Mandibular osteotomies

GUIDED BY: PRESENTED BY:

DR D.S. GUPTA DR NASIM
 CONTENTS
Introduction
History
Goals of mandibular osteotomies
Surgical anatomy- Vessels, Nerves, Muscles
Classification
Sagittal split osteotomy
IVRO
Body osteotomy- Anterior & Posterior
Subapical Osteotomies- Anterior,Posterior, Total
Genioplasty
Complications
Conclusion
 INTRODUCTION
Orthognathic in Greek (Orthos- straight ; Gnathos- jaw)
 Orthognathic surgery refers to surgical procedures designed to correct
jaw deformities.
Orthognathic surgery is the art and science of diagnosis, treatment
planning, and execution of treatment by combining orthodontics and
oral and maxillofacial surgery to correct musculoskeletal, dentoosseous,
and soft tissue deformities of the jaws and associated structures.
history
Hullihen (1849): first person to
surgically correct jaw deformity
(anterior open bite) using mandibular
sub-apical osteotomy

Blair (1900): Horizontal osteotomy of

the mandibular ramus to correct
mandibular prognathism

Von Eiselberg (1906): Body osteotomy

  Limberg(1925)
Posterior oblique vertical ramal
osteotomy, external approach

 Wassmund(1927)
Vertical subcondylar
osteotomy inverted L-
osteotomy.
Hofer(1936) demonstrated an anterior
mandibular alveolar osteotomy to
advance anterior teeth in correction of
a mandibular dentoalveolar retrusion.

Horizontal sliding osteotomy

first described by Hofner
(1942)
 Caldwell & co-workers
C-osteotomy

Schuchardt (1942)
Sagittal split osteotomy
 Trauner (1955): Inverted-L osteotomy for mandibular
prognathism

 Hugo Obwegeser (1955): Described the technique of

intraoral bilateral sagittal split osteotomy (BSSO)

 BSSO modified by Dalpont in 1958,

Hunsuck in 1968 and Epker in 1977

 Heinz Köle (1968): Described

genioplasty for open bite
Caldwell & Letterman (1954):
Vertical sub-sigmoid osteotomy

Moose (1964): Intra-oral approach

sub-condylar osteotomy

Winstanley (1968): Lateral approach

Obwegeser & Trauner (1955):
discussed in literature

Dalpont (1961): Vertical cut

modification

Hunsuck (1968): Short lingual cut

Spiessl (1976): Rigid internal fixation

Bell & Schendel (1977) & Epker

(1978): Minimal soft tissue stripping
Orthognathic Surgery and a Tale of How Three Procedures Came to Be: A Letter to the Next Generations of Surgeons
.Obwegeser, Hugo L. Clinics in Plastic Surgery, Volume 34, Issue 3, 331 - 355
 Basic Therapeutic Goals For
mandibular Orthognathic Surgery
To establish proper function ( normal mastication, speech, respiratory function)

To establish aesthetics ( Establishment of facial harmony)

Provide stability (Prevention of short and long term relapse)

Minimizing of treatment time

 VASCULAR NERVES
STRUCTURES

MUSCLES

Surgical anatomy
Ramus procedures
1. Bilateral sagittal split osteotomy
2. Vertical ramus osteotomy
3. Inverted L osteotomy
4. C osteotomy

Body procedures
1. Anterior to mental foramen
2. Posterior to mental foramen

Subapical procedures
1. Anterior
2. Posterior
3. Total

Genioplasty
 Sagittal split ramus osteotomy
• Movement of the dentate segment in all 3 dimensions

Indications • Procedure of choice for advancement ≤ 10 mm

• Mandibular setback ≤ 7 mm
• Minor asymmetries

• Severe decreased posterior mandibular body height

Contraindications • Extremely thin medial-lateral width of ramus

• Severe ramus hypoplasia
• Severe mandibular asymmetries

• Adequate bony interface for fast healing

• Advance, setback or rotate the mandible
Advantages • Occlusal plane can be altered
• Correct most asymmetries
• No need to strip the muscles of mastication

• Inferior alveolar nerve at risk

Disadvantages • High risk of inadvertent buccal plate fractures (bad split)
• Angle contouring not possible
 Blair (1907)
 Published the horizontal flat
subcondylar osteotomy of
the mandible to correct
class II dysgnathias by
advancement of the
mandibular body.
Schuchardt(1942)
Cortical osteotomy was
performed in an oblique way
starting from just above the
lingula and reaching the
buccal cortex 1 cm more
caudally without touching the
inferior alveolar nerve (IAN).
 Trauner andObwegeser 1957

