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Life-threatening hemorrhage from a Le Fort I osteotomy
CASE REPORTS
Life-threatening Hemorrhage from a Le Fort I Osteotomy RICNEY F. NEWHOUSE, LT COL, DC, DMD,* STERLING R. SCHOW, LT COL, DC, DMD,t RICHARD A. KRAUT, LT COL, DC, DDS,:f: AND JOHN C. PRICE, LT COL, MC, MD§ Severe hemorrhage associated with orthognathic surgery rarely occurs. When a significant episode happens, it can usually be attributed to the maxillary artery or one of its branches. Damage to the internal carotid artery and subsequent life-threatening hemorrhage during an orthognathic procedure has never been previously reported.
ligated. This was accomplished without obvious decrease in the bleeding. Bilateral packing of the maxillary antra and pterygopalatine fossas combined with wire stabilization of the maxilla ultimately controlled the hemorrhage. The estimated blood loss to this point was 10,500 ml. The patient was transferred to the surgical intensive care unit (SICD). A loud S3 secondary to fluid overload developed. A complete blood count showed a hematocrit value of 48%. The patient was responsive to verbal commands and neurologically intact. On the first postoperative day, she was essentially stable except for repeated temperature spikes thought to be due to the pressure packs. Arrangements were made to transfer the patient to Brooke Army Medical Center (BAMC) for angiographic studies before removal of the packs. The patient with a nasoendotracheal tube in place was transferred by helicopter. En route, the patient's nasocndotracheal tube became disconnected and displaced into the nasopharynx. On arrival at BAMC, she was cyanotic and in respiratory distress. An arterial blood gas determination at that time revealed a P0 2 of 32 torr. Following reconnection of the nasoendotracheal tube, the SICD staff noted that the patient was moving only her right side, and that copious tracheal secretions were being produced. Since her respiratory status did not improve. a tracheostomy was done to gain adequate control of the airway. Angiography was performed to determine the source of hemorrhage and to establish a reasonable approach to control recurrent bleeding before the removal of the packing material. Angiography revealed a traumatic arteriovenous (A-V) fistula involving the right internal carotid artery and internal jugular vein at the base of the skull (Fig. I). No intracranial flow could be seen from the right internal carotid artery. but collateral supply of the right cerebral hemisphere was observed from the left side (Figs. 2 and 3). The surgeons now faced a dilemma: further surgery to repair the fistula or observation in light of the patient's questionable neurologic status. The possibility of major recurrent hemorrhage at an inopportune time and/or septicemia from the packs prompted a decision to operate. Thus, shortly after the diagnosis of a traumatic A-V fistula, the patient underwent a neck exploration to ligate the internal carotid artery and obliterate the jugular foramen with a muscle graft. Following this, the maxilla was mobilized. the packs were removed, and the maxilla was restabilized. This was accompanied with minimal hemorrhage. The surgeons noted that the right pterygoid plates were completely separated from the sphenoid base as well as the maxilla. The patient had an essentially stable postoperative course but retained a dense left hemiparesis. Addition-
Report of a Case On July 29, 1980, a healthy 32-year-old white woman was admitted to the Oral and Maxillofacial Surgery Service of another hospital for correction of vertical maxillary excess and mandibular retrognathia. This was to be accomplished via Le Fort I osteotomy and mandibular autorotation. The review of systems, past medical history, and past surgical history was noncontributory. Physical examination was significant for vertical maxillary excess, increased lower facial height, mandibular retrognathia, and lip incompetence. The remainder of her examination was unremarkable. On July 30, 1980, the patient was taken to the operating room, where. under general nasoendotracheal anesthesia. a Le Fort I osteotomy was accomplished by incorporating a bilateral 8 mm ostectomy posteriorly and a bilateral 6 mm ostectomy anteriorly. The osteotomies were made with a reciprocating saw. The lateral nasal walls and nasal septum were sectioned with a forked nasal gouge and the bilateral pterygomaxillary dysjunction was effected with a curved osteotome. No significant bleeding was encountered to this time. Manipulation of the maxilla into a down-fractured position was attended with profuse arterial hemorrhage from the right posterior region. Attempts to visualize the source of the bleeding were unsuccessful. Immediate measures to stabilize the patient included multiple arterial and venous cutdowns, infusion of 15 units of packed erythrocytes, two units of autologous whole blood, four units of plasmanate, and four units of fresh frozen plasma. The right external carotid artery was
* Chief Resident,
Oral and Maxillofacial Surgery Service. t Chief, Oral and Maxillofacial Surgery Service. :j: Assistant Chief, Oral and Maxillofacial Surgery Service. § Chief, Head and Neck Surgery. Received from the Oral and Maxillofacial Surgery Service, Brooke Army Medical Center, Fort Sam Houston, Texas. Address correspondence and reprint requests to Dr. Newhouse. The opinions or assertions contained herein are thc private views of the authors and are not to be construed as reflecting the views of the Department of the Army or Department of Defense. 0278-2391/82'0200'0117 SOO.6O
© American Association of Oral and Maxillofacial Surgeons
117
ally, it was noted that cranial nerves X and XII had been injured during the initial procedures. Now, three months status after complication, she is walking with a leg brace, the tracheostomy has been removed , and her maxilla is well healed. Understandably, the patient has a pronounced malocclusion .
