Complications in

Orthognathic Surgery
A Report of 1000 Cases
Megan T. Robl, DDS, MDa,*, Brian B. Farrell, DDS, MDa,b,
Myron R. Tucker, DDSb

KEYWORDS
 Complications  Orthognathic  Surgery

KEY POINTS
 Multiple complications secondary to orthognathic surgery are evaluated based on a study of 1000
consecutive procedures.
 Complications may develop in the preoperative, intraoperative, and postoperative stages of patient
care.
 A thorough understanding of intraoperative and postoperative complications allows the appropriate
steps to be taken to maximize an esthetic and functional endpoint.

Multiple factors come into play when treating the
individual with a dentofacial deformity to provide
the most esthetic and functional result.1 Because
of the precise planning required and complexity
of the surgery, a multitude of levels exist from
which errors can occur. For even the most experi-
enced surgeon, unforeseen complications may
arise. Obstacles that may lead to complications
can be divided as:
 Preoperative
 Intraoperative
 Postoperative
In this article, the authors review complications
by studying those that occur in the previously
listed phases of treatment. One thousand consec-
utive patients who underwent orthognathic sur-
gery performed by the senior author over a
5-year time period were evaluated. These cases
included 337 mandibular osteotomies, 274 maxil-
lary osteotomies, and 389 combined osteotomies.
complications, management of these situations,
and resolution of the complications.
COMPLICATIONS RESULTING FROM
PREOPERATIVE PLANNING ERRORS
The introduction of computer-aided surgical simu-
lation has greatly enhanced the efficiency and ac-
curacy of orthognathic surgery. Computer-aided
surgical simulation allows dentofacial deformities
to be better visualized and evaluated with relation
to roll, pitch, and yaw. This 3-dimensional virtual
plan can then be transferred to the operating
room via a prefabricated splint. In traditional treat-
ment planning, the workup involves reproduction
of the occlusal discrepancy on a semiadjustable
articulator through facebow transfer. The occlusal
relationship is referenced through measurement of
fixed points. Manipulation can then be completed
with the occlusal correction subsequently re-
mounted. Errors and inaccuracies in this model
oralmaxsurgery.theclinics.com

Table 1 provides a more precise breakdown of the surgery can contribute to compounding errors
procedures. Reviewing these cases provides a that are ultimately transferred to the operating
better understanding of the most common room and patient. Often, incorrect centric relation

a
Carolinas Center for Oral and Facial Surgery, 411 Billingsley Road, Suite 105, Charlotte, NC 28211, USA;
b
Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New
Orleans, LA, USA
* Corresponding author.
E-mail address: meganroblddsmd@gmail.com

