C 1996 The British Assoc~atmn of Oral and Maxillafacial

Surgeons

REVIEW

ARTICLE

Stability of orthognathic surgery: a review of rigid fixation

J. E. Van Sickels, D. A. Richardson

Department of Oral and Musillofucial Texas, USA

Surgery: University of Texas, Health Science Center ut San Antonio,

SUMMARY. The use of rigid fixation with orthognathic surgery was greeted by both excitement and healthy concern when it began to find its way into the literature approximately 10 years ago. The purpose of this paper is to review the literature and make comments based on the experience of the senior author on whether one of the early premises was true. Has rigid fixation improved stability with orthognathic surgery? The authors chose to examine mandibular advancements treated with a bilateral sagittal split osteotomy and maxillary osteotomies treated with a Le Fort I osteotomy. When compared to wire osteosynthesis, rigid fixation has improved stability; however, the individual move associated with the osteotomy must he considered. In some cases, auxiliary techniques should he used to ensure stability. Condylar resorption with mandibular advancement continues to he an area of concern.

In a relatively short period of time, the use of rigid fixation of bony segments in orthognathic surgery has become a standard of care. There are several reasons for this change including shorter periods of hospital stay and patient convenience. Minimal or no immobilization of the jaws allows patients to function sooner, to resume their daily activities sooner, and return to work earlier. Earlier function and airway management has changed hospital practice. Procedures which had once been done in an inpatient environment are now being done as an outpatient.1.2 Complex procedures that would have been difficult with wire osteosynthesis are easier to execute with rigid fixation.3*4 While rigid fixation has brought new possibilities to the treatment of dentofacial and craniofacial deformities, there are many questions that remain. Advocates of rigid fixation suggested that with rigid fixation one would change bone healing and eliminate relapse.5 The question remains, With use of rigid fixation has stability of common orthognathic surgical procedures improved? The purpose of this paper is to review the existing data to determine if rigid fixation has improved stability with routinely used orthognathic surgical procedures for the mandible and maxilla. Due to volume of articles available, selected papers have been chosen to illustrate points to be made. The first part of the paper is a critical review of the literature. The discussion and conclusions section has more editorial comments, which reflect the senior authors beliefs and practice. The surgical procedures that will be examined are advancement of the mandible by a bilateral sagittal split osteotomy (BSSO) and maxillary surgery with a Le Fort I osteotomy. These two procedures were chosen because they are the most frequently per279

formed operations, and the literature has the most information regarding stability with their use. MANDIBULAR ADVANCEMENT WITH A BSSO

A review of the literature on this topic is complicated by several factors. There is considerable variability in the way that surgery is done between one surgeon and another. In addition, techniques used to stabilize segments have considerable variability. Several techniques are considered under the broad term wire osteosynthesis. These include inferior border wire, circumferential wire, and superior border wire. For the sake of this paper these different stabilization techniques will be considered as one group. Where it is known, the specific technique will be mentioned. In a similar fashion, there are multiple techniques that are considered when the term rigid fixation is used. These include the use of a lag screw technique, position screws, and plates. This does not even consider the composition of the material used and the different manufactures developing these materials. Additionally, there are different size screws and number of screws placed to stabilize the mandible. In this paper we will limit our review to studies where at least three screws per side were used and consider all 2 mm systems as similar. Short-term relapse Stability of mandibular advancements has been divided into short term and long term relapse.-9 Several papers noted that relapse with wire osteosynthesis occurred during and soon after maxillomandibular fixation.6x0. Schendel and Epker6 noted unaccept-

