Continuing Medical Education Complications of Orthognathic ...
Continuing Medical EducationComplications of Orthognathic SurgeryPravin K. Patel, MD, FACS,* David Erik Morris, MD,1 Andrew Gassman, MD2Complications in orthognathic surgery may stem & unfavorable aesthetic changes that may resultfrom occurrences at anyone of many time points from orthognathic surgery.during the course of the patient’s treatment: pre- & pertinent issues in performing orthognathicoperative judgment and planning, perioperative surgery in the older patient.orthodontic care, or intraoperatively. This article 2. List the...specifically addresses those complications that arise & complications specifically associated with max-as a result of intraoperative technique. Such illary osteotomy.complications may broadly be characterized as & complications specifically associated with man-airway, vascular, neurologic, infectious, skeletal, dibular osteotomy. & points in intraoperative airway managementor aesthetic in nature. For each type, specific and avoiding endotracheal tube damage .complications, their prevention, and their treatment & points in avoiding and treating intraoperativeare discussed. hemorrhage.Key Words: Orthognathic, maxillofacial, complications 3. Recall the... & blood supply to the osteotomized segments following LeFort 1 and bilateral sagittal splitTARGET AUDIENCE mandibular osteotomies.This CME activity is intended for craniofacial & specific neurologic deficits that may accompanysurgeons, pediatric plastic surgeons, maxillofacial maxillary and mandibular osteotomies andsurgeons, and other physicians with an interest in the genioplasty.diagnosis, management and treatment of craniofacial & technical points in avoiding unfavorableabnormalities and other congenital disorders. osteotomies.LEARNING OBJECTIVES O rthognathic surgery is unique in thatAfter completing this activity, a physician should be the surgical procedure necessarily takesable to: place within a temporal context of pre-1. Describe the... surgical orthodontic preparation, surgical planning, the procedure itself, and postsurgical & most common complications occurring with orthodontic completion. An optimal result relies on maxillary and mandibular osteotomies. success at each of these stages and on close collabora- *Associate Professor of Surgery and Neurosurgery, Feinberg tion between the surgeon and the orthodontistSchool of Medicine, Northwestern University, Chief of Plastic & throughout the duration of treatment. As a corollary,Maxillofacial Surgery, Shriners Hospitals for Children, and Chief, complications may arise from shortcomings at anyCranioMaxillofacial Surgery, The Craniofacial Center and the stage of treatment. Although all are interrelated,Division of Plastic Surgery, University of Illinois School ofMedicine; 1Assistant Professor of Surgery, The Craniofacial Center this article focuses primarily on those complicationsand the Division of Plastic Surgery, University of Illinois at that originate with the orthognathic procedure.Chicago, School of Medicine, and Attending Surgeon, Plastic and For a surgeon to optimize results while bothMaxillofacial Surgery, Shriners Hospitals for Children, Chicago;and 2General Surgery Resident, Department of Surgery, Loyola minimizing complications and striving to performUniversity Medical Center, Maywood, Illinois. procedures safely, it is prudent for the surgeon to The Authors have disclosed that they have no significant periodically assess his or her approach. The goal ofrelationships with or financial interest in any commercial this article is to review those complications that occurcompanies that pertains to this educational activity. during orthognathic surgery. In doing so, we cite key Lippincott CME Institute has identified and resolved all faculty contributions from important previous works thatconflicts of interest regarding this educational activity. Address correspondence and reprint requests to Dr. Pravin K. have addressed complications, whereas we alsoPatel, The Craniofacial Center, University of Illinois at Chicago, 811 include examples of complications that we haveS. Paulina Street, Chicago, IL 60607; E-mail: email@example.com encountered to better illustrate points. In addressing 975 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 18, NUMBER 4 July 2007Table 1. Complications Classified by Type and the specific treatment objectives and goals that can and can not be achieved. The surgeon must notAirwayVascular underestimate the psychological impact that theHemorrhage change in facial appearance and the stress of theVascular compromise postoperative recovery might have on the patient.Neurologic While the surgeon and the orthodontist might beInfectiousSkeletal pleased with the aesthetic outcome, the patient mayUnfavorable osteotomy not be. Many centers, including that of the authors,Tooth injury insist that patients meet with the center’s psycholo-NonunionPostoperative malocclusion gist pre- and postoperatively. Family members,Temporomandibular joint disorders spouse, or significant other should be stronglyUnfavorable aesthetic result encouraged to attend such discussions, because postoperatively these people, sometimes more so than the patient, may have difficulty adjusting to the change in appearance, not willing to accept aprevention of complications, we focus on points that change from the person who was always familiar tohave been well documented; other points raised are them. These points particularly apply to certainpearls that our mentors and predecessors have groups of patients: those with bimaxillary protru-gratefully taught us. Finally, some are lessons that sion and older patients. Patients with bimaxillarywe have painfully learned through treating compli- protrusion carry the greatest risk of assuming acations we have encountered. postoperative ‘‘aged’’ appearance as a result of relaxation of the soft tissues of the midface afterPREOPERATIVE CONSIDERATIONS LeFort I osteotomy with posterior positioning. The surgeon should be forceful during the preoperativeM