Orthognathic Surgery for Patients with Maxillofacial ...docshare02.docshare.tips/files/25217/252177637.pdf · Orthognathic Surgery for Patients with Maxillofacial Deformities RANDOLPH

Orthognathic Surgery forPatients with MaxillofacialDeformities
RANDOLPH C. ROBINSON, MD, DDS; REBECCA L. HOLM, RN, MSN, CNOR
www.aorn.org/CE

5.3

ove dentalropharyn-be coordi-e patient’se patient’sde LeFortthognathicion of thepatient to

10) 28-49.

s, maxillo-nt sur-action

ABSTRACT

Orthognathic surgery is performed to alter the shape of the jaws to improcclusion stability, improve temporomandibular joint function, open the ogeal airway, and improve the patient’s facial proportions. Surgery mustnated with orthodontic treatment. The surgeon develops a plan based on thmeasurements and performs the planned procedure on plaster models of thjaw and teeth to obtain the proper jaw position. Surgical techniques incluprocedures and distraction osteogenesis. Possible complications of orprocedures include airway compromise, numbness, and nonunion or malunbones. Postoperative instructions include an emphasis on the need for theconsume a blended diet for six weeks after surgery. AORN J 92 (July 20© AORN, Inc, 2010. doi: 10.1016/j.aorn.2009.12.030

Key words: jaw surgery, orthognathic surgery, maxillofacial deformitiefacial surgery, bilateral sagittal split osteotomy, mandibular advancemegery, intermaxillary fixation, LeFort osteotomy, cranial bone graft, distrosteogenesis, sleep apnea.

rom tstraigatho,s surge jawthe re

tional andse difficultiestion of orth-surgery.

and thee mandiblese of thel bone, justtemporoman-

and aesthet-sely defined

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ontact

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The term orthognathic comes fGreek terms ortho, meaning “mal, in proper order,”1 and gn

ing jaw2; thus, orthognathic surgery istraighten the jaws. Deformities of thmaxilla, mandible) and midface and

indicates that continuing education

are available for this activity. Earn the c

by reading this article, reviewing the pur

objectives, and completing the online Exa

Learner Evaluation at http://www.aorn.o
contact hours for this article expire July 31, 20
28 AORN Journal ● July 2010 Vol 92 No

heht, nor-mean-ery tos (ie,sulting

misalignment of the teeth create funcaesthetic difficulties for patients. Thecan be corrected through the combinaodontics (ie, braces) and orthognathic

ANATOMYThe maxilla contains the upper teeth,mandible contains the lower teeth. Tharticulates or functions against the baskull in conjunction with the temporaanterior to the ear canal, to form thedibular joint (TMJ). For best functionics, the top teeth should fit in a preci

t hours

hours

oal and

ion and

. The

position with the bottom teeth (Figure 1). If13.

doi: 10.1016/j.aorn.2009.12.030

1 © AORN, Inc, 2010

http://www.aorn.org/CE

gene, a peis canect chcial a

in eithay h

ng an(Figu

d byay re

axilloeen tlone2 mm

ain anxcessing, sdeforhich

rt funnship

iorati

way to treat

d postopera-nd mandibu-id fixationay. This sur-who cannot

ressure forapnea.

BLEMShe patient’sagnose andfacial sur-patient’s

ify the occlu-ification of. Angle, MD,A class Irelationshipsion, thewhich). With a

is larger thanin relation-). In addi-

ately in alltransverse).

s, thea prendiblthe t

nt.

r jaw cane” in which

ORTHOGNATHIC SURGERY FOR MAXILLOFACIAL DEFORMITIES www.aornjournal.org

growth problems occur as a result oftrauma, or functional habits, howeverjaws may not be proportional, and thdifficulties (ie, malocclusion) that affjoint function, airway patency, and faics. Growth discrepancies can occurmaxilla or mandible. A person also mcombination of unequal growth causibite” in which the teeth do not touchSome of these issues can be correcteodontia. An orthodontist, however, mmend that a patient consult with a msurgeon if the growth difference betwcannot be corrected by orthodontics athere are discrepancies of more than3 mm).

Jaw deformities may cause TMJ pfunction. A person may experience etooth wear as well as difficulty chewing, or breathing. Some cases of jawcan lead to obstructive sleep apnea, wresult in problems with lung and heaRestoring the proper anatomic relatiotween the jaws

� helps reestablish normal function,� helps protect against further deter

Figure 1. For best function and aestheticof the maxilla (ie, upper jaw) should fit indefined position with the teeth of the malower jaw). The mandible articulates withbone to form the temporomandibular joi

the TMJs and teeth, and

tics,rson’scause

ewing,esthet-er the

ave a“openre 2).

orth-com-facialhe jaws(ie, ifto

d dys-ivepeak-mitymay

ction.be-

on of

� opens the posterior pharyngeal airsevere sleep apnea.

Figure 3 shows the preoperative antive airway change when maxillary alar advancement is combined with rigto open the posterior pharyngeal airwgery is especially helpful for patientstolerate continuous positive airway ptreatment of severe obstructive sleep

COMMON MAXILLOFACIAL PROEvaluating the relationship between tteeth and face is important to help ditreat maxillofacial problems. Maxillogeons evaluate the relationship of themandible to his or her face and classsion (ie, bite) by using Angle’s classmalocclusion, named after Edward Hthe father of modern orthodontics.3,4

occlusion is a normal bite and facial(Figure 4A). With a class II malocclumandible is smaller than the maxilla,makes the chin look small (Figure 4Bclass III malocclusion, the mandiblethe maxilla, making the chin protrudeship to the rest of the face (Figure 4Ction, the face can grow disproportionthree planes (ie, vertical, horizontal,

teethcisely

e (ie,emporal

Figure 2. Growth discrepancies of eithelead to problems such as an “open bit
the teeth do not touch.
AORN Journal 29

nd rigthe

ms, cwhy npropoterm

so, werforroces

asure

utral

aluation of

ment of the

rison of the

relation-

rd lateral

be performed

rmine the

apse poten-

are com-

formation to

an.

ir dental bite

l dental

reated with

letal

ntal and

problems are

masked by

ng face shape

and the pa-

se the posi-

skull or jaws

the maxillo-

atients can

n and TMJ

rgeon must

er a patient

ay require

rse of treat-

orthognathic

of defor-

ntal and

th orthodon-

at come imp

July 2010 Vol 92 No 1 ROBINSON—HOLM

Furthermore, midline discrepancies aleft cants (ie, angles from the right tooccur. These types of skeletal problebined with dental crowding, explainson is truly symmetrical or perfectly

Proper diagnosis is important to dewhether surgery is necessary and, ifticular surgical procedure should be pThe four elements of the diagnostic pclude a

� clinical facial examination (ie, me

Figure 3. Maxillofacial abnormalities thmise a patient’s airway (A) often can bby surgery (B).

of the patient’s soft tissue relationships

30 AORN Journal

ht-to-left) canom-o per-rtioned.

inehat par-med.s in-

ments

taken with his or her head in a ne

position),

� clinical dental examination (ie, ev

tooth position),

� study model analysis (ie, measure

jaw/tooth relationship), and

� cephalometric analysis (ie, compa

patient’s facial skeleton to normal

ships and ratios based on a standa

head radiograph).

Residual facial growth analysis may

in some younger patients to help dete

appropriate timing of surgery and rel

tial. All of these diagnostic elements

bined with functional and aesthetic in

arrive at a diagnosis and treatment pl

Patients requiring alteration of the

or jaws fall into one of three groups.

� Group 1—The patient has minima

crowding or rotation that can be t

orthodontics alone and has no ske

deformity.

� Group 2—The patient has both de

skeletal problems but the skeletal

not obvious and could possibly be

orthodontic treatment. The resulti

may not be satisfactory, however,

tient’s bite may be unstable becau

tion of the teeth and shape of the

are compromised. The instability of

facial position for this group of p

lead to relapse of the malocclusio

problems. The orthodontist and su

work together to determine wheth

requires surgery. These patients m

repeated evaluation during the cou

ment. In general, not performing

surgery on patients with this level

mity is compromised treatment.

