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 cate-
gorized according to a hierarchy of evidence-based
medicine. The strongest evidence is that derived from
randomized, clinical trials or, even better, a meta-
analysis 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 chap-
ters 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 or-
thognathic 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 high-
est 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: Robert_Bays@emoryhealthcare.org
(R.A. Bays).
1042-3699/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1042-3699(02)00098-5
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
230 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242

Table 1
Neurosensory loss after bilateral sagittal split osteotomy
Reference Sample size Follow-up (mo) Subjective loss (%) Objective loss (%)
Ylikontiola et al [7] 30 12 0 7
Blomqvist et al [2] 48 12 35
Nishioka et al [4] 12 12 67 75
Schultze-Mosgau et al [5] 12 12 17
Ylikontiola et al [8] 30 12 31
Jaaskelainen et al [3] 23 12 26.1
Westermark et al [6] 548 24 39 39
Mean 21.35 35.3 33.1

use of small monocortical plates reduces the inci-
dence 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 fixa-
tion. 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 follow-
up 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
with a BSSO? Isolated genioplasty is associated with
a mean neurosensory loss of 17% for subjective
reporting and 10% for objective testing at a min-
imum 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 contri-
bution 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.)
 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242 231

Table 2
Neurosensory loss after transoral vertical ramus osteotomy
Reference Sample size Follow-up (mo) Subjective loss (%) Objective loss (%)
Westermark et al [84] 650 24 9 9
Tuinzing et al [12] 150 12 14
Tornes [11] 55 ? 1.8
Zaytoun et al [13] 15 ? 0
Hall et al [9] 42 12 2.4
Massey et al [10] 14 ? 0
Mean 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 docu-
mented. 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.
ment of the descending palatine neurovascular bun-
dle 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

Infraorbital nerve injury The incidence of infections in orthognathic sur-

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 osteot-
omies. 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].
gery is difficult to evaluate because most studies
combine all orthognathic procedures. Numerous anti-
biotic 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 anti-
biotics after the perioperative period is marginal.

Descending/greater palatine nerve injuries

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
Relapse may be defined as a postoperative move-
ment 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] 10 > 12 30 10
Posnick et al [15] 20 12 10
Mean 16.7 10
232 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242

Table 4
Neurosensory loss after bilateral sagittal split osteotomy / genioplasty
Reference Sample size Follow-up (mo) Subjective loss (%) Objective loss (%)
Posnick et al [15] 21 12 67
Nishioka et al [4] 3 12 100 100
Westermark et al [6] 71 24 44 44
Mean 21 50.9 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 evalu-
ation 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, con-
dylar 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 com-
plication, 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.)
 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242
bicortical screws and monocortical plates. The poten-
tial for condylar torque and increased IAN compres-
sion 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 move-
ment [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 (idio-
pathic 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, includ-
ing 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 con-
dition with high predilection for Angle’s class II,
white women (especially women with high mandib-
ular plane angles). It has been reported, albeit less
frequently, in men [41,37].
Fig. 3. Mean percentage continued posterior movement for TOVRO. (See Fig. 1 for explanation.)
233
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 corrobo-
rated 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
234 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242
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.
Maxillary repositioning
Maxillary surgical repositioning is far more com-
plex than mandibular repositioning because the max-
illa can be moved in an infinite variety of directions
and is rarely moved along one pure vector. There are
some meaningful data regarding maxillary advance-
ments, superior repositioning, and inferior reposition-
ing. In all cases, the direction that the maxilla moved
the most is the one evaluated, but one must remem-
ber that other directional moves usually have been
made simultaneously.
Maxillary advancement
Maxillary advancement may be performed in
isolation or in conjunction with a mandibular proce-
dure. Many patients who require maxillary advance-
ment also require inferior repositioning. Studies that
reflect pure values for the relapse stability of max-
illary 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
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 superior repositioning
Superior repositioning is generally regarded as
one of the most stable surgical procedures in or-
thognathic 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 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 pro-
cedure. Most studies that evaluated the relapse asso-
 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242 235

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.)
236 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242

Fig. 7. Mean percentage posterior relapse for Le Fort I impaction. (See Fig. 1 for explanation.)

