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Complications of orthognathic surgery
Oral Maxillofacial Surg Clin N Am 15 (2003) 229 – 242
Complications of orthognathic surgery Robert A. Bays, DDS*, Gary F. Bouloux, BDS, MDSc, FRACDS Division of Oral and Maxillofacial Surgery, Emory University School of Medicine, Clinic Building B, 1365-B Clifton Road, Atlanta, GA 30322, USA
Evidenced-based medicine criteria are becoming the standards by which clinical studies are rated [1]. Articles that evaluate clinical outcomes can be categorized according to a hierarchy of evidence-based medicine. The strongest evidence is that derived from randomized, clinical trials or, even better, a metaanalysis of several randomized, controlled trials. The next strongest evidence is derived from cohort studies. This is followed by evidence that is derived from case control series. Isolated case reports provide the weakest evidence in this hierarchy. Numerous chapters in various texts have reported a wide spectrum of complications of orthognathic surgery based on all four of these types of evidence. Little has been added in the recent literature regarding the range or types of complications. A few studies have tightened our focus on the already known complications of orthognathic surgery with regard to prevalence and severity. This article concentrates on studies that report complications with the weight of randomized clinical trials or cohort studies. Where possible, a metaanalysis has been performed to provide the highest level of evidence-based medicine. Means for all statistics are weighted to account for the different sample sizes. Where original publications provided adequate information, confidence intervals (error bars on figures) were determined that allow the reader to determine the range that is required to be 95% certain that if the study were repeated the new mean would fall within that range. Where narrow confidence
* Corresponding author. E-mail address: [email protected] (R.A. Bays).
intervals are shown, this suggests a high degree of precision and reproducibility. When the confidence interval crosses the null value (ie, 0%), the results are not statistically significant, although they may still be clinically important.
Neurosensory changes Inferior alveolar nerve injury Although inferior alveolar nerve (IAN) injury has been reported as a result of several mandibular operations, its association with the bilateral sagittal split osteotomy (BSSO) is well documented [2 – 8]. Evaluation of these studies is confounded by the numerous techniques that have been used to perform the operation and methods and timing of postsurgical neurosensory changes. Variations in technique include the use of burs, saws, blunt or heavy chisels, sharp, thin chisels, and spreaders to complete the osteotomy. The method of fixation may include interosseous wiring plus intermaxillary fixation, bicortical lag screws, bicortical position screws, monocortical plates, or a combination of these. There is no ‘‘standard technique’’ to provide guidance, and outcome study comparison is difficult. For BSSO with rigid internal fixation (RIF), the postoperative incidence of IAN neurosensory loss varies from 0% to 75% (Table 1), with a mean of 35% for subjective reporting and 33% for objective testing at a mean follow-up of 21 months [2 – 8] (Fig. 1). The methods of data collection for subjective and objective parameters vary considerably, which would be likely to influence the results. Whether the
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Table 1 Neurosensory loss after bilateral sagittal split osteotomy Reference
Sample size
Follow-up (mo)
Subjective loss (%)
Ylikontiola et al [7] Blomqvist et al [2] Nishioka et al [4] Schultze-Mosgau et al [5] Ylikontiola et al [8] Jaaskelainen et al [3] Westermark et al [6] Mean
30 48 12 12 30 23 548
12 12 12 12 12 12 24 21.35
0 35 67
use of small monocortical plates reduces the incidence of IAN injury when compared to bicortical position screws is not clear. Mandibular setback may be performed using BSSO with rigid fixation or transoral vertical ramus osteotomies (TOVRO) with or without skeletal fixation. Although strong data that compare the incidence of IAN injury with BSSO and TOVRO are lacking, existing studies report a lower incidence of IAN injury with TOVRO. The range of neurosensory loss varies from 0% to 70% (Table 2), with a mean of 9% for subjective and objective testing at a mean followup of 21 months [6,9 – 13] (Fig. 1). The influence of fixation on the incidence of IAN injury with TOVRO is not known. Does the addition of a genioplasty increase the risk of IAN injury when performed simultaneously
Objective loss (%) 7 75 17
31 39 35.3
26.1 39 33.1
with a BSSO? Isolated genioplasty is associated with a mean neurosensory loss of 17% for subjective reporting and 10% for objective testing at a minimum follow-up of 12 months [14,15] (Fig. 1, Table 3). There is some evidence that a simultaneous combined BSSO and genioplasty increases the risk of IAN sensory loss when evaluated at a mean of 21 months [6,14,15] (Fig. 1, Table 4). The mean neurosensory loss for combined BSSO (RIF) and genioplasty is 51% for subjective reporting and 46% for objective testing (Fig. 1). A lack of standardized BSSO technique in these studies makes the contribution of the genioplasty to the IAN deficit difficult to discern with certainty. It has been suggested that the two procedures may produce a ‘‘double crush’’ injury of the IAN resulting in less ability to recover [15]. It is not known whether this outcome would be
Fig. 1. Mean percentage of patients with neurosensory deficit. (Circle size indicates relative sample size.)
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Table 2 Neurosensory loss after transoral vertical ramus osteotomy Reference
Sample size
Follow-up (mo)
Subjective loss (%)
Objective loss (%)
Westermark et al [84] Tuinzing et al [12] Tornes [11] Zaytoun et al [13] Hall et al [9] Massey et al [10] Mean
650 150 55 15 42 14
24 12 ? ? 12 ?
9 14 1.8 0 2.4 0 8.8
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improved if the two procedures were performed at separate operations. Lingual nerve injury It is well accepted that the lingual nerve is occasionally injured during BSSO. Unfortunately, the incidence of lingual nerve injury is poorly documented. There only seems to be one study available, which is a retrospective survey of patients, and it is unfortunately weakened by significant recall bias [16]. Further studies are required to evaluate the incidence of lingual nerve injury after BSSO. Infraorbital nerve injury The infraorbital nerve is probably rarely severed during Le Fort I maxillary surgery, but traction and compression injuries are common. Fortunately most of this trauma occurs beyond the confines of the osseous canal. As with the BSSO, there are many described techniques for performing Le Fort osteotomies. Most surgeons use the total down fracture technique verified and popularized by Bell [17]. The incidence of infraorbital nerve neurosensory deficits at 12 months has been reported to be as high as 6% when tested objectively [5].
