J Oral Maxillofac Surg
70:1678-1691, 2012
Unusual and Rare Complications of
Orthognathic Surgery: A Literature Review
Ben J. Steel, BDS, MFDS RCSEd,* and Martin R. Cope, FRCS†
An old surgical adage states: if you have not had any
complications, you have not done enough surgery
yet. The diverse range of procedures that collectively
come under the umbrella term of orthognathic sur-
gery are widely recognized to be safe,1-10 although it
has been consistently stated that clinicians must re-
main vigilant to the unexpected.11-14 Numerous ex-
amples of unusual or rare complications of such pro-
cedures have been published. The purpose of this
literature review is to gather reported complications
of orthognathic surgery, and provide a discussion
relating to those classified as unusual or rare.
It is accepted that there may be no clear boundary
between complications that are more usual versus
unusual. For the purposes of this review, unusual is
considered to be a complication that may not nor-
mally be considered as part of the consent or surgical
planning process. It is accepted that there would be
inherent inaccuracies in attempting to quantify the
incidence of many of these complications by a review
of this kind, except where already published figures
are available, because publication bias favors the
more unusual. This may lead to some complications
being under-represented in the literature and the true
incidence not being appreciated. Therefore it is not
the intention of this review to provide incidences;
rather, our intent is to bring together all reported
unusual complications in a comprehensive review to
remind the clinician of the possible unusual risks of
this surgery.
During the consent process, it is clearly inappropri-
ate to routinely discuss all of these rare complications
with the patient; however, individual circumstances
may impart relevance to some of them. It is important
*Senior House Officer, Oral and Maxillofacial Surgery Depart-
ment, James Cook University Hospital, Middlesbrough, United
Kingdom.
†Consultant, Humberside Maxillofacial Unit, Hull Royal Infir-
mary, Hull, United Kingdom.
Address correspondence and reprint requests to Dr Steel: Oral
and Maxillofacial Surgery Department, James Cook University Hos-
pital, Middlesbrough TS4 3BW, United Kingdom; e-mail: b_steel_
1_the@yahoo.co.uk
© 2012 American Association of Oral and Maxillofacial Surgeons
0278-2391/12/7007-0$36.00/0
doi:10.1016/j.joms.2011.05.010
1678
that the clinician is fully informed and able to answer
questions, should they arise. The scope of this review
includes all those orthognathic procedures performed
on the mandible or maxilla, with the exclusion of
distraction techniques and more complex Le Fort II
and III procedures. For the purposes of this article,
the term “complication” refers to an unintended con-
sequence of the surgery that causes harm to the pa-
tient, occurring either intraoperatively or early or late
postoperatively. A few of these complications were
not necessarily related to the orthognathic procedure
per se but occurred during general anesthesia for that
purpose.
The relative safety of these procedures has been
confirmed by a number of reviews of orthognathic
surgery patients. A large series of 2,049 patients con-
ducted by Van de Perre et al2 identified 1 patient
death and 39 patients with primary and 5 with sec-
ondary severe (life-threatening) complications. The
others comprised 2 severe bradycardias, 2 tracheos-
tomies, 4 prolonged intubations or reintubations, 4
intermaxillary fixation (IMF) releases due to respira-
tory distress, and 26 major bleeds. The secondary
complications comprised 3 cases of deep vein throm-
bosis (heparinization not used) and 2 of aspiration
atelectasis. A review of 1,294 consecutive patients
undergoing orthognathic surgery by Chow et al3 re-
ported a complication rate of 9.7%, which included
7.4% of patients who had postoperative infections.
No serious or rare events attributable to the surgery
itself were recorded. Panula et al4 reviewed 655 of
their osteotomy patients, finding only 1 serious com-
plication (an intraoperative bleed), with altered sen-
sation in the inferior alveolar nerve distribution being
the most common (32%). A prospective study of
1,000 patients by Kramer et al5 found the Le Fort I
operation to be safe, with intraoperative or perioper-
ative complications of some kind occurring in 6.4% of
cases, including extensive bleeding in 1.1%. In a study
of 821 patients by Ayoub et al,15 only 12 patients
needed surgical intervention for early postoperative
complications.
Materials and Methods
Studies and case reports published up to August
2010 were located by use of systematic searches in
the PubMed and Embase electronic databases, with
STEEL AND COPE
an emphasis on those published after 1980 and
limited to the English-language literature. Keywords
included complications, rare, unusual, orthognathic, os-
teotomy, Le Fort I, sagittal split, ramus, genioplasty,
maxillary, and mandibular. In addition, the databases of
individual key journals including the Journal of Oral
and Maxillofacial Surgery, British Journal of Oral and
Maxillofacial Surgery, and Journal of Craniomaxillo-
facial Surgery were searched by use of the same terms.
The full texts of relevant articles were obtained
and the references checked against those already
identified.
Results
The volume of material published on the complica-
tions of orthognathic surgery is very large, which
relates to both more common and more unusual
events. In the same vein, a significant number of case
reports or case series pertaining to the unusual were
identified, overall showing a long list of complications
of a wide range of forms and severities. A vast major-
ity of studies located refer to the Le Fort I osteotomy,
bilateral sagittal split osteotomy (BSSO), or vertical
subsigmoid ramus osteotomy. An overview of the more
common complications is shown in Table 1, with other
rarer complications listed in Table 2. These are dis-
cussed in detail in the main text.
The unusual and rare complications identified by
the search process will now be explored in more
detail.
Neurologic Complications
Neurosensory disturbance is a well-recognized
complication of orthognathic surgery. Effects on the
inferior alveolar nerve are common after mandibular
procedures.1,16-18 The effect of the BSSO on this nerve
was subject to a systematic review by Collela et al.16
This review pooled data from 7 eligible studies and
found the incidence of objective neurosensory im-
pairment to be 63.3% 7 days postoperatively, 49.2%
after 14 days, 42.5% after 1 month, 33% after 6
months, and 12.8% after 1 year. Surprisingly, the in-
cidence of lingual nerve damage meanwhile has been
quoted in various reports as 9.3%,17 18%,19 and
19.4%20 after sagittal split osteotomy, although these
data were collected through patient questionnaires.
The true incidence of sensory disturbance to this
nerve, as tested objectively, is believed to be much
lower. Hegtvedt and Zuniga21 reported an isolated
case caused by direct nerve injury by the fixation
plate placed on the superior aspect of the mandible.
