oral surgery oral medicine oral pathology

WA scC~riC,n.T ,,,1 endodontics NplC~ dental radiology

Volume 60, Number 5. Novrmhrr. I985

oral surgery
Editor:

ROBERT

B. SMRA,

D.D.S.

School of Dental Medicine, Tufts University I Kneeland Street Boston, Massachusetts 021 I1

The sagittal split osteotomy of the mandible

Myer S. Leonard, M.D., D.D.S.,* Paul Ziman. D.D.S.,** Richard Bevis, D.D.S., Ph.D..** Gerald Cavanaugh, D.D.S., Ph.D., ** Michael T. Speidel, D.D.S., iU.S.,** and Frank Worms, D.D.S., M.S.,** Minneapolis, Minn.
DENTAL SCHOOL, UNIVERSITY OF MINNESOTA

Modifications of the sagittal split osteotomy of the mandible have essentially reduced the major drawbacks of the procedure, such as condyle displacement, short-term skeletal relapse, and protracted maxillomandibular fixation and mental nerve dysesthesia. These techniques have proved effective over a period of 4 years in fifty-seven patients treated.
(ORAL SURG. ORAL MED. ORAL PATHOL. 60~459-466, 1985)

t is now almost 30 years since the sagittal split osteotomy of the mandible (SSO) for the correction of the retrognathic and prognathic mandible was first described.lW3 The procedure is innovative, versatile, and widely used despite the well-documented morbidity related to it.4-6 The complications associated with the procedure can be divided into two groups. In the first group are the surgical considerations that involve blood loss, difficulties of access,the splitting techniques, avoidance of the inferior alveolar nerve, and edema subsequent to the surgery. The second group of postsurgical considerations involve the protracted or permanent dysesthesia of the mental nerve, condylar displacement, and potential for relapse of the occlusion. Numerous articles in the literature describe modifications of the technique which address, among other items, the role of the muscles in re1apse,7.8 methods and duration of fixation,9*o condylar posi*Department of Oral and Maxillofacial **Deoartment of Orthodontics. Surgery.

tioning techniques,1-6and changes in the location of the bony cuts. I* I8Despite these attempts at improvement, somesurgeonsstill report a varying percentage of relapses.lo* 19-** To overcome some of these difficulties, we have introduced several modifications that have been tested in more than fifty-seven patients over a period of 4 years at the University of Minnesota.
MENTAL NERVE DYSESTIIESIA

A matter of great concern in the procedure is the high incidence of protracted dysesthesia of the mental nerve. Trauma to the inferior alveolar nerve probably occurs most frequently at the time of the splitting of the ramus, becausethe nerve may well be adherent to the proximal segment of bone. During attempts to detach it from the proximal segment, the nerve may be avulsed or, if any vascular supply to the nerve is interrupted, then the nerve may remain in continuity but suffer ischemic changes, and these may be sufficient to prevent the return of sensation to the lip. There are numerous occasions when
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Fig.

2.

Proximal segment orienting device(PSOD) with

paddle. bone above the level of the lingula on the anteromedial aspect of the mandible. Once the corticocancellous bone junction distal to the second molar is detected, no further bone is removed at this point. An oscillating saw is inserted at the junction, and the cut is made up the anterior border of the mandible to join the horizontal cut on the mechai aspect of the mandible. At first, a small blade is used, but subsequently a long reciprocating (3 cm) blade is inserted to deepen the cut. Great care is taken to keep the blade placed laterally. Becausethe blade approaches the medial aspect of the ramus above the lingula, it can be used to saw through to the posterior border of the ramus. The cut is not extended beyond the distal aspect of the first molar, where a vertical cut is made. This vertical cut can be made with either a fissure bur or a short reciprocating saw. Becausethe nerve is almost always in the cancellous bone, by placing the saw blade far laterally one limits the chance of traumatizing the inferior alveolar nerve. Great care has to be taken in splitting the bone because the lateral segment is very thin. Very fine and very sharp chisels are recommended for use in splitting the bone. The inner aspect of the lateral plate of the bone is examined after the split, and if any evidence of the lips of the bony canal is noted, then these bony projections are smoothed down so that they will not impale the nerve when the segments are fixated. This procedure has now been used on 57 patients between 1981 and 1984. Of the 114 mental nerves tested, 91 responded to a pinprick and had normal sensation. Seven had no response, and more than 2 years has elapsed since their surgical procedures; 14 underwent surgery within the past 3 to 4 months. Normally, the sensation in the gingival tissues around the mandibular incisors is the first to return, followed by objective sensation in the lips and, finally, subjective sensation. No relation between the duration of anesthesia or paresthesia and the type of procedure has been noted. Complete sensation can return in as little as 3 days or can take as long as 18