Oral Maxillofacial Surg Clin N Am 26 (2014) 599–609

http://dx.doi.org/10.1016/j.coms.2014.08.008
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600 Robl et al
Table 1
Procedures in the 1000 cases
Procedure
Mandibular osteotomies
Total
Isolated Mandible
Double jaw
Bilateral sagittal split osteotomy
TOVRO
Subapical (total)
Maxillary osteotomies
Total
Isolated Maxilla
Double jaw
Single piece
Segmental
records may not be identified during the preoper-
ative phase of treatment, only to be discovered
during the intraoperative or postoperative period.
Use of virtual surgical planning eliminates many
of the uncertainties that go into preparing a case.
Computer-aided surgical simulation is addressed
in the article “Virtual Surgical Planning in Orthog-
nathic Surgery” by Drs Franco, Farrell, and Tucker
elsewhere in this issue.
It is essential to understand the patient’s func-
tional and esthetic challenges to ensure that sur-
gery will address their concerns. Proper patient
education is necessary to comprehend not only
the surgery itself, but also the postoperative
course. Visual aids at the preoperative visits, using
current computer programming software (eg, Dol-
phin Aquarium, Dolphin Software, Chatsworth, CA,
USA) in addition to prediction imaging, can provide
the patient with further insight into their treatment.
Patient willingness and motivation directly impact
the patient’s satisfaction and compliance in the
postoperative period.
In this series of 1000 patients, there were no
significant complications identified as a result of
errors in the presurgical planning phase.
INTRAOPERATIVE COMPLICATIONS
Hemorrhage
A review of the literature reveals a number of reports
concerning bleeding. All indicate that serious bleeds
are rare.2–4 No intraoperative bleeding problems
requiring secondary intervention were observed in
the 1000 cases reviewed. One patient returned to
the operating room to control and reduce bleeding
immediately after a Lefort I osteotomy. The de-
scending palatine vessels were recauterized and a
surgical pack was placed. Three patients required
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a nasal packing in the post anesthesia care unit.
No patient returned for bleeding problems after hos-
pital discharge. In similar studies involving compli-
n cations in orthognathic surgery, Panula and
colleagues5 reviewed 655 patients, reporting 1
case of a serious bleed. Kramer and colleagues6
726 found extensive bleeding in 1.1% of a prospective
337 study of 1000 patients. A survey by Lanigan7 of
389 approximately 800 oral and maxillofacial surgeons
684 found 18 cases of serious intraoperative bleeding
35 and 21 cases of postoperative bleeding.
7 Intraoperative complications may occur sec-
ondary to maxillary or mandibular osteotomies.
663 Hemorrhagic complications associated with os-
247 teotomies through the posterior maxilla have
389 been well documented.8 Understanding the perti-
321 nent head and neck anatomy, common sources
342 of hemorrhage can be elucidated. Vessels most
often involved include the descending palatine ar-
teries, pterygoid venous plexus, masseteric artery,
retromandibular vein, and the facial artery. Maxil-
lary venous bleeding most commonly involves
the pterygoid venous plexus. If the bleed is arterial,
the vessels most commonly associated are termi-
nal branches of the maxillary artery, often the de-
scending palatine and sphenopalatine arteries.
Cauterizing the descending palatine vessels at
the time of surgery can prevent a postoperative
bleed. During pterygomaxillary dysjunction (maxil-
lary downfracture), the maxillary artery and its
branches are the most susceptible to injury.6
Bleeding may also result from a superiorly posi-
tioned pterygoid plate fracture after pterygomaxil-
lary dysjunction that results in internal carotid
artery hemorrhage. The sharp edges of the de-
tached pterygoid plates forced back during the
downfracture are implicated in lacerating the inter-
nal carotid artery and jugular vein.6 Should
bleeding occur during surgery, the following steps
allow one to properly achieve hemostasis.
1. Initial measures include hypotensive anesthesia,
adequate visualization, and direct pressure.
2. Hemoclip or electrocautery may be utilized in
addition to local measures, such as Surgicel
(oxidized cellulose sponges; Ethicon, Somer-
ville, NJ, USA) or Avitene (microfibrillar bovine
collagen; Medline, Mundelein, IL, USA).
3. In cases where there is persistent low-pressure
bleeding (pterygoid venous plexus area) packing
often stops the oozing, but once removed
bleeding continues. In such cases, the osteot-
omy can be completed and fixated with packing
placed, leaving the tail of packing exposed
through the posterior aspect of the incision. The
packing is then easily removed on the following
day, usually with resolution of the bleeding.