An increase in tactile threshold on the palate and
maxillary gingivae after Le Fort I osteotomy has been
noted in 64% of patients.22 Allodynia in the distribu-
1679
Table 1. COMMON COMPLICATIONS OF
ORTHOGNATHIC SURGERY
Postoperative nausea and vomiting
Temporary tympanomimetic changes
Acute infection
Chronic infection
Sinusitis
Excessive bleeding
Soft-tissue damage
Localized skin burns
Tooth injury
Loss of pulpal vitality
Periodontal disease
Gingival recession
Nerve exposure
Inferior alveolar nerve disturbance
Lingual nerve disturbance
Temporary taste disturbance
Instrument fracture
Instrument/screw loss
Foreign body
Buccal/lingual plate fracture
Bad split
Incomplete/undesirable fracturing
Malunion
Condylar resorption
Temporomandibular joint effects
Relapse—skeletal and dental
Screw loosening
Instrument fracture
Respiratory difficulty
Neck pain
Malocclusion
Steel and Cope. Complications of Orthognathic Surgery. J Oral
Maxillofac Surg 2012.
tion of the inferior alveolar nerve has been described
by Vaughan Thomas and Cronin23 after a BSSO pro-
cedure, which required treatment with a spinal cord
stimulator and then a right motor cortex stimulator.
Reports of injuries to other nerves appear to be
restricted mainly to the facial nerve, mainly during
mandibular procedures. A retrospective study of
1,747 BSSO patients by de Vries et al24 found an
incidence of cranial nerve VII palsy of 0.26% per side
(total of 9 patients). Almost 95% of the osteotomies
included were setbacks, representing a much higher
risk of this complication when compared with man-
dibular advancements. This is in agreement with
other published studies, because a majority of reports
are related to setbacks.24-26 A review by Choi et al27 of
3,105 patients who underwent a BSSO at a hospital in
Taiwan reported an incidence of facial nerve palsy of
0.1%, representing the 6 patients who had unilateral
facial weakness. The conclusion from that review was
that complete recovery is expected in most cases (5
of 6). A review by Lanigan and Hohn28 found that a
majority of these palsies recover within a period of a
few weeks to a year after injury, although 3 of the 9
1680 COMPLICATIONS OF ORTHOGNATHIC SURGERY

Table 2. SUMMARY OF UNUSUAL/RARE

nerve ischemia through reflex sympathetic vaso-
COMPLICATIONS OF ORTHOGNATHIC SURGERY spasm, fracture and posterior displacement of the
styloid process, and compression by postoperative
Injury to cranial nerves II, III, IV, V, VI, VII, VIII, X, XI, edema.26,29,31-33 This complication has also been re-
and XII
Ophthalmoplegia ported after intraoral subcondylar ramus osteotomy.34
Neurosensory deafness The only report of facial nerve effects related to max-
Secretomotor rhinopathy illary surgery is a single report after combined Le Fort
Frey syndrome I osteotomy and BSSO.31 In this case it was thought
Altered tear secretion likely that the cause of the palsy was related to the
Hemolacria
Blindness mandibular procedure, through the pressure pack
Adie pupil used on the medial aspect of the ascending ramus
Retrobulbar hemorrhage pressuring the facial nerve, rather than the maxillary
Brain abscess procedure. The rarity of facial nerve damage is at-
Actinomycosis tested to by the lack of any instances located in a
Bone graft donor-site infection
Osteonecrosis of maxilla/mandible review of 2,049 patients by Van de Perre et al.2
Avulsion of maxilla Frey syndrome was reported by Guerissi and Stoy-
Condylar dislocation anoff35 presenting in the cheek of a patient 6 months
Condylar resorption (progressive, idiopathic, condylar after Le Fort I osteotomy by use of the Obwegeser
atrophy) technique. This was postulated to be due to aberrant
Vomero-sphenoidal disarticulation
CSF leak regeneration of secretomotor fibers from the auricu-
Cerebrovascular accident (stroke, subarachnoid lotemporal nerve entering the long buccal nerve as a
hemorrhage) result of direct surgical trauma to the former.
Severe hemorrhage Bilateral hypoesthesia in the dermatome of the my-
Arteriovenous fistula/false aneurysm/carotid-cavernous lohyoid nerve has been reported after genioplasty,36
sinus fistula
Cavernous sinus thrombosis with direct trauma from the bone saws used sug-
Malignant hyperpyrexia/herniation of tube cuff/tube gested as a mechanism. Normal sensation returned in
sectioning the reported case within 6 months.
Conversion disorder Palsy of cranial nerves X, XI, and XII was described
Severe clinical depression by Baddour et al37 in a patient who also had a life-
Acute pulmonary edema/apnea
Pneumomediastinum/pneumothorax threatening intraoperative bleed. It was thought that
Surgical ciliated cyst these palsies were caused by either the maxillary
Traumatic neuroma downfracture or the insertion of pressure packs to
Dysphagia control bleeding. Newhouse et al38 also described
Compartment syndrome palsies of cranial nerves X and XII in a 32-year-old
Perforated lateral nasal wall/septum
Oroantral/oronasal fistula female patient who underwent a Le Fort I osteotomy.
Loss of orthodontic bracket into airway There was a significant intraoperative bleed, and fur-
Severe eustachian tube malfunction ther surgery was undertaken to repair an arterio-
Ischemic finger injury venous fistula between the internal carotid artery and
Death internal jugular vein close to the base of the skull.
Steel and Cope. Complications of Orthognathic Surgery. J Oral Postulated causes for these palsies included trauma
Maxillofac Surg 2012. during maxillary downfracture, during placement of
pressure packs, or during later exposure for treatment
of the fistula.
