CRANIOMAXILLOFACIAL DEFORMITIES/SLEEP DISORDERS/COSMETIC SURGERY

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Is It Necessary to Free the Inferior 60
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7 Alveolar Nerve From the Proximal 62
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9 Segment in the Sagittal Split 64
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Osteotomy?
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11 Q1 67
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13 Q18 Srinivas Susarla, DMD, MD, MPH,* 69
14 Russell Ettinger, MD,y and Thomas B. Dodson, DMD, MPHz 70
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Purpose: When the inferior alveolar nerve (IAN) is contained within the proximal segment after a mandib-
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17 ular sagittal split osteotomy (SSO), conventional teaching is to release the nerve so that it freely enters the 73
18 distal segment. However, manipulation of the IAN may cause further injury. The purpose of this study was to 74
19 measure IAN neurosensory recovery in SSOs when the nerve was not freed from the proximal segment. 75
20 Materials and Methods: This was a prospective split-mouth study of patients undergoing bilateral 76
21 sagittal split osteotomy (BSSO). The sample was composed of patients who underwent a BSSO in which 77
22 the IAN was intact bilaterally but freely entering the distal segment on 1 side (IANDI) and contained within 78
23 the proximal segment on the other (IANPR). The outcome of interest was time to functional sensory recov- 79
24 ery (FSR) in the IAN, measured in days. Descriptive, bivariate, and Kaplan-Meier statistics were computed. 80
25 P # .05 was considered statistically significant. 81
26 Results: Twenty patients undergoing 40 SSOs were included as study patients. The sample’s mean age 82
27 was 19.0  2.4 years (range, 15 to 26 years); there were 13 female patients. Of the patients, 15 underwent 83
28 BSSO whereas 5 underwent BSSO plus genioplasty. The planned mean composite 3-dimensional mandib- 84
29 ular movements for IANDI and IANPR were 6.3  2.8 mm (range, 2.5 to 12.3 mm) and 6.3  2.3 mm (range, 85
30 2.7 to 10.8 mm), respectively (P = .96). All patients achieved FSR in the bilateral IAN distributions within 86
31 1 year of surgery (range, 34 to 284 days). The median times to FSR were 100 days for IANDI and 101 days for 87
32 IANPR (P = .64). 88
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Conclusions: In patients undergoing SSOs, maintaining the IAN within the proximal segment of the
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35 mandible may not affect neurosensory recovery. 91
36 Ó 2020 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial 92
37 Surgeons 93
38 J Oral Maxillofac Surg -:1-7, 2020 94
39 95
40 The mandibular sagittal split osteotomy (SSO) remains unfavorable splits of the proximal segment, Posnick5 96
41 an important tool for the management of dentofacial described a modification of SSO that places the medial 97
42 Q5 deformities involving the lower jaw.1-10 To prevent horizontal osteotomy cut below the lingula. This 98
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44 *Assistant Professor, Craniofacial Center, Division of Oral and Conflict of Interest Disclosures: Dr Susarla has stock options in 100
45 Maxillofacial Surgery and Division of Plastic and Craniofacial Polarity TE. 101
46 Surgery, Seattle Children’s Hospital, and Department of Oral and Address correspondence and reprint requests to Dr Susarla: 102
47 Maxillofacial Surgery, University of Washington School of Craniofacial Center, Seattle Children’s Hospital, 4800 Sand Point 103
48 Dentistry, Seattle, WA. Way NE, Seattle, WA 98105; e-mail: srinivas.susarla@ Q4 104
49 yAssistant Professor, Craniofacial Center, Division of Oral and seattlechildrens.org 105
50 Maxillofacial Surgery and Division of Plastic and Craniofacial Received January 23 2020 106
51 Surgery, Seattle Children’s Hospital, Seattle, WA. Accepted March 6 2020 107
52 zProfessor and Chairman, Department of Oral and Maxillofacial Ó 2020 Published by Elsevier Inc. on behalf of the American Association of Oral 108
53 Surgery, University of Washington School of Dentistry, Seattle, WA. and Maxillofacial Surgeons 109
