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Complications in Orthognathic Surgery

Article  in  Journal of Craniofacial Surgery · January 2018

DOI: 10.1097/SCS.0000000000004238

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 BRIEF CLINICAL STUDIES
Complications in
Orthognathic Surgery
Sergio Olate, DDS, PhD,!y Eder Sigua, DDS, MSc,y
Luciana Asprino, DDS, PhD,y
and Márcio de Moraes, DDS, PhDy
Abstract: The aim of this study was to analyze the presence of
complications related to orthognathic surgery performed by sur-
geons in train. A retrospective study was conducted between 2005
and 2014, analyzing the clinical records of patients treated in the
authors’ Department. Patients who underwent orthognathic surgery
were included, under a bidimensional analysis and with the con-
ventional orthosurgical sequence; intraoperative complications
were identified, such as the occurrence of a bad split, bleeding,
tissue injury, among others and postoperative variables such as
impaired sensation, infection, and alterations in the osteosynthesis
systems. A statistical analysis was done using x2 and Student t tests,
considering a statistical significance when P < 0.05. Two hundred
fifty patients were included with an average follow-up of 13
months; 62.8% were women and 37.2% were men; 18.8% of the
subjects presented some type of intraoperative or postoperative
complication; excluding relapse and complications due to loss of
bonding of the orthodontic device, a 12.4% complication rate was
observed; intraoperative complications were 8% and postoperative
complications 10.4%. Only the sensorineural alterations were asso-
ciated with the mandibular surgery (P < 0.05). Finally, orthognathic
surgery is relatively safe and produces a low number of complica-
tions when it is performed by surgeons in train.
Key Words: Complication, dentofacial deformity, orthognathic
surgery
O rthognathic surgery is a set of techniques, in the main safe and
versatile, that resolve important functional and esthetic altera-
tions. Although the reported complications are limited, when they
occur, increase the surgery time, the risk of permanent deficiencies
and the need for reoperations, and also make the patient’s quality of
life difficult.1– 3
The surgeon’s experience has been linked to the presence of
more or fewer alterations, but recent studies by Al-Nawas et al4
have indicated that young surgeons can have a performance similar
to more experienced surgeons in terms of complications.
Some studies have reported complications associated with
orthognathic surgery, separating them according to operation.
Kim and Park5 reported findings in subjects between 20 and 29 years
and 15 and 19 years of age. Intraoperative complications due to
From the !Division of Oral and Maxillofacial Surgery, Universidad de La
Frontera, Temuco, Chile; and yDivision of Oral and Maxillofacial
Surgery, State University of Campinas, Piracicaba, Brazil.
Received April 15, 2017.
Accepted for publication October 4, 2017.
Address correspondence and reprint requests to Prof Sergio Olate, DDS,
PhD, División de Cirugı́a Oral y Maxilofacial, Universidad de La
Frontera, Claro Solar 115, Temuco, Chile, 4780000;
E-mail: sergio.olate@ufrontera.cl
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004238
The Journal of Craniofacial Surgery " Volume 00, Number 00, Month 2017
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
nerve injuries or bad fractures in osteotomies were 3.7%, excessive
bleeding in 2%, damage to soft tissues in 2%, and exposure of the
inferior alveolar nerve in 1.3%.
Bad splits appear among the most common;6 modifications to
the technique and the use of other osteotomy systems have been
proposed as options to reduce the risk of bad splits.7 Likewise, some
anesthetic protocols also have been implemented to reduce intra-
operative bleeding and to decrease the possibility of vascular
injuries.8
In the postoperative stage, impaired sensation is related to
patient discomfort;6 however, other authors have described some
of these alterations as being inherent to the procedure, considering
that a significant percentage can present sensorial limitations that
may or may not cause changes to the patient’s daily life.5,6
Complications in surgical procedures require constant assess-
ment, and the aim of this study was to analyze the complications
presented in patients treated with orthognathic surgery.
