Int. J. Oral Maxillofac. Surg.

2005; 34: 247–251

doi:10.1016/j.ijom.2004.06.009, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery
A. Al-Bishri1, Z. Barghash2,
Neurosensory disturbance after J. Rosenquist1, B. Sunzel1
1
Department of Maxillofacial Surgery,
University Hospital MAS, Malmö, Sweden;

sagittal split and intraoral 2

Folktandvard Nyhem, Halmstad, Sweden

vertical ramus osteotomy: as

reported in questionnaires and
patients’ records
A. Al-Bishri, Z. Barghash, J. Rosenquist, B. Sunzel:Neurosensory disturbance after
sagittal split and intraoral vertical ramus osteotomy: as reported in
questionnaires and patients’ records. Int. J. Oral Maxillofac. Surg. 2005; 34:
247–251. # 2004 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. This retrospective study aimed at evaluating the long-term incidence of

neurosensory disturbance (NSD) after sagittal split osteotomy (SSO) and intraoral
vertical ramus osteotomy (IVRO). Furthermore, a comparison was made between
the results obtained by questionnaires and information in the patient records in the
evaluation of nerve function. Finally, the degree of discomfort caused by the NSD
was evaluated.
One hundred and twenty-nine patients, who underwent IVRO (79 patients) and
SSO (50 patients), were included. Questionnaires were mailed to the patients at
least one year after the operation. The records of all patients, who returned the
questionnaires, were reviewed.
The results of NSD obtained by questionnaires and records differed indicating a
disagreement between the judgement of the surgeon and the patient’s opinion.
Key words: sagittal split osteotomy; intraoral
Long lasting NSD was underestimated by the surgeon as compared to the vertical ramus osteotomy; neurosensory
patient’s subjective symptom. Long lasting NSD was reported in 7.5% disturbance; inferior alveolar nerve injury.
(questionnaire), 3.8% (record) after IVRO and in 11.6% (questionnaire) and 8.1%
(record) after SSO. Accepted for publication 8 June 2004

