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British Journal of Oral and Maxillofacial Surgery 50 (2012) 97–101

Review
Review of evidence for the use of steroids in orthognathic
surgery
Soudeh Chegini a , Daljit K. Dhariwal b,c,∗
a Wexham Park Hospital, Wexham, Slough, Berkshire SL2 4HL, United Kingdom
b Oral and Maxillofacial Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom
c Nuffield Department of Surgery, University of Oxford, United Kingdom

Accepted 4 November 2010

Available online 12 February 2011

Abstract

Primarily, steroids are used routinely in orthognathic surgery to reduce swelling, but there is no nationally accepted regimen for the use of
glucocorticoids in the UK. This article examines the evidence base for the use of steroids to reduce swelling, nausea, vomiting, and pain, and
looks at evidence of the ratio of risks:benefits in orthognathic surgery and related publications. Evidence supports their use preoperatively,
but the timing of this and their postoperative use may be contentious. The current regimens are associated with little morbidity and low cost.
A well designed multi-centre study whose design would allow objective measures of swelling is required to resolve the areas of debate.
© 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Orthognathic; Glucocorticoids; Osteotomy; Post-operative nausea; Post-operative vomiting

Introduction nathic surgery, oral surgery, and orthopaedic surgery. Papers

Steroids are advocated for reduction of postoperative pain,
swelling, trismus, nausea, and vomiting in patients having
orthognathic surgery. Swelling and inflammation contribute
towards pain and trismus, but inflammation is an important
part of wound healing. Extensive swelling can compromise
the airway, the recovery of patients, and surgical outcome.1
This article reviews the current evidence for the use of steroids
in orthognathic surgery.
that investigated the use of glucocorticoids and their effects
on swelling, pain, trismus, nausea, recovery, and incidence of
complications were selected. In addition, studies mentioned
in these articles that had not been identified in the initial
search were also included. Papers that did not have a full
article available were excluded.
Physiology of glucocorticoids

Method The body produces a continuous background level of corti-

We searched the English language publications using
PubMed for articles about glucocorticoids or steroids, orthog-
∗ Corresponding author at: Oral and Maxillofacial Surgery, John Radcliffe
Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom.
Tel.: +44 7780673567; fax: +44 01865743108.
E-mail addresses: Daljit.Dhariwal@orh.nhs.uk,
daljitdhariwal@hotmail.com (D.K. Dhariwal).
sol that peaks before waking and after every meal. Further
release occurs with the fright-or-flight response and in times
of starvation. Surgery combines psychological, physical, and
metabolic stresses from anaesthesia that stimulate its release.
The primary action of exogenous glucocorticoid drugs is
on the carbohydrate metabolism with varying mineralocorti-
coid actions equivalent to dose (Table 1). The physiological
actions of both cortisol and exogenous glucocorticoids have
a delay of several hours.2

