77
RUBIN AND SANRLIPPO
References 1. Awwad EE, Abouzahr K, Sundaram M: Massive mandibular osteolysis in progressive systemic sclerosis. Orthopedics 10: 803, 1987 2. Seifert MH, Steigerwald JC, Cliff MM: Bone resorption of the mandible in progressive systemic sclerosis. Arthritis Rheum 18:507-l, 1975 3. Webe.r DD, Blunt MH, Caldwell JB: Fracture of the mandibular rami complicated by scleroderma. J Oral Surg 28:860, 1970
J Oral
White SC, Frey NW, Blaschke DD, et al: Oral radiographic changes in patients with systemic sclerosis (xleroderma). J Am Dent Assoc 94:1178, 1977 Traiger J: Scleroderma, its oral manifestations. Oral Surg 14: 117, 1961 Smith DB: Sclerodenna, its oral manifestations. Oral Surg 11: 865, 1958 Marmary Y, Glaiss R, Pisanty S: Scleroderma: Oral manifestations. Oral Surg 52:32, 1981
MaxillofacSurg
50:??-79,
1992
Transient Facial Nerve Palsy Following Orthognathic Surgery: A Case Report UGO CONSOLO,
MD, DDS, MS,* AND ATTILIO
Combined mandibular and maxillary osteotomy is now a widely used procedure in orthognathic surgery. ’ The surgical techniques are well standardized and carry a low complication rate. Besides the more common neurologic complications a&cting the second and third divisions of the trigeminal nerve, which are known to be related to anatomic variability and to the operator’s technical ability, there are rarer complications a&cting the sixth and seventh nerves due to causes that are often difficult to determine.2” The following report describes such a case. Report of Case A 19-year-old boy with a mandibular prognathism associated with a sag&al underdevelopment and vertical overdevelopment of the upper jaw was treated by bilateral sag&al ramus osteotomies using the modification of Gotte5 and by Le Fort I maxillary osteotomy. The operation was preceded by infiltration with a vasoconstrictor (omipressinum; Por-8Sandoz, Wanderpharma AG, Bern) in the perimandibular region of the ascending ramus and at the angles of the mandible, and in the upper jaw from the pyriform apertures to Received from the Faculty of Medicine and Surgery, Postgraduate School of Maxillofacial Surgery, Institute of Clinical Dentistry, University of Verona, Verona, Italy. * Associate Professor. t Assistant Professor. Address correspondence and reprint requests to Dr Consolo: c/o Clinica Odontoiatrica, deU’Univ&ti degli Studi di Verona, Ospedale Policlinico, via Delle Menegone, 37 134 Verona, Italy. 0 1992American Association of Oral and Maxillofacial Surgeons 0278-2391/92/5001-0018!$3.00/0
SALGARELLI,
MD, DDSt
the retrozygomatic
region. Preparation of the medial osteotomy of the left mandibular ramus proved laborious because of difficulty in inserting the channel retractor due to the obstacle created by the posterior vertical overdevelopment of the upper jaw. However, the remainder of the osteotomy, which was completed by means of chisels, was performed without any particular difficuIlty. No other complications arose during the mandibular phase of the operation. The maxillary osteotomy was performed by removing a posterior wedge of bone bilaterally, and bringing the maxilla forward en bloc 4 mm and raising it 4 mm, with a posterior rotation of 2 mm, as in the preoperative simulation. The maxilla was fixed by wire osteosynthesis to the pyriform notches and to the zygomatic processes. The operation was completed by inserting an interocclusal splint and by applying maxillomandibular fixation. Ice packs were applied for the first 24 hours in the immediate postoperative period. Forty-eight hours following the operation, the patient showed a lack of facial muscle tonus on the left side of the face, which was difficult to assess owing to the postoperative swelling (Fig 1). At discharge, reduction of the swelling revealed a complete left facial nerve palsy. Clinical examination showed a total loss of activity of the orbicularis oculi, the corrugator supercilii, the frontalis, the major zygomatic, the levator anguli oris and the buccinator muscles (Fig 2). Taste function was intact, as was the stapedial reflex. The patient performed functional rehabilitation exercises at home to restore facial muscle tonus. At 4 weeks postoperatively, he showed a distinct improvement, with partial recovery of facial muscle tonus (Fig 3). By 6 weeks, complete, spontaneous resolution of the clinical situation had occurred (Fig 4).
