HEAD & NECK CME

ABBREVIATION KEY
BSSO 5 bilateral sagittal split
osteotomy
CBCT 5 conebeam CT
LF1 5 Le Fort I osteotomy
TMJ 5 temporomandibular joint

Radiologist’s Guide to Orthognathic Received September 28, 2021;

Surgery accepted April 11, 2022.

From the Department of Radiology (M.L.,
C.D.P., S.S.), NewYork-Presbyterian/
Weill Cornell Medicine, New York, New
M.A. Lum, G.S. Reeve, C.D. Phillips, and S.B. Strauss York; and Division of Oral and
Maxillofacial Surgery (G.R.), NewYork-
Presbyterian/Weill Cornell Medicine,
New York, New York.
Previously presented as an electronic
Educational Exhibit at the 59th Annual
CME Credit Meeting of the American Society of
The American Society of Neuroradiology (ASNR) is accredited by the Accreditation Council for Continuing Medical Education Neuroradiology, May 22–26, 2021;
(ACCME) to provide continuing medical education for physicians. The ASNR designates this journal-based CME activity for a Virtual.
maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their
participation in the activity. To obtain Self-Assessment CME (SA-CME) credit for this activity, an online quiz must be successfully Please address correspondence to Mark
completed and submitted. ASNR members may access this quiz at no charge by logging on to eCME at [Link]. Lum, MD, Department of Radiology,
Nonmembers may pay a small fee to access the quiz and obtain credit via [Link]. NewYork-Presbyterian/Weill Cornell
Medical Center, 525 East 68th Street,
New York, NY 10065; email: [Link]
.lum@[Link]
[Link]
ABSTRACT
Disclosures
Orthognathic surgery, which focuses on improving maxillomandibular alignment, is increas- Based on the information received from
ingly used for both functional and cosmetic purposes. Common indications include malocclu- the authors, Neurographics has
determined that there are no financial
sion, obstructive sleep apnea, and congenital dentofacial anomalies. Due to the prevalence of disclosures or conflicts of interest to
in-office imaging performed by oral and maxillofacial surgeons, radiologists are not routinely report.
involved in the perioperative evaluation of patients undergoing orthognathic surgery. An
understanding of modern surgical techniques and anatomy is necessary to recognize the
normal and abnormal postsurgical findings.

Learning Objective: To familiarize radiologists with the role of imaging in the postoperative
evaluation after orthognathic surgery and the imaging appearance of both common and rare
complications

INTRODUCTION of radiology literature reviewing expected

Orthognathic surgery, or corrective jaw and unexpected findings after orthognathic
surgery, encompasses techniques aimed at surgery. The last major articles included a
improving maxillomandibular alignment 2-part series by Kaplan et al,2,3 published
for a variety of dentofacial conditions. in 1988, covering postoperative radiogra-
Advances in surgical technique as well as phy, which has since been replaced by CT.
the advent of CT and anatomic 3D model- In this article, we highlight normal and
ing led to an increase in its use since the abnormal perioperative imaging findings in
1980s.1 As the discipline of oral and max- the setting of orthognathic surgery and
illofacial surgery continues to expand, it is underscore key imaging descriptors rele-
important for radiologists to be familiar vant to surgical management.
with modern orthognathic surgical techni-
ques. At most centers, routine preoperative IMAGING PARADIGM IN ORTHOGNATHIC
and postoperative imaging is performed SURGERY
and interpreted by oral surgeons in the Radiography has been the mainstay of den-
office with dental radiographs and cone- tal imaging, offering high-resolution, low-
beam CT (CBCT). Conventional maxillofa- dose evaluation of dentofacial structures.
cial CT is generally reserved for instances Panoramic radiographs provide a compre-
when a postoperative complication is sus- hensive overview of the teeth, mandible,
pected. However, there is a relative paucity maxilla, and temporomandibular joints,

Neurographics 2023 January-March;13(1):35–45; [Link] | 35

 Additionally, there are a number of adjunctive occlusal indi-
ces that incorporate specific dentofacial measurements, high-
lighting the complexity of the pretreatment evaluation.15
Thus, it is not the role of the radiologist to diagnose or clas-
sify malocclusion, which is best assessed by clinical examina-
tion and dental models.

Obstructive Sleep Apnea

Obstructive sleep apnea is a multifactorial disease that may
be due to velopharyngeal or craniofacial abnormalities.
Maxillomandibular advancement surgery has been shown
to be an effective treatment in obstructive sleep apnea re-
fractory to continuous positive airway pressure.16 The main
therapeutic mechanism is through the increased tension on
the pharynx, which enlarges the upper airway. As the name
implies, maxillomandibular advancement involves both
maxillary and mandibular osteotomies to maintain a stable
FIG 1. Axial CBCT at the level of the maxillary alveolus. CBCT is lower and functional occlusion.
dose and provides adequate bony detail for preoperative planning at
the cost of spatial resolution and more pronounced artifacts, particularly
aliasing (arrows). Congenital Dentofacial Anomalies
Orthognathic surgery can be used to correct a variety of den-
while lateral radiographs allow comprehensive cephalomet- tofacial anomalies such as cleft lip and cleft palate, midface
ric analysis. Serial panoramic radiographs are frequently hypoplasia, and micrognathia. The goals of these surgeries
obtained in the postoperative setting to assess healing and are to create a harmonious facial profile and improve func-
alignment. While these are not typically interpreted by radi- tional outcomes related to mastication or airway problems.
ologists, it is important to understand their utility in the con- More complex syndromic anomalies may require additional
text of the perioperative evaluation. craniofacial surgery such as monobloc advancement, fronto-
CBCT is an adjunctive technique particularly useful in orbital advancement, and Le Fort III osteotomies that are of-
the preoperative evaluation, overcoming the limitations of ten performed in a staged fashion. These advanced craniofa-
distortion, superimposition, and magnification inherent to cial techniques are beyond the scope of this article but are
2D imaging.4,5 First introduced into dental practice in the mentioned for completeness.
late 1990s, in-office CBCT has since become widespread in
orthodontics and oral surgery.6 Compared with conven- COMMON COMPONENTS OF MODERN
tional multidetector CT, CBCT offers faster, lower-dose ORTHOGNATHIC SURGERY
examinations at the cost of more pronounced artifacts,
such as beam-hardening and aliasing, and poorer soft-tis- Le Fort I Osteotomy
sue evaluation (Fig 1).4,7–9 Other drawbacks of CBCT are Similar to the eponymous fracture pattern, Le Fort I osteot-
the nonstandardized imaging protocols and technical speci- omy (LF1) involves a horizontal incision through the maxillary
fications10 as well as the heightened legal liability for oral ridge, lateral nose, inferior maxillary sinus, and pterygomaxil-
surgeons who have various levels of formal training in lary junction (Fig 2). The LF1 is versatile, allowing maxillary
interpretation.11–13 Additionally, there is limited availabil- movement in all 3 planes. It is commonly used in the treatment
ity of CBCT in the hospital setting. For these reasons, con- of malocclusion, obstructive sleep apnea, vertical maxillary
ventional CT is favored in the postoperative setting when excess or deficiency, and cleft lip and palate.17
complications are suspected. The segmental variant of LF1 involves additional vertical os-
teotomies through the hard palate, allowing correction of
INDICATIONS FOR ORTHOGNATHIC SURGERY transverse maxillary deficiency (ie, narrow palate).18 Segmental
LF1 can be subdivided into 2-piece or 3-piece variants (Figs 3
Malocclusion and 4). In 2-piece LF1, a midline vertical osteotomy extends
Malocclusion refers to misalignment of the maxillary and through the central incisors; in the 3-piece LF1, bilateral
mandibular dental arches. Minor malocclusion can be man- oblique osteotomies extend through the lateral incisors and
aged by orthodontics alone, while more severe malocclusion canines or, less commonly, through the canines and first bicus-
may require surgical management. Most commonly, maloc- pid teeth. U-shaped osteotomies are also frequently incorpo-
clusion affecting the anterior-posterior dimension can be rated in segmental LF1 to reduce tension on the palatal mucosa
classified by the relationship of the molars and canines, (Fig 3B2, -C2 and Fig 4B1, -C1).19 It is important to not mis-
whereas malocclusion affecting the transverse dimension is take these additional osteotomies in the segmental variants for
referred to by terms such as “crossbite” or “Brodie bite.”14 undesired fractures.

36 | Neurographics 2023 January-March;13(1):35–45; [Link]

 whereas “distal” in the context of dental anatomy indicates
“away from midline.” Indications for mandibular osteot-
omy include malocclusion, obstructive sleep apnea, and iso-
lated mandibular deficiency or excess.20 BSSO is often
performed in conjunction with LF1 but can also be done in
isolation. A variety of other mandibular osteotomies exist
such as internal vertical ramus osteotomy and inverted L-os-
teotomy. These are less common but are used in situations
in which they are anatomically better suited for the desired
surgical movements.

Genioplasty
Genioplasty is an adjunctive surgical technique for chin
augmentation, involving a horizontal osteotomy through
the parasymphyseal mandible (Fig 2). Genioplasty is most
commonly performed for cosmetic purposes and is fre-
quently performed in conjunction with LF1 and/or BSSO.
It is also frequently performed in conjunction with maxillo-
mandibular advancement surgery for obstructive sleep
FIG 2. 3D CT rendering of the face demonstrates 3 common components
of orthognathic surgery: LFI (blue band), bilateral sagittal split osteot- apnea, because the genioplasty places additional tension on
omy (red band), and genioplasty (orange band). the genioglossus muscle, providing benefit to the airway.21

Mandibular Osteotomy NORMAL POSTOPERATIVE FINDINGS: CT CHECKLIST

The most common mandibular osteotomy used in ortho- Maxillofacial CT is not performed as part of the routine
gnathic surgery is the bilateral sagittal split osteotomy postoperative evaluation in the setting of orthognathic sur-
(BSSO), which involves oblique vertical incisions through gery but rather only when complications are suspected.
the mandibular body–ramus junctions (Fig 2). This oblique Understanding the normal postoperative appearance after
osteotomy creates 2 segments: a proximal (posterior) seg- orthognathic surgery is important to recognizing these com-
ment containing the temporomandibular joint and buccal plications and to avoid misidentification of normal postop-
plate and a distal (anterior) segment containing the lingual erative anatomy as pathology. Below are 4 elements that
plate and dentate portion of the mandible. Note that the should be explicitly evaluated on postoperative CT, which
term “distal” in the context of BSSO indicates “anterior,” are also summarized in the Table.

FIG 3. A1–C1, Annotated frontal 3D CT reconstructions of the face and axial “cut-in” 3D CT reconstructions of the maxilla (A2–C2) illustrate the osteot-
omy components in standard, 2-piece, and 3-piece LF1, respectively. All 3 involve the typical transverse incisions of the LF1 (dotted red lines in A1–
C1), but the segmental variants include vertical osteotomies (blue lines in B2 and C2). Additional U-shaped osteotomies are often included in the seg-
mental variants (green crescents in B2 and C2) to reduce tension on the palatal mucosa.

Neurographics 2023 January-March;13(1):35–45; [Link] | 37

FIG 4. Axial (A1–C1) and coronal (A2–C2) CT images of the maxilla of 3 patients who underwent standard, 2-piece, and 3-piece LF1, respectively. B1
and B2, In 2-piece segmental LF1, a midline vertical osteotomy extends between the central incisors (arrow), not to be confused with the median pala-
tine suture (chevrons in A1 and A2). C1 and C2, In a 3-piece segmental LF1, 2 bilateral oblique osteotomies extend between the lateral incisors and can-
ines (arrows). Note the additional U-shaped osteotomies in the segmental variants (arrowheads).

Table: Summary of findings that should be included in the CT report after orthognathic surgery
Report Element Clinical Question Clinical Relevance

Healing Is there appropriate healing of the osteotomies? Is alignment Malunion and nonunion should be recognized early as they
anatomic? may prompt revision surgery
TMJ Are the mandibular condyles normally positioned? Is there Condylar malposition can result in an undesirable bite; condy-
evidence of condylar resorption? Are there signs of devel- lar resorption and temporomandibular osteoarthrosis are
oping osteoarthrosis (ie, joint space narrowing, osteophyte secondary signs of pathologic joint remodeling
formation, subchondral changes)?
Nasal septum Is the cartilaginous septum nearly midline? Has septal mor- In addition to cosmetic concerns, septal buckling can cause
phology changed? nasal airway obstruction and may require septoplasty
Hardware Is hardware intact? Is there evidence of loosening? Hardware loosening can be a secondary sign of infection

Healing Temporomandibular Joint

Normal healing after orthognathic surgery is typically assessed Temporomandibular joint (TMJ) dysfunction after or-
by patient history, clinical examination, and dental radio- thognathic surgery, particularly BSSO, has been exten-
graphs. While postoperative CT is not routinely performed, it sively studied. The incidence of TMJ dysfunction,
is important for the radiologist to recognize normal healing however, is confounded because many patients requiring
patterns to correctly identify nonunion and malunion. Due to surgery have pre-existing TMJ disease.25 It is thought
the biomechanics of speech and mastication as well as differ- that mandibular osteotomies alter TMJ biomechanics,
ences in blood supply, mandibular osteotomies are at higher possibly leading to pathologic joint remodeling. This can
risk of nonunion compared with maxillary osteotomies.22,23 result in either degenerative joint disease or condylar
Several studies have compared mandibular healing to long resorption, the latter of which may also lead to retrogna-
bone healing,24 and the same principles are thought to apply thia or apertognathia.26,27 Additionally, in the immediate
to both. However, few studies have documented the typical postoperative setting, postoperative condylar malposi-
CT appearance of the healing mandible. On the basis of our tion can lead to an undesirable open bite or other maloc-
experience, nonbridging callus should be seen by 2 weeks, clusion.25 Panoramic radiographs are a good screening
with bridging callus visualized at 6 weeks. By 12 weeks, frac- tool for TMJ disease, but CT can provide additional
ture lucency should be nearly imperceptible (Fig 5). As with detail such as subchondral changes. Radiologists should
other skeletal fractures, alignment of the osteotomy should comment on the condylar position, morphology, and
also be assessed. signs of osteoarthrosis.

38 | Neurographics 2023 January-March;13(1):35–45; [Link]

FIG 5. Postoperative axial CT images of the mandible of 4 different patients who underwent BSSO at different time points (postoperative week is
abbreviated POW on the figure). A, At 2 weeks, some nonbridging callus (arrowheads) is visible. B, At 8 weeks, bridging callus (arrowheads) is begin-
ning to form. C, At 12 weeks, healing is nearly complete, with some residual fracture lucency in the right mandible (arrowhead). Note the abnormal
lucency and erosion along the left osteotomy (arrow), which was found to have nonunion and infection. D, At 1 year, the osteotomy is fully healed
with a faint residual sclerotic line (arrowhead).

POSTOPERATIVE COMPLICATIONS: EARLY

Postoperative complications can be divided into early or
late. The postoperative time point of a study in addition to
the clinical history can help guide the radiologist’s search
pattern. In this section, we review complications that are
more likely to present within the first week.

Airway Compromise
Some degree of respiratory distress after orthognathic sur-
gery occurs in up to 20% of patients.29 This is multifactorial
FIG 6. A 27-year-old woman with dysphagia 7 days after LF1 and BSSO. and can be related to aspiration, atelectasis, complications
Axial (A) and coronal (B) CT of the upper oropharynx demonstrates of intubation, hemorrhage, or edema.25 These are usually
edema surrounding surgical hemostatic material used to control intrao- transient and do not require emergent intervention. Life-
perative bleeding (arrowhead) adjacent to the right pterygoid osteot- threatening airway compromise is rare but can be due to
omy, resulting in narrowing and slight leftward deviation of the
expanding hematoma. Orthognathic surgery, particularly
oropharynx (asterisk). The uvula is also deviated to the left (arrow). The
patient was observed overnight, and her symptoms improved with con- LF1, is associated with a relatively high intraoperative blood
servative management. loss and transfusion rate.32,33 Hemorrhage or edema or
both in the pterygomaxillary region, which can be due to
Nasal Septum injury of the maxillary artery branches or pterygoid venous
Maxillary surgery including LF1 frequently alters nasal plexus,34,35 may lead to oropharyngeal narrowing (Fig 6).
morphology. The cartilaginous nasal septum is at particu-
Unfavorable Split
lar risk for undesirable deviation due to nasotracheal extu-
An unfavorable split, colloquially referred to as a “bad
bation or inadequate septal reduction during maxillary
split,” is a specific complication of the BSSO in which there
impaction and repositioning.28–30 A redundant septum in
is an undesirable or unanticipated fracture pattern with a
the setting of inadequate septal reduction results in buck-
reported incidence of 2%–10%.36 In order from more com-
ling. Thus, the position of the nasal septum should be
mon to less common, unfavorable splits can involve the buc-
described in the report. Because nasal septal deviation is
cal plate, lingual plate, coronoid, and condyle.37,38 They
inherently common, comparison with preoperative imag- can also have a more complex, comminuted pattern (Fig 7).
ing, if available, is important. An unfavorable split may require the surgeon to place addi-
tional hardware to replace the fractures segments or poten-
Hardware tially put the patient into maxillomandibular fixation to
Orthognathic surgery typically involves plate and screw fixa- allow union of the fracture segments.
tion. As with other skeletal fixation hardware, complications
include loosening, fracture, and infection. Hardware fracture Epistaxis
after orthognathic surgery is not well-described, presumably Epistaxis is another form of vascular injury that can occur
due to its relative rarity. Infection, on the other hand, is more after LF1, often presenting within hours, and may be due to
common and is the most common indication for hardware injury of the sphenopalatine artery or traumatic nasotra-
removal followed by patient discomfort.31 Infection may be cheal intubation.35 The sphenopalatine artery is the terminal
heralded by loosening characterized by abnormal lucency branch of the internal maxillary artery and a major contrib-
surrounding the screws or by plate separation. utor to Kiesselbach plexus, the rich anastomotic network of

Neurographics 2023 January-March;13(1):35–45; [Link] | 39

FIG 7. A 29-year-old man with malocclusion immediately noticeable after BSSO. A, Axial CT of the mandible demonstrates an unfavorable split on the
right mandible, characterized by a comminuted subcondylar fracture (arrowhead). B, Coronal CT of the mandible demonstrates that the major proxi-
mal fracture fragment is laterally displaced (arrows), resulting in a widened osteotomy. C, The 3D reconstruction of the fracture (arrowhead) appears
less dramatic due to the overlapping fracture fragments. The patient was managed conservatively with maxillomandibular fixation for closed reduc-
tion followed by elastic physiotherapy.

FIG 8. A 28-year-old man with massive epistaxis 6 days after LF1 and
BSSO. A, Axial CTA of the head at the level of the maxillary sinuses dem-
onstrates hyperdense blood in the right maxillary sinus and posterior
nasal cavity (arrowheads). The distal right internal maxillary artery tra-
verses posterior to the LF1 defect in the posterior wall of the right maxil-
lary sinus (arrow). No active extravasation is identified on CTA. B,
Lateral selective DSA of the right sphenopalatine artery does not dem-
onstrate active extravasation but shows increased blush in the
Kiesselbach plexus (red circle), indicative of hyperemia. The distal sphe-
nopalatine artery was embolized with polyvinyl alcohol particles, and
the patient’s epistaxis improved.

vessels in the anterior nasal septal area responsible for most FIG 9. A 19-year-old man with premature removal of an occlusal stent,
epistaxis.39 Occasionally, postoperative epistaxis is refrac- resulting in a change in bite 4 days after LF1 (postoperative week is
abbreviated POW on the figure). Axial (A1) and coronal (A2) preopera-
tory to conservative management and will be further eval-
tive CBCT of the face demonstrates mild rightward nasal septal devia-
uated on CTA or conventional angiography. While findings tion (arrows). Axial (B1) and coronal (B2) CT of the face at postoperative
on CTA are frequently negative in epistaxis, in part due to week 4 after segmental LF1 demonstrates increased rightward nasal sep-
the small caliber of the injured vessel and beam-hardening tal deviation (arrowheads). Note the increased widening of the left nasal
vestibule and common meatus (asterisk). Premature removal of the sup-
artifacts from osseous structures, in the postoperative set-
porting occlusal stent led to maxillary arch collapse and ultimately buck-
ting, it can identify active extravasation, vessel irregularity, ling of the nasal septum. The patient subsequently underwent septoplasty.
or other vascular lesions such as pseudoaneurysm, discussed Preop indicates preoperative.
below.39 This identification can, in turn, reduce the proce-
dural time and contrast used in subsequent conventional an- reduce the size of the nasal airway and ultimately lead to
giography.40 Figure 8 illustrates the intimate relationship breathing problems. A challenge for the radiologist in identi-
between the internal maxillary artery and LF1. fying pathologic postoperative septal deviation in the post-
operative setting is the high prevalence of septal deviation in
Nasal Septal Deviation the general population.41 Comparison with preoperative
As alluded to previously, nasal septal deviation can result imaging or buckling morphology can be helpful (Fig 9).
from traumatic nasotracheal intubation or inadequate septal
reduction during maxillary impaction in LF1, which is used POSTOPERATIVE COMPLICATIONS: DELAYED
to reduce vertical maxillary excess.28 Nasal septal deviation Delayed complications are often insidious, and clinical his-
is not only a cosmetic concern; septal redundancy can tory and examination can be helpful. In this section, we

40 | Neurographics 2023 January-March;13(1):35–45; [Link]

 soft-tissue infections elsewhere, typical findings on a con-
trast-enhanced CT include skin thickening, subcutaneous
fat stranding, and a rim-enhancing collection compatible
with abscess (Fig 10).
Osteomyelitis, on the other hand, can be more challeng-
ing to identify. MR imaging is typically the preferred tech-
nique for osteomyelitis; however, it has limited sensitivity in
the postoperative setting due to susceptibility from fixation
hardware and particularly braces. On CT, osteomyelitis
may manifest as delayed healing, cortical erosions, or reac-
tive periosteal bone formation (Fig 11). Because most ortho-
gnathic surgeries are symmetric, comparison with the
contralateral side is particularly helpful. Additionally, sur-
rounding soft-tissue inflammatory changes may be a helpful
ancillary finding.

