This young man was riding his bike to work when the signal turned red. He braked suddenly, which caused the car that was tailgating him to rear end his bike. This sudden impact caused him to lose his balance and fall directly on his chin. Of note, he was not wearing a helmet at the time of the accident. There were some minor bruises and lacerations, but what caused him great alarm were the grating noises he heard upon attempting to open his mouth and speak.

Realizing that something was not right, onlookers at the site of the accident informed his parents over his mobile phone and took him to a nearby hospital for treatment. Doctors at the hospital administered first aid with thorough debridement of his lacerations due to the presence of road dirt. He was also administered a tetanus toxoid to avoid the possibility of tetanus.

His parents had reached the hospital by then and they were informed that their son had multiple fractures to his lower jaw. They referred the patient and his parents to Balaji Dental and Craniofacial Hospital as it is renowned for facial fracture surgery in India. Many patients with fractures of the jaws are referred to us because we are a specialty jaw fracture surgery hospital.

Dr SM Balaji examined the patient and ordered imaging studies upon their arrival at the hospital. This revealed that the patient had a displaced fracture of the body of the mandible on the left along with a nondisplaced ramus fracture on the right. He also had a fractured lower left second premolar tooth.

All the findings were explained to the patient and his parents. It was advised that he emergently undergo open reduction and internal fixation of the two fractures with titanium plates and screws along with extraction of the fractured tooth. They were also informed that his jaws would be wired shut for a period of 2-3 weeks following surgery to allow for the bones to be held stable during the healing period. They were in complete agreement with the treatment plan and signed the written informed consent for surgery.
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The patient was taken to the operating room and placed under general anesthesia. The fracture sites were accessed through intraoral incisions to avoid any visible scars on the patient’s face from the surgery. The fractured tooth was then extracted.

The displaced body of the mandible fracture was addressed first. The fractured segments of the mandible were stabilized and fixed using titanium plates and screws. A similar procedure was then performed on the right ramus fracture. Correct occlusion was ascertained before fixing the fracture with the titanium plates and screws. The patient’s jaws were then wired shut using Intermaxillary fixation.
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The patient was advised to stay on a liquid diet until his jaw wiring was removed and to stay on a soft diet for a further fortnight after that. Surgical results were excellent and the patient and his parents expressed their complete satisfaction at the results of the surgery.

A 14-year old boy

A 14-year-old boy form Meghalaya came to our hospital with a complaint of difficulty in breathing and facial swelling. The patient complained that he felt a heaviness in his face. The parent’s described that the swelling was growing in size. They requested for immediate correction of the swelling.

Fibrous dysplasia

Fibrous dysplasia is a disorder where normal bone and marrow is replaced with fibrous tissue. This results in the formation of weak bone. Thereby leading to expansion. It may result in fracture and can cause bone deformity. Certain people may feel pain associated with fibrous dysplasia. Functional impairment can also occur. Fibrous dysplasia is not cancerous but may pre-dispose to cancer in about 1% of the population.

Treatment of choice

As such, there is no cure for fibrous dysplasia other than symptomatic treatment. A fracture is treated if evident. Bony expansion is treated surgically. Fibrous dysplasia may require cosmetic correction depending on the position and the size of the lesion.  In this case, fibrous dysplasia was involving the maxilla, zygoma, floor of the orbit and nasal cavity. Thereby, causing functional impairment.

Investigations

Thorough clinical, radiological and histopathological examination done. A biopsy was done. The biopsy results revealed fibrous dysplasia. CT scan revealed fibrous dysplasia involving the maxilla, zygoma, nasal cavity and extending up to the orbital floor. Maxillofacial surgeon Dr.S.M.Balaji planned to resect the entire fibrous tissue.

Procedure

Incision placed Intraorally. Mucoperiosteal flap elevated. The entire fibrous bone was resected and burred down completely. It was also made flush with the surrounding bone. The surgery was a great success.

Results

The patient was able to breathe well after the surgery. He no longer felt a heaviness in his face. He expressed his joy after the surgery. He stated that his face felt lighter than before. The entire procedure was done intra orally and hence there was no scar on the face.

She presented with a complaint of backwardly placed upper jaw. This gave her an aged look. She was also unhappy with her face. The patient wanted to have a more pleasing face. She was unable to bite and chew food.

