​This young boy fell from a chair directly onto his chin when he was around 2 years of age. He had suffered a minor cut to his chin, which was sutured at a local dispensary at his hometown of Kangeyam, a town famous for bulls in South India. A minor pain had persisted in his temporomandibular joints, but his parents had ignored his complaints. He too had stopped complaining after a while and the incident had been forgotten.
As the boy grew up, his parents had begun noticing a developing asymmetry to his lower face. His mandible was slowly begun deviating to the right side with the right side of the mandible being shorter than the left side. He had slowly begun developing chewing problems and speech problems, which progressively became worse with time.
They took him to a local oral surgeon who ordered an OPG of his jaws. This revealed that the patient had ankylosis of the right temporomandibular joint. The surgeon had referred the patient to Balaji Dental and Craniofacial Hospital in Chennai as it was a specialty center for TMJ ankylosis surgery in India.
Dr SM Balaji examined the patient and formulated a treatment plan, which was explained in detail to the patient’s parents. The patient had an asymmetric mandible because of the long standing ankylosis of the right temporomandibular joint. This would have to be corrected through jaw reconstruction surgery with the use of distractors, but the ankylosis release surgery had to be performed first. They consented for surgery and the patient was scheduled for ankylosis release surgery. Surgery was performed successfully and the TMJ ankylosis was released. The second stage of the treatment plan would be distraction osteogenesis.
The patient had impacted lower left third and lower right second and third molars on presentation at this time. It was explained to the parents that these had to be extracted before performing the distraction osteogenesis surgery for the mandible. Upon consultation with the anesthesiologist, it was decided to induce anesthesia through nasal fiberoptic bronchoscopic intubation as the patient had very minimal mouth opening.
The patient was prepped was surgery and anesthesia was induced through nasal fiberoptic bronchoscopic intubation with a certain degree of difficulty. Once anesthesia was established, the impacted molar teeth were extracted without event. The patient recovered uneventfully from anesthesia.
It was explained to the parents that the extraction sockets had to heal completely with filling in of bony tissue. This bone had to get consolidated fully with normal trabecular architecture as surrounding bone. Once radiographic evidence of this had been confirmed, the patient would be scheduled for distraction osteogenesis surgery. The patient’s parents were in full agreement with the treatment planning and were scheduled to return back to the hospital in approximately six to eight month’s time.

Patient with long standing facial asymmetry due to hemifacial microsomia

This young man who is from a small town in Maharashtra first began noticing a gradually developing facial asymmetry for a few years now. He also began noticing that it was progressively becoming difficult to chew and speak compared to a few years ago. This had led to him developing avoidance behavior with regarding to meeting people and eating certain classes of foods. His day to day functioning was becoming affected by this and he was becoming very worried by this problem.

This asymmetry also made him develop the habit of tilting his head until it nearly touched his shoulders to conceal this facial asymmetry from casual observers. He developed severe neck spasms as a result of this debilitating habit of tilting his neck. This neck pain was keeping him up at night and this lack of sleep was making him irritable. He was also feeling chronically angry at this turn of events in his life. This problem was slowly beginning to consume his thought process and affect every aspect of his life including his professional life.

Deciding that something had to be done about this, he and his parents met an oral surgeon to get to the root of the problem and also to find out the cause of the severe neck pain. The surgeon explained that the patient had very prominent facial asymmetry and that his occlusal cant was also askew. His diagnosis for the patient was hemifacial microsomia. He said that the patient required facial asymmetry correction surgery.

​He educated them on the various aspects of treatment available to the patient and said that they needed to go to a specialty center for facial asymmetry surgery in India. The patient and his parents were thus referred to Balaji Dental and Craniofacial Hospital in Chennai, India for definitive surgical management of his problem

Treatment planning explained and consent obtained for distraction osteogenesis
Dr SM Balaji met with the patient and obtained a detailed history. This was followed by detailed imaging studies including a 3D CT scan. Facial biometric scan was also obtained in order to make treatment planning easy. This revealed a ramus that was shorter by 10 cm on the left side when compared to the right. Planned surgical intervention would be through simultaneous maxillary and mandibular distraction for setting right the problem for the patient. The rationale behind treatment planning was fully explained to the patient and his parents who expressed understanding and agreed to surgery.

Bilateral sagittal split osteotomy of the mandible
Sagittal split osteotomy was performed on the left mandibular ramus after successful induction of general anesthesia. A Univector ramus distractor was then utilized for the distraction osteogenesis. This was fixed with screws to the two side of the distracted segments of the mandible. Distraction functioning was deemed to be adequate after a thorough check and the incision was then closed with sutures.
Maxillary distraction followed mandibular distraction. A Le Fort I maxillary osteotomy was performed through a vestibular incision. Left sided dysjunction of the maxilla followed by stabilization of the two distracted segments was performed.

Establishment of facial symmetry through distraction osteogenesis
A latency period of seven days would be followed by distraction osteogenesis of the mandible. This period was for stabilization of the distracted site. A distraction of 1 mm would be performed each day for a total of 10 mm of distraction in ten days. The distractors would then be left in place for a period of three months for the new bone to consolidate at the distracted site.
This would result in establishment of facial symmetry for the patient. The patient and his parents expressed their satisfaction at the results of the surgery before final discharge from the hospital.