Complications and failures in orthognathic surgery

This paper reviews the literature about the most relevant complications in daily orthognathic surgery. Although orthognathic surgery has proven to be relatively safe, patients who undergo such maxillofacial orthopaedic surgery must be aware of the side effects of this combined treatment. Immediate life-threatening complications are very rare. They can in most cases be avoided by good anaesthetic and surgical techniques and adequate postoperative care. The most frequently encountered perioperative problem in maxillary surgery is excessive blood loss, whilst subjective neurosensory disturbance is the most frequent complication in mandibular surgery. Good co-operation between orthodontist and surgeon is essential to prevent most immediate and late postoperative problems and nearly all unsatisfactory results.     

Orthognathic surgery of a patient with oligodontia: alternative technique for intermaxillary fixation

ABSTRACT: Oligodontia may cause various problems during orthognathic surgery because it may be difficult to fix the surgical guide splints. The aim of this clinical report was to present an alternative technique for intermaxillary fixation of a patient with oligodontia and facial deformity. A 20-year-old male patient, whose 8 maxillary and 11 mandibular teeth were congenitally missing, was treated using bimaxillary orthognathic surgery. Before the surgical approach, fixed mandibular prosthesis containing pins on the vestibule sides of the crowns was constructed to provide anchorage for intermaxillary splint and to achieve occlusal stability and vertical dimension during the surgery. This prosthesis was also used to hang intraoral elastics during the postoperative orthodontic treatment. At the end of treatment, these pins were cut, composite restoration material was applied to camouflage the places of the pins, and the patient continued to use this prosthesis. The patient gained an appropriate facial aesthetics and oral function using multidisciplinary approach.     

Incidence of nasolacrimal injury and turbinectomy--associated atrophic rhinitis with Le Fort I osteotomies

Injury to the lacrimal system can occur with trauma, craniofacial surgery, rhinoplasty and nasal antrostomy. Nasolacrimal duct injury may potentially occur with Le Fort I superior repositioning. Atrophic rhinitis is also a potential complication secondary to turbinectomy required during Le Fort I superior repositioning. A review of thirty-four cases over three years of Le Fort I osteotomies with superior repositioning found no postoperative lacrimal injury and no subsequent atrophic rhinitis associated with turbinectomy. An anatomical study relating the position of the nasolacrimal duct opening within the inferior meatus and the distance available for maxillary impaction is reviewed.     

Benign paroxysmal positional vertigo as a complication of orthognathic surgery

Benign paroxysmal positional vertigo (BPPV) is a clinical disorder that may develop following surgical trauma to the maxilla, for example as a result of closed sinus lifting with the use of mallet and osteotome during implant surgery. We proposed that BPPV may also occur following maxillary Le Fort osteotomy during orthognathic surgery. In a prospective study of 50 consecutive cases of orthognathic surgery, we observed that one patient developed BPPV in the postoperative period following bimaxillary orthognathic surgery. The patient was a 23-year-old woman who met the strict criteria for a diagnosis of BPPV, including a positive Dix–Hallpike test. We have described BPPV in more detail and have discussed the necessity of increasing awareness and knowledge of surgeons about BPPV as a possible complication of craniomaxillofacial surgery.     

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唇腭裂患者常伴有不同程度的颌骨畸形,需要进行正颌外科治疗,手术方法包括常规正颌外科手术和上颌骨牵引成骨术。常规正颌外科手术最常用的是Le Fort Ⅰ型截骨术,适用于轻至中度的上颌后缩畸形,有时还需要配合双侧下颌升支矢状劈开截骨术(BSSRO)和颏成形术,以进一步改善面型和咬合关系。上颌骨牵引成骨术可采用外置式或内置式牵引器进行,截骨线可根据治疗需要采用Le Fort Ⅰ型截骨线或上颌前部截骨线。正颌外科和牵引成骨术各有其优点和局限性,如何选择合适的治疗方案应综合分析患者病情及医生临床经验,并与患者充分沟通,才能取得良好的矫治效果。     

Considerations for orthognathic surgery during growth, part 2: maxillary deformities.

