Traumatic arteriovenous malformation following maxillary Le Fort I osteotomy

Iatrogenic Arteriovenous Fistula between the Middle Meningeal Artery and Pterygoid Venous Plexus Secondary to a Le Fort I Osteotomy: A Case Report

Le Fort I osteotomy is a common surgical technique for correcting jaw deformities. Although it is generally a safe procedure, there have been cases of postoperative vascular complications, which include arteriovenous fistulas. Published reports describe the development of arteriovenous fistulas that originate from the maxillary artery after this procedure; nevertheless, no cases of arteriovenous fistulas arising from the middle meningeal artery (MMA) have been reported. We present the case of a 19-year-old woman who developed pulsatile tinnitus immediately following a Le Fort I osteotomy. Angiography with proximal flow control of the external carotid artery showed an arteriovenous fistula between the extracranial portion of the MMA and the pterygoid venous plexus. The fistula was successfully treated using coil embolization, preserving the maxillary artery, which results in tinnitus resolution. In this report, the effectiveness of endovascular treatment for arteriovenous fistulas of the MMA that occur following a Le Fort I osteotomy was demonstrated. Angiography with proximal flow interruption was effective in shunt location detection.

Delayed Epistaxis which Was Developed after Orthognathic Surgery with Le Fort I Osteotomy and Managed by Endoscopic Cauterization

A case of delayed epistaxis from the mucosa behind the right side of the inferior nasal mucosa 11 days after orthognathic surgery by Le Fort I osteotomy is presented. The patient was a 31-year-old man who underwent orthognathic surgery under general anesthesia. No abnormal findings were found during or after the operation. The patient was discharged from the hospital 10 days postoperatively. However, bleeding from the right nasal cavity occurred suddenly on the night after discharge, and he presented to our hospital again. The epistaxis was stopped once by nasal packing containing 0.001% epinephrine and systemic infusion of carbazochrome sulfonic acid and tranexamic acid. However, when the nasal packing was removed the next day, right nasal epistaxis was observed again. Curvature of the nasal septum and thickening of the inferior turbinate mucosa were seen on inspection; although, no active bleeding point was identified. Decreased nasal mucosa thickening and bleeding were observed after nasal packing containing 0.02% epinephrine. When the inside of the nasal cavity was observed endoscopically, an approximately 2 mm laceration was found in the mucosa behind the side wall of the right inferior nasal mucosa, and bleeding from the same part was confirmed. After endoscopic cauterization for hemostasis of the nasal mucosa, no rebleeding was observed. Although delayed epistaxis after Le Fort I osteotomy are often performed CT angiography to confirm the bleeding site, endoscopic cauterization would be primarily useful because of less invasiveness.

Evaluating Morphology of the Pterygomaxillary Junction and Its Association With the Orbit in Different Facial Skeletal Relationships

PURPOSE

The etiology for blindness after Le Fort I osteotomy is poorly understood. The authors propose that a study of the morphology and anatomical relationship of the pterygomaxillary junction to orbital vital structures may be crucial for understanding the possible etiology.

MATERIALS AND METHODS

This retrospective observational study involved analysis of data procured from computed tomography scans of individuals who were categorized into 4 groups based on their skeletal characteristics: skeletal Class I, II, and III and cleft lip palate (CLP). The outcome variables included i) the height, width, and thickness of the pterygomaxillary junction (PTMJ) which represent its morphology and ii) distance of the PTMJ to the superior orbital fissure and optic canal, to demonstrate its proximity to orbital vital structures. Primary outcome measures were to i) compare variance of the outcome variables across groups, ii) determine association between PTMJ morphology and its proximity to the orbit, and iii) determine association between skeletal morphology and the outcome variables. Data were analyzed using descriptive and inferential statistics to study variance and association.

RESULTS

Forty patients (80 sides) were divided into 4 groups. The CLP group demonstrated maximum height and thickness of the PTMJ, whereas the Class II group demonstrated the minimum (P < .001 and P = .001, respectively). The CLP group demonstrated the closest proximity of the PTMJ to orbital vital structures (P < .001), with Class II being the farthest (P < .001). There was a weak positive correlation between the PTMJ height and its thickness and width, whereas a moderate negative correlation was seen between the PTMJ height and its distance from the optic canal and superior orbital fissures (P < .001).