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ment of the descending palatine neurovascular bundle is controversial, however. It may be preserved, inadvertently damaged, or ligated and divided. It has been shown that preservation of the neurovascular bundle is not required for perfusion of the maxilla, nor is it required for neurosensory recovery [18,19]. Despite ligation and division of the neurovascular bundle, sensory recovery does occur [18] and is most likely to represent collateral axonal sprouting from adjacent nerves.
Infection The incidence of infections in orthognathic surgery is difficult to evaluate because most studies combine all orthognathic procedures. Numerous antibiotic regimens also have been used without any standardization. Overall, the incidence of infection is reported to be between 0% and 18% with either a perioperative [20 – 23] or a combined perioperative and postoperative antibiotic course [20 – 22,24 – 26]. Rates of infection between 0% and 53% have been reported without antibiotics [23 – 26]. Whereas the use of antibiotics seems to reduce the incidence of infection, the evidence to support continuing antibiotics after the perioperative period is marginal.
Descending/greater palatine nerve injuries Relapse During Le Fort osteotomy it is recognized that the nasopalatine and posterior, middle, and anterior superior alveolar nerves are completely severed as an intrinsic part of the surgical procedure. Manage-
Relapse may be defined as a postoperative movement either toward the preoperative position or farther away from it. Although a mean relapse for a
Table 3 Neurosensory loss after genioplasty Reference
Sample size
Follow-up (mo)
Subjective loss (%)
Objective loss (%)
Nishioka et al [14] Posnick et al [15] Mean
10 20
> 12 12
30 10 16.7
10 10
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Table 4 Neurosensory loss after bilateral sagittal split osteotomy / genioplasty Reference
Sample size
Follow-up (mo)
Subjective loss (%)
Objective loss (%)
Posnick et al [15] Nishioka et al [4] Westermark et al [6] Mean
21 3 71
12 12 24 21
67 100 44 50.9
100 44 46.3
particular study and procedure may be 0, there may still be significant relapse in both directions for individual patients such that the overall mean relapse of 0 may be meaningless. A meta-analysis of all the literature using RIF provides the most accurate evaluation of relapse. The wide 95% confidence interval for many studies reflects the imprecise results, and as such these studies should be reviewed with some caution. Relapse is usually three dimensional, with vertical, horizontal, and sagittal components that may occur concurrently. For statistical reasons, relapse has been divided arbitrarily into horizontal and vertical components, depending on the procedure. Relapse of mandibular ramus osteotomies may be caused by mandibular condyle positioning intraoperatively, condylar remodeling or resorption, surface remodeling, or osteotomy slippage. The latter should be minimal with the use of adequate RIF.
Different methods of cephalometric analysis have been used in myriad studies undertaken to evaluate relapse. For BSSO or TOVRO, intramandibular measurements are theoretically more accurate for evaluating stability, but most studies for these and all orthognathic procedures use the cranial base as a reference. The influence of condylar position on relapse must be kept in mind. Bilateral sagittal split osteotomy advancement Bilateral sagittal split osteotomy for advancement has been the most extensively studied in terms of relapse. Relapse rates have been reported from 6 months up to several years. 12 months seems to be a minimal period over which to evaluate this complication, although additional relapse may occur for many years thereafter. The methods of RIF include
Fig. 2. Mean percentage relapse for BSSO advancement. (Circle size indicates relative sample size; error bars indicate 95% confidence interval; positive percent equals relapse toward preoperative position; negative percent equals relapse in same direction as surgery.)
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bicortical screws and monocortical plates. The potential for condylar torque and increased IAN compression with lag screws mitigates against their use, and in no studies evaluated in this article were lag screws used for fixation. Relapse for advancement range from a 34% relapse to a 9% continued forward movement [27 – 35] (Fig. 2). The mean relapse at a mean follow-up of 17 months is 8%. Condylar resorption Condylar resorption has been reported as a source of relapse. Although not relapse per se, this process represents pathologic and destructive remodeling. It is known to occur in the general population (idiopathic condylar resorption) and in the orthodontic populations without orthognathic surgery. Whether it occurs more frequently in orthognathic surgery patients is not known. Although several case series have been reported [36 – 38], a small number of retrospective studies have reported on the frequency of condylar resorption with a range of 2.3% to 26% [39 – 42]. All studies included a BSSO, although many concurrent procedures were performed, including Le Fort I osteotomy and genioplasty. The criteria used to diagnose condylar resorption varied between studies, which likely accounted for the large range reported. Condylar resorption continues to be a condition with high predilection for Angle’s class II, white women (especially women with high mandibular plane angles). It has been reported, albeit less frequently, in men [41,37].
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Transoral vertical ramus osteotomy and bilateral sagittal split osteotomy setback Mandibular ramus surgery for setback has been the subject of far fewer studies despite the fact that it has been done in this country for many more years than any other orthognathic procedure. The TOVRO with and without fixation and BSSO with rigid fixation have been used for mandibular setback. Studies indicate that the two procedures manifest relapse in opposite directions. TOVRO has been shown to have a relapse range of 5% to 12%, with a mean relapse of 9% with a continued posterior movement at a mean follow-up of 10 months [43 – 45] (Fig. 3). The follow-up was inadequate at only 6 months in one study [44]. BSSO setback has been shown to have a relapse range of 10% to 62%, with a mean relapse of 22% in the anterior direction at a mean follow-up of 28 months [45 – 48] (Fig. 4). The potential role of overzealous posterior ‘‘seating’’ of the proximal segment at the time of surgery together with clockwise rotation of the proximal segment and subsequent lengthening of the pterygomasseteric envelope may contribute to the larger relapse seen compared to BSSO advancement. Growth should not be a factor, because all class III patients should be followed with serial cephalometric evaluation until growth has been documented to cease and corroborated by hand-wrist radiographs. From a practical standpoint, return to an edge-to-edge occlusion is problematic for the orthodontic completion of the case. Cautious seating of the proximal segment or
Fig. 3. Mean percentage continued posterior movement for TOVRO. (See Fig. 1 for explanation.)