A local dentist had mentioned that her upper jaw was small at a young age. He stated that she will have orthodontic problems in the future. He started noticing the difference when she was in a mixed dentition period. He had suggested that she would require orthognathic surgery at a later age or risk developing jaw joint pain.

He had reviewed her at about 18 years of age. During which he noticed that she did not have a proper bite relationship. The upper and lower teeth were completely malaligned. She had a lot of dental issues. There was also a noticeable anterior crossbite. The roof of her mouth was normal after surgical correction of cleft palate.​

​She had an abnormal bite. The upper and lower jaw was in an abnormal position. Every single tooth including the upper molars was also abnormally placed. She had an anterior and posterior crossbite. This is also known as a complete crossbite. The patient had a more curved facial profile. Her profile was concave. This showed that she needed advancement of the maxilla.

​Radiological evaluation revealed backwardly placed upper jaw. This was due to restricted growth of maxilla. The growth of mandible was normal. Since the maxillary jaw growth was restricted, the mandible looked longer. The upper front teeth were placed inside the lower front teeth.

​Maxillofacial surgeon Dr.S.M.Balaji advised upper jaw surgery by bringing the maxilla forward.   Maxillary advancement was planned by Le Fort I osteotomy. The segment was to be fixed using Ti plates and screws. An incision made in the maxilla. Flap elevated. Bone cuts made above the apices of the teeth. Pterygomaxillary dysjunction done.  The maxillary segment was mobilized. The maxilla was pulled forward. It was brought in occlusion and fixed using Titanium plates and locking screws (Ti L plate). The maxillary vestibular region was sutured.

​The patient was greatly satisfied with the results. The surgery was successfully performed. The maxilla was successfully brought forward. The anterior crossbite and posterior crossbite was corrected. The patient will, however, require post-surgical orthodontic treatment for minimal teeth alignment.

A 3-month old baby boy born with unilateral cleft lip & palate was brought to our hospital by his parents seeking the best treatment for cleft lip and palate. The parents were perturbed after seeing their firstborn son’s condition.
Maxillofacial Surgeon Dr. S.M. Balaji performed the primary repair surgery for unilateral cleft lip using Modified Millard’s technique. Following surgery, the baby appeared to be like any other baby of his age with minimal to no scar. The parents were greatly pleased with the results. Consecutively cleft palate correction surgery will be done.

A 4-month old baby boy born with unilateral cleft lip & palate was brought to our hospital by his parents seeking the best possible treatment for the cleft defect. The parents were greatly depressed and complained about the difficulty in feeding him.
Under the expert care of Cranio-Maxillofacial Surgeon Dr. S.M. Balaji, the primary lip repair surgery for unilateral cleft lip was carried out using Modified Millard’s technique. Immediately post surgery, the baby’s appearance improved greatly and he was able to feed well. The parents were very glad about the results and were thrilled as their baby had hardly any post-surgical scars. Cleft palate correction surgery will be done at a later date. 

​This is a case of macrostomia (lateral facial cleft) in a 1 year old baby girl from Siliguri. The parents brought the baby seeking the best surgical treatment for the correction of wide mouth and the asymmetric appearance of the baby without much visible scars on the face.
Surgical correction of macrostomia is challenging and more complex as it aims in restoring back the normal appearance while at the same time maintaining the normal functions like speech, blowing, etc.
Maxillofacial Surgeon Dr. S. M. Balaji successfully corrected the macrostomia using vermillion return flap technique. Results are immediate and the parents feel very happy to see the negligible scar formation, following suture removal.

Successful reconstruction of the upper lip attempts to maintain the anatomic and physiological relationship of the philtrum (central portion of upper lip) and the base of the nose.

This is the case of secondary cleft lip and nose deformity in a 22 year old boy from Nepal. He is a known bilateral cleft lip and palate patient where the primary cleft lip and palate surgeries where done elsewhere in his hometown. He had defective appearance of the nose and lip due to which he lost his self confidence and he was very conscious about the appearance.
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Maxillofacial Surgeon Dr. S. M. Balaji successfully corrected both the nose and lip defect together using Abbe flap technique. In the first stage a flap of tissue was taken from the lower lip, rotated across the lips and used to reconstruct the thin central portion of the upper lip, with the base of the flap still attached to the lower lip. Simultaneously in the same procedure itself, reduction rhinoplasty was done to correct the broad nose. After blood supply was established in a few days, the second stage surgery to divide the flap was done. The defect was corrected giving the upper lip a more natural, enhanced form. Results are immediate, both the nose and upper lip defect are corrected giving improved appearance and this boosted the boy’s confidence.

