JOURNAL CLUB
Presented By- Dr Abdul Qahar Qureshi
Major Vascular Complications ofOrthognathic Surgery:
Hemorrhage Associated With LeFort I Osteotomies
Impact Factor-1.47 Cited by - 137
J Oral Maxillofac Surg 48:561·573. 1990
DENNIS T. LANIGAN, JULIANA H.HEY, ROGER A.
Vascular Supply of Maxillary region
INTRODUCTION
Introduction Major hemorrhage associated with Le Fort I osteotomies
Is an infrequent complication in a great number of these operations performed.
Nature of Intraoperative or postoperative hemorrhage can be :
• Venous
• Arterial
• Both
Venous • Source - Pterygoid plexus
Arterial• It is more persistent and may be recurrent postoperatively• Management is difficult• Source – maxillary artery-terminal branches especially
descending palatine / spheno-palatine• Cause – use of osteotome to separate maxillary tuberosity
from pterygoid plates or during downfracture procedure
Postoperative bleeding following LeFort I osteotomies generally presents as epistaxis and usually occurs initially within the first 2 weeks following surgery
Patient with craniofacial malformation are more susceptible to this complication.
Other vessels that may be damaged:• Posterior superior alveolar artery• Descending palatine artery (more commonly involved)
Descending palatine artery gets damaged during
• Pterygomaxillary dysjunction & downfracture procedures
• Horseshoe shaped palatal osteotomy
• Posterior maxillary surgery • Total maxillary alveolar procedure
• Lack of visualization
Down fracture procedure
Material and Methods
Material and Methods
RESULTS
Results
Conventional Le Fort I osteotomy, without segmentation, is highly safe for the correction of deformities involving the maxilla
Preservation of descending palatine arteries does not seem to be determinant to vascular blood flow to the osteotomized maxilla, except in the presence of other unfavourable factors
The occurrence of ischemic complications is more frequent in segmented surgery, mainly when associated with ligature of the descending palatine arteries and with movements such as superior repositioning, transverse expansion and advancement
More studies are needed to evaluate vascular complications in patients with facial asymmetry.
DISCUSSION
Discussion Causes of Major intraoperative haemorrhage:
• mechanical disruption of blood vessels or problem of haemostasis from inadequate platelet function or coagulopathy
• Ingestion of aspirin or aspirin-containing cold medicines results in generalized oozing
Intraoperative venous haemorrhage can usually be managed by pressure packing, whereas
arterial bleeding can usually be controlled by
• clamping the vessel and• using electrocoagulation or • haemoclips
Management
Management Visualization of problem area
Assess the general condition of patient
Monitoring of vital signs
Completion of osteotomy to allow application of direct pressure , vascular clips or electro cautery
Anterior or posterior nasal packing
Packing of maxillary antrum
Use of topical haemostatic agents in the pterygomaxillary region
External carotid artery ligation
Selective embolization of the maxillary artery and its terminal branches
Intravascular fluids & blood transfusion
Deliberate controlled hypotension
Management
Use of bilateral large Foley catheters as posterior nasal packs during active brisk bleeding
Use of commercial balloon catheters for anterior & posterior nasal packing
Use of Frazier suction tip for suctioning nose reveals whether bleeding is arterial or venous
For minor bleeding advice patient on• Bed rest• mild sedation and• observation
For brisk bleeding • Anterior & posterior nasal packs for 3-5 days• supplemental oxygen by mask to prevent systemic problems such
as hypoxia or hypercapnea
Note : nasal packing can lead to mucosal excoriation, necrosis or infection
Management
Angiography and embolization may be preferred when haemorrhage occurs early or recurrent later in the postoperative phase
Transantral ligation of maxillary artery & its branches for controlling epistaxis
Note : Complications reported from transantral ligation of the maxillary artery include blindness and ophthalmoplegia
Investigations
Investigations At the time of bleeding
• Complete blood count, for typing and cross match
• Coagulation studies
• Angiograms will also rule out whether a ruptured pseudo aneurysm of the maxillary artery or one of its terminal branches, especially the sphenopalatine artery , could be the cause of the problem
Advice
Avoid heavy physical activity, either through work or exercise during the first month postoperatively
Avoid raising their blood pressure via a Valsalva manoeuvre such as straining while passing a stool by using stool softeners
Maxillary perfusion after ligation of descending palatine artery
Le Fort 1 OsteotomyJ Oral Maxillofac Surg 55:51-55, 1997
THOMAS B. DODSON, ROBERT A. BAYS AND MICHAEL C. NEUENSCHWANDER
Impact Factor-1.47 Cited by – 104
INTRODUCTION
Introduction Complications of lefort 1 osteotomy:
Postoperative haemorrhage
• It is rare but life threatening• Source of bleeding is descending palatine artery
• Descending palatine artery (DPA) should be preserved by ligating for preventing the above complications
Introduction
DPA ligation is done for the following reasons:
• Optimization of maxillary vascular integrity and
• Decreases the risk of ischemic necrosis
• Facilitates mobilization of the maxilla
• Decreases the risk of uncontrolled postoperative bleeding caused by a lacerated DPA
IntroductionNote:
Note: Risk of vascular complications associated with ligating the vessel is minimal because of adequate collateral circulation
Lacerated non ligated DPA
Excessive bleeding
& hypotens
ion
Compromise
maxillary
perfusion
MATERIAL & METHODS
Materials & Methods
• This is prospective randomized clinical study,they enrolled a study sample composed of 34 patients undergoing Le Fort I osteotomy. The patients were randomly assigned to either study group 1 (16) (DPA ligated) or group 2 (18) (DPA preserved).
