Sorvin V.A., Drobyshev A.Y., Kurakin K.A., Klipa I.A., Shipika D.V., Zaborovsky V.V. Analysis and prevention of intraoperative complications of surgical treatment in patients with congenital anomalies of the jaws. Rossijskij zhurnal Head and neck Russian Journal. 2019;7(4):42–52 (in Russian).
Purpose of the study. The main task of orthognathic surgery is to achieve facial harmony and correction of skeletal deformities of the jaw and occlusion. In orthognathic surgery, pre-surgical preparation, surgical planning and post-surgical orthodontic management of the patient are indispensable. At various stages of treating patients, various errors and complications may occur. The main objective of this study is to analyze the complications of surgical treatment of patients at the intraoperative stage; a comparison of the structure of operations according to the frequency of complications in certain years of the period 2012-2017; comparison of the frequency of complications of different localization; comparing the frequency of complications of varying severity and creating a modern working classification of complications.
Material and methods. In the period from 2012 to 2017, 1329 orthognathic surgeries were performed in the Department of Maxillofacial and Plastic Surgery of the MSUMD. All patients admitted to the clinic of MSUMD were consulted by the maxillofacial surgeons together with orthodontists and related specialists according to indications. Comprehensive examination of patients included a clinical examination, examination of the face and oral cavity, anthropometric examination of the face and gypsum models of the jaws, X-ray examination of the maxillofacial region (computed tomography), photometric examination of the patient’s face, magnetic resonance imaging of the temporomandibular joint (MRI of the TMJ). Among 1329 operations, 89 clinical cases of intraoperative complications were identified. Among intraoperative complications during operations on the maxilla there were bleeding (damage to the maxillary artery, palatine arteries and their branches); damage or fracture of the roots of the teeth (when installing mini-screws or segmental osteotomy); uncontrolled fracture lines of osteotomated bone fragments (in the area of the hillocks of the upper jaw and pterygoid plate of the sphenoid bone); deviation of the nasal septum with insufficient resection and mobilization of the septum during the rotation of the upper jaw; perforation of the mucous membrane of the hard palate with sharp instruments for segmental osteotomy; breaking off the reciprocating saw during the formation of the line of osteotomy. In osteotomy of the lower jaw, damage to the mandibular nerve (rupture or incision with sharp surgical instruments) was encountered; bleeding (damage to the mandibular vessels); uncontrolled fracture lines of osteotomated bone fragments (in the condylar process, body and lower jaw branch); unsatisfactory displacement and positioning of the condylar process; with genioplasty – poor positioning of the chin relative to the cosmetic center. Based on the data of the Department of Maxillofacial and Plastic Surgery, and data from the world literature, a classification of intraoperative complications of surgical treatment of patients with congenital anomalies of the jaw was compiled and proposed. In the classification, complications were divided by localization (upper jaw, lower jaw, chin) and severity: Class I (adverse events that did not require a fundamental change in the tactics of the operation and did not lead to further consequences for the patient); Class II (adverse events with possible further consequences for the patient); Grade III (adverse events that often were not recognized on time, therefore, their correction was not carried out during the operation and entailed significant consequences for the patient).
The results of the study.
According to the results, the frequency of complications over the years was statistically significantly different: in 2015 there were fewer complications than in 2012; in 2016 there were fewer complications than in 2012 and 2013. Thus, the number of complications decreased from 2012 to 2017, with an increase in the number of operations. When comparing the frequency of occurrence of complications of different localization, the most common complications are localized in the lower jaw, the least often in the chin. When comparing the frequency of occurrence of complications of various types for the period 2012-2017, it was revealed that trauma of the mandibular nerve is most common. Complications such as poor positioning of the condylar process of the lower jaw and uncontrolled fracture of the jaw are also common. When comparing the incidence of complications of different severity classes in certain years of the indicated period, it was revealed that most often complications of class III, least often, complications of class I.
Conclusion Minimization of complications during surgery is achieved by drawing up a clear plan based on a thorough preoperative diagnosis. To prevent neurosensory deficiency of various areas of the face and trauma of the mandibular nerve, an assessment of the location of the nerve should be performed according to the results of a computer tomogram. The intraoperative treatment of rupture of the mandibular nerve is its crosslinking with monofilament thread 6/0. To prevent an unsatisfactory fracture of the jaw, it is recommended to remove the third molars at least 6 months before the operation, due to their location in the cut line of the lower jaw. It is necessary to clearly follow the methods for splitting jaw fragments. As a treatment for an uncontrolled fracture of jaw fragments, osteosynthesis is performed with additional mini-plates. Recommended manual control of the correct position of the condylar processes when positioning the lower jaw, satisfactory closure of the dentition, in the absence of the latter — re-fixation of bone fragments for the prevention of dysfunction of the temporomandibular joint. With rupture and the formation of a defect in the nasal mucosa during its detachment on the upper jaw, subsequent suturing is performed. Prevention of tooth root injury with a drill is ensured by the presence of a certain distance between the roots of the teeth by an orthodontist at the preoperative stage. In the presence of a root fracture or exacerbation of chronic periodontitis, the injured tooth is removed. In the presence of perforation of the tooth root with a drill, its endodontic treatment is performed. This type of surgical treatment belongs to the category of complex reconstructive operations, and one of the criteria for a good result of orthognathic surgery is the great experience of both the operating surgeon and the operating team as a whole.
Key words: congenital anomalies of the jaw, classification of intraoperative maxillary complications of surgical treatment, orthognathic surgery
The authors declare no conflict of interest.
Source of financing: not specified.
For citation: Sorvin V.A., Drobyshev A.Y., Kurakin K.A., Klipa I.A., Shipika D.V., Zaborovsky V.V. Analysis and prevention of intraoperative complications of surgical treatment in patients with congenital anomalies of the jaws. Rossijskij zhurnal Head and neck Russian Journal. 2019;7(4):42–52 (in Russian).
The authors are responsible for the originality of the data presented and the possibility of pub-lishing illustrative material – tables, figures, photographs of patients.