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British Journal of Oral and Maxillofacial Surgery 52 (2014) 767–768
Short communication
Unusual cause of iatrogenic anterior open bite after bilateral sagittal split mandibular advancement osteotomy L. Wong, A. Currie, M. Abu-Serriah ∗ Department of Oral and Maxillofacial Surgery, John Radcliffe Hospital, Oxford, OX3 9DU, UK Accepted 20 May 2014 Available online 11 June 2014
Abstract We describe a case of anterior open bite after bilateral sagittal split mandibular advancement osteotomy. The discrepancy in height between the proximal and distal segments at the osteotomy sites damaged the soft tissue and caused bony interferences. Removal of the maxillary third molars and bilateral removal of bony interferences of the distal segments using a bur led to full resolution and a good orthognathic outcome on follow-up. © 2014 Published by Elsevier Ltd. on behalf of The British Association of Oral and Maxillofacial Surgeons.
Keywords: Sagittal split osteotomy; Anterior open bite; Osteotomy; BSSO
Introduction Bilateral sagittal split osteotomy of the mandible, first described in 1957 by Trauner and Obwegeser, has since undergone various modifcations.1 Complications have often been reported and include nerve injury, unfavourable splits, infection, and relapse.2 We present a case of anterior open bite that was caused by bony interference between the distal segment of the mandible and the maxilla after bilateral sagittal split mandibular advancement osteotomy. This is an unusual postoperative complication and, to our knowledge, has not been reported before. Case report A fit and well 18-year-old man underwent joint orthognathic planning at the Department of Oral and Maxillofacial Surgery, John Radcliffe Hospital, Oxford, for correction of a ∗
Corresponding author.
class II, division 2 malocclusion with deep overbite and retrognathic mandible. After a course of orthodontic treatment, he underwent bilateral sagittal split mandibular advancement of 8 mm. The osteotomised mandible was fixed in the planned position using 2.0 titanium plates and screws (Stryker Corporation, Kalamazoo, USA), and he was discharged the next day. At follow-up the following day he had an anterior open bite of 2 mm so the orthodontist applied anterior orthodontic elastics. Ten days later, he reported pain, localised gingival swelling and an inability to bring the maxillary and mandibular anterior teeth together. Clinical examination showed a 2 mm anterior open bite and localised soft tissue damage in the retromolar region caused by the maxillary second molars (Fig. 1). Both maxillary third molars were unerupted, and there was palpable bilateral bony interferences in the retromolar regions. Clinical and radiographic examinations showed that fixation was stable and there was no evidence of condylar dislocation, but there was an appreciable anterior step between the distal and proximal segments of the ramus of the mandible (Figs. 2 and 3).
http://dx.doi.org/10.1016/j.bjoms.2014.05.011 0266-4356/© 2014 Published by Elsevier Ltd. on behalf of The British Association of Oral and Maxillofacial Surgeons.
768
L. Wong et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 767–768
showed good occlusion and healing of the soft tissue. The anterior open bite resolved completely.
Discussion
Fig. 1. Soft tissue swelling and traumatic ulceration in the left retromolar region caused by tissue trapped between the maxillary second molar and posterior part of the distal segment.
Fig. 2. Postoperative orthopantogram showing interference of the advanced distal segment and posterior maxilla (arrows).
In our patient, the low mandibular angle, the degree of advancement required to correct the dental and skeletal abnormalities, and the position of the mandibular lingula contributed to the discrepancy between the proximal and distal segments. The relation of the posterior maxilla to the anterior superior border of the advanced distal segment may also have been implicated. Muscular relaxation caused by general anaesthesia and possible distraction of the condyles made it difficult to identify the presence of bony interference intraoperatively. Pain and swelling during the immediate postoperative period concealed the problem and manual guidance into occlusion seemed satisfactory. It was only after 10 days when the postoperative swelling had resolved that the poor response to postsurgical orthodontics, persistence of the anterior open bite, and obvious damage to the intraoral soft tissue became more obvious. To avoid this complication in the future, we recommend that clinicians check for bony interferences in mandibular advancement osteotomy and, where appropriate, contour the distal mandibular segments and remove the maxillary third molars.
Conflict of Interest The authors declare no conflict of interest
Ethics statement/confirmation of patient permission Patient consent was obtained for clinical photograph.
Acknowledgement The authors of this paper would like to thank Miss Heather Nevard, Consultant Orthodontist at the John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, for the provision of orthodontic treatment. Fig. 3. Appreciable step between the superior aspects of the proximal and distal segments at the left osteotomy site.
The patient returned to theatre 12 days after the initial operation. The maxillary third molars were removed and an acrylic trimming bur was used to remove bony interferences of the distal segments bilaterally. Excess granulation tissue was excised and the wounds were closed primarily using polyglactin 910 sutures (Vicryl). Recovery was uneventful and clinical examination during follow-up appointments
References 1. Trauner R, Obwegeser H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. I. Surgical procedures to correct mandibular prognathism and reshaping of the chin. Oral Surg Oral Med Oral Pathol 1957;10:677–89. 2. Bays RA, Bouloux GF. Complications of orthognathic surgery. Oral Maxillofac Surg Clin North Am 2003;15:229–42.
