e17

CLINICS IN
PLASTIC
SURGERY
Clin Plastic Surg 34 (2007) e17–e29

Pitfalls in Orthognathic Surgery:

Avoidance and Management
of Complications
David E. Morris, MDa,b,*, Lun-Jou Lo, MD
c
,
Alexander Margulis, MDd,e

- Pitfalls in patient selection, evaluation Infection

and surgical planning Dental injury
- Pitfalls in surgical technique Malocclusion
The midface - Summary
The mandible - References
- Complications following maxillary
or mandibular osteotomy

Complications in orthognathic surgery may arise
as a result of events at any point in the timeline of
the patient’s treatment: during preoperative plan-
ning, perioperative orthodontic care, or during the
surgery itself. This article primarily addresses the com-
plications that arise as a result of the intraoperative
technique. Complications may be characterized by
type: airway, vascular, neurologic, infectious, skeletal
(Box 1), and although the relevant anatomy differs,
most of these complications may occur with either
maxillary or mandibular procedures. One also can
define complications by the associated procedure
(Box 2). In this article, complications are grouped
by procedure. The initial discussion focuses on those
occurring during maxillary surgery, namely the Le-
Fort I type osteotomy and segmental osteotomy.
The second section discusses those occurring during
mandibular procedures, namely the bilateral sagittal
split osteotomy (BSSO), segmental osteotomy, and
genioplasty.
Pitfalls in patient selection, evaluation,
and surgical planning
Avoiding intraoperative complications begins with
a clear strategic plan based on accurate preoperative
anatomic and functional evaluations by both the
orthodontist and the surgeon. Early evaluation by
both orthodontist and surgeon facilitates collabora-
tion from the outset of care. This early meeting
should include discussion of the anticipated time
course of the preoperative and the postoperative

a
Division of Plastic, Reconstructive, and Cosmetic Surgery, The Craniofacial Center, University of Illinois at
Chicago, 811 S. Paulina, Chicago, IL 60612, USA
b
Shriners Hospitals for Children, 2211 N. Oak Park Avenue, Chicago, IL 60707, USA
c
Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, and Chang Gung Uni-
versity, 5 Fu-shin Street, Kweishan, Taoyuan 333, Taiwan
d
Hebrew University School of Medicine, Jerusalem, Israel
e
Department of Plastic and Reconstructive Surgery, Hadassah Medical Center, P.O. Box 12000, Jerusalem,
Israel 91120
* Corresponding author.
E-mail address: demorrismd@sbcglobal.net (D.E. Morris).

0094-1298/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.cps.2007.05.011
plasticsurgery.theclinics.com
e18 Morris et al

