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The Bilateral Sagittal Split Mandibular Ramus Osteotomy a,,b,c,d,e, *, Johan P. Reyneke, BChD, MChD, FCMOS (SA), PhD a f Carlo Ferretti, BDS, MDent (MFOS), FCD (SA) MFOS
KEYWORDS
Mandibular repositioning Mandubular osteotomy Internal rigid fixation Surgical sequence
KEY POINTS
Sound technical craft requires a consistent surgical routine. Knowledge of the tips and traps associated with each surgical step makes surgical efforts occur smoothly. Correct positioning of the mandibular condyle in the glenoid fossa is mandatory for successful treatment outco The application of an established step-by-step operating technique prevents intraoperative uncertainty and o operative complications.
Introduction The correction of dentofacial deformities demands accurate treatment planning for the orthodontic preparation and subsequent surgery. It is also mandatory that the surgical correction tion be perfo perform rmed ed accu accurat rately ely to ensure ensure predi predict ctab able le and and successful outcomes. This article describes the technique for the sagittal split mandibular ramus osteotomy in a step-by-step fashion with tips and traps with each step. In 1970, J M Ferrer in said: “it must be recognized that at every operation the surgeon inevitably injures the patient; this injury can and must be minimized by the use of careful, gentle, and accurate accurate surgical surgical technique.” technique.” Sound technical craft, science, and operating experience all come come toget together her to make make most most surg surgic ical al proced procedure uress occu occur r smoothly and successfully. No 2 surgeons’ surgical techniques are identical; however, there are certain basic principles that have to be adhered to when performing orthognathic surgery. This will not only ensure good surgical outcome but also limit complicatio complications. ns. Moreover, Moreover, important details of diagnosis diagnosis and
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The authors declare that there are no commercial commercial or financial con-
management of operative complications are diffi ter, since no 2 complications are ever identical. Although the anatomy and shape of the hum lends lends itse itself lf to spli splitt ttin ingg in a sagi sagitt ttal al plane, plane, osteotomy of the mandible remains a challengin Over the last 30 years, the ingenuity of modificati origina original technique as described by Obweges Obwegeser an 1955,3 development of special instruments,4 and i of surgical skills have made it possible to achieve s relatively quickly and atraumatically. The surgica ing of the mandib mandible le has develop developed ed from from a procedure to outpatient surgery (in some parts of Each surgeon should develop a routine that wi surgica surgicall team to anticip anticipate ate each each step, step, thus inc ciency ciency and decreas decreasing ing operatin peratingg time time and eve postoperative morbidity.6 The surgic surgical al techniq technique ue of the sagitt sagittal al spli ramus osteotomy can be performed in 32 steps. E Read Free For 30this Days Sign tips up to vote on title have certain and traps.
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Step 1dinfiltrate the soft tissue with
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At least 5 mm of nonkeratinized mucosa should be left buccally at the lower end of the incision for ease of suturing later.
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Step 3dbuccal subperiosteal dissection Strip the periosteum from the body and anterior aspect of the mandibular ramus to allow for adequate visualization. Dissection must remain subperiosteal, decisive, clean, and neat. It is not necessary to strip the entire masseter muscle attachment off the mandibular angle. Total stripping of the muscle will result in dead space and encourage swelling and hematoma formation.
Step 4dsuperior subperiosteal dissection Strip the lower fibers of the temporalis muscle off the anterior border of the ramus. Dissect the periosteum from the internal oblique ridge down to the medial aspect of the retromolar area. Place a swallowtail (forked or notched) retractor over the anterior border and pull upwards for good visualization.
Step 5dexposure of the lingula
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Perforation of the periosteum in this area may hemorrhage (usually from the medial pteryg however it often subsides spontaneously.