54 This project was supported in part by the Department of Oral and 0278-2391/20/30233-0 110
55 Maxillofacial Surgery’s Education and Research Fund and the Labora- https://doi.org/10.1016/j.joms.2020.03.008
111
56 Q3 tory for Applied Clinical Research. 112

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113 modification is particularly useful in situations in follows: Among patients undergoing bilateral sagittal 169
114 which the lingula is located in close proximity to the split osteotomies (BSSOs), do patients in whom the 170
115 condylar neck or the ascending ramus is thin near IAN is retained in the proximal segment have an 171
116 the lingula, with no substantial marrow space be- increased risk of persistent objective neurosensory 172
117 tween the outer and inner cortices, such as in congen- deficit when compared with patients whose nerve is 173
118 ital mandibular deformities (Figs 1, 2), or in which the free in the distal segment? We hypothesized that there 174
119 nerve has a more cephalad entrance into the would be no difference in neurosensory recovery for 175
120 Q6 mandible.2 A medial horizontal osteotomy below the IAN when it was completely freely entering the 176
121 the lingula allows for more favorable propagation of distal segment vs when it was retained within the 177
122 the proximal osteotomy into the retrolingular fossa proximal segment. Our specific aims were 1) to iden- 178
123 but comes at the expense of a greater likelihood of tify a cohort of patients undergoing BSSO in which the 179
124 the inferior alveolar nerve (IAN) being contained nerve was completely free on 1 side and contained 180
125 within the proximal segment. within the proximal segment on the other and 2) to 181
126 An accepted practice in SSO is to free a tethered IAN measure and compare functional sensory recovery 182
127 from the proximal segment after the split.1-3,5 Theoret- (FSR) of the IAN between sides. 183
128 ically, this is performed to reduce tension on the nerve 184
129 and, by extension, reduce neurosensory disturbance. 185
130 The nerve is typically freed by selective bony removal
Materials and Methods 186
131 from the lingula medially, in conjunction with meticu- STUDY DESIGN 187
132 lous dissection of the nerve from the endo-cortex of This was a prospective split-mouth study. The sam- 188
133 the proximal segment laterally. Such maneuvers, ple was derived from the population of patients under- 189
134 even when performed carefully, may injure the nerve. going BSSO performed by a single surgeon (S.S.) over a 190
135 The degree of manipulation of the IAN in SSO has been 29-month period (July 2017 to December 2019). The 191
136 shown to be associated with the degree of postopera- inclusion criteria were 1) patients who underwent a 192
137 tive neurosensory disturbance.2,10,11 BSSO with a medial horizontal osteotomy below the 193
138 The purpose of this study was to measure IAN lingula (halfway between the mandibular occlusal 194
139 neurosensory recovery in patients undergoing SSO in plane and lingula typically but closer to the mandib- 195
140 which the nerve was not freed from the proximal ular occlusal plane if no appreciable marrow space 196
141 segment. The specific research question was as was present superior to this); 2) patients in whom 197
142 the IAN was intact bilaterally and noted to be 198
143 completely freely entering the distal segment on 1 199
144 side (ie, separated from the proximal segment, intact, 200
145 and requiring no further manipulation) but contained 201
146 and intentionally maintained within the proximal 202
147 segment on the other side; and 3) a follow-up period 203
148 of up to 1 year postoperatively to assess FSR of the 204
149 IAN. Postoperative neurosensory evaluations were Q7 205
150 completed at 1 week, 3 weeks, 6 weeks, 3 months, 206
151 6 months, and 12 months. Patients who underwent 207
152 simultaneous genioplasties were included if the 208
153 mental nerves were intact bilaterally. All operations 209
154 were completed in a standard fashion; resident and 210
155 fellow involvement was consistent in all cases. Pa- 211
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156 tients were excluded from the study if they underwent 212
157 a BSSO in which the nerves were freely entering the 213
158 distal segments bilaterally, had a visible IAN injury, or 214
