COMPLICATIONS IN

ORTHOGNATHIC
SURGERY

DR SANKAR VINOD V
PROF & HEAD, MAR BASELIOS DENTAL COLLEGE
KOTHAMANGALAM
Introduction

 In spite of your best efforts complications do

happen
 Multi Disciplinary Approach
 Informed consent
 PREOPERATIVE
 INTRAOPERATIVE
 POSTOPERATIVE

The Journal Of Craniofacial Surgery / Volume 18, Number 4 July 2007

 Nerve damage (12.1%),
 infection (3.4%),
 problems with fixative materials (2.5%),
 temporomandibular joint disorder (2.1%),
 undue fracture (1.8%),
 scarring problems (1.7%),
 and hemorrhage (1.4%)
PREOPERATIVE

 Errors and inaccuracies in model surgery

 Unsatisfactory bite registration
 Discrepancy in mounting the cast
 Improper model surgery
 Warpage of splints
 Incorrect centric relation records
 Use of virtual and computer aided surgical
simulation
 Eliminate dental
compensation
 Levelling the arches
 Failure to manage transverse
discrepancy
 Root divergence
 Manage tooth size
discrepancies
 Patient Psychology

“ Why the mirror lies: In people with body

dysmorphic disorder, distorted self image could
be the result of brain’s abnormal processing of

”
visual input

MOTIVATION
UNREALISTIC EXPECTATION
INFORMED CONSENT
MEDICAL HISTORY
INTRAOPERATIVE
Endotracheal Tube Injury And Airway Compromise
Hemorrhage
 neurosensory deficit in the
region innervated by the inferior
alveolar nerve; mild in 32% of
patients (183 of 574) and
disturbing in 3% of patients
(18/574).
 severe intraoperative bleeding
in 1 patient necessitating major
blood transfusions and later
embolization of the internal
maxillary artery.
 Maxillary Osteotomies

 During pterygomaxillary dysjunction

(maxillary downfracture), the maxillary
artery and its branches are the most
susceptible to injury
 may also result from a superiorly
positioned pterygoid plate fracture
after pterygo-maxillary dysjunction
that results in internal carotid artery
hemorrhage.
Maxilla –Le Fort 1
Mandibular osteotomies injury to
 facial artery and vein
 inferior alveolar artery
 retromandibular vein
Avoided with In IVRO, the vessels at risk include the
masseteric and inferior alveolar
 careful subperiosteal dissection of the
medial ramus vessels, vessels supplying the medial
pterygoid, and the maxillary artery
 use of a medial ramal retractor for the
medial horizontal
 corticotomy
 use of an inferior border retractor for the
lateral splitting
 Temporary packing with cottonoids soaked
in a vasoconstrictor and firm pressure for ten
minutes will control the bleeding
Management
1. Initial measures include hypotensive anesthesia, adequate visualization,
and direct pressure.
2. Hemo-clip or electrocautery -----Surgicel
3. packing, leaving the tail of packing exposed through the posterior aspect of the
incision. Nasal packing can be applied in cases of severe bleeding.
4. External carotid ligation has been implied previously in the literature; however,
collateral circulation limits the success.
5. Ultimately, arteriography with embolization can be used as a last resort
The incidence of permanent injury
to the lingual nerve was 2/100
patients(95% CI 1 to 3/100) or 0/100
nerves (95% CI 0 to 1/100).
Neurosensory
Disturbance
BSSO
 If the inferior alveolar nerve does initially
remain in the proximal segment requiring
significant manipulation and repositioning,
a 2-fold increase in the chances of
neurosensory Disturbance (Svartz 1983)
 Age is probably the most influential
factor determining return of sensation after
bilateralsagittal split osteotomy(Robl et al)
 Torvey reported transection of the
inferior alveolar occuring in 3.5% of a series
of BSSROs
 lingual nerve
 lip chin paresthesia
 MAXILLARY OSTEOTOMIES
 nasopalatine and superior alveolar nerves
that are inevitably transected with the
LeFort I osteotomy Genioplasty
 sensory loss in the infraorbital nerve superficial distal fibers of the
distribution is temporary 1.5% to 2%-
incidence mental nerve are transected with
 Sensory deficits of the teeth, palatal the mucosal incision and the
mucosa, and buccal mucosa gradually mental nerve is at risk
resolve over a 12- to 18-month period
 Rare neurologic deficits of the second, third,
fourth, fifth, sixth, tenth, and twelfth cranial
nerves have been report due to occur as a
result of unfavorable fractures ascending
into the cranial base

