Prevention and management of vascular necrosis in Le Fort I osteotomies

Prevention and management of vascular necrosis in Le Fort I osteotomies
August 2004
Johan P. Reyneke, MChD, FCMFOS(SA)
Journal of Oral and Maxillofacial Surgery Online
In most of the orthognathic procedures that are performed to correct dentofacial deformities, the vascular supply to hard and soft tissues is manipulated. This also holds true when performing the Le Fort I down fracture procedure. Excellent work on revascularization, wound healing, and quantification of pre- and postoperative blood flow in rhesus monkeys has improved our knowledge of the biological basis for undertaking maxillary osteotomies. We however still do not completely understand the alteration of the hemodynamics. In fact, despite various modifications in the design of bony and soft tissue incisions during surgery, vascular necrosis remains a rare, but real complication. Once the maxilla is down fractured the maxillary hard and soft tissues are dependent on its blood supply from the palatal and posterior buccal soft tissue pedicles. The blood flow through these pedicles could be influenced by the following:
Stretching of the pedicle by significant dento-osseous repositioning
Multiple segmentalization of the maxilla
Routine transection or ligation of the descending palatine artery
Significant transverse palatal expansion
Transverse laceration of the palatal soft tissue
Compression of the palatal soft tissue
Palatal soft tissue scaring, ie, previous surgery in cleft palate patients
Hypotensive anesthesia
By adhering to sound surgical principles the risk of vascular necrosis may not be eliminated, but significantly reduced. The surgeon should always be alert for initial signs of vascular compromise.
Initial treatment of vascular necrosis should involve good oral hygiene, frequent saline irrigation, hyperbaric oxygen therapy, and antibiotics to prevent secondary infection. Although hyperbaric oxygen may not prevent necrosis it may limit the extent of the necrosis. It may also hasten delineation of the necrotic tissue and assist debridement.
Reconstruction may require closure of the defects with soft tissue flaps and bone grafts, while lost teeth may be replaced with a prosthesis or dental implants.
References
Bell WH, Fonseca RJ, Kennedy JW, et al: Bone healing and revascularization after total maxillary osteotomy. J Oral Surg 33:253, 1975
Meyer MW, Cavanagh GD: Blood flow changes after orthognathic surgery: Maxillary and mandibular subapical osteotomy. J Oral Surg 34:495, 1976
Lanigan DT, Hey JH, West RA: Aseptic necrosis following maxillary osteotomies: Report of 36 cases. J Oral Maxillofac Surg 48:142, 1990
Publishing and Reprint Information
Rivonia, South Africa
Copyright ий 2004 by Elsevier Inc.
doi: 10.1016/j.joms.2004.05.038