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