0266-4356/$ – see front matter © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2010.11.019
98 S. Chegini, D.K. Dhariwal / British Journal of Oral and Maxillofacial Surgery 50 (2012) 97–101
Table 1
Equivalent anti-inflammatory doses of glucocorticoids and their mineralocorticoid action. The doses do not take into account the duration of action.
Drug Dose equivalent to
5 mg prednisolone
Prednisolone 5 mg
Dexamethasone 750 ␮g
Hydrocortisone 20 mg
Methylprednisolone 4 mg
Inflammation
The classic signs of rubor (erythema), tumor (swelling), calor
(hot), and dolor (pain) are the hallmarks of inflammation.
At a biochemical level, the response to mechanical, phys-
ical, or chemical stimuli involves the breakdown of cell
membrane phospholipids into arachidonic acid, leukotrienes,
and prostaglandins, which increase capillary permeabil-
ity, dilatation, and movement of fluid into extracellular
spaces.3,4 Cyclooxygenase-1 (COX1) and COX2 are impor-
tant enzymes in this process, and glucocorticoids inhibit their
synthesis. They also inhibit cytokines produced by local
damaged cells, which encourage leukocyte migration and
phagocytosis.
Swelling
A small number of trials have examined the effect of gluco-
corticoids on swelling in orthognathic surgery. Munro et al.
compared a preoperative dose of dexamethasone 0.5 mg/kg
followed by a two-day postoperative dose of 0.25 mg/kg/day
with placebo in children having mandibular or maxillary
osteotomy. They found no significant reduction in facial
swelling when photographs were assessed subjectively by
an independent observer.5
Computed tomograms (CT) allow more objective evalu-
ation of swelling. In a cohort study of 39 patients having
Le Fort I or transoral vertical osteotomy, facial swelling, as
assessed on CT, was reduced at 24 and 72 h, and was attributed
to the timing of the dose of methylprednisolone.6 However,
this evidence is weak as it is based on a retrospective study
with no control group for comparison.
In a randomised prospective double blind trial, 23
patients who required bilateral sagittal split osteotomy of the
mandible were split into three groups and were given either
placebo, preoperative dexamethasone 16 mg intravenously,
or preoperative dexamethasone 16 mg intravenously with
three postoperative 8 mg doses intravenously every 6 h. In
both dexamethasone groups there was a significant (p < 0.5)
reduction in facial swelling on postoperative day one as
assessed by computer scanning of clinical photographs, and
there was no statistical difference between the two groups.7
This highlights the importance of giving glucocorticoids pre-
operatively, but shows no additional therapeutic value in their
postoperative use up to three days after operation, and sug-
gests that glucocorticoid treatment may have a ceiling effect.
Half life (h) Mineral corticoid
potency
16–36 0.8
36–54 0
8 8
18–40 0.5
The effect of the postoperative doses after three days was not
measured, but is not considered clinically important.
In patients having maxillary osteotomy for facial dysmor-
phia, a preoperative dose of methylprednisolone 1.5 mg/kg
with three further doses on the subsequent three days reduced
facial oedema.8 No control group was given a single preop-
erative dose alone.
Pain
Postoperative pain can delay recovery, increase the duration
of the hospital stay, increase healthcare costs, and reduce
patient satisfaction. Glucocorticoids are widely given to
reduce pain associated with inflammation.
The inflammatory soup contains bradykinins and
prostaglandins, which reduce the pain threshold of local
pain receptors, and induce a positive feedback loop with
the release of neuropeptides, which further stimulate inflam-
mation. In addition, tissue trauma can directly damage pain
receptors and their axons.4
Glucocorticoids dampen local inflammation, and thereby
reduce pain, and may have a neuromodulatory effect reducing
peripheral and central sensitisation.4 The mechanisms are not
well understood. In patients having third molars extracted,
glucocorticoids are associated with reduced swelling and
pain, but the lack of correlation between the two suggests
that the neuromodulatory effect has clinical relevance.9
We found no trials that measured the analgesic proper-
ties of glucocorticoids in orthognathic surgery. However, we
may extrapolate some evidence from third molar extractions
in randomised double blind control trials that compare inter-
ventions on bilateral teeth of the same patient (Table 2). This
experimental set-up reduces the interpersonal variation in the
