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Complications associated with surgically assisted rapid palatal expansion without pterygomaxillary separation
J Stomatol Oral Maxillofac Surg 118 (2017) 279–282
Available online at
ScienceDirect www.sciencedirect.com
Original Article
Complications associated with surgically assisted rapid palatal expansion without pterygomaxillary separation§ S. Cakarer *, B. Keskin, S.C. Isler, E. Cansiz, A. Uzun, C. Keskin Istanbul University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Istanbul, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 November 2016 Accepted 13 June 2017 Available online 19 June 2017
Introduction: The purpose of this retrospective clinical study was to evaluate the surgical complications associated with the surgically assisted rapid palatal expansion (SARPE) which does not involve pterygomaxillary separation (PMS). Patients and methods: A total of 40 (25 females, 15 males) skeletally mature patients, who had the diagnosis of maxillary transverse maxillary deficiency (TMD), were treated surgically under local or general anesthesia. The mean follow-up time was 6 months. Results: Recorded perioperative and postoperative complications were discussed within the current literature. No serious complications were observed intraoperatively. Eight patients (20%) showed postoperative complications including neurosensory deficits, maxillary sinus infection, epistaxis, fistula formation and incisional dehiscence. Discussion: Neurosensory deficits were the most common findings. The present findings suggest that minor complications were observed associated with SARPE without PMS. The technique may be performed safely also under local anesthesia.
C 2017 Elsevier Masson SAS. All rights reserved.
Keywords: Maxillary expansion Complication Orthognatic surgery
1. Introduction
2. Materials and methods
A transverse maxillary deficiency (TMD) may be treated either orthodontically or surgically. If the deficiency is large, the recommended approach is surgically assisted rapid palatal expansion (SARPE), as performed in the present study [1]. Various authors differ in terms of the areas considered to be resistant to lateral maxillary expansion. The piriform aperture pillars, zygomatic buttresses, pterygoid junctions, and midpalatal synostosed suture have been considered to be resistant to expansion. Dysjunction of the pterygoid plates is at the discretion of the surgeon. The literature is inconclusive in terms of the effect of pterygomaxillary separation (PMS) on the outcomes of SARPE [2,3]. Therefore, we evaluated the outcomes of SARPE without PMS in terms of both intra- and postoperative complications, in the context of the current literature. The advantages and disadvantages of local and general anesthesia were also assessed.
We retrospectively reviewed data on all patients who underwent SARPE at Istanbul University Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, from January 2014 through March 2016. The study was approved by our institutional ethics committee. The same surgical team performed all operations using the same technique. The orthodontist applied a tooth-borne, fixed, hyrax-type, palatal expansion screw 1 or 2 days before surgery (Fig. 1). We collected data on intra- and postoperative complications during the 6 months after surgery. The inclusion criteria were skeletal maturity with a bilateral TMD > 5 mm; good oral hygiene; and healthy periodontal structures. The exclusion criteria were the presence of any maxillary sinus disease, previous maxillomandibular intervention. Predictive variables included demographic parameters (age and gender) and the type of the anesthesia applied (local or general). The primary outcome was the presence or absence of postoperative complications.
§ The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: http://www. textcheck.com/certificate/tu5wbQ. * Corresponding author. E-mail address: [email protected] (S. Cakarer).
2.1. Statistical analysis
http://dx.doi.org/10.1016/j.jormas.2017.06.008 C 2017 Elsevier Masson SAS. All rights reserved. 2468-7855/
Statistical analysis was performed using the Number Cruncher Statistical System 2007 (NCSS, Kaysville, UT, USA). We used the
S. Cakarer et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 279–282
280
Fig. 1. The view of the tooth-borne expansion device.
independent t-test to compare descriptive variables (means SD). The chi-squared test was used to evaluate qualitative data. A Pvalue < 0.05 was considered to reflect statistical significance. We found no significant difference between the complication-negative and -positive groups in age, gender, or type of anesthesia (Table 1). The complication rate was 20% but all complications were minor. Fig. 2. Intraoperative view of the Le Fort I osteotomy line.