CONCLUSIONS

Morphology of the PTMJ varies with facial skeletal relationship and also influences the relationship of the PTMJ with the orbital vital structures. This may be critical in understanding the pathophysiology of blindness after Le Fort I osteotomies.

A rare complication of an Arteriovenous shunt after bimaxillary surgery

The most common complications following bimaxillary surgery are inferior alveolar nerve damage, hemorrhage, and relapse. Severe complications are rare, but few cases of vascular arteriovenous malformation, cavernous sinus thrombosis, formation of an aneurysm or arteriovenous shunting are reported in literature. We present a case of a 20-year-old male patient who developed a right sided tinnitus and visible pulsations close to the mandibular angle on the right side after bimaxillary surgery. CT-angiography and subsequent digital subtraction angiography (DSA) six months after surgery showed an arteriovenous fistula (AVF) from the external carotid artery to the external jugular vein. The AVF was treated by endovascular coil embolization. At six months after intervention there were no residual complaints. We discuss the possible etiology and trauma mechanisms that might have caused this pathology and present recommendations to avoid this type of complications.

Evaluation of the Pterygomaxillary Separation Pattern in Le Fort I Osteotomy Using Different Cutting Instruments

PURPOSE

Pterygomaxillary separation (PMS) is considered the main reason for serious complications associated with Le Fort I osteotomy. The aim of this study was to evaluate whether a piezo surgery, ultrasonic bone scalpel, or conventional bur used in Le Fort I osteotomy has an influence on PMS patterns.

MATERIALS AND METHODS

Using a retrospective cohort study design, we enrolled a sample composed of patients who underwent orthognathic surgery. The primary predictor variables were the cutting instruments (ultrasonic bone scalpel, piezo surgery, and Lindeman bur) used to perform Le Fort I osteotomy. Other variables were demographic and anatomic parameters. The outcome variable was the type of PMS pattern, classified as follows: type 1, PMS at the pterygomaxillary junction (ideal PMS); type 2, PMS at the greater palatine foramen; type 3, PMS from the posterior wall of the maxillary sinus; and type 4, PMS with lateral or medial pterygoid fracture. Anatomic parameters, that is, the thickness and width of the pterygomaxillary junction and distance of the greater palatine foramen, were measured on preoperative cone-beam computed tomography images. The pattern of PMS was evaluated on postoperative cone-beam computed tomography. Data were analyzed using analysis of variance and the Pearson χ² test. P < .05 was considered statistically significant.

RESULTS

This study sample was composed of 96 PMSs in 48 patients. The most common type of PMS was type 1 (58), followed by type 4 (21), type 2 (10), and type 3 (7). A statistically significant relation was found between the cutting instrument and the ideal separation (type 1 PMS) pattern (P = .032), and the highest rate of the ideal separation pattern was seen in the ultrasonic bone scalpel group, at 24 of 32, compared with 22 of 38 in the piezo surgery group and 12 of 26 in the conventional bur group.

CONCLUSIONS

According to the study, the ultrasonic bone scalpel is safer than other cutting instruments in terms of the ideal separation of the pterygomaxillary junction.

Carotid jugular fistula after Le Fort I osteotomy

Le Fort I osteotomy is the technique most applied worldwide in the treatment of dentoskeletal deformity involving the maxilla. Even though it is considered a very safe technique with good intra- and postoperative results, many complications have been described. This paper presents a case of carotid jugular fistula developed in a 22-year-old white male submitted to Le Fort I osteotomy for the treatment of anteroposterior maxillary deficiency, and discusses the possible aetiology and management of this serious complication.

Radiologic anatomy of the maxillary artery in the pterygopalatine area applied to Le Fort 1 osteotomies

PURPOSE

In Le Fort 1 osteotomies there is a risk of injuring the maxillary artery, during the pterygomaxillary (PM) disjunction. To improve the knowledge of the relation between the maxillary artery and the PM suture, an anatomic study of the pterygopalatal fossa has been performed.

METHODS

The study was based on CT scan head with vascular injection of the supraaortic trunks in 92 patients. The vertical length of the PM junction and the position of maxillary artery in relation to PM junction have been measured on a parasagittal plane passing through the lateral surface of the PM junction, and on a plane where the PM suture is the highest.