Step 6dmedial ramus osteotomy
Use a Lindeman or 701 fissure bur, aim at the notch and angle the osteotomy parallel to the occlusal p The convexity of the internal oblique ridge may lingula. If visualization is difficult, the ridge shoul with a large trimming burr (Fig. 3). Terminate the osteotomy just posterior to the the fossa (see Fig. 2). If the osteotomy is terminated short of the fos will tend to split anterior to the foramen, leaving alveolar nerve and canal attached to the proxima When a mandibular setback procedure or a clo tion of the maxillomandibular complex will be p small segment of bone should be removed sup osteotomy. This will prevent bony interferences following setback of the mandible or superior rot distal segment (clock wise rotation).
Step 7dsagittal osteotomy
Use a saw or 701-fissure bur; start at the media Start the medial dissection from above and then dissect infeosteotomy superiorly, and stay just inside the buc You're Readingthe a Preview riorly (Fig. 1). mandibular ramus and body (Fig. 4). Stay subperiosteal at all times. Ensure the osteotomy is made through the cor Unlock full access with a free5 trial. Carefully identify the lingula and ensure visualization. imately mm). The presence of an impacted third molar toot fere (ideally impacted third molars should be rem Download With Free Trial 9 months before surgery). However the tooth shou as bone, and the osteotomy performed through t
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Mandibular Ramus Osteotomy
A large pear-shaped vulcanite drill is used to reduce the bone and increase the visibility of the lingula. Fig. 3
Step 8dbuccal osteotomy of the mandibular body
Remove the swallowtail (forked or notched) retractor and place a channel retractor at the lower border of the body. Start the buccal osteotomy at the lower border, and join it superiorly with the vertical osteotomy (see Fig. 4). You'reinReading a Preview Ensure that the cortex of the lower border is included the osteotomy (Fig. 5). The actual start of the split should be at the Fig. a5 freeThe buccal osteotomy should include the ling Unlock full access with trial. lower border and include the lingual cortex. the lower border (arrow ). Failure to include the lowe Cut toward the mandible and feel the bur perforate the result in a short split. cortex; however, be careful not to damage the inferior alveolar Download nerve. The inferior border cut should be preferably slightly With Free Trial angled posterior emedially, not at a right angle to the buccal holding wire is optional; however, it allows cortex, so the initiation of the split begins in the proper diposition and maintain the condyle in the fossa wh rection and osteotomes may be inserted easily. rigid fixation. The holes of the positioning wires should be dri way that the proximal segment is directed distal distance between the holes after repositioning t Step 9ddrill holes for a holding wire Read Free Foron 30this Days Sign up to vote title should be 4 mm. For a patient requiring an useful advancement of 6 m Useful Not Positioning the condyle in the glenoid fossa is the most Cancel anytime. should be drilled 10 mm apart. After advanceme step of the and should be performed as a Special important offer for students: Onlyprocedure $4.99/month. the holes will be 4 mm apart with the hole in the d separate step prior to placement if rigid fixation. The use of a anterior and the hole in the proximal posterior (
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( A) A 6 mm mandibular advancement is planned. Arrows show removal of a segment of bone from the anterior part segment. The positioning holes are therefore drilled 10 mm apart with the anterior hole on the distal segment (1). Foll advancement, the holes will be 4 mm apart with the wire in a Class II direction supporting the condyle (2). ( B) A 6 mm mandi is planned. The positioning holes are drilled 2 mm apart with the anterior hole on the proximal segment (1). Following a 6 m the distal segment, the holes will be 4 mm apart with the wire in a Class II direction supporting the condyle (2). Fig. 6
accurate positioning of the proximal segment and the lower borders during condylar positioning (see
Step 11dplace reference marks Reference marks are placed on either side of the vertical buccal osteotomy. Alignment of these marks will ensure
Step 12dlavage
You're ReadingWash a Preview the surgical area thoroughly with saline
gently place a small sponge in it. Once the osteoto been completed on one side, it is recommended t side to be completed before proceeding to split th
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Download With Free Trial Step 13ddefine the osteotomy
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Use a 10 mm wide osteotome to tap alon osteotomy line from the medial osteotomy down buccal osteotomy below (see Fig. 7). It is important to support the mandible when Read Free For 30this Days Sign up to to vote on title and soft tissu contralateral side prevent hard the side already Usefulsplit. Not useful Cancel anytime. The osteotomy cuts are only defined at this sta attempt to split to completely separate the segm Vigorous indiscriminate tapping may fracture
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Mandibular Ramus Osteotomy
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6 When the inferior alveolar canal splits toward the proximal side, the surgeon should stop the procedure and carefully dissect the medial wall of the canal from the proximal segment using a small osteotome. Use a small nontoothed forceps to remove the bony canal from the bundle.