Box 1: Complications classified by type patient’s dissatisfaction with his/her features and
of the aspects of appearance that the patient wishes
Airway to be different. The surgeon, the orthodontist, and
Vascular
the patient must share a common understanding
Hemorrhage
of the patient’s facial aesthetic disharmony, asym-
Vascular compromise of the osteotomized
segment metry, and malocclusion. The psychologic impact
Neurologic of surgery on facial appearance must not be under-
Infectious estimated. Many centers, including those of the
Skeletal authors, insist that patients meet with the center’s
Unfavorable osteotomy psychologist before and after the surgery. Family
Tooth injury members and significant others are encouraged to
Nonunion attend such discussions because sometimes these
Postoperative malocclusion individuals, more than the patient, may have diffi-
Temporomandibular joint disorders culty adjusting to the change in the patient’s post-
Unfavorable aesthetic result
operative appearance. A negative comment from
a family member or friend may jeopardize the
orthodontics, the goals of the treatment, and the patient’s acceptance of the outcome.
financial issues. Particular emphasis should be placed on patients
Successful treatment begins with the surgeon’s who have bimaxillary protrusion and on older
and orthodontist’s intimate understanding of the patients. Those who have bimaxillary protrusion
pose the greatest risk of assuming a postoperative
‘‘aged’’ appearance as a result of the relaxation of
Box 2: Complications categorized by site
midfacial soft tissues following LeFort I osteotomies
Occurring with maxillary or mandibular or anterior segmental osteotomies with posterior
osteotomy positioning. The surgeon should be particularly
Infection thorough in discussing anticipated outcomes with
Instrumentation exposure older patients (particularly those over 30 years)
Unanticipated fracture for two reasons. First, older patients seem to have
Malunion or nonunion
difficulty in adjusting to their change in body
Malocclusion
image. Second, the changes in soft tissue in older
Skeletal relapse
Injury to dentition patients are less reflective of the underlying skeletal
Avascular necrosis of the osteotomized changes and thus are less predictable than those of
segment younger patients, who have more compliant soft
Gingival recession tissues. In older patients, additional aesthetic proce-
Devitalization of teeth dures may be needed.
Unique to maxillary osteotomy
Nasal septal deviation Pitfalls in surgical technique
Infraorbital nerve traction injury
Unanticipated fracture (pterygoid plate, The midface
sphenoid bone, middle cranial fossa) Airway complications
Injury to internal maxillary artery or branches Typically, orthognathic procedures are performed
Arteriovenous fistulas (carotid-cavernous sinus) with nasotracheal intubation because this approach
Ophthalmic injury easily allows intraoperative maxillary–mandibular
Lacrimal duct injury fixation. Nasal intubation can be difficult in
Maxillary sinusitis
patients who have cleft lip and palate requiring or-
Velopharyngeal insufficiency
thognathic surgery, especially if they previously
Unique to mandibular osteotomy have had a pharyngeal flap for velopharyngeal
Inferior alveolar nerve injury insufficiency. The alternatives in these cases include
Hemorrhage (inferior alveolar artery, intubation with fiberoptic guidance, exchange
masseteric artery)
over a stent after oral intubation, and using orotra-
Condylar resorption
cheal intubation with the oral tube positioned pos-
Malpositioned segment(s)
Unfavorable split terior to the molar teeth at the time of the
maxillary–mandibular fixation. Orotracheal intu-
Genioplasty bation can be challenging and thus is less prefera-
Mental nerve injury ble. During LeFort I osteotomy the nasotracheal
Inferior mandibular border contour irregularity
tube is at risk of injury by an osteotome or a saw
Ptosis of the mentalis muscle
during the septal–vomer disjunction (medially)

and the osteotomy of the lateral nasal wall (along
the lateral aspect of the tube) (Fig. 1) [1]. Several
maneuvers may help reduce the risk of such in-
juries. Using a guarded osteotome to perform the
septal disjunction before maxillary osteotomy
allows room to place the reciprocating saw against
the lateral nasal sidewall; this technique deflects
the septum and the nasotracheal tube to the oppo-
site side, decreasing the risk of injury to the tube.
The maxillary osteotomy, performed with a recipro-
cating saw, is directed from medial to lateral and
thus away from the tube. If the osteotomy is per-
formed from lateral to medial, however, a malleable
retractor is placed between the bony lateral nasal
sidewall and the dissected nasal mucosa to protect
the tube. If injury does occur, tube exchange is eas-
ier before the completion of the maxillary osteoto-
my [2]. Posterior oropharyngeal packing can be
helpful when the balloon tubing is lacerated and
a mild air leak results, especially at a time in the
operation when tube exchange would be difficult.
There are several reasons for increased airway
resistance after the surgery. The most common are
the intermaxillary fixation and the nasal airway
obstruction that typically follow LeFort I osteotomy
[3]. To reduce this resistance, many surgeons prefer
not to apply maxillary–mandibular fixation or to
apply only guiding elastics in the immediate posto-
perative period. Coughing or straining with agita-
tion can cause a fracture or an avulsion of the
internal fixation hardware. Avoiding maxillary–
mandibular fixation may also reduce the risk of
this complication.
Maxillary repositioning may change the position
of the anterior nasal spine, the septal cartilage, and
the vomer, resulting in septal deviation and nasal
airway obstruction. Following maxillary reposition-
ing, the new location of these structures should be
assessed. When they are deviated from the midline,
especially in cases of maxillary impaction, the sep-
tum should be trimmed to prevent buckling and
Fig. 1. Endotracheal tube position following nasotracheal intubation. (A) The balloon tubing can be injured dur-
ing septal-vomer separation. (B) The tubing or endotracheal tube itself may be injured by the saw during osteot-
omy through the medial buttress. This picture demonstrates the medial-to-lateral direction of the saw in an
effort to minimize tube injury.
Pitfalls in Orthognathic Surgery e19
to allow return to the midline. Additionally, the
inferior turbinates should be assessed as a potential
source of postoperative nasal airway obstruction in
cases of maxillary impaction.
Oronasal lacerations and fistula
Oronasal fistula is uncommon but may occur, par-
ticularly after segmental maxillary osteotomies
(Fig. 2). Palatal expansion greater than 6 to 8 mm
increases the risk of soft tissue breakdown [4].
Care should be taken to avoid tears in the palatal
mucosa, and any lacerations should be repaired in
a tension-free manner whenever possible. If pri-
mary repair is not possible because it would require
elevation of palatal flaps impacting the blood sup-
ply to the maxilla, then repair should be delayed
and performed as a separate surgical procedure
once the maxilla is healed. Many smaller lacerations
typically close spontaneously. Tears can be best
avoided by attention to detail when sectioning the
hard palate. Hydrostatic elevation of the palatal
mucosa along the osteotomy line just before sec-
tioning helps. When significant widening is needed,
multiple parasagittal palatal osteotomies should be
made to distribute the distance of the expansion
required.
Velopharyngeal insufficiency
Velopharyngeal insufficiency that has been treated
previously with pharyngeal flap surgery may restrict
maxillary advancement. In these patients, the pha-
ryngeal flap may need to be taken down before Le
Fort I advancement. Conversely, velopharyngeal in-
sufficiency may result from the maxillary advance-
ment and is most likely to occur in individuals
who have a history of cleft palate and who already
have some degree of velopharyngeal insufficiency
before the procedure. In these patients, a pharyngeal
flap or sphincter pharyngoplasty may be required
later to improve symptoms if velopharyngeal insuf-
ficiency persists.
e20 Morris et al