Laser Doppler flowmetry (LDF) was used to measure maxillary gingival blood flow (GBF) during Le Fort I osteotomy.
Materials & Methods
RESULTS
Results
Before ligation (or simulated ligation) of the DPA, the mean GBF for groups 1 and 2 was 11.4 to 8.6 and 11.9 to 9.4 mL/min/ 100 g tissue, respectively (P = .88)
After ligation of the DPA in group 1, the mean GBF was 10.0 -+ 7.7 mL/min/lOO g tissue.
At the corresponding time in group 2 (DPA preserved), the mean GBF was 12.6 t 9.4 mL/min/ 100 g tissue.
The difference in mean GBF between groups 1 and 2 was not statistically significant
DISCUSSION
Discussion
The purpose of this study was to detect the effect of ligating the DPA on maxillary GBF during Le Fort I osteotomy by measuring anterior maxillary GBF using LDF in two samples of patients randomized to ligation or preservation of the DPA
The results of this study suggest that ligation of the DPA was not associated with a change in anterior maxillary GBF during Le Fort I osteotomy.
Discussion Because preservation of the DPA does not optimize
perfusion, but
• may increase the risk of postoperative hemorrhage,• lengthen surgery time, and • restrict anterior repositioning of the maxilla
The results of this study demonstrate that ligation of the DPA had no measurable effect on anterior maxillary GBF during Le Fort I osteotomy.
VASCULAR CONSIDERATIONS IN THE LEFORT I
OSTEOTOMY:: results of analysis of 16 cases
Rev. Clín. Pesq. Odontol., Curitiba, v. 5, n. 2, p. 165-173, maio/ago. 2009
Ophir Ribeiro Júniora, Alexandre Meireles Borbaa, Celso Luiz Ferrazb, Jayro Guimarães Júniorc
INTRODUCTION
Introduction • Ischemic complications of le fort 1 which can
compromise the descending palatine arteries include:
• Dehiscence
• Periodontal defects
• Teeth devitalisation
• Non union and
• Partial or complete loss of the maxilla
MATERIALS & METHODS
MATERIALS AND METHODS
• A clinical analysis of 16 cases was submitted to this osteotomy, evaluating bone healing in situations such as ligature of the descending palatine artery, bone segmentation and different types of surgical movement.
MATERIALS AND METHODS
MATERIALS AND METHODS
MATERIALS AND METHODS
MATERIALS AND METHODS
MATERIALS AND METHODS
RESULTS
• Mild complications occurred in two patients who had osteotomies in two places. Both had ligature of the palatine descending arteries and superior repositioning with impaction of the posterior maxilla greater than 4 mm.
Results
Results
Results
DISCUSSION
Discussion
Principles for the Le Fort I osteotomy are based on anatomic and surgical techniques
Aim is to maintain the soft tissue pedicle and thereby the blood supply of bone tissue
Surgical approach includes limiting the incision up to the first molars bilaterally and not detaching the gingival mucosa
Discussion
By cutting the posterior superior alveolar and the nasopalatine arteries through the osteotomies of the lateral part of the maxilla and the nasal septum, the blood supply to the bone then comes from the descending palatine artery and from the microvasculature of the palate and the gingiva
Discussion
Transient ischemic period
• This period is responsible for most of the ischemic sequel by a vascular proliferation that allows tissue healing.
• this period only compromises maxillary healing in the presence of other complication factors such as
the magnitude and direction of the surgical movement multiple segmentations and the presence of underlying vascular compromise
Discussion Controversies related in maintaining the descending
palatine arteries are:
• Preserving the descending palatine arteries increases postoperative bleeding risks due to possible laceration of their walls
• But their preservation optimizes healing and diminishes the risk of tissue necrosis
Discussion
Note: when the descending palatine arteries were ligated a drastic reduction of total maxillary blood flow was observed
• The palatine pedicle is enough for the blood supply of the maxilla
Discussion
In the absence of descending palatine arteries, the collateral microvasculature from other arteries maintains viability of this pedicle up to revascularization of the severed bone areas
Collateral microvasculature includes:
• Ascending pharyngeal artery • Facial artery
Discussion Possible causes for such complications:
• Relationship between Bone segmentation & some surgical movements
• Ligature or lesion of DPA
Note: Complications affects mostly the anterior region of maxilla
Modified incisions maintaining an additional pedicle in the anterior region are proposed to minimize complications in segmented osteotomies
Discussion Factors contributing to this include
• Bone marrow lesions causing diminished blood supply to
pedicle
• Type of incision
• Number of bone segments
• Ligature of the descending palatine arteries
• Amount of bone teeth repositioning,
• lesion of the vascular pedicle
• and hypotensive anaesthesia
Discussion Surgical movements include
• stretching,• compression or • laceration of the palatine pedicle
Movements more associated with the development of ischemic sequelae are:
• Superior repositioning• Advance• Expansion, in particular when the maxilla is segmented
Conclusions
Conventional Le Fort I osteotomy, without segmentation, is highly safe for the correction of deformities involving the maxilla
Preservation of descending palatine arteries does not seem to be determinant to vascular blood flow to the osteotomized maxilla, except in the presence of other unfavourable factors
Conclusions The occurrence of ischemic complications is more frequent
in segmented surgery, mainly when associated with ligature of the descending palatine arteries and with movements such as superior repositioning, transverse expansion and advancement
More studies are needed to evaluate vascular complications in patients with facial asymmetry
Procedure of Lefort 1 Osteotomy