RESULTS

The height of the PM junction on the plane passing through the lateral surface of the PM junction was 6.86 ± 2.67 mm, and the maxillary artery was located 18.22 ± 3.79 mm from the most inferior point of the PM junction. The maximum PM junction height was 13.96 ± 3.03 mm, and at this place the maxillary artery was located 18.85 ± 3.26 mm from the most inferior point of the PM junction. The distance between these two planes was 5.14 ± 2.02 mm.

CONCLUSIONS

According to our results, the height of the PM junction is less than 14 mm and during the PM disjunction there is a risk of injuring the maxillary artery 18 mm above the inferior extremity of the PM junction.

Vascular changes in hard palate sialolipoma: Sialoangiolipoma or vascular malformation?

Palate sialolipomas are rare. Less than 10 cases located in the hard palate are reported to our knowledge. We report a case of hard palate sialolipoma, peculiar by the intratumor vascular patterns. A 67-year-old man presented with a 1.5 cm lesion of the oral hard palate. The lesion was surgically resected. On microscopy, the lesion, partly encapsulated, consisted of a proliferation of mature adipocytes containing normal minor salivary gland tissue and branching intratumoral vessels of varied size with irregularly thickened wall and papillary projections or tufts. The microscopic features of the tumor we report suggest that vascular malformation-like patterns may occur in sialolipomas of the hard palate. This morphological vascular peculiarity should be acknowledged since it may represent source of hemorrhage.

Preoperative and Postoperative CT Scan Assessment of Pterygomaxillary Junction in Patients Undergoing Le Fort I Osteotomy: Comparison of Pterygomaxillary Dysjunction Technique and Trimble Technique-A Pilot Study

PURPOSE

To determine the rate of complications and occurrence of pterygoid plate fractures comparing two techniques of Le Fort I osteotomy i.e., Classic Pterygomaxillary Dysjunction technique and Trimble technique and to know whether the dimensions of pterygomaxillary junction [determined preoperatively by computed tomography (CT) scan] have any influence on pterygomaxillary separation achieved during surgery.

MATERIALS AND METHODS

The study group consisted of eight South Indian patients with maxillary excess. A total of 16 sides were examined by CT. Preoperative CT was analyzed for all the patients. The thickness and width of the pterygomaxillary junction and the distance of the greater palatine canal from the pterygomaxillary junction was noted. Pterygomaxillary dysjunction was achieved by two techniques, the classic pterygomaxillary dysjunction technique (Group I) and Trimble technique (Group II). Patients were selected randomly and equally for both the techniques. Dysjunction was analyzed by postoperative CT.

RESULTS

The average thickness of the pterygomaxillary junction on 16 sides was 4.5 ± 1.2 mm. Untoward pterygoid plate fractures occurred in Group I in 3 sides out of 8. In Trimble technique (Group II), no pterygoid plate fractures were noted. The average width of the pterygomaxillary junction was 7.8 ± 1.5 mm, distance of the greater palatine canal from pterygomaxillary junction was 7.4 ± 1.6 mm and the length of fusion of pterygomaxillary junction was 8.0 ± 1.9 mm.

DISCUSSION

The Le Fort I osteotomy has become a standard procedure for correcting various dentofacial deformities. In an attempt to make Le Fort I osteotomy safer and avoid the problems associated with sectioning with an osteotome between the maxillary tuberosity and the pterygoid plates, Trimble suggested sectioning across the posterior aspect of the maxillary tuberosity itself. In our study, comparison between the classic pterygomaxillary dysjunction technique and the Trimble technique was made by using postoperative CT scan. It was found that unfavorable pterygoid plate fractures occurred only in dysjunction group and not in Trimble technique group. Preoperative CT scan assessment was done for all the patients to determine the dimension of the pterygomaxillary region. Preoperative CT scan proved to be helpful in not only determining the dimensions of the pterygomaxillary region but we also found out that thickness of the pterygomaxillary junction was an important parameter which may influence the separation at the pterygomaxillary region.

CONCLUSION

No untoward fractures of the pterygoid plates were seen in Trimble technique (Group II) which makes it a safer technique than classic dysjunction technique. It was noted that pterygoid plate fractures occurred in patients in whom the thickness of the pterygomaxillary junction was <3.6 mm (preoperatively). Therefore, preoperative evaluation is important, on the basis of which we can decide upon the technique to be selected for safer and acceptable separation of pterygomaxillary region.