The most common surgical procedures
for correction of mandibular deformities
are the sagittal split (SSO) and intraoral
vertical ramus osteotomies (IVRO).
SSO was described by SCHUCHARDT in
194219, and later modified by TRAUNER
& OBWEGESER in 195722. Since then var-
ious modifications1,5,8 have been added
to assure good bone healing, avoid unfa-
vourable fracture, eliminate the need
0901-5027/030247+05 $30.00/0
for postoperative intermaxillary fixation
(IMF) and decrease the incidence of
neurosensory disturbance (NSD). The
need for postoperative IMF was elimi-
nated by the introduction of internal
rigid fixation. NSD after SSO remains
the main drawback of this operation
with an incidence ranging from 9%14
to 84.6% objectively and 100% sub-
jectively23.
# 2004 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
The vertical ramus osteotomy was
described first as an extraoral procedure
by LIMBERG13 in 1925 and later by CALD-
2
WELL & LETTERMAN in 1954. The main
disadvantages were extraorally visible
scars, condylar sag, necrosis of the distal
tip of the proximal segment and the
need for postoperative IMF. MOOSE15 in
1964 overcame the disadvantage of the
facial scar by introducing an intraoral
248 Al-Bishri et al.
approach. HALL & MCKENNA in 19877
advised that a portion of the medial
pterygoid muscle should remain attached
to the distal tip of the proximal segment
in order to eliminate the disadvantages
of condylar sag and ischemic necrosis of
the distal tip of the proximal segment.
Postoperative IMF is still the main
drawback of the intraoral vertical ramus
osteotomy (IVRO).
The main advantage of the IVRO over
the SSO is the comparatively low inci-
dence of NSD that ranges from 0%25 to
35%23.
The higher incidence of NSD after
SSO can be explained by more technical
difficulties and closer proximity to the
nerve during the operation compared to
the IVRO. Injuries to the inferior alveo-
lar nerve during SSO may occur due to
stretching of the nerve during medial
retraction, adherence of the nerve to the
proximal segment after splitting, direct
manipulation of the nerve, bony rough-
ness on the medial side of the proximal
segment or segment mobilization20.
Osteosynthesis may induce injuries to
the inferior alveolar nerve by compres-
sion of the nerve during fixation or by
direct injury to the nerve. Severance of
the nerve may also occur during osteot-
omy procedure.
In IVRO, nerve injury could occur if
the osteotomy line is too close to the
mandibular foramen. This is a concern
particularly if the surgeon wants a long
proximal segment. Accidental medial
movement of the proximal segment after
the osteotomy could also contribute to
nerve injury.
The aims of this study were to evalu-
ate NSD after SSO and IVRO, asses the
difference between questionnaire and
patient’s record in evaluating of the
NSD and evaluate the discomfort caused
by NSD after SSO and IVRO.
Material and methods
One hundred and twenty-nine patients
who underwent bilateral IVRO (79
patients, 42 females and 37 males) and
bilateral SSO (50 patients, 31 females
and 19 males) between 1995 and 1999 at
the department of Maxillofacial Surgery,
University Hospital MAS, Malmö, Swe-
den, were included in this study. The age
of the patients ranged between 15 and 58
years with an average of 36.5 years.
Questionnaires were mailed to the
patients at least one year after the
operation. Ninety-six completed ques-
tionnaires (74%) were returned, 53 ques-
tionnaires from the IVRO patients (30
female and 23 male) and 43 from the
SSO patients (27 female and 16 male).
Patients were queried about perceived
sensory change along the distribution of
the lingual and/or inferior alveolar
nerves after the operation, duration of
these changes, the effect of the changes
on their life, and their satisfaction with
the result of the operation. A visual ana-
logue scale (VAS) graded from 0 (no
discomfort) to 10 (intolerable discom-
fort) was included for the evaluation
(see the questionnaire form).
To evaluate the effect of the NSD on
the patients, the grades of the VAS were
interpreted as follows: 0–2 mild discom-
fort, 2–4 mild to moderate discomfort,
4–6 moderate discomfort, 6–8 moderate
to severe discomfort, and 8–10 severe
discomfort.
A contact telephone number was pro-
vided for any further questions and a
stamped addressed envelope was
included for the return of the question-
naire.
The records of all patients who
returned the questionnaire were revie-
wed to identify any reported NSD after
the operation. In our department, all
patients are routinely followed up to18
months after the operation. During the
18 months follow up the NSD was
always tested subjectively by asking the
patients and objectively by using a den-
tal probe to assess the sensory changes
along the distribution of the mental
nerve (lower lip and chin).
All patients went through the same
sequence of pre- and postoperative
orthodontic treatment, treatment plan-
ning, surgical treatment and follow up.
Cephalometric radiographs were taken
preoperatively, immediately postopera-
tively, immediately after the release of
intermaxillary fixation (IVRO), 6 months
and 18 months postoperatively.
Surgical procedure
In preparation for surgery under general
anaesthesia, a local anaesthetic, mepiva-
cain with adrenaline (5 mg/ml þ 5 mg/
ml; Carbocain-adrenalin, Astra-Zeneca,
Sweden), was infiltrated in the operating
area. Antibiotics and cortisone were rou-
tinely administered to all patients during
Table 1. NSD after IVRO and SSO as reported in returned questionnaires and patients record
Record review
Operation Total sides Immediate
IVRO 106 8 4
SSO 86 33
the first 24 h (benzyl penicillin 3 g  3
or clindamycin 600 mg  3 in case of
penicillin allergy and 4 mg betametha-
sone  4) starting immediately before
the operation. To avoid postoperative
swelling of the lower lip and abrasion of
the corner of the mouth a steroid cream
was frequently used throughout the
operation.
The surgical technique for both sagit-
tal split osteotomy and vertical ramus
osteotomy were performed as described
by TERRY & WHITE21. Intermaxillary
fixation of the IVRO was achieved by
using orthodontic brackets and stainless
steel wires (0.4 mm). The wound was
sutured with 4-0 Vicryl. All patients
were kept on intermaxillary fixation
for 4–6 weeks postoperatively. In the
SSO the final fixation on each side
was achieved with two or three bicorti-
cal positional screws through a trans-
buccal approach. No intermaxillary fixa-
tion was used postoperativly with the
exception of guiding elastics.
Results
Intraoral vertical ramus osteotomy
Questionnaires
Fifty-three completed questionnaires
representing 106 operated sides were
returned and analyzed.
The returned questionnaires reported
immediate NSD after IVRO in 11 oper-
ated sides (10.4%); three of them
regained full sensibility during the first
year whereas eight (7.5%) sides had
long lasting NSD. In one of the patients,
the NSD was bilateral (Table 1).
Four patients out of seven (57%) with
long lasting NSD described the effect of
the disturbance as mild (Fig. 2).
Ninety-eight percent of the patients
operated for IVRO were satisfied with
the result of the operation. The only
patient, who was dissatisfied, did not
have any long lasting NSD after the
operation.
Record review
In the files of the 53 patients with 106
operated sides, who returned completed
Questionnaires
Long lasting Immediate Long lasting
11 8
7 25 10