2.2. Surgical technique All patients were informed that they could choose between general or local anesthesia. Seven patients preferred local anesthesia and thirty-three preferred general anesthesia. During the operation, all patients received local anesthetics to ensure hemostasis prior to incision. A full-thickness maxillary vestibular incision, extending from the first molar to the contralateral first molar, was performed, followed by subperiosteal dissection exposing the maxilla from the piriform rim to the buttress. Attached gingiva in the region of the interdental osteotomy was atraumatically and minimally elevated to prevent possible tissue necrosis of the anterior maxilla. An osteotomy at Le Fort I level was created using a straight fissure burr [1] (Fig. 2). PMS was not performed but bilateral nasal osteotomies were created. The expansion device was activated before performance of the interdental osteotomy; separation then followed. Interdental osteotomy was performed with the aid of a round burr; transpalatal osteotomy featured the use of a spatular osteotome (Fig. 3). The expansion device was then closed and the flap repositioned and sutured.
was noted. Electrocauterization was used to manage small bleedings.
3. Results
3.2. Postoperative complications
The study cohort consisted of 40 patients, of whom slightly more than half (62.5%) were female. The median follow-up time was 6 months.
Eight patients (20%) developed postoperative surgical complications. One patient experienced epistaxis 5 days after surgery. Hemostasis was attained by applying an anterior nasal pack. One patient developed a maxillary sinus infection 2 weeks after surgery and four complained of numbness of the anterior maxilla. One patient with cleft lip-palate (CLP) syndrome developed a fistula at the site of the prior palatal cleft. He underwent iliac crest augmentation to manage the fistula. One patient exhibited wound dehiscence at the anterior maxilla 1 week after surgery. The wound
3.1. Intraoperative complications During operation, the osteotome became displaced from the palatal mucosa in three patients. The mucosa was sutured and no postoperative dehiscence was observed. No hemorrhagic problem
Fig. 3. Intraoperative view of the interdental separation.
Table 1 Evaluation of the complication regarding age, gender and anesthesia.
Age Gender Male Female Anesthesia type General anesthesia Local anesthesia
Complication ( ) n: 32
Complication (+) n: 8
Total n: 40
P
23.50 5.23
24.38 5.53
23.67 5.23
0.678
13 19
40.63% 59.38%
2 6
25.00% 75.00%
15 25
37.50% 62.50%
0.414
26 6
81.25% 18.75%
7 1
87.50% 12.50%
33 7
82.50% 17.50%
0.677
S. Cakarer et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 279–282
was resutured and no further problem was reported. No asymmetric/inadequate expansion, and no dental or periodontal problem was noted in any patient.
4. Discussion Although SARPE is commonly performed, little information is available on the prevalence of postoperative complications including pain, hemorrhage, infection, sinusitis, periodontal bone loss, tooth devitalization/loss, palatal mucosal ulceration, asymmetric expansion, relapse, or more serious issues including aseptic necrosis and orbital complications [1]. Some reported unusual complications included orbital compartment syndrome, bilateral lingual anesthesia, and development of a nasopalatine canal cyst [2]. Several authors have avoided surgical separation of the pterygomaxillary junction, thus rendering surgery noninvasive. No consensus has yet emerged on whether PTS is appropriate during SARPE [4]. Few details on intra- and postoperative complications associated with SARPE without PMS have appeared [3]. Therefore, we discuss the complications of the present study to inform oral and maxillofacial surgeons, and orthodontists. 4.1. Anesthesia for SARPE SARPE can be performed under general or local anesthesia. Authors vary in their views as to whether SARPE without PMS is safe in terms of bleeding problems developing under local anesthesia [5–8]. In the present study, only seven patients selected local anesthesia without any additional sedation. SARPE without PMS was safe in such patients. The principal problem was (psychological) trauma during the lateral nasal wall osteotomies. However, all patients were discharged 8 h after operation. We injected methylprednisolone intravenously prior to operation to minimize postoperative facial edema and found this to be useful. One advantage of general anesthesia (from the viewpoint of the surgeon) is that the patient is hypotensive during operation. We consider it necessary to cease hypotensive anesthesia prior to wound closure to allow any possible hemorrhage to be identified [9]. 