159 did not undergo a BSSO. Institutional board approval 215
160 was granted for this work (SCH STUDY00002308), 216
161 FIGURE 1. Morphologically atypical mandibular ramus in a pa- 217
tient with craniofacial microsomia. The lingula is located high and and the guidelines of the Declaration of Helsinki
162 posterior along a foreshortened ramus, resulting in a potentially were followed at all times. 218
Q8
163 increased risk of subcondylar osteotomy with horizontal medial os- 219
164 teotomy above the lingula (red line). An infralingular approach for 220
the medial ramus cut (green line) will decrease the risk of an unfavor- STUDY VARIABLES
165 able split but may result in the inferior alveolar nerve being tethered
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166 to the proximal segment. The primary study predictor variable was the status 222
167 Susarla, Ettinger, and Dodson. Inferior Alveolar Nerve in SSO. J of the IAN, classified as the IAN completely freely 223
168 Oral Maxillofac Surg 2020. entering the distal segment (IANDI, Fig 3A) or the 224

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FIGURE 2. A, Morphologically atypical mandibular ramus in a patient with Pierre Robin sequence who had undergone prior mandibular
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distraction in infancy. B, The ascending ramus at and above the lingula (red line) is extremely narrow (2 to 3 mm) and has no appreciable Q17
248 marrow space. 304
249 Susarla, Ettinger, and Dodson. Inferior Alveolar Nerve in SSO. J Oral Maxillofac Surg 2020. 305
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251 IAN contained within the proximal segment (IANPR, peripheral nerve injuries; the MRC scale has been vali- 307
252 Fig 3B). The outcome variable of interest was the dated by Mackinnon and Dellon12 for use in hand sur- 308
253 time to FSR of the IAN. FSR was defined according to gery and subsequently adapted for use to assess 309
254 the criteria developed by the British Medical Research functional recovery of the IAN and lingual nerve after 310
255 Council (MRC) for assessing sensory recovery of surgical repair.13-15 The MRC scale ranges from S0 311
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278 FIGURE 3. A, The inferior alveolar nerve (asterisk) is completely freely entering the distal mandibular segment after sagittal split osteotomy. B, 334
279 In the same patient, on the right side, after sagittal split osteotomy, the inferior alveolar nerve (asterisk) is contained within the proximal segment. 335
280 Susarla, Ettinger, and Dodson. Inferior Alveolar Nerve in SSO. J Oral Maxillofac Surg 2020. 336

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337 (no recovery) to S4 (complete recovery by objective sample. Paired bivariate statistics were computed to 393
338 testing). For IAN injuries, a score of S3 or higher identify any differences between the study groups 394
339 signifies FSR (Table 1).13,14 As defined in previous regarding the magnitude of mandibular movement. A 395
340 studies on IAN repair, patients with static 2-point time-to-event (Kaplan-Meier) analysis was used to esti- 396
341 discrimination of less than 20 mm, superficial pain mate and compare the time to FSR between the IANDI 397
342 (pinprick, temperature), and tactile sensation (light and IANPR groups. For all analyses, P #.05 was consid- 398
343 touch, brushstroke direction) without over-reaction ered statistically significant. 399
344 were classified as having FSR of the IAN. A single exam- 400
345 iner (S.S.) performed all postoperative assessments at 401
Results
346 serial postoperative visits up to 1 year postoperatively. 402
347 Sensation in the ipsilateral supraorbital nerve distribu- The sample was composed of 20 patients with a 403
348 tion was used as a positive control. Reliability in neuro- mean age of 19.0  2.4 years (range, 15 to 26 years); 404
349 sensory testing was established by comparing serial there were 13 female patients. The median duration 405
350 assessments across all domains from the positive con- of follow-up was 175 days (interquartile range, 120 406
351 trol from 10 randomly selected patients (intraclass cor- to 360 days). Of the patients, 15 underwent BSSO 407
352 relation coefficient $ 0.95, P < .001). whereas 5 underwent BSSO plus genioplasty. Bimaxil- 408
