The assessment of blood loss in orthognathic surgery for prognathia

Current Orthognathic Surgery Practice Patterns Among Academic OMS

OBJECTIVE

Currently there is variation in perioperative care of orthognathic surgery patients and limited clinical practice guidelines. The current orthognathic surgery practice patterns among US academic OMFS training centers have not been described. The purpose of this study is to describe the practice patterns among US academic OMFS training centers.

DESIGN

The study design is cross-sectional. Data was collected through a survey of the sample.

SETTING

OMFS programs in the US.

PARTICIPANTS

Academic OMFS. 573 surgeons were contacted and 85 responses were received.

MAIN OUTCOME MEASURE

Descriptive and bivariate statistics were reported.

RESULTS

Respondents were 87% male and worked in full-time academic (80%), part-time academic (19%), or military settings (1%). Thirty-one percent have practiced for 30 years or more and then 29% with 11-20 years, 18% with 21-30 years, 12% with 6-10 years and 11% with 1-5 years. Twenty-six percent of respondents perform 20-40 orthognathic surgeries a year, 22% perform less than 20 surgeries a year, 21% perform 40-60 surgeries per year, and 19% perform more than 100 surgeries per year. Intraoperatively, 48% of surgeons request a mean arterial pressure of 60-64 mmHg, 25% utilize tranexamic acid (TXA), 85% report a blood loss of less than 400 milliliters, and 93% report a blood transfusion rate of <1%.

CONCLUSION

There are variations in orthognathic surgery practice patterns with limited clinical practice guidelines. Only 13 of the 32 survey questions had a single response holding a simple majority. This study demonstrates the need for further research and evidence-based protocols and decision making.

Anterior Maxillary Distraction Osteogenesis With Bone-borne Intraoral Buccal Devices for Maxillary Hypoplasia With Cleft Lip and Palate

Anterior maxillary distraction osteogenesis (AMDO) surgery for cleft lip and palate involves distraction of a segment of the anterior maxilla and advancement using 2 intraoral buccal bone-borne distraction devices. The anterior part of the maxilla is advanced anteriorly with less relapse which increases maxillary length and does not affect speech. We aimed to evaluate the effects of AMDO, including lateral cephalometric changes. Seventeen patients who had undergone this procedure were included in this retrospective study. The distractors were activated by 0.5 mm twice a day after a 3-day latency period. Lateral cephalometric radiographs were evaluated preoperatively, after distraction and removal of distractors, which were compared using the paired Student's t test. Anterior maxillary advancement was obtained in all patients with a median of 8.0 mm. Complications included nasal bleeding and loosening of distractors; however, there was no tooth damage or abnormal movement. The mean sella-nasion-A point (SNA) angle increased significantly, from 74.91° to 79.66°, the A point-nasion-B point angle from -0.38° to 4.34°, and the perpendicular line from nasion to Frankfort Horizontal (NV)-A point from -5.11 to 0.08 mm. The mean anterior nasal spine-posterior nasal spine length increased significantly from 50.74 to 55.10 mm, and the NV-Nose Tip from 23.59 to 26.27 mm. The mean relapse rate of NV-A was 11.1%. AMDO with bone-borne distractor resulted in less relapse and effectively corrected the maxillary retrusion.

What are the Effects of Internal Fixation on Trigeminal Neurosensory Function and the Temporomandibular Joints Following Intraoral Vertical Ramus Osteotomy?

PURPOSE

Intraoral vertical ramus osteotomy (IVRO) has, traditionally, been accomplished without internal fixation, necessitating a period of maxillomandibular fixation (MMF). With advances in instrumentation, internal fixation of IVRO is feasible, obviating the need for MMF. The purpose is to investigate the effects of transoral internal fixation on the prevalence of third division trigeminal nerve (CNV3) injury, temporomandibular joint (TMJ) arthralgia, and surgical site bleeding following IVRO.

MATERIALS AND METHODS

A retrospective study was conducted on patients who underwent IVRO at Vanderbilt University Medical Center between January 2017 and December 2020. The primary predictor variable was fixation status-internal fixation versus MMF. The primary outcome variable was postoperative CNV3 neurosensory disturbance. The secondary outcome variables were TMJ arthralgia and surgical site bleeding. Statistical analysis included Fisher's exact test and McNemar's Chi-squared test.

RESULTS

Seventy two subjects (59 IVROs without internal fixation and 65 IVROs with internal fixation) were studied. The frequency of CNV3 neurosensory deficit was 0% in the IVRO without internal fixation group and 3.1% in the IVRO with internal fixation group (P = .49). Within group analysis showed a decreased frequency of postoperative TMJ arthralgia compared to preoperative records in both groups (IVRO without internal fixation group, P = .04 and IVRO with internal fixation group, P = .004). The frequency of active surgical site bleeding controlled with local measures was 1.7% in the IVRO without internal fixation group and 3.1% in the IVRO with internal fixation group (P = 1).

CONCLUSION

Internal fixation of IVRO is associated with low incidence of neurosensory deficit, TMJ arthralgia, and active surgical site bleeding.

The use of an ultrasonic curettage device in orthognathic surgery decreases surgery-related blood loss

Objective

This study aimed to compare the use of a powered instrument (PI) and ultrasonic curettage device (ULCD) with intraoperative blood loss (IOBL), drain volume (DV), calculated blood loss (CBL), and hidden blood loss (HBL) in orthognathic surgery.

Methods

We included 163 patients who underwent bimaxillary surgery in our department. CBL was calculated from the preoperative and postoperative hemoglobin levels using the "hemoglobin balance method." CBL is an indicator of the amount of perioperative blood loss. HBL was calculated by subtracting IOBL and DV from CBL.

Results

The PI group consisted of 61 patients (17 males and 44 females, age: 24.9 ± 9.5 years), and the ULCD group consisted of 102 patients (40 males and 62 females, age: 23.1 ± 7.8 years). In the PI group, the median IOBL, DV, CBL, and HBL were 540.0 (interquartile range [IQR] 380.0-670.0), 113.0 (IQR 77.0-147.0), 1000.0 (IQR 751.4-1248.6), and 285.8 (IQR 151.0-476.4) ml, respectively. In the ULCD group, the median IOBL, DV, CBL, and HBL were 327.5 (IQR 200.0-455.0), 105.5 (IQR 75.3-136.0), 759.5 (IQR 594.9-944.2), and 294.2 (IQR 120.8-456.9) ml, respectively. IOBL and CBL were significantly reduced with ULCD use, but no significant differences were observed in DV and HBL.

Conclusions

This study showed that IOBL decreased with ULCD use, resulting in a decrease in CBL. Conversely, bleeding parameters (DV and HBL), which reflect the amount of bleeding that occurs after wound closure, did not show a decrease with ULCD use.

Determining Morbidity of Adding Genioplasty to Bimaxillary Orthognathic Surgery

BACKGROUND

Patients with dentofacial anomalies may undergo orthognathic surgery to address functional and aesthetic concerns. Past works have evaluated determinants affecting length of stay (LOS) in patients undergoing upper and/or lower jaw surgery alone. No studies have assessed the addition of genioplasty to double-jaw (Lefort I, bilateral sagittal split osteotomy (BSSO))) surgery and its effect on LOS and other outcomes. This study investigates whether the addition of genioplasty incurs additional morbidity to patients undergoing complex orthognathic surgery.