able postsurgical results occurred more frequently with large advancements. The adverse movement of osseous structures after surgery could be linear, rotary, or a combination of both. Most of the relapse they noted occurred soon after the surgical procedure. Relapse which occurs during the first 6-8 weeks is known as early relapse and is usually due to movement at the osteotomy site. Early relapse has also been seen with rigid fixation.12-15 Several studies with bicortical screws showed relapse is associated with larger advancements. In a paper by Gassmann, Van Sickels and ThrashI it was noted that early relapse occurred at the osteotomy site. They described linear and rotary changes occurring at the junction of the proximal and distal segments accounting for the relapse. The authors speculated that large advancements place increasing amounts of stretch on the surrounding soft tissue envelope. In addition, cases where there are larger movements, have smaller amounts of bone at the interface between the segments. Gassmann, Van Sickels, and Thrash,15 suggested early relapse might be prevented with skeletal wires and a period of maxillomandibular fixation. Both animal and clinical studies have shown relapse can be reduced by skeletal wires.6,16-9 In 1980, Schendel and Epker6 noted skeletal fixation prevented osseous relapse in cases with wire osteosynthesis. In 1986, Ellis and Gallo16 showed an insignificant mean horizontal relapse of 8.9% at pogonion in 20 patients during the period of fixation when skeletal wires were combined with wire osteosynthesis and an eight week period of fixation. Van Sickels looked at two groups of patients undergoing large advancements both who had three 2 mm bicortical screws placed at the osteotomy site where one group had additional skeletal wires placed and were kept in maxillomandibular fixation for 1 week. He noted significant differences between the two groups in the first 6 weeks and from the initial postoperative period to the long term examination point. He did note that while stability was markedly improved with up to 13 mm of advancement in the group with screws and wires, relapse was seen with larger advancements. He speculated on the importance of the maxillomandibular fixation and whether using elastic traction between skeletal wires would be equally effective. Mayo and Ellis18 studied short term stability of the mandible following advancement surgery in two groups of animals, one with dental maxillomandibular fixation and the second with skeletal suspension wires plus dental maxillomandibular fixation with wire osteosynthesis. The study showed both horizontal and vertical movement was significantly better in the group with skeletal wires and maxillomandibular fixation. In a later study, by the same group, a group of animals with wire osteosynthesis and skeletal suspension, did equally well as a group that was treated with bicortical screws.19
Long-term relapse

It has been defined as a change in shape of the condyle from normal to finger shaped with loss of height and later decrease in posterior facial height. 23,26 Its incidence has been reported to be between 2.3% and 7.7% of patients treated by a BSSO to advance the mandible.8~20~27It has been seen with one and two jaw procedures where the BSSO was stabilized with superior border wires, plates and bicortical screws.8,20,23,27,28 Radiographic signs of condylar resorption were first noted at 6 months or more after surgery with a range of 6-17 months.27 Additional relapse has occurred following secondary surgeries.22,27,29 There are several theories as to why it occurs. Kerstens et ~1.~ suggested that surgery stimulates a process in the bone by increased load on the joint. They felt the process may be initiated by disk displacement and immobilization. Arnett et aL2* suggested that mediolateral torquing or posterior displacement of the condyle with rigid fixation may be associated with condylar resorption and late relapse. Ellis and Hinton3 sacrificed twelve animals who had undergone a BSSO that was fixed with either wires or bicortical screws. Animals who had posterior displacement of the condyles showed evidence of resorption of the posterior surface of the condyle and anterior surface of the postglenoid spine. They stated that alterations in condylar position may induce remodeling changes within the TMJ. Condylar resorption has been noted more frequently in females with high mandibular planes, preoperative temporomandibular dysfunction, large mandibular advancement and distal segment counter clockwise rotation.20,23,27 Scheerlinck et ~1.~ noted progressive condylar resorption was four times greater for advancements greater than 10 mm than for those for advancements between 5 and 10 mm. Van Sickels17 noted the group of large advancements that were fixed and further stabilized by suspension wires showed early relapse but were stable after 6 weeks. However, the group that only had bicortical screws showed both early and late relapse. Link and Nickerson reviewed 38 patients who had some stage of internal derangement of temporomandibular joint prior to surgery. Fifteen of thirty patients with followup of greater than 12 months developed new arthrosis after orthognathic surgery. All arthrosis occurred in previously deranged joints. They suggested that new loading of deranged joints after surgery may be a cause of a new arthrosis and skeletal relapse.

