Maxillofacial Surgery

This is a surgery of either/ both of our jaws or chin involving their repositioning into a more aesthetic and functionally pleasing and harmonious spatial relation with the rest of the face. It not only helps in improving the facial profile and cosmetics but leads to a better functional relation of the jaws often relieveing jaw joint pains and improvement of chewing efficiency. At our centre, we utilise the technology of peizoelectricty to cut bone as it is least harmful to native bone and causes no harm to adjacent nerves, blood vessels and other soft tissues.

Most common reasons for getting orthognathic surgery:

• Protrusive lower jaw
• Receeded (backward) chin
• Gummy smile
• Long face
• Protrusive upper jaw
• Asymmetrical face
• Post-traumatic deformity
• Cleft mid-facial hypoplasia

Planning for the Surgery :

• If you feel you are a candidate of corrective jaw surgery or want to find out how to improve your facial profile, the first step is to book your consultation with your facio-maxillary surgeon
• When you visit the clinic, a physical examination of your face is done and your functional and esthetic needs are understood
• The alignment of your teeth is examined
• A basic Xray is done, in some cases a CT scan may be asked for
• Once the initial assessment is done, Computer software is used to plan the amount of change in position needed in the jaw in question and the best new position decided
• The case planning is done with a team of experts involving your jaw surgeon, an orthodontist, a dentist and the anaesthetist
• The computer planning is shown to you before finalising for surgery
• A basic check up is done to assess fitness for surgery including a basic blood work up
• Only those cases are taken for surgery where the planning shows achievable results with anticipated benefit in function of the patient , provided he is cleared by the anaesthesia team for surgery
• For all jaw surgery cases, orthodontic treatment is a must. For some cases it is started before the surgery, for some it is done after the surgery
• The overall time frame for orthodontic treatment lasts 6 months- 18 months.

About the Surgery :

• It is performed from within the mouth and is completely scar-less
• It is usually performed under anaesthesia
• Most cases are done as day-care procedure
• The surgery usually lasts 2-3 hours
• To keep the new position of the jaw/chin in place, fixation is done with bio-inert, sterile titanium plates
• These plates are extremely fine and thin and cannot be felt or seen from the outside
• Being bio-inert they can be left as such for lifetime, unless in rare scenarios they get infected
• Once the neo-jaw position is established, wounds are closed using resorbable(dissolving) stitches

About the recovery period:

• You can start basic diet after 4 hours from being shifted out of OT
• However, you are advised semi-solid-liquid diet for uptil 4 weeks from procedure
• You may start walking and taking care of your own daily needs right from next day of surgery
• However, physical exercise, cardio workouts etc are allowed only after few (~6)weeks after your doctor gives you the appropriate fitness
• Leave period from office is usually 2 days, can go upto a week
• Results can be seen roughly immediately, however final result takes about a month to set in
• Pain and discomfort are adequately managed with appropriate pain killers and antibiotics
• Swelling usually subsides completely in 4 weeks, although it starts to subside from week 2

Common side-effects:

• Temporary numbness of lower lip, upper lip, cheek
• Temporary swelling of the involved part of the face
• Temporary decrease in chewing efficiency
• Temporarily reduced mouth opening
• Wound infection

Untoward side effects seen due to unskilled practice:

• Incorrect positioning/ relapse
• Permanent nerve damage
• Wrong alignment of teeth
• Jaw joint pain
• Tooth loss

2. FACIAL NARROWING/ RESHAPING SURGERY

This is the surgery involving reshaping of the face to give it a narrower, longer and more feminine look. It is a minimally invasive procedure in which your bone is shaved/scrapped off to get the desired results. It does not involve separation of the jaw or placing any titanium plates.