inimizing intraoperative complications begins with a clear operative plan that is basedon accurate preoperative anatomic and functional discussion with older patients, particularly in those over 30 years of age. This is for two reasons; first, younger patients seem to more easily adjust to theirevaluation by both the orthodontist and surgeon. change in appearance than do older patients. Second,Although orthodontic evaluation and planning is the soft tissue changes of younger patients are morebeyond the scope of this article, a few salient points predictable and reflective of underlying skeletalare worthwhile. First, the patient should be evalu- changes than those of older patients with lessated as early as possible by both the orthodontist compliant soft tissues.and the surgeon to facilitate collaboration from theoutset of care. When there is a strong likelihood that SURGICALLY RELATED COMPLICATIONSsurgery will be indicated, this discussion ideally isbefore the start of orthodontic treatment. Second,as early as possible, the surgeon and orthodontistshould together make a realistic expectation for the C omplications that may occur with surgery are outlined in Table 1. The following discussion is arranged by type of complication. Within the discus-treatment timeline, including length of time for pre- sion of each type, those associated with the maxilla,operative orthodontics, timing of surgery, and length the mandible, and the chin are addressed separatelyof time for postsurgical orthodontics. The patient (Tables 2Y5).should be part of this discussion from the outset.This helps to avoid the psychologic toll on patientsand especially among teenagers resulting from a Table 2. Complications Specifically Associated Withlong period of orthodontic treatment in an effort to Maxillary Osteotomyavoid surgery followed by an inevitable recommen-dation of surgery to a tired, dissatisfied patient. This Nasal septal deviation Infraorbital nerve traction injuryalso is the time for a realistic discussion of any fi- Unanticipated fracture (pterygoid plate, sphenoid bone, middle cranial fossa)nancial commitment that would be required of the Injury to internal maxillary artery or branchespatient or family rather than in the midst of treat- Arteriovenous fistulas (carotidYcavernous sinus)ment when surgery becomes inevitable. Ophthalmic injury Lacrimal duct injury It is important that the patient, the orthodontist, Maxillary sinusitisand the surgeon have a common understanding of Velopharyngeal insufficiencythe patient’s facial aesthetic and functional concerns976 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
COMPLICATIONS OF ORTHOGNATHIC SURGERY / Patel et alTable 3. Complications Specifically Associated With fixation have reduced the likelihood of prolongedMandibular Osteotomy postoperative intubation.6,7 Intermaxillary fixation increases airway resistance, reducing peak air flow,Inferior alveolar nerve injuryHemorrhage (inferior alveolar artery, masseteric artery) and patients who have undergone a LeFort I procedureCondylar resorption in addition will necessarily have some degree of nasalMalpositioned segment(s) airway obstruction.8,9 For these reasons, many prefer no maxillaryYmandibular fixation or only guiding elastics during the immediate recovery period.Airway Postoperative septal deviation and airway obstruction may result from LeFort I osteotomy.Airway management is critical because nasoendotra- Nasal asymmetry and preexisting septal deviationcheal intubation is necessary to facilitate intraopera- should be identified preoperatively. Intraoperatively,tive maxillaryYmandibular fixation. Nasal intubation careful attention must be placed on the positions ofcan be difficult in patients with clefts requiring the anterior nasal spine, septal cartilage, and vomer.orthognathic surgery who have previously undergone Failure to shorten these structures during maxillarya pharyngeal flap. Intubation can be accomplished impaction will force them from the midline, causingwith fiberoptic guidance or exchange over a stent after buckling and nasal airway obstruction.oral intubation. Occasionally, nasal intubation is notpossible and, although less preferable, the procedure Oronasal Fistulacan be accomplished with orotracheal intubation andwith the oral tube positioned retromolar at the time of Oronasal fistulae, although rare, may occur aftermaxillaryYmandibular fixation. This is frequently segmental maxillary osteotomies. These tend to occurawkward, however, and unplanned extubation may along the anterior hard palate. In general, palatal ex-be more likely to occur. During LeFort I osteotomy, pansion greater than 8 mm increases the risk of softthe nasotracheal tube is particularly at risk at the times tissue breakdown.10 Intraoperatively, care should beof septalYvomerine dysjunction and with the osteot- taken to avoid tears in the palatal mucosa. If pri-omy of the lateral nasal wall on the side of the tube. mary repair is not possible, then closure using aThe tube itself or the tube to its balloon can be bone graft should be considered. Small fistulae tendlacerated or transected by the osteotome or by the to close spontaneously. When the oral nasal fistulareciprocating saw (Fig 1).1Y4 In the case of complete are significant in size, palatal flaps can not be ele-transection, immediate air leak or loss of air exchange vated for primary closure to maintain blood sup-is evident with blood within the endotracheal tube. ply at the time of the initial surgery and will require To prevent endotracheal tube injury, it is prefer- a secondary procedure for closure. Postoperatively,able to first perform the septal dysjunction with a patients should be advised to avoid intense noseguarded osteotome; this facilitates placement of the blowing.reciprocating saw, because the septum and nasotra-cheal tube are deflected to the opposite side, decreasing Velopharyngeal Insufficiencyrisk of injury to the tube. The maxillary osteotomy with Velopharyngeal insufficiency is most likely to occura reciprocating saw should