COMPARISON

PAPERS

Plates versus position screws

Progressive condylar resorption resulting in late relapse has been noted by a series of authors.8,20-25

Several authors have suggested that plates used to stabilize the fragments may have an advantage over bicortical screws because they may minimize rotation of mandibular condyles.8,31 Stability with plates has not been investigated to the same extent as bicortical screws. Blomqvist and Isaksson32 compared shortterm stability seen when two groups of patients underwent mandibular advancement using either

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three bicortical position screws or monocortical screws and plates. They noted there was no difference in the stability between the two groups. Both showed instability the further the mandible was advanced. Wire osteosynthesis versus hicortical screws Watzke, Turvey, Phillips and Proffit33 published a paper in 1990 where they evaluated the stability of two groups of patients who underwent a BSSO for mandibular advancement; one group was fixed by screws and the second by wires. The authors do not say whether either groups had suspension wires in addition to their fixation technique. At 6 weeks after surgery, Points B and Pg came forward 2-4 mm in 18% of the sample with screws. There was almost no tendency for the mandible to slip posterior during this period. Eighteen percent of the sample had superior movement of the mandibular incisor. The wire group, in contrast, had 50% of the sample move posteriorly 2-4 mm at 6 weeks. The mandibular plane increased 2-4 degrees largely due to upward movement of gonion. When changes from postsurgery to 1 year were analyzed, the differences between the groups were not as obvious. In the screw group, B point moved forward 0.33 mm and superiorly 1.37 mm. There was considerable variability within the group. Pg moved forward in 25% of the group and posterior in 20% of the group. In the wire group 40%1of sample had posterior movement of Pg while 15% of the sample had anterior movement of the landmarks. Overall there were similar movements between the groups with the exception that there was more rotation of the proximal segment in the wire group than in the screw group. The study was complicated and, therefore, hard to interpret because of several methodological flaws. While the majority of the surgery appears to have been done by one surgeon, different surgeons were involved. Different techniques were employed in both the screw and wire groups. The screw group had 21 patients who had 2 mm position screws while 14 had 2 mm lag screw technique or with 3.5 mm compression screws. The wire group had 27 patients who were treated with a figure of eight superior border wire, 2 with circumferential wires and 6 with superior border wires. Both groups were advanced similar amounts, screws 6.8944.4 mm at Pg and wires 6.45 k 5.1 mm. However, the large standard deviations indicate there were large advancements in both groups. While making overall comparisons easier, multiple previous studies have shown that early relapse is more prevalent with large advancements. Relapse in some of the sample in each group would obscure subtle differences between the groups. At 6 weeks postsurgery, the authors noted that some patients had the splints still in place while they were removed in others. Most likely the patients who had screws had their splints removed before 6 weeks while those with wires still had them in place. This would make the wire group look worse at 6 weeks but improved at 1 year. The forward movement in both groups was due to vertical settling when the

splints were removed and some occlusal changes. This data suggests there is more long term relapse/ resorption in the rigid fixation group: however, due to the multiple problems in the study design, that conclusion can not be made with this paper. MAXILLA-LE FORT I

