complications in orthognathic surgey
TRANSCRIPT
Chaitanya diviPg, dept of omfsSibar dental college
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
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A complication is so named because it complicates the situation.
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“No 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.”
― Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science
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Pre-surgical Intra - operativePost – operative
Dimitroulis 1998 J Adult Orthod Orthognath Surg
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Lack of pre treatment objectives
Laboratory errors
Orthodontics
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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
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Inability to perform the ideal procedure
Undesired esthetic and occlusal results
Creation of new problems and revision procedures
Presurgical : Lack of pre treatment objectives
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Unsatisfactory bite registration
Discrepancy in mounting the cast
Improper model surgery
Warpage of splints
Presurgical : Laboratory errors
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Insufficient decompensation Inadequate transverse coordination Uncorrected tooth size problems Inadequate preoperative root divergence in segmental surgery Active orthodontic wires at surgery Orthodontic appliances
Presurgical : Orthodontics
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Presurgical
Intraoperative
Post operative.
Vascular - Hemorrhage Neural Fragmentation
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Incidence : 1-1.1%
Causes:- Supra-periosteal reflection- Posterior wall osteotomy cut directed superiorly - Forced downfracture and mobilization of maxilla- Elevation of nasal mucosa from nasal floor
Intraoperative: Hemorrhage in Maxilla
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Intraoperative: Hemorrhage in Maxilla
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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
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Thomas Teltzrow Journal of Cranio-Maxillofacial Surgery (2005) 33, 307–313
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
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Intraoperative
Vascular
Neural
Unwanted fragmentation
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Neuropraxia
Axonotemesis
Neurotemesis
Intraoperative: Nerve injuries
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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
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Prevention:Management
Tension-free suturing of nerve
Osteotomy designProtectionChisel placementDecompression of lateral fragment
Intraoperative: Nerve injuries - Mandible
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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 –Facial N.
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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 –Lingual N
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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 –Maxilla
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Intraoperative
Vascular
Neural
Unwanted fragmentation
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“Deviation from osteotomy line during osteotomy procedure, resulting in osteotomy in area unrelated to surgery”
Maxilla Mandible
Intraoperative: Fragmentation
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Factors:
Bone architecture Bone density Unanticipated fractures Difficult fixation Impacted third molar
Intraoperative: Fragmentation
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Sequalae : Infection Sequestration of the fragments Delayed bone healing Pseudoarthrosis Post operative instability & Relapse TMJ
Intraoperative: Fragmentation
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Presurgical
Intraoperative
Post operative
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POSTOPERATIVE
Loss of vascularity : aseptic necrosis Anatomic variations: Nose, Lips Nonunion/delayed union Infection Occlusal disturbances TMJ dysfunction Relapse
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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
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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
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Dr Hall HD -1978.
15 years - medically fit female - Le Fort I osteotomy with maxillary rib graft augmentation + BSSO + genioplasty
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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,
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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 necrosis
Postoperative: loss of vascularity - mandible
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Risk in IVRO > BSSO Maintain buccal & lingual pedicles in extensive
genioplasty Excess advancement: stretches nutrient vessel
• Ischemic tissue: intraoral free graft.• Meticulous irrigation – supportive therapy• HBO therapy promotes neovascularization• Reconstruction
Management
Postoperative: loss of vascularity - mandible
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Loss of vascularity : aseptic necrosisNoseLipNonunion/delayed unionInfectionOpen bite and lateral shiftTMJ dysfunctionRelapse Alteration in Nasal form
- Septum - Alar Base
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Nasal Septum deviation:- Maxillary impaction : encroachment on
Presurgical dimension of nasal septum- Maxillary advancement buckling
Failure to reposition : - Septal deviation – obstruction- Abnormal position of columella/nasal tip
Postoperative: Nose
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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
Management-Reoperation- Delayed septoplasty
Postoperative: Nose
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Alteration in alar base and perioral structures
Alar base widening Prominent alar groove Upturning of nasal tip – obtuse nasolabial angle Flattening and thinning of upper lip Downturning of labial commisures
Postoperative: Nose
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Alar cinch suture
Pyriformplasty
Alteration in alar base and perioral structures
Postoperative: Nose
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Postoperative: Lip
V-Y closure of the lip is done to prevent the shortening of the lip.