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Fig. 4. Mean percentage relapse for BSSO setback. (See Fig. 1 for explanation.)
construction of the surgical splint in a slight class II position may ameliorate this problem. The consensus seems to be that true skeletal relapse is not as significant a problem in mandibular setback surgery as are the biomechanical considerations involved in the performance of the surgery.
advancement with RIF [49 – 56] (Fig. 5). Relapse tends to be proportionately greater with greater advancements. Bone grafting large advancements (>8 mm) may help to reduce relapse [55].
Maxillary repositioning
Superior repositioning is generally regarded as one of the most stable surgical procedures in orthognathic surgery [49,52,57 – 59] (Figs. 6 and 7). Relapse rates for maxillary superior repositioning with RIF have been reported to range from 0% to 18% for the anterior maxilla (A point). Relapse rates for the posterior nasal spine range from 7% relapse to a 6% continued superior movement. The mean relapse rates are 11% and 3% for the anterior and posterior maxilla, respectively, at a mean follow-up of 14 months. The stability of superior repositioning when used to close an open bite has been questioned [60], but no data suggest that superior repositioning for open bite is less stable than for treatment of vertical maxillary excess.
Maxillary surgical repositioning is far more complex than mandibular repositioning because the maxilla can be moved in an infinite variety of directions and is rarely moved along one pure vector. There are some meaningful data regarding maxillary advancements, superior repositioning, and inferior repositioning. In all cases, the direction that the maxilla moved the most is the one evaluated, but one must remember that other directional moves usually have been made simultaneously. Maxillary advancement Maxillary advancement may be performed in isolation or in conjunction with a mandibular procedure. Many patients who require maxillary advancement also require inferior repositioning. Studies that reflect pure values for the relapse stability of maxillary advancements are rare. Relapse rates of 5% to 19% have been reported, with a mean of 11% at average follow-up of 15 months for maxillary
Maxillary superior repositioning
Maxillary inferior repositioning Inferior repositioning intuitively gives the most concern because of the space created between the maxilla and the cranial base. Rigid fixation has been instrumental in increasing the stability of this procedure. Most studies that evaluated the relapse asso-
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Fig. 5. Mean percentage relapse for Le Fort I advancement. (See Fig. 1 for explanation.)
ciated with inferior repositioning contained small numbers of patients, so care must be taken in the assessment of the data presented. Relapse rates for maxillary inferior positioning with RIF range from 9% to 54% for the anterior maxilla (A point) and from 21% to 167% for the posterior maxilla (poste-
rior nasal spine) [49,61 – 63] (Figs. 8 – 10). The mean relapse rates are 28% and 70% for the anterior and posterior maxilla, respectively, at a mean follow-up of 14 months. Although the reasons for such wide ranges are not clear, technical differences may account for some of the variability. Bone graft-
Fig. 6. Mean percentage anterior relapse for Le Fort I impaction. (See Fig. 1 for explanation.)
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Fig. 7. Mean percentage posterior relapse for Le Fort I impaction. (See Fig. 1 for explanation.)
ing is common in most reports. The greatest stability was achieved by using techniques that offer some bone-to-bone contact [64]. There does not seem to be any evidence to suggest that the relapse rates are different in one- versus two-jaw procedures or segmental versus one-piece maxillary osteotomies [61].
Maxillary transverse widening Increasing transverse maxillary width may be performed by surgically assisted rapid palatal expansion or multipiece segmentalization at the time of Le Fort osteotomy. It is beyond the scope of this article to discuss the indications and limitations of the two
Fig. 8. Mean percentage anterior relapse for Le Fort I downgraft. (See Fig. 1 for explanation.)
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Fig. 9. Mean percentage posterior relapse for Le Fort I downgraft. (See Fig. 1 for explanation.)
procedures. Suffice it to say that at times the surgeon and orthodontist have a choice and at other times one of these procedures is clearly preferential. With the limited material available, however, it is clear that the surgically assisted rapid palatal expansion is considerably more stable in holding transverse widening of
the maxilla. The relapse rates for surgically assisted rapid palatal expansion at a mean follow-up of 28 months range from 8% to 14%, with a mean of 11% at the molar region [65 – 67]. Only a single study has reported on the stability of transverse width after segmental Le Fort osteotomy, with a mean relapse
Fig. 10. Mean percentage relapse for multiple piece Le Fort I (MPLFI) or surgically assisted rapid palatal expansion (SRPE). (See Fig. 1 for explanation.)
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rate of 49% at the molar region at a minimum followup of 8 months [68].
Periodontal defects with segmental Le Fort I osteotomies The potential for periodontal defects with segmental surgical procedures has been an area of some concern. This has been the focus of several studies, but there is little evidence to suggest an increased incidence of clinically significant periodontal defects [69 – 73]. It is apparent that periodontal defects rarely follow Le Fort segmentalization. When they happen, however, they are dramatic and of great consequence to patients, especially if they occur in the anterior region.
Unfavorable splits with the bilateral sagittal split osteotomy Intuitively, the presence of a third molar in the mandible would seem to increase the chances of an unfavorable split when attempting a BSSO. The data are contradictory, however. Some authors have found no difference in the incidence of unfavorable splits with or without third molars [74,75]. Others have found an increased incidence with impacted third molars in younger patients but not in patients over age 20 [76]. Unfortunately, these studies are retrospective and all have the potential for selection bias. Age differences between groups prevent a direct comparison. Experienced surgeons also have conducted these studies, which may not indicate the potential problems of bad splits for the less experienced.
Temporomandibular disorders Whereas much has been written regarding the correlation between temporomandibular disorders (TMD) and occlusion, the effect of orthognathic surgery on TMD has not received as much attention. Arguably, many researchers believe that malocclusion plays some role in TMD. Many of the studies that correlated TMD and orthognathic surgery have been retrospective (with inherent bias) and lack the control that is intrinsic with a randomized, clinical trial. Various clinical criteria, including myofascial pain, capsular pain, joint noises, and range of motion, have been used inconsistently between the studies. The conclusions drawn in this article are the result of an analysis of many disparate studies.
