Complications of Orthognathic Surgery

COMPLICATIONS OF
ORTHOGNATHIC
SURGERY

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INDIAN DENTAL ACADEMY
Leader in continuing dental education



CONTENTS
• INTRODUCTION
• VASCULAR COMPLICATION
• ASEPTIC NECROSIS
• DELAYED UNION OF BONE FRAGMENTS
• NON-UNION OF BONE FRAGMENTS

•DENTAL AND PERIODONTAL INJURY
•FISTULAS
• NASAL COMPLICATIONS
•MAXILLARY SURGERY COMPLICATION
•MANDIBULAR SURGERY
COMPLICATION


• ORTHODONTIC COMPLICATIONS
• OTHER COMPLICATION


INTRODUCTION

•
•
•

Orthognathic surgery is one of the
fast developing branch in oral and
maxillo-facial surgery.
It is probably the most gratifying field
in the whole maxillofacial surgery
Orthognathic surgery in conjunction
with orthodontics can do wonders in
improving the appearance of the face

• Typical,facial alteration by surgery
•

enhances physical appearance,
thereby increases the confidence.
Increase in the number of complication
due to increased number of surgeries
performed for facial aesthetics.


ANATOMY
•MAXILLA CONSIST OF :
A body
4 processes-zygomatic
-Palatine
-Frontal
-Alveolar
lateral surface of maxilla:Anterio lateral
:Posterio lateral
Anterio lateral surface also called as malar
surface which shows canine fossa,superiorly

infra orbital foramen exist, above foramen
Orbital plate of maxilla,laterally malar surface
attaches to zygomatic bone,medially to frontal
and nasal bone,posteriolaterally by infra
temporal surface
•From lower surface of body of maxilla arises
alveolar process
•Anterior nasal spine –a bony projection just
below nasal aperture
•Nasal cavity divided by nasal septum
•Palatine process unites medially with
alveolar process,hard palate is formed by
palatal process of maxilla and horizontal plate
of palatine bone

Mandible
•Forms major part of lower 1/3 of face and
contributes significantly to facial aesthetics
•Mandible consist of
horse shoe shaped
body
2 vertical rami
•External surface in midline has mental
protuberance inferiorly,incisive fossa
superiorly and laterally canine eminance
•Mental foramen is apical to the premolars
•Body unites with the ramus at gonial angle
•The junction of alveolar process and the
ramus is masked by external oblique ridge

Which extends anteriorly till mental foramen
And upward to the coronoid process
•The ramus of mandible exhibits anteriorly
the coronoid process with tendons of
temporalis attached to it and posteriorly to the
condylar head and neck
•Concavity between condylar and coronoid
process is called as sigmoid or mandibular
notch
•Medial surface of the ramus exhibits on its
lower half the roughened area where medial
pterygoid inserts
•Mandibular foramen at the center of ramus
admits inferior alveolar nerve

VASCULAR SUPPLY
ARTERIAL SUPPLY
1.External carotid artery
2.Facial artery
3.Lingual artery
4.Maxillary artery
5.Superficial temporal artery
VENOUS SUPPLY
1.Facial vein
2.Retromandibular vein
3.internal jugular vein

NERVE SUPPLY
1.Motor nerve is Facial nerve
its 5 branches are –Temporal
Zygomatic
Buccal
Mandibular
Cervical
2.Sensory nerve is Trigeminal nerve
its 3 branches are – Opthalmic
Maxillary
Mandibular


Vascular complication
•HEMORRHAGE
MAXILLA - Acute injury Turvey and
Fonseca proposed that most likely vessels
at risk of injury during maxillary Surgery are
Internal Maxillary artery and Greater
palatine artery
~Massive blood loss can occur from injury
to Internal Carotid artery and Internal
jugular vein
~Thrombosis of internal carotid artery can
occur during surgery,mortality rate of 40%
and additional 52% patient left with
neurological deficit

~Delayed hemorrhage can occur as early
as night of surgery of maxillary lefort-I to as
late as 9 days post-operatively
~During separation of maxillary tuberosity
from pterygoid plates maximum risk of injury
is to internal maxillary artery and its
branches.