4. Nasal packing can be applied in cases of
severe bleeding.
5. External carotid ligation has been implied previ-
ously in the literature; however, collateral circu-
lation limits the success of this option.9
6. Ultimately, arteriography with embolization can
be used as a last resort.
A lack of surgical hemostasis, failure to recog-
nize the relevant anatomy, and altered vascular
anatomy in certain cases may lead to continued
hemorrhage. In addition, hypotensive anesthesia
during the procedure may mask delayed bleeding.
Secondary hemorrhages usually occur in the
range of 7 to 14 days postoperatively, often from
necrosis of the vessel wall that was initially injured
at the time of surgery with temporary clotting but
subsequent breakdown of the clot and a larger
portion of the vessel wall.10 Options for managing
a secondary hemorrhage may be through injection
of vasoconstrictor, nasal or antral packing, surgi-
cal exploration, or with the help of interventional
radiology. If this is handled with surgical ligation
or embolization, control of the source of the hem-
orrhage should be achieved as close to the bleed
as possible. This minimizes the possibility of a re-
bleed from the collateral circulation. An interven-
tional radiologist may utilize gelfoam, surgicel,
avitene, polyvinyl acetate, embospheres, and
onyx as hemostatic agents to control bleeds.11
In mandibular osteotomies, hemorrhage may
result from injury to the maxillary artery, the facial
artery and vein, the inferior alveolar artery, and the
retromandibular vein. If the procedure is an in-
traoral vertical ramus osteotomy, the vessels at
risk differ somewhat and include the masseteric
and inferior alveolar vessels, vessels supplying
the medial pterygoid, and the maxillary artery.
Table 2 lists the most commonly implicated sour-
ces of bleeding.
Table 2
Common sources of bleeding during
osteotomies
Maxilla Mandible
Arterial
Descending palatine Masseteric
Internal Maxillary Facial
Sphenopalatine Inferior alveolar
Internal carotid Medial pterygoid
Venous
Pterygoid plexus Facial vein
Inferior alveolar
Retromandibular
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Complications in Orthognathic Surgery 601
Neurosensory Disturbance
Some degree of neurosensory disturbance is an
inherent sequelae in any orthognathic procedure.
It is important to educate patients before the pro-
cedure so that they are prepared for this in the
postoperative course. Factors influencing neuro-
sensory disturbance include:
1. Patient age
2. Nature of the nerve injury
3. Variation in surgical technique
4. Surgeon experience
5. Concomitant surgery (genioplasty)
6. Follow-up time
7. Methods used for assessment (subjective or
objective)
Depending on these factors, there are 4 basic
outcomes in terms of neurosensory recovery:
1. The patient may have complete return of
sensation
2. Incomplete return clinically but the patient is
unaware of the sensory deficit
3. Incomplete return and the patient is aware of
the deficit but it is not associated with problems
4. The patient is aware of the deficit and bothered
by the loss of sensation
Patient education carries a direct relationship
with success in the postoperative course. There
must be a realistic assessment of expected neuro-
sensory outcome based on the age of the patient in
addition to the procedure being performed. Virtual
surgical planning and computed tomography en-
ables accurate anatomic identification and locali-
zation of the inferior alveolar nerve. This allows
the surgeon to enter the operating room knowing
how far the inferior alveolar nerve is located from
the inferior border of the mandible in addition to
its position buccal/lingually. Knowing the exact
spatial relationship to the anatomic borders of the
mandible is invaluable information when making
the vertical osteotomy cut. Fig. 1 provides an ex-
ample of the nerve analysis available through vir-
tual surgical planning.
Protection of the inferior alveolar nerve during
surgery is a priority. If the nerve does initially
remain in the proximal segment requiring signifi-
cant manipulation and repositioning, a 2-fold in-
crease in the chances of neurosensory
disturbance.12 One must provide gentle retraction
for access and visualization to minimize stretch
injury to the nerve. On fixating the mandible, it is
important to eliminate any compression of the
nerve that may result from bony elevations within
the osteotomy or from compression owing to
fixation techniques.
602 Robl et al
Fig. 1. Nerve analysis provided by Medical Modeling.
In our study of outcomes from orthognathic sur-
gery, we found the following results, which are
provided in Table 3. In the majority of patients,
neurosensory deficit was not a long-term problem.
Management of nerve injury during surgery can
contribute significantly to the patient’s recovery.
If transection is noted, tension-free reapproxima-
tion is performed. Care must be taken to release
proximal and distal segments of the nerve to allow
for passive anastomosis. Epineural sutures can
then be placed. Generally, a 7-0 or 8-0 monofila-
ment nonresorbable nylon suture can be used in
a simple interrupted fashion.13 A complete tran-
section of the inferior alveolar nerve occurred in
21 cases or 1.5% of the time. Of the 383 patients
with complete return of sensation, no patient was
over 38 years of age; 82% were under the age of
18. Of the 14 patients with a residual neurosensory
deficit who were bothered by the loss of sensation,
Table 3
Reported neurosensory deficits (n 5 769)
Deficit
Complete return of sensation
Incomplete return but patient unaware
of sensory deficit
Incomplete return, patient aware of deficit
but not associated with problems
Patient aware of deficit and bothered by
loss of sensation
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the minimum age was 38 years. This supports the
belief that age is probably the most influential fac-
tor determining return of sensation after bilateral
sagittal split osteotomy.
During mandibular surgery, the lingual nerve is
also at risk for injury. This may occur during
dissection or as a result of impingement from
screw fixation. Often, this is transient; however,
this deficit is more problematic for patients than
that of lip/chin paresthesias. The literature reports
studies of lingual nerve deficits to range between 1
and 12%.14
Neurosensory disturbance during the Lefort pro-
cedure may also result in long-term deficits in a
small percentage of individuals. In the senior au-
thor’s experience, 2.2% of individuals reported
deficit to the upper lip long term and 9% to the
teeth, palate, and gingiva.
The Unfavorable Split of Sagittal Ramus
Osteotomies
For many, the dreaded complication of orthog-
nathic surgery is the unfavorable split of a sagittal
osteotomy. In combined jaw surgery, there are a
variety of techniques based on surgeon prefer-
ence.15 Some choose to perform maxillary sur-
gery first; others may make mandibular cuts
then proceed to maxillary surgery, and some sur-
geons perform mandibular surgery and fixation
first. In double jaw surgery performing mandibular
surgery first, a bad split becomes especially prob-
lematic if management of segment position is not
possible because the positioning reference for
maxillary surgery (based on the fixated mandible)
is lost.
Key technical elements to minimize the possi-
bility of a bad split include:
1. Saw cut must extend into the retrolingular
depression (Fig. 2)
2. Adequate thickness of the buccal cortex should
be preserved to prevent a buccal plate fracture
(Fig. 3)
3. The junction of the medial and vertical cuts
should be rounded with avoidance of acute
line angles (see Fig. 3)
4. The cut at the inferior border should provide
adequate thickness of bone to maintain the
n
facial portion of the inferior border on the prox-
468 imal segment (Fig. 4)
213
The most important aspect of the osteotomy is
to ensure proper inferior border separation. During
74
the sagittal osteotomy, monitor for equal separa-
tion of the osteotomy throughout the entire extent.
14
It may be necessary to refine the inferior border or
retrolingular depression cuts to aid in equal
 Complications in Orthognathic Surgery 603

