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Managing Orthognathic

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Subramaniam Pram Kumar

on 20 August 2013

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Transcript of Managing Orthognathic

Managing Orthognathic
Post operative Complications

Any complications that occurs immediately after surgery & onwards - post op complications...
Time based....
Immediate post op
Swelling & Hematoma
Post operative nausea & vomitting
Early stage post op
Wound dehiscence
Avascular Necrosis
Bone Healing/Fixation
Early Relapse (Condylar Sag, Idiopathic Condylar resorption, Poor fixation, Unsatble Final position)
Neurosensorial deficit
Long Term
Relapse/Skeletal instability
Fixation & Hardware failure (Exposure/infection/loss plate & screw/ discomfort caused by plate & screw)
TMJ pain
Neuronal deficit
Patient dissatisfaction
Dental & Periodontal Problem
Loss of gonial angle, chin projection - caused by resorption
Systemic complications vs Local Complications
Systemic Complications
Acute Renal Failure
Compromised airway
Anesthesia related
Malignant Hyperthermia
Drug toxicity
Psychiatric Disorders
Body dysmorphic disorder
Conversion disorders
Post operative Nausea & Vomitting
Local Complications
Avascular Necrosis
Dental & Periodontal Problem
Dental injury - root transection, root shaving
Periodontal - widening of PDL
Pulpal injury - internal/external resorption, abscess
Neurosensorial Disturbances
Motor nerve damage - unlikely
Sensory nerve damage
Infraorbital nerve
Superior alveolar nerve
Lingual nerve
Inferior dental nerve
Mental nerve
TMJ & Mandibular Dysfunction
TMJ clicking
Mandibular deviation
TMJ pain
Mandibular swelling
Cheek swelling
Neck swelling
Nostril edema
Tracheal & Laryngeal edema
Delayed healing & Infection
Wound breakdown
Dental abscess
Pus discharge
Osteotomy site based
Maxillary, Mandibular and Chin osteotomy site
Neurosensory disturbance
Sensory - anesthesia, hyperasthesia, hypoaesthesia
Weakened muscle ability / weakened bite force
Vascular complication
Avascular necrosis
Dental Trauma
Root resection
Dental shaving
Dental crown fracture
Loosening of teeth - adjacent to osteotomy site
TMJ - condylar resorption, TMJ dsyfunction
Osteotomy Healing - malunion, non union, delayed union
Hardware failure - loose fixation, incorrect alignment
Soft tissue
Swelling - neck and face
Nasal - swelling and edema
Airway compromised
Neck swelling
Oral swelling - tongue and floor of mouth raised
Infection, Seroma, Hematoma
Delayed healing & wound breakdown
Source of bleeding
Pterygoid venous plexus
Post superior alveolar artery
Medial & Lateral pterygoid ms
Inferior alveolar artery
Internal maxillary artery
Facial artery
Retromandibular vein
Kiesselbach plexus
submental ms
genioglossus ms
Swelling & Edema
Generalized Post op swelling - acceptable unless airway is compromised
Incidence of serious post op bleeding is 1-12.5%
Often due to improperly managed intra op problems
Suspect hematoma - swelling, unilateral, increasing in size, fluctuant
if pulsatile - could be due to an arterial bleed

MX: release IMF, identify site of hematoma, release suture and evacuate, if collection is brownish, old blood - only monitor condition following evacuation
If the collection is red and continous oozing or bleeding noted - suggest further exploration under GA/LA - requiring ligation or packing
Neurosensory Disturbance
Hardware Failure
Pain & Discomfort caused by hardware post operatively - consider remove (if bone already consolidate)
Management of Complications

Should airway be compromised:
Release IMF
Monitor BP, PR, RR, and SaO2
Oropharyngeal suction to clear secretion
Reestablish airway - oropharyngeal tube, endotracheal tube or even tracheostomy
Identify any region causing swelling in particular
Localized facial swelling
For generalized facial swelling -
use of corticosteriod cover (iv) and ice pack for heat control
Locate swelling region
- require suture release
or reexploration under LA/GA
-evacuation of seroma
Nasal edema
Advocate Sinus precaution
Oxymetazoline (to allow nasal vascular vasoconstriction)
Piriton (H2 Histamine Antagonist - reduces mast cells and histamine release)
MacIntosh RB: Experience with the sagittal osteotomy of the mandibular ramus: A 13 year review. J Oral Maxillofac Surg 8:151, 1981; El Deeb M, Wolford L and Bevis R. Complications of orthognathic surgery. Clin Plast Surg 16:825, 1989; Van de Perre JP, Stoelinga PJ, Blijdorp PA, et al: Perioperative morbidity in maxillofacial orthopaedic surgery: A retrospective study. J Craniomaxillofac Surg 24:263, 1996
Identify bleeding site
Systemic effects
Maxilla – damaged pterygoid venous plexus,
Superior alveolar arteries

