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Surgical removal of the huge ameloblastoma - benign tumor of mandible and reconstruction in a single stage without any scars on the face

11/10/2017

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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.
Preoperative 3DCT scan view showing complete labial plate destruction with inferior alveolar canal disruption
Preoperative facial view showing distinguished swelling in right side of face
Rib graft obtained to reconstruct the mandibular defect
Benign tissue removed in toto with involved bone
Intraoral mandibular view after giving enough marginal clearance
Inferior alveolar nerve isolated and preserved
Huge mandibular defect reconstructed using rib graft
Immediately after suturing
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Resection of huge mandibular tumor and reconstruction using univector intraoral mandibular distraction technique

16/8/2016

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This is a case of ameloblastoma involving right side of mandible. Resection and reconstruction of the huge mandibular defect was done without any bone grafting using distraction osteogenesis. Maxillofacial Surgeon Dr. S. M. Balaji successfully corrected using univector intraoral mandibular distraction technique. Simultaneous resection of huge tumor and reconstruction using native bone was done using distraction osteogenesis. By sequential activation of the distractor device, the native bone was made to grow and fill the entire bone defect. Patient feels happy to have both removal and reconstruction of the entire jaw bone defect without any bone graft. 
Preoperative view showing weel defined swelling in the lower border of mandible and note the skin over the swelling is inflammed
Intraoperative view showing exposure of the lesion through submandibular approach followed by resection
Resected specimen
Adaptation and fixation of the plate guided univector unidirectional straight mandibular distractor
Fixation of the mesh foot plates and completion of planned osteotomy
Primary closure of the surgical wound.
Sequential OPG showing the movement of the transport disc with daily activation
Postoperative OPG showing bone formation following distraction osteogenesis
Postoperative view showing maintained contour of the lower jaw without any visible scars on the face
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Advanced transport Distraction osteogenesis technique for reconstruction of lower jaw after tumor removal

11/2/2016

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A 55 year old patient reported to our hospital with a large, bony swelling in the anterior portion of the lower jaw (mandible). He had said that the swelling had gradually increased in size over the past 1 year and there was spontaneous loss of few lower teeth over the last 6 months. He also reported of altered sensation in the lower lip for past 3 weeks which was his main concern.
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 A 3D CT scan was taken to gauge the extent of the lesion. A biopsy was done which showed the lesion to be a multiple cystic ameloblastoma (tumor) of the lower jaw. Maxillofacial Surgeon Dr. S. M. Balaji removed the entire bony tumor along with the involved bone and reconstructed the defective portion of mandible using the native bone itself without any bone graft by following advanced transport guided distraction osteogenesis technique.

The entire affected portion of the lower jaw was ressected with 1.5 cm marginal clearance followed by reconstruction using titanium plate guided bilateral tripod multi docking complex univector Herford plate guided mandibular transport distractor.

After 5 days of latency period, the distractors were activated at a rate of 0.5mm twice per day (on both sides) until the transport discs had reached the canine region on both sides (amount of distraction on the right side was 46mm and on the left 43.2mm). Following consolidation period of 3 months and radiological evidence of corticalization, the distractors were removed. And complete dental implant rehabilitation done for lower arch in the newly formed healthy bone. Cosmetically well blended fixed ceramic prosthesis given.
X-ray showing tumor in the lower jaw
3DCT scan view showing huge tumor involving more than half of the lower jaw
Intraoperative view showing removal of huge tumor mass intraorally
Complete removal of the tumor mass along with the involved bone in toto
Planning for the fixation of the transport distractor device to the mandible
After tumor removal, fixation of reconstruction plate and segments distracted 1 mm per day
During transport distraction
During distraction
After completion of distraction
After completion of the distraction - facial view
After removal of the distractors and fixing the fragments to the reconstruction plate to achieve the 'U' form of the lower jaw
Healthy new bone formation seen in postoperative 3DCT scan
Postoperative intraoral view showing enhanced healing and augmented new alveolar bone formation
Implants placed in the reconstructed lower jaw
Following dental implant rehabilitation cosmetically well blended fixed ceramic prosthesis placed
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Jaw Reconstruction with recombinant technology for tumor resection

29/10/2014

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A 32 year old man reported to our hospital with the complaint of 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 which made him under huge depression.

After thorough clinical and radiological examination, Maxillofacial Surgeon  Dr. S. M. Balaji diagnosed it as ameloblastoma involving the right side angle and ramus of the mandible. Surgery was planned to remove the lesion and reconstruct the affected jaw portion in a single stage. Through submandibular incision, complete removal of the benign lesion along with the involved teeth with sufficient clearance of the bone under General anesthesia.  Long bone plate was fixed along with costochondral graft which was harvested was fixed to it. Miracle protein rhBMP-2 was wrapped over the costochondral graft to induce new bone formation. Incision was closed in layers. Patient was happy to have both removal and reconstruction in a single surgery. Postoperative OPG after 4 months showed good healing with healthy bone formation. 
Preoperative OPG showing huge lesion in the right angle and ramus region of the lower jaw
Preoperative facial view showing swelling in right lower half of the face
Costochondral graft harvested to reconstruct the affected portion of lower jaw
Gingivomucoperiosteal flap raised and affected portion of the lower jaw was exposed after stabilizing with long bone plate
Through submandibula incision wide excision of the benign lesion was done along with the involved teeth in toto
Lingual surface of the excised bone showing complete removal of the affected jaw bone along with the huge benign lesion
Harvested costochondral graft fixed with the bone plate
Harvested graft was wrapped with the miracle protein rhBMP-2 to induce new bone formation
Immediate postoperative view showing complete layer closure of the submandibular incision
4month postoperative OPG showing complete healing of the bone
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Successful reconstruction of face after tumor resection

9/4/2014

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A 40 year old man reported to our hospital with the complaints of huge swelling in the left side of face. He gave the history of previous surgery done elsewhere, were they have removed a tumor extra orally but it got recurred. He also explained about the nature of swelling as he had noticed the swelling 2 years back. But the swelling was small at that time, later it started to grow slowly and extended to the present size now. Initially he had tenderness in the cheek region, but later there was no pain.

After thorough clinical and radiological examinations, it was diagnosed as recurrent Neurofibroma. Maxillofacial surgeon Dr. S. M. Balaji skillfully planned to remove the tumour completely as well as to reconstruct his face. Through the previously operated nasolabial scar, the tumor was exposed by raising the infra orbital skin. Tumor was separated from the maxilla and zygomatic bone and removed completely. Tumor was adherent to the previously operated site which was also detached and removed completely.

The ectropion (turning out of the lower eyelid) in the left eye was repaired with lateral canthotomy incision and orbital septal return flap technique. The inferior tarsal plate was sutured with supra orbital periosteum. Excess skin in the nasolabial area was excised and wound closed in layers.

Pre operative view showing huge swelling in left side of the face extending to lower border of left eye
Incision made in the previously operated naso labial scar region
Tumor mass retrated completely from the adjacent soft tissue
Tumor mass detached from the adjacent soft tissue and in the previously operated scar region
Entire tumor mass removed along with the attachment in the adjacent tissues
Mucosal flap approximation checked
Bony prominence in the tumor region was identified
Bony prominence was reduced with surgical bur
Mucosal flap approximation done
Ectropion in left lower eyelid correction done with lateral canthotomy
Orbital septal return flap technique was done
Enhanced appearance of face with good approximation of soft tissues in layers
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