osteotome at its inferior aspect by palpation is crit-

ical to avoiding injury to the vessels within the pter-
ygopalatine fossa. Hemorrhage from this site can be
rapid and usually can be controlled by dense pack-
ing of the fossa. Ligation of the maxillary or carotid
artery is rarely necessary [7].

Fig. 2. Oronasal fistula from a multisegmented
maxilla.
Hemorrhage
A thorough preoperative bleeding history should be
taken, with particular attention to medications and
supplements that have anticoagulant properties
and to a history of excessive bleeding following rel-
atively minor trauma. Before the surgery, a local an-
esthetic with a vasoconstrictor and application of
controlled hypotensive anesthesia help reduce gen-
eralized bleeding and the need for blood transfu-
sion and also improve visualization [5]. With
maxillary osteotomy, the vessels at risk are the
greater palatine artery, the maxillary artery, and
the pterygoid plexus [6]. Bleeding from the de-
scending palatine vessels occurs when the posterior
aspect of the lateral nasal wall osteotomy is made.
This bleeding usually stops spontaneously; persis-
tent bleeding is controlled by vascular clips or bipo-
lar cautery following the downfracture of the
maxilla. Because the pterygomaxillary separation
is not visualized directly, placement of the
Vascular compromise
Mucosal degloving, osteotomies, and repositioning
of the facial skeletal elements may reduce the blood
supply to the osteotomized segment significantly.
This reduction in blood supply can affect both the
skeletal and soft tissue elements (pulp, periodonti-
um, and gingiva) (Fig. 3). Usually, this vascular
compromise is transient and has no significant clin-
ical impact on the outcome [6]. Devitalization of
the teeth, periodontal defects, and segmental bone
loss have been described following LeFort I osteot-
omy, however. These complications often have
been attributed to incisions, to excessive stripping
of the periosteum, to scars in the palatal mucosa
(secondary to previous cleft surgery), to interdental
or segmental osteotomies with loss of the attached
gingiva, and to transverse expansion with an exces-
sive stripping of the palatal mucosa. When a persis-
tent intraoperative gingival cyanosis is noted during
the surgery, one may consider returning the maxilla
to its original position and a subsequent readvance-
ment using distraction osteogenesis.
Neurologic complications
Sensory loss in the infraorbital nerve distribution
usually is temporary with a nearly complete recov-
ery; the long-term incidence of sensory loss is
approximately 1.5% to 2%. Permanent anesthesia
usually occurs as a result of extensive soft tissue

