XXI Oral and Maxillofacial Surgery Brazilian XXI Oral and Maxillofacial Surgery Brazilian Congress Congress

Vitória, ES, BrazilVitória, ES, Brazil

““Unintended Unintended ““Unintended Unintended consequencesconsequences

-- can we curb them?” can we curb them?” peter ward booth fds frcs peter ward booth fds frcs

I’ll start at the “end” !I’ll start at the “end” !•• Orthognathic surgery is Orthognathic surgery is highly effective:highly effective:••Patient satisfactionPatient satisfaction••Cost effectiveCost effective••Cost effectiveCost effective

•• Br J Oral Maxillofac Surg. 1996 Jun;34(3):210Br J Oral Maxillofac Surg. 1996 Jun;34(3):210--3. Perceptions of outcome following orthognathic surgery.3. Perceptions of outcome following orthognathic surgery.•• Cunningham SJ, Hunt NP, Feinmann C Cunningham SJ, Hunt NP, Feinmann C

•• Int J Adult Orthodon Orthognath Surg. 2001;16(2):99Int J Adult Orthodon Orthognath Surg. 2001;16(2):99--107.107.•• Patient satisfaction following orthognathic surgical correction of skeletal Class III malocclusion.Patient satisfaction following orthognathic surgical correction of skeletal Class III malocclusion.•• Zhou YH, Hägg U, Rabie AB.Zhou YH, Hägg U, Rabie AB.

•• J Oral Maxillofac Surg. 2008 Oct;66(10):2110J Oral Maxillofac Surg. 2008 Oct;66(10):2110--5.5.•• Recovery after orthognathic surgery: shortRecovery after orthognathic surgery: short--term healthterm health--related quality of life outcomes.related quality of life outcomes.•• Phillips C, Blakey G 3rd, Jaskolka M.Phillips C, Blakey G 3rd, Jaskolka M.

Unintended consequences in Unintended consequences in orthognathic surgeryorthognathic surgery

•• Surgical Surgical misadventuresmisadventuresmisadventuresmisadventures

•• Disappointing Disappointing outcomesoutcomes

Surgical “misadventure”Surgical “misadventure”

•• A polite expression for a A polite expression for a surgical “mistake” !surgical “mistake” !

•• It may happen with traineesIt may happen with trainees•• It may happen on a “bad” dayIt may happen on a “bad” day•• But it should not happen at allBut it should not happen at all

preventionprevention•• “high volume” surgeons get “high volume” surgeons get better results & less better results & less complicationscomplications–– In UK: cleft surgeons must treat 40 In UK: cleft surgeons must treat 40 –– In UK: cleft surgeons must treat 40 In UK: cleft surgeons must treat 40 new babies per yearnew babies per year

•• also includes anaesthetists and also includes anaesthetists and orthodontistsorthodontists

Disappointing outcomesDisappointing outcomes

•• These are mainly poor aesthetic These are mainly poor aesthetic outcomesoutcomes

•• Also:Also:––Surgical complicationsSurgical complications–– instabilityinstability

Some key “outcomes”Some key “outcomes”•• Final aestheticsFinal aesthetics

••Did the patient/surgeon like the Did the patient/surgeon like the result?result?

•• Surgical complicationsSurgical complications••Were they significant for the patient?Were they significant for the patient?

•• StabilityStability

Some key “outcomes”Some key “outcomes”

•• Final aestheticsFinal aesthetics••How did the patient like the result?How did the patient like the result?

Poor aestheticsPoor aesthetics

•• Usually planning errorsUsually planning errors•• Usually planning errorsUsually planning errors

Is this good planning?Is this good planning?

I don’t think so ! I don’t think so !

The orthodontist felt his result was The orthodontist felt his result was very good very good

––but do we sometimes but do we sometimes also forget the also forget the

soft tissue?soft tissue?

Most trainees will spot the AOB & Most trainees will spot the AOB & long facelong face-- but ears and eyes?but ears and eyes?

Another planning errorAnother planning error

•• A “push back” A “push back” genioplastygenioplasty

•• Ptosis of chinPtosis of chin

•• Flat “witches” Flat “witches” chinchin

The planning processThe planning process

•• Decide the ideal aestheticsDecide the ideal aesthetics

•• The orthodontics & surgery adapt The orthodontics & surgery adapt to that ideal to that ideal

•• The orthodontics & surgery adapt The orthodontics & surgery adapt to that ideal to that ideal

••not the other way round !not the other way round !

