Case presentation in maxillofacial surgery

1. a presentation by Dr. Abhijeet
Kamble

3.  A 21 year old male patient reported with an alleged history of Road
traffic accident in the month of February 2021, with a chief complaint
of facial asymmetry and difficulty in chewing & malocclusion for the
last past 2 years.
 He had an operation done twice in the year 2021 and subsequently
in 2022.
3
Case History

4. PHYSICAL
EXAMINATION
PHYSICAL
EXAMINATION
4

5. Extra Oral Examination
5
 Gross facial asymmetry.
 A scar is evident wrt to right infra
orbital region.
 Prominent malar eminence bilaterally.
 lip incompetence.
 Slight Chin deviation evident towards
right side.

6. Extra Oral EXAMINATION
6
zy
go
Facial width
Mandible width
Pre-operative extra-oral photograph

7. INTRA ORAL EXAMINATION
1 Midline shift
Dearranged
occlusion with right
posterior cross bite
2
Palatal perforation
3
+ wrt right side
anterior hard palate
region
7
1
2
Mouth opening
adequate

8. INVESTIGATION
S
3D CT
OPG
8 Latero - posterior displacement of the malar

9. NCCT FACE
9

10. DIAGNOSIS
Post-Traumatic Pan Facial Residual
Deformity
?
?
1 0

11. Treatment Planning
PATIENTS PRIMARY CONCERN
Diagnostic work up
 Plaster models of upper and lower dental arches
to calculate the amount of discrepancy in
occlusion and to plan the osteotomies in the
mandible, surgical grid to calculate the
discrepancies in the zygoma by correlating with
both the side, on clinical and radiological
pictures.
Treatment planning
 A mandible reconstruction
1 1
SURGICAL PLANNING
 Inability to chew food.
 Regurgitation of fluids while drinking.
 Nasal twang.
 Facial disharmony.
PRINCIPAL GOALS OF RECONSTRUCTION
 Return anatomical alignment of the bony
skeleton, (restore both the function and pre
injury 3D facial contours)
 To establish proper facial projection, and a
proper facial height.
 secure proper skeletal support before
addressing the soft tissue.

12. Treatment Planning
Management of Pan facial fracture
 Gruss et al. advised reduction of zygomatic arch
and malar projection first to reestablish the
―Outer facial frame, before NOE or ―Inner
facial frame is reduced.
 Merville recommended ―Top to Bottom
sequence if NOE was involved in pan facial
fracture.
 Tulio and Sesenna believed establishment of
condyles together with mandibular arch is the
appropriate first step.
 Manson and Glassman advised fixing palatal
fracture first and then using the maxillary arch as
a template for restoration of mandibular arch.
1 2
SURGICAL PLANNING
 Theories ― Bottom up & inside out,
 or ―Top down & outside in.

13. Treatment planning
1. Paramedian unilateral Le Fort I osteotomy Wrt right side.
2. Followed by Symphysis reduction, Maxillomandibular fixation to achieve
occlusion will re-establish lower facial width and projection, and posterior
facial height.
3. Fixation and reduction of Right side Zygomatico-Maxillary complex, restore
facial projection and width.
Bottom up & inside out,

14. THANK YOU