The growing patient can present to the clinician with significant dentofacial deformities that require surgical correction. In some cases, certain functional, esthetic, and psychosocial factors may necessitate early surgical intervention. Although there is extensive literature on the effects and stability of orthognathic surgical correction of maxillary deformities in adults, the same is not true for the pediatric and adolescent growing patient. Not much is known about the predictability of orthognathic surgical procedures performed during growth or the effects such procedures have on subsequent facial growth. There is always the possibility that secondary corrective procedures may be required after the initial corrective surgery. This article presents recommendations based on available research and personal clinical experience in surgical correction of maxillary deformities in growing patients. The common maxillary dentofacial deformities, age considerations, and surgical alternatives and sequencing are presented. The treatment of mandibular deformities is addressed in Part 1 of this article.     

Posttraumatic obstruction of lacrimal pathways: a retrospective analysis of 58 consecutive naso-orbitoethmoid fractures

Posttraumatic dacryostenosis represent a troublesome sequela for patients who have sustained centrofacial trauma and can determine complexity in diagnosis and treatment. This article, based on a retrospective analysis of 58 patients with naso-orbitoethmoidal (NOE) trauma, reports the incidence of posttraumatic dacryostenosis and the evolution of such impairments in consideration of fracture type. Experience in diagnosis and treatment is illustrated, and surgical outcomes 6 months after external dacryocystorhinostomy (DCR) are reported. Posttraumatic epiphora was observed in 27 patients with NOE fractures (46.5%). In 10 cases, temporary epiphora was encountered and spontaneous recovery of lacrimal drainage within 5 months was observed. In the remaining 17 cases, permanent epiphora was registered and a frequent association with delayed treatment of facial fracture repair or bone loss in the lacrimal district was found. Surgical reconstruction of lacrimal pathways was performed 6 months after primary surgery, with external DCRs in all 17 patients with epiphora and the presence of nasolacrimal duct obstruction observed with dacryocystorhinography. External DCR with a large rhinostomy achieved a success rate of 94% in the reconstruction of lacrimal drainage. Such a technique proved to be effective in the treatment of posttraumatic dacryostenosis, although patients considered the temporary presence of external scars and stenting material to be a major problem.     

Delayed presentation of pseudoaneurysm after Le Fort I osteotomy

Although the osteotome is positioned in close vicinity to the maxillary artery and its branches during ptergomaxillary separation in a Le Fort I osteotomy, postoperative complications from vascular injuries are rare. The following report describes an unusual occurrence of a maxillary artery pseudoaneurysm following a Le Fort I and bilateral sagittal-split osteotomies for correction of mandibular and maxillary asymmetries in a patient with Goldenhar syndrome. This was recognized 8 months after the procedure when the patient developed acute facial swelling and required an emergent angiogram for uncontrolled bleeding. Vascular anatomy in the ptergomaxillary area is reviewed. A level of suspicion of occult vascular injuries in patients with sudden onset of unilateral facial swelling after orthognathic surgery, even months after the procedure, is recommended.     

Soft to hard tissue movement ratios: orthognathic surgery in a Hispanic population

Prediction of the movement ratio of soft to hard tissues is an important part of an orthodontic and orthognathic treatment plan. Previous studies have shown that various ethnic populations have significantly different average cephalometric measurements when compared to European-American norms. Therefore, a difference may exist in soft to hard tissue movement ratios in different ethnic populations. This study was undertaken to create norms for soft to hard tissue movement ratios for orthognathic surgery in a Hispanic population. These results were compared to previously published data on European-American populations. Presurgical and postsurgical cephalographs were traced and analyzed. The data were divided into 3 groups based on the surgical procedure performed: maxillary surgery alone, mandibular surgery alone, and treatment with a combination of maxillary and mandibular surgery. The results indicate that differences exist in soft to hard tissue ratios between the European-American and Hispanic populations. It is important to incorporate ratios for patients of Hispanic descent into a treatment planning protocol so that these patients are treated appropriately.     