Numerous studies support the notion that orthognathic surgery decreases the overall prevalence of TMD signs and symptoms [40,77 – 84]. All studies included BSSO with the less frequent inclusion of Le Fort I, bimaxillary osteotomies, and TOVRO. With respect to orthognathic surgery patients with preexisting TMD, subjective improvement ranges from 0% to 75%, with a mean of 18% [40,78 – 84]. Objective improvement ranges from 7% to 72%, with a mean of 48% [40,77,80 – 83]. Subjective worsening of preexisting TMD has a range of 0% to 29%, with a mean of 13% [78 – 80]. Objective worsening was reported only in one study with a mean of 20% [80]. Although it is apparent that a group of patients with preexisting TMD will obtain subjective and objective improvement, a second group will experience deterioration in the same signs and symptoms. Finally, a third group of patients without preexisting TMD will develop problems. The reported range is 0% to 33%, with a mean of 18% [40,77,79 – 84]. The possibility exists that the development of TMD after surgery may be unrelated to the surgical procedure. One comparative study showed an increase in the incidence of TMD in a group of orthognathic surgery candidates who elected not to proceed with surgery [81]. Similarly, it is possible for surgery patients with preexisting TMD to show an improvement in signs and symptoms that are not related to the surgical procedure but rather the natural progression of the disorder. Rigid internal fixation was used in all studies, although some studies also used intermaxillary fixation for a group of patients [79,83,84]. There did not seem to be a difference in the course of TMD when comparing RIF with intermaxillary fixation. Patients who underwent TOVRO were treated with intermaxillary fixation. TOVRO with intermaxillary fixation and without interosseous fixation faired better than BSSO with rigid fixation [79,84]. Whether this is the result of the surgical procedure or the fixation type is not clear. As with the relapse data, this may indicate an overzealous positioning of the proximal segment during BSSO at the time of surgery that ‘‘posteriorizes’’ the condyle in the fossa and results in increased TMD.
Miscellaneous complications There are numerous reports of rare complications associated with orthognathic surgery. It is not possible to evaluate the incidence of these case reports, and the etiology is often unclear or speculative. Many of these complications are mentioned but not elaborated in this article for the sake of completeness. One
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can be assured that all of these complications occur at a prevalence of far less than 0.1%. Some instances of rare complications reported with bilateral sagittal split osteotomy are as follows:
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Pneumomediastinum [100]: 1 case, which
resolved
Summary Intraoperative hemorrhage that required special
intervention [85]: 10 cases Aseptic necrosis [86]: 1 case Facial nerve palsy [87]: 9 cases
Instances of rare complications reported with Le Fort I are as follows: Blindness [88]: 3 cases, 2 of which were
permanent Nasolacrimal obstruction or injury [88,89]:
3 cases treated with dacrocystorhinostomy or turbinectomy/septoplasty Postoperative hemorrhage that required intervention [90]: 21 cases Intraoperative hemorrhage that required special intervention [90,91]: 18 cases Orbital compartment syndrome [92]: 1 case Avascular necrosis [93]: 36 cases (most of which were segmental) False aneurysm of sphenopalatine artery [91]: 2 cases False aneurysm of maxillary artery [91]: 1 case Carotid-cavernous sinus fistula [91]: 1 case Vomerosphenoidal dysarticulation [94]: 1 case Cranial nerve III palsy [95]: 1 case, which spontaneously resolved Maxillary sinusitis [96]: 4 cases Keratitis [88]: 3 cases
Rare complications reported with surgically assisted rapid palatal expansion include the following: Cranial nerve III palsy [97]: 1 case, which
spontaneously resolved Rare complications reported with genioplasty include the following: Intraoperative hemorrhage that required special
intervention [85]: 1 case Instances of rare complications reported with bimaxillary osteotomies include the following: Dysphagia caused by upper esophageal spasm
[98,99]: 2 cases, 1 of which was treated with myotomy
Most of the common complications of orthognathic surgery occur frequently enough that they must be discussed with each patient in detail. Unfortunately, it is usually impossible to predict which patients will experience a specific complication. Age is the strongest indicator for potential complications, especially permanent nerve deficit. Large orthognathic skeletal moves seem to have greater relapse potential. Commonly held beliefs may not stand up to evaluation of the evidence, such as the proposition that mandibular setbacks are more stable than most other orthognathic surgical procedures. TMDs may be improved somewhat by correction of a malocclusion with orthognathic surgery, but orthognathic surgery is not a primary treatment for TMD and there is a subset of patients whose symptoms worsen after surgery. There is a small, but real, risk that orthognathic surgery may create TMD problems de novo.
