bsso complications

Journal of Cranio-Maxillofacial Surgery (2005) 33, 307–313

r 2005 European Association for Cranio-Maxillofacial Surgery

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doi:10.1016/j.jcms.2005.04.005, available online at http://www.sciencedirect.com

Perioperative complications following sagittal split osteotomy of the mandible

Thomas TELTZROW1, Franz-Josef KRAMER2, Andrea SCHULZE3, Carola BAETHGE3,Peter BRACHVOGEL1

1Department of Oral and Maxillofacial Surgery (Chairman: Prof. Dr. Dr. N. C. Gellrich), Medical University of

Hannover, Germany; 2Department of Oral and Maxillofacial Surgery (Chairman: Prof. Dr. Dr. H. Schliephake),

Georgia-Augusta University Goettingen, Germany; 3Department of Orthodontics (Chairman: Prof. Dr. R. R.

Miethke), Humboldt University, Charite Berlin, Germany

SUMMARY. Introduction: The aim of this study was to review complications in a series of 1264 consecutivepatients who were operated in a single centre during a 20-year-period. Material and methods: Complicationswere documented, their incidences calculated and compared with data from the literature. Results: In 35patients (2.8%) infection developed requiring extraoral incision and drainage; in 27 patients (2.1%) the inferioralveolar nerve was inadvertently cut; 18 patients (1.4%) had to undergo re-operation due to bending or fracture ofosteosynthesis material; 15 patients (1.2%) suffered from bleeding complications; in 12 patients (0.9%) anunfavourable split occurred. In 8 patients (0.6%) foreign bodies were left in situ; in 7 patients a partial weakness ofthe facial nerve occurred, which was permanent in 1 patient. Six patients (0.5%) with a significantly higher agethan average (mean: 33.6 years in comparison with 23.1 years) developed non-union at the site of osteotomy, andthe mandible had to be bone grafted. Two patients (0.2%) developed osteomyelitis, and in one patient airwayproblems led to a need for tracheostomy (0.1%). Conclusion: Although some of these complications of bilateralsagittal split with osteotomy carry severe limitations in health related quality of life, it remains an overall safeprocedure, demanding, however, comprehensive informed consent. Good knowledge of technical reasons for thesecomplications should help to reduce their incidence. r 2005 European Association for Cranio-MaxillofacialSurgery

Keywords: complication; orthodontic surgery; sagittal split; BSSO

INTRODUCTION

Orthognathic surgery is undertaken all over the worldand has proved highly successful for correctingskeletal maxillofacial anomalies. Increased knowl-edge about anatomy and the progress made inanaesthesia, has ensured that it can be carried outwith safe and predictable results (Bell and Schendel,1977). Bilateral sagittal splitting of the ascendingramus of the mandible (BSSO) alone or in combina-tion with other techniques has been an integral partof combined surgical and orthodontic treatment sinceit was introduced by Trauner and Obwegeser (1955).As these operations are usually elective proceduresand in some cases only for aesthetic purposes,knowledge of the potential risks is essential for thesurgeon, orthodontist and patient. Furthermore it iscrucial to understand the mechanism of complica-tions to minimize potential risks.There are a number of papers dealing with

complications of sagittal split operations alone(Behrmann, 1972; MacIntosh, 1981; Martis, 1984;Turvey, 1985) or complications of orthognathicsurgery in general (Van de Perre et al., 1996;Acebal-Bianco et al., 2000; Maurer et al., 2001).

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Other authors focus on selected complications:Lanigan et al. (1991) concentrate on haemorrhage,Jones and Van Sickels (1991), Consolo and Salgarelli(1992), De Vries et al. (1993) and Sakashita et al.(1996) report about facial nerve injuries. Technicalnotes have been published by Van Sickels et al. (1985)and Mommaerts (1992) concerning the managementof bad splits.

The aim of this study was to review intraoperativeand early postoperative complications followingBSSO based on 20 years experience in a singlemedical centre.