Most common reasons for getting Facial Narrowing:

• Prominent jaw angles
• Softening of angular chin
• Improving square chin shape
• Correcting asymmetry of the face
• Projecting jawline

Planning for the Surgery :

• If you feel you are a candidate of Facial narrowing/ reshaping surgery or want to find out how to improve your facial profile, the first step is to book your consultation with your facio-maxillary surgeon
• When you visit the clinic, a physical examination of your face is done and your functional and esthetic needs are understood
• The alignment of your teeth is examined
• A basic Xray is done, in some cases a CT scan may be asked for
• Once the initial assessment is done, Computer software is used to plan the amount of reshaping or shaving to be done
• The case planning is done with a team of experts involving your jaw surgeon and the anaesthetist
• The computer planning is shown to you before finalising for surgery
• Your expectation is best understood when the planning is done digitally
• A basic check up is done to assess fitness for surgery including a basic blood work up

About the Surgery :

• It is performed from within the mouth and is completely scar-less
• It is usually performed under anaesthesia
• Most cases are done as day-care procedure
• The surgery usually lasts 1-2 hours
• Wounds are closed using resorbable(dissolving) stitches

About the recovery period:

• You can start basic diet after 4 hours from being shifted out of OT
• However, you are advised semi-solid-liquid diet for uptil a week from procedure
• You may start walking and taking care of your own daily needs right from next day of surgery
• However, physical exercise, cardio workouts etc are allowed only after ~10 days after your doctor gives you the appropriate fitness
• Leave period from office is usually 2 days, can go upto a week
• Results can be seen roughly immediately, however final result takes about a month to set in
• Pain and discomfort are adequately managed with appropriate pain killers and antibiotics
• Swelling usually subsides completely in 3 weeks, although it starts to subside from week 1

Common side-effects:

• Temporary numbness of lower lip, upper lip, cheek
• Temporary swelling of the involved part of the face
• Temporary decrease in chewing efficiency
• Temporarily reduced mouth opening
• Wound infection
• Skin bruising

Untoward side effects seen due to unskilled practice:

• Incorrect shaving, excessive removal
• Asymmetrical correction
• Permanent nerve damage
• Sagging skin

3. CLEFT LIP AND PALATE SURGERY

Cleft lip and Palate is a congenital condition in which the patient is born with a cut/separation in the upper lip and the palate inside the mouth. The surgery of this condition is done in infancy (within a year) in ideal scenarios, although it can be done anytime after detection provided other patient related factors are in control. Apart from the lip and palate surgery, the patient needs multiple other surgeries to function, look and feel optimally.

COMMON PROCEDURES IN CLEFT LIP & PALATE PATIENTS:

1. Cheiloplasty and Palatoplasty (Lip and Palate Repair)
2. Surgery for Speech
3. Alveolar Bone Grafting
4. Secondary lip revision
5. Cleft maxillary hypoplasia (Retrognathic upper jaw )
6. Rhinoplasty

1. Cheiloplasty and Palatoplasty (Lip and Palate Repair)
   Cleft lip repair is usually done at 3 months of age if the baby is deemed healthy by the doctor. This surgery restores the baby’s ability to take mother’s feed and suckle milk from the breast. It also restores the facial aesthetics of the baby by joining the gap of the upper lip. Palatoplasty which is done around 9-12 months of age, is very crucial for the proper functioning of the oral cavity of the baby. It seals the mouth from the nose and hence stops the milk and other foods from entering the nasal cavity. It also helps normalising the swallowing process of the baby. Another crucial function it achieves is for speech development in the baby.
2. Surgery for Speech
   Patients born with cleft palate often have speech difficulties like hypernasal tone, difficult articulation etc. This is due to the malpositioned muscles of the palate which are very important for speech (they seal of oral cavity from nasal cavity). There are various surgical procedures that improves the speech of these patients. The best one is decided by the qualified cleft surgeon. These surgeries entail repositioning of these palatal muscles or aiding in the mechanism of oro-nasal closure.
   Even the best surgery for speech relies on regular speech therapy of the patient. We have at our centre, the best speech therapists of the city.
3. Alveolar Bone Grafting
   In cleft patients, the gap/separation often extends to the tooth bearing area of the upper jaw causing a discontinuity of the same. This cleft of the alveolus prevents normal eruption of the front teeth. Since these teeth are very important for functioning of the mouth and also for facial aesthetics, the cleft alveolus surgery becomes an important step in achieving the overall functional goal in a patient born with cleft lip and palate. In this surgery, bone is filled in the gap of the alveolus to achieve jaw continuity.
4. Secondary lip revision
   Often an ill-corrected cleft lip in childhood leaves the patient dissatisfied when they become more aware of their facial aesthetic needs. These situations also reveal an inadequate form achieved of the lip. Revision or redo surgeries can be done at any time the patient desires and can restore the look, feel and function of the upper lip.
5. Cleft maxillary hypoplasia (Retrognathic upper jaw )
   The upper jaw in patients of cleft lip and palate (operated or unoperated) in backwardly placed (retrognathic) due to multiple reasons. This gives a dish-shaped/ concave appearance to the face. This gives a more aged look to the face and it is also very tell-tale of the presence of cleft condition in childhood. At the right age, we provide multiple solutions to this condition. The upper jaw is advanced forward in multiple ways, which is decided by your cleft surgeon. Dr.Shreya is specially trained in ‘Anterior Maxillary Distraction’ for a cleft upper jaw(maxilla) which is one of the best known ways of bringing the upper jaw forward into the best position. The planning for these surgeries is done digitally (on computer software) so that exact measurements are made before surgery and the final position can be envisioned before-hand.
6. Cleft Rhinoplasty
   Cleft lip causes distortion of the shape of the nose as well. There is bending of the septum, ill defined nasal lip, depressed nasal cartilages and asymmetry of the normal side vs cleft side of nose. This can be corrected by a certified cleft surgeon