 Increased the gap between

the horizontal cuts to 25
mm, preserving IAN. (The
Sagittal Split)
 Dalpont (1961)

Advanced the oblique

cut towards molar
region and made it
vertical through the
lateral cortex
 Hunsuck(1968)

 Shortened the cut

through the medial
cortex taking it only as
far as the mandibular
foramen.
BELL SCHENDEL (1977) &
EPKER (1978)

 Hunsuck technique is adopted but on

the lateral aspect the vertical cut is
taken downwards from an oblique line
through outer cortex to lower border
where the lower border is sectioned.
 Minimal detachment of the
pterygomassetric sling there is
decreased intra- osseous ischemia, and
necrosis of the proximal segment.
 Jeter described technique of
Development of rigid internal
placing 3 bicortical 2.0 mm
fixation by Spiessl in 1974
replaced osteosynthesis by wire position screws to fix the
fixation or IMF. proximal and distal segments.

Blomqvist and others showed Recently good stability after

no significant difference in
BSSO is also shown by
terms of relapse between
monocortical screws with polylactate bone plates and
miniplates and bicortical screws screws.
for mandibular advancement.
 SURGICAL
TECHNIQUE
 complications
Condylar Sag
• Malocclusion
• Unfavorable splits
• Relapse
• Nerve injury
• TMJ dysfunction and hypomobility
• Hemorrhage
 Bad split
1) Fracture of buccal cortex of body of mandible.
2) Fracture of buccal cortex involving body and
ramus of mandible.
3) Fracture of the retromolar segment distal to the
second molar.
4) Fracture of the vertical osteotomy the medial
aspect of the ramus anterior to the IAN foramen.
 To prevent:
1) Follow meticulous surgical technique
2) Ensure completion of osteotomy cuts
before splitting

 To manage:
1) Redefine osteotomy
2) Prompt fixation of attached bone, removal
of detached bone
 VERTICAL SUB-SIGMOID
RAMUS OSTEOTOMY
• Horizontal mandibular excess

Indications • Re-operation & advancement

• Protrusion or retrusion with restricted intraoral access
• Limited rotation of dentate segment

• Mandibular advancement
Contraindications • Vertical lengthening
• Recent condylar fractures

• Simple and rapid procedure,

Advantages • Less incidence of inferior alveolar nerve damage
• Less TMJ complaints

• Difficult to control the position of the condyle

Disadvantages •
•
Increased healing time
Difficult to use rigid fixation intraorally
• MMF for 4 to 8 weeks and long term interarch elastics to control occlusion
 MODIFICATIONS

Modification by Moule: Modification by Bell (1980):

• Shaded area is removed • Slight curvature
• Allows for a wider pedicle
• Not recommended routinely • More protection to IAN
 Complications
Bleeding
Massetric artery and vein
Reposition proximal segment, pack the osteotomy site and external pressure for 5-10min

Nerve injury
IAN: 1-8%
Nerve is loosely tethered when it enters canal
Angled shank of the saw
Rigid fixation not necessary

Unfavorable osteotomy
Abort the procedure and treat like a fracture
Continue the procedure and fix the fractured segment
 inverted L osteotomy
• Mandibular hypoplasia with deficient ramus width
• Mandibular protrusion
Indications • Large asymmetry
• Recontouring of deficient angle

Contraindications • Vertical shortening

• Best procedure for lengthening

of the ramus
Advantages • Bypasses the need for
coronoidotomy
• Less condylar sag

• Usually requires transcutaneous approach

Disadvantages • Difficult placement of hardware
• Grafting required in advancement cases
 Mandibular body osteotomies
• Mandibular prognathism with increased body length
• To utilize space from extraction sites / missing teeth
Indications • Limited advancements in the body (with bone graft)
• Anterior open bite closure
• Progenia correction

Contraindications • When deformity is outside the mandibular body

• Superior stability
Advantages • Can close "tooth gaps"
• Within the dental arch

• Puts the inferior alveolar nerve at risk

Disadvantages • Requires more rigid fixation
• Advancements require bone grafting
History
a) 1907 – first described by Blair – extraoral procedure
b) Dingman (1944) – combination of I/O and E/O

Anatomic considerations
a) Distal segment is set back into a wider proximal segment - Reduction in bone
contact
b) Torquing of proximal segment
c) Position of inferior alveolar nerve