METHODS

This was a retrospective cohort study of patients undergoing orthognathic surgery at Yale-New Haven Hospital. Clinical and demographic information were compared across the "double"- and "triple"-jaw cohorts with t tests and Chi-squared analyses. Multivariable linear and logistic regression analyses were utilized to assess the impact of genioplasty when controlling for baseline patient differences.

RESULTS

A total of 27 patients received Lefort I and BSSO (double-jaw), and 224 received Lefort I, BSSO, and genioplasty (triple-jaw). Six (22.2%) double-jaw patients were segmental and fifty-eight (25.9%) triple-jaw patients were segmental (p > 0.05), during the study period. Triple-jaw surgery was associated with increased operative time (+ 41.1 min, p < 0.01). There was no increase in LOS, postoperative nausea and vomiting, opioid use, hematoma, or infection (p > 0.05).

CONCLUSIONS

This study attempted to determine if triple-jaw surgery could influence patients' LOS and other surgical outcomes compared to double-jaw surgery. Only the operative time was significantly affected. This indicates that incorporation of a genioplasty can provide aesthetic benefit without incurring significant additional morbidity to the patient.

LEVEL OF EVIDENCE III

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Development and Validation of a Nomogram to Predict the Risk of Blood Transfusion in Orthognathic Patients

OBJECTIVE

This study aims to establish a nomogram to predict the probability of blood transfusion in patients with preoperative autologous blood donation before orthognathic surgery.

METHODS

The authors conducted a retrospective case-control study on consecutive orthognathic patients with preoperative autologous blood donation from January 2014 to December 2020. The outcome variable was the actual transfusion of autologous blood (ATAB). Predictors included patients' demographics, preoperative blood cell test, vital signs, American Society of Anesthesiologists classification, surgical procedure, operation duration, and blood loss. Univariable and multivariable logistic regressions were performed to identify independent risk factors associated with ATAB. A nomogram was constructed to predict the risk for ATAB. The performance of the nomogram was evaluated using the area under the receiver operating characteristic curve, calibration curve and the consistency index.

RESULTS

A total of 142 patients (75 males and 67 females) with an average age of 22.72 ± 5.34 years donated autologous blood before their orthognathic surgery. Patients in the transfusion group (n = 56) had significantly lower preoperative red blood cell counts (4.74 ± 0.55 × 109/L versus 4.98 ± 0.45 × 109/L, P = 0.0063), hemoglobin (141.48 ± 15.18 g/dL versus 150.33 ± 14.73 g/dL, P = 0.0008), and hematocrit (41.05% ± 4.03% versus 43.32% ± 3.42%, P = 0.0006), more bimaxillary osteotomies (92.86% versus 56.98%, P < 0.001), longer operation duration (348.4 ± 111.10 minutes versus 261.6 ± 115.44 minutes, P < 0.001), and more intraoperative blood loss (629.23 ± 273.06 ml versus 359.53 ± 222.84 ml, P < 0.001) than their counterparts (n = 86) in the non-transfusion group. Univariable and multivariable logistic regression demonstrated that only hemoglobin (adjusted odds ratio [OR] 0.864, 95% confidence interval [CI]:0.76-0.98, P = 0.026), operation procedures (adjusted OR 8.14, 95% CI:1.69-39.16, P = 0.009), and blood loss (adjusted OR 1.006, 95% CI:1.002-1.009, P < 0.001) were independent risk factors for ATAB. The area under the receiver operating characteristic curve of the nomogram was 0.823. The consistency index of the nomogram was 0.823. The calibration curve illustrated that the nomogram was highly consistent with the actual observation.

CONCLUSIONS

The nomogram is a simple and useful tool with good accuracy and performance in predicting the risk for blood transfusion.

Gender-specific differences in haemostatic parameters and their influence on blood loss in bimaxillary surgery

Objective

The objectives of this prospective cohort study were to establish gender-related differences in blood loss and haemostatic profiles associated with bimaxillary surgery. In addition, we aimed to identify if any gender differences could be established which might help predict blood loss volume.

Materials and methods

Fifty-four patients (22 males; 32 females) undergoing bimaxillary surgery for skeletal dentofacial deformities were eligible for inclusion. Blood samples were taken 1 day preoperatively and 48 h postoperatively for detailed gender-specific coagulation analysis incorporating global coagulation assays (endogenous thrombin potential) and specific coagulation parameters. Blood loss was measured at two different time points: (1) the end of surgery, visible intraoperative blood loss (IOB) using ‘subtraction method’; and (2) 48 h postoperatively perioperative bleeding volume (CBL-48 h) using ‘haemoglobin-balance method’ and Nadler’s formula. Correlation and regression analyses were performed to identify relevant parameters affecting the amount of blood loss.

Results

Significant differences in IOB and CBL-48 h were observed (p < 0.001). Men had higher IOB versus women, lacking statistical significance (p = 0.056). In contrast, men had significantly higher CLB-48 h (p = 0.019). Reduced CBL-48 h was shown to be most closely associated with the level of Antithrombin-III being decreased in females.

Conclusions

Male gender is associated with higher IOB and CBL-48 compared with females. Gender does not affect IOB regarding haemostatic profile but does correlate strongly with procedure length. Conversely, CBL-48 is closely associated with gender-specific imbalances in the anticoagulant system.

Clinical relevance

Knowledge of gender-related differences will help clinicians establish predictive factors regarding excessive blood loss in orthognathic surgery and identify at-risk patients.

Predictors of Blood Loss During Orthognathic Surgery and the Need for Pre-Deposit Autologous Blood Donation

ABSTRACT

The aim of this study was to identify the clinico-laboratory predictors of relative blood loss (RBL) during orthognathic surgery and determine the need for predeposit autologous blood donation (PABD) for the surgery. Using a retrospective study design, 297 patients who underwent bimaxillary orthognathic surgery between 2016 and 2020 were enrolled. To investigate patient-specific risk factors, we calculated the allowable blood loss (ABL) for each patient and RBL as the ratio of estimated intraoperative blood loss (EIBL) to ABL. The correlations between the clinico-laboratory variables and EIBL and RBL were analyzed using stepwise multivariate regression analysis, and independent t test and one-way ANOVA were performed.There was no significant difference in transfusion rate between the PABD group (N = 202/279) and non-PABD group (N = 77/279) (P = 0.052). Sex (P < 0.001), body mass index class (P = 0.001), operative time (P < 0.001), and baseline hematocrit (P < 0.001) were significant predictors of EIBL and RBL. EIBL exceeded ABL in only 2 patients. The significant factors of RBL in orthognathic surgery were hematocrit, body mass index, and operative time. Clinicians should be more careful about bleeding in patients with low baseline hematocrit level or high body mass index, or those expected to undergo prolonged surgeries owing to a complicated surgical plan. The need for PABD before orthognathic surgery is low.

Bone marrow space volume of the mandible influencing intraoperative blood loss in bilateral sagittal split osteotomy: A pilot Study

The aim of this study was to investigate whether the bone marrow space volume of the mandible affects blood loss during bilateral sagittal split osteotomy (BSSO). Sixteen patients who underwent BSSO in our hospital were included in this study. Bone marrow space volume of the mandible was measured by analyzing images from computed tomography. Blood loss during BSSO was measured by weighing gauze, measuring suctioned blood, and adjusting for the volume of irrigation solution used during BSSO. Mean blood loss during BSSO for the 16 patients was 200.5 ml, and patients were divided into: Group I, with less than mean blood loss; and Group II, with greater than mean blood loss. Total bone marrow space volume was significantly greater in Group II (12,450.7 ± 2644.3 mm³) than in Group I (9130.3 ± 3005.8 mm³; P<0.05). A correlation between bone marrow space volume and blood loss during BSSO was suggested, and these results are beneficial for surgeons planning and preparing the orthognathic surgery.