4. FACIAL TRAUMA MANAGEMENT

Road traffic accidents and inter-personal violence are two of the main causes of facial trauma. Trauma to the face can lead to fractures of upper jaw (maxilla), lower jaw(mandible), jaw joint (condyle & TMJ), middle of the face (Zygomatic complex fractures), orbits and forehead (frontal bone fractures). This can lead to malocclusion (malalignment of teeth) leading to inability to chew and eat, pain and discomfort, disfigurement of face, inability to open the mouth, numbness of various parts of face, sinking in of the eye, blurring of vision etc.

Timely treatment by an expert is quintessential as delays can cause malunion or nonunion of the fracture and treatment from inexperienced surgeon can lead to loss of function of jaws and jaw joint pains.

A. Primary Fracture fixation with Plating or IMF

It is best to treat the fracture right after it has been detected after stabilising the general condition of the patient. If there are other life threatening injuries sustained they are addressed before facial fracture treatment. Once other injuries are ruled out, facial fracture treatment should be instated so that the patient can return to normal eating, chewing , talking again.

In our practice, we ensure the following things when treating facial fracture patients :

• Prompt treatment
• Earliest return to function- talking and eating
• Scarless procedures
• Use of international grade plates and screws that are bio-inert, thin and strong. These can’t be felt from outside and can be left untouched
• Restoring shape of face to pre-trauma times

About the recovery period:

• The cases are done under general anaesthesia
• Most surgeries last 2-4 hours, but it is dependant on extent of fracture and location
• We might place elastics binding your upper and lower teeth for a few weeks period depending on the requirement
• After plating, liquid and semi-solid diet can be resumed almost immediately
• Patients are usually discharged a day after surgery

Complications:

• Failure of hardware
• Numbness of nerves temporarily
• Temporary pain and swelling

Untoward side effects seen due to unskilled practice:

• Screw insertion into a tooth root
• Inadvertent tooth avulsion
• Nerve damage
• Malocclusion
• Mobile bone segments

B. Secondary deformity Correction

We often see patients who have not gotten their facial fractures treated at the first stage (within 2 weeks). This is usually due to lack of diagnosis or neglect. This causes the fractured bones to either not heal (non-union) or heal in the wrong position (mal-union). This leaves them with misaligned jaws, hindering mastication and speech. It also causes disfigurement and jaw joint pains. 

At our centre, these patients too can be treated even if at a later stage. Secondary correction is done to restore the function of the jaws due to malunion of the fractures, achieve good intercuspation of teeth so that the patient is able to chew and eat like before. It is also done to achieve the shape of the face to its pre-trauma form.