4.2. Hemorrhage It has been speculated that PMS performed using an osteotome might trigger postoperative vascular events. In maxilla-down fracture cases, other factors, including late wound infection, a pseudoaneurysm, a high-level pterygoid plate fracture, and injuries to the descending palatine and sphenopalatine arteries during forward maxillar mobilization, may trigger life-threatening hemorragia. However, SARPE is associated with low morbidity, especially when compared to maxilla-down fracture. In the large SARPE case series (376 patients) of Politis et al., no life-threatening hemorragia was noted [10]. On the other hand, Mehra et al. reported a case of delayed life-threatening epistaxis after SARPE [11]. Embolization has been used widely to treat vascular injuries and head-and-neck bleeding, and to manage epistaxis, intracranial aneurysms, and arterio-venous fistulae [12]. To the best of our knowledge, the requirement for embolization of a postoperative hemorrhage developing after SARPE has not been reported in the literature. Anterior and/or posterior nasal packing for 3–5 days is the standard method used to treat epistaxis. In several case series of hemorrhage developing after Le Fort I osteotomies, the vast majority of initial episodes occurred within the first 14 postoperative days [13]. Dergin et al. retrospectively evaluated complications after SARPE. Of all patients, 20% developed nasal bleeds
281
[14]. In the present study, only one patient (2.5%) developed epistaxis 5 days after surgery. Hemostasis was achieved via anterior nasal packing. As we did not perform PMS, the probable cause of hemorrhage was traumatic osteotomy of the lateral nasal wall. During such osteotomy, the osteotome should not be directed medially or superiorly to prevent possible damage to the inferior turbinate and the nasal mucoperiosteum. Also, during SARPE, management of an injury to the descending palatine artery can be more difficult than in maxilla-down fracture cases because it is not possible to view the vessel directly. Also, risk of hemorrhage is reduced if the surgeon remains in the subperiosteal plane when working laterally, thus not dissecting soft tissue [15]. 4.3. Maxillary sinus infection Persistent maxillary sinusitis (that requires treatment) is thought to be uncommon after Le Fort osteotomy, but the true incidence remains unclear. Such sinusitis may be caused by: (1) changes in the mechanism by which sinus mucus is cleared; (2) retention of a blood clot in the sinus cavity; (3) dental infection; (4) a foreign body; or, (5) anatomical blockage of the osteomeatal opening. The most common cause is unrecognized preoperative chronic sinusitis [9]. In the present study, one patient developed a maxillary sinus infection. She presented with a complaint of defluxion. Computed tomography (CT) revealed congestion of the left middle meatus. We consulted with ear, nose, and throat (ENT) specialists and performed functional endoscopic sinus surgery (FESS) under general anesthesia. During examination, we observed pus draining from the maxillary sinus to the inferior meatus via a fistula, and a foreign body. This was removed and diagnosed histopathologically as an aspergillosis. We prescribed penicillin and metronidazole. Three weeks later, the patient was completely asymptomatic. Fungal infection of the maxillary sinus after SARPE is unusual. The trauma associated with the lateral nasal wall osteotomies may trigger fistula formation from the inferior meatus to maxillary sinus, thus modifying the flora of the maxillary sinus by introducing a fungus. To manage such complications, CT of the maxillary sinus and consultation with ENT specialists are advised. Some unusual reported complications of SARPE were delayed life-threatening epistaxis and bilateral lingual anesthesia [11,16]. In the present study, the aspergillosis in the maxillary sinus might be considered unusual. 4.4. Nerve injury Alterations in blood flow and injury to the branches of the maxillary nerve have been reported to cause tooth numbness and paresthesia of the lips and the infraorbital region [14]. Subjective changes in somatosensory function, cutaneous numbness, and numbness of the facial and palatal gingiva, have also been reported in the literature [17,18]. Four of our patients reported temporary bilateral numbness of the teeth and the gingiva, with temporary bilateral slight facial paresthesia, possibly associated with trauma to the infraorbital nerve imparted by the tissue retractors. All numbness resolved by 6 months after surgery. 