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The Bilateral Sagittal Split Mandibular

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.

Introduction management of operative complications are difficult to mas-


ter, since no 2 complications are ever identical.
The correction of dentofacial deformities demands accurate Although the anatomy and shape of the human mandible
treatment planning for the orthodontic preparation and sub- lends itself to splitting in a sagittal plane, the surgical
sequent surgery. It is also mandatory that the surgical correc- osteotomy of the mandible remains a challenging procedure.
tion be performed accurately to ensure predictable and Over the last 30 years, the ingenuity of modifications1,2 to the
successful outcomes. This article describes the technique for original technique as described by Obwegeser and Trauner in
the sagittal split mandibular ramus osteotomy in a step-by-step 1955,3 development of special instruments,4 and improvement
fashion with tips and traps with each step. of surgical skills have made it possible to achieve surgical goals
In 1970, J M Ferrer in said: it must be recognized that at relatively quickly and atraumatically. The surgical reposition-
every operation the surgeon inevitably injures the patient; this ing of the mandible has developed from a life-threatening
injury can and must be minimized by the use of careful, gentle, procedure to outpatient surgery (in some parts of the world).5
and accurate surgical technique. Each surgeon should develop a routine that will enable the
Sound technical craft, science, and operating experience all surgical team to anticipate each step, thus increasing effi-
come together to make most surgical procedures occur ciency and decreasing operating time and eventually limit
smoothly and successfully. No 2 surgeons surgical techniques postoperative morbidity.6
are identical; however, there are certain basic principles that The surgical technique of the sagittal split mandibular
have to be adhered to when performing orthognathic surgery. ramus osteotomy can be performed in 32 steps. Each step will
This will not only ensure good surgical outcome but also limit have certain tips and traps.
complications. Moreover, important details of diagnosis and

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.

Atlas Oral Maxillofacial Surg Clin N Am - (2015) -e-


1061-3315/15/$ - see front matter 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2015.10.005 oralmaxsurgeryatlas.theclinics.com
2 Reyneke & Ferretti

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.

Step 3dbuccal subperiosteal dissection Step 6dmedial ramus osteotomy


Strip the periosteum from the body and anterior aspect of the
Use a Lindeman or 701 fissure bur, aim at the notch of the ligula
mandibular ramus to allow for adequate visualization.
and angle the osteotomy parallel to the occlusal plane (Fig. 2).
Dissection must remain subperiosteal, decisive, clean, and
The convexity of the internal oblique ridge may obscure the
neat.
lingula. If visualization is difficult, the ridge should be reduced
It is not necessary to strip the entire masseter muscle
with a large trimming burr (Fig. 3).
attachment off the mandibular angle. Total stripping of the
Terminate the osteotomy just posterior to the lingula into
muscle will result in dead space and encourage swelling and
the fossa (see Fig. 2).
hematoma formation.
If the osteotomy is terminated short of the fossa, the bone
will tend to split anterior to the foramen, leaving the inferior
Step 4dsuperior subperiosteal dissection alveolar nerve and canal attached to the proximal segment.
When a mandibular setback procedure or a clockwise rota-
Strip the lower fibers of the temporalis muscle off the anterior tion of the maxillomandibular complex will be performed, a
border of the ramus. small segment of bone should be removed superior to the
Dissect the periosteum from the internal oblique ridge down osteotomy. This will prevent bony interferences in this area
to the medial aspect of the retromolar area. following setback of the mandible or superior rotation of the
Place a swallowtail (forked or notched) retractor over the distal segment (clock wise rotation).
anterior border and pull upwards for good visualization.

Step 7dsagittal osteotomy


Step 5dexposure of the lingula
Use a saw or 701-fissure bur; start at the medial horizontal
Start the medial dissection from above and then dissect infe- osteotomy superiorly, and stay just inside the buccal cortex of
riorly (Fig. 1). the mandibular ramus and body (Fig. 4).
Stay subperiosteal at all times. Ensure the osteotomy is made through the cortex (approx-
Carefully identify the lingula and ensure visualization. imately 5 mm).
The presence of an impacted third molar tooth may inter-
fere (ideally impacted third molars should be removed at least
9 months before surgery). However the tooth should be treated
as bone, and the osteotomy performed through the tooth.

Fig. 1 The subperiosteal dissection on the medial aspect of the


mandibular ramus is started superiorly (arrow) and carefully car- Fig. 2 The medial osteotomy is angled parallel to the occlusal
ried downwards to identify the lingula. plane and carried past the lingula into the fossa (arrow).
Mandibular Ramus Osteotomy 3

Fig. 3 A large pear-shaped vulcanite drill is used to reduce the


bone and increase the visibility of the lingula.