Most common reasons for getting secondary deformity correction after trauma:

• Misalignment of teeth (malocclusion)
• Difficulty in eating and chewing
• Asymmetrical face
• Sunken eye
• Blurry vision
• Scar on the face

Planning for the Surgery:

• When you visit the clinic, your Xrays from the time of accident will be examined
• Fresh Xrays will be advised to assess the current positioning of the jaw bones
• Your primary complaints will be understood and discussed
• If the fracture occurred within a span of 6 weeks, the advised treatment plan would be removal of the tissues formed at fracture edges and plating in desired position
• If more than 6 weeks have elapsed from the time of accident, corrective jaw surgery is usually advised
• This involves taking impressions of the teeth (by laser scanning or conventional means)
• Thereafter, a CT scan may be advised
• Digital and virtual surgical planning is then done to assess the amount of repositioning of jaws needed
• The same is communicated with the patient
• Possibility of orthodontic treatment is also discussed

About the Surgery :

• It is performed from within the mouth and is completely scar-less
• It is usually performed under anaesthesia
• The surgery usually lasts 2-3 hours
• To keep the new position of the jaw/chin in place, fixation is done with bio-inert, sterile titanium plates
• These plates are extremely fine and thin and cannot be felt or seen from the outside
• Being bio-inert they can be left as such for lifetime, unless in rare scenarios they get infected
• Once the neo-jaw position is established, wounds are closed using resorbable(dissolving) stitches

About the recovery period:

• You can start basic diet after 4 hours from being shifted out of OT
• However, you are advised semi-solid-liquid diet for uptil 4 weeks from procedure
• In some cases, elastics may have to be placed between the upper and lower teeth for muscle re-engineering
• You may start walking and taking care of your own daily needs right from next day of surgery
• However, physical exercise, cardio workouts etc are allowed only after few (~6)weeks after your doctor gives you the appropriate fitness
• Leave period from office is usually 2 days, can go upto a week
• Results can be seen roughly immediately, however final result takes about a month to set in
• Pain and discomfort are adequately managed with appropriate pain killers and antibiotics
• Swelling usually subsides completely in 4 weeks, although it starts to subside from week 2

Common side-effects:

• Temporary numbness of lower lip, upper lip, cheek
• Temporary swelling of the involved part of the face
• Temporary decrease in chewing efficiency
• Temporarily reduced mouth opening
• Wound infection
• Mild occlusal discrepancy

Untoward side effects seen due to unskilled practice:

• Incorrect positioning/ relapse
• Permanent nerve damage
• Wrong alignment of teeth
• Jaw joint pain
• Tooth loss

C. Scarless Orbit fracture treatment:

Fractures of the orbit can occur due to road traffic accidents, sports injuries or assault. They lead to sunken eye (enopthalmos), blurry vision, lowered orbital level etc. Orbital fractures are best diagnosed by doing a CT scan of the orbit. Once it is deciphered which wall of the orbit has been affected, the appropriate surgery can be done.

About the surgery:

• Orbit fracture treatment usually requires reconstruction of the orbital wall involved so that the structure of the orbit is re-established on which the eye-ball rests
• If this is not done, the eye-ball may be left in a lowered position or too sunken in
• Orbital wall reconstruction at our centre is done using the transconjunctival approach which leaves no scar on the face
• The materials used for the reconstruction are such that they no cause no adverse reaction to the eye-ball and at the same time provide adequate support to the fractured areas
• We offer computer guided surgical planning for the patient as well in which we use software to assess the extent of damage to the orbit and the amount of correction required.
• Further, we utilise 3-D printing technology to fabricate the reconstruction material which is identical to the normal side orbit so that bilateral symmetry of orbits is achieved
• This surgery is always planned with an orbital surgery board consisting of your maxillofacial surgeon, oculoplastic surgeon and anaesthesiologist

About the recovery period:

• It is a 4hr surgery on an average
• It is done under general anaesthesia
• You are admitted to the hospital for an average of 2-3 days
• You can start basic diet after 4 hours from being shifted out of OT
• An eye-dressing is placed for initial few days
• You may start walking and taking care of your own daily needs right from next day of surgery
• However, physical exercise, cardio workouts etc are allowed only after few (~6) weeks after your doctor gives you the appropriate fitness
• Leave period from office is usually a week
• Pain and discomfort are adequately managed with appropriate pain killers and antibiotics
• Swelling usually subsides completely in 4 weeks, although it starts to subside from week 2