PATIENTS AND METHODS

Between 1982 and 2002, 1264 bilateral sagittal splitshave been performed in this single medical centre. Alloperations were consecutively documented in acomputerized data base. The majority of operationswas carried out according to the classical Obwegesertechnique (Trauner and Obwegeser, 1955), onlyoccasionally modifications were performed asindicated by anatomical variations. The male tofemale ratio was 450: 814 and the mean age 23.1 years

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308 Journal of Cranio-Maxillofacial Surgery

(14 to 53 years). In 124 patients (i.e. less than 10%),131 major complications were encountered, in 6 ofthose more than one complication were observed.Between 1982 and 1991, all patients were treated

using wire osteosynthesis and intermaxillary fixation(MMF). Since 1991, rigid internal fixation withminiplates was used routinely and during the firstyears, MMF was still used for periods of up to 4weeks. As experience was gained, this period becameshorter and from 1993, even elastics were not usedpostoperatively any more.All patients received an antimicrobial single-shot

prophylaxis using Penicillin G (10 million I.U.), orClindamycin (600mg) intravenously in addition to asingle dose of corticosteroids (Prednisolone, 250mg)immediately before the beginning of the operation.Extra-oral exit vacuum-drains were inserted at theend of the operation and removed on the secondpostoperative day.Postoperative Hb concentrations of 8.0 g/dl in

healthy adolescents were considered as tolerable.The possibility of preoperative autodonation wasoffered to every patient (Newman et al., 1971; Hansenet al., 1986; Kay, 1987).In a computerized data base all relevant individual

informations on each patient was collected (e.g. typeof dysgnathia, movement of segments, orthodontictreatment plan and undesirable conditions of eachoperation). For those patients affected by complica-tions, files, radiographs and models were reviewed. Ina retrospective analysis, all complications occurringduring the operation and up 48 h postoperativelywere assessed, classified and compared with thefrequencies described in the literature. Additionally,extremely rare complications such as fractures ofosteosynthesis material or osteomyelitis were regis-tered even when they exceeded the 48 h limit.Unfavourable long-term occurrences like relapse,

TMJ symptoms and hypoaesthesia of the inferioralveolar nerve were not evaluated in this study. Thesecomplications can only be reviewed after months,have to be quantified and should be regarded inrelation to the patients’ subjective findings. Thesecomplications were part of a different investigation.

RESULTS

From a total of 124 patients with major perioperativecomplication, 44 were male and 80 were female(Table 1). In 971 patients a bignathic osteotomy was

Table 1 – Patient data

Total number ofpatients

Number of patientswith complications

Male 450 44Female 814 80Mandiblular osteotomyalone

293 55

Bimaxillary procedure 971 69

performed, whereas in 293 patients the operation waslimited to the mandible. Patients with proceduresrestricted to the maxilla were not evaluated in thisstudy.

Life-threatening events

HaemorrhageLarger vessels in proximity close to the osteotomyinclude the internal carotid artery, the retromandib-ular vein, the facial vein and artery and the vesselsassociated with the inferior alveolar nerve. Bleedingcomplications were recorded when there was need fortransfusion or when there was a need for re-intervention (excessive haematoma or acute bleed-ing). Fifteen patients suffered from bleeding, 7 ofwhom needed blood transfusions (Table 2). Mostoften the retromandibular vein was affected. Bleedingfrom the facial artery was encountered only once andbleeding from the inferior alveolar vessel-nervebundle was never a serious problem. However, in 9patients, the exact vessel could not be determined.Four patients had to be reoperated due to massivehaematoma.

Airway obstructionIn this group of patients, one tracheostomy becamenecessary due to airway obstruction after massiveswelling and haematoma. Thus, tracheostomy was anextreme exception, but several patients with maxillo-mandibular fixation (MMF) suffered from reducedairway space and early release of MMF wasnecessary to reduce respiratory distress.

Mechanical problems

Bad splitBad splits can affect the buccal or lingual corticalplate of the mandible or the condylar neck (Fig. 1). Aspecial form of a bad split is an isolated fracture ofthe coronoid process while the ramus remains intact.Unfavourable osteotomy patterns were encounteredin 12 patients (Table 3). Simple buccal plate fractureswere most common and were seen in 6 patients.Unfavourable fractures of the coronoid process wereencountered in 3, condylar fractures in 2 and, leastcommon, a lingual plate fracture in 1 patient.

Whenever possible, bad splits were managed by avariation of osteosynthesis. In most cases, subsequentmaxillo-mandibular fixation was necessary (Fig. 2).

Table 2 – Haemorrhage

Author (year) Patients Occurrence Incidence (%)

Behrmann (1972) 600 228 38MacIntosh (1981) 236 16 1.7Martis (1984) 258 1 0.4Turvey (1985) 128 3 2.2Present data (2003) 1264 15 1.0

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(A) (B) (C)

Fig. 1 – Illustration of different fracture patterns of a bad split: (A) fracture of buccal cortex; (B) fracture of coronoid process; (C) fracture ofcondylar process.