4.5. Complications in patients with cleft lip and palate Orthognathic surgery is usually the final phase of treatment in CLP patients. More than 25% of such patients develop significant maxillary hypoplasia that requires both local surgical intervention and maxillary Le Fort I osteotomy [19]. The present study included only two CLP patients. The cleft area was opened after termination of expansion in one patient with a slight unilateral cleft palate. This patient underwent secondary surgery, including iliac crest bone augmentation; the defect was closed successfully. No further
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282
complaint was noted. Generally, the cleft maxilla is narrow and may require surgical expansion. Wolford and Stevao [3] described soft tissue techniques permitting surgical expansion of the maxilla while maintaining a viable blood supply to all segments [20]. The complications associated with Le Fort I osteotomy are well-known, but those of SARPE in CLP patients are not. Prospective cohort studies are required. 4.6. Dehiscence In the present study, we performed complete Le Fort I incisions exposing the anterior maxilla from the first molar to the first contralateral molar. This afforded an optimal surgical view for dissection of the lateral nasal mucosa, lateral nasal osteotomy, and interdental osteotomy. A full horizontal vestibular incision was created 5 mm above the mucogingival junction to prevent possible necrosis. Our preference is to create the incision via electrocautery and then modify it using a #15 blade. In the present study, only one patient experienced dehiscence of this incision 1 week after operation, but the bone was not exposed. The incision line was resutured and no other complaint was noted. Incisions may be created with a scalpel, via electrocautery, or both, depending on the preference of the surgeon. We prefer to use a Colorado tip to ensure both good hemostasis and surgical precision, as reported by Sullivan [21]. It is important, during incision, to spare sufficient soft tissue to allow appropriate closure at the end of the operation. It is thus important to create the incision at least 5 mm above the mucogingival junction. Disclosure of interest The authors declare that they have no competing interest. Acknowledgement The authors thank ‘‘ARK Biostatistical Office’’ for the statistical analyses. References [1] Williams BJ, Currimbhoy S, Silva A, O’Ryan FS. Complications following surgically assisted rapid palatal expansion: a retrospective cohort study. J Oral Maxillofac Surg 2012;70:2394–402. [2] Suri L, Taneja P. Surgically assisted rapid palatal expansion: a literature review. Am J Orthod Dentofacial Orthop 2008;133:290–302.
[3] Hamedi Sangsari A, Sadr-Eshkevari P, Al-Dam A, Friedrich RE, Freymiller E, Rashad A. Surgically assisted rapid palatomaxillary expansion with or without pterygomaxillary disjunction: a systematic review and meta-analysis. J Oral Maxillofac Surg 2016;74:338–48. [4] Kilic E, Kilic B, Kurt G, Sakin C, Alkan A. Effects of surgically assisted rapid palatal expansion with and without pterygomaxillary disjunction on dental and skeletal structures: a retrospective review. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:167–74. [5] Furquim LZ, Janson G, Furquim BD, Iwaki Filho L, Henriques JF, Ferreira GM. Maxillary protraction after surgically assisted maxillary expansion. J Appl Oral Sci 2010;18:308–15. [6] Rana M, Gellrich NC, Rana M, Piffko´ J, Kater W. Evaluation of surgically assisted rapid maxillary expansion with piezosurgery versus oscillating saw and chisel osteotomy – a randomized prospective trial. Trials 2013;17:49. http:// dx.doi.org/10.1186/1745-6215-14-49. [7] Robiony M, Polini F, Costa F, Zerman N, Politi M. Ultrasonic bone cutting for surgically assisted rapid maxillary expansion (SARME) under local anaesthesia. Int J Oral Maxillofac Surg 2007;36:267–9. [8] Hernandez-Alfaro F, Mareque Bueno J, Diaz A, Page´s CM. Minimally invasive surgically assisted rapid palatal expansion with limited approach under sedation: a report of 283 consecutive cases. J Oral Maxillofac Surg 2010;68:2154–8. [9] Posnick JC. Risk and complications specific to Le fort I osteotomy, Principles and Practice of Orthognathic Surgery. Ch.17.2013 [10] Politis C. Life-threatening haemorrhage after 750 Le Fort I osteotomies and 376 SARPE procedures. Int J Oral Maxillofac Surg 2012;41:702–8. [11] Mehra P, Cottrell DA, Caiazzo A, Lincoln R. Life-threatening, delayed epistaxis after surgically assisted rapid palatal expansion: a case report. J Oral Maxillofac Surg 1999;57:201–4. [12] Avelar RL, Goelzer JG, Becker OE, de Oliveira RB, Raupp EF, de Magalha˜es PS. Embolization of pseudoaneurysm of the internal maxillary artery after orthognathic surgery. J Craniofac Surg 2010;21:1764–8. [13] Garg S, Kaur S. Evaluation of post-operative complication rate of Le Fort I osteotomy: a retrospective and prospective study. J Maxillofac Oral Surg 2014;13:120–7. [14] Dergin G, Aktop S, Varol A, Ugurlu F, Garip H. Complications related to surgically assisted rapid palatal expansion. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:601–7. [15] Humber CC, Lanigan DT, Hohn FI. Retrograde hemorrhage (hemolacria) from the lacrimal puncta after a Le Fort I osteotomy: a report of 2 cases and a review of the literature. J Oral Maxillofac Surg 2011;69:520–7. [16] Chuah C, Mehra P. Bilateral lingual anesthesia following surgically assisted rapid palatal expansion: report of a case. J Oral Maxillofac Surg 2005;63:416– 8. [17] Thygesen TH, Bardow A, Norholt SE, Jensen J, Svensson P. Surgical risk factors and maxillary nerve function after Le Fort I osteotomy. J Oral Maxillofac Surg 2009;67:528–36. [18] Je˛drzejewski M, Smektała T, Sporniak-Tutak K, Olszewski R. Preoperative, intraoperative, and postoperative complications in orthognathic surgery: a systematic review. Clin Oral Investig 2015;19:969–77. [19] Saltaji H, Major MP, Alfakir H, Al-Saleh MA, Flores-Mir C. Maxillary advancement with conventional orthognathic surgery in patients with cleft lip and palate: is it a stable technique? J Oral Maxillofac Surg 2012;70:2859–66. [20] Wolford LM, Stevao EL. Correction of jaw deformities in patients with cleft lip and palate. Proc (Bayl Univ Med Cent) 2002;15:250–4. [21] Sullivan SM. Techniques in orthognathic surgery. An issue of atlas of the oral and maxillofacial surgery clinics of North America. Elsevier; 2016.
Available online at
ScienceDirect www.sciencedirect.com
Original Article
Complications associated with surgically assisted rapid palatal expansion without pterygomaxillary separation§ S. Cakarer *, B. Keskin, S.C. Isler, E. Cansiz, A. Uzun, C. Keskin Istanbul University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Istanbul, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 November 2016 Accepted 13 June 2017 Available online 19 June 2017
Introduction: The purpose of this retrospective clinical study was to evaluate the surgical complications associated with the surgically assisted rapid palatal expansion (SARPE) which does not involve pterygomaxillary separation (PMS). Patients and methods: A total of 40 (25 females, 15 males) skeletally mature patients, who had the diagnosis of maxillary transverse maxillary deficiency (TMD), were treated surgically under local or general anesthesia. The mean follow-up time was 6 months. Results: Recorded perioperative and postoperative complications were discussed within the current literature. No serious complications were observed intraoperatively. Eight patients (20%) showed postoperative complications including neurosensory deficits, maxillary sinus infection, epistaxis, fistula formation and incisional dehiscence. Discussion: Neurosensory deficits were the most common findings. The present findings suggest that minor complications were observed associated with SARPE without PMS. The technique may be performed safely also under local anesthesia.
C 2017 Elsevier Masson SAS. All rights reserved.
Keywords: Maxillary expansion Complication Orthognatic surgery
1. Introduction
2. Materials and methods
A transverse maxillary deficiency (TMD) may be treated either orthodontically or surgically. If the deficiency is large, the recommended approach is surgically assisted rapid palatal expansion (SARPE), as performed in the present study [1]. Various authors differ in terms of the areas considered to be resistant to lateral maxillary expansion. The piriform aperture pillars, zygomatic buttresses, pterygoid junctions, and midpalatal synostosed suture have been considered to be resistant to expansion. Dysjunction of the pterygoid plates is at the discretion of the surgeon. The literature is inconclusive in terms of the effect of pterygomaxillary separation (PMS) on the outcomes of SARPE [2,3]. Therefore, we evaluated the outcomes of SARPE without PMS in terms of both intra- and postoperative complications, in the context of the current literature. The advantages and disadvantages of local and general anesthesia were also assessed.