be directed from medial to in individuals with a history of cleft palate and inlateral, thus directed away from the nasotracheal tube. those patients having some degree of velopharyngealIf, however, the osteotomy is performed in the opposite insufficiency preoperatively. Such patients shoulddirection (ie, lateral to medial), a malleable is placedbetween the lateral nasal sidewall and the nasalmucosa is dissected to guard the tube. If injury occurs, Table 4. Complications Occurring With Maxillary orexchange of the nasotracheal tube is easier before the Mandibular Osteotomymaxillary osteotomy is completed.4 In the case oflaceration of the tube to the balloon and a resulting Infectious Instrumentation exposuremild air leak, especially at a point in the case at which Unanticipated fracturetube exchange would be difficult, posterior orophar- Devitalization of teethyngeal packing can be helpful. Malunion/nonunion Most patients are extubated immediately after the Relapse Injury to dentitionsurgical procedure.5 Internal fixation with titanium Malocclusionplates and screws and postoperative maxillar- Avascular necrosisyYmandibular fixation with dental elastics over wire 977 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 18, NUMBER 4 July 2007Table 5. Complications Associated With Genioplasty palatine vessels occurs when the posterior aspect of the lateral nasal wall osteotomy is made and, in mostMental nerve injuryInferior mandibular border contour irregularity circumstances, spontaneously stops. When bleedingGingival recession persists, it is easily controlled by vascular clips orPtosis of the mentalis muscle bipolar electrocautery once the maxilla is down- fractured. Because the separation of the pterygopa- latine plate with an osteotome is not directlyhave a speech pathologist included as part of the visualized, placement of the osteotome at its inferiorpreoperative workup and postoperative monitoring. aspect by palpation is critical to avoid injury to the vessels within the pterygopalatine fossa. The margin of safety is approximately 10 mm.16 Hemorrhage,Vascular Hemorrhage when it does occur, can be rapid and usually is bestAny preexisting coagulopathy should be determined controlled by dense packing of the fossa withthrough a history and physical examination. Patients cottonoid. In the vast majority of cases, bleeding,should be specifically asked about a history of ex- although significant, is easily controlled by localcessive bleeding after minor injuries or bleeding measures. In rare circumstances, direct ligation of theafter following previous procedures such as den- maxillary or carotid artery would be necessary.18tal work. In addition, a careful medication history Generally, bleeding persists until the maxilla isshould be taken, paying particular attention to the downfractured and will nearly always be signifi-use of medications such as aspirin, other medica- cantly diminished by the time the maxilla is reposi-tions with anticoagulant properties, and to herbal tioned with internal fixation.or nonformulary medications whose composition Significant hemorrhage with mandibular osteot-might not be clear. These should be stopped long omy (bilateral sagittal split osteotomy or intraoralbefore surgery. vertical osteotomy) is uncommon.18,22 The vessels at The use of local anesthetic with a vasoconstrictor risk include the inferior alveolar artery, maxillaryand controlled hypotensive anesthesia significantly artery, facial artery, retromandibular vein, and thereduces generalized bleeding and the need for blood pterygoid venous plexus.23 With careful subperios-transfusion while greatly improving visualization teal dissection of the medial ramus and the use of aof the operative field.11,12 One study demonstrated medial ramal retractor for the medial horizontalcontrolled operative hypotension to reduce blood corticotomy and the use of an inferior borderloss by approximately 44%.13 Significant hemorrhage retractor for the lateral splitting, vascular injury isis uncommon and when it occurs, it is more likely avoided in most circumstances. When bleedingwith maxillary osteotomies.6,13 With maxillary occurs, temporary packing with cottonoids soakedosteotomy, the vessels at risk include the greater in a vasoconstrictor and firm pressure for tenpalatine vessels, the maxillary artery, and the minutes will control the bleeding in the vastpterygoid plexus.14,15 Bleeding from the descending majority of the cases. When bleeding persists despiteFig 1 Endotracheal tube position after nasotracheal intubation. (A) The balloon tubing can be injured duringseptalYvomerine separation. (B) The tubing or endotracheal tube itself may be injured by the saw during osteotomythrough the medial buttress. This photograph demonstrates the medial-to-lateral direction of the saw in an effort tominimize tube injury.978 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
COMPLICATIONS OF ORTHOGNATHIC SURGERY / Patel et alconservative measures, the source should be identi- the LeFort I osteotomy.17 It may be damaged duringfied and ligated. This may require completing the the posterolateral nasal wall osteotomy. Such injuriesramal osteotomy to allow visualization.10 Despite all can be avoided by stopping the osteotomy at theprecautions, uncommon acute and subacute vascu- palatine bone and keeping it as low as possible nearlar complications, which may be life-threatening, the tuberosity. The descending palatine artery maycan occur. These include arteriovenous fistulae, false also be compromised during pterygomaxillaryaneurysms, carotid cavernous fistulae, and carotid separation and may require pterygopalatine fossaartery thrombosis.24Y29 packing. The maxillary arteries may be damaged during pterygomaxillary separation. This representsPostoperative Bleeding a vascular insult that may significantly compromise vascularity to the maxilla.Postoperative hematoma is more common aftermandibular surgery. Some surgeons have found Vascular Compromisethat the routine use of closed suction drains left for1 day in the angle