Journal of Cranio-Maxillofacial Surgery (2005) 33, 307313

r 2005 European Association for Cranio-Maxillofacial Surgery

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 TELTZROW
1
, Franz-Josef KRAMER
2
, Andrea SCHULZE
3
, Carola BAETHGE
3
,
Peter BRACHVOGEL
1
1
Department of Oral and Maxillofacial Surgery (Chairman: Prof. Dr. Dr. N. C. Gellrich), Medical University of
Hannover, Germany;
2
Department of Oral and Maxillofacial Surgery (Chairman: Prof. Dr. Dr. H. Schliephake),
Georgia-Augusta University Goettingen, Germany;
3
Department 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 consecutive
patients who were operated in a single centre during a 20-year-period. Material and methods: Complications
were documented, their incidences calculated and compared with data from the literature. Results: In 35
patients (2.8%) infection developed requiring extraoral incision and drainage; in 27 patients (2.1%) the inferior
alveolar nerve was inadvertently cut; 18 patients (1.4%) had to undergo re-operation due to bending or fracture of
osteosynthesis material; 15 patients (1.2%) suffered from bleeding complications; in 12 patients (0.9%) an
unfavourable split occurred. In 8 patients (0.6%) foreign bodies were left in situ; in 7 patients a partial weakness of
the facial nerve occurred, which was permanent in 1 patient. Six patients (0.5%) with a signicantly higher age
than average (mean: 33.6 years in comparison with 23.1 years) developed non-union at the site of osteotomy, and
the mandible had to be bone grafted. Two patients (0.2%) developed osteomyelitis, and in one patient airway
problems led to a need for tracheostomy (0.1%). Conclusion: Although some of these complications of bilateral
sagittal split with osteotomy carry severe limitations in health related quality of life, it remains an overall safe
procedure, demanding, however, comprehensive informed consent. Good knowledge of technical reasons for these
complications should help to reduce their incidence. r 2005 European Association for Cranio-Maxillofacial
Surgery
Keywords: complication; orthodontic surgery; sagittal split; BSSO
INTRODUCTION
Orthognathic surgery is undertaken all over the world
and has proved highly successful for correcting
skeletal maxillofacial anomalies. Increased knowl-
edge about anatomy and the progress made in
anaesthesia, has ensured that it can be carried out
with safe and predictable results (Bell and Schendel,
1977). Bilateral sagittal splitting of the ascending
ramus of the mandible (BSSO) alone or in combina-
tion with other techniques has been an integral part
of combined surgical and orthodontic treatment since
it was introduced by Trauner and Obwegeser (1955).
As these operations are usually elective procedures
and in some cases only for aesthetic purposes,
knowledge of the potential risks is essential for the
surgeon, orthodontist and patient. Furthermore it is
crucial 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 orthognathic
surgery in general (Van de Perre et al., 1996;
Acebal-Bianco et al., 2000; Maurer et al., 2001).
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. Technical
notes have been published by Van Sickels et al. (1985)
and Mommaerts (1992) concerning the management
of bad splits.
The aim of this study was to review intraoperative
and early postoperative complications following
BSSO based on 20 years experience in a single
medical centre.
PATIENTS AND METHODS
Between 1982 and 2002, 1264 bilateral sagittal splits
have been performed in this single medical centre. All
operations were consecutively documented in a
computerized data base. The majority of operations
was carried out according to the classical Obwegeser
technique (Trauner and Obwegeser, 1955), only
occasionally modications were performed as
indicated by anatomical variations. The male to
female ratio was 450: 814 and the mean age 23.1 years
ARTICLE IN PRESS
307
(14 to 53 years). In 124 patients (i.e. less than 10%),
131 major complications were encountered, in 6 of
those more than one complication were observed.
Between 1982 and 1991, all patients were treated
using wire osteosynthesis and intermaxillary xation
(MMF). Since 1991, rigid internal xation with
miniplates was used routinely and during the rst
years, MMF was still used for periods of up to 4
weeks. As experience was gained, this period became
shorter and from 1993, even elastics were not used
postoperatively any more.
All patients received an antimicrobial single-shot
prophylaxis using Penicillin G (10 million I.U.), or
Clindamycin (600 mg) intravenously in addition to a
single dose of corticosteroids (Prednisolone, 250 mg)
immediately before the beginning of the operation.
Extra-oral exit vacuum-drains were inserted at the
end of the operation and removed on the second
postoperative day.