� Group 3—The patient has both de

skeletal problems and requires bo

pro-roved

are tics and surgery to resolve the problem.5

urgeon musta maxillofa-first alignwith braces.

ntil afterve the den-ree of ab-bring the

th orthodon-inal maxillo-mise, TMJ-would notcorrection in

result in theion after sur-se, and couldem com-2 or group

with surgeryose patientsmust reversergery, whichent time.

2 to 18n. In someelp positionsplint fortent jointeon set thethe orth-ite correc-three to six

lso may re-ral dentist.ects the den-her in a pre-

on is toect facialther andurgeon is

e effee: cla), an

III malocclusion (C).


TREATING A PATIENT WITH AMAXILLOFACIAL DEFORMITYAn orthodontist and a maxillofacial swork together to treat a patient withcial deformity. The orthodontist mustthe teeth in the maxilla and mandibleThis may make the bite look worse usurgery. The orthodontist has to remotal compensation to show the full degnormality. If the orthodontist were toteeth as close to normal as possible witia, the patient would still have the origfacial problems (eg, airway comprorelated pain); furthermore, the surgeonhave the space necessary to make fullthe bones. This misguided effort wouldpatient’s teeth being in the wrong positgery, with increased potential for relaplimit the surgical correction. This problmonly occurs when patients with group3 defects initially elect not to proceedand only have orthodontia. If one of thchooses surgery later, the orthodontistthe tooth position to prepare for the suadds months to the orthodontic treatm

An orthodontist usually requires 1months to align the patient’s dentitiopatients, a bite splint is required to hthe joints, and the patient wears thistwo to three months. Attaining consisposition preoperatively helps the surgjaws correctly. The patient returns toodontist after surgery to finalize the btion. This usually takes an additionalmonths to complete. Some patients aquire some tooth reshaping by a geneThe reshaping (ie, odontoplasty) corrtal anatomy so that the teeth fit togetcise, comfortable manner.

The role of the maxillofacial surgemove the facial bones to restore corrrelationships so that the teeth fit togethe jaw functions normally. An oral s

ct ofss Id class

Figure 4. Angle’s classification and ththe occlusion on the shape of the facocclusion (A), class II malocclusion (B

responsible for removing the wisdom teeth six

AORN Journal 31

s impeforers. Afurgeor bothhe sutil th

e bonsix t

wed.lan baan thtric trThe socednd terefern mamod

sitionpositiitioneferenposiplasbe r

tient’sion.

nathic proce-or a hospi-

rgeon or thes a history

. Depending, the patientplete bloodr blood

nt, the pa-taken,

nt’s chart forg ho

cedure inter models toteral view (A),


months before surgery. This timing ito allow the extraction sites to heal borthognathic surgical procedure occuorthodontist positions the teeth, the smoves the maxilla or the mandible orect the facial and dental positions. Tthen monitors the patient’s healing unhave ossified in the new position. Thbe allowed to heal for approximatelyweeks before normal chewing is allo

The surgeon develops a surgical pvarious patient measurements. The pltested and confirmed on a cephalomeusing computer software (Figure 5).then performs the planned surgical prplaster models of the patient’s jaws a(Figure 6) and uses these models forduring the actual surgery. The surgeoplastic transitional splint or jig on theuses this splint or jig in surgery to pomandible according to the maxillaryposition the maxilla based on the posmandible, depending on his or her prThe surgeon determines the final bitemaking cuts between the teeth on theillary model (Figure 7). The jaw may

Figure 5. Cephalometric tracing showinillofacial surgery is planned.

on the model until the proper position is o

32 AORN Journal

ortanttheter thento cor-

rgeone boneses musto eight

sed onen isacingurgeonure onethencekes ael andthe

on or toof thece.

tion byter max-eshaped

this then guides the changes to the pamouth to improve the final bite posit

PREOPERATIVE PREPARATIONThe surgeon may perform the orthogdure in an ambulatory surgery centertal. Before the day of surgery, the supatient’s primary care provider obtainand performs a physical examinationon the patient’s age and health statusmay need preoperative tests (eg, comcount, blood type and cross-match fotransfusion, urinalysis, chest x-rays).

During the preoperative appointmetient has final x-rays and photographswhich the surgeon places in the patie

w max-

Figure 6. The surgeon performs the proadvance on anatomically accurate plasrelate the mandible with the maxilla: la

btained; frontal view (B).

rgicaland

and mfaceb

rmineto th

g thed thelacinpatierstan

chewieasilystructany foear limedquestbers

nformt is a

ativeedicacal asnt’s kal pro

a hospitalon anti-

hen the pa-or recliner,

arm blanketsserts a

s preopera-minutes be-

s in the pre-d discusscedure lastsl anesthesia.

ss, the anes-consent for

al guardian.patient andwer anyry. After alltient or legalfor surgery.

preopera-iew the

aring thewith the

n band, anding nurseing con-igned. Thefor any con-nursing

roblems,current med-or previous

hetic prob-t last ate orhe patient’sbeen an-s a care plan

he OR, therform allneeded im-

ware are

ies (iter m


reference. The surgeon takes final sument measurements, bite registration,impressions for plaster study modelsspecial jaw joint registration called aregistration (ie, a device used to detepositional relationships of the maxillafor the purpose of properly positionincast on an articulator).6 The nurse angeon provide preoperative teaching, pticular emphasis on ensuring that thehis or her family members fully undeneed for a diet that does not requireblended so that is can be swallowedsix weeks after surgery. The nurse inpatient that he or she should not eateight hours before surgery but that cl(eg, water, apple juice) may be consufour hours before surgery. When thethe patient and his or her family membeen answered, the surgeon obtains isent from the patient or, if the patienfrom the patient’s legal guardian.

On the day of surgery, the preoperidentifies the patient and obtains a msurgical history and performs a physiment. The nurse determines the patieedge and understanding of the surgic

Figure 7. The surgeon makes osteotomincisions) between the teeth in the plascast to create a precise occlusal fit.

postoperative recovery, and discharge instr

move-dental

akes aowthee TMJdentalsur-g par-nt andd theng (ie,) fors theod

quidsup toions ofhaveed con-minor,

nursel andsess-nowl-cedure,

After having the patient change intogown, the nurse helps the patient putthromboembolic device stockings. Wtient is settled in the preoperative bedthe nurse provides the patient with wto maintain normothermia and then inperipheral IV line. The nurse preparetive antibiotics to be administered 60fore the surgical incision is made.

The anesthesia care provider arriveoperative area to assess the patient anplans for anesthesia. The surgical prothree to six hours and requires generaAfter explaining the anesthesia procethesia care provider obtains informedanesthesia from the patient or the legThe surgeon arrives to meet with thehis or her family members and to anslast-minute questions regarding surgequestions have been answered, the paguardian signs the informed consent

The circulating nurse arrives in thetive area to assess the patient and revpatient’s medical record. After comppatient’s verbal identity confirmationpatient’s medical record, identificatioblood identification band, the circulatensures that all documentation, includsents, is complete and appropriately scirculating nurse assesses the patientditions that might affect perioperativecare (eg, allergies, musculoskeletal pprocedure-specific positioning needs,ications and when last taken, existingairway complications, previous anestlems) and ascertains when the patiendrank fluids. The nurse ensures that tand family members’ questions haveswered, after which he or she preparespecific to this patient (Table 1). In tcirculating nurse and scrub person penecessary counts and confirm that allplants, equipment, supplies, and hard

e,axillary

uctions. available before the patient’s arrival in the OR.

