excellent uptodate complications of maxillary orthognathic surgery

1. Complications of maxillary
orthognathic surgery
Dr Jameel Kifayatullah
Oral maxillofacial surgeon KCD

2. Complications
INTRAOPERATIVE COMPLICATIONS
 HEMORRHAGE
 VASCULAR COMPLICATIONS
 ISCHEMIA
 LACERATION OF LACRIMAL DUCT
 TRIGEMINOCARDIAC REFLEX
 TOOTH DAMAGE
 NASAL DEFORMITY
 STABILITY AND EARLY RELAPSE
 UNANTICIPATED MAXILLARY FRACTURES

3. Complications
Postoperative
 DELAYED BLEEDING
 AVASCULAR NECROSIS
 OPHTHALMOLOGICAL COMPLICATIONS
 INFECTION
 LONG TERM STABILITY
 ESTHETICS
 DISTURBANCE OF SOMATOSENSORY FUNCTION
 NON-UNION

4. Complications Common to all
procedures
• Postoperative infection
• Hardware exposure
• Unanticipated fractures
• Devitalization of teeth
• Malunion and/or nonunion
• Malocclusion
• Relapse
• Injury to teeth
• Gingival recession and/or periodontal complications
• Respiratory decompensation
• Bleeding

5. Hemorrhage
• Intraoperative or postoperative hemorrhage
can be life threatening (Although rare)
Intraoperative precautions
• optimize venous drainage by elevating the
head (reverse Trendelenburg position) and
under controlled hypotension. In this way the
monitored arterial pressure correlates to the
true intracerebral pressure

6. REVERSE TRENDELENBURG POSITION

7. HOW TO MINIMISE BLEEDING
DURING SURGERY
• To minimize blood loss, a preoperative
vestibular injection of local anesthetic with
vasoconstrictor is used to reduce oozing of the
mucosa, meticulous subperiosteal dissection
is performed, and packing with gauze or
cauterization or ligation of bleeding vessels is
also used.

8. Bleeding from vessels
• If major bleeding occurs, it can be either
arterial from the maxillary artery and its
branches or venous from the pterygomaxillary
plexus
• In general the descending major palatine
artery or the sphenopalatine artery is the
origin, or more seldom the nasoethmoidal
artery.

9. Bleeding from vessels
• An injury to the descending palatine
artery may occur when dissecting or
reducing the lateral wall of the nose ,
going too high and too far back (no more
than 25 to 30 mm), or by separating the
maxilla from the pterygoid process with
the osteotome. The length of the medial
wall of the sinus from the piriform rim to
the descending palatine artery is
approximately 34 mm. It is, however,
essential that the dissection of the lateral
nasal wall be done in such a way that any
uncontrolled fracture of the pterygoid
plate with disruption of the
pterygopalatine fossa can be avoided

10. Pterygomaxillary dysjunction
• Mean height of the pterygomaxillary
suture is 14.6 mm (range 11-18 mm) and that
the mean distance from the inferior junction
maxilla/pterygoid plate to the most inferior
position of the internal maxillary artery,
entering the pterygopalatine fossa, is 25 mm
(range 23-28 mm). This is important to know
if you use an osteotome, such as an
Obwegeser or Kawamoto osteotome, with a
width of 10 to 15 mm, for dissecting the
pterygomaxillary junction. Downward
direction of all instruments is crucial in this
step. Any forceful, uncontrolled
downfracture should be avoided.
• An upward and posteriorly oriented
osteotome will not reliably separate
the maxilla from the pterygoid plates.
It is also associated with increased
risk of bleeding from the pterygoid
plexus and internal maxillary artery.

11. Lacerated vessel
• When visualization of the lacerated vessel is
not possible, immediately packing and
continuing the osteotomy until the
downfracture has taken place is advised. In
cases of direct access, clipping is the first
choice . If the artery disappears in the canal,
compression with a bone chip or resorbable
hemostatic agent should be tried

12. Bleeding from pterygoid plexus
• Cauterization and hemostatic agents are the
therapy of choice for venous bleeding from
the pterygoid plexus.