This patient reported to me with the complaint of facial swelling for past 5 months which became noticeable for last 10 days. After thorough clinical, radiological and histopathological examination, Maxillofacial Surgeon Dr. S. M. Balaji diagnosed it as Odontogenic keratocyst (OKC) involving the entire left body and anterior region of the mandible.
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Surgical treatment was planned to remove the entire cystic lesion and reconstruct the affected jaw portion in a single stage. Costal rib graft was harvested for the reconstruction of the mandible. Through intraoral approach, crevicular incision was placed in the mandibular anterior teeth region extending posterior till mandibular notch, gingivomucoperiosteal flap was raised, cystic lesion was surgically exposed and the affected portion was removed along with the involved teeth in toto and reconstruction was done using long titanium bone plate and costal graft maintaining the contour of the mandible. After successful graft uptake, dental rehabilitation will be done using dental implants in the newly formed bone.

This is the case of post traumatic secondary facial deformity in a 25 year old boy from Kolkata. He gave a history of RTA 3 years back and had first aid, primary reconstruction surgeries elsewhere.
On examination, he had defective left eye prosthesis and deformed nose. He was very conscious about his looks and lost his confidence due to the defective appearance. 
Maxillofacial Surgeon Dr. S. M. Balaji surgically corrected the defective appearance of the boy without much visible scars on his face. The defective eye prosthesis was removed and orbital content was reconstructed using buccal tissue graft and silicone orbital implant. Artificial eye prosthesis in close resemblance to that of the right eye was fixed. This improved his overall appearance. Through the previous scar, defective ala of nose was corrected using chondral graft obtained from the rib cartilage. The boy is very happy for the successful facial reconstruction. This helps in regaining his self confidence.  

A 3-month-old baby boy born with bilateral cleft lip and palate was brought to our hospital by his parents from Mauritius for specialized cleft lip & palate surgery.
Maxillofacial Surgeon Dr. S.M. Balaji performed the primary cleft lip correction surgery by following Paul Black’s technique to correct the lip enabling the baby to feed well.  Subsequently cleft palate surgery will be done to completely rehabilitate the child. 

A young man from Singapore reported to me with the complaint of huge swelling in the right side of his face. He added that the size of the swelling was increasing progressively which made his face asymmetrical. He was very cautious about this progressive swelling. Added he had histopathological examination of the intraoral tissue done elsewhere diagnosing as plexiform ameloblastoma.
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After thorough clinical and radiological examination, Maxillofacial Surgeon  Dr. S. M. Balaji planned to remove the lesion and reconstruct the affected jaw portion in a single stage. Intraorally, complete removal of the benign lesion with sufficient clearance of the bone was done following rib graft which was obtained was fixed to it. Patient was happy to have both removal and reconstruction in a single surgery.

This is a case of 3 months old baby boy with incomplete bilateral cleft lip from Bangladesh. Maxillofacial Surgeon Dr. S.M. Balaji surgically corrected the cleft lip defect by following Paul Black's technique. Results are  immediate. Immediate postoperative view following suture removal shows negligible scar formation.  ​

A 30-year-old man from Bangladesh was suffering from severe pain and swelling in his right side of lower jaw. He also complained of difficulty to open his mouth wide and bite and chew foods. He was advised by his family doctor in his home town to go to Balaji Dental and Craniofacial Hospital at Chennai, India, for specialized treatment.

Maxillofacial Surgeon Dr. S.M. Balaji thoroughly evaluated his jaw defect clinically and using advanced 3D CT scan. The scan images showed that he had multiple and extensive areas of bone loss that appeared to resemble large cystic tumors involving the almost entire right side of lower jaw.
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Biopsy of the lesion was done which proved it to be odontogenic keratocysts. Dr. Balaji planned a complete reconstruction of the lower jaw right side, using the man’s own rib graft. The affected portion of the lower jaw bone was surgically removed. Diseased portions of the bone were completely and thoroughly removed to ensure that there is no recurrence. A costochondral cartilage graft (rib graft) was taken and used to reconstruct the lower law. The man feels very happy for the surgery outcome and the entire surgery was done intra orally avoiding external scar formation.
4 months follow-up
4 months postoperative digital OPG and 3DCT shows good bone formation. Dental implants fixed in the newly formed bone with good stability and retention.