In 1989. Larsen et ~1.~ noted there was very little difference between maxilla stabilized by plates and those stabilized by wires. However, they included a variety of moves in both of their groups. Maxillary stability cannot be studied without examining the movement that was attempted with the initial surgery. Impaction Most surgeons agree that maxillary impaction is a very stable movement. Proffit et ~1.~~noted that the vertical position of the maxilla was stable in approximately 80% of patients who underwent superior repositioning of the maxilla and were stabilized with wire fixation. In a later study from the same institution, 49 patients who underwent a minimum of 2 mm impaction were followed for at least 5 years. They noted modest long-term skeletal and dental changes that were unrelated to the age of the patient, stability during the first postsurgical year, or segmentation of the maxilla at surgery. No rigid fixation was included in this group. Advancement In 1987, Carlotti and Schende13 studied 30 patients who underwent maxillary advancement stabilized by wire osteosynthesis. They had cases with both isolated maxillary surgery and two jaw procedures. Eight cases had larger than desired postoperative movement. They attributed the undesirable movement to preoperative orthodontic flaring of the central incisors. They concluded that suspension wires and bone grafting were sufficient to obtain skeletal stability in cases of maxillary advancement up to 11 mm. When surgery is more complex, they recommended rigid fixation. Luyk and Ward-Booth38 reviewed their results in 11 patients who underwent maxillary advancement with rigid fixation and intermaxillary fixation for 6 weeks. The mean maxillary advancement in a horizontal direction was 3.7 mm. They noted there was no significant relapse. Louis et ~1.~ studied maxillary advancement in three groups of patients with obstructive sleep apnea who underwent bimaxillary advancement. One group had their maxilla advanced an average of 4.7 + 0.8 mm, the second was advanced 8.2 + 0.9 mm. while the third was advanced 12.3k2.8 mm. All patients had miniplates in the maxilla and bicortical screws in the mandible. There was slightly more relapse as the maxillas were advanced; however, there was no statistical differences between the groups. Egbert et ~1. compared two groups of patients

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undergoing maxillary advancement. This study is particularly interesting because all surgeries were done by the same surgeon. Twelve patients were treated by wire osteosynthesis with intermaxillary fixation for 4 weeks, and 13 had rigid fixation and training elastics for 4 weeks. Postsurgical horizontal change for both groups was in a posterior direction. Comparison of the mean values between the two groups suggested improved stability with rigid fixation; however, this difference was not statistically significant. In contrast, there was a significant difference between the two groups in the vertical direction with the wire group showing more vertical settling one year after surgery.
Setback

Open bite

We did not tind any papers in the literature which specifically addressed the stability of an isolated group of patients who underwent maxillary setbacks. In the senior authors experience, this particular move is technically more difficult to execute; however, it is very stable when plates are used to stabilize the segments. Frequently, osseous gaps are present in the anterior maxilla which require bone grafts to fill the voids and give a scaffold for osseous regeneration. In contrast, with wire osteosynthesis, this type of move is prone to further upward movement.
Inferior

Inferior repositioning of the maxilla has been traditionally very unstable.41-43 Quejada et aL4i noted that over 50% of the relapse of maxillary osteotomies stabilized with wire fixation occurred during the period of maxillomandibular fixation and the remaining relapse occurred within the first 6 months after surgery. Hedemark and Freihoffer42 reviewed 12 cases of maxillary surgery where the maxilla had been brought down and stabilized with wire osteosynthesis. Ten of the twelve moved upwards. They concluded that the downward movement of the maxilla is especially unstable and that one has to either overcorrect or search for possibilities of stabilization other than wire stabilization. Van Sickels and Tucker44 noted that even with rigid fixation, maxilla which are positioned in an inferior direction can be vertically impacted after surgery. Furthermore, postoperative movement may result in a non union. Ellis et ~1.~~ studied the stability of inferior movement of the maxilla using different techniques to fix the maxilla. One group had wire fixation of the maxilla and bone graft. The second had a similar procedure with the addition of myotomies of the masseter and temporalis muscles. The third had a bite opening appliance before down-grafting. The fourth group underwent down-grafting with rigid internal fixation. All of the groups had relapse; however, the animals who underwent rigid fixation had the most stable results, followed by the myotomy and bite opening group. The least stable group was the one with wire osteosynthesis and bone grafts.

