Illustrated Manual of

Orthognathic Surgery

Osteotomies of the Mandible

Peter Kessler
Nicolas Hardt
Kensuke Yamauchi
Editors

123
Illustrated Manual of Orthognathic
Surgery
Peter Kessler • Nicolas Hardt
Kensuke Yamauchi
Editors

Illustrated Manual of
Orthognathic Surgery
Osteotomies of the Mandible
Editors
Peter Kessler Nicolas Hardt
Department of Cranio-Maxillofacial Kantonsspital Lucerne
Surgery Clinic and Policlinic
Maastricht University Medical Center of Cranio-Maxillofacial Surgery
Maastricht, The Netherlands Lucerne, Switzerland

Kensuke Yamauchi
Department of Oral & Maxillofacial
Surgery
Tohoku University Sendai
Sendai, Miyagi, Japan

ISBN 978-3-031-06977-2    ISBN 978-3-031-06978-9 (eBook)

https://doi.org/10.1007/978-3-031-06978-9

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
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Preface

The aim of orthognathic surgery is to correct developmental or acquired skel-

etal deformities of the viscerocranium, the skeleton of the face and jaws.
Over the last decades, significant progress has been made in the surgical
technique of the various approaches to correct the jaw position, as well as in
the fixation of the osteotomized segments by plate and screw osteosynthesis
including instrumentation and intraoperative quality control by various forms
of guided surgery.
Although the basic surgical principles have remained more or less
unchanged, numerous new computer-based planning techniques have been
introduced, as well as new technical procedures, which have refined the surgi-
cal methods and significantly improved and facilitated the treatment of com-
plex maxillofacial deformities.
Detailed surgical planning is essential for a successful clinical outcome.
Treatment includes a precise treatment plan, the right choice of instruments
for a particular surgical procedure, a thorough surgical routine and adherence
to the surgical guidelines and detailed surgical steps.
Although similar treatment objectives exist, there are important differ-
ences between osteotomy techniques. It is important that the surgeon inter-
ested is aware of these differences to ensure an effective and safe surgical
routine in the care of patients with facial deformities.
The choice of an optimal osteotomy method depends on many factors, the
indication, the therapeutic goal, the medical conditions, the experience of the
surgeon, and the extent of the surgical procedure.
The main objective of this manual is to present practical guidelines for the
most commonly used surgical osteotomy techniques in the mandible, includ-
ing a complete and detailed description of the individual surgical steps in
these surgical procedures. Techniques such as bilateral sagittal split osteot-
omy (BSSO), bilateral vertical osteotomies, segmental mandibular osteoto-
mies, and chin osteotomies are discussed in detail.
In addition—depending on the surgical procedure—the variable and vari-
ous surgical risks are listed and the most frequent surgical complications and
their avoidance through careful and precise surgical approaches are
presented.
The manual focuses on the anatomical prerequisites that place high
demands on the surgeon and lead to the indications for the various osteotomy
procedures.

v
vi Preface

The presented surgical guidelines and advice are based on the current lit-
erature as well as on the personal, long-term surgical experience of the
authors.
We thank all co-authors for their excellent contributions. We would like to
thank the S.O.R.G., which has always benevolently supported the financial
framework of this project.
We especially thank Mr. Keisuke Koyama, DDS, who contributed the per-
fect illustrations. Special thanks to Mrs. Rachael Kessler, who with infinite
patience did the layout in English.

Maastricht, The Netherlands Peter Kessler

Luzern, Switzerland  Nicolas Hardt
Sendai, Japan  Kensuke Yamauchi
Contents

Part I Introduction to Orthognathic Surgery in the Mandible

1 
Evolution of the Surgical Standard Techniques����������������������������   3
Peter Kessler and Nicolas Hardt
2 
Classification and Facial Patterns�������������������������������������������������� 17
Peter Kessler and Nicolas Hardt
3 
Types of Osteotomies in the Mandible ������������������������������������������ 23
Peter Kessler and Nicolas Hardt
4 
Definition of Standard Procedures ������������������������������������������������ 27
Peter Kessler and Nicolas Hardt

Part II Ramus Split Osteotomies / Bilateral Sagittal Split

Osteotomies (BSSO) - General Planning

5 The Patient���������������������������������������������������������������������������������������� 41
Veronique C. M. L. Timmer, Peter Kessler, and Nicolas Hardt
6 
Radiology and Basic Measurements���������������������������������������������� 51
Veronique C. M. L. Timmer, Peter Kessler, and Nicolas Hardt
7 
General Planning and Preoperative Assessment�������������������������� 59
Veronique C. M. L. Timmer, Peter Kessler, and Nicolas Hardt
8 
Preparations for the Surgical Procedure �������������������������������������� 67
Veronique C. M. L. Timmer, Peter Kessler, and Nicolas Hardt
9 
Osteosynthesis for Sagittal Splitting���������������������������������������������� 73
Peter Kessler and Nicolas Hardt
10 
Pre- and Peri-operative Care in Orthognathic Surgery -
Anesthesiology and CMF-Surgery ������������������������������������������������ 89
Pia-Marina Guardiola, Peter Kessler, and Nicolas Hardt
11 
Postoperative Care in Orthognathic Surgery�������������������������������� 101
Peter Kessler, Veronique C. M. L. Timmer, and Nicolas Hardt

vii
viii Contents

Part III Bilateral Ramus Split Osteotomies (BSSO) - Surgical

Principles

12 Principles
 of the BSSO – Clinical Aspects ������������������������������������ 109
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie
13 Relation
 of Cortical Versus Cancellous Bone – The
Crucial Ratio������������������������������������������������������������������������������������ 113
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie
14 Anatomical
 Reference Points – Indispensable Aids���������������������� 119
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie
15 General
 Rules in Sagittal Splitting – Five Steps���������������������������� 121
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie
16 BSSO
 Relevant Clinical and Topographic Anatomy
(Studies and Variations)������������������������������������������������������������������ 127
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie
17 Strategic
 Surgical Approach and Technical Details���������������������� 137
Peter Kessler and Nicolas Hardt
18 Intraoperative
 Hazards and Risks������������������������������������������������� 155
Peter Kessler and Nicolas Hardt
19 Surgical Tricks���������������������������������������������������������������������������������� 169
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie
20 Post-Surgical
 Complications and Care������������������������������������������ 183
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Part IV Mandibular Deficiency - Surgical Technique - BSSO

21 Indications for Mandibular Advancement������������������������������������ 195

Peter Kessler and Suen An Nynke Lie
22 Sagittal
 Split and Mandibular Advancement�������������������������������� 201
Peter Kessler and Suen An Nynke Lie
23 Special
 Surgical Aspects in Mandibular Advancement -
Flaring���������������������������������������������������������������������������������������������� 215
Peter Kessler and Suen An Nynke Lie
24 Intermolar
 Mandibular Distraction Osteogenesis IMDO������������ 219
Suen An Nynke Lie and Peter Kessler
25 Retromolar
 Mandibular Distraction Osteogenesis RMDO �������� 227
Suen An Nynke Lie and Peter Kessler

Part V Mandibular Excess - Surgical Technique - BSSO

26 Indications
 for Mandibular Setback���������������������������������������������� 235
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie
Contents ix

27 
Sagittal Split and Mandibular Setback������������������������������������������ 239
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie
28 
Special Surgical Aspects in Mandibular Setback�������������������������� 245
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie
29 Mandibular Excess – Modifications and Surgical
Alternatives�������������������������������������������������������������������������������������� 247
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Part VI Asymmetries, Vertical and Horizontal Rotation,

Mandibular Flaring - Surgical Techniques

30 Introduction - Asymmetries, Vertical and Horizontal

Rotation, Mandibular Flaring - Surgical Techniques������������������ 251
Peter Kessler and Kensuke Yamauchi
31 Diagnosis in Mandibular Asymmetries, Vertical and
Horizontal Rotation ������������������������������������������������������������������������ 253
Peter Kessler and Kensuke Yamauchi
32 
Surgical Correction in Mandibular Asymmetry �������������������������� 257
Kensuke Yamauchi and Peter Kessler

Part VII Mandibular Excess: class III Setback/Surgical

Technique-IVRO

33 
Indications for Mandibular Setback/Advancement Using
IVRO or Inverted L Osteotomy������������������������������������������������������ 275
Kensuke Yamauchi and Peter Kessler
34 
Vertical Ramus Osteotomy and Mandibular Setback������������������ 277
Kensuke Yamauchi and Peter Kessler
35 
The Inverted L Osteotomy�������������������������������������������������������������� 279
Kensuke Yamauchi and Peter Kessler

Part VIII Alveolar Segment Osteotomies

36 
Types of Segmental Alveolar Osteotomies in the Mandible �������� 285
Peter Kessler and Nicolas Hardt
37 
Indications for Segmental Osteotomies in the Mandible�������������� 287
Peter Kessler and Nicolas Hardt
38 Preoperative Planning and Preparation for Surgery in
Segmental Mandibular Osteotomies���������������������������������������������� 289
Peter Kessler and Nicolas Hardt
39 Anatomical, Surgical, and Technical Aspects�������������������������������� 293
Peter Kessler and Nicolas Hardt
x Contents

40 Lateral
 Mandibular Step Osteotomy/Ostectomy, Posterior
Subapical Osteotomy and Anterior Body Osteotomy������������������ 303
Peter Kessler and Nicolas Hardt
41 Intraoperative
 Risks in Segment Osteotomies: Danger
Points and Errors ���������������������������������������������������������������������������� 309
Peter Kessler and Nicolas Hardt
42 Tricks and Typical Mistakes ���������������������������������������������������������� 313
Peter Kessler and Nicolas Hardt

Part IX Chin Osteotomies

43 Indications
 for Chin Osteotomy/Genioplasty and Standard
Procedures���������������������������������������������������������������������������������������� 319
Peter Kessler and Nicolas Hardt
44 Principle Surgical Technique���������������������������������������������������������� 325
Peter Kessler and Nicolas Hardt
45 Intraoperative
 Risks: Danger Points—Postoperative
Complications���������������������������������������������������������������������������������� 333
Peter Kessler and Nicolas Hardt

Part X The Temporomandibular Joint

46 Introduction�������������������������������������������������������������������������������������� 339
Barbara Gerber and Nadeem Saeed
47 Diagnosis and Classification������������������������������������������������������������ 341
Barbara Gerber and Nadeem Saeed
48 Clinical Assessment�������������������������������������������������������������������������� 343
Barbara Gerber and Nadeem Saeed
49 Management Strategies ������������������������������������������������������������������ 345
Barbara Gerber and Nadeem Saeed
50 Controversy�������������������������������������������������������������������������������������� 353
Barbara Gerber and Nadeem Saeed
Index���������������������������������������������������������������������������������������������������������� 355
 Part I
Introduction to Orthognathic
Surgery in the Mandible
 Evolution of the Surgical
Standard Techniques
1
Peter Kessler and Nicolas Hardt

Contents
1 Inverted L Osteotomy and C Osteotomy  7
2  he Development of Horizontal Ramus Osteotomies to Extended
T
Sagittal Ramus Splitting  9
3 Oblique Retromolar Osteotomy  13
4 Conclusion  14
References  14

Abstract no significant progress in dysgnathia surgery,

until rapid development began in the 1950s.
The correction of mandibular prognathia, first
Both in Central Europe and in the United States,
performed by Vilray Blair more than 100 years
new surgical techniques were introduced into
ago in the United States, was the beginning of
dysgnathia surgery of the mandible, but also for
dysgnathia surgery (Blair, Cosmos 1906;48:817-
the upper jaw and midface.
820; Surg Gynecol Obstet. 1907;4:67-78; Int J
In 1955, H. Obwegeser initiated a major
Orthodont 1915;1(8)1:395–432). As early as the
progress in orthognathic surgery with the
beginning of the twentieth century, various sur-
bilateral sagittal splitting of the ascending
gical procedures were developed for the correc-
ramus of the lower jaw to treat mandibular
tion of mandibular malocclusions in the
prognathism. The surgical method underwent
horizontal mandibular body and in the ascend-
continuous modifications, such as the
ing ramus. Between 1914 and 1945 there was
enlargement of the bone attachment surface
and the associated application of the sagittal
splitting technique even in cases of mandibu-
P. Kessler (*) lar retrognathism. Bone splitting and seg-
Department of Cranio-Maxillofacial Surgery, ment stabilization have also been significantly
Maastricht University Medical Center, modified and improved, allowing complete
Maastricht, The Netherlands
e-mail: [email protected] mobilization of the fragments without com-
promising the supplying soft tissue structures
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of on the one hand and functionally stable
Cranio-Maxillofacial Surgery, Lucerne, Switzerland osteosynthesis of the segments on the other

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 3

P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_1
4 P. Kessler and N. Hardt

(Bell et al., Surgical correction of dentofacial The modern surgical development of transoral
deformities Vol. 1-3. Saunders;1980; Bell, J sagittal splitting of the mandibular ramus for the
Oral Maxillofac Surg. 2018;76(12):2466- treatment of mandibular growth disorders (dys-
2481; Kashani and Rasmusson, A Textbook gnathia) was preceded in the first half of the
of Advanced Oral and Maxillofacial Surgery– twentieth century by various surgical procedures
Volume 3. IntechOpen;2016). with extraoral and later intraoral accesses [1–4].

Keywords Review of Surgical Procedures

Evolution of mandibular osteotomy and • Horizontal Ramus Osteotomy
splitting techniques · Classification of • Subcondylar Osteotomy
dysgnathias · Development of orthognathic • Oblique Osteotomy
surgery · Basic osteotomy procedures · • Vertical Oblique Osteotomy
Classification of surgical corrections · • Shaped Osteotomy
Ramus osteotomies · Sagittal mandibular
split · Bilateral sagittal split osteotomy · After first attempts to correct mandibular
BSSO · Segment osteotomies · growth deficiency by step and sliding osteotomies
Chin osteotomies · Genioplasty · in the body of the mandible (Fig. 1.1) [5, 6], the
Complications focus of correction of mandibular growth impair-

Fig. 1.1 Surgical correction of retrognathia (a) Sliding osteotomy of the body of the mandible (Angle) (b) Subapical
step osteotomy in the mandibular body (v. Eiselsberg) ©Copyright Keisuke Koyama 2020. All rights reserved
1 Evolution of the Surgical Standard Techniques 5

a b c

d e

Fig. 1.2 Development of oblique/vertical mandibular oste- Oblique osteotomy by Robinson et al. (d) “Inverted L” oste-
otomy—according to Bell et al. [1, 51] (a) Subcondylar oste- otomy by Wassmund (e) “C” osteotomy by Caldwell et al.
otomy by Blair (b) Oblique osteotomy by Limberg (c) ©Copyright Keisuke Koyama 2020. All rights reserved

a b c

Fig. 1.3 The development from the subcondylar osteot- Blair [30]) (b) Perthes [34] (c) Winstanley (1968)
omy to the vertical osteotomy. Different lengths of intra- ©Copyright Keisuke Koyama 2020. All rights reserved
oral vertical ramus osteotomies (IVRO) (a) (Blair [29];

ment soon shifted to the area of the ascending various modifications of the sliding osteotomies
ramus of the mandible. Blair in 1906 performed in different planes (Fig. 1.2) [8–11].
the first osteotomy of the mandibular body for the In Europe, Berger performed the first hori-
correction of horizontal mandibular excess and zontal condylectomies in 1892. Dufourmentel
described three distinct problems [7]: et al. 1921/1932 and Kostecka in 1926/1934 pre-
ferred the subcondylar osteotomies for the cor-
• Cutting of the bone. rection of mandibular prognathias. All surgeons
• Replacing the segment to a new position. chose for a preauricular approach [12–15].
• Fixation of the segments. Subsequently subcondylar osteotomies had
undergone numerous variations which finally led
Subsequently, numerous variants of mandibu- to the development of the intraoral vertical
lar ramus osteotomies were published, including ramus osteotomy (IVRO) (Fig. 1.3).
6 P. Kessler and N. Hardt

a b c

Fig. 1.4 First oblique vertical ramus osteotomy accord- Osteotomy (b) Rotational movement of the mandible (c)
ing to Limberg [11]. Extraoral-cervical approach for cor- Situation after correction with anterior open bite
rection of mandibular retrognathia and open bite (a) ©Copyright Keisuke Koyama 2020. All rights reserved

In 1925 Limberg was the first to develop an

oblique vertical osteotomy of the mandibular
ramus by an extraoral-cervical approach to cor-
rect mandibular retrognathia with an open bite
(Fig. 1.4) [11].
Due to unpredictable stability of the osteoto-
mized segments, e.g., displacement of the proxi-
mal segment through the temporal and medial
pterygoid muscles, sagging of the posterior seg-
ment due to stripping of the masseter and medial
pterygoid muscles, modifications of the IVRO
were developed. Longer osteotomy lines starting
at the sigmoid notch and ending in the region of
the mandibular angle with lesser muscular dis-
section should prevent dislocation of the seg- Fig. 1.5 Vertical oblique osteotomy with cortico-­
cancellous bone graft according to Robinson [19]
ments [16]. ©Copyright Keisuke Koyama 2020. All rights reserved
Oblique vertical and true vertical ramus oste-
otomy variants were inaugurated by Hinds in
1958, Robinson in 1957/1958, and Caldwell and The work of Hall et al. and Hall and McKenna
Letterman in 1954. All surgeons performed the in the 1970s further popularized the procedure,
osteotomy by an extraoral approach. The devel- and Hall’s work in the 1980s helped quantify
opment led to the first intraoral vertical osteot- clinical outcomes and proposed technique
omy performed by Hebert et al. in 1970. refinements to minimize proximal segment
The development culminated in the first intra- “sag” [1, 18].
oral vertical osteotomy (IVRO) performed in For vertical osteotomies, Robinson first inte-
1968 by Winstanley with a dental drill. A signifi- grated iliacal cortico-cancellous bone grafts into
cant advance in the IVRO technique was reported the osteotomy gap in 1957 (Fig. 1.5). This was
by Herbert et al. in 1970 with the use of the especially necessary in cases where mandibular
motorized oscillating saw [17]. advancement was indicated. The bone transplants
1 Evolution of the Surgical Standard Techniques 7

a b

Fig. 1.6 (a) Vertical osteotomy with partial decortication (b) Integration of cortico-cancellous graft into the osteotomy
defect [20] ©Copyright Keisuke Koyama 2020. All rights reserved

In 1957 Robinson and Lytle refrained from

additional intersegmental bone grafting and per-
formed only direct interosseous osteosynthesis of
the proximal fragment (Fig. 1.7).