ing is common in most reports. The greatest stabil-
ity 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 re-
lapse rates are different in one- versus two-jaw pro-
cedures or segmental versus one-piece maxillary
osteotomies [61].
Maxillary transverse widening
Increasing transverse maxillary width may be
performed by surgically assisted rapid palatal expan-
sion 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.)
 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242 237

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 consid-
erably 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.)
238 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242
rate of 49% at the molar region at a minimum follow-
up of 8 months [68].
Periodontal defects with segmental
Le Fort I osteotomies
The potential for periodontal defects with seg-
mental 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 inci-
dence 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 ante-
rior 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 retrospec-
tive and all have the potential for selection bias. Age
differences between groups prevent a direct com-
parison. 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 malocclu-
sion 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 or-
thognathic 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]. Subjec-
tive 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 pos-
sible 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 fixa-
tion 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 intermax-
illary 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 dur-
ing 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 pos-
sible to evaluate the incidence of these case reports,
and the etiology is often unclear or speculative. Many
of these complications are mentioned but not elabo-
rated in this article for the sake of completeness. One
 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242
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:
 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 inter-
vention [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
 lowing sagittal split osteotomy in the mandible: a
Maxillary sinusitis [96]: 4 cases
 prospective clinical study. Plast Reconstr Surg 1998;
Keratitis [88]: 3 cases
Rare complications reported with surgically as-
sisted 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
239
 Pneumomediastinum [100]: 1 case, which
resolved
Summary
Most of the common complications of orthognath-
ic 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 stron-
gest indicator for potential complications, especially
permanent nerve deficit. Large orthognathic skeletal
moves seem to have greater relapse potential. Com-
monly held beliefs may not stand up to evaluation of
the evidence, such as the proposition that mandibular
setbacks are more stable than most other orthognath-
ic surgical procedures. TMDs may be improved
somewhat by correction of a malocclusion with or-
thognathic 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.
References
[1] Guyatt G, Sackett D, Sinclair J, et al. Users’ guide to
the medical literature: IX. A method for grading health
care recommendations. JAMA 1995;274:1800 – 4.
[2] Blomqvist J, Alberius P, Isaksson S. Sensibility fol-
102:325 – 33.
[3] Jaaskelainen S, Peltola J, Lehtinen R. The mental
nerve blink reflex in the diagnosis of lesions of the
inferior alveolar nerve following orthognathic surgery
of the mandible. Br J Oral Maxillofac Surg 1996;
34:87 – 95.
[4] Nishioka G, Zysset M, Van Sickels J. Neurosensory
disturbance with rigid fixation of the bilateral sagittal
split osteotomy. J Oral Maxillofac Surg 1987;45:
20 – 6.
[5] Schultze-Mosgau S, Krems H, Ott R, et al. A prospec-
tive electromyographic and computer-aided thermal
sensitivity assessment of nerve lesions after sagittal