region are of particular benefit. With degloving, osteotomy, and repositioning of theThese drain blood that would have otherwise facial skeletal elements, there is a significant reduc-accumulated within the dissected cavity and may tion in blood supply to the osteotomized segment.also reduce the degree of postoperative swelling. The vascular compromise affects not only the skeletalPatients with an expanding hematoma should of component, but also the dentition and the associatedcourse be reexplored immediately. soft tissue elements (pulp, periodontium, and gin- Postoperative nasal bleeding after LeFort I giva). In the vast majority of cases, this vascularosteotomy typically resolves spontaneously but compromise is transient and has no significantmay require packing. Ongoing bleeding requires clinical impact on outcome.29,30further treatment and evaluation. Anterior and The vascularity of the LeFort I downfracturedposterior nasal packing with release of maxilloman- segment is derived primarily from the soft palate anddibular fixation may be necessary for hemostasis. If from the buccal soft tissue pedicle because the greaterbleeding persists, then this should be followed by palatine vessels are frequently divided in the courseangiography with possible embolization and surgical of the osteotomy and mobilization (Fig 2).29,31reexploration. External carotid ligation is a last resort Although the reduction in blood supply is transient,for hemostatic control. devitalization of the teeth, periodontal defects, and When not ligated, the descending palatine artery segmental bone loss have been described.32,33is the primary source of postoperative bleeding from These often have been attributed to incisions thatFig 2 The blood supply to the maxilla. After down fracture the maxilla derives its vascularity from the ascendingpharyngeal and palatine arteries. 979 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 18, NUMBER 4 July 2007compromise the vascularity, excessive stripping ofthe periosteum, compromised palatal mucosa(secondary to previous cleft palate surgery), inter-dental or segmental osteotomies with loss of theattached gingiva, and transverse expansion withexcessive stripping of the palatal mucosa. Whencyanosis of the gingiva is noted intraoperativelyand vascularity does not return with reversal ofhypotension, thought should be given to returningthe maxilla to the original position and reassessingthe surgical approach. In this case, readvancementcan subsequently be done gradually using distrac-tion osteogenesis, either surgically controlled withimplanted devices or with orthopedic elastictraction forces. Like with maxillary surgery, avascular necro-sis with mandibular surgery is uncommon.29,34 Fig 3 Gingival recession after genioplasty with exposureThe blood supply to the mandible is derived from the of hardware.inferior alveolar artery and primarily from thenutrient vessels through the muscular attachments to such patients, especially when preoperative radio-of the masseter and pterygoid muscles.35 With the graphs reveal small, abnormal condyles and thesagittal split ramus osteotomy, extensive stripping of potential for this outcome should be discussed.the masseter from the buccal cortex may compromise Compared with the vertical oblique osteotomy, thethe blood supply to the distal-most region of the bilateral sagittal split osteotomy maintains a moreproximal segment where internal fixation hardware robust blood supply to the condyles making avas-is placed. Avascular necrosis, although uncommon, cular necrosis less likely than with the former.can occur with resulting loss of fixation and skeletal Progressive condylar resorption changes theinstability. The blood supply to the distal element is condylar morphology to a finger-like form; this canderived from the attachment of the pterygoid muscle be associated with a loss in posterior facial height.to the lingual cortex. The pterygomasseteric sling that Progressive resorption may lead to the developmentmust be divided to allow adequate mobilization of class II occlusion. Symptoms begin asymmetricallyshould be performed through the osteotomy between and progress at varying degrees to bilateral jointthe buccal and lingual cortices. Although wide dysfunction. Continued resorption results in an openperiosteal stripping is necessary to allow visualiza- bite. There is no treatment for active condylartion for ramal osteotomies, care should be taken to resorption. There is only the indeterminate benefitexpose only that which is necessary. of a centric relation splint aimed at decreasing Excess periosteal stripping of the chin during condylar stress and pain during the postoperativeosseous genioplasty may cause avascular necrosis period. Typically intervention must be delayed atwith resulting bony resorption and deformity of the least 6 months until resorption is presumed to begenioplasty segment. Vascular compromise to the complete. After 6 months, a single photon emissionsegment may also manifest as gingival recession in computed tomography scan may be useful tothat segment (Fig 3). The periosteum should be evaluate the exact degree of resorption. In cases ofstripped only to the degree necessary for osteotomy. severe resorption, total joint reconstruction may eventually be required.Condylar Resorption NeurologicCondylar resorption is a late complication that be-comes evident within the first several years after With the exception of the nasopalatine and superiorsurgery. Thus, following patients beyond the first alveolar nerves that are inevitably transected withyear of surgery is important. It is idiopathic in nature; the LeFort I osteotomy, sensory loss in the infra-however, there is a predilection for young women orbital nerve distribution is temporary with nearlywith preoperative class II occlusion and a history of complete recovery, because the infraorbital nerve istemporomandibular joint (TMJ) dysfunction.36 Cau- well visualized and the vast majority of osteotomiestion should be used in offering orthognathic surgery are inferior to the foramen. The long-term incidence980 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