Common side-effects:

• Temporary numbness cheek
• Temporary swelling of the involved part of peri-orbital area
• Blurry vision temporarily
• Inadequate projection of globe
• Redness of eye
• Infection of implant

Untoward side effects seen due to unskilled practice:

• Incorrect positioning/ relapse
• Permanent nerve damage
• Extrusion of reconstructive material

5. TEMPORO-MANDIBULAR JOINT (TMJ)/ JAW JOINT MANAGEMENT

The jaw joints seated in our lower jaw are responsible for the opening & closing function of the mouth. They can get afflicted with various disorders like fracture, TMJ Ankylosis, Internal derangement, muscle spasms , jaw locking etc. This usually lead to pain in front of ear, inability to open the mouth, inability to close the mouth, pain while chewing, sounds while chewing etc

Most common reasons to seek for TMJ management:

• Inability to open the mouth
• Jaw lock
• Clicking sounds from in front of ear during opening and closing of mouth
• Pain in front of ear
• Fracture of the joint

Planning for management:

• Upon your visit to an oral and maxillofacial surgeon, you are thoroughly examined
• This includes examination of your TMJ’s , dentition, bite and cervical muscles
• Xray is done is see the bony structure of the joint
• Special xray may be asked for in specific circumstances

After diagnosing the condition, the following treatment options are provided:

1. Conservative/ medical management:
   The condition is deemed fit to be managed by medications, lifestyle modifications and splints or devices
2. Semi- invasive:
   This involves joint wash out (Arthrocentesis) which is a step before opting for surgery. It involves placing needles in the joint and washing it of the chemicals accumulated and depositing medication.
3. Surgery of the TMJ:
   This is often the last resort in TMJ when all measures have failed. It is a high precision surgery and is advisable to be done only by experts.

6. ORAL SURGERY/ DENTOALVEOLAR SURGERY

Surgery involving the tooth bearing areas of the jaws includes surgical tooth extraction, jaw cysts and tumor removal, dental implant placement and bone grafting and augmentation of jaws.

• Jaw cyst and tumor surgery
  A jaw cyst is a formation of a hollow or fluid filled cavity in either of our jaw bones. It is often associated with an impacted wisdom tooth or an infected/ root canal treated tooth. If left as such, the cysts gradually increase in size leading to appearance of swelling of jaws and face, looseing up of teeth and pain. When left untreated, the expand to large sizes, erode into nasal cavity or our sinuses if found in the upper jaw, or lead to fracture of lower jaw.
  The best treatment of such jaw cysts is to remove them in-toto or to relieve the pressure of fluids within them. Apart from removing the cyst, it is also advised at our centre to re-fill these cavities with appropriate and carefully selected bone grafts so that the jaw regains its strength and we can replace the missing teeth at a later stage.
  At our centre, we utilise piezoelectric technology for accessing bone cysts and also use PRF and PRP (platelet rich fibrin, platelet rich plasma) for bone regeneration.
• Wisdom tooth removal
  As evolution would have it, our last molars which are the last to erupt often coinciding (or not) with us becoming wise individuals, find no place in the jaws to erupt in a normal erect position. Hence these teeth lie often half erupted and at angles to the other teeth. It is ‘wise’ to get them removed as they become a source of repeated gum and jaw infections, cyst formation and jaw weakening.
  The removal of these teeth is done under local anaesthesia and is complete within 45 minutes. Some bone may have to be removed in order to access the tooth.
  Some pain and swelling can be anticipated after the procedure although it subsides in 3-4 days.
• Dental Implant placement
  Dental implants are the new boom in the dental science field, and for good reason. They are in most cases, the closest substitute to a natural tooth and help the patient be able to eat the same kind of food they were able to chew into before losing their tooth.
  Dental implants are metal screws that anchor into the jaw bone and have a projection outside the jaw onto which a crown is cemented.
  These surgeries require careful planning using CBCT and computer aided software.