split osteotomy and Le Fort I osteotomy. J Oral Maxil-
lofac Surg 2001;59:128 – 39.
[6] Westermark A, Bystedt H, Von Konow L. Inferior
alveolar nerve function after mandibular osteotomies.
Br J Oral Maxillofac Surg 1988;36:425 – 8.
[7] Ylikontiola L, Kinnunen J, Oikarinen K. Comparison
of different tests assessing neurosensory disturbances
after bilateral sagittal split osteotomy. Int J Oral Max-
illofac Surg 1998;27:417 – 21.
240 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242
[8] Ylikontiola L, Kinnunen J, Oikarinen K. Factors af-
fecting neurosensory disturbance after mandibular bi-
lateral sagittal split osteotomy. J Oral Maxillofac Surg
2000;58:1234 – 9.
[9] Hall D, Chase D, Payor L. Evaluation and refinement
of the intraoral vertical subcondylar osteotomy. J Oral
Surg 1975;33:333 – 41.
[10] Massey G, Chase D, Thomas P, et al. Intraoral oblique
osteotomy of the mandibular ramus. J Oral Surg 1974;
32:755 – 9.
[11] Tornes K. Extraoral and intraoral vertical subcondylar
ramus osteotomy for correction of mandibular prog-
nathism. Int J Oral Maxillofac Surg 1987;16:671 – 7.
[12] Tuinzing D, Greebe R. Complications related to the
intraoral vertical ramus osteotomy. Int J Oral Surg
1985;14:319 – 24.
[13] Zaytoun H, Phillips C, Terry B. Long-term neurosen-
sory deficits following transoral vertical ramus and
sagittal split osteotomies for mandibular prognathism.
J Oral Maxillofac Surg 1986;44:193 – 6.
[14] Nishioka G, Mason M, Van Sickels J. Neurosensory
disturbance associated with the anterior mandibular
horizontal osteotomy. J Oral Maxillofac Surg 1988;
46:107 – 10.
[15] Posnick J, Al-Qattan M, Stepner N. Alteration in fa-
cial sensibility in adolescents following sagittal split
and chin osteotomies of the mandible. Plast Reconstr
Surg 1996;97:920 – 7.
[16] Jacks S, Zuniga J, Turvey T, et al. A retrospective
analysis of lingual nerve sensory changes after man-
dibular bilateral sagittal split osteotomy. J Oral Max-
illofac Surg 1998;56:700 – 4.
[17] Bell W. Le Fort I osteotomy for correction of maxil-
lary deformities. J Oral Surg 1975;33:412 – 26.
[18] Bouloux G, Bays R. Neurosensory recovery after li-
gation of the descending palatine neurovascular bun-
dle during Le Fort I osteotomy. J Oral Maxillofac
Surg 2000;58:841 – 5.
[19] Dodson T, Bays R, Neuenschwander M. Maxillary
perfusion during Le Fort I osteotomy after ligation
of the descending palatine artery. J Oral Maxillofac
Surg 1997;55:51 – 5.
[20] Bentley K, Head T, Aiello G. Antibiotic prophylaxis
in orthognathic surgery: a 1-day versus 5-day regi-
men. J Oral Maxillofac Surg 1999;57:226 – 30.
[21] Fridrich K, Partnoy B, Zeitler D. Prospective analysis
of antibiotic prophylaxis for orthognathic surgery.
Int J Adult Orthod Orthogn Surg 1994;9:129 – 31.
[22] Ruggles J, Hann J. Antibiotic prophylaxis in intraoral
orthognathic surgery. J Oral Maxillofac Surg 1984;
42:797 – 801.
[23] Zijderveld S, Smeele L, Kostense P, et al. Preopera-
tive antibiotic prophylaxis in orthognathic surgery: a
randomized, double-blind, and placebo-controlled
clinical study. J Oral Maxillofac Surg 1999;57:
1403 – 6.
[24] Martis C, Karabouta I. Infection after orthognathic
surgery, with and without preventive antibiotics.
Int J Oral Surg 1984;13:490 – 4.
[25] Peterson L, Booth D. Efficacy of antibiotic prophy-
laxis in intraoral orthognathic surgery. J Oral Surg
1976;34:1088 – 91.
[26] Yrastorza J. Indications for antibiotics in orthognathic
surgery. J Oral Surg 1976;34:514 – 6.
[27] Abeloos J, De Clerq C, Neyt L. Skeletal stability
following miniplate fixation after bilateral sagittal
split osteotomy for mandibular advancement. J Oral
Maxillofac Surg 1993;51:366 – 9.
[28] Berger J, Pangrazio-Kulbersh V, Bacchus S, et al.
Stability of bilateral sagittal split ramus osteotomy:
rigid fixation versus transosseous wiring. Am J Orthod