A 3-months-old baby boy born with unilateral cleft lip and palate defect from West Bengal was brought to our hospital by his parents for surgical correction of cleft lip defect.
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Maxillofacial Surgeon Dr. S.M. Balaji successfully performed the cleft lip repair using modified Millard’s technique.  The baby’s appearance was remarkable improved and he was able to feed well. His parents feel very happy to have the cleft lip treated with negligible scar formation.

​Difficulties faced – in patient’s words

​Maxillofacial Surgeon Dr. S. M. Balaji planned to remove the failed infected bone graft done elsewhere and to reconstruct the lower jaw in a single surgery. He approached the surgical site intraorally and removed the dislodged bone graft and sequestrum completely. Adjacent infected bone was removed with bone curette. A rib graft was taken and fixed to the lower jaw left side to reconstruct the defect. rhBMP-2 was placed to increase the efficiency of new bone formation. Mucosal flaps were approximated in layers. The patient is very happy to have entire surgery done in single stage without any scar on the face. The functionality of the lower jaw was also regained efficiently.

A 5 year old boy was brought to our hospital with a complaint of decreased mouth opening and facial deformity by birth. His parent’s gave the history of multiple surgical correction of TMJ ankylosis done elsewhere. He had unsightly extraoral scar due to previous surgeries. He gave a history of having undergone distraction osteogenesis treatment for the left side of the lower jaw in some other hospital elsewhere, but the treatment subsequently failed.

Now on examination he had facial asymmetry, severely retruded lower jaw (mandible), flattened lower face with complete restriction in mouth opening and shift of chin towards left side.
3DCT of facial bones revealed obliterated left temporomandibular (joint jaw) joint space, elongated coronoid process, and reduced ramal height and prominent antegonial notch. The case was diagnosed as true left TMJ bony ankylosis with developing secondary facial deformity. 
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Maxillofacial Surgeon Dr. S. M. Balaji successfully performed bony ankylosis release surgery and transportation of growth centre using costochondral junction obtained from rib cartilage. Postoperative mouth opening was adequate. Following complete dental rehabilitation done to treat the badly broken and decayed teeth, boy’s parents were asked to continue the mouth opening exercise at least 2 months after surgery. 

3 months old baby girl from West Bengal was brought to our hospital by her parents seeking for cleft correction. Maxillofacial Surgeon Dr. S. M. Balaji successfully corrected the unilateral cleft lip defect using modified Millard’s technique. Results are immediate, with negligible scar formation. ​

A 36 year old woman reported to our hospital with the complaint of missing teeth along with the bone in the front region of lower jaw. She added that the anterior mandibular segment was removed due to ameloblastoma and reconstruction plate was fixed few years back elsewhere and she was not able to chew foods and speak well due to missing teeth along with the bone. She wanted permanent reconstruction of her mandible and fixed teeth.
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After thorough clinical and radiological examination, Maxillofacial Surgeon Dr. S. M. Balaji planned to reconstruct her mandibular defect using costochondral rib graft following which dental implants will be fixed into the newly formed bone. Intraorally, the infected mobile mandibular reconstruction plate and screws placed elsewhere were removed and reconstructed using costochondral rib graft along with the titanium mandibular reconstruction plate. Incision was closed in layers. Patient feels very happy to have complete reconstruction in a single surgery. Following new bone formation fixed dental implant replacement will be done for her missing teeth.  

​30 year old women reported to our hospital with the complaints of swelling in right side lower half of the face. She also said that this swelling was there for a very long period with occasional numbness in the right side of the face.
After thorough clinical, radiological and histopathological examination, Maxillofacial Surgeon Dr. S. M. Balaji diagnosed it as odontogenic keratocyst (OKC) involving right body and ramus of the mandible. He planned to remove the entire lytic lesion and reconstruction of the affected portion of the mandible in the same surgery. Costochondral graft was obtained from the ribs to reconstruct the mandible. Through intraoral approach, after raising gingivomucoperiosteal flap extending distally, the entire lesion along with the affected portion of mandible was removed in toto. Harvested rib graft was used to reconstruct the defective region of mandible. Patient is very happy to have both removal of the entire lesion and reconstruction of the affected portion of mandible in the same surgery.