METHODS
A retrospective study was designed of patients treated in the
Division of Oral and Maxillofacial Surgery at the State University
of Campinas between 2005 and 2014 in the postgraduate program in
Oral and Maxillofacial Surgery. When undergoing surgery, the
patients included signed an informed consent that authorized the
execution of this study; the entire process respected the Helsinki
Declaration.
Patients were included without discriminating for gender and
who were between 18 and 55 years of age, subjected to a conven-
tional orthosurgical treatment with the orthodontic sequence and
preoperative dental preparation, orthognathic surgery under general
anesthesia, and orthodontic completion. Patients who were outside
the protocol such as those operated with ‘‘surgery first’’ or ‘‘surgery
early’’ were excluded; also excluded were patients operated on
under 3-dimensional surgery concepts.
All the patients were operated by surgeons in train using the
maxillary protocol first in the case of bimaxillary surgeries; they
received a standardized general anesthesia technique and local
anesthetic at the incision and osteotomy sites. The osteotomies
were performed with a reciprocating saw; in all the patients, a
maxillomandibular block was used during fixation of the maxilla
and fixation of the mandible. Osteosynthesis was carried out with
systems 2.0 and 1.5 in the maxilla, mandible, and chin regions;
maxillary fixation was achieved with 4 L-plates and the mandible
with 1 bicortical screw and 1 monocortical fixation plate, with 3
bicortical screws or with 2 plates and monocortical screws.
The intraoperative variables were bad splits in the osteotomies,
complications in the osteotomy, injuries to nearby tissues and poor
positioning of segments, deficiencies in the osteosynthesis and
alterations in the orthodontic devices; the postoperative variables
were associated with infections, the presence of total paresthesia for
more than 6 months or paresthesia presented as a spontaneous
complaint by the patient in postoperative checkups, damage to soft
tissues like papillae (for example in patients of segmentations)
or mucosal lacerations, loss of fixation and movement of bone
segments.
The analyses were made with descriptive statistics using the
SPSS 23 (IBM, New York, USA) software, using the x2 and Student
t tests, considering statistical significance when P < 0.05.
RESULTS
Four hundred forty-five patients were treated in the Division of Oral
and Maxillofacial Surgery at the State University of Campinas; after
review of medical chart, 250 patients were included. The patients
were followed up for 6 to 60 months with an average of 13 months.
1
Brief Clinical Studies The Journal of Craniofacial Surgery " Volume 00, Number 00, Month 2017

TABLE 1. Intraoperative Complications Observed in 20 Subjects

ID Sex Age Angle Class Surgery Complication

1 F 43 III Maxilla/ mandible Bad split

2 F 24 II Maxilla/ mandible Bad split
3 F 18 II Maxilla/ mandible/chin Orthodontic appliances problem
4 F 35 II Maxilla/ mandible Bad split
5 M 27 III Maxilla/ mandible Orthodontic appliances problem
6 F 27 III Maxilla/ mandible Bad split
7 F 31 II Mandible/chin Bad split
8 M 20 III Maxilla/ mandible Bad split
9 M 20 III Maxilla Orthodontic appliances problem
10 F 18 III Mandible Bad split
11 F 21 II Maxilla/chin Bleeding
12 F 40 III Maxilla/ mandible Bad split
13 M 42 III Maxilla/ mandible Orthodontic appliances problem
14 F 30 II Maxilla Orthodontic appliances problem
15 F 23 I Maxilla Orthodontic appliances problem
16 M 21 I Maxilla Orthodontic appliances problem
FIGURE 1. (A) Exposition of the inferior alveolar nerve, in relation to the buccal
17 M 23 III Maxilla/ mandible Dental problem/ apicectomy
and lingual cortical bone; the nerve has to be removed from the buccal plate
18 M 18 III Mandible Bad split and can be altered in sensorial response after surgery. (B) Bad split in sagittal split
19 F 37 II Mandible/chin Soft tissue lesions osteotomy, using a long plate to as osteosynthesis to fix distal and proximal
20 F 28 II Mandible Bad split segment and 2 screws in the upper side to fix a fractured bone. (C) Bad split in
sagittal split osteotomy, showing the absence of the buccal wall of the mandible;
bad split was related to deficient blade saw position and bad position in the
chisel installation. (D) Plate and screw removed from the sagittal split ramus
osteotomy, 6 weeks after surgery; failure in suture and postoperative infection
could be the causes for the bone sequestration. (E) Panoramic radiograph
The study group was comprised of 157 subjects (62.8%) women showing a set of plates and screw used to resolve a bad split osteotomy in the
and 93 subjects (37.2%) men. In general terms, 18.4% (46 subjects) mandible.