AORN Journal 33

ofacial

statement

t’s respiratoryaintained or

from baseline

t is free fromsymptoms ofed bys objects.t is free fromsymptoms ofed to.t is free from

d retainedjects.

ble continued)


TABLE 1. Nursing Care Plan for Patients Undergoing Orthognathic Surgery for MaxillDeformities

Diagnosis Nursing interventions Outcome indicator Outcome

Ineffectiveairwayclearanceand risk foraspiration

� Identifies baseline respiratorystatus

� Identifies physiological status� Reports deviation in diagnostic

study results� Reports deviation in arterial blood

gas studies� Monitors physiological parameters� Monitors changes in respiratory

status� Uses monitoring equipment to

assess respiratory status� Evaluates respiratory status

� The patient is breathingspontaneously with supplementaloxygen without assistance ontransfer at the time of dischargefrom the OR or procedure room tothe postanesthesia care unit.

� The patient’s oxygen saturation andrespiratory rate are in the expectedrange at discharge from thepostanesthesia care unit.

� The patienstatus is mimprovedlevels.

Risk for injuryand risk forperioperativepositioninginjury

� Confirms patient identity� Assesses baseline skin condition� Identifies baseline tissue perfusion� Identifies baseline musculoskeletal

status� Identifies physical alterations that

require additional precautions forprocedure-specific positioning

� Verifies the surgical procedure,surgical site, and laterality

� Implements protective measuresbefore the surgical or invasiveprocedure

� Applies safety devices� Positions the patient� Implements protective measures

to prevent skin/tissue injurycaused by mechanical sources

� Uses supplies and equipmentwithin safe parameters

� Performs required counts� Maintains continuous surveillance� Evaluates tubes and drains to

ensure they are functioning asplanned

� Evaluates musculoskeletal status� Evaluates for signs and symptoms

of physical injury to skin andtissue

� Evaluates results of the surgicalcount

� The patient’s skin condition otherthan the incision is unchangedbetween admission and dischargefrom the OR.

� The patient’s pressure pointsdemonstrate hyperemia for lessthan 30 minutes.

� The counts are accurate, correct,or reconciled according to facilitypolicy.

� The patiensigns andinjury causextraneou

� The patiensigns andinjury relatpositioning

� The patienunintendeforeign ob

(ta

34 AORN Journal

atienR be

d surg

memberse patiente out with

d the OR

ry for

statement

t is free fromsymptoms of

t ord supportmonstratese of nutritionalent related toal procedure.


INTRAOPERATIVE CAREThe circulating nurse transports the pOR and assists the patient onto the Oconfirm the patient’s identity, planne

TABLE 1. (continued) Nursing CaMaxillofacial Deformities

Diagnosis Nursing interven

Risk forinfection

� Assesses susceptibilitinfection

� Implements aseptic te� Classifies the surgical� Minimizes the length o

invasive procedure bycare

� Protects from cross-co� Initiates traffic control� Administers prescribed

treatments� Performs skin prepara� Maintains continuous� Administers care to wo� Monitors for signs and

of infection� Evaluates factors asso

increased risk of postoinfection at the compleprocedure

� Evaluates progress ofhealing

� Evaluates for signs anof infection through 30the perioperative proc

Imbalancednutrition: lessthan bodyrequirementsandineffectivehealthmaintenance

� Identifies baseline gasstatus

� Assesses nutritional hapatterns

� Assesses psychosociaspecific to the patient’status

� Provides instruction redietary needs

� Includes the patient orsupport person in periteaching

� Evaluates response toinstruction

procedures, allergies, and any necessary eq

t to thed. Toical

ment and supplies, all surgical teamstop to introduce themselves, greet thby name, and perform the surgical timthe patient, the informed consents, an

an for Patients Undergoing Orthognathic Surge

Outcome indicator Outcome

e

ng

ation

lactic

anceitestoms

withe

f the

tomsafter

� The patient has a clean, primarilyclosed surgical wound covered witha dry, sterile dressing at dischargefrom the OR.

� The patient’s wound is intact andfree from signs of infection 30 daysafter surgery.

� The patiensigns andinfection.

tinal

d

sional

g

atedive

nal

� The patient describes therecommended postoperativenutritional intake regimen for therecovery period at the time ofdischarge.

� The patient describes theappropriate home management ofsymptoms that affect nutritionalintake (eg, sore throat, nausea,vomiting) at the time of discharge.

� The patiendesignateperson deknowledgmanagemthe surgic

re Pl

tions

y for

chniquwoundf theplanni

ntamin

prophy

tionsurveillund ssymp

ciatedperativtion o

wound

d sympdays

edure

trointes

bits an

l issues nutrit

gardin

designoperat

nutritio

uip- schedule. The circulating nurse places sequential

AORN Journal 35

atienevicetientgicaler legg onoverand ad, thethe patienfacinthat

ures tll-bopatie

ities cquireency

quipme). Tan e

the anis in

careinduce proeal tutracheout os, whor nsam

rt a rn surgal inctubeoid th

tube. Theologitapes

l anes

toperative

dwellingof the pro-

gical unitAfter re-ularly his orlating nurseal bone graftthat prepon the pa-’s shoulders,

al preps, theatient andsurgical unitThe surgeon

k to mini-stomach

notes theheet to facili-

lar portion ofe maxillary

, craniofacial,s a reinforcedincision,or reposi-.


compression device leggings on the pturns on the sequential compression dThe circulating nurse observes the parect anatomic alignment and physiolotioning, places pillows under the lowprevent the patient’s heels from restinOR bed, and secures the safety straptient’s thighs.7 To allow the surgeonadequate access to the head of the belating nurse carefully pads and tucksarms at his or her sides, placing the parms in a neutral position with palmsward and confirming with the patientsition is comfortable.6 The nurse enspatient remains warm by placing a futemperature-regulating blanket on the

Patients with maxillofacial deformpresent airway challenges that may retional equipment and supplies. Emergcarts contain specialized anesthesia e(eg, a fiber-optic intubating endoscopculating nurse, therefore, ensures thatgency airway cart or any equipmentsia care provider anticipates needingroom and remains with the anesthesiavider to assist with intubation. Aftergeneral anesthesia, the anesthesia carintubates the patient with a nasotrachTypically, he or she secures the nasoover the patient’s forehead to keep itway of the surgeon. In some instancemore extensive midface, craniofacial,procedures are to be performed at thethe anesthesia care provider may inseforced endotracheal tube orally. Whebegins, the surgeon makes a submentand passes the connecting end of thethe floor of the patient’s mouth to avfor a tracheotomy or for changing thetion later in the procedure (Figure 8)thesia care provider applies ophthalmment to the patient’s eyes and gentlyclosed. The surgeon then injects loca
with epinephrine into the surgical area to m
36 AORN Journal

t andunit.

for cor-posi-s tothe

the pa-ssistantcircu-

atient’st’sg in-

the po-hat thedy,nt.anaddi-airwayent

he cir-mer-esthe-thepro-

ingviderbe.al tubef theen

asale time,ein-eryisionthroughe needposi-

anes-c oint-them

thesia

mize intraoperative bleeding and pospain.

The circulating nurse inserts an inurinary catheter because of the lengthcedure and then applies an electrosurdispersive pad to the patient’s thigh.checking the patient’s position, particher tucked arms and hands, the circuperforms the facial, mouth, and crani(CBG) site preps. The nurse ensuressolution does not run under the tapetient’s eyes or pool under the patientneck, or head.

After the completion of the surgicsurgeon and scrub person drape the pposition the suction, drill, and electrohand piece in its holster on the field.inserts an x-ray-detectable throat pacmize blood draining into the patient’sduring surgery. The circulating nursethroat pack placement on the count state closing counts.