Postoperative Hb concentrations of 8.0 g/dl in
healthy adolescents were considered as tolerable.
The possibility of preoperative autodonation was
offered to every patient (Newman et al., 1971; Hansen
et al., 1986; Kay, 1987).
In a computerized data base all relevant individual
informations on each patient was collected (e.g. type
of dysgnathia, movement of segments, orthodontic
treatment plan and undesirable conditions of each
operation). For those patients affected by complica-
tions, les, radiographs and models were reviewed. In
a retrospective analysis, all complications occurring
during the operation and up 48 h postoperatively
were assessed, classied and compared with the
frequencies described in the literature. Additionally,
extremely rare complications such as fractures of
osteosynthesis 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 inferior
alveolar nerve were not evaluated in this study. These
complications can only be reviewed after months,
have to be quantied and should be regarded in
relation to the patients subjective ndings. These
complications were part of a different investigation.
RESULTS
From a total of 124 patients with major perioperative
complication, 44 were male and 80 were female
(Table 1). In 971 patients a bignathic osteotomy was
performed, whereas in 293 patients the operation was
limited to the mandible. Patients with procedures
restricted to the maxilla were not evaluated in this
study.
Life-threatening events
Haemorrhage
Larger vessels in proximity close to the osteotomy
include the internal carotid artery, the retromandib-
ular vein, the facial vein and artery and the vessels
associated with the inferior alveolar nerve. Bleeding
complications were recorded when there was need for
transfusion or when there was a need for re-
intervention (excessive haematoma or acute bleed-
ing). Fifteen patients suffered from bleeding, 7 of
whom needed blood transfusions (Table 2). Most
often the retromandibular vein was affected. Bleeding
from the facial artery was encountered only once and
bleeding from the inferior alveolar vessel-nerve
bundle was never a serious problem. However, in 9
patients, the exact vessel could not be determined.
Four patients had to be reoperated due to massive
haematoma.
Airway obstruction
In this group of patients, one tracheostomy became
necessary due to airway obstruction after massive
swelling and haematoma. Thus, tracheostomy was an
extreme exception, but several patients with maxillo-
mandibular xation (MMF) suffered from reduced
airway space and early release of MMF was
necessary to reduce respiratory distress.
Mechanical problems
Bad split
Bad splits can affect the buccal or lingual cortical
plate of the mandible or the condylar neck (Fig. 1). A
special form of a bad split is an isolated fracture of
the coronoid process while the ramus remains intact.
Unfavourable osteotomy patterns were encountered
in 12 patients (Table 3). Simple buccal plate fractures
were most common and were seen in 6 patients.
Unfavourable fractures of the coronoid process were
encountered in 3, condylar fractures in 2 and, least
common, a lingual plate fracture in 1 patient.
Whenever possible, bad splits were managed by a
variation of osteosynthesis. In most cases, subsequent
maxillo-mandibular xation was necessary (Fig. 2).
ARTICLE IN PRESS
Table 1 Patient data
Total number of
patients
Number of patients
with complications
Male 450 44
Female 814 80
Mandiblular osteotomy
alone
293 55
Bimaxillary procedure 971 69
Table 2 Haemorrhage
Author (year) Patients Occurrence Incidence (%)
Behrmann (1972) 600 228 38
MacIntosh (1981) 236 16 1.7
Martis (1984) 258 1 0.4
Turvey (1985) 128 3 2.2
Present data (2003) 1264 15 1.0
308 Journal of Cranio-Maxillofacial Surgery
Mechanical overload
Miniplate osteosynthesis alone carries the risk of
inappropriate strains bending or even causing frac-
ture of plate. In 18 patients, morphological changes
of miniplates demanded re-intervention. Clinical
signs were rapid development of an open bite and
massive relapse. Radiologically, bending of one or
both plates was recognizable on the lateral cephalo-
gram (Fig. 3).
Non-union
Non-union was observed in 6 patients and was never
a consequence of massive infection. Infection as an
aetiological factor cannot be fully excluded but no
pus was seen in any patient. Nevertheless swelling
and pain were found leading to the need for
antimicrobial treatment. Most often an anterior open
bite developed rapidly as a sign of non-union. In
those 6 patients, bone grafting became necessary after
instability had been observed. Healing was supported
by means of MMF for 46 weeks. The average age of
patients suffering from this complication was sig-
nicantly higher with a mean of 33.6 years (range:
2841 years) at the time of operation compared with
the overall average age of patients with complications
(23.1 years).
