Major Surgeries

Facial Trauma:
An oral and maxillofacial specialist is thoroughly qualified to repair facial injuries. These professionals are well versed in emergency care, acute treatment, and long-term reconstruction and rehabilitation – not just for physical reasons, but for emotional ones as well. Injuries to the face, by their very nature, impart a high degree of emotional as well as physical trauma to patients. The science and art of treating these injuries requires special training involving a “hands on” experience and an understanding of how the treatment provided will influence the patient’s long-term function and appearance.

Dr. Karthikeyan and his team meet and exceed these modern standards.  They are trained,  skilled and uniquely qualified to manage and treat facial trauma. They are on staff at local hospitals and deliver emergency room coverage for facial injuries, which include the following conditions:

  •   Facial lacerations
  •   Intraoral lacerations
  •   Avulsed (knocked out) teeth
  •   Fractured facial bones (cheek, nose, or eye socket)
  •   Fractured jaws (upper and lower jaw)

The Nature of Maxillofacial Trauma

There are a number of possible causes of facial trauma, such as motor vehicle accidents, accidental falls, sports injuries, interpersonal violence, and work-related injuries. Types of facial injuries can range from injuries to teeth to extremely severe injuries to the skin and bones of the face. Typically, facial injuries are classified as soft tissue injuries (skin and gums), bone injuries (fractures), or injuries to special regions (such as the eyes, facial nerves, or the salivary glands).
Soft Tissue Injuries of the Maxillofacial Region

When soft tissue injuries, such as lacerations, occur on the face they are repaired by suturing. In addition to the obvious concern of providing a repair that yields the best cosmetic result possible, care is taken to inspect for and treat injuries to structures such as facial nerves, salivary glands, and salivary ducts (or outflow channels). Dr.Karthikeyan is a well-trained oral and maxillofacial surgeon and is proficient at diagnosing and treating all types of facial lacerations.

Bone Injuries of the Maxillofacial Region

Fractures to the bones in the face are treated in a similar manner to fractures in other parts of the body. The specific form of treatment is determined by various factors, which include the location of the fracture, the severity of the fracture, and the age and general health of the patient. When an arm or leg is fractured a cast is often applied to stabilize the bone to allow for proper healing. Since a cast cannot be placed on the face, other means have been developed to stabilize facial fractures.

One of these options involves wiring the jaws together for certain fractures of the upper and/or lower jaw. Certain other types of fractures of the jaw are best treated and stabilized by the surgical placement of small plates and screws at the involved site. This technique of treatment can often allow for healing and eliminates the necessity of having the jaws wired together for around one month. This technique is called “rigid fixation” of a fracture. The relatively recent development and use of rigid fixation has profoundly improved the recovery period for many patients, allowing them to return to normal function more quickly.

The treatment of facial fractures should be accomplished in a thorough and predictable manner. More importantly, the patient’s facial appearance should be minimally affected. An attempt at accessing the facial bones through the fewest incisions necessary is always made. At the same time, the incisions that become necessary are designed to be small and, whenever possible, are placed so that the resultant scar is hidden.

Injuries to the Teeth & Surrounding Dental Structures

Isolated injuries to teeth are quite common and may require the expertise of various dental specialists. Oral surgeons usually are involved in treating fractures in the supporting bone, or in replanting teeth that have been displaced or knocked out. These types of injuries are treated by one of a number of forms of splinting (stabilizing by wiring or bonding teeth together). If a tooth is knocked out it should be placed in salt water or milk. The sooner the tooth is re-inserted into the dental socket the better chance it will survive. Therefore, the patient should see a dentist or oral surgeon as soon as possible. Never attempt to wipe the tooth off, since remnants of the ligament that hold the tooth in the jaw are attached and are vital to the success of replanting the tooth. Other dental specialists may be called upon, such as endodontists, who may be asked to perform root canal therapy, and/or restorative dentists, who may need to repair or rebuild fractured teeth. In the event that injured teeth cannot be saved or repaired, dental implants are often now utilized as replacements for missing teeth.

The proper treatment of facial injuries is now the realm of specialists who are well versed in emergency care, acute treatment, long-term reconstruction, and rehabilitation of the patient.

Orthognathic Surgery (Jaw Surgery)

Orthognathic surgery is needed when the top and bottom jaws don’t meet correctly and/or teeth don’t adequately fit within the jaw. Teeth are straightened with orthodontics, and corrective jaw surgery repositions a misaligned jaw. This not only improves facial appearance, but also ensures that teeth meet correctly and function properly.

