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Orthognathic complications
1.
2. CONTENTS
⢠Presurgical
⢠Intraoperative
⢠Vascular
⢠Neural
⢠Unwanted fragmentation
⢠Post operative
⢠Loss of vascularity : aseptic necrosis
⢠Nose
⢠Lip
⢠Infection
⢠Nonunion/delayed union
⢠Occlusal disturbances
⢠TMJ dysfunction
⢠Relapse
⢠Rare complications
3. âUnintended consequence of the surgery that causes harm
to the patient, occurring either intra-operatively or early
and late post-operatively.â
⢠A complication is so named because it complicates the
situation.
4. ⢠âNo matter what measures are taken, doctors will
sometimes falter, and it isn't reasonable to ask that we
achieve perfection. What is reasonable is to ask that we
never cease to aim for it.â
â˘
â Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science
5. N = 1000 patients (1983-2002)
INTRA AND PERIOPERATIVE COMPLICATIONS OF THE LEFORT IINTRA AND PERIOPERATIVE COMPLICATIONS OF THE LEFORT I
OSTEOTOMY: A PROSPECTIVE EVALUATION OF 1000 PATIENTSOSTEOTOMY: A PROSPECTIVE EVALUATION OF 1000 PATIENTS
Kramer; J CrFac Surg Vol 15,6 Novâ04
6. Incidence of complications and problems related to orthognathic surgeryIncidence of complications and problems related to orthognathic surgery
Su-Gwan Kim, Sun-Sik Park ; JOMS 65;2438-2444,2007
N = 301 (1998-2005)
Neurosensory deficit - IAN - Commonest complication 73.3% - BSSO.
Bleeding in Lefort I â most serious complication â Maxillary a.
Inappropriate fragmentation - 5% - BSSO
7. SUMMARYSUMMARY
⢠Total range of Incidence of complications â 6.4-9.7%
⢠Complication rates: more - craniofacial deformities
⢠Commonest : paresthesia with IAN ď 36%- 91%
⢠Most serious â bleeding (immediate/delayed)
⢠Avg. infection rates :1.1%-4%
⢠Ischemic necrosis rare: more with multiple segmentation
10. Pre-surgical
Lack of pre-treatment objectives
⢠Failure to recognize underlying skeletal abnormality
⢠Unexpected adverse growth
⢠Lack of patient co-operation
⢠Gross skeletal deformity correction:
mainly orthodontics & minimal surgery
11. Inability to perform the ideal procedure
Undesired esthetic and occlusal results
Creation of new problems and revision procedures
Presurgical : Lack of pre treatment objectives
20. Management :
- Visualization of problem area
- Rapid completion of osteotomy: down fracture maxilla
- Packing and direct pressure, vascular clips, electrocautery
Turvey TA, Fonseca RJ: J Oral Surg 38:92, 1980
Intraoperative: Hemorrhage in Maxilla
21. Thomas Teltzrow Journal of Cranio-Maxillofacial Surgery (2005)
33, 307â313
Vessels at risk :
-Inferior alveolar A.
- Internal carotid A.
- Massetric A.
- Retromandibular
vein
- Facial vein
BSSO
medial aspect : Inf alv artery
lower margin: facial a. damage
IVRO
sigmoid notch: Massetric artery
ramus Inferior: Inf Alv artery
Intraoperative: Hemorrhage in Mandible
24. Causes for Inf Alv Nerve damage:
Dissection
Splitting
Movements
Stabilization: comp- injury
Canal - natural pathway for direct nerve regeneration.
Intraoperative: Nerve injuries - Mandible
Predisposing factors?
Low mandibular body height
Inferior position of nerve
25. Inferior alveolar n. injury
Prevention:
Management
Tension-free suturing
of nerve
Osteotomy design
Protection
Chisel placement
Decompression of lateral fragment
Steroids
Intraoperative: Nerve injuries - Mandible
26. Causes:
⢠Retraction medially behind ramus
⢠Extension of distal segment beyond prox. segment
⢠Haematoma
⢠Genioplasty : direct trauma to marginal branch
⢠Sagittal split : direct trauma to trunk
Intraoperative: Nerve injuries âFacial N.
