Downloaded 985 times
Uploaded byArjun Shenoy
Orthognathic complications
This document discusses various complications that can occur with orthognathic surgery, including: - Common intraoperative complications are nerve injuries, most often to the inferior alveolar nerve during mandibular surgery, and hemorrhage, usually from the maxillary arteries. - Frequent postoperative issues involve neurosensory deficits, nonunion or delayed bone healing, and infections, which have been reported in up to 9.7% of patients. - Other risks include loss of vascularity leading to aseptic necrosis of the maxilla or mandible, nasal deformities, malocclusion, and TMJ dysfunction. Careful planning and technique aim to minimize complications while pursuing the benefits of orthognathic
More Related Content
Similar to Orthognathic complications
More from Arjun Shenoy
![CASE_PRESENTATION_ON_subdural_hematoma(SDH)[1 FINAL PPT]-1.pptx](https://cdn.slidesharecdn.com/ss_thumbnails/casepresentationonsubduralhematomasdh1finalppt-1-260129172522-d405d375-thumbnail.jpg?width=640&height=640&fit=bounds)
Orthognathic complications
- 2. CONTENTS • Presurgical • Intraoperative •Vascular • Neural • Unwanted fragmentation • Post operative • Loss of vascularity : aseptic necrosis • Nose • Lip • Infection • Nonunion/delayed union • Occlusal disturbances • TMJ dysfunction • Relapse • Rare complications
- 3. “Unintended consequence ofthe surgery that causes harm to the patient, occurring either intra-operatively or early and late post-operatively.” • A complication is so named because it complicates the situation.
- 4. • “No matterwhat measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.” • ― Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science
- 5. N = 1000patients (1983-2002) INTRA AND PERIOPERATIVE COMPLICATIONS OF THE LEFORT IINTRA AND PERIOPERATIVE COMPLICATIONS OF THE LEFORT I OSTEOTOMY: A PROSPECTIVE EVALUATION OF 1000 PATIENTSOSTEOTOMY: A PROSPECTIVE EVALUATION OF 1000 PATIENTS Kramer; J CrFac Surg Vol 15,6 Nov’04
- 6. Incidence of complicationsand problems related to orthognathic surgeryIncidence of complications and problems related to orthognathic surgery Su-Gwan Kim, Sun-Sik Park ; JOMS 65;2438-2444,2007 N = 301 (1998-2005) Neurosensory deficit - IAN - Commonest complication 73.3% - BSSO. Bleeding in Lefort I – most serious complication – Maxillary a. Inappropriate fragmentation - 5% - BSSO
- 7. SUMMARYSUMMARY • Total rangeof Incidence of complications – 6.4-9.7% • Complication rates: more - craniofacial deformities • Commonest : paresthesia with IAN 36%- 91% • Most serious – bleeding (immediate/delayed) • Avg. infection rates :1.1%-4% • Ischemic necrosis rare: more with multiple segmentation
- 8. CLASSIFICATIONCLASSIFICATION Pre-surgical Intra - operative Post– operative Dimitroulis 1998 J Adult Orthod Orthognath Surg
- 9. PRESURGICAL Lack of pretreatment objectives Laboratory errors Orthodontics
- 10. Pre-surgical Lack of pre-treatmentobjectives • Failure to recognize underlying skeletal abnormality • Unexpected adverse growth • Lack of patient co-operation • Gross skeletal deformity correction: mainly orthodontics & minimal surgery
- 11. Inability to performthe ideal procedure Undesired esthetic and occlusal results Creation of new problems and revision procedures Presurgical : Lack of pre treatment objectives
- 12. Unsatisfactory bite registration Discrepancyin mounting the cast Improper model surgery Warpage of splints Presurgical : Laboratory errors
- 13. • Insufficient decompensation •Inadequate transverse coordination • Uncorrected tooth size problems • Inadequate preoperative root divergence in segmental surgery • Active orthodontic wires at surgery • Orthodontic appliances Presurgical : Orthodontics
- 14. Presurgical Intraoperative Post operative. Vascular -Hemorrhage Neural Fragmentation
- 15.
- 16. • Incidence :1-1.1% Causes: - Supra-periosteal reflection - Posterior wall osteotomy cut directed superiorly - Forced downfracture and mobilization of maxilla - Elevation of nasal mucosa from nasal floor Intraoperative: Hemorrhage in Maxilla
- 17.
- 19.
