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Prevention and management of bad splits in sagittal split osteotomies
Symposia
ANESTHESIA MANAGEMENT: WHAT WOULD YOU DO WITH THIS PATIENT? Presented on Saturday, October 2, 2004, 8:00 am—10:00 am Moderator: Jefferey Dembo, DDS, Lexington, KY (no abstract provided)
SYMPOSIUM ON PREVENTION AND MANAGEMENT OF ORTHOGNATHIC SURGERY COMPLICATIONS Presented on Saturday, October 2, 2004, 9:00 am—11:00 am Moderator: Roger A. West, DMD, Seattle, WA
Prevention and Management of Bad Splits in Sagittal Split Osteotomies
Prevention and Management of Vascular Necrosis in Le Fort I Osteotomies
Myron R. Tucker, DDS, Charlotte, NC
Johan P. Reyneke, MChD, FCMFOS(SA), Rivonia, South Africa
The bilateral sagittal ramus osteotomy (BSRO) has become the procedure most frequently performed by oral and maxillofacial surgeons for correction of mandibular deformities. A variety of complications may be encountered while performing the actual separation of the proximal and distal segments of the mandible resulting in unanticipated fractures or “bad splits.” These unanticipated fractures can be classified into the following four groups: (1) proximal segment fractures, mandible intact without adequate bone for sagittal overlap, (2) proximal segment fracture, adequate bone for sagittal overlap, (3) proximal segment fracture, mandible separated, and (4) lingual segment fractures. Prevention is focused on adequate osteotomy design, eliminating sharp angle where abnormal stress occurs on bony segments, completion of adequate cuts into the retrolingular depression and through the inferior border, and careful separation of the segments. If a fracture occurs, fractured segments should be reconsolidated if possible. The segments should be rigidly fixated whenever possible providing stable continuity between the most proximal portion of the mandible and the distal segment. Fractured segments should be incorporated into the fixation scheme to avoid unfavorable post surgical positional changes. In some cases grafting may be required. References Tucker MR, Ochs MW: Use of rigid internal fixation for management of intraoperative complications of mandibular sagittal split osteotomy. Int J Adult Orthop Orthog Surg 3:71, 1988 Van Sickels JE, Tucker MR: Complications of orthognathic surgery, in Peterson LJ (ed): Principles of Oral and Maxillofacial Surgery. Philadelphia, PA, JB Lippincott, 1992 Sinclair PM, Thomas PM, Tucker MR: Common complications in orthognathic surgery: Etiology and management, in Bell WH (ed): Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992
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In most of the orthognathic procedures that are performed to correct dentofacial deformities, the vascular supply to hard and soft tissues is manipulated. This also holds true when performing the Le Fort I down fracture procedure. Excellent work on revascularization, wound healing, and quantification of pre- and postoperative blood flow in rhesus monkeys has improved our knowledge of the biological basis for undertaking maxillary osteotomies. We however still do not completely understand the alteration of the hemodynamics. In fact, despite various modifications in the design of bony and soft tissue incisions during surgery, vascular necrosis remains a rare, but real complication. Once the maxilla is down fractured the maxillary hard and soft tissues are dependent on its blood supply from the palatal and posterior buccal soft tissue pedicles. The blood flow through these pedicles could be influenced by the following: 1. Stretching of the pedicle by significant dentoosseous repositioning 2. Multiple segmentalization of the maxilla 3. Routine transection or ligation of the descending palatine artery 4. Significant transverse palatal expansion 5. Transverse laceration of the palatal soft tissue 6. Compression of the palatal soft tissue 7. Palatal soft tissue scaring, ie, previous surgery in cleft palate patients 8. Hypotensive anesthesia By adhering to sound surgical principles the risk of vascular necrosis may not be eliminated, but significantly reduced. The surgeon should always be alert for initial signs of vascular compromise. Initial treatment of vascular necrosis should involve good oral hygiene, frequent saline irrigation, hyperbaric oxygen therapy, and antibiotics to prevent secondary AAOMS • 2004
