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

COMPLICATIONS OF
ORTHOGNATHIC SURGERY

INDIAN DENTAL ACADEMY
Leader in continuing dental education

www.indiandentalacademy.com

Selection of patient
– Psychological
– Neuromuscular disorders
– Multiple deformities – syndromes
– Multiple treatments


Assessment of patient
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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

Dentition
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Periodontal state
Caries
Saveable teeth
Restorations
Occlusion


Temporomandibular joints
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Symptoms
Assessment
Radiography
Pathology


Radiography
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Cephalometry
Orthopantomography
Periapicals
OMs – skull
CT scans


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


Models/articulation
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Arch size/relationships
Occlusion
Tooth position
Overbite, overjet
Occlusal curves
Molar relationship

Treatment planning
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Psychological
Photocephalometric
Dental
Presurgical orthodontics


Essential
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Accurate patient reevaluation
Correct selection – surgical procedure
Accurate prediction tracing
Accurate model surgery


Appropriate dental/model surgery
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Tooth size – occlusion
Occlusal plane – AOBs
Arch width – expansion/collapse
– Orthodontic – surgical – orthopaedic

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Space closure
Short roots – resorption
Root convergence
Surgical deficiencies
– Skill, ortho, fixation, instrumentation

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Failure to follow treatment plan
Teeth off basal bone – unstable
Orthodontic failure

Operative complications
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Patient care – anaesthesia etc
Maxillary surgery
Mandibular surgery
TMJs
Nerve injury
Vascular injury

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
• Septal deviation – prevention

• Alar base – cinch suture
• Nerve damage – stretch/pressure
• Teeth – interdental osteotomies,
damage, devitalised, periodontal,
extruded! PREVENT
• Nasal airway – max. rise
– Turbinates, post-choanal height

• Bleeding
– Local anaesthesia
– Hypotension
– Careful surgery
– Vascular compromise – maxillary, greater
palatine, sphenopalatine vessels, pterygoid
veins, int carotid, Le Fort I/II (D Lanigan
1990s)

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

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

• 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

• Specific problems related to operative
procedure
– Modified sagittal split
– Vertical subsigmoid
– Body osteotomy
– Segmental/genioplasty
– Inv L/postcondylar graft

TMJ function
• Pre-existing dysfunction
– Abnormal load, muscle action

• Internal derangement
– Prevention – recognise no overload joint
– Avoid posterior open bite


Nerve injury
• Type – neuropraxia, axonotmesis,
neurotmesis, neuroma
Management – timing, primary repair,
Nerve grafting, ID, lingual, facial


Post surgery – immediate – ICU
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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

Postop. follow up
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?IMF period
Elastic traction/orthopaedic
Functional appliances
?Genioplasty


Post surgical orthodontics
• Avoid opening bite
• Adequate retention


Velopharyngeal insufficiency
• Secondary cleft deformity
• Craniofacial cases
• Access osteotomies – split soft palate


Miscellaneous
• Scars
• Sinus infection
• Plate problems


Poor results – due to:
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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!

Immediate preoperative
assessment
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Planning – final check
Cessation of growth
Speech assessment
Medical state, eg, URTIS, menses,
drugs – NSAIDs
• Adequate records
• Consent

Operative area
• Anaesthesia – airway
• Theatre preparation – sterility,
instrumentation, staffing
• Surgery – incisions, bone cuts,
vascularity, nerve function, teeth


Late complications – local (1)
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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

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

Sagittal split osteotomy (1)
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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%)

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

Vertical subsigmoid osteotomy (IO)
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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

Other procedures
• Body ostectomy/osteotomy
– ID, BG, teeth, stability+, fixation

• Postcondylar graft – children
– Graft material, complications EAM

• Genioplasty – advance/retrude, sup/inf
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Incisions – 2 line closure
Nerve damage
Asymmetry
Aseptic necrosis
Modifications – Köle, Sailer

Late complications
• General
– Death
– Pulmonary atelectasis/pneumonia
– Neurological – ulnar/popliteal
– Vascular DVT, pulm. embolus
– Pancreatitis
– Pressure sores
– Baldness – coronal flaps

Final thoughts!
• Medicolegal complications arise from:
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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.

Leader in continuing dental education


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

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