the plan of treatment of deformities of the jaws includes pre - surgical orthodontic treatment designed to eliminate dental compensations present ( i.e. , the anomalies of the teeth that have taken place ) and the preparation of the dental arches in relation to the scheduled surgery . in the field of orthodontics and surgery ,
studies have been carried out to improve some characteristics like the modulus of elasticity and frictional modulus of orthodontic appliances .
although the le fort i osteotomy is a safe surgical technique , many complications have been reported with a low incidence of occurrence .
these include swelling , haemorrhage , infections , nerve injuries , bone necrosis , tmj problems , periodontal disease , ophthalmic and middle ear disorders , dysphagia and psychological problems .
in particular , vascular complications can arise from direct trauma to the vessels due to the blind nature of the osteotomy in the maxillary posterior area .
unwanted fracture lines may also extend to the pterygopalatine fossa , skull base and to the orbit . as a rule , the osteotome position during pterygomaxillary separation is contiguous to the internal maxillary artery ( i m a ) , therefore , complications are rare .
the entire course of internal maxillary artery ( i m a ) from its retro - mandibular origin to its termination within the pterygopalatine fossa is vulnerable to iatrogenic injury .
therefore , to avoid possible delayed complications and facilitate their management , continuous postoperative monitoring is essential .
the descending palatine artery is the vessel most often involved in traumatic injuries during orthognatic surgery of the maxilla .
less often , the maxillary artery and its terminal branches , the pterygoid venous plexus , the internal carotid artery , and internal jugular vein may be damaged .
we present a case of an extended cervico - facial haematoma due to delayed bleeding from the terminal branches of the maxillary artery after orthognatic surgery .
a 23-year - old man was referred to the department of maxillofacial surgery , university of verona , italy for the surgical correction of a class iii asymmetric malocclusion [ figure 1a ] .
the patient underwent a le fort i osteotomy , with impaction of the maxilla associated with an epker mandibular bilateral sagittal split ramus osteotomy , with maxillary advancement and rigid internal fixation of the mandible with four miniplates ( osteomed ) , and four miniplates for the upper maxilla as well .
class iii asymmetric malocclusion the patient had a medical history of one wisdom tooth extraction , performed under local anaesthesia .
preoperative vital parameters were : temperature , 36.4c ; heart rate , 62 bpm ; blood pressure , 120/65 mmhg ; respiration rate , 17 breaths per minute and 100% oxygen saturation .
preoperative laboratory tests showed rbc , 4.86 e + 12/l ; hb , 14.1 g / dl ; ht , 43.1% ; coagulation tests were normal ( prothrombin time 1.05 inr , activated partial thromboplastin time 1.18 and fibrinogen 241 mg / dl , clauss method 7.11
the patient received a single - shot antimicrobial prophylaxis using 1 gm of amoxicillin , in addition to a single dose of corticosteroids ( 1 gm of methylprednisolone ) one hour before the operation .
the surgical procedure was performed in general hypotensive anaesthesia , with the following parameters : blood pressure , 100/70 mmhg ; heart rate , 80 beats per minute and 100% oxygen saturation .
sevoran , fentanile , remifentanyle , 1500 ml of crystalloids and 500 ml of colloids were infused .
the first post - surgery day , the patient developed a gradual dispnea together with neck swelling .
a cat scan with contrast agent was performed , showing a parapharyngeal thickening , with dislocation and compression of upper airways ; laboratory values were ht , 34.9 % ; hb , 12.3 g / dl ; rbc count , 3.81 e + 12/l .
after 5 hours , a progressive worsening of the general condition led to immediate intubation .
laboratory results in the emergency room were ht , 28.2% ; hb , 9.9 g / dl ; rbc count , 3.06 e + 12/l ; prothrombin time , 1.20 inr , activated partial thromboplastin time , 1.18 and fibrinogen , 452 mg / dl .
the patient was sedated with midazolam and diprivan and was given amoxicillin vial gm , 1 fl every 8 hour a day and methylprednisolone vial 125 : 1 vial 3/die .
the same night , a cat scan showed a wider extension of the haematoma on the upper and lower airways , together with a decrease in the diameter of the parapharyngeal space [ figure 1a and b ] .
the patient underwent a bilateral carotid arteriography [ figure 2 ] , and a slight bleeding from the palatine branches of the left ascending pharyngeal artery which was probably closed by the arterial spasm induced by the catheter was revealed .
other cat slices did n't show a significant difference in comparison with the first cat .
haematoma on the upper and lower airways the patient underwent a bilateral carotid arteriography on the second postoperative day , the patient 's general condition improved with a progressive normalization of laboratory tests values . on the fourth postoperative day ,
total recovery from haematoma was achieved within two months and the final clinical check showed a healthy appearance with good occlusion .
le fort i osteotomy is a standard orthognatic surgery procedure used for the correction of dentofacial deformities .
it was first described by vom lagenbeck in 1859 and it was used for the first time in 1927 by wassmund .