Discussion
FIGURE I. Right common carotid subtraction a rteriogram, lateral view, depicting a traumatic arteriovenous (A-V) fistula between the right internal carotid artery (lCA) and the right internal jugular vein (IJV). Contrast media was injected into the common carotid artery IA), traveled via the ICA (D) to the A-V fistula (C) at the base of the skull and was immediately shunted down the IJV (D).
An internal carotid artery hemorrhagic episode has never been reported as a complication of orthognathic surgery. Converse I reported several cases in which hemorrhage during maxillofacial osteotomies were secondary to maxillary artery trauma. Turvey' 'and Fonesca" report that the major source of severe hemorrhage during maxillary surgery is the maxillary artery. The reader is directed "to their excellent discussion of the anatomy of the pterygopalatine fossa. Also, reference is made to the design of posterior maxillary osteotomies and the proper use of osteotomes for pterygomaxillary dysjunction." Posterior maxillary anatomy would suggest that osteotomies directed inferiorly into the pterygomaxillary junction are at significantly less risk of major hemorrhage. Thus, once clear of the second molar root apices, one should try to angle the posterior lateral maxillary' osteotomy low into the pterygomaxillary fissure. If the situation allows, the osteotomy may be directed into the tuberosity and preclude manipulation further posteriorly. In this case, use of a reciprocating saw dictated a
FIGURE 2 tleft). Right verteb ral arteriogram, lateral view . Retrograde filling of the internal carotid artery (A) is seen via the circle of Willis indicating interruption of normal blood flow. FIGURE 3 tright), Left internal carotid arteriogram, anteroposterior view, demon strating flow to the right cerebral hemisphere (A) via the circle of Willis.
119
NEWHOUSE ET AL.
straight cut to the pterygoid plates and, in combination with an 8 mm ostectomy, categorically placed the superior cut well into the pterygopalatine fossa. Notably, profuse hemorrhage was not encountered during malleting of the pterygomaxillary junction, but only when the down fracture was effected. We speculate that with pterygomaxillary dysjunction the right pterygoid complex was detached, and a sharp bony edge was forced posteriorly, lacerating the vessels during down fracture manipulation. With the loss of a posterior point of stabilization for the maxilla (with fracture of the pterygoids from the sphenoid base), the entire pterygomaxillary complex was possibly forced posteriorly during the down-fracturing maneuver. Speculation on the mechanism of injury to nerves X and XII is also warranted. The nerves are in proximity to the involved vessels, situated medially and between them in the upper neck. The injury possibly occurred with maxillary down fracture, insertion of pressure packs, or during exposure for treatment of the A-V fistula. The last possibility is
unlikely, as the nerves were identified and protected during this procedure. The decision to treat the A-V fistula immediately can be credited with averting the further disaster of additional major hemorrhage. At surgery, the internaljugular vein was found dilated and near rupture. Conclusion
A unique complication of elective orthognathic surgery has been reported, This case demonstrates that even though most major hemorrhagic episodes during midfacial surgery are due to maxillary artery trauma the possibility of internal carotid artery hemorrhage is a possible complication. References I. Converse JM, Wood-Smith 0, McCarthy JG: Report on a
series of 50 craniofacial operations. Plast Reconstr Surg 55:283-293, 1975 2. Turvey TA, Fonseca RJ: The anatomy of the internal maxillary artery in the pterygopalatine fossa: its relationship to maxillary surgery. J Oral Surg 38:92-95, 1980
A Large Dentigerous Cyst Associated with a Supernumerary Tooth DOUGLAS S. MOST, DDS,* AND EDWARD P. ROY, DMDt Dentigerous cysts are a common pathologic entity. However, when associated with a supernumerary tooth, they are not common. Our report is unusual because it demonstrates a dentigerous cyst associated with a supernumerary tooth (central incisor) that involved both maxillary sinuses. Our search of the English language literature of the past ten years failed to reveal a similar case. Report of a Case A 30-year-old oriental man, well developed and well nourished, reported pain in the mandibular right third molar area and swelling of the right maxillary mucogingival fold area. Examination revealed a mesioangular mandibular right third molar and an obvious swelling of the buccal aspect of the alveolus in the maxillary right quadrant, with some obliteration of the mucogingival fold. Upon palpation, there was obvious movement of the un-
* Oral and maxillofacial surgeon in private practice. t General practitioner in private practice. Address correspondence and reprint requests to Dr. Douglas Most: Parkview Professional Building, Brunswick, ME 04011.