Discussion In the 2,400 orthognathic surgery operations performed in our clinic since 1973, there has been only
78
FIGURE I. Patient 48 hours after surgery. There is substantial postoperative swelling and inability to close the left eye.
TRANSIENT FACIAL NERVE PALSY
FIGURE 3. Patient 4 weeks after surgery showing of facial muscle tonus.
partial
recovery
one other case of a complication affecting the seventh cranial nerve.(j It is essential to distinguish between facial deficits due to central lesions and those due to peripheral lesions. In the central type, there is partial paralysis, because the lower facial muscles contralateral to the lesion are paralyzed, while the orbicularis oculi, the corrugator supercilii, and the frontalis muscles, which receive bilateral cortical fibers, continue to function, albeit to a reduced extent. Peripheral paralysis is subdivided into intrapetrosal
and extrapetrosal types. In the case of lesions of the facial nerve in its intrapetrosal tract, ie, before emergence of the chorda tympani and the stapedius nerve, the patient experiences deficient taste sensitivity and hyperacusia, which is particularly marked for low tones. Our case presented no taste or hearing deficits and had impairment of the entire left hemifacial region. We can therefore rule out both a central type and intrapetrosal peripheral paralysis. We believe the facial palsy was caused by a peripheral
FIGURE 2. Patient 10 days after surgery. There is a deficit of the mimetic muscles on the left side of the face.
FIGURE 4. Patient 6 weeks after surgery showing complete resolution of the facial palsy.
79
CONSOLO AND SALGARELLI
extrapetrosal lesion, characterized by total paralysis with a lack of voluntary motility of all the mimetic muscles ipsilateral to the lesion. In view of the patient’s clinical course and, particularly, the resolution of the symptoms in a very short time (4 to 6 weeks), the nerve lesion was probably of the neurapraxic type. Owing to the surgical technique used, it is difficult to make a very precise pathogenetic interpretation. Nevertheless, in view of the clinical course, we can rule out neurotmesis due to direct damage to the nerve, and can interpret the neuropraxic event in terms of either ischemia or compression. Ischemia could have occurred during an excessively deep infiltration of the vasoconstrictor at perimandibular level, posterior to the ascending ramus of the mandible into the parotid parenchyma. Compression, on the other hand, may have been of various origins. One hypothesis, reported in the literature, is slippage of the Lindemann bur into the perimandibular soft tissues during the medial osteotomy, with ensuing hemorrhage or direct damage to the nerve. In our case, this possibility can be ruled out, because the bur never penetrated beyond the channel retractor and there was no abnormal bleeding. Stajcic’s’ suggestion of compression of the nerve due to pushing back of the distal segment may be a possibility, although the posterior movement in our case was only 6 mm. A more acceptable explanation, however, might be that compression occurred from the use of surgical retractors in the depth of the wound and, particularly, to the forcible insertion of the channel retractor on the medial side of the mandible. A final possibility is that compression occurred from the substantial postoperative swelling at the perimandibular level. The literature we consulted contained only seven reported cases of damage to the facial nerve as a result of sagittal mandibular osteotomies. Behrman reported four cases of facial nerve involvement in a surgical series of 600 operations; two of the four cases had persistence of the nerve deficit for more than 7 weeks.* Politi et al reported a case of facial nerve palsy after bilateral sagittal osteotomy at the angle of the jaw, which regressed after 3 months, resulting in a Frey’s syndrome.6 Taher reported a case after sagittal man-