THE SURGICAL PROCEDURESome surgeons perform the mandibuthe procedure first; others perform th

Figure 8. During more extensive midfaceor nasal procedures, the surgeon passeendotracheal tube through a submentalwhich avoids the need for tracheostomytioning of the tube later in the procedure

ini- portion first. In a procedure requiring work on

surgor s

makethe c

er orext t

akesmanthatnerve

joinswithhindth use jawgittalObwther

maneral sas BSt prochich

ion tochednce nAftere mothe

s it tlint.

oks fos theforceon. Tnd isilt ar

y, theer jaw

itaniud theme in

moved at ablem, andpermanently.rgeon mayoper fit. Thisjoints andposition.sosseousient’s mouth.mandible, he

ile the pa-s the joint

e right posi-omething ise plates aschieved. Inthe teethmon in the

ll use thisen other

eg, bilateralusually is

e surgeonary fixationing thendibular

a techniqueadvancemente lower jaw


both mandible and maxilla, when theforms the mandibular portion first, heplaces a bite block and retractor andincision in the patient’s mouth insidefollowed by an osteotomy on the outsurface of the body of the mandible nfirst or second molar. The surgeon mzontal osteotomy on the inside of theramus (ie, the vertical part of the jawtains the joint) above the mandibularit enters the lower jaw. The surgeonteotomy on the outside of the ramuson the inside by a third osteotomy belars in the area where the wisdom toobe. He or she then gently fractures ththese incisions so that it splits in a sa(ie, a sagittal split osteotomy). HugoMD, DDS, who is considered the faorthognathic surgery, developed thisis performed on both sides (ie, bilatesplit osteotomies) and is referred to a

One key aspect of the sagittal spliprotection of the mandibular nerve, wthrough the bone and supplies sensatlower lip and chin. The nerve is stretthis procedure, so all patients experieness for a few months after surgery.surgeon completes the splits, he or shdistal part of the mandible containingits new position and temporarily wiremaxillary teeth using a transitional spsurgeon uses the braces and extra hosecuring wires. The surgeon positiontient’s TMJs using two directions ofsure that they are in the proper posititechnique is called bivector seating atant because a proper bite must be buproper joint position.

In mandibular advancement surgergeon produces a gap to bring the lowward. He or she spans this gap with tplates and screws on each side to holble rigidly in position (Figure 9). In so
a patient may be able to feel the bone plat
eon per-hes anheek,lateralo thea hori-dibularcon-where

the os-the onethe mo-ed toalongplane

egeser,ofuver. ItgittalSO.8

edure istravelsthe

duringumb-theves the

teeth too theTher the

pa-to en-hisimpor-ound

sur-for-

m bonemandi-stances,

this may require that the plates be relater date. Generally, this is not a prothe plates and screws remain in placeIn mandibular setback surgery, the sutrim some extra bone to obtain the prtype of plate fixation is gentle on thedoes not cause them to torque out ofOther fixation techniques include transcrew fixation placed through the pator cheek with a transcutaneous trocar

When the surgeon has secured theor she unwires the patient’s teeth whtient is still on the OR bed and checkposition to ensure everything is in thtion. If the surgeon determines that sout of alignment, he or she moves thnecessary until the right position is arare instances, the surgeon must wiretogether for six weeks. This was compast, and although some surgeons stitechnique in single jaw surgery or whtypes of osteotomies are performed (vertical oblique ramus osteotomy), itnot required.

If osseous wire fixation is used, thmust provide postsurgical intermaxill(ie, wire the mouth shut) after removthroat pack. After completing the ma

Figure 9. The plate and screws illustratefor rigid fixation used during mandibularsurgery to span the gap created when this brought forward.

es, and portion of the surgical procedure, the surgeon

AORN Journal 37

ng thped bstud

rk inry anear hul Tefath

eFortre se

rmitietomy

ntalrgicalw abo0A).1

midalin inper jm a td fro

iofacthe faial ba

the oe. Firpatieon me the

r shef thees it sthe loit is

ltipleate. Ueen tosteo

patient’s(C) osteotomy

locations.


corrects the maxilla, if necessary, usiLeFort I osteotomy procedure develoLeFort, MD, a French anatomist whofacial fractures and published his woThe bone cuts used to correct maxillacraniofacial deformities continue to bname. Building on LeFort’s work, PaMD, a French surgeon considered thecraniofacial surgery, developed the Lprocedure to compensate for even mocraniofacial midface and orbital defoThere are three levels of LeFort osteo

� LeFort I—Also known as a horizolary osteotomy, the fracture or suoccurs at the base of the upper jaapices of the teeth roots (Figure 1

� LeFort II—Also known as a pyraomy because the surgical cuts begmidfacial bones (especially the upmeet above the nasal bones to forlar section of bone that is detacheskull (Figure 10B).12(p696)

� LeFort III—Also known as a cranjunction or transverse osteotomy,bones are separated from the cran(Figure 10C).13(p193)

The LeFort I procedure is used fornathic surgery described in this articlsurgeon makes an incision inside themouth under the upper lip. The surgecuts in the bone below the eyes, abovand through the nasal passages. He obreaks the bone free from the base othe pterygomaxillary suture and movupper teeth fit together with those ofjaw. Often, to obtain the best results,sary for the surgeon to perform a muLeFort I osteotomy to expand the palthe surgeon makes the incisions betweral incisors and the canines, but thecan be made between any teeth.

The surgeon temporarily wires the
teeth together again to give him or her the
38 AORN Journal

ey Renéied1901.9

disssier,er ofIII

veres.10

.

maxil-cutve the1(p379)

osteot-the

aw) andriangu-m the

ial dis-cialse

rthog-st, thent’sakesteeth,

thenskull ato thewer

neces--piecesually,

he lat-tomies

Figure 10. The LeFort I (A), II (B), and III

best

betweoteBG

igureharv

he pan clos

two

arger, thetakebone

ng boed frooes n, whilve bof borese

s whoon betion oniums topd oveillarythesee andwent

ormed at thethe patient’sprove air-e examples

ostoperativedergone


bite. The surgeon places bone graftsincisions to provide stability and promhealing. The surgeon may harvest a Cthe patient’s skull for this purpose (FThe patient’s head is not shaved, andgrafts from this area does not cause tmuch postoperative pain. The surgeoincision with staples that are removedafter surgery.

In more extensive situations with lmovement and, therefore, larger gapsmay determine that it is necessary tograft from the hip. Another source ofis a bone bank. The advantage of usibank grafts is that no bone is harvestpatient. Bone bank tissue, however, dwork as well as a patient’s own boneries no donor risks and does not invobank costs. Another option is the usemorphogenetic protein. This option isspecial situations, such as for patientence relapse or for osteotomy nonuniof its expense. To hold the final posimaxilla, the surgeon places more titaplates and miniscrews on the patient’fasten the bone alongside the nose anfirst molars along the zygomatic maxtress. Occasionally, patients can feelas well. Figure 12 shows preoperativerative photos of a patient who under

Figure 11. Cranial bone graft site.

I orthognathic surgery.

en thefasterfrom11).

estingtientes theweeks

bonesurgeona bonegrafts

nem theotch car-onene

rved forexperi-

causef thebonejaw tor thebut-platespostop-LeFort

Additional procedures may be perfsame time as jaw surgery to enhancefacial balance and aesthetics or to imflow through the patient’s nose. Som

Figure 12. Lateral preoperative (A) and p(B) photographs of a patient who has un
LeFort I orthognathic surgery.
AORN Journal 39

lasty

urger

alar

s.

plasty

theni

midlin

of th

ay pe

eth in thehe then

final correc-ior-posteriorusing screws,ware need

tage of thethe supra-

glossalirway dimen-lant, butot used be-ook unnaturalmusculature.

shape of thehrough thethe appear-

mps on thegoal is too fit the faceent’s ideal.upper noseproportional.e patient’st and graft itrove nasal

rbinate re-

n is anotherformed (Fig-urgeon at-der the eyemay be con-

o be a partFor exam-

heek implantstruction ofcheeks givesthe patient’smore se-LeFort III

cess of

givemuscsuprarationtive xthe c


of additional surgeries include geniop

chin surgery), rhinoplasty (ie, nasal s

cheek augmentation (eg, zygomatic, m

mentation), or distraction osteogenesi

Genioplasty, also known as mento

volves advancing, shortening, or leng

chin or adjusting the chin to a more

tion (Figure 13). If further correction

deficiency is required, the surgeon m

Figure 13. Genioplasty is performed tobalance and to reposition the mentalisimprove lip elevation and advance themuscles in cases of sleep apnea. Illustproposed procedure (A) and postoperawith hardware in place illustrating howlips, and nose are aligned (B).

sliding advancement by horizontally cuttin

40 AORN Journal

(ie,

y),

aug-

, in-

ng the

e posi-

e jaw

rform a

bone above the chin and below the teanterior part of the mandible. He or sslides the bone forward to make thetion to any vertical, midline, or anterdeformity. The surgeon fixes the boneplates, or wires. Rarely does this hardto be removed. One important advansliding genioplasty is that it advanceshyoid muscles and increases the retrospace, thus improving the patient’s asions. Some surgeons use a chin impmost of the time, a chin implant is ncause it has a tendency to shift and land does not advance the suprahyoid

Rhinoplasty is used to correct thenose, the patient’s ability to breathe tnose, or both. Procedures that correctance of the nose include reducing buupper nose or reshaping the tip. Theensure that the nose is proportioned tand is as close as possible to the patiSometimes, reducing a bump on themakes the tip look more rotated andSometimes, the surgeon must take thnose completely apart and then sculpto turn up and narrow the tip. To impbreathing, a septoplasty or inferior tuduction can be performed.

