GOOD MORNING

Mandibular Orthognathic Surgery

Presented By:
Dr Shahid Shaikh
 Content
 Introduction
 Definition
 Historical Background
 Surgical anatomy of mandible
 Surgical Procedure
◦ Bilateral Sagittal Split Osteotomy
◦ Vertical Ramus Osteotomy
◦ Genioplasty
◦ Subapical Osteotomy
 Complications
 References
 Introduction
 Dentofacial deformities affect approximately 20 % of
population.

 Patient with dentofacial deformities may

demonstrate various degrees of fucntional and
esthetic compromise.

 The most important indication of need for

orthognathic surgery is usually psychological effect
resulting from unaesthetic appearance of a
dentofacial deformity.
 Several factors presenting either collectively or
individually may indicate need for orthognathic
surgery. Such as
◦ Impaired mastication

◦ Temporomandibular pain and dysfunction

◦ Susceptibility to caries

◦ Periodontal diseases
 Definition
 The word orthognathic comes
from the greek word ortho meaning
straighten, and gnathia, meaning jaw.

 Orthognathic surgery is defined as the ‘art and science of

diagnosis, treatment planning, and execution of treatment
by combining orthodontics and oral and maxillofacial
surgery to correct musculoskeletal, dento-osseous and
soft tissue deformities of the jaws and associated
structures. (Fonseca vol. 2 Orthognathic surgery)
History
 Hullihen, who in 1849 was the first to describe a
mandibular osteotomy.

Hullihen’s mandibular subapical osteotomy

 50 years later when Angle described a body osteotomy
done by V.P. Blair
 This technique, with minor modifications, was advocated
until the 1970s.

Blair’s body osteotomy.

Blair’s ramus osteotomy
 An intraoral technique was not suggested until Ernst
discussed his procedure approximately 25 years later.

 This method of correcting mandibular deformities was

used for almost 60 years, but because of its lack of
postoperative stability, it has fallen into disuse.
 Berger (1897) described a condylar osteotomy for the
correction of prognathism.

 The subcondylar osteotomy was first reported by Limberg

in 1925 as an extraoral technique
 A variation of the vertical subcondylar osteotomy was
suggested by Wassmund in 1927
 which is similar to what is now called the inverted L
osteotomy.

 The intraoral approach to the subcondylar osteotomies is

relatively new, having first been described by Moose in 1964
 Caldwell and colleagues further modified inverted L by
adding a horizontal cut just above inferior border of
mandible to create what is now called the C osteotomy.
 The greatest development in osteotomies of vertical ramus
is sagittal osteotomy, credited to Obwegeser and Trauner,
but generally now used in a fashion modified from original
technique described in 1955.
 Lane has been mentioned as developer of a form
of sagittal osteotomy, with parallel horizontal bone
cuts made through medial and lateral cortices of
vertical ramus.
 1953 ----- 1st patient operated by Obwegesar
◦ on the same patient Richard traunar perform L shape
osteotomy.

 1954 ----- Schuchardt perform & publish it locally.

 1957 ----- Obwegeser&Trauner popularized technique,

especially in North America.
 1961 ----- Giorgio DalPont’s modification
 1968 ----- Hunshuck – modification is variation of lingual
cut.

 Kent & Hinds in 1971 initially presented use of single tooth

osteotomies of the mandible.

 Macintosh closely followed with his description of total

mandibular alveolar osteotomy in 1974.
 1974 ----- Spiessl introduced screw rigid internal fixation

 1977 ----- Epker claimed modifications

 1977 -----Bell & Schendel asserted that securing segments

increased stability.

 Despite other modifications, osteotomy remains very

similar to that described by Obwegeser and DalPont.
 Surgical anatomy
 Vascular Supply
◦ Bell and Levy’s work demonstrated that blood flow
through mandibular periosteum could easily maintain a
sufficient blood supply to teeth of a mobile segment.

◦ They also demonstrated that there is sufficient blood

supply from surrounding soft tissues, even if inferior
alveolar artery was obstructed.
◦ Peripheral blood vessels quickly take over for the anterior
mandible.

◦ Proximal segment of the vertical subsigmoid osteotomy-

through the TMJ capsule & lateral pterygoid muscle.

◦ Greater distance from apices of teeth not only minimizes

direct pulpal injury but increases vascular pedicle to
mobile segment as well.
 The Muscle
◦ Orthognathic surgery affects muscles in primarily two
ways:
 it changes the length of a muscle or
 it changes the direction of muscle function.

◦ The vertical ramus is a thin, dense structure with little

marrow that is entirely sheathed by masticatory muscles.

◦ Its antero-superior portion, the coronoid process,

provides attachment for the temporalis muscle
 Franco and colleagues theorized that
◦ Stretching of medial pterygoid muscle and
◦ Elongation of anterior fibers of masseter and temporalis
muscles from clockwise rotation of proximal segment

◦ Both can contribute to relapse in lengthening muscles of

pterygomasseteric sling.