COMPLICATIONS OF ORTHOGNATHIC SURGERY / Patel et alof sensory loss is approximately 1.5% to 2% and may alveolar nerve is reported to range from 24% tooccur as a result of extensive traction from soft tissue 85%.19,20,47,50Y52 Correlation between the surgeon’sretraction or from compression at the time of plate intraoperative assessment of nerve injury and post-fixation.14,37,38 The greater palatine nerve is fre- operative neurosensory deficit is poor, thus reactingquently transected with the posterior osteotomy but to perceived nerve injury that does not includewithout apparent significant sensory disturbance to complete transection is, in most circumstances, notthe patient. Sensory deficits of the teeth, palatal indicated.10,53 When transection is identified intrao-mucosa, and buccal mucosa tend to gradually resolve peratively, however, the nerve should be repaired.over a 12- to 18-month period. Other rare neurologic Other neurologic deficits with SSO have beendeficits of the second, third, fourth, fifth, sixth, tenth, reported.54 The lingual nerve may be affected withand twelfth cranial nerves have been reported. 39Y43 the osteotomy of the inferior border, especially whenThese are likely to occur as a result of unfavorable the inferior border saw is used. Seventh nerve palsy isfractures ascending into the cranial base. uncommon, but with the close proximity of the nerve In contrast, sensory deficit is a major concern to the posterior border of the ramus, injury can occur;with mandibular osteotomies because the nerve is the incidence has been reported to be between 0.4%not visualized and the surgeon primarily relies on and 1%.19,20,55 Unlike with SSO, the risk of nerveanatomic data not specific for the individual patient injury with intraoral vertical osteotomy is theoreti-(Fig 4).19,20,47 Of the mandibular procedures, the cally less; however, long-term sensory deficit rangessagittal split osteotomy (SSO) of the ramus carries the from 2.3% to 14%.23,48,56 This is attributed to thegreatest risk of sensory loss.23,48 The inferior alveolar inability to directly visualize the foramen locatednerve is at risk at virtually every point during the medially and placement of the vertical osteotomycourse of the SSO procedure: exposure of the medial well posteriorly based on lateral landmarks. Despiteramus, horizontal osteotomy of the medial ramus, the significant incidence of neurosensory loss,vertical osteotomy of the buccal cortex, osteotomy patients are rarely bothered and few, if any, mentionalong the external oblique ridge, splitting of the it unless specifically asked by the surgeon. None-ramus between the proximal and distal segments, theless, this should be frankly discussed with theand finally with fixation. Despite all precautions, a patient before surgery, and if unaccepting of thesignificant percentage of patients will have sensory sensory loss and tradeoff for the benefits of occlusion,loss with or without nerve transection. Transection mandibular surgery should not be offered.apparent at the time of the operation is reported With osseous genioplasty, superficial distalto be between 1.3% and 18%.6,22,47Y49 Even without fibers of the mental nerve are transected with thetransection, long-term sensory loss of the inferior mucosal incision and the mental nerve is at risk inFig 4 The course of the inferior alveolar nerve through the mandible. Note the proximity of the nerve to the buccal cortex. 981 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 18, NUMBER 4 July 2007proximity to the osteotomy. Ideally, the osteotomy Unfavorable Osteotomiesshould be placed 5 to 6 mm below the foramen as With the LeFort I osteotomy, uncontrolled fracturesthe nerve within the canal descends inferior to extending into the cranial base may occur when thebefore exiting the foramen. There may be insuffi- osteotomies are incomplete and downfracture iscient bone below the foramen, however, to safely attempted or when the osteotome is improperlycarry out the osteotomy at this level. At times, positioned during pterygopalatine dysjunction. Suchextending the mucosal incision or a second fractures may result in one of the rare, yet wellposterior exposure of the inferior mandibular described, vascular, neurologic, or ophthalmicborder will facilitate visualization and the osteot-omy. Despite precautions, the long-term sensory complications.59Y61 The downfracture should occurdeficit has been reported to be as high as with digital pressure alone and Rowe dysimpaction forceps used only for mobilization once the maxilla is20%.48,52,53 When osseous genioplasty is com- separated from its base. Frequently with digitalbined with a bilateral sagittal split osteotomy, as pressure, sites of resistance can be identified andis frequently done, the long-term sensory deficit these tend to occur at the posterior aspect ofsignificantly increases from approximately 10% the lateral nasal wall and the posterior maxillarywith genioplasty and 30% with a sagittal split wall where the reciprocating saw was not positionedosteotomy alone to 70% when combined. 