recovery from general anesthesia. The patient had symmetrical eyes with correction of the left eye ptosis. The patient expressed her satisfaction before discharge from the hospital.
Patient suffers a comminuted frontal bone fracture from trauma
The patient suffered a trauma to the right supraorbital region. This resulted in a comminuted fracture of the supraorbital region with involvement of the rim. He presented to our hospital for definitive management of his fracture.
Examination of the patient with treatment plan presentation
Dr SM Balaji, facial trauma care specialist, examined the patient and ordered a 3D CT scan of the region. This demonstrated a comminuted supraorbital fracture of the frontal bone. The treatment plan was then explained to the patient who consented to surgery.
Surgical correction of comminuted frontal bone fracture with four hole plates
Under general anesthesia, the fracture was first approached through a supratarsal fold incision. The supraorbital rim fracture segments were then elevated and stabilized. Two Titanium four hole plates and screws were then used to fix the rim fracture. Another incision was then made superior to the left eyebrow. The supraorbital fracture segments were then elevated and stabilized. Another four hole plate was then utilized to fix the supraorbital fracture segments. Both incisions were then closed with sutures. Care was taken to protect the supraorbital nerve throughout the surgery.
Successful rehabilitation of the patient after comminuted frontal bone fracture
There was no residual deformity of the region after surgery. The patient expressed total satisfaction at the results of the surgery before discharge.