- 20. Management : - Visualizationof problem area - Rapid completion of osteotomy: down fracture maxilla - Packing and direct pressure, vascular clips, electrocautery Turvey TA, Fonseca RJ: J Oral Surg 38:92, 1980 Intraoperative: Hemorrhage in Maxilla
- 21. Thomas Teltzrow Journalof Cranio-Maxillofacial Surgery (2005) 33, 307–313 Vessels at risk : -Inferior alveolar A. - Internal carotid A. - Massetric A. - Retromandibular vein - Facial vein BSSO medial aspect : Inf alv artery lower margin: facial a. damage IVRO sigmoid notch: Massetric artery ramus Inferior: Inf Alv artery Intraoperative: Hemorrhage in Mandible
- 22.
- 23. • Neuropraxia • Axonotemesis •Neurotemesis Intraoperative: Nerve injuries
- 24. Causes for InfAlv Nerve damage: Dissection Splitting Movements Stabilization: comp- injury Canal - natural pathway for direct nerve regeneration. Intraoperative: Nerve injuries - Mandible Predisposing factors? Low mandibular body height Inferior position of nerve
- 25. Inferior alveolar n.injury Prevention: Management Tension-free suturing of nerve Osteotomy design Protection Chisel placement Decompression of lateral fragment Steroids Intraoperative: Nerve injuries - Mandible
- 26. Causes: • Retraction mediallybehind ramus • Extension of distal segment beyond prox. segment • Haematoma • Genioplasty : direct trauma to marginal branch • Sagittal split : direct trauma to trunk Intraoperative: Nerve injuries –Facial N.
- 27. Lingual nerve injuries- uncommon Causes: • Variable course of nerve on medial aspect of mandible • No protection to nerve while stripping on medial aspect • Bicortical screws for BSSO : overpenetration Intraoperative: Nerve injuries –Lingual N
- 28. • Not studiedas thoroughly as mandible • Terminal branches of infra-orbital nerve • Clean incision Gentle dissection retraction • Usually temporary • Recovery 2-8 weeks. Intraoperative: Nerve injuries –Maxilla
- 29.
- 30. “Deviation from osteotomyline during osteotomy procedure, resulting in osteotomy in area unrelated to surgery” Maxilla Mandible Intraoperative: Fragmentation
- 31. Factors: • Bone architecture •Bone density • Unanticipated fractures • Difficult fixation • Impacted third molar Intraoperative: Fragmentation
- 32. Sequalae : • Infection •Sequestration of the fragments • Delayed bone healing • Pseudoarthrosis • Post operative instability & Relapse • TMJ Intraoperative: Fragmentation
- 33.
- 34. POSTOPERATIVE Loss of vascularity: aseptic necrosis Anatomic variations: Nose, Lips Nonunion/delayed union Infection Occlusal disturbances TMJ dysfunction Relapse
- 35. Aseptic necrosis: • Anteriormaxillary osteotomy • Transversal maxillary segmentations • Transection/kinking of vascular pedicle • Major anatomical irregularities • Poor flap design, Tearing of flaps Postoperative: loss of vascularity - maxilla
- 36. Consequences : -Loss ofentire maxilla or segment, -Flattening of papilla, Non vital teeth Prevention -Tease out descending palatine vessels during intrusion/retrusion -Fewer Segmentation: avoid small segments -Avoid damage to pedicle Postoperative: loss of vascularity - maxilla
- 37. • Dr HallHD -1978. • 15 years - medically fit female - Le Fort I osteotomy with maxillary rib graft augmentation + BSSO + genioplasty
- 38. • 3 stagesurgical plan - hyperbaric oxygen + prosthodontics involvement • Initially 30 treatments of hyperbaric oxygen at 2.4 kPa. • At the first operation- remaining maxillary teeth were removed + maxillary sinus and necrotic alveolar bone debrided + alveolus reconstruction with an iliac crest graft secured with miniscrews and cancellous bone,
- 39. • Interruption inInf Alv artery: - mandibular br of sublingual artery - mental artery • Complete stripping of mucoperiosteum: - compromise periosteal blood supply - medullary supply is already compromised Osteotomized segment : like free autogenous graft necrosis Postoperative: loss of vascularity - mandible
- 40. • Risk inIVRO > BSSO • Maintain buccal& lingual pedicles in extensive genioplasty • Excess advancement: stretches nutrient vessel • Ischemic tissue: intraoral free graft. • Meticulous irrigation – supportive therapy • HBO therapy promotes neovascularization • Reconstruction Management Postoperative: loss of vascularity - mandible