Malar (eg, zygomatic) augmentatioadjunctive procedure that may be perure 14). In malar augmentation, the staches an implant to the bone just unto help build up the cheekbone. Thissidered cosmetic; however, it can alsof the total reconstruction procedure.ple, in cleft lip or palate repair, the cprocedure is part of the overall reconthe facial deformity. Building up thebetter facial proportions and restoresappearance. Use of cheek implants invere cases helps avoid the need for aprocedure.

Distraction osteogenesis is the pro

facialle tohyoidof the

-rayhin,

g the lengthening a bone by cutting it, allowing it to

s, andactiv

ts ancal bo

gap. It isnsolidationved, themoved

one malarr sur


heal in a latency phase for seven daystretching it 1 mm per day during thephase (Figure 15). The surgeon mounnal device on either side of the surgi

Figure 14. Preoperative (A and B) and paugmentation, maxillary and mandibula

to hold them in place and then distracts th

thenationinter-ne cuts

so that new soft bone grows into thethen allowed to calcify during the cophase. When the lengthening is achiesmall activation pin in the cheek is re

perative (C and D) views of a patient who has underggery, and rhinoplasty.

osto

e pieces and the resulting scar fades to a fine white line.

AORN Journal 41

wheere jat’s biistracdvancnt reqeks toeal. W. Distarge

at can ber the same

y);

rinses ande blood andck. The cir-et that theia care pro-c or orogas-

bloody

merged fromf discharge

vider maynt maintainoral airway

maxillaryites down onhe surgeonws shut. If, however,patientsecure andn emergencye anesthesiaube in placere wired

p the pa-e headCBG site

w. After thed the patient,t to a supineates the

ulating nurseet and assistser the patient

osteoA); Papplie

and Pactiv

ector


Distraction osteogenesis may be usedpatient has TMJ problems or more sevciencies. Distraction corrects the patienmay transfer less force into the joint. Dalso be used in the midface when the arequired is large (Figure 16). The patieexternal halo for approximately six wetain proper alignment until the bones hdistraction, bone grafting is not neededprovides greater long-term stability in l

Figure 15. The three stages of distractionlatency, activation, and consolidation (x-ray of an internal distraction device amandibular rami before activation (B);x-ray of a distraction procedure duringwith the yellow arrows indicating the vdistraction (C).

advancements.

42 AORN Journal

n aw defi-te andtion canementuires anmain-ith

raction

Additional cosmetic procedures thperformed at the same time and undeanesthesia include

� a blepharoplasty (ie, eyelid surger� liposuction;� TMJ surgery; or� a face-lift.

At the end of surgery, the surgeonsuctions the patient’s mouth to removdebris and then removes the throat paculating nurse notes on the count shethroat pack is removed. The anesthesvider temporarily inserts a nasogastritric tube to empty the stomach of anydrainage.

If the patient has not completely ethe effects of anesthesia at the time ofrom the OR, the anesthesia care proinsert a nasal airway to help the patiehis or her airway until fully alert. Anshould be avoided as it can shift theand mandibular bones if the patient bit while emerging from anesthesia. Tdoes not usually wire the patient’s jawiring the jaws together is necessarythe circulating nurse ensures that theleaves the OR with wire cutters in aeasily accessible location in case of athat requires access to the airway. Thcare provider leaves the nasogastric tpostoperatively if the patient’s jaws ashut.

The surgeon and scrub person wratient’s head with a bulky, compressivdressing to minimize oozing from theand help reduce swelling along the jaanesthesia care provider has extubatethe surgical team transfers the patienposition on the recovery bed and elevhead of the bed 30 degrees. The circcovers the patient with a warm blankthe anesthesia care provider to transf

genesis:norexd to theanorexation,s of

to the postanesthesia care unit (PACU).

fied ostruct

U nuoxygthe b

oxyge

airway ob-urse appliesd maxillaswelling.anesthesia,the endo-

ent will ex-

and C), andesis p ).


POSTOPERATIVE RECOVERYThe PACU nurse administers humidito the patient via a mist mask and inpatient to take deep breaths. The PACmonitors the patient’s vital signs andration levels and elevates the head of30 degrees. Monitoring the patient’s

Figure 16. A patient shown before distrafter a successful distraction osteogen

ration is crucial because of the risk of pos

xygens therseen satu-ed ton satu-

tive airway complications (eg, acutestruction as a result of edema). The nice packs to the patient’s mandible anfor comfort and to reduce soft tissueWhen the patient is fully awake fromhe or she may have a sore throat fromtracheal or nasogastric tube. The pati

n osteogenesis (A), with distraction device applied (Brocedure of the midface using an external device (D

actio

topera- perience a moderate amount of blood oozing from

AORN Journal 43

PAConingigured, caomitinht fot. PoMan

a (eg,ntraory littre str, mopain.the ps to m

le if the pa-e nurse

ers how toatient avoidatients aret of swal-be preparedif needed.hydrochlo-

al edema andial ice packsnt is notnurse pro-by the

nurse re-

comfort,ions u


the incisions and from the nose. Theassists the patient with intraoral suctineeded to manage these secretions (Fbecause bloody drainage, if swallowetribute to postoperative nausea and v

Typically, the patient stays overnigway monitoring and pain managementive pain is an individual experience.tients describe areas of lip paresthesiburning, itching, tingling) related to itissue stretching but seem to need vemedication. Other patients may requior intramuscular pain medications (egmeperidine, fentanyl) to relieve their

The nurse ensures that the head ofbed remains elevated 30 to 40 degree

Figure 17. The first postoperative nightswelling, and learning to handle secret

mize oozing and swelling and that wire cu

44 AORN Journal

U nurseas17)

n con-g.

r air-stopera-y pa-

perativele painong IVrphine,

atient’sini-

are conspicuous, secure, and accessibtient’s jaws have been wired shut. Thteaches the patient and family membperform oral suctioning to help the pswallowing bloody drainage. Some pvery sensitive to even a small amounlowed drainage, so the nurse shouldto administer antiemetic medicationsHe or she administers oxymetazolineride nasal spray to minimize intranasbleeding and rotates the patient’s facto minimize facial edema. If the patieexperiencing nausea or vomiting, thevides ice chips and fluids as toleratedpatient.

On the first postoperative day, the

be difficult for the patient as he or she deals with dissing suction.

can

tters moves the patient’s urinary catheter several hours

schargent caient apatienssing

ary toon tyelastisurg

e hea

lling

o the

helphowore

nce o. Evetics wed diack oe notopera

mentof pl

s from the

reate stability

e teeth.

ructions with

embers or

ll lose 7 lb

period be-

adequate cal-

equate nutri-

urse reminds

bers of the

d diet and

healing. The

mL irrigation

as been

the blended

uth. Squeeze

ose.

nt not to

weeks after

ed with

nd saline

atient or sup-

ce with any

ns to call

g

rmal oozing

red;

F (38° C);

ted, rapid,

nge in bone

rolled with

resolve; and

as a rash or

e patient and

d the dis-

orthotrol ths.


before the patient is scheduled for diallow time to assess whether the patiurine normally. After helping the patto the bathroom, the nurse helps theand then removes the bulky head drediscretion of the surgeon.