48,52 at its maximal depth. A thin osteotome can beHowever, when sensory loss does occur it is introduced through the osteotomy of the anteriorfrequently limited to a small region that is rarely wall until resistance is felt. The osteotome should beof concern to the patient. directed inferiorly, away from the orbital floor, andInfection the posterior wall perforated with downward digital pressure until the maxilla downfractures. In patientsPostoperative surgical infection is uncommon after with developmental dentofacial deformities, inorthognathic surgery. The incidence is less than whom the posterior maxillary wall is thin, the1%.6,18,54Y56 Like with most operative procedures, maxilla readily downfractures favorably. In patientsthe risk of infection increases with the length and with clefts and craniofacial deformities, however, thetype of operative procedure. Bacterial contamination posterior wall is often excessively thick and anis inevitable and the use of perioperative prophy- osteotome may be needed to fully complete thelactic antibiotics is common.54,57,58 The potential for osteotomy. Although the traditional LeFort I readilyinfection is more common when a transbuccal downfractures, the downfracture of the higher levelapproach is used for fixation of the sagittal split LeFort I osteotomies that include the body of theosteotomy segments. Frank abscesses should be zygoma does not readily occur and requires thedrained (Fig 5). This may be done percutaneously surgeon to direct the osteotomy of the posterioror intraorally with surgical drainage indicated if the lateral maxillary wall from the pterygoid plate super-former is inadequate. iorly with an osteotome. Visualization is difficultFig 5 (A) Transverse and (B) coronal computed tomography sections demonstrating postoperative infection with abscessoriginating in the left angle region after bilateral sagittal split osteotomy. The abscess has tracked inferiorly in the softtissues of the neck. (C) Aspiration of purulent fluid from the abscess.982 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
COMPLICATIONS OF ORTHOGNATHIC SURGERY / Patel et aland requires a three-dimensional understanding ofthe skeletal anatomy. Unfavorable fractures that occur with sagittalsplit osteotomies of the ramus occur with anincidence of 3% to 23%.6,19,21,46 These includecondylar neck, lingual plate, and buccal platefractures. The ‘‘ideal’’ split may be technicallydifficult to achieve depending on anatomic variations(eg, variation in ramal width) and, with this, theability to place and direct the osteotomes.19 Condylarneck fractures occur when the horizontal osteotomyis misdirected posteriorYsuperiorly instead ofhorizontal to the occlusal plane. Buccal platefractures occur typically when the vertical osteot-omy at the inferior border is incomplete andsagittal split with the osteotome is attempted.Lingual plate fracture may occur, originating nearthe ascending ramus, when the mandibular thirdmolars have not been previous extracted. For thisreason, unerupted third molars should be Fig 6 Postoperative malocclusion with a significantextracted 6 to 12 months before surgery to avoid anterior open bite after LeFort I and bilateral sagittal splituncontrolled fractures and to allow ease of osteotomies. Condyles were improperly positioned at theinternal fixation.62 When an unplanned fracture time of the fixationdoes occur intraoperatively, depending on itspattern and whether the distal segment isadvanced or set back, the surgery may proceed; cies can frequently be managed by class III or class IIhowever, treatment of the fracture requires the dental elastics and/or orthopedic appliances ifprinciples of fracture management and prolonged minimal (edge-to-edge incisal relation). However,postoperative maxillaryYmandibular fixation. 6 more significant recurrence of the initial preoperativeAlternatively, the procedure may need to be occlusion in most circumstances necessitates a returnabandoned and the fractures allowed to heal before to the operating room. In most circumstances, earlyreturning to the operating room. failure occurs as a result of inadequate mobilization of the repositioned jaws, bony interferences andDental Injury instability not appreciated with repositioning, con- dyles not passively seated within the glenoid fossa atThe risk of tooth injury is minimized with careful the time of fixation, and issues related to thepreoperative planning. Tooth fracture or loss may internal plate/screw fixation. Immediately after theoccur while performing interdental osteotomies. operation, care should be taken on the part of thePresurgical orthodontics should provide adequate anesthesiology staff to wake patients in a gentle,spacing for anticipated osteotomies and osteotomies relaxed fashion to avoid altering the repositionedshould be performed with microburrs. Periapical segments and fixation hardware loosening orfilms are useful adjuncts to determine the safe depth breakage resulting from coughing, straining, andfor osteotomies. Postoperatively, teeth may be jawclenching. For those patients in whom this is afollowed clinically by their color.10 Tooth compro- concern, and who are to remain in elastics post-mise is treated secondarily through endodontic operatively, the surgeon should consider leavingintervention. This may include extraction and pros- the patient out of intermaxillary fixation initiallythetic replacement, sometimes with osseointegrated and placing elastics 2 to 3 days later in a moreimplants and bone grafts in the case of associated relaxed setting. Additionally, occlusal relapse canalveolar loss. occur late, long after the initial surgery, and is a result of complex etiology of functional dental andPostoperative Malocclusion muscular forces reestablishing equilibrium andSurgical malocclusion (Fig 6) is uncommon but can remodeling of the facial skeleton. Long-term followoccur and becomes readily evident in the early up is important and management directed towardpostoperative period. 6,62Y64 Early relapsing tenden- the causes. 