perception of pain. Patients can also be asked which interven-
tion they preferred, but this subjective assessment may vary
for the same patient from day to day.10 Preoperative glucocor-
ticoids reduce patient-perceived pain, and therapeutic levels
may be achieved hours after the time of operation when the
effects of the local anaesthetic have worn off. All the stud-
ies showed that after two to three days the analgesic effect
of glucocorticoids is no longer significant, which supports
the use of a short postoperative regimen. In addition, non-
steroidal anti-inflammatory drugs (NSAIDs) are also potent
COX inhibitors, and there are possible cumulative effects of
the two drugs.
Glucocorticoid therapy has been compared with alter-
native analgesia and saline as control.11,12 Patients having
 S. Chegini, D.K. Dhariwal / British Journal of Oral and Maxillofacial Surgery 50 (2012) 97–101
Table 2
Effect of glucocorticoids on pain in third molar extraction trials.
Drug Dose
Betamethasone 9 mg IM preoperatively
Methylprednisolone 40 mg IV preoperatively
Dexamethasone and 50 mg 8 mg IV preoperatively and 4 mg
diclofenac preoperatively and IV postoperatively
postoperatively
Dexamethasone 8 mg IV preoperatively and 6
methylprednisolone doses of 5 mg PO postoperatively
orthognathic surgery commonly require multiple analgesic
drugs, and it is the ability of glucocorticoids to reduce this
need that is clinically relevant. In a double blind randomised
trial of 100 patients, the cumulative effect of an NSAID and
glucocorticoid achieved significantly better pain relief than a
NSAID alone.11
Orthopaedic procedures cause similar local trauma to
orthognathic surgery as they affect bone and the surround-
ing soft tissues. In a review of studies of arthroscopic knee
surgery, the calculated total analgesic requirement of a cohort
of patients mirrored the results from oral surgery trials
(Table 2). Patients’ pain scores, rescue analgesic require-
ments, recovery time, and hospital stay were all reduced
by glucocorticoid treatment.4 Some studies, however, have
shown no significant analgesic effect. The authors hypoth-
esised that glucocorticoids do not produce changes in the
variables of pain when there is not enough oedema and
trauma, but another explanation may be that the studies did
not use glucocorticoids for long enough or at a high enough
dose for the relative trauma of the procedure.
Trismus
We know of no studies that examine the effect of steroids
on trismus in orthognathic surgery, however, maximal mouth
opening after removal of bilateral third molars is improved
at two and seven days after operation with corticosteroid
cover.13
Antiemetic
The pathways that induce nausea and vomiting are complex
and involve numerous receptors acting at multiple sites; this is
reflected in the wide range of antiemetic medication available.
Recent studies have suggested that nausea and vomiting are
separate phenomena and should be studied independently.
Receptors involved in the process can be targeted selec-
tively to treat or prevent postoperative nausea and vomiting
(PONV), which is a combination of stimulation of the
higher centres and the chemoreceptor trigger zone by
anaesthetic agents.14 The gastrointestinal tract and vagal
99
Result No. of molars First author and
reference
Pain reduced on day 3. 48 Skjelbred9
96% of patients preferred the
steroid regimen
Pain reduced on day 1. 40 Holland10
80% of patients preferred the
steroid regimen
Significantly reduced pain 100 Bamgbose11
(p < 0.5) up to day 2
Pain significantly reduced on day 22 Zandi12
2 (p < 0.05)
afferents activate the vomiting centre by stimulation of 5-
hydroxytryplamine-3 (5-HT3 ) receptors, and the vestibular
system responds to motion. Glucocorticoids reduce PONV
by depleting 5-HT3 in neural tissue and prevent its release
in the gut, and they have a synergistic action with 5-HT3
antagonists.15
The specific efficacy of glucocorticoids as antiemetics
has not been studied in patients having oral or maxillofacial
surgery. PONV has a negative impact on patient satisfaction
and comfort. It also increases recovery time, the duration of
hospital stay, and episodes of unplanned admission to hos-
pital because of intractable PONV. Repeated surveys have
shown that patients fear PONV more than pain in the post-
operative period while physicians commonly think that pain
is the patient’s biggest concern.16
In a retrospective cross-sectional analytical survey of
553 consecutive patients who had maxillary or mandibular
osteotomies, or both, there was a 40% incidence of PONV.14