Step osteotomy
a) Mandibular prognathism
b) Retrognathism
c) Asymmetry
d) Apertognathia
 Complications
Nerve damage

Damage to the roots of teeth

Periodontal defects at the osteotomy

sites

Nonunion
Posterior Body Osteotomy
 Subapical osteotomies

 Anterior subapical osteotomy

 Posterior subapical osteotomy
 Total alveolar ostetotomy
 Indications:
• Correction of nonskeletal open bite
/ bimaxillary protrusion
• Level the plane of occlusion
• Uprighting the anterior teeth to a
more normal angulation
Posterior subapical
osteotomy

 Indications:
• Correction of supraeruption of
posterior mandibular teeth.
• Abnormal buccal or lingual
positioning of teeth when
orthodontics is not feasible.
  Indications:
• Malocclusion due to mandibular
dentoalveolar deformity.
Total subapicalosteotomy • Occlusal discrepancies without
associated esthetic changes
 complications

Loss of bone and / or teeth in the osteotomised segment

Loss of tooth vitality

Periodontal defects

Nonunion /malunion

Malocclusion

Neurosensory disturbances
genioplasty
 history
Converse(1950), discussed the Trauner and Obwegeser, (1957), Converse and Wood-Smith
Hofer(1942) first described feasibility of bone grafts used the horizontal osteotomy described various applications
horizontal sliding osteotomy--- introduced through intraoral through an intraoral incision and versatility of, the horizontal
extraoral incision approaches with de-gloving of the anterior osteotomy
mandible

Hinds and Kent(1969) realize

the importance of maintaining
Reichenbach and colleagues
the soft tissue attachment
(1965)proposed wedge Introduction of hydroxyapatite
along the inferior segment and
osteotomy and vertical as grafts in 1980s
the role of these attachments
shortening of the chin
in achieving maximal soft tissue
change
 VERTICAL AUGMENTATION
VERTICAL REDUCTION GENIOPLASTY GENIOPLASTY
 HORIZONTAL REDUCTION
AUGMENTATION GENIOPLASTY GENIOPLASTY
 STRAIGHTENING
GENIOPLASTY

SLIDING
GENIOPLASTY
DOUBLE SLIDING ALLOPLASTIC
GENIOPLASTY AUGMENTATION
Propeller
GENIOPLASTy
 COMPLICATIONS

White JB, Dufresne CR. Management and avoidance of complications in chin augmentation. Aesthet Surg J. 2011;31(6):634-
642. doi:10.1177/1090820X11415516
 healing
One week of healing:
Immediate post operative: Two weeks post operatively:
Well vascularized proximal & distal
General intramedullary circulation segment Well perfused proximal segment, avascular
zone around osteotomy & no reattachment
Osteotomy margins –avascular No e/o soft tissue rettachment/
Increased circulation at the osteotomized
Cortical ischemia in soft tissue flaps revascularization cortices
Reduce pulpal & periodontal flow Isolated areas of subperiosteal bone e/o subperiosteal bone formation
formation

Twelve weeks post Six weeks post operatively: Three weeks post operatively:
operatively: Circulation reconstituted across
Complete soft tissue reattachment
Signs of vascular anastomosis
Continuous cortex present the osteotomy site Thickening of the reattached periosteum
Flaps revascularized Osteoids and new bone formation thru out
Bony remodelling at the site marrow
of union e/o muscle attachment Distinct organization of new blood vessels
 conclusion
Surgeons are endowed with a wide variety of osteotomy techniques to correct a
deformed mandible, with possibility of repositioning segments in almost every
conceivable plane.

The osteotomy technique selection must be based on the location (body, ramus,
alveolus) and extent of deformity.

Regardless of the osteotomy technique, prudent soft tissue dissection must be

performed to preserve vitality to the osteotomized segment.

Rigid fixation and a favourable occlusion is warranted to provide long-term stable

results.
 references
Oral and maxillofacial surgery Volume II Orthognathic Surgery
,Raymond J. Fonseca ,D. M. D.
Essentials of orthognathic surgey, J P Reyneke
Oral and maxillofacial surgery volume I, Peter Ward Booth
Reyneke JP, Ferretti C. The Bilateral Sagittal Split Mandibular Ramus
Osteotomy. Atlas Oral Maxillofac Surg Clin North Am. 2016;24(1):27-
36. doi:10.1016/j.cxom.2015.10.005
White JB, Dufresne CR. Management and avoidance of complications
in chin augmentation. Aesthet Surg J. 2011;31(6):634-642.
doi:10.1177/1090820X11415516