Introduction
Maxillectomy and mandibulectomy are common surgical procedures for the treatment of orofacial tumors. The most common reported intraoperative complication with these procedures is hemorrhage.1–4 This is particularly true for patients undergoing caudal maxillectomy,4 as inadvertent trauma to the maxillary, infraorbital, and sphenopalatine blood vessels can occur during the osteotomy. Other complications can occur in the immediate or convalescent postoperative period, including aspiration pneumonia, surgical site dehiscence, oronasal fistula formation, and sialocele formation.1,5–7
Intraoperative hemorrhage can impede visualization of the surgical field. As a result, identification and ligation of the injured vessels is difficult, prolonging surgical times and potentially leading to life-threatening blood loss. A 2018 report4 evaluating factors associated with intraoperative complications in 193 dogs undergoing oncologic maxillectomies found that 53.4% exhibited excessive surgical bleeding, of which 42.7% required a blood transfusion for acute hypovolemic anemia. This was consistent with prior studies4,8,9 that reported 30% to 50% of dogs undergoing maxillectomy required transfusion for profound intraoperative hemorrhage. In contrast to maxillectomies, however, a 2021 study1 found that 4 of 279 (1.4%) dogs undergoing mandibulectomy required a blood transfusion for acute hypovolemic anemia.1
Some authors have recommended performing osteotomies rapidly to allow more time to apply ligation to control bleeding, suggesting that excessive or profound hemorrhage is unavoidable.2,4 However, rapid identification of hemorrhage may be difficult or impossible in locations where vessels may retract into osseous recesses.10,11 Common carotid or external carotid arterial ligation has been well documented in human medicine to stop active hemorrhage during surgical procedures or to preemptively prevent or reduce risk for surgical procedures with a high risk of bleeding.2,10,11 Comparable approaches have been proposed in veterinary medicine including preemptive ligation of the maxillary and carotid arteries.2,11
Surgical instruments used to perform osteotomies during maxillofacial surgery often include oscillating or sagittal bone saws, high-speed electrical and air-driven dental units, low-speed electrical units, and osteotomes with mallets.2,3,5,12–24 What these instruments have in common is indiscriminate cutting of any hard or soft tissue in their path. The speed at which these instruments cut bone may be relatively quick, but secondary injury to local soft tissues is increased.25
Another instrument that can be utilized for maxillofacial surgery is the piezoelectric unit (Figure 1). Piezoelectric surgery utilizes ultrasonic micro-oscillations at a rate of 28 to 36 oscillations/s, which allows the instrument to cut mineralized tissues with precision while sparing the soft tissues.20,26–28 There is low acoustic impact and high tactile sensitivity, allowing for less pressure for effect and enabling improved ergonomic handing of the instrument for the operator.17,29 Simultaneous sterile irrigation also rinses away blood to improve visibility and creates an environment for cavitation that has the additional benefit of cauterizing small vessels.15,26,29 Human studies utilizing piezosurgery for maxillofacial surgery have also reported improved postoperative healing and patient comfort.19 Due to the technically complex nature of oncologic maxillectomy and mandibulectomy and proximity to major vessels, piezosurgical units may be utilized for procedures that have high risk of hemorrhage.
Photographs illustrating the surgical setup of a piezosurgical unit with attached irrigation, handpiece, and cutting tips (A), closeups of the digital screen (B), handpiece with a BS1 cutting tip (C), and bone-cutting kit (D). Figure 1 was designed with the assistance of Carol Jennings, Multimedia Producer, from the College of Veterinary Medicine at Cornell University.
Citation: Journal of the American Veterinary Medical Association 261, 9; 10.2460/javma.23.03.0130
Few reports have systematically documented the risks or benefits of using a piezoelectric unit to perform osteotomies during maxillectomy and mandibulectomy in dogs.3,15 The purpose of this study was to document the intraoperative complication rate in patients undergoing oncologic maxillectomy or mandibulectomy when using a piezoelectric unit to perform osteotomies.
