COMPLICATIONS OF
ORTHOGNATHIC SURGERY

INDIAN DENTAL ACADEMY
Leader in continuing dental education

www.indiandentalacadem...
Selection of patient
– Psychological
– Neuromuscular disorders
– Multiple deformities – syndromes
– Multiple treatments

w...
Assessment of patient
•
•
•
•
•
•
•
•
•
•

Head position
Centric occlusion
Rest position lips
Lip length – tooth exposure
...
Dentition
•
•
•
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•

Periodontal state
Caries
Saveable teeth
Restorations
Occlusion

www.indiandentalacademy.com
Temporomandibular joints
•
•
•
•

Symptoms
Assessment
Radiography
Pathology

www.indiandentalacademy.com
Radiography
•
•
•
•
•

Cephalometry
Orthopantomography
Periapicals
OMs – skull
CT scans

www.indiandentalacademy.com
Photography
• Colour transparencies/photos
• Planning – profile/full face 1:1s
• 3D imaging

www.indiandentalacademy.com
Models/articulation
•
•
•
•
•
•

Arch size/relationships
Occlusion
Tooth position
Overbite, overjet
Occlusal curves
Molar ...
Treatment planning
•
•
•
•

Psychological
Photocephalometric
Dental
Presurgical orthodontics

www.indiandentalacademy.com
Essential
•
•
•
•

Accurate patient reevaluation
Correct selection – surgical procedure
Accurate prediction tracing
Accura...
Appropriate dental/model surgery
•
•
•

Tooth size – occlusion
Occlusal plane – AOBs
Arch width – expansion/collapse
– Ort...
Operative complications
•
•
•
•
•
•

Patient care – anaesthesia etc
Maxillary surgery
Mandibular surgery
TMJs
Nerve injury...
Maxillary surgery (1)
• Loss of teeth and bone, aseptic necrosis –
vascular compromise – flaps, poor surgery
– Rx hyperbar...
Maxillary surgery (2)
• Alar base – cinch suture
• Nerve damage – stretch/pressure
• Teeth – interdental osteotomies,
dama...
Maxillary surgery (3)
• Bleeding
– Local anaesthesia
– Hypotension
– Careful surgery
– Vascular compromise – maxillary, gr...
Surgical problems
• Cleft Le Fort I – pterygoids, palatine bone
Separation, lateral wall, segmental surgery!
• Le Fort II ...
Mandibular surgery (1)
• Condylar sag, AP relapse + AOB
• Haemarthrosis, relapse, condylar
repositioning
• Improper platin...
Mandibular surgery (2)
• Tooth extrusion in fixation, bone relapse
(large advances)
– Teeth problems/relapse – use skeleta...
Mandibular surgery (3)
• Specific problems related to operative
procedure
– Modified sagittal split
– Vertical subsigmoid
...
TMJ function
• Pre-existing dysfunction
– Abnormal load, muscle action

• Internal derangement
– Prevention – recognise no...
Nerve injury
• Type – neuropraxia, axonotmesis,
neurotmesis, neuroma
Management – timing, primary repair,
Nerve grafting, ...
Post surgery – immediate – ICU
•
•
•
•

Airway IMF, NT/NP tubes, suction
Bleeding/circulation - ?blood transfusion
Swellin...
Postop. follow up
•
•
•
•

?IMF period
Elastic traction/orthopaedic
Functional appliances
?Genioplasty

www.indiandentalac...
Post surgical orthodontics
• Avoid opening bite
• Adequate retention

www.indiandentalacademy.com
Velopharyngeal insufficiency
• Secondary cleft deformity
• Craniofacial cases
• Access osteotomies – split soft palate

ww...
Miscellaneous
• Scars
• Sinus infection
• Plate problems

www.indiandentalacademy.com
Poor results – due to:
•
•
•
•
•
•
•
•
•
•
•

Incorrect diagnosis
Inappropirate Rx plan
Unstable orthodontics
Wrong surgic...
Immediate preoperative
assessment
•
•
•
•

Planning – final check
Cessation of growth
Speech assessment
Medical state, eg,...
Operative area
• Anaesthesia – airway
• Theatre preparation – sterility,
instrumentation, staffing
• Surgery – incisions, ...
Late complications – local (1)
•
•
•
•
•

Pain
Ocular – acuity, diplopia, positional
Airway – nasal, laryngo-tracheal
CSF ...
Late complications – local (2)
• Dental – loss, extrusion, perio, periapical
infection
• Fistulae OAF, ONF
• Hardware – pl...
Sagittal split osteotomy (1)
•
•
•
•

Sensitive technique, training, instrumentation
Impacted teeth – risk poor split
Unfa...
Sagittal split osteotomy (2)
• Relapse – common, dental >sk > rigid,
increased over 6mm, rotation?, setback
late growth
• ...
Vertical subsigmoid osteotomy (IO)
•
•
•
•
•
•
•
•
•
•
•

Critical instrumentation
Subcondylar and angle, poor splits
Nerv...
Other procedures
• Body ostectomy/osteotomy
– ID, BG, teeth, stability+, fixation