1 Inverted L Osteotomy and C

Osteotomy

Variants of the oblique vertical osteotomy were

the modified C-shaped osteotomies.
These were first described in 1927 by
Wassmund, who performed an arcuate osteotomy
of the ramus in the form of a C-shaped arch with
simultaneous mandibular advancement and
Fig. 1.7 Vertical osteotomy without a cortico-cancellous
simultaneous closure of an open bite.
graft into the osteotomy defect and direct interosseous wiring
[21] ©Copyright Keisuke Koyama 2020. All rights reserved The C-shaped osteotomy and the inverted L
osteotomy were primarily operated via a transfa-
cial approach (Fig. 1.8) [22–28].
were either fixed by wire osteosyntheses or Hawkinson published the arcing osteotomy in
inserted between the segments after partial decor- the ascending ramus in 1968. By doing this he
tication (Fig. 1.6) [20]. improved the bone-to-bone contact in the osteot-
8 P. Kessler and N. Hardt

omy area. This osteotomy was recommended for The vertical component of the inverted L oste-
dysgnathia where additional mandibular rota- otomy resembled a subcondylar ramus osteotomy
tions were required in contrast to straight or lin- with an additional lower oblique and an upper
ear mandibular movements [23]. horizontal component to achieve greater apposi-
tion of the bone (Fig. 1.9).

a b

Fig. 1.8 C-shaped osteotomy of the ramus by Wassmund [43] (a) Outline of the osteotomy (b) Osteotomy and reloca-
tion of the distal segment ©Copyright Keisuke Koyama 2020. All rights reserved

Fig. 1.9 The C osteotomy and the inverted vertical L osteotomy [22] (a) Osteotomy design (b) Relocation of the distal
segment, wire osteosynthesis ©Copyright Keisuke Koyama 2020. All rights reserved
1 Evolution of the Surgical Standard Techniques 9

2 The Development The earliest documented sagittal ramus oste-

of Horizontal Ramus otomy, however, was published by Perthes
Osteotomies to Extended already in 1924 (Fig. 1.11). Then still the transfa-
Sagittal Ramus Splitting cial approach was used.
In 1959 Kazanjian and Converse contributed
The basic development of the sagittal split has to the technical development of the mandibular
led from a purely horizontal osteotomy [29– ramus split by performing a sagittal oblique
34] to an oblique sagittal osteotomy [10], ramus osteotomy from the proximal-medial side
through a partially stepped sagittal split oste- to the caudal-lateral aspect to obtain the widest
otomy [25–27], to a complete and longer possible bone contact between the segments, but
stepped osteotomy of the ramus [35]. Later still used an extraoral approach [10].
extended splitting variants were presented by With regard to the transoral approach Ernst
Obwegeser, and finally the long stepped sagit- was the first to present a set of instruments to that
tal split was inaugurated by Dal-Pont end (special cheek retractors and a long, straight
(Fig. 1.10) [1, 4]. handsaw and a screwed guide channel, 1927) and
As Bloomquist stated in 1992, the sagittal split cut the ramus horizontally above the foramen as
ramus osteotomy (SSRO) is perhaps the most early as in 1934 [31–33]. The transoral approach
significant development among the numerous by Ernst was a groundbreaking advance, but it
mandibular osteotomies of the vertical ramus took almost 20 years before the intraoral approach
[36]. became the surgical standard [37].

a b c

d e f

Fig. 1.10 Development of the sagittal split osteotomy (a) (e) Dal Pont [44] (f) Hunsuck [45] ©Copyright Keisuke
Perthes osteotomy (1924) (b) Kazanjian and Converse Koyama 2020. All rights reserved
(1951) (c) Schuchardt [26] (d) Trauner & Obwegeser [35]
10 P. Kessler and N. Hardt

According to Bell, Schuchardt was the first Trauner and Obwegeser performed the two-­
who created a proximal-medial bone step in the stage osteotomy in 1955 by relocating the second
ramus from an intraoral approach in 1955, from osteotomy deliberately into the lateral buccal
which the oblique sagittal splitting of the ramus aspect of the mandibular ramus, thereby
took place (Fig. 1.12) [1, 38]. ­prolonging the sagittal split and forming a broad
bone contact (Fig. 1.13).
Two years later, in 1957, Trauner and
Obwegeser located the lateral-horizontal osteot-
omy line more caudally into the region of the
mandibular angle to improve bone-to-bone con-
tact/overlap and enhance the stability of the lat-
eral segment.
In 1959, Obwegeser adjusted the lateral oste-
otomy line as a vertical bone cut in the pre-­
angular region and suggested the use of this
surgical approach for both the prognathic and
retrognathic mandible.
In Obwegeser’s original description of his
technic in 1959 the lateral osteotomy is shown
distal of the second molar. The lingual osteotomy
line lies about 8–10 mm below the sigmoid notch
Fig. 1.11 Earliest depiction of the sagittal split osteot-
(Fig. 1.14).
omy of the Ramus by Perthes [34] (transfacial approach)
©Copyright Keisuke Koyama 2020. All rights reserved

a b

Fig. 1.12 The development of the sagittal split osteotomy from Schuchardt (a) to the Trauner/Obwegeser technique (b)
(intraoral approach) ©Copyright Keisuke Koyama 2020. All rights reserved
1 Evolution of the Surgical Standard Techniques 11

Dal Pont modified Obwegeser’s sagittal split- The original publication of 1959 is in Italian lan-
ting technique in 1959 by locating the lateral/ guage [39–42].
buccal osteotomy incision forward into the region
of the second molar to further increase the bone 1. The sagittal retromolar osteotomy, in which a
overlap (Figs. 1.14, 1.15 and 1.16). This tech- sufficiently thick cancellous bone layer
nique has been published in English only in 1961. between the two cortical plates allows a con-

a b

c d

Fig. 1.13 Complete and extended stepped osteotomy of setback (d) mandibular advancement ©Copyright Keisuke
the ramus according to Trauner and Obwegeser (1955) (a) Koyama 2020. All rights reserved
buccal osteotomy (b) lingual osteotomy (c) mandibular
12 P. Kessler and N. Hardt

Fig. 1.15 Dal Pont distinguished in 1959 two sagittal

osteotomy forms depending on the intercortical cancel-
lous bone mass ©Copyright Keisuke Koyama 2020. All
Fig. 1.14 Extended splitting variants on the buccal side rights reserved
by Obwegeser [39, 40] and DalPont [41] ©Copyright
Keisuke Koyama 2020. All rights reserved

Fig. 1.16 Sagittal retromolar osteotomy The ramus of Fig. 1.17 The sagittal split on the lingual side ends in the
the mandible is split between the medial and lateral corti- region of the lingula ©Copyright Keisuke Koyama 2020.
cal plates. The split extends to the posterior border of the All rights reserved
mandible (as indicated by the shaded lines) ©Copyright
Keisuke Koyama 2020. All rights reserved

tinuous splitting of the ramus up to the poste- In this situation Dal Pont advocated splitting
rior edge of the ascending ramus. Notice the of the medial segment anterior to the posterior
wide overlap of both segments (Fig. 1.16). margin of the ramus and pleaded for a lingual
2. The retromolar osteotomy, in which there is split just below the mandibular nerve-vessel bun-
insufficient cancellous bone volume, so that a dle, an aspect later emphasized by Hunsuck in
safe splitting may be limited. 1968 (Fig. 1.17).
1 Evolution of the Surgical Standard Techniques 13

3 Oblique Retromolar Hunsuck effect), Hunsuck proposed in 1968 to

Osteotomy fundamentally limit the extent of the lingual
osteotomy posterior to the mandibular foramen
The split in the ramus does not extend to the pos- so that the split will be just below the mandibu-
terior border, usually because there is little can- lar foramen in order to reduce subperiosteal
cellous bone between the two cortical plates. exposure of the ramus and surgical trauma to
In order to reduce the unpredictable and the neurovascular vessel bundle on the one
uncontrollable course of the sagittal split in the hand, and to limit undesirable splitting compli-
lower-inferior cleavage region (so-called cations on the other (Fig. 1.18).

Fig. 1.18 Dal Pont–Hunsuck type of osteotomy which gual osteotomy—SLO (a) mandibular advancement (b)
comes through the medial cortex above the lingula and mandibular setback ©Copyright Keisuke Koyama 2020.
anteriorly to the posterior border of the ramus—short lin- All rights reserved
14 P. Kessler and N. Hardt

4 Conclusion 8. Dingman RO. Surgical correction of the mandibular

prognathism. Am J Orthod. 1944;30(11):683–92.
9. Dingman RO. Surgical correction of development
The sagittal split osteotomy, according to deformities of the mandible. Plastic Reconstr Surg.
Trauner-Obwegeser/Dal Pont, has decisive 1948;3(2):124–46.
advantages, a wide medullary bone contact as a 10. Kazanjian V, Converse J. The surgical treatment
of facial injuries. 2nd ed. Baltimore: Williams a.
prerequisite for uncomplicated bone healing Wilkins; 1959.
and universal applicability in prognathic and 11. Limberg A. Treatment of open-bite by means of plas-
retrognathic isolated and combined bimaxillary tic oblique osteotomy of the ascending rami of the
surgery. It is the most widely used technique mandible. Dent Cosmos. 1925;67:1191–200.
12. Berger P. Du traitement chirurgical du prognathisme.
today. These: Lyon; 1892.
One of the most important innovations in the 13. Dufourmentel M. Le Traitement chirurgical du prog-
sagittal splitting process was the introduction of set nathisme. Presse Méd. 1921:235–7.
and lag screw osteosynthesis by Spiessl [46, 47]. 14. Dufourmentel M, Darcissac M. Quelques cas de
résections condyliennes unilatérales et bilatérales
Broad experience has shown that the stable avec présentation d’anciens opérés. Revue de Stomat.
osteosynthetic fixation of the segments enabled 1932;34(6):340.
uncomplicated, rapid bone healing, a signifi- 15. Kostecka F. A contribution to the surgical treatment of
cant reduction in the relapse frequency, a sta- open bite. Int J Orthod. 1934;28:1082–92.
16. Fox GL, Tilson HB. Mandibular retrognathia: a
ble condyle position and improved patient review of the Iiterature and selected cases. J Oral
comfort [4]. Surg. 1976;34:53–61.
Since the first publication, the sagittal split 17. Hebert JM, Kent JN, Hinds EC. Correction of progna-
osteotomy has been modified in various ways thism by an intraoral vertical subcondylar osteotomy.
J Oral Surg. 1970;33:384.
[48–50, 52]. The numerous surgical techniques 18. Hall HD, Chase DC, Payor LG. Evaluation and refine-
and modifications reflect the collective but also ment of the intraoral vertical subcondylar osteotomy.
the individual interest in this technique, as well as J Oral Surg. 1975;33:333.
the individually different surgical experiences of 19. Robinson M. Micrognathism corrected by vertical
osteotomy. Of ascending ramus and iliac bone graft:
the authors. a new technique. Oral Surg Oral Med Oral Pathol.
1957;10:1125–30.
20. Caldwell JB, Amaral WJ. Mandibular micrognathism
References corrected by vertical osteotomy in the rami and iliac
bone graft. J Oral Surg. 1960;18:3–15.
21. Robinson M, Lytle JJ. Micrognathism corrected by
1. Bell HW, Proffit WR, White RP. Surgical correction
vertical osteotomies of the rami without bone grafts.
of dentofacial deformities Vol. 1–3. Saunders; 1980.
Oral Surg Oral Med Oral Pathol. 1962;15:641–5.
2. Kashani H, Rasmusson L. Osteotomies in orthogna-
22. Caldwell JB, Hayward JR, Lister RL. Correction of
thic surgery. In: Hosein M, Motamedi K, editors. A
mandibular retrognathia by vertical-L osteotomy: a
textbook of advanced oral and maxillofacial surgery–
new technique. J Oral Surg. 1968;26:259–64.
volume 3. IntechOpen; 2016.
23. Hawkinson RT. Retrognathia correction by means
3. Steinhäuser EW. Historical development of
of an arcing osteotomy in the ascending ramus. J
orthognathic surgery. J Craniomaxillofac Surg.
Prosthet Dent. 1968;20:77–86.
1996;24:195–204.
24. Hayes PA. Correction of retrognathia by modified
4. Steinhäuser EW. Rückblick auf die Entwicklung der
"C" osteotomy of the ramus sagittal osteotomy of the
Dysgnathiechirurgie und Ausblick. Mund-Kiefer- und
mandibular body. J Oral Surg. 1973;31:682–6.
Gesichtschirurgie. 2003;7:371–9.
25. Schuchardt K. Ein Beitrag zur chirurgischen
5. Angle EH. Double resection for treatment of mandib-
Kieferorthopädie unter Berücksichtigung ihrer
ular protrusion. Dent Cosmos. 1903;45:268–74.
Bedeutung für die Behandlung angeborener und
6. von Eiselsberg J. Über Plastik bei Ektropium des
erworbener Kieferdeformitäten bei Soldaten. Dtsch
Unterkiefers (Progenie). Wien Klin Wochenschr.
Zahn Mund Kieferheilkd. 1942;9:73.
1906;19:1505–8.
26. Schuchardt K. Formen des offenen Bisses und ihre
7. Blair VP. Instances of operative correction
operativen Behandlungsmöglichkeiten. In: Fortschr
of malrelation of the jaws. Int J Orthodont.
Kiefer–Gesichtschir 1955; 1:222–230.
1915;1(8):395–432.
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27. Schuchardt K. Experience with the surgical treat- 41. Dal Pont G. L'osteotomia retromolare par la converzi-
ment of some deformities of the jaws: prognathia, one della progenia. Minerva Chir. 1959;14:1138.
microgenia and open bite. In: Wallace AB, editor. 42. Obwegeser HL. The indication for surgical correction
Transactions of the International Society of Plastic of mandibular deformity by sagittal splitting tech-
Surgeons. Second congress. Baltimore: Williams and nique. Br J Surg. 1963;1:157–60.
Wilkins; 1961. p. 73–8. 43. Wassmund M. Frakturen und Luxationen des
28. Weinstein I. C-osteotomy for correction of man- Gesichtsschädels unter Berücksichtigung der
dibular retrognathia: report of cases. J Oral Surg. Komplikationen des Hirnschädels. In: Klinik und
1971;29:358. Therapie. Praktisches Lehrbuch, Vol. 20. Meusser,
29. Blair VP. Report of a case of double resection for the Berlin 1927.
correction of protrusion of the mandible. Cosmos. 44. Dal Pont G. Retromolar osteotomy for the correction
1906;48:817–20. of prognathism. J Oral Surg. 1961;19:42–7.
30. Blair VP. Operations of the jaw bone and face. Surg 45. Hunsuck EE. A modified intraoral sagittal splitting
Gynecol Obstet. 1907;4:67–78. technic for correction of mandibular prognathism. J
31. Ernst F. Die Prognathie. In: Kirschner M, Nordmann Oral Surg. 1968;26:250–3.
O, editors. Die Chirurgie Bd. IV 1. Berlin: Urban u. 46. Spiessl B. The sagittal splitting osteotomy for cor-
Schwarzenberg; 1927. p. 803–11. rection of mandibular prognathism. Clin Plast Surg.
32. Ernst F. Über die chirurgische Beseitigung der 1982;9(4):491–507.
Prognathie des Unterkiefers. Deutsche zahnärztl 47. Tucker MR. Surgical correction of mandibular
Wschr. 1934;37:949–53. excess. Atlas Oral Maxillofac Surg Clin North Am.
33. Ernst F. Über die chirurgische Beseitigung der 1993;1:29–39.
Prognathie des Unterkiefers. Zentralbl Chir. 48. Epker BN. Modification in the sagittal osteotomy of
1938;65:179. the mandible. J Oral Surg. 1977;35:157–9.
34. Perthes G. Die Kieferköpfchen und ihre operative 49. Spiessl B. Osteosynthese bei sagittaler Osteotomie
Behandlung. Arch Klin Chir. 1924;1333:425. nach Obwegeser-Dal Pont. Fortschr Kieferheilkd
35. Trauner R, Obwegeser HL. The surgical correction of Gesichtschir. 1974;18:145–8.
mandibular prognathism and retrognathia with consid- 50. Wolford LM, Davis WM. Mandibular inferior border
erations of genioplasty. Surgical procedures to correct split: a modification in the sagittal split osteotomy. J
mandibular prognathism and reshaping the chin. Part Oral Maxillofac Surg. 1990;48:92–4.
I. Oral Surg Oral Med Oral Pathol. 1957;10:677–89. 51. Bell B. A history of orthognathic surgery
36. Bloomquist DS. Principles of mandibular orthogna- in North America. J Oral Maxillofac Surg.
thie surgery. In: Peterson LJ, Andresano AT, Marciani 2018;76(12):2466–81.
RD, Roser SM, editors. Principles of oral and max- 52. Obwegeser HL. Orthognathic surgery and a tale
illofacial surgery. Philadelphia: Lippincott; 1992. of how three procedures came to be: a letter to
p. 1415–63. the next generations of surgeons. Clin Plast Surg.
37. Hoffmann-Axthelm W. Chirurgie der Zahnstellungs- 2007;34:331–55.
und Kieferanomalien. In: Hoffmann-Axthelm W,
Neumann HJ, Pfeifer G, Stiebitz R, editors. Die
Geschichte der Mund-, Kiefer- und Gesichtschirurgie.
Berlin: Quintessenz-Verlag; 1995. Further Readings
38. Fonseca RJ, Marciani RD, Turvey TA. Oral and max-
illofacial surgery. Orthognathic surgery, esthetic sur- Hoffmann-Axthelm W, Neumann HJ, Pfeifer G,
gery, cleft and craniofacial surgery. Saunders; 2009. Stiebitz R. Die Geschichte der Mund-, Kiefer- und
39. Obwegeser HL, Trauner R. Zur Operationstechnik Gesichtschirurgie. Quintessenz: Berlin, 1995.
bei der Progenie und anderen Unterkieferanomalien. Steinhäuser EW. Historical development of orthognathic
Dtsch Zahn Kieferheilkd. 1955;23:1. surgery. J CranioMaxillofac Surg. 1996;24:195–204.
40. Obwegeser HL. The surgical correction of mandibular
prognathism with consideration of genioplasty. Oral
Surg Oral Med Oral Path. 1957;10:677–89.
 Classification and Facial
Patterns
2
Peter Kessler and Nicolas Hardt

Contents
1 Introduction  18
2  keletal Dysgnathia 
S 18
2.1 S ymmetric Dysgnathia  18
2.2 A  symmetric Dysgnathia  18
3 Dentoalveolar Dysgnathia  19
4 Surgical Classification of Dysgnathias  19
5 Asymmetric Skeletal Growth Disorders  19
6  acial Patterns in Typical Forms of Dysgnathia 
F 20
6.1 Mandibular Growth  20
6.2 Anterior Mandibular Rotational Growth Pattern  20
7 Conclusion  21
References  22

Abstract was essential for the development of system-

atic treatment concepts in order to enable
The skeletal position of the jaws is genetically
structured treatments in the first place, which
determined. Typical positional relationships
must also be communicated internationally
of the jaws include classifiable occlusal forms
(Becking et al., Ned Tijdschr Tandheelkd
and externally recognizable, almost typifying
2007; 114(1):34–40).
esthetic features of each face. Classification
Keywords
P. Kessler (*)
Department of Cranio-Maxillofacial Surgery, Facial growth pattern · Classification of
Maastricht University Medical Center, dysgnathias · Dentoalveolar dysgnathia ·
Maastricht, The Netherlands Skeletal dysgnathia
e-mail: [email protected]
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 17

P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_2
18 P. Kessler and N. Hardt

1 Introduction Dysgnathias, where mostly all three vectors

are affected:
Dysgnathia refers to a disturbance of the regular
jaw and tooth row relationship between the man- Mandible:
dible and maxilla. The different forms of dys-
gnathias can be classified on the basis of clinical • Mandibular micrognathia.
differences in the size and positional relationship • Mandibular macrognathia.
of the jaws to each other and according to their • Chin microgenia.
radiological manifestation. • Chin macrogenia.
The positional anomalies can be classified
according to the sagittal, vertical, and transversal Maxilla:
orientation of the jaws into skeletal dysgnathias
(dento-maxillofacial) and dentoalveolar dys- • Maxillary macrognathia.
gnathias. In addition, the third group are the • Maxillary micrognathia.
cranio-­
maxillofacial disorders associated with
dysgnathia [1]. Often different forms of dysgnathia are com-
bined with each other. If dysgnathias are present
in both the lower jaw and the upper jaw, they are
2 Skeletal Dysgnathia called bimaxillary dysgnathias.

In skeletal dysgnathia, the positional relation-

ship of the bases of the jaws to the skull and Note
skull base is affected (neurocranium), whereby • Dysgnathias are often present in differ-
the positional relationship of the jaws to each ent directions in space.
other is usually also disturbed, e.g., through dis- • Combinations of the aforementioned
proportional growth of the facial skeleton malformations are common.
(viscerocranium). • Although, from a practical point of view,
The relationship of the mandible to the base of a skeletal anomaly can often be reduced
the skull is mediated by the temporomandibular to a vector (sagittal, transverse, vertical),
joints, whereby dysgnathias can in turn result in principle all dysgnathias include
from condylar growth disorders. Condylar three-dimensional growth deficits.
growth disorders represent a separate entity. • Occasionally, all three dimensions are
Symmetric and asymmetric dysgnathias can be affected to a similar, usually however, to
distinguished [1, 2]. a different extent.