- 41. POSTOPERATIVE Alteration in Nasalform - Septum - Alar Base Loss of vascularity : aseptic necrosis Nose Lip Nonunion/delayed union Infection Open bite and lateral shift TMJ dysfunction Relapse
- 42. Nasal Septum deviation: -Maxillary impaction : encroachment on Presurgical dimension of nasal septum - Maxillary advancement buckling Failure to reposition : - Septal deviation – obstruction - Abnormal position of columella/nasal tip Postoperative: Nose
- 43. Intraop - Resection ofinferior aspect of septum - Trim septal spurs if present - Trim bone from nasal crest of maxilla - Groove in superior aspect of maxilla Septal deviation - How to avoid? Management -Reoperation - Delayed septoplasty Postoperative: Nose
- 44. Alteration in alarbase and perioral structures • Alar base widening • Prominent alar groove • Upturning of nasal tip – obtuse nasolabial angle • Flattening and thinning of upper lip • Downturning of labial commisures Postoperative: Nose
- 45. Alar cinch suture Pyriformplasty Alterationin alar base and perioral structures Postoperative: Nose
- 46. POSTOPERATIVE Loss of vascularity: aseptic necrosis Nose Lip Nonunion/delayed union Infection Occlusal disturbances TMJ dysfunction Relapse Rare Complications
- 47. Postoperative: Lip V-Y closureof the lip is done to prevent the shortening of the lip.
- 48. POSTOPERATIVE Loss of vascularity: aseptic necrosis Nose Lip Infection Nonunion/delayed union Occlusal disturbances TMJ dysfunction Relapse Rare complications
- 49. PREVELANCE OF POSTOPERATIVECOMPLICATIONS AFTER ORTHOGNATHIC SURGERY: A 15-YEAR REVIEW LOP KEUNG CHOW, BALDEV SINGH, NABIL SAMMAN. JOMS 65:984-992,2007 • N = 1294 patients ; 2910 procedures-1070 -bimax; 224-single jaw • Total complication rate – 9.7% (out of this – 7.4% - infection) • Higher infection rate (17.3%) in single pre-op dose of antibiotics than patients on postop antibiotics
- 50. POSTOPERATIVE Loss of vascularity: aseptic necrosis Nose Lip Infection Nonunion/delayed union Occlusal disturbances TMJ dysfunction Relapse Blindness
- 51. Causes Local compromised bloodsupply scarring , large advancement large bite force - habits postero-superior positioning Systemic co-morbities- smoking Prevention : principles of fixation techniques graft Bone gaps > 5mm auxillary forms of stabilization Postoperative: Nonunion/delayed union - maxilla
- 52. Causes : • Instabilityof fixation devices • Avascular necrosis • Large advancements with less bony contact (>7mm) • Post op trauma • Parafunctional habits IVRO > BSSO Postoperative: Nonunion/delayed union - mandible
- 53. POSTOPERATIVE Loss of vascularity: aseptic ncecrosis Nose Lip Nonunion/delayed union Infection Occlusal disturbances TMJ dysfunction Relapse Rare Complications
- 54. POSTOPERATIVE - OCCLUSALDISTURBANCES - Posterior interference: maxilla when patient in IMF - Maxilla fixed with condyles out of glenoid fossa - Hardware Failure - screws and plates - Fragmentation - Edema in joints - Condylar torque, condylar sag, incorrect placement of fragments - BSSO- failure of rigid fixation at the osteotomy site, occlusal shifts during fixation, and finally condylar sag
- 55. Open Bites Management : -minor discrepancies aggressive orthodontics - Posterior open bite < 3mm vertical elastics - Severe discrepancies surgery POSTOPERATIVE - OCCLUSAL DISTURBANCES
- 56. POSTOPERATIVE - OCCLUSALDISTURBANCES Lateral shift Causes: –Inadequate advancement of one side –Equal advancement with midline shift –Torqueing of the proximal segment Management: –Elastic traction
- 57. Postoperative Loss of vascularity: aseptic ncecrosis Nose Lip Nonunion/delayed union Infection Open bite and lateral shift TMJ dysfunction Relapse Rare Complications
- 58. Intraoperative position ofcondyle influenced by: • Incorrect vector during condylar positioning • Incomplete or green-stick split prevents condylar seating • Muscular, ligamentous or periosteal interference • Intra-articular hemorrhage or edema • Flexion in proximal segment while placing rigid fixation POSTOPERATIVE – TMJ DYSFUNCTION
- 59. • TMDs 20-25% in normal population • Karabouta & Martis – 40.8% TMDs post BSSO • White – 49.3% Condylar Sag Immediate / late change in position of condyle in the glenoid fossa after surgical establishment of a preplanned occlusion and rigid fixation of the bone fragments, leading to a change in the occlusion Reyneke ; BJOMS (2002) 40, 285–292 POSTOPERATIVE – TMJ DYSFUNCTION