Postoperative stability of two common ramus osteotomy procedures for the correction of mandibular prognathism: A randomized controlled trial

The aim of this randomized controlled trial was to compare the skeletal stability between sagittal split ramus osteotomy (SSRO) and intraoral vertical ramus osteotomy (IVRO) in the treatment of mandibular prognathism. Patients presenting with mandibular prognathism and scheduled for orthognathic surgery were randomized into either the SSRO group or the IVRO group. Changes at B-point were assessed by serial tracing of lateral cephalograms, which were taken preoperatively, and at 2 weeks, 6 months, 1 year, and 2 years postoperatively. Ninety-eight patients were recruited, with 49 patients in each group. Between 2 weeks and 6 months postoperatively, there was significantly more surgical relapse in the horizontal direction (anterior movement) in the SSRO group when compared with the IVRO group (1.83 mm (SD 2.91 mm) vs 0.49 mm (SD 2.32 mm); p = 0.019). At 2 years, there was more surgical relapse in the horizontal direction in the SSRO group than in the IVRO group (0.27 mm (SD 0.34 mm) vs 0.10 mm (SD 0.29 mm); p = 0.014). There were also more absolute changes (irrespective of direction) at B-point in the SSRO group than in the IVRO group at postoperative 6 months, 1 year, and 2 years (p = 0.016, 0.049, and 0.045, respectively). The amounts of change at B-point as percentages of total mandibular setback were 1.3% and 3.5% in the IVRO group and SSRO group, respectively. There were no differences in vertical changes between the two groups at any time points. In conclusion, the horizontal stability at B-point was shown to be superior in the IVRO group compared with the SSRO group in the correction of mandibular prognathism during the 2-year follow-up. Although the exact clinical importance of this difference is unknown at this time, this possible benefit may be an important key factor when deciding which osteotomy technique to employ for mandibular setback.

Major Complications and Associated Risk Factors for Osseous Genioplasty with Bimaxillary Orthognathic Surgery: An American College of Surgeons-National Surgical Quality Improvement Program Analysis

PURPOSE

Patients with significant dentofacial deformities undergoing aesthetic and functional orthognathic surgery may often require genioplasty to advance the position of the pogonion relative to B point. No study to date has evaluated nationally registered data pertaining to addition of osseous genioplasty to bimaxillary orthognathic surgery and its associated clinical outcomes.

METHODS

Data was extracted from the National Surgical Quality Improvement Program from 2010 to 2018 using current procedural terminology codes pertaining to Le Fort I osteotomy (LF), bilateral sagittal split osteotomy (BSSO), and osseous genioplasty (G) and divided into 2 cohorts: bimaxillary orthognathic surgery with and without osseous genioplasty. Thirty-day postoperative outcomes inherently recorded within National Surgical Quality Improvement Program were identified and recorded. Chi-squared analysis and unpaired 2-tail t tests were performed between the cohorts and their respective outcomes to determine significant relationships with significance set as P < 0.05.

RESULTS

There were 373 patients double- or triple-jaw patients identified from the years 2010 to 2018. The most common recorded indication for LF/BSSO was maxillary hypoplasia (27.3%) and mandibular hypoplasia (6.8%). The most common indications for LF/BSSO/G were maxillary hypoplasia (16.1%) and maxillary asymmetry (16.1%). In comparison to LF/BBSO only, LF/BSSO/GP was not associated with any differences in the rate of surgical (0.0% versus 0.31%, P = 0.72) or medical complications (0.0% versus 0.63%, P = 0.60), in addition to unplanned readmissions (0.0% versus 1.56% versus P = 0.41) or reoperations (0.0% versus 1.25%, P = 0.46). However, osseous genioplasty addition was associated with increased overall operating time (271.77 versus 231.75 minutes, P = 0.04).

CONCLUSIONS

Osseous genioplasty does not alter short-term, 30-day complication rate when performed with bimaxillary orthognathic surgery. As reoperation rates remained relatively unchanged, it can be inferred that immediate adverse events or patient dissatisfaction were not apparent within 30 days. Although mean operating time is slightly longer, cardiopulmonary resuscitation without medical comorbidity was achieved at the conclusion of the procedure.

Determination of blood loss in bimaxillary surgery: does the formula and the time point affect results?

The amount of blood loss determined in orthognathic surgery differs greatly among studies. This can be attributed to the inhomogeneity in study cohorts analysed, but may also be a result of the varying methodologies used for blood loss determination. However, this has yet to be explored. Thus, the aim of this study was to investigate the extent to which the formula and time point used to measure blood loss affect the blood loss volume, determined in a homogeneous cohort undergoing bimaxillary surgery. Blood loss was calculated at 24 and 48 hours postoperatively using the haemoglobin balance method and the formula of Hurle et al. The estimated total blood volume was established based on the formulae of Nadler et al. and Choi et al. Differences in blood loss volume with respect to time point and formula were analysed and compared. Fifty-four patients were included in the final analysis. Statistically significant differences in blood loss were observed: a significant increase in the blood loss volume from 24 hours to 48 hours postoperatively was detected. When comparing the formulae used, blood loss differed significantly at 24 hours after surgery; however no such difference resulted at 48 hours postoperatively. These findings imply that the time point of measuring blood loss is highly relevant, whereas the formulae applied seem to have less of an impact on the blood loss volumes calculated.

Comparison of Efficacy of Dexmedetomidine and Clonidine Infusion to Produce Hypotensive Anesthesia in Patients Undergoing Orthognathic Surgery: A Randomized Controlled Trial

PURPOSE

The purpose of the study was to compare the efficacy of dexmedetomidine (DEX) and clonidine (CLON) infusion to produce hypotensive anesthesia in patients undergoing orthognathic surgery.

MATERIAL AND METHODS

The investigators designed a randomized controlled trial on patients undergoing orthognathic surgery. Patients were randomized into 2 groups (DEX and CLON group). The DEX group patients received loading dose of 1 ug/kg DEX over 10 minutes followed by 0.2 to 0.5 ug/kg/hour as maintenance dose. Similarly, CLON group patients received 3 ug/kg loading dose followed by maintenance dose of 0.3 to 2 ug/kg/hour. Primary objectives were to compare the quality of surgical field, duration of surgery, amount of blood loss and secondary objectives were to compare total and rescue analgesia used, need for blood transfusion and associated adverse effects. The P value of <.05 was taken significant at confidence interval of 95%.

RESULTS

The study sample included 30 patients (15 in each group), (m:f = 1:1.1) requiring orthognathic surgery. Single jaw cases were 11 (DEX:CLON = 4:7) and bijaw cases were 19 (DEX:CLON = 11:8) in number. There was statistically insignificant difference in quality of surgical field between 2 groups (P = .15). Duration of surgery was 293.33 ± 58.75 and 247 ± 70.45 minutes in the DEX and the CLON group, respectively (P = .06). Blood loss was more in the DEX group (316.61 ± 147.19 mL) than the CLON group (263.33 ± 112.54 mL), (P = .71). Total drug used (P = .33) and rescue analgesia (P = .25) was less in the DEX group. Adverse effects were more in the CLON than the DEX group.