2.1 Symmetric Dysgnathia

2.2 Asymmetric Dysgnathia
Symmetric dysgnathias where only one vector is
affected: Mandibular unilateral asymmetries.

• Sagittal dysgnathia—prognathism versus • Laterognathism.

retrognathism. • Hemimandibular hyperplasia/elongation.
• Vertical dysgnathia—vertical overgrowth • Hemimandibular hypoplasia.
including open bite and deep bite. • Unilateral condylar hyperplasia.
• Transversal dysgnathia—symmetric laterog- • Unilateral condylar hypoplasia.
nathism/crossbite. • Isolated unilateral dento-maxillofacial growth
disorders.
2 Classification and Facial Patterns 19

Maxillary unilateral asymmetries. 4 Surgical Classification of

Dysgnathias
• Unilateral maxillary hyperplasia.
• Unilateral maxillary hypoplasia. (Adapted from [3])
Sagittal-skeletal
Dysgnathia Dentoalveolar Dysgnathia
3 Dentoalveolar Dysgnathia Overdeveloped lower face
Skeletal mandibular Dentoalveolar protrusion and
prognathism dento-maxillofacial
Dentoalveolar dysgnathias are skeletal growth prognathism
disorders that are restricted to one or both alve- Chin macrogenia
olar processes including the teeth, with the jaw Underdeveloped lower face
base correctly positioned. Combinations of dif- Skeletal mandibular Dentoalveolar retrusion and
ferent dentoalveolar malocclusions are retrognathism dento-maxillofacial
retrognathism
common.
Skeletal mandibular
Dentoalveolar occlusal anomalies—espe- micrognathia
cially in the sagittal plane—are divided into three Chin microgenia
classes: High lower face
Class I—regular occlusion is defined by the Chin macrogenia Dentoalveolar open bite
position of the canines and the mesio-buccal cusp Low lower face
Chin microgenia Dentoalveolar deep/closed bite
of the first molar in the maxilla which occludes in
Underdeveloped midface
the buccal groove of the ­mandibular first molar. Maxillary hypoplasia
Overbite and overjet of the incisors must be regu- Maxillary
lar, no midline deviation. retrognathism
Class II—distal occlusion. Mandibular
Class II/1—distal occlusion with extruded pseudo-prognathism
Overdeveloped midface
front.
Maxillary hyperplasia Dentoalveolar protrusion
Class II/2—distal occlusion with deep bite. Maxillary prognathism
Class III—mesial occlusion. Transversal growth disorders
Mandibular
hypoplasia
Mandibular
hyperplasia
Note
Chin hypoplasia
• The motivation of the patient is leading Chin hyperplasia
in the decision-making process for sur- Maxillary hypoplasia
gical orthognathic treatment. Maxillary hyperplasia
• Complex combined orthodontic and
surgical therapy should only be per-
formed on patients who know the needs
and risks of combined treatment and are 5 Asymmetric Skeletal Growth
able to meet the treatment Disorders
requirements.
• The prerequisite is a clear agreement • Skeletal laterognathia.
between patient and surgeon on the • Hemimandibular hyperplasia/elongation.
achievability of the treatment goals. • Unilateral condylar hyper−/hypoplasia.
20 P. Kessler and N. Hardt

6 Facial Patterns in Typical matched by a vertical increase in the condylar

Forms of Dysgnathia region of the posterior mandible. As the teeth
show a vertical growth pattern, this must be
The three basic facial growth patterns are: matched by vertical growth in the condylar region
or the mandible will show a posterior inclination
A. Hyperdivergent facial growth pattern. [2, 5].
B. Neutral facial growth pattern.
C. Hypodivergent facial growth pattern.
6.2 Anterior Mandibular
The neutral growth pattern is generally con- Rotational Growth Pattern
sidered the ideal facial growth scheme because it
makes a straight facial profile with good dental Growth of the orofacial region is quantitatively
occlusion possible (Fig. 2.1b). described by locating the center of mandibular
A posterior growth rotation is seen in the rotation relative to the cranial base. The anterior
“long face” syndrome with an anterior open bite rotational growth pattern is associated with an
(Fig. 2.1a). These cases have short rami with increase in vertical condylar growth and reduced
steep mandibular plane angles. dentoalveolar height [4, 5].
The anterior growth rotation can be associated The center of mandibular rotation is defined by
with prognathism when the mandibular growth far the ratio of vertical facial growth—anterior versus
exceeds the maxillary growth in the horizontal direc- posterior facial height—and the direction of con-
tion. It can also lead to ­bimaxillary protrusion as rep- dyle growth. To achieve the occlusal level, the
resented in Fig. 2.1 on the right (Fig. 2.1c) [2, 5]. molars must show stronger vertical growth than
the incisors. In class II patients with open bite, e.g.,
changes in growth pattern reduce or stop favorable
6.1 Mandibular Growth anterior mandibular rotation and redirect the mean
condylar growth vector more posteriorly.
The mandible is suspended from the cranial base In extreme cases, a reduced facial height may
and there are two separate growth centers. The also reduce the volume of the elevating muscles
anterior downward movement of the maxilla is that results in a wider maxillary buccal space. In

a b c

Fig. 2.1 Basic facial growth patterns [4] (a) Hyperdivergent (b) Neutral (c) Hypodivergent ©Copyright Keisuke
Koyama 2020. All rights reserved
2 Classification and Facial Patterns 21

a b c

d e f

Fig. 2.2 Various types and typical forms of dysgnathias rognathism. Moderate retrognathia with maxillary dento-
[6]. (a) Mandibular retrognathism. Retrognathism with alveolar protrusion and deep bite. (e) Overdeveloped
steep mandibular angle. Pronounced overbite and overjet. face—long face. Long flat lower face with severe func-
Chronic breathing through the mouth. (b) Mandibular tional problems of the tongue, extreme open bite and
prognathism. Prognathism of the lower jaw with retrogna- insufficient lip closure. (f) Low lower face. Extremely
thic maxilla and midface hypoplasia. (c) Underdeveloped deep bite with reduced lower facial height. ©Copyright
face. Brachyfacial growth pattern with low facial height, Keisuke Koyama 2020. All rights reserved
dentoalveolar protrusion in both jaws. (d) Mandibular ret-

this situation, the transversal growth will result in 7 Conclusion

a buccal overjet. A lingual crossbite is almost
never present in anterior mandibular rotation or No planning and no therapy without classifica-
short face growth patterns. tion. Classification of dysgnathia is essential
The reduction in facial height is found almost for functional and esthetic treatment.
exclusively in the lower face and is associated Furthermore, the classification defines the
with a reduction in vertical alveolar cooperation between orthodontists and sur-
development. geons. Both must speak this common language,
Figure 2.2 illustrates typical facial pattern which is based on a generally accepted classifi-
variations in pronounced growth-related isolated cation. It also gives the patient certainty and the
or combined dysgnathias of the maxillo-­ possibility of comparison when a therapeutic
mandibular complex. alternative is presented.
22 P. Kessler and N. Hardt

References 4. Isaacson RJ, Erdman AG, Hultgren BW. Facial and

dental effects of mandibular rotation craniofacial biol-
ogy, monograph no. 10, Craniofacial growth series.
1. Becking AG, Hoppenreijs TJM, Tuinzing
University of Michigan; 1981.
DB. Disturbances of growth and development of the
5. Berkowitz S. Orthodontic analysis and treatment
maxillofacial skeleton. Ned Tijdschr Tandheelkd.
planning in patients with craniofacial anomalies. In:
2007;114(1):34–40.
Wolfe SA, Berkowitz S, editors. Plastic surgery of
2. Hultgren BW, Isaacson RJ, Erdman AG, Worms FW,
the facial skeleton. Boston, Toronto: Little, Brown;
Rekow ED. Growth contributions to class II correc-
1989.
tions based on models of mandibular morphology. Am
6. Ricketts ARE. The biology of occlusion and the tem-
J Orthod. 1980;78(3):310–20.
poromandibular joint. In: Modern man, 1972.
3. Spiessl B. Osteosynthese bei sagittaler Osteotomie
nach Obwegeser-Dal Pont. Fortschr Kieferheilkd
Gesichtschir. 1974;18:145–8.
 Types of Osteotomies
in the Mandible
3
Peter Kessler and Nicolas Hardt

Contents
1 Introduction  23
2  urgical Corrections in the Lower Jaw 
S 24
2.1 Ramus Osteotomies  24
2.2 Mandibular Body Osteotomies  24
2.3 Segmental Osteotomies  24
2.4 Chin Osteotomies  24
3 Classification of Surgical Corrections  24
4 Conclusion  25
Further Reading  25

Abstract Keywords

Corrections of the bite position in skeletal Classification of dysgnathias · Development

malformations or esthetic corrections with the of orthognathic surgery · Basic osteotomy
aid of the skeleton can only be achieved by procedures · Ramus osteotomies · Sagittal
osteotomies and relocation of bone and soft mandibular split · Bilateral sagittal split
tissue components. The nomenclature of com- osteotomy · BSSO · Segment osteotomies ·
mon osteotomies must be clearly understood. Chin osteotomies · Genioplasty · Chin
They can be applied individually, in combina- osteotomy
tion, and in both jaws.

P. Kessler (*)
1 Introduction
Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center, Orthognathic surgery includes surgical interven-
Maastricht, The Netherlands tions on the facial skeleton to restore normal ana-
e-mail: [email protected]
tomical and functional intermaxillary
N. Hardt (*) relationships in patients with maxillo-mandibular
Kantonsspital Lucerne, Clinic and Policlinic of
anomalies affecting the face.
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 23

P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_3
24 P. Kessler and N. Hardt

The compartments of the facial skeleton can • Anterior mandibular body step
be surgically repositioned through a variety of osteotomy-ostectomy.
established osteotomies, redefining facial con- • Posterior mandibular body step
tours such as the facial profile. osteotomy-ostectomy.
Most mandibular deformities can essentially • Inter- or retromolar vertical osteotomy com-
be treated with four basic osteotomy procedures, bined with distraction osteogenesis - DOG.
which in turn can be combined with each other.

2.3 Segmental Osteotomies

2 Surgical Corrections
in the Lower Jaw Segmental osteotomies are differentiated into

1. Ramus osteotomies. • Anterior segmental osteotomies.

2. Mandibular body osteotomies. • Posterior segmental osteotomies.
3. Segmental osteotomies.
4. Chin osteotomies.
2.4 Chin Osteotomies

2.1 Ramus Osteotomies Chin osteotomies are differentiated into.

are differentiated into. • Augmentation/advancement genioplasty.

• Reduction genioplasty.
• Sagittal split ramus osteotomy. • Straightening genioplasty.
• Vertical ramus osteotomy. • Lengthening genioplasty.
• Inverted L- and C-ramus osteotomy.

3 Classification of Surgical
2.2 Mandibular Body Osteotomies Corrections

Mandibular body osteotomies are differentiated into. See Table 3.1

Table 3.1 Classification of orthognathic procedures in the mandible

Classification of surgical correction possibilities in the lower jaw through transoral accesses
Ramus osteotomies Body osteotomies Segmental osteotomies
Sagittal split ramus osteotomy Anterior mandibular body step Anterior segmental
osteotomy-ostectomy osteotomies
Vertical ramus osteotomy Posterior mandibular body step Posterior segmental
osteotomy-ostectomy osteotomies
Inverted L- and C-ramus Inter-or retromolar osteotomy for distraction –
osteotomy osteogenesis - DOG
– Augmentation/advancement genioplasty –
– Reduction genioplasty –
– Straightening genioplasty –
– Lengthening genioplasty –
3 Types of Osteotomies in the Mandible 25

4 Conclusion Fonseca RJ, Marciani RD, Turvey TA. Oral and maxillo-
facial surgery. Orthognathic surgery, esthetic surgery,
cleft and craniofacial surgery. Saunders. 2009;
Brief and concise listing of possible mandibular Reyneke JP. Essentials of orthognathic surgery.
osteotomy techniques including genioplasties. Quintessence Publishing Co Inc; 2019.
The planning and technical procedure and the Steinhäuser EW. Rückblick auf die Entwicklung der
Dysgnathiechirurgie und Ausblick. Mund-Kiefer- und
appropriate indications are described in the fol- Gesichtschirurgie. 2003;7:371–9.
lowing parts.

Further Reading
Bell HW, Proffit WR, White RP. Surgical correction of
dentofacial deformities. Saunders. 1980;1-3
 Definition of Standard Procedures
4
Peter Kessler and Nicolas Hardt

Contents
1  ilateral Sagittal Split Osteotomy - BSSO/Osteotomies in the
B
Mandible 28
1.1 .Indications—Standard Sagittal Split Osteotomy 28
1.2 .Surgical Principle—BSSO 28
1.3 .Sagittal Splitting as Setback Surgery 29
1.3.1 Principle 29
1.4 .Sagittal Splitting as Advancement Surgery 30
1.4.1 Principle 30
1.5 .Mandibular Body Osteotomy 30
1.6 .Stepwise Osteotomy 30
1.6.1 Principle 30
1.7 .Horizontal Mandibular Distraction Osteogenesis 31
1.7.1 Indication 31
1.7.2 Principle 31
1.8 .The Anterior Mandibulotomy 32
1.8.1 Indications 32
1.8.2 Technique 32
2 Segmental Alveolar Osteotomies 33
2.1 .Anterior Subapical Osteotomy 33
2.1.1 Principle 33
2.2 .Posterior Subapical Osteotomy 34
2.2.1 Indication 34
2.2.2 Principle 34
3 Chin Osteotomies 34
4  rincipal Surgical Techniques in Chin Osteotomies
P 35
4.1 Horizontal Sliding Genioplasty 35

P. Kessler (*)
Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center,
Maastricht, The Netherlands
e-mail: [email protected]
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 27

P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_4
28 P. Kessler and N. Hardt

4.2  orizontal Sliding Osteotomy

H 35
4.3 Oblique Osteotomy for Chin Advancement 35
4.4 Jumping Genioplasty 36
4.5 Centering Genioplasty 36
4.6 Two-Tiered or Tandem Genioplasty 36
4.7 Chin Wing Osteotomy 36
4.8 Less Common Variants and Alternatives 36
5 Conclusions 36
References 37

Abstract
surfaces. This allows an extensive displace-
The surgical standard interventions are differen- ment of the bone segments in both posterior
tiated between procedures in the region of the and anterior directions (mandibular setback or
mandibular angle and ascending ramus—con- advancement).
cerning the sagittal and vertical osteotomy to Advantages:
perform the typical sagittal split—and stepped
or oblique osteotomies in the tooth-bearing • Possibility of a functionally stable fixation of
mandibular body for horizontal shifts. In addi- the fragments.
tion, segmental anterior and posterior partial • Due to stable fixation reduced risk of recur-
osteotomies of the horizontal branch and chin rence and pseudarthrosis.
osteotomies are distinguished. Combinations of • No visible scars.
these procedures are possible.

Keywords
1.1 Indications—Standard
Classification of dysgnathias · Orthognathic Sagittal Split Osteotomy
surgery · Basic osteotomy procedures ·
Classification of surgical corrections · Ramus The versatility of the BSSO allows the lower jaw
osteotomies · Sagittal mandibular split · to be shifted into a functionally ideal position:
Bilateral sagittal split osteotomy · BSSO ·
Mandibular advancement · Mandibular 1. Anterior displacement to correct a skeletal
setback · Segment osteotomies · Distraction class II malocclusion or a large overjet.
osteogenesis · Chin osteotomies · Genioplasty 2. Posterior repositioning (setback surgery) to
correct a class III malocclusion with reversed
overjet.
3. Horizontal and vertical rotation to correct a
mandibular asymmetry or an open or
1 Bilateral Sagittal Split crossbite.
Osteotomy - BSSO/
Osteotomies in the Mandible
1.2 Surgical Principle—BSSO
The transoral approach to the sagittal splitting
of the mandible in the region of the jaw angle A successful split will result in the split region in
as described by Trauner and Obwegeser [1] a lateral monocortical segment with little cancel-
and modified by Dal Pont in [2] ensures a max- lous bone and a medial monocortical segment
imum overlap of the proximal and distal bone with much more cancellous bone.
4 Definition of Standard Procedures 29

Lateral aspect

Medio-lingual aspect

Distal segment (arrow)

Fig. 4.1 Course of the osteotomy lines in a typical BSSO

according to Obwegeser-Dal Pont: Bucco-lateral and
medio-lingual osteotomy lines (–––) and sagittal connect-
ing osteotomy (−------). Red arrow = proximal segment,
blue arrow = distal segment [3] ©Copyright Keisuke
Koyama 2020. All rights reserved

The division is performed by three bone cuts

Proximal segment (arrow)
(osteotomies), which are applied vertically-­
laterally and horizontally-medially; both are con- Fig. 4.2 Split mandibular segments after sagittal osteot-
nected by a sagittal osteotomy line (Fig. 4.1). omy. The inferior alveolar nerve is ideally fully embedded
The principle of the sagittal splitting is the in the medio-distal mandibular segment. Only a thin layer
of cancellous bone remains on the lateral-proximal segment
division of the ascending ramus into a proximal-­ [3] ©Copyright Keisuke Koyama 2020. All rights reserved
lateral and a distal-medial segment in a sagittal
plane (Fig. 4.2). 1.3 Sagittal Splitting as Setback
In the sagittal splitting osteotomy (SSO), the Surgery
buccal vertical osteotomy lies directly behind the
second molar. The linguo-medial osteotomy runs 1.3.1 Principle
about 8–10 mm below the semilunar notch and In mandibular prognathism, after SSO and repo-
the sagittal connecting osteotomy runs medially sitioning of the mandible, the proximal segment
along the anterior edge (external oblique line) of is shortened according to the distance by which
the ascending ramus. the mandible has been setback (Fig. 4.3).
30 P. Kessler and N. Hardt

Fig. 4.3 Mandibular Excess—Prognathism. Situation displacement). The overlapping buccal bone lamella is
after sagittal split and mandibular setback. The removed [3]. ©Copyright Keisuke Koyama 2020. All
red arrow marks the posterior repositioning (backward rights reserved

1.4 Sagittal Splitting

as Advancement Surgery

1.4.1 Principle
In mandibular retrognathism the SSO is the same
as in mandibular prognathism. After sufficient
mobilization the mandible will be advanced.
There is no need to shorten the segments (Fig. 4.4).

1.5 Mandibular Body Osteotomy

Osteotomies in the tooth-bearing body of the

mandible are now only performed for very selec-
tive indications, such as the anterior mandibulot- Fig. 4.4 Mandibular Deficiency—Retrognathism, SSO
omy, anterior ostectomy, and the stepwise with horizontal mandibular advancement. Note bone
overlap ©Copyright Keisuke Koyama 2020. All rights
osteotomy.
reserved

1.6 Stepwise Osteotomy 1.6.1 Principle

Methodically, this type of osteotomy can be used
This type of osteotomy is preferred for very as a segmental or total osteotomy to reposition
selected cases of prognathism with anterior open the anterior section of the mandible in any desired
bite, excessive mandibular growth in the anterior direction, e.g., into a posterior position with/
dentoalveolar block, a negative overjet, and without a cranial tilt.
asymmetries of the mandibular arch, especially if
the first or second premolars are missing or need
to be extracted (Figs. 4.5 and 4.6) [4].
4 Definition of Standard Procedures 31

1.7 Horizontal Mandibular

Distraction Osteogenesis

Retromolar and intermolar mandibular distrac-

tion osteogenesis are forms of bone distraction
surgery. The decisive advantage of distraction
osteogenesis is the combined, simultaneous
growth of soft tissue together with the growth of
bone tissue. Both guarantee postoperative stabil-
ity using a dynamic technique (Figs. 4.7 and 4.8).

1.7.1 Indication
Only class II dysgnathias can be treated by dis-
traction. Horizontal distraction to lengthen the
mandible applying retromolar distractors is rarely
indicated. This concerns, e.g., pronounced cases
Fig. 4.5 The stepwise body osteotomy can be used for a
of mandibular retrognathia, such as mandibular
segmental alveolar osteotomy or total osteotomy of the man-
dible ©Copyright Keisuke Koyama 2020. All rights reserved hypoplasia (unilateral or bilateral hypoplasia of
the mandible) and micrognathia, severe cleft
facial malformations and congenital craniofacial
anomalies/malformations such as hemifacial
microsomia as well as retrognathia with TMJ-­
ankylosis and facial asymmetries. Intermolar
osteotomies, on the other hand, can be used pri-
marily in younger class II patients to avoid stan-
dard treatment with BSSO at the end of growth.
Above all, this can save treatment time.