dibular osteotomy,’ and Stajcic a case following combined maxillary and mandibular osteotomy.’ All authors used one of the techniques proposed by Obwegeser in 1957,9 by Dal Pont in 196 1,I0 or by Gotte in 1966,5 all of which are characterized by medial osteotomy of the ascending ramus performed up to the posterior border. The Epker “short lingual cut” technique,” which does not involve performing a medial osteotomy up to the posterior border of the mandible, may help to avoid direct and indirect damage to the facial nerve from a hematoma caused by difficulty in controlling the Lindemann bur up to the posterior edge of the mandibular ramus. However, in view of the fact that facial nerve palsy is such a rare complication, it does not justify using this type of osteotomy instead of the other methods available only for this reason. References 1. Gotte P: Problemi, esperienze e risultati nel trattamento chirurgico della progenia dai punti di vista estetico e funzionale. Rivista Italiana di Chirurgia Plastica 2: 1, I970 2. Behrman SJ: Complications of sagittal osteotomy of the mandibular ramus. J Oral Surg 305.54, 1972 3. Moser K, Freihofer HPM: Long-term experience with simultaneous movement of the upper and lower jaw. J Maxillofac Surg 8:271. 1980 4. Reiner S, Willoughby JM: Transient abducens nerve palsy following A Le Fort I maxillary osteotomy: Report of a case. J Oral Maxillofac Surg 46:70 I, 1988 5. Gotte P: Sulla terapia chirurgica del progenismo. Esperienze e risultati ottenuti mediante una moditicazione de1 metodo introrale di Obwegeser. Min Stomat I : 12, 1966 6. Politi M, Ferronato G, Gotte P: La sindrome di Frey come complicanza post-intervento per correzione di frattura al condilo e all’angolo mandibolare e in seguito ad intervento di osteotomia sagittale bilaterale all’angolo mandibolare. Archivio Stomat 24:289, 1983 7. Stajcic Z, Roncevic R: Facial nerve palsy following combined maxillary and mandibular osteotomy. J Craniomaxillofac Surg 18:192, 1990 8. Taher AAY: Facial palsy: A complication of sagittal ramus osteotomy (Obwegeser-Dal Pont technique). Report of a case. Quintessence Int 19:229. 1988 9. Trauner R, Obwegeser HL: The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Oral Surg Oral Med Oral Pathol 10:667. 1957 10. Dal Pont G: L’osteotomia retromolare per la correzione della progenia. Min Chir 14:I 138, I958 1I. Epker BN: Modifications in the sagittal osteotomy of the mandible. J Oral Surg 35: 157. 1977
RUBIN AND SANRLIPPO
References 1. Awwad EE, Abouzahr K, Sundaram M: Massive mandibular osteolysis in progressive systemic sclerosis. Orthopedics 10: 803, 1987 2. Seifert MH, Steigerwald JC, Cliff MM: Bone resorption of the mandible in progressive systemic sclerosis. Arthritis Rheum 18:507-l, 1975 3. Webe.r DD, Blunt MH, Caldwell JB: Fracture of the mandibular rami complicated by scleroderma. J Oral Surg 28:860, 1970
J Oral
White SC, Frey NW, Blaschke DD, et al: Oral radiographic changes in patients with systemic sclerosis (xleroderma). J Am Dent Assoc 94:1178, 1977 Traiger J: Scleroderma, its oral manifestations. Oral Surg 14: 117, 1961 Smith DB: Sclerodenna, its oral manifestations. Oral Surg 11: 865, 1958 Marmary Y, Glaiss R, Pisanty S: Scleroderma: Oral manifestations. Oral Surg 52:32, 1981
MaxillofacSurg
50:??-79,
1992
Transient Facial Nerve Palsy Following Orthognathic Surgery: A Case Report UGO CONSOLO,
MD, DDS, MS,* AND ATTILIO
Combined mandibular and maxillary osteotomy is now a widely used procedure in orthognathic surgery. ’ The surgical techniques are well standardized and carry a low complication rate. Besides the more common neurologic complications a&cting the second and third divisions of the trigeminal nerve, which are known to be related to anatomic variability and to the operator’s technical ability, there are rarer complications a&cting the sixth and seventh nerves due to causes that are often difficult to determine.2” The following report describes such a case. Report of Case A 19-year-old boy with a mandibular prognathism associated with a sag&al underdevelopment and vertical overdevelopment of the upper jaw was treated by bilateral sag&al ramus osteotomies using the modification of Gotte5 and by Le Fort I maxillary osteotomy. The operation was preceded by infiltration with a vasoconstrictor (omipressinum; Por-8Sandoz, Wanderpharma AG, Bern) in the perimandibular region of the ascending ramus and at the angles of the mandible, and in the upper jaw from the pyriform apertures to Received from the Faculty of Medicine and Surgery, Postgraduate School of Maxillofacial Surgery, Institute of Clinical Dentistry, University of Verona, Verona, Italy. * Associate Professor. t Assistant Professor. Address correspondence and reprint requests to Dr Consolo: c/o Clinica Odontoiatrica, deU’Univ&ti degli Studi di Verona, Ospedale Policlinico, via Delle Menegone, 37 134 Verona, Italy. 