Table 3 – Bad split


Behrmann (1972) 600 10 1.7MacIntosh (1981) 236 16 6.8Martis (1984) 258 5 1.9Turvey (1985) 128 9 7.0Van de Perre et al. (1996) 1233 97 7.9Acebal-Bianco et al. (2000) 463 8 1.7Maurer et al. (2001) 371 34 9.2Present data (2003) 1264 12 1.0

Fig. 2 – Orthopantomogramm of a salvage procedure in a bad split:additional plate on the left ascending ramus, maxillo-mandibularfixation anchored to circumferential wires.

(A) (B)

Fig. 3 – Lateral cephalograms; (A) bending of plates; (B) correctedposition (of plates) after replating.

Perioperative complications following sagittal split osteotomy of the mandible 309

Mechanical overloadMiniplate osteosynthesis alone carries the risk ofinappropriate strains bending or even causing frac-ture of plate. In 18 patients, morphological changesof miniplates demanded re-intervention. Clinicalsigns were rapid development of an open bite andmassive relapse. Radiologically, bending of one orboth plates was recognizable on the lateral cephalo-gram (Fig. 3).

Non-unionNon-union was observed in 6 patients and was nevera consequence of massive infection. Infection as anaetiological factor cannot be fully excluded but nopus was seen in any patient. Nevertheless swellingand pain were found leading to the need forantimicrobial treatment. Most often an anterior openbite developed rapidly as a sign of non-union. Inthose 6 patients, bone grafting became necessary afterinstability had been observed. Healing was supportedby means of MMF for 4–6 weeks. The average age ofpatients suffering from this complication was sig-nificantly higher with a mean of 33.6 years (range:28–41 years) at the time of operation compared withthe overall average age of patients with complications(23.1 years).

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Table 6 – Nerve injury – trauma to facial nerve


Behrmann (1972) 600 4 0.7MacIntosh (1981) 236 1 0.4De Vries et al. (1993) 1747 9 0.5Acebal-Bianco et al. (2000) 463 2 0.4Maurer et al. (2001) 371 5 1.4Present data (2003) 1264 7 0.6

Fig. 4 – Orthopantomogram showing a lost bracket posteriorly atthe right mandibular angle.


Infection

Despite single-dose of perioperative antibiotic pro-phylaxis, 35 patients developed infections needingextraoral incision (Table 4). Additionally, in all 35patients antibiotics and MMF were used to preventnon-union. In one patient, osteomyelitis developed,which resolved after decortication and long-termantibiotic treatment.

Nerve injury

Section of the inferior alveolar nerve occurred in 27patients (Table 5). This number represents only thosein whom the damage was seen intraoperatively. Therate of unobserved nerve trauma might be higher.In 7 patients, a postoperative facial palsy occurred

(Table 6) but resolved completely in 6 within 4 weeks.Its mechanism is still a matter of speculation. In onecase, the weakness of the facial nerve remainedfollowing coagulation of a life-threatening bleedingvessel near the site of the osteotomy.

Foreign bodies

In 8 patients, foreign bodies were left behind andwere visible on postoperative radiographs (Fig. 4).Fractured burs and orthodontic brackets were themost common ones. Infection was never a conse-quence. When the osteosynthesis material wasremoved, most of these foreign bodies could then beretrieved.

DISCUSSION

Rare complications related to BSSO can be sub-divided into life-threatening events, mechanicalproblems during or after operation, and miscella-neous complications affecting the patients’ well

Table 4 – Infection


MacIntosh (1981) 236 13 5.7Martis (1984) 258 2 0.8Acebal-Bianco et al. (2000) 463 36 7.8Present data (2003) 1264 35 2.8

Table 5 – Nerve injury — (inadvertent) sectioning of inferioralveolar nerve


Behrmann (1972) 600 24 4.0MacIntosh (1981) 236 4 1.7Turvey (1985) 128 9 7.0Van de Perre et al. (1996) 1886 24 1.3Maurer et al. (2001) 371 12 3.2Present data (2003) 1264 27 2.1

being. Life threatening events include excessivebleeding and airway obstruction by oedema orhaematoma. Airway obstruction has ceased to be aproblem since the development of internal rigidfixation made MMF obsolete. Mechanical problemsconsist of unfavourable bone splits, mostly of thebuccal cortical plate, and mechanical failure ofosteosynthesis. Miscellaneous complications include:infection, facial palsy, transsection of the inferioralveolar nerve and foreign bodies left in the surgicalfield.