British Journal of Oral and Maxillofacial Surgery 52 (2014) 767–768
Short communication
Unusual cause of iatrogenic anterior open bite after bilateral sagittal split mandibular advancement osteotomy L. Wong, A. Currie, M. Abu-Serriah ∗ Department of Oral and Maxillofacial Surgery, John Radcliffe Hospital, Oxford, OX3 9DU, UK Accepted 20 May 2014 Available online 11 June 2014
Abstract We describe a case of anterior open bite after bilateral sagittal split mandibular advancement osteotomy. The discrepancy in height between the proximal and distal segments at the osteotomy sites damaged the soft tissue and caused bony interferences. Removal of the maxillary third molars and bilateral removal of bony interferences of the distal segments using a bur led to full resolution and a good orthognathic outcome on follow-up. © 2014 Published by Elsevier Ltd. on behalf of The British Association of Oral and Maxillofacial Surgeons.
Keywords: Sagittal split osteotomy; Anterior open bite; Osteotomy; BSSO
Introduction Bilateral sagittal split osteotomy of the mandible, first described in 1957 by Trauner and Obwegeser, has since undergone various modifcations.1 Complications have often been reported and include nerve injury, unfavourable splits, infection, and relapse.2 We present a case of anterior open bite that was caused by bony interference between the distal segment of the mandible and the maxilla after bilateral sagittal split mandibular advancement osteotomy. This is an unusual postoperative complication and, to our knowledge, has not been reported before. Case report A fit and well 18-year-old man underwent joint orthognathic planning at the Department of Oral and Maxillofacial Surgery, John Radcliffe Hospital, Oxford, for correction of a ∗
Corresponding author.
class II, division 2 malocclusion with deep overbite and retrognathic mandible. After a course of orthodontic treatment, he underwent bilateral sagittal split mandibular advancement of 8 mm. The osteotomised mandible was fixed in the planned position using 2.0 titanium plates and screws (Stryker Corporation, Kalamazoo, USA), and he was discharged the next day. At follow-up the following day he had an anterior open bite of 2 mm so the orthodontist applied anterior orthodontic elastics. Ten days later, he reported pain, localised gingival swelling and an inability to bring the maxillary and mandibular anterior teeth together. Clinical examination showed a 2 mm anterior open bite and localised soft tissue damage in the retromolar region caused by the maxillary second molars (Fig. 1). Both maxillary third molars were unerupted, and there was palpable bilateral bony interferences in the retromolar regions. Clinical and radiographic examinations showed that fixation was stable and there was no evidence of condylar dislocation, but there was an appreciable anterior step between the distal and proximal segments of the ramus of the mandible (Figs. 2 and 3).
http://dx.doi.org/10.1016/j.bjoms.2014.05.011 0266-4356/© 2014 Published by Elsevier Ltd. on behalf of The British Association of Oral and Maxillofacial Surgeons.
768
L. Wong et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 767–768
showed good occlusion and healing of the soft tissue. The anterior open bite resolved completely.
Discussion
Fig. 1. Soft tissue swelling and traumatic ulceration in the left retromolar region caused by tissue trapped between the maxillary second molar and posterior part of the distal segment.
Fig. 2. Postoperative orthopantogram showing interference of the advanced distal segment and posterior maxilla (arrows).
In our patient, the low mandibular angle, the degree of advancement required to correct the dental and skeletal abnormalities, and the position of the mandibular lingula contributed to the discrepancy between the proximal and distal segments. The relation of the posterior maxilla to the anterior superior border of the advanced distal segment may also have been implicated. Muscular relaxation caused by general anaesthesia and possible distraction of the condyles made it difficult to identify the presence of bony interference intraoperatively. Pain and swelling during the immediate postoperative period concealed the problem and manual guidance into occlusion seemed satisfactory. It was only after 10 days when the postoperative swelling had resolved that the poor response to postsurgical orthodontics, persistence of the anterior open bite, and obvious damage to the intraoral soft tissue became more obvious. To avoid this complication in the future, we recommend that clinicians check for bony interferences in mandibular advancement osteotomy and, where appropriate, contour the distal mandibular segments and remove the maxillary third molars.
Conflict of Interest The authors declare no conflict of interest
Ethics statement/confirmation of patient permission Patient consent was obtained for clinical photograph.
Acknowledgement The authors of this paper would like to thank Miss Heather Nevard, Consultant Orthodontist at the John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, for the provision of orthodontic treatment. Fig. 3. Appreciable step between the superior aspects of the proximal and distal segments at the left osteotomy site.
The patient returned to theatre 12 days after the initial operation. The maxillary third molars were removed and an acrylic trimming bur was used to remove bony interferences of the distal segments bilaterally. Excess granulation tissue was excised and the wounds were closed primarily using polyglactin 910 sutures (Vicryl). Recovery was uneventful and clinical examination during follow-up appointments
References 1. Trauner R, Obwegeser H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. I. Surgical procedures to correct mandibular prognathism and reshaping of the chin. Oral Surg Oral Med Oral Pathol 1957;10:677–89. 2. Bays RA, Bouloux GF. Complications of orthognathic surgery. Oral Maxillofac Surg Clin North Am 2003;15:229–42.