patients in the study of de Vries et al24 showed in- Traumatic neuroma of the inferior alveolar nerve
complete recovery. Sammartino et al29 concluded has been described in patients who have had mandib-
that a majority of such injuries are transient, and ular osteotomies.39,40 One was found 11 years after a
reported 2 cases with delayed onset and spontaneous BSSO was performed: an incidental finding in the
recovery. Lanigan and Hohn reported 2 cases related ascending ramus on a side that exhibited complete
to mandibular advancement, as did Macintosh.30 In 1 mental anesthesia.40
case occult high-level subcondylar fracture reportedly Stroke was reported by Newhouse et al38 in a pa-
allowed the condylar neck to be positioned more tient who underwent a Le Fort I osteotomy. A signif-
posteriorly, thus applying traction to the main trunk icant intraoperative bleed occurred when the sepa-
of the nerve, and in the other, traction on the nerve rated maxilla was manipulated downward. Control
was thought to have been caused by placement of a was effected with pressure packs and wiring of the
pressure pack in the retromolar area.28 Other possible maxilla, although the next day during helicopter
causes include direct trauma by retractor placement, transfer to another unit for angiography, the nasotra-
STEEL AND COPE
cheal tube became disconnected, leading to cyanosis
and respiratory distress. At this point, it was noted
that the patient had a left hemiparesis. Angiography
showed a traumatic arteriovenous fistula between the
internal carotid artery and internal jugular vein on the
right side. The patient subsequently underwent ex-
ploration of this area and obliteration of the right
jugular foramen with a muscle graft. It is reported that
the patient retained a dense left hemiparesis with
some improvement and also had cranial nerve X and
cranial nerve XII palsies. It was suggested that with
pterygomaxillary dysjunction, the right pterygoid
complex was also detached, forcing a sharp piece of
bone posteriorly, thus lacerating the vessels and caus-
ing the vascular injury. Another case of left-sided
hemiparesis was reported by Brady et al41 after com-
bined Le Fort I osteotomy and BSSO, in which internal
carotid artery thrombosis occurred, thought to result
from a neck flexion–induced intimal tear.
Subarachnoid hemorrhage was reported by Bendor-
Samuel et al42 in a 14-year-old male patient undergo-
ing Le Fort I osteotomy. A presumptive diagnosis of
cavernous sinus thrombosis, with cranial nerve III
palsy, was made on the second postoperative day. On
the eighth postoperative day, the patient had a sud-
den massive headache develop and a computed to-
mography (CT) scan showed subarachnoid hemor-
rhage, with a carotico-cavernous fistula and internal
carotid artery aneurysm visible on angiography. The
postulated cause was a possible skull base fracture,
although none was visible on the CT scans.
Secretomotor rhinopathy was reported by Marais
and Brookes.43 This seems to be the only reported
case of this complication. A 33-year-old skeletal Class
II woman underwent a Le Fort I procedure, and clear
rhinorrhea and lacrimal hypersecretion developed at
3 days postoperatively. Investigations ruled out a ce-
rebrospinal fluid (CSF) leak, hypersensitivity, and in-
fection, with bulky inferior turbinates the only struc-
tural feature of note. Resolution occurred with
regular use of an anticholinergic inhaler, although the
lacrimal hypersecretion persisted. The cause was
thought to have related to sphenopalatine ganglion
dysfunction by a local hematoma or its fibrous orga-
nization, shifting the autonomic balance toward a
parasympathetic predominance.
Reduced hearing after Le Fort I osteotomy in cleft
patients was reported by Gotzfried and Thumfart.44
Twenty-six cleft lip and palate patients had preoper-
ative and postoperative audiometric testing, and in
nine who had normal preoperative hearing, a deteri-
oration was observed; conversely, others had an im-
provement in hearing. The deteriorations were likely
caused by edema and/or hematoma formation in the
eustachian tubes resulting from the surgery or naso-
1681
tracheal intubation. Reversal to preoperative values
was typical.
Ophthalmic Complications
Lack of tearing has been reported after Le Fort I
osteotomy.8,45,46 Various explanations have been pro-
posed, including damage to the greater petrosal or
vidian nerves, which could interrupt parasympathetic
supply to the lacrimal gland.46 In the case reported by
Tomasetti et al,45 recovery was complete by 8 months
postoperatively. Conversely, excessive tearing has
been reported,38,45,47 in some cases identified as re-
lating to nasolacrimal duct damage.45,48 Hemolacria
(bleeding from the lacrimal puncta) was reported by
Humber et al49 in 2 patients, both after Le Fort I
advancements. This was thought to be a result of
minor surgical trauma to the vessels in the nasal wall
accompanied by a small tear in the nasolacrimal duct.
The bleeding presented soon after surgery in 1 pa-
tient, which was treated with nasal packing, and 8
days postoperatively in another, which was treated
conservatively.
A review by Newlands et al50 identified 5 cases of abdu-
cens palsy,51-54 3 cases of oculomotor palsy,46,54,55 and 1
case where both palsies were present together.56 Other
cases of abducens palsy have been reported.52,54,57-59
Most presented immediately after surgery, although
cases have been reported up to 5 days postoperatively.59
Bendor-Samuel et al42 reported a case of oculomo-
tor palsy after a Le Fort I osteotomy in a cleft patient
with CT evidence of cavernous sinus thrombosis and
subarachnoid hemorrhage. Recovery was almost com-
plete at 12 months, with residual ophthalmoplegia on
upward gaze in the affected eye. The other reported
cases of oculomotor palsy have been attributed to
transmitted force or hematoma.46,55
Complete isolated abducens palsy was reported by
Hanu-Cernat and Hall59 occurring 5 days after a Le
Fort I osteotomy. This was unilateral on the right side,
with CT showing a fracture of the right pterygoid
plate and blood in the right side of the sphenoid
sinus. Over a period of 6 weeks, with no intervention,
a complete recovery was made. It was postulated that
the cause may have been compression or distraction
of cranial nerve VI due to a suspected hairline fracture
in the sphenoid sinus extending toward the orbit and
causing temporary displacement. Watts57 described a
case of an 18-year-old female patient in whom a right-
sided abducens nerve palsy developed on the first post-
operative day after a standard Le Fort I osteotomy,
which took 7 weeks to resolve. Postulated causes of
abducens palsy in other Le Fort I cases include direct
trauma to the medial aspect of the cavernous sinus51 and
a pre-existing carotid aneurysm.42
1682
The review of Newlands et al50 also presented a
case of concurrent oculomotor and abducens palsy.
In a 33-year-old female patient who underwent Le
Fort I maxillary impaction, a complete left-sided pto-
sis and almost complete left-sided ophthalmoplegia
developed, with sparing of pupillary reflexes, over
the first 24 hours postoperatively. Oculomotor func-
tion recovered by 1 week and abducens by 10 weeks.
Fracture at the superior orbital fissure was thought to
have been causative. This appears to be only the
second report of such palsies occurring simultane-
ously after this surgery.