- 60. Postoperative – TMJdysfunction Condylar sag Central Peripheral I & II
- 62. • The condyleis seated with the condylar seating tool + light digital pressure at the angle • resultant vector is anterosuperior
- 66. Change in shapeof the condyle from normal to finger shaped with loss of height and later decrease in posterior facial height. Van Damme JCMS 1994 ; 22, 53-58 Incidence : 2.3% and 7.7% of BSSO advancement Postoperative – TMJ dysfunction Condylar Resorption
- 67. POSTOPERATIVE Loss of vascularity: aseptic ncecrosis Nose Lip Nonunion/delayed union Infection Open bite and lateral shift TMJ dysfunction Relapse Rare Complications
- 68. Stability depends on: - Adequate presurgical orthodontics - Long-term maxillomandibular fixation (MMF) - Nonrigid fixation that allow muscular adaptation - Minimal muscle alteration - Good bony contact, and control of the proximal segment POSTOPERATIVE - RELAPSE
- 69. Factors : • Magnitudeof mandibular advancement or setback, • Stretch of surrounding soft tissue, • Positioning of mandibular condyles • Method of fixation • Growth of mandible • skeletal behavior among hyper/hypodivergent skeletal patterns POSTOPERATIVE – RELAPSE MANDIBLE
- 70. • Obligate relapseafter mandibular advancements >7mm • Mandibular setback >12 mm - less skeletal relapse • Closure of anterior open bite with only mandibular osteotomies POSTOPERATIVE – RELAPSE MANDIBLE How to reduce/avoid : • Counterclockwise rotation of the mandible be avoided • Mandibular advancement limited to < 7mm • Bimaxillary surgery
- 71. Depends on : •Degree of surgical advancement • Degree of inferior repositioning of anterior maxilla • Use of bone grafts in large advancements POSTOPERATIVE – RELAPSE MAXILLA
- 72. Other Causes : -Increased soft tissue stretching results in drift of the screws during bone healing - Reduced area of bone contact at the lateral aspects of the maxilla - compromised union - Preoperative scarring - Cleft maxilla Postoperative – Relapse Maxilla
- 73. • Postoperative relapsewas not considerable after total maxillary setback surgery. • Although the amount of maxillary setback was greater, postoperative relapse did not increase significantly. • Significant osseous regeneration at the pterygomaxillary region occurred in the early phase of recovery.
- 74. • On average,18% of the horizontal maxillary repositioning was lost. • Most of the change (89%) occurred during the first 6 months postoperatively. • Relapse increased significantly with degree of surgical advancement and degree of inferior repositioning of anterior maxilla.
- 75. Remedy for prevention: •Advance the maxilla at least 2mm more than the ideal overjet to compensate for relapse • Provision of a period of MMF (3—4 weeks) in addition to rigid fixation in large advancements – Postoperative – Relapse Maxilla - Management Van Sickels BJOMS 1996;34:279—85.
- 76. POSTOPERATIVE Loss of vascularity: aseptic ncecrosis Nose Lip Nonunion/delayed union Infection Open bite and lateral shift TMJ dysfunction Relapse RARE COMPLICATIONS
- 77. RARE COMPICATIONS BLINDNESS (vasculaturedamage/hypoxia) LOSS OF FUNCTION OF LACRIMINAL GLAND CRANIAL NERVE PALSIES DAMAGE TO INTERNAL CAROTID ARTERY
- 78. • Abnormalities ofthe pterygoid plates ranging from mild hypoplasia to complete absence. • Excessive thickness of the posterior maxillary wall, which is normally hypoplastic,
- 79. Devastating complication –mechanism not clear • Immediate swelling eyelids • 1st post-op unable to open eye • Manual lift –no light perception • Intense chemosis, loss of abduction, pupillary dilatation 88
- 80. • MRI- NAD •CT- Complex fractures of the pterygoid plates on both sides greater wing sphenoid, sinus • Bone fragments in inferior orbital fissure
- 81. PTERYGOMAXILLARY DYSJUNCTION schuchardt 1942 Maxillarytuberosity + Pyramidal process of palatine bone + Pterygoid plates of sphenoid Disarticulated easily during childood (melsen & ousterhout 1987) Complexity of sutures increases with age Cause: adverse transmission of forces to skull base via sphenoid bone Precaution during Pterygomaxillary dysjunction
- 82. RARE COMPICATIONS BLINDNESS (vasculaturedamage/hypoxia) LOSS OF FUNCTION OF LACRIMINAL GLAND CRANIAL NERVE PALSIES DAMAGE TO INTERNAL CAROTID ARTERY
- 84. • Color Doppler– left internal carotid flow
- 85.