We retrospectively reviewed data on all patients who underwent SARPE at Istanbul University Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, from January 2014 through March 2016. The study was approved by our institutional ethics committee. The same surgical team performed all operations using the same technique. The orthodontist applied a tooth-borne, fixed, hyrax-type, palatal expansion screw 1 or 2 days before surgery (Fig. 1). We collected data on intra- and postoperative complications during the 6 months after surgery. The inclusion criteria were skeletal maturity with a bilateral TMD > 5 mm; good oral hygiene; and healthy periodontal structures. The exclusion criteria were the presence of any maxillary sinus disease, previous maxillomandibular intervention. Predictive variables included demographic parameters (age and gender) and the type of the anesthesia applied (local or general). The primary outcome was the presence or absence of postoperative complications.
§ The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: http://www. textcheck.com/certificate/tu5wbQ. * Corresponding author. E-mail address: [email protected] (S. Cakarer).
2.1. Statistical analysis
http://dx.doi.org/10.1016/j.jormas.2017.06.008 C 2017 Elsevier Masson SAS. All rights reserved. 2468-7855/
Statistical analysis was performed using the Number Cruncher Statistical System 2007 (NCSS, Kaysville, UT, USA). We used the
S. Cakarer et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 279–282
280
Fig. 1. The view of the tooth-borne expansion device.
independent t-test to compare descriptive variables (means SD). The chi-squared test was used to evaluate qualitative data. A Pvalue < 0.05 was considered to reflect statistical significance. We found no significant difference between the complication-negative and -positive groups in age, gender, or type of anesthesia (Table 1). The complication rate was 20% but all complications were minor. Fig. 2. Intraoperative view of the Le Fort I osteotomy line.
2.2. Surgical technique All patients were informed that they could choose between general or local anesthesia. Seven patients preferred local anesthesia and thirty-three preferred general anesthesia. During the operation, all patients received local anesthetics to ensure hemostasis prior to incision. A full-thickness maxillary vestibular incision, extending from the first molar to the contralateral first molar, was performed, followed by subperiosteal dissection exposing the maxilla from the piriform rim to the buttress. Attached gingiva in the region of the interdental osteotomy was atraumatically and minimally elevated to prevent possible tissue necrosis of the anterior maxilla. An osteotomy at Le Fort I level was created using a straight fissure burr [1] (Fig. 2). PMS was not performed but bilateral nasal osteotomies were created. The expansion device was activated before performance of the interdental osteotomy; separation then followed. Interdental osteotomy was performed with the aid of a round burr; transpalatal osteotomy featured the use of a spatular osteotome (Fig. 3). The expansion device was then closed and the flap repositioned and sutured.
was noted. Electrocauterization was used to manage small bleedings.
3. Results
3.2. Postoperative complications
The study cohort consisted of 40 patients, of whom slightly more than half (62.5%) were female. The median follow-up time was 6 months.
Eight patients (20%) developed postoperative surgical complications. One patient experienced epistaxis 5 days after surgery. Hemostasis was attained by applying an anterior nasal pack. One patient developed a maxillary sinus infection 2 weeks after surgery and four complained of numbness of the anterior maxilla. One patient with cleft lip-palate (CLP) syndrome developed a fistula at the site of the prior palatal cleft. He underwent iliac crest augmentation to manage the fistula. One patient exhibited wound dehiscence at the anterior maxilla 1 week after surgery. The wound
3.1. Intraoperative complications During operation, the osteotome became displaced from the palatal mucosa in three patients. The mucosa was sutured and no postoperative dehiscence was observed. No hemorrhagic problem
Fig. 3. Intraoperative view of the interdental separation.
Table 1 Evaluation of the complication regarding age, gender and anesthesia.