CONCLUSION

The results of the present study showed no significant difference between the 2 groups for any parameter. It can be concluded that both dexmedetomidine and clonidine are effective and safe in achieving controlled hypotension and safe operative field visibility.

Intraoperative Blood Loss and Postoperative Pain in the Sagittal Split Ramus Osteotomy and Intraoral Vertical Ramus Osteotomy: A Literature Review

Purpose

The purpose of the present study was to review the literature regarding the blood loss and postoperative pain in the isolated sagittal split ramus osteotomy (SSRO) and intraoral vertical ramus osteotomy (IVRO).

Materials and Methods

Investigating the intraoperative blood loss and postoperative pain, articles were selected from 1970 to 2021 in the English published databases (PubMed, Web of Science, and Cochrane Library). Article retrieval and selection were performed by two authors, and they independently evaluated them based on the eligibility criteria. The articles meeting the search criteria had especially at least 30 patients.

Results

In the review of intraoperative blood loss, a total of 139 articles were retrieved and restricted to 6 articles (SSRO: 4; IVRO: 2). In the review of postoperative pain, a total of 174 articles were retrieved and restricted to 4 articles (SSRO: 3; IVRO: 1). The mean blood loss of SSRO and IVRO was ranged from 55 to 167 mL and 82 to 104 mL, respectively. The mean visual analog scale (VAS) scores of the first postoperative day were 2 to 5.3 in SSRO and 2.93 to 3.13 in IVRO. The mean VAS scores of the second postoperative day were 1 to 3 in SSRO and 1.1 to 1.8 in IVRO.

Conclusion

Compared to traditional SSRO, IVRO had a significantly lower amount of blood loss. However, the blood transfusion is not necessary in a single-jaw operation (SSRO or IVRO). Postoperative pain was similar between SSRO and IVRO.

Predictors of Red Blood Cell Transfusion in Bimaxillary Orthognathic Surgery: A Retrospective Study

Background: Orthognathic surgery requires red blood cell (RBC) transfusions more frequently than other oral and maxillofacial surgeries. The purpose of this study was to identify reliable predictors for RBC transfusion during bimaxillary orthognathic surgery (BOS). Methods: This retrospective study reviewed 1,616 electronic medical records of patients who underwent BOS during a 5-year period at Seoul National University Dental Hospital. The perioperative variable data were collected from electronic medical records and analyzed by dividing patients into the two groups (non-transfusion and transfusion group). Results: Of the 1,616 patients, 1,311 patients were excluded. The remaining 305 patients were divided into non-transfusion (NTF, n = 256) and transfusion (TF, n = 49) groups. Univariate logistic regression analysis revealed that age, body mass index, the presence of several adjunctive surgeries (including genioplasty, extraction, and mandibular angle reduction), preoperative hemoglobin (Hb) and prothrombin time, surgical time, amount of fluid infusion and blood loss, and mean pulse rate during surgery were significant factors predicting RBC transfusion. Multivariate logistic regression analysis revealed that preoperative Hb and blood loss amount during surgery were significantly related to RBC transfusion in BOS patients. Conclusion: Since blood loss amounts could not be measured preoperatively, we found that the independent predictor associated with RBC transfusion during BOS was a low preoperative Hb level.

Operative time, length of stay and reoperation rates for orthognathic surgery

Orthognathic surgery improves quality of life in terms of oral function and facial aesthetics. Our aim was to establish and compare operative time and length of inpatient stay for orthognathic procedures, and to assess the reoperation rate. Departmental electronic data base was used to identify all patients undergoing orthognathic surgery in a single unit between the 01/01/2016 and the 01/08/2018. 251 patients were identified who underwent 409 orthognathic surgery procedures. The mean operating time for a bimaxillary osteotomy (n=107) was 139.3 min. For single jaw procedures, the mean operating time for a Le Fort I osteotomy (n= 42) was 82.2 min and for a bilateral sagittal split osteotomy (BSSO) (n= 102) was 80.3min. Bimaxillary osteotomy combined with genioplasty (n=17) this increased the operating time on average by 31 min. and of a BSSO combined with a genioplasty (n=14) by 27 mins. The mean postoperative hospital stay was 1.2 ± 0.2 days. 96.4% patients spent only one postoperative night in hospital. 6/251 (2.4%) patients required re-operation. In regression analysis, age was the only significant factor in increasing length of stay (p<0.008), 95% CI 0.03-0.2). Our review shows short operating times and postoperative inpatient stays in a large cohort of patients undergoing orthognathic surgery. This is combined with a low reoperation rate. This may point to a patient benefit from high volume orthognathic centres.

Intraoperative blood loss and surgical time according to the direction of maxillary movement

Background

Excessive bleeding is one of the most severe complications of orthognathic surgery (OGS). This study investigated the associations of intraoperative blood loss and surgical time with the direction of maxillary movement.

Methods

This retrospective study involved patients who underwent OGS from October 2017 to February 2020. They were classified based on whether maxillary setback was performed into groups A1 and B1, respectively. Relative blood loss (RBL, %) was used as an indicator to compare intraoperative blood loss between the two groups. The surgical time of the two groups was also measured. Subsequently, the patients were reclassified based on whether posterior impaction of the maxilla was performed into groups A2 and B2, respectively. RBL and surgical time were measured in the two groups. Simple linear and multiple regression analyses were performed. P-values <0.05 were considered to indicate statistical significance.

Results

Eighteen patients were included. The RBL and surgical time for the groups were: A1, 13.15%±5.99% and 194.37±42.04 minutes; B1, 12.41%±1.89% and 196.50±46.07 minutes; A2, 13.94%±3.82% and 201.00±39.70 minutes; and B2, 9.61%±3.27% and 188.84±38.63 minutes, respectively. Only RBL showed a statistically significant difference between the two groups (A2 and B2, P=0.04).

Conclusions

Unlike maxillary setback, posterior impaction of the maxilla showed a significant association with RBL during surgery. When performing posterior impaction of the maxilla, clinicians need to pay particular attention to surgery and postoperative care.

How to approach orthognathic surgery in patients who refuse blood transfusion

Background

Some patients who need surgery refuse a blood transfusion because of their religious beliefs or concerns about blood-borne infections. In recent years, bloodless surgery has been performed successfully in many procedures, and is therefore of increasing interest in orthognathic surgery.

Methods

Ten Jehovah’s Witnesses who visited our bloodless surgery center for orthognathic surgery participated in this study. To maintain hemoglobin (Hb) levels above 10 g/dL before surgery, recombinant erythropoietin (rEPO) was subcutaneously administered and iron supplements were intravenously administered. During surgery, acute normovolemic hemodilution (ANH) and induced hypotensive anesthesia were used. To elevate the Hb levels to >10 g/dL after surgery, a similar method to the preoperative approach was used.

Results

The 10 patients comprised three men and seven women. Their average Hb level at the first visit was 11.1 g/dL. With treatment according to our protocol, the average preoperative Hb level rose to 12.01 g/dL, and the average Hb level on postoperative day 1 was 10.01 g/dL. No patients needed a blood transfusion, and all patients were discharged without any complications.

