Reyneke2015.pdf-Bsso Steps PDF
Reyneke2015.pdf-Bsso Steps PDF
Reyneke2015.pdf-Bsso Steps PDF
Ramus Osteotomy
Johan P. Reyneke, BChD, MChD, FCMOS (SA), PhD a,b,c,d,e,*,
Carlo Ferretti, BDS, MDent (MFOS), FCD (SA) MFOS f
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 outcome.
The application of an established step-by-step operating technique prevents intraoperative uncertainty and often post-
operative complications.
The authors declare that there are no commercial or financial con- Step 1dinfiltrate the soft tissue with
flicts of interest as well as any funding sources regarding the work. vasoconstrictor
a
Department of Maxillofacial and Oral Surgery, University of the
Western Cape, Cape Town, South Africa The lips should be kept lubricated with steroid ointment
b
Department of Oral and Maxillofacial Surgery, University of Okla-
throughout the surgical procedure.
homa, Oklahoma City, OK, USA
c The area of dissection is infiltrated with a local anesthetic
Department of Oral and Maxillofacial Surgery, University of Florida
College of Dentistry, Gainesville, FL, USA containing a vasoconstrictor (epinephrine in a concentration of
d
Division of Oral and Maxillofacial Surgery, Universidad Autonoma de 1:100,000) 10 minutes before surgery.
Nueva Leon, Monterrey, Mexico
e
Center for Orthognathic Surgery, Cape Town Mediclinic, Cape Town
8001, South Africa Step 2dthe soft tissue incision
f
Department of Maxillofacial and Oral Surgery, Faculty of Health
Sciences, Chris Hani Baragwanath Hospital, University of the Witwa-
tersrand, Johannesburg, South Africa An incision is made through the mucosa, muscle, and perios-
* Corresponding author. Department of Maxillofacial and Oral Sur- teum from just lingual to the external oblique ridge, halfway
gery, University of the Western Cape, Cape Town, South Africa. up the mandibular ramus superiorly to mesial of the
E-mail address: johanrey@worldonline.co.za second molar inferiorly.
At least 5 mm of nonkeratinized mucosa should be left Perforation of the periosteum in this area may cause brisk
buccally at the lower end of the incision for ease of suturing hemorrhage (usually from the medial pterygoid muscle);
later. however it often subsides spontaneously.
Alternative techniques
Fig. 4 (A) The completed sagittal osteotomy is demonstrated Step 10ddrill a hole for the condylar positioner
(arrow 1). Start the buccal osteotomy at the inferior border and
connect it to the vertical osteotomy (arrow 2). (B) The buccal The hole is drilled in the buccal cortex of the distal segment
osteotomy is completed in a slight posterior medial direction to and angled posteriorly. The hole serves as a purchase point for
facilitate the introduction of the Reyneke splitting osteotome and the condylar positioning instrument during condylar positioning
to initiate and direct the split in the proper direction. (Fig. 7).
4 Reyneke & Ferretti
Fig. 6 (A) A 6 mm mandibular advancement is planned. Arrows show removal of a segment of bone from the anterior part of the proximal
segment. The positioning holes are therefore drilled 10 mm apart with the anterior hole on the distal segment (1). Following 6 mm
advancement, the holes will be 4 mm apart with the wire in a Class II direction supporting the condyle (2). (B) A 6 mm mandibular setback
is planned. The positioning holes are drilled 2 mm apart with the anterior hole on the proximal segment (1). Following a 6 mm setback of
the distal segment, the holes will be 4 mm apart with the wire in a Class II direction supporting the condyle (2).
Step 11dplace reference marks accurate positioning of the proximal segment and alignment of
the lower borders during condylar positioning (see Fig. 7).
Reference marks are placed on either side of the vertical
buccal osteotomy. Alignment of these marks will ensure Step 12dlavage
First stage
Fig. 8 A Reyneke splitter is placed into the buccal osteotomy on the lower border of the mandible (1). The splitter and an osteotome,
placed into the superior aspect of the vertical osteotomy, are gently rotated (1 & 2). The lower border should separate from the distal
segment including the lower border of the mandible (3).
Visualize and ensure that: The inferior alveolar foramen and proximal part of the
nerve canal should detach from the proximal segment.