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[72] Mordenfeld A, Andersson L. Periodontal and pulpal condition of the central incisors after midline osteotomy of the maxilla. J Oral Maxillofac Surg 1999;57: 523 – 9. [73] Morgan T, Fridrich K. Effects of the multiple-piece maxillary osteotomy on the periodontium. Int J Adult Orthod Orthogn Surg 2001;16:255 – 65. [74] Mehra P, Castro V, Freitas R, et al. Complications of the mandibular sagittal split ramus osteotomy associated with the presence or absence of third molars. J Oral Maxillofac Surg 2001;59:854 – 8. [75] Precious D, Lung K, Pynn B, et al. Presence of impacted teeth as a determining factor of unfavorable splits in 1256 sagittal-split osteotomies. Oral Surg 1998;85:362 – 5. [76] Reyneke J, Tsakiris P, Becker P. Age as a factor in the complication rate after removal of unerupted/ impacted third molars at the time of mandibular sagittal split osteotomy. J Oral Maxillofac Surg 2002;60: 654 – 9. [77] De Clerq C, Abeloos J, Mommaerts M, et al. Temporomandibular joint symptoms in an orthognathic surgery population. J Craniomaxillofac Surg 1995; 23:195 – 9. [78] Egermark I, Blomqvist J, Cromvik U, et al. Temporomandibular dysfunction in patients treated with orthodontics in combination with orthognathic surgery. Eur J Orthod 2000;22:537 – 44. [79] Hu J, Wang D, Zou S. Effects of mandibular setback on the temporomandibular joint: a comparison of oblique and sagittal split ramus osteotomy. J Oral Maxillofac Surg 2000;58:375 – 80. [80] Onizawa K, Schmelzeisen R, Vogt S. Alteration of temporomandibular joint symptoms after orthognathic surgery: comparison with healthy volunteers. J Oral Maxillofac Surg 1995;53:117 – 21. [81] Panula K, Somppi M, Finne K, et al. Effects of orthognathic surgery on temporomandibular joint dysfunction: a controlled prospective 4-year follow-up study. Int J Oral Maxillofac Surg 2000;29:183 – 7. [82] Smith V, Williams B, Stapleford R. Rigid internal fixation and the effects on the temporomandibular joint and masticatory system: a prospective study. Am J Orthod Dentofacial Orthop 1992;102:491 – 500. [83] Timmis D, Aragon S, Van Sickels J. Masticatory dysfunction with rigid and nonrigid osteosynthesis of sagittal split osteotomies. Oral Surg 1986;62: 119 – 23. [84] Westermark A, Shayeghi F, Thor A. Temporomandibular dysfunction in 1516 patients before and after orthognathic surgery. Int J Adult Orthod Orthogn Surg 2001;16:145 – 51. [85] Lanigan D, West R. Hemorrhage following mandib-
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Complications of orthognathic surgery Robert A. Bays, DDS*, Gary F. Bouloux, BDS, MDSc, FRACDS Division of Oral and Maxillofacial Surgery, Emory University School of Medicine, Clinic Building B, 1365-B Clifton Road, Atlanta, GA 30322, USA
Evidenced-based medicine criteria are becoming the standards by which clinical studies are rated [1]. Articles that evaluate clinical outcomes can be categorized according to a hierarchy of evidence-based medicine. The strongest evidence is that derived from randomized, clinical trials or, even better, a metaanalysis of several randomized, controlled trials. The next strongest evidence is derived from cohort studies. This is followed by evidence that is derived from case control series. Isolated case reports provide the weakest evidence in this hierarchy. Numerous chapters in various texts have reported a wide spectrum of complications of orthognathic surgery based on all four of these types of evidence. Little has been added in the recent literature regarding the range or types of complications. A few studies have tightened our focus on the already known complications of orthognathic surgery with regard to prevalence and severity. This article concentrates on studies that report complications with the weight of randomized clinical trials or cohort studies. Where possible, a metaanalysis has been performed to provide the highest level of evidence-based medicine. Means for all statistics are weighted to account for the different sample sizes. Where original publications provided adequate information, confidence intervals (error bars on figures) were determined that allow the reader to determine the range that is required to be 95% certain that if the study were repeated the new mean would fall within that range. Where narrow confidence
* Corresponding author. E-mail address: [email protected] (R.A. Bays).
intervals are shown, this suggests a high degree of precision and reproducibility. When the confidence interval crosses the null value (ie, 0%), the results are not statistically significant, although they may still be clinically important.
Neurosensory changes Inferior alveolar nerve injury Although inferior alveolar nerve (IAN) injury has been reported as a result of several mandibular operations, its association with the bilateral sagittal split osteotomy (BSSO) is well documented [2 – 8]. Evaluation of these studies is confounded by the numerous techniques that have been used to perform the operation and methods and timing of postsurgical neurosensory changes. Variations in technique include the use of burs, saws, blunt or heavy chisels, sharp, thin chisels, and spreaders to complete the osteotomy. The method of fixation may include interosseous wiring plus intermaxillary fixation, bicortical lag screws, bicortical position screws, monocortical plates, or a combination of these. There is no ‘‘standard technique’’ to provide guidance, and outcome study comparison is difficult. For BSSO with rigid internal fixation (RIF), the postoperative incidence of IAN neurosensory loss varies from 0% to 75% (Table 1), with a mean of 35% for subjective reporting and 33% for objective testing at a mean follow-up of 21 months [2 – 8] (Fig. 1). The methods of data collection for subjective and objective parameters vary considerably, which would be likely to influence the results. Whether the
1042-3699/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1042-3699(02)00098-5
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Table 1 Neurosensory loss after bilateral sagittal split osteotomy Reference
Sample size
Follow-up (mo)
Subjective loss (%)
Ylikontiola et al [7] Blomqvist et al [2] Nishioka et al [4] Schultze-Mosgau et al [5] Ylikontiola et al [8] Jaaskelainen et al [3] Westermark et al [6] Mean
30 48 12 12 30 23 548
12 12 12 12 12 12 24 21.35
0 35 67
use of small monocortical plates reduces the incidence of IAN injury when compared to bicortical position screws is not clear. Mandibular setback may be performed using BSSO with rigid fixation or transoral vertical ramus osteotomies (TOVRO) with or without skeletal fixation. Although strong data that compare the incidence of IAN injury with BSSO and TOVRO are lacking, existing studies report a lower incidence of IAN injury with TOVRO. The range of neurosensory loss varies from 0% to 70% (Table 2), with a mean of 9% for subjective and objective testing at a mean followup of 21 months [6,9 – 13] (Fig. 1). The influence of fixation on the incidence of IAN injury with TOVRO is not known. Does the addition of a genioplasty increase the risk of IAN injury when performed simultaneously
Objective loss (%) 7 75 17
31 39 35.3
26.1 39 33.1
with a BSSO? Isolated genioplasty is associated with a mean neurosensory loss of 17% for subjective reporting and 10% for objective testing at a minimum follow-up of 12 months [14,15] (Fig. 1, Table 3). There is some evidence that a simultaneous combined BSSO and genioplasty increases the risk of IAN sensory loss when evaluated at a mean of 21 months [6,14,15] (Fig. 1, Table 4). The mean neurosensory loss for combined BSSO (RIF) and genioplasty is 51% for subjective reporting and 46% for objective testing (Fig. 1). A lack of standardized BSSO technique in these studies makes the contribution of the genioplasty to the IAN deficit difficult to discern with certainty. It has been suggested that the two procedures may produce a ‘‘double crush’’ injury of the IAN resulting in less ability to recover [15]. It is not known whether this outcome would be
Fig. 1. Mean percentage of patients with neurosensory deficit. (Circle size indicates relative sample size.)