◦ This can result in a change in mandibular position as has

been documented by Yellich and colleagues
 Nerves

 In most cases in orthognathic surgery avoiding injury to

marginal mandibular branch of facial nerve is achieved
because soft tissue anatomy in patients undergoing the
surgery has not been disturbed by disease or trauma.

 The course of the inferior alveolar nerve into vertical

ramus and then through body of mandible makes it
extremely susceptible to damage from almost every
mandibular surgical procedure.
 The lingula of the mandible is a sharp tongue-shaped bony
projection on the medial aspect of ramus.

 At a distance between 7.5 to 13.3 mm above the

lingula

Buccal and lingual cortex fusion occurs at a rate

of
◦ 20% in the anterior ramus
◦ 39% in the posterior ramus
 Position of IAN at second molar
 Bone thickness from mandibular canal to buccal plate- 7.2
+/- 1.47 mm

Int. J. Oral Maxillofac. Surg,

2008
 The mandibular foramen lies at a mean distance of 8.3 mm
below the tip of lingula.
 The lingula is positioned 4.9mm + 3.5mm above occlusal
plane.
 Therefore neurovascular bundle generally enters
mandibular foramen inferior to mandibular occlusal plane.
 Surgical Procedure
 The surgical treatment of the deformities of the mandible
must be considered in all the three dimensions.

 A number of osteotomy techniques are now available to

correct different types of lower jaw deformities.
 According to the site of operation, the techniques may
be divided into

 Ramus Osteotomy
◦ Bilateral Sagittal Split Osteotomy
◦ Vertical Ramus Osteotomy
◦ Inverted “L” & “c” osteotomy

 Body osteotomies
◦ Anterior body osteotomies
◦ Posterior body osteotomies
 Sub apical osteotomies
◦ Anterior subapical osteotomy

◦ Posterior subapical osteotomy

◦ Total subapical osteotomy

 Genioplasty
◦ Augmentation Genioplasty
◦ Reduction Genioplasty
◦ Straightening Genioplasty
◦ Lengthening Genioplasty
Bilateral Sagittal Split Osteotomy

 Indications
◦ Symmetric and asymmetric mandibular advancement.

◦ Vertical lengthening of ascending mandibular ramus.

◦ Correction of open bite.

◦ Symmetric mandibular setback.

◦ Minor asymmetric mandibular setback.

Mandibular Deficiency
 Mandibular Deficiency solely reflects anatomic position of
mandible in relation to maxilla.
 Sagittal discrepency --- Class II molar relation
 Mandibular Deficiency is most frequent indication for BSSO.
Long face Short face
 Characteristics of man. deficiency
 Normal & short anterior face height
 Anterior deep bite
 Well developed chin button
 Increased A/B difference
 Class II canine and molar
 Mandibular Prognathism
Clinical Features
 Prominent lower third of face
 Molar relation – class III
 Abtuse gonial angle
 Concave profile
 Posterior crossbite – narrow & short upper arch but
broad lower arch
 Diminished labio mental fold
Surgical procedure

Intraoral incision just lingual to external oblique ridge

Visualization of lingula Parallel horizontal osteotomy
Buccal osteotomy start at lower border & is angled slightly oblique to
enhance split.
 Hole for engagement of condylar positioner
 Split is started by tapping 10 mm wide osteotome
along verticle osteotomy
 Neurovascular bundle carefully dissect from
proximal segment by blunt instrument.
 Condyle is carefully pushed in superiorly and
slightly anteriorly.
 In past , osteosynthesis was achieved with upper border
wire , lower border wire or circum ramus body wire.

 Now a days possible method of fixation are

◦ Screw fixation

◦ Miniplate fixation

◦ Resorbable implant fixation

 With transbuccal trocar bicortical holes are
drilled and bicortical screws placed.
 Before osteotomy site is closed it is wise to proof the
occlusion.

 MMF is released ,the splint removed and fucntion such

as mouth opening , left right lateral and protrusive
fuction are checked.

 If the function is not smooth the fixation has to be

redone.
 Vertical Ramus Osteotomy
 1st described by Caldwell and
Letterman in 1954- extra oral

 Introduced by Moose in 1964-

intra-oral technique performed
from lingual aspect

 Wistanley, 1968- performing the

technique from the lateral aspect
of the mandible
 Comparison between SSRO and VRO
SSRO VRO
OSTEOTOMY PA Saggital split Latero medial cut
Open procedure Blind procedure
Along IAN Rear to IAN
Frequent exposure of IAN No exposure of IAN
BONE HEALING Contact on marrow to Contact on cortex to
marrow cortex
BONE FIXATION Rigid internal fixation No fixation
CONDYLAR HEAD Original position New equilibrated position
POST OP IMF None or shorter period Required
PROGNOSIS Weakely dependent on PT Strongly dependent on PT
Indications

