Orthognathic Surgery-Induced Fibrinolytic Shutdown Is Amplified by Tranexamic Acid.

PURPOSE: Little is known of the systemic effects of oral and maxillofacial surgery on the hemostatic balance, including the biochemical effects of tranexamic acid (TXA), on fibrin clot lysis. The present study investigated the effects of orthognathic surgery on fibrin lysis, fibrin structure, and D-dimer and evaluated the effect of TXA on these fibrinolytic measures. MATERIALS AND METHODS: The present double-blind, controlled, and randomized, placebo study included patients referred to the Department of Oral and Maxillofacial Surgery at the University Hospital of Southern Denmark-Esbjerg from August 2014 through September 2016. The patients were elective and had a diagnosis of maxillary or mandibular deficiency, either excessive or asymmetric. All patients underwent bimaxillary orthognathic surgery (OS) with or without maxillary segmentation or additional genioplasty. The patients were blindly randomized to treatment with TXA or placebo. The primary predictor variable was OS. The secondary predictor variable was an intravenous dose of 1 g of TXA or equivalent placebo preoperatively. Blood samples were collected before surgery and 5 hours after the initiation of surgery. The primary outcome variable was lysis of fibrin. The fibrin structure properties and D-dimer were secondary outcome measures. The Mann-Whitney U test was used for the within-group comparisons. The Wilcoxon signed rank test was used for the between-group comparisons. RESULTS: The sample included 96 patients; 45 received placebo and 51 received TXA. Fibrin lysis decreased after OS (P < .001). The fibrinolytic shutdown decreased significantly more in the TXA group than in the placebo group (P < .001). OS altered the fibrin structure properties with comparable effects in the 2 groups. D-dimer increased postoperatively but significantly less so in the TXA group than in the control group (P < .001). CONCLUSIONS: OS is associated with fibrinolytic shutdown and alters fibrin structure properties, driving the hemostatic balance in a prothrombotic direction. The fibrinolytic shutdown is significantly amplified by TXA.

Prevention of Bleeding in Orthognathic Surgery--A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: The objective of the present study was to evaluate the efficacy of hemostatic adjuncts on intraoperative blood loss (IOB) in orthognathic surgery (OS) detected by randomized controlled trials (RCTs) of the highest quality. MATERIALS AND METHODS: A search of the Medline, Cochrane, Embase, and Web of Science databases was performed in January 2015, and the risk of bias was assessed using the Jadad and Delphi scales. The predictor variable was the hemostatic measures, and the main outcome variable was the total IOB volume. The secondary outcome variables were the hemoglobin and hematocrit and operating time. This review is registered at PROSPERO (CRD42014014840). RESULTS: Eleven trials were included for review. The individual trials demonstrated the effects on IOB from hypotensive anesthetic regimens, the use of aprotinin, and the herbal medicine Yunnan Baiyao. Six studies of tranexamic acid (TXA), with 288 patients, were suitable for a meta-analysis of continuous data. TXA reduced IOB by an average of 171 mL (95% confidence interval [CI] -230 to -112; P < .00001). Its topical use yielded similarly significant results (mean difference -197, 95% CI -319 to -76; P < .001). A subgroup analysis showed a decreased operating time in the TXA groups by an average of 15 minutes (mean difference -14.78, 95% CI -22.21 to -7.35; P < .0001). CONCLUSIONS: Efficient hemostatic adjuncts exist for OS. Our meta-analysis showed that TXA significantly reduces IOB by an average of one third, regardless of whether it was given intravenously (IV) or applied topically. Additional RCTs are needed to confirm the effect of topical TXA in OS, and larger studies of intravenous administration are needed before any routine recommendations. No hemostatic effect of hypotensive anesthesia was found, mainly owing to imprecise descriptions of the blinding procedures. Transparent and uniform trial reporting is thus encouraged in future studies.

Improved apnea-hypopnea index and lowest oxygen saturation after maxillomandibular advancement with or without counterclockwise rotation in patients with obstructive sleep apnea: a meta-analysis.

