Iwanaga 2017
Iwanaga 2017
Iwanaga 2017
Clinical Paper
Orthognathic Surgery
Abstract. The sagittal split ramus osteotomy and intraoral vertical ramus osteotomy
carry the potential risk of postoperative nerve paralysis, bleeding, and fracture and
dislocation of the condyle. In 1992, Choung first described the intraoral vertico-
sagittal ramus osteotomy for the purpose of avoiding postoperative dislocation of
the condyle. However, there is still potential for damaging the inferior alveolar
nerve and maxillary artery with this technique. The authors have developed a
modified technique to minimize these risks. An evaluation of surgical experience
and patient outcomes with the use of this technique is presented herein. One hundred
twenty-two sides in 97 Japanese patients diagnosed with a jaw deformity were
analyzed. This technique includes a horizontal osteotomy that is performed at a
higher position than in the original Choung procedure. Intraoperatively, there was
no unexpected bleeding from the operative site. Proximal segment dislocation from
the glenoid fossa was observed on one side (0.82%). Non-union of the osteotomy Key words: mandibular osteotomy; anatomy;
intraoperative complications; postoperative
was not observed in any patient. Intraoperative fracture of the coronoid process
complications; hemorrhage; maxillary artery;
occurred in 2.46%, but none necessitated treatment of the fracture. Nerve inferior alveolar nerve; sagittal split ramus
dysfunction was found in 2.46% at the 12-month postoperative follow-up. The osteotomy.
modified technique presented herein was developed to reduce postoperative nerve
dysfunction and intraoperative hemorrhage. Accepted for publication 6 June 2017
The sagittal split ramus osteotomy condyle. In 1992, Choung first described aims: minimize condylar displacement,
(SSRO) and the intraoral vertical ramus the intraoral vertico-sagittal ramus minimize inferior alveolar nerve damage,
osteotomy (IVRO) are currently the most osteotomy (IVSRO) for the purpose of and reduce postoperative iatrogenic
common orthognathic surgical procedures avoiding the postoperative dislocation of temporomandibular joint (TMJ) symp-
for jaw deformities1,2. However, both of the condyle that results from rotational toms.
these procedures carry the potential risk of movement of the condyle-bearing In Choung’s experience, the IVSRO
postoperative nerve damage, bleeding, fragment3,4. Choung developed the resulted in no dislocation of the condyle3.
and fracture and dislocation of the IVSRO to achieve the following three Although Choung reported that IVSRO
0901-5027/000001+05 ã 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Iwanaga J, et al. Intraoral vertico-sagittal ramus osteotomy: modification of the L-shaped osteotomy,
Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.06.003
YIJOM-3715; No of Pages 5
2 Iwanaga et al.
showed better outcomes than SSRO and and postoperative complications (e.g., mid-sigmoid notch area inferior to the
IVRO, the number of patients treated was unexpected bleeding, proximal segment anti-lingula prominence and then inferior-
very small. Therefore, further data are dislocation from the glenoid fossa, non- ly to the upper half of the mandible
needed to confirm the results. Since the union of the osteotomy, intraoperative (Fig. 1A). A vertical osteotomy with a
development of the IVSRO, few studies fracture of the coronoid process, nerve partial thickness cut is made with a
have applied this technique to patients, dysfunction) were recorded. The same Lindemann bur to the sigmoid notch as
and these studies have reported different surgeon performed all operations and all a guide groove (Figs 1B and 2). Additional
outcomes5–11. However, the IVSRO still patients received preoperative and postop- full-thickness cutting of the subcondylar
has the potential for damaging the inferior erative orthodontic treatment. notch area is performed with a sagittal saw
alveolar nerve and maxillary artery, as The inclusion criteria for the subjects (Fig. 1C). A Lindemann bur is inserted
well as other complications12. To provide were (1) at least 12 months of follow-up, horizontally at the same level as the
a potentially safer outcome, the present and (2) the patient had undergone IVSRO mandibular foramen. The horizontal
authors have developed a modified either unilaterally or bilaterally. Genio- osteotomy is performed, protecting the
‘L-shaped’ IVSRO technique (based on plasty (n = 19) and removal of the buccal soft tissue using a ramus retractor. Next,
the Choung I osteotomy) for the treatment fat pad (n = 3) were supplementary pro- the proximal and distal segments are split
of jaw deformities that might reduce the cedures in these cases. Patients who had with a thin spatula osteotome or bone-
potential for nerve and artery damage. The conditions or a history indicating a greater separator, and the L-shaped osteotomy is
aim of this study was to evaluate the out- propensity to altered recovery patterns, or completed (Fig. 1D).
comes of this modified L-shaped IVSRO systemic conditions such as a pre-existing The proximal and distal segments of the
technique performed at the authors’ orofacial sensory disturbance, a history of mandible were not fixed with wires or with
hospital. facial trauma or operation, diabetes mel- a plate and screws in any of the patients.
litus, or significant psychiatric disorders After surgery, intermaxillary fixation was
were excluded from this study. performed for 1 week and elastic
Materials and methods intermaxillary fixation for 6 months or
more.