Although it is not normally necessthe patient’s teeth together, the surgeapplies orthodontic rubber bands (ie,the patient’s braces the morning afterElastics are important to

� control the patient’s bite during thprocess (Figure 18),

� compensate for postoperative swetends to shift the patient’s bite,

� help give some small movement tand

� seat the TMJs.

Most patients find that the elasticscrease some of the initial discomfort;the bands make eating and drinking mcult, and it may require some persistepatient’s part to drink adequate fluidsthe patient is able to remove the elasassistance, drink the prescribed blendform oral care, and put the elastics bhooks on the braces. Most patients ardo this very well during the first postweek because of swelling. The placeelastics is important, but the patterns

Figure 18. Postoperative placement ofrubber bands (ie, elastics) used to conpatient’s bite during the healing proces

vary from surgeon to surgeon. In some cas

e ton passmbulatet dressat the

wirepicallycs) onery.

ling

that

teeth,

de-ever,diffi-n thentually,ithoutet, per-n theable totiveof theacement

surgeon uses skeletal suspension wire

anterior nasal spine and the chin to c

without placing excessive force on th

The nurse discusses discharge inst

the patient and the patient’s family m

caregiver (Table 2). Most patients wi

to 15 lb during the six-week recovery

cause of the difficulty of consuming

ories. To combat problems with inad

tion and dehydration, the discharge n

the patient and his or her family mem

importance of maintaining the blende

consuming enough fluids for optimal

nurse provides the patient with a 60-

syringe on which a rubber catheter h

placed. This works well for injecting

foods and fluids into the patient’s mo

bottles also are available for this purp

The nurse also instructs the patie

blow his or her nose for up to four

surgery. Nasal secretions are manag

suction, the use of oxymetazoline, a

nasal spray.

The discharge nurse informs the p

port persons to call the surgeon’s offi

questions or concerns. Specific reaso

include that the patient is experiencin

� excessive bleeding beyond the no

that does not resolve or is bright

� a temperature greater than 100.4°

� excessive swelling that is unexpec

and unilateral;

� shifting of his or her bite or a cha

position;

� severe pain or pain that is uncont

pain medications;

� nausea or vomiting that does not

� problems with medications, such

itching.

The nurse and surgeon ensure that th

his or her family members understan

dontice

es, the charge instructions.

AORN Journal 45

NCEdiffe

mon

in, mood)

t’s postoper-

from the

r surgery.surgeon.

, sleep with

ay remove

in case you

ranial bone

the risk of

be taken in

ing.from the

eggs, thin

ut particularsurgery.

itching


THE POSTOPERATIVE EXPERIEHow patients perceive their recovery

ever, Figure 19 demonstrates the com

TABLE 2. Discharge Instructions

� Oozing of blood and swelling� Expect oozing of blood from the incis� Consider renting a home suction mac� Use ice packs to the face and jaw for� Keep your head elevated while sleep

several pillows behind your back and� Personal care

� Keep the elastic bands on your bracethe bands to eat and perform oral ca

� Brush your teeth with a soft child’s to� Rinse your mouth with water after ea� You may shower the day after surger

experience light-headedness.� You may gently wash your hair the da

graft site.� Do not blow your nose for four weeks

infection.� Use saline nasal spray as needed to� Rinse your mouth with warm saltwate

� Medications� Take liquid antibiotics according to in� Take liquid pain medication accordin� Take steroid pills, which can be crush

decreasing doses and should not be� Contact your surgeon to obtain a pre� Use oxymetazoline nasal spray, 2 pu

nose; after 3 days, switch to saline na� Diet

� Remain on a blended diet that does nmashed potatoes) to ensure adequat

� Drink extra fluids to prevent dehydrat� Activity

� You may return to work after 2 week� You may resume light exercise after 4� Do not resume contact sports for 8 w

sports or activities you wish to pursu� Specific reasons to call your surgeon afte

� excessive bleeding (beyond the norm� temperature greater than 100.4° F (3� excessive swelling that is unexpected� shifting of the bite or a change in the� severe pain or pain that is uncontrolle� nausea or vomiting that does not res� problems with medications (eg, rash,

gression of five typical aspects of surgical

46 AORN Journal

rs; how-

pro-

ery (ie, swelling, bruising, energy, pa

during the first two weeks of a patien

ative course. This information comes

your mouth and nose. This is normal for two to three days after oral suctioning; obtain a prescription for the rental from your48 hours to decrease swelling.approximately two weeks after surgery to decrease swelling (eg

ix to eight weeks to guide the bite and support the jaws; you mn replace them.sh after eating.d brushing; do not use alcohol-based mouthwashes.se a stool or a bench in the shower or have someone present

surgery to remove blood and surgical prep solution from the c

use this causes air to move into your cheeks and may increase

ut any dried blood and mucus.s four times per day to help the incisions heal.

ons to prevent infection.tructions to prevent postoperative pain.

d taken with juice or yogurt, to decrease swelling; these are totinued abruptly. Follow instructions carefully.n for antinausea medication if you experience nausea or vomit

ach nostril, twice a day for 3 days to decrease oozing of bloodray.

uire chewing (eg, fruit smoothies, applesauce, soft scrambledtion.not use a straw.

s.Facial protection at that time is required; ask your surgeon abotermine whether there are contraindications after orthognathicarge include

ing) that does not resolve or is bright red;which indicates a fever;, and on one side of the face or jaw;osition;rescribed medications;r).

ions inhine fo24 to

ing forneck).

s for sre, theothbruting any but u

y after

beca

wash or rinse

structig to insed andisconscriptioffs in esal sp

ot reqe nutriion; do

s.weekeeks.

e to der dischal ooz8° C),, rapidbone pd by p

olve; o

recov- surgeon author’s 26 years of experience caring for

ery.

ng (ie

nd ar

ative

etime

our w

welli

ry. T

from

unt o

diffic

eek.

comb

ugh t

ss can

equir

rform

rder

labili

ss than

t. Most

ss or a

es that the

surgery. The

edications

week after

atient often

. The surgeon

otics with a

ion (eg, ibu-

le.

y, the pa-

is seldom

atients feel

behind them

lems, so

elling and

nces a low

nd the in-

the averagefirst two

ermis


patients undergoing orthognathic surg

ing (ie, the dark blue line) and bruisi

green line) begin soon after surgery a

obvious on the third to fifth postoper

and begin to decrease thereafter. Som

bruising of the face may take up to f

resolve. A small amount of residual s

continue for several months.

Most patients feel tired after surge

of energy (ie, the purple line) results

general anesthesia, the moderate amo

loss experienced during surgery, and

eating and drinking during the first w

loss usually is less than 500 mL, but

with the stress of surgery, this is eno

the patient feeling fatigued. Blood lo

significant enough for the patient to r

transfusion, but this is rare. When pe

maxillary surgery, surgeons usually o

and cross-match to ensure blood avai

Figure 19. Although recovery is differenintensity of swelling, bruising, energy,postoperative weeks. (Reprinted with p

should the need arise.