Conclusions

This study presents a way to manage patients who refuse blood transfusions while undergoing orthognathic surgery. rEPO and iron supplementation were used to maintain Hb levels above 10 g/dL. During surgery, blood loss was minimized by a meticulous procedure and induced hypotensive anesthesia, and intravascular volume was maintained by ANH. Our practical approach to orthognathic surgery for Jehovah’s Witnesses can be applied to the management of all patients who refuse blood transfusions.

Intraoperative Blood Loss in Maxillofacial Trauma Surgery

Background and Objectives

This study is aimed to assess the intraoperative blood loss of patients with maxillofacial bone fracture surgical intervention and to assess their need for blood transfusion.

Materials and Methods

In this retrospective study, intraoperative blood loss of 206 patients with facial bone fractures, who underwent surgery between 2017 and 2018, was retrieved. The patient's demographic information, the amount of blood loss, the type of facial bone fracture, and the patient's requirement for blood products were evaluated.

Results

The average amount of intraoperative blood loss was 77.6 ml, and none of the patients required a blood transfusion during the operation in this group of patients. maxillofacial bone fracture was most common in young males. The leading cause of fractures was motor vehicle accident. There was a reverse correlation between the patient's age and surgical blood loss, but there was no statistically significant relationship between the patient's gender and intraoperative surgical blood loss.

Conclusion

The results of the present study show that preparation for blood transfusion in patients with maxillofacial traumatic bone fracture requiring surgery is uncommon if patients have no systemic disease or specific blood dyscrasias preoperatively.

Is there a hidden blood loss in orthognathic surgery and should it be considered? Results of a prospective cohort study

The aim of this prospective observational study was to investigate the parameter 'hidden blood loss' (HBL) in the context of orthognathic surgery, incorporating undetected bleeding volumes occurring intra- and postoperatively. Orthognathic bleeding volumes were recorded at three different time points. At the end of the operation the visible intraoperative blood loss (VBL) was measured. Additionally, the perioperative blood loss was calculated 24 h and 48 h postoperatively using the 'haemoglobin balance method'. Analysis of the HBL was based on the difference between the visible intraoperative blood loss (VBL) and calculated blood loss (CBL), determined 48 h after surgery. 82 patients (male 33, female 49) were included in this study, of whom 41 underwent bimaxillary surgery and of whom 41 underwent Bilateral Sagittal Split Osteotomy (BSSO). Statistically significant differences with reference to the absolute bleeding volumes were found when comparing the two treatment modalities. In terms of HBL, a bleeding volume of 287.2 ml (±265.9) in the bimaxillary group and 346.9 ml (±271.3) in the BSSO cohort was recorded. This accounted for 32.2% (bimaxillary surgery) and 62.6% (BSSO) of the CBL after 48 h (BIMAX vs. BSSO, p < 0.001). HBL is a valuable adjunct to record within the perioperative management of orthognathic surgery to further improve patient safety and postoperative outcomes.

Clinical anatomy of the accessory mandibular foramen: application to mandibular ramus osteotomy

PURPOSE

An accessory foramen around the mandibular foramen is called an accessory mandibular foramen (AMF). The clinical anatomy of the AMF has not been well described. The aim of this study was to reveal the clinical anatomy of the AMF for a better understanding of its implication during ramus surgeries.

METHODS

Twenty-two sides fresh-frozen cadaveric heads with a mean age of 76.2 ± 14.4 years at death underwent dissection. The neurovascular bundles passing through the AMF were observed. Additionally, a hemi-face of a latex injected embalmed cadaver was dissected medially to laterally and the neurovascular bundles of the AMF investigated.

RESULTS

A unilateral foramen, bilateral foramina, and absence of foramina were found in 45.4%, 18.2%, and 36.4%, respectively. The origin of the neurovascular bundle entering the AMF was a branch of the maxillary artery in 20% and a tributary of the inferior alveolar vein in 80%. In the latex embalmed cadaver, the AMF was found to contain a branch from the maxillary artery and a tributary of the maxillary vein.

CONCLUSION

Given the practical meaning of the specific AMF located in the operative field of the ramus osteotomy, we suggest these be named "foramina for ramus osteotomy."

Blood loss and operative time associated with orthognathic surgery utilizing a novel navigation system in cleft lip and palate patients

PURPOSE

This retrospective study evaluated the volume of blood loss and operative time associated with management of nongrowing patients with cleft lip and palate (CLP) using bimaxillary orthognathic surgery (OGS) designed by a three-dimensional (3D) computer-assisted simulation and navigation for orthognathic surgery (CASNOS) system.

METHODS

This study included 53 skeletal Class III nongrowing patients with unilateral CLP who underwent bimaxillary OGS using either the CASNOS protocol (n = 30) or the traditional two-dimensional (2D) method (n = 23). The skeletal parameters of jaw-bone components, the levels of hemoglobin (Hb) and hematocrit (Hct) were measured before and after surgery. The estimated blood loss and actual blood loss (ABL) were also calculated.

RESULTS

The two groups did not differ significantly with regard to the demographic parameters (age, gender, and body mass index), the preoperative skeletal parameters and surgical changes of jaw-bone components. The mean ABL of the CASNOS group was significantly lower than that of the control group (915.6 ± 280.5 vs. 1204.9 ± 201.0 ml, p < 0.001), and the changes in Hb and Hct level also followed a similar pattern in both groups. The mean operative time was significantly shorter in the CASNOS group compared with the control group (384.2 ± 48.5 vs. 469.0 ± 94.9 min, p < 0.001).

CONCLUSION

This study demonstrated that the application of the 3D CASNOS approach in OGS for the management of complicated Class III nongrowing patients with CLP significantly shortened the operative time and reduced ABL in comparison with the traditional 2D methods.

Propofol Versus Remifentanil: Which One Is More Effective in Reducing Blood Loss During Orthognathic Surgery? A Randomized Clinical Trial

PURPOSE

Propofol and remifentanil are 2 useful drugs used in induced hypotensive anesthesia. The purpose of this study was to compare the effects of these drugs on intraoperative blood loss, transfusion requirements, and hemodynamic status during standardized orthognathic surgical procedures.

MATERIALS AND METHODS

In this double-blind randomized clinical trial, 50 consecutive healthy patients with Class III skeletal deformity were candidates for bimaxillary orthognathic surgery at Qaem Hospital, Mashhad University of Medical Sciences (Mashhad, Iran), from November 2016 until December 2017. These patients were randomly assigned to 2 equal-number groups to receive hypotensive anesthesia with propofol or remifentanil. Neither the surgeon nor the patients were aware of the study groups, whereas both the student and anesthesiologist were not blinded. Age and gender were recorded, and mean blood loss, mean arterial pressure, and mean heart rate, as well as duration of surgery and duration of general anesthesia, were monitored intraoperatively. The hypotensive anesthetic drugs were the primary predictor variables and the mean blood loss volume was the main outcome in this research. The independent t test and χ² test were performed for data analysis using SPSS software (version 16; SPSS, Chicago, IL).

RESULTS

In this study, 25 patients with a mean age of 22.25 ± 3.31 years were investigated in each group. The mean blood loss volume was 578.26 ± 95.14 mL and 366.67 ± 64.92 mL in the propofol and remifentanil groups, respectively. The independent-samples t test showed that mean blood loss was significantly lower in the remifentanil group than in the propofol group (P = .001). Furthermore, the mean arterial blood pressure was significantly lower in the remifentanil group than in the propofol group (85 ± 20 mm Hg vs 95 ± 15 mm Hg, P < .001).