ARTICLE IN PRESS
(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 of
condylar process.
Table 3 Bad split
Author (year) Patients Occurrence Incidence (%)
Behrmann (1972) 600 10 1.7
MacIntosh (1981) 236 16 6.8
Martis (1984) 258 5 1.9
Turvey (1985) 128 9 7.0
Van de Perre et al. (1996) 1233 97 7.9
Acebal-Bianco et al. (2000) 463 8 1.7
Maurer et al. (2001) 371 34 9.2
Present 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-mandibular
xation anchored to circumferential wires.
(A) (B)
Fig. 3 Lateral cephalograms; (A) bending of plates; (B) corrected
position (of plates) after replating.
Perioperative complications following sagittal split osteotomy of the mandible 309
Infection
Despite single-dose of perioperative antibiotic pro-
phylaxis, 35 patients developed infections needing
extraoral incision (Table 4). Additionally, in all 35
patients antibiotics and MMF were used to prevent
non-union. In one patient, osteomyelitis developed,
which resolved after decortication and long-term
antibiotic treatment.
Nerve injury
Section of the inferior alveolar nerve occurred in 27
patients (Table 5). This number represents only those
in whom the damage was seen intraoperatively. The
rate 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 one
case, the weakness of the facial nerve remained
following coagulation of a life-threatening bleeding
vessel near the site of the osteotomy.
Foreign bodies
In 8 patients, foreign bodies were left behind and
were visible on postoperative radiographs (Fig. 4).
Fractured burs and orthodontic brackets were the
most common ones. Infection was never a conse-
quence. When the osteosynthesis material was
removed, most of these foreign bodies could then be
retrieved.
DISCUSSION
Rare complications related to BSSO can be sub-
divided into life-threatening events, mechanical
problems during or after operation, and miscella-
neous complications affecting the patients well
being. Life threatening events include excessive
bleeding and airway obstruction by oedema or
haematoma. Airway obstruction has ceased to be a
problem since the development of internal rigid
xation made MMF obsolete. Mechanical problems
consist of unfavourable bone splits, mostly of the
buccal cortical plate, and mechanical failure of
osteosynthesis. Miscellaneous complications include:
infection, facial palsy, transsection of the inferior
alveolar nerve and foreign bodies left in the surgical
eld.
There are a number of publications discussing the
incidence of this kind of perioperative complica-
tions (Martis, 1984; Turvey, 1985; Van Sickels
et 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; Maurer
et al., 2001). Even less is known about the occurrence
of serious perioperative morbidity resulting from
elective maxillofacial orthognathic surgery. Assess-
ment of a large number of patients is rare and limited
to very few studies (Van de Perre et al., 1996; Acebal-
Bianco et al., 2000). Moreover, a comparison between
different studies is difcult due to varying denitions
of unfavourable events, and variable observation
periods.
Some authors published numbers based on osteot-
omy sites, while others prefer to calculate on the basis
of the number of patients. Though it might have been
more accurate to use osteotomy sites, comparability
of several studies is only possible on the basis of
patient numbers, due to the lack of information in
many publications. Moreover, complications such
ARTICLE IN PRESS
Table 4 Infection
Author (year) Patients Occurrence Incidence (%)
MacIntosh (1981) 236 13 5.7
Martis (1984) 258 2 0.8
Acebal-Bianco et al. (2000) 463 36 7.8
Present data (2003) 1264 35 2.8
Table 5 Nerve injury (inadvertent) sectioning of inferior
alveolar nerve
Author (year) Patients Occurrence Incidence (%)
Behrmann (1972) 600 24 4.0
MacIntosh (1981) 236 4 1.7
Turvey (1985) 128 9 7.0
Van de Perre et al. (1996) 1886 24 1.3
Maurer et al. (2001) 371 12 3.2
Present data (2003) 1264 27 2.1
Table 6 Nerve injury trauma to facial nerve
Author (year) Patients Occurrence Incidence (%)
Behrmann (1972) 600 4 0.7
MacIntosh (1981) 236 1 0.4
De Vries et al. (1993) 1747 9 0.5
Acebal-Bianco et al. (2000) 463 2 0.4
Maurer et al. (2001) 371 5 1.4
Present data (2003) 1264 7 0.6
Fig. 4 Orthopantomogram showing a lost bracket posteriorly at
the right mandibular angle.