1. The lower border of the mandible splits toward the proximal The osteotome is now replaced by a larger Obwegeser
segment osteotome and the small Reyneke splitter by the larger
2. The neurovascular bundle is intact and separates from the splitter; the split can now be completed.
proximal segment. The neurovascular bundle often remains attached to the
proximal segment, especially in cases where the mandible is
antero-posteriorly excessive or asymmetric (excessive side), in
Second stage the presence of an unerupted third molar tooth, and when
there is unilateral condylar hyperplasia (excessive side).
Rotate the instruments further. As soon as the surgeon realizes that the neurovascular
The lower border should continue to split toward the bundle is still attached, the split should be stopped and the
proximal segment, and the neurovascular bundle should detach bundle carefully detached from the segment using a blunt
from the proximal segment. (Howarth) dissector.
6 Reyneke & Ferretti
When the inferior alveolar canal splits toward the proximal attention not to damage the inferior alveolar neurovascular
side, the surgeon should stop the procedure and carefully bundle. Use a small straight osteotome placed at the superior
dissect the medial wall of the canal from the proximal segment aspect of the vertical ramus osteotomy and a Reyneke splitter
using a small osteotome. Use a small nontoothed forceps to low down in the buccal osteotomy and complete the split.
remove the bony canal from the bundle. Replace the separated bony segment and fixate it with a lag
screw while the nonfractured segments can be fixated by
either bicortical or plate fixation.
The bad split
An unfavorable split can be prevented by meticulously Fracture of the buccal cortex involving the body and
following the surgical steps. However, in case the split does not ramus of the mandible
proceed favorably, stop the procedure and identify the prob-
lem under good vision. It is much easier to salvage the proce- Early diagnosis
dure if a potential problem is recognized early. A small fracture line occurs on the buccal aspect of the body,
The following section describes the features if an unfavor- about halfway down the buccal osteotomy, and runs superiorly
able or bad split. toward the coronoid notch. The lower border remains attached
to the distal segment (see Fig. 11).
Fracture of the buccal cortex of the mandibular body The buccal osteotomy should be redefined at the lower
border. Correct the problem as a buccal plate fracture.
Early diagnosis
The buccal cortex start splitting; however, the lower border Late diagnosis
remains attached, and a small fracture is detected in the The buccal cortex including the coronoid process detaches
segment. from the mandible. The segment remains attached to the
Redefine the buccal osteotomy, especially around the lower temporal muscle and should not be removed.
border. The proximal and distil segments are still attached, and
Place the small Reyneke splitter low down in the buccal every effort should be made to salvage the small part of the
osteotomy and recapture the lower border to fracture it with proximal segment still attached at the lower border.
the cortex of the proximal segment. Redefine the buccal osteotomy at the lower border. Care-
Place bicortical screws in the nonfractured part of the fully start the split along the fracture line of the cortex and
segment as well as through the small fractured segment. complete the split.
Alternatively use plate fixation. There will now be little bone contact between the 2 seg-
ments, and plate fixation should be used. Secure the fractured
Late diagnosis segment with bicortical screws.
If diagnosed late, the buccal cortex will be totally separated
from the mandible. Remove the bone segment and place it in a
saline soaked sponge. Redefine the remaining part of the The split occurs anterior to the inferior alveolar
osteotomy, especially the lower border (Fig. 9). Pay special foramen
Early diagnosis
This complication usually occurs if the horizontal osteotomy is
left short of the lingula (Step 6) (Fig. 10). To prevent inferior
alveolar nerve damage and long-term neurosensory problems,
early diagnosis is imperative (Step 14).
Carefully redefine and extend the horizontal osteotomy
beyond the lingula into the fossa posterior to the lingula.
Complete the split under good vision and ensure that the split
occurs beyond the lingula, and the neurovascular bundle de-
taches from the proximal segment.
Late diagnosis
The split is completed and segments are separated. Care
should be taken not to manipulate the segments excessively.
Extend the horizontal osteotomy past the lingula. Dissect the
bony cannel from the proximal segment. Carefully remove the
bony cannel from the neurovascular bundle.
Fig. 9 Late diagnosis of a buccal plate fracture. The buccal The retromolar aspect of the distal segment is often fragile,
aspect of the proximal segment has fractured and separated from especially when a third molar tooth is still present (Fig. 11).
the mandibular body. Carefully recapture the lower border of the Care should be taken not to lever against this part of the jaw
proximal segment and complete the osteotomy (arrow). during the splitting maneuvere (Step 14).