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 superi-
orly with the vertical osteotomy (see Fig. 4).
Ensure that the cortex of the lower border is included in the
osteotomy (Fig. 5). The actual start of the split should be at the
Fig. 5 The buccal osteotomy should include the lingual cortex at
lower border and include the lingual cortex.
the lower border (arrow). Failure to include the lower border will
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
nerve. The inferior border cut should be preferably slightly
angled posterioremedially, not at a right angle to the buccal holding wire is optional; however, it allows the surgeon to
cortex, so the initiation of the split begins in the proper di- position and maintain the condyle in the fossa while applying
rection and osteotomes may be inserted easily. rigid fixation.
The holes of the positioning wires should be drilled in such a
way that the proximal segment is directed distally. The ideal
Step 9ddrill holes for a holding wire distance between the holes after repositioning the segments
should be 4 mm.
Positioning the condyle in the glenoid fossa is the most For a patient requiring an advancement of 6 mm, the holes
important step of the procedure and should be performed as a should be drilled 10 mm apart. After advancement of 6 mm,
separate step prior to placement if rigid fixation. The use of a the holes will be 4 mm apart with the hole in the distal segment
anterior and the hole in the proximal posterior (Fig. 6A).
For setback procedures (ie, 6 mm), the holes should be
drilled 2 mm apart (anterior in the distal segment and posterior
in the proximal segment). Once the mandible is set back, the
holes will be 4 mm apart (see Fig. 6B).

Alternative techniques

Some surgeons make use of a bone clamp to hold the segments


in position. However, there is a danger that the segments will
be compressed, which may lead to peripheral condylar sag.

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

Wash the surgical area thoroughly with saline solution and


gently place a small sponge in it. Once the osteotomy cuts have
been completed on one side, it is recommended that the other
side to be completed before proceeding to split the mandible.

Step 13ddefine the osteotomy

Use a 10 mm wide osteotome to tap along the vertical


osteotomy line from the medial osteotomy downward to the
buccal osteotomy below (see Fig. 7).
It is important to support the mandible when splitting the
contralateral side to prevent hard and soft tissue damage on
the side already split.
The osteotomy cuts are only defined at this stage; make no
attempt to split to completely separate the segments.
Vigorous indiscriminate tapping may fracture the buccal
cortical plate or even cause trauma to the temporomandibular
joint (hemarthrosis or disc displacement).

Step 14dsplitting the mandible

The actual splitting of the mandible can be divided into 2


stages.

First stage

The mandible should be supported at all times by the channel


retractor and digital pressure to protect the temporomandib-
Fig. 7 The hole for the condylar positioner is made on the lower ular joint.
border of the proximal segment (1). Reference lines are marked Place a large 10 mm osteotome superiorly into the sagittal
over the buccal osteotomy line (2). The sagittal osteotomy is osteotomy and a small Reyneke splitter into the buccal
initiated by tapping along the vertical osteotomy with a 10 mm osteotomy to engage the lower border of the mandible (Fig. 8).
osteotome (3). Rotate the 2 instruments gently but firmly.
Mandibular Ramus Osteotomy 5

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.

Fracture of the retromolar aspect of the distal


segment

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

Fig. 11 summarizes the four typical patterns of bad splits


that may occur.

Step 15dstripping the pterygomasseteric sling

Place a curved periosteal elevator (J-stripper) between the


segments and strip the muscle attachments from the distal
segment.
This step will also ensure that no greenstick bony attach-
ments remain between the 2 segments. Protect the neuro-
muscular bundle at all times. Insufficient stripping and any
remaining bony attachments will lead to difficulty in reposi-
tioning of the distal segment and inaccurate condylar
positioning.

Step 16dstripping the medial pterygoid muscle


and stylomandibular ligament

Failure to strip these structures will interfere with positioning


the distal segment and may lead to unfavorable rotation of the
proximal segment (Fig. 12).

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.

Fig. 11 The 4 typical fracture lines of bad splits are demon-


strated: buccal plate fracture (1), buccal plate fracture including
the coronoid process (2), a fracture short of the lingula (3), and a Fig. 12 The pterygoid muscle and stylomandibular ligament is
retromolar fracture (4). stripped off the medial aspect of the mandibular angle (arrow).
8 Reyneke & Ferretti

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).

Step 25dtightening the holding wires


Step 20
The teeth are still secured in the planned occlusion by inter-
Note the position of the inferior alveolar neurovascular bundle maxillary fixation. The surgeon should hold the proximal
and the socket of the third molar (if a tooth was present and segment in its desired position (as described in Step 24), while
removed). the assistant gently tightens the holding wire.
View the segment while the wire is tightened to ensure that
Step 21dmobilize the bone segments the segments are not forced together.
The wire should hold the segments passively together.
Remove the sponge placed following splitting the first side Excessive force or overtightening of the wire will displace the
(Step 12). Support the proximal segment with the index finger condyle in the fossa and lead to peripheral (medioelateral)
and pull the distal segment gently but firmly anteriorly. condylar malpositioning.
Adequate mobilization will ensure that the soft tissue drape The author does not recommend the use of a bone clamp at
will allow free positioning of the distal segment. this stage because of concerns of generating condylar torque.
Clamps such as the Sullivan BSSO clamp (Biomet Microfixation,
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.

Step 23dremove bone from the proximal


segment in class III mandibular setback cases

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

Bicortical screw fixation

During placement of ridged fixation several factors should be


considered:

 The position of the inferior alveolar neurovascular bundle


(see Step 18)
 The distal root of the lower second molar
 Thickness of the bone to estimate the length of the
screws (a depth gauge may be used)
 Ensure that the drill perforate both bone cortices
 Configure the position of the holes to ensure stable fixa-
tion (ie, in a triangular fashion or in a straight line at the
upper border)
 Place enough screws for adequate fixation (3e4 screws
are usually sufficient)

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

Step 30dPlace intra and extraoral sutures References

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.

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