上颌LeFort型截骨与颏成形术后继发下颌骨外科纤毛囊肿：罕见病例报道及文献复习

手术后引起的纤毛囊肿是一种极少见的术后并发症,在正颌外科术后的相关报道更为罕见。本文报告1例患者在接受上颌骨LeFortI型截骨与颏成形手术后2年,出现下颌颏部膨隆,影像学检查显示为颏部囊性占位．手术刮除病灶并取出钛板,病理学检查显示囊壁为假复层纤毛柱状上皮衬里,诊断为外科纤毛囊肿。回顾文献表明。正颌术后继发颌骨囊肿极为少见,其原因可能为术中上颌黏膜易位所致。     

Early orthognathic surgery with three-dimensional image simulation during presurgical orthodontics in adults

To correct dentofacial deformities, three-dimensional skeletal analysis and computerized orthognathic surgery simulation are used to facilitate accurate diagnoses and surgical plans. Computed tomography imaging of dental occlusion can inform three-dimensional facial analyses and orthognathic surgical simulations. Furthermore, three-dimensional laser scans of a cast model of the predetermined postoperative dental occlusion can be used to increase the accuracy of the preoperative surgical simulation. In this study, we prepared cast models of planned postoperative dental occlusions from 12 patients diagnosed with skeletal class III malocclusions with mandibular prognathism and facial asymmetry that had planned to undergo bimaxillary orthognathic surgery during preoperative orthodontic treatment. The data from three-dimensional laser scans of the cast models were used in three-dimensional surgical simulations. Early orthognathic surgeries were performed based on three-dimensional image simulations using the cast images in several presurgical orthodontic states in which teeth alignment, leveling, and space closure were incomplete. After postoperative orthodontic treatments, intraoral examinations revealed that no patient had a posterior open bite or space. The two-dimensional and three-dimensional skeletal analyses showed that no mandibular deviations occurred between the immediate and final postoperative states of orthodontic treatment. These results showed that early orthognathic surgery with three-dimensional computerized simulations based on cast models of predetermined postoperative dental occlusions could provide early correction of facial deformities and improved efficacy of preoperative orthodontic treatment. This approach can reduce the decompensation treatment period of the presurgical orthodontics and contribute to efficient postoperative orthodontic treatments.     

Cone beam computed tomography volumetric airway changes after orthognathic surgery: a systematic review

The aim of this systematic review was to provide a structured overview of three-dimensional airway volume changes in relation to various orthognathic surgeries. Clinical human studies performing pre- and postoperative three-dimensional airway volume assessments to investigate volumetric changes of the airway after orthognathic surgery were included. Pre-determined inclusion and exclusion criteria were applied in an extensive search of the PubMed, Embase, and Web of Science electronic databases. The cut-off date was set to January 1, 2022. Forty-one articles reporting retrospective and prospective case–control and case series studies were included. All studies were determined to be of medium quality (moderate risk of bias). The included studies were categorized by type of intervention. Pre- and postoperative volumes were extracted from the available data, and volume changes as a percentage of the preoperative levels were calculated. Isolated mandibular setback surgery generally decreased the airway volume. Isolated maxillary or mandibular advancement, bimaxillary advancement, and surgically assisted maxillary expansion generally increased the airway volume in the total airway and oropharynx, among which the effect of bimaxillary advancement surgery appeared most significant. High heterogeneity exists in the terminology and definitions of the airway and its segments. A more uniform methodology for airway volume measurement is needed to provide an insight into the impact on the airway of specific types of surgical intervention. In conclusion, airway volumes are affected after orthognathic surgery, which may be of clinical significance, especially in patients who are predisposed to obstructive sleep apnoea.     

Precision of maxillary repositioning during orthognathic surgery: A prospective study

The purpose of this study was to evaluate the accuracy of surgical splints and an external reference point to reposition the maxilla during orthognathic surgery. Before surgery, a radiological marker was inserted inside the orthodontic bracket of the first right maxillary molar. A surgical splint was utilized to reposition the maxilla in the sagittal and coronal planes after the osteotomy. The vertical position was established by measuring the distance between a Kirschner wire inserted at bony nasion and the orthodontic wire. Preoperative and postoperative cephalometric radiographs were obtained and manually traced. The radiological marker and the tip of the right maxillary incisor were used as specific landmarks. Their displacement on the pre- and postoperative radiographs was measured. The actual surgical movement of the maxilla was compared to the initial surgical planning. 23 patients met the inclusion criteria to participate in the study. The mean difference between the planned and executed movements of the maxilla was 0.1 mm (p = 0.71). The difference was not statistically significant for any given movements of the maxilla. The use of surgical splints made from model surgery combined with an external reference point at bony nasion is accurate methods for repositioning the maxilla during orthognathic surgery.     