353 Secondary study variables were age (in years), lary surgery was performed in 18 patients. No unfavor- 409
354 gender (female or male), and mandibular operation able splits or IAN injuries occurred within the cohort; 410
355 (BSSO alone vs BSSO plus genioplasty) with or without no otherwise eligible patients were excluded because 411
356 maxillary osteotomies. All cases underwent virtual sur- of an IAN or mental nerve injury. The mean composite 412
357 gical planning. The absolute magnitude of planned planned 3-dimensional mandibular movements for 413
358 mandibular movement was measured for each side IANDI and IANPR were 6.3  2.8 mm (range, 2.5 to 414
359 as ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
p the composite of the 3-dimensional movement ffi 12.3 mm) and 6.3  2.3 mm (range, 2.7 to 415
360 Q9 ðDsagittal 2 þ Dvertical 2 þ Dtransverse2 Þ. For 10.8 mm), respectively (P = .96). 416
361 example, a patient with mandibular movement charac- Figure 4 shows the Kaplan-Meier curve for time to 417
362 terized by 6 mm of sagittal advancement, 2 mm of FSR in both the IANDI and IANPR groups. All patients 418
363 transverse correction, and 2 mm of vertical correction achieved FSR in the bilateral IAN distributions within 419
364 would have a net absolute movement of 6.6 mm. 1 year of surgery (range, 34 to 284 days). The median 420
365 times to FSR were 100 days for IANDI and 101 days for 421
366 STATISTICAL ANALYSES
IANPR. No significant difference in time to FSR was 422
367 found between the IANDI and IANPR groups 423
368 Data were entered into a statistical database (IBM (P = .64). The median times to FSR in patients under- 424
369 SPSS, version 25.0; IBM, Armonk, NY) for analysis. going SSO alone were 100 days for IANDI and 425
370 Descriptive statistics were computed for the study 102 days for IANPR; the median times to FSR in those 426
371 undergoing SSO plus genioplasty were 100 days for 427
372 IANDI and 100 days for IANPR. 428
Table 1. ASSESSMENT OF FUNCTIONAL SENSORY
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LEVEL
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Grade FSR Required Parameters
Discussion
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376 In this work, we sought to measure IAN neurosen- 432
377 S0 No No sensation sory recovery after SSO of the mandible when the 433
378 S1 No Pain sensation—deep nerve was contained within the proximal segment 434
379 S1+ No Pain sensation—superficial versus when it was completely free. We hypothesized 435
S2 No Pain and touch sensation
380 that there would be no difference in neurosensory re- 436
S2+ No Pain and touch sensation with
381 some over-reaction
covery based on the status of the IAN. Using a retro- 437
382 S3 Yes Same as S2+ but without over- spective split-mouth design evaluating 40 SSOs in 20 438
383 response and with static 2PD patients, we found that the time to FSR was not signif- 439
384 of 15-20 mm icantly different between sides when the nerve was 440
385 S3+ Yes Same as S3 but with static 2PD contained within the proximal segment compared 441
386 of 7-15 mm with when it was freely entering the distal 442
387 S4 Yes Same as S3+ but with static segment. The strength of this design is that each pa- Q10 443
388 2PD < 7 mm tient serves as his or her own control, thereby 444
389 Abbreviations: FSR, functional sensory recovery; 2PD, 2- reducing the influence of other factors that may affect 445
390 point discrimination. nerve healing (eg, age and medical comorbidities). In 446
391 Susarla, Ettinger, and Dodson. Inferior Alveolar Nerve in SSO. J addition, we found no significant difference in the 447
392 Oral Maxillofac Surg 2020. magnitude of mandibular movement between the 2 448

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482 FIGURE 4. Kaplan-Meier curve for functional sensory recovery (FSR) after sagittal split osteotomies in which the nerve was completely freely 538
483 entering the distal mandibular segment (IANDI) versus contained within the proximal segment (IANPR). The median times to FSR were 100 days 539
for IANDI and 101 days for IANPR. There was no significant difference in the time to FSR (P = .64).
484 540
Susarla, Ettinger, and Dodson. Inferior Alveolar Nerve in SSO. J Oral Maxillofac Surg 2020.