Open bite skeletal discrepancies can have a multitude of causes. 45 Correct of an op en bite can be done by surgery in the maxilla or mandible. Probably the most frequent correction of patients with open bites is done by surgery in the maxilla. Stability of open bite cases corrected by maxillary surgery is probably related more to the management of transverse problems of the dentition and tongue problems that it is to anterior-posterior or vertical discrepancies or the hardware used to fix the maxilla.46*47 There are cases where the stability of the maxillary surgery is related to tongue size or tongue function. Frohlich et ~1.~~studied tongue pressures in 21 children before and after surgical reduction of the tongue. Most of these subjects had either anterior or posterior open bites present. They noted that 12 months after surgery resting tongue pressures were lower than before the tongue reduction surgery, and were closer to those of a reference sample. A tongue reduction in selected cases may help close an open bite. Haymond et a1.47retrospectively studied 38 patients with skeletal pre-operative open bite treated with small plate internal fixation to assess surgical/orthodontic stability. Eighty-six percent of the sample had a stable result. Fifty percent of relapses were due to transverse relapse of orthodontically expanded maxillary arches. The authors concluded that stable results can be achieved in treating skeletal open bite when small plate internal fixation is used and proper consideration given to the cause of skeletal open bite when planning.

DISCUSSION

AND CONCLUSIONS

From the preceding review it is evident that there are many factors that need to be considered when examining the question of stability. There are cases where it makes no difference whether wires osteosynthesis or rigid fixation is used. There are others where it is clear that rigid fixation does improve stability. The factors which appear to have the most influence on stability are whether the upper or lower jaw is being moved, which direction they are being moved, and how much they are being moved. The following sections will discuss upper and lower jaw surgery. The first conclusion that can be drawn for all surgical procedures is that whether wires osteosynthesis or rigid fixation is used, relapse can occur.
Mandibular advancement: early relapse

Early relapse occurring with the use of wire osteosynthesis and a mandibular advancement has been well recognized with some authors reporting as much as 90% relapse occurring during maxillomandibular fixation.6,7*48,4g This lead to a variety of suggestions to minimize relapse including overcorrection of the occlusion, opening of the posterior bite, suprahyoid myotomy, using a sternal mandibular brace, and skeletal fixation in addition to maxillomandibular

fixation.7,4sm51 Of these techniques, skeletal fixation and suprahyoid myotomy remain options to use whenever the mandible is advanced, and stability is in question. With the advent of rigid fixation it was thought that relapse would be a problem of the past due to accelerated bone healing.s.52~53 Ellis et a1.s4 studied 23 adult rhesus monkeys who underwent mandibular advancement by a BSSO fixed either by three bicortical screws or wire osteosynthesis. The results showed that the two groups of animals underwent markedly different patterns of osseous healing. The osteotomy sites in the wire osteosynthesis animals were filled with callus which then formed bone. In the rigid fixation sites there was direct bony deposition. It is important to remember that these same animals were used for stability studies and that the wire osteosynthesis group stabilized by skeletal wires did as well as the rigid fixation group. While the initial premise was wrong, rigid fixation does give improved stability over dental fixation for small advancements. However, when dealing with larger advancements, auxiliary techniques need to be considered. Those that have efficacy are skeletal wires and suprahyoid myotomy. The evidence for suspension wires is clear from the previous discussion. The role of maxillomandibular fixation is debatable. Evidence for suprahyoid myotomy is not as clear. Clinical studies have not shown a suprahyoid myotomy to be effective.51 However, animal studies have shown a suprahyoid myotomy to be effective. Most likely, a suprahyoid myotomy is not as effective as skeletal suspension wires but has a smaller effect. If screws cannot be used in a case, then one should use an inferior border wire coupled with suspension wires. From the paper by Watzke et a1.33 it is obvious that superior border wire fixation does not control the proximal segment. In 1985 Singer and Bay?j compared superior border wires to inferior border wires used to stabilize a BSSO. They found that the inferior border wiring technique produced significant less antero-superior rotation of the proximal segment and less increase in the gonial angle than the superior border wiring technique.
Mandibular advancement: long-term relapse

