Some complications of major oral surgery and their prevention and management

Abstract

WHEN one reflects upon the considerable number of cases of jaw injury and facial skeletal deformity operated upon annually--each carrying with it the potential risk of upper respiratory tract obstruction--the incidence of mortality and morbidity seems to be remarkably low. However, despite this fact, the number of what might be termed 'near misses' is conjectural and the literature appears to be unnaturafly scant on this subject. As Gissane and Bull (1962) point out, the number of road traffic accidents has increased at an alarming rate over the past 15 years and the rise continues. Since an increasing number of patients are now able to undergo corrective surgery of the jaws because of improved surgical techniques and safer, more efficient anaesthesia, it is justifiable to assume that surgery which particularly concerns oral surgeons will increase in the foreseeable future. In a short contribution such as this, it is not intended to enter into detailed statistical analyses, discussion of the numerous types of operative procedures, nor complications such as sepsis, malunited fractures nor failed bone grafts since these do not, in the vast majority of cases, endanger the patient's life. For the purpose of this paper, it will be assumed that all cases under discussion involve mandibular-maxillary fixation and surgery performed under general anaesthesia. In the case of mandibular fractures alone, the patient is left in the post-operative state with an impaired oral airway. Maxillary fractures introduce the added complication of a possibly impaired nasal airway and free bleeding into the nasopharynx which is not readily accessible to direct control. Corrective operations, unlike fractures, induce the main trauma at the time of surgery and the degree of post-operative swelling is a matter of speculation (many fractures have reached their maximum swelling by the time that the operation begins). Also, whether the mandible is repositioned backwards or forwards, the tongue will come to occupy a different position to the pre-operative state and add to the patient's discomfort and inability to control it in its new position. Brook et al (1962) are of the opinion that 'the most common cause of upper airway obstruction is the toneless tongue' and the tongue is certainly hypotonic in many cases of extensive jaw injuriesaccidental or iatrogenic. It should be remembered that reconstructive operations on the mandible, such as ostectomies and osteotomies, can produce enormous swelling of the face and the upper part of the neck and in the presence of a complete or near complete dentition, intermaxillary fixation, whether by cap-splints, eyelet wires or arch bars, can virtually exclude the mouth as an effective route for adequate respiration. Thus, the patency of the nasal air passages is of vital importance to survival.