Patients concerns are Patients concerns are paramountparamount

•• BUT…….BUT…….

•• Are their concerns Are their concerns •• Are their concerns Are their concerns realistic?realistic?

•• Can you help them?Can you help them?

The “team”The “team”•• specialist nursespecialist nurse•• surgeonsurgeon•• orthodontistorthodontist––maxillofacial technician with maxillofacial technician with ––maxillofacial technician with maxillofacial technician with special interestspecial interest

–– anaesthetists with special anaesthetists with special interestinterest

–– clinical psychologistclinical psychologist

But I suggest the team meets But I suggest the team meets early in the day! early in the day!

Planning from the patient is Planning from the patient is essentialessential

•• THENTHEN

–– Look at models to see if it possibleLook at models to see if it possible

–– Look at XLook at X--raysrays•• PathologyPathology••Orthodontic planningOrthodontic planning••Computer simulationComputer simulation

General assessmentGeneral assessment•• tall, shorttall, short

•• fat, thinfat, thin

•• male, femalemale, female•• male, femalemale, female

•• syndrome?syndrome?

•• other problemsother problems

Model surgery should:Model surgery should:

provide image of occlusionprovide image of occlusionprovide data about surgical provide data about surgical movementsmovements

CEPHALOMETRIC ANALYSISCEPHALOMETRIC ANALYSIS

Don’t plan from “numbers”!

33--D imaging can be helpful in D imaging can be helpful in many waysmany ways

33--D planningD planning

•• This is now availableThis is now available

•• A complete lecture?A complete lecture?•• A complete lecture?A complete lecture?•• ThreeThree--dimensional treatment planning of orthognathic surgery dimensional treatment planning of orthognathic surgery

in the era of virtual imaging.in the era of virtual imaging.••

•• Swennen GR, Mollemans W, Schutyser F.Swennen GR, Mollemans W, Schutyser F.•• J Oral Maxillofac Surg. 2009 Dec;67(12):2703J Oral Maxillofac Surg. 2009 Dec;67(12):2703

Assessing Surgery Outcome using Surface Shape AnalysisAssessing Surgery Outcome using Surface Shape Analysis

T. J. Hutton1, S. J. Cunningham1*, L. Winchester2, P. Ward-Booth2 and P. Hammond1

1Eastman Dental Institute, UCL, 256 Grays Inn Road, London WC1X 8LD2Queen Victoria Hospital, Holtye Road, East Grinstead, Sussex

University College LondonFor Oral Health Care Sciences

http://www.eastman.ucl.ac.uk

Eastman

Dental

Institute

A

B

A B

long face

class II class I class III

F C

D

E

DE

CF

short face

Soft tissues extremely Soft tissues extremely important yet hard to predictimportant yet hard to predict

Explain!Explain!

•• Good planning involves good Good planning involves good explanations to the patientsexplanations to the patients

––VerbalVerbal––VerbalVerbal

––WrittenWritten

–– visualvisual

Let’s look at some difficult Let’s look at some difficult areas & may be some areas & may be some

solutionssolutions

•• Avoiding unwanted nasal Avoiding unwanted nasal deformitydeformitydeformitydeformity

•• Commonly seen after maxillary Commonly seen after maxillary advancement/impactionadvancement/impaction

Over projection of the tipOver projection of the tipalmost “look down” her nose!almost “look down” her nose!

Impaction of maxillaImpaction of maxillanose too broad nose too broad –– tip elevatedtip elevated

nasal flarenasal flare•• cynch suturecynch suture

••changes the width changes the width of the alar of the alar basebaseONLYONLYONLYONLY

••Not permanentNot permanent

••Nose still looks Nose still looks “squashed”“squashed”

A solution?A solution?

•• Make the cuts “low”Make the cuts “low”

•• Remove bone from the nasal Remove bone from the nasal rimrim

Low le fort 1Low le fort 1

•• the cutthe cut

XS is XS is herehere

–– XS is XS is herehere

Remove bone from nasal rimRemove bone from nasal rim

•• remove bone from remove bone from around the pyriform around the pyriform rimrim

•• and see “daylight” and see “daylight” •• and see “daylight” and see “daylight” between alar basesbetween alar bases

nasal rim resectionnasal rim resection

•• minimal change in minimal change in nasal shape with nasal shape with 9mm 9mm advancementadvancement9mm 9mm advancementadvancement

minimal change in nasal minimal change in nasal shapeshape

Another unintended Another unintended consequenceconsequence

•• The low angle class II patientThe low angle class II patient

Too much chin projectionToo much chin projection

•• An unhappy An unhappy postpost--op patientop patient

•• Looks too Looks too aggressiveaggressive

Over projection of the chinOver projection of the chinin low angle Class II patientsin low angle Class II patients•• This is preventable!This is preventable!