0 1992American Association of Oral and Maxillofacial Surgeons 0278-2391/92/5001-0018!$3.00/0
SALGARELLI,
MD, DDSt
the retrozygomatic
region. Preparation of the medial osteotomy of the left mandibular ramus proved laborious because of difficulty in inserting the channel retractor due to the obstacle created by the posterior vertical overdevelopment of the upper jaw. However, the remainder of the osteotomy, which was completed by means of chisels, was performed without any particular difficuIlty. No other complications arose during the mandibular phase of the operation. The maxillary osteotomy was performed by removing a posterior wedge of bone bilaterally, and bringing the maxilla forward en bloc 4 mm and raising it 4 mm, with a posterior rotation of 2 mm, as in the preoperative simulation. The maxilla was fixed by wire osteosynthesis to the pyriform notches and to the zygomatic processes. The operation was completed by inserting an interocclusal splint and by applying maxillomandibular fixation. Ice packs were applied for the first 24 hours in the immediate postoperative period. Forty-eight hours following the operation, the patient showed a lack of facial muscle tonus on the left side of the face, which was difficult to assess owing to the postoperative swelling (Fig 1). At discharge, reduction of the swelling revealed a complete left facial nerve palsy. Clinical examination showed a total loss of activity of the orbicularis oculi, the corrugator supercilii, the frontalis, the major zygomatic, the levator anguli oris and the buccinator muscles (Fig 2). Taste function was intact, as was the stapedial reflex. The patient performed functional rehabilitation exercises at home to restore facial muscle tonus. At 4 weeks postoperatively, he showed a distinct improvement, with partial recovery of facial muscle tonus (Fig 3). By 6 weeks, complete, spontaneous resolution of the clinical situation had occurred (Fig 4).
Discussion In the 2,400 orthognathic surgery operations performed in our clinic since 1973, there has been only
78
FIGURE I. Patient 48 hours after surgery. There is substantial postoperative swelling and inability to close the left eye.
TRANSIENT FACIAL NERVE PALSY
FIGURE 3. Patient 4 weeks after surgery showing of facial muscle tonus.
partial
recovery
one other case of a complication affecting the seventh cranial nerve.(j It is essential to distinguish between facial deficits due to central lesions and those due to peripheral lesions. In the central type, there is partial paralysis, because the lower facial muscles contralateral to the lesion are paralyzed, while the orbicularis oculi, the corrugator supercilii, and the frontalis muscles, which receive bilateral cortical fibers, continue to function, albeit to a reduced extent. Peripheral paralysis is subdivided into intrapetrosal
and extrapetrosal types. In the case of lesions of the facial nerve in its intrapetrosal tract, ie, before emergence of the chorda tympani and the stapedius nerve, the patient experiences deficient taste sensitivity and hyperacusia, which is particularly marked for low tones. Our case presented no taste or hearing deficits and had impairment of the entire left hemifacial region. We can therefore rule out both a central type and intrapetrosal peripheral paralysis. We believe the facial palsy was caused by a peripheral
FIGURE 2. Patient 10 days after surgery. There is a deficit of the mimetic muscles on the left side of the face.
FIGURE 4. Patient 6 weeks after surgery showing complete resolution of the facial palsy.