Oral Maxillofacial Surg Clin N Am 26 (2014) 599–609

Prevention And
Management
 Virtual surgical planning and
computed tomography enables
accurate anatomic identification
and localization of the inferior
alveolar nerve.
 gentle retraction for access and
visualization to minimize stretch
injury to the nerve.
 On fixating the mandible
eliminate any compression of the
nerve that may result from bony • If transection of nerve is noted, tension-free re approximation is
elevations within the osteotomy or performed.
from compression owing to • Care must be taken to release proximal and distal segments of the
fixation techniques. nerve to allow for passive anastomosis.
• Epineural sutures can then be placed. Generally, a 7-0 or 8-0
monofilament non resorbable nylon suture can be used ina simple
interrupted fashion
UNFAVOURABLE FRACTURES
 With the LeFort I
 uncontrolled fractures
extending into the cranial base
 may occur
 when osteotomies are
incomplete and down
fracture is attempted
 when the osteotome is
improperly positioned during
pterygopalatine dysjunction
 Sagittal RamusOsteotomies
 Condylar neck fractures
 when the horizontal osteotomy i s
misdirected posterior superiorly instead
of horizontal to the occlusal plane
 Unerupted third molars should be
extracted 6 to 9 months before surgery
to avoid uncontrolled fractures and to
allow ease of internal fixation
 Incidence of unfavourable splits after
a BSSO in between 3% and 20%.
 The fracture lines and cuts of a
bilateral sagittal split osteotomy
including the most common
unfavourable fractures

I, fracture of buccal plate.

a, horizontal, b, vertical
(n = 11);
II, fracture of lingual plate
(n = 5);
III, fracture of coronoid
process (n = 0);
IV, fracture of condylar
neck (n = 1).
O”Ryan F:Complications of orthognathic surgery Oral
maxillofacial Surg Clin North Am 1990;2:593
Role of Third molars
is controversial
 Incidence of unwanted splits with impacted
third molar was 0.94% and without impacted
third molar was 2.62% (000E 85: 362,1998).
 Higher incidence of unfavorable splits
during SSO with impacted third molars
during surgery. (JOMS 60:654, 2002).
 Proximal segment fractures are more
common in the absence of third molars and
Distal segment fractures more common in
the presence of third molars (JOMS :
70:1935-1943, 2012, JOMS 59:854, 2001)
 Reyneke et al found that presence of third
molars in younger patients is associated with
higher unfavorable fractures.
 Mehra et al – distal segment # - more in
young individuals with impacted third molars
, proximal segment # - more in older
individuals without third molars
Prevention Of
“Bad Split”
Management
Oro–Antral
Communication
 Commonly associated with
segmental maxillary
osteotomy
 Osteotomies in the midline
 palatal tears
 Obturation of open fistulas
using a soft“suck-down”
material made from the final
model
POST OPERATIVE
Early Late

• Post Operative Swelling • Delayed Hemorrhage

• Nausea & Vomiting • Neurologic Dysfunction
• Infection • Poor Esthetics
• Deviation In Occlusion & • Bone Healing
Segment Positions
• Fixation
• Devitalization Of Teeth &
Periodontal Problems • Development Or Worsening
Of TMD
Post operative swelling
Excessive Swelling

Potential airway compromise

Release of MMF
Surgical trauma
INTUBATION
Length of surgery
Tracheostomy
Post operative medication
Patient characteristics
Post Operative Nausea & Vomiting
 Most common – all types of surgeries
 Up to 40 % incidence in orthognathic surgical patients

Predisposing factors
Dehydration
Females
Esophageal rupture
Procedure duration
Wound dehiscence
Prior migraine,
Bleeding
vertigo
Hematoma
Motion sickness
Aspirations of gastric
Opioid use
contents
High post op pain
Death
Volatile anesthetic
use
Postoperative hematoma

 common after mandibular surgery

 use of closed suction drains left for 1 day in the angle region are of particular
benefit.
 Postoperative nasal bleeding after LeFort I osteotomy resolves spontaneously
but may require packing
 When not ligated, the descending palatine artery is the primary source of
postoperative bleeding from the LeFort I osteotomy
 compromised during pterygo-maxillary separation and may require
pterygopalatine fossa packing
 maxillary arteries may be damaged during pterygomaxillary separation.
 J Oral Maxillofac Surg 65:984-992, 2007
Infection
 very low with orthognathic
surgery
 Minor infections were treated
with small incisions and
drainage with continued
antibiotic coverage.
 Major infections requiring
more aggressive orthognathic surgery–related complication rate was
debridement, bone grafting, 9.7%, of which 7.4% was related to postoperative
or both. infection.
58.3% were acute infection and 41.7% were chronic
infection.
 ContributingFactors

1. Smoking (local and systemic impact)

2. Osteotomy design
Avascular 3. Flap design and management
necrosis
4. Segment movement/rotation

5. Stretching and pinching of the tissue

6. Splints
Mandibular Surgery

• uncommon
• occur with resulting loss of fixation and skeletal instability.

