a comprehensive review of various complications of orthognathic surgery

2. Complications of orthognathic
surgery
GUIDE: DR. APOORVA MOWAR
READER

3. 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

4. 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)

5. 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

6.  During surgery
 After surgery

7. Complications seen during surgery
 Segmented boney fragments
 Excessive bleeding
 Soft tissue damage
 Nerve exposure
 Instrument fracture
 Tooth damage

8. Post operative complications
 Sensory impairment
 Respiratory difficulty
 Neck pain
 Anterior open bite
 Gastro intestinal diseases
 TMJ dysfuntion
 Condylar resorption

9. Inappropriate bone fragmentation
Sagital split osteotomy
5%
14 %
Kim and Park 2007
MacIntosh 1981

10. Inappropriate bone fragmentation
 Sequestrum formation
 Delayed union
 Non union
 Fibrotic union

11. 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

12.  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

13. Other vessels that may be damaged:
 Lefort I procedure: 0-0.7%
 Descending palatine
 Sphenopalatine
 Pterygoid venous plexuses

14. 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.

15. Tooth damage
 1 % Kim and Parker 2007 in Lefort I osteotomy and
genioplasty combined with anterior subapical
osteotomy.

16. 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.

17. 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

18. 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)

19. 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

20. 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).

21.  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

22. 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.

23. 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.

24. 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

25. 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

26. 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

27. 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

28. Infection
 Hinders normal healing
 Prolongs entire healing period
 Cause--- subcutaneous hematomas
serous exudates
previously infected tissues or irradiated
tissues

29. Infection
 Factors-- Age
 Length of surgery
 Type of orthognathic procedure
 Use of prophylactic antibiotics
Chow et al JOMS 2007

30. 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

31. 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

32. Skeletal and bony complications
 Condylar resorption
 TMJ dysfunction
 Osteonecrosis of maxilla/ mandible
 Avulsion of maxilla

33. 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

34. 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

35. Osteonecrosis of mandible
 Six cases---1990
 Ovezealous stripping of pterygomassetric sling

36. 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.

37. 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

38. 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

39. Anaesthetic complications
 Malignant hyperpyrexia
 Herniation of the airway tube cuff
 Sectioning of the endotracheal tube

40. Psychological complication
 Conversion disorder
 Depression
 4- day Blues
 Postsurgical discomfort, pain and neurologic
disturbance were found to correlate with postsurgical
altered emotional state.

41. 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.

42. Conclusion
 When a true complication occurs early recognition,
rapid response and effective resolution are essential.

45. 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