13. Severe arterial bleeding
• If severe arterial bleeding occurs and ligation
and packing are unsuccessful, immediate
angiography and embolization are
unavoidable. In extreme situations, ligation of
the external carotid artery is an option. If this
is not done intermediately, a later risk of
aseptic necrosis of the maxilla may arise.

14. Vascular complications
• To prevent any thromboembolic complications
antithrombotic prophylaxis is administered
starting preoperatively for a maximum of 3 days.
further precautions recommended are to use
venous compression stockings during surgery

15. Ischemia(maintenance of vascularity
to osteotomised segment)
• The blood flow in the attached gingiva and
alveolar bone will be decreased, as these
areas are usually supplied by the superior
alveolar artery, which is dissected by the
buccal approach. Nevertheless, it is important
to place the circumvestibular incision high
above the mucogingival junction and to keep
the attached gingiva in place so that later
recessions due to scarring can be prevented

16. CIRCUMVESTIBULAR INCISION

17. POSTOPERATIVE ISCHEMIA RISKS
• The amount of mobilization especially in
anterior and downward direction
• increases in patients with anatomic and
iatrogenic irregularities such as cleft lip and
palate or craniofacial dysplasia
• The method of mobilization of the maxilla is
also important. It must be done gently but
forcefully, without too much compression of
the palatal pedicle.

18. Treatment of prolonged ischemia
If prolonged ischemia of the vestibular
mucosa is observed:
• minimize the hypotensive anesthesia
• inject anticoagulation agents
• do warm packing of the maxilla with gauze
sponges
• Gentle and careful wound closure without
tension

19. Laceration of the Lacrimal Duct
• Laceration of the lacrimal duct may occur if the osteotomy
through the piriform rim and the lateral nasal wall is
designed too high.
• nasolacrimal duct is located 10 to 14 mm posterior from
the piriform aperture and approximately 15.5 mm above
the nasal floor
PREVENTION
• It is advisable to place the osteotomy beneath the anterior
attachment of the inferior turbinate and the infraorbital
foramen, as well as to elevate the nasal mucoperiosteum
where the meatus of the nasolacrimal duct ends, not to
injure the ostium or the canal of the duct itself

20. Lateral nasal wall showing the distance from the anterior
attachment of the inferior turbinate to the nasolacrimal canal
orifice. IT, inferior turbinate; MT, medial turbinate; OL, high Le
Fort I osteotomy; OLD, ostium of nasolacrimal duct
OSTIUM OF NASOLACRIMAL
DUCT
IT
MT

21. Lacrimal duct
• Diagram of the relationship
between the high Le Fort I
osteotomy and the meatal
portion of the nasolacrimal
duct. The meatal portion of
the nasolacrimal duct can
be protected by detaching
the mucosa from the lateral
nasal wall and placing a
periosteal elevator between
the mucosa and the lateral
wall as the osteotomy is
accomplished
Meatal portion
nasolacrimal
duct
Osteotomy
line

22. LACRIMAL DUCT

23. LACRIMAL DUCT LACERATION
Treatment of laceration
• If a disruption has occurred during osteotomy,
a persistent epiphora and recurrent
dacrocystitis may result. This may require
surgical intervention by doing an endonasal
endoscopic dacryocystorhinostomy

24. Dacryocystorhinostomy (DCR)
• Dacryocystorhinostomy (DCR) surgery is a
procedure that aims to eliminate fluid and
mucus retention within the lacrimal sac, and
to increase tear drainage for relief of epiphora
(water running down the face)

26. Trigeminocardiac reflex
• Cardiac complications such as asystole,
bradycardia, and cardiac dysrhythmias can
occur during ophthalmic or maxillofacial
surgeries and can be lethal in rare cases.
Stimulation of the maxillary branch of
trigeminal nerve, greater palatine nerve, or
posterior superior alveolar nerve leads to
vagus nerve stimulation, which activates the
parasympathetic nerve system, and
consequently leads to dysrhythmia.