Dentofacial Orthop 2000;118:397 – 403.
[29] Dolce C, Van Sickels J, Bays R, et al. Skeletal stabil-
ity after mandibular advancement with rigid versus
wire fixation. J Oral Maxillofac Surg 2000;58:
1219 – 27.
[30] Hoffman G, Moloney F, Effeney D. The stability of
facial advancement surgery (in the management of
combined mid and lower dento-facial deficiency).
J Craniomaxillofac Surg 1994;22:86 – 94.
[31] Lee J, Piecuch J. The sagittal ramus osteotomy:
stability of fixation with internal miniplates. Int J Oral
Maxillofac Surg 1992;21:327 – 30.
[32] Mobarak K, Espeland L, Krogstad O, et al. Man-
dibular advancement surgery in high angle and low
angle class II patients: different long term skeletal
responses. Am J Orthod Dentofacial Orthop 2001;
119:368 – 81.
[33] Mommaerts M. Lag screw versus wire osteosynthesis
in mandibular advancements. Int J Adult Orthod Or-
thogn Surg 1991;6:153 – 60.
[34] Van Sickels J. A comparative study of bicortical
screws and suspension wires versus bicortical screws
in large mandibular advancements. J Oral Maxillofac
Surg 1991;49:1293 – 6.
[35] Watzke I, Turvey T, Phillips C, et al. Stability of
mandibular advancement after sagittal osteotomy
with screw or wire fixation: a comparative study.
J Oral Maxillofac Surg 1990;48:108 – 21.
[36] Crawford J, Stoelinga P, Blijdorp P, et al. Stability
after reoperation for progressive condylar resorption
after orthognathic surgery: report of seven cases.
J Oral Maxillofac Surg 1994;52:460 – 6.
[37] Hoppenreijs T, Stoelinga P, Grace K, et al. Long-term
evaluation of patients with progressive condylar re-
sorption following orthognathic surgery. Int J Oral
Maxillofac Surg 1999;28:411 – 8.
[38] Moore K, Gooris P, Stoelinga P. The contributing role
of condylar resorption to skeletal relapse following
mandibular advancement surgery: report of 5 cases.
J Oral Maxillofac Surg 1991;49:448 – 60.
[39] Bouwman J, Kerstens H, Tuinzing D. Condylar re-
sorption in orthognathic surgery: the role of intermax-
illary fixation. Oral Surg 1994;78:138 – 41.
[40] Cutbirth M, Van Sickels J, Thrash W. Condylar re-
sorption after bicortical screw fixation of mandibular
advancement. J Oral Maxillofac Surg 1998;56:
178 – 82.
 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242
[41] De Clerq C, Neyt L, Mommaerts M, et al. Condylar
resorption in orthognathic surgery: a retrospective
study. Int J Adult Orthod Orthogn Surg 1994;9:
233 – 40.
[42] Merkx M, Van Damme P. Condylar resorption after
orthognathic surgery: evaluation of treatment in 8 pa-
tients. J Craniomaxillofac Surg 1994;22:53 – 8.
[43] Greebe R, Tuinzing D. Overcorrection and relapse
after the intraoral vertical ramus osteotomy: a one-
year postoperative review of thirty-five patients. Oral
Surg 1982;54:382 – 4.
[44] Phillips C, Zaytoun H, Thomas P, et al. Skeletal alter-
ations following TOVRO or BSSO procedures. Int J
Adult Orthod Orthogn Surg 1986;1:203 – 13.
[45] Proffit W, Phillips C, Dann C, et al. Stability after
surgical-orthodontic correction of skeletal class III
malocclusion. I. Mandibular setback. Int J Adult Or-
thod Orthogn Surg 1991;6:7 – 18.
[46] Mobarak K, Krogstad O, Espeland L, et al. Long-term
stability of mandibular setback surgery: a follow-up
of 80 bilateral sagittal split osteotomy patients. Int J
Adult Orthod Orthogn Surg 2000;15:83 – 95.
[47] Schatz J, Tsimas P. Cephalometric evaluation of sur-
gical-orthodontic treatment of skeletal class III mal-
occlusion. Int J Adult Orthod Orthogn Surg 1995;10:
173 – 80.
[48] Sorokolit C, Nanda R. Assessment of the stability of
mandibular setback procedures with rigid fixation.
J Oral Maxillofac Surg 1990;48:817 – 22.
[49] Bays R. Maxillary osteotomies utilizing the rigid ad-
justable pin (RAP) system: a review of 31 clinical
cases. Int J Adult Orthod Orthogn Surg 1986;1:
275 – 97.
[50] Egbert M, Hepworth B, Myall R, et al. Stability of Le