Mandibular vascular injury
~Internal carotid artery injury can occur
during sagittal split osteotomy
~Injury to internal maxillary artery are also
reported
~Injury due to improper handling of
instrument
1.due to forceful placement of channel
retractor on the lingual surface of the
mandible
2.forceful use of mallet and chisel on
the medial aspect of the mandible

ASEPTIC NECROSIS
~Major loss of hard and soft tissue can
occur due to compressed blood supply
~flattening of dental papilla, loss of gingiva
to periodontal defects in area of osteotomy
~Due to excessive stripping of bone
aseptic vascular necrosis of proximal
segment with sagittal split osteotomy
~In 1974 Gammer et al noted that bone
usually revascularised, if not occurs
substantial loss of bone can occur

NON UNION,DELAYED UNION
OF BONE
MAXILLA
due to local or systemic factor
compromised because of previous
surgery,as in cleft palate
large advancement

MANDIBLE
Avascular necrosis,insufficient bone contact
and instability of bone fragment

Any para-functional movement of jaw

Can be treated effectively By
prolonged RIF

DENTAL AND PERIODONTAL
INJURIES
~related to poor planning and
technical errors during surgery
~common problems are cut teeth,loss
of teeth,post-operative R.C.T and
periodontal defects
~minimum of 3mm of space left
during placement of osteotomy cut
between teeth
~cut should be 5mm above root apex

Periodontal bone
loss And gingival
recession


FISTULAS
~Oronasal and
oroantral region
~injury from
saw,osteotome,
rotary instrument
~while attempting to
stretch midpalatal
tissue


NERVE INJURY
A.Sensory nerve
MAXILLA

Parasthesia of teeth and
mucosa is more common.
~usually sensation comes to normal with in
6 to 12 months
~injury to greater palatine neuro vascular
bundle can cause permanent numbness


MANDIBLE
~Injury to inferior alveolar nerve
can occur during sagittal split
osteotomy
~Injury to lingual nerve can also
occur but it is rare any dissection
on lingual aspect of mandible in 3rd
molar region can injure nerve


B.Motor nerve
~injury to facial nerve is more common with
Extra oral approach than intra oral approach
~facial nerve injury have been reported both
with sagittal split and vertical sub-condylar
osteotomy
~It causes partial or total paralysis
Retractor on
medial aspect
extending
behind ramus

Extension of distal fragment beyond
proximal segment

NASAL AND SINUS COMPLICATION
A.Alteration in nasal form and septum

~repositioning of maxilla requires
manipulation of nasal components
and sinus as a result of these
manipulation
Complication can occur
~due to maxillary osteotomy
adverse effect on alar base,nasal
tip,supra tip depression may result in
un aesthetic www.indiandentalacademy.com facial
postoperative

~Maxillary septum is disarticulated from
entire maxilla during lefort,anterior
maxillary surgery special attention
should be given while repositioning the
septum
~Septal deviation and obstruction can
occur during maxillary superior
repositioning
B.Nasal valve
~Internal nasal anatomy,nasal airway
resistance altered breathing pattern

~as nasal valve is the smallest cross
section of nose alteration in this area
can cause nasal breathing problems
C.ALAR BASE
~excessive alar base widening
~increased prominence of alar groove
~upturning of nasal tip
~flattening and thinning of upper lip
~down turning of labial commisures


D.SINUS INFECTION
~due to inadequate drainage and open fistula
~infection associated with alloplastic implant
~retention of large blood clots
~pre existing disease
~foreign object –wires, bone plates,screws


MODEL SURGERY
~it is done immediately before orthognathic
Surgery
~it is important to use a face bow transfer to
mount the cast on a semi adjustable
articulator so that exact condyle-tooth
relationship are recorded
Model surgery serves two purposes
1.To verify that planned movements are
possible
2.To prepare occlusal wafer splint

OCCUSAL SPLINT
~it is placed immediately after orthognathic
surgery in positioning the teeth in proper
occlusion for stability
~it is made on dental cast that shows the
result of model surgery
~it should be thin to produce the least amount
of separation of the teeth
~it should be 2mm thick in its thinnest part to
resist breakage

MODIFICATION OF SPLINT
~reduction of depth of occlusal index to
remove interferences
~patient must able to do lateral excursion
and bite up and down
~maintain adequate thickness (2mm)
~provision of removal of splint for cleaning
ball end clasp can be placed

MAXILLARY SURGERY
COMPLICATIONS
A.LE-FORT I OSTEOTOMY
B.ANTERIOR SUB-APICAL
OSTEOTOMY
C.POSTERIOR SUB-APICAL
OSTEOTOMY


A.LE FORT-I OSTEOTOMY
~HEMMORHAGE

Injury to internal
carotid artery

Internal jugular vein


~INJURY TO PALATE
intra operatively rowe disimpaction forceps
are used to disimpact maxilla,beak of forcep
injure palate

