Orthognathic complications

Complications in Orthognathic Surgery

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 of the 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 matter what 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 = 1000 patients (1983-2002)
INTRA AND PERIOPERATIVE COMPLICATIONS OF THE LEFORT I INTRA 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 complications and problems related to orthognathic surgery Incidence 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 range of 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 pre treatment objectives
Laboratory errors
Orthodontics

10. Pre-surgical
Lack of pre-treatment objectives
•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 perform the ideal procedure
Undesired esthetic and occlusal results
Creation of new problems and revision procedures
Presurgical : Lack of pre treatment objectives

12. Unsatisfactory bite registration
Discrepancy in 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. Maxillary descending palatine

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. Pterygomaxillary dysjunction (commonest cause)

19. Intraoperative: Hemorrhage in Maxilla

20. Management :
- Visualization of 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 Journal of 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. Intraoperative
Vascular
Neural
Unwanted fragmentation

23. •Neuropraxia
•Axonotemesis
•Neurotemesis
Intraoperative: Nerve injuries

24. Causes for Inf Alv 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 medially behind 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 studied as 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. Intraoperative
Vascular
Neural
Unwanted fragmentation

30. “Deviation from osteotomy line 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. Presurgical
Intraoperative
Post operative

34. POSTOPERATIVE
Loss of vascularity : aseptic necrosis
Anatomic variations: Nose, Lips
Nonunion/delayed union
Infection
Occlusal disturbances
TMJ dysfunction
Relapse

35. Aseptic necrosis:
•Anterior maxillary 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 of entire 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 Hall HD -1978.
•15 years - medically fit female - Le Fort I osteotomy with maxillary
rib graft augmentation + BSSO + genioplasty

38. •3 stage surgical 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 in Inf 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 in IVRO > 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 Nasal form
- 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 of inferior 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 alar base 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
Alteration in 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 closure of 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 POSTOPERATIVE COMPLICATIONS 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 blood supply
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 :
•Instability of 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 - OCCLUSAL DISTURBANCES
- 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 - OCCLUSAL DISTURBANCES
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 of condyle 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 – TMJ dysfunction
Condylar sag
Central Peripheral I &
II

62. •The condyle is seated with the condylar seating tool + light digital
pressure at the angle
•resultant vector is anterosuperior

66. Change in shape of 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 :
•Magnitude of 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 relapse after 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 relapse was 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 (vasculature damage/hypoxia)
LOSS OF FUNCTION OF LACRIMINAL GLAND
CRANIAL NERVE PALSIES
DAMAGE TO INTERNAL CAROTID ARTERY

78. •Abnormalities of the 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
•1
st
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
Maxillary tuberosity
+
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 (vasculature damage/hypoxia)
LOSS OF FUNCTION OF LACRIMINAL GLAND
CRANIAL NERVE PALSIES
DAMAGE TO INTERNAL CAROTID ARTERY

84. •Color Doppler – left
internal carotid flow

85. POST-OP 1

86. POST-OP 19

87. POST-OP 2 MONTHS
CONCLUSION
•Congenital hypoplasia
internal carotid

88. •Statistically significant reduction 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. •3
rd
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 condition of unknown orgin
•Anisocoria-inequality of pupils
•Damage to innervation of ciliary muscles / ciliary ganglion
•Complete recovery in 48 hours

93. Facial Dysmorphophobia
•Distorted perception 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- Constricted eosophageal 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. WITCH’S CHIN

99. “A surgeon who has not come to cross paths with
complications,
is the one who has not operated enough ”

100. CONCLUSION
When a true complication occurs, early recognition, rapid
response and effective resolution is essential

101. REFERENCES
Contemporary Oral and Maxillofacial 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.