derlying cortical bone from the second molar to the canine. This entire quadrant was asymptomatic. All of the maxillary teeth were vital; none were missing. A panoramic radiograph (Fig. 1) revealed a large radiolucency that apparently occupied the entire right antrum, extended across the midline, and occupied approximately one half of the left antrum. A radiopaque toothlike structure was noted just to the left of midline. Additional radiographs (posteroanterior, lateral, and Waters' views) were obtained. The Waters' view (Fig. 2) confirmed the extent of the lesion and revealed destruction of the right lateral walJ of the sinus. The patient was hospitalized, and, while he was under general anesthesia, we performed the folJowing procedure. A full-thickness mucoperiosteal flap was raised extending from the right tuberosity area, across midline, to the distal aspect of the maxillary left first premolar. The incision followed the gingival sulcus. The underlying cortical plate in the right maxillary region was bulging. Using a curette and ronguers, we removed this thin bony plate. Immediately adjacent to the bone was a "sac/ike" lining. Decortication was performed from the maxillary right second molar to the maxillary right canine. Approximately 1 ern of sound alveolar bone was left intact to insure support of the teeth. The cyst was inadvertently ruptured, and copious amounts of thick brown material
0278-2391/82/0200'0119 SOO.4O © American Association of Oral and Maxillofacial Surgeons
Life-threatening Hemorrhage from a Le Fort I Osteotomy RICNEY F. NEWHOUSE, LT COL, DC, DMD,* STERLING R. SCHOW, LT COL, DC, DMD,t RICHARD A. KRAUT, LT COL, DC, DDS,:f: AND JOHN C. PRICE, LT COL, MC, MD§ Severe hemorrhage associated with orthognathic surgery rarely occurs. When a significant episode happens, it can usually be attributed to the maxillary artery or one of its branches. Damage to the internal carotid artery and subsequent life-threatening hemorrhage during an orthognathic procedure has never been previously reported.
ligated. This was accomplished without obvious decrease in the bleeding. Bilateral packing of the maxillary antra and pterygopalatine fossas combined with wire stabilization of the maxilla ultimately controlled the hemorrhage. The estimated blood loss to this point was 10,500 ml. The patient was transferred to the surgical intensive care unit (SICD). A loud S3 secondary to fluid overload developed. A complete blood count showed a hematocrit value of 48%. The patient was responsive to verbal commands and neurologically intact. On the first postoperative day, she was essentially stable except for repeated temperature spikes thought to be due to the pressure packs. Arrangements were made to transfer the patient to Brooke Army Medical Center (BAMC) for angiographic studies before removal of the packs. The patient with a nasoendotracheal tube in place was transferred by helicopter. En route, the patient's nasocndotracheal tube became disconnected and displaced into the nasopharynx. On arrival at BAMC, she was cyanotic and in respiratory distress. An arterial blood gas determination at that time revealed a P0 2 of 32 torr. Following reconnection of the nasoendotracheal tube, the SICD staff noted that the patient was moving only her right side, and that copious tracheal secretions were being produced. Since her respiratory status did not improve. a tracheostomy was done to gain adequate control of the airway. Angiography was performed to determine the source of hemorrhage and to establish a reasonable approach to control recurrent bleeding before the removal of the packing material. Angiography revealed a traumatic arteriovenous (A-V) fistula involving the right internal carotid artery and internal jugular vein at the base of the skull (Fig. I). No intracranial flow could be seen from the right internal carotid artery. but collateral supply of the right cerebral hemisphere was observed from the left side (Figs. 2 and 3). The surgeons now faced a dilemma: further surgery to repair the fistula or observation in light of the patient's questionable neurologic status. The possibility of major recurrent hemorrhage at an inopportune time and/or septicemia from the packs prompted a decision to operate. Thus, shortly after the diagnosis of a traumatic A-V fistula, the patient underwent a neck exploration to ligate the internal carotid artery and obliterate the jugular foramen with a muscle graft. Following this, the maxilla was mobilized. the packs were removed, and the maxilla was restabilized. This was accompanied with minimal hemorrhage. The surgeons noted that the right pterygoid plates were completely separated from the sphenoid base as well as the maxilla. The patient had an essentially stable postoperative course but retained a dense left hemiparesis. Addition-