~ANSTHESIA RELATED
cut in endo tracheal tube during
surgery,some times patient need to be re
intubated

~EMPHYSEMA
cervical and facial region,some reports of
air in soft tissues of head,neck and chest
following lefort www.indiandentalacademy.com
I osteotomy

~HEMATOMA
laceration to descending palatine artery
during down fracture lefort I

~DELAYED HEMMORHAGE
~NON UNION,DELAYED UNION OF
BONE
~NERVE INJURY
~OPTHALMIC COMPLICATION


B.ANTERIOR SUB APICAL
OSTEOTOMY
~periodontal defects
In between teeth and
loss of blood supply
to teeth adjacent to
osteotomy cuts
~discoloration of
teeth
~periapical bone loss


C.POSTERIOR SUB APICAL
OSTEOTOMY

~most commonly periodontal defects and
loss of vascularity

~wound dehiscence ,change in colour and
tone of mucosa prolongs healing


MANDIBULAR SURGERY
COMPLICATION
A.SAGITTAL SPLIT OSTEOTOMY
B.TRANS ORAL VERTICAL
RAMUS OSTEOTOMY
C.COMBINED VERTICAL RAMUS
AND SAGITTAL OSTEOTOMY
D.INFERIOR BORDER
OSTEOTOMY
E.ANTERIOR SUB APICAL
OSTEOTOMY

F.POSTERIOR SUB APICAL
OSTEOTOMY
G.TOTAL SUB APICAL
OSTEOTOMY
H.OTHER COMPLICATIONS


A.SAGITTAL SPLIT OSTEOTOMY
FRACTURE BONE FRAGMENT
~ it is a problem seen more frequently with
mandibular surgical procedure
~incidence of proximal segment fracture 1-3%
whereas distal segment fracture 0.8%
~management of fracture depends on location and
size of fracture


1.proximal segment mandible intact
~when buccal fragment
shear of usually cause is
inadequate bone cut
~the bone split must be
completed by making a
deep groove on the
inferior border and
connecting with
previous groove
~larger fragment should
be stabilized with wires
or screws and plates

2.proximal segment split complete
~when fracture occur
more superiorly at the
ramus of mandible in
horizontal direction


~fracture of condyle with coronoid and
angle of mandible in separate fragment


3.lingual segment fracture
~occurrence is less
frequent because of
frequently impacted 3rd
molar
~when unwanted
fracture occurs surgeon
should complete the
split along the original
planned osteotomy
lines

~a wedge of bone can
Be taken from buccal
aspect and placed on
lingual aspect
~stabilization can be
done wires or screws
and plate


4.lateral displacement
~it can occur during
vertical sub condylar
osteotomy
~proximal fragment or
condylar fragment may
be displaced medially or
laterally


5.medially displacement
~in some fractures condylar fragment can
Be displaced medially
~in such cases post operatively patient
complains of irritation of pharynx


NERVE AND VESSELS INJURY
~injury to mandibular nerve can occur, extreme
care must be taken to maintain the continuity
of neurovascular bundle
~bleeding may occur from inferior alveolar
neuro vascular bundle,some times facial
vessels may be lacerated during surgery
~less common injury to retromandibular vein
which lies adjacent to posterior border of ramus


B.TRANS ORAL VRETICAL
RAMUS OSTEOTOMY
~complication in this
procedure is rare
~occasionally hemorrhage
results from injury to
massetric artery
~injury to retromandibular
vein


C.COMBINED VERTICAL RAMUS
AND SAGITTAL OSTEOTOMY
~injury to inferior
alveolar neurobundle
~splitting of bone
fragment producing a
fracture of anterior
projection of lateral
cortical plate anterior to
ramus segment


D.INFERIOR BORDER
OSTEOTOMY
~ dead space almost
always is created after
segments are repositioned
~wound dehiscence is
more likely to occur
~loss of keratinized tissue
and periodontal defects
can occur anterior teeth

E.ANTERIOR SUB APICAL
OSTEOTOMY
~trauma to mental nerve
Which causes loss of
sensation in anterior
region
~planned osteotomy cuts
minimize injury to nerve


F.POSTERIOR SUB APICAL
OSTEOTOMY
~blood supply can interrupt
causing devitalization of
the segment
~teeth may not respond to
stimulation for 6 to 12
month
~periodontal bone defect
Neurovascular bundle
decompression

G.TOTAL SUB APICAL OSTEOTOMY
~injury to neuro vascular
bundle and long term
sensory disturbances
~injury to root apex