Fort I osteotomy with maxillary advancement: a com-
parison of combined wire fixation and rigid fixation.
J Oral Maxillofac Surg 1995;53:243 – 8.
[51] Hoffman G, Moloney F. The stabilities of facial os-
teotomies. Part 5. Maxillary advancement with mini-
plate and screw fixation. Australas Dent J 1996;41:
21 – 7.
[52] Krekmanov L, Lilja J, Ringqvist M. Maxillary osteot-
omies without postoperative intermaxillary fixation
(anterior, superior and inferior repositioning of entire
maxilla): a clinical and cephalometric study. Scand J
Plast Reconstr Surg 1989;23:125 – 32.
[53] Louis P, Waite P, Austin R. Long-term skeletal stabil-
ity after rigid fixation of Le Fort I osteotomies with
advancements. Int J Oral Maxillofac Surg 1993;22:
82 – 6.
[54] Proffit W, Phillips C, Prewitt J, et al. Stability after
surgical-orthodontic correction of skeletal class III
malocclusion. II. Maxillary advancement. Int J Adult
Orthod Orthogn Surg 1991;6:71 – 80.
[55] Waite P, Tejera T, Anucul B. The stability of maxil-
lary advancement using Le Fort I osteotomy with and
without genial bone grafting. Int J Oral Maxillofac
Surg 1996;25:264 – 7.
[56] Wardrop R, Wolford L. Maxillary stability following
241
downgraft and/or advancement procedures with stabi-
lization using rigid fixation and porous block hydroxy-
apatite implants. J Oral Maxillofac Surg 1989;47:
336 – 42.
[57] Arpornmaeklong P, Heggie A. Anterior open-bite
malocclusion: stability of maxillary repositioning
using rigid internal fixation. Australas Orthod J
2000;16:69 – 81.
[58] Hennes J, Wallen T, Bloomquist D, et al. Stability of
simultaneous mobilization of the maxilla and mandi-
ble utilizing internal rigid fixation. Int J Adult Orthod
Orthogn Surg 1988;3:127 – 41.
[59] Hoppenreijs T, Freihofer H, Stoelinga P, et al. Skeletal
and dento-alveolar stability of Le Fort I intrusion os-
teotomies and bimaxillary osteotomies in anterior
open bite deformities: a retrospective three-centre
study. Int J Oral Maxillofac Surg 1997;26:161 – 75.
[60] Denison T, Kokich V, Shapiro P. Stability of maxil-
lary surgery in openbite versus nonopenbite mal-
occlusions. Angle Orthod 1989;59:5 – 10.
[61] Perez M, Sameshima G, Sinclair P. The long-term
stability of Le Fort I maxillary downgrafts with rigid
fixation to correct vertical maxillary deficiency. Am J
Orthod Dentofacial Orthop 1997;112:104 – 8.
[62] Proffit W, Phillips C, Turvey T. Stability after surgi-
cal-orthodontic correction of skeletal class III mal-
occlusion. III. Combined maxillary and mandibular
procedures. Int J Adult Orthod Orthogn Surg 1991;
6:211 – 25.
[63] Wagner S, Reyneke J. The Le Fort I downsliding
osteotomy: a study of long-term hard tissue stability.
Int J Adult Orthod Orthogn Surg 2000;15:37 – 49.
[64] Bays R, Hegtvedt A, Timmis D. Maxillary or-
thognathic surgery. In: Peterson LJ, Indresano AT,
Marciani RD, Roser SM, editors. Principles of oral
and maxillofacial surgery. Philadelphia: J.B. Lippen-
cott; 1992. p. 1349 – 99.
[65] Bays R, Greco J. Surgically assisted rapid palatal ex-
pansion: an outpatient technique with long-term
stability. J Oral Maxillofac Surg 1992;50:110 – 3.
[66] Pogrel M, Kaban L, Vargervik K, et al. Surgically
assisted rapid maxillary expansion in adults. Int J
Adult Orthod Orthogn Surg 1992;7:37 – 41.
[67] Stromberg C, Holm J. Surgically assisted, rapid max-
illary expansion in adults: a retrospective long-term
follow-up study. J Craniomaxillofac Surg 1995;23:
222 – 7.
[68] Phillips C, Medland W, Fields H, et al. Stability of
surgical maxillary expansion. Int J Adult Orthod Or-
thogn Surg 1992;7:139 – 46.
[69] Carroll W, Haug R, Bissada N, et al. The effects of
the Le Fort I osteotomy on the periodontium. J Oral
Maxillofac Surg 1992;50:128 – 32.
[70] Dorfman H, Turvey T. Alterations in osseous crestal
height following interdental osteotomies. Oral Surg