Report of a Case On July 29, 1980, a healthy 32-year-old white woman was admitted to the Oral and Maxillofacial Surgery Service of another hospital for correction of vertical maxillary excess and mandibular retrognathia. This was to be accomplished via Le Fort I osteotomy and mandibular autorotation. The review of systems, past medical history, and past surgical history was noncontributory. Physical examination was significant for vertical maxillary excess, increased lower facial height, mandibular retrognathia, and lip incompetence. The remainder of her examination was unremarkable. On July 30, 1980, the patient was taken to the operating room, where. under general nasoendotracheal anesthesia. a Le Fort I osteotomy was accomplished by incorporating a bilateral 8 mm ostectomy posteriorly and a bilateral 6 mm ostectomy anteriorly. The osteotomies were made with a reciprocating saw. The lateral nasal walls and nasal septum were sectioned with a forked nasal gouge and the bilateral pterygomaxillary dysjunction was effected with a curved osteotome. No significant bleeding was encountered to this time. Manipulation of the maxilla into a down-fractured position was attended with profuse arterial hemorrhage from the right posterior region. Attempts to visualize the source of the bleeding were unsuccessful. Immediate measures to stabilize the patient included multiple arterial and venous cutdowns, infusion of 15 units of packed erythrocytes, two units of autologous whole blood, four units of plasmanate, and four units of fresh frozen plasma. The right external carotid artery was
* Chief Resident,
Oral and Maxillofacial Surgery Service. t Chief, Oral and Maxillofacial Surgery Service. :j: Assistant Chief, Oral and Maxillofacial Surgery Service. § Chief, Head and Neck Surgery. Received from the Oral and Maxillofacial Surgery Service, Brooke Army Medical Center, Fort Sam Houston, Texas. Address correspondence and reprint requests to Dr. Newhouse. The opinions or assertions contained herein are thc private views of the authors and are not to be construed as reflecting the views of the Department of the Army or Department of Defense. 0278-2391/82'0200'0117 SOO.6O
© American Association of Oral and Maxillofacial Surgeons
117
ally, it was noted that cranial nerves X and XII had been injured during the initial procedures. Now, three months status after complication, she is walking with a leg brace, the tracheostomy has been removed , and her maxilla is well healed. Understandably, the patient has a pronounced malocclusion .
Discussion
FIGURE I. Right common carotid subtraction a rteriogram, lateral view, depicting a traumatic arteriovenous (A-V) fistula between the right internal carotid artery (lCA) and the right internal jugular vein (IJV). Contrast media was injected into the common carotid artery IA), traveled via the ICA (D) to the A-V fistula (C) at the base of the skull and was immediately shunted down the IJV (D).
An internal carotid artery hemorrhagic episode has never been reported as a complication of orthognathic surgery. Converse I reported several cases in which hemorrhage during maxillofacial osteotomies were secondary to maxillary artery trauma. Turvey' 'and Fonesca" report that the major source of severe hemorrhage during maxillary surgery is the maxillary artery. The reader is directed "to their excellent discussion of the anatomy of the pterygopalatine fossa. Also, reference is made to the design of posterior maxillary osteotomies and the proper use of osteotomes for pterygomaxillary dysjunction." Posterior maxillary anatomy would suggest that osteotomies directed inferiorly into the pterygomaxillary junction are at significantly less risk of major hemorrhage. Thus, once clear of the second molar root apices, one should try to angle the posterior lateral maxillary' osteotomy low into the pterygomaxillary fissure. If the situation allows, the osteotomy may be directed into the tuberosity and preclude manipulation further posteriorly. In this case, use of a reciprocating saw dictated a
FIGURE 2 tleft). Right verteb ral arteriogram, lateral view . Retrograde filling of the internal carotid artery (A) is seen via the circle of Willis indicating interruption of normal blood flow. FIGURE 3 tright), Left internal carotid arteriogram, anteroposterior view, demon strating flow to the right cerebral hemisphere (A) via the circle of Willis.