Who Needs Orthognathic Surgery?

People who can benefit from orthognathic surgery include those with an improper bite, or jaws that are positioned incorrectly. Jaw growth is a gradual process and in some instances, the upper and lower jaws may grow at different rates. The result can be a host of problems that may affect chewing function, speech, or long-term oral health and appearance. Injury to the jaw and birth defects can also affect jaw alignment. Orthodontics alone can correct bite problems when only the teeth are involved. Orthognathic surgery may be required for the jaws when repositioning is necessary.

Difficulty in the following areas should be evaluated:

  • Difficulty in chewing, biting, or swallowing
  • Speech problems
  • Chronic jaw or TMJ pain
  • Open bite
  • Protruding jaw
  • Breathing problems

Any of these symptoms can exist at birth, be acquired after birth as a result of hereditary or environmental influences, or as a result of trauma to the face. Before any treatment begins, a consultation will be held to perform a complete examination with x-rays. During the pre-treatment consultation process, feel free to ask any questions that you have regarding your treatment. When you are fully informed about the aspects of your care, you and your dental team can make the decision to proceed with treatment together.

Technology & Orthognathic Surgery

Dr. Karthikeyan uses modern computer-aided techniques and three-dimensional models to show you exactly how your surgery will be approached. Using comprehensive facial x-rays and computer video imaging, we can show you how your bite will be improved and even give you an idea of how you’ll look after surgery. This helps you understand the surgical process and the extent of the proposed treatment.

The surgery can move your teeth and jaws into a new position that results in a more attractive, functional, and healthy dental-facial relationship.

What to Expect

Corrective jaw surgery is a significant intervention requiring many months of preparation.
The surgery is performed in the hospital and can last between one to four hours.
Hospital stays of one to three days are normal.

Braces are maintained during surgery and may need to be removed six to twelve months after surgery.
The greatest impact of orthognathic surgery is the recovery phase.

Patients typically may be off work/school from two weeks to one month after surgery.

Return to normal chewing function may take 2 months and full function may take three months.

Our goal is to ensure you are well taken care of during and after surgery.

Weekly appointments are required for up to two months after surgery.

Sleep Apnea

People with obstructive sleep apnea (OSA) have disrupted sleep and low blood oxygen levels. When obstructive sleep apnea occurs, the tongue is sucked against the back of the throat. This blocks the upper airway and airflow stops. When the oxygen level in the brain becomes low enough, the sleeper partially awakens the obstruction in the throat clears, and the flow of air starts again, usually with a loud gasp.

Repeated cycles of decreased oxygenation lead to very serious cardiovascular problems. Additionally, these individuals suffer from snoring during sleep, excessive daytime sleepiness, depression, and loss of concentration.
Some patients have obstructions that are less severe called Upper Airway Resistance Syndrome (UARS). In either case, the individuals suffer many of the same symptoms.

The first step in treatment resides in recognition of the symptoms and seeking appropriate consultation. Oral and maxillofacial surgeons offer consultation and treatment options.

In addition to a detailed history, the doctors will assess the anatomic relationships in the maxillofacial region. With cephalometric (skull x-ray) analysis, the doctors can ascertain the level of obstruction. Sometimes a naso-pharyngeal exam is done with a flexible fiber-optic camera. To confirm the amount of cardiovascular compromise and decreased oxygenation levels, a sleep study may be recommended to monitor an individual overnight.

There are several treatment options available. An initial treatment may consist of using a nasal CPAP machine that delivers pressurized oxygen through a nasal mask to limit obstruction at night. One of the surgical options is an uvulo-palato-pharyngo-plasty (UPPP), which is performed in the back of the soft palate and throat. A similar procedure is sometimes done with the assistance of a laser and is called a laser assisted uvulo-palato-plasty (LAUPP). In other cases, a radio-frequency probe is utilized to tighten the soft palate. These procedures are usually performed under light IV sedation in the office.

In more complex cases, the bones of the upper and lower jaw may be repositioned to increase the size of the airway (orthognathic surgery). This procedure is done in the hospital under general anesthesia and requires a one to two day overnight stay in the hospital.

OSA is a very serious condition that needs careful attention and treatment. Most major medical plans offer coverage for diagnosis and treatment.