The bad split An unfavorable split can be prevented by meticulously following the surgical steps. However, in case the split does not proceed favorably, stop the procedure and identify the problem under good vision. It is much easier to salvage the procedure if a potential problem is recognized early. The following section describes the features if an unfavorable or bad split.
Fracture of the buccal cortex of the mandibular body
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attention not to damage the inferior alveolar n bundle. Use a small straight osteotome placed at aspect of the vertical ramus osteotomy and a Rey low down in the buccal osteotomy and compl Replace the separated bony segment and fixate screw while the nonfractured segments can b either bicortical or plate fixation.
Fracture of the buccal cortex involving the ramus of the mandible
Early diagnosis A small fracture line occurs on the buccal aspect about halfway down the buccal osteotomy, and ru toward the coronoid notch. The lower border rema to the distal segment (see Fig. 11). The buccal osteotomy should be redefined a border. Correct the problem as a buccal plate fra
Early diagnosis Late diagnosis The buccal cortex start splitting; however, the lower border The buccal cortex including the coronoid proc remains attached, and a small fracture is detected in the from the mandible. The segment remains atta segment. temporal muscle and should not be removed. Redefine the buccal osteotomy, especially around the lower The proximal and distil segments are still border. every effort should be made to salvage the smal Place the small Reyneke splitter low down in the buccal proximal segment still attached at the lower bord osteotomy and recapture the lower border to fracture it with Redefine the buccal osteotomy at the lower b the cortex of the proximal segment. fully start the split along the fracture line of th Place bicortical screws in the nonfractured part of the You're Reading a Preview complete the split. segment as well as through the small fractured segment. There will now be little bone contact betwee Alternatively use plate fixation. Unlock full access with a free trial. ments, and plate fixation should be used. Secure t segment with bicortical screws. Late diagnosis If diagnosed late, the buccal cortex will be totally separated from the mandible. Remove the bone segment andDownload place it in a With Free Trial The split occurs anterior to the inferior alv saline soaked sponge. Redefine the remaining part of the foramen osteotomy, especially the lower border (Fig. 9). Pay special
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Early diagnosis This complication usually occurs if the horizontal left short of the lingula (Step 6) (Fig. 10). To pre Free Forand 30this Days Sign to vote on title neurosenso alveolarRead nerveup damage long-term early diagnosis is imperative (Step 14). Useful Not useful Cancel anytime. Carefully redefine and extend the horizon beyond the lingula into the fossa posterior Complete the split under good vision and ensure t
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Mandibular Ramus Osteotomy
Fig. 11 summarizes the four typical patterns of that may occur.
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Step 15dstripping the pterygomasseter
Place a curved periosteal elevator (J-stripper segments and strip the muscle attachments fro segment. This step will also ensure that no greenstick b ments remain between the 2 segments. Pro muscular bundle at all times. Insufficient stripp remaining bony attachments will lead to difficul tioning of the distal segment and inaccu positioning.
Step 16dstripping the medial pterygoid and stylomandibular ligament
Failure to strip these structures will interfere wit the distal segment and may lead to unfavorable ro proximal segment (Fig. 12).
Step 17 The split has been completed; however, the neurovascular bundle, lingula, and superior aspect of the inferior alveolar canal remains attached to the proximal segment ( arrow ). Fig. 10
The author is in favor of the removal of impacted 9 months before surgery. Due to circumstanc necessary to remove third molars during the You're Readingosteotomy a Preview procedure.
