Purpose: To evaluate a method to identify condylar sag intraoperatively by clinical examination after bilateral sagittal split osteotomy (BSSO). Methods: We. Condylar sag is an immediate or late alteration in the position of the condylar process in the glenoid fossa after the fixation of the osteotomy. Peripheral condylar sag (type II) had developed in three of these patients. In 15 patients central sag was diagnosed. One-week postoperatively, three patients.
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Hippocrate, Brussels, Belgium. The aim of this study was to determine whether orthognathic surgery is associated with any complications, and what type of complications may occur. The titles and abstracts of the electronic search results were screened and evaluated by two observers for eligibility according to the inclusion and exclusion criteria. A total of articles were identified, and we retained 44 articles for the final analysis. The Prisma diagram flowchart demonstrates our selection scheme.
For the purpose of this study, the Cochrane data extraction form was modified. One review author extracted data from the included studies, and the second author checked all of the forms. The hierarchy of evidence classification from the UK NHS Centre for Reviews and Dissemination was used to assess the level of evidence for the retrieved studies. An evaluation of the obtained studies revealed the existence of a large number of varied complications associated with orthognathic surgery procedures.
Oral and maxillofacial surgeons, orthodontists, and the surgical team need to prevent such complications during preoperative, intraoperative, and postoperative periods to increase the safety of orthognathic surgery procedures. This review was registered on http: The online version of this article doi: Orthognathic surgery procedures are frequently used to correct skeletal angle class II and III deformities, dentomaxillofacial deformities, mandibular laterognathia, and maxillofacial asymmetries [ 1 — 4 ].
As with any surgical procedure, various preoperative, intraoperative, and postoperative complications may occur. Two systematic reviews of orthognathic surgery complications have been previously published on the following topics [ 15 ]: The systematic review on blood loss presents some methodological pitfalls.
The research equation used in this study to identify relevant articles resulted in the identification of only seven articles. In addition, the data investigation was performed by only one reviewer, and the assessment of the potential risk of bias was unclear.
Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy.
The article investigated a narrow group of possible complications. The methodology of the second systematic review [ 1 ] was well designed and provided reliable conclusions. However, it was limited to the description of complications associated with only one type of orthognathic surgery procedure BSSO.
Therefore, we wanted to provide an extensive systematic review of complications in orthognathic surgery according to strict requirements of evidence-based medicine. The null hypothesis was that complications are inherent to orthognathic surgery procedures. The aim of our study was to answer to dag clinical question asking what are the complications associated with orthognathic surgery. No publication date restrictions were imposed.
All systematic reviews, randomized controlled trials, clinical trials were considered.
English, German, French, or Polish language articles were included in the search. Patients of any age who had any orthognathic surgery procedure were evaluated in this review. The second search using Embase Library was performed and updated on The additional search with the same search equation was performed in Google Scholar and by browsing references of acquired studies on Studies not meeting the inclusion criteria were excluded from further evaluation.
Any discrepancies in the selection were settled through discussion.
A total of references from the automatic database searches and 36 supplementary references after a manual search were included for evaluation.
A total of full-text articles The included articles contained five randomized controlled trials A Prisma diagram flowchart presents the selection scheme Fig. Information obtained from the data extraction forms were as follows: Risk of bias in individual studies: To provide the most reliable evidence, a critical appraisal of all included randomized controlled trials RCTs and clinical trials CTs was performed Online Resources 1 — 2.
The Cochrane Collaboration Tool for the assessment of risk of bias was used to conduct this assessment.
The overall judgment was assessed as high or unclear risk when one or more key domains were assessed as high or unclear. The low-risk judgment was assigned when all key domains were assessed as low risk.
Most of the references searched in the databases constituted case reports, case series, reviews, or comparative studies Clinical trials CT represented a smaller group of studies With respect to the time of exposure, complications occurred preoperatively, intraoperatively, and postoperatively. RCTs and CTs are crucial to evidence-based medicine as the most reliable source of information; therefore, only these types of studies were included in our evaluation.
RCTs and CTs searched during our review presented the following complications: A critical appraisal of all included randomized controlled trials [ 6 — 10 ] and clinical trials [ 11 — 49 ] was performed to provide the most reliable evidence.
Of all of the clinical trials, only three studies [ 273041 ] were assessed as low risk, one third was classified as high risk [ 11 — 141621 — 23344243 ], and the remaining 20 articles exhibited unclear risk [ 1517 — 2024 — 26282931 — 3335 — 4044 — 49 ] Online Resource 2.
Sah results demonstrated that only 3 out of 44 assessed studies [ 273041 ] met all of the requirements of our critical appraisal. The most common reason for an unclear or high-risk designation was the unblinded evaluation of clinical outcomes. The first records of the use of Le Fort I osteotomy and bilateral sagittal split mandibular osteotomy BSSO procedures for the correction of midfacial deformities were described in the s [ 50 ] and in [ 51 ], respectively.
The earliest article describing complications associated with such a procedure dates back condyylar [ 52 ].
The rate of reported complications has gradually increased with time, from only one study in to 14 studies inas orthognathic surgery has become more widely accepted, and is now a frequently performed surgical method for correcting maxillomandibular dysmorphoses. However, the total number of complications might be underestimated because surgeons may be unable to condjlar report the complications due to their own professional obligations and involvement. Following orthognathic surgery, patients may encounter laceration or disruption as also stretching of the cranial nerves, especially the inferior alveolar nerve IAN during BSSO.