Nine cases of blindness can be found in the litera-
ture.42,45,58,60-63 Lanigan et al46 conducted a survey of
oral and maxillofacial surgeons (OMSs) in North
America, receiving nearly 800 responses. Among
these, 2 cases of blindness were identified. One in-
volved a 33-year-old female patient who, the morning
after a Le Fort I osteotomy and BSSO, complained of
right-sided blindness. She was found to have no light
perception in that eye, a fixed dilated pupil with
reduced consensual light reflex, and partial cranial
nerve III palsy. It was thought that the cause was a
fractured skull base related to high pterygoid dysjunc-
tion due to thick bone from a previous osteotomy. CT
showed a bone fragment either very close to or in the
canalicular optic nerve. High-dose steroids failed to
give a resolution, and the blindness persisted. An-
other patient had vision limited to counting fingers
after Le Fort I osteotomy and genioplasty. A group of
surgeons in Taiwan described 2 cases of blindness,
both related to Le Fort I osteotomy.58 An 11-year-old
girl with bilateral cleft lip and palate and midface
hypoplasia underwent Le Fort I osteotomy with fitting
of an external distractor device. On the second post-
operative day, the patient complained of total right-
sided blindness. There was no light perception, and
the direct pupillary reflex was absent. The clinical
impression was of right traumatic optic neuropathy.
CT showed subarachnoid hemorrhage in the basal
and subpontine cisterns. Angiography showed a rup-
tured aneurysm at the junction of the basilar and right
posterior cerebral arteries and another in the ophthal-
mic segment of the internal carotid artery. A traumatic
origin for these aneurysms could not be confirmed,
but they were thought to be responsible for the blind-
ness in this patient, who had only light perception 3
months later. The second case involved a 12-year-old
boy with a left-sided cleft lip and palate who had a Le
Fort I osteotomy. He complained of vision loss in his
left eye. He also had a right abducens palsy, although
CT and magnetic resonance imaging failed to offer
any explanation. Recovery was limited to seeing hand
movements at 50 cm after 2 years. Bendor-Samuel et
al42 reported blindness with partial recovery in a
30-year-old male patient after a second Le Fort I pro-
COMPLICATIONS OF ORTHOGNATHIC SURGERY
cedure. Complete blindness of the right eye was
noted postoperatively with a Marcus Gunn pupil. CT
showed evidence of swelling of the optic nerve and
skull base fracture. One case reported by Cheng et
al63 in 2007 occurred in a patient with hypoplasia of
the left internal carotid artery. Light perception and
pupillary reflexes were absent immediately after Le
Fort I and intraoral vertical subsigmoid ramus osteot-
omies. Insomnia and anxiety with uncooperative and
regressive behavior developed in this patient. Ex-
trapyramidal motor effects also occurred. Magnetic
resonance imaging showed hypoxia of the basal gan-
glia, and no signal from the internal carotid artery
could be detected. A diagnosis of hypoxic damage to
the basal ganglia and optic nerve was made, which
resolved gradually.
Of the 9 reported cases of blindness, 5 were of
unknown cause, whereas 1 was due to arterial aneu-
rysm, 2 were attributed to propagation of the ptery-
gomaxillary dysjunction fracture through the skull
base (as investigated by Girotto et al60), and 1 was due
to hypoperfusion of the optic nerve.45 There was no
recovery in 3 cases, light perception returned in 3,
hand movements were visible in 1, fingers could be
counted in 1, and visual acuity showed much im-
provement in 1.
Adie pupil was reported on the first postoperative
day after a Le Fort I procedure by Sirikumara and
Sugar64; however, it was not clear whether there was
any causal link or whether it was just coincidence.
The review of Lanigan et al46 described a case of
retrobulbar hemorrhage whose signs were noticed
when the surgical drapes were removed at the end of
a Le Fort I advancement procedure. An ophthalmo-
logic opinion was sought and lateral canthotomy per-
formed. Li et al65 published a further case of acute
orbital compartment syndrome due to retrobulbar
hemorrhage in a 34-year-old woman undergoing bilat-
eral posterior segmental maxillary osteotomies. Eyelid
edema and proptosis of the left eye were noted upon
removal of the drapes at the end of the operation, and
despite megadose steroid therapy, mannitol, and lat-
eral canthotomy, the patient reportedly never re-
gained useful acuity in the eye.
Infective Complications
Baker et al66 reported a case of brain abscess in a
15-year-old male patient who had a Le Fort I osteot-
omy, BSSO, and genioplasty. The medical history of
the patient is not mentioned besides hemifacial mi-
crosomia, but he was diagnosed with a right frontal
lobe abscess about 4 weeks postoperatively, having
shown acute mental status deterioration after chronic
low-grade pyrexia. Craniotomy and intravenous anti-
biotic administration successfully treated the infec-
STEEL AND COPE
tion. Purported etiologies were spread of bacteria
from the paranasal air sinuses, especially the eth-
moidal air cells, or retrograde spread of bacteria
through seeding into the pterygoid venous plexus.
Iliac abscess occurring 4 years after orthognathic sur-
gery for which an iliac graft was harvested has been
described by De Riu et al.67 A 4 ⫻ 3– cm monocortical
corticocancellous block had been taken from the inner
table of the left iliac crest to provide a graft for a max-
illary advancement. The abscess was thought to have
been due to a foreign-body granuloma related to bone
wax placed in the area. This appears to be the only case
of this complication being reported.
Six cases of actinomycosis after orthognathic sur-
gery can be identified.68-70 Ozaki et al68 reported a
case of actinomycosis occurring in the left subman-
dibular area, which presented as a 2 ⫻ 3– cm swelling
6 months after BSSO with advancement. The infection
resolved with 2 months of antibiotic therapy. This
pattern of infection conforms to general principles of
cervicofacial actinomycosis because surgery is a
known predisposing factor.
Skeletal/Bony Complications
OSTEONECROSIS OF MAXILLA
Various anecdotal reports exist, but contrary to
popular myth, a published report of necrosis of a
whole maxilla does not appear to exist in the English-
language language. A survey of OMSs in the United
States by Sher,71 from whom 35 responses were re-
ceived, identified 1 case of “sloughed maxilla (entire)”
although no details are given. There are various pub-
lished cases of partial necrosis. A review by Lanigan et
al72 identified 51 such cases, of which 36 were de-
tailed in the article. The extent of the necrosis ranged
from just the maxillary central incisor pulps to the
whole of the alveolar ridge and all of the premaxilla.
Various other patterns were seen between these ex-
tremes, including just the premolar segment and the
alveolar ridge on 1 side only. Pedeira et al73 reported
a case of maxillary aseptic necrosis in a middle-aged
female smoker who underwent a Le Fort I osteotomy
and BSSO, which was successfully treated with hyper-
baric oxygen. The exact extent of the necrosis is not
described, but the mucosa overlying the maxilla was
described as ischemic, with generalized maxillary gin-
gival recession and an ulcer on the left side of the
hard palate on the seventh postoperative day, with
complete resolution by the 22nd day.