Swell-

, the

e most

day

s, the

eeks to

ng may

his lack

having

f blood

ulty

Blood

ined

o leave

be

e a

ing

a type

ty

Pain after orthognathic surgery is le

for some surgeries but is still significan

patients describe it as a sense of fullne

pressure-type pain. The red line indicat

pain is the greatest the first night after

surgeon orders strong oral pain relief m

for the patient to take at home the first

surgery. During the second week, the p

needs narcotic pain relief only at night

may instruct the patient to replace narc

nonsteroidal anti-inflammatory medicat

profen) after the second week if possib

The last aspect of surgical recover

tient’s mood (ie, the light blue line),

discussed, but it is important. Most p

relieved initially to have the surgery

and anticipate resolution of their prob

their emotions are labile. After the sw

bruising set in and the patient experie

energy level, pain, difficulty eating, a

each patient, there are similarities. This graph plotsand mood levels that patients experience during thesion from R. Robinson, MD, DDS.)

t forpain,

convenience of manipulating the elastic bands, he

AORN Journal 47

d irritonounUsua

the pacan chis orhouldand faest msurg

surgrisk

d andn somthesia

memationsk que. Co

tient

e a per, thll pasthes

ients1

lth cao discll preies, iillicind ps

vomnts uverehe sumemted w, ma

od los

s canty to openase, or inter-ns resultingbite splintsperson’s life,

J surgery.during sur-y requireprocedures

has been cuth, if severery to refrac-

shift of teethafter correc-n some casesl growth of

pping, dis-bsequentlings, rootor implants

nts for sixause the jawhat suppliesin. The re-two years.patients

ch should

ough rare,equiresning.ite of thetes that aretibiotics and

seen becausee mouth. Inessary, the


or she may experience depression anGenerally, these feelings are most prthe third or fourth postoperative day.the seventh postoperative day, wheneating and drinking more easily andthe elastic bands without assistance,spirits begin to improve. The nurse stime discussing this with the patientmembers to prepare them and to suggsuccessfully weather the aftermath of

COMPLICATIONS AND RISKSThere are risks associated with anygeneral anesthesia. General surgicalanesthetic risks can range from milversible to severe, permanent, and istances fatal. The surgeon and anesprovider give the patient and familyinformation about possible complicthat they have the opportunity to asand become as informed as possibletions can permanently affect the paor her family.

Underlying conditions may increasrisk for certain complications; howevtential for complications exists with aThere is a risk of death related to anefive to six deaths per one million patexample, as with any procedure. Heaviders should encourage the patient tcomplete medical history, including atests, hospitalizations, surgeries, injurtions, medications, allergic reactions,use, smoking, alcohol consumption, alogical treatments.

At least one episode of nausea andoccurs in approximately 40% of patieing orthognathic procedures; more secations are rare but still possible.15 Tshould inform the patient and familythe complications specifically associasurgery (eg, TMJ problems, nonunionrelapse, tooth damage, numbness, blo
infection, scarring, distraction device failu
48 AORN Journal

ability.ced onlly bytient is

hangeherspendmilyeans to

ery.

ery ands and

re-e in-carebersso

stionsmplica-and his

atient’se po-tients.ia (ie,4), forre pro-lose avious

nfec-t drugycho-

itingndergo-compli-rgeonbers ofith jawlunion,s, bone

� Temporomandibular joint problempresent as joint pain, limited abilithe mouth, degenerative joint disenal disk dislocations. Complicatiofrom TMJ problems may requireand medications for the rest of arevision jaw surgery, or actual TM

� Nonunion occurs when bones cutgery do not heal correctly and mafurther surgery and bone graftingto successfully heal.

� Malunion occurs when bone thatheals in the wrong position, whicenough, will require further surgeture and reset the bone correctly.

� Relapse happens when there is aor bones to their original positiontion, requiring further treatment. Ithis may be related to late residuathe facial bones.

� Tooth damage may present as chicoloration, and tooth death and suloss. This may require crowns, filcanals, extraction, bone grafting,to repair.

� Numbness is present in all patieto eight weeks after surgery becmust be split around the nerve tsensation to the lower lip and chturn of sensation can take up toAt the end of two years, 15% ofcontinue to have numbness, whibe considered permanent.16

� Blood loss averages 500 mL. Althsevere blood loss can occur that rtransfusion and can be life threate

� Bone infection may occur at the ssurgery or around the fixation plaused, in which case, additional ansurgery may be required.

� Scarring that does occur is rarelymost of the incisions are inside thcases where skin incisions are nec

re). scars can be large and visible. Treatment of

r reviars ardepe

ars arnes cay neion isly and

devit.

functiwingith tn altenshipand

f thecan hperso

or

nary.essed

ionaryessed

tion ofore/gloed Jan

ssociaory/tim

atmeng for OO: M

riam-wl&va�

the pa

Denver, CO:

: the LeFort I,andible, and

. 2007;34(3):

d a tale of howthe next genera-;34(3):331-355.

l. A noveladvancement.5.. Boston, MA:

y. Boston, MA:

ry. Boston, MA:

anesthesia. Ex-/mortality_010.

tion and man-White R,of Dentofacial

er; 2003:695.ittal osteotomyew. J Maxillo-

, is aark Mead-

CO. Asurgery; a& Johnson,

ubsidiary ofkholder inared affili-sing poten-ation of

R, is the, Denver,Meadows

e, CO. Mst could be

flict of in-


this complication may require scasteroid injections. Although all scmanent, their effect on the patienthow visible or problematic the sc

� Distraction devices that lengthen boor jam. If this occurs, the device mreplaced or removed. If the distractlayed, the bone may heal too quickreoperation. The screws holding thealso loosen and require replacemen

CONCLUSIONJaw deformities may cause pain, dyscessive tooth wear, and difficulty cheing, or breathing. Many people live wproblems all their lives, but there is aRestoring the proper anatomic relatiojaw helps reestablish normal functionprotect against further deterioration oand the TMJs. Maxillofacial surgerysolve these problems and improve acomfort and self-esteem, allowing himlive a happier and healthier life.

References1. Ortho. Stedman’s Online Medical Dictio

www.stedmans.com/section.cfm/45. Acc25, 2010.

2. Gnatho. Stedman’s Online Medical Dictwww.stedmans.com/section.cfm/45. Acc25, 2010.

3. AAO Glossary 2008. American Associaodontics. http://www.braces.org/knowmupload/2008-AAO-Glossary.pdf. Access2010.

4. History of dentistry. American Dental Ahttp://www.ada.org/public/resources/hist19cent.asp. Accessed January 25, 2010.

5. Arnelt W, McLaughlin R. Overview, trere-stated. In: Facial and Dental Plannindontists and Oral Surgeons. St Louis, MElsevier; 2004:2-3.

6. Facebow. MedlinePlus. http://www2.me.com/cgi-bin/mwmednlm?book�MedicaAccessed January 25, 2010.

7. Recommended practices for positioning
the perioperative practice setting. In: Perioper
sion ore per-nds one.an failed to bede-require

ce can

on, ex-, speak-hesernative.of the

helpsteethelp re-n’sher to

http://January

. http://January

Orth-ssary/uary 24,

tion.eline_

t goalsrtho-

osby/

ebsterfacebow.

tient in

Standards and Recommended Practices.AORN, Inc; 2010:327-350.

8. Patel PK, Novia MV. The surgical toolsbilateral sagittal split osteotomy of the mthe osseous genioplasty. Clin Plast Surg447-475.

9. Obwegeser HL. Orthognathic surgery anthree procedures came to be: a letter totions of surgeons. Clin Plast Surg. 2007

10. Vachiramon A, Yen SL, Lypka M, et amodel surgery technique for LeFort IIIJ Craniofac Surg. 2007;18(5):1230-123

11. LeFort I. Stedman’s Medical DictionaryHoughton Mifflin Co; 1995:379.

12. LeFort II. Stedman’s Medical DictionarHoughton Mifflin Co; 1995:696.

13. LeFort III. Stedman’s Medical DictionaHoughton Mifflin Co; 1995:193.

14. Rosenberg H. Mortality associated withpert pages. http://expertpages.com/newsanesthesia.htm. Accessed February 19, 2

15. Thomas D, Sarver M, Myron R. Prevenagement of complication. In: Proffit W,Sarver D, eds. Contemporary TreatmentDeformity. St Louis, MO: Mosby/Elsevi

16. MacIntosh RB. Experience with the sagof the mandibular ramus: a 13-year revifac Surg. 1981;9(3):151-165.

Randolph C. Robinson, MD, DDScraniofacial and cosmetic surgeon, Pows Cosmetic Surgery, Lone Tree,owner of Park Meadows Cosmetic Sconsultant and speaker for JohnsonInc, and Ethicon Endo-Surgery, a sJohnson & Johnson, Inc; and a stocAcuNetx, Inc, Dr Robinson has declations that could be perceived as potial conflicts of interest in the publicthis article.