310 Journal of Cranio-Maxillofacial Surgery
as mechanical failure of osteosynthesis or airway
obstruction are not restricted to the site of osteotomy.
Consequently, in this study all the gures were
calculated on the basis of patient numbers.
Some reports have to be highlighted for historical
reasons. One publication cited most often is that by
Behrmann (1972) who surveyed cases operated on by
64 American surgeons in different departments. In
addition to the critical composition of data, the
experience of American surgeons with BSSO at that
time was short and the complication rate correspond-
ingly high. Another publication many authors refer
to was written 1981 by MacIntosh reviewing his
experience of 13 years with sagittal mandibular split
procedures. He found considerably fewer complica-
tions than Behrmann (1972) reecting that 10 years of
experience with the technique made it safer and more
reliable.
Literature discussing variables inuencing the rate
of complications is scarce. MacIntosh observed that
non-union was more common in older patients.
Turvey (1985) compared the complication rate of
the Dal Pont modication with the classical Obwe-
geser technique and found no signicant differences.
Life threatening events
Van de Perre et al. (1996) reviewed 2049 patients who
underwent orthognathic surgery. They subdivided
severe complications into primary complications
(tracheostomy, major postoperative bleeding, re-
intubation, death, asystole, premature release of
MMF for respiratory distress) and secondary com-
plications (deep venous thrombosis, aspiration at-
electasis). No such general medical complication was
encountered in the present sample.
Haemorrhage
In the literature, there are no uniform criteria
dening bleeding complications. Incidence varied
between 0.39 and 38% (Table 2) are reecting the
heterogeneous denitions from just obstructing the
surgeons view (MacIntosh, 1981) to a life-threatening
event. 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 anaesthetics
containing 1:100,000 adrenaline injected before the
operation, electrocautery or compression. Excessive
blood loss might follow surgical damage of larger
vessels. Although excessive blood loss is a phenom-
enon related mainly to maxillary surgery, the need for
blood transfusion in mandibular operations is occa-
sionally necessary. As orthognathic surgery is elec-
tive, preoperative autotransfusion should be
considered (Marciani and Dickson, 1985; Neuwirth
et al., 1992; Puelacher et al., 1998). In accordance
with Lanigan et al. (1991) most of the bleeding
complications were associated with injury to the
retromandibular vein.
Airway obstruction
There are no other records reporting the frequency of
tracheostomy following BSSO. In one patient, a
tracheostomy had to be performed postoperatively
due to massive swelling and haematoma. After
bimaxillary surgery with segmentation of the maxilla
and wire osteosynthesis, opening of the MMF would
have been detrimental to the operative result. The use
of rigid xation, however, has eliminated the need for
MMF (Buckley et al., 1989; Van Sickels and
Richardson, 1996). Moreover the elimination of
postoperative MMF since 1993 improved the sub-
jective well-being signicantly.
Mechanical problems
Bad split
Bad splits examined were quite rare when compared
with the literature. The rates found in the literature
ranged from 1.7 to 9.1% (Table 3). MacIntosh (1981)
reported a higher rate of unfavourable splits but he
considered the Hunsuck modication (Hunsuck,
1968) to be a bad split.
In this group, an incidence of 1.0% was observed. In
addition to this low incidence, most of these bad splits
were simple buccal plate fractures, which could easily be
repaired by an extra plate. The alternative of delaying
the operation to allow for consolidation was not done.
In the management of these fractures, a variety of
methods was described ranging from simple addi-
tional osteosynthesis to resection of the coronoid
process in order to use it as a free cortical graft
(Mommaerts, 1992; Van de Perre et al., 1996). In the
present group both strategies were used, resulting in
stable re-ossication and union of the osteotomized
fragments.
Overload
Deformation or fracture of the osteosynthesis was
rare until 2001 when a suspected change in the
strength of miniplates led to a series of patients
suffering from this complication. As a consequence of
mechanical plate failure, all patients now receive a
bicortical positioning screw in addition to the
miniplate, thus avoiding any further bending of the
plate.