–– 3 point landing3 point landing–– 3 point landing3 point landing

–– Change the occlusal plane Change the occlusal plane angleangle

––SubSub--apical apical

3 point landing3 point landing

Effect of 3 point landing on chin pointEffect of 3 point landing on chin point

Change the occlusal planeChange the occlusal plane

treated by rotation of occlusal treated by rotation of occlusal plane (biplane (bi--max.)max.)

SubSub--apical procedureapical procedure

•• Long tedious Long tedious operationoperation

•• Produces a Produces a step, which step, which fills the fills the labial grovelabial grove

Clefts have special problemsClefts have special problems

The problems to consider The problems to consider

––effect of speecheffect of speech

––stabilitystability

––aestheticsaesthetics

What are the risk factorsWhat are the risk factors

•• The size of the movement The size of the movement often neededoften needed

•• Excessive scar tissue Excessive scar tissue posteriorlyposteriorly

speechspeech

•• “good speech before good “good speech before good speech afterwards”speech afterwards”

•• distraction has changed that! distraction has changed that! ••2cms + are now possible2cms + are now possible

distraction & speechdistraction & speech

post distractionpost distraction

Stability remains a problemStability remains a problem

•• Relapse rates much higher Relapse rates much higher than non cleft patientsthan non cleft patients

•• Even distraction has not Even distraction has not overcome the tension in the overcome the tension in the scarred soft tissuesscarred soft tissues

aestheticsaesthetics

•• The problem of the nose with The problem of the nose with large advancements of the large advancements of the maxillamaxillamaxillamaxilla

•• Scarred upper lip adds to poor Scarred upper lip adds to poor aestheticsaesthetics

Le Fort 1 still left dropping tip Le Fort 1 still left dropping tip ––post tip graftpost tip graft

full face is less successfulfull face is less successful

Beware of asymmetriesBeware of asymmetries

•• Often “Pan Facial”Often “Pan Facial”––So correcting the chinSo correcting the chin––Highlights to upper facial Highlights to upper facial ––Highlights to upper facial Highlights to upper facial asymmetryasymmetry

•• Correct the Correct the chinchin

•• The mid face The mid face then more then more obviousobvious

We may also create our own We may also create our own asymmetries!asymmetries!

centrelines off to the right by 7mm

My error in the model surgery

I am grateful to I am grateful to Paul Thomas for these next Paul Thomas for these next

2 images2 images2 images2 images

transverse arch transverse arch asymmetries (yaw)asymmetries (yaw)

•• Difficult to Difficult to diagnose unless diagnose unless large large large large

•• Easily created Easily created during model during model surgerysurgery

Some key “outcomes”Some key “outcomes”

•• Surgical complicationsSurgical complications•• Surgical complicationsSurgical complications••How was the surgery for the patient?How was the surgery for the patient?

Surgical complicationsSurgical complications

•• ImmediateImmediate••AirwayAirway

––BleedingBleeding

––SwellingSwelling

bleedingbleeding

•• Intra operative measuresIntra operative measures

–– Hypotensive GAHypotensive GA–– Hypotensive GAHypotensive GA

–– Local Anesthetic with Local Anesthetic with vasoconstrictorvasoconstrictor

–– “head up” on operation table“head up” on operation table

Post Op. measuresPost Op. measures

•• Nurse uprightNurse upright•• Tranexamic acidTranexamic acid•• Ice packs Ice packs –– little valuelittle value•• Ice packs Ice packs –– little valuelittle value

swellingswelling

•• SteroidsSteroids

•• Operation typeOperation type•• Operation typeOperation type••Ice packs & arnica don’t Ice packs & arnica don’t help!!help!!

swellingswelling

•• steroids do helpsteroids do help••CT’s at 24, 72 hrs !!CT’s at 24, 72 hrs !!••60% (maxilla) 40% 60% (maxilla) 40% ••60% (maxilla) 40% 60% (maxilla) 40% (mandible) reduction(mandible) reduction. . AJOMS 1984AJOMS 1984Schaberg SJ, Stuller CB, Edwards SMSchaberg SJ, Stuller CB, Edwards SM

Swelling in floor of mouth Swelling in floor of mouth greatest riskgreatest risk

••SubSub--apical apical proceduresprocedures•• genioplastygenioplasty•• genioplastygenioplasty

swelling gets better swelling gets better

Longer term postLonger term post--op. op. complicationscomplications

•• Nerve damageNerve damage

“numbness”“numbness”

•• always follows a sagittal split?always follows a sagittal split?

