Post-operative avascular necrosis of the maxilla: a rare complication following orthognathic surgery

Abstract

We present a patient with sickle cell trait who suffered avascular necrosis of the maxilla as a complication of maxillary osteotomy. Understanding the blood supply of the maxilla and how possible patient related, anaesthetic and operative factors affect it, is important in understanding how the vascularity of the maxilla can become compromised in a surgical procedure. The perioperative parameters were analysed to identify any prognostic elements. Avascular necrosis of the maxilla is a rare complication of orthognathic surgery with few cases reported in the literature. There are identifiable risk factors that can influence the blood supply of the maxilla. Careful preoperative assessment is required to exclude patient factors that have the potential to affect tissue vascularity. This in conjunction with sound anaesthetic and surgical technique should all minimize the risk of avascular necrosis. Even so it is still possible for this rare complication to occur.

Computer-Assisted Microvascular Free Flap Reconstruction and Implant Rehabilitation of the Maxilla—Treatment of a Rare Post-orthognathic Complication

“…This is due to the robust collateral vascular supply from the ascending pharyngeal arteries, ascending palatine arteries, and mucosal alveolar anastomotic network overlying the maxilla [12]. More extensive osteonecrosis is likely to require surgical debridement with autogenous or allogenic bone grafting [4,8,9]. In our case, nonsurgical measures such as strict oral hygiene, PENTO, and HBOT had minimal clinical response.…”

“…Although rare, cases of post-orthognathic avascular necrosis of partial or total maxilla continue to be reported in the literature periodically [1,8,9]. Due to sufficient collateral vascular perfusion of the maxilla via the ascending pharyngeal arteries, ascending palatine arteries, and rich network of alveolar branches of the internal maxillary artery, even after the ligation of the descending palatine arteries and/or multiple osteotomies [12,[14][15][16][17], the incidence of vascular compromise of the osteotomized segments remains extremely low (\ 1%).…”

“…In addition, several studies have also identified potential risk factors associated with ANM such as variations in anatomy (i.e., vascular anomalies, and cranio-facial deformities), and medical comorbidities (i.e., tobacco smoking, hematological conditions, and autoimmune disease) [8]. Common reported intraoperative risk factors include large anterior movements greater than 9-10 mm, multiple segmental osteotomies, large transverse expansions, poor soft tissue handling or excessive soft tissue Fig.…”

“…Common risk factors associated with ANM include multiple segmental osteotomies, large anterior movements ([ 9 mm) or transverse expansion, surgeon inexperience with unusual intraoperative surgical techniques and handling of soft tissues, and additional medical comorbidities [1][2][3]. Although there have been reports of ANM in the literature, most involve relatively small segments of the maxillary alveolus and are managed with conservative local therapy [2][3][4][5][6][7][8][9][10][11].…”

Preoperative screening for sickle cell disease and guidance from the National Institute for Health and Care Excellence (NICE)

“…We would like to share our recent experience concerning a patient with a known sickle cell trait undergoing orthognathic treatment at our unit. 3 The operation planned was a Le Fort I and posterior segment osteotomy. After an uneventful procedure and recovery period, the patient returned for review at 2 weeks with obviously devascularised tissue bilaterally.…”