Materials and Methods
Medical records of dogs that underwent mandibulectomy or maxillectomy for the treatment of oral neoplasia at the Companion Animal Hospital at Cornell University between 2012 and 2022 were evaluated. Dogs were included if osteotomies were performed using a piezoelectric unit and complete medical records up to and through the perioperative period were available. The type of surgical procedure was categorized based on location of osteotomies as previously described in the literature.5,30,31 Total mandibulectomies were excluded because they do not involve an osteotomy, while extended subtotal mandibulectomy cases were excluded because the mandibular artery is ligated prior to the osteotomy.32
Records were considered complete if they included preanesthetic bloodwork (CBC and serum biochemistry profile or point-of-care bloodwork for patients < 7 years of age with benign tumors confirmed via histopathology), CT imaging of the head, histopathologic diagnosis, surgical report, anesthetic records, and immediate postoperative hospital monitoring/treatment records. Point-of-care bloodwork included PCV, serum total protein, BUN, and blood glucose. Advanced imaging of the head was utilized to evaluate the extent of tumor invasion, determine whether the tumor was resectable, and design the individual surgical protocol. Additional data obtained included breed, age, sex, body weight, patient size, surgical time if available, and location and extent of surgery.
Surgeries were performed following standard techniques5,30,31 by either an American Veterinary Dental College board-certified specialist or a closely supervised specialist in training. Anesthesia was performed under direct supervision of a board-certified veterinary anesthesiologist. Ethics committee approval was not required for enrollment given the retrospective nature of the study.
All records included were assessed for the primary complication of interest (ie, severe intraoperative hemorrhage). Severe hemorrhage was differentiated from routine surgical bleeding by subjective documentation of nonroutine bleeding in the medical record and objective signs of acute hypovolemic anemia including tachycardia, hypotension, paradoxical bradycardia, and the need for administration of blood products.
Records were evaluated for intraoperative administration of blood products due to severe hemorrhage, and the need for administration of blood products was compared based on whether the patient underwent maxillectomy or mandibulectomy, the location of surgery, tumor type, and size of the patient.
Statistical analysis
Continuous variables were assessed for normality via the Shapiro-Wilk test; approximately normally distributed variables were reported as mean ± SD, while nonnormal variables were reported via median, range, and IQR. The Wilcoxon rank sum test was used to compare group medians for nonnormal variables, while Spearman rank correlation was used to examine the relationship between nonnormal continuous variables. Simple logistic regression was used to determine the association between continuous variables and the presence or absence of complications, while relative risks (RRs) and associated 95% CIs, along with the χ2 test or Fisher’s exact test, were used to assess the relationships between categorical variables. Multivariable linear regression and multivariable logistic regression were performed using stepwise backward selection with a retention threshold of P < .2, with final models checked for 2-way statistical interaction. Significance was defined as P < .05. Normality of residuals in linear regression was visually assessed via inspection of normal QQ plots. The linearity of the relationship between continuous predictors and the logit of the response variable in logistic regression was checked via the Box-Tidwell test. All statistical testing was performed using commercial statistical software (SAS version 9.4; SAS Institute Inc).
Results
Ninety-eight cases met the inclusion criteria, representing 41 maxillectomies (41.84%) and 57 mandibulectomies (58.16%). Patient body weight ranged from 2.6 to 70.5 kg (median, 28.05; IQR, 16.80). Patient age ranged from 6 months to 15 years (mean, 7.79 ± 3.15 years). Fifty-five (56.12%) patients were male (49 castrated, 6 intact), and 43 (43.87%) patients were female (40 spayed, 3 intact). A total of 33 breeds were identified; the most common were mixed-breed dogs (29 dogs [29.59%]), followed by Labrador Retrievers (14 dogs [12.28%]) and Golden Retrievers (7 dogs [7.14%]).
Thirteen tumor types were represented, including canine acanthomatous ameloblastoma (31 dogs [31.63%]), oral squamous cell carcinoma (19 dogs [19.39%]), peripheral odontogenic fibroma (12 dogs [12.24%]), plasmacytoma (8 dogs [8.16%]), osteosarcoma (8 dogs [8.16%]), multilobular tumor of bone or osteochondrosarcoma (5 dogs [5.10%]), oral malignant melanoma (4 dogs [4.08%]), and fibrosarcoma (3 dogs [3.06%]). The remaining 8.19% consisted of 4 undifferentiated sarcomas, 1 amyloid-producing odontogenic tumor, 1 peripheral nerve sheath tumor, and 1 undifferentiated carcinoma.
Of the patients that underwent maxillectomy procedures, 16 (39.02%) were unilateral rostral, 9 (21.95%) were bilateral rostral, 3 (7.31%) were central, and 13 (31.70%) were caudal. Of the patients that underwent mandibulectomy procedures, 11 (19.29%) were unilateral rostral, 28 (49.12%) were bilateral rostral, 6 (10.52%) were rim (marginal) excisions, and 12 (21.05%) were subtotal.