Non-union
In 6 patients, a non-union without microbial infec-
tion was encountered. Some authors suggest a
positive correlation between age and increased risk
of malunion (MacIntosh, 1981). Patients, especially
those over 40 years, are prone to delayed union or
non-union. In this group, a similar positive correla-
tion between age and pseudarthrosis was found. Two
principles of therapy were suggested to treat non-
union: as a conservative approach to apply MMF for
more than 6 weeks (MacIntosh, 1981), or alterna-
tively, bone grafting in combination with rigid
internal xation. As aetiological factors for disturbed
healing of the bony fragments, the following reasons
ARTICLE IN PRESS
Perioperative complications following sagittal split osteotomy of the mandible 311
should be considered: insufcient area of contact
(Jonsson et al., 1979), soft tissue interposition or bone
necrosis resulting from ischaemia in the proximal
segment after extensive stripping of the muscular
sling (Grammer et al., 1974; Grammer and Carpenter,
1979). Jonsson et al. (1979) have pointed out that a
broad area of overlap does not necessarily mean a
broad area of contact between the segments. This is
obvious especially in mandibular asymmetries.
Infection
With a frequency of 2.8% the incidence of infection is
considered to be low in this group (Table 4). This
indicates 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 the
result was compromised due to the infection. It was
noteworthy, however, that in 5 patients the infection
arose 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: the
highest reported rate was 4%, the lowest 1.3% (Table
5). The low rate of direct transsection of the inferior
alveolar nerve can be attributed to the classical
Obwegeser approach, because conning 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 third
of the range between 0.43% and 1.35%. Facial nerve
paralysis has been reported mainly in conjunction with
setback-procedures (Acebal-Bianco et al., 2000). The
suspected mechanism is compression of the facial
nerve near the skull base. Other possible ways of
trauma are haematoma, or direct trauma either to the
marginal branch during chin osteotomy (Acebal-
Bianco et al., 2000) or to the trunk during sagittal split.
Foreign bodies
Foreign bodies left behind never lead to clinical
symptoms and were generally removed together with
the osteosynthesis material after consolidation of the
osteotomy (6 months later). Although of low clinical
importance, legal problems might arise especially
when the patient is not fully informed about cause
and nature of this complication.
CONCLUSION
This retrospective analysis, on a large group of
patients who underwent bilateral sagittal split proce-
dures shows that it can be carried out with a very high
degree of safety.
For legal reasons, it is necessary to mention typical
complications during preoperative counselling. Not
only should the patient be informed of the frequency
of complications, but also they should be told of its
implications in later life. Here the elective character
of orthognathic surgery is of special importance.
References
Acebal-Bianco F, Vuylsteke PL, Mommaerts MY, De Clercq CA:
Perioperative complications in corrective facial orthopedic
surgery: a 5-year retrospective study. J Oral Maxillofac Surg 58:
754760, 2000
Behrmann SJ: Complications of sagittal osteotomy of the
mandibular ramus. J Oral Surg 30: 554561, 1972
Bell WH, Schendel SA: Biologic basis for modication of the
sagittal ramus split operation. J Oral Surg 35: 362369, 1977
Buckley MJ, Tulloch JF, White Jr. RP, Tucker MR: Complications
of orthognathic surgery: a comparison between wire xation
and rigid internal xation. Int J Adult Orthodon Orthognath
Surg 4: 6974, 1989
Consolo U, Salgarelli A: Transient facial nerve palsy following
orthognathic surgery: a case report. J Oral Maxillofac Surg 50:
7779, 1992
de Vries K, Devriese PP, Hovinga J, van den Akker HP: Facial
palsy after sagittal split osteotomies. A survey of 1747 sagittal
split osteotomies. J Cranio-Maxillofac Surg 21: 5053, 1993
Gallagher DM, Epker BN: Infection following intraoral surgical
correction of dentofacial deformities: a review of 140
consecutive cases. J Oral Surg 38: 117120, 1980
Grammer FC, Carpenter AM: A quantitative histologic study of
tissue responses to ramal sagittal splitting procedures. J Oral
Surg 37: 482485, 1979
Grammer FC, Meyer MW, Richter KJ: A radioisotope study of the
vascular response to sagittal split osteotomy of the mandibular
ramus. J Oral Surg 32: 578582, 1974
Hansen E, Martin E, Heim MU: Current aspects of autologous
transfusion. Anaesthesist 35: 577580, 1986
Heo MS, Song MY, Lim JJ, Lee SS: Foreign-body granuloma
occurring in the mandible subsequent to orthognathic surgery:
a case report. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 91: 483485, 2001
Hunsuck EE: A modied intraoral sagittal splitting technique for
correction of mandibular prognathism. J Oral Surg 26:
250253, 1968
Jones JK, Van Sickels JE: Facial nerve injuries associated with
orthognathic surgery: a review of incidence and management. J
Oral Maxillofac Surg 49: 740744, 1991
Jonsson E, Svartz K, Welander U: Sagittal split technique. III.