27. Lingual nerve injuries - uncommon
Causes:
⢠Variable course of nerve on medial aspect of mandible
⢠No protection to nerve while stripping on medial aspect
⢠Bicortical screws for BSSO : overpenetration
Intraoperative: Nerve injuries âLingual N
28. ⢠Not studied as thoroughly as mandible
⢠Terminal branches of infra-orbital nerve
⢠Clean incision Gentle dissection retraction
⢠Usually temporary
⢠Recovery 2-8 weeks.
Intraoperative: Nerve injuries âMaxilla
30. âDeviation from osteotomy line during osteotomy procedure,
resulting in osteotomy in area unrelated to surgeryâ
Maxilla Mandible
Intraoperative: Fragmentation
31. Factors:
⢠Bone architecture
⢠Bone density
⢠Unanticipated fractures
⢠Difficult fixation
⢠Impacted third molar
Intraoperative: Fragmentation
32. Sequalae :
⢠Infection
⢠Sequestration of the fragments
⢠Delayed bone healing
⢠Pseudoarthrosis
⢠Post operative instability & Relapse
⢠TMJ
Intraoperative: Fragmentation
34. POSTOPERATIVE
Loss of vascularity : aseptic necrosis
Anatomic variations: Nose, Lips
Nonunion/delayed union
Infection
Occlusal disturbances
TMJ dysfunction
Relapse
35. Aseptic necrosis:
⢠Anterior maxillary osteotomy
⢠Transversal maxillary segmentations
⢠Transection/kinking of vascular pedicle
⢠Major anatomical irregularities
⢠Poor flap design, Tearing of flaps
Postoperative: loss of vascularity - maxilla
36. Consequences :
-Loss of entire maxilla or segment,
-Flattening of papilla, Non vital teeth
Prevention
-Tease out descending palatine vessels during intrusion/retrusion
-Fewer Segmentation: avoid small segments
-Avoid damage to pedicle
Postoperative: loss of vascularity - maxilla
37. ⢠Dr Hall HD -1978.
⢠15 years - medically fit female - Le Fort I osteotomy with maxillary
rib graft augmentation + BSSO + genioplasty
38. ⢠3 stage surgical plan - hyperbaric oxygen + prosthodontics
involvement
⢠Initially 30 treatments of hyperbaric oxygen at 2.4 kPa.
⢠At the first operation- remaining maxillary teeth were removed +
maxillary sinus and necrotic alveolar bone debrided + alveolus
reconstruction with an iliac crest graft secured with miniscrews and
cancellous bone,
39. ⢠Interruption in Inf Alv artery:
- mandibular br of sublingual artery
- mental artery
⢠Complete stripping of mucoperiosteum:
- compromise periosteal blood supply
- medullary supply is already compromised
Osteotomized segment : like free autogenous graft ď
necrosis
Postoperative: loss of vascularity - mandible
41. POSTOPERATIVE
Alteration in Nasal form
- Septum
- Alar Base
Loss of vascularity : aseptic necrosis
Nose
Lip
Nonunion/delayed union
Infection
Open bite and lateral shift
TMJ dysfunction
Relapse
42. Nasal Septum deviation:
- Maxillary impaction : encroachment on Presurgical
dimension of nasal septum
- Maxillary advancement ď buckling
Failure to reposition :
- Septal deviation â obstruction
- Abnormal position of columella/nasal tip
Postoperative: Nose
43. Intraop
- Resection of inferior aspect of septum
- Trim septal spurs if present
- Trim bone from nasal crest of maxilla
- Groove in superior aspect of maxilla
Septal deviation - How to avoid?