Singh et al74 reported a case of near-total necrosis
of the maxillary alveolus after Le Fort I osteotomy and
rib graft augmentation, which was seen and treated
some 8 years after the procedure, which had been
undertaken by another specialty. It is said that the
1683
majority of the alveolar ridge and teeth had to be
removed, with treatment involving hyperbaric oxy-
gen therapy, iliac crest graft, and implant-supported
prosthodontics.
AVULSION OF MAXILLA
Bendor-Samuel et al42 described an instance of avul-
sion of the left hemi-maxilla and palate in a 20-year-old
male patient with repaired bilateral cleft lip and palate
undergoing intended Le Fort I osteotomy with iliac
crest bone graft. Overzealous undermining of the mu-
cosa through what was presumably a horseshoe inci-
sion allowed the entire left bony segment complete
with dentoalveolar segment and attached gingiva to
be completely detached and avulsed. After stripping
of this attached gingiva, the segment was replaced in
the pre-osteotomy position, with the right side being
advanced as planned. The avulsed segment survived,
and further surgery was not undertaken.
OSTEONECROSIS OF MANDIBLE
Six case reports were located by a review of man-
dibular aseptic necrosis in 1990.75 Two of these were
published as case histories, one after BSSO and the
other after BSSO with genioplasty. In the former the
patient was a 38-year-old woman with no predispos-
ing medical factors. A technetium bone scan showed
a large area on 1 side from the premolars posteriorly
including all of the ramus except the coronoid and
condylar neck areas to be avascular. Hyperbaric oxy-
gen treatment and antibiotic therapy led to only a
5-mm piece of bone eventually being sequestered.
The cause was thought to have been overzealous
stripping of the pterygomasseteric sling. In the latter
case a 14-mm advancement of the genial fragment
was undertaken while still attached to its lingual mus-
culature. During removal of the fixation wires at a
later date, the whole of this piece of bone was
avulsed. It was replaced and effectively served as a
free bone graft. The size of the advancement was said
to have led to the loss of the muscular attachments. A
further case restricted to the anterior mandible was
reported in 1972.76
Dislocation of the condyles was reported by Wein-
berg et al77 as a case report of an 18-year-old woman
who presented after a fall 1 week after bilateral ex-
traoral subcondylar osteotomies. The patient’s symp-
toms are not described, but radiographs showed ante-
rior dislocation of the right condyle despite the dental
occlusion reportedly being the same as that of the im-
mediate postoperative period. This condylar position
persisted, although extensive remodeling was noted. It
was thought that this dislocation may have been intro-
duced in an iatrogenic manner during surgery.
Condylar resorption is a known uncommon com-
plication of orthognathic surgery, leading to relapse.
1684
The terminology is confusing, with the condition var-
iously described as progressive or idiopathic condylar
resorption or as condylar atrophy. The term “idio-
pathic” does not apply in this case because surgery
can be identified as a precipitating factor. Differenti-
ation between these separate terms is unclear. The
condition is well-represented in the literature, but few
incidence figures relating to after orthognathic sur-
gery are available. Scheerlinck et al78 reported an
incidence of 7.5% after BSSO in 106 patients. A larger
sample of 222 BSSO patients studied by Bortslap et
al,79 using rigid diagnostic criteria, quoted 4% at 2
years postoperatively. All of the patients in the resorp-
tion group showed clinically measurable relapse. A
review of previously published studies by Gill et al80
identified risk factors for this, comprising female gender,
mandibular retrognathia associated with an increased
maxillary-mandibular plane angle, pre-existing condylar
resorption, and surgery including posterior displace-
ment of the condyles or upward and forward rotation of
the mandible. Purported causes of this complication are
remodeling of the condyle-fossa complex in response to
altered loading patterns or compromise of the temporo-
mandibular joint vasculature inducing avascular necro-
sis, thus leading to condylar resorption.81 Cases de-
scribed as condylar atrophy have been reported,82-84
including 1 associated with temporomandibular joint
osteoarthrosis after bimaxillary surgery.85 It may be a
difficult condition to manage, with various approaches
described comprising nonsurgical treatment with
splints, orthodontics, or restorative dentistry or repeat
surgical procedures, including joint replacement.86
CSF leak after orthognathic surgery is a very rare
event, with only 2 cases reported in the literature.87,88
Gruber et al87 reported a case in a 19-year-old woman
who had Le Fort I impaction and BSSO and showed a
CSF leak from the nostril at 3 days postoperatively,
which resolved after placement of a lumbar drain.
Vomero-sphenoidal disarticulation has been re-
ported once, by Smith and Heggie.89 In a 20-year-old
healthy female patient undergoing bimaxillary surgery
to correct a Class III skeletal relationship, the vomer
remained articulated with the maxillae after downfrac-
ture. Subsequently, during use of rongeurs to reduce an
irregular piece of nasal septum, the vomer was unex-
pectedly delivered. It was not replaced, and no adverse
consequences were reported, with the cause of the
complication suggested as slippage of the osteotome
during sectioning of the cartilaginous septum.
Bleeding Complications
Various injuries to the internal carotid arteries have
been reported in the literature: false aneurysms, arte-
riovenous fistulae, hemorrhage, and thrombosis.90
One case of thrombosis presented as decreased left
COMPLICATIONS OF ORTHOGNATHIC SURGERY
arm movement after Le Fort I osteotomy and BSSO,
developing into hemiparesis. The cause was thought
to have been an intimal tear, which may have oc-
curred because of neck hyperextension and lateral
flexion.91 A similar presentation was noted by Sanni et
al91 after BSSO, which may have been due to a blunt
blow from a channel retractor placed lingual to the
mandible or indirect trauma from malleting during
the sagittal split. A good review of the possible
mechanisms of injury to the internal carotid artery
in relation to orthognathic surgery is provided by
Baddour et al.90
Numerous reviews of the complications of orthog-
nathic surgery have concluded that serious bleeds are
rare in these patients.2,4,5 A prospective study of 35 Le
Fort I patients by O’Regan and Bharadwaj92 found no
instances of serious bleeding. A survey of OMSs in the
United States by Lanigan et al93 identified 18 cases of
serious intraoperative bleeding and 21 cases of post-
operative bleeding among around 800 responses. All
were related to Le Fort I procedures, and a majority
were said to be from the descending palatine and
sphenopalatine arteries, with fewer from the ptery-
goid venous plexus. All of these patients required
transfusions, and all of the postoperative bleeds oc-
curred within 2 weeks, except 1 that occurred after 5
weeks and was brought on by heavy lifting. The
sphenopalatine and maxillary arteries are thought to
be particularly important sources of significant arte-
rial bleeding.