Fig. 3. Ischemic changes to the maxilla demonstrated in two patients. Patient 1 (A, B) is a noncleft patient with
maxillary deficiency who underwent LeFort 1 osteotomy with 11 mm advancement. (A) Gingival ischemic
changes on postoperative day 14. (B) Improvement in gingival appearance on postoperative day 28. There
remains concern about gingival recession as the ultimate outcome. (C) Patient 2 is a 21 yr old woman who under-
went LeFort 1 osteotomy with 4 mm of posterior intrusion and upper anterior segmental (Wassmund)
osteotomy with 5 mm setback. At postoperative day 10 she was noted to have compromised circulation in
the anterior maxillary segment, characterized by white mucosa and plate exposure. She developed mucosal
and partial bone necrosis on the buccal aspect however circulation to the palatal aspect remained adequate.
This was treated conservatively with the hope of revascularization of the areas with marginal blood supply.
The figure shows the patient 16 months following operation; she eventually required removal of the anterior
necrotic bone and all six teeth.
 Pitfalls in Orthognathic Surgery e21

retraction or plate compression [8]. Sensory deficits
of the teeth, palatal mucosa, and buccal mucosa
tend to resolve gradually over a 12- to 18-month pe-
riod. Neurologic deficits of the second, third,
fourth, fifth, sixth, tenth, and twelfth cranial nerves
have been reported but are extremely rare (Fig. 4)
[9,10]. These injuries tend to occur as a result of un-
favorable fractures ascending into the cranial base.
Relapse
Relapse within the immediate surgical period is
caused by inadequate mobilization of the maxilla.
The maxilla must be mobilized fully so that it can
be advanced passively into the surgical splint. Al-
though mobilization can be achieved in most non-
cleft cases, in cleft cases all soft tissue scars must be
released completely. If intraoperative advancement
is not possible, gradual distraction of the maxilla
should be planned as an alternative.
Skeletal complications: unfavorable
osteotomies
With the LeFort I osteotomy, uncontrolled fractures
extending into the cranial base may occur when
downfracture is attempted despite incomplete
osteotomies or when the osteotome is positioned
improperly during the pterygopalatine disjunction.
Such fractures may result in one of the rare but well-
described vascular, neurologic, and ophthalmic
complications [10–12]. The downfracture should
be performed with digital pressure only, and Rowe
disimpaction forceps should be used only for the
mobilization after the maxilla is separated from
its base. With digital pressure, sites of resistance
can be identified. These sites tend to occur at the
posterior aspect of the lateral nasal wall and at the
posterior maxillary wall where the reciprocating
saw was not positioned at its maximal depth.
A thin osteotome can be introduced through the os-
teotomy of the anterior wall until the resistance is
felt. The osteotome should be directed inferiorly,
away from the orbital floor, and the posterior wall
should be perforated under downward digital pres-
sure until the maxilla fractures. In patients who
have developmental dentofacial deformities the
posterior maxillary wall is thin, and the maxilla
fractures down readily. In patients who have clefts
and craniofacial deformities, however, the posterior
wall often is excessively thick, and an osteotome
may be needed to complete the osteotomy. When

Fig. 4. Radiographic studies of an 11-year-old patient who had bilateral cleft lip and palate who underwent
LeFort I osteotomy for maxillary hypoplasia and developed perioperative right monocular blindness and tempo-
rary numbness in the right upper and lower extremities. (A) CT scan on postoperative day 2, demonstrating
hematoma behind the posterior clinoid process. (B) CT demonstrating dissecting aneurysm of the basilar artery.
(C) Oblique angiogram demonstrating basilar artery aneurysm near the junction of the right posterior cerebral
artery. (D) Different oblique view of angiogram demonstrates aneurysm with a stalk on the ophthalmic segment
of the left internal carotid artery. (From: Lo LJ, Hung KF, Chen YR. Blindness as a complication of LeFort I osteot-
omy for maxillary distraction. Plast Reconstr Surg 2002;109(2):688–98; with permission.)
e22 Morris et al

Fig. 5. Comparison of the os-

teotomy between the conven-
tional LeFort I type (red line)
and the higher-level midfacial
osteotomy (black dashed line)
to include the body of the zy-
goma. Unlike the conven-
tional LeFort I osteotomy,
which extends directly poste-
rior toward the pterygoid
plate, the posterior maxillary
wall osteotomy must be di-
rected to the inferior ptery-
goid plate with the higher
level midfacial osteotomy.