Fig. 1. Corticocancellous junction distal and buccal to secondmolar.

surgeons know that the nerve has remained intact but sensation has not returned. The incidence of irreversible disturbance of sensation to the mental nerve has been given as low in 15sz3 and has high as 82%,24 and other authors have given figures somewhere in between these two extremes.2s-29 A thorough examination of this complication of the procedure was carried out by Svartz and associates,3o who reported that 47% of their patients still had nerve disturbance 2 years after the operation, though only 10% of the patients claimed discomfort from these disturbances. In order to reduce even further the incidence of disturbance of nerve sensation, Spiessl recommends decortication of the external oblique line of the mandible on the proximal segment and removal of bone until the boundary between the cancellous bone and cortex is readily apparent. An osteotome is then guided along this border and, with light taps, only the cortical plate of bone will be fractured off. The drawback to this approach is that, if one uses lag screws, then frequently this area of bone is neededand too much is lost in determining the site of the corticocancellous junction. In the dissection of twenty cadavers and in more than 100 procedures by this technique, we found the nerve to be in the cancellous bone. However, on occasion we have seen the nerve canal dipping into the cortical bone significantly, and one authority states that the inferior alveolar neurovascular bundle may be in the cortical bone.32 In order to position a cut so that only the cortical bone will be split off and yet not remove the amount of bone that Spiessl does, we have used a small round bur to dust away the cortical bone at the height of the alveolar ridge distal and buccal to the first or second molar (Fig. 1). The same bur is used to take down a small amount of

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Fig.

3. PSOD before (A) and after (B) contouring.

months, with the most frequent period being between 4 and 8 months. Although we use lag screws for fixation of the segments, we do not agree with Paulus and Steinhauser that the lag screw technique is associated with a higher incidence of nerve dysesthesia than when the segments are secured with a wire loop.
CONDYLE POSITION

The importance of the position of the condyle has recently received considerable attention.11-62 33 To establish the position of the proximal segment, we use a device (proximal segment orienting devicePSOD) that permits accurate location of the condyle in relation to the maxilla prior to the segmentsbeing split. Since the maxilla will not shift and the proximal segment should have the same position postoperatively, reapplication of the device to the maxilla after intermaxillary fixation has been established will permit the proximal segment to be maneuvered into its preoperative position and clamped there while lag screws are inserted. The PSOD is a plastic device that is hinged at the center (Fig. 2), thus permitting it to be used on maxillas of a wide range in arch dimension. The inner ledge is applied to the facial surfaces of the maxillary teeth and the plastic ledge can be contoured easily to maximize the fit (Fig. 3). When the fit is deemed satisfactory, separating solution is painted on the maxillary teeth and acrylic varnish is painted on the ledge of the PSOD. Quick-setting acrylic is flowed onto the ledge of the PSOD, and the device is applied against the facial surface of the maxillary teeth. Excess acrylic is quickly removed from around the orthodontic brackets. The aim is to get as snug a fit as possible. A PSOD is prepared for each side; the right one extends from the right maxillary first molar to the left first premolar and the left device is reciprocally positioned.34 A brass paddle is secured with two small screws to