Baddour et al37 reported a case of a life-threatening
intraoperative bleed localized only to the right pos-
terior region that occurred after pterygoid plate sep-
aration and did not respond to external carotid artery
ligation. The patient in the same case also showed
palsies of cranial nerves X through XII. Figures per-
taining to significant bleeding during or after BSSO
have been quoted at 0.38%94 and 1.2%.95 At least 13
cases of serious bleeding related to a vertical subsig-
moid osteotomy have been reported,96,97 and 2 for
genioplasties, including 1 where an ooze from that
site led to floor-of-mouth hematoma and tongue ele-
vation, necessitating tracheostomy.97
Severe epistaxis is a distinct clinical presentation of
what may be the same cause of bleeding as the other
hemorrhages described previously and is known to be
rare after Le Fort I osteotomy, Lanigan and West97
quoted an incidence of 0.75%. Solomons and Blumgart98
reported the case of a 20-year-old male patient in whom
2 significant epistaxes developed, one 4 weeks postop-
eratively and the second about 10 weeks postopera-
tively. The latter episode led to life-threatening blood
loss and hypovolemic shock and was found to be caused
by a false aneurysm of the left internal maxillary artery,
which was then successfully embolized. Other reported
STEEL AND COPE
cases of postoperative epistaxis have been caused by
similar vascular phenomena.99
A review in 1991 examined the vascular complica-
tions of orthognathic surgery.99 Three cases of false
aneurysm were described. All occurred after Le Fort I
osteotomy, presenting between 6 days and 6 weeks
postoperatively with epistaxis; they were massive in 2
cases. Two were thought to be of the sphenopalatine
artery and one of the maxillary artery itself. A surgical
trauma etiology is implicated by partial occlusion and
extravasation of an artery, forming a hematoma that
then organizes and undergoes endothelialization. A
case of post-osteotomy arteriovenous fistula, in the
form of carotico-cavernous fistula, was also described.
Its signs were noted in the recovery room immedi-
ately after a Le Fort I advancement. The fistula was
successfully embolized, but its possible causes were
not alluded to. Other authors have reported false
aneurysms61,100 (including after a mandibular proce-
dure101), carotico-cavernous fistulae,102-104 and other
arteriovenous fistulae.105-108 Albernaz and Tomsick109
reported 2 cases of arteriovenous fistulae of the max-
illary artery after Le Fort I osteotomies. In both cases
the fistulae were successfully embolized, leading to
complete cessation of symptoms. The cause was be-
lieved likely to have been untoward fractures from
pterygomaxillary dysjunction extending to the ptery-
gomandibular fossa. A false aneurysm of the facial
artery was reported by Pappa et al,110 presenting with
a severe bleed 1 week after BSSO, and another case by
Madani et al111 involving trauma 4 weeks after a Le
Fort I osteotomy. Hemmig et al112 reported a patient
with a ruptured pseudoaneurysm of the sphenopala-
tine artery, presenting as extreme recurrent epistaxis.
As well as these cases, other instances of abnormal
vascular lesions occurring postoperatively and suc-
cessfully embolized have been reported.113 Silva et
al114 provided a good review of pseudoaneurysms
arising in relation to orthognathic surgery. Cavernous
sinus thrombosis has also been reported after orthog-
nathic surgery.115
Deep vein thrombosis is known to be rare among
orthognathic surgery patients, with an incidence of
0.00035% published.116 In a review of 129 such pa-
tients treated in Liverpool, 2 cases of deep vein throm-
bosis were identified, neither of which progressed to
pulmonary embolism.117
Anesthetic Complications
Malignant hyperpyrexia has been reported during a
segmental osteotomy procedure.118 It is known that
dental procedures can act as a trigger for such an
event,119 which involves an abnormality of muscle
metabolism, of genetic origin, manifesting as wide-
spread skeletal muscle contraction, hypercatabolism,
1685
and hyperthermia upon exposure to volatile anes-
thetic agents or succinylcholine chloride. It is a seri-
ous condition, requiring aggressive management. In
the case reported by Monaghan and Hindle,118 sur-
gery was terminated 70 minutes into the operation,
and malignant hyperpyrexia diagnosed by a combina-
tion of tachycardia of 160 beats/min, cyanosed ve-
nous ooze, and noticeably warm skin. Another case
was reported by Laureano et al.120
Herniation of the airway tube cuff leading to occlu-
sion of the tube lumen has been reported during an
osteotomy procedure, although the operation was
not required to be terminated.121
Sectioning of the endotracheal tube has been re-
ported,122,123 an event obviously capable of produc-
ing severe intraoperative ventilatory difficulties. Pagar
et al122 reported 2 cases of such an event, during
which the tubes to the cuff and the endotracheal
tubes themselves were incompletely cut, although
not to the extent that reintubation was required.
A case of contact granuloma of the vocal cords was
described by Chua et al,124 which was related to
pressure necrosis of the mucosa overlying the vocal
processes of the arytenoid cartilages caused by an
endotracheal tube in situ for 4 hours during an or-
thognathic procedure. There is only 1 other report of
this complication, which is itself rare, during orthog-
nathic procedures.125 Bilateral nodules on the aryte-
noids in 1 patient were diagnosed as contact granu-
lomas after a 3.5-hour intubation for an orthognathic
procedure.126
Acute intraoperative pulmonary edema in a 16-year-
old female patient undergoing BSSO was reported by
Kademani et al.127 Induction with propofol was
achieved after diazepam, vecuronium, cefazolin, and
dexamethasone were administered. Ten minutes into
the procedure, acute hypertension developed, later
followed by pink frothy exudate within the endotra-
cheal tube. An intraoperative chest radiograph showed
fulminant pulmonary edema, and an electrocardiogram
showed sinus tachycardia. Pharmacologic attempts
were made to resolve this, and normotension was
re-established over the next 30 minutes. A full recov-
ery was made. It was suggested that the initial hyper-
tension was related to adrenaline in the local anes-
thetic, with the pulmonary edema precipitated by an
intravenous infusion of esmolol given in an attempt to
reduce the blood pressure. Such an event occurring
under anesthesia is very rare. Acute postoperative
dyspnea was reported by Aziz et al128 in an 18-year-old
female patient who had undergone a Le Fort I and
vertical subsigmoid ramus osteotomy (VSRO), which
presented immediately postoperatively. The mecha-
nism was thought to have been right middle and
lower lobe atelectasis due to obstruction by aspirated
material.