the maxilla is sectioned at a higher level, to include
the body of the zygoma, the downfracture may be
difficult, and the surgeon should direct the osteoto-
my of the posterior lateral maxillary wall toward the
pterygoid plate (Fig. 5). Visualization is difficult,
and the surgeon should have a three-dimensional
understanding of the skeletal anatomy.
During the exposure of the mandibular body,
subperiosteal dissection helps avoid injury to the
inferior alveolar artery where it enters the mandible
medially. Bleeding resulting from injury along the
course of the artery usually stops spontaneously.
If it does not, the artery can be dissected away
from the inferior alveolar nerve and carefully

Unfavorable aesthetic outcome

Following orthognathic surgery, the final aesthetic
appearance is a composite of skeletal, soft tissue,
and dental changes. Whereas some aesthetic short-
comings are best treated with an additional skeletal
surgery, others can be treated with soft tissue proce-
dures. Following maxillary surgery the overim-
pacted and the overretruded maxilla are the two
most commonly seen skeletal base disproportions;
both give the patient an aged appearance [13].
Adequate correction often requires additional skel-
etal surgery to lengthen or advance the maxilla.
Many surgeons advocate an alar cinch suture with
V-Y vestibular closure to prevent adverse soft tissue
changes after Le Fort 1 advancement. If the appear-
ance of the nose or lip remains unacceptable, the
patient may benefit from a subsequent rhinoplasty
or lip augmentation. Patients should be forewarned
of these possible adverse changes and the need for
corrective surgery at a later stage.

The mandible
Hemorrhage
Significant hemorrhage after mandibular osteo-
tomy (BSSO or intraoral vertical osteotomy) is
uncommon yet can occur (Fig. 6). [14–18]. The ves-
sels at risk include the inferior alveolar, the maxil-
lary, and the facial arteries, the retromandibular
vein, and the pterygoid venous plexus [19]. Careful
subperiosteal dissection, retraction of soft tissues,
and lateral splitting help avoid vascular injuries in
most patients.
Fig. 6. Postoperative ecchymosis. This 27-year-old
male underwent BSSO with 10 mm setback and re-
duction genioplasty of 7 mm for mandibular progna-
thism and long chin. He denied medical diseases
other than being a hepatitis B carrier and denied tak-
ing any anticoagulants. The operation was uncompli-
cated and intraoperative blood loss was 250 ml. The
photo taken on postoperative day 4 reveals extensive
subcutaneous ecchymosis over the lower face, neck
and chest. This was treated expectantly and his post-
operative course was otherwise unremarkable.