CONCLUSIONS

Hypotensive anesthesia with remifentanil, in comparison with propofol, significantly reduces mean blood loss during orthognathic surgery, which decreases the transfusion requirements and disadvantages of transfusion and blood loss.

Propofol-remifentanil is More Effective than Propofol-fentanyl in Decreasing Intraoperative Blood Loss during Sagittal Split Ramus Osteotomy

This study retrospectively compared blood loss during sagittal split ramus osteotomy in patients receiving propofol-remifentanil (R group) and those receiving propofol-fentanyl (F group). All patients underwent sagittal split ramus osteotomy under general anesthesia during the 3-year 4-month period between October 2007 and February 2011 in an operating room at Tokyo Dental College Suidobashi Hospital. Blood loss in the R group was significantly less than that in the F group. Mean arterial pressure and heart rate, measured at 20 and 15 min after tracheal intubation, respectively, were both lower in the R group. No marked change was observed in blood pressure in the R group under general anesthesia, however. Volume of urine was also larger in the R group. The results of this study suggest that remifentanil is effective in reducing intraoperative blood loss during sagittal split ramus osteotomy.

Perioperative red blood cell transfusion in orofacial surgery

In the field of orofacial surgery, a red blood cell transfusion (RBCT) is occasionally required during double jaw and oral cancer surgery. However, the question remains whether the effect of RBCT during the perioperative period is beneficial or harmful. The answer to this question remains challenging. In the field of orofacial surgery, transfusion is performed for the purpose of oxygen transfer to hypoxic tissues and plasma volume expansion when there is bleeding. However, there are various risks, such as infectious complications (viral and bacterial), transfusion-related acute lung injury, ABO and non-ABO associated hemolytic transfusion reactions, febrile non-hemolytic transfusion reactions, transfusion associated graft-versus-host disease, transfusion associated circulatory overload, and hypersensitivity transfusion reaction including anaphylaxis and transfusion-related immune-modulation. Many studies and guidelines have suggested RBCT is considered when hemoglobin levels recorded are 7 g/dL for general patients and 8-9 g/dL for patients with cardiovascular disease or hemodynamically unstable patients. However, RBCT is occasionally an essential treatment during surgeries and it is often required in emergency cases. We need to comprehensively consider postoperative bleeding, different clinical situations, the level of intra- and postoperative patient monitoring, and various problems that may arise from a transfusion, in the perspective of patient safety. Since orofacial surgery has an especially high risk of bleeding due to the complex structures involved and the extensive vascular distribution, measures to prevent bleeding should be taken and the conditions for a transfusion should be optimized and appropriate in order to promote patient safety.

Prophylactic embolisation of the internal maxillary artery in patients with ankylosis of the temporomandibular joint

The aim of the present study was to assess the efficacy of using prophylactic embolisation of the internal maxillary artery to minimise the risk of bleeding during gap arthroplasty. We studied a prospective series of 14 patients with ankylosis of the temporomandibular joint (TMJ) between January 2011 and February 2016, who were under the care of one surgeon. They were all treated by embolisation of the internal maxillary artery 24hours before gap arthroplasty. The main outcome variable was estimated blood loss, and others included the need to extend the gap arthroplasty, and the risk of reankylosis. We studied nine women and five men, mean (SD) age 51 (18) years, seven with unilateral and seven with bilateral ankylosis. Their mean (SD) estimated blood loss was 136 (77) ml, which we considered to be minimal. Patients were followed-up at six-monthly intervals, during which time there was no reankylosis or limitation of mouth opening. No patient lost more than 250ml blood in total. Prophylactic embolisation of the internal maxillary artery seems to be beneficial and safe in the management of selected cases of ankylosis of the TMJ.

Comparison of intraoperative blood loss between four different surgical procedures in the treatment of bimaxillary protrusion

OBJECTIVE

This study was aimed at investigating the correlation between intraoperative blood loss and operation-related factors in the treatment of bimaxillary protrusion with four different procedures.

STUDY DESIGN

Ninety-four patients were separated into the following four surgical groups: group 1: anterior subapical osteotomy of the maxilla (ASO Mx) + bilateral parasymphyseal osteotomy of the mandible (BPsO Md) + genioplasty (GeP); group 2: ASO Mx + BPsO Md; group 3: ASO Mx + ASO Md + GeP; and group 4: ASO Mx + ASO Md. Patient- and operation-related factors (age, intraoperative blood loss, operation time, and preoperative and postoperative blood parameters) were compared among the four groups.

RESULTS

The mean operation time and intraoperative blood loss were 438.7 minutes and 369.9 mL in group 1; 432.5 minutes and 356.5 mL in group 2; 393.3 minutes and 387.3 mL in group 3; and 353.5 minutes and 289.5 mL in group 4. Intergroup differences in intraoperative blood loss were not significant. A significant correlation between intraoperative blood loss and operation time was found in group 4 but not in the other groups.

CONCLUSIONS

No significant differences in blood loss were found among the four different surgical procedures in the treatment of bimaxillary protrusion.

Predictors of blood loss during orthognathic surgery: outcomes from a teaching institution

PURPOSE

The objective of the study was to correlate different orthognathic surgical procedures with operating time and blood loss, reported from an accredited resident training institution.

METHODS

Ninety-five patient records were evaluated retrospectively. Individual blood volume, percent blood volume lost (BVL), and estimated blood loss (EBL) for each patient were recorded and correlated with operating time (OT). Statistics included independent t tests, one-way analysis of variance, and linear regression.

RESULTS

The mean OT for all procedures was 203 min with mean blood loss 556 ml. Mean EBL for males was 676 ml versus 468 ml for females. Overall BVL was 12.4 %, while for males, BVL was 13.3 % compared to 11.8 % for females. For a single orthognathic procedure (n = 45), mean OT 145 min., EBL 414 ml, and BVL 9.0 %; two procedures (n = 41), mean OT was 239 min., EBL 659 ml, and BVL 15 %; three procedures (n = 9), mean OT 328 min, EBL 793 ml, and BVL was 17 %.

CONCLUSION

Examination of individual procedures suggests a shorter OT for Le Fort I procedures with slightly greater EBL. Concomitant orthognathic procedures are associated with greater OT and EBL. Blood volume should be calculated for male and female patients separately. Percent BVL can be predicted based on OT using a basic equation.

Correlation Between Blood Loss and Patient-Related Factors in the Bilateral Parasymphyseal Osteotomy

The aim of this study was to determine the correlation between pre- and postsurgical loss of blood and blood components among patients undergoing treatment of facial deformities by bilateral parasymphyseal osteotomy (BPsO).The pre- and postoperative values of blood components were determined in 30 facial deformity patients who underwent orthognathic surgery by hypotensive anesthesia. Correlations among the blood loss, sex, age, operation time, and reduced values of blood components were assessed by a correlation matrix. The mean blood loss and operation time were 437.5 (± 52.5) mL and 355.8 (± 209.42) minutes, respectively. Two patients included in this study had required blood transfusion. The mean reduced red blood cell (× 10/μL), hemoglobin (g/dL), and hematocrit (%) were -1.02, -2.98, and -9.18, respectively. There was no significant correlation between blood loss and other related factors (eg, age, operation time, and reduced blood components). All patients, however, showed significantly lower values of blood components after surgery. In conclusion, no significant factor was associated with blood loss and reduced blood components among patients undergoing BPsO. Furthermore, hypotensive anesthesia is a well-accepted method to reduce blood loss during orthognathic surgery.