983 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 18, NUMBER 4 July 2007Unfavorable Aesthetic Outcomes more effective care to patients. Seemingly small technical issues in the operating room can signifi-After orthognathic surgery, the final aesthetic out- cantly affect the outcome resulting in reoperationcome is derived from skeletal, soft tissue, and dental and/or additional months of orthodontics.changes. Some aesthetic shortcomings are besttreated with repeat skeletal surgery, whereas otherscan be treated through soft tissue revisions. With REFERENCESmaxillary surgery, the overimpacted and the over- 1. Pager DN, Kupperman AW, Stern M. Cutting of theretruded maxilla are the two most commonly seen nasotracheal tube: an unusual complication of the maxillaryskeletal base disproportions; both of these give the osteotomies. J Oral Surg 1978;36:313Y314 2. Mosby EL, Messer EJ, Nealis MF, et al. Intraoperative damagepatient an aged appearance.65 While vertically short- to nasotracheal tubes during maxillary surgery. Report ofening the lip at the nasal sill is an option in correcting cases. J Oral Surg 1978;36:963Y964the overimpacted maxilla, however in the vast 3. Schwartz LB, Sordill WC, Liebers RM, et al. Difficulty inmajority of the cases, reversing the skeletal reposi- removal of accidentally cut endotracheal tube. J Oral Max- illofac Surg 1982;40:518Y519tioning is required to achieve an aesthetically 4. Peskin RM, Sachs SA. Intraoperative management of partiallypleasing long-term outcome. With aging the upper severed endotracheal tube during orthognathic surgery.lip naturally lengthens and a minimal degree of vertical Anesth Prog 1986; Sept/Oct:247Y251excess is desired. With maxillary advancement, the alar 5. Haber-Cohan A, Rothman M. A survey of extubation practices following orthognathic surgery. J Oral Maxillofac Surgwidth increases and excess dental display may occur. 1988;46:269Y279An alar cinch suture and a ‘‘V’’ to ‘‘Y’’ lip closure 6. Van de Perre JP, Stoelinga PJ, Blijdorp PA, et al. Perioperativeshould be considered to adjust for the soft-tissue morbidity in maxillofacial orthopedic surgery; retrospective study. J Craniomaxillofac Surg 1996;24:263Y270response. If unacceptable nasal changes or lip thinness 7. Buckley MJ, Tulloch JFC, White RP, et al. Complications ofremain, then the patient may require later rhinoplasty orthognathic surgery: a comparison between wire fixation andor lip augmentation for aesthetic resolution. rigid internal fixation. Int J Orthodon Orthognath Surg Mandibular osteotomy and genioplasty result in 1989;4:69Y74 8. Williams JG, Cawood JI. Effect of intermaxillary fixation onlower facial skeletal contour changes. Both poorly pulmonary function. Int J Oral Maxillofac Surg 1990;19:76Y78designed osteotomies and poor soft tissue handling 9. Kohono M, Nakajima T, Someya G. Effects of maxilloman-can be associated with undesirable aesthetics of the dibular fixation on respiration. J Oral Maxillofac Surg 1993;51:992Y996lower face. With mandibular setback and correction 10. Bays RA. Complications of orthognathic surgery. In: Kaban LB,of macrogenia, the neck contour is adversely affected, Pogrel MA, Perrott DH, eds. Complications in Oral andand with excessive soft tissue laxity a secondary Maxillofacial Surgery. Philadelphia: WB Saunders Co, 1997:procedure is frequently needed to improve the 193Y221 11. Schaberg SJ, Kelly JF, Terry BC, et al. Blood loss andcontour. Chin ptosis results from excessive soft tissue hypotensive anesthesia in orofacial corrective surgery. J Oralelevation with improper reattachment of the mentalis Surg 1976;34:147Y156muscle during genioplasty. Postoperatively, the 12. Fromme GA, McKensy RA, Gould AB, et al. Controlled hypotension for orthognathic surgery. Anesth Analg 1986;patient with lip incompetence and mentalis strain 65:683Y686during lip closure may require revision genioplasty 13. Lanigan DT, Hey JH, West RA. Major vascular complicationswith vertical shortening for correction. Chin advance- of orthognathic surgery: hemorrhage associated with LeFort Iment should be done with care in women requesting osteotomies. J Oral Maxillofac Surg 1990;48:561Y573 14. Tung CC, Chen YR, Bendor-Samuel R. Surgical complicationscorrection for recessive chin. Over advancement, of the LeFort I osteotomy: a retrospective review of 146 cases.which is more tolerant in men, may not be in Chang Gung Med J 1995;18:102Y108women. As a rule of thumb, the chin should not be 15. Epker BN. Vascular considerations in orthognathic surgery. II.advanced beyond the lower lip border. Maxillary osteotomies. Oral Surg Oral Med Oral Pathol 1984;57:473Y478 16. Turvey T, Fonseca RJ. The anatomy of the internal maxillary artery in the pterygopalatine fossa: its relationship to maxillaryCONCLUSION artery. J Oral Surg 1980;38:92Y95 17. Lanigan DT, West RA. Management of postoperative haemor-Orthognathic surgery provides a means of effectively rahge following LeFort I maxillary osteotomy. J Oral Max-correcting dental malocclusions and facial disharmo- illofac Surg 1984;42:367Y375 18. Martis CS. Complications after mandibular sagittal splitnies whether they are congenital, developmental, or osteotomy. J Oral Maxillofac Surg 1984;42:101Y107posttraumatic in nature. While doing so, complica- 19. MacIntosh RB. Experience with a sagittal osteotomy of thetions may arise at any one or multiple stages of care: mandibular ramus: a 13-year review. J Oral Maxillofac Surgorthodontic and surgical planning, intraoperative, or 1981;9:151Y165 20. Lanigan DT, Hey J, West RA. Haemorrhage followingperioperative orthodontic care. The surgeon involved mandibular osteotomies: a reported 21 cases. J Oral Maxillofacmust continually reconsider how to provide safer, Surg 1991;49:713Y724984 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
COMPLICATIONS OF ORTHOGNATHIC SURGERY / Patel et al21. Turvey TA. Intraoperative complications of sagittal osteotomy 44. Guernsey LH, De Champlain RW. Sequelae and complications of the mandibular ramus: incidence and management. of the intraoral sagittal osteotomy in the mandibular rami. Oral J Oral Maxillofac Surg 1985;43:504Y509 Surg 1971;32:176Y19222. Tuinzing DB, Greebe RB. Complications related to the 45. Zaytoun HS, Phillips C, Terry BC. Long-term neurosensory intraoral vertical ramus osteotomy. Int J Oral Surg 1985;14: deficits following transoral vertical ramus and sagittal split 319Y324 osteotomies for mandibular prognathism. J Oral Maxillofac23. Lanigan DT, Hey JH, Wst RA. Major vascular complications of Surg 1986;44:193Y196 orthognathic surgery: false aneurysms and arterio-venous 46. Van Merkesteyn JPR, Groot RH, Van Leeuwaarden R, et al. fistulas following orthognathic surgery. J Oral Maxillofac Intraoperative complications in sagittal and vertical ramus Surg 1991;49:969Y975 osteotomies. Int J Oral Maxillofac Surg 1987;16:665Y67024. Lanigan DT, Tubman DE. Carotid cavernous sinus fistula 47. Nishioka GJ, Zyssett MK, Van