Maxillofacial Surgery Overview

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Questions and Answers

Which of the following is NOT a pathologic reason for maxillofacial surgery?

Musculoskeletal and Craniofacial Abnormalities

Dental Osseous Misalignment

Soft Tissue Deformities

Genetic Predisposition (correct)

Why is airway management particularly important during maxillofacial surgery?

The surgery is often lengthy and requires multiple positions.

Surgical interventions can potentially compromise airway access. (correct)

The use of general anesthesia increases the risk of aspiration.

Patients are often dehydrated due to pre-operative fasting.

What is the recommended endotracheal tube type for nasal intubation during maxillofacial surgery?

Tracheostomy Tube

Oral Endotracheal Tube

Ring-Adair-Elwyn (RAE) Endotracheal Tube (correct)

Laryngeal Mask Airway

What is the primary concern related to postoperative nausea and vomiting (PONV) after maxillofacial surgery?

Risk of aspiration of gastric contents due to limited airway access. (B) Signup and view all the answers

In general, what is the maximum estimated blood loss during a complex maxillofacial surgery?

1500 mL (A) Signup and view all the answers

Which of the following conditions is NOT a direct indication for orthognathic surgery as described in the provided content?

Pulpal necrosis (D) Signup and view all the answers

What is a common psychological reason that may require orthognathic procedures?

Maxillary insufficiency and prognathia (D) Signup and view all the answers

Which statement best describes the nature of maxillofacial trauma?

It can involve blunt force or penetrating injuries resulting in significant damage. (C) Signup and view all the answers

What might be a secondary consequence of blunt trauma to the maxillofacial region?

Formation of secondary projectiles causing additional injuries (B) Signup and view all the answers

Which of these indicates a more complex requirement for maxillofacial surgery?

Facial reconstruction after traumatic injury (D) Signup and view all the answers

Which of the following is NOT a key characteristic of a Le Fort I fracture/osteotomy as described in the text?

The fracture passes through the zygomaticomaxillary junction. (B) Signup and view all the answers

Based on the text, what is the primary purpose of using titanium plates and screws in Le Fort I osteotomy?

To secure the repositioned maxilla and maintain its stability. (D) Signup and view all the answers

Where does the Le Fort II fracture specifically travel through?

The nasal bridge via the nasofrontal suture, the maxillae via the frontal process, the lacrimal bones, the inferior orbital floor/rim, frequently through the orbital foramen, and finally through the anterior wall of the maxillary sinus; the base of the pyramid is formed as the fracture lines travel beneath the zygoma, traverse the pterygo-maxillary fissure, and extend through the pterygoid plates. (A) Signup and view all the answers

Why is the Le Fort II osteotomy considered a major surgical undertaking?

It involves extensive bone manipulation and requires multiple surgical incisions, causing significant blood loss and potential complications like post-operative edema and pain. (D) Signup and view all the answers

Considering the complexity of the Le Fort II osteotomy, which of these is a crucial factor for optimal patient recovery?

Close monitoring of the patient's breathing during the initial hours after surgery is crucial, as they may experience respiratory distress due to edema and pain, potentially requiring assisted ventilation. (C) Signup and view all the answers

What is the most likely reason why the Le Fort II osteotomy is not commonly performed?

This procedure is highly complex, requires multiple incisions, and carries a high risk of complications. Alternative surgical techniques are often preferred when possible. (D) Signup and view all the answers

In the context of a Le Fort III fracture, what is the primary structural consequence of the separation of the face from the calvaria?

The skull is segmented into three mobile components – the calvaria, face, and mandible. (A) Signup and view all the answers

What is the most likely reason why the Le Fort III fracture is sometimes referred to as 'craniofacial dysjunction'?

The fracture involves a complete separation of the cranium from the facial bones. (B) Signup and view all the answers

In the description of the Le Fort III fracture, why is the extension of the fracture line into the optical canals generally prevented?

The thick sphenoid bone physically blocks the fracture line from reaching the optical canals. (C) Signup and view all the answers

Why is the mandibular sagittal split osteotomy (MSSO) categorized as one of the 'simpler' orthognathic procedures?

The procedure is performed on a single bone, the mandible, making it less complex than procedures involving multiple bones. (A) Signup and view all the answers

What is the primary purpose of the titanium plates and screws used in the mandibular sagittal split osteotomy (MSSO)?