There are a number of publications discussing theincidence of this kind of perioperative complica-tions (Martis, 1984; Turvey, 1985; Van Sickelset al., 1985; Kaplan et al., 1988; Lanigan et al.1991; Mommaerts, 1992; Lacey and Colcleugh, 1995;Sakashita et al., 1996; Van de Perre et al., 1996;Acebal-Bianco et al., 2000; Heo et al., 2001; Maureret al., 2001). Even less is known about the occurrenceof serious perioperative morbidity resulting fromelective maxillofacial orthognathic surgery. Assess-ment of a large number of patients is rare and limitedto very few studies (Van de Perre et al., 1996; Acebal-Bianco et al., 2000). Moreover, a comparison betweendifferent studies is difficult due to varying definitionsof unfavourable events, and variable observationperiods.

Some authors published numbers based on osteot-omy sites, while others prefer to calculate on the basisof the number of patients. Though it might have beenmore accurate to use osteotomy sites, comparabilityof several studies is only possible on the basis ofpatient numbers, due to the lack of information inmany publications. Moreover, complications such

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as mechanical failure of osteosynthesis or airwayobstruction are not restricted to the site of osteotomy.Consequently, in this study all the figures werecalculated on the basis of patient numbers.Some reports have to be highlighted for historical

reasons. One publication cited most often is that byBehrmann (1972) who surveyed cases operated on by64 American surgeons in different departments. Inaddition to the critical composition of data, theexperience of American surgeons with BSSO at thattime was short and the complication rate correspond-ingly high. Another publication many authors referto was written 1981 by MacIntosh reviewing hisexperience of 13 years with sagittal mandibular splitprocedures. He found considerably fewer complica-tions than Behrmann (1972) reflecting that 10 years ofexperience with the technique made it safer and morereliable.Literature discussing variables influencing the rate

of complications is scarce. MacIntosh observed thatnon-union was more common in older patients.Turvey (1985) compared the complication rate ofthe Dal Pont modification with the classical Obwe-geser technique and found no significant differences.

Life threatening events

Van de Perre et al. (1996) reviewed 2049 patients whounderwent orthognathic surgery. They subdividedsevere complications into primary complications(tracheostomy, major postoperative bleeding, re-intubation, death, asystole, premature release ofMMF for respiratory distress) and secondary com-plications (deep venous thrombosis, aspiration at-electasis). No such general medical complication wasencountered in the present sample.

HaemorrhageIn the literature, there are no uniform criteriadefining bleeding complications. Incidence variedbetween 0.39 and 38% (Table 2) are reflecting theheterogeneous definitions from just obstructing thesurgeon’s view (MacIntosh, 1981) to a life-threateningevent. In the present group, the bleeding complica-tions occurred in 1.2% cases.Minor bleeding in sagittal split procedures can

usually be easily controlled using local anaestheticscontaining 1:100,000 adrenaline injected before theoperation, electrocautery or compression. Excessiveblood loss might follow surgical damage of largervessels. Although excessive blood loss is a phenom-enon related mainly to maxillary surgery, the need forblood transfusion in mandibular operations is occa-sionally necessary. As orthognathic surgery is elec-tive, preoperative autotransfusion should beconsidered (Marciani and Dickson, 1985; Neuwirthet al., 1992; Puelacher et al., 1998). In accordancewith Lanigan et al. (1991) most of the bleedingcomplications were associated with injury to theretromandibular vein.

Airway obstructionThere are no other records reporting the frequency oftracheostomy following BSSO. In one patient, atracheostomy had to be performed postoperativelydue to massive swelling and haematoma. Afterbimaxillary surgery with segmentation of the maxillaand wire osteosynthesis, opening of the MMF wouldhave been detrimental to the operative result. The useof rigid fixation, however, has eliminated the need forMMF (Buckley et al., 1989; Van Sickels andRichardson, 1996). Moreover the elimination ofpostoperative MMF since 1993 improved the sub-jective well-being significantly.