axhasen in 1934 and schuchardt in 1942 described the use of an osteotome to separate the pterygomaxillary suture .
bell studied the biological basis for maxillary osteotomy , bone healing and revascularization after corticotomy .
it is of great importance to understand the mechanism of the complications in order to minimize the potential risks .
vessel injury may occur when the maxillary tuberosity is separated from the pterygoid plates with an osteotome , or during the downfracture procedure .
precious reported that pterygomaxillary separation can be achieved safely and easily by leverage alone without the use of a pterygoid chisel .
he described the use of tessier 's spreaders , together with digital manipulation to achieve pterygomaxillary separation followed by maxillary mobilization .
smith 's 3-prong spreaders , turvey 's maxillary expanders , and modified mobilisation forceps are also used to aid leverage . in le fort
i osteotomy , most often , a haemorrhage arises from the branches of i m a .
. collaterals of the i m a include the posterior , superior , alveolar , infraorbital , greater palatine , lesser palatine , ascending pharyngeal , vidian , and sphenopalatine
. the descending palatine artery may be a common source of bleeding during and after le fort i osteotomy because of its anatomic location in the posteromedial wall of the maxillary sinus .
arterial haemorrhage tends to be more persistent and can be recurrent , which makes it more difficult to manage
. bleeding can occur intraoperatively during the osteotomy , but also within the first 2 weeks following surgery and generally presenting as epistaxis . in some cases ,
even months after the procedure , there can be a delayed presentation of pseudoaneurysm . in order to investigate the major cause of bleeding after a le fort osteotomy
a cat scan is useful to define the newly established bone anatomy , the location of the pathology , and the vessel relationships to the fracture line .
a cat scan with contrast agents provides faster , easily detectable and interesting clues for the type of pathology of the affected side .
treatment modalities used to arrest postoperative haemorrhage include nasal packing , packing of the maxillary antrum , reoperating with clipping or electrocoagulation of the bleeding vessels , the use of topical haemostatic agents in the pterygomaxillary region and selective embolization of the maxillary artery and its terminal branches .
according to literature , different embolization materials have been used with various degrees of success for pseudoaneurysm treatment : gelfoam , gianturco coils , stainless steel coils with gelatin or dacron fibres , guide wires , detachable balloons , n - butyl cyanoacrylate , autologous clot , polivinil alcohol , complex platinum coils , guglielmi detachable coils .
concerns about the risk of haemorrhage as a result of pterygomaxillary separation led to the development of an osteotomy technique anterior to the pterygomaxillary suture .
rohner described an endoscopically assisted le fort i osteotomy to ensure preservation of the descending palatine artery .
ueki et al . recently reported the use of an ultrasonic bone curette to mobilize the pterygoid process , thus avoiding the damage to the descending palatine vessels .
for the authors , the ultrasonic bone curette offers a safe procedure for performing pterygoid process fractures , without damaging the surrounding tissues .
this technique allows surgeons to perform procedures in the pterygomaxillary area to safely mobilize the pterygoid process . during the intraoperative phase
a straight follow - up of the patients is important in cases who may show vascular hypersensivity , able to cause a vessel spasm release the day after the operation .
new trends for ambulatory surgery reduce costs for patients but can increase medical responsibility . for legal reasons , even if it is necessary to mention typical complications during preoperative counselling , it is ideal to follow up on patients with standard checkups . not only should the patient be informed about the frequency of complications , but he should also be told about its implications in later life .
once a frequent complication , haemorrhage has become rare when the surgical technique is handled by an experienced orthognatic surgeon . sometimes , despite preoperative planning and a careful surgical technique
it is important to check immediate or delayed postoperative bleeding also , using a protocol that can take care of day surgery patients .
an increased knowledge of the basic biology of the le fort i osteotomy , the development of instruments specially designed for this le fort i procedure and the use of hypotensive anaesthesia have dramatically reduced the morbidity and duration of this procedure .
 although the le fort i osteotomy is a safe surgical technique , many complications have been reported . 
 we present a case of an extended cervico - facial haematoma due to delayed bleeding from the terminal branches of the maxillary artery after orthognatic surgery . 
 a 23-year - old man was referred to our observation for the surgical correction of a class iii asymmetric malocclusion . 
 the patient underwent a le fort i osteotomy , with impaction of the maxilla , associated with an epker mandibular bilateral sagittal split osteotomy , with maxillary advancement and rigid internal fixation of the mandible with four miniplates and another four for the upper maxilla as well . 
 the first post - surgery day , the patient developed a gradual dispnea together with neck swelling . by second postoperative day 
 , the patient 's general condition improved with a progressive normalization of laboratory tests values . 
 the computerised axial tomography ( cat ) scan confirmed a decrease in the parapharyngeal thickening . 
 total recovery was achieved within two months , the final clinical check showed a healthy appearance with good occlusion . 
 an increased knowledge of the basic biology of the le fort i osteotomy , the development of instruments specially designed for the le fort i procedure and the use of hypotensive anaesthesia could reduce the morbidity and duration of this procedure . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION