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. In 35 patients (2.8%) infection developed requiring extraoral incision and drainage; in 27 patients (2.1%) the inferior alveolar nerve was inadvertently cut; in 18 patients (1.4%) had to undergo re-operation due to bending or fracture of osteosynthesis material; in 12 patients (0.9%) an unfavourable split occurred.
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. In 35 patients (2.8%) infection developed requiring extraoral incision and drainage; in 27 patients (2.1%) the inferior alveolar nerve was inadvertently cut; in 18 patients (1.4%) had to undergo re-operation due to bending or fracture of osteosynthesis material; in 12 patients (0.9%) an unfavourable split occurred.
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. In 35 patients (2.8%) infection developed requiring extraoral incision and drainage; in 27 patients (2.1%) the inferior alveolar nerve was inadvertently cut; in 18 patients (1.4%) had to undergo re-operation due to bending or fracture of osteosynthesis material; in 12 patients (0.9%) an unfavourable split occurred.
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