more academic than factual. Both short-term and long-term relapse appear to be similar whether screws or plates are used. Both have problems the further the mandible is advanced. That condylar torque can occur with bicortical screws is a distinct possibility. However, it remains to be seen if there is a greater incidence of temporomandibular symptoms with plates versus bicortical screws. Whether nerve injuries are any more frequent when bicortical screws are used remains to be seen. In the senior authors practice, bicortical screws are routinely used for mandibular advancements, while plates are used for setbacks, large advancements, and asymmetry cases. This practice is based more on practical and technical experience than scientific data. While lag screws have been used to fix a BSSO. laboratory work has not shown them to be more effective than position screws.5.57 Foley et a1.57 demonstrated there was no significant difference in rigidity between compression and bicortical screws for a BSSO. They did show that an inverted L pattern was significantly more stable than screws placed in a linear fashion. Whether it is better to use an inverted L pattern for large advancements is unknown. The senior author believes this only puts more load on the condyles. Therefore, it is our practice not to use a lag screw technique or inverted L pattern for large advancements but to supplement bicortical screws with skeletal suspension wires.
MAXILLARY OSTEOTOMIES

Progressive condylar resorption leading to long-term relapse is now recognized as a small but important cause of relapse in patients undergoing one or two jaw mandibular advancements. The association between pre-existing temporomandibular symptoms and condylar resorption may suggest the need to delay surgery on symptomatic patients. The association between large advancements and condylar resorption suggests that early increased load leads to late condylar resorption/remodeling. Perhaps the same techniques used to prevent early relapse may be helpful to prevent long-term relapse. It is interesting that Van Sickels17 did not see long-term relapse in his patients who had large advancements fixed by bicortical screws which were supplemented by skeletal wires and maxillomandibular fixation. The argument over plates versus screws is probably

As the literature search reveals, the maxilla behaves very differently depending on how it is moved.58 For maxillary impaction, the surgical move is very stable, and very small hardware is necessary to stabilize the maxilla. There is sparse data on setbacks of the maxilla; however, as mentioned earlier it is our impression that this is also a very stable move. The size of the hardware is dependent on whether a bony gap exists after the surgical move. Advancement of the maxilla and especially inferior movement of the maxilla is not as stable as the two previous moves.58 It is with these two moves that rigid fixation has been shown to be superior to wire osteosynthesis. With both of these moves larger and stiffer plates need to be used. Maxillary advancements stabilized with rigid fixation are more stable than those stabilized with wire osteosynthesis; however, are susceptible to relapse with larger moves. Frequently, prior to surgery, dental compensations are still present secondary to tongue and lip pressures. In our practice it is common to advance the maxilla at least 2 mm more than an ideal overjet. This is to compensate for dental deficiencies and relapse. Orthodontically it is easier to orthopedically retract an advanced maxilla than it is to try to hold one that is relapsing into an end to end incisor situation, Alternatively, one could use a period of maxillomandibular fixation. In the paper by Luyk and Ward-Booth38, three of their patients had cleft lips and palates. Due to the scaring in the