Intraoperative Hemorrhage and Postoperative Sequelae after Intraoral Vertical Ramus Osteotomy to Treat Mandibular Prognathism

Objective. To investigate the factors affecting intraoperative hemorrhage and postoperative sequelae after orthognathic surgery. Materials and Methods. Eighty patients with mandibular prognathism underwent surgical mandibular setback with intraoral vertical ramus osteotomy (IVRO). The correlation between the blood loss volume and postoperative VAS with the gender, age, and operating time was assessed using the t-test and Spearman rank correlation coefficient. The correlation between the magnitude of mandibular setback with the presence of TMJ clicking symptoms and lip sensation was also assessed. Results. The mean operating time and blood loss volume for men and women were 249.52 min and 229.39 min, and 104.03 mL and 86.12 mL, respectively. The mean VAS in men and women was 3.21 and 2.93, and 1.79 and 1.32 on the first and second postoperative days. There is no gender difference in the operating time, blood loss, VAS, TMJ symptoms, and lip numbness. The magnitude of mandibular setback was not correlated with immediate and long-term postoperative lip numbness. Conclusion. There are no gender differences in the intraoperative hemorrhage and postoperative sequelae (pain, lip numbness, and TMJ symptoms). In addition, neither symptom was significantly correlated with the amount of mandibular setback.

Assessment of hematologic parameters before and after bimaxillary orthognathic surgery

PURPOSE

The purpose of the study was to evaluate changes of hematologic parameters in bimaxillary surgery.

METHODS

Fifty-three patients were prospectively evaluated and divided into groups based on the surgical procedure and sex (predictor variables). Hemoglobin, red blood cells, hematocrit, and platelet were the primary outcome variables, operation time the secondary outcome, and the patients' age and weight the other variables.

TRIAL REGISTRATION

NCT02364765 (U.S. National Institutes of Health, clinicaltrials.gov).

RESULTS

There was statistically significant difference between all hematologic parameters before and after surgery, for both men and women, and for all surgical groups. There was a positive correlation between operative time and the decrease (in %) of the hematologic parameters. Linear regression analysis suggested that the Hb values decrease 0.083 % for every minute increase in the operation time, and 0.066, 0.066, and 0.010 % for RBC, Hct, and platelet count, respectively. There was a negative correlation between weight and all hematologic parameters. Correlations between age and hematologic parameters were not statistically significant. Almost all correlations between age, weight, sex, and the surgery group and the hematologic parameters were considered as very weak. Only one patient was transfused.

CONCLUSIONS

It is suggested that operation time and patient's weight play a bigger role than patient's age and sex in the decrease of hematologic parameters after bimaxillary surgery.

Operative Time, Airway Management, Need for Blood Transfusions, and In-Hospital Stay for Bimaxillary, Intranasal, and Osseous Genioplasty Surgery: Current Clinical Practices

PURPOSE

The purpose of this study was to assess operative time, perioperative airway management, early postoperative cardiopulmonary health, need for blood transfusion, and in-hospital stay associated with simultaneous bimaxillary, intranasal, and osseous genioplasty surgery.

MATERIALS AND METHODS

The authors executed a retrospective cohort study derived from patients treated by 1 surgeon at a single institution from 2009 through 2014. The sample consisted of a consecutive series of patients with symptomatic chronic obstructed nasal breathing and a dentofacial deformity (DFD). All underwent at least a Le Fort I osteotomy, sagittal ramus osteotomies, septoplasty, inferior turbinate reduction, and osseous genioplasty. For each patient, the design of the osteotomies and the fixation techniques were consistent. The outcome variables included need for blood transfusion, operating time, success of nasotracheal intubation, time and place of extubation, early postoperative cardiopulmonary health, length of in-hospital stay, and need for readmission after surgery.

RESULTS

For the 166 patients studied, the average age was 25 years (range, 13 to 65 yr; 87 female patients [52%]). The primary patterns of presenting DFD included long face (43 of 166, 26%), maxillary deficiency (41 of 166, 25%), asymmetric mandibular excess (37 of 166, 22%), short face (28 of 166, 17%), and mandibular deficiency (15 of 166, 9%). Forty-two patients (25%) were confirmed to have symptomatic obstructive sleep apnea. The open wound operating time averaged 2 hours 59 minutes (standard deviation, 32 minutes). Only 3 of the 166 patients (1.8%) received blood transfusions. All patients underwent successful nasotracheal intubation. Ninety-six percent of patients were extubated in the operating room and the remaining 4% were extubated in the recovery room. No patients required reintubation or tracheostomy. One hundred thirty-seven patients (83%) were discharged after a 1- or 2-night in-hospital stay. Twenty-five (15%) required a 3-night stay and 4 (2%) required a 4-night hospital stay to achieve adequate oral intake. None of the patients required readmission.

CONCLUSIONS

This study confirms efficient surgical and anesthesia care for patients undergoing simultaneous bimaxillary orthognathic, intranasal, and osseous genioplasty. Anticipating safe nasotracheal intubation with extubation soon after surgery and a limited need for blood transfusion has proved to be the norm. This study confirmed an average in-hospital stay of 2 nights after complex orthognathic surgery without need for readmission.

Predictors of intra-operative blood loss and blood transfusion in orthognathic surgery: a retrospective cohort study in 92 patients

Background

Patients undergoing orthognathic procedures can require blood transfusions. The objectives of this study were to evaluate the predictors of intra-operative blood loss in patients undergoing orthognathic procedures and the transfusion rates and practices of our institution.

Materials and methods

This retrospective study included 92 patients who underwent the following four types of orthognathic procedures: Group 1, bimaxillary; Group 2, bimaxillary with bone grafts; Group 3, LeFort I osteotomies; and Group 4, LeFort I osteotomies with bone grafts. The intra-operative blood loss, operative time, age, gender and pre- and post-operative HGB and HCT were assessed.

Results

The mean blood loss for all groups was 650 ± 397.8 mL, and there were differences in blood loss between the four groups (p = 0.211). The mean operative time was 5 hours and 32 minutes. There were no differences in intra-operative blood loss between the genders or the BMI categories. The operative time was moderately correlated with the intra-operative blood loss (p < 0.001, r =0.332). Eighteen of the 92 patients (19.5%) received blood transfusions. The mean intra-operative blood loss was higher among the patients who received transfusions (p < 0.001).

Conclusions

The only predictor of intra-operative blood loss was operative time. The observed transfusion rate was higher than those that have been reported for similar procedures; thus, our institution needs to revisit our transfusion policy and use more time-efficient techniques in the operating room.

Comparative analysis of the amount of postoperative drainage after intraoral vertical ramus osteotomy and sagittal split ramus osteotomy

Objectives

The purpose of this retrospective study was to compare the amount of postoperative drainage via closed suction drainage system after intraoral vertical ramus osteotomy (IVRO) and sagittal split ramus osteotomy (SSRO).

Materials and Methods

We planned a retrospective cohort study of 40 patients selected from a larger group who underwent orthognathic surgery from 2007 to 2013. Mean age (range) was 23.95 (16 to 35) years. Patients who underwent bilateral IVRO or SSRO were categorized into group I or group II, respectively, and each group consisted of 20 patients. Closed suction drainage system was inserted in mandibular osteotomy sites to decrease swelling and dead space, and records of drainage amount were collected. The data were compared and analyzed with independent t-test.