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Table 2 Neurosensory loss after transoral vertical ramus osteotomy Reference
Sample size
Follow-up (mo)
Subjective loss (%)
Objective loss (%)
Westermark et al [84] Tuinzing et al [12] Tornes [11] Zaytoun et al [13] Hall et al [9] Massey et al [10] Mean
650 150 55 15 42 14
24 12 ? ? 12 ?
9 14 1.8 0 2.4 0 8.8
9
improved if the two procedures were performed at separate operations. Lingual nerve injury It is well accepted that the lingual nerve is occasionally injured during BSSO. Unfortunately, the incidence of lingual nerve injury is poorly documented. There only seems to be one study available, which is a retrospective survey of patients, and it is unfortunately weakened by significant recall bias [16]. Further studies are required to evaluate the incidence of lingual nerve injury after BSSO. Infraorbital nerve injury The infraorbital nerve is probably rarely severed during Le Fort I maxillary surgery, but traction and compression injuries are common. Fortunately most of this trauma occurs beyond the confines of the osseous canal. As with the BSSO, there are many described techniques for performing Le Fort osteotomies. Most surgeons use the total down fracture technique verified and popularized by Bell [17]. The incidence of infraorbital nerve neurosensory deficits at 12 months has been reported to be as high as 6% when tested objectively [5].
9
ment of the descending palatine neurovascular bundle is controversial, however. It may be preserved, inadvertently damaged, or ligated and divided. It has been shown that preservation of the neurovascular bundle is not required for perfusion of the maxilla, nor is it required for neurosensory recovery [18,19]. Despite ligation and division of the neurovascular bundle, sensory recovery does occur [18] and is most likely to represent collateral axonal sprouting from adjacent nerves.
Infection The incidence of infections in orthognathic surgery is difficult to evaluate because most studies combine all orthognathic procedures. Numerous antibiotic regimens also have been used without any standardization. Overall, the incidence of infection is reported to be between 0% and 18% with either a perioperative [20 – 23] or a combined perioperative and postoperative antibiotic course [20 – 22,24 – 26]. Rates of infection between 0% and 53% have been reported without antibiotics [23 – 26]. Whereas the use of antibiotics seems to reduce the incidence of infection, the evidence to support continuing antibiotics after the perioperative period is marginal.
Descending/greater palatine nerve injuries Relapse During Le Fort osteotomy it is recognized that the nasopalatine and posterior, middle, and anterior superior alveolar nerves are completely severed as an intrinsic part of the surgical procedure. Manage-
Relapse may be defined as a postoperative movement either toward the preoperative position or farther away from it. Although a mean relapse for a
Table 3 Neurosensory loss after genioplasty Reference
Sample size
Follow-up (mo)
Subjective loss (%)
Objective loss (%)
Nishioka et al [14] Posnick et al [15] Mean
10 20
> 12 12
30 10 16.7
10 10
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Table 4 Neurosensory loss after bilateral sagittal split osteotomy / genioplasty Reference
Sample size
Follow-up (mo)
Subjective loss (%)
Objective loss (%)
Posnick et al [15] Nishioka et al [4] Westermark et al [6] Mean
21 3 71
12 12 24 21
67 100 44 50.9
100 44 46.3
particular study and procedure may be 0, there may still be significant relapse in both directions for individual patients such that the overall mean relapse of 0 may be meaningless. A meta-analysis of all the literature using RIF provides the most accurate evaluation of relapse. The wide 95% confidence interval for many studies reflects the imprecise results, and as such these studies should be reviewed with some caution. Relapse is usually three dimensional, with vertical, horizontal, and sagittal components that may occur concurrently. For statistical reasons, relapse has been divided arbitrarily into horizontal and vertical components, depending on the procedure. Relapse of mandibular ramus osteotomies may be caused by mandibular condyle positioning intraoperatively, condylar remodeling or resorption, surface remodeling, or osteotomy slippage. The latter should be minimal with the use of adequate RIF.
Different methods of cephalometric analysis have been used in myriad studies undertaken to evaluate relapse. For BSSO or TOVRO, intramandibular measurements are theoretically more accurate for evaluating stability, but most studies for these and all orthognathic procedures use the cranial base as a reference. The influence of condylar position on relapse must be kept in mind. Bilateral sagittal split osteotomy advancement Bilateral sagittal split osteotomy for advancement has been the most extensively studied in terms of relapse. Relapse rates have been reported from 6 months up to several years. 12 months seems to be a minimal period over which to evaluate this complication, although additional relapse may occur for many years thereafter. The methods of RIF include
Fig. 2. Mean percentage relapse for BSSO advancement. (Circle size indicates relative sample size; error bars indicate 95% confidence interval; positive percent equals relapse toward preoperative position; negative percent equals relapse in same direction as surgery.)
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bicortical screws and monocortical plates. The potential for condylar torque and increased IAN compression with lag screws mitigates against their use, and in no studies evaluated in this article were lag screws used for fixation. Relapse for advancement range from a 34% relapse to a 9% continued forward movement [27 – 35] (Fig. 2). The mean relapse at a mean follow-up of 17 months is 8%. Condylar resorption Condylar resorption has been reported as a source of relapse. Although not relapse per se, this process represents pathologic and destructive remodeling. It is known to occur in the general population (idiopathic condylar resorption) and in the orthodontic populations without orthognathic surgery. Whether it occurs more frequently in orthognathic surgery patients is not known. Although several case series have been reported [36 – 38], a small number of retrospective studies have reported on the frequency of condylar resorption with a range of 2.3% to 26% [39 – 42]. All studies included a BSSO, although many concurrent procedures were performed, including Le Fort I osteotomy and genioplasty. The criteria used to diagnose condylar resorption varied between studies, which likely accounted for the large range reported. Condylar resorption continues to be a condition with high predilection for Angle’s class II, white women (especially women with high mandibular plane angles). It has been reported, albeit less frequently, in men [41,37].