had some type of complication. When the subjects with relapse
from the surgery or problems with the orthodontic device were
excluded, the number of subjects dropped to 31 subjects (12.4%)
with some type of complication.
Of the patients with complications, 18 patients had undergone
TABLE 2. Postoperative Complications Observed in 26 Subjects
monomaxillary surgery, 24 were double procedures (bimaxillary or
monomaxillary surgery with genioplasty), and 4 patients were in ID Sex Age Angle Class Surgery Complication
maxillary, mandibular, and chin surgeries. The average age of the
subjects with complications was 31.6 years of age, with 31 subjects 1 F 32 III Maxilla/ mandible Relapse
being women and 15 being men. 2 F 49 III Maxilla Infection/ sinusitis
The intraoperative complications (Table 1) totaled 20 patients 3 F 59 II Maxilla/ mandible/chin Neurosensory deficits
(8%), of which 8 had deficiencies in the orthodontic device, either 4 F 42 II Maxilla/ Mandible/chin Neurosensory deficits
by breakage or because it lost its bonding, 10 patients with a bad 5 M 36 III Maxilla/ mandible Neurosensory deficits
split in the sagittal split osteotomy (Fig. 1), 1 patient with increased 6 M 31 III Maxilla/ mandible Infection
bleeding during the surgery, 1 patient with dental injury verified 7 F 22 III Maxilla/ mandible Neurosensory deficits
during surgery, and 1 patient with damage to the lower lip. 8 M 31 II Maxilla/ mandible Relapse
In the postoperative stage (Table 2), complications were con- 9 M 40 III Maxilla Relapse
firmed in 26 subjects (10.4%). 8 subjects (3.2%) presented relapse 10 M 39 III Maxilla/ mandible Relapse
of the movement with a need for another surgery in 6 patients, 6 11 F 46 II Mandible Neurosensory deficits
patients (2.4%) presented postoperative infection, 8 subjects (3.2%) 12 F 38 II Maxilla/ mandible Infection/ sinusitis
had important sensorineural alterations (Fig. 1), 2 subjects had 13 F 35 III Maxilla Gingival tissue problem
gingival alterations, and 2 subjects presented osteosynthesis mate- 14 F 28 III Maxilla/chin Neurosensory deficits
rial exposure due to suture dehiscence. 15 F 27 III Maxilla Relapse
The type of complication could not be associated with the type 16 F 39 III Maxilla/ mandible Relapse
of facial deformity (P > 0.05), nor was it possible to relate it to the 17 F 34 II Maxilla/ mandible/chin Neurosensory deficits
number of osteotomies performed (P > 0.05), although the sensori- 18 M 39 III Maxilla Infection/ sinusitis
neural alterations were associated significantly with mandibular 19 F 30 I Mandible/chin Infection
surgery (P ¼ 0.031). 20 F 31 III Maxilla segmental Gingival tissue problem
21 F 26 N Maxilla Relapse
22 M 19 III Mandible Neurosensory deficits
DISCUSSION 23 F 49 II Maxilla Wound or suture problem
Orthognathic surgery has been developed as a successful technique 24 F 23 III Maxilla Infection
with low complications. Bock9 reported that orthognathic surgery is 25 F 41 II Maxilla/ mandible Wound or suture problem
relatively safe, even in patients with cognitive limitations, which 26 M 23 II Maxilla Relapse
would not exacerbate any type of complication.