The predictability of inferior medial canthus as a stable external vertical reference point in maxillary repositioning surgery

The purpose of this study was to investigate the predictability of using the inferior medial canthus as a stable external reference point for establishment of the vertical dimension in maxillary orthognathic surgery. Ten consecutive patients with skeletal Class II malocclusion and open bite who underwent orthognathic reconstructive surgery were included in the study. Prediction tracings were completed preoperatively and superimposed on an immediate postoperative lateral cephalometric radiograph. In 7 patients, the vertical positioning of the maxillary incisal edge on the immediate postoperative lateral cephalometric radiograph showed no difference from the superimposed preoperative prediction tracing. One patient showed 1 mm difference and 2 patients showed 2 mm difference from the preoperative prediction tracings. All cases resulted in acceptable maxillary incisal exposure relative to upper lip stomion. It is concluded that the inferior medial canthus can be used as a reproducible external vertical reference for orthognathic surgery when the technique described herein is used.     

Combining single- and double-tooth osteotomies with traditional orthognathic surgery

Combining large-segment orthognathic surgery and unitooth or small-segment surgery is an effective approach to deal with a wide range of dentofacial deformities that have minor to severe occlusal problems. The indications for combining single- or double-tooth osteotomies with traditional orthognathic surgery were patients with dentofacial deformities and malocclusion requiring stable correction within a short overall treatment period. From 1991 to 1998, a total of 36 patients underwent combination single- or double-tooth-segment osteotomy with traditional orthognathic procedures performed at Chang Gung Memorial Hospital. The indications for surgery were maxillary protrusion (N = 5), bimaxillary protrusion (N = 19), mandibular prognathism with maxillary protrusion (N = 11), and noncleft maxillary retrusion (N = 1). The types of osteotomies performed were the Le Fort I, the anterior segmental osteotomies of the maxilla or the mandible, the palatal split, and the posterior segment in combination with single-tooth or double-tooth segments. Follow-up ranged from 12 months to 6 years and showed stability in the movements with no complications. There was no loss of any "osteotomized" segment. The average overall treatment time was approximately 18 months--5 months preoperative and 13 months postoperative orthodontic treatment. This was at least 6 months shorter in duration compared with traditional orthognathic surgery. Combining traditional orthognathic surgery with single- or double-tooth segments allows us to treat complex dentofacial deformities in the vertical, transverse, and sagittal dimensions with differential repositioning of all segments, either major or minor, simultaneously. The authors' experience with 36 consecutive patients evidence good results and demonstrate the procedure to be safe with minimal complications.     

虚拟手术设计在双颌正颌手术中的精准性研究

目的评估虚拟手术设计在双颌正颌手术中的精准性,以期为临床提供参考。方法纳入需行双颌正颌手术的患者30例,利用CT数据和牙弓平面扫描数据建立复合颅骨模型,在Dolphin Imaging 11.7 Premium软件上模拟上颌骨LeFort I型骨切开术和双侧下颌支矢状骨劈开术,必要时行颏成形术,利用3D打印的手术导板将虚拟手术设计转移到术中。选择3个平面:眶耳平面(FHP)、面中平面(垂直于FHP且通过鼻根点)和冠状面(垂直于FHP且通过蝶鞍点)。选择6个标志点:上、下颌中切牙的近中接触点(UI、LI)以及上下颌第一磨牙的近中颊尖(U6-R、U6-L、L6-R、L6-L)。在虚拟手术模型和真实术后模型上测量选定标志点和对称平面之间的距离,并计算两模型之间的线性差异和总体平均线性差异(UI、LI、U6-R、U6-L、L6-R、L6-L分别与眶耳平面、面中平面和冠状面之间距离的平均差异)。确定由咬合平面、腭平面和下颌平面分别与眶耳平面和面中平面构成的角度值,并计算虚拟手术模型和真实术后模型之间的角度差异和总体平均角度差异。结果借助3D打印手术导板,虚拟手术设计被成功转移至实际手术中,所有患者术后对面型和咬合都很满意。虚拟与真实模型间的总体平均线性差异为0.81 mm(上颌骨0.71 mm,下颌骨0.91 mm);总体平均角度差异为0.95°(相对于眶耳平面的平均角度差异为1.10°,相对于面中平面的平均角度差异为0.83°)。结论虚拟手术设计有助于牙颌面畸形的诊断和治疗计划的制定,可以增加双颌正颌手术中骨块定位的精准性。     