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488 groups. For the range of mandibular movements after SSO, including modifications in osteotomy design 544
489 observed (2.7 to 10.8 mm), leaving the IAN within and instrumentation.2-5,23-25 545
490 the proximal segment of the mandible after SSO does Placing the horizontal medial ramus cut above the 546
491 not appear to significantly impact postoperative lingula is designed to result in a split in which the 547
492 neurosensory recovery. nerve is free of the proximal segment. The short- 548
493 Neurosensory recovery after BSSO has been studied coming of this approach is that, for certain mandibular 549
494 extensively.16-25 The IAN is exposed along its morphologies, placing the osteotomy above the lin- 550
495 intraosseous course as a result of sagittal splitting of gula may increase the risk of a condylar process frac- 551
496 the mandible, rendering it susceptible to varying ture. Placing the osteotomy below the lingula 552
497 degrees of injury. Lacerations of the IAN have been reduces the risk of an unfavorable split but increases 553
498 reported to occur up to 5% of the time.5-7 Most the likelihood of the nerve being tethered within the 554
499 patients undergoing SSOs have objective and proximal segment. 555
500 subjective neurosensory deficits in the IAN distribution Classic teaching of SSO instructs the surgeon to 556
501 after surgery.17-21 When the nerve is intact, complete completely free the IAN from the proximal segment 557
502 sensory recovery occurs in most patients within if it remains tethered after the split. Freeing the nerve 558
503 Q11 6 months of surgery.6-8,26 Numerous studies have evalu- typically requires dissection from the endo-cortex of 559
504 ated techniques for reducing neurosensory disturbance the proximal segment and additional osteotomies 560

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 6 INFERIOR ALVEOLAR NERVE IN SSO

561 near the lingula. Even when performed carefully, these segment is not predicated on the direction of move- 617
562 maneuvers, at a minimum, create neurapraxia but can ment. The limited sample size in this study precludes 618
563 lead to higher-grade injuries. our ability to assess for changes related to the direction 619
564 There are some limitations to this work that merit of movement; this is an interesting avenue for 620
565 consideration. First, because this study was a prospec- future research. 621
566 tive split-mouth study, whereby every patient served Finally, we chose to include patients undergoing 622
567 as his or her own control and a single surgeon per- simultaneous genioplasties with patients undergoing 623
568 formed all operations, the sample size was limited to SSO alone. It is well established that patients undergo- 624
569 40 SSOs (20 in each group). The median times to ing simultaneous genioplasty procedures have a 625
570 FSR were 100 days for IANDI and 101 days for IANPR; higher likelihood of persistent neurosensory distur- 626
571 the study was underpowered to detect a bance.19,20,22 In this context, the inclusion of patients 627
572 Q12 difference. However, the magnitude of this observed undergoing simultaneous genioplasties may be seen as 628
573 difference is not clinically relevant in the context of a confounding factor, but this is largely mitigated by 629
574 Q13 neurosensory recovery after SSO. The proportions of the study design. Because this was a split-mouth study 630
575 IANs with FSR within 6 months of surgery were equiv- with patients included only if they had intact IAN and 631
576 alent: FSR was achieved in 90% of IANDI cases and 90% mental nerves, each patient served as his or her own 632
577 of IANPR cases. All patients had FSR in the bilateral IAN control. With consistent technique on each side by 633
578 distributions by 1 year postoperatively (the longest the same surgeon, the variability in neurosensory re- 634
579 time to FSR was 284 days). covery in the context of simultaneous genioplasty is 635
580 Second, the median duration of follow-up was minimized. Indeed, no difference was noted in the me- 636
581 approximately 6 months; this may be considered a dian times to FSR between patients undergoing genio- 637
582 relatively short follow-up duration for assessing neuro- plasties and those undergoing SSO alone. 638
583 sensory function. This is not a substantial limitation, as In conclusion, there is no difference in postopera- 639
584 the outcome of interest was the time, in days, to FSR; tive neurosensory recovery of the IAN after SSO 640
585 patients remained in the study until they reached FSR when the nerve is maintained within the proximal 641
586 or 1 year postoperatively, whichever came segment versus freely entering the distal segment. 642
587 Q14 first. Previous reports on neurosensory recovery after Nearly all patients will achieve FSR within 6 months 643
588 SSO have shown that most patients have return of of surgery. 644
589 sensation within 6 months of surgery7,8,26; reports 645
590 on patients undergoing repair of IAN and lingual nerve 646
591 injuries have shown that FSR can occur as early as 7 to References 647
592 34 days after nerve repair.14,15,27 648
593 Third, patient age is a well-established risk factor for 1. Patel PK, Novia MV: The surgical tools: The LeFort I, bilateral 649
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YJOMS59118_proof
10 April 2020
3:56 pm
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