Published on February 25, 2014
Complications of orthognathic surgery GUIDE: DR. APOORVA MOWAR READER
Unusual and rare complications of orthognathic surgery: A Literature Review BEN J. STEEL AND MARTIN R. COPE J ORAL MAXILLOFAC SURG 70: 1678-1691, 2012
Complication : Unintended consequence of the surgery that causes harm to the patient, occurring either intra operatively or early and late postoperatively. (Ben J Steel et al JOMS 2012)
Common complications Post operative nausea Instrument fracture Foreign body and vomiting Infection Excessive bleeding Soft tissue damage Localized skin burns Loss of pulpal vitality Periodontal disease Gingival recession Nerve exposure Temporary taste disturbance Instrument/ screw loss Bad split Malunion Condylar resorption TMJ effects Relapse- skeletal/ dental Respiratory difficulty Screw loosening Neck pain malocclusion
During surgery After surgery
Complications seen during surgery Segmented boney fragments Excessive bleeding Soft tissue damage Nerve exposure Instrument fracture Tooth damage
Post operative complications Sensory impairment Respiratory difficulty Neck pain Anterior open bite Gastro intestinal diseases TMJ dysfuntion Condylar resorption
Inappropriate bone fragmentation Sagital split osteotomy 5% 14 % Kim and Park 2007 MacIntosh 1981
Inappropriate bone fragmentation Sequestrum formation Delayed union Non union Fibrotic union
Excessive bleeding Acc to Behrman one quarter of the surgeons reported maxillary, inferior alveolar and facial arteries Sagital split osteotomy 2% 10.7 % Kim and parker 2007 MacIntosh 1981 Lefort I procedure 1.5 % Kim and parker 2007
Bleeding from Inferior Alveolar artery : severance of the vessel by a sharp tool. artery is torn by distal bone fragment Bleeding can be prevented by limiting the depth of the instrument penetration and accurately evaluating the nerve and the vascular structure before osteotomy. Bleeding from facial artery: Dissection Osteotomy of the mandibular margin Avoided by limiting the instrument to the lower margin of the periosteum
Other vessels that may be damaged: Lefort I procedure: 0-0.7% Descending palatine Sphenopalatine Pterygoid venous plexuses
Management of hemorrhage Visualization of the problem area. Completion of osteotomy to allow application of direct pressure, vascular clips or electrocautery. Deliberate controlled hypotension Intravascular fluids and blood transfusion. Anterior and posterior nasal packing ECA ligation Embolisation of the maxillary artery.
Tooth damage 1 % Kim and Parker 2007 in Lefort I osteotomy and genioplasty combined with anterior subapical osteotomy.
Soft tissue injury 2 % Kim and Parker 2007 Prolonged traction on the lips or mucosa to secure the operative field and facilitate access Surgical instrument can scrape soft tissue. Vaseline or antibacterial ointment before and after surgery to prevent soft tissue laceration and abrasion.
Neurologic Complications Infraorbital, inferior alveolar and lingual nerves are in close proximity to osteotomy cuts Inferior alveolar nerve lies in the path of instrumentation and is at risk for transection. Inferior alveolar nerve 73.3% 27.8% (> 1 year) Kim and Parker 2007 Ow and Cheung 2009 Lingual nerve 9.3 % 18% 19.4% Al-Bishri et al 2004 Cunningham et al 1996 Jacks et al 1998
Inferior alveolar nerve Paresthesia Post operatively 63.3 % 7 days 49.2 % 14 days 42.5% 1 month 33% 6 month 12.8% 1 year (Ben J Steel et al JOMS 2012)
Inferior alveolar nerve Paresthesia Nerve distraction & secession Cut ----bone dissection Tear ----- separation & movement of the distal and proximal segment. Compression injury during stabilization of the distal fragments. Large mandibular advancement Unfavorable fracture
Facial nerve palsy 0.26 % per side (9 patients) De Vries et al 95 % in set back procedure Choi et al ---0.1 % Majority of the palsies recover within a period of few weeks to a year after injury (Lanigan and Hohn).
In mandibular advancement (laningan and Hohn) High level subcondylar fracture-----condylar neck positioned more posteriorly, thus applying traction to the main trunk of the nerve Traction to the nerve caused by placement of pressure pack in the retromolar area. Other causes: Direct trauma by retractor placement Nerve ischemia (reflex sympathetic vasospasm) Fracture and posterior displacement of styloid process Compression by post operative edema
1. Frey syndrome: (Guerissi and Stoyanoff) 6 months after lefort I osteotomy (Obwegeser technique) Due to aberrant regeneration of secretomotor fibers from the Auriculotemporal nerve entering the long buccal nerve as a result of direct surgical trauma to the former. 2. Bilateral hypoesthesia in the dermatome of the mylohyoid nerve (genioplasty) Direct trauma from the bone saw Normal sensation returned within 6 months. 3. Palsy of X, XI, XII ((Baddour et al ) Life threatening intra operative bleeding. Maxillary down fracture Insertion of pressure pack to control bleeding. At the time of pterygomaxillary dysjunction ------pterygoid complex got detached----sharp piece of bone posteriorly-----lacerating the vessels and causing vascular injury.
4. Secretomotor rhinopathy: (Marais and Brookes) Rhinorrhea + lacrimal hypersectretion 3 days post operatively (Lefort I) Sphenopalatine ganglion dysfunction by a local hematoma or fibrous organization shifting the autonomic balane towards a parasympathetic predominance. 5. Reduced hearing -----cleft patients + Lefort I (Gotzfried and Thumfart) Edema/ hematoma formation in the eustachain tubes.