Fig. 1. The difference between immediate and long lasting NSD in both record review (RR) and
questionnaire (Q).
questionnaires, immediate NSD was
recorded in eight operated sides (7.5%).
Four of them regained full sensibility
over a period of one year, leaving four
sides (3.8%) with long lasting NSD
(Fig. 1).
Sagittal split osteotomy
Questionnaires
Questionnaires were returned from 43
patients with 86 operated sides. Immedi-
ate NSD was reported in 25 operated
sides (29%), 15 sides regained full sen-
Fig. 2. Patients discomfort after SSO and IVRO according to the questionnaire.
Neurosensory disturbance after sagittal split
sibility after one year while the remain-
ing 10 sides (11.6%) continued to have
long lasting NSD.
Fifty percent of the patients with NSD
after SSO described the effect of NSD
as mild to moderate (Fig. 2).
Four out of the 43 patients (9%) were
not satisfied with the result of the opera-
tion but only one attributed the dissatis-
faction to sensory impairment.
Record review
Reviewing of the 43 patients, who
returned the questionnaires, showed
249
immediate NSD in 33 operated sides
(38.4%). Twenty-six of the affected
sides regained full sensibility during the
first postoperative year; thus seven oper-
ated sides (8.1%) remained with long
lasting NSD (Fig. 1).
Discussion
The evaluation of NSD along the distri-
bution of the inferior alveolar nerve
(chin and lower lip) can be performed
by either purely subjective (question-
naires), relatively objective (static light
touch, brush directional discrimination,
two-point discrimination, and thermal
discrimination) and purely objective (tri-
geminal somatosensory evoked poten-
tials (TSEP)16, sensory nerve action
potential (SNAP)9, and blink reflex
(BR)10) methods. The purely objective
methods of evaluation are not easily
applicable. Thus most studies depend on
subjective and the relatively objective
evaluation; the latter always considered
by many authors as an objective evalua-
tion. Some authors4,17,23 have shown
that patients’ subjective evaluations give
a higher incidence of NSD than rela-
tively objective evaluations while others
have reported the opposite12,26. A good
correlation between the subjective eva-
luation and 2-point discrimination
(objective test) has also been reported3.
However, it is only the patient who
experience whether his/her sensibility
has been changed. Therefore, in this
study we chose the subjective evaluation
to assess the NSD after sagittal split
osteotomy.
Upon reviewing the literature one finds
big differences in the armamentarium
used in objective evaluation tests of
NSD. This could lead to differences in
the definition of NSD. Such disad-
vantages could be solved by standardi-
zation of the instrument used for the tests
as described by GHALI & EPKER6 in 1989.
The reported immediate postoperative
NSD after SSO in the previous studies
was high ranging from 54%17 to
100%23. The high incidence of the
immediate NSD could be caused by
direct manipulation of neurovascular
bundle during the operation, which often
becomes swollen. As the bundle is con-
fined to a limited bony space after fixa-
tion, nerve damage (neurapraxia) could
occur. Neurapraxia is an interruption in
conduction of the impulse down the
nerve fiber, there is no axonal degenera-
tion and the recovery takes place with-
out wallerian degeneration11,18. This is
probably a biochemical lesion caused by
250 Al-Bishri et al.