Fig. 2. Saw cut extending into retrolingular

depression.

separation. The different types of unfavorable Fig. 4. Facial portion of inferior border staying with
splits and their management are described. proximal segment creating a J-shaped curvature.

1. Proximal segment fractures with adequate

bone for sagittal overlap (Fig. 5): The mandible
remains intact because the osteotomy is
incomplete and there is a smaller fracture of
the lateral cortex with adequate bone available
for sagittal overlap. To remedy this, perform a
sagittal osteotomy of the remaining portion of
the inferior border. Then, position the proximal
segment and stabilize it with screw or plate
fixation. The fractured segment can also be
secured as a free graft using plates/screws.
One may want to consider additional plates
and screws if necessary.

Fig. 5. Proximal segment fracture with adequate

bone for sagittal overlap managed with screw fixa-
Fig. 3. Rounded junction of medial and vertical cuts tion of proximal to distal segment in addition to screw
with adequate thickness of buccal cortex. fixation of the free graft.

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604 Robl et al
2. Proximal segment fractures with insufficient
bone for sagittal overlap (Fig. 6): The mandible
remains intact with the osteotomy incomplete
and there is a loss of a large portion of buccal
segment. There is inadequate bone available
for sagittal overlap. Management involves verti-
cal ramus osteotomy on the remaining intact
portion of the ramus with control of the prox-
imal segment. The proximal segment can then
be fixed to the distal segment. The buccal frag-
ment can then be used to overlap the defect.
3. Proximal segment fractures with mandible
separated (Fig. 7): The osteotomy is achieved
with the mandible separated and in multiple
pieces. There is a resulting proximal segment
with discontinuity. Management includes rees-
tablishing continuity using small bone plates.
The proximal segment can then be reattached
to the distal segment using a screw technique.
Any areas of overlap may be helpful to allow
initial screw stabilization.
4. Lingual segment fracture (Fig. 8): Prevention of
lingual segment fractures may come from early
removal of third molars approximately 9 months
to 1 year before an osteotomy.16 In addition,
there should be adequate thickness of bone in
the lingual segment and careful separation of
the superior portion of the osteotomy with
avoidance of fulcruming on the lingual seg-
ment. Management involves fixation of the
proximal segment to the distal segment using
bone plates followed by screw fixation of the
lingual segment to the proximal segment. This
provides stability to the distal segment as well
as the fractured lingual segment.
Fig. 6. (A) Proximal segment with insufficient bone for sagittal overlap managed with vertical osteotomy of
remaining ramus. (B) Buccal fragment then used to overlap defect.
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In a review of the 684 bilateral sagittal split os-
teotomy surgeries, bad splits were observed in
3.9% of the cases. This included a total of 11 major
fractures requiring significant revision of the os-
teotomy or alteration of the fixation technique. In
16 cases, there were minor bone fractures that
did not require significant modification of the in-
tended surgery. None of the bad splits altered
the overall patient outcome. The patients were
not placed into maxillomandibular fixation and
there were no resulting infections.
Oro–Antral Communication
During maxillary surgery, design of the segmental
osteotomy must keep in mind the relevant anat-
omy. Bone is thickest in the midline where tissue
is the thinnest. Osteotomies in the midline are
more likely to result in palatal tears and these
may be less likely to heal than when a tear occurs
laterally, in thicker tissue.17 Therefore, parasagittal
cuts for a segmental osteotomy near the lateral
aspect of the nasal floor places them over thin
bone and thick, more elastic, vascularized tissue
(Fig. 9). Despite proper site selection and careful
surgery, violation of palatal mucosa may occur.
In most cases, small tears do not need treatment
and heal uneventfully. If a larger opening is pre-
sent, it can be managed by placing a very small
amount of collagen membrane layer in the tear;
the area is dried and then sealed with dermabond
(Fig. 10).
In some cases, a persistent fistula may present.
Initial treatment includes routine sinus manage-
ment with decongestants, nasal spray, and