Mandible – damaged retromandibular vein, inferior alveolar artery

Genial – submental artery bleeding

Nasal – Kiesselbach plexus bleeding

Systemic effect
Increased blood pressure
Underlying history of hypocoagulability (drugs, bleeding disorder, platelet deficiency, coagulation factor deficiency)
Remove IMF – assess bleeding site and advocate control – pressure, control using tranexamic acid, surgicel, gelfoam or even reexplore & ligate
Do necessary coagulation/bleeding studies – PT, APTT, Coag profile
Packing – anterior or posterior nasal tamponade or use of merocel to control bleeding
If unable to arrest bleeding or locate source of profuse bleeding consider doing
Packing of maxillary sinus (if maxillary bleeding)
Angiographic embolization
Consider ligation of external carotid artery in cases of extreme emergencies
Skeletal relapse
Immediate post op - dental relapse (open bite, cross bite)
Place patient on Elastics & monitor
Update radiographs to identify any problems at osteotomy site
If mal aligned osteotomy cut is the main problem - consider reoopening surgical site to correct it as soon as possible
For mild relapse - occlusal rehabilitation(orthodontics/prosthesis)
If relapse occurs in the long term
take radiography to assess any TMJ remodelling or resorption
If TMJ resorption is the main culprit (Idiopathic Condylar resorption) then,
Issue bite stabilizing splint
Occlusal rehabilitation
Conservative monitoring
Second surgery
Residual asymmetry
Bony asymmetry involving mandibular angle or mandibular inferior body prominence, zygomatic prominence - consider second surgery (trimming and recontouring)
If asymmetry include skeletal canting of maxilla - then consider reoperating the patient to correct it
How does nerve injury occur in Orthognathic surgery?
Indirect trauma
Compression by bones
Compression by surgical edema
Neural edema
Direct Trauma
Compression, Tear or cut with surgical instruments
Stretching during manipulation of osteotomized bony segments
( Ylikontiola 2002)
Managing Inferior Alveolar Nerve Injury
According to type of Nerve Injury Sustained
Follow up, review and Neurosensory testing
Use pharmacologic means for pain control : eg. Steroid, NSAIDs, Vit B12, antihistamines, vasodilators, diuretics
Follow up and review
Nerve Decompression if no improvement after 1-3 months
Symptomatic tx needed – use of conservative methods: TENS, Heat therapy, Low lever laser tx etc..
Neurosurgery is indicated (reapproximation, graft etc)
Managing Lingual Nerve Injury
Corticosteroids- reduce inflammatory reaction
Follow up review, NST
Topical application – capsaicin + lidocaine/EMLA
Tricyclic antidepressant (effective in traumatic neuralgia)
Membrane stabilizers-anticonvulsant, lidocaine der., muscle relaxant
Acrylic stent (if needed) to cover painful site
Surgical repair – neurorraphy, decompression, grafting
Injury to IAN, LN, Facial Nerve bothers patients
Injury to greater palatine or infraorbital nerve doestn't seem to bother patients
(De Jongh et al. 1986, Karas et al. 1990, De Mol van Otterloo et al.1991)
Managing Facial Nerve Injury
Neurosensory Testing and muscle weakness assessment(EMG)
Follow up and review
In case of Bell’s Palsy
Physiotherapy/Acupunture/Low intensity Laser therapy
Corticosteroid (If nerve injury is temporary, will work well) – Salineas et al.2004 (Cochrane)
If Electroneurography or EMG studies- indicate intact but degenerating nerve- CN VII decompression can be attempted (Harvard Facial Paralysis Institute)
Facial nerve grafting accordingly, if indicated…
Goal of management for infection
Secure and Maintain patient’s airway
Monitor vital signs
Supportive care as necessary
Surgical drainage of infection
Removal of source of infection
Identification of etiology bacteria
Selection of proper antibiotics
Normal 36.5-37.5 degree C
Varies among people
Need to look at trend, eg. Spikes, etc..
CBC – white count
Normal range 5.0-10.0 x 10^9/L
Elevated when infection is present
C-reactive protein (CRP)
Normal serum level <10mg/L
Mild inflammation 10-40mg/L
Active infection and bacterial infection 40-200mg/L
Severe bacterial infections >200mg/L
If infection or pus collection is noted then, drainage is required to quickly quell the spread of infection
Delaying the drainage will lead to catastrophic sequelae
Antibiotics effect is usually limited in region of infection especially in case of poor vascularization
CT scan may be needed as well if the infection loci cannot be localized well clinically or if the surgeon suspect deeper plane involvement
Supportive Care
Anti-pyretic agents to control fever
NSAIDS, aspirin, paracetamol
Rehydrate patient as necessary
Correct electrolyte disturbance
Pain management
Anemia, Dehydration
Monitor post op HB
If Hemoglobin below 7 - consider blood transfusion