• Postcondylar graft – children
– Graft...
Late complications
• General
– Death
– Pulmonary atelectasis/pneumonia
– Neurological – ulnar/popliteal
– Vascular DVT, pu...
Final thoughts!
• Medicolegal complications arise from:
–
–
–
–

•
•
•
•

Poor communication
Poor planning
Inappropriate c...
www.indiandentalacademy.com
Leader in continuing dental education

www.indiandentalacademy.com
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Complications of orthognathic surgery /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Complications of orthognathic surgery /certified fixed orthodontic courses by Indian dental academy

  1. 1. COMPLICATIONS OF ORTHOGNATHIC SURGERY INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Selection of patient – Psychological – Neuromuscular disorders – Multiple deformities – syndromes – Multiple treatments www.indiandentalacademy.com
  3. 3. Assessment of patient • • • • • • • • • • Head position Centric occlusion Rest position lips Lip length – tooth exposure Midline alignments – symmetry Interalar width – nose Columella - lip relationship Chin position and shape Facial height Malar orbital relationship www.indiandentalacademy.com
  4. 4. Dentition • • • • • Periodontal state Caries Saveable teeth Restorations Occlusion www.indiandentalacademy.com
  5. 5. Temporomandibular joints • • • • Symptoms Assessment Radiography Pathology www.indiandentalacademy.com
  6. 6. Radiography • • • • • Cephalometry Orthopantomography Periapicals OMs – skull CT scans www.indiandentalacademy.com
  7. 7. Photography • Colour transparencies/photos • Planning – profile/full face 1:1s • 3D imaging www.indiandentalacademy.com
  8. 8. Models/articulation • • • • • • Arch size/relationships Occlusion Tooth position Overbite, overjet Occlusal curves Molar relationship www.indiandentalacademy.com
  9. 9. Treatment planning • • • • Psychological Photocephalometric Dental Presurgical orthodontics www.indiandentalacademy.com
  10. 10. Essential • • • • Accurate patient reevaluation Correct selection – surgical procedure Accurate prediction tracing Accurate model surgery www.indiandentalacademy.com
  11. 11. Appropriate dental/model surgery • • • Tooth size – occlusion Occlusal plane – AOBs Arch width – expansion/collapse – Orthodontic – surgical – orthopaedic • • • • Space closure Short roots – resorption Root convergence Surgical deficiencies – Skill, ortho, fixation, instrumentation • • • Failure to follow treatment plan Teeth off basal bone – unstable Orthodontic failure www.indiandentalacademy.com
  12. 12. Operative complications • • • • • • Patient care – anaesthesia etc Maxillary surgery Mandibular surgery TMJs Nerve injury Vascular injury www.indiandentalacademy.com
  13. 13. Maxillary surgery (1) • Loss of teeth and bone, aseptic necrosis – vascular compromise – flaps, poor surgery – Rx hyperbaric O2, prosthesis! – Circumcrestal bone • Relapse – rigid/non rigid fixation – Max advancement ?BG ?distance – Sup repositioning – stability good. Bone contact, – Inf repositioning – relapse BG – expansion – stable • Oronasal fistula – closure www.indiandentalacademy.com • Septal deviation – prevention
  14. 14. Maxillary surgery (2) • Alar base – cinch suture • Nerve damage – stretch/pressure • Teeth – interdental osteotomies, damage, devitalised, periodontal, extruded! PREVENT • Nasal airway – max. rise – Turbinates, post-choanal height www.indiandentalacademy.com
  15. 15. Maxillary surgery (3) • Bleeding – Local anaesthesia – Hypotension – Careful surgery – Vascular compromise – maxillary, greater palatine, sphenopalatine vessels, pterygoid veins, int carotid, Le Fort I/II (D Lanigan 1990s) www.indiandentalacademy.com
  16. 16. Surgical problems • Cleft Le Fort I – pterygoids, palatine bone Separation, lateral wall, segmental surgery! • Le Fort II – nasolacrimal damage, positioning • Le Fort III – canthi, orbits, eyes, enophthalmos, diplopia, cranial – CSF, anosmia, telescoping – BG • Fixation problems – plates, screws, wires – External cranial fixation, BG – Occlusal wafers/splints www.indiandentalacademy.com
  17. 17. Mandibular surgery (1) • Condylar sag, AP relapse + AOB • Haemarthrosis, relapse, condylar repositioning • Improper plating/wiring, rotation proximal fragments, poor splints • Inaccurate cuts, teeth in osteotomy line, age • Soft tissues – muscle tension. AP/vertical relapse, suprahyoid myotomy www.indiandentalacademy.com
  18. 18. Mandibular surgery (2) • Tooth extrusion in fixation, bone relapse (large advances) – Teeth problems/relapse – use skeletal fixation • Inadequate type/length of fixation – Relapse, malocclusion • Non-union – reoperate fixation BG www.indiandentalacademy.com
  19. 19. Mandibular surgery (3) • Specific problems related to operative procedure – Modified sagittal split – Vertical subsigmoid – Body osteotomy – Segmental/genioplasty – Inv L/postcondylar graft www.indiandentalacademy.com