1.7.2 Principle
Three-dimensional increase of bone volume by
horizontal distraction of the lower jaw. The dis-
traction is carried out with bone—less frequently
combined bone and tooth-anchored—unidirec-
tional or bi-multidirectional distractors. The dis-
traction rate is usually 1 mm/day divided into two
fractions of 0.5 mm [6].
Fig. 4.6 Rigid internal fixation after lateral body osteot-
omy is performed with miniplates [4] ©Copyright
Keisuke Koyama 2020. All rights reserved
32 P. Kessler and N. Hardt

a b

Fig. 4.7 Horizontal mandibular distraction [5] (a) Vertical osteotomy and placement of distractor on the buccal side.
(b) Distraction distal of the last molar tooth ©Copyright Keisuke Koyama 2020. All rights reserved

a b

Fig. 4.8 (a) Intermolar vertical osteotomy as special activation of distractor ©Copyright Keisuke Koyama
form of horizontal mandibular distraction (b) Vertical 2020. All rights reserved
mandibular osteotomy between first and second molar,

1.8 The Anterior Mandibulotomy 1.8.2 Technique

This problem can be overcome in two ways:
1.8.1 Indications 1. Two vertical osteotomy lines mostly distal to the
Occasionally, in patients with a short lower canines lead to a three-piece mandible, whereby
face, there is very little bone between the root the middle segment can be shifted verti-
tips of the incisors and the lower edge of the cally (Fig. 4.9a).
mandible. In such cases adequate vertical seg- 2. Combination of the abovementioned tech-
ment relocation cannot be achieved without nique with a horizontal osteotomy in the chin
damaging the tips or leaving a precariously thin area (genioplasty), resulting in a four-piece
strut of cortical bone (Fig. 4.9). mandible (Fig. 4.9b).
4 Definition of Standard Procedures 33

Fig. 4.9 Representation of the vertical (a), or vertical and horizontal osteotomy lines (b) for displacement of the man-
dibular middle segment. ©Copyright Keisuke Koyama 2020. All rights reserved

The mandibular front segment is then set down

and fixed as planned, and shifts the chin bone
downward, thus avoiding any bone loss. The ante-
rior inferior dentoalveolar height is increased and
improves the lower facial proportions. Bone
plates must be used for stable fixation [7].

2 Segmental Alveolar
Osteotomies

2.1 Anterior Subapical Osteotomy Fig. 4.10 The subapical area can be clearly exposed and
provides sufficient access for the subapical osteotomy
An anterior subapical osteotomy is indicated ©Copyright Keisuke Koyama 2020. All rights reserved
when there is a skeletal class I relationship, but a
vertical frontal bone excess or deficiency cannot the segment is possible. Surgically, the subapical
be corrected by orthodontic treatment. area provides sufficient access for the osteotomy
under the root tips (Fig. 4.10). The subapical area
2.1.1 Principle is reached through an intraoral, vestibular
The anterior subapical osteotomy allows the incision.
mandibular alveolar segment to be repositioned The horizontal osteotomy is performed sub-
in any desired direction. Even a slight tilting of apically approx. 5 mm below the root tips and is
34 P. Kessler and N. Hardt

then connected with two interdental vertical oste- The correction of chin disharmonies can be
otomies between the canines and the first premo- performed surgically by three-dimensional
lars, the segment is then carefully mobilized and reduction, advancement, or augmentation of the
adjusted to the preoperatively predetermined chin segment, namely vertically, transversely,
position (Fig. 4.10). and sagittally.
The determination of the chin anomaly types
is objectified at the jaw position to the orthograde
2.2 Posterior Subapical profile line.
Osteotomy The following basic types of shape deviations
are distinguished (Fig. 4.11):
2.2.1 Indication
Correction of super-erupted molars in the man- Microgenia
dible or ankylosis of posterior teeth. Small chin is present with an overall deficiency
of bone, generally in all three dimensions.
2.2.2 Principle
The transoral incision starts at the anterior edge Retrogenia
of the vertical ramus and continues into the Chin is not necessarily small but is positioned
canine area. posterior to its desired position. Pure retrogenia
In the area of the intended osteotomy, the inci- exists when the occlusion is normal. If there is
sion is made marginally, starting one tooth width mandibular retrognathia, the retrogenia is
behind, respectively in front of the intended pos- secondary.
terior and anterior vertical osteotomies. The two
vertical oblique incisions are made and connected Macrogenia
with the horizontal subapical osteotomy. Chin is large in size. As with microgenia, macro-
The periosteal attachment of the segment is genia can exist with normal occlusion or be asso-
removed only in the area of the osteotomy lines. ciated with mandibular prognathism.
This ensures the soft tissue contour and perfusion
of the segment.
The horizontal osteotomy is performed subapi-
cally about 5 mm below the root tips. The horizon-
tal osteotomy is then connected to the two vertical
osteotomies between the first molar and the sec-
ond premolar. After mobilization of the segment,
the posterior segment can be repositioned.

3 Chin Osteotomies

Various craniofacial skeletal deficiencies such as

the deep bite of class II or class III and the open
bite can be simultaneously associated with mor-
phological changes of the chin, which vary
greatly from one individual to another. Class II
Fig. 4.11 Disharmonic chin shapes objectified at the
mandibles might be associated with microgenia chin position to the mandible and the orthograde profile
or retrognathia, whereas in a class III relation line. ©Copyright Keisuke Koyama 2020. All rights
(prognathism) is often related with progenia. reserved
4 Definition of Standard Procedures 35

4 Principal Surgical
Techniques in Chin
Osteotomies

Chin reshaping can provide a more pronounced

facial appearance in patients undergoing orthog-
nathic surgery. The “sliding” genioplasty has the
most potential for reshaping the chin.
The following surgical variants (sliding oste-
otomies and ostectomies) are distinguished:

4.1 Horizontal Sliding

Genioplasty Fig. 4.12 Horizontal osteotomy—horizontal sliding
osteotomy with vertical augmentation—augmentation
genioplasty. ©Copyright Keisuke Koyama 2020. All
Indications:
rights reserved
The sliding genioplasty serves:

• To build up a chin prominence. rial can be used for vertical augmentation

• For chin elongation in cases with too short (Fig. 4.12) [8].
vertical lower faces.
• For horizontal reduction of a prominent chin. Chin Reduction Genioplasty
• For rotation and straightening of an asymmet- During reduction, a piece of bone is removed, the
ric chin. chin is pulled backward and sometimes moved
• Advancement of a receded chin. upward. To achieve this a bone disc under the
• For vertical reduction of a chin with excess root tips is osteotomized and removed, but the
height. shape of the chin prominence itself is not
• For vertical augmentation and lengthening of changed. The chin prominence is shifted dorsally.
a shortened chin. The chin can also be reduced by grinding away
the caudal edge of the chin. This measure inevita-
A transoral approach is obligatory. The anterior bly and irreversibly leads to the loss of the origi-
mandibular base—if necessary also the lateral nal shape of the chin apex [8].
base up to the mandibular angle—is osteoto-
mized and repositioned in the desired position.
A distinction is made between the following 4.3 Oblique Osteotomy for Chin
genioplasties: Advancement

Osteotomy for chin advancement and elevation

4.2 Horizontal Sliding Osteotomy of the chin apex.
Chin forward displacement with simultaneous
Chin Augmentation Genioplasty rotation of the chin upward [9]. The advantage of
After horizontal osteotomy, the lower fragment this technique is that it allows maximum forward
can be pushed directly forward, similar to a and upward displacement of the chin apex
drawer that is opened, until its posterior cortex (Fig. 4.13). It is very important that the muscles
is in contact with the anterior cortex of the sym- remain attached to the bony chin. As a result, the
physis. A vertical dislocation to lengthen the muscle attachments are also shifted upward and
chin is possible. In addition, bone-graft mate- forward, thus relaxing the entire perioral region.
36 P. Kessler and N. Hardt

Fig. 4.13 Oblique osteotomy for chin advancement

©Copyright Keisuke Koyama 2020. All rights reserved Fig. 4.14 Chin wing osteotomy ©Copyright Keisuke
Koyama 2020. All rights reserved

4.4 Jumping Genioplasty

covers the entire lower mandibular base
The lower border fragment is lifted so it rests on (Fig. 4.14) [11].
the main mandibular segment, thereby shortening The monocortical osteotomy line runs in a
the chin vertically as well as giving more antero- descending direction from above the mandibular
posterior projection than can be obtained by the angle to inferior below the mandibular canal and
sliding genioplasty. the mental foramen and then bi-cortically to the
middle of the chin.

4.5 Centering Genioplasty

4.8 Less Common Variants
The lower fragment is moved horizontally to cor- and Alternatives
rect a transversal asymmetric deformity.
However, depending on the individual situation,
double horizontal osteotomies, reduction osteot-
4.6 Two-Tiered or Tandem omies, wedge osteotomies, propeller genioplas-
Genioplasty ties, triple and quadruple osteotomies, and
genioplasties with interposition grafts of various
A double horizontal osteotomy is performed. materials are also performed.
Whereas simple genioplasty can be easily per- Chin corrections can be performed as isolated
formed by sliding or jumping osteotomies, or combined intervention with any orthognathic
extreme chin advancement, i.e., an advancement surgery of the maxilla and/or the mandible.
greater than 10 mm, requires the use of the Besides the procedures mentioned here, the
double-­step sliding technique [10]. chin region can also be corrected with augmenta-
tion materials up to individualized implants.

4.7 Chin Wing Osteotomy

5 Conclusions
The chin wing osteotomy is performed as an
aesthetic correction not only of the chin but In this part, the common surgical techniques for
also of the mandibular lower margin, either replacement of the mandible are presented [1, 2,
only in the front part of the lower margin or it 12]. Whenever possible, an osteotomy in the
4 Definition of Standard Procedures 37

r­etromolar region (BSSO) will always be pre- mandibular prognathism and reshaping the chin. Part
I. Oral Surg Oral Med Oral Pathol. 1957;10:677–89.
ferred over segmental osteotomies because they 2. Dal Pont G. L'osteotomia retromolare par la converzi-
carry more risks and offer significantly fewer one della progenia. Minerva Chir. 1959;14:1138.
correction options. Special forms of osteotomies 3. Wolfe SA, Berkowitz S. Plastic surgery of the facial
in the region of the ascending mandibular ramus, skeleton. Little Brown; 1989.
4. Kashani H, Rasmusson L. Osteotomies in orthogna-
the inverted L osteotomy and the inverted vertical thic surgery. In: Hosein M, Motamedi K, editors. A
ramus osteotomy (IVRO) are discussed in detail textbook of advanced Oral and maxillofacial surgery,
in part VII. The chin osteotomy is a procedure vol. 3. IntechOpen; 2016.
often used to correct asymmetries in the frontal 5. Michel C, Reuther J. Orthopädische Chirurgie. In:
Hausamen E, Machtens E, Reuther J, editors. Mund-,
but lateral view on the patient. Genioplasties can Kiefer- und Gesichtschirurgie. Operationslehre und
be used alone or in combination. Atlas. Springer; 1995.
Knowledge of the long evolution of osteotomy 6. Karun V, Agarwal N, Singh V. Distraction osteogen-
techniques in the context of orthognathic surgery esis for correction of mandibular abnormalities. Nat l
J Maxillofac Surg. 2013;4(2):206–13.
in the mandible facilitates understanding of the 7. Harris M, Reynolds IR. Fundamentals of orthognathic
BSSO as the standard and basic technique for all surgery. Saunders; 1991.
orthognathic correction procedures. Classification 8. Hoenig JF. Sliding osteotomy genioplasty for facial
and definition of diagnosis-related treatment aesthetic balance: 10 years of experience. Aesthet
Plast Surg. 2007;31(4):384–91.
options creates systematics in patient handling, 9. Joos U, Delaire J, Scheibe B, Schilli W. Funktionelle
but also in training as well as comparability of Aspekte der Kinnplastik. Fortschr Kiefer Gesichtschir.
results. 1981;26:86.
On this basis, complementary and alternative 10. Wiese KG. Extreme chin advancement with tan-
dem genioplasty. Mund Kiefer Gesichts Chir.
treatments can be understood. Also, the combina- 1997;1(1):105–7.
tion with other technical procedures, but also the 11. Triaca A, Brusco D, Guijarro-Martínez R. Chin wing
limitations of monomaxillary treatments, become osteotomy for the correction of hyperdivergent skel-
clear. etal calss III deformity: technical modification. Br J
Oral Maxillofac Surg. 2015;53(8):775–7.
12. Dal Pont G. Retromolar osteotomy for the correction
of prognathism. J Oral Surg. 1961;19:42–7.
References
1. Trauner R, Obwegeser HL. The surgical correction of
mandibular prognathism and retrognathia with consid-
erations of genioplasty. Surgical procedures to correct
 Part II
Ramus Split Osteotomies / Bilateral
Sagittal Split Osteotomies
(BSSO) - General Planning
 The Patient
5
Veronique C. M. L. Timmer, Peter Kessler,
and Nicolas Hardt

Contents
1 Intake  42
2  linical Examination and Photo Documentation 
C 42
2.1 Examination of the Face from Top to Bottom  43
3  ental Examination 
D 49
3.1 A dditional Clinical Examination  49
3.2 How to Proceed  49
3.3 Facebow  50
4 Conclusion  50
Further Reading  50

Abstract face but are less accurate in depicting soft tis-

sues. However, soft tissue evaluation and pre-
An accurate orthognathic planning is based on
diction of soft tissue changes after surgery are
a combination of clinical examination, imag-
essential to obtain a satisfying end result for
ing, and facial analysis. Röntgen imaging com-
the patient as well as for the surgeon.
monly used for orthognathic diagnosis and
Therefore, physical examination and anal-
planning includes conventional X-rays or cone-
ysis of the facial soft tissues remain a funda-
beam computerized tomography (CBCT).
mental step in orthognathic planning. This
Especially CBCT can reproduce an accu-
chapter will discuss the chronological steps of
rate visualization of the bone structures of the
planning in orthognathic surgery. The fre-
quently used radiologic imaging modalities
V. C. M. L. Timmer (*) · P. Kessler (*) and their technical background and clinical
Department of Cranio-Maxillofacial Surgery, indications will be briefly evaluated.
Maastricht University Medical Center,
Maastricht, The Netherlands
e-mail: [email protected]; Keywords
[email protected]
Patient · Intake · Clinical examination · Photo
N. Hardt (*)
documentation · Radiology · Basic measure-
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland ments · Panoramic radiograph · Lateral

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 41

P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_5
42 V. C. M. L. Timmer et al.

cephalogram · Cone-beam computerized • Are the wishes of the patient realistic and can
tomography (CBCT) · Cephalometric we meet their expectations?
analysis · Facial analysis · Soft tissue analysis
· Computer-based planning · General plan- The motivation of the patient needs to be taken
ning · 2D-Planning · 3D-Planning · into account to achieve a good end result where
Simulation surgery · Preoperative assessment the patient is satisfied and happy with.
· Preparations for the surgical procedure

2 Clinical Examination
1 Intake and Photo Documentation

The first step of the planning process already Close observation of the face and profile pro-
starts with the intake of a new patient. For every vides a prediction of which jaw movements
surgeon, it is essential to discover the motivation need to be made during surgery. It is preferable
of the patient to undergo invasive surgery. Few that the orthognathic planner has seen the
question examples to ask the patient and patient himself rather than relying solely on
yourself: photo documentation. The photographer’s abil-
ity to obtain standardized and reproducible pho-
• Any functional problems involving speaking tographs is critical to planning accurate surgical
or eating? jaw repositioning.
• Problems with breathing or apnea? An experienced photographer can provide
• Complaints about joint pain? reliable photographs suitable for planning, but a
• Is the motivation for surgery more related to less experienced photographer can produce pho-
the esthetics of the face? tographs that lead to critical planning errors.

Fig. 5.1 Natural head position, frontal view

5 The Patient 43

Photo documentation and evaluation of the –– Are there any severe asymmetries present
face should always be done in a standardized way that may suggest craniofacial deformities?
with the patient in natural head position, ears vis- • The rule of thirds
ible, and the patient should not wear jewelry dur-
ing the photo shoot. Horizontal lines divide the face into three sections
which are ideally equal in vertical height (Fig. 5.2).
• The natural head position is a position of the
head with the patient standing straight and –– The upper border of the face is indicated by
looking straight to a point in the distance or to the hair line.
him/herself in the mirror (Fig. 5.1). –– The second horizontal line is indicated by the
eyebrows/glabella.
–– The third horizontal line is indicated by the
2.1 Examination of the Face alar base of the nose and subnasal point.
from Top to Bottom –– The lower border of the face is indicated by
the edge of the chin (menton point).
Frontal (portrait) position with closed lips, both
ears visible: The lower facial third can be divided by a hori-
zontal line through the lips. The height of the upper
• Assess the overall harmony of the face. lip to the subnasal point should ideally be 50% of
–– Do the proportions of the face look the lower lip height to the menton point (Fig. 5.3).
natural?
–– What is the shape of the face? (long, short, • Facial midline
broad)

Fig. 5.2 Rule of thirds

44 V. C. M. L. Timmer et al.

Fig. 5.3 Analysis of the lower facial third

Fig. 5.4 Facial midline

5 The Patient 45

The facial midline is a vertical center line through The rule of five
the glabella/nasion and subnasal point. The philtrum The face can be divided vertically into five
can be used as an anatomical landmark when there is equal sections (Fig. 5.5).
no asymmetry as in cleft lips, e.g. (Fig. 5.4). In a well-proportioned face:
Assess the following anatomical landmarks:
Deviation of the tip of the nose (pronasale). • The intercanthal width should be even to the
Deviation of the chin point (pogonion). width of the eyes (medial to lateral canthus).
Compare left and right orbito-zygomatic • The nose and chin should be positioned in the
complex. center section of the five.
Position of the eyebrows, eyes, ears, nose, and • The width of the alar base is ideally as wide as
mouth. or a bit wider than 1/5 of the face.
• The mouth is positioned in the center section.
Note
• The width of the mouth should equal the inter-
pupillary distance.
Be aware that every individual face has
slight asymmetries.

Fig. 5.5 Rule of five

46 V. C. M. L. Timmer et al.

Fig. 5.6 Photo relaxed upper lip position with close-up

• Frontal position with relaxed soft tissues Frontal position when smiling and showing
where the lips are slightly parted: teeth:
• Assess the relation of the upper lip to the front Assess the relation of the upper lip to the
teeth. The dental show with relaxed facial tis- upper front teeth: The dental show when smiling
sue should be around 1–2 mm (Fig. 5.6). should ideally be 9–10 mm, but is dependent on
• Assess the dental midline of the upper teeth. the length of the crowns (Fig. 5.7).
5 The Patient 47

Fig. 5.7 Frontal portrait with a smile

Gummy smile. • Profile position in 90° with relaxed soft tissues

Dental midlines of upper and lower teeth. (Fig. 5.8).
Occlusal canting. (45° profile pictures can be added as well):
Evaluate the following structures:

Tip • Profile shape: convex, concave, straight.

Occlusal canting can be evaluated using a • Skeletal relation of the mandible and maxilla.
wooden spatula. The spatula is placed hori- • Mandibular angle.
zontally in occlusion at the height of the • Projection of infraorbital rim.
premolars. Check the cervical region of the • Projection and shape of the nose.
cuspids and premolars besides the tips of • Projection of the lips, competence and
the teeth; the tips of the cuspids can be support.
worn down and may affect the accuracy of • Projection of the chin.
your observation. • Soft tissues, muscle tension.
48 V. C. M. L. Timmer et al.

Fig. 5.8 Profile 90° and 45°

5 The Patient 49

3.1 Additional Clinical

Note Examination
Be aware of a “Sunday-bite”: a habitual
forward posturing of the mandible to • Dental impressions or intraoral scans of the
compensate the sagittal deficit in upper and lower teeth.
overjet. • Bite registration in centric relation with a thick
wax bite. The bite registration can also be taken
with the intraoral scanner. The centric relation
is a reproducible mandibular position with the
3 Dental Examination condyles in the most superior-posterior posi-
(Fig. 5.9) tion in the fossa and the teeth in occlusion.

• Dental hygiene and general condition of the

gum and teeth. 3.2 How to Proceed
• Number of teeth present.
• Occlusion: angle classification. • No assistance of the patient when trying to
• Deep bite/palate bite, traumatic bite, open find the right occlusion.
bite. • Guide the chin with one hand on the chin point
• Cross bite. and the other hand on the head of the patient
• Midline shift. (chin point guidance technique).
• Dental compensation. • The patient needs to be in an upright seated
position.

Fig. 5.9 Occlusion and dental arches

50 V. C. M. L. Timmer et al.

3.3 Facebow Further Reading

With a single jaw mandibular osteotomy, precise Meneghini F, Biondi P. Clinical facial analysis. Springer-­
Verlag Berlin Heidelberg; 2021.
model surgery planning using a facebow and ana- Proffit WR, Raymond P, White RP, Sarver
tomical articulator is not required. DM. Contemporary treatment of dentofacial defor-
mity. India: Elsevier; 2012.
Steinhäuser EW, Janson I. Kieferorthopädische Chirurgie,
Eine interdisziplinäre Aufgabe, Band I. Quintessenz-­
4 Conclusion Verlag GmbH. 1988;

The quality of the preoperative preparation deter-

mines the success of the treatment. The surgeon
must be familiar with the individual planning
steps in order to be able to implement them intra-
operatively. An essential part of the planning is
the cephalometric analysis.
 Radiology and Basic
Measurements
6
Veronique C. M. L. Timmer, Peter Kessler,
and Nicolas Hardt

Contents
1  adiological Imaging
R 52
1.1 P anoramic X-Ray 52
1.2 L  ateral Cephalometric X-Ray 52
1.3 Cone-Beam Computed Tomography (CBCT) 53
1.4 Multi-Slice Computed Tomography (MSCT) 55
1.5 CT-Based Distance Measurements in the Pre-­Masseteric Region (Buccal
Osteotomy) 55
1.6 CT-Based Distance Measurements in the Region of the Mandibular Angle 56
2 Conclusion 57
References 57

Abstract
• The panoramic radiograph (panoramic X-ray).
Radiological imaging is an adjunct to the clin- • The lateral cephalometric X-ray of the skull.
ical examination. Imaging is needed to obtain • The cone-beam computed tomography
a complete picture of the patient, to provide (CBCT).
precise and individualized planning, and to
detect hidden pathologies. Occasionally the multi-slice computed
The standard preoperative radiological exam- tomography (MSCT).
ination and assessment before a planned surgical
treatment in the orthognathic surgery includes: Keywords

Radiology · Basic measurements · Panoramic

V. C. M. L. Timmer (*) · P. Kessler (*) radiograph · Lateral cephalogram · Cone-
Department of Cranio-Maxillofacial Surgery, beam computerized tomography (CBCT) ·
Maastricht University Medical Center, Cephalometric analysis · Facial analysis ·
Maastricht, The Netherlands
e-mail: [email protected];
Soft tissue analysis · Computer-based
[email protected] planning · General planning · 2D Planning ·
N. Hardt (*)
3D Planning · Simulation surgery ·
Kantonsspital Lucerne, Clinic and Policlinic of Preoperative assessment · Preparations for the
Cranio-Maxillofacial Surgery, Lucerne, Switzerland surgical procedure

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 51

P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_6
52 V. C. M. L. Timmer et al.

1 Radiological Imaging The panoramic X-ray is not used in the actual

orthognathic planning process concerning the
1.1 Panoramic X-Ray positioning of the jaws, but it can easily be used
for postoperative follow-up imaging (Fig. 6.4).
The panoramic X-ray is a standardized diagnostic
tool in preoperative screening of maxillofacial
patients. It gives a general overview of the develop- 1.2 Lateral Cephalometric X-Ray
ment of the teeth, the presence of third molars, and
dental pathology, such as root resorption or periapi- The lateral cephalometric X-ray represents a lat-
cal lesions. Furthermore, it shows basic informa- eral view of the whole skull (Fig. 6.5). The X-ray
tion about the mandibular shape, TMJ morphology, is taken with the patient in a standardized repro-
and the mandibular canal (Figs. 6.1, 6.2, 6.3, 6.4). ducible position, perpendicular to the X-ray
Radiological findings can alter the course of beam: in natural head position with the patient
the original surgery planning. For example, exist- looking straight forward to a point in the far dis-
ing M3s in the mandible are preferred to be tance with relaxed facial soft tissues.
removed before BSSO to decrease the risk of a The lateral cephalometric images are used in
bad split during surgery. Any other hidden pathol- orthodontics for cephalometric analysis, tracing,
ogy revealed on panoramic X-ray, like mandibu- and follow-up of the development of the jaws and
lar cysts or periapical granuloma, should be teeth during orthodontic treatment.
properly treated before undergoing elective
orthognathic surgery.

Fig. 6.3 A preoperative panoramic X-ray of a patient

with an evident left midline-shift of the mandible. Note
the changes in the bone structure of the right condylar
head. A possible unilateral condylar hyperplasia or other
Fig. 6.1 A preoperative panoramic X-ray of an orthog- (TMJ) pathology should be excluded before orthognathic
nathic patient with partially impacted third molars. Ideally correction of the mandibular asymmetry can be planned
the wisdom teeth need to be removed before the BSSO is
performed to reduce the risk of a bad split during surgery

Fig. 6.4 A postoperative panoramic X-ray of a patient

after BSSO treatment with advancement of the mandible.
Fig. 6.2 A preoperative panoramic X-ray of an orthogna- The osteotomy lines on both sides of the mandible are
thic patient showing an accidental finding [1] (should be clearly visible and the osteosynthesis material can be eval-
further investigated before any orthognathic surgery will uated. The condyles are both positioned in the mandibular
be performed) fossa
6 Radiology and Basic Measurements 53

a b

Fig. 6.5 Two examples of preoperative lateral cephalometric X-rays: (a) Patient with a skeletal class II and deep bite
based on mandibular hypoplasia (b) Patient with a skeletal class III based on a mandibular hyperplasia

Important items to evaluate on a lateral cepha- of the position and course of the mandibular
lometric X-ray for the orthognathic surgeon: canal. The data set is a prerequisite for three-­
dimensional planning in any planning program.
• The sagittal relationship of the maxilla and Furthermore, the CBCT images allow the
mandible to the skull base before and after assessment of skeletal anomalies and asymme-
surgery. tries in a coronal, transversal, and sagittal plane,
• The angulation of the maxilla and mandible to which cannot be achieved with conventional
each other and to the skull base. X-rays (Fig. 6.6). Cone-beam data sets also allow
• The angulation of the mandibular angle. for the evaluation of the soft tissue structures of
• The angulation of the incisors according to the the face so that the gain of information by the
base of upper and lower jaw. CBCT is invaluable. From this and medicolegal
• Soft tissue analysis with the focus on the pro- point of view, a three-dimensional skull or jaw
jection of the nose, lip position, and chin. X-ray should be considered obligatory.

1.3 Cone-Beam Computed Note

Tomography (CBCT) The CBCT-based preoperative visualization
of the prospective osteotomy area allows the
The CBCT is widely used for the tomographic surgeon an individual risk assessment and
and three-dimensional evaluation of possible risk management with regard to technique
norm deviations of osseous dento-maxillofacial and procedure of the osteotomy.
structures and for the closer differentiation of It also facilitates the preoperative infor-
pathological findings such as the three-­ mation of the patient about possible diffi-
dimensional position of the wisdom teeth. Other culties and complications during the
dental and skeletal anomalies can be visualized intervention.
such as supernumerary teeth or the determination
54 V. C. M. L. Timmer et al.

Fig. 6.6 Determination of the mandibular canal from the post molar region to the first molar on the right mandibular
side
6 Radiology and Basic Measurements 55

1.4 Multi-Slice Computed In 29 % <= 2mm

Tomography (MSCT) In 45 % <= 3mm
In 14 % <= 4mm
In 7 % <= 5mm
In some rare cases of complex dysgnathias, In 5 % > 5mm
severe facial asymmetries, and patients suffering
from soft or hard tissue deficits, a MSCT scan
can be indicated. For intraoperative navigation
thin-slice MSCT’s deliver the best quality data. lingual buccal
In asymmetric cases and cases with hard tissue
deficits, MSCT data can be used to analyze
changes in the shape, size, and volume of osse-
ous, but also soft tissue structures. IAN
MSCT delivers the best quality data in the
evaluation and measurement of the prospective Fig. 6.7 Distance measurement of cancellous bone thick-
mandibular osteotomy region, with regard to the ness between the mandibular canal and the buccal cortex
bone quality, transverse extension of the man- in the inferior region of the buccal vertical osteotomy
(IAN = inferior alveolar nerve)
dibular body, the width of the buccal and lingual
mandibular cortico-cancellous bone, and the
cortex and the mandibular canal vary between 7.0
position and intrabony course of the inferior alve-
and 1.5 mm and correspond to the existing can-
olar nerve (IAN). With standard X-rays, state-
cellous bone thickness between the two struc-
ments or measurements in the transverse plane
tures (Figs. 6.7, 6.8) [2].
are impossible.
The mean distance is 2.9 mm with a standard
The use of computerized tomographic X-ray
deviation of ±1.2 mm. In detail, the distance-­
techniques in the jaws allows the exact definition
maintaining cancellous bone layer between the
and marking of position and course of the man-
mandibular canal and buccal cortex is:
dibular canal, as well as the distance between the
mandibular canal and the buccal cortex. • In 29% ≤ 2 mm.
The width of cancellous bone between the • In 45% ≤ 3 mm.
mandibular canal and the buccal cortex is essen- • In 14% ≤ 4 mm.
tial for the exact planning of the buccal vertical • In 7% ≤ 5 mm.
osteotomy (Fig. 6.6). • 5 mm.
This precise control of the individual nerve
course on the one hand and the relationship of the
IAN to the surrounding cortico-cancellous struc-
tures on the other hand allows an individual risk Note
assessment of possible nerve injuries caused by The distances between the mandibular
surgical splitting. This and the fact that CBCT or canal and the buccal cortex are small and
MSCT’s in particular are required as the basis for variable in the pre-angular and angular
computer-based planning make three-­dimensional region of the mandible [2, 3].
X-rays indispensable today. In the inferior region of the buccal verti-
cal osteotomy there is on average only a
narrow cancellous bone zone between the
1.5 CT-Based Distance nerve canal and the buccal cortex.
Measurements in the Pre-­ The average mean value of the cancel-
Masseteric Region (Buccal lous bone layer is 2.9 mm +/−1.2 mm. In
Osteotomy) 58%, the thickness of the cancellous bone
layer is between 2 and < 4 mm and in 45%
At the caudal end of the buccal vertical osteot- it is < 3 mm.
omy, the metric distances between the buccal
56 V. C. M. L. Timmer et al.

1.6 CT-Based Distance area of the cranial osteotomy zone on the lingual
Measurements in the Region side of the ascending ramus starting at the lowest
of the Mandibular Angle point of the mandibular foramen in 2 mm inter-
vals down to 22 mm inferior to the foramen led to
Serial preoperative horizontal CT-based mea- the following result:
surements of the distance between the mandibu-
lar canal and the external buccal cortex in the • In 25% of the cases the mandibular canal was
in direct contact with the lateral cortical
30 bone.
• In 75% there was no direct contact between
25 the mandibular canal and the lateral buccal
20 cortex (p < 0.05).
15
The vertical contact area between the lat-
10 eral, external cortex and the canal varied
between 2 and 18 mm (average 10.6 ± 4.9 mm)
5
(Fig. 6.9).
0
<2mm <3mm <4mm <5mm <5mm

Fig. 6.8 Distance measurement between mandibular

canal and buccal cortex in mm in the inferior region of the
buccal vertical osteotomy (n = 58) [2]

Fig. 6.9 Relationship of the mandibular canal to the lateral cortex of the mandibular ramus [1, 4–6]. ©Copyright
Keisuke Koyama 2020. All rights reserved
6 Radiology and Basic Measurements 57

2 Conclusion taler Ramusosteotomie des Unterkiefers. Mund Kiefer

Gesichtschir. 2004;8(1):18–23.
3. Bell HW, Proffit WR, White RP. Surgical correction
Radiographic analysis is a condition sine qua non of dentofacial deformities, vol. 1–3. Saunders; 1980.
for surgery in general and orthognathic surgery in 4. Huang CY, Yu-Fang L. Anatomical position of the
particular. The basis and standard of careful plan- mandibular canal in relation to the buccal cortical bone
in Chinese patients with different dentofacial relation-
ning are three-dimensional imaging procedures. ships. J Formos Med Assoc. 2016;115(11):981–90.
Two-dimensional X-ray photos are taken for 5. Rich J, Golden BA, Phillips C. Systematic review of
overview and rough orientation. preoperative mandibular canal position as it relates to
postoperative neurosensory disturbance following the
sagittal split ramus osteotomy. Int J Oral Maxillofac
Surg. 2014;43(9):1076–1081. Thieme, Stuttgart.
References 6. Yoshioka I, Tanaka T, Khanal A, Habu M, Kito S,
Kodama M, Oda M, Wakasugi-Sato N, Matsumoto-­
1. Yamamoto R, Nakamura A, Ohno K, Michi Takeda S, Fukai Y, Tokitsu T, Tomikawa M, Seta Y,
K. Relationship of the mandibular canal to the lat- Tominaga K, Morimoto YJ. Relationship between
eral cortex of the mandibular ramus as a factor in the inferior alveolar nerve canal position at mandibular
development of neurosensory disturbance after bilat- second molar in patients with prognathism and pos-
eral sagittal split osteotomy. Oral Maxillofac Surg. sible occurrence of neurosensory disturbance after
2002;60(5):490–5. sagittal split ramus osteotomy. Oral Maxillofac Surg.
2. Pilling E, Schneider M, Mai R, Eckelt U. Präoperative 2010;68(12):3022–7.
Lagebestimmung des Canalis Mandibulae vor sagit-
 General Planning
and Preoperative Assessment
7
Veronique C. M. L. Timmer, Peter Kessler,
and Nicolas Hardt

Contents
1 2D Cephalometric Analysis 60
1.1 Tracing 60
1.2 Marking of Anatomical Landmarks and Planes 60
1.3 Analysis 60
1.3.1 Important Angles Used for Measuring Skeletal Relations 61
1.3.2 Important Angles Used for Measuring Dental Relations 61
2 Soft Tissue Analysis 61
2.1 Planning 62
2.1.1 Mandibular Retrognathism. 62
2.1.2 Mandibular Prognathism and Maxillary Retrognathism. 63
2.1.3 Mandibular Retrognathism and Maxillary Prognathism. 63
3 3D Imaging and 3D Planning 64
3.1
Using Virtual Surgery Planning 64
3.2 Summary of the Advantages of 3D Imaging and 3D Planning 65
4 Conclusion 66
References 66

Abstract

After clinical diagnosis and evaluation of the

current situation of the patient’s face, profile,
and dentition, the surgeon must decide which
treatment procedure will be necessary. Will one-
V. C. M. L. Timmer (*) · P. Kessler (*) jaw surgery be sufficient to achieve the desired
Department of Cranio-Maxillofacial Surgery, final result, or is it better to perform corrective
Maastricht University Medical Center,
surgery in both jaws? And if correction in one
Maastricht, The Netherlands
e-mail: [email protected]; jaw is sufficient, should the surgery be per-
[email protected] formed in the upper or lower jaw? The surgical
N. Hardt (*) plan, which includes the actual movements of
Kantonsspital Lucerne, Clinic and Policlinic of the jaw, provides guidance during surgery and a
Cranio-Maxillofacial Surgery, Lucerne, Switzerland prediction of the final result. A 2D cephalomet-

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 59

P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_7
60 V. C. M. L. Timmer et al.

ric analysis on the lateral cephalogram is per- • Nasion (N): Most anterior point of the naso-
formed to predict the sagittal transposition of frontal suture.
the bony structures. Three-dimensional analysis • Sella (S): Center of Sella turcica.
is used to prepare for surgery. • Basion: Most caudal point of the clivus.
• Articulare (Ar): Intersection point of the skull
Keywords base with the dorsal contour of the mandibular
Clinical examination · Diagnosis · Photo ascending ramus.
documentation · Radiology · Basic measure- • A-point (A): Deepest point in the anterior con-
ments · Panoramic radiograph · Lateral tour of the superior alveolar process.
cephalogram · Cone beam computerized • B-point (B): Deepest point in the anterior con-
tomography (CBCT) · Cephalometric analysis · tour of the inferior alveolar process.
Facial analysis · Soft tissue analysis · • Pogonion (Pg): Most anterior point of the chin
Computer-based planning · General planning · bone.
2D Planning · 3D Planning · Simulation • Gnathion (Gn): Most caudal point of the man-
surgery · Preoperative assessment · dibular symphysis.
Preparations for the surgical procedure • Gonion angle (tgo): Intersection point of
ramus line and mandibular line.
• Anterior nasal spine (ANS): Most anterior
point of the maxilla.
1 2D Cephalometric Analysis • Posterior nasal spine (PNS): Most
posterior point of the posterior nasal spine/
1.1 Tracing maxilla.
• Infraorbitale (Io): Most caudal point of the
The analysis starts with a tracing of the anatomi- infraorbital rim.
cal structures on the lateral cephalometric X-ray: • Is: Most anterior point of the upper central
incisor.
• Bone structures including sella turcica, nasal • Isa: Apex of the upper central incisor.
bone, orbit, maxilla, and mandible. • Ii: Most anterior point of the lower central
• Soft tissue structures including forehead, incisor.
nose, lips, chin, and anterior neck. • Iia: Apex of the lower central incisor.
• Teeth: First molar and central incisor in upper • Axis through Is and Isa.
and lower jaw. • Axis through Ii and Iia.

Most important planes for cephalometric

1.2 Marking of Anatomical analysis:
Landmarks and Planes
• NSL: Nasion-Sella Line: Horizontal line con-
The cephalometric analysis in orthognathic sur- necting Sella with Nasion.
gery includes a reduced number of reference • NL: Nasal line: Horizontal line connecting
points and lines for surgical necessities compared ANS (Sp) with PNS (Pm).
to the orthodontic analysis [1, 2]. • ML: Mandibular line: Horizontal line con-
Evaluation of the lateral cephalometric X-ray necting Gonion with Gnathion.
of the skull of a patient in central/habitual occlu-
sion (eugnathia, Angle Class I). The essential
dentoalveolar and skeletal reference points and 1.3 Analysis
lines as well as the ratio of upper and lower osse-
ous facial height show standard values. The Segner-Hasund analysis (1991) has proven
Most important cephalometric landmarks: itself for planning in orthognathic surgery:
7 General Planning and Preoperative Assessment 61

1.3.1 Important Angles Used

for Measuring Skeletal
Relations
• SNA: Sagittal relation of the maxilla related to
the skull base. Evaluates the amount of pro−/
retrognathism of the maxilla.
• SNB: Sagittal relation of the mandible related
to the skull base. Evaluates the amount of
pro−/retrognathism of the mandible.
• ANB: Angulation between the sagittal posi-
tion of the maxilla and mandible.
• SNPg: Sagittal relation of the chin related to
the skull base.
• Mandibular angle: Angulation of the ascend-
ing mandibular ramus related to the lower
mandibular border. Evaluates the vertical
growth of the mandible: long face/short face.
• ML-NL: Angulation between the mandibular
and maxillary bases: a large angle is related to
open bite, a small angulation is related to deep
bite.
• ML-SNL: Angulation between the mandibular Fig. 7.1 The projection of soft tissue landmarks to the
base and the skull base. true vertical line (TVL). The distance between the land-
• NL-SNL: Angulation between the maxillary marks and TVL is measured horizontally and compared to
standardized mean values. Soft tissue landmarks named
base and the skull base. are glabella (G’), soft tissue orbital rim (OR’), nasal tip
(NT), soft tissue A’ point (A’), upper lip anterior (ULA),
1.3.2 Important Angles Used lower lip anterior (LLA), soft tissue B′ point (B′), and soft
for Measuring Dental Relations tissue pogonion (Pg’) ©Copyright Keisuke Koyama 2020.
All rights reserved
• NL–Is: Angulation of upper incisor to maxil-
lary base, proclination/retroclination of the
upper incisors. esthetic line according to Ricketts [3], H-line—
• ML–Ii: Angulation of the lower incisor to harmony line according to Holdaway [4, 5], or
mandibular base, proclination/retroclination the soft tissue analysis according to Schwarz [6].
of the lower incisors. These soft tissue analyses are based on the
• Is–Ii: Vertical angulation between the axis of Frankfurt horizontal plane or the cranial base,
upper and lower incisor. which can differ evidently among patients.
The more recently developed true vertical line
(TVL) analysis is based on the use of the natural
2 Soft Tissue Analysis head position and a true vertical through the sub-
nasal soft tissue point perpendicular to the natu-
In contrast to the analysis of the bony base, which ral head position (Fig. 7.1).
is based on internationally recognized landmarks The projection of the soft tissue landmarks to
and analysis procedures, soft tissue analysis is the TVL are measured horizontally. The individual
subject to sociocultural and genetic-ethnic influ- values should be compared to the standardized val-
ences. Various concepts are applied, which can- ues of the socio-ethnic group the patient belongs to.
not be said to be universally valid. Independent of which soft tissue analysis is
Several recognized analytical methods are used, it should always be taken into account that
used: S-line according to Steiner, E-line— the bone movement of the jaws does not result in
62 V. C. M. L. Timmer et al.

a 1:1 ratio soft tissue movement. Furthermore, means of a surgical simulation using plaster mod-
soft tissue thickness and dentoskeletal factors els of the teeth rows. By measuring the difference
such as the orthodontic positioning of the upper in distance between the old and the new position
and lower incisors also play an important factor of the jaws, the surgeon can check the new posi-
in the outcome of facial profile and esthetics. Soft tion of the jaws pre- and later intraoperatively
tissue analysis should always be combined with before osteosynthetic fixation.
clinical examination and cephalometric analysis. During planning, the surgeon must always have
the esthetic aspects of the patient in mind in order
to transfer the skeletal movements to the face.
2.1 Planning Examples of cephalometric analyses with
regard to the planning of surgery:
The size of the aforementioned angles and addi-
tional vertical and horizontal relational determi- 1. Mandibular retrognathism—Fig. 7.3.
nations are compared to standardized reference 2. Mandibular prognathism with maxillary ret-
measurements based on mean values, which must rognathism—Fig. 7.4.
be consistent with the age, gender, and ethnicity 3. Mandibular retrognathism and maxillary
of the patients. The Asian population has differ- prognathism—Fig. 7.5.
ent facial morphology than the European or
African population (Fig. 7.2). 2.1.1 Mandibular Retrognathism.
Men and women also differ in facial propor- Figure 7.3 As a consequence of the cephalomet-
tions. This should be taken into account in plan- ric analysis, for later surgical planning skeletal
ning. Based on this information, the new—in the harmonization will prospectively be achieved by
best case ideal—position of the lower and/or correction of the mandibular base. This is
upper jaw can be calculated and planned by achieved by anterior displacement of the lower

Fig. 7.2 The TVL in the individual patient’s profile photodocumentation in a European and Asian face
7 General Planning and Preoperative Assessment 63

Fig. 7.3 Mandibular retrognathism with Angle Class II Fig. 7.5 Mandibular retrognathia and maxillary protrusion
occlusion with a retrusive jaw base relation and relatively in a patient with Angle Class II malocclusion with a wide
harmonious vertical jaw base relation: distal occlusion, sagittal step (overjet) and a deep bite vertically and a sagittal-
retrusive occlusion, increased vertical overbite distal, vertically slightly open jaw base relation©Copyright
©Copyright Keisuke Koyama 2020. All rights reserved Keisuke Koyama 2020. All rights reserved

jaw, combined with a simultaneous correction of

the pogonion, if necessary.