Distraction Osteogenesis

Distraction osteogenesis (DO) is a relatively new method of treatment for selected deformities and defects of the jaw and skull. Although it was first used in 1903, in the 1950’s the Russian orthopedic surgeon, Dr. Gabriel Ilizarov, slowly perfected the surgical and postoperative management of distraction osteogenesis treatment to correct deformities and repair defects in the arms and legs. His work went mostly unnoticed until he presented to the Western Medical Society in the mid-1960s.

Distraction osteogenesis was first used to treat defects of the oral and facial region in 1990. Since then, the surgical and technological advances made in the field of distraction osteogenesis have provided oral and maxillofacial surgeons with a safe and predictable method to treat selected deformities.

Frequently Asked Questions about Distraction Osteogenesis

What does the term distraction osteogenesis mean?

Simply stated, distraction osteogenesis means the slow movement apart (distraction) of two bony segments in a manner such that new bone is allowed to grow and fill in the gap created by the separating bony segments.

Is the surgery for distraction osteogenesis more involved than “traditional surgery” for a similar procedure?

No. Distraction osteogenesis surgery is usually done on an outpatient basis with most of the patients going home the same day of surgery. The surgical procedure itself is less invasive so there is usually less pain and swelling.

Will my insurance company cover the cost of osteogenesis surgical procedure? Most insurance companies will cover the cost of the osteogenesis surgical procedure provided that there is adequate and accurate documentation of the patient’s condition. Of course, individual benefits within the insurance company policy vary. After you are seen for your consultation at our office, we will assist you in determining whether or not your insurance company will cover a particular surgical procedure.

Is distraction osteogenesis painful?

Since all distraction osteogenesis surgical procedures are done while the patient is under general anesthesia, pain during the surgical procedure is not an issue. Postoperatively, you will be supplied with appropriate analgesics (pain killers) to keep you comfortable, and antibiotics to fight off infection. Activation of the distraction device to slowly separate the bones may cause mild discomfort. In general, the slow movement of bony segments produces discomfort roughly similar to having braces tightened.

What are the benefits of distraction osteogenesis vs. traditional surgery for a similar condition?

Distraction osteogenesis surgical procedures typically produce less pain and swelling than the traditional surgical procedure for a similar condition. Distraction osteogenesis eliminates the need for a second surgical site to harvest bone graft material. Lastly, distraction osteogenesis is associated with greater stability when used in major cases where significant movements of bony segments are involved.

What are the disadvantages of distraction osteogenesis?

Distraction osteogenesis requires the patient to return to the surgeon’s office frequently during the initial two weeks after surgery. This is necessary because in this time frame the surgeon will need to closely monitor the patient for any infection and teach the patient how to activate the appliance. In some cases, a second minor office surgical procedure is necessary to remove the distraction appliance.

Can distraction osteogenesis be used instead of bone grafts to add bone to my jaws?

Yes. Recent advances in technology have provided the oral and maxillofacial surgeon with a distraction device that can be used to slowly grow bone in selected areas of bone loss that has occurred in the upper and lower jaws. The newly formed bone can then serve as an excellent foundation for dental implants.

Does distraction osteogenesis leave scars on the face?

No. The entire surgery is performed within the mouth and the distraction devices used remain inside the mouth. There are no facial surgical incisions made, therefore, no facial scars result.

Are there any age limitations for patients who can receive osteogenesis?

No. Distraction osteogenesis works well on patients of all ages. In general, younger the patient shorter the distraction time and faster the consolidation phase. Adults require slightly longer period of distraction and consolidation because the bone regenerative capabilities are slightly slower than those of adolescence or infants

Cleft Lip & Palate

Cleft lip:

During early pregnancy separate areas of a child’s face develop individually and then join together, including the left and right sides of the roof of the mouth and lips. However, if the sections don’t meet the result is a cleft. If the separation occurs in the upper lip, the child is said to have a cleft lip.

A completely formed lip is important not only for a normal facial appearance but also for sucking and to form certain sounds made during speech. A cleft lip is a condition that creates an opening in the upper lip between the mouth and nose. It looks as though there is a split in the lip. It can range from a slight notch in the colored portion of the lip to complete separation in one or both sides of the lip extending up and into the nose. A cleft on one side is called a unilateral cleft. If a cleft occurs on both sides, it is called a bilateral cleft.

A cleft in the gum may occur in association with a cleft lip. This may range from a small notch in the gum to a complete division of the gum into separate parts. A similar defect in the roof of the mouth is called a cleft palate.