Mechanical problems

Bad splitBad splits examined were quite rare when comparedwith the literature. The rates found in the literatureranged from 1.7 to 9.1% (Table 3). MacIntosh (1981)reported a higher rate of unfavourable splits but heconsidered the Hunsuck modification (Hunsuck,1968) to be a bad split.

In this group, an incidence of 1.0% was observed. Inaddition to this low incidence, most of these bad splitswere simple buccal plate fractures, which could easily berepaired by an extra plate. The alternative of delayingthe operation to allow for consolidation was not done.

In the management of these fractures, a variety ofmethods was described ranging from simple addi-tional osteosynthesis to resection of the coronoidprocess in order to use it as a free cortical graft(Mommaerts, 1992; Van de Perre et al., 1996). In thepresent group both strategies were used, resulting instable re-ossification and union of the osteotomizedfragments.

OverloadDeformation or fracture of the osteosynthesis wasrare until 2001 when a suspected change in thestrength of miniplates led to a series of patientssuffering from this complication. As a consequence ofmechanical plate failure, all patients now receive abicortical positioning screw in addition to theminiplate, thus avoiding any further bending of theplate.

Non-unionIn 6 patients, a non-union without microbial infec-tion was encountered. Some authors suggest apositive correlation between age and increased riskof malunion (MacIntosh, 1981). Patients, especiallythose over 40 years, are prone to delayed union ornon-union. In this group, a similar positive correla-tion between age and pseudarthrosis was found. Twoprinciples of therapy were suggested to treat non-union: as a conservative approach to apply MMF formore than 6 weeks (MacIntosh, 1981), or alterna-tively, bone grafting in combination with rigidinternal fixation. As aetiological factors for disturbedhealing of the bony fragments, the following reasons

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should be considered: insufficient area of contact(Jonsson et al., 1979), soft tissue interposition or bonenecrosis resulting from ischaemia in the proximalsegment after extensive stripping of the muscularsling (Grammer et al., 1974; Grammer and Carpenter,1979). Jonsson et al. (1979) have pointed out that abroad area of overlap does not necessarily mean abroad area of contact between the segments. This isobvious especially in mandibular asymmetries.

Infection

With a frequency of 2.8% the incidence of infection isconsidered to be low in this group (Table 4). Thisindicates that antimicrobial prophylaxis was ade-quate (Gallagher and Epker, 1980; Ozaki et al., 1992).Infection requiring incision and drainage occurred

only in a very small number and in none of these theresult was compromised due to the infection. It wasnoteworthy, however, that in 5 patients the infectionarose more than 4 weeks after the operation.

Nerve injury

The rate of direct trauma to the inferior alveolar nerve(2.1) corresponds closely to that of other authors: thehighest reported rate was 4%, the lowest 1.3% (Table5). The low rate of direct transsection of the inferioralveolar nerve can be attributed to the classicalObwegeser approach, because confining the osteot-omy to the retromolar region provides better protec-tion to the neurovascular bundle (Turvey, 1985).In comparison with other authors, the probability

of facial nerve dysfunction (0.6%) is in the lower thirdof the range between 0.43% and 1.35%. Facial nerveparalysis has been reported mainly in conjunction withsetback-procedures (Acebal-Bianco et al., 2000). Thesuspected mechanism is compression of the facialnerve near the skull base. Other possible ways oftrauma are haematoma, or direct trauma either to themarginal branch during chin osteotomy (Acebal-Bianco et al., 2000) or to the trunk during sagittal split.

Foreign bodiesForeign bodies left behind never lead to clinicalsymptoms and were generally removed together withthe osteosynthesis material after consolidation of theosteotomy (6 months later). Although of low clinicalimportance, legal problems might arise especiallywhen the patient is not fully informed about causeand nature of this complication.

CONCLUSION

This retrospective analysis, on a large group ofpatients who underwent bilateral sagittal split proce-dures shows that it can be carried out with a very highdegree of safety.For legal reasons, it is necessary to mention typical

complications during preoperative counselling. Not

only should the patient be informed of the frequencyof complications, but also they should be told of itsimplications in later life. Here the elective characterof orthognathic surgery is of special importance.

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Dr. Dr. Thomas TELTZROW

Joachim-Friedrich-Str. 3, 10711 Berlin, Germany.

Tel.:+49511 807 7170;Fax: +49 511 807 7173E-mail: [email protected]

Paper received 26 May 2004Accepted 13 April 2005

bsso complications

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