the end of the device. The PSOD with paddle attachment is applied to the maxillary teeth prior to the splitting of the mandible. The mandible is placed in the preoperative occlusion and two Jine score marks are made alongside the paddle on the proximal segment (Fig. 4). After the split has been completed and the mandible placed in maxillomandibular fixation, reapplication of the PSOD will enable the operator to maneuver the proximal segment until the score marks realign with the paddle extension. The segments can then be grasped with bone-holding forceps until secured with screws or wires. In this way, the proximal segment will be located in its presurgical position. Since all our patients are required to undergo preand postsurgical laterally corrected laminagraphs,35 it is possible to closely examine the positional changes of the condyle in an anteroposterior and superoinferior position. Such a study is currently under way, but preliminary observations have shown the device to be of great assistance in repositioning the condyle accurately. Indeed, several grossly inaccurate positions of the proximal segment would have occurred in the correction of prognathic patients with apertognathia had we not been using the device. In addition, the device helps prevent rotation of the posterior border and angle of the mandible. Maintaining their position postoperatively is a great advantage, particularly in patients who are to undergo a forward sagittal osteotomy. The accurate positioning of the condyle which the PSOD permits is probably a very important factor in minimizing and even preventing early skeletal relapse.
MAXILLOMANDl8ULAR FIXATION

A retrospective study of twenty-five patients who have undergone sagittal split osteotomy of the mandible revealed that the primary objection to the entire procedure was the duration of intermaxillary

462 Leonard et al.

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Fig. 4. PSOD in position with paddle and score marks on ramus prior to split.

tance. By comparison, internally fixed screws offer rigid and long-term stability without lengthy fixation while enhancing the speed and strength of the bony BUTTRESS repair.40-42 Spiessl and others have long experience with this Fig. 5. Buttress tap. method of fixation and report virtually no long-term relapse9. 16,434 with the use of three screws per side if the condyle is properly positioned. fixation. Because there is no wiring technique which There is, however, considerable lack of underreduces the average 6 to 8 weeks of maxillomandibustanding as to how lag screws function. This misconlar fixation to a more reasonable duration, the use of lag screws has evolved. This most ingenious innovaception and puzzlement can usually be summarized tion was first applied to maxillofacial surgery by in four questions: (1) Why not use self-tapping screws? (2) What do taps do? (3) If the threads of Spiess1.36 For this particular application, the lag screws depend upon having a proximal segment hole the pretapped screws are so sharp, why do they not with a greater diameter than the medially placed cut their own threads in the bone? (4) Why not tap distal segment hole. The latter is tapped to the both holes, that is, use drills of the same diameter on diameter of the former, and a tapped screw of the proximal and distal segments? These questions sufficient length is inserted to join the segments. are very important and are worthy of complete Wires exert no coefficient of friction and, apart from answers. maintaining the bony fragments in apposition and 1. Why not use a self-tapping screw? Self-tapping preventing splaying of the segments with resultant screws create their own threads and function by hematoma formation, accomplish little in the way of compressing the material into which they are placed stable fixation.g,37*38 By contrast, orthopedic surgical between the threads. Thus, if a self-tapping screw is experience has shown that lag screws assure a high applied to wood or plastic, then wood or plastic is coefficient of fixation without microfracture.3g Anicompressedbetween the threads of the screw. Bone, mal studies indicate that the period of intermaxillary however, is a living substance and the compression fixation should last until at least the bony scar is force exerted between the threads by a self-tapping stronger than the memory of the visco-elastic properscrew is such as to bring about microfracture. Over a ties of the muscle. From studies on monkeys, Reitzik period of time this leads to resorption of a few suggested that this should be 20 to 26 weeks.37*40 microns of bone, and this is sufficient to cause Wire fixation for this duration is impractical and loosening of the screws. Thus, self-tapping screws do undesirable and meets with very poor patient accepnot provide a stable fixation.

LMi& \\\\

Fig.

6. Screw action in bone.

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7. A, Trocar. B, Removable point. C, Cheek ring. D, Handle to hold ring. E, 2.7 mm drill guide. F, 2.0 mm drill guide.
Fig.