119
NEWHOUSE ET AL.
straight cut to the pterygoid plates and, in combination with an 8 mm ostectomy, categorically placed the superior cut well into the pterygopalatine fossa. Notably, profuse hemorrhage was not encountered during malleting of the pterygomaxillary junction, but only when the down fracture was effected. We speculate that with pterygomaxillary dysjunction the right pterygoid complex was detached, and a sharp bony edge was forced posteriorly, lacerating the vessels during down fracture manipulation. With the loss of a posterior point of stabilization for the maxilla (with fracture of the pterygoids from the sphenoid base), the entire pterygomaxillary complex was possibly forced posteriorly during the down-fracturing maneuver. Speculation on the mechanism of injury to nerves X and XII is also warranted. The nerves are in proximity to the involved vessels, situated medially and between them in the upper neck. The injury possibly occurred with maxillary down fracture, insertion of pressure packs, or during exposure for treatment of the A-V fistula. The last possibility is
unlikely, as the nerves were identified and protected during this procedure. The decision to treat the A-V fistula immediately can be credited with averting the further disaster of additional major hemorrhage. At surgery, the internaljugular vein was found dilated and near rupture. Conclusion
A unique complication of elective orthognathic surgery has been reported, This case demonstrates that even though most major hemorrhagic episodes during midfacial surgery are due to maxillary artery trauma the possibility of internal carotid artery hemorrhage is a possible complication. References I. Converse JM, Wood-Smith 0, McCarthy JG: Report on a
series of 50 craniofacial operations. Plast Reconstr Surg 55:283-293, 1975 2. Turvey TA, Fonseca RJ: The anatomy of the internal maxillary artery in the pterygopalatine fossa: its relationship to maxillary surgery. J Oral Surg 38:92-95, 1980
A Large Dentigerous Cyst Associated with a Supernumerary Tooth DOUGLAS S. MOST, DDS,* AND EDWARD P. ROY, DMDt Dentigerous cysts are a common pathologic entity. However, when associated with a supernumerary tooth, they are not common. Our report is unusual because it demonstrates a dentigerous cyst associated with a supernumerary tooth (central incisor) that involved both maxillary sinuses. Our search of the English language literature of the past ten years failed to reveal a similar case. Report of a Case A 30-year-old oriental man, well developed and well nourished, reported pain in the mandibular right third molar area and swelling of the right maxillary mucogingival fold area. Examination revealed a mesioangular mandibular right third molar and an obvious swelling of the buccal aspect of the alveolus in the maxillary right quadrant, with some obliteration of the mucogingival fold. Upon palpation, there was obvious movement of the un-
* Oral and maxillofacial surgeon in private practice. t General practitioner in private practice. Address correspondence and reprint requests to Dr. Douglas Most: Parkview Professional Building, Brunswick, ME 04011.
derlying cortical bone from the second molar to the canine. This entire quadrant was asymptomatic. All of the maxillary teeth were vital; none were missing. A panoramic radiograph (Fig. 1) revealed a large radiolucency that apparently occupied the entire right antrum, extended across the midline, and occupied approximately one half of the left antrum. A radiopaque toothlike structure was noted just to the left of midline. Additional radiographs (posteroanterior, lateral, and Waters' views) were obtained. The Waters' view (Fig. 2) confirmed the extent of the lesion and revealed destruction of the right lateral walJ of the sinus. The patient was hospitalized, and, while he was under general anesthesia, we performed the folJowing procedure. A full-thickness mucoperiosteal flap was raised extending from the right tuberosity area, across midline, to the distal aspect of the maxillary left first premolar. The incision followed the gingival sulcus. The underlying cortical plate in the right maxillary region was bulging. Using a curette and ronguers, we removed this thin bony plate. Immediately adjacent to the bone was a "sac/ike" lining. Decortication was performed from the maxillary right second molar to the maxillary right canine. Approximately 1 ern of sound alveolar bone was left intact to insure support of the teeth. The cyst was inadvertently ruptured, and copious amounts of thick brown material
0278-2391/82/0200'0119 SOO.4O © American Association of Oral and Maxillofacial Surgeons