Rebecca L. Holm, RN, MSN, CNOclinical editor of the AORN JournalCO, and a perioperative nurse, ParkCosmetic Surgery Center, Lone TreHolm has no declared affiliation thaperceived as posing a potential con

ativeterest in the publication of this article.

AORN Journal 49

http://www.stedmans.com/section.cfm/45




http://www.braces.org/knowmore/glossary/upload/2008-AAO-Glossary.pdf

http://www.braces.org/knowmore/glossary/upload/2008-AAO-Glossary.pdf

http://www.ada.org/public/resources/history/timeline_19cent.asp

http://www.ada.org/public/resources/history/timeline_19cent.asp

http://www2.meriam-webster.com/cgi-bin/mwmednlm?book=Medical%26va=facebow



http://expertpages.com/news/mortality_anesthesia.htm

http://expertpages.com/news/mortality_anesthesia.htm

.3.aorn.org/CE

EXAMINATION
CONTINUING EDUCATION PROGRAM
5wwwOrthognathic Surgery for Patients

with Maxillofacial Deformities

thognathic

ic surgery.c surgery.

ur conve-e Exami-

PURPOSE/GOAL

To educate perioperative nurses about care of patients undergoing orsurgery for maxillofacial deformities.

OBJECTIVES

1. Describe how maxillofacial deformities affect patients.2. Explain treatment options for maxillofacial deformities.3. Discuss perioperative nursing care of patients undergoing orthognath4. Describe postoperative complications that can occur after orthognathi

The Examination and Learner Evaluation are printed here for yonience. To receive continuing education credit, you must complete thnation and Learner Evaluation online at http://www.aorn.org/CE.

pain a

brea

s.4, 4, an

en th

ormal.lla.illa.no di

eth as closetia before

correct facialtogether and

d mandible tompensation.onths before

eshaping the.

vides duringesor her familyed for a

QUESTIONS

1. Jaw deformities may cause1. excessive tooth wear.2. temporomandibular joint (TMJ)

dysfunction.3. difficulty chewing, speaking, or

ing.4. obstructive sleep apnea.5. problems with the heart and lung

a. 1 and 2 b. 3 andc. 1, 2, 3, and 4 d. 1, 2, 3

2. A class II malocclusion occurs whtient’sa. bite and facial relationship are nb. mandible is larger than the maxic. mandible is smaller than the maxd. teeth are misaligned and there is

in the jaw size.


nd

th-

d 5

e pa-

fference

3. The orthodontist should bring the teto normal as possible with orthodonmaxillofacial surgery.a. true b. false

4. The maxillofacial surgeona. moves the facial bones to restore

relationships so that the teeth fitthe jaw functions normally.

b. aligns the teeth in the maxilla anremove the preexisting dental co

c. removes the wisdom teeth six msurgery.

d. corrects the dental anatomy by rteeth so they fit together properly

5. Patient education that the nurse prothe preoperative appointment includ1. ensuring that the patient and his

members fully understand the ne
blended diet for six weeks after surgery.
1 © AORN, Inc, 2010

http://www.aorn.org/CE

any fo

rink ck coff

the pthe p

4, and

l defopera

ntions

ssess

y statutatus.od ga

nd 5, 4, an

rgicaleet ab

evate the headees to reduce

ber bands on

the healing

4, 4, and 5

ent may

5, 4, and 5

linical editor

director, Cen-

perceived as

CE EXAMINATION www.aornjournal.org

2. instructing the patient not to eathours before surgery.

3. explaining that the patient may duids (eg, water, apple juice, blacto four hours before surgery.

4. obtaining informed consent fromor, if the patient is a minor, fromparents or legal guardian.a. 1 and 2 b. 3 andc. 1, 2, and 3 d. 1, 2, 3

6. Because patients with maxillofaciacan present airway challenges, preand intraoperative nursing interveinclude1. using monitoring equipment to a

tory status.2. evaluating respiratory status.3. monitoring changes in respirator4. identifying baseline respiratory s5. reporting deviation in arterial blo

studies.a. 1 and 3 b. 2, 4, ac. 2, 3, 4, and 5 d. 1, 2, 3

7. In the LeFort ___ procedure, the subegin in the midfacial bones and mnasal bones.

The behavioral objectives and examination fo

and Helen Starbuck Pashley, RN, MA, CNOR

ter for Perioperative Education. Ms Holm, Ms

posing potential conflicts of interest in the publicati

od eight

lear liq-ee) up

atientatient’s

4

ormitiestiveshould

respira-

s.

s

d 5

cutsove the

a. I b. IIc. III d. IV

8. Postoperatively, the nurse should elof the patient’s bed at least 30 degrswelling of the face and airway.a. true b. false

9. The surgeon places orthodontic rubthe patient’s braces to1. control the patient’s bite during

process.2. make eating and drinking easier.3. help seat the TMJs.4. decrease discomfort.5. help prevent shifting of the bite.

a. 1 and 2 b. 2 andc. 1, 3, 4, and 5 d. 1, 2, 3

10. After maxillofacial surgery, the patiexperience1. swelling.2. blood oozing from incisions.3. lip paresthesias.4. nausea or vomiting.5. pain.

a. 1 and 3 b. 4 andc. 1, 2, and 5 d. 1, 2, 3

program were prepared by Rebecca Holm, RN, MSN, CNOR, c

al editor, with consultation from Susan Bakewell, RN, MS, BC,

ley, and Ms Bakewell have no declared affiliations that could be

r this

, clinic

Pash

on of this article.

AORN Journal 51

.3.aorn.org/CE

LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
5wwwOrthognathic Surgery for Patients

with Maxillofacial Deformitiesne thon proe item

tives o

ities aHigh

llofaci5. Hof pat

ns tha

ease y

al objeighation fs 2.resultquest

? (Select all

eam regarding

change/im-

ting with phy-ceptance of

luate the ef-rvals until the

ractice.

e as a resultt all that

relevant to my

ch otherschange.

ort to make a

e verify thecontinuing

This evaluation is used to determito which this continuing educatimet your learning needs. Rate th

described below.

OBJECTIVES

To what extent were the following objeccontinuing education program achieved?

1. Describe how maxillofacial deformpatients. Low 1. 2. 3. 4. 5.

2. Explain treatment options for maxideformities. Low 1. 2. 3. 4.

3. Discuss perioperative nursing careundergoing orthognathic surgery.Low 1. 2. 3. 4. 5. High

4. Describe postoperative complicatiooccur after orthognathic surgery.Low 1. 2. 3. 4. 5. High

CONTENT

5. To what extent did this article incrknowledge of the subject matter?Low 1. 2. 3. 4. 5. High

6. To what extent were your individumet? Low 1. 2. 3. 4. 5. H

7. Will you be able to use the informarticle in your work setting? 1. Ye

8. Will you change your practice as areading this article? (If yes, answer

applicant who successfully completes this program


e extentgrams as

f this

ffect

alighients

t can

our

ctives

rom thisNoof

ion

8A. How will you change your practicethat apply)1. I will provide education to my t

why change is needed.2. I will work with management to

plement a policy and procedure.3. I will plan an informational mee

sicians to seek their input and acthe need for change.

4. I will implement change and evafect of the change at regular intechange is incorporated as best p

5. Other:

8B. If you will not change your practicof reading this article, why? (Selecapply)1. The content of the article is not

practice.2. I do not have enough time to tea

about the purpose of the needed3. I do not have management supp

change.4. Other:

9. Our accrediting body requires that wtime you needed to complete the 5.3

program:

dentialing Center

eptance of this

rs. Each

#8A. If no, answer question #8B.) education contact hour (318-minute)

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Creapproves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for accactivity for relicensure.

Event: #10053; Session: #4017 Fee: Members $26.50, Nonmembers $53

The deadline for this program is July 31, 2013.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answe
can immediately print a certificate of completion.
1 © AORN, Inc, 2010

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