Fig. 9. A, Tap handle, tap, and sleeve. B, Length of tap exposed (in mm) is governed by position of sleeve against head of tap.

Fig.

8. A, Depth gauge. B, Close-up of hooked end.

2. What are taps? A tap is a mechanical device in which the core diameter of the instrument is slightly less than the diameter of the drill bit that made the hole. However, the threads are extremely sharp, and in sagittal osteotomies a 2.7 mm. tap is used; this means that the diameter of the outer threads is 2.7. They function by creating a thread 2.7 mm. in diameter, and the debris falls into a flute within the tap; thus, one does not have to reverse the tap one turn for every three turns forward. The type of tap used in the ASIF system is a buttress tap (Fig. 5) and this is ideal for obtaining a maximum load in one direction. This means that as the screw goesin, it will draw the distal segment to the proximal segment and compress the latter between the head of the screw and the distal segment. 3. Why do the screws not make their own threads in the bone? The answer to this frequently asked question is that the screw will not engage in the bone until its threads fall into the cut made by the tap (Fig. 6). Thus, it will then turn after it is screwed in

and always follow the path created by the tap. Examination of Fig. 6 will show that after the screw becomesmore firmly seated,then the distal fragment will be pulled toward the head of the screw and compress the proximal segment. 4. Why not tap both holes? This technique is sometimes advocated but is completely improper. The reason is that if one were to tap both holes, then it would be possible for the screw to engage firmly in the proximal segment, and yet there might still be some distance before the distal segment would be brought up tight against the proximal segment. It is very important in this procedure that the proximal segment be the gliding hole and thus untapped and have a diameter of 2.7 mm and that the distal segment have the thread or tapped hole and be drilled with a 2.0 mm diameter drill and then tapped to a diameter of 2.7 mm. Placement of the lag screws begins with puncture of the cheek via a small incision along the lower border of the mandible approximately opposite the vertical cut of the osteotomy. A trocar (Fig. 7) is inserted through the cheek, the point is removed and a cheek-holding ring is attached to the trocar, and then a 2.7 mm hole is drilled into the proximal segment. Care is taken to place the hole well away from the neurovascular canal. A specifically con-

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Fig.

10. Screws in

place. II. Forward sagittal split osteotomy

Preoperative Postoperative

I. Change in angulation of long axis of left and right condyles to midsagittal plane and to each other before and after sagittal split osteotomy in prognathic patients (backward sagittal split)
Table
Preoperative Postoperative

Table

1. Left condyle: Midsagittal plane Right condyle: Midsagittal plane Left condyle: Right condyle 2. Left condyle: Midsagittal plane Right condyle: Midsagittal plane Left condyle: Right condyle 3.: Left condyle: Midsagittal plane Right condyle: Midsagittal plane Left condyle: Right condyle 4. Left condyle: Midsagittal plane Right condyle: Midsagittal plane Left condyle: Right condyle 5. Left condyle: Midsagittal plane Right condyle: Midsagittal plane Left condyle: Right condyle 6. Left condyle: Midsagittal plane Right condyle: Midsagittal plane Left condyle: Right condyle
Data This try. derived was from a patient prewith and postoperative right condylar CT scans. hyperplasia

76 74 144 65 71 137 45 84 130 55 64 120 75 19 156 57 71 130

and gross

73 71 144 55 67 122 49 66 II5 43 60 102 64 12 137 52 63 II5

asymme-

1. Left condyle: Midsagittal plane Right condyle: Midsagittal plane Left condyle: Right condyle 2. Left condyle: Midsagittal plane Right condyle: Midsagittal plane Left condyle: Right condyle 3. Left condyle: Midsagittal plane Right condyle: Midsagittal plane Left condyle: Right condyle 4. Left condyle: Midsagittal plane Right condyle: Midsagittal plane Left condyle: Right condyle