Early diagnosis Unlock access with a free trial. Carefully remove the impacted third molar tooth. Use full plate fixation.
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Late diagnosis Remove the impacted third molar tooth. Take care not to damage the inferior alveolar nerve. Use plate fixation.
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The presence of impacted third molars during the SSO will often prevent ideal bone contact and may also weaken the retromolar aspect of the distal segment. Remove the third molars and take care not to damage the inferior alveolar nerve or fracture the retromolar bone. The presence of a third molar (or tooth socket) will jeopardize the placement of rigid fixation.
Step 18dsmooth the contact areas of the segments Use a large pear shaped reduction bur to smooth contact areas. Take care not to damage the inferior alveolar nerve.
Step 19dplace the holding wire
superb surgery; however, if the condyle is accurately into the glenoid fossa, the procedure method of condylar positioning described developed during the performance of more than eral sagittal split osteotomies over a period of 3 Place the condylar positioner into the hole dr 10. Support the angle of the mandible by ext pressure. Apply light posterior pressure on the positioner time digital superior and slightly anterior pre mandibular angle. Note the vectors of force in Fig. give the surgeon control of the proximal segment a ness of the anatomic relationship between the con fossa. Use the reference lines, marked in Step 11, lower borders of the segments and prevent unfav tion of the proximal segment (Fig. 14).
Feed a 0.018-inch wire (25gauge) through theholes (see Step 9).
Step 25dtightening the holding wires
Step 20
The teeth are still secured in the planned occlus maxillary fixation. The surgeon should hold segment in its desired position (as described in Ste the assistant gently tightens the holding wire. View the segment while the wire is tightened t Step 21dmobilize the bone segments the segments are not forced together. The wire should hold the segments passi Excessive force or overtightening of the wire will Remove the sponge placed following splitting the first side Readingcondyle a Preview in the fossa and lead to peripheral (me (Step 12). Support the proximal segment with theYou're index finger condylar malpositioning. and pull the distal segment gently but firmly anteriorly. Unlock full access with a free trial. does not recommend the use of a b The author Adequate mobilization will ensure that the soft tissue drape this stage because of concerns of generating cond will allow free positioning of the distal segment. Clamps such as the Sullivan BSSO clamp (Biomet M Note the position of the inferior alveolar neurovascular bundle and the socket of the third molar (if a tooth was present and removed).
Download With Free Trial Step 22dplace the teeth into the planned occlusion In 2-jaw cases, when the mandibular surgery is performed first, an intermediate surgical splint is used. In 2-jaw cases when the mandibular surgery is performed second or for single-jaw mandibular surgery cases, the use of a final splint is optional. Fixate the teeth into occlusion using 0.014-inch or 28 gauge wires.
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Step 23
remove bone from the proximal
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Mandibular Ramus Osteotomy
Bicortical screw fixation
During placement of ridged fixation several facto considered:
The position of the inferior alveolar neurovas (see Step 18) The distal root of the lower second molar Thickness of the bone to estimate the screws (a depth gauge may be used) Ensure that the drill perforate both bone cor Configure the position of the holes to ensure tion (ie, in a triangular fashion or in a straigh upper border) Place enough screws for adequate fixation are usually sufficient)
Use a sharp drill and apply light pressure wit when drilling the holes. Undue pressure may displ segments, the condyle or the occlusion. Use copious water cooling. If the shaft forced against the trocar, it will generate heat a skin and subcutaneous tissue in contact with the trocar. Angle the holes lightly backward to support the condyle. Once a hole is drilled the assistant should loa with an appropriate length on the screwdriver, ( You're Readingscrewdriver a Previewis a handy instrument at this time). View the bone segments carefully when applyi to ensure the screw engages the lingual cortex Unlock full access with a free trial. placing the position of the segments. Fig. 14 The positioning wire may be removed at this stage; Keep in mind that bicortical screws are self however, it is optional, and it may serve as additionalDownload fixation (1). With Freeonly Trial need to be turned to engage. No exc The reference lines allow for adequate alignment of the segments required. (2). Three bicortical screws are demonstrated as internal rigid Make sure that the segments are not compre fixation (3). intersegmental gaps should not be closed by tig screws. This will displace the condyle and result Jacksonville, FL, USA) are designed to preclude this if judisag. ciously utilized. The small bone defects should be grafted.