Age Gender Male Female Anesthesia type General anesthesia Local anesthesia
Complication ( ) n: 32
Complication (+) n: 8
Total n: 40
P
23.50 5.23
24.38 5.53
23.67 5.23
0.678
13 19
40.63% 59.38%
2 6
25.00% 75.00%
15 25
37.50% 62.50%
0.414
26 6
81.25% 18.75%
7 1
87.50% 12.50%
33 7
82.50% 17.50%
0.677
S. Cakarer et al. / J Stomatol Oral Maxillofac Surg 118 (2017) 279–282
was resutured and no further problem was reported. No asymmetric/inadequate expansion, and no dental or periodontal problem was noted in any patient.
4. Discussion Although SARPE is commonly performed, little information is available on the prevalence of postoperative complications including pain, hemorrhage, infection, sinusitis, periodontal bone loss, tooth devitalization/loss, palatal mucosal ulceration, asymmetric expansion, relapse, or more serious issues including aseptic necrosis and orbital complications [1]. Some reported unusual complications included orbital compartment syndrome, bilateral lingual anesthesia, and development of a nasopalatine canal cyst [2]. Several authors have avoided surgical separation of the pterygomaxillary junction, thus rendering surgery noninvasive. No consensus has yet emerged on whether PTS is appropriate during SARPE [4]. Few details on intra- and postoperative complications associated with SARPE without PMS have appeared [3]. Therefore, we discuss the complications of the present study to inform oral and maxillofacial surgeons, and orthodontists. 4.1. Anesthesia for SARPE SARPE can be performed under general or local anesthesia. Authors vary in their views as to whether SARPE without PMS is safe in terms of bleeding problems developing under local anesthesia [5–8]. In the present study, only seven patients selected local anesthesia without any additional sedation. SARPE without PMS was safe in such patients. The principal problem was (psychological) trauma during the lateral nasal wall osteotomies. However, all patients were discharged 8 h after operation. We injected methylprednisolone intravenously prior to operation to minimize postoperative facial edema and found this to be useful. One advantage of general anesthesia (from the viewpoint of the surgeon) is that the patient is hypotensive during operation. We consider it necessary to cease hypotensive anesthesia prior to wound closure to allow any possible hemorrhage to be identified [9]. 4.2. Hemorrhage It has been speculated that PMS performed using an osteotome might trigger postoperative vascular events. In maxilla-down fracture cases, other factors, including late wound infection, a pseudoaneurysm, a high-level pterygoid plate fracture, and injuries to the descending palatine and sphenopalatine arteries during forward maxillar mobilization, may trigger life-threatening hemorragia. However, SARPE is associated with low morbidity, especially when compared to maxilla-down fracture. In the large SARPE case series (376 patients) of Politis et al., no life-threatening hemorragia was noted [10]. On the other hand, Mehra et al. reported a case of delayed life-threatening epistaxis after SARPE [11]. Embolization has been used widely to treat vascular injuries and head-and-neck bleeding, and to manage epistaxis, intracranial aneurysms, and arterio-venous fistulae [12]. To the best of our knowledge, the requirement for embolization of a postoperative hemorrhage developing after SARPE has not been reported in the literature. Anterior and/or posterior nasal packing for 3–5 days is the standard method used to treat epistaxis. In several case series of hemorrhage developing after Le Fort I osteotomies, the vast majority of initial episodes occurred within the first 14 postoperative days [13]. Dergin et al. retrospectively evaluated complications after SARPE. Of all patients, 20% developed nasal bleeds
281
[14]. In the present study, only one patient (2.5%) developed epistaxis 5 days after surgery. Hemostasis was achieved via anterior nasal packing. As we did not perform PMS, the probable cause of hemorrhage was traumatic osteotomy of the lateral nasal wall. During such osteotomy, the osteotome should not be directed medially or superiorly to prevent possible damage to the inferior turbinate and the nasal mucoperiosteum. Also, during SARPE, management of an injury to the descending palatine artery can be more difficult than in maxilla-down fracture cases because it is not possible to view the vessel directly. Also, risk of hemorrhage is reduced if the surgeon remains in the subperiosteal plane when working laterally, thus not dissecting soft tissue [15]. 