Trigeminocardiac reflex in bimaxillary orthognathic surgery: case review

The trigeminocardiac reflex (TCR) is a rare but clinically significant phenomenon characterized by bradycardia, hypotension, or asystole triggered by trigeminal nerve stimulation during maxillofacial surgery. It necessitates prompt recognition and management to ensure patient safety. TCR has been reported in orthognathic surgery, particularly during specific surgical maneuvers.

We report the case of a 36-year-old male who experienced TCR during bimaxillary orthognathic surgery. Detailed documentation of the patient's clinical characteristics, intraoperative events, and management strategies was included. Additionally, we conducted a systematic review of the literature using Medline, Embase, Web of Science, and Scopus databases to identify cases of TCR in orthognathic surgery published from 1989 onward. Keywords included "trigeminocardiac reflex," "orthognathic surgery," "Le Fort I," and "bilateral sagittal split osteotomy".

We present the case of a patient who experienced transient bradycardia and asystole during mandibular manipulation and pterygomaxillary disjunction. The episode was successfully managed with atropine and cessation of triggering maneuvers. Additionally, a systematic review identified 10 cases of TCR in orthognathic surgery, most of which occurred during Le Fort I osteotomies, particularly during maxillary downfracture, followed by bilateral sagittal split osteotomies. Common manifestations included bradycardia and asystole. Management strategies involved cessation of surgical stimuli, administration of anticholinergic agents, and, in one severe case, cardiopulmonary resuscitation.

TCR in orthognathic surgery is a significant risk requiring vigilance and prompt management. Understanding its triggers, maintaining intraoperative monitoring, and employing preventive strategies, such as gentle manipulation and proper anesthesia protocols, are essential for optimizing patient safety.