Posttraumatic arteriovenous malformation of the face: a case report

BACKGROUND

Head and neck arteriovenous malformations (AVMs) are reported to occur in 0.1% of the population. Extracranial AVMs account for only 8.1% of head and neck AVMs. Of these, traumatically acquired AVMs of the face are generally reported as quite rare. When secondary to trauma, the lesion is usually supplied by a single vessel, as compared to the multiple vessels often seen with congenital etiology.

OBJECTIVES

Understanding of regional anatomy is paramount when assessing and managing facial injuries. As an integral health care provider for the facial trauma patient, it is the responsibility of the emergency physician to recognize this rare pathologic lesion necessary to coordinate surgical management of the traumatic AVM.

CASE REPORT

We present a case report of a patient who sustained a facial laceration complicated by the development of a vascular malformation. The facial laceration in this case report highlights the complexity of wound evaluation and management when treating patients in the emergency department.

CONCLUSION

Traumatic AVMs are quite rare in the head and neck and are mostly seen in the extremities. Although rare, they have been reported after typical facial trauma as well as elective surgical procedures. The management of such lesions may include selective embolization or surgical exploration with ligation. Emergency physicians and facial trauma surgeons are challenged with recognizing and treating these rare but very real vascular lesions. It is our hope that this case report provides an overview of posttraumatic AVMs in the head and neck.

An arteriovenous fistula of the maxillary artery as a complication of Le Fort I osteotomy

INTRODUCTION

The Le Fort I osteotomy, one of the most common techniques used to correct dento-midfacial deformities, is generally considered to be operatively safe. However, sometimes this procedure can lead to fatal vascular complications.

MATERIALS AND METHODS

This article describes a fifty-year-old woman with a giant facial venous malformation. The patient underwent a Le Fort I osteotomy in order to correct an open bite. The surgery was complicated by the development of an arteriovenous fistula (AVF) between the maxillary artery and the venous malformation, the diagnosis of which was made by ultrasound doppler. Neuroradiological embolisation process of the maxillary artery was performed in order to close the AVF.

RESULTS

The total fistula obliteration and a Class I occlusion were obtained.

CONCLUSIONS

The reported case suggests the necessity of a multidisciplinary process (involving both maxillofacial and neuroradiology teams) for the treatment of dento-midfacial deformities in relation to vascular malformations. This modality is the only way to guarantee minimization of morbidity (according to patient's expectations).

[Maxillary distraction complications in cleft patients]

INTRODUCTION

Cleft lip and palate (CLP) patients often present with a class III malocclusion in connection with a three dimensional maxillary hypoplasia. Twenty-five to 60% of these patients require a maxillary advancement. Two solutions are possible: orthognathic surgery and maxillary distraction. The purpose of this study was to evaluate the complications of the maxillary distraction in CLP patients.

MATERIALS AND METHODS

Data was collected from the records of patients treated at our Surgery Unit between 2000 and 2007. Among the eight patients (four male and four female), five presented a bilateral CLP, two a unilateral CLP and one a unilateral cleft lip associated to a soft palate cleft. The average age at surgery was 17 years old. All had a Le Fort I osteotomy with a pterygomaxillary disjunction. The first two patients had external distractors and the six following internal ones. After a seven-day latency, activation was led to the rate of 1mm per day twice. The period of consolidation was four months on average. The maxillary advancement varied between 7 and 19 mm with an average of 12.6mm. The average follow-up was four years.

RESULTS

We encountered difficulties and/or complications in seven patients: one intraoperatively haemorrhage, one avulsion of a tooth fixed at the pterygoid process during the osteotomy, three device failures, two cases of significant pains during activation, one dissociation of the dental anchorage of an external system, two labial ulcerations and one maxillary sinusitis by migration of the 18.

DISCUSSION

Difficulties of maxillary distraction in CLP patients are very frequent. The majority is related to the distractors and did not interfere with the final result. But this frequency must be taken into account in the indication and in the choice of the material. Two types of complications can occur during distraction: those related to the osteotomy and those related to the material. The complications related to the osteotomy are in connection with the cicatricial ground of the CLP. They are not specific of the distraction. We especially managed complications related to the material. The social benefit of the internal distractors is undeniable, but the design of certain models must be reexamined to improve their tolerance.