22 year old men reported to our hospital seeking to correct his deviated nose which greatly affected his facial appearance. He gave a history of road traffic accident 2 years back where he had severe injury on the nasal bones. He was very much disappointed as his nose was completely deviated to the right side giving asymmetric facial appearance.
Maxillofacial Surgeon Dr. S.M. Balaji successfully performed the cosmetic rhinoplasty. Vertically nasal septal cartilage height was trimmed by medial osteotomy to reduce the height of the nose. Deviation along with the width of the nose was reduced by lateral osteotomy technique. Thus deviated nose and size of the framework of the nose was corrected from inside the nose to avoid any scars on the face (closed rhinoplasty technique).
A balance between the nose shape and facial profile was achieved for a more pleasing appearance. The patient was very happy to have a narrower, shapely nose that enhanced his facial profile with absolutely no scarring. 

A 22 year old girl reported to our hospital for the surgical correction of asymmetry over the left side of the face. Facial asymmetry may be present in cases of hemifacial microsomia, TMJ ankylosis or may have resulted following condylar fractures. This patient had a mandibular deficiency at the ramus level and deficiency measured almost 14 mm with a resultant occlusal cant.
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After thorough clinical and radiological examination Maxillofacial Surgeon Dr. S. M. Balaji planned to correct the facial asymmetry using internal distraction osteogenesis with maxillomandibular distractor. Paragingival incision was placed over the left angle region along the anterior border of ramus. Full thickness mucoperiostal flap was reflected buccally and bone exposed. The direction of the osteotomy cut and positioning of the distractor is the most important as it determines the vector of distraction and this determines the direction of the bone growth. The distractor device was positioned and fixed using screws. Osteotomy is then completed along the medial cortex. Distractor device was checked and wound closure done. Le Fort I osteotomy was completed in maxilla. After a latency period of 5 days, distraction at the rate of 1 mm per day was accomplished and facial asymmetry was successfully corrected. Patient feels very happy to have the facial asymmetry correction without any scars on the face.

A 3-month-old baby boy born with unilateral cleft lip and palate was brought to our hospital by his parents for specialized treatment of the cleft defect.
Maxillofacial Surgeon Dr. S.M. Balaji successfully performed the primary cleft lip repair using modified Millard’s technique.  Right away after surgery the baby’s appearance was remarkable improved and he was able to feed well. His parents were very happy to have the cleft lip treated with negligible scar formation. After few months cleft palate repair will be done.

A 4-month-old baby boy born with unilateral cleft lip and palate was brought to our hospital by his parents for specialised treatment of the cleft defect.
Maxillofacial Surgeon Dr. S.M. Balaji successfully performed the primary cleft lip repair using modified Millard’s technique.  Right away after surgery the baby’s appearance was remarkably improved and he was able to feed well. His parents were very happy to have the cleft lip treated with negligible scar formation. After few months cleft palate repair will be done.

This is a 15-month-old boy who was referred by Dr. K. K. Raja, Head of the Department, Oral and Maxillofacial Surgery, SRM Dental College and Hospital to Dr. S. M. Balaji for the purpose of demonstrating a cleft lip repair as part of the preconference live surgical demonstration of the 10th World Cleft Lip, Palate, and Craniofacial Congress. Oral and maxillofacial surgeon Dr. S. M. Balaji decided to proceed with a modified Millard Noordhoff left-sided cleft lip repair.  This was performed at Balaji Dental and Craniofacial Hospital, Chennai.
This surgery was done to rehabilitate him and help him feed normally as good nutrition is extremely essential for an actively growing little child to develop normally in all parameters. From the aesthetic point of view also, the importance of this surgery is paramount as it would enable him to interact well with his peers as well as other older individuals.
The surgery was a complete success.  The scar that resulted from this was negligible and his parents expressed their appreciation of how Dr. S. M. Balaji was helping in transforming his life for the better.