64 71 I34 49 51 99 62 55 II8 73 59 I34

61 61 137 41 47 88 60 57 II7 65 62 133

strutted drill guide (Fig. 7) permits one to drill a 2.0 mm diameter hole through the 2.7 mm diameter hole and into the distal segment. This guide is used so that the tolerance of the drill bit will be extremely low and the narrow hole will be centered within the larger hole. The depth of the hole from the lateral surface of the proximal segment to the medial surface of the distal segment is determined by using a depth guide (Fig. 8, A and B). The hole is then tapped. In order that the tap should not pass deep into the structures in the floor of the mouth, we have developed a tap sleeve which is passed over the tap and exposesonly the determined depth of the bone

(Fig. 9, A and B). In this way, the tap cannot proceed beyond the medial aspect of the distal segment. A screw is then inserted and tightened to a finger-tight pressure, with care being taken not to strip the threads (Fig. 10). Although SpiessP recommends insertion of three screws on each side, we have found that the best results are accomplished if, after one screw has been inserted on, say, the right side, we position the left ramus in its preoperative position as determined by the PSOD and then clamp the segments and insert two screws on the left side. We then return to the right side and insert two more screws,making a total of three screws for this side. Finally, the third screw is inserted on the left side. In addition, if screws are to be inserted near the superior border of the proximal and distal segments, then the bone clamp should be in place; otherwise, some splaying of the segments can occur. By alternating the screw insertion from side to side, we minimize the torquing that may occur if all three are inserted at once. The principle is akin to securing a wheel on a car when one tightens the bolts in a diagonal rather than a

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sequential manner. One 5-O nylon suture is usually sufficient to close the skin wound. The occlusion can be released at once, but we usually keep the patients in fixation with elastic binders for 4 or 5 days, as we have found that this considerably reduces the pain and soreness that occurs if no fixation is applied. By the second postoperative day patients can eat soft foods, and within a month they can return to a normal diet. Apart from the dramatic reduction of the period of maxillomandibular fixation, there is better handling of oral secretions, easier speech,and a quicker return to ones occupation. In addition, the psychological impact of long-term maxillomandibular fixation cannot be overstated for those patients who are highly visible and/or work with people on a regular basis. Thus, patients no longer need choose between living with a dentofacial deformity and long-term maxillomandibular fixation. The screws may remain in vivo forever. However, in an extremely thin person the screws may be palpable beneath the skin and may be objectionable to the patient. On one occasion we found it necessary to remove the screws for this reason. Use of the screws without the PSOD is not recommended, as unpredictable torquing, rotational, and displacement movements of the segmentscan go undetected, thus compromising the final results. One criticism that has been made of this procedure is that there is a higher incidence of torquing of the condyle and a higher incidence of temporomandibular joint dysfunction. We had the opportunity to examine ten patients who had pre- and postoperative CT scans. Although the pre- and postoperative cuts were not absolutely identical, nevertheless, by applying a tracing of the preoperative condyle to the best fit of the postoperative condyle, we were able to get a very accurate comparison. Examination was made of the angle between the long axis of the condyles and the midsagittal plane preoperatively and postoperatively, and then the intercondylar angle was also examined preoperatively and postoperatively. Tables I and II show these results, and it is apparent that, contrary to what might have been thought, the intercondylar angle is not grossly changed. Will and associate? report a high incidence of mandibular joint dysfunction following mandibular advancement procedures, but this has not been our experience. In the fifty-seven patients followed over a period of 4 years, we have had only three patients who had any temporomandibular joint dysfunction postoperatively. Two of these patients had forward sagittal split osteotomies and one had a backward

sagittal split, and in two casesthe symptoms of pain and deviation on movement cleared up within a few months postoperatively and well before orthodontic treatment was complete. It may well be that the very shortened period of intermaxillary fixation is responsible for reducing the incidence of temporomandibular joint dysfunction in our patients,
CONCLUSION