Recorded surgical times for all 98 reported surgeries ranged from 0.58 to 6.58 hours (median, 2.46 hours; IQR, 1.58 hours). Surgical times for maxillectomies ranged from 0.83 to 6.58 hours (median, 2.73 hours; IQR, 1.75 hours), and surgical times for mandibulectomies ranged from 0.58 to 5.58 hours (median, 2.41; IQR, 1.50 hours; Table 1). In univariable analyses, surgical time did not differ significantly between mandibulectomies and maxillectomies (Wilcoxon rank sum P = .6019), nor was it significantly associated with dog weight (Spearman rank correlation, 0.116; P = .2703). The surgery time for caudal procedures, including caudal maxillectomy and subtotal mandibulectomy (range, 2.00 to 6.58 hours; median, 3.41; IQR, 1.70), was significantly longer than that of more rostral procedures (range, 0.58 to 5.70 hours; median, 2.20; IQR, 1.21; Wilcoxon rank sum P < .0001). Multivariable linear regression predicting the natural logarithm of surgical time by age, body weight, sex, neuter status, caudal vs rostral location, and mandibulectomy vs maxillectomy found that caudal location (P < .0001) was retained in the model and was associated with a 64.33% increase in the length of surgery.
The range of surgical times by anatomical location, demonstrating similar surgical times between maxillectomy and mandibulectomy and significant increase in surgical time for the most caudal procedures. Unit of measurement is in hours.
Surgical location | No. | Median | Range | IQR |
---|---|---|---|---|
Maxillectomy | 39a | 2.73 | 0.83–6.58 | 1.75 |
Unilateral rostral | 16 | 2.13 | 0.83–4.98 | 1.46 |
Bilateral rostral | 8 | 2.08 | 1.00–3.95 | 1.19 |
Central | 3 | 2.08 | 1.25–5.70 | 4.45 |
Caudal | 12 | 3.94 | 2.33–6.58 | 1.62 |
Total | 0 | — | — | — |
Mandibulectomy | 53b | 2.41 | 0.58–5.58 | 1.5 |
Unilateral rostral | 11 | 2.33 | 1.50–4.25 | 0.75 |
Bilateral rostral | 25 | 2.33 | 1.00–5.50 | 1.66 |
Rim excision | 6 | 1.96 | 0.58–2.66 | 0.75 |
Caudal | 0 | — | — | — |
Subtotal | 11 | 3.25 | 2.00–5.58 | 1.33 |
aTwo dogs did not have surgical time recorded.
bFour dogs did not have surgical time recorded.
When evaluating for the complication of interest, 1 of 98 (1.02%) cases received blood products due to reported excessive surgical bleeding with corresponding paradoxical bradycardia, premature ventricular beats, and acute drop in RBC level. Presurgical PCV was 55%, intraoperative PCV was 24%, and postoperative PCV (following a single unit of packed RBCs) was 36%. This patient was a large-breed (37.9-kg) 10-year-old spayed female Staffordshire Bull Terrier with a 5-cm-long osteochondrosarcoma that was treated with a caudal maxillectomy; surgical time was 3.58 hours.
Other complications were recorded when available and separated into categories for < 24 hours after surgery and 2 weeks after surgery. Within 24 hours of surgery, 33 cases (34.02%) were documented to have facial/hemifacial swelling, of which 19 (57.57%) were classified as mild, 12 (36.36%) as moderate, and 2 (6.06%) as severe. Other documented 24-hour complications included lip entrapment in 2 dogs (2.06%), epistaxis in 10 dogs (10.30%), inappetence in 15 dogs (15.46%), drooling in 2 dogs (2.06%), and an intraoperative iatrogenic fracture of a marginally resected mandibular tumor that required immediate fracture repair in 1 dog (1.02%). Fifty cases (51.54%) had no reported complications at the 2-week recheck, and 19 cases (19.58%) were lost to follow-up. Eight (20%) of the maxillectomy procedures developed lip entrapment that required no further intervention, 2 (4.87%) had intermittent sneezing episodes, and 1 (2.43%) had mild drooling. Three (5.26%) of the mandibulectomy procedures developed lip entrapment that required no further intervention; 7 (12.28%) had mandibular drift, of which 2 (28.57%) required additional procedures; and 8 (14.03%) had areas of dehiscence that were managed medically. Of the 7 dogs with mandibular drift, 6 underwent subtotal mandibulectomies.