Fig. 7. Proximal segment fracture with the mandible
separated managed with reestablishing continuity
using small bone plates. Screw technique then used
to reattach proximal to distal segment.
antibiotics. Obturation of open fistulas using a soft
“suck-down” material made from the final model
usually results in significant shrinkage or complete
elimination of the fistula. Among the 1000 cases,
Fig. 8. Management of lingual segment fracture
utilizing small bone plate then screw fixation of
proximal to distal segment.
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Complications in Orthognathic Surgery 605
there were 12 small palatal tears associated with
segmental maxillary surgery. Nine of these were
treated with tissue glue and 3 had no treatment.
In all 12 instances, no patients developed a persis-
tent fistula lasting longer than 3 weeks or required
secondary surgery for closure.
POSTOPERATVE COMPLICATIONS
After orthognathic surgery, some degree of
postoperative discomfort is expected. Some pa-
tients may exhibit extreme pain, prolonged
swelling, marked bruising, and infection.2 How-
ever, all patients described an initial postoperative
complaint of a sore throat.1 Fortunately, the expec-
tant neurosensory deficit masks some of the
discomfort in the recovery period. Additionally,
every patient will have a varying degree of edema
dependent on the time in surgery, extent of tissue
manipulation, skin type, and any nonsteroidal
anti-inflammatory drug or aspirin use. For the pur-
poses of this study, bruising was recorded if there
was obvious facial discoloration at the first postop-
erative appointment (usually 5–7 days postopera-
tively). Only 20% of patients showed signs of
bruising at the first postoperative visit.
Infection
Infection is obviously a potential complication with
any surgical procedure. Fortunately, the rates of
infection are very low with orthognathic surgery.
Of the infections, 21 were in the mandible and 4
in the maxilla. The results studied were divided
into minor and major infections. Minor infections
were those demonstrating superficial wound in-
fections, and were treated with small incisions
and drainage with continued antibiotic coverage.
Major infections were defined as those requiring
more aggressive debridement, bone grafting, or
both. Three such cases occurred in the mandible
and 1 in the maxilla. This accounts for an overall
infection rate of 2.4% in the mandible and 0.5%
in the maxilla.
Vascular Compromise
Problems with wound healing may be owing to a
variety of causes. In maxillary surgery particularly,
this may involve some degree of avascular necro-
sis of bone and soft tissue (Fig. 11). Contributing
factors associated with avascular necrosis include:
1. Smoking (local and systemic impact)
2. Osteotomy design
3. Flap design and management
4. Segment movement/rotation
5. Stretching and pinching of the tissue
6. Splints
606 Robl et al

Fig. 9. Illustration (A) and clinical photo (B) to illustrate design of segmental osteotomy with parasagittal cuts to
best avoid palatal tears.