PURPOSE: This study investigated whether patients with obstructive sleep apnea (OSA) who undergo maxillomandibular advancement (MMA) with counterclockwise (CCW) rotation compared with those who undergo MMA without CCW rotation have better outcomes. MATERIALS AND METHODS: This was a systematic review with meta-analysis. The Medline and Cochrane databases were searched for randomized controlled trials using Medical Subject Headings. The predictor variable was operative technique, namely MMA with or without CCW rotation of the maxillofacial complex. The key outcome variables were changes in pre- and postsurgical values of pharyngeal volume measured on computed tomogram or cone-beam computed tomogram and changes in Apnea-Hypopnea Index (AHI) and lowest oxygen saturation (LSAT) values after surgery. Data were subjected to a meta-analysis based on odds ratios (OR) with 95% confidence intervals (CIs) and P values lower than .05 by χ(2) test were considered significant. RESULTS: Twenty-one randomized controlled trials were identified and 4 were assessed for the variables of interest. Postoperative AHI and LSAT measurements showed vast improvement. The sample was not large enough to make a correlation between pharyngeal volume changes and surgical method used. Postoperative parameters included an AHI lower than 5 (OR = 14.9; 95% CI, 2.7-83.5; P = .002), an AHI lower than 20 (OR = 114.8; 95% CI, 23.5-561.1; P <.00001), pooled results of a 50% decrease in the AHI (OR = 6.1; 95% CI, 2.2-17.0; P = .0006), and an increase greater than 90% in LSAT measurements during sleep (OR = 6.0; 95% CI, 1.8-19.9; P = .003). The funnel plot showed no evidence of publication bias. CONCLUSION: CCW-MMA or MMA in patients with OSA results in a statistically meaningful decrease in postoperative AHI and a statistically meaningful increase in postoperative LSAT.

Corticosteroid administration in oral and orthognathic surgery: a systematic review of the literature and meta-analysis.

PURPOSE: This study evaluated the effect of corticosteroid (CS) administration on edema, analgesia, and neuroregeneration in conjunction with surgical dental extraction, orthognathic surgery, and the risk of developing side effects. MATERIALS AND METHODS: A systematic search of the literature was made. The primary predictor variable was CS administration and the outcome variables were edema, pain, and infection. A meta-analysis was performed. The risk of other side effects was evaluated through a simple review. RESULTS: In oral surgery, most clinical trials showed a significant decrease in edema (P < .0001) after CS, and local injection of methylprednisolone > or =25 mg was expected to result in a significant decrease in edema. Regarding the analgesic effect, several clinical trials showed a decrease in pain after CS (P < .0001). Further, CS administration resulted in a slightly higher risk of infection (relative risk, 1.0041), but with a P value of .89. CS could be administered with no increased risk of infection. In orthognathic surgery, methylprednisolone > or =85 mg administered intravenously seemed sufficient to produce a significant decrease in edema, and several trials pointed toward a neuroregeneration effect, but no statistical analysis could be performed. Regarding the risk of other side effects, in oral surgery, a minimal risk of chronic adrenal suppression was seen; in orthognathic surgery, an elevated risk of avascular osteonecrosis, steroid-induced psychosis, and adrenal suppression was seen. There were no reports of decreased healing. CONCLUSION: These findings suggest that the administration of CS in oral surgery decreases edema and pain significantly, with no higher risk of infection and with a minimum risk of other side effects.

Brånemark and ITI dental implants in the human bone-grafted maxilla: a comparative evaluation.

The development of new characteristics concerning implant surface makes it interesting to clinically compare different implant systems in the bone-grafted maxilla. The aim of this evaluation was to compare clinical data of a two-staged procedure on the augmented extremely atrophic maxilla using either Brånemark- or ITI-fixures. In 25 patients (18 females, seven males) the severely atrophied maxilla was reconstructed with autogenous iliac or mandibular bone and either Brånemark or ITI implants. Seventy-eight Brånemark implants and 80 SLA-ITI implants were inserted in the augmented bone and the patients were followed between 20 and 67 months post implantation. The bone graft was transplanted to add bony volume in the maxillary sinus, the anterior floor of the nose and/or the alveolar ridge. After a healing period of 4(1/2) months, dental implants were inserted and left for healing for 8 months. Twelve consecutive patients received machine-surfaced Brånemark fixtures and 13 consecutive patients received SLA-ITI fixtures. Gradual loading was applied after healing abutment application. After 6 months the permanent prosthetic reconstruction was provided to the patient, either as a fixed or removable bridge. Comparison in survival rate was performed: 15 machined Brånemark fixtures were lost, resulting in an overall survival rate of 81%. Two ITI fixtures were lost, resulting in an overall survival rate of 98%. The results of this evaluation show that sandblasted large grit acid etched surface-treated ITI implants has a significant higher survival rate than machine-surfaced Brånemark implants in autogenous grafted maxillary bone.