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Transoral vertical ramus osteotomy and bilateral sagittal split osteotomy setback Mandibular ramus surgery for setback has been the subject of far fewer studies despite the fact that it has been done in this country for many more years than any other orthognathic procedure. The TOVRO with and without fixation and BSSO with rigid fixation have been used for mandibular setback. Studies indicate that the two procedures manifest relapse in opposite directions. TOVRO has been shown to have a relapse range of 5% to 12%, with a mean relapse of 9% with a continued posterior movement at a mean follow-up of 10 months [43 – 45] (Fig. 3). The follow-up was inadequate at only 6 months in one study [44]. BSSO setback has been shown to have a relapse range of 10% to 62%, with a mean relapse of 22% in the anterior direction at a mean follow-up of 28 months [45 – 48] (Fig. 4). The potential role of overzealous posterior ‘‘seating’’ of the proximal segment at the time of surgery together with clockwise rotation of the proximal segment and subsequent lengthening of the pterygomasseteric envelope may contribute to the larger relapse seen compared to BSSO advancement. Growth should not be a factor, because all class III patients should be followed with serial cephalometric evaluation until growth has been documented to cease and corroborated by hand-wrist radiographs. From a practical standpoint, return to an edge-to-edge occlusion is problematic for the orthodontic completion of the case. Cautious seating of the proximal segment or
Fig. 3. Mean percentage continued posterior movement for TOVRO. (See Fig. 1 for explanation.)
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Fig. 4. Mean percentage relapse for BSSO setback. (See Fig. 1 for explanation.)
construction of the surgical splint in a slight class II position may ameliorate this problem. The consensus seems to be that true skeletal relapse is not as significant a problem in mandibular setback surgery as are the biomechanical considerations involved in the performance of the surgery.
advancement with RIF [49 – 56] (Fig. 5). Relapse tends to be proportionately greater with greater advancements. Bone grafting large advancements (>8 mm) may help to reduce relapse [55].
Maxillary repositioning
Superior repositioning is generally regarded as one of the most stable surgical procedures in orthognathic surgery [49,52,57 – 59] (Figs. 6 and 7). Relapse rates for maxillary superior repositioning with RIF have been reported to range from 0% to 18% for the anterior maxilla (A point). Relapse rates for the posterior nasal spine range from 7% relapse to a 6% continued superior movement. The mean relapse rates are 11% and 3% for the anterior and posterior maxilla, respectively, at a mean follow-up of 14 months. The stability of superior repositioning when used to close an open bite has been questioned [60], but no data suggest that superior repositioning for open bite is less stable than for treatment of vertical maxillary excess.
Maxillary surgical repositioning is far more complex than mandibular repositioning because the maxilla can be moved in an infinite variety of directions and is rarely moved along one pure vector. There are some meaningful data regarding maxillary advancements, superior repositioning, and inferior repositioning. In all cases, the direction that the maxilla moved the most is the one evaluated, but one must remember that other directional moves usually have been made simultaneously. Maxillary advancement Maxillary advancement may be performed in isolation or in conjunction with a mandibular procedure. Many patients who require maxillary advancement also require inferior repositioning. Studies that reflect pure values for the relapse stability of maxillary advancements are rare. Relapse rates of 5% to 19% have been reported, with a mean of 11% at average follow-up of 15 months for maxillary
Maxillary superior repositioning
Maxillary inferior repositioning Inferior repositioning intuitively gives the most concern because of the space created between the maxilla and the cranial base. Rigid fixation has been instrumental in increasing the stability of this procedure. Most studies that evaluated the relapse asso-
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Fig. 5. Mean percentage relapse for Le Fort I advancement. (See Fig. 1 for explanation.)
ciated with inferior repositioning contained small numbers of patients, so care must be taken in the assessment of the data presented. Relapse rates for maxillary inferior positioning with RIF range from 9% to 54% for the anterior maxilla (A point) and from 21% to 167% for the posterior maxilla (poste-
rior nasal spine) [49,61 – 63] (Figs. 8 – 10). The mean relapse rates are 28% and 70% for the anterior and posterior maxilla, respectively, at a mean follow-up of 14 months. Although the reasons for such wide ranges are not clear, technical differences may account for some of the variability. Bone graft-
Fig. 6. Mean percentage anterior relapse for Le Fort I impaction. (See Fig. 1 for explanation.)
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Fig. 7. Mean percentage posterior relapse for Le Fort I impaction. (See Fig. 1 for explanation.)
ing is common in most reports. The greatest stability was achieved by using techniques that offer some bone-to-bone contact [64]. There does not seem to be any evidence to suggest that the relapse rates are different in one- versus two-jaw procedures or segmental versus one-piece maxillary osteotomies [61].
Maxillary transverse widening Increasing transverse maxillary width may be performed by surgically assisted rapid palatal expansion or multipiece segmentalization at the time of Le Fort osteotomy. It is beyond the scope of this article to discuss the indications and limitations of the two
Fig. 8. Mean percentage anterior relapse for Le Fort I downgraft. (See Fig. 1 for explanation.)
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237
Fig. 9. Mean percentage posterior relapse for Le Fort I downgraft. (See Fig. 1 for explanation.)
procedures. Suffice it to say that at times the surgeon and orthodontist have a choice and at other times one of these procedures is clearly preferential. With the limited material available, however, it is clear that the surgically assisted rapid palatal expansion is considerably more stable in holding transverse widening of
the maxilla. The relapse rates for surgically assisted rapid palatal expansion at a mean follow-up of 28 months range from 8% to 14%, with a mean of 11% at the molar region [65 – 67]. Only a single study has reported on the stability of transverse width after segmental Le Fort osteotomy, with a mean relapse
Fig. 10. Mean percentage relapse for multiple piece Le Fort I (MPLFI) or surgically assisted rapid palatal expansion (SRPE). (See Fig. 1 for explanation.)
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rate of 49% at the molar region at a minimum followup of 8 months [68].