 Horizontal mandibular excess

 Mandibular asymmetry
 Minor occlusal discrepancy after isolated Le Fort I
osteotomy
◦ Asymmetric lateral open bite
◦ Failure to achieve passive rotation of the mandible after the
release of MMF

 Patients with significant TMJ complaints

Contraindications
 Advancement of the distal segment

 Aesthetic assessment of the soft tissues of the neck is the

integral factor in planning mandibular set back by ramus
surgery

 Recent condylar fractures

◦ Should be differed for 6-12 months
Advantages
 Can be performed on OPD basis

 Inherent anatomic architecture of the mandible poses

little interference to place the cuts

 Less chance of damaging the IAN bundle

 Found to have curable effects in pts with pre-op TMD

 Less incidence of condylar sag

Vertical Ramus Osteotomy

 Incision is made over external oblique ridge

 Final occlusion is guided by wafer splint

 MMF is performed with loop wires that maintain lateral

overlapping of proximal segment.

 Overlapping is reevaluated

 Wound closed and an active drain with negative

pressure is inserted.
 After 7 to 10 days MMF is removed and active
physiotherapy is begun.

 Self exercise to maximise hinge opening ,protrusion and

lateral excrusion should be guided.

 Open bite tendency should be evaluated carefully every day

or on alternate day during first week of physiotherapy.

 If Open bite tendency greater than 2mm MMF should

perform again.
 Inverted L & C osteotomy
 These are designs in the vertical ramus that include
both the condyle and coronoid in the same segment

 Most commonly done via an extra- oral approach

 The basic techniques for C & L are same, with only

modification being inferior horizontal cut in the C
osteotomy.
 Indications
◦ Large advancements >12mm
◦ Mandibular setback -10mm or more-bypasses the
need for coronoidectomy
◦ Secondary correction of proximal segment
malrotation following BSSO
◦ Simultaneous advancement and lengthening of ramus
in case of severe ramus under development.

 Less risk of condylar sag compared with VRO

 Vertical osteotomy is made at least 7 mm in front of the
posterior border and extends to a point of the inferior
border just in front of the angle.

 The horizontal cut is made above mandibular foramen

 Arcing the inferior cut was suggested to permit increased
bone contact as the distal segment was advanced
 Mandibular Body Osteotomy

 Mandibular body osteotomy surgical procedures

can be performed
1. Between adjacent teeth.
2. Through pre-existing edentulous space.
3. Through the extraction sites.
 Anterior Body Osteotomy
 Whenever the osteotomies are performed anterior to the
mental foramen, it is termed as anterior body osteotomy

Indication
 Mandibular prognathism with functional posterior
occlusion
 Class III malocclusion with or without anterior open bite,
where the posterior teeth cross bite is dental in nature
(can be corrected by orthodontics).
Posterior Body Osteotomy

 Whenever the osteotomies are performed posterior to

the mental foramen, it is termed as posterior body
osteotomy
 Indication
◦ In selected cases, with class III deformity,
◦ For correction of crossbite
 Revascularization & healing
 Blood flow is crucial for revascularisation and healing.

 Blood flow will be decreased in the areas where the

mucoperiosteum will be elevated.
 Immediate post-operatively
◦ Intermedullary circulation between the proximal and
distal segments
◦ Margins of osteotomy- avascular

 One week post-op

◦ Level of hypervascularity around surgical site
◦ No soft tissue re-attachment
◦ Isolated areas of sub- periosteal bone formation
 2 weeks post-op
◦ Avascular zone at the proximal osteotomy site
◦ Necrotic zone at the distal osteotomy site
◦ No soft tissue attachment at the distal necrotic zone

 3 weeks post-op
◦ Soft tissue re-attachment
◦ Vascular anastamoses between proximal and distal
segments
◦ Osteoid formation through out marrow formation
 6 weeks post-op
◦ Circulation reconstituted across the osteotomy site
◦ Soft tissue re- attachment established

 12 weeks post- op
◦ Circulation between the segments is continuous
 Referenses
 Oral and maxillofacial surgery: Fonseca Vol. 2 Orthognathic Surgery
: first edition
 Oral and maxillofacial surgery: Fonseca vol. III: Second edition
 Principles of oral and maxillofacial surgery- Peterson 2nd edition
 Essentials of orthognathic surgery-Reyneke 2nd edition
 Maxillofacial surgery-Peter Ward Booth
 Evaluation of mandibular anatomy related to sagittal split ramus
osteotomy using 3-dimensional computed tomography scan images
I.H.Yu. Y.K.Wong
 Accuracy of Using the Antilingula as a Sole Determinant of Vertical
Ramus Osteotomy Position . J Oral Maxillofac Surg, 2007
Thank you