Abducens and occulomotor nerve palsy ----lefort I osteotomy Cavernous sinus thrombosis Subarachnoid haemorrhage Hematoma Fracture of pterygoid plate----blood in the right side of the sphenoid sinus Direct trauma to the medial aspect of the cavernous sinus Pre- existing carotid aneurysm Fracture of superior orbital fissure
Optic nerve palsy---lefort I 9 reported cases Arterial aneurysm Propogation of pterygomaxillary dysjunction fracture through the skull base (Girotto et al) Hypoperfusion of optic nerve
Respiratory difficulty Gasping and wheezing Patient may breath much faster or slowly than normal Breathing may be deeper / more shallow Skin appearance and temperature----moist and flushed; pale, ashen or cyanotic and feel cool to touch Pain and tightness in chest Paresthesia of the hands, feet or lips
Infection Without antibiotics----rate of infection 10 – 15% Tucker and Ochs----2.4% - mandibular procedure 0.5% - maxillary procedures kim and Park--- 1 % Baker et al -----a case of brain abscess- lefort I osteotomy 6 cases of actinomycosis
Infection Hinders normal healing Prolongs entire healing period Cause--- subcutaneous hematomas serous exudates previously infected tissues or irradiated tissues
Infection Factors-- Age Length of surgery Type of orthognathic procedure Use of prophylactic antibiotics Chow et al JOMS 2007
Short term Vs Long term course of antibiotics Lindeboom et al 600 mg clindamycin I/V Single dose---5.6% Single day ----2.8% No statistical difference Fridrich et al High dose short term therapy---7.1% Long term therapy---6.3% No statistical difference Baquain et al Short term Vs long term No statistical difference Danda et al Single dose (1 gm ampicillin I/V)----9.3% Single day (1 Gm + 500 mg ampicillin I/V)-----2.7% No statistical difference Bentley et al Long term group---6.7% Short term group---- 60% Statistically significant Chow et al Single dose---17.3% Multiple dose (2-14 days)--5.1% Statistically signifcant
Microbiology Complex endogenous oral bacteria Polymicrobial Aerobic and anaerobic gram positive cocci and gram negative rods Anaerobic----gram negative bacteroids Aerobic----hemolytic streptococcus Chow et al JOMS 2007
Skeletal and bony complications Condylar resorption TMJ dysfunction Osteonecrosis of maxilla/ mandible Avulsion of maxilla
Condylar resorption 1- 31% 6.1% BSSO Pre existing TMJ internal derangement. High mandibular plane angle Posteriorly inclined condylar neck Large advancements Ow and Cheung 2009
Osteonecrosis of maxilla 1 case of sloughed off maxilla (entire maxilla) Laningan et al – 51 cases of partial necrosis Maxillary central incisor pulp, whole of alveolar ridge or all of the premaxilla. Treatment Hyperbaric oxygen therapy Iliac crest graft Implant supported prosthodontics
Osteonecrosis of mandible Six cases---1990 Ovezealous stripping of pterygomassetric sling
Avulsion of maxilla Intraoperative complication Bendor- Samuel et al ---- avulsion of left hemi maxilla and palate in a 20 year male patient with repaired bilateral cleft lip and palate undergoing lefort I tpe osteotomy with iliac crest bone graft.
Anterior open bite Higher tendency in high angle patients when mandible is advanced. Distal fragment is rotated counterclock wise to achieve proper occlusion Stretches suprahyoid muscle and pterygomassetric sling thereby contributing the tendency towards relapse. Sn-MeGo angle > 32 degrees
Ophthalmic complications Lack of tearing Lefort I osteotomy Excessive tearing Damage to greater petrosal/ vidian nerve --interrupt parasympathetic supply to the lacrimal gland. Nasolacrimal duct damage Hemolacria (bleeding from lacrimal puncta) Lefort I osteotomy Retrobulbar hemorrhage Bilateral posterior segmental maxillary osteotomies Minor surgical trauma to the vessels in the nasal wall accompanied by a small tear in the nasolacrimal duct
Anaesthetic complications Malignant hyperpyrexia Herniation of the airway tube cuff Sectioning of the endotracheal tube
Psychological complication Conversion disorder Depression 4- day Blues Postsurgical discomfort, pain and neurologic disturbance were found to correlate with postsurgical altered emotional state.
Other complications: Dysphagia -----constricted eosophageal sphincter--- hypoestesia due to change in anatomy of the hyoid region, which may have led to reduced tension in the suprahyoid musculature and hence reduced dilator effect on sphincter Perforation of the lateral nasal mucosa by fixation screws Oroantral and oronasal fisula Eustachain tube malfuncion----due to damage to tensor veli palatini Dental malocclusion---skeletal / dental relapse.
Conclusion When a true complication occurs early recognition, rapid response and effective resolution are essential.
Reoperations 16 (3%) Counterclockwise rotation of proximal segment 5 Severe secondary bleeding/ gross swelling 6 Infection 26 Maxillary sinusitis 6 Acne on chin 5 Root injured by drill 10 Severe relapse 16 (3%) Mild relapse 50 (8%) Occlusal outcome unsatisfactory 15 (3%) Mild neurosensory deficit of IAN 183 (32%) Disturbing neurosensory deficit of IAN 18 (3%) Condylar resorption---total partial 58 (11%) 30 TMJ problems 167 (29%) Osteosynthesis material removed 48 (8%) Panula et al JOMS 2001
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