Nonunion and Malunion

Postoperative healing that does not progress as expected or
heals with nonanatomic alignment can be deemed nonunion
FIG 10. A 21-year-old man with left-jaw swelling 13 weeks after LF1,
BSSO, and genioplasty. Axial CT at the level of the genioplasty demon-
and malunion, respectively. Nonunion and malunion are
strates extensive infiltration of the premandibular soft tissues, eccentric thought to be relatively uncommon, but rates are not widely
to the left with marked skin thickening (arrowheads) but no drainable reported. Risk factors include age, infection, parafunctional
fluid collection consistent with cellulitis. activity, and systemic disease that may impair healing.25,36
There is no widely accepted definition of nonunion, but on
review complications that are more likely to present beyond the basis of our experience, the absence of bridging callus at
the first postoperative week. 6 weeks should raise suspicion (Fig 12). Rotational forces
and muscular pull about the BSSO can lead to malalignment
Infection as well (Fig 13).25
Orthognathic surgery is considered clean-contaminated sur-
gery and is expected to have a higher rate of postoperative Pseudoaneurysm
infection compared with noncontaminated procedures. External carotid artery pseudoaneurysm after orthognathic
Estimated rates vary widely from 1% to 33%.42 Skin and surgery is a rare delayed complication, with an incidence of
soft-tissue infections are more clinically overt and poorly <1%.43 This is likely due to the small caliber of the external
evaluated on CBCT, which is also less readily available in carotid artery branches, because injury is more likely to
emergency settings, due to the lower contrast resolution of result in transection. However, pseudoaneurysm can be a se-
nonosseous structures.4 The superior soft-tissue resolution rious cause of uncontrolled postoperative bleeding. Early
of conventional CT is also clinically important in distin- recognition on angiography is necessary to minimize mor-
guishing postoperative cellulitis from abscess because the bidity and mortality. Pseudoaneurysms are more common
latter may require incision and drainage.42 As with skin and with LF1, in which they typically involve maxillary artery

FIG 11. A 38-year-old woman with left-sided jaw pain 12 weeks after LF1 and BSSO. Axial CT images of the mandible in bone (A) and soft-tissue (B)
algorithms demonstrate asymmetric widening of the left BSSO with irregular erosions (arrowhead) as well thickening of the left masseter muscle (as-
terisk), which demonstrates indistinct margins. C, Precontrast axial T1 image through the mandible shows loss of the normal marrow signal in the left
mandibular body with cortical indistinctness (arrow), consistent with osteomyelitis, confirmed by biopsy. Note the prominent susceptibility artifacts
from LF1 plates (chevrons), highlighting a limitation of MR imaging in the postoperative setting. P indicates posterior.

Neurographics 2023 January-March;13(1):35–45; [Link] | 41

FIG 12. A 43-year-old woman with a clicking sensation 6 weeks after LF1 and BSSO. A, Axial CT images of the mandible demonstrate no appreciable
callus formation at either of the BSSOs. Zoomed-in coronal CT images of the right (B1) and left (B2) sagittal split osteotomies (arrowheads) also do
not demonstrate callus suspicious for nonunion. On revision BSSO, both osteotomies were easily opened.

FIG 13. A 19-year-old woman presenting for routine follow-up 6 weeks after BSSO (postoperative week is abbreviated POW on the figure). Panoramic
dental x-rays at postoperative week 0 (A1) and postoperative week 6 (A2) demonstrate superior rotation of the proximal BSSO segments (red lines).
Also note the change in alignment of the second molars (blue lines). B, Zoomed-in coronal CT of the mandibles confirms superior displacement and
rotation of the proximal segments (red lines) due to a combination of fixation failure and the pull of the temporalis tendons on the coronoid proc-
esses. Also note some nonbridging callus formation (arrowheads).