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N = 1294 patients ; 2910 procedures-1070 -bimax; 224-single jaw Total complication rate – 9.7% (out of this – 7.4% - infection) Higher infection rate (17.3%) in single pre-op dose of antibiotics than
patients on postop antibiotics
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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
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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
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- 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
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Open BitesManagement :- minor discrepancies aggressive orthodontics- Posterior open bite < 3mm vertical elastics- Severe discrepancies surgery
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Lateral shift Causes:
◦Inadequate advancement of one side ◦Equal advancement with midline shift◦Torqueing of the proximal segmentManagement: ◦Elastic traction
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Intraoperative position of condyle influenced by: Incorrect vector during condylar positioning Incomplete or green-stick split prevents condylar
seating Muscular, ligamentous or periosteal interference Intra-articular hemorrhage or edema Flexion in proximal segment while placing rigid fixation
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TMDs 20-25% in normal population Karabouta & Martis – 40.8% TMDs post BSSO White – 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, 285–292
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Central Peripheral I & II
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The condyle is seated with the condylar seating tool + light digital pressure at the angle
resultant vector is anterosuperior
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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 BSSO advancement
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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
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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
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Obligate relapse after mandibular advancements >7mm Mandibular setback >12 mm - less skeletal relapse Closure of anterior open bite with only mandibular
osteotomies How to reduce/avoid : • Counterclockwise rotation of the mandible be avoided• Mandibular advancement limited to < 7mm• Bimaxillary surgery
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Depends on :
Degree of surgical advancement Degree of inferior repositioning of anterior Use of bone grafts in large advancements
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Other Causes : - Increased soft tissue stretching 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
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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.
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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.
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Remedy for prevention:
Advance the maxilla at least 2mm more than the ideal overjet to compensate for relapse
Provision of a period of MMF (3—4 weeks) in addition to rigid fixation in large advancements –
Postoperative – RelapseMaxilla - Management
Van Sickels BJOMS 1996;34:279—85.
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RARE COMPICATIONS
BLINDNESS (vasculature damage/hypoxia)LOSS OF FUNCTION OF LACRIMINAL GLAND
CRANIAL NERVE PALSIESDAMAGE TO INTERNAL CAROTID ARTERY
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Devastating complication – mechanism not clear Immediate swelling eyelids
1st post-op unable to open eye
Manual lift –no light perception
Intense chemosis, loss of abduction, pupillary dilatation
88
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Maxillary tuberosity + Pyramidal process of palatine bone +Pterygoid plates of sphenoid
Disarticulated easily during childood (melsen & ousterhout 1987)Complexity of sutures increases with ageCause: adverse transmission of forces to skull base via sphenoid bonePrecaution during Pterygomaxillary dysjunction
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RARE COMPICATIONS
BLINDNESS (vasculature damage/hypoxia)
LOSS OF FUNCTION OF LACRIMINAL GLAND
CRANIAL NERVE PALSIES
DAMAGE TO INTERNAL CAROTID ARTERY
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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.
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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.
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Distorted perception of one’s self appearance Defect may be imagined Minor defect excessive concern No other mental disorder associated ‘Doctor shopping’ and frequent requests for surgery History taking – most important Psychiatric counselling
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Cognitive behavior therapy (CBT) –
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
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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
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Dysphagia- Constricted eosophageal sphincter hypoesthesia due to change in anatomy of the hyoid region- reduced tension in supra-hyoid musculature – reduced dilator effect on sphincter
Perforation of lateral nasal mucosa by fixation screws
OAF, Eustachian tube malfunction- damage TVP
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“A surgeon who has not come to cross paths with complications,
is the one who has not operated enough ”
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When a true complication occurs, early recognition, rapid response and effective resolution is essential
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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.
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