In univariable analyses, dogs undergoing maxillectomy were more likely to experience complications within 24 hours compared with mandibulectomy (RR, 1.86 [95% CI, 1.25 to 2.76]), but were not significantly more likely to have complications at the 2-week recheck (RR, 0.84 [95% CI, 0.46 to 1.55]); conversely, caudal location was not significantly associated with complications within 24 hours (rostral vs caudal: RR, 0.77 [95% CI, 0.52 to 1.15]), but was associated with complications at the 2-week recheck (RR, 0.52 [95% CI, 0.23 to 0.90]). Location, sex, neuter status, age, and body weight were not significantly associated with either 24-hour or 2-week complications. In multivariable logistic regression predicting the odds of complications within 24 hours by age, body weight, sex, neuter status, caudal versus rostral location, and mandibulectomy versus maxillectomy, the only significant predictor was mandibulectomy (OR, 0.23 vs maxillectomy [95% CI, 0.09 to 0.58]; P = .0020), with body weight also retained (OR, 1.03 [95% CI, 0.99 to 1.07]; P = .1053). For complications at the 2-week recheck, caudal location (OR, 3.32 vs rostral [95% CI, 1.07 to 10.30]; P = .0382) was the sole remaining significant predictor, with age (OR, 0.89 [95% CI, 0.76 to 1.05]; P = .1574) also retained in the model.
Discussion
In the 10-year period captured in the present study, 1 of 98 (1.02%) cases of dogs undergoing oncologic maxillectomy or mandibulectomy required administration of blood products due to severe intraoperative hemorrhage. Intraoperative hemorrhage has been consistently reported as the most common complication during caudal maxillectomies, with transfusion rates ranging from 30% to 50%.2,4,8,9 These observations, although inconsistent with our findings, are unsurprising given the proximity of the osteotomy sites to the maxillary artery and its prominent branches. The variety of surgical procedures included represented the full spectrum of described surgical techniques with the explicit exclusion of total and extended subtotal mandibulectomy cases.5,30,31 Additionally, patient age, size, breed, tumor type, and tumor location described in the present data set were comparable to previous studies.1,2,4,5,8 While direct comparison to previous studies is not ideal, the variables noted here are similar to previous reports, with the exception of the cutting instrument. Therefore, the notably low intraoperative hemorrhage rate observed in this study was likely aided by the use of a piezoelectric surgical unit. However, other factors such as appropriate case selection, familiarity with the anatomy, diagnostic imaging, surgical planning, and skill all play an important role in the outcomes of these challenging surgeries.
The single patient that received a blood transfusion was 1 of 13 (7.69%) dogs that underwent a caudal maxillectomy. The anesthetic record demonstrated paradoxical bradycardia. While this deviates from the classic signs of tachycardia and hypotension typically seen in cases of acute hemorrhage, 1 possibility for this change is myocardial hypoxia as a result of acute hypovolemic anemia. This would explain the bradycardia and ventricular beats as early indicators for the need of packed RBCs.