2 # 2017 Mutaz B. Habal, MD

Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery " Volume 00, Number 00, Month 2017
Technical modifications, such as the use of piezoelectric sys-
tems, could be advantageous in some orthognathic surgery proce-
dures;7 however, Shirota et al10 conducted a comparative study on
the sagittal split osteotomy using a piezoelectric system and sepa-
rator in 1 patient and a Lindemann drill and chisel in other patients,
demonstrating that the use of a piezoelectric system does not
represent significant differences when intraoperative bleeding
and postoperative impaired sensation are analyzed.
Intraoperative Complications
The relapse of the surgical movement is associated with plan-
ning errors, intraoperative difficulties, anatomical limitations, or
limitations in the postoperative orthodontics,11 so their analysis
must also be linked to the stability of the surgical movement.12 Our
results showed 8 patients with some degree of relapse, with 6
patients being reoperated to improve their condition.
The bad split produced in the mandible is one of the most
important complications in the performance of orthognathic sur-
gery. Common factors in the bad split are related to incomplete
osteotomies13 and the presence of third molars, although the rele-
vance of the latter has not been fully defined14 since the simulta-
neous extraction of third molars with the sagittal split osteotomy
may not increase the rate of intraoperative complications.15 The
study by Robl et al6 described 684 sagittal split osteotomies where
3.9% presented a separation or bad split in the osteotomy. Kim and
Park5 reported that the bad split was present in 3.7%, followed by
excessive intraoperative bleeding (2%).
Our results show that 10 subjects (2.5%) presented bad splits in
the sagittal split osteotomy, which is comparable to other studies.
The bad split could not be linked to the type of facial deformity, for
example in the case of a smaller mandible like class II subjects or a
larger mandible like class III subjects (P > 0.05), probably due to
the low number in the sample. In the same direction, bad splits could
not be related to the presence of third molar in the osteotomy
(P > 0.05).
In terms of vascular complications, these were low in our
sample, considering that only 2 patients were involved. Steel and
Cope16 conducted an extensive review to establish prevalent com-
plications, relating a series of complications classified as common
and others as rare or unusual; they reported that a large part of the
vascular complications, even with the death of patients, can be
associated with maxillary downfracture in the Le Fort I osteotomy
and pterygomaxillary disjunction, where traction and trauma can
play important roles.
In 655 patients, Panula et al13 reported only 1 serious patient of
hemorrhaging. Kramer et al17 presented only 1.1% with complica-
tions of significant bleeding, whereas Robl et al6 indicated that the
presence of vascular lesions could occur in patients who smoke,
with shortcomings in the osteotomy design, alterations to the flap
design, movement or rotation of the bone segment, aggressive
movement of the soft tissue, and alterations in the bone division
in the osteotomy. Our results show 1 patient of significant bleeding
in the surgery, of maxillary origin, likely related to maxillary
mobilization, which was resolved with local measures.
Another complication associated with the intraoperative phase is
dental injuries, with maxillary segmentation being mainly associ-
ated with these complications.1 Of the 85 patients described by Ho
et al,1 27% had complications: 3 subjects with devitalized teeth, 3
with periodontal problems, and 1 with tooth loss. However, in the
series by Posnick et al,18 with 262 subjects operated on with
segmentation, 6 teeth were involved in periodontal alterations
(15 of 1008 sites, 1.5%), 3 anterior teeth presented endodontic
injuries, and 2 had nasal communication; Robl et al6 observed that 4
teeth in 1000 patients required endodontic treatment, in teeth
# 2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
adjacent to osteotomies. Our patients also report a low number
of teeth damaged in the surgery, considering also that only 1 patient
of the 46 complications presented maxillary segmentation as part of
the procedures.
Postoperative Complications
Steel and Cope16 reported that nerve alterations are common in
orthognathic surgery, so establishing their status as a complication
may be questionable. Some degrees of sensorineural alterations are
inherent to osteotomies in orthognathic surgery, with 3 conditions
being observed: full recovery of sensation, incomplete recovery
with or without daily problems for the patient, and definitive
sensory loss. In the study by Robl et al,6 60.9% had a full recovery
of sensation, 37.3% presented partial loss with or without discom-
fort for the patient, and 1.8% presented full sensory loss; of the
patients who had a partial recovery all were under 38 years of age,
indicating that age may be relevant to this recovery.