Mandibular Ramus Osteotomy 7
Step 17
Fig. 10 The split has been completed; however, the neuro- The author is in favor of the removal of impacted third molars
vascular bundle, lingula, and superior aspect of the inferior alve- 9 months before surgery. Due to circumstances it is often
olar canal remains attached to the proximal segment (arrow). necessary to remove third molars during the sagittal split
osteotomy procedure.
Early diagnosis
Carefully remove the impacted third molar tooth. Use plate
fixation.
Late diagnosis
Remove the impacted third molar tooth. Take care not to
damage the inferior alveolar nerve. Use plate fixation.
The presence of impacted third molars during the SSO will superb surgery; however, if the condyle is not positioned
often prevent ideal bone contact and may also weaken the accurately into the glenoid fossa, the procedure will fail. The
retromolar aspect of the distal segment. Remove the third method of condylar positioning described here has been
molars and take care not to damage the inferior alveolar nerve developed during the performance of more than 5200 bilat-
or fracture the retromolar bone. The presence of a third molar eral sagittal split osteotomies over a period of 36 years.
(or tooth socket) will jeopardize the placement of rigid Place the condylar positioner into the hole drilled in Step
fixation. 10. Support the angle of the mandible by extraoral digital
pressure.
Step 18dsmooth the contact areas of the Apply light posterior pressure on the positioner and at the same
time digital superior and slightly anterior pressure on the
segments mandibular angle. Note the vectors of force in Fig. 13. This will
give the surgeon control of the proximal segment and an aware-
Use a large pear shaped reduction bur to smooth contact areas. ness of the anatomic relationship between the condyle and the
Take care not to damage the inferior alveolar nerve. fossa.
Use the reference lines, marked in Step 11, to align the
Step 19dplace the holding wire lower borders of the segments and prevent unfavorable rota-
tion of the proximal segment (Fig. 14).
Feed a 0.018-inch wire (25 gauge) through the holes (see Step 9).
With the teeth wired into occlusion, the proximal should now
be gently pushed posteriorly. There will now be an overlap
between the 2 bone segments, which should coincide with the
planned amount of setback.
Remove enough bone to allow free repositioning of the
proximal segment.
Refrain from forcing the proximal segment posteriorly to
achieve a good fit at the vertical buccal osteotomy. This will
force the condyle distally in the glenoid fossa resulting in
Fig. 13 Positioning of the condyle. Posterior pressure on
condylar malpositioning.
the positioning instrument (1) and extraoral digital pressure on
the angle of the mandible pushing superiorly and slightly anteri-
Step 24dpositioning the condyle orly (2) will give the surgeon control of the proximal segment
(3). Once the surgeon is confident that the condyle is
This is a challenging maneuver and certainly the most positioned correctly in the fossa, the assistant can tighten the
important step of the procedure. The surgeon may perform positioning wire (4).
Mandibular Ramus Osteotomy 9
Use a sharp drill and apply light pressure with the trocar
when drilling the holes. Undue pressure may displace the bone
segments, the condyle or the occlusion.
Use copious water cooling. If the shaft of the drill is
forced against the trocar, it will generate heat and burn the
skin and subcutaneous tissue in contact with the tube of the
trocar.
Angle the holes lightly backward to support the repositioned
condyle.
Once a hole is drilled the assistant should load the screw
with an appropriate length on the screwdriver, (a motorized
screwdriver is a handy instrument at this time).
View the bone segments carefully when applying the screw
to ensure the screw engages the lingual cortex without dis-
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-tapping and
however, it is optional, and it may serve as additional fixation (1).
need only to be turned to engage. No excessive force is
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 compressed or any
fixation (3).
intersegmental gaps should not be closed by tightening the
Jacksonville, FL, USA) are designed to preclude this if judi- screws. This will displace the condyle and result in peripheral
ciously utilized. sag.
The small bone defects should be grafted.
Step 26dplacement of the trocar
Plate fixation
Ridged fixation may be placed through an intra- or extraoral
approach. The principles also apply when plates are used as a fixation
An extraoral stab incision is made through the skin just method.
below the lower border of the mandible. An appropriate plate is selected to allow for at least 2
The trocar is now placed through the stab, and the perios- screws to be placed on each side of the osteotomy. One or 2
teum is perforated intraorally. Angle the trocar superiorly to plates may be used; however, most surgeons use only one
avoid damage to the neurovascular bundle or displace the bone 2.0 mm plate.
segments. Bend the plate to fit accurately to the bone and position the
By using the Reyneke intraoral trocar, the ridged fixation plate to allow for placement of the posterior screws first. Two
may be placed through an intraoral approach. The use of this bicortical (or unicortical) screws are placed through the pos-
approach is influenced by the presence of a third molar, bone terior holes.
thickness, position of the inferior alveolar nerve, and adequate The unicortical screws engaging the distal segment are then
access to appropriately orient the screws through the placed while the proximal segment is held in place by either
segments. the holding wire or a positioning instrument.