For this study, careful surgical planning and use of piezoelectric surgery were adequate in avoiding significant hemorrhage. Prior reports have recommended temporary or permanent carotid ligation, which is not without its own inherent risks and complications, including hemorrhage, prolonged surgical time, and trauma to the vasosympathetic trunk, recurrent laryngeal nerve, and internal jugular vein.11 Postoperative sequelae can also include hematoma formation, retinal damage, and cerebral ischemia.11
The most commonly used bone-cutting instrument for maxillectomy and mandibulectomy procedures has traditionally been the oscillating saw, although other rotary instruments as well as an osteotome and mallet have also been reported.2,4,8,9 The power osteotomy instruments convert electric or air-driven energy into mechanical energy that creates heat at the cutting surface, increasing risk of osteonecrosis and local tissue damage.15,21 Typically, bone-cutting burs used in rotary handpieces are thicker compared with piezoelectric tips, increasing the volume of bone lost during osteotomies and increasing the torque and drilling force needed to be effective.21 These factors limit the design and precision of the osteotomy, are indiscriminate in the damage inflicted to soft tissues in the vicinity, and reduce tactile feedback to the operator.2,21,25,33,34
In human medicine, oral surgeons use piezoelectric units to reduce the risk of intraoperative hemorrhage for many types of delicate maxillofacial procedures.12,16,20,26,35–40 Piezoelectric surgery utilizes ultrasonic micro-oscillations at frequencies that cut mineralized tissues and spare soft tissues.20,26–28 As a result, piezoelectric surgical handpieces do not require much operator pressure for effect, allowing for improved ergonomics, high tactile sensitivity, and preservation of fine motor control of the handpiece, which make this useful for cutting bone intimately associated with nerves and vessels such as that of the jaw.15,17,25,29 Modern piezoelectric units also include a cold LED light to enhance surgical field visualization and continuous sterile saline irrigation that rinses debris from the surgical site, avoids overheating, and provides a solution for cavitation, which cauterizes small vessels and provides a bactericidal effect.15,26 Piezoelectric tips are narrow and come in various angles and lengths allowing for a variety of osteotomy designs, including semilunar and deeply angled cuts.21,35,41 These factors allow for precise bone cutting, reduced soft tissue damage, increased visibility, and sterilization of the surgical site.3,14,16,26,36,42–46
Histomorphological studies have demonstrated that piezoelectric surgery results in increased local expression of bone morphogenic proteins and transforming growth factor as well as decreased inflammatory cytokines such as interleukin 1β for better bone healing compared with conventional surgery.18,21,26,38,47 Human studies19,29,48 describe improved healing with up to 50% less postoperative swelling and patients requiring up to 50% less postoperative analgesia when osteotomies were performed with a piezoelectric unit compared with when they were performed with conventional oscillating saws.
One cited disadvantage of piezoelectric surgery is relatively increased surgical time, with 1 study reporting that osteotomies in hard or cortical bone take up to four times as long as traditional osteotomies.12,13,15,41,49 However, a human medical study41 comparing conventional instrumentation with piezoelectric surgery for impacted third premolar extraction found that the gap in surgical duration closed as operators gained experience with piezosurgical units, eventually reaching parity. Moreover, any prolongation of surgical time with a piezotome is arguably offset by the benefits associated with the lack of severe hemorrhage, reduced costs and risks of blood product administration, and improved surgical outcome.
When evaluating surgical time in the current cohort, both bivariant analysis and multivariable linear regression found no significant difference between maxillectomies and mandibulectomies; however, surgical time for caudal surgeries was significantly longer than that of more rostral surgeries. This finding is expected, given that the complexity of the anatomy caudally necessitates more delicate dissection, careful osteotomy, and closure.
Limitations for this study are consistent with its retrospective nature. For example, case controls, where a separate cohort of patients would have undergone the same procedure using different cutting instruments, would have been ideal. Given that cases were collected from a teaching hospital setting over a period of time, the skill level of the multiple operators varied, and this would likely have had an impact on surgical time. To compensate, strict inclusion criteria were used. Future studies using a prospective approach should be considered to best delineate complication rates when all variables, other than the cutting instrument, are kept consistent.
Statistical analysis showed that maxillectomy procedures were more likely to lead to complications within the first 24 hours postoperatively than mandibulectomies. However, this was not the case at 2 weeks postoperatively. The complications noted within the first 24 hours were mild and largely self-limiting. When complications at the 2-week mark were assessed, caudal procedures were found to be more likely to lead to complications. This was particularly true for caudal mandibulectomies, as they sometimes resulted in significant mandibular drift necessitating treatment of the ensuing occlusal trauma. Interestingly, surgical site dehiscence has previously been reported as being the most common complication associated with maxillectomies, especially for caudal procedures; in contrast, the most common sequelae in the current study included lip entrapment, swelling, and self-limiting epistaxis, with no surgical site dehiscence reported.1,4 Eight of 57 cases (14.04%) undergoing mandibulectomy had small areas of surgical site dehiscence that did not require further surgical intervention. It is difficult to discern the exact reasons for lack of dehiscence in the maxillectomies included in this study. However, a combination of careful surgical planning, good technique, and appropriate instrumentation likely contributed.
Results of this study show that intraoperative hemorrhage requiring the use of blood product during or immediately after a maxillectomy is rare when using a piezoelectric unit to perform osteotomies and is much lower than that previously reported. This study also corroborates the results of previous studies that indicated intraoperative hemorrhage is rare for mandibulectomies.
Acknowledgments
The authors have nothing to declare.
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