Kim and Park5 indicated that postoperative complications
related to the recovery of sensation appeared in 65% of the cases,
whereas Panula et al13 reported that the main complication observed
in the postoperative stage was sensorineural deficit in 32% of the
patients. It is possible that the definition of this variable has a bias,
and considering impaired sensation as expected or normal has
differences in the results observed. In our series, the direct question
to the patient regarding discomfort and impaired sensation as a
problem was only reported in 7 patients, demonstrating 2.8% of
impaired sensation as a postoperative complication, although the
number of patients who reported sensorineural alterations to vary-
ing degrees was 87 (34.8%) of 250 subjects.
Damage to other nerves (not the inferior alveolar nerve) was
not identified in our sample, although Bowe et al 2 confirmed
patients of nerve paralysis in 0.06 of each 100 nerves studied; the
causes could be related to tissue compression with retractors, a
styloid process fracture with movement or direct compression as a
result of retraction of the distal segment.19 In the same vein,
McLeod and Bowe20 reported that the incidence of permanent
damage to the lingual nerve was 2 in every 100 patients and the
presence of permanent damage to the infraorbital nerve would be
extremely rare. Regarding rare complications, Steel and Cope,16
in an extensive review with respect to ophthalmic alterations,
described 9 patients of amaurosis present in the literature. In our
sample no type of paralysis or severe injury like amaurosis was
observed.
Infection and complications associated with osteosynthesis plate
exposure appear as another possible alteration. Davis et al3 con-
ducted a study of prevalence of surgical site infections in 2268
patients where no demographic variable was associated with the
increase in the infection risk; the operating time was lower in
subjects who did not present infections and subjects who underwent
bimaxillary surgeries were significantly correlated with infections
compared with monomaxillary surgeries. Ultimately, 8% had some
type of infection, 62% of the initial infections occurred in the
mandible, and 78% of the recurring infections also occurred in the
mandible. The infection was diagnosed between days 11 and 15
after the surgery. Our results presented 6 patients (2.4%) of
postoperative infection and all were solved with antibiotics.
In the analysis of infections, Chow et al21 conducted a 15-year
retrospective study of 2910 orthognathic procedures; the complica-
tions appeared in 9.7% of the patients, of which 7.4% were
associated with postoperative infections without associating them
with any type of specific surgery; the resolution of this complication
occurred without alterations to the orthognathic procedure. In the
series of Robl et al,6 with 1000 surgeries, only 21 patients of
infection were in the mandible and 4 patients in the maxilla,
3
 Brief Clinical Studies The Journal of Craniofacial Surgery
demonstrating a low percentage (2.5%) in this complication, which
is in relation to our results which were 2.4%.
The removal of plates and screws due to exposure in the wound
or suture dehiscence appeared in 5 of our patients. Little et al22
indicated that 10.4% of the patients required removal of the
osteosynthesis, with only 8 of the 516 plates being in the maxilla
and 19 of the 338 plates in the mandible; most were removed within
the first year of the surgery. Failures in osteosynthesis, with plate
fractures or limitation in the efficiency of screws, appeared in 2 of
the 1000 patients of Robl et al,6 demonstrating that it is not a
common complication in orthognathic surgery. Our patients under-
went osteosynthesis removal due to infection with material expo-
sure or simply due to material exposure or palpation near the
mucosa, causing discomfort in the patient when chewing.
Finally, based on this investigation, we can conclude that
orthognathic surgery presents a low number of complications
and is a relatively safe procedure when it is performed by a surgeon
in train.