To stabilize the repositioned segments of the mandible and ensure proper bone fusion. (B) Signup and view all the answers

Why is it crucial to assess both nares for patency, even if one nasal passage appears significantly narrower during the preoperative evaluation for nasal intubation?

Because it's essential to prepare both nares for potential intubation, even if only one is used. (C) Signup and view all the answers

Which of the following accurately describes the role of the turbinates in the nasal cavity?

They are responsible for humidifying and warming incoming air, contributing to respiratory efficiency. (A) Signup and view all the answers

What is the fundamental reason why airway management for maxillofacial surgery requires a discussion with the surgeon?

To determine the type and complexity of the surgical procedure, which directly influences the necessary airway management technique. (D) Signup and view all the answers

What is the primary reason for padding between the forehead and the endotracheal tube connector during nasal intubation?

To mitigate pressure injury to the forehead (B) Signup and view all the answers

During maxillofacial surgery, which statement regarding blood loss management is most accurate?

Blood availability is critical for moderate and major surgical procedures. (B) Signup and view all the answers

What risk is associated with using a standard endotracheal tube instead of a specialized nasal RAE tube?

Necrosis of the nare and surrounding tissues (B) Signup and view all the answers

Which of these interventions is NOT specifically mentioned as contributing to the prevention of postoperative nausea and vomiting (PONV) in maxillofacial surgery?

D5 (C) Signup and view all the answers

Besides tracheal edema developing during maxillofacial procedures, what other significant factor directly impacts the decision to intubate or extubate a patient after surgery?

The degree of difficulty encountered during the initial intubation (D) Signup and view all the answers

Which of these factors is NOT directly mentioned as a contributor to the development of PONV in maxillofacial surgery?

Excessive fluid intake during surgery (D) Signup and view all the answers

Based on the text, which of these actions is NOT recommended as a strategy to reduce or prevent PONV in a patient undergoing maxillofacial surgery?

Offering the patient a light meal before surgery (B) Signup and view all the answers

Which condition is NOT a consideration before extubation after mandibular surgeries?

Required deep extubation (C) Signup and view all the answers

Which complication is characterized by the loss of blood supply to the bone after mandibular sagittal split osteotomy?

Avascular necrosis (D) Signup and view all the answers

Which complication involves injury to the nerve that provides sensation to the lower lip and chin area post-surgery?

Mental nerve injury (B) Signup and view all the answers

Which of the following complications is characterized by changes in the condyle's surface that can lead to joint issues?

Condylar resorption (B) Signup and view all the answers

Which complication associated with mandibular osteotomy can lead to difficulties with chewing and speaking due to altered jaw alignment?

Malocclusion (D) Signup and view all the answers

Which complication related to Le Fort osteotomies specifically affects the drainage system of the eye?

Lacrimal duct injury (A) Signup and view all the answers

What complication might arise during Le Fort osteotomy that involves altered airflow and could lead to speech difficulties?

Velopharyngeal insufficiency (B) Signup and view all the answers

Study Notes

Maxillofacial Surgery Indications

Maxillofacial surgery encompasses a wide range of procedures, from simple (e.g., tooth extraction) to complex (e.g., facial reconstruction).
Indications include severe tooth decay (caries), nerve damage (pulpal necrosis), tooth pain (odontalgia), orthodontic correction, impacted tooth removal, and cosmetic enhancements.
Orthognathic procedures on the maxilla and mandible are performed for psychological/aesthetic reasons, medical concerns, or functional/developmental abnormalities.
Maxillofacial injuries result from blunt force trauma (e.g., car accidents), penetrating trauma, or burns. Trauma can cause extensive injury by creating secondary projectiles (teeth/bone fragments) damaging soft tissue.
Specific indications include maxillary insufficiency, prognathism, micrognathia, retrognathia, maxillomandibular asymmetry, temporomandibular joint/facial pain, and obstructive sleep apnea.
Examples include surgical correction of maxillary insufficiency and prognathism for improved appearance and dental alignment.
Le Fort I fractures/osteotomy involve the maxillary alveolar rim, impacting nasal septum, pyriform rims, apices of teeth, zygomaticomaxillary junction, pterygoid plates, and pterygomaxillary junction.
Surgical incisions are intraoral, at the upper lip-gum junction.
Bony separation is via oscillating saw.
Maxilla mobilization may be segmental or complete.
Maxillary repositioning is by millimeters, secured with titanium plates and screws.
Procedure duration ranges from 2.5 to 3.5 hours, but can be longer.
Patient age impacts procedure length due to bone density.
Procedure advances the midface for improved aesthetics, dental occlusion, and nasal/airway function.
Often performed in office/outpatient settings.
Blood loss may range from 250-1500mL.