Periodontal defects with segmental Le Fort I osteotomies The potential for periodontal defects with segmental surgical procedures has been an area of some concern. This has been the focus of several studies, but there is little evidence to suggest an increased incidence of clinically significant periodontal defects [69 – 73]. It is apparent that periodontal defects rarely follow Le Fort segmentalization. When they happen, however, they are dramatic and of great consequence to patients, especially if they occur in the anterior region.
Unfavorable splits with the bilateral sagittal split osteotomy Intuitively, the presence of a third molar in the mandible would seem to increase the chances of an unfavorable split when attempting a BSSO. The data are contradictory, however. Some authors have found no difference in the incidence of unfavorable splits with or without third molars [74,75]. Others have found an increased incidence with impacted third molars in younger patients but not in patients over age 20 [76]. Unfortunately, these studies are retrospective and all have the potential for selection bias. Age differences between groups prevent a direct comparison. Experienced surgeons also have conducted these studies, which may not indicate the potential problems of bad splits for the less experienced.
Temporomandibular disorders Whereas much has been written regarding the correlation between temporomandibular disorders (TMD) and occlusion, the effect of orthognathic surgery on TMD has not received as much attention. Arguably, many researchers believe that malocclusion plays some role in TMD. Many of the studies that correlated TMD and orthognathic surgery have been retrospective (with inherent bias) and lack the control that is intrinsic with a randomized, clinical trial. Various clinical criteria, including myofascial pain, capsular pain, joint noises, and range of motion, have been used inconsistently between the studies. The conclusions drawn in this article are the result of an analysis of many disparate studies.
Numerous studies support the notion that orthognathic surgery decreases the overall prevalence of TMD signs and symptoms [40,77 – 84]. All studies included BSSO with the less frequent inclusion of Le Fort I, bimaxillary osteotomies, and TOVRO. With respect to orthognathic surgery patients with preexisting TMD, subjective improvement ranges from 0% to 75%, with a mean of 18% [40,78 – 84]. Objective improvement ranges from 7% to 72%, with a mean of 48% [40,77,80 – 83]. Subjective worsening of preexisting TMD has a range of 0% to 29%, with a mean of 13% [78 – 80]. Objective worsening was reported only in one study with a mean of 20% [80]. Although it is apparent that a group of patients with preexisting TMD will obtain subjective and objective improvement, a second group will experience deterioration in the same signs and symptoms. Finally, a third group of patients without preexisting TMD will develop problems. The reported range is 0% to 33%, with a mean of 18% [40,77,79 – 84]. The possibility exists that the development of TMD after surgery may be unrelated to the surgical procedure. One comparative study showed an increase in the incidence of TMD in a group of orthognathic surgery candidates who elected not to proceed with surgery [81]. Similarly, it is possible for surgery patients with preexisting TMD to show an improvement in signs and symptoms that are not related to the surgical procedure but rather the natural progression of the disorder. Rigid internal fixation was used in all studies, although some studies also used intermaxillary fixation for a group of patients [79,83,84]. There did not seem to be a difference in the course of TMD when comparing RIF with intermaxillary fixation. Patients who underwent TOVRO were treated with intermaxillary fixation. TOVRO with intermaxillary fixation and without interosseous fixation faired better than BSSO with rigid fixation [79,84]. Whether this is the result of the surgical procedure or the fixation type is not clear. As with the relapse data, this may indicate an overzealous positioning of the proximal segment during BSSO at the time of surgery that ‘‘posteriorizes’’ the condyle in the fossa and results in increased TMD.
Miscellaneous complications There are numerous reports of rare complications associated with orthognathic surgery. It is not possible to evaluate the incidence of these case reports, and the etiology is often unclear or speculative. Many of these complications are mentioned but not elaborated in this article for the sake of completeness. One
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can be assured that all of these complications occur at a prevalence of far less than 0.1%. Some instances of rare complications reported with bilateral sagittal split osteotomy are as follows:
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Pneumomediastinum [100]: 1 case, which
resolved
Summary Intraoperative hemorrhage that required special
intervention [85]: 10 cases Aseptic necrosis [86]: 1 case Facial nerve palsy [87]: 9 cases
Instances of rare complications reported with Le Fort I are as follows: Blindness [88]: 3 cases, 2 of which were
permanent Nasolacrimal obstruction or injury [88,89]:
3 cases treated with dacrocystorhinostomy or turbinectomy/septoplasty Postoperative hemorrhage that required intervention [90]: 21 cases Intraoperative hemorrhage that required special intervention [90,91]: 18 cases Orbital compartment syndrome [92]: 1 case Avascular necrosis [93]: 36 cases (most of which were segmental) False aneurysm of sphenopalatine artery [91]: 2 cases False aneurysm of maxillary artery [91]: 1 case Carotid-cavernous sinus fistula [91]: 1 case Vomerosphenoidal dysarticulation [94]: 1 case Cranial nerve III palsy [95]: 1 case, which spontaneously resolved Maxillary sinusitis [96]: 4 cases Keratitis [88]: 3 cases
Rare complications reported with surgically assisted rapid palatal expansion include the following: Cranial nerve III palsy [97]: 1 case, which
spontaneously resolved Rare complications reported with genioplasty include the following: Intraoperative hemorrhage that required special
intervention [85]: 1 case Instances of rare complications reported with bimaxillary osteotomies include the following: Dysphagia caused by upper esophageal spasm
[98,99]: 2 cases, 1 of which was treated with myotomy
Most of the common complications of orthognathic surgery occur frequently enough that they must be discussed with each patient in detail. Unfortunately, it is usually impossible to predict which patients will experience a specific complication. Age is the strongest indicator for potential complications, especially permanent nerve deficit. Large orthognathic skeletal moves seem to have greater relapse potential. Commonly held beliefs may not stand up to evaluation of the evidence, such as the proposition that mandibular setbacks are more stable than most other orthognathic surgical procedures. TMDs may be improved somewhat by correction of a malocclusion with orthognathic surgery, but orthognathic surgery is not a primary treatment for TMD and there is a subset of patients whose symptoms worsen after surgery. There is a small, but real, risk that orthognathic surgery may create TMD problems de novo.
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