Patients and protocol Modified L-shaped IVSRO procedure
One hundred and twenty-two sides (56 This procedure comprises a modified
Results
right, 66 left; 25 bilateral) in 97 Japanese version of the L-shaped IVSRO technique
patients who had been diagnosed with a (Choung I osteotomy)3. The initial All of the 97 patients who underwent the
jaw deformity and underwent IVSRO dur- incision is made from the anterior border IVSRO procedure did so under general
ing the years 1998–2016 at the Dental and of the ascending ramus to the external anesthesia through nasotracheal intuba-
Oral Medical Center, Kurume University oblique line at the level of the second tion. The amount of mandibular move-
Hospital, were evaluated retrospectively. molar. The lateral surface of the mandible ment ranged from 11 to 2 mm (mean
Twenty-four of the patients were male and extending from the sigmoid notch to the 3.3 3.4 mm) on the right side and
73 were female; they ranged in age from upper half of the mandible is exposed with from 9 to 5 mm (mean
17 to 54 years (mean age 23.44 6.74 a ramus retractor following the initial 2.8 3.6 mm) on the left side.
years). The study protocol was approved incision. A portion of the temporalis Intraoperatively, there was no unex-
by the institutional ethics committees and tendon is stripped off the coronoid process pected bleeding from the operative site.
the study was performed in accordance with a Bauer retractor to identify the Proximal segment dislocation from the
with the requirements of the Declaration anterior aspect of the sigmoid notch. glenoid fossa was observed on one side
of Helsinki (64th WMA General Assem- The medial surface of the mandible is also (0.82%), which was treated in a second
bly, Fortaleza, Brazil, October 2013). exposed to avoid injury to the maxillary surgery. Non-union of the osteotomy was
The anesthesia used, amount of man- artery. Decortication is performed parallel not seen in any patient (Fig. 3). Intraop-
dibular movement (right, left), and intra- to the original sagittal plane from the erative fracture of the coronoid process
Fig. 1. Procedure for the modified L-shaped IVSRO technique: (A) decortication of the cortical bone; (B) partial thickness cutting with a
Lindemann bur; (C) full-thickness cutting with the sagittal saw; (D) completion of the modified L-shaped osteotomy.
Please cite this article in press as: Iwanaga J, et al. Intraoral vertico-sagittal ramus osteotomy: modification of the L-shaped osteotomy,
Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.06.003
YIJOM-3715; No of Pages 5
Fig. 2. Medial view of the left mandibular ramus with Bauer retractors and a Lindemann bur.
Fig. 3. Changes on standing postero-anterior radiographs: (A) immediately after surgery; (B) 3 months after surgery; (C) 10 months after surgery.
occurred on three sides (2.46%) and none 3.8%), and bleeding or hemorrhage (rang- displacement and postoperative nerve dys-
of these necessitated additional treatment ing from 5.0% to 9.3%)5,10. Originally, the function3; Choung did not mention the risk
for the fracture. Postoperative nerve dys- main purpose of this procedure was to of hemorrhage, which results from injury
function was seen on three sides (2.46%) decrease the incidence of condylar to the maxillary artery.
at the 12-month follow-up (Table 1). SSRO and IVRO have a reported
Table 1. Intra- and postoperative complica- incidence of postoperative proximal seg-
tions. ment displacement ranging from 13.2%
Discussion
Total %
(10/76)13 to 88.3% (53/60)14 and from
Since Choung first developed the 1.3% (8/638)15 to 72.0% (36/50)16,
‘straight’ IVSRO3, it has been applied to Unexpected bleeding 0 0 respectively. These reported incidences
patients with skeletofacial deformities. Proximal segment dislocation 1 0.82 have included both slight displacement
Non-union 0 0
Reported complications include condylar Fracture of the coronoid process 3 2.46
of the condyle that does not require
dislocation (ranging from 0% to 1.3%), Nerve dysfunction 3 2.46 retreatment and dislocation of the condyle
nerve dysfunction (ranging from 0% to that needs to be relocated. In the present
Please cite this article in press as: Iwanaga J, et al. Intraoral vertico-sagittal ramus osteotomy: modification of the L-shaped osteotomy,
Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.06.003
YIJOM-3715; No of Pages 5
4 Iwanaga et al.
study, dislocation requiring repeat surgery Yamamoto et al.23 concluded that separat- Patient consent
occurred in 0.82% of cases (1/122 sides). ing the inferior alveolar nerve from the
Not required.
Choung explained the reason why IVSRO outer cortical bone without any injury was
could avoid displacement of the condyle, difficult if the width of the bone marrow
based on the theory that the osteotomy was less than 0.8 mm. These results dem- References
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easier to protect the inferior alveolar
2009;135:809–19.
neurovascular bundle. Even though this No funding.
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Fax: +81 942 31 7704
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Please cite this article in press as: Iwanaga J, et al. Intraoral vertico-sagittal ramus osteotomy: modification of the L-shaped osteotomy,
Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.06.003