1979;48:120 – 5.
[71] Kwon H, Pihlstrom B, Waite D. Effects on the peri-
odontium of vertical bone cutting for segmental os-
teotomy. J Oral Maxillofac Surg 1985;43:952 – 5.
242 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242
[72] Mordenfeld A, Andersson L. Periodontal and pulpal
condition of the central incisors after midline osteot-
omy 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 associ-
ated 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 im-
pacted 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 sag-
ittal split osteotomy. J Oral Maxillofac Surg 2002;60:
654 – 9.
[77] De Clerq C, Abeloos J, Mommaerts M, et al. Tem-
poromandibular joint symptoms in an orthognathic
surgery population. J Craniomaxillofac Surg 1995;
23:195 – 9.
[78] Egermark I, Blomqvist J, Cromvik U, et al. Temporo-
mandibular dysfunction in patients treated with ortho-
dontics 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 ob-
lique and sagittal split ramus osteotomy. J Oral Max-
illofac Surg 2000;58:375 – 80.
[80] Onizawa K, Schmelzeisen R, Vogt S. Alteration of
temporomandibular joint symptoms after orthognath-
ic surgery: comparison with healthy volunteers. J Oral
Maxillofac Surg 1995;53:117 – 21.
[81] Panula K, Somppi M, Finne K, et al. Effects of or-
thognathic surgery on temporomandibular joint dys-
function: 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. Temporomandib-
ular 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-
ular osteotomies: a report of cases. J Oral Maxillofac
Surg 1991;49:713 – 24.
[86] Lanigan D, West R. Aseptic necrosis of the mandible:
report of two cases. J Oral Maxillofac Surg 1990;48:
296 – 300.
[87] De Vries K, Devriese P, Hovinga J, et al. Facial palsy
after sagittal split osteotomies: a survey of 1747 sag-
ittal split osteotomies. J Craniomaxillofac Surg 1993;
21:50 – 3.
[88] Lanigan D, Romanchuk K, Olson C. Ophthalmic
complications associated with orthognathic surgery.
J Oral Maxillofac Surg 1993;51:480 – 94.
[89] Shoshani Y, Samet N, Ardekian L, et al. Nasolacrimal
duct injury after Le Fort I osteotomy. J Oral Maxillo-
fac Surg 1994;52:406 – 7.
[90] Lanigan D, Hey J, West R. Major vascular complica-
tions of orthognathic surgery: hemorrhage associated
with Le Fort I osteotomies. J Oral Maxillofac Surg
1990;48:561 – 73.
[91] Lanigan D, Hey J, West R. Major vascular complica-
tions of orthognathic surgery: false aneurysms and
arteriovenous fistulas following orthognathic surgery.
J Oral Maxillofac Surg 1991;49:571 – 7.
[92] Li K, Meara J, Rubin OP. Orbital compartment syn-
drome following orthognathic surgery. J Oral Maxil-
lofac Surg 1995;53:964 – 8.
[93] Lanigan D, Hey J, West R. Aseptic necrosis following
maxillary osteotomies: report of 36 cases. J Oral
Maxillofac Surg 1990;48:142 – 56.
[94] Smith K, Heggie A. Vomero-sphenoidal disarticula-
tion during the Le Fort I maxillary osteotomy: report
of case. J Oral Maxillofac Surg 1995;53:465 – 7.
[95] Carr R, Gilbert P. Isolated partial third nerve palsy
following Le Fort I maxillary osteotomy in a patient
with cleft lip and palate. Br J Oral Maxillofac Surg
1986;24:206 – 11.
[96] Bell C, Thrash W, Zysset M. Incidence of maxillary
sinusitis following Le Fort I maxillary osteotomy.
J Oral Maxillofac Surg 1986;44:100 – 3.
[97] Lanigan D, Mintz S. Complications of surgically as-
sisted rapid palatal expansion: review of the literature
and report of a case. J Oral Maxillofac Surg 2002;60:
104 – 10.
[98] Gaukroger M. Dysphagia following bimaxillary os-
teotomy. Br J Oral Maxillofac Surg 1993;31:189 – 90.
[99] Nagler R, Peled M, Laufer D. Prolonged dysphagia
after orthognathic surgery: report of a case and review
of the literature. J Oral Maxillofac Surg 1996;54:
523 – 5.
[100] Piecuch J, West R. Spontaneous pneumomediastinum
associated with orthognathic surgery. Oral Surg 1979;
48:506 – 8.