ligated. Cauterization poses a risk to the nerve and
should be avoided. For persistent bleeding, as may
occur when the masseteric or the facial artery is in-
jured during mandibular osteotomy, temporary
packing with pressure is sometimes helpful. Signif-
icant facial artery injuries require isolation of the
vessel and its ligation [4].
During the exposure of the medial surface of the
ramus, vascular injury may occur after a loss of the
subperiosteal dissection plane and an inadvertent
supraperiosteal dissection. In dissecting the medial
ramus, it is helpful to start the dissection anteriorly
and to proceed in a posterosuperior direction.
A backcut in the periosteum can be made at the su-
perior extent of the dissection, where the perios-
teum is less mobile, to avoid tearing it and
injuring the underlying vasculature. Using cotton
gauze to pack the medial ramus usually slows the
bleeding; in other cases, the split may need to be
completed before bleeding from the posterior ram-
al border can be controlled. Despite all the precau-
tions, unusual vascular complications can occur.
Some of these complications can be life threaten-
ing. These include arteriovenous fistulae, false aneu-
rysms, carotid cavernous fistulae, and carotid artery
thrombosis [19–20].
Vascular compromise
As with maxillary surgery, avascular necrosis is un-
common in mandibular procedures [21,22]. The
blood supply to the mandible is derived from the in-
ferior alveolar artery and primarily from the nutrient
vessels through the muscular attachments of the
masseter and the pterygoid muscles [23]. When per-
forming sagittal split osteotomy (SSO) of the ramus,
extensive stripping of the masseter muscle from the
buccal cortex may compromise the blood supply
to the distal region of the proximal segment, where
the internal fixation hardware is placed. Avascular
necrosis, although uncommon, can occur with a re-
sulting loss of the fixation and skeletal instability.
Fig. 7. (A) Panorex demonstrates hardware configuration following genioplasty. (B) Exposure of the two supe-
rior screws.
Pitfalls in Orthognathic Surgery e23
The blood supply to the distal element is derived
from the attachment of the pterygoid muscle to the
lingual cortex. The pterygomasseteric sling must be
divided to allow adequate mobilization through
an osteotomy between the buccal and lingual corti-
ces. Although wide periosteal stripping is necessary
to allow visualization of the ramal osteotomies,
care should be given to expose only the necessary
portion of the mandible.
Excessive periosteal stripping of the chin during
the osseous genioplasty may cause avascular necro-
sis with a subsequent bony resorption of the genio-
plasty segment. Vascular compromise to the
segment also may manifest as gingival recession
in that segment (Fig. 7). The periosteum should
be stripped only to the degree necessary to perform
an osteotomy.
Neurologic complications
In contrast to the Le Fort I osteotomy, sensory defi-
cit is a major concern during mandibular surgery,
because the nerve is not visualized, and the surgeon
relies primarily on anatomic data that are not spe-
cific for the individual patient [24]. Of the mandib-
ular procedures, the SSO of the ramus carries the
greatest risk of sensory loss [25]. The inferior alveo-
lar nerve is at risk at virtually every point during the
course of the SSO procedure: during exposure of the
medial ramus, horizontal osteotomy of the medial
ramus, vertical osteotomy of the buccal cortex, os-
teotomy along the external oblique ridge, splitting
of the ramus between the proximal and distal seg-
ments, and finally during the fixation. A significant
percentage of patients have sensory loss with or
without nerve transection. The incidence of a com-
plete transection, apparent at the time of the oper-
ation (Fig. 8), is reported to be between 1.3% and
18% [17,24–27]. Even without visible transection,
the long-term sensory loss of the inferior alveolar
nerve is reported to range from 24% to 85%
[14,15,24,28–30] The correlation between the
e24 Morris et al
Fig. 8. Right inferior alveolar nerve transection during bilateral sagittal split osteotomy. (A) End of transected
nerve held with forceps. (B) Note the contour of the osteotomy split in cross section. This unfavorable split wraps
inferomedially, including the inferomedial rim (arrow) with the proximal segment incorporating the nerve lat-
erally, causing avulsion. The distal nerve was then mobilized for repair.
surgeon’s intraoperative assessment of the nerve in-
jury and the postoperative neurosensory deficit is
poor; thus reacting to a perceived nerve injury
that does not include complete transection is, in
most circumstances, not indicated [4]. When tran-
section is identified intraoperatively, however, the
nerve should be repaired with standard techniques.
Other neurologic deficits have been reported af-
ter SSO. The lingual nerve may be affected during
the osteotomy of the inferior border, especially
when the inferior border saw is used. Seventh nerve
palsy is uncommon, but with the close proximity of
the nerve to the posterior border of the ramus, in-
jury can occur; the incidence has been reported to
be between 0.4% and 1% [14,15,31]. The risk of
a nerve injury with intraoral vertical osteotomy is
less than with an SSO, but the incidence of long-
term sensory deficit is still between 2.3% and 14%
[18,25]. This deficit is attributed to the inability to
visualize the medially located foramen directly. De-
spite the significant incidence of neurosensory loss,
patients rarely are bothered, and few, if any, men-
tion it unless specifically asked by the surgeon.
Nonetheless, this complication should be discussed
frankly with the patient before surgery.
During osseous genioplasty, superficial distal fi-
bers of the mental nerve are transected with the mu-
cosal incision, and the mental nerve is at risk of
transaction in proximity to the osteotomy site. Ide-
ally, the osteotomy should be placed 5 to 6 mm be-
low the foramen, because the nerve within the canal
descends before exiting the foramen. The bone be-
low the foramen might be insufficient, however, to
carry out the osteotomy at this level safely. At times,
extending the mucosal incision or a second posterior
exposure of the inferior mandibular border
facilitates visualization of the osteotomy site. De-
spite these precautions, the incidence of long-term
sensory deficit has been reported to be as high as
20% [29,32,33]. When an osseous genioplasty is
combined with a BSSO, the incidence of a long-
term sensory deficit significantly increases, from
approximately 10% with a genioplasty and 30%
with a sagittal split osteotomy alone, to 70% [29,32].
Skeletal complications: unfavorable
osteotomies
The incidence of unfavorable fractures that occur
during SSO of the ramus (Fig. 9) may be as high
as 3% to 23% [15,17,26,27]. These fractures in-
clude condylar neck, lingual plate, and buccal plate
fractures. The ‘‘ideal’’ split may be technically diffi-
cult to achieve depending on anatomic variations
(eg, variation in ramal width), and this difficulty
may affect the ability to place and to direct the
bony cuts [15]. Condylar neck fractures occur
when the horizontal osteotomy is misdirected pos-
teriorly and superiorly instead of horizontal to the
occlusal plane. Buccal plate fractures typically occur
when the vertical osteotomy at the inferior border is
incomplete and a sagittal split with the osteotome is
attempted. The inferior border should be cut fully
before attempting the split. Lingual plate fracture
originates near the ascending ramus and may occur
when the mandibular third molars have not been
extracted before the surgery. For this reason, uner-
upted third molars ideally are extracted 6 to 12
months before surgery to avoid uncontrolled frac-
tures and to allow internal fixation [34]. When an
unplanned fracture does occur intraoperatively, de-
pending on its pattern and on whether the distal
segment advances or sets back, the surgery may
 Pitfalls in Orthognathic Surgery e25