1686
Apnea of 9 hours’ duration was reported by O’Ryan
and Ebker129 in a healthy female patient after an
orthognathic procedure, which was found to be due
to a qualitative and quantitative defect in the enzyme
cholinesterase, of genetic origin. Previous general an-
esthetics had been uneventful.
Pneumomediastinum and pneumothorax have been
reported rarely as complications.130-135 Edwards et al130
detailed 2 cases occurring after orthognathic surgery.
Both involved young women (aged 16 and 21 years)
having Le Fort I osteotomies (1 also had a BSSO and
genioplasty). In the first patient respiratory distress de-
veloped 14 hours postoperatively, and investigations
showed minimal collapse of the left lung. Alveolar rup-
ture caused by high intra-alveolar pressure resulting
from mucus plugs and ventilation with an Ambubag
(Ambu A/S, Baltorpbakken, Denmark) was suggested to
be explanatory. The second case presented similarly,
with a left apical pneumothorax and a degree of subcu-
taneous emphysema, which has been reported else-
where.136,137 In both cases this resolved spontaneously.
Complete left lung collapse due to spontaneous pneu-
mothorax was reported by Goodson et al,134 and bilat-
eral pneumothorax and pneumomediastinum after pos-
itive pressure ventilation were reported in 2010.135 A
case of mediastinal emphysema after Le Fort I osteotomy
was reported in 1986.133 In a literature review on the
subject, McKenzie and Rosenberg137 located 2 cases of
surgical subcutaneous emphysema arising from orthog-
nathic surgery.
Psychological Complications
Orthognathic surgery is capable of having a dra-
matic improvement on various psychological param-
eters but conversely has been reported to sometimes
have a detrimental impact.138,139 A review by Cun-
ningham et al139 presented a case of a 26-year-old
female patient who underwent a bimaxillary proce-
dure to treat a retrusive mandible. After surgery, the
patient and her mother described problems adapting
to the new situation. The patient’s parents divorced
several months later, reportedly because of their feel-
ing of unpreparedness for the outcomes of surgery, in
terms of both the healing period and the personality
changes of their daughter. Conversion disorder (a
disorder whereby neurologic symptoms occur
without organic neurologic cause, with stress being
held responsible) has been reported after orthog-
nathic surgery.140
Depression is said to be relatively frequent among
orthognathic patients postoperatively, in common
with many other surgical procedures,141 especially
when IMF is used.125 The “4-day blues” is a well-
recognized and common phenomenon, although a
majority of such cases are not thought to represent
COMPLICATIONS OF ORTHOGNATHIC SURGERY
true clinical depression; its incidence, however, ap-
pears to be underappreciated. A study by Kiyak et
al142 into the emotional impact of orthognathic sur-
gery showed significantly higher scores for tension
and fatigue immediately after surgery than nonsurgi-
cal controls and raised anger-hostility that took up to
5 months to decline. Postsurgical discomfort, pain,
and neurologic disturbance were found to correlate
with a postsurgical altered emotional state.
Other Complications
Death is recognized as an exceedingly rare compli-
cation relating to orthognathic surgery. Of numerous
large case series published, only 1 death has been
described. Van de Perre et al,2 from a series of 2,049
patients, reported the death of a 17-year-old male
patient who was described as being slightly mentally
retarded. He underwent a staged bimaxillary osteot-
omy to address gross vertical and transverse maxillary
hyperplasia. The maxillary procedure was completed
without any problem, followed by BSSO with genio-
plasty 3 months later. Six hours postoperatively, a
cardiac arrest developed in the patient, and attempts
to resuscitate him failed. The cause was thought to
have been a pre-existing cardiomyopathy. Another
death was reported by Waack143 as part of a series of
63 consecutive Le Fort I patients. A healthy 15-year-
old female patient died on the first postoperative day
from unknown causes, with a postmortem examina-
tion failing to identify a cause of death.
Nagler et al144 reported a case of prolonged dys-
phagia in a 29-year-old female patient who underwent
a Le Fort I maxillary intrusion and BSSO with advance-
ment and rotation. After nasogastric tube removal 1
week postoperatively, profound dysphagia occurred,
which persisted for 7 weeks. Pharyngeal manometry
showed spasm of the upper esophageal sphincter,
and barium swallow fluoroscopy showed no bolus
passage beyond the pharynx despite seemingly nor-
mal esophageal peristalsis on endoscopy. A speech
therapist provided swallowing retraining for 5 weeks,
followed by sudden resolution and resumption of
normal swallowing 2 weeks later. Psychiatric assess-
ment found the patient to be regressive, obsessive,
and compulsive with a limited intellectual perfor-
mance. The authors suggested the mechanism in this
case was a globus sensation due to central inhibition
caused by a compromised psychological condition.
Gaukroger145 reported complete immediate postop-
erative dysphagia in a 22-year-old male patient who
underwent Le Fort I maxillary advancement and BSSO
setback with fitting of IMF. He was unable to even
swallow his own saliva for 4 weeks, despite periodical
release of the IMF, hence being fed by nasogastric
tube. Esophagoscopy showed a tightly closed upper
STEEL AND COPE
esophageal sphincter, balloon dilatation of which was
only successful for a few hours, which necessitated
myotomy of the muscle leading to complete resolu-
tion. A hypothesis for this was a change in the anat-
omy of the hyoid region, which may have led to
reduced tension in the suprahyoid musculature and
hence a reduced dilator effect on the sphincter.
Spontaneous leg compartment syndrome has been
reported as a complication after orthognathic surgery.
Strickland and Westrich146 described 2 cases, 1 with
mandibular osteotomy for deformity and another with
Le Fort I osteotomy, where leg pain indicated develop-
ment of this syndrome on the second and first postop-
erative days, respectively. Both patients needed 4-com-
partment fasciotomy. Beadnell et al147 also described a
case and listed possible causes as incorrect positioning
of the patient or leg straps and postoperative muscular
trauma. A case reported by Teeples et al148 was thought
to have been due to a drug interaction between the
anesthetic or postoperative medications, or the effect of
antidepressant drugs superimposed on chronic, mild,
exercise-induced compartment syndrome.