Genioplasty

• Excess periosteal stripping of the chin

• resulting bony resorption and deformity of the
• genioplasty segment
• also manifest as gingival recession inthat segment
 Avascular Necrosis

 Maxillary osteotomy

• attributed to incisions that compromise the vascularity, excessive stripping

of the periosteum
• compromised palatal mucosa(secondary to previous cleft palate surgery)
• Interdental or segmental osteotomies with loss of the attached gingiva
• transverse expansion with excessive stripping of the palatal mucosa
Initially she had 30 treatments of
hyperbaric oxygen at 2.4 kPa.

At the first operation most of her

remaining maxillary teeth were
removed. The maxillary sinus
and necrotic alveolar bone
were debrided, and the alveolus
was reconstructed with an
vascularized iliac crest graft.

A further 10 hyperbaric
treatments
Management
 Verify there is no splint impingement
 Eliminate mobility
 Utilize a tissue dressing such as
Vaseline gauze
 Antibiotics (local or systemic).
 Hyperbaric oxygen may aid in a
more expedient demarcation of vital
and nonvital tissue;
 more aggressive treatment, provide
debridement only when and where
the area of necrosis is well
demarcated.
 Ultimately, the area may require
removal of teeth with subsequent
bone grafting and implant
placement.
LOSS OF PULP VITALITY
 necrosis of the pulp may require endodontic treatment
 many teeth recover without treatment -return to normal coloration,
and respond to pulp testing

PERIODONTAL DEFECTS

 Le Fort segmentalization

 great consequence to patients, especially if they occur in the ante-

rior region.
Unfavourable
nasolabial aesthetics
Lefort I AMO
1. Septal deviation
2. Inadequate turbinate removal (with septal
deviation can increase obstruction)
3. Alar base widening
4. Tip over-rotation
5. Dorsal deformities

 reduce the ANS to prevent excessive

rotationof the nasal tip
 alar base cinch suture and V-Y closure
 A twisting dorsum and tip deviation may
be related to inadequate septum
reduction.
 Pyriformplasty –vertical impactions
PYRIFORM PLASTY
Velo-pharyngeal insufficiency

 cleft palate
 patients having some degree of velopharyngeal insufficiency preoperatively.
 Pharyngeal flap at the time of maxillary advancement is not recommended.
This manipulation may compromise circulation to the maxillary dentoalveolar
flaps, dislocate the freshly stabilized maxillary segments by retraction to view
the pharynx, or cause postoperative airway compromise (Posnick and Tomp-
son, 1995
 David et a1 (1977) found that with more than 10 mm of advancement, there is
deterioration in VP effectiveness.
 Sader et al (1977) found that maxillary advancement up to 7 mm is possible
without speech deterioration
MALOCCLUSION

 may be overcome with Immediate anterior open bite

guidance elastics and 1. Inadequate removal of posterior
improved neuromuscular interferences
reprogramming with displacement of the condyles from the
fossa during fixation

Late open bite development

1. Collapse of transverse expansion
a.Lack of intraoperative methods to
maintain expansion (grafting, splint
placement)
b.Lack of postoperative efforts by the
orthodontist to maintain expansion
(transpalatal arch)
2. Orthodontic relapse
3. Decreased vertical ramus height from
condylar resorption
4. Additional growth
Mandibular Dysfunction

 Hypomobility
 Reduction in Bite Force (Early post – op period for 6 weeks)
 TMJ Dysfunction
- Most of patients improve their TMJ disorders after surgical
repositioning
- Forceful manipulation – intra capsular edema – forward projection
of mandible.
 Prolonged MMF :
- Temporary Muscle Atrophy, Degenerative changes in TMJ
- Post operative physiotherapy for 2 months
Temporomandibular Joint
Dysfunction
 Temporomandibular joint symptoms may improve,deteriorate, or
remain similar to that before surgery.