2.1.2 Mandibular Prognathism

and Maxillary Retrognathism.
Figure 7.4 As consequence of the cephalometric
analysis, the necessity of a bimaxillary skeletal
jaw base harmonization can be derived for treat-
ment planning. This should be achieved by ven-
tral (anterior) repositioning of the upper jaw and
a dorsal (posterior) displacement of the lower jaw
simultaneously combined with a reduction of the
pogonion, if necessary.

2.1.3 Mandibular Retrognathism

and Maxillary Prognathism.
Figure 7.5 As a consequence of the cephalometric
analysis, the necessity of skeletal harmonization in
the maxillary and mandibular base area arises for
Fig. 7.4 Cephalometric tracing of a patient with mandibu- treatment planning. In the upper jaw, however,
lar prognathism and maxillary retrognathia in a patient with only a dorsal and cranial displacement in the ante-
an Angle Class III occlusion and anterior open bite and a
rior region may be necessary (segment). At the
more horizontally directed sagittal-mesial growth pattern
with vertically open jaw base relation (vertical malocclu- same time, the lower jaw should be shifted ven-
sion) ©Copyright Keisuke Koyama 2020. All rights reserved trally by means of a BSSO. The vertical changes
64 V. C. M. L. Timmer et al.

can be insignificant in terms of interbasal relation tain facial deformities or craniofacial syndromes.
and of upper and lower facial height ratio However, due to difficult accessibility and high
costs, these imaging modalities are not suitable for
routine imaging in orthognathic surgery planning.
3 3D Imaging and 3D Planning The CBCT is the most accessible 3D imaging
tool for the general OMF surgeon and available
Performing orthognathic surgery on a patient in private dental and orthognathic practices. By
means movement of the maxilla or mandible in combining CBCT data with intraoral scanning
three dimensions: tools, the entire orthognathic planning process
can be performed in a virtual 3D environment
• Translation in the sagittal, vertical, and trans- without the need for dental models and articula-
vers plane. tors. The analysis of the preoperatively planned
• Rotational movements around the sagittal, movements of the osteotomized bone segments
vertical, and transverse axis, described as of the maxilla and mandible, the simulation of
pitch, roll, and yaw. the operation, increases the intraoperative accu-
racy and the predictability of the results [7–9].
If you use two-dimensional imaging as a basis
for planning, you will never get a true representa-
tion of a real three-dimensional object like the 3.1 Using Virtual Surgery Planning
skull and not all three-dimensional movements
can be realistically planned and predicted. • The desired osteotomy lines can be visualized
Within the spectrum of 3D imaging modalities, on a virtual 3D skull model (Fig. 7.6).
MSCT and magnetic resonance imaging (MRI) • The bone segments of the upper and lower jaw
have been available for years. Both modalities are can be brought into the desired position and
used in cranio-maxillofacial surgery to assess cer- the effect of this positioning on the treatment

a b

Fig. 7.6 An example of a 3D virtual planning of a bimaxillary osteotomy with genioplasty (a) frontal view (b) lateral view
7 General Planning and Preoperative Assessment 65

goal can be examined and if necessary In addition, the CBCT enables quality control
corrected. in postoperative imaging by comparing preopera-
• In rotational movements of the mandible the tive virtual planning with actual results. The
impact of flaring on the proximal segments actual fracture patterns of the osteotomy lines
and the TMJ can be visualized (Fig. 7.7). and the position of the condyles can be accurately
• Cephalometric analysis can be generated from assessed. The final result is compared with the
the 3D data set (Fig. 7.8). preoperatively planned positioning of the jaws.
• The virtual planning can be used for the pro- This allows the accuracy of translational and
duction of CAD/CAM interocclusal wafers. rotational movements of the bone and soft tissue
• Patient-specific implants (fixation plates) with structures to be controlled and planning improved.
individualized cutting and drill guides can be This improves the performance and results of
made. combined orthognathic planning and surgery. In
• 3D photographs of the face can be added to addition, the use of virtual planning software and
the planning software to visualize facial soft three-dimensional imaging allows us to easily
tissue changes before and after surgery. exchange data and improve communication
between the multiple involved practitioners
including the surgeon, orthodontist, and techni-
cian and to evaluate the teaching success of edu-
cational programs.

3.2 Summary of the Advantages

of 3D Imaging and 3D
Planning

• A realistic three-dimensional representation

of the anatomical structures of the face can be
obtained.
• A precise planning of all jaw movements in
the three-dimensional space of translation
Fig. 7.7 The rotation of the mandible will cause some (sagittal, transverse, and vertical) and rotation
flaring on the right sight: Note the overlap of the lingual (pitch, yaw, roll) is possible.
side of the mandibular segment with the distal mandibular • Precision in planning leads to more precision
segment
during surgery and to more predictable end
results.
• A virtual 3D procedure can be performed
without dental casts.
• Interocclusal wafers or waferless surgery with
drilling templates and patient-specific osteo-
synthesis plates can be generated using CAD/
CAM technology.
• 3D allows more accurate postoperative imag-
ing for the evaluation of osteotomy lines.
• The patient can be informed more adequately
about the surgical procedure. A pre- and post-­
operative simulation can be shown to give the
patient a better idea of the procedure and the
Fig. 7.8 3D cephalometric analysis final result.
66 V. C. M. L. Timmer et al.

• A comparison of the pre- and post-operative 2. Steinhäuser EW, Janson I. Kieferorthopädische

Chirurgie Bd. I. Berlin, Chicago, London, Sao Paulo,
situation can lead to new insights in planning Tokyo: Quintessenz; 1988.
and surgical techniques. 3. Ricketts RM. New persepectives on orientation and
• Teaching and communication are improved by their benefits to clinical orthodontics–part I. Angle
3D technology. Orthod. 1975;45(4):238–48.
4. Holdaway RA. A soft-tissue cephalometric analysis
and its use in orthognathic treatment planning. Part I
Am J Orthod 1983;84(1):1–28.
4 Conclusion 5. Holdaway RA. A soft-tissue cephalometric analysis
and its use in orthognathic treatment planning. Part II
Am J Orthod 1984;85(4):279–293.
The two-dimensional X-ray analysis is used for 6. Schwarz AM. Wie der angehende Kieferorthopäde
preparation and initial orientation. If the treating Gesicht und Schädel verstehen lernt. I. Auflage. Wien/
team and the patient decide to correct a dys- Innsbruck: Urban&Schwarzenberg; 1955.
gnathia for functional and esthetic reasons, three-­ 7. Ackerman L, Proffit WL, Sarver DM, Ackerman MB,
Martin RK. Pitch, roll, and yaw: describing the spatial
dimensional surgical planning is inevitable in orientation of dentofacial traits. J Orthod Dentofacial
order to keep the surgical risks of the procedure Orthop. 2007;131(3):305–10.
as small as possible and achieve the treatment 8. Segner D, Hasund A. Individualisierte Kephalometrie.
goal as good as possible. 3. Auflage. Hamburg: Segner; 1988.
9. Swennen GR, Schutyser J, Filip AC, Hausamen
JE. Three-Dimensional Cephalometry. A Color Atlas
and Manual. Springer; 2006.
References
1. Hardt N, Paulus GW. Kephalometrische Aspekte
bei der Korrektur von Gesichtsdeformitäten. In:
Mühlbauer W, Anderl H, editors. Kraniofaziale
Fehlbildungen. Stuttgart, New York: Thieme; 1983.
 Preparations for the Surgical
Procedure
8
Veronique C. M. L. Timmer, Peter Kessler,
and Nicolas Hardt

Contents
1  Short Guideline for the Patient Journey in Orthognathic Surgery 
A 68
1.1 The First Contact—Basic Analysis  68
2  ake a Thorough Medical History and Deliver Appropriate
T
Information  68
2.1 The Second Contact  68
2.2 The Third Contact  70
3  pecific Advice 
S 70
3.1 T he Week before Surgery  70
3.2 The Operation Day  70
3.3 Pre- and Perioperative Medication  70
4 Instructions at the End of Operation  71
5 Conclusion  71
Further Reading  71

Abstract ventions as well as possible, solid planning and

problem analysis is required. Only in this way
Orthognathic surgery is considered to be one of
can trust between patient and surgeon develop
the elective forms of treatment in most cases. In
and lead to a successful result. The necessary
order to ensure the safety of the extensive inter-
patient contacts must be well structured in
order to be able to work effectively and in a tar-
geted manner. The presence of an orthodontist
may be desirable in the initial phase.
V. C. M. L. Timmer (*) · P. Kessler (*)
Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center, Keywords
Maastricht, The Netherlands
e-mail: [email protected];
Patient · Patient contacts · Guidelines ·
[email protected]
Radiology · Computer-based planning ·
N. Hardt (*)
General planning · 2D-Planning ·
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland 3D-Planning · Simulation surgery ·

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 67

P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_8
68 V. C. M. L. Timmer et al.

Preoperative assessment · Preparations for the • Dental show when smiling: Does the patient
surgical procedure · Medication · Patient have a gummy smile?
journey · Postoperative Instructions • For sagittal displacement: Assess rotational
components in lateral view.
• Think of flaring in case of transversal
shifting—yaw?
1 A Short Guideline • Remember: With mandibular misalignment, a
for the Patient Journey sagittal component is often connected to a
in Orthognathic Surgery transverse one.
• Is a chin osteotomy necessary for aesthetic
1.1 The First Contact—Basic reasons?
Analysis

• Always be friendly and empathic! Most 2 Take a Thorough Medical

patients are a little scared. History and Deliver
• Look at the patient and the patient’s face from Appropriate Information
all sides to get a first impression: at rest and
while smiling. 2.1 The Second Contact
• Is the patient in orthodontic treatment?
• Is the patient sent for surgical preparation or Collection of all clinical parameters for orthog-
just seeking for information? nathic surgery (Fig. 8.1):
• Place a wooden spatula between the rows of
teeth and compare the occlusal plane with the • Clinical facial analysis and measurements in
bipupillary line: parallel? Cant? detail—anthropometry.
• Check the centerline of the jaws in relation to • Photo documentation.
the face. • Impressions or intraoral scan, wax bite in a
• Dental show: sufficient, too little, too much: relaxed head position.
2–3 mm crown length should be visible with • Evaluation of orthodontic pretreatment.
relaxed upper lip. • Radiological imaging.
8 Preparations for the Surgical Procedure 69

Fig. 8.1 Personal remarks as a reminder (in Dutch language)

70 V. C. M. L. Timmer et al.

2.2 The Third Contact • Patient is informed, hospital and OR know

about the planned procedure?
• Inform the patient and, if necessary, the • Patient-labeled implants, if necessary individ-
patient’s family and relatives about the treat- ually manufactured, have been delivered and
ment plan. Explain the procedure and show sterilized?
the treatment simulation. • Is the model surgery available digitally or on a
• Mention all relevant risks of a surgical inter- plaster model?
vention and also name alternatives or conse- • Are splints required and manufactured?
quences of not having the treatment. • Have splints been checked for accuracy?
• Explain the patient management—admission,
ward, transport, etc.—all around the surgical
treatment. 3.2 The Operation Day
• Send the patient to the preoperative anesthe-
siologic consultation. • Is the patient present?
• Check your records for completeness and • Is the patient fasting and ready to undergo the
assign an operation date after the patient has surgery?
documented his informed consent in an appro- • Is the surgical team present?
priate form. • The OR should be prepared, everyone in the
medical supply chain must be informed: ward,
transport, OR preparation, OR nurses, the
3 Specific Advice anesthesia team, the staff in the operating
room.
• Advise the patient to ensure healthy sleep for • The technical equipment must be prepared:
a few days before the procedure, not to con- Instruments and implants available.
sume alcohol or tobacco. This lifestyle should • The planning material needed to perform the
be maintained for at least 2 weeks after the operation must be in the operating room and
surgery. should be labeled to the patient—case
• Advise the patient that the intake of food will specific.
be more difficult after surgery. The patient • Briefing and time-out procedure with all rele-
will lose weight. vant professionals involved.
• Liquid and soft or softly cooked food should • The surgery begins with the induction of
be prepared for the first 2 weeks. anesthesia.
• After 2 weeks the patient can build up his or
her diet: Pasta, rice, boiled vegetables, pota-
toes, bread without hard edges, soft meat. 3.3 Pre- and Perioperative
• Dairy products are suitable but should only be Medication
recommended if good oral hygiene is
maintained. The patient should be able to
­ After anesthetic induction, a suitable, weight-­
enjoy normal diet after 6 weeks. adapted antibiotic is given and a single dose of
16 mg dexamethasone.

3.1 The Week before Surgery • Nasal intubation.

• Positioning of the patient, usually in supine
• Is the planning complete? Cephalometry position with head in the body axis, head not
done? Photos of good quality available? Does hanging in extension/flexion.
planning and patient match? • Disinfection of the surgical area and sterile
• Patient’s written consent to the procedure doc- covering.
umented? If underage: do the parents agree • Local anesthesia for BSSO: Para mandibular
with the operation? and lingual with a suitable dental local anes-
8 Preparations for the Surgical Procedure 71

thetic with vasoconstrictor, e.g., Ultracain-­ • Position head and upper body at least 30°
forte, 4 ampoules, two per side. high.
• Documentation of the incision. • Cool wound area: cool packs and individual
cooling masks are suitable.
• Start feeding with water and tea.
Note
A possible antibiotic regimen can be as fol-
lows: cefazolin and metronidazole at the 5 Conclusion
initiation, continuing postoperatively with
amoxicillin-clavulanic acid. Careful preparation of orthognathic treatment
reduces adverse events during the surgical proce-
dure. This increases the probability of success,
patient satisfaction, and strengthens the confi-
Usually the patient will be extubated on the dence of the treating team in its capabilities.
OR. After ensuring safe spontaneous breathing, Confidential guidance of the patient through the
the patient is transferred to the recovery ward for entire treatment protocol is essential, and the
further postoperative observation. The patient technical possibilities help in this.
usually remains there for 3 h. Afterwards, the
patient is transferred to the normal ward. See the
patient there and tell the patient how the surgery Further Reading
went. If necessary, inform his family.
Hardt N, Paulus GW. Kephalometrische Aspekte bei der
Korrektur von Gesichtsdeformitäten. In: Mühlbauer
W, Anderl H, editors. Kraniofaziale Fehlbildungen.
4 Instructions at the End Stuttgart, New York: Thieme; 1983.
of Operation Proffit WR, Raymond P, White RP, Sarver
DM. Contemporary Treatment of Dentofacial
Deformity. India: Elsevier; 2012.
• If necessary, wafers and intermaxillary fixa- Schwarz AM. In: Auflage I, editor. Wie der angehende
tion elastics remain intraorally. Inform the Kieferorthopäde Gesicht und Schädel verstehen lernt.
anesthesiologist or recovery staff to cut the Wien/Innsbruck: Urban& Schwarzenberg; 1955.
elastics in occurrence of an emergency Segner D, Hasund A. Individualisierte Kephalometrie.
Hamburg: Auflage, Signer; 1988.
situation. Steinhäuser EW, Janson I. Kieferorthopädische
• Continue antibiotic therapy for at least 24 h. Chirurgie Bd. I. Chicago, London, Sao Paulo, Tokyo:
• Pain medication is based on acetaminophen Quintessenz–Berlin; 1988.
(paracetamol) and NSAIDs. Swennen GR, Schutyser J, Filip AC, Hausamen JE
Three-Dimensional Cephalometry. A Color Atlas and
• Repeat dexamethasone doses of 8 mg 10 and Manual Springer 2006.
20 h after the procedure.
 Osteosynthesis for Sagittal
Splitting
9
Peter Kessler and Nicolas Hardt

Contents
1 Wire Osteosynthesis/Intermaxillary Fixation 74
2  igid Internal Segment Fixation
R 74
2.1 Advantages of Rigid Internal Fixation (RIF) 75
2.2 Long-Term Versus Short-Term MMF 75
3 Osteosynthesis Techniques 75
4  igid Screw Osteosynthesis
R 75
4.1 Rigid Bicortical Compression Screw Osteosynthesis 75
4.1.1 Application 76
4.2 Rigid Bicortical Positioning Screw Osteosynthesis 76
4.2.1 Application 77
5  igid Internal Fixation: Osteosynthesis Plates
R 78
5.1 Rigid Monocortical Miniplate Osteosynthesis 78
5.2 Conventional Osteosynthesis Plates 78
5.3 Open Sagittal Split Osteosynthesis Plate 79
5.3.1 Application 79
5.4 Closed Sagittal Split Plates with Sliding Function 79
5.5 Monocortical Miniplate-Osteosynthesis Versus Bicortical Compression
and Positioning Screw Osteosynthesis 79
6  steosynthesis and Segment Positioning
O 80
6.1 Osteosynthesis with Intersegmental Distance 80
6.2 Condylar Position after BSSO and Bicortical Screw Fixation 80
6.3 Osteosynthesis with Temporomandibular Dysfunction and Intersegmental
Gaps 81
7  igid Osteosynthesis and Condylar Head Position
R 81
7.1 Postoperative Changes in Condylar Position 81
7.2 Rotation of the Condyle 82

P. Kessler (*)
Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center, N. Hardt (*)
Maastricht, The Netherlands Kantonsspital Lucerne, Clinic and Policlinic of
e-mail: [email protected] Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 73

P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_9
74 P. Kessler and N. Hardt