Step 27ddrill the holes and for the place of rigid Step 28dremove the intermaxillary fixation and
fixation check the occlusion
The proximal and distal segments can be fixated by means of To ensure that the condyles will settle and have been posi-
bicortical screws or plate fixation. tioned correctly, the occlusion should not be checked
10 Reyneke & Ferretti
immediately following removal of the intermaxillary fixation. The final position of the bone segments is demonstrated in
Wait a few minutes. Fig. 14.
Gently open and close the mouth and translate the
mandible from side to side.
With light finger pressure, the mouth is closed and the oc-
clusion checked. The occlusion should be exactly as planned or Step 32dapply a pressure bandage
fit perfectly into the surgical splint. The author is not in favor
of a final splint, as it may hide small discrepancies at this The pressure bandage is removed 1 day following surgery, at
stage. which time the postoperative physiotherapy is commenced.
Over the past three decades our knowledge and under-
standing of all aspects of orthognathic surgery has increased
Step 29dintraoperative diagnosis of a greatly. Not only has there been an evolution in the sophisti-
malocclusion cation of diagnostic skills and treatment planning, but through
experience, surgical techniques have attained a level enabling
An incorrect occlusion at this stage may be caused by: surgeons to treat the most complex jaw deformities with
confidence.
Incorrect condylar position (condylar sag) There is a magnitude of instruments available to facilitate
Failure of fixation the surgeons technique. It is preferable, however, that the
Displacement of the occlusion during placement of the surgeon develops a familiarity with a small selected group of
ridged fixation instruments that will ultimately achieve the same goal.
Inaccurate surgical splint No matter how accurate and meticulous the surgeon, com-
Intracapsular edema or hemarthrosis and condylar disc plications may and will occur during and after orthognathic
displacementdthese problems may only become surgery. The surgeon should therefore have a routine and an
apparent postoperatively. understanding of the step-by-step sequence of the procedure.
For each step, there are relevant tips to improve the outcome.
It is imperative that an incorrect occlusion not be accepted. The surgeon should also be aware of specific traps that may
lead to consequences or complications. This will enable him or
There is no better time to address the problem than at this
stage. The intraoperative differential diagnosis of an incorrect her to recognize and manage a complication before it occurs.
occlusion is important for the correction of the problem.7
Resorbable sutures are used intraorally and non-resorbable 1. Hunsuck EE. A modified intraoral sagittal splitting technique for the
sutures extraorally. The extraoral sutures are removed 2 days correction of mandibular prognathism. J Oral Surg 1968;26:249e50.
postoperatively. 2. Epker BN. Modifications in the sagittal split osteotomy of the
mandible. J Oral Surg 1977;35:157e9.
3. Obwegeser H, Trauner R, Obwegeser H. Zur Operationstechnik bei
Step 31dplace intermaxillary elastics der Progenia und anderen Unterkieferanomalien. Dtsch Zahn Mund
Kieferhlkd 1955;23:11e25.
One 4-oz. 0.25-inch elastic is placed on each side. 4. Reyneke JP. Essentials in orthognathic surgery. Chapter 4. 2nd
The elastics are placed in a triangular fashion usually in the edition. Chicago: Quintessence; 2010. p. 209e18.
5. Reyneke JP. Basic guidelines for the surgical correction of mandib-
canine region.
ular anteroposterior deficiency and excess. Clin Plast Surg 2007;34:
The direction of the elastics should reinforce the surgical
501e17.
movement (ie, Class II elastics for mandibular advancement 6. Reyneke JP. The sagittal split mandibular ramus osteotomy surgical
and a Class III pattern for mandibular setback procedures). manual. Jacksonville (FL): Walter Lorenz Surgical; 1999.
Keep in mind that the purpose of the elastics is to override 7. Reyneke JP, Ferretti C. Intraoperative diagnosis of condylar sag
the proprioception and not to correct an incorrect occlusion or after bilateral sagittal split ramus osteotomy. Br J Oral Maxillofac
condylar sag. Surg 2002;40:285e92.