Fig. 9. A variety of unfavorable splits can occur. The top row illustrates a near horizontal osteotomy of the ramus
and placement of a plate followed by completion of the sagittal split. The bottom row illustrates fragments of
the proximal segment that have been inadvertently fractured (left and center) and complete transection of the
distal segment just posterior to the molar (right).

proceed after a prompt treatment of the fracture
that requires attention to the principles of fracture
management and a prolonged postoperative maxil-
lary–mandibular fixation. Alternatively, the proce-
dure may need to be abandoned and the fracture
allowed to heal before returning to the operating
room.
Condylar resorption
Condylar resorption is a late complication that usu-
ally occurs 7 to 27 months after the surgery. The
cause is unknown, but there is a predilection for
this complication in young women who have preop-
erative class II malocclusion and a prior history of
temporomandibular joint dysfunction [35]. Cau-
tion should be used in offering orthognathic surgery
to such patients, especially when preoperative radio-
graphs reveal small, abnormal condyles. Compared
with the vertical oblique osteotomy, the BSSO main-
tains a more robust blood supply to the condyles,
making avascular necrosis less likely.
Progressive condylar resorption changes the
condylar morphology to a fingerlike form and can
be associated with a loss in posterior facial height.
Progressive resorption may lead to the development
of class II malocclusion. The symptoms begin asym-
metrically and progress at varying degrees to a bilat-
eral joint dysfunction. Continuing resorption results
in an open bite. There is no efficient treatment for
active condylar resorption. The benefit of a centric
relation splint is temporary. The surgeon must wait
at least 6 months, until the resorption is assumed
to be complete, before attempting another interven-
tion. After 6 months, a single-photon emission CT
scan may be useful to evaluate the exact degree of
the resorption. In cases of severe resorption, total
joint reconstruction may eventually be required.
Unfavorable aesthetic outcome
Mandibular osteotomy and genioplasty often result
in changes in lower facial skeletal contours. Poorly
designed osteotomies and/or poor soft tissue
e26 Morris et al