Important predictive factors were age (15–25 years), previ-
ous history of motion sickness or PONV, or both, vertigo,
or migraine headaches, use of volatile general anaesthet-
ics, postoperative pain, and use of analgesic opioid drugs.
Female patients had a 20% increased incidence of PONV, a
smaller increase than in other studies, some of which have
shown an increased incidence of two or three times. In con-
trast with other studies, this group did not find an increase
in PONV among non-smokers or obese patients. Bimaxil-
lary osteotomy is the strongest predictive factor for PONV
and may be attributed to the longer operating time. Maxil-
lary osteotomy has a higher risk of PONV than mandibular
osteotomy, which is probably related to greater postoperative
bleeding and the emetogenic nature of blood. Hypotensive
anaesthesia, which is routinely used in orthognathic proce-
dures to reduce blood loss may in itself induce PONV.14,16
A quantitative systematic review of the use of glucocor-
ticoids to treat PONV showed that in studies that compared
dexamethasone with placebo, the number needed to treat to
prevent early and late vomiting was 7.1 (95% CI 4.5–18) and
3.8 (95% CI 2.9–5). Two adult trials analysed the effect of
dexamethasone on nausea; the number needed to treat was 4.3
(95% CI 2.3–26).15 In combined treatment with dexametha-
100 S. Chegini, D.K. Dhariwal / British Journal of Oral and Maxillofacial Surgery 50 (2012) 97–101
Table 3
Complications of short-term glucocorticoid treatment.
Allergic reaction – skin reaction/anaphylaxis
Skin changes – steroid acne/paper thin skin/bruising
Increased serum glucose
Adrenal suppression (if high dose)
Disturbance of wound healing
Impaired immunity
Increased cardiovascular risk
Increased morbidity in pre-existing peptic ulcer disease
Glaucoma
Psychiatric disturbance – change in mood/psychosis
sone and a 5-HT3 receptor antagonist, the mean incidence
of early nausea was 3.9% (95% CI 1–7%), and early vom-
iting was 1.4% (95% CI 0.2–3%). When using single drug
regimens, 5-HT3 receptor antagonists are superior to a sin-
gle intraoperative dose of dexamethasone 8 mg in preventing
PONV.
Complications of steroids
The complications of glucocorticoid treatment can be divided
according to dose and duration of treatment. Long-term (more
than one week) use of corticosteroids can cause iatrogenic
Cushing syndrome. The side effects of short-term use are
listed in Table 3.
Complications are rare and, to our knowledge, only one
study that investigated glucocorticoid treatment in orthog-
nathic surgery has reported steroid-induced acne; none have
recorded severe complications.17 Butler et al. measured the
postoperative serum cortisol concentrations of patients under-
going major maxillofacial operations. They had been given
dexamethasone more than 20 mg intraoperatively, and 60 mg
postoperatively. Despite these high doses, normal serum cor-
tisol concentrations were restored by day seven.18
The commonest complication of glucocorticoid treatment
is a rise in serum glucose concentration. In healthy patients
this has little importance, but diabetic patients experience
a temporary loss of glycaemic control. In a randomised,
double-blind, placebo-controlled trial on the postoperative
body mass results of patients having laparoscopic gastric
bypass surgery who were given dexamethasone 8 mg intraop-
eratively, the maximum blood glucose value at 12-h follow-up
in the dexamethasone group (10.4 (1.6) mmol/L−1 ) was
significantly higher than in controls (8.8 (1.7) mmol/L−1 )
(p < 0.05).19 All patients in this trial were clinically obese
with impaired glucose tolerance, but patients who have
orthognathic surgery are rarely from this risk group. Clini-
cally, a higher blood glucose concentration is not as important
as an unpredictable level that is difficult to control.
In addition to hyperglycaemia, exogenous glucocorticoids
may produce drug dependent mineralocorticoid effects on
the body, which manifest with fluid retention (important for
patients with underlying cardiac or renal disease). Combined
with a vascular effect this causes a rise in blood pressure, and
can be seen in patients both with and without hypertension.4
Pulsed steroid therapy in dermatology patients has been
shown to increase the incidence of cardiovascular events,
particularly in “at risk” groups.4
Glucocorticoids retard fibroblasts, but the clinical signifi-
cance of this is debatable as wound healing is not affected
by their short-term use in animal models, and in patients