This article summarizes the rationale, principles, and techniques developed to improve the stability of and reduce the morbidity common to the sagittal split osteotomy. Our approach, involving a proximal segment orienting device that uses the maxilla as a stable reference and internal fixation with lag screws, has reduced the incidence of temporomandibular joint dysfunction and the period of maxillomandibular fixation and had eliminated early skeletal relapse. The modification of the bony cut has minimized very substantially the incidence of nerve dysesthesia.
REFERENCES 1. Trauner R, Obwegeser HL: The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Part 1. Surgical procedures to correct mandibular prognathism and reshaping of the chin. OR.U. SURG ORAL MED ORAL PATHOL 10: 677, 1957. 2. Trauner R. Obwegeser HL: The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Part II. Operating methods for microgenia and distoclusion. ORAL. SURG ORAL ME-D ORAL PATHOI. IO: 889, 1957. 3. Obwegeser HL: The indications for surgical correction of mandibular deformity by the sagittal splitting technique. Br J Oral Surg I: 157, 1964. 4. Behrman SJ: Complications of sagittal osteotomy of the mandibular ramus. J Oral Surg 30: 554-56 1. 1972. 5. White QP. et al: Evaluation of sagittal split-ramus osteotomy in 17 patients. J Oral Surg 17: 851-855. 1969. 6. Macintosh R: Experience with sag&al osteotomy of the mandibular ramus: a three year review. J Maxillofac Surg 8: 151-165, 1981. I. Steinhauser EW: Advancement of the mandible by sagittal ramus split and suprahyoid myotomy. J Oral Surg 31: 516, 1973. 8. Wessberg G, Schendel S, Epker BN: The role of suprahyoid myectomy in surgical advancement of the mandible via sagittal split ramus osteotomies. J Oral Surg 40: 273, 1982. 9. Paulus GW, Steinhauser EW: A comparative study of wire osteosynthesis versus bone screws in the treatment of mandibular prognathism. J Oral Surg 54: 2-6. 1982. 10. Schendel SA. Epker BN: Results after mandibular advancement surgery: an analysis of 87 cases. J Oral Surg 38: 265. 1980. 11. Epker BN: Modifications in the sagittal osteotomy of the mandible. J Oral Surg 35: 157-159, 1977. 12. Booth D: Control of proximal segment by lower border wiring in sagittal split osteotomy. J Maxillofac Surg 9: 126-128. 1981. 13. Leonard M: Preventing rotation of the proximal fragment in the sagittal ramus split operation. J Oral Surg 34: 942, 1976.

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Oral Surg. November, I985 31. Spiessl B: New concepts in maxillofacial bone surgery, New York, 1976, Springer Verlag, p. 118. 32. Ailing CC: Pe&onal comm&ations. 33. EDker BN. Wessberg GA: Mechanisms of earlv skeletal relapse following surgical advancement of the man&ble. Br J Oral Surg 20: 175-182, 1982. 34. Leonard MS: Maintenance of condylar position after the sagittal split osteotomy of the mandible. J Oral Maxillofac Surg 43: 391-392, 1985. 35. Rittersma J, vander Veld ACM, van Go01AV, Ko-pendraier J: Stable fragment fixation in orthognathic surgery: review of 30 cases. J Oral Surp. 39: 671. 1981. 36. Spiessl B: Osteosynthesebei sagittaler osteotomy nach Obwegeser/Dal Pont. In Schuchardt K: Fdrtschritte der Kiefer-und Gesichtschirurgie, Stuttgart, 1974, Georg Thieme Verlag, vol. 18, pp. 145-148. 37. Reitzik M, Schoorl W: Bone repair in the mandible: a histologic and biometric comparison between rigid and semirigid fixation. J Oral Maxillofac Surg 41: 215-2 18, 1983. 38. Perren SM: Physical and biological aspects of fracture healing with special reference to internal fixation. Clin Orthop Rel Res 138: 175, 1979. 39. Perren SM, Huggler A, Russenberger M, et al: The reaction of cortical bone to compression. Acta Orthop Stand, Suppl. 125, 196b. 40. Reitzik M: Skeletal and dental changes after surgical correction of mandibular prognathism. J Oral Surg 38: 109, 1980. 41. White kA, Punjabi MM, So-thuick WO: The effects of compression and cyclic loading on fracture healing-a quantitative biomechanical study. J Biomech 10: 233, 1977. 42. Steinhauser EW: Bone screws and plates in orthognathic surgery. Br J Oral Surg 11: 209-216, 1982. 43. Schilli W: Compression osteosynthesis.J Oral Surg 35: 802, 1977. 44. Hadjianghelou 0: Zuricher Erfahringen mit der zugschraubenosteosynthese bei der sagittalen spaltung des ramus. Fortschr Kiefer Gesichtschir 26: 94, 198I. 45. Kundert M, Hadjianghelou 0: Condylar displacement after sagittal splitting of the mandibular rami: a short-term radiographic study. J Maxillofac Surg 8: 278-287, 1980.
Reprint requests to:

14 Zecha JJ, et al: Adjustable retainer in sagittal ramus-split osteotomy. Int J Oral Surg 7: 36-48, 1978. 15. Souyris F: Sagittal splitting and bicortical screw fixation of the ascending ramus. J Maxillofac Surg 6: 198-203, 1978. 16. Schmoker A, Spiessl B, Gensheimer TH: Funktionsstabile osteosyntheseund simitographie bei der sagittalen osteotomie des aufsteigenden astes. Schweiz Monatsschr Zahnheilkd 86: 582-605, 1916. 17. Dal Pont G: Retromolar osteotomy for the correction of prognathism. J Oral Surg 19: 42-27, 1961. 18. Hunsuck EE: A modified intraoral sagittal splitting technique for correction of mandibular prognathism. J Oral Surg 26: 249-252, 1968. 19. Kohn MW: Analysis of relapse after mandibular advancement surgery. J Oral Surg 36: 676-684, 1978. 20. McNeil1 RW, Hooley JR, Sundberg RJ: Skeletal relapse during intermaxillary fixation. J Oral Surg 31: 212-227, 1973. 21. Poulton DR, Ware WH: Surgical-orthodontic treatment of severe mandibular retrusion. Part I. Am J Orthod 59: 244-264, 1971; Part 11.Am J Orthod 63: 237-255, 1973. 22. Will LA, Joondeph DR, Hohl TH, West RA: Condylar position following mandibular advancement: its relationship to relapse. J Oral Maxillofac Surg 47: 578-588, 1984. 23. Trauner R: Ergebnisse von nachkontrollen kieferorthopadischer operationen. Fortschr Kiefer Gesichtschir 18: 64-71, 1974. 24. Niederdellmann H, Dieckmann J: Neurologische storungen nach chirurgischer korrektur der progenie und makrogenie. Fortschr Kiefer Gesichtschir 18: 186-188, 1974. 25. White RP Jr: Evaluation of sagittal split ramus osteotomy in I7 patients. J Oral Surg 27: 85, 1969. 26. Behrmann SJ: Complications of sagittal osteotomy of the mandibular ramus. J Oral Surg 30: 554-561, 1972. 27. Grimm G, Beitlich E: Kritische bewertung der operationsergebnisse von 101 progeniefallen unter besonderer berucksichtigung des verfahrens nach Obwegeser-Dal Pont. Dtsch Zahn Mund Kieferheilkd 61: 295-3 13, 1973. 28. Koblin I, Reil B: Die sensibilitat der unterlippe nach schonung bzw. durchtrennung des nervus alveolaris inferior bie progenieoperationen. Fortschr Kiefer Gesichtschir 18: 15I 154, 1974. 29. Simpson W: The results of surgery for mandibular prognathism. Br J Oral Surg 12: 166-176, 1974. 30. Svartz K, Ahlborg G, Finne K, Nethunder G: Nerve disturbances after sagittal split osteotomy. Int J Oral Surg 12: 279-280. 1983.

Dr. Myer S. Leonard Hennepin Faculty Associates 825 South 8th St. Minneapolis, MN 55404