handling can be associated with undesirable aes-
thetics of the lower face. Mandibular setback results
in less well-defined cervico-mental contour and
a need for soft tissue procedures to improve the ap-
pearance of the neck. With genioplasty, chin ptosis
may result from an excessive soft tissue dissection
and an improper reattachment of the mentalis mus-
cle after the genioplasty. Patients who have lip
incompetence and mentalis strain during lip
closure may require revision surgery with vertical
shortening. Many patients who have long-standing
mentalis strain continue to exhibit this characteris-
tic even with adequate skeletal correction. In
women, chin advancement should be done conser-
vatively and should not extend beyond the lower lip
vermilion; the labial–mental sulcus should not be
overly deep. Asymmetry after osseous genioplasty
should be assessed with particular attention at the
time of surgery. After fixation of the genioplasty seg-
ment, the chin should be checked for symmetry
from all angles and should be repositioned if indi-
cated. Additionally the discontinuity at the inferior
border may need to be addressed; certainly the
patient should be forewarned of this possibility.
Complications following maxillary
or mandibular osteotomy
Infection
Postoperative surgical infection is uncommon fol-
lowing orthognathic surgery. The reported inci-
dence is less than 1% [14,26,36–38]. When
infection occurs, it is usually associated with the
mandibular osteotomy. As with most surgical pro-
cedures, the risk of infection increases with the
length of the procedure. Following the SSO proce-
dure, the surgical field should be thoroughly irri-
gated with saline to remove all bone chips and
dust. Some surgeons advocate placing closed sec-
tion drains overnight. Bacterial contamination is in-
evitable, and the use of perioperative prophylactic
antibiotics is common [36,39,40]. Frank abscesses
should be drained (Fig. 10) percutaneously or

Fig. 10. (A) Transverse and (B) coronal CT sections demonstrating postoperative infection with abscess originat-
ing in the left angle region following bilateral sagittal split osteotomy. The abscess has tracked inferiorly in the
soft tissues of the neck. (C) Aspiration of purulent fluid from the abscess.
 Pitfalls in Orthognathic Surgery e27

Fig. 11. (A) Preoperative cephalogram. (B) Postoperative malocclusion with significant anterior open bite following
LeFort 1 and bilateral sagittal split osteotomies. Condyles were improperly positioned at the time of the fixation.

intraorally; surgical drainage is indicated when aspi- breakage of the fixation by coughing, straining,
ration is inadequate. and jaw clenching (Fig. 12). For patients in whom
relapse is a concern, the surgeon might consider
Dental injury omitting intermaxillary fixation initially and plac-
The risk of dental injury is minimized with careful ing elastics 2 to 3 days after the procedure in a
preoperative planning. Tooth fracture or loss may more relaxed setting. Additionally, an occlusal re-
occur from interdental osteotomies. Presurgical or- lapse can occur late, long after the initial surgery.
thodontics should provide adequate space for antic- Late relapse usually results from complex func-
ipated osteotomies. Interdental osteotomies should tional dental and muscular forces re-establishing
be performed with microburrs. Periapical films are equilibrium and remodeling of the facial skeleton.
useful adjuncts to determine the safe depth for Long-term follow-up is important, and the manage-
the osteotomies. Postoperatively teeth may be fol- ment is targeted toward the causes.
lowed clinically by their color [4]. Tooth compro-
mise is treated secondarily with endodontic or
Summary
prosthodontic techniques.
Orthognathic surgery provides a means of correct-
Malocclusion ing dental malocclusions and facial disharmonies
Postsurgical malocclusion (Fig. 11) is uncommon effectively, whether they are congenital,
but can occur and becomes readily evident in the
early postoperative period [26,34,41,42]. A ten-
dency toward early relapsing, if minimal, often
can be managed by class III or class II dental elastics
and/or orthopedic appliances (edge-to-edge incisal
relation). More significant recurrence of the initial
preoperative occlusion necessitates a return to the
operating room. In most circumstances, early re-
lapse occurs as a result of one or more of the follow-
ing: inadequate mobilization of the repositioned
jaws; bony interferences and instability not appreci-
ated during the repositioning; condyles dislodged
from the glenoid fossa at the time of fixation; and
failure of the internal plate/screw fixation systems.
Immediately after the operation the anesthesiology Fig. 12. Failure of titanium fixation of LeFort I seg-
staff should take care to awaken the patient in a gen- ment. Note the avulsed screw and broken plate.
tle, relaxed fashion to avoid abnormal forces on the This failure resulted in a non-union that required
repositioned jaws and potential loosening or bone grafting.
e28 Morris et al
developmental, or posttraumatic in nature. Com-
plications may arise at any one of the multiple
stages of care. Seemingly small technical issues in
the operating room can affect the outcome signifi-
cantly, resulting in additional operations and/or ad-
ditional months of orthodontics.
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