79
CONSOLO AND SALGARELLI
extrapetrosal lesion, characterized by total paralysis with a lack of voluntary motility of all the mimetic muscles ipsilateral to the lesion. In view of the patient’s clinical course and, particularly, the resolution of the symptoms in a very short time (4 to 6 weeks), the nerve lesion was probably of the neurapraxic type. Owing to the surgical technique used, it is difficult to make a very precise pathogenetic interpretation. Nevertheless, in view of the clinical course, we can rule out neurotmesis due to direct damage to the nerve, and can interpret the neuropraxic event in terms of either ischemia or compression. Ischemia could have occurred during an excessively deep infiltration of the vasoconstrictor at perimandibular level, posterior to the ascending ramus of the mandible into the parotid parenchyma. Compression, on the other hand, may have been of various origins. One hypothesis, reported in the literature, is slippage of the Lindemann bur into the perimandibular soft tissues during the medial osteotomy, with ensuing hemorrhage or direct damage to the nerve. In our case, this possibility can be ruled out, because the bur never penetrated beyond the channel retractor and there was no abnormal bleeding. Stajcic’s’ suggestion of compression of the nerve due to pushing back of the distal segment may be a possibility, although the posterior movement in our case was only 6 mm. A more acceptable explanation, however, might be that compression occurred from the use of surgical retractors in the depth of the wound and, particularly, to the forcible insertion of the channel retractor on the medial side of the mandible. A final possibility is that compression occurred from the substantial postoperative swelling at the perimandibular level. The literature we consulted contained only seven reported cases of damage to the facial nerve as a result of sagittal mandibular osteotomies. Behrman reported four cases of facial nerve involvement in a surgical series of 600 operations; two of the four cases had persistence of the nerve deficit for more than 7 weeks.* Politi et al reported a case of facial nerve palsy after bilateral sagittal osteotomy at the angle of the jaw, which regressed after 3 months, resulting in a Frey’s syndrome.6 Taher reported a case after sagittal man-
dibular osteotomy,’ and Stajcic a case following combined maxillary and mandibular osteotomy.’ All authors used one of the techniques proposed by Obwegeser in 1957,9 by Dal Pont in 196 1,I0 or by Gotte in 1966,5 all of which are characterized by medial osteotomy of the ascending ramus performed up to the posterior border. The Epker “short lingual cut” technique,” which does not involve performing a medial osteotomy up to the posterior border of the mandible, may help to avoid direct and indirect damage to the facial nerve from a hematoma caused by difficulty in controlling the Lindemann bur up to the posterior edge of the mandibular ramus. However, in view of the fact that facial nerve palsy is such a rare complication, it does not justify using this type of osteotomy instead of the other methods available only for this reason. References 1. Gotte P: Problemi, esperienze e risultati nel trattamento chirurgico della progenia dai punti di vista estetico e funzionale. Rivista Italiana di Chirurgia Plastica 2: 1, I970 2. Behrman SJ: Complications of sagittal osteotomy of the mandibular ramus. J Oral Surg 305.54, 1972 3. Moser K, Freihofer HPM: Long-term experience with simultaneous movement of the upper and lower jaw. J Maxillofac Surg 8:271. 1980 4. Reiner S, Willoughby JM: Transient abducens nerve palsy following A Le Fort I maxillary osteotomy: Report of a case. J Oral Maxillofac Surg 46:70 I, 1988 5. Gotte P: Sulla terapia chirurgica del progenismo. Esperienze e risultati ottenuti mediante una moditicazione de1 metodo introrale di Obwegeser. Min Stomat I : 12, 1966 6. Politi M, Ferronato G, Gotte P: La sindrome di Frey come complicanza post-intervento per correzione di frattura al condilo e all’angolo mandibolare e in seguito ad intervento di osteotomia sagittale bilaterale all’angolo mandibolare. Archivio Stomat 24:289, 1983 7. Stajcic Z, Roncevic R: Facial nerve palsy following combined maxillary and mandibular osteotomy. J Craniomaxillofac Surg 18:192, 1990 8. Taher AAY: Facial palsy: A complication of sagittal ramus osteotomy (Obwegeser-Dal Pont technique). Report of a case. Quintessence Int 19:229. 1988 9. Trauner R, Obwegeser HL: The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Oral Surg Oral Med Oral Pathol 10:667. 1957 10. Dal Pont G: L’osteotomia retromolare per la correzione della progenia. Min Chir 14:I 138, I958 1I. Epker BN: Modifications in the sagittal osteotomy of the mandible. J Oral Surg 35: 157. 1977