Neurophysiologic examination with electroneuromyography enables the exact classification of nerve injury into either the axonal or demyelinating type, which allows the accurate prediction of recovery and the risk of neuropathic pain [ 29 ]. On the other hand, axonal injury often recovers incompletely, and slowly, over condjlar or even years, and entails a higher risk of pain developement [ 29 ].
The subjective symptoms of altered sensation were classified according to the general sensory system dysfunction classification [ 29 ] into three categories: Subjective symptoms of sensory alteration are more important after axonal rather than with demyelinating injuries [ 29 ]. Methods for testing sensory nerve function can be divided as follows: The same authors found a significantly higher prevalence of paresthesia on the left side [ 37 ].
In their opinion, a higher prevalence of IAN disturbance on the left side suggests the importance of asymmetry in the relationship between the surgeon and the operative field or asymmetry of sa surgical procedure. Further risk factors for IAN injury and impairment are the following: Additionally, Terijoki-Oksa et al.
Patients with altered sensation were faced not only with unfamiliar sensory experience of their confylar, chin, and mouth, but also had problems with facial function. Problems with function that are frequently reported include the following: The infraorbital nerve ION is another cranial nerve that may be exposed to injury during orthognathic surgery procedures. Changes in cutaneous, mucosal, and sg thresholds occurred as a result of LeFort I osteotomy, and significant side effects such as cutaneous numbness and hypersensitivity, as well as intraoral numbness in the facial and palatal gingiva, are associated with that procedure [ 44 ].
Furthermore, segmentation of the maxilla additionally decreased sensory function in the palate and gingiva [ 44 ]. Despite these sensory problems, many patients were satisfied with their surgical results and would recommend the condylad procedure to other patients needing a combined orthodontic surgical treatment [ 44 ]. Temporomandibular joint TMJ disorders represent the second most commolny described complication after orthognathic surgery After surgery, patients may suffer from TMJ dysfunction, derangement of the condylar surface, condylar resorption, or malocclusion as a result of condylar sag [ 10112233 ].
Consensus on the influence of orthognathic surgery on TMJ dysfunction has also not yet been achieved [ 33 ]. Some investigators have reported a favorable effect of orthognathic surgery on TMJ dysfunction; however, other studies did not show an improvement of TMJ symptoms, and TMJ function worsened in some patients [ 33 ].
Intraoral oblique ramus osteotomy with maxilla-mandibular fixation appears to be more favorable for TMJ than BSSO with rigid fixation, especially in patients with preoperative symptoms [ 24 ]. However, Nemeth et al.
Diverse TMJ symptoms may occur after orthognathic surgery, ranging from intra-articular noise [ 53 — 55 ], pain, clicking, and crepitus, to condylar resorption [ 56 ]. Surgeons should be aware of the risk of condylar resorption, especially when the patient is a female and exhibits a high preoperative plane angle, small condyles on panoramic X-raysclass II angle deformity requiring wide mandibular advancement, and a posteriorly inclined condylar neck [ 2256 ].
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Condylar sag can be defined as an immediate or late change in position of the condyle in the glenoid fossa after the surgical establishment of preplanned occlusion and rigid fixation of cobdylar bone fragments, leading to changes in the occlusion [ 1011 ]. This condition is divided into central and peripheral categories, which are divided into peripheral condylar sag type I and peripheral condylar sag type II.
This division is based on the relationship between the articular surfaces [ 11 ]. Possible risk factors include the following: The most important part of surgery for avoiding such complications is the positioning of bony fragments and rigid fixation. Methods that help to cope with these challenges include the following: Hemorrhage after LeFort I surgery was described in 9. The most serious hemorrhage during or after Le Fort I osteotomy happens as a sa of pterygomaxillary separation [ 1921 ]. The risk of arterial bleeding from the posterior maxilla usually arises from the descending palatine artery or less frequently from the maxillary artery and its branches.
Serious hemorrhage from the pterygoid venous plexus occurs less frequently [ 19 ]. The patterns of fracture of the pterygoid plates in conventional pterygomaxillary dysjunction seem to have a great influence on the occurrence of bleeding.
According to a trial by Regan et al. Based on the given studies, condylzr was indicated as the most common complication in maxillary surgery [ 12 ]. In contrast to the incidence of the manageable hemorrhage, the life-threatening postoperative hemorrhage after Le Fort osteotomy is rare and varies between an incidence of 0 and 0.
Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy.
A combination of conservative and surgical treatment is initiated in most cases of life-threatening hemorrhage. Conservative treatment consists of controlling blood pressure and administering intravenous fluids and blood transfusion. The surgical approach includes simple nasal packing, revision osteotomy, and ligation of the branches of external carotid artery [ 1421 ].
Auditory tube function and hearing problems were citated in 6. Some aural symptoms tinnitus, fullness, otalgia and auditory changes may occur as a consequence of surgical edema or lymphoedema and hematoma [ 38 ]. Nasotracheal intubation may also cause swelling of the soft tissues in the nasotracheal area, blocking the Eustachian tube, and precipitating middle ear effusion [ 38 ].