Patient perceptions of orthognathic surgery

A retrospective study of ninety orthognathic surgery patients was conducted to investigate (1) their presurgical concerns and motivations, (2) their preoperative preparation for surgery, and (3) their perceptions of the postsurgical outcome. All subjects completed a twenty-three-item questionnaire and Rotter's Locus of Control Inventory. Statistical date analyses were performed by means of frequency distributions, chi-square, Spearman's r, and Fisher's exact probability tests. The results are presented as thirteen tentative conclusions categorized into three broad areas: motivations and concerns, presurgical preparation, and postsurgical outcome. In the area of motivations and concerns, those with primarily esthetic motivations have less initial reticence toward having orthognathic surgery and less difficulty adjusting to their new appearance than those with strong functional incentives. Younger patients and those patients with strong cosmetic motivations are less concerned about surgical risks. Under the category of presurgical preparation, more females than males desire to speak to a previous orthognathic surgery patient. Patients who receive inadequate explanation of the surgical procedure are more likely to be emotionally unprepared. One of the leading factors in patient dissatisfaction with surgery is the patient's experience of postoperative "surprises." In the area of postsurgical outcome, two-jaw operations precipitate more pain complaints than single-arch procedures. With time, however, patients tend to forget the degree of postoperative pain. Maxillary surgical procedures lead to less severe pain complaints than mandibular procedures, but there are more initial complaints of breathing difficulties and sinus problems following maxillary procedures. Surgical goal fulfillment does not guarantee that a patient would re-elect to have the treatment.     

数字化技术用于25例患者正颌手术效果评价

目的:应用数字化技术辅助正颌外科三维重建测量、术前诊断、手术设计与模拟、导板制作、导航验证和效果评估,探索制订更加科学、合理的数字化诊治方法和流程。方法:选取25例先天性牙颌面畸形患者,术前行颅颌面CT扫描,将CT数据导入Mimics 20.0软件,建立数字化原始模型。确定三维重建测量硬组织标志点并进行测量、分析、诊断、手术方案设计和导板制作。术中采用手术导航系统,进行上颌骨设计位置的确认、固位验证和骨打磨精确导引。术后1周复查颅颌面CT,并进行设计方案的术后验证。采用SPSS 24.0软件包对数据进行统计学分析。结果:25例患者均按照数字化正颌外科设计及流程完成手术,术后效果达到术前设计方案的要求。术后实际数字化三维重建头模与术前预测头模相比,10个骨性标志点在X、Y、Z三维方向上均无统计学差异（P>0.05）。结论:采用数字化技术辅助正颌外科诊断、手术设计和实施具有精准、微创的优越性。     

Surgical treatment of a skeletal Class III patient using customized brackets based on the CAD/CAM virtual orthodontic system

The computer-aided design/computer-aided manufacturing (CAD/CAM) virtual orthodontic system produces customized brackets, indirect bonding jigs, and archwires based on a three-dimensional virtual setup. In surgical cases, this system helps to visualize the final occlusion during diagnosis and to efficiently plan individualized presurgical orthodontic treatments. A 20-year-old female patient with a skeletal Class III malocclusion, maxillary protrusion, and lip protrusion was successfully treated with orthognathic surgery and orthodontic treatment with maxillary first premolar extractions. The CAD/CAM system was applied for efficient treatment, with a total active treatment time of 16 months. In this case report, the applicability of the CAD/CAM virtual orthodontic system for orthognathic surgery cases is demonstrated. Suggestions are also made to overcome the limitations and to maximize the advantages of this system during orthodontic treatment of patients undergoing orthognathic surgery.