  20. 20. TMJ function • Pre-existing dysfunction – Abnormal load, muscle action • Internal derangement – Prevention – recognise no overload joint – Avoid posterior open bite www.indiandentalacademy.com
  21. 21. Nerve injury • Type – neuropraxia, axonotmesis, neurotmesis, neuroma Management – timing, primary repair, Nerve grafting, ID, lingual, facial www.indiandentalacademy.com
  22. 22. Post surgery – immediate – ICU • • • • Airway IMF, NT/NP tubes, suction Bleeding/circulation - ?blood transfusion Swelling – drainage, steroids Infection – antibiotics, careful soft tissue closure • Analgesia – (Sedation X) • General – DVT, PE, UTI, chest infection www.indiandentalacademy.com
  23. 23. Postop. follow up • • • • ?IMF period Elastic traction/orthopaedic Functional appliances ?Genioplasty www.indiandentalacademy.com
  24. 24. Post surgical orthodontics • Avoid opening bite • Adequate retention www.indiandentalacademy.com
  25. 25. Velopharyngeal insufficiency • Secondary cleft deformity • Craniofacial cases • Access osteotomies – split soft palate www.indiandentalacademy.com
  26. 26. Miscellaneous • Scars • Sinus infection • Plate problems www.indiandentalacademy.com
  27. 27. Poor results – due to: • • • • • • • • • • • Incorrect diagnosis Inappropirate Rx plan Unstable orthodontics Wrong surgical procedure Poor patient co-operation Inability to obtain planned position Relapse – AOB approx 10% (4:40) – 5yr follow up Poor occlusion – unstable Inadequate mobilisation Poor fixation Unknown cause! www.indiandentalacademy.com
  28. 28. Immediate preoperative assessment • • • • Planning – final check Cessation of growth Speech assessment Medical state, eg, URTIS, menses, drugs – NSAIDs • Adequate records • Consent www.indiandentalacademy.com
  29. 29. Operative area • Anaesthesia – airway • Theatre preparation – sterility, instrumentation, staffing • Surgery – incisions, bone cuts, vascularity, nerve function, teeth www.indiandentalacademy.com
  30. 30. Late complications – local (1) • • • • • Pain Ocular – acuity, diplopia, positional Airway – nasal, laryngo-tracheal CSF leak Neurosurgical deficit V – IO, ID, lingual, VII, III-IV-VI, I, II • Asymmetry • Occlusal problems www.indiandentalacademy.com
  31. 31. Late complications – local (2) • Dental – loss, extrusion, perio, periapical infection • Fistulae OAF, ONF • Hardware – plates, screws, wires • Mucocoeles, cysts • Speech • Relapse – sk, dental, ortho • TMJ • Psychological www.indiandentalacademy.com
  32. 32. Sagittal split osteotomy (1) • • • • Sensitive technique, training, instrumentation Impacted teeth – risk poor split Unfavourable split 3-20% Nerve damage 2-85%m Turvey 1985 3-5%, others 9% at 1yr, ?rigid fixation – the same • Bleeding operative 1-2%, later – rare • Proximal segment malposition – common – stability – aesthetics (van Merkesteyn 2%) www.indiandentalacademy.com
  33. 33. Sagittal split osteotomy (2) • Relapse – common, dental >sk > rigid, increased over 6mm, rotation?, setback late growth • Aseptic necrosis – stripping angle, modified split, rigid fixation • TMJ – opening <rigid fixation, condylar lysis < BSSU • Non-union, delayed?, infection www.indiandentalacademy.com
  34. 34. Vertical subsigmoid osteotomy (IO) • • • • • • • • • • • Critical instrumentation Subcondylar and angle, poor splits Nerve injury low 3.5% Bleeding 2% ID/masseteric/maxillary arteries Proximal segment, medial pterygoid attachment Relapse – AOB + late anterior change Facial nerve damage – rare Aseptic necrosis – proximal fragment tip TMJ – trismus, IMF, condylar sag/lysis Modifications Inv L – extra/intra oral osteotomy Coronoidectomy www.indiandentalacademy.com
  35. 35. Other procedures • Body ostectomy/osteotomy – ID, BG, teeth, stability+, fixation • Postcondylar graft – children – Graft material, complications EAM • Genioplasty – advance/retrude, sup/inf – – – – – Incisions – 2 line closure Nerve damage Asymmetry Aseptic necrosis Modifications – Köle, Sailer www.indiandentalacademy.com
  36. 36. Late complications • General – Death – Pulmonary atelectasis/pneumonia – Neurological – ulnar/popliteal – Vascular DVT, pulm. embolus – Pancreatitis – Pressure sores – Baldness – coronal flaps www.indiandentalacademy.com
  37. 37. Final thoughts! • Medicolegal complications arise from: – – – – • • • • Poor communication Poor planning Inappropriate consent Poor records No operation – no complications If you never have seen it, you have not done enough If it can happen, it will – to somebody, somewhere My patient deserves something better than this. www.indiandentalacademy.com
  38. 38. www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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