Most vulnerable areasMost vulnerable areas

••Medial retractorMedial retractor

Most vulnerable areasMost vulnerable areas

••Close to cortexClose to cortex

what makes it worse?what makes it worse?

•• surgeon!surgeon!••ScrewsScrews worse than plates(Fujioka 2000)worse than plates(Fujioka 2000)••ScrewsScrews•• Plates Plates worse than wires Lemke worse than wires Lemke

•• patient's age (above 25?) patient's age (above 25?) 496 cases 40% overall Westermark 1999496 cases 40% overall Westermark 1999

What about distraction and What about distraction and numbness?numbness?

•• No good studiesNo good studies•• Animal studies suggest nerve Animal studies suggest nerve •• Animal studies suggest nerve Animal studies suggest nerve damage is present but minimaldamage is present but minimal

(Wang 2002)(Wang 2002)

“numbness”“numbness”

•• “Numb” but how important“Numb” but how important–– 32% numb but 3% “a problem” Panula 655 32% numb but 3% “a problem” Panula 655 ptspts

•• Leo Stassen’s presentation Leo Stassen’s presentation •• Leo Stassen’s presentation Leo Stassen’s presentation on patient’s “choice”on patient’s “choice”

Some key “outcomes”Some key “outcomes”

•• StabilityStability••How long did correction last?How long did correction last?

stabilitystability

•• Factors which cause Factors which cause instabilityinstability––Size of movementSize of movement––Size of movementSize of movement––DirectionDirection––Other factorsOther factors

Size of movementSize of movement

••Even if Even if this was a this was a non cleft non cleft ––non cleft non cleft ––instability instability can be can be expectedexpected

Size of movementSize of movement

•• size of movementsize of movement•• more than 7mm or more than 7mm or •• more than 7mm or more than 7mm or inferior inferior (Van Sickels (Van Sickels 1996 BJOMS)1996 BJOMS)

Direction increases Direction increases instabilityinstability

•• “Against” “Against” muscle pullmuscle pull••ForwardsForwards••ForwardsForwards••downwardsdownwards

Other factorsOther factors

•• FixationFixation•• AgeAge•• “pathology”“pathology”•• “pathology”“pathology”

Type of fixationType of fixation

•• at 5yrs.at 5yrs.••rigid fixation “stable”rigid fixation “stable”••wire 40% relapsewire 40% relapse••wire 40% relapsewire 40% relapse

••BUT overjet relapse is BUT overjet relapse is equalequal

•• Am J Orthod Dentofacial Orthop 2002 Am J Orthod Dentofacial Orthop 2002

Jun;121(6)Jun;121(6)

Type of fixationType of fixation

••better better with semiwith semi--rigid rigid rigid rigid fixation fixation (Dolce 2002)(Dolce 2002)

“pathology”“pathology”

•• condylar resorptioncondylar resorption••worse with screw worse with screw fixation* (causes fixation* (causes fixation* (causes fixation* (causes rotation at TMJ?)rotation at TMJ?)••IdiopathicIdiopathic*Van Sickels 10% study of 100pts 2001*Van Sickels 10% study of 100pts 2001

Condylar resorptionCondylar resorption

••Young females Young females --why???why???

Increasing stabilityIncreasing stability

•• Good planningGood planning––Bimax, change occlusial planeBimax, change occlusial plane

•• Distraction ???Distraction ???•• Distraction ???Distraction ???•• Prolonged retentionProlonged retention

Avoiding unexpected consequencesAvoiding unexpected consequences•• Final aestheticsFinal aesthetics

••Careful “team” planningCareful “team” planning

•• Surgical complicationsSurgical complications•• Surgical complicationsSurgical complications••Be aware of the potential problemsBe aware of the potential problems

•• StabilityStability••Warning the “at risk” patientsWarning the “at risk” patients

I am most grateful to my colleaguesI am most grateful to my colleaguesSurgeonsSurgeons OrthodontistsOrthodontistsKen Sneddon Lindsay WinchesterKen Sneddon Lindsay WinchesterJeremy Collyer Alex CashJeremy Collyer Alex Cash

Allan ThomAllan Thom

I am also grateful to your I am also grateful to your President & CommitteePresident & Committee

muito obrigadomuito obrigado