Management
-Reoperation
- Delayed septoplasty
Postoperative: Nose
44. Alteration in alar base and perioral structures
⢠Alar base widening
⢠Prominent alar groove
⢠Upturning of nasal tip â obtuse nasolabial angle
⢠Flattening and thinning of upper lip
⢠Downturning of labial commisures
Postoperative: Nose
46. POSTOPERATIVE
Loss of vascularity : aseptic necrosis
Nose
Lip
Nonunion/delayed union
Infection
Occlusal disturbances
TMJ dysfunction
Relapse
Rare Complications
48. POSTOPERATIVE
Loss of vascularity : aseptic necrosis
Nose
Lip
Infection
Nonunion/delayed union
Occlusal disturbances
TMJ dysfunction
Relapse
Rare complications
49. PREVELANCE OF POSTOPERATIVE COMPLICATIONS AFTER
ORTHOGNATHIC SURGERY: A 15-YEAR REVIEW
LOP KEUNG CHOW, BALDEV SINGH, NABIL SAMMAN. JOMS 65:984-992,2007
⢠N = 1294 patients ; 2910 procedures-1070 -bimax; 224-single jaw
⢠Total complication rate â 9.7% (out of this â 7.4% - infection)
⢠Higher infection rate (17.3%) in single pre-op dose of antibiotics than
patients on postop antibiotics
50. POSTOPERATIVE
Loss of vascularity : aseptic necrosis
Nose
Lip
Infection
Nonunion/delayed union
Occlusal disturbances
TMJ dysfunction
Relapse
Blindness
51. Causes
Local compromised blood supply
scarring , large advancement
large bite force - habits
postero-superior positioning
Systemic co-morbities- smoking
Prevention :
principles of fixation techniques
graft Bone gaps > 5mm
auxillary forms of stabilization
Postoperative: Nonunion/delayed union - maxilla
52. Causes :
⢠Instability of fixation devices
⢠Avascular necrosis
⢠Large advancements with less bony contact (>7mm)
⢠Post op trauma
⢠Parafunctional habits
IVRO > BSSO
Postoperative: Nonunion/delayed union - mandible
53. POSTOPERATIVE
Loss of vascularity : aseptic ncecrosis
Nose
Lip
Nonunion/delayed union
Infection
Occlusal disturbances
TMJ dysfunction
Relapse
Rare Complications
54. POSTOPERATIVE - OCCLUSAL DISTURBANCES
- Posterior interference: maxilla when patient in IMF
- Maxilla fixed with condyles out of glenoid fossa
- Hardware Failure - screws and plates
- Fragmentation
- Edema in joints
- Condylar torque, condylar sag, incorrect placement of fragments
- BSSO- failure of rigid fixation at the osteotomy site, occlusal shifts
during fixation, and finally condylar sag
55. Open Bites
Management :
- minor discrepancies ď aggressive orthodontics
- Posterior open bite < 3mm ď vertical elastics
- Severe discrepancies ď surgery
POSTOPERATIVE - OCCLUSAL DISTURBANCES
56. POSTOPERATIVE - OCCLUSAL DISTURBANCES
Lateral shift
Causes:
âInadequate advancement of one side
âEqual advancement with midline shift
âTorqueing of the proximal segment
Management:
âElastic traction
57. Postoperative
Loss of vascularity : aseptic ncecrosis
Nose
Lip
Nonunion/delayed union
Infection
Open bite and lateral shift
TMJ dysfunction
Relapse
Rare Complications
58. Intraoperative position of condyle influenced by:
⢠Incorrect vector during condylar positioning
⢠Incomplete or green-stick split ď prevents condylar seating
⢠Muscular, ligamentous or periosteal interference
⢠Intra-articular hemorrhage or edema
⢠Flexion in proximal segment while placing rigid fixation
POSTOPERATIVE â TMJ DYSFUNCTION
59. ⢠TMDs ď 20-25% in normal population
⢠Karabouta & Martis â 40.8% TMDs post BSSO
⢠White â 49.3%
Condylar Sag
Immediate / late change in position of condyle in the glenoid
fossa after surgical establishment of a preplanned occlusion and
rigid fixation of the bone fragments, leading to a change in the
occlusion
Reyneke ; BJOMS (2002) 40, 285â292
POSTOPERATIVE â TMJ DYSFUNCTION
62. ⢠The condyle is seated with the condylar seating tool + light digital
pressure at the angle
⢠resultant vector is anterosuperior
63.