Perforation of the lateral nasal mucosa by fixation
screws has been reported by Levine and Super149 in
the case of a patient who had postoperative nasal
congestion and pain after a Le Fort I maxillary ad-
vancement with fixation using 7-mm screws. Surgical
removal and replacement with shorter screws were
necessary. Perforation of the nasal septum has also
been reported.150
Oroantral and oronasal fistulae have been re-
ported as a complication by El Deeb et al12 should
slight tears in the oral and antral or nasal mucosa
correspond. These authors state that oronasal fistu-
lae are more common when the maxillae are seg-
mentalized or expanded.
Laureano Filho et al151 reported loss of an orth-
odontic bracket into the airway during an orthog-
nathic procedure.
Grundig et al152 reported a case of postoperative
recurrent eustachian tube malfunction with middle
ear effusion in a 22-year-old female patient after Le
Fort I advancement in Germany. This did not respond
to grommet insertion, and investigations showed a
forward dislocation of the pterygoid hamulus on the
same side as well as damage to the tensor veli palatini
muscle, purported to be causative. Klemm et al105
reported a case of tinnitus and hearing loss in a 36-
year-old who underwent the same operation, as
caused by an arteriovenous fistula of the left maxillary
artery, embolization of which led to resolution of the
problem. Wong et al153 reported a cleft palate pa-
tient who was found to have a patulous eustachian
tube by investigations undertaken in response to
the patient’s complaint of autophony 3 months
after a Le Fort I procedure. This abnormal patency
1687
of the tube was said to have possibly been caused
by the surgery or subsequent scarring, although
there was no direct evidence of this and coinci-
dence could not be excluded.
The entity of a “surgical ciliated cyst” has been
reported after elective orthognathic surgery.154-160 Al-
though studies in the Japanese literature have re-
ported a prevalence of 20%,161 there is very little
published material in the English-language literature.
Sugar et al155 described a case of this pathology pre-
senting in the maxillary buccal sulcus 3 years after a
Le Fort I osteotomy. As the name suggests, they are
typically lined by respiratory epithelium and the
pathogenesis is hypothesized to involve antral mu-
cosa trapped in the surgical wound, or closure of the
ostium.151 Shakib et al156 reported an unusual case in
the midline of the palate 7 years after a Le Fort I
osteotomy. Koutlas et al157 reported a case in the left
mandibular ramus diagnosed 13 years after maxillary
and mandibular osteotomy procedures, thought to
relate to respiratory epithelium traumatically admit-
ted to the area. Two other mandibular cases resulted
from the use of nasal bone and cartilage grafts in the
area.158,159
Dental malocclusion after orthognathic surgery
may be encountered relatively frequently due to skel-
etal and/or dental relapse. It is, however, rare for
failure of fixation to be responsible. Such an event is
likely to require reoperation. Three cases were re-
ported by Ellis and Esmail,162 all undergoing BSSO
with advancement. In 2 of these patients anterior
open bites developed, 1 of which was successfully
rectified orthodontically after about 5 weeks, and the
third case had a 4-mm left midline shift. Radiographs
showed that these malocclusions had resulted from
bending of the single miniplate used to fixate the
osteotomized segments, thought to be part of a rota-
tional movement. Such an event has not been previ-
ously reported, although mechanical failure of osteot-
omy miniplates was described by Fujioka et al.163
One of the more bizarre complications in the liter-
ature is that of an ischemic finger injury caused by a
pulse oximetry probe being in the same place for too
long during an orthognathic procedure during which
hypotensive anesthesia was used.164
Rarer complications for which further details are
not available are as follows:3 herpes labialis, corneal
ulcer, recurrent laryngeal nerve palsy, and arytenoid
cartilage dislocation.
Discussion
It is clear that orthognathic surgery is a safe area of
oral and maxillofacial surgery, although it carries a
number of rare risks depending on the exact tech-
niques used. This review has identified reports of the
1688
plethora of complications, some with only 1 reported
case, ranging across all possibilities from neurologic,
infective, bony, and bleeding to psychological, anes-
thetic, and other complications. We feel satisfied that
this review has achieved its goal to describe the re-
ported unusual and rare complications of orthog-
nathic surgery and believe that the search strategy
was sufficiently rigorous to render it unlikely that
complications were missed. As previously mentioned,
reviews of this kind are affected by publication bias,
because it is likely that reports of more unusual com-
plications will have a higher chance of being pub-
lished. This may skew the apparent probability of
occurrence as suggested by the subject literature.
Therefore, unless published figures for incidence are
available, this review does not inform the reader of
the incidence of these complications because such a
calculation is not accurately permitted from the liter-
ature. Indeed, provision of such figures was never an
aim of the review. Rather, it has acted as a medium
through which to learn from the experiences of other
surgeons.
Many of the rare complications reported after max-
illary orthognathic surgery share a common etiologic
basis and pathogenesis because of the inherent risks
of the maxillary downfracture and pterygomaxillary
dysjunction. These risks include life-threatening hem-
orrhage, stroke, acute subarachnoid hemorrhage,
carotid-cavernous or other arteriovenous fistulae, false
aneurysms, cavernous sinus thrombosis, central nervous
system leaks, ophthalmic complications (including
blindness, ophthalmoplegia, dry eye, and hemolacria),
secretomotor rhinopathy, neurosensory deafness, and
death. The etiology of these complications may relate to
untoward fractures that extend to the base of the skull,
orbit, or pterygopalatine fossa, in conjunction with the
pterygomaxillary dysjunction and/or maxillary down-
fracture. A second possibility is potential damage to
neurovascular structures from traction, shearing,
compression, or contrecoup injuries through forces
transmitted during the pterygomaxillary dysjunction
by use of an osteotome or during the maxillary down-
fracture. These maneuvers become even more dan-
gerous if the pterygomaxillary dysjunction or maxil-
lary downfracture is traumatic in nature. A significant
proportion of the complications described in this ar-
ticle have been thought to have resulted from events
occurring during this stage of the operation, showing
its importance.165
A large number of complications for orthognathic
surgery have been described in the literature. This
review has served to act as a reminder to clinicians
of what unusual and rare complications have been
reported.
COMPLICATIONS OF ORTHOGNATHIC SURGERY
Acknowledgments
The authors offer many thanks to S. T. Crank and C. Mannion for
their valuable advice on this article.
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