Expert: Joel S. Teig, DMD, Diplomate ABOMS, retired - 1/5/2010

Question
QUESTION: Hi:

Thank you very much explaining why the RPE and expansion of the maxilla most likely caused a pocket in my cheek leaving a depression. However, may I ask: the pocket occurred only on the left side and not my right so, why only one side and not bilateral? I attached a photo of my face to show the left cheek v. right cheek

Rod

ANSWER: Rod -  From viewing the picture you provided it appears that the left cheek depression is not from poor alignment of bone.  Rather, the localized depression that I see in your picture often indicates a scar tissue depression.  The scar tissue is often from an infection that healed creating fibrous tissue (scar like tissue) that caused the cheek to become bound down to the bone.  Without seeing you xrays, I cannot be sure of the cause, but the location is over the sinus.  The depression could be from a sinus problem with a hole in the bone at the depression.  Again, I cannot be sure without examining you, but that is the appearance.  

I don't remember if you have gone back to the doctor who did the surgery to discuss this depression.  If not, do that.  If the doctor was seen and gave you no answer, you need to be examined by another board certified oral and maxillofacial surgeon.  Just so you know, the repair of that depression can, most likely, be corrected with placement of implant material under the tissue.

So get yourself evaluated by either your surgeon or a different one.  If you have additional questions or need the name of a different surgeon in your area, you can get back to me, tell me where you live and I can provide names.

---------- FOLLOW-UP ----------

QUESTION: Hi Teig:

So just to clarify. The pocket in the cheek was not caused most likely by the expansion of the maxilla by the rapid palatal expander which you first suggested, but rather by an infection? I have attached an Xray: anterior-posterior taken at the Health Sciences on Dec 12th. I hope it can help.

So, if the depression resulted from an infection the bigger question is then what caused the infection? My first surgery was Dec 07 and I have been wearing braces every since. My second surgery is in Feb which at that time the surgeon will move forward my maxilla by about 6 inches.

I am hoping to get evaluated by another maxilla facial surgeon in my area, St. John's Newfoundland. His name is Dr. Poon.

Thanks, Rod

ANSWER: Rod - I may have been limiting in what I said about an infection cause.  Infections can cause it if the infection resolves and scars down the tissues to the bone, producing the depression.  It is also possible that during the surgery for the expansion the doctor trapped tissue and that also could have also produced a depression.  In that situation, a surgical release from inside your mouth could regain normal anatomy in the area. Before this next surgery, it is important to discuss the depression with the doctor in advance of the surgery.  The doctor, besides advancing the maxilla, needs to determine the cause of the depression and release it.  

I think getting a second opinion from Dr. Poon, who is a board certified oral and maxillofacial surgeon is a good idea.  Regaining the normal anatomy with releasing of the depression cause is important for the overall cosmetic result.

---------- FOLLOW-UP ----------

QUESTION: Hi Dr. Teig:

Thank you following up to my questions about why I have a depression in my left cheek. I hope the general public benefit from such discussion then follow up with their surgeon.

Overall, it appears that there are many explanations (infection, scarring, etc.) why a depression has appeared on my left cheek, but would it help you lean toward any particular explanation knowing that when I pinch both my left and right cheek I notice a discernable difference in the amount of soft tissue I am pinching? In other words, my left cheek appears to have less soft tissue (ie., fat) than my right cheek.

Finally, what diagnostic test (eg., CT scan) would most help with diagnosis?

Thanks, Rod  

Answer
Eos - It doesn't matter which is the cause, now there is excessive scarring and that is causing the depression.  An MRI might give a better definition, but whatever the cause, the repair, if you choose to have it must be done by a surgeon who knows how to release the area and possibly fill the soft tissue space created in the release.