27. Trigeminocardiac reflex
• In most cases, heart rate and blood pressure
return to normal while arrhythmia disappears
upon temporary cessation of surgery.
• When bradycardia accompanied by refractory
bradycardia, asystole, and hypotension
persists, anticholinergic drugs (atropine 0.2-
1.0 mg, glycopyrrolate 0.1-0.4 mg) are injected

29. Tooth Damage
• In order to prevent tooth damage during
maxillary Lefort I osteotomy a distance of
approximately 5 mm above the apices should be
respected
• In segmental Lefort I osteotomy the root damage
can be avoided by carefully diverging the roots at
pre-surgical orthodontics
• Interdental osteotomy should be made using fine
osteotomes to prevent damage to the teeth

30. Tooth Damage

31. Nasal septum
The nasal septum is
composed of four
structures:
• perpendicular plate of
ethmoid bone
• vomer bone
• septal nasal cartilage
• maxillary crest

32. Nasal bone Anatomy

33. Caudal septum of nose

34. Nasal DEFORMITY
• During superior
maxillary
positioning(vertical
impaction) inferior
portion of cartilaginous
nasal septum should be
exposed and trimmed
to prevent bowing or
clicking of nasal
septum.

35. NASAL DEFORMITY
• An inferior
turbinectomy is
performed to prevent
nasal obstruction in
cases of significant
superior positioning of
maxilla

36. Stability and Early Relapse
• The crucial points in stability include the means of internal
fixation, changes of maxillary position, and quality of bone
• Relapse of maxilla can be observed in patients who have
undergone large anterior and inferior movements
especially in a patient with thin bone ,inadequate bony
contact ,poor fixation and parafunctional habbits.
• Anterior and downward movements of the maxilla need to
be grafted for reasons of stability.
• Failure of osteosynthesis may occur in fragile structured
maxilla independent of planned movement
• Relapse in early postoperative period is treated
conservatively using orthodontic therapy

37. Unanticipated Maxillary fractures
• In stepped osteotomy the bone leading to
zygomatric buttress may be thin and easily
prone to fracture
• Management: use a plate on either side of
gap/fractured bone segment and reinserting
the fragment behind the plate

38. Unanticipated maxillary fractures
• Most common fracture with Lefort surgery is
unpredictable fracture that occur in pterygoid
plate region
• Inappropriate placement of curved osteotome
during pterygomaxillary dysjunction can result
in propagation of fracture into skull base
causing neurovascular and ophthalmic
complications. Downward direction of all
instruments is crucial in this step

39. Unanticipated maxillary fractures
• Overimpaction of maxilla
• Underimpaction of maxilla
Avoided with the use of internal or external
reference points

40. Unanticipated maxillary fractures
Maxilla underimpacted after surgery:
• removal of plates and screws with placement
of skeletal suspension wires in the outpatient
setting
• Return to surgery to reposition and stabilize
the maxilla into the correct position warranted

41. Unanticipated Maxillary fractures
Maxilla overimpacted after surgery:
• Consider reoperation

42. Post operative
DELAYED BLEEDING
• Delayed bleeding in early postoperative
period(2 weeks) generally occurs from maxilla
due to clot dislodgement or rupture of a
maxillary vessel
• Conservative treatment: local vasoconstrictor
sprays and placement of anterior or posterior
nasal packing to temponade the
bleeding.blood complete exam, patients
health status review
• Packing removed 24-48 hours later

43. Delayed bleeding
• Bleeding refratory to conservative methods or
massive epistaxis: require urgent evaluation
by interventional radiology and embolisation
of offending vessel
• Not available:do surgical ligation of offending
vessel

44. AVASCULAR NECROSIS(VASCULAR
COMPROMISE)/ASEPTIC NECROSIS
• Aseptic necrosis is a bone
condition that results from
poor blood supply to an
area of bone, causing
localized bone death. This is
a serious condition because
the dead areas of bone do
not function normally, are
weakened, and can
collapse. Aseptic necrosis is
also referred to as avascular
necrosis or osteonecrosis.