having third molars extracted.3,20 In theory, a reduction in
swelling around the wound should enhance the local circula-
tion which may paradoxically improve wound healing. The
effect on wound healing of multiple doses of preoperative and
postoperative glucocorticoids in patients having orthognathic
surgery has not been evaluated.
The biological effect of glucocorticoids on wound heal-
ing is thought to increase the risk of a number of adverse
gastrointestinal events such as gastritis, formation of an ulcer,
and gastrointestinal bleeding.4 This is important if the patient
has other risk factors with the concomitant prescription of
NSAIDs.
Adrenal suppression may occur after patients are given
high dose glucocorticoids. A preoperative dose of dexam-
ethasone 8 mg does not suppress adrenal function, and allows
electrolyte levels to return to normal by day seven.
In an audit to assess the incidence of complications of
short-term use of corticosteroids, Precious et al. found that of
1276 adults who had had orthognathic surgery with glucocor-
ticoid therapy, only 8 (all women) developed steroid-induced
acne.17
Steroids can increase intraocular pressure; this ceases to
increase when glucocorticoids are stopped.21 Patients with
pre-existing primary open angle glaucoma, connective-tissue
disease, type-1 diabetes mellitus, high myopia, or a first-
degree relative with primary open angle glaucoma are at
particular risk.
The psychiatric effects of glucocorticoids are another
uncommon but recorded complication. Median onset of psy-
chiatric symptoms after the start of steroid treatment can be
as short as three to four days. The symptoms are short-lived
and recovery can take a week after the medication is stopped.
There is a ratio of 2:1 that predisposes women, and those with
systemic lupus erythematosus (SLE) are at higher risk with
long-term steroid treatment.22
Alternatives to steroids
Postoperative oedema can be reduced by using a surgi-
cal drain to remove extracellular fluid and collections to
prevent the accumulation of inflammatory substances. In a
randomised trial, a rubber drain was as effective as gluco-
corticoid therapy in reducing trismus, but not as effective in
reducing postoperative pain or absolute facial oedema.12
A cold press or “mock press” applied in 10 healthy vol-
unteers caused a physiological increase in serum cortisol,
beta-endorphin, and ACTH, and raised the pain threshold,23
but the exact mechanism is not clear. In a comparison of con-
 S. Chegini, D.K. Dhariwal / British Journal of Oral and Maxillofacial Surgery 50 (2012) 97–101
trols with patients having third molars extracted, 45 min of
ice compression was found to significantly reduce pain three
days after operation.24
Conclusion
Glucocorticoids are given to patients to relieve postopera-
tive pain, swelling, trismus, and nausea and vomiting after a
wide variety of surgical procedures including orthognathic
surgery. They are thought to improve the patient’s expe-
rience of recovery, reduce the risk of complications, and
reduce healthcare costs. The stress response can be reduced
by a shorter operating time and less manipulation of tis-
sue.
Preoperative glucocorticoid therapy is effective in reduc-
ing postoperative swelling in orthognathic surgery,25 but the
dose and duration of treatment remains contentious, and the
additional value of postoperative doses remains uncertain.
After operation patients commonly require multiple anal-
gesic drugs, and it is the ability of glucocorticoids to reduce
analgesic and antiemetic requirements that seems to be clin-
ically relevant. In orthognathic surgery, steroids are given
for their other properties, but the relation between the type
and dose of glucocorticoid drug, and the requirement for
analgesia needs to be established.
At present there is little evidence for an “ideal” therapeu-
tic dose of glucocorticoid in orthognathic surgery. Regimens
used currently may be reduced if combined with cold-press
and drains, and they benefit from a cumulative effect with
NSAIDs and synergistic antiemetics.
Given the safe use of short-term high dose glucocorti-
coids and evidence of several benefits, it is difficult to justify
withholding their use on the grounds of a lack of evidence.
Similarly, it may not be ethical to propose a clinical trial that
compares glucocorticoid therapy with placebo, but trials that
compare preoperative with combined preoperative and post-
operative regimens in patients having orthognathic surgery
are needed.
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