In event of HB level below 8 & pt symptomatic - Shortness of breath, palor, lethargic - also consider blood transfusion
Always check osteotomy site for sign of pallor - likely to cause avascular necrosis
Dental & Periodontal
Root shaving or transection
Update radiography (Periapical, OPG)
Monitor and review
No treatment required if asymptomatic
Non vital teeth, pulp necrosis or abscess, periodontal problem
Refer to periodontist, endodontist
Good oral hygiene maintenance
Monitor, update radiography
Root canal treatment
If teeth cannot be salvaged - suggest xn + occlusal rehab
Avascular necrosis
Hyperbaric oxygenation
Oral hygiene maintenance
Give supportive care and reassurance to pt
Occlusal malignment
Refer to orthodontic care
Look for signs of dehydration - skin turgor, mucosa dryness, pulse rate, blood pressure, input output mismatch etc..
Begin with fluid transfusion, but encourage oral intake of fluids as quickly as possible
Monitor body fluids electrolyte and nutrien levels as well - Liver & renal function, UE
Non functional plates & screw - loose plates
To be removed as soon as possible
Infected plates and screw
For acute phase infection - cover with Antibiotics
Ultimately - explore surgical and remove the necessary plates as well any surrounding fibrotic or infected tissues
(Van Strijen PJ et al. 2001, Crawford JG et al. 1994)
Van Strijen PJ, Breuning KH, Becking AG, Tuinzing DB. Condylar resorption following distraction osteogenesis: a case report. J Oral Maxillofac Surg 2001 Sep;59(9):1104-7
Crawford JG, Stoelina PJW, Blijdorp PA, Brouns JJA. Stability after reoperation for progressive condylar resorption after orthognathic surgery: report of seven cases. J Oral Maxillofac Surg 1994 May;52(5):460-6
Ow A, Cheung LK. Bilateral sagittal split osteotomies versus mandibular distraction osteogenesis: a prospective clinical trial comparing inferior alveolar nerve function and complications. Int J Oral Maxillofac Surg 2010 Aug;39(8):756-60
Merkx MAW, Van Damme PA. Condylar resorption after orthognathic surgery. Evaluation of treatment in 8 patients. J Cranio maxillofac Surg 1994 Feb;22(1):53-8.
Peterson - Oral and Maxillofacials Surgery (Complications following Orthognathic Surgery)
De Mol van Otterloo JJ, Tuinzing DB, Greebe RB & van der Kwast WAM (1991) Intra- and early postoperative complications of Le Fort I osteotomy: A retrospective study on 410 cases. J Craniomaxillofac Surg 19: 217–222.
De Jongh M, Barnard D & Birnie D (1986) Sensory nerve morbidity following Le Fort I osteotomy. J Maxillofac Surg 14: 10–13.
Jacks SC, Zuniga JR, Turvey TA & Schalit C (1998) A retrospective analysis of lingual nerve sensory changes after mandibular bilateral sagittal split osteotomy. J Oral Maxillofac Surg 56: 700–704
Jääskeläinen SK, Peltola JK, Forssell K & Vähätalo K (1995) Evaluating function of the inferior alveolar nerve with repeated nerve conduction tests during mandibular sagittal split osteotomy. J Oral Maxillofac Surg 53: 269–279.
Jones JK & Van Sickels JE (1991) Facial nerve injuries associated with orthognathic surgery: A review of incidence and management. J Oral Maxillofac Surg 49: 740–744.
Jones DL & Wolford LM (1990) Intraoperative recording of trigeminal evoked potentials during orthognathic surgery. Int J Adult Orthod Orthognath Surg 5: 167–174.
Karas ND, Boyd SB & Sinn DP (1990) Recovery of neurosensory function following orthognathic surgery. J Oral Maxillofac Surg 48: 124–134..
Schendel SA & Epker BN (1980) Results after mandibular advancement surgery: An analysis of 87 cases. Journal of Oral Surgery 38: 265–282.
Westermark A (1999) On inferior alveolar nerve function after sagittal split osteotomy of the mandible. (dissertation) Kongl Karolinska Medico Chir Inst, Stockholm, 10–13.
Van Sickels JE, Hatch JP, Dolce C, Bays RA & Rugh JD (2002) Effects of age, amount of advancement, and genioplasty on neurosensory disturbance after a bilateral sagittal split osteotomy. J Oral Maxillofac Surg 60: 1012– 1017.
Ylikontiola L (2002) Neurosensory disturbance after bilateral sagittal split osteotomy. (dissertation) Acta Univ Oul D 685: 32–33
Varied success rate
Thank you
Merkx MAW & Van Damme PA, 1994
Asymmetry caused by soft tissue
Soft tissue deficiency - compensate with synthetic filler (eg. silicone, medpore, PEEP) or autograft transplant (microfat lipo injection)
Nasal asymmetry - septal deviation, alar base widening, collapsed nasal collumela
consider rhinnoplasty & grafting with alloplastic or autograft cartilage, nasal septal trimming
Not all asymmetries can be corrected, some are too minor or patients would be too demanding
Reassurance and conservative monitor,
Psychiatric referral for unreasonable demands
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