45. AVASCULAR /ASEPTIC NECROSIS
• Ischemic complications can appear to different
degrees:
loss of tooth vitality
periodontal defects,
loss of tooth
loss of segments up to the entire maxilla

46. Avascular/aseptic necrosis
• Risks increased with
Segmental maxillary osteotomies
Large maxillary advancements
smoking
Causes
kinked vascular pedicle in palatal mucosa
iatrogenic tearing of palatal flaps

47. TREATMENT OF AVASCULAR NECROSIS
Initial treatment:
• identify the problem and provide supportive care i.e
irrigation,chlorhexidine mouth wash, oral hygiene
instructions
• stabilise the mobile maxillary segment in OT.
• release MMF and do comprehensive
assessment
• Consider Comprehensive prophylactic systemic
antibiotics
• HBO therapy (20-30 dives)

48. Treatment of avascular necrosis
Delayed /long term management
• allowing sufficient time for demrcation of necrotic
segments(months)
• Conservative removal of non viable bone segments and
teeth
• Repair of any associated oroantral and oronasal
fistulae
• Reconstruction with free fibula along with soft tissue
• Dental implants and prosthetic reconstruction after
grafting

49. OPHTHALMOLOGICAL
COMPLICATIONS
• Blindness(0.25%) rare after Lefort I osteotomy
Cause: pterygoid maxillary disjunction
i)If this is done too forcefully it may
result in uncontrolled fracture lines
and bleeding
ii) Compression in the pterygoid palatine
fossa up to the superior orbital fissure and
optic foramen is another risk
Treatment: If optic nerve damage and its origin are diagnosed,
instant decompression of the optic nerve and application of
corticosteroids may help, but recovery rates are poor

50. Other ophthalmological
complications
• Consequences of forces transmitted during
pterygomaxillary separation: decrease in visual acuity,
extraocular muscle dysfunction, neuroparalytic keratitis,
and injuries of the lacrimal apparatus resulting in epiphora
and keratitis sicca .
• These indirect forces may be traction, compression, or
contre coup trauma to structures running through the
superior orbital fissure and in the pterygopalatine fossa.
Management:
• an ophthalmologic consultation
• acute computed tomography (CT)
scan, becomes urgent

51. Infection
• Septic complications in maxillary orthognathic surgery rare--the reason
being that antibiotic prophylaxis is standard
• Patients who suffered from maxillary sinusitis before orthognathic surgery
are in greater danger of developing an infection postoperatively.
Further causes
• Retention of a hematoma
• lack of vascularization
• edema
• compromised nasal airflow
• Free autologous bone grafts or interpositions of hydroxyapatite blocks
may be at higher risk of infection as well
• In cases of MAXILLARY SINUSITIS postoperatively, vestibular draining and
lavage are sufficient in general under antibiotic medication.
• Local abscesses arising from sutures, such as alar cinch sutures with
nonresorbable materials, are possible and must be excised

52. LONG TERM STABILITY
• Risk factors
1) Where the maxilla was moved?
2) how it was stabilised?
3) Whether an isolated or combined bimaxillary procedure
was conducted ?
4) Any stretching of soft tissues
and muscles, such as the pterygomasseteric muscle sling or
the thick, inelastic palatal mucosa(NEUROMUSCULAR
ADAPTATION)

53. Long term stability
How to achieve long term stability?
• Avoid Extreme changes in angulation of the occlusal and
facial planes
• only a change of the occlusal plane up to 9 degrees can be
tolerated(j reyeneke)
• Stabilization with rigid internal fixation improves stability
• bridging gaps with bone grafts on the Le Fort I level in vertical
changes helps increase long-term stability of the maxilla
• Mobilised maxilla must be maneuvured into new position
without any traction or force(under constant pressure even
stable screws can begin moving via resorption)
•

54. Long term stability
How to achieve long term stability?
• avoid unbalanced and heavy occlusal
forces(cause micromovements and
overloading at osteotomy gaps)
• Clenching and bruxism need treatment
• Use only soft diet postoperatively
• Avoid micromovements at healing sites(results
in fibrous union requiring replacement of
osteosynthesis and bone grafting)