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palate, advancement of the maxilla is more difficult. Welch58 suggested that a Le Fort I advancement in a cleft palate patient was extremely unstable. However, a recent paper by Ayliffe, Banks and Martins9 showed plate fixation was superior to extraoral frame supplemented by intermaxillary fixation in a large series of cleft palate patients. In the experience of the senior author, rigid fixation in addition maxillomandibular fixation for a period of 3-4 weeks is helpful to prevent relapse in these cases. Inferior movement of the maxilla is one of the more challenging moves that can be made with the maxilla. While rigid fixation is clearly superior to wire osteosynthesis, it does not assure absolute stability. It is important to note in the paper by Ellis, Carlson and Frydenlund43 that while the rigid fixation group did the best, all of the groups had relapse. The group that had myotomies did better than the wire osteosynthesis group alone. For large inferior movements, myotomies may be necessary as an adjunct to the surgical procedure. Alternatively, as suggested in the paper by Van Sickels and Tucker,44 additional rigid pins going from the superior aspect of the maxilla to the splint may help stabilize a case where the maxilla was moved in an inferior direction. Stability of the maxilla cannot be discussed without noting if there were additional mandibular movement. Several authors have noted with wire osteosynthesis that when the mandible was advanced, it had an adverse effect on maxillary position.60s61 In 1988 Skoczylas et a1.62 compared the results seen in two different groups of patients who underwent maxillary impaction with mandibular advancement. Fifteen patients had skeletal plus dental maxillomandibular fixation, and fifteen had rigid internal fixation using bone plates in the maxilla and bicortical bone screws in the mandible. The authors found no statistically significant difference between the experimental groups. However, the amount of variability in postsurgical stability in the group with skeletal plus dental maxillomandibular fixation was greater than that found in the group with rigid internal fixation. In the senior authors experience, an unstable result occurs in two jaw cases fixed with rigid fixation when the mandible is advanced large amounts. When a case is set up for a large advancement, large stiff plates are used on the maxilla combined with suspension wires and a brief period of maxillomandibular fixation. Open bite deformity illustrates that it is more important to understand the underlying skeletal problem than what type of hardware is being used. The advent of rigid fixation has helped markedly in treating this skeletal discrepancy. No more is it necessary to do two jaw surgeries to close an open bite.45 However, allowing extensive orthodontic expansion to eliminate multiple segmental surgery is setting the patient up for vertical relapse, no matter how rigid the fixation appliances are.47 References
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14. Kirkpatrick TB, Woods MG, Swift JQ, Markowitz NR. Skeletal stability following mandibular advancement and rigid fixation. J Oral Maxillofac Surg 1987; 45: 5722576. 15. Gassamann CJ, Van Sickels JE, Thrash WJ. Causes, location and timing of relapse following rigid fixation after mandibular advancement. J Oral Maxillofac Sum 1990: 48: 450-454. 16. Ellis E, Gallo JW. Relapse following-mandibular advancement with dental plus skeletal maxillomandibular fixation. J Oral Maxillofac Surg 1986; 44: 509-515. 17. Van Sickels JE. A comparative study of bicortical screws and suspension wires versus bicortical screws in large mandibular advancements. J Oral Maxillofac Surg 1991; 49: 1293-1296. 18. Mayo KH, Ellis E. Stability of the mandible after advancement and use of dental plus skeletal maxillomandibular fixation: An experimental investigation in Macaca mulatta. J Oral Maxillofai Surg 1987; 45: 243-250. 19. Ellis E. Revnolds S. Carlson DS. Stabilitv of the mandible following advancement: A comparison of three postsurgical fixation techniques. Am J Orthod Dentofacial Orthop 1988;
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Kerstens HCJ, Tuinzing DB, Golding RP, van der Kwast WAM. Condylar atrophy and osteoarthritis after bimaxillary surgery. Oral Surg Oral Med Oral Path01 1990; 69: 274-279. 2 1. Phillips RM, Bell WH. Atrophy of mandibular condyles after sagittal ramus split osteotomy: report of a case. J Oral Surg 1987; 36: 45549. 22. Crawford JG, Stoelinga PJW, Blijdorp PA, Brouns JJA. Stability after reoperation for progressive condylar resorption after orthognathic surgery: report of seven cases.J Oral Maxillofac Surg 1994; 52: 460-466. 23. Merkx MAW, Van Damme PA. Condylar resorption after orthognathic surgery. J Craniomaxillofac Surg 1994; 22:
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The Authors
Joseph E. Van Sickels. DDS Professor and Senior Surgeon. Darius A. Richardson, DMD, MD Resident Department of Oral and Maxillofacial Surgery. University Texas. Health Science Center at San Antonio. USA

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Correspondence and requests for offprints to Joseph E. Van Sickels, Department of Oral and Maxillofacial Surgery, University of Texas. HSCSA, 7703 Floyd Curl Drive, San Antonio. Texas 78284-7908. USA

Paper received 12 September Accepted I April 1996

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