H. OTHER COMPLICATIONS
SALIVARY INJURY
~ injury to parotid gland are possible with
extra oral procedure
~ painless fistula can occur in first week of
surgery
CONDYLAR
MALPOSITIONING
~inability to orient and
maintain condylar
position

~commonly encountered problem is “condylar
Sag” which is most commonly occurs with
trans oral vertical ramus osteotomy
~in condylar sag posterior segment is
separated with tooth bearing segment
~in some cases class-2 molar relationship,
anterior open bite occurs immediately after
release of fixation


FACIAL SCARS
~with extra oral techniques chances of facial
Scars are more
~this technique was traditionally used
COMPLICATION OF AUGMENTATION WITH
IMPLANTS
~bony defects or deficiencies in maxilla or
Mandible
~bony defects are often expressed in facial
Contours

AUGMENTATION MATERIAL
~autogenous bone and cartilage
~allogenous bone and cartilage
~alloplastic materials eg; silastic,proplast,
hydroxylapatite
AUGMENTATION PROCEDURES
~paranasal augmentation
~infra orbital malar augmentation
~anterioinferior mandibular border
augementation
~posterioinferior mandibular border
augmentation

~anteriolateral mandibular augmentation
~chin augmentation
COMPLICATION
~if dehiscence occurs with implants correcting
the problem is difficult,loss of implant may
occur if wound does not heal with secondary
intention
~wound infection can also be a serious
consequence
~shifting and migration of implant

POST-OPERATIVE ORTHODONTIC
COMPLICATION
ANTERIOR OPEN BITE
~it can be due to condylar distraction with
Mandibular surgery
~inadequate posterior impaction in lefort I
Surgery
~it can be managed with headgear


LATERAL OPEN BITE
~no occlusal contact of posterior teeth after
Surgery
~tripod effect should be created to prevent
Forcing of condyle head into the fossa
~after buccal segment are in occlusion splint
And composite can be removed
~several month of archwire stabilization is
Necessary

ASYMMETRY
~midline asymmetry frequently occurs
together with buccal segment asymmetry
~it is important to identify source of problem
~submentovertex radiograph can be helpful

MAXILLA
~if asymmetry exist in maxilla headgear,
Heavy elastics can be helpful
~posterior crossbite bilaterally cross elastics
Can be used

~In severe cases asymmetrical headgear
Is used to correct rotated maxilla

MANDIBLE
~due to surgical malposition crossbite and
Midline discrepancy
~sufficient elastic traction is applied in
Appropriate vector to achieve good occlusion


TEMPROMANDIBULAR JOINT
DYSFUNCTION
A.SHORT TERM
~some patients develop TMJ problem after
surgery
~there can be acute or gradual increase in
symptoms
~acute condition can be managed with
anti-inflammatory and physical therapy like
1.EMG bio feed back and relaxation training
2.ultrasound
3.spray and stretch
4.friction massage

B.LONG TERM
~condylar resorption has been noted after
wire osteosynthesis and rigid fixation
~studies have shown that majority of relapse
Is due to movement at osteotomy site and
not at the condyle


SURGICAL RELAPSE
PROFFIT AND WHITE (1970),A.O,were
among the first to mention relapse after
surgical-orthodontic therapy. They felt that
relapse could be avoided by concentrating
on eliminating the original causes
contributing to the original malocclusion as
much as possible, and by not operating while
patients are still growing


POULTON AND WARE (1971),AJO,
stated that, “Probably the suprahyoid
muscles, which have been lengthened, are
the main force contributing to the relapse.”

Theories for relapse:
AJO-DO 1991

satrom, sinclair, wolford

1. stretching of the muscles of mastication and
the suprahyoid musculature,
2. condylar distraction during surgery,
3. upward and forward rotation of the
mandible, 4. changes in rotational position
between the proximal and distal segments.

Numerous fixation techniques to
reduce postsurgical relapse:
1.upper- and lower-border wiring
2.Steinmann pins to stabilize the maxilla
3.skeletal-wire fixation
4.rigid fixation
Studies that examined independent mandibular
advancements and maxillary LeFort I procedures
have indicated a strong tendency toward reduced
amounts of relapse when either skeletal-wire
fixation or rigid fixation is used.

Three principles that influence
post-surgical stability
I) Stability is greatest when soft tissues
are relaxed during the surgery and
least when they are stretched
II) Neuromuscular adaptation is essential
requirement for stability
III) Neuromuscular adaptation affects
muscular length, not muscular orientation

“An ounce of prevention
is worth a pound
of cure”


THANK - U
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Complications of Orthognathic Surgery

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