Cleft Palate:

The palate is the roof of your mouth. It is made of bone and muscle and is covered by a thin, wet skin that forms the covering inside the mouth. You can feel your own palate by running your tongue over the top of your mouth. Its purpose is to separate your nasal cavity from your mouth. The palate has an extremely important role during speech because when you talk it prevents air from blowing out of your nose instead of your mouth. The palate is also very important when eating; it prevents food and liquids from going up into the nose.

As in cleft lip, a cleft palate occurs in early pregnancy when separate areas of the face develop individually and do not join together properly. A cleft palate occurs when there is an opening in the roof of the mouth. The back of the palate is called the soft palate and the front is known as the hard palate. A cleft palate can range from just an opening at the back of the soft palate to a nearly complete separation of the roof of the mouth (soft and hard palate).

Sometimes a baby with a cleft palate may have a small chin and a few babies with this combination may have difficulties breathing easily. This condition may be called Pierre Robin sequence.

Since the lip and palate develop separately, it is possible for a child to be born with a cleft lip, palate or both. Cleft defects occur in about 1 out of every 800 babies.

Children born with one or both of these conditions usually need the skills of several professionals to manage the problems associated with the defect such as feeding, speech, hearing, and psychological development. In most cases, surgery is recommended. When surgery is done by an experienced, qualified oral and maxillofacial surgeon can be quite positive.

Cleft Lip Treatment

Cleft lip surgery is usually performed when the child is about ten years old. The goal of surgery is to close the separation, restore muscle function, and provide a normal shape to the mouth. The nostril deformity may be improved as a result of the procedure, or may require a subsequent surgery.

Cleft Palate Treatment

A cleft palate is initially treated with surgery safely when the child is between 7 to 18 months old. This depends upon the individual child and his/her own situation. For example, if the child has other associated health problems, it is likely that the surgery will be delayed.

The major goals of surgery are to:

Close the gap or hole between the roof of the mouth and the nose

Reconnect the muscles that make the palate work

Make the repaired palate long enough so that it can perform its function properly

There are many different techniques that surgeons will use to accomplish these goals. The choice of techniques may vary between surgeons and should be discussed between the parents and the surgeon prior to surgery.

The cleft hard palate is generally repaired between the ages of 8 and 12, when the cuspid teeth begin to develop. The procedure involves placement of bone from the hip into the bony defect, and closure of the communication from the nose to the gum tissue in three layers. It may also be performed in teenagers and adults as an individual procedure, or combined with corrective jaw surgery.

What Can Be Expected After The Surgery?

After the palate has been fixed children will immediately have an easier time swallowing food and liquids. However, in about one out of every five children that have the cleft palate repaired, a portion of the repair will split, causing a new hole to form between the nose and mouth. If small, this hole may result in only an occasional minor leakage of fluids into the nose. If large however, it can cause significant eating problems, and most importantly, can even affect how the child speaks. This hole is referred to as a “fistula,” and may need further surgery to correct.

ZYGOMATIC IMPLANTS

We use Zygomatic implants routinely when there is not enough bone for ordinary implants. Zygomatic implants are used to provide support for implant bridgework where there has been a substantial amount of bone lost from the upper jaw, and ordinary dental implants cannot be used on their own to support a bridge.

The implants are longer than ordinary dental implants, and engage the very strong bulk of bone that forms the cheekbone. This means that the implants can be used as an alternative to complex bone grafting operations, making it possible to carry out surgery in just one simple stage.

Typically two Zygomatic implants are used along with 2-4 ordinary dental implants. Where bone availability is even more limited, four zygomatic implants may be used.

We routinely fit a fixed resin bridge on the same day as the implants are placed. This has been incredibly exciting for our patients, most of whom have been able to be rid of their dentures in just one day, (instead of having graft treatments over a 9-18 month period and several different operations, as was previously the case).

Treatment with zygomatic implants is very similar from the patient’s perspective to conventional implant treatment. Treatment usually starts by ‘designing’ the teeth by making a ‘set-up’ arrangement of teeth in the new desired position. As patients who need zygomatic implants have usually lost large amounts of supporting bone, this can make a huge amount of difference to appearance, correcting the ‘collapse’ or loss of face height that is often present where dentures have been worn for a long time.

We use 3D scanning, technology to produce a precise replica model of the upper jaw bone. This allows us to visualize the precise shape and topography of the jaw and cheekbone, without having to carry out a wide surgical exposure. We often also use special ‘guides’ that help us to accurately put implants directly into the correct position. So as to make the experience as comfortable as possible, this sort of treatment usually takes place under intra-venous sedation or general anesthesia.

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