64.
65.
66. Change in shape of the condyle from normal to finger shaped with
loss of height and later decrease in posterior facial height.
Van Damme JCMS 1994 ; 22, 53-58
Incidence : 2.3% and 7.7% of ď BSSO advancement
Postoperative â TMJ dysfunction
Condylar Resorption
67. POSTOPERATIVE
Loss of vascularity : aseptic ncecrosis
Nose
Lip
Nonunion/delayed union
Infection
Open bite and lateral shift
TMJ dysfunction
Relapse
Rare Complications
68. Stability depends on :
- Adequate presurgical orthodontics
- Long-term maxillomandibular fixation (MMF)
- Nonrigid fixation that allow muscular adaptation
- Minimal muscle alteration
- Good bony contact, and control of the proximal segment
POSTOPERATIVE - RELAPSE
69. Factors :
⢠Magnitude of mandibular advancement or setback,
⢠Stretch of surrounding soft tissue,
⢠Positioning of mandibular condyles
⢠Method of fixation
⢠Growth of mandible
⢠skeletal behavior among hyper/hypodivergent skeletal patterns
POSTOPERATIVE â RELAPSE
MANDIBLE
70. ⢠Obligate relapse after mandibular advancements >7mm
⢠Mandibular setback >12 mm - less skeletal relapse
⢠Closure of anterior open bite with only mandibular osteotomies
POSTOPERATIVE â RELAPSE
MANDIBLE
How to reduce/avoid :
⢠Counterclockwise rotation of the mandible be avoided
⢠Mandibular advancement limited to < 7mm
⢠Bimaxillary surgery
71. Depends on :
⢠Degree of surgical advancement
⢠Degree of inferior repositioning of anterior maxilla
⢠Use of bone grafts in large advancements
POSTOPERATIVE â RELAPSE
MAXILLA
72. Other Causes :
- Increased soft tissue stretching ď results in drift of the
screws during bone healing
- Reduced area of bone contact at the lateral aspects of the
maxilla - compromised union
- Preoperative scarring - Cleft maxilla
Postoperative â Relapse
Maxilla
73. ⢠Postoperative relapse was not considerable after total maxillary
setback surgery.
⢠Although the amount of maxillary setback was greater,
postoperative relapse did not increase significantly.
⢠Significant osseous regeneration at the pterygomaxillary region
occurred in the early phase of recovery.
74. ⢠On average, 18% of the horizontal maxillary repositioning was lost.
⢠Most of the change (89%) occurred during the first 6 months
postoperatively.
⢠Relapse increased significantly with degree of surgical advancement
and degree of inferior repositioning of anterior maxilla.
75. Remedy for prevention:
⢠Advance the maxilla at least 2mm more than the ideal overjet
to compensate for relapse
⢠Provision of a period of MMF (3â4 weeks) in addition to rigid
fixation in large advancements â
Postoperative â Relapse
Maxilla - Management
Van Sickels BJOMS 1996;34:279â85.
76. POSTOPERATIVE
Loss of vascularity : aseptic ncecrosis
Nose
Lip
Nonunion/delayed union
Infection
Open bite and lateral shift
TMJ dysfunction
Relapse
RARE COMPLICATIONS
78. ⢠Abnormalities of the pterygoid plates ranging from mild
hypoplasia to complete absence.