- 86.
- 87. POST-OP 2 MONTHS CONCLUSION •Congenital hypoplasia internal carotid
- 88. • Statistically significantreduction in intraoperative blood loss • Statistically significant correlation between the surgeon's perception of the quality of the surgical field and intraoperative blood pressure, • No statistically significant decrease in operative time when hypotensive anesthesia was used.
- 89. • 3rd post-op day- CSF discharge - left nostril, • confirmed by laboratory analysis- did not resolve • CT cysternogram was performed. • A lumbar drain was placed and the CSF leak resolved over several days. There were no long-term sequelae.
- 90. • Nuerological conditionof unknown orgin • Anisocoria-inequality of pupils • Damage to innervation of ciliary muscles / ciliary ganglion • Complete recovery in 48 hours
- 93. Facial Dysmorphophobia • Distortedperception of one’s self appearance • Defect may be imagined • Minor defect excessive concern • No other mental disorder associated • ‘Doctor shopping’ and frequent requests for surgery • History taking – most important • Psychiatric counselling
- 94. Cognitive behavior therapy(CBT) - effective treatment BDD. A meta-analysis found CBT more effective than medication after 16 weeks of treatment. CBT may improve connections between the orbitofrontal cortex and the amygdala
- 95. CONVERSION DISORDER, 4-DAY BLUES,DEPRESSION • Arises from the situation that has overwhelmed their usual ability to cope - hysteria • reassure them of recovery, minimize secondary gain that may prolong recovery, honest disclosure about diagnosis, and reinforce
- 97. OTHERS • Dysphagia- Constrictedeosophageal sphincter hypoesthesia due to change in anatomy of the hyoid region- reduced tension in supra-hyoid musculature – reduced dilator effect on sphincter • Perforation of lateral nasal mucosa by fixation screws • OAF, Eustachian tube malfunction- damage TVP
- 98.
- 99. “A surgeon whohas not come to cross paths with complications, is the one who has not operated enough ”
- 100. CONCLUSION When a truecomplication occurs, early recognition, rapid response and effective resolution is essential
- 101. REFERENCES Contemporary Oral andMaxillofacial Surgery- Larry J. Peterson Oral and Maxillofacial Surgery 2nd Edition- Raymond J. Fonseca volume 3 Essentials of Orthognathic Surgery- Johan P. Reyneke Online resource via Science-direct & Pub-Med.
Editor's Notes
- #9 SURGERY CAN GET MESSED UP EVEN BEFORE YOU OPERATE ALTERNATELY BASED ON THE MAGNITUDE OF COMPLICATIONS OR LAWYER FEES
- #40 When hemodynamics of intramedullary and periosteal circulation are altered in orthognathic surgery, many cortical, medullary and soft tissue blood vessels become more functional
- #45 Superior reposition of maxilla increase in cross-sec area decrease airway resistance increase in breathing.
- #52 large bite force – parafunctional habits postero-superior positioning of maxilla insufficient bony interface.
- #61 Central sag : Condyle positioned inferiorly in the glenoid fossa no contact with fossa (Fig. 1A). Removal of the IMF and in the absence of intracapsular edema or hemarthrosis, the condyle moves superiorly malocclusion Peripheral sag: Type 1 : condyle positioned inferior with peripheral fossa contact . Type 2 : correct condyle position in fossa, , incorrect rigid fixation flexural stress in the proximal segment
- #70 To reduce the increased anterior facial height in patients with a hyperdivergent facial pattern, for example, surgeons might rotate the mandible counterclockwise. This movement is considered to be an unfavorable movement leading to relapse.
- #94 Dissatisfaction with appearance is common.