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
 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

the IMF was removed immediately after
the fixation and the occlusions were
checked with light digital pressure on the
chin.
The patients were then woken rapidly
(maintaining the intubation) in a state of
conscious analgesia and sedation and
invited to open and close their mouths
and to move the mandible laterally.
 Condylar Resorption
 late complication
 Incidence : 2.3% and 7.7% of  BSSO advancement
 Change in shape of the condyle from normal to finger shaped with loss of height and later
decrease in posterior facial height.
 evident within the first several years after Surgery
 predilection for young women with preoperative class II occlusion and a history of
temporomandibular joint (TMJ) dysfunction
 intervention must be delayed at least 6 months until resorption is presumed to be complete
 After 6 months, a SPECT scan may be useful to evaluate the exact degree of resorption
 In cases of severe resorption, total joint reconstruction may eventually be required
Fixation failure
Some of the clinical signs of or nonunion include:
1. Palpable mobility of segments
2. Clinical evidence of persistent infection
3. Open bite tendency
4. Class III occlusion on the affected side
5. Midline shift toward the opposite side
6. Premature contact on the side of the nonunion

If a problem is suspected with a MANDIBULAR OSTEOTOMY early, options for treatment

include the following:
1. Limiting patient function and thus mobility through heavy elastics/maxillomandibular
fixation
2. More aggressive approach of reoperation with reinforcement of the fixation
MAXILLARY OSTEOTOMY

Surgical management in a malunion or nonunion of the maxilla involves:

1. Recreation of the osteotomy with aggressive mobilisation

2. Removal of all fibrous tissue
3. Passive repositioning of segments
4. Rigid fixation to resist segment displacement
(consider auxiliary fixation, trans palatal support)
5. Grafting for continuity
 OBSTRUCTIVE SLEEP APNEA SYNDROME

 Prevention of this complication is best done at the planning stage.

 A prognathic patient with a snoring history might be advised to

undergo a preoperative sleep study to rule out associated OSAS.

 Treatment considerations may then favor maxillary advancement

rather than mandibular setback if OSAS is diagnosed.
PRE OPERATIVE PHOTOS
PRE OPERATIVE X-RAY
POST OPERATIVE X-RAY
POST OPERATIVE PHOTOS
PRE OPERATIVE X-RAY
Root resorption noted wrt 36 & 46
Aseptic Necrosis

 Case done on 5/6/2018 – 27 yr old female- undergoing presurgical

for past 2 yrs
 After 1 week- ischemia noted in palatal aspect
 After 15 days- it spread to labial gingiva of anterior maxillary
segment
 Antibiotics, pentoxifylline, vit E, HBO therapy (7 dives- - 16day
onwards)
 Blood investigation showed normocytic, normochromic anemia
(Hb 9.8)- 2 pints of blood transfused
PRE OPERATIVE
PRE OPERATIVE X-RAYS
POST OPERATIVE X-RAY
7 th DAY POST OPERATIVE
15 th DAY POST OPERATIVE
3 rd MONTH POST OPERATIVE
PROSTHODONTIC REHABILITATION
  In reviewing these complications, a better understanding of
how to not only manage them, but also to prevent their
occurrence can be gained.
 By educating all surgical patients through informed consent,
CONCLUSION we can prepare them for what will come with the surgical
procedure.
 Continued advances in the field of orthognathic surgery,
especially with the inclusion of virtual surgical planning,
have served to modernize our treatment planning with
balanced results and happier patients.

A Surgeon who has not come to cross paths with complications, is the one who has not operated enough
Prof Dr Varghese Mani
REFERENCES
 Surgical correction of Facial Deformities- Dr Varghese Mani
 Orthognathic surgery – Principles and Practice- J C Posnick
 Complications with orthognathic surgery – Fonseca
 Complications in Orthognathic Surgery A Report of 1000 CasesMegan T. Robl, DDS, MDa,*, Brian B. Farrell,
DDS, MDa,b,Myron R. Tucker, DDS Oral Maxillofacial Surg Clin N Am 26 (2014) 599–609
 Complications of Orthognathic Surgery Pravin K. Patel, MD
 Complications of orthognathic surgery Robert A. Bays, DDS*,Gary F. Bouloux, Oral Maxillofacial Surg Cli n N
Am 15 (2003) 229–242
 Prevalence of Postoperative Complications After Orthognathic Surgery: A 15-Year Review Lop Keung
ChowJ Oral Maxillofac Surg 65:984-992, 2007
 Prevalence of Surgical Site Infections Following Orthognathic Surgery:A Retrospective Cohort Analysis
Clayton M. Davis, BSc, DDS,* Curtis E. Gregoire, DDS J Oral Maxillofac Surg 74:1199-1206, 2016
 Incidence of Complications and Problems Related to Orthognathic Surgery Su-Gwan Kim, DDS J Oral
Maxillofac Surg 65:2438-2444, 2007
 Incidence of Complications and Problems Related to Orthognathic Surgery:A Review of 655
PatientsKari Panula, DDS,* Kaj Finne, DDS,†and Kyo¨sti Oikarinen J Oral Maxillofac Surg 59:1128-1136,
2001
Thank You