Avascular necrosis may occur between osteot-
omy cuts in segmental maxillary surgery. Manage-
ment involves the following steps:
1. Verify there is no splint impingement
2. Eliminate mobility
3. Utilize a tissue dressing such as Vaseline gauze
Antibiotics (local or systemic) may be used at
the discretion of the surgeon. Hyperbaric oxygen
may aid in a more expedient demarcation of vital
and nonvital tissue; however, it does not affect
the ultimate outcome.18–20
For more aggressive treatment, provide debride-
ment only when and where the area of necrosis is
well demarcated. Minimal bone should be re-
moved usually involving only conspicuous necrotic
sequestra. One should allow granulation through
secondary intention rather than primary closure.
Ultimately, the area may require removal of teeth
with subsequent bone grafting and implant place-
ment. The authors observed cases of necrosis, pri-
marily evidenced by loss of gingival tissue. All of
these cases were segmental maxillary surgery
and all of these patients were smokers. One of
the cases resulted in the loss of 2 teeth. All other
cases were managed with local care without surgi-
cal debridement. Two of the patients eventually re-
quired gingival grafts.
Endodontic Therapy
After orthognathic surgery, loss of vascularity to
the dentition is rare, but initial loss of response to
pulpal stimulation is common. Long-term sup-
pressed response to stimulation can occur, but
does not necessarily mean a tooth requires end-
odontic therapy. Teeth, like all other tissue, can
bruise. This becomes apparent with initial discol-
oration. Although some teeth may eventually
have necrosis of the pulp and require endodontic
treatment, many teeth recover without treatment,
return to normal coloration, and respond to pulp
testing. In our group of 1000 patients, 4 teeth
adjacent to segmental surgical sites required root
canal therapy. Three of the teeth were associated
with maxillary surgery (0.9% of segmental cases).
Four teeth in 3 other patients required endodontic
treatment not clearly associated with their orthog-
nathic surgery.

Fig. 10. Management of palatal tear (A) with collagen membrane layer and dermabond at the time of surgery
and (B) 8 weeks postoperatively.

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 Complications in Orthognathic Surgery 607

Fig. 11. (A) Avascular necrosis. Tissue appearance immediately after surgery ultimately managed with Vaseline
gauze (B). (C) Appearance 2 months after surgery.

Nasal Abnormalities end of the procedure to control width, because

Nasal abnormalities can be seen after maxillary
surgery. The following can occur as illustrated in
Fig. 12:
1. Septal deviation
2. Inadequate turbinate removal (with septal devi-
ation can increase obstruction)
3. Alar base widening
4. Tip over-rotation
5. Dorsal deformities
Septal correction can be performed postoper-
atively if necessary from an intraoral approach
(Fig. 13). The following steps can be utilized in
an office setting. The septum is dissected off
the floor and the most inferior portion resected
to allow passive repositioning. It can then be su-
tured back to the anterior nasal spine (ANS). In
the senior author’s experience, there were 2
cases of significant septal deviation managed in
this manner. Keep in mind that for prevention of
the nasal deformity after surgery, one must
reduce the ANS to prevent excessive rotation
of the nasal tip. A twisting dorsum and tip devia-
tion may be related to inadequate septum reduc-
tion. An alar base cinch suture is placed at the
soft tissue reflection leads to widening of the
nose.
Malocclusion
There are a variety of thoughts to consider when
a postoperative malocclusion occurs. Below we
review resulting malocclusions and common
causes.
Immediate anterior open bite
1. Inadequate removal of posterior interferences
with displacement of the condyles from the
fossa during fixation
Late open bite development
1. Collapse of transverse expansion
a. Lack of intraoperative methods to maintain
expansion (grafting, splint placement)
b. Lack of postoperative efforts by the ortho-
dontist to maintain expansion (transpalatal
arch)
2. Orthodontic relapse
3. Decreased vertical ramus height from condylar
resorption
4. Additional growth

Fig. 12. Profile view (A), frontal view (B), and worm’s eye view (C) of nasal deformities after orthognathic surgery.
Tip over-rotation (A, B) illustrated along with septal deviation (C).

