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Complications of Bimaxillary Orthognathic Surgery

Dr N.J. Rutherford Associate Professor A.C.H. Smith

Definitions
Bimaxillary surgery involves orthognathic procedures on both the mandible and maxilla Generally these procedures are the Le Fort I osteotomy and the Bilateral Sagittal Split osteotomy Other procedures may include genioplasty and rhinoplasty

Historical Perspective
In the last twenty years bimaxillary surgery has become accepted as a relatively safe procedure Prior to this complications were more frequent due to the following
Poor instrumentation Lack of scientific studies Poor techniques Prolonged procedures Traditional methods of fixation Anaesthetic related problems

Complications
All surgical procedures have complications and morbidities Most complications are prevented by planning and awareness If you never do surgery, you never get surgical complications If you do enough surgery you will have complications The aim is to minimise incidence of morbidity

Complications
Systemic Local Preoperative Intraoperative Postoperative
Short Term Long Term

Systemic
Cardiovascular / Renal
Hypovolaemia Shock Stroke Acute Renal Failure

Respiratory
Airway Compromise Aspiration Atelectasis Pneumonia

Systemic
Anaesthetic Related
Anaphylaxis Malignant Hyperthermia Drug Toxicity

Pain Psychiatric
Body Dysmorphic Disorder Conversion Disorder

Local
As discussed in following slides Balance of the orthodontic treatment objective and surgical treatment objective

Preoperative
Inadequate planning
Cephalometrics Impressions Facebow/articulator Model

surgery Surgical Wafers

Operative
Failure to achieve the surgical objective Haemorrhage Maxilla
Devascularization Inability to mobilize maxilla Inability to reduce vertical height Unfavourable osteotomy pattern Condylar distraction Nasal septum deviation

Operative
Mandible

Inappropriate split
Buccal plate fracture Lingual plate Fracture Condylar split

Inferior alveolar nerve


Nerve in proximal segment Neuropraxia, Neuronometsis, Axonometsis

Facial Nerve Lingual Nerve

Operative
Mandible
Inadequate

external oblique ridge reduction Damage to dental and related structures

Operative
Fixation problems
Inadequate Fixation Large osteotomy gaps Inadequate bony apposition Inadequate condylar position

Soft tissue Injuries

Lips, cheeks, nose

Damage to surrounding structures Immediate relapse

Postoperative
Cardiovascular

Short Term

Secondary Haemorrhage Avascular Necrosis maxillary segments Haematoma formation

Infection Bone Healing / Fixation


Failed Fixation Delayed Union Mal / Nonunion

Postoperative
Early Relapse

Short Term

Poor fixation Unstable final postion Condylar sag Idiopathic Condylar Resorption

Extrusion of teeth Neuronal Deficit

Paraesthesia, anaesthesia, dysaesthesia, hyperaesthesia

Postoperative
Relapse Fixation
Exposure

Long Term

/ Infection

T.M.J. Pain Neuronal Deficits Patient Disatisfaction

Reducing Complications
Adequate Planning
Listen to the patient concerns Set realistic goals for treatment Communication with orthodontist

Accuracy of preoperative work up


Assessment of growth Models Articulation Model surgery

Reducing Complications
Meticulous Surgery
Good

instrumentation Assistance Adequate force Careful dissection

Consider Autologous blood donation Careful postoperative followup