⢠Excessive thickness of the posterior maxillary wall, which is
normally hypoplastic,
79. Devastating complication â mechanism not clear
⢠Immediate swelling eyelids
⢠1st
post-op unable to open eye
⢠Manual lift âno light perception
⢠Intense chemosis, loss of
abduction, pupillary dilatation
88
80. ⢠MRI- NAD
⢠CT- Complex fractures of the pterygoid plates on both sides
greater wing sphenoid, sinus
⢠Bone fragments in inferior orbital fissure
81. PTERYGOMAXILLARY DYSJUNCTION
schuchardt 1942
Maxillary tuberosity
+
Pyramidal process of palatine bone
+
Pterygoid plates of sphenoid
Disarticulated easily during childood (melsen & ousterhout 1987)
Complexity of sutures increases with age
Cause: adverse transmission of forces to skull base via sphenoid bone
Precaution during Pterygomaxillary dysjunction
88. ⢠Statistically significant reduction in intraoperative blood loss
⢠Statistically significant correlation between the surgeon's perception
of the quality of the surgical field and intraoperative blood pressure,
⢠No statistically significant decrease in operative time when
hypotensive anesthesia was used.
89. ⢠3rd
post-op day - CSF discharge - left nostril,
⢠confirmed by laboratory analysis- did not resolve
⢠CT cysternogram was performed.
⢠A lumbar drain was placed and the CSF leak resolved over several
days. There were no long-term sequelae.
90. ⢠Nuerological condition of unknown orgin
⢠Anisocoria-inequality of pupils
⢠Damage to innervation of ciliary muscles / ciliary ganglion
⢠Complete recovery in 48 hours
91.
92.
93. Facial Dysmorphophobia
⢠Distorted perception of oneâs self appearance
⢠Defect may be imagined
⢠Minor defect ď excessive concern
⢠No other mental disorder associated
⢠âDoctor shoppingâ and frequent requests for surgery
⢠History taking â most important
⢠Psychiatric counselling
94. Cognitive behavior therapy (CBT) - effective treatment BDD.
A meta-analysis found CBT more effective than medication after 16
weeks of treatment.
CBT may improve connections between the orbitofrontal cortex and
the amygdala
95. CONVERSION DISORDER,
4-DAY BLUES, DEPRESSION
⢠Arises from the situation that has overwhelmed their usual
ability to cope - hysteria
⢠reassure them of recovery, minimize secondary gain that
may prolong recovery, honest disclosure about diagnosis,
and reinforce
96.
97. OTHERS
⢠Dysphagia- Constricted eosophageal sphincter hypoesthesia
due to change in anatomy of the hyoid region- reduced
tension in supra-hyoid musculature â reduced dilator effect
on sphincter
⢠Perforation of lateral nasal mucosa by fixation screws
⢠OAF, Eustachian tube malfunction- damage TVP
99. âA surgeon who has not come to cross paths with
complications,
is the one who has not operated enough â
100. CONCLUSION
When a true complication occurs, early recognition, rapid
response and effective resolution is essential
101. REFERENCES
Contemporary Oral and Maxillofacial Surgery- Larry J. Peterson
Oral and Maxillofacial Surgery 2nd Edition- Raymond J. Fonseca
volume 3
Essentials of Orthognathic Surgery- Johan P. Reyneke
Online resource via Science-direct & Pub-Med.
Editor's Notes
SURGERY CAN GET MESSED UP EVEN BEFORE YOU OPERATE
ALTERNATELY BASED ON THE MAGNITUDE OF COMPLICATIONS OR LAWYER FEES
When hemodynamics of intramedullary and periosteal circulation are altered in orthognathic surgery, many cortical, medullary and soft tissue blood vessels become more functional
Superior reposition of maxilla ď increase in cross-sec area ď decrease airway resistance ď increase in breathing.
large bite force â parafunctional habits
postero-superior positioning of maxilla ď insufficient bony interface.
Central sag :
Condyle positioned inferiorly in the glenoid fossa ď no contact with fossa (Fig. 1A).
Removal of the IMF and in the absence of intracapsular edema or hemarthrosis, the condyle moves superiorly ď malocclusion
Peripheral sag:
Type 1 : condyle positioned inferior with peripheral fossa contact .
Type 2 : correct condyle position in fossa, , incorrect rigid fixation ď flexural stress in the proximal segment
To reduce the increased anterior facial height in patients with a hyperdivergent facial pattern, for example, surgeons might rotate the mandible counterclockwise. This movement is considered to be an unfavorable movement leading to relapse.