4.3. Maxillary sinus infection Persistent maxillary sinusitis (that requires treatment) is thought to be uncommon after Le Fort osteotomy, but the true incidence remains unclear. Such sinusitis may be caused by: (1) changes in the mechanism by which sinus mucus is cleared; (2) retention of a blood clot in the sinus cavity; (3) dental infection; (4) a foreign body; or, (5) anatomical blockage of the osteomeatal opening. The most common cause is unrecognized preoperative chronic sinusitis [9]. In the present study, one patient developed a maxillary sinus infection. She presented with a complaint of defluxion. Computed tomography (CT) revealed congestion of the left middle meatus. We consulted with ear, nose, and throat (ENT) specialists and performed functional endoscopic sinus surgery (FESS) under general anesthesia. During examination, we observed pus draining from the maxillary sinus to the inferior meatus via a fistula, and a foreign body. This was removed and diagnosed histopathologically as an aspergillosis. We prescribed penicillin and metronidazole. Three weeks later, the patient was completely asymptomatic. Fungal infection of the maxillary sinus after SARPE is unusual. The trauma associated with the lateral nasal wall osteotomies may trigger fistula formation from the inferior meatus to maxillary sinus, thus modifying the flora of the maxillary sinus by introducing a fungus. To manage such complications, CT of the maxillary sinus and consultation with ENT specialists are advised. Some unusual reported complications of SARPE were delayed life-threatening epistaxis and bilateral lingual anesthesia [11,16]. In the present study, the aspergillosis in the maxillary sinus might be considered unusual. 4.4. Nerve injury Alterations in blood flow and injury to the branches of the maxillary nerve have been reported to cause tooth numbness and paresthesia of the lips and the infraorbital region [14]. Subjective changes in somatosensory function, cutaneous numbness, and numbness of the facial and palatal gingiva, have also been reported in the literature [17,18]. Four of our patients reported temporary bilateral numbness of the teeth and the gingiva, with temporary bilateral slight facial paresthesia, possibly associated with trauma to the infraorbital nerve imparted by the tissue retractors. All numbness resolved by 6 months after surgery. 4.5. Complications in patients with cleft lip and palate Orthognathic surgery is usually the final phase of treatment in CLP patients. More than 25% of such patients develop significant maxillary hypoplasia that requires both local surgical intervention and maxillary Le Fort I osteotomy [19]. The present study included only two CLP patients. The cleft area was opened after termination of expansion in one patient with a slight unilateral cleft palate. This patient underwent secondary surgery, including iliac crest bone augmentation; the defect was closed successfully. No further
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complaint was noted. Generally, the cleft maxilla is narrow and may require surgical expansion. Wolford and Stevao [3] described soft tissue techniques permitting surgical expansion of the maxilla while maintaining a viable blood supply to all segments [20]. The complications associated with Le Fort I osteotomy are well-known, but those of SARPE in CLP patients are not. Prospective cohort studies are required. 4.6. Dehiscence In the present study, we performed complete Le Fort I incisions exposing the anterior maxilla from the first molar to the first contralateral molar. This afforded an optimal surgical view for dissection of the lateral nasal mucosa, lateral nasal osteotomy, and interdental osteotomy. A full horizontal vestibular incision was created 5 mm above the mucogingival junction to prevent possible necrosis. Our preference is to create the incision via electrocautery and then modify it using a #15 blade. In the present study, only one patient experienced dehiscence of this incision 1 week after operation, but the bone was not exposed. The incision line was resutured and no other complaint was noted. Incisions may be created with a scalpel, via electrocautery, or both, depending on the preference of the surgeon. We prefer to use a Colorado tip to ensure both good hemostasis and surgical precision, as reported by Sullivan [21]. It is important, during incision, to spare sufficient soft tissue to allow appropriate closure at the end of the operation. It is thus important to create the incision at least 5 mm above the mucogingival junction. Disclosure of interest The authors declare that they have no competing interest. Acknowledgement The authors thank ‘‘ARK Biostatistical Office’’ for the statistical analyses. References [1] Williams BJ, Currimbhoy S, Silva A, O’Ryan FS. Complications following surgically assisted rapid palatal expansion: a retrospective cohort study. J Oral Maxillofac Surg 2012;70:2394–402. [2] Suri L, Taneja P. Surgically assisted rapid palatal expansion: a literature review. Am J Orthod Dentofacial Orthop 2008;133:290–302.
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