REFERENCES
1. Ho MW, Boyle MA, Cooper JC, et al. Surgical complications for
segmental Le Fort I osteotomy. Br J Oral Maxillofac Surg 2011;49:562–
566
2. Bowe DC, Gruber EA, McLeod NM. Nerve injury associated with
orthognathic surgery. Part 1: UK practice and motor nerve injuries. Br J
Oral Maxillofac Surg 2016;54:362–365
3. Davis C, Gregoire CE, Steeves TW, et al. Prevalence of surgical site
infections following orthognathic surgery: a retrospective cohort
analysis. J Oral Maxillofac Surg 2016;74:1199–1206
4. Al-Nawas B, Kämmerer PW, Hoffmann C, et al. Influence of osteotomy
procedure and surgical experience on early complications after
orthognathic surgery in the mandible. J Craniomaxillofac Surg
2014;42:e284–e288
5. Kim SG, Park SS. Incidence of complications and problems related to
orthognathic surgery. J Oral Maxillofac Surg 2007;65:2438–2444
6. Robl MT, Farrel BB, Tucker MR. Complications in orthognathic
surgery. A report of 1000 cases. Oral Maxillofac Surg Clin N Am
2014;26:599–609
7. Olate S, Pozzer L, Unibazo A, et al. LeFort I segmented osteotomy
experience with piezosurgery in orthognathic surgery. Int J Clin Exp
Med 2014;7:2092–2095
4 #
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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8. Carlos E, Monnazzi MS, Castiglia YM, et al. Orthognathic surgery with
or without induced hypotension. Int J Oral Maxillofac Surg
2014;43:577–580
9. Bock JJ, Maurer P, Otto C, et al. Complications of orthodontic-
orthognathic surgery treatment in mentally handicapped patients. J
Craniomaxillofac Surg 2006;34:156–161
10. Shirota T, Kamatani T, Yamaguchi T, et al. Effectiveness of
piezoelectric surgery in reducing surgical complications after bilateral
sagittal Split osteotomy. Br J Oral Maxillofac Surg 2014;52:219–222
11. Han JJ, Yang HJ, Lee SJ, et al. Relapse after SSRO for mandibular
setback movement in relation to the amount of the mandibular setback
and intraoperative clockwise rotation of the proximal segment. J
Craniomaxillofac Surg 2014;42:811–815
12. Proffit WR, Turvey TA, Phillips C. The hierarchy of stability and
predictability in orthognathic surgery with rigid fixation: an update and
extensión. Head Face Med 2007;30:21
13. Panula K, Finne K, Oikarinen K. Incidence of complications and
problems related to orthognathic surgery: a review of 655 patients. J
Oral Maxillofac Surg 2001;59:1128–1136
14. Mehra P, Castro V, Freitas RZ, et al. Complications of the mandibular
sagittal split ramus osteotomy associated with the presence or absence
of third molars. J Oral Maxillofac Surg 2001;59:854–858
15. Steinbacher DM, Kontaxis KL. Does simultaneous third molar
extraction increase and perioperative complications in orthognathic
surgery. J Craniofac Surg 2016;27:923–926
16. Steel BJ, Cope MR. Unusual and rare complications of orthognathic
surgery: a literature review. J Oral Maxillofac Surg 2012;70:1678–1691
17. Kramer FJ, Baethage C, Swennen G, et al. Intra- and perioperative
complications of the Le Fort I osteotomy: a prospective evaluation of
1000 patients. J Craniofacial Surg 2004;15:971–977
18. Posnick JC, Adachie A, Choi E. Segmental maxillary osteotomies in
conjunction with bimaxillary orthognathic surgery: indications-safety-
outcome. J Oral Maxillofac Surg 2016;74:1422–1440
19. Dendy RA. Facial nerve paralysis following sagittal split mandibular
osteotomy: a case report. Br J Oral Surg 1973;11:101–105
20. McLeod NM, Bowe DC. Nerve injury associated with orthognathic
surgery. Part 3: lingual, infraorbital and optic nerves. Br J Oral
Maxillofac Surg 2016;54:372–375
21. Chow LK, Singh B, Chiu WK, et al. Prevalence of postoperative
complications after orthognathic surgery: a 15-year review. J Oral
Maxillofac Surg 2007;65:984–992
22. Little M, Langford RJ, Bhanji A, et al. Plate removal following
orthognathic surgery. J Craniomaxillofac Surg 2015;43:1705–1709
2017 Mutaz B. Habal, MD