ANESTHESIA MANAGEMENT: WHAT WOULD YOU DO WITH THIS PATIENT? Presented on Saturday, October 2, 2004, 8:00 am—10:00 am Moderator: Jefferey Dembo, DDS, Lexington, KY (no abstract provided)
SYMPOSIUM ON PREVENTION AND MANAGEMENT OF ORTHOGNATHIC SURGERY COMPLICATIONS Presented on Saturday, October 2, 2004, 9:00 am—11:00 am Moderator: Roger A. West, DMD, Seattle, WA
Prevention and Management of Bad Splits in Sagittal Split Osteotomies
Prevention and Management of Vascular Necrosis in Le Fort I Osteotomies
Myron R. Tucker, DDS, Charlotte, NC
Johan P. Reyneke, MChD, FCMFOS(SA), Rivonia, South Africa
The bilateral sagittal ramus osteotomy (BSRO) has become the procedure most frequently performed by oral and maxillofacial surgeons for correction of mandibular deformities. A variety of complications may be encountered while performing the actual separation of the proximal and distal segments of the mandible resulting in unanticipated fractures or “bad splits.” These unanticipated fractures can be classified into the following four groups: (1) proximal segment fractures, mandible intact without adequate bone for sagittal overlap, (2) proximal segment fracture, adequate bone for sagittal overlap, (3) proximal segment fracture, mandible separated, and (4) lingual segment fractures. Prevention is focused on adequate osteotomy design, eliminating sharp angle where abnormal stress occurs on bony segments, completion of adequate cuts into the retrolingular depression and through the inferior border, and careful separation of the segments. If a fracture occurs, fractured segments should be reconsolidated if possible. The segments should be rigidly fixated whenever possible providing stable continuity between the most proximal portion of the mandible and the distal segment. Fractured segments should be incorporated into the fixation scheme to avoid unfavorable post surgical positional changes. In some cases grafting may be required. References Tucker MR, Ochs MW: Use of rigid internal fixation for management of intraoperative complications of mandibular sagittal split osteotomy. Int J Adult Orthop Orthog Surg 3:71, 1988 Van Sickels JE, Tucker MR: Complications of orthognathic surgery, in Peterson LJ (ed): Principles of Oral and Maxillofacial Surgery. Philadelphia, PA, JB Lippincott, 1992 Sinclair PM, Thomas PM, Tucker MR: Common complications in orthognathic surgery: Etiology and management, in Bell WH (ed): Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992
14
In most of the orthognathic procedures that are performed to correct dentofacial deformities, the vascular supply to hard and soft tissues is manipulated. This also holds true when performing the Le Fort I down fracture procedure. Excellent work on revascularization, wound healing, and quantification of pre- and postoperative blood flow in rhesus monkeys has improved our knowledge of the biological basis for undertaking maxillary osteotomies. We however still do not completely understand the alteration of the hemodynamics. In fact, despite various modifications in the design of bony and soft tissue incisions during surgery, vascular necrosis remains a rare, but real complication. Once the maxilla is down fractured the maxillary hard and soft tissues are dependent on its blood supply from the palatal and posterior buccal soft tissue pedicles. The blood flow through these pedicles could be influenced by the following: 1. Stretching of the pedicle by significant dentoosseous repositioning 2. Multiple segmentalization of the maxilla 3. Routine transection or ligation of the descending palatine artery 4. Significant transverse palatal expansion 5. Transverse laceration of the palatal soft tissue 6. Compression of the palatal soft tissue 7. Palatal soft tissue scaring, ie, previous surgery in cleft palate patients 8. Hypotensive anesthesia By adhering to sound surgical principles the risk of vascular necrosis may not be eliminated, but significantly reduced. The surgeon should always be alert for initial signs of vascular compromise. Initial treatment of vascular necrosis should involve good oral hygiene, frequent saline irrigation, hyperbaric oxygen therapy, and antibiotics to prevent secondary AAOMS • 2004