7.3 Change of the Intercondylar Distance 82

8 Osteosynthesis and Trauma of the Alveolar Nerve 85
9 Osteosynthesis and Bone Healing 85
10 Removal of Osteosynthesis Material 85
11  evascularization and Bone Healing
R 85
11.1 Immediately Postoperative 86
11.2 One Week Postoperative 86
11.3 Two Weeks Postoperative 86
11.4 Three Weeks Postoperative 86
11.5 Six Weeks Post-op 86
11.6 12 Weeks Postoperative 86
12 Conclusion 86
References 86

Abstract ligatures was necessary to secure the occlusion of

the osteotomized mandible or mandibular seg-
All osteosynthesis techniques evolved from
ments [1].
traumatology. There, the anatomically correct
The positionally stable adaptation osteosyn-
and stable positioning of fracture ends is the
thesis of the early days was able to prevent
goal of treatment. In orthognathic surgery, how-
unintentional fragment displacement, but
ever, the displacement of bone segments is the
immobilization of the segments under func-
goal of treatment, which places different
tional loading was not guaranteed.
demands on osteosynthesis techniques. Under
aspects of stability, functional adaptation, and
masticatory function, the functionally stable
osteosynthesis, originally developed by Champy 2 Rigid Internal Segment
for traumatology, has gained acceptance. Fixation

Keywords With the development of less invasive and less

morbid osteotomy designs, questions about gen-
3D Planning in orthognathic surgery · eral osteotomy stability arose. The transition
Simulation surgery · Preoperative assess- from extended intermaxillary fixation and wire
ment · Preparations for the surgical proce- osteosynthesis to rigid internal fixation has raised
dure · Wire osteosynthesis · Screw questions about the most effective fixation tech-
osteosynthesis · Bicortical screw fixation ·
nique. These questions represent a still ongoing
Plate osteosynthesis · Monocortical plate debate and discussion as measures have been
osteosynthesis · Rigid fixation · Plates and taken to optimize patient outcomes and minimize
screws · Intermaxillary fixation (IMF) · patient morbidity.
Condylar head · TMJ · Plate removal Instead of the conventional non-rigid wire fixa-
tion or circum-mandibular cerclages with mandib-
ulo-maxillary fixation, the rigid internal segment
1 Wire Osteosynthesis/ fixation with screw osteosynthesis according to
Intermaxillary Fixation Spiessl [2–4] was introduced and replaced the wire
osteosynthesis and long-term intermaxillary
Prior to the introduction of stable osteosynthesis, fixation.
long-term mandibulo-maxillary fixation for at
least 6–8 weeks with alloyed splints and wire
9 Osteosynthesis for Sagittal Splitting 75

The principle of “functionally stable osteosyn- osteosynthesis and short-term MMF immobiliza-
thesis” requires prerequisites for success: tion was shown to significantly reduce the risk of
secondary TMJ long-term problems, as func-
• A direct interfragmentary contact of the split
tional stability allows the patient to undergo early
segment surfaces for undisturbed bone healing.
physiotherapy with opening exercises as well as a
• A long-term secure positioning of the proxi-
rapid onset of the preoperative jaw function [10].
mal and distal bone segments.
• A reliable possibility to position the
condyles.
3 Osteosynthesis Techniques
Depending on the interfragmentary osteosyn-
thesis used—lag screw or positional screw osteo- Interfragmentary, stable fixation is achieved
synthesis—bone healing proceeds either as either by a:
primary or secondary bone healing [2, 4–8]. Screw fixation as
• Lag screw osteosynthesis—bicortical com-
pression screw osteosynthesis or
2.1 Advantages of Rigid Internal
• Adjustable screw osteosynthesis—bicortical
Fixation (RIF)
positioning screw osteosynthesis.
• RIF by screw fixation. or by:
• RIF by plate fixation. Plate and screw osteosynthesis as

The many advantages of internal fixation make • Monocortical miniplate osteosynthesis.

RIF an effective and predictable method in the
surgical treatment of mandibular osteotomies [9].
4 Rigid Screw Osteosynthesis
The outstanding advantages of RIF are:
• Fast and uncomplicated bone healing due to a The use of osteosynthesis screws was the first
broad bone contact of the split segments. form of stable and rigid osteosynthesis:
• Secure segment stability and predictable sur-
gical results. • Rigid bicortical compression screw osteosyn-
• Stable results in mandibular advancement, thesis with 2.7/2.0 mm screws.
setback and correction of asymmetry. • Rigid bicortical positioning screw osteosyn-
• Minor positional changes of the masticatory thesis with 2.0 mm screws.
muscles—prevention of a relapse through
muscular traction. 4.1 Rigid Bicortical Compression
• Early restoration of functions, without a long-­ Screw Osteosynthesis
lasting mandibulo-maxillary fixation (MMF).
• Controlled positioning of the temporomandibu- The principle of lag or compression screw
lar joints, which preventively reduces TMJ dys- osteosynthesis consists in the creation of a
functions and TMJ long-term consequences. threaded and gliding hole so that when the screw
is tightened, an approximation/compression of
the osteotomized segments is achieved
2.2 Long-Term Versus Short-Term (Fig. 9.1). The positioning of the fragments is
MMF not easy due to the application of tension and
compression and is not always successful [4, 7,
The comparison between long-term immobility 11–14].
with MMF prior to the introduction of stable
76 P. Kessler and N. Hardt

Fig. 9.2 Position scheme for compression screw applica-

tion in equidistant position according to [3] ©Copyright
Keisuke Koyama 2020. All rights reserved

Position of the two anteriorly positioned

screws: external oblique line (“oblique screw”)
Fig. 9.1 Principles of compression screw osteosynthesis:
By creating a threaded and sliding hole segment fixation is and mandibular base (“base screw”). The posi-
achieved during tightening the screw by compression of tion of the oblique and base screws are anatomi-
the segments [11] ©Copyright Keisuke Koyama 2020. All cally clearly defined in recognizable regions.
rights reserved
Ensure that the osteosynthesis screws are evenly
spaced (Fig. 9.2).
• Drill a sliding hole on the lateral side of the In addition to the classic screw application
split (proximal segment) in the diameter of the there are several variants (Fig. 9.3).
screw to be used. The triangular configuration of the screw posi-
• Drill a screw channel through the sliding hole tion across the mandibular nerve canal presented
in the diameter of the screw core. One must less stress loading than the linear configuration,
pay attention to the direction. Measure the total and hence provided better stability. When the
length of the drill channel for perfect screw fit. screws were aligned in a linear setting, the stress
values were four times higher, implying a less
4.1.1 Application stable fixation. Neither two nor three screws
Bicortical screw osteosynthesis is usually per- applied at the superior border appeared to be bet-
formed transbuccally under instrumentation with ter at exploiting the increased thickness of the cor-
a transbuccal trocar that can hold the drill, depth tical bone encountered in this region (external
gauge, tap, screwdriver, and screw. oblique line).
The system of interfragmentary compression
using lag screws (2.7 mm diameter/alternatively
2.0 mm) consists of a buccal cortical gliding hole 4.2 Rigid Bicortical Positioning
and a lingual cortical screw thread. The screw head Screw Osteosynthesis
causes compression of the lateral segment, and the
lingual screw thread causes screw fixation [15]. As a functionally stable alternative to compres-
Usually three compression screws are used. sion screw osteosynthesis, the distance- and
The localization for the compression screw appli- angle-maintaining, non-compressive position
cation is carried out in the classical way, taking screw osteosynthesis was developed, which clini-
into account the course of the IAN and the posi- cally offers a rigidity equivalent to compression
tion of the second molars. osteosynthesis.
9 Osteosynthesis for Sagittal Splitting 77

Fig. 9.3 Variants of compression screw application after mandibular split [16] ©Copyright Keisuke Koyama 2020. All
rights reserved

compression osteosynthesis (lateral/medial

torqueing of the condyle) (Fig. 9.4) [8, 17–19].

4.2.1 Application
The segments are fixed on both sides by two
self-­tapping titanium screws each above and
one screw below the mandibular canal, which
are screwed in over the sleeve of the cheek tro-
car after pressure less pre-drilling with a twist
drill.
A depth gauge inserted in the drill hole is
used to determine the correct screw length,
whereby the screw should protrude beyond the
lingual cortex by a maximum of two thread
turns.
To ensure a stable connection of the osteoto-
mized bone segments for practice, the position-
ing screws must be able to grip the buccal and
lingual segments bicortically [17–19].
The intersegmental gap existing when both
Fig. 9.4 Principle of bicortical position screw osteosyn-
thesis: By creating two threaded holes, the intersegmental
threads are applied remains when the screws are
gap is preserved when tightening the screw according to tightened (Figs. 9.5 and 9.6).
[11] ©Copyright Keisuke Koyama 2020. All rights In positioning screw osteosynthesis the bony
reserved gap will be bridged by secondary bone healing
processes [8, 17].
In contrast to compression screw osteosynthe- Due to the anatomical conditions, however, in
sis, the interfragmentary gap between the seg- some cases only one screw can be implanted cra-
ments remains intact when the position screws nial to the mandibular canal, so that in these
are tightened (Fig. 9.4) [17]. cases two screws must be inserted caudally of
In addition, this form of osteosynthesis avoids the canal to render sufficient stability for early
the possible dislocation of the condyle during mobilization in functionally stable osteosynthe-
sis [17–19].
78 P. Kessler and N. Hardt

Fig. 9.7 Conventional miniplate osteosynthesis for sta-

Fig. 9.5 Stable fixation of the segments by adjusted posi- ble internal fixation
tioning screws. Note: No bone contact, no bone compres-
sion at the level of the osteosynthesis screws [20]
©Copyright Keisuke Koyama 2020. All rights reserved

well as for maxillary and segmental osteotomies

[21–23].
A distinction is made between different plate
types:

• Conventional osteosynthesis plates.

• Open sagittal split plates with sliders.
• Closed sagittal split plates with sliders.

5.2 Conventional Osteosynthesis

Plates

As a standard, variably shaped fixation plates

of the system size 2.0 mm and monocortical
screws of 2.0 mm diameter are used for stable
Fig. 9.6 Standard positioning of screws in bicortical internal fixation after sagittal split osteotomies
positioning screw osteosynthesis ©Copyright Keisuke
of the mandible (Fig. 9.7). The mandible is
Koyama 2020. All rights reserved
subject to greater chewing forces and has a
thicker bone structure than the maxilla [16,
5 Rigid Internal Fixation: 24].
Osteosynthesis Plates The shape and thickness of the plate and
screw system depends on the selected osteot-
5.1 Rigid Monocortical Miniplate omy line, the desired degree of stability, and
Osteosynthesis the extent of bone displacement. The rigidity
of the osteosynthesis plates can also be influ-
The miniplate has also proven to be a reliable enced by the choice of different titanium grad-
fixation device for mandibular osteotomies as ings (Fig. 9.8).
9 Osteosynthesis for Sagittal Splitting 79

Fig. 9.10 Closed sagittal split sliding plates ©Copyright

Keisuke Koyama 2020. All rights reserved

thesis is achieved on the distal mandibular seg-

ment with four additional screws. The slider is
an aid for intraoperative occlusion adjustment
and will be removed when the osteosynthesis is
completed [11].
Fig. 9.8 Standard osteosynthesis set 2.0 mm plates and
screws in routine use in the operation theater
5.4  losed Sagittal Split Plates
C
with Sliding Function

Fixation of a sagittal split in the horizontal man-

dibular ramus with a closed, semirigid sagittal
split plate with slider option (Figs. 9.10 and
9.11).

5.5 Monocortical Miniplate-

Osteosynthesis Versus
Bicortical Compression
and Positioning Screw
Fig. 9.9 Open sagittal split plate with sliding function
©Copyright Keisuke Koyama 2020. All rights reserved Osteosynthesis

In follow-up examinations, no significant differ-

5.3 Open Sagittal Split ences were found in terms of rigidity and relapse
Osteosynthesis Plate behavior in mandibular advancement between
miniplate osteosynthesis with monocortical
5.3.1 Application screws and bicortical screw osteosynthesis [22].
After ideal positioning of the proximal segment However, excessive postoperative shear stress
(joint), the osteosynthesis plate with the slider is caused by strong traction from the masseteric and
fixed to the proximal segment (2 screws) and a medial pterygoid muscle can—in exceptional
temporary osteosynthesis is performed through cases—lead to bending of the monocortical
the sliding element: sliding screw in the distal osteosynthesis plate, with the distal segment
segment close to the osteotomy (Fig. 9.9). rotating clockwise and the proximal segment
After checking the pre-planned occlusal rotating counterclockwise. An open bite can
position, the final completion of the osteosyn- develop [25].
80 P. Kessler and N. Hardt

a b

c d

Fig. 9.11 Closed sagittal split plates with sliding func- (c) Check occlusion, IMF. If correct, completion of screws
tion: Stepwise approach to stable fixation: (a) One screw distal segment (d) Check occlusion, removal of the slider,
proximal segment, check occlusion, IMF, fixation of the if occlusion is correct ©Copyright Keisuke Koyama 2020.
slider (b) Completion of screw fixation proximal segment All rights reserved

6 Osteosynthesis and Segment after 6 months by secondary bone healing even

Positioning without osteoplasty.
For diastases of more than 5 mm in width, it is
6.1 Osteosynthesis recommended to fill up the gap/split with autog-
with Intersegmental Distance enous cancellous or cortico-cancellous bone or a
suitable bone replacement material [26].
Intersegment interferences between the proximal Even if a wider intersegmental bone gap
and distal segments after BSSO is not always persists, rigid screw or plate fixation together
avoidable. Positioning of the proximal segment with a gap filling cortico-cancellous bone
(TMJ) in a central condylar position in combina- graft ensures sufficient stability, since the
tion with bicortical screw osteosynthesis is some- bone graft can be rigidly fixed in position by
times associated with a wide osteotomy gap and osteosynthesis.
a corresponding reduction of the bony attach-
ment surface, especially when a horizontal dislo-
cation of the mandible is indicated to correct a 6.2 Condylar Position after BSSO
midline deviation. and Bicortical Screw Fixation
Straight anterior and posterior repositioning
of the mandible as well as small rotational or lat- A rigid, forced screw fixation disregarding inter-
eral movements lead to only small gaps in the segmental bone gaps can causally lead to a
osteotomy area, which are spontaneously bridged change of the condylar head and condylar disc
9 Osteosynthesis for Sagittal Splitting 81

position. This may lead to condylar resorption, on the three-dimensional jaw repositioning: sagit-
damages to the articular disc, and relapse. tal, vertical, horizontal-rotational.
By placing the osteosynthesis in the region Under the given circumstances of the anatomi-
of the distal segment posterior to the last molar cal shape of the mandibular body, a forced, gap-­
with interposition of a bone graft in the area of free adaptation of the fragments can lead to a
the segment gap, changes in the joint position more or less large change in position of the proxi-
can be avoided even with compression screw mal segment and the temporomandibular joint.
osteosynthesis. Positioning screw osteosynthe- The design of the mandibular split—long or short,
sis or miniplate osteosynthesis have an even vertical or more horizontal—also plays a decisive
more favorable effect on a functionally correct role. The position of the tooth-bearing distal man-
condyle position and avoidance of a relapse dibular body is determined by the occlusion and
[26, 27]. intermaxillary fixation and cannot be changed.
There is a consensus that rigid screw osteo-
synthesis can lead to unfavorable and unphysio-
6.3 Osteosynthesis logical changes in the transverse intercondylar
with Temporomandibular distance, the axial inclination of the condylar
Dysfunction heads, and the horizontal and vertical positioning
and Intersegmental Gaps of the condyles affecting the condylar-fossa rela-
tion negatively [26, 28, 29].
In patients with manifest temporomandibular Changes in the positional relationships
joint dysfunction, a BSSO with mandibular repo- between condylar head and fossa forced by rigid
sitioning can be performed. However, the follow- osteosynthesis can generally have long-term
ing principles should be observed when planning effects on the form and function of the TMJ and
the operation [26, 27]. cause degenerative changes such as osteoarthri-
tis/osteoarthrosis or condylar head resorption.
• All bony interference between proximal and However, in most patients, the condyle under-
distal segment should be removed. goes remodeling, resorption, and other adaptive
• The condylar head should be passively guided changes with little or no temporomandibular
into the glenoid fossa during surgery. joint symptoms.
• Not too rigid fixation with monocortical mini-
plate osteosynthesis is recommended for seg-
ment fixation. The use of compression or 7.1 Postoperative Changes
positioning screws should be avoided. in Condylar Position

Reasons for condylar position changes:

7 Rigid Osteosynthesis
and Condylar Head Position • Rotation of the proximal segment.
• Condylar sag.
Unlike in traumatology, in orthognathic surgery • Torque on the proximal segment.
the split jaw segments enter into a completely new
positional relationship with each other after surgi- Condylar positioning changes can lead to:
cal correction caused by changes in the occlusion.
Due to the parabolic, distally diverging lower jaw • Skeletal mandibular relapse.
body and the individually different shape variants • Malocclusion.
of the jaw angle, variable interfragmentary rela- • Hypomobility.
tionships, such as diastasis, compression, rota- • Remodeling of the condyle.
tional or lateral dislocation, can occur depending • Pain.
82 P. Kessler and N. Hardt

a b

Fig. 9.13 Condylar torque (a) Position of split mandibu-

lar segments before repositioning (b) Medial/lateral
torque on the condyle due to proximal segment interfer-
Fig. 9.12 Interference of the proximal bone segments ence ©Copyright Keisuke Koyama 2020. All rights
supporting the TMJ with axial (AR) and frontal (FR) rota- reserved
tion of the condylar segment after pronounced mandibular
advancement after a sagittal split ©Copyright Keisuke
Koyama 2020. All rights reserved

Unilateral
Central
7.2 Rotation of the Condyle Bilateral

Axial (AR) and frontal (FR) rotations of the con- Condylar

sag
dylar segment can occur if the proximal bone Type I
segment interferes with the distal segment after Peripheral
significant mandibular advancement (Fig. 9.12). Type II

Fig. 9.14 Types of condylar sag (Condyle displacement)

7.3 Change of the Intercondylar according to [31]
Distance
ble, the position of the temporomandibular joint
The intercondylar width can change when com-
can be unfavorably influenced by disturbing
pression screws are used. In a mandibular setback
influences [31–33].
procedure, medial condylar torque of the proxi-
mal mandibular segment may occur, narrowing Interfering factors are:
the intercondylar distance.
In the mandibular advancement procedure, • Active displacement of the temporomandibu-
lateral condylar torque can occur with an increase lar joint head during osteosynthesis due to
in intercondylar distance (Fig. 9.13) [30]. pressure.
The consequences of torque or displacement • Displacement due to bony interference
of the condyle can be an immediate or later (flaring).
change in position of the condyle in the glenoidal • Incomplete split.
fossa, the so-­called central or peripheral condylar • Muscular traction (especially horizontal pter-
sag (condyle displacement) with edema in and ygoid muscle.
around the joint and intermediate occlusal dis- • Traction by ligament.
crepancies (Fig. 9.14). After splitting the mandi- • Intra- or periarticular edema or hematoma.
9 Osteosynthesis for Sagittal Splitting 83

Fig. 9.15 Central Condylar Sag due to inferior traction on the proximal segment during osteosynthesis ©Copyright
Keisuke Koyama 2020. All rights reserved

1. Central Condylar Sag by the occlusion. Late relapse from condylar

The central form can be recognized intra- resorption may result in malocclusion. On the
operatively by the fact that an anterior open long term the mandible falls back into a class
bite occurs after RIF when the IMF is opened. II position (Fig. 9.16).
The mandible falls back into a class II posi-
tion (Fig. 9.15). The explanation is assumed More difficult to visualize is lateral luxation/
to be a slumping back of the condyle into its displacement of the temporomandibular joint
habitual position. This means that during head, whereby there is a displacement of the mid-
osteosynthesis the condyles were luxated lines after opening the IMF. This can be very
inferiorly or anteriorly-caudally from their subtle and is more difficult to detect. The condyle
habitual position. is in incorrect relation to the glenoid fossa.
2. Peripheral Condylar Sag: Type I and II Creating the gap between the bone segments in
In the peripheral form, two forms are dis- mandibular advancement, a bowing effect may
tinguished. First, TMJ compression may happen by the tension on the condyle and ramus
occur in the temporomandibular joint in ante- due to forces by rigid fixation. Once the IMF is
rior direction by unfavorable retraction during removed, the tension on the ramus is released
RIF, resulting in an open bite in the posterior causing the condyle to move medially and slide
region after opening the IMF. This type is inferiorly on the medial wall of the fossa causing
sometimes difficult to be diagnosed intraop- a posterior open bite (Fig. 9.17).
eratively, because the contact between the The most serious consequences of condylar
condyle and glenoid fossa may be supported sagging are antero-inferior condylar displace-
84 P. Kessler and N. Hardt

Fig. 9.16 Peripheral Condylar Sag—type I—due to anterior dislocation of the condyle during osteosynthesis Copyright
Keisuke Koyama 2020. All rights reserved

Fig. 9.17 Peripheral condylar sag—type II—due to a bowing effect on the proximal segment (white line). An antero-­
inferior dislocation of the condyle may result ©Copyright Keisuke Koyama 2020. All rights reserved
9 Osteosynthesis for Sagittal Splitting 85

ment, condylar resorption, and skeletal instability According to Spiessl [2], however, it is not the
with an incalculable influence on the postopera- process of bone healing that is decisive for bone
tive mandibular position [31]. consolidation, but rather that a functionally stable
fixation of bone segments is guaranteed until
bone healing occurs.
Note
From a clinical perspective, primary intramem-
Malposition of the condyle in the glenoid
branous bony healing is not the true therapeutic
fossa—condylar sag—can occur as goal. It is irrelevant whether bone consolidation is
immediate or late change in the position achieved indirectly through secondary differentia-
of the condyle after RIF leading to occlu- tion of fibrous or cartilagenous tissues or through
direct primary regeneration of osteons. [2]
sal disturbances.
Causes:
Incorrect vector in condylar positioning.
Intra-articular bleeding, edema, and bend- 10 Removal of Osteosynthesis
ing of the proximal segment when Material
applying rigid fixation.
The removal of osteosynthesis plates and
screws has been advocated with the argument
that osteosynthesis plates act as loadbearing
8 Osteosynthesis and Trauma plates without exposing the bone to the full
of the Alveolar Nerve range of physiological stresses and increasing
the risk of fractures of the osteosynthesis mate-
The incidence of neurosensory disturbances of the rial. In contrast, the more delicate osteosynthe-
IAN after rigid osteosynthesis is 1–15% [26, 27]. sis plates according to the load-sharing concept
Experimental studies suggest that rigid inter- of Champy et al. [34] reduce the risk of
nal fixation—primarily compression screw underloading.
osteosynthesis rather than positioning screw The basic argument against removing these
osteosynthesis—can lead to neurosensory distur- implants is that the incidence of infection and
bances. Positioning screws ensure a constant dis- other complications is relatively low. In addition,
tance between the split segments and prevent the removal of the implants poses a morbidity
undesirable compression of the IAN. risk for the patient. Infections, nerve injuries, and
Incorrect screw placement can compress, con- anesthetic complications cannot be excluded.
strict, or transect the IAN. In order to avoid this Costs are also caused by this procedure.
complication, the course of the nerve must be The removal of osteosynthesis material should
radiologically verified before screw placement, be based on the presence of patient complaints,
especially in the area of the mandibular base plate exposure, and loosening or fracture of the
(“base screw”). implant.