Mandibular Osteotomy

Mandibular osteotomy is a surgical procedure involving the mandible.
Three distinct facial fracture types, classified by Le Fort categories. Airway management considerations are crucial.
Potential considerations before extubation after mandibular surgeries: avascular necrosis, inferior alveolar artery bleeding, mental nerve injury, proximal segment malposition, condylar resorption, gingival recession, unanticipated fractures, inferior mandibular border contour irregularity, masseteric artery bleeding, and unfavorable sagittal split.
Potential complications: bleeding, devitalization of teeth, gingival recession, hardware exposure, malocclusion, malunion/nonunion of bone, postoperative infection, respiratory decompensation, and dental injury.
Potential complications associated with Le Fort osteotomies include arteriovenous fistulas, fractures to the pterygoid plate, sphenoid bone, and middle cranial fossa, infraorbital nerve traction injury, lacrimal duct injury, Stensen duct injury, velopharyngeal insufficiency, vascular necrosis, maxillary sinusitis, nasal-septal buckling, nasal-septal deviation, and ophthalmic duct injury.

Le Fort II Fracture/Osteotomy

Le Fort II fracture forms a pyramidal shape traversing the nasal bridge through the nasofrontal suture and the maxilla via the frontal process.
The fracture extends through the lacrimal bones, inferior orbital floor/rim (often through the orbital foramen), and anterior maxillary sinus wall.
The base of the pyramid extends beneath the zygoma, across the pterygo-maxillary fissure, and into the pterygoid plates.
Le Fort II osteotomy is not common, typically reserved for cases of significant facial growth deficiency requiring simultaneous movement of facial center, maxilla, and nose.
Surgical incisions include upper lip-gum junction, bi-coronal (ear-to-ear across the crown), and transconjunctival or blepharoplasty incisions.
Significant blood loss is expected, potentially requiring blood transfusions.
Extensive bruising and edema are likely.
High postoperative pain and potential for nausea and vomiting are common. Intubation, sedation, and assisted/controlled mechanical ventilation are required for at least 24 hours.
Nasal intubation is contraindicated in Le Fort II/III fractures with potential cribriform plate damage.

Le Fort III Fracture/Osteotomy

Le Fort III fracture produces separation of the face from the calvaria.
As a result, the skull has three "mobile" components: the calvaria, face, and mandible, rather than the normal two segments (mandible and skull).
The Le Fort III fracture is also called craniofacial dysjunction.
The Le Fort III begins similarly to the Le Fort II, with separation of the nasofrontal and frontomaxillary sutures.
The fracture traverses the medial orbit walls, nasolacrimal groove, and ethmoid bone.
Extension into the optic canals is often prevented by the sphenoid bone.
Fracture lines traverse the orbital floor and lateral wall (zygomaticofrontal junction and zygomatic arch).
The fracture lines complete through the base of the ethmoid perpendicular plate, vomer, and sphenoid pterygoid plates.
Le Fort III procedures are reserved for patients with severe midfacial growth deficiencies.
Surgical techniques are similar to Le Fort II, involving significant dissection, long duration, high bruising/edema, and potential for substantial blood loss requiring transfusions.
Postoperative management includes intubation, sedation with assisted/controlled mechanical ventilation for at least 24 hours post-op.
Nasal intubation is contraindicated in Le Fort III fractures with potential cribriform plate damage.

Mandibular Sagittal Split Osteotomy (MSSO)

MSSO involves incisions near the third molars (often extracted 6 months prior).
The mandible is split bilaterally.
A few millimeters of bone may be removed or added for desired mandibular length correction.
Titanium plates and screws stabilize the splits.
Typically the least time-consuming orthognathic procedure (1.5-2.5 hours).
Often combined with Le Fort I procedures to correct facial growth disparities.

Airway Management

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Postoperative Nausea and Vomiting (PONV) Management

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Blood Loss Management

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Extubation Considerations

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Description

This quiz covers key aspects of maxillofacial surgery, including indications, airway management techniques, and strategies for managing postoperative nausea and vomiting. It also highlights the importance of monitoring blood loss during these complex procedures.