Results

The closed suction drainage system was removed at 32 hours postoperatively, and the amount of drainage was recorded every 8 hours. In group I, the mean amount of drainage was 79.42 mL in total, with 31.20 mL, 19.90 mL, 13.90 mL, 9.47 mL, and 4.95 mL measured at 0, 8, 16, 24, and 32 hours postoperatively, respectively. In group II, the mean total amount of drainage was 90.11 mL, with 30.25 mL, 25.75 mL, 19.70 mL, 8.50 mL, and 5.91 mL measured at 0, 8, 16, 24, and 32 hours postoperatively, respectively. Total amount of drainage from group I was less than group II, but there was no statistically significant difference between the two groups (P=0.338). There was a significant difference in drainage between group I and group II only at 16 hours postoperatively (P=0.029).

Conclusion

IVRO and SSRO have different osteotomy design and different extent of medullary exposure; however, our results reveal that there is no remarkable difference in postoperative drainage of blood and exudate.

Assessment of Intraoperative Blood Loss during Oral and Maxillofacial Surgical Procedures in a Nigerian Tertiary Health Care Center

Background. Reports on estimated amount of blood loss in maxillofacial surgical procedures will guide clinicians through units of blood required for each procedure. The aim of the study was to assess the amount of blood loss and duration of surgery. Methods. All cases of maxillofacial surgical procedures done under GA in the MFU theatre, from January 2007 to December 2013, were included in the study. Pre- and postoperative haematocrit values, number of units of whole blood requested and used, amount of blood loss, and duration of surgery were recorded. Results. 139 patients were analyzed, of which 75 (54.0%) were males and 64 (46.0%) were females. Fifty-six (40.3%) cases involved soft tissues. Eighty-three cases involved hard tissues. Age range was 2 months to 78 years; mean ± (SD) was 21.3 ± (18.5) years. Isolated unilateral cleft lip had the lowest mean value of estimated blood loss of 10.4 ± 10.8 mLs and also the lowest duration of surgery of 58 (76) minutes. There was no significant relationship between both parameters for cleft lip. Fractures of the mandible had mean blood loss of 352 mLs and duration was 175 min. Conclusion. In this study, there was significant relationship between estimated blood loss and duration of surgery for mandibular and zygomatic complex fractures.

Intraoperative blood loss and blood transfusion requirements in patients undergoing orthognathic surgery

Procedures for the surgical correction of dentofacial deformities may produce important complications, whether due to the potential for vascular injury or to prolonged surgery, both of which may lead to severe blood loss. Fluid replacement with crystalloid, colloid, or even blood products may be required. The aim of this study was to assess blood loss and transfusion requirements in 45 patients (18 males and 27 females; mean age 29.29 years, range 16-52 years) undergoing orthognathic surgery, assigned to one of two groups according to procedure type-rapid maxillary expansion or double-jaw orthognathic surgery. Preoperative hemoglobin and hematocrit levels and intraoperative blood loss were measured. There was a substantial individual variation in pre- and postoperative hemoglobin values (10.3-17 and 8.8-15.4 g/dL, respectively; p < 0.05). Mean hematocrit values were 41.53 % preoperatively (range 31.3-50.0 %) and 36.56 % postoperatively (range 25-43.8 %) (p < 0.05). Mean blood loss was 274.60 mL (range 45-855 mL). Only two patients required blood transfusion. Although blood loss and transfusion requirements were minimal in the present study, surgical teams should monitor the duration of surgery and follow meticulous protocols to minimize the risks.

Intraoperative hypertensive crisis secondary to an undiagnosed pheochromocytoma during orthognathic surgery: a case report

Increased blood pressure (BP) during orthognathic surgery may result in excessive blood loss, poor surgical field visualization, and longer surgical time and require blood transfusion. When uncontrollable high BP is encountered in an otherwise healthy patient during orthognathic surgery, the diagnosis of pheochromocytoma should be considered. Pheochromocytomas are rare neuroendocrine tumors of the chromaffin cells of the adrenal medulla or extra-adrenal paraganglia (sympathetic ganglia) that secrete catecholamine. They are present in approximately 0.05 to 0.2% of hypertensive patients. Patients can present with hypertension, tachycardia, headaches, and diaphoresis. The clinical presentation may vary and a wide spectrum of nonspecific symptoms may be encountered. The elevated BP can be intermittent (40%) or permanent (60%). About 10% of pheochromocytomas are hereditary and they can be a feature of multiple endocrine neoplasia type 2. This report describes the case of a 29-year-old patient with a large pheochromocytoma of the right adrenal gland undiagnosed before orthognathic surgery.

Risk of maxillary artery injury during an intraoral vertical ramus osteotomy in Japanese patients is high--is it enough just to avoid damaging the inferior alveolar nerve?

PURPOSE

Since managing a case in which the maxillary artery was injured during intraoral vertical ramus osteotomy (IVRO) with intraoperative transcatheter arterial embolization, we have conducted preoperative vascular computed tomography (CT) evaluations of the maxillary artery course in patients scheduled to undergo mandibular bone osteotomy. The aim of the present study was to describe the anatomy of the maxillary artery in the infratemporal artery in Japanese patients.

MATERIALS AND METHODS

The study design was a prospective case series. The study sample included all patients who had undergone IVRO from October 2009 to December 2012. We evaluated the positional relationship between the maxillary artery and the mandible using CT vascular imaging before surgery. The primary outcome variable was the requirement for subperiosteal dissection on the medial surface of the mandible from the perspective of the intersection of the route of the maxillary artery with the IVRO osteotomy line.

RESULTS

A total of 156 sides from 78 patients who had undergone mandibular bone osteotomy were included in the present study. The maxillary artery course was positioned directly below the mandibular notch in approximately one half of the cases, necessitating subperiosteal dissection on the medial surface of the mandible.

CONCLUSIONS

IVRO is a common surgical procedure that can be safely and easily conducted in conjunction with endoscopy. However, improved maxillary artery damage prevention methods are recommended, such as subperiosteal dissection on the medial surface of the mandible and filling the medial surface of the mandibular ramus with gauze.

Morphologic features of the mandibular ramus associated with increased surgical time and blood loss in sagittal split-ramus osteotomy

PURPOSE

To determine whether specific morphologic features of the mandibular ramus can predict increased surgical time and blood loss in sagittal split-ramus osteotomy (SSRO).

MATERIALS AND METHODS

The clinical and morphologic features of the mandibular ramus, obtained from computed tomographic images (n=50), were analyzed to predict the surgical time, the time required for ablation of the medial mandibular ramus, and the time required for sectioning of the mandible in performing a modified Obwegeser SSRO.

RESULTS

Significant factors associated with surgical time were an anterior border of the ramus at least 10.5 mm wide, a maximal length of the thickened ramus of at least 8.5 mm, and a distance from the mandibular incisor to the posterior border of the mandible of at least 97.5 mm. There were significant differences in blood loss between the 2 axial aspects of the medial ramus.

CONCLUSIONS

The greater protrusion of the medial oblique ridge, thickened ramus, and longer distance from the mandibular incisors to the posterior border of the mandible may increase the surgical time and blood loss in patients undergoing classic SSRO. When planning or performing an SSRO, the morphologic features obtained from computed tomographic images may help surgeons gain a better understanding of the potential difficulties when the surgical site involves the medial aspect of the ascending ramus of the mandible.