Postoperative rest conditions. A radiographic follow-up study.
Int J Oral Surg 8: 8994, 1979
Kaplan PA, Tu HK, Koment MA, Bennion JW, Ruskin JD:
Radiography after orthognathic surgery. Part I. Normal
appearance. Radiology 167: 191194, 1988
Kay LA: The need for autologous blood transfusion. Br Med J
(Clin Res Ed) 294: 137139, 1987
Lacey MS, Colcleugh RG: Infected screws in patients treated by
mandibular sagittal split osteotomy. J Oral Maxillofac Surg 53:
510512, discussion 513, 1995
Lanigan DT, Hey J, West RA: Hemorrhage following mandibular
osteotomies: a report of 21 cases. J Oral Maxillofac Surg 49:
713724, 1991
MacIntosh RB: Experience with the sagittal osteotomy of the
mandibular ramus: a 13-year review. J Maxillofac Surg 9:
151165, 1981
Marciani RD, Dickson LG: Autologous transfusion in
orthognathic surgery. J Oral Maxillofac Surg 43: 201204, 1985
Martis CS: Complications after mandibular sagittal split
osteotomy. J Oral Maxillofac Surg 42: 101107, 1984
Maurer P, Otto C, Eckert AW, Schubert J: Complications in
surgical treatment of malocclusions. Report of 50 years
experience. Mund Kiefer Gesichtschir 5: 357361, 2001
Mommaerts MY: Two similar bad splits and how they were
treated. Report of two cases. Int J Oral Maxillofac Surg 21:
331332, 1992
ARTICLE IN PRESS
312 Journal of Cranio-Maxillofacial Surgery
Neuwirth BR, White Jr. RP, Collins ML, Phillips C: Recovery
following orthognathic surgery and autologous blood transfusion.
Int J Adult Orthodon Orthognath Surg 7: 221228, 1992
Newman MM, Hamstra R, Block M: Use of banked autologous
blood in elective surgery. J Am Med Assoc 218: 861863, 1971
Ozaki W, Abubaker AO, Sotereanos GC, Patterson GT: Cervicofacial
actinomycosis following sagittal split ramus osteotomy: a case
report. J Oral Maxillofac Surg 50: 649652, 1992
Puelacher W, Hinteregger G, Nussbaumer W, Braito I, Waldhart
E: Preoperative autologous blood donation in orthognathic
surgery: a follow-up study of 179 patients. J Cranio-Maxillofac
Surg 26: 121125, 1998
Sakashita H, Miyata M, Miyamoto H, Miyaji Y: Peripheral facial
palsy after sagittal split ramus osteotomy for setback of the
mandible. A case report. Int J Oral-Maxillofac Surg 25:
182183, 1996
Trauner R, Obwegeser H: Zur Operationstechnik bei der Progenie
und anderen Unterkieferanomalien. Dtsch. Zahn-, Mund- u.
Kieferheilk. 23: 1126, 1955
Turvey TA: Intraoperative complications of sagittal osteotomy of
the mandibular ramus: incidence and management. J Oral
Maxillofac Surg 43: 504509, 1985
Van de Perre JP, Stoelinga PJ, Blijdorp PA, Brouns JJ, Hoppenreijs
TJ: Perioperative morbidity in maxillofacial orthopaedic
surgery: a retrospective study. J Cranio-Maxillofac Surg 24:
263270, 1996
Van Sickels JE, Jeter TS, Theriot BA: Management of an
unfavorable lingual fracture during a sagittal split osteotomy. J
Oral Maxillofac Surg 43: 808809, 1985
Van Sickels JE, Richardson DA: Stability of orthognathic surgery:
a review of rigid xation. Br J Oral Maxillofac Surg 34:
279285, 1996
Dr. Dr. Thomas TELTZROW
Joachim-Friedrich-Str. 3, 10711 Berlin, Germany.
Tel.: +49 511 807 7170;
Fax: +49 511 807 7173
E-mail: teltzrow-hannover@t-online.de
Paper received 26 May 2004
Accepted 13 April 2005
ARTICLE IN PRESS
Perioperative complications following sagittal split osteotomy of the mandible 313