COMPLICATIONS OF ORTHOGNATHIC SURGERY
INDIAN DENTAL ACADEMY Leader in continuing dental education
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Selection of patient – Psychological – Neuromuscular disorders – Multiple deformities – syndromes – Multiple treatments
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Assessment of patient • • • • • • • • • •
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 www.indiandentalacademy.com
Dentition • • • • •
Periodontal state Caries Saveable teeth Restorations Occlusion
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Temporomandibular joints • • • •
Symptoms Assessment Radiography Pathology
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Radiography • • • • •
Cephalometry Orthopantomography Periapicals OMs – skull CT scans
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Photography • Colour transparencies/photos • Planning – profile/full face 1:1s • 3D imaging
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Models/articulation • • • • • •
Arch size/relationships Occlusion Tooth position Overbite, overjet Occlusal curves Molar relationship www.indiandentalacademy.com
Treatment planning • • • •
Psychological Photocephalometric Dental Presurgical orthodontics
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Essential • • • •
Accurate patient reevaluation Correct selection – surgical procedure Accurate prediction tracing Accurate model surgery
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Appropriate dental/model surgery • • •
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 www.indiandentalacademy.com
Operative complications • • • • • •
Patient care – anaesthesia etc Maxillary surgery Mandibular surgery TMJs Nerve injury Vascular injury www.indiandentalacademy.com
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 www.indiandentalacademy.com • Septal deviation – prevention
Maxillary surgery (2) • Alar base – cinch suture • Nerve damage – stretch/pressure • Teeth – interdental osteotomies, damage, devitalised, periodontal, extruded! PREVENT • Nasal airway – max. rise – Turbinates, post-choanal height www.indiandentalacademy.com
Maxillary surgery (3) • Bleeding – Local anaesthesia – Hypotension – Careful surgery – Vascular compromise – maxillary, greater palatine, sphenopalatine vessels, pterygoid veins, int carotid, Le Fort I/II (D Lanigan 1990s) www.indiandentalacademy.com
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 www.indiandentalacademy.com
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 www.indiandentalacademy.com
Mandibular surgery (2) • 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 www.indiandentalacademy.com
Mandibular surgery (3) • Specific problems related to operative procedure – Modified sagittal split – Vertical subsigmoid – Body osteotomy – Segmental/genioplasty – Inv L/postcondylar graft www.indiandentalacademy.com
TMJ function • Pre-existing dysfunction – Abnormal load, muscle action
• Internal derangement – Prevention – recognise no overload joint – Avoid posterior open bite
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Nerve injury • Type – neuropraxia, axonotmesis, neurotmesis, neuroma Management – timing, primary repair, Nerve grafting, ID, lingual, facial
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Post surgery – immediate – ICU • • • •
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 www.indiandentalacademy.com
Postop. follow up • • • •
?IMF period Elastic traction/orthopaedic Functional appliances ?Genioplasty
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Post surgical orthodontics • Avoid opening bite • Adequate retention
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Velopharyngeal insufficiency • Secondary cleft deformity • Craniofacial cases • Access osteotomies – split soft palate
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Miscellaneous • Scars • Sinus infection • Plate problems
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Poor results – due to: • • • • • • • • • • •
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! www.indiandentalacademy.com
Immediate preoperative assessment • • • •
Planning – final check Cessation of growth Speech assessment Medical state, eg, URTIS, menses, drugs – NSAIDs • Adequate records • Consent www.indiandentalacademy.com
Operative area • Anaesthesia – airway • Theatre preparation – sterility, instrumentation, staffing • Surgery – incisions, bone cuts, vascularity, nerve function, teeth
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Late complications – local (1) • • • • •
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 www.indiandentalacademy.com
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 www.indiandentalacademy.com
Sagittal split osteotomy (1) • • • •
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%) www.indiandentalacademy.com
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 www.indiandentalacademy.com
Vertical subsigmoid osteotomy (IO) • • • • • • • • • • •
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 – – – – –
Incisions – 2 line closure Nerve damage Asymmetry Aseptic necrosis Modifications – Köle, Sailer www.indiandentalacademy.com
Late complications • General – Death – Pulmonary atelectasis/pneumonia – Neurological – ulnar/popliteal – Vascular DVT, pulm. embolus – Pancreatitis – Pressure sores – Baldness – coronal flaps www.indiandentalacademy.com
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. www.indiandentalacademy.com
www.indiandentalacademy.com Leader in continuing dental education
www.indiandentalacademy.com