concussion or shock-like injuries to the IVRO and 84.6% of SSO operated sides. the effect as moderate to severe and
fiber. Compression or relatively mild, ZAYTOUN et al.27 reported no NSD after none of them described the effect as a
blunt blows, bring about neurapraxia. IVRO and 68% in the SSO one year severe effect, all the four patients were
There is a temporary loss of function, after the operation. WESTERMARK et al.24 above the age of 40 years. This coin-
which is reversible within hours to reported an incidence of NSD of 9%in cided with the result reported by WES-
25
months of the injury (the average is 6–8 the IVRO and 39.4% in the SSO. TERMARK et al. in 1999 in that the
weeks). The difference in the incidence of older patients paid more attention to the
In our study, the record of the patients immediate NSD after SSO and IVRO NSD than the younger patients did.
showed immediate postoperative NSD in among both questionnaires and the Regarding patient satisfaction 98% of
33 operated sides (38.4%) while the patient’s records was significant. the IVRO and 91% of the SSO patients
returned questionnaire showed that 25 The NSD was described as mild in were satisfied. The only one patient who
operated sides (29%) was affected by 57% of the affected patients in the was not satisfied in the IVRO group was
NSD. Of those 26 of the affected sides IVRO group and no patient described not affected by NSD but due to func-
according to the patient’s record and 15 his disturbance as moderate to severe or tional reason. Out of the four patients
affected side according to the question- severe. Fifty percent (four patients) of who were not satisfied in the SSO group
naire regained full sensibility during the the affected patients in the SSO describe only one was due to NSD.
first postoperative year. Thus long lasting
NSD was present in 8.1% and 11.6% of
operated side according to the patient’s
record and the questionnaire, respec-
tively. Appendix A.Questionnaire
On the other hand, the immediate
NSD after IVRO was reported in eight
(7.5%) and 11 operated sides (10.4%) in
records and questionnaires, respectively.
Long lasting NSD after IVRO was 3.8%
of the operated sides (four sides) in the
records and 7.5% (eight sides) in the
questionnaire.
Our result showed higher incidence of
immediate NSD after SSO in the records
than in the questionnaires, while the
opposite was true in the case of IVRO.
This could reflect a higher concern and
expectation of surgeons on NSD after
SSO than after IVRO. It might also be
difficult for the patients to remember a
mild short NSD immediately after the
operation when asked a year or more
later. The absence of nerve manipulation
during IVRO operation could also con-
tribute to the lower incidence of the
immediate NSD after the operation.
In the case of long lasting NSD, the
returned questionnaires showed higher
incidence than the reviewed records for
both SSO and IVRO. The higher inci-
dence of the long lasting NSD in the
questionnaire comparing to the patients
records is in agreement with the results
reported by PRATT et al. 199617.
Our study showed a lower incidence
of the long lasting NSD after IVRO
compared to SSO (IVRO, 3.8% in the
reviewed record and 7.5% in the retur-
ned questionnaire, SSO, 8.1% in the
reviewed records and 11.6% in the
returned questionnaire) these results are
in agreement with the results reported
previously. WALTER & GREGG23 observed
that their patients subjectively com-
plained of chronic NSD in 70% of
IVRO and 100% of SSO, whereas an
objective test indicated NSD in 35% of

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Address:
Awwad Al-Bishri
Department of Maxillofacial Surgery
Malmö University Hospital (MAS)
205 02 Malmö
Sweden.
Tel: þ46 40 333109
Fax: þ46 40 336205
E-mail : albishri@hotmail.com