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608 Robl et al
Fig. 13. Intraoral approach to septal correction.
In this 1000 case experience, 2 patients (0.2%)
who underwent a bilateral sagittal split osteotomy
with rigid internal fixation demonstrated malocclu-
sions and could not function into the splint on the
first postoperative day. These patients were re-
turned to the operating room and the fixation was
revised without any further complication. An impor-
tant point to keep in mind is that subtle occlusal dis-
crepancies may be overcome with guidance elastics
and improved neuromuscular reprogramming.
Temporomandibular Joint Dysfunction
In patients with preexisting temporomandibular
joint dysfunction, thorough documentation of mus-
cle and joint dysfunction is essential. Orthognathic
surgery can potentially benefit joint dysfunction
through the establishment of a balanced, stable,
and reproducible occlusion; however, this is
difficult to predict with any degree of certainty.
Temporomandibular joint symptoms may improve,
deteriorate, or remain similar to that before sur-
gery. Eighty-six patients had interincisal opening
of less than 40 mm after surgery. Eighty-two of
the procedures were associated with mandibular
osteotomies. Forty-two of the asymptomatic pa-
tients initially developed new temporomandibular
joint symptoms. Less than 1% of these individuals
had symptoms that persisted for greater than
6 months postoperatively, although 3 of the pa-
tients did eventually require conservative therapy
and arthroscopy.
Fixation Failure
One of the most common, significant postoperative
complications is a fixation failure of the mandibular
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osteotomy, usually resulting from technical difficulty
during surgery. This can be problematic if not re-
cognized early in the postoperative period because
it is likely to result in malocclusion, nonunion, and,
potentially, proximal segment rotation and resorp-
tion. Surgical correction can then become much
more technically difficult. Some of the clinical signs
of fixation failure or nonunion include:
1. Palpable mobility of segments
2. Clinical evidence of persistent infection
3. Open bite tendency
4. Class III occlusion on the affected side
5. Midline shift toward the opposite side
6. Premature contact on the side of the nonunion
If a problem is suspected with a mandibular
osteotomy early, options for treatment include
the following:
1. Limiting patient function and thus mobility through
heavy elastics/maxillomandibular fixation
2. More aggressive approach of reoperation with
reinforcement of the fixation
If the problem is addressed later, then fixation
may be reinforced, intraoral debridement per-
formed, and bone grafting done, if necessary, in
the absence of infection. This approach parallels
that for managing nonunion of a mandibular frac-
ture. In this group of 1000 patients (726 mandibular
osteotomies), there were 2 cases of fixation failure
in the mandible. One patient required debridement
and replacement of fixation; the second case
required debridement, replacement of fixation,
and bone grafting.
In conservative management of the mobile
maxilla, consideration is given to soft diet, discon-
tinuation or decreased strength of elastic traction,
modified splint to balance occlusion, local and
systemic management of infection, elimination of
parafunctional habits, and close observation. Sur-
gical management in a malunion or nonunion of
the maxilla involves:
1. Recreation of the osteotomy with aggressive
mobilization
2. Removal of all fibrous tissue
3. Passive repositioning of segments
4. Rigid fixation to resist segment displacement
(consider auxiliary fixation, transpalatal support)
5. Grafting for continuity
One case of a nonunion of the maxilla resulted in
the need for revision of the osteotomy, fixation and
bone grafting.
According to a study by Falter and colleagues,21
the need for plate removal was indicated in infec-
tion, clinical irritation, hardware fracture, and patient

request. In addition, resorbable plates and screws
have also been used for fixation in orthognathic sur-
gery. In a study comparing resorbable with titanium
fixation plates, greater complications rates were
noted in the group who received a resorbable plate
(18.3%) compared with the titanium group (8.6%).
These patients had a greater prevalence of postop-
erative open bite and surgical relapse.22
SUMMARY
Orthognathic surgery provides an effective means
for the correction of facial disharmonies to provide
patients with a functional occlusion. With any
procedure, regardless of surgeon experience,
complications may arise. In reviewing these com-
plications, a better understanding of how to not
only manage them, but also to prevent their occur-
rence can be gained. By educating all surgical pa-
tients through informed consent, we can prepare
them for what will come with the surgical proce-
dure. Most complications are common to orthog-
nathic surgical procedures and can be discussed
with the patent in detail before the procedure.
Continued advances in the field of orthognathic
surgery, especially with the inclusion of virtual sur-
gical planning, have served to modernize our
treatment planning and bring patients to an ideal
result.
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