Seckets JE. Neurosensory following Le Fort I osteotomy. J Oral Maxillofac Surg disturbance with rigid fixation of the bilateral sagittal split 1987;45:969Y975 osteotomy. J Oral Maxillofac Surg 1987;45:20Y2625. Habal MB. A carotid cavernous sinus fistula after maxillary 48. Posnick JC, Al-Qattan MM, Stepner NM. Alteration in facial osteotomy. Plast Reconstr Surg 1986;77:981Y985 sensibility in adolescents following sagittal split and chin26. Lanigan DT. Injuries to the internal carotid artery following osteotomies of the mandible. Plast Reconstr Surg 1996;97: orthognathic surgery. Int J Adult Orthodon Orthognath Surg 920Y927 1988;4:215Y220 49. Upton LG, Rajvanakan M, Hayward JR. Evaluation of27. Lai JP, Hsieh CH, Chen YR, et al. Unusual late vascular the regenerative capacity of the inferior alveolar nerve complications of sagittal split osteotomy of the mandibular following surgical trauma. J Oral Maxillofac Surg 1987;45: ramus. J Craniofacial Surg 2005;16:664Y668 212Y21628. Bendor-Samuel R, Chen YR, Chen P. Unusual complications 50. Jacks SC, Zuniga JR, Turvey TA, et al. A retrospective analysis of the Le Fort 1 osteotomy. Plast Reconstr Surg 1995;96: of lingual nerve sensory changes after mandibular bilateral 1289Y1296 sagittal split osteotomy. J Oral Maxillofac Surg 1998;56:700Y70429. Epker BN. Vascular considerations in orthognathic surgery. I. 51. de Vires K, Devriesse P, Huvinga J, et al. Facial palsy Mandibular osteotomies. Oral Surg Oral Med Oral Pathol 1984; after sagittal split osteotomies. J Craniomaxillofac Surg 57:467Y472 1993;21:50Y5330. Bell WH, You ZH, Fin RA, et al. Wound healing after multi- 52. Lindquist CC, Obeid G. Complications of genioplasty done segmental Le Fort I osteotomy and transection of the descending alone or in conjunction with split ramus osteotomy. Oral Surg palatine vessels. J Oral Maxillofac Surg 1985;53:1425Y1433 1988;66:13Y1631. Bell WH, Fonseca RJ, Kennedy JW, et al. Bone healing and 53. Nishioka GJ, Mason M, Van Sickets JE. Neurosensory dis- revascularization after total maxillary osteotomy. J Oral Surg turbance with the anterior mandibular horizontal osteotomy. 1975;33:253Y260 J Oral Maxillofac Surg 1986;46:107Y11032. Lanigan DT, Hey JH, West RA. Aseptic necrosis following 54. Ruggles JE, Hann JR. Antibiotic prophylaxis in intra oral maxillary osteotomies: report of 36 cases. J Oral Maxillofac orthognathic surgery. J Oral Maxillofac Surg 1984;42:797Y801 Surg 1990;48:142Y156 55. Gallagher DM, Epker BN. Infection following intra oral33. de Mol Van Otterloo JJ, Tuinzing DB, Greebe RB, et al. Intra surgical correction of dento-facial deformities: a review of and early post operative complications of the LeFort I 140 consecutive cases. J Oral Surg 1980;38:117Y120 osteotomy: a retrospective study on 410 cases. J Craniomax- 56. Kramer FJ, Baethge C, Swennen G, et al. Intra-and perioperative illofac Surg 1991;19:217Y222 complications of the LeFort I osteotomy: a prospective34. Lanigan DT, West RA. Aseptic necrosis of the mandible: evaluation of 1000 patients. J Craniofac Surg 2004;15:971Y977 report of two cases. J Oral Maxillofac Surg 1990;48:296Y300 57. Baqain ZH, Hyde N, Patrikidou A, et al. Antibiotic prophylaxis35. Castelli WA, Nasjleti CE, Diasperez R. Interruption of the for orthognathic surgery: a prospective randomized clinical arterial inferior alveolar flow and its effects on mandibular trial. Br J Oral Maxillofac Surg 2004;42:506Y510 collateral circulation and dental tissues. J Dent Res 1975;54: 58. Otten JE, Weingart D, Hilger Y, et al. Penicillin concentration in 708Y715 the compact bone of the mandible. Int J Oral Maxillofac36. Merkx MA, Van Damme PA. Condylar resorption after Surg 1991;20:310Y312 orthognathic surgery: evaluation and treatment in eight 59. Robinson P, Hendy C. Pterygoid plate fractures caused by patients. J Craniomaxillofac Surg 1994;22:53Y58 the LeFort I osteotomy. Br J Oral Maxillofac Surg 1986;24:37. Kahberg KE, Engstrom H. Recovery of the maxillary sinus and 198Y202 tooth sensibility after LeFort I osteotomy. Br J Oral Maxillofac 60. Precious DS, Goodday RH, Bouget L, et al. Pterygoid plate Surg 1987;25:68Y73 fracture in Le Fort I osteotomy with and without pterygoid38. de Jongh M, Barnard D, Birnie D. Sensory nerve morbi- chisel: a computerized tomographic evaluation of 58 patients. dity following LeFort I osteotomy. Maxillofac Surg 1986;14:10Y13 J Oral Maxillofac Surg 1993;51:151Y15339. Carr RJ, Gilbert P. Isolated partial third nerve palsy following 61. Renick B, Symington JM. Postoperative computed tomography LeFort I maxillary osteotomy in a patient with a cleft lip and study of pterygomaxillary separation during the LeFort I palate. Br J Oral Maxillofac Surg 1986;24:206Y211 osteotomy. J Oral Maxillofac Surg 1991;49:1061Y106540. Watts PG. Unilateral abducent nerve plasty: a rare complica- 62. El Deeb M, Wolford L, Bevis R. Complications of orthognathic tion following LeFort I maxillary osteotomy. Br J Oral surgery. Clin Plast Surg 1989;16:825Y840 Maxillofac Surg 1984;22:212Y215 63. Moening JE, Garrison BE, Lapp TH, et al. Early screw removal41. Lanigan DT, Romanchuk K, Olsen CK. Ophthalmic complica- for correction of occlusal discrepancies following rigid internal tions associated with orthognathic surgery. J Oral Maxillofac fixation in orthognathic surgery. Int J Adult Orthodon Surg 1993;51:480Y494 Orthognath Surg 1990;5:225Y23242. Sirikumara M, Sugar AW. Adie’s pupil following LeFort I 64. Bell WH, Jacobs JD, Quejada JG. Simultaneous repositioning of maxillary osteotomy: a complication or coincidence? Br J Oral the maxilla, mandible, and chin. Treatment planning and Maxillofac Surg 1990;28:306Y308 analysis of soft tissues. Am J Orthodont 1986;89:28Y5043. Lo LJ, Hunk KF, Chen YR. Blindness as a complication of 65. Schendel SA, Mason ME. Adverse outcomes in orthognathic LeFort I osteotomy for maxillary distraction. Plast Reconstr surgery and management of residual problems. Clin Plast Surg Surg 2002;109:688Y698; discussion 699Y700 1997;24:489Y505 985 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.