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The principles also apply when plates are used method.
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immediately following removal of the intermaxillary fixation. Wait a few minutes. Gently open and close the mouth and translate the mandible from side to side. With light finger pressure, the mouth is closed and the occlusion checked. The occlusion should be exactly as planned or fit perfectly into the surgical splint. The author is not in favor of a final splint, as it may hide small discrepancies at this stage.
Step 29dintraoperative diagnosis of a malocclusion An incorrect occlusion at this stage may be caused by:
Incorrect condylar position (condylar sag) Failure of fixation Displacement of the occlusion during placement of the ridged fixation Inaccurate surgical splint Intracapsular edema or hemarthrosis and condylar disc displacementdthese problems may only become apparent postoperatively.
It is imperative that an incorrect occlusion not be accepted. There is no better time to address the problem than at this stage. The intraoperative differential diagnosis of an incor rect occlusion is important for the correction of the problem.7
The final position of the bone segments is dem Fig. 14.
Step 32dapply a pressure bandage
The pressure bandage is removed 1 day followin which time the postoperative physiotherapy is co Over the past three decades our knowle standing of all aspects of orthognathic surgery h greatly. Not only has there been an evolution in cation of diagnostic skills and treatment planning experience, surgical techniques have attained a surgeons to treat the most complex jaw defo confidence. There is a magnitude of instruments available the surgeon’s technique. It is preferable, howev surgeon develops a familiarity with a small selec instruments that will ultimately achieve the same No matter how accurate and meticulous the su plications may and will occur during and after o surgery. The surgeon should therefore have a ro understanding of the step-by-step sequence of th For each step, there are relevant tips to improve t The surgeon should also be aware of specific tra lead to consequences or complications. This will e her to recognize and manage a complication befo
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Step 30dPlace intra and extraoral sutures References Unlock full access with a free trial.
1. Hunsuck EE. A modified intraoral sagittal splitting tec Resorbable sutures are used intraorally and non-resorbable correction sutures extraorally. The extraoral sutures are removed 2 days Download With Free Trialof mandibular prognathism. J Oral Surg 196 2. Epker BN. Modifications in the sagittal split ost postoperatively.
Step 31dplace intermaxillary elastics
Master youraresemester with The elastics placed in a triangular fashionScribd usually in the canine region. The direction of the elastics should reinforce the surgical & The New York Times movement (ie, Class II elastics for mandibular advancement One 4-oz. 0.25-inch elastic is placed on each side.
Special offer students: Onlyfor $4.99/month. and afor Class III pattern mandibular setback procedures).
Keep in mind that the purpose of the elastics is to override
mandible. J Oral Surg 1977;35:157 e9. 3. Obwegeser H, Trauner R, Obwegeser H. Zur Operatio der Progenia und anderen Unterkieferanomalien. Dts Kieferhlkd 1955;23:11 e25. 4. Reyneke JP. Essentials in orthognathic surgery. edition. Chicago: Quintessence; 2010. p. 209 e18. 5. Reyneke JP. up Basic for the surgical correcti Read Free Foron 30this Days Sign to guidelines vote title Plast ular anteroposterior deficiency and excess. Clin Not useful Useful 501e17. Cancel anytime. 6. Reyneke JP. The sagittal split mandibular ramus osteo manual. Jacksonville (FL): Walter Lorenz Surgical; 19 7. Reyneke JP Ferretti C. Intraoperative diagnosis of
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