55. Esthetics
• Most critical regions for esthetic complaints
after maxillary surgery are the
1) nose 2) Smile 3) increase of soft tissue in
midface
Lefort I procedure broadens the nasal base and
changes nasal tip projection
Reduction of nasal septum necessary after
LEFORT I procedure for nose and septum to be
in midline position

56. ESTHETICS
• NOSE: Flaring of nostrils after LEFORT I
osteotomy
• Using an alar cinch suture, the mobilized
periosteum, paranasal musculature, and
indirectly the crus laterale can be
anchored to the area of the anterior
nasal spine by nonresorbable suture

57. Nasal flaring
Nasal flaring Alar cinch suture

58. ESTHETICS
LIP SMILE :
The movement of the cheilion(ANGLE OF LIPS)
in horizontal and vertical directions can be
improved with an alar cinch using muco-
musculo-periosteal V-Y sutures.
So a V-Y closure of maxillary incision should be
undertaken to ensure appropriate lip
thickness and vertical lip positioning in smile
and repose.

59. ESTHETICS

60. Disturbance of somatosensory
function
Nerves in the operating feld during Lefort I
osteotomy
• The posterior superior alveolar nerve, middle
and anterior superior alveolar nerves,
(branches of the maxillary nerve V2)
• The infraorbital nerve branches (a purely
sensory nerve derived from the second
maxillary division of the trigeminal nerve).

61. Infraorbital nerve

62. INFRAORBITAL NERVE AND ITS
BRANCHES

63. INFRAORBITAL NERVE BRANCHES

64. Infraorbital nerve branches
• The infraorbital nerve (V2), after emerging
from the infraorbital foramen, divides into
four branches: the inferior palpebral, external
nasal, internal nasal, and superior labial
nerves. They supply the lower eyelid and
upper lip as well as the lateral portion of the
nose and ala, cheek, and mucous
membranes lining the cheek and upper lip.

65. Infraorbital nerve damage
• Disturbance may include changes in tactile
perception (touch perception),two point
discrimination(the ability to discern
that two nearby objects touching the
skin) sensitivity to heat on the skin in
the mid-face area, the upper lip, the gingiva, and
mucosa of the palate or vestibule as well as the
sensitivity of the upper teeth

66. How to avoid damage to nerve
• careful preparation and handling of retractors
during surgery
• Low circumvestibular incision
• the horizontal bone cut should be done at
least 5 mm above the apices in respect of
vitality and sensitivity of the teeth

67. Non Union of the Maxilla
• Local factors
• Systemic factors

68. Non Union of Maxilla
Local Factors
• compromised blood supply:
poor surgical planning/scarring from
previous surgery (Cleft palate patient)
• patients with parafunctional activity
• patients who exert excessive masticatory
forces
• occlusal irregularities/interferences
unstable maxillary movement(anteroinferior)

69. Non Union of Maxilla
Systemic factors
Interferes with healing/poor wound healing
Diabetes Mellitus:
smoking
Immunocompromised illness

70. Prevention of Non Union
• For unstable maxillary movement (inferior
repositioning) bone plates and screws combined
with additional forms of stabilisation inc skeletal
suspension wires(Circumzygomtic or piriform rim
wires) as well as period of IMF ranging from 1-6
weeks recommended.
• Bone gaps of 5-6 mm or greater from large
maxillary advancements:Allogeneic bone grafting
at pillars of maxilla (Piriform rim,zygomatic
buttres)

71. BONE GAPS GRAFTED AT PIRIFORM RIM AND ZYGOMATICOBUTTTRESS REGION

72. NON UNION
Physical Findings
• Mobility of maxilla during maximal
intercuspation/Patient able to move maxilla
superiorly by simply clenching teeth together

73. NON UNION MAXILLA
• Early management
a short period of IMF For neovascularisation
at bone gap
If Patient already in IMF :removal of IMF Allow
functional remodelling and bony consolidation
Flat plane occlusal splints :to distribute
occlusal forces more evenly and appropriately

74. Non Union Maxilla
Late Management
• aggressive mobilization
• removal of fibrous tissue,
• grafting, preferably with autogenous tissue
• application of rigid fixation.