branches. Much rarer are pseudoaneurysms after BSSO, necrosis of the mandible is exceedingly rare, with only a few
which can involve the facial artery (Fig 14).44 case reports in the literature.51 The teeth and the periodon-
tium of the mandible are primarily supplied by the inferior
Avascular Necrosis alveolar artery. Similar to the maxilla, the mandible has a
The maxilla has a redundant vascular supply, making it rela- rich collateral supply, and it has been shown that the mental
tively resistant to ischemia. For example, studies have artery and mandibular branch of the sublingual artery can
shown that sacrifice of the descending palatine artery, which adequately compensate when the inferior alveolar artery is
supplies the hard and soft palates, does not overall decrease occluded.52
maxillary perfusion,45–47 likely due to collateral flow from
the ascending pharyngeal and facial arteries.48,49 However, Inferior Alveolar Nerve Injury
avascular necrosis of the maxilla has been documented as a The inferior alveolar nerve is a mixed sensory and motor
rare complication after LF1, with 1 series estimating an inci- branch of the mandibular nerve (V3) and traverses the infe-
dence of 0.2%.50 This can result in tooth devitalization rior alveolar canal. Inferior alveolar nerve injury is thought
requiring extraction. On CT, avascular necrosis may present to be the most common complication after BSSO, often due
as subtle thinning of the alveolar ridge (Fig 15). Attention to to direct manipulation. The incidence ranges widely, likely
the maxillary tooth roots and alveolar bone levels can help due to differences in assessment, but has been estimated
identify this devastating complication. Of note, avascular to be up to 85%.53 Symptoms referrable to the inferior

42 | Neurographics 2023 January-March;13(1):35–45; [Link]

FIG 14. A 15-year-old man with brisk bleeding from the left BSSO site 5 days after the operation. The patient was transferred to interventional radiol-
ogy to identify the source of bleeding. A, Lateral, left common carotid artery DSA demonstrates a pseudoaneurysm arising from the facial artery (as-
terisk). B, Delayed lateral DSA shows contrast blush (arrow) anterior to the pseudoaneurysm (asterisk), consistent with active extravasation. The
pseudoaneurysm was successfully treated with a liquid embolic. C, The final lateral spot image shows the relationship of the embolized pseudoaneu-
rysm (asterisk) to the BSSO plates (arrowhead).

FIG 15. A 25-year-old woman with tooth pain after 2-piece segment LF1 and BSSO (postoperative week is abbreviated POW on the figure). A,
Panoramic dental x-ray at postoperative week 8 shows relative maxillary lucency overlying the incisors (arrows). B, Dental examination at postopera-
tive week 12 shows gingival recession around the central incisors exposing the tooth roots (arrowheads). Axial (C), sagittal (D), and 3D (E) CT images
of the mandible at postoperative week 20 reveal thinning of the buccal cortex overlying the central and lateral incisors (arrowheads), most pro-
nounced about the right central incisor (arrows), consistent with avascular necrosis. F, The patient required extraction of all 4 maxillary incisors fol-
lowed by bone graft and dental implants.

alveolar nerve (eg, chin numbness) are transient in most

cases, but up to one-third of patients may report chronic
sensory disturbances.54 Intraoperatively, the inferior alveo-
lar nerve can be repositioned when the nerve is freed from
the proximal BSSO segment by bony undermining.55 Thus,
the position of the inferior alveolar nerve after BSSO cannot
be always inferred on postoperative CT (Fig 16). It is impor-
tant for radiologists to understand that inferior alveolar
nerve injury is a common, but it is not a radiologic diagnosis
FIG 16. A 57-year-old man with chronic right-chin numbness after LF1,
BSSO, and genioplasty for maxillary hypoplasia 2 years ago. Axial (A)
in the postoperative setting.
and coronal (B) CT images of the mandible demonstrate BSSO with plate
and screw fixation. On the right, a posterior screw appears to penetrate CONCLUSIONS
the alveolar canal (arrowhead). The interpreting radiologist raised suspi-
cion for nerve impingement; however, review of the operative note
Even though radiologists are not routinely involved in the
revealed that the inferior alveolar nerves were freed from the proximal perioperative evaluation after orthognathic surgery, it is im-
segment and completely covered in the distal segment. portant to recognize the role of imaging. Maxillofacial CT is

Neurographics 2023 January-March;13(1):35–45; [Link] | 43

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