9 Osteosynthesis and Bone 11 Revascularization and Bone

Healing Healing

The aim of rigid fixation is the stability of the The revascularization of the bone segments and
mandibular bone segments and a predictable and the bone consolidation process takes place in
complication-free bone healing. The fact that phases [35].
rigid fixation enables primary bone healing favors
this form of osteosynthesis.
86 P. Kessler and N. Hardt

11.1 Immediately Postoperative • Circulation reconstituted across the osteotomy

site.
The intermedullary circulation between the prox- • Soft tissue reattachment established.
imal and distal mandibular segment is interrupted
immediately after the mandibular split. The oste-
otomy margins are avascular. 11.6 12 Weeks Postoperative

• Intramedullary circulation between the proxi- Reconstitution of a continuous circulation

mal and distal segments. between the bone segments.
• Margins of osteotomy—avascular.
• Circulation between the segments is
continuous.
11.2 One Week Postoperative

Hypervascularization of the osteotomy gap and 12 Conclusion

the surrounding soft tissues. No soft tissue reat-
tachment yet, isolated areas of subperiosteal bone Rigid internal osteosynthesis is a prerequisite for
formation early functional treatment in osteotomies of the
maxillofacial skeleton. This principle helps to
• Level of hypervascularization around surgical avoid long, functionally disadvantageous inter-
site. maxillary fixation. Patient-specific implants help
• No soft tissue reattachment. to transfer preoperative planning to the surgical
• Margins of osteotomy—avascular. site and help to prevent malpositioning. Depending
on the individual initial situation, plate removal
should be considered after bony consolidation.
11.3 Two Weeks Postoperative

• Avascular zone at the proximal osteotomy References

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Gesichtschir. 1974;18:145–8.
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Berlin, Heidelberg, New York: Springer; 1976. 1994;52(11):1133–7.
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 Pre- and Peri-operative Care
in Orthognathic Surgery -
10
Anesthesiology and CMF-Surgery

Pia-Marina Guardiola, Peter Kessler,

and Nicolas Hardt

Contents
1  reoperative Phase
P 90
1.1 A nesthesiology: Preoperative Checks 90
1.2 Pre-op Medical Examination for Orthognathic Procedures 90
1.3 Orthognathic Procedures (Mandibular +/− Maxillary Osteotomies) 90
2 CMF Surgery: Preoperative Checks 91
3  nesthesiology
A 91
3.1 P reoperative Medications: Have to Be Continued as a General Rule 91
3.2 Procedure in Patients with Platelet Aggregation Inhibitors 91
4  nesthesia and CMF Surgery: Preoperative Assessment
A 92
4.1 Intubation Form: Decision with CMF Surgeon 92
4.2 Intubation Problems 92
4.3 Patients: Positioning: Determination with CMF Surgeon 95
5  erioperative Phase: Anesthesia procedure in CMF Surgery
P 96
5.1 Preparation 96
5.2 Anesthesia Induction 97
5.3 Maintenance: ITN Anesthesia 97
5.4 Recovery: Emergence 97
5.5 Documentation 98
6  erioperative Phase: Prophylactic Measures in CMF Surgery
P 98
6.1 Perioperative Prophylaxis with Antibiotics 98
6.2 Perioperative Pain Prophylaxis 98
6.3 Perioperative Prophylaxis against Swelling 99
6.4 Postoperative Nausea and Vomiting: PONV Prophylaxis 99
7 Conclusion 99
References 99

P.-M. Guardiola (*)

Departement of Anesthesiology, Intensive Care
and Pain Medicine, Hirslanden Klinik St. Anna,
Lucerne, Switzerland
P. Kessler (*)
Department of Cranio-Maxillofacial Surgery, Maastricht N. Hardt (*)
University Medical Center, Maastricht, The Netherlands Kantonsspital Lucerne, Clinic and Policlinic of
e-mail: [email protected] Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 89

P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_10
90 P.-M. Guardiola et al.

Abstract Keywords

Modern perioperative care is complex and Clinical examination · Anamnesis ·

involves a large number of staff from multiple Preoperative assessment · Preparations for the
disciplines. Patient outcomes depend on well- surgical procedure · Anesthesiologic protocols ·
designed processes, consistent clinical prac- Preoperative check · Medication · Antibiotics ·
tice, and effective communication. The Cortisone · Edema · Preparation for surgery ·
peri- and postoperative care should be a uni- Intubation · Difficult airway · Documentation ·
fied process of multiple coordinated steps Extubation · Pain management
(Kwon and Laskin, Quintessence Publishing
2001; Kerridge, Best Pract Res Clin Obstet
Gynaecol 20(1):23–40, 2006).
The flow of information in the surgical pro-
cess is based on standardized pre-, peri-, and 1 Preoperative Phase
postoperative checks, notes, and orders in the
operating room, the recovery ward, and the 1.1 Anesthesiology: Preoperative
normal patient ward. Checks
Preoperative protocol establishes what is
thought to be the pathology of the patient and The preoperative check includes at the entrance to
what procedure is planned for the operation an the operating room, the surgeons name, the
anesthesia. patients ID with birth date, marked operation side,
It indicates that the appropriate preopera- the existence of all necessary laboratory examina-
tive tests have been performed and reviewed. tions, medical examinations including allergies,
It also confirms the presence of an informed the execution of the preoperative medical orders
consent document (operative permit). Surgical with regard to the medicamentous prescriptions
care provided to a patient requires a written, and a pre-existing continuous medication and con-
signed, informed consent document. Often firms the existence of the patient’s approval of the
referred to as an “op permit,” it is an essential operation and anesthesia [1, 2].
part of the medical record. It must be properly
completed prior to any invasive, anesthetic, or
other procedure that involves any significant 1.2 Pre-op Medical Examination
risk to the patient. for Orthognathic Procedures
Preoperative checks and orders assure that
the patient is ready for surgery and all preop- The preoperative examination serves to the dif-
erative medical instructions have been per- ferentiation between patients without and with
formed. All necessary laboratory exams, systemic diseases (diagnosis-related examina-
X-rays, consultations, and permits must be tion) as well as to the classification of the surgical
ordered in a timely manner to ensure their risk (intervention-specific examination).
availability before surgery. Similarly, preop-
erative determination of the intubation manner
between anesthesia and CMF surgery is essen- 1.3 Orthognathic Procedures
tial in particular with regard to possible intu- (Mandibular +/− Maxillary
bation problems. Osteotomies)
Perioperative notes include the anesthesia
induction, anesthesia maintenance, and intra- Are to be attributed to surgical risk class B like,
operative ongoing monitoring and documen- e.g., large laparoscopic surgery, large spinal sur-
tation of the patient’s vital functions, as well gery, joint replacement, carotid surgery, endovas-
as documentation of all perioperative prophy- cular and vascular prosthesis. Surgical interventions
lactic measures taken for a successful without of risk class B/C in healthy patients <60 years
adverse events postoperative course. require an intervention-specific examination.
10 Pre- and Peri-operative Care in Orthognathic Surgery - Anesthesiology and CMF-Surgery 91

The basic examination includes the • Cephalometric Analysis.

following: • 3D Imaging and 3D Planning
1. Laboratory analysis. • Maxillofacial—technical aids:
Hematology: Small blood count-Indices—­
RBC/WBC/Hb. –– Intermaxillary splints, wafers, etc.

Note 3 Anesthesiology
Anemia management standards:
Hemoglobin under <12 g/l no elective 3.1 Preoperative Medications:
surgery. Have to Be Continued
as a General Rule

Coagulation-Indices: INR. Especially:

Electrolytes + Creatinine: Na—K. • Antiarrhythmics.
2. Height and weight. • Anticonvulsants.
3. Further preoperative parameters include: • Steroids.
• Thyroid hormones.
• ECG findings. • Parkinson therapy.
• Preoperatively prescribed drugs. • Contraceptives.
• Presence of organ-specific X-ray documents
and X-ray findings. Others Have to Be Paused:
• Informed Consent: Anesthesia and the opera- • Discontinuation of platelet aggregation inhibi-
tive procedure. tors (7–10 days before surgery) is possible if
allowed by the general practitioner or
4. NPO Status: Liquid and Food Care. cardiologist.
In elective procedures, a dietary NPO of 6 h is • Antidiabetics have to be adapted.
necessary before the procedure. For clear liq- • Antidepressants.
uids, a grace period of 2–4 h applies. • Oral anticoagulants—after feedback with gen-
Permanent medications are taken on the day eral practitioner.
of surgery with a sip of water. • Ginko-compounds—as they effect
coagulation.
• Antihypertensive medications such as calcium
2 CMF Surgery: Preoperative antagonists, ACE inhibitors and Angiotensin
Checks II antagonists.
• Diuretics.
Checking the completeness of the preoperative
radiologic documentation, the preoperative docu-
mentation of the planning documents and the sur- 3.2 Procedure in Patients
gical technical aids for maxillofacial osteotomy. with Platelet Aggregation
Inhibitors
• Maxillofacial X-rays:
Aspirin—ASA Acetylic Salicylic Acid
–– Cephalometric X-rays. For primary prophylaxis: should be discontin-
–– Panorama X-ray. ued 10 days before surgery.
–– Lateral cephalometric X-ray.
–– Cone-beam computed tomography (CBCT). Aspirin—ASA Acetylic Salicylic Acid
–– Multi-slice computed tomography (MSCT). For secondary prophylaxis has to be continued.
92 P.-M. Guardiola et al.

Plavix and Analogs 4.2 Intubation Problems

Usually set off 7–10 days before surgery, after
feedback with GP or cardiologist. Any intubation problems in maxillofacial proce-
dures require mutual preoperative information
between anesthesia and CMF surgery and the
4 Anesthesia and CMF Surgery: mutual professional coordination of the procedure.
Preoperative Assessment
4.2.1 Difficult Airway: Definition
• Intubation form. Intubation is considered difficult if it is “difficult
• Intubation difficulties. or impossible” to perform direct laryngoscopy
• Estimation of ITN difficulties. and to introduce the endotracheal tube into the
• Patients positioning. larynx and trachea [3–5].
All hospitals must have algorithms for difficult
airways, which have to be followed to ensure
4.1 Intubation Form: Decision patients safety.
with CMF Surgeon Generally associated with a difficult airway in
CMF surgery are:
4.1.1 Types of Endotracheal Tubes
(ETT): Intubation • Anatomical oropharyngeal bottlenecks and
obstacles or functional changes.
• Oro-tracheal Intubation/Standard tube/Prefor­ • Oropharyngeal malformations.
med Tube. • Obstacles due to pre-intervention: scarring
• Naso-tracheal intubation. and stricture by scarring.
• Tracheostomy Tubes. • Post-tumor states.
• Injuries: Scarcity stricts/synechia.
4.1.2 Intubation: Technique • Endonasal hyperplasia/septum deviations/
endonasal malformations.
• Standard procedure: Laryngoscopy. • Cervical neck mobility impairment.
• Optic enhanced Laryngoscopy (Type-C-MAC).
• Fiber-optic Intubation/awake or sleeping.
Note
4.1.3 Naso-tracheal Intubation: Iatrogenic injuries with bleeding and swell-
In CMF Operations ing associated with intubation attempts.

Naso-tracheal intubation is indicated in fol-

lowing CMF operations:
• Interventions on the lower jaw, upper jaw and • Functional movement restrictions of the oral
upper floor and tongue. opening due to
• Surgically necessary intermaxillary wiring/ –– Jaw joint diseases/arthrosis/ankylose/juve-
fixation—IMF. nile arthritis/myofascial pain syndrome/
• For oral intubation barriers. jaw joint diseases with mouth-opening
disabilities such as joint discopathy like
­
discus luxation and joint osteoarthritis.
Note
• Skeletal variants of facial skull growth (skel-
Naso-tracheal Intubation is the standard for etal dysgnathias).
maxillofacial osteotomies: –– Isolated mandibular hypoplasia/hyperpla-
Reasons are: sia/retrognathia/prognathia.
Intraoperative occlusion setting associated –– Combined mandibular–maxillary retrogna-
with intraoperative intermaxillary fixation. thias/prognathias.
• Macroglossia.
10 Pre- and Peri-operative Care in Orthognathic Surgery - Anesthesiology and CMF-Surgery 93

• Extreme obesity. The examination should be carried out on the

• Carious front teeth: Compromised sight with watchful, upright sitting patient, who opens
the laryngoscope. his mouth as far as possible and stretches
out his tongue as much as possible
Specific problems associated with a difficult air- (Fig. 10.1).
way in orthognathic maxillofacial osteotomies are Upper Lip Bite Test [8].
Mandibular Protrusion Test [9]
Skeletal Dysgnathias Determining whether the patient can bite the
Since patients with skeletal dysgnathias may have upper lip with the lower incisors? If the patient
altered size relations of the jaw compartments cannot do so, intubation is most likely to be
and/or movement restrictions of the oral opening, associated with difficulties (Fig. 10.2).
possible intubation difficulties must be expected.

In the Case of Predictable Difficult

Intubation
Note
Indications of difficult laryngoscopy and
1. Optic laryngoscopic device with C-
intubation in CMF Operations are:
Mac and D-Blade and a pre-bent tube
• Obesity. with an introducer.
• Mandibular retrognathia/prognathia/max- 2. Consider fiber-optic intubation at awake
illary hyperplasia. patient.
• Oral opening restriction <30 mm.
• Impaired neck mobility.
• Low thyro-mental or sterno-mental
distance. Class 1
Shows mandibular advancement beyond the
upper teeth. Lower incisors can be protruded
anterior the upper incisors.

4.2.2 Estimation of ITN Difficulty Class 2

Mallampati Test [6, 7] Shows that the mandible cannot be advanced
The test allows conclusions to be drawn about the beyond the upper teeth. The lower incisors can
size of the tongue in relation to the oropharynx be brought edge to edge with the upper
and thus to potential obstacles in laryngoscopy. incisors.

Fig. 10.1 Modified Mallampati classification. Graduation bed visible. Grade II: soft palate and uvula visible. Grade
of the visibility of oropharyngeal structures: palate arches III: soft palate and base of the uvula visible. Grade IV: soft
and tonsils depending on size and form of the tongue. palate not visible. ©Copyright Keisuke Koyama 2021. All
Grade I: soft palate, uvula, mouth, and front and rear tonsil rights reserved
94 P.-M. Guardiola et al.

Fig. 10.2 Upper lip bite test: Class 1—Lower incisors 3—Cannot bite upper lip ©Copyright Keisuke Koyama
can bite upper lip above the vermillion line Class 2— 2021. All rights reserved
Lower incisors can bite below the vermillion border Class
10 Pre- and Peri-operative Care in Orthognathic Surgery - Anesthesiology and CMF-Surgery 95

Class 3 4.3 Patients: Positioning:

Shows that the lower incisors cannot reach the Determination with CMF
upper teeth. The lower incisors cannot be brought Surgeon
edge to edge with the upper incisors.
Advancement of the mandible may be consid- The so-called “sniffing position” or Jackson posi-
ered a favorable sign for intubation without com- tion is considered optimal position for anesthesia
plications in association with moving of the initiation and intubation.
tongue (Fig. 10.3). The patient lies flat on the back, his head is
lightly underlaid with an intubation cushion or
4.2.3 Anamnestic ITN Difficulties upholstery ring. Due to additional reclination, the
Of great importance are also targeted questions airways are open to the maximum.
and pre-existing data on intubation difficulties in The oral cavity, pharynx, and larynx form an
previous anesthesia or pre-surgery on the mouth, almost straight axis and thus release the view of
nose, larynx, or trachea. the larynx (Fig. 10.4).
Patients with known intubation problems in
previous anesthesias are often in possession of an
anesthesia card with an exact identification of the
problem encountered [10].

Fig. 10.3 Mandibular Protrusion Test

96 P.-M. Guardiola et al.

a 5 Perioperative Phase:
Anesthesia procedure
in CMF Surgery

The actual anesthesia consists of 5 phases:

• Preparation: iv line, basic monitoring and if
necessary enhanced monitoring.
• Anesthesia Induction.
• Maintenance.
• Recovery, Emergence.
• Documentation.
b

5.1 Preparation

• Check allergies and drugs.

• Check anesthetic equipment.
–– Connection of monitoring.
–– Peripheral-venous access.
–– Infusion start.
• Monitoring.
• Basic Monitoring
c
Continuous measurement of vital parameters:

• ECG.
• Puls oximetry.
• Non-invasive blood pressure measurement.
• Capnometry.
• Inspiratory O2 concentration.
• In- and expiratory measurement of inhalation
anesthetics, if used.
• Respiratory parameters and pressures.
• Temperature.
• Neuromuscular monitoring.
Fig. 10.4 Course of the intubation axis (a) Head in body • BIS monitoring.
axis without vertical displacement or flexion-extension • Advanced Monitoring at ITN
(b) Head in elevated position without flexion-extension –– Invasive blood pressure measurement-artery.
(c) Head in elevated position with maximum extension
opens a straight intubation pathway ©Copyright Keisuke –– Cerebral blood flow and O2 consumption.
Koyama 2021. All rights reserved –– Monitoring urinary output with urinary
catheter.
10 Pre- and Peri-operative Care in Orthognathic Surgery - Anesthesiology and CMF-Surgery 97

5.2 Anesthesia Induction 5.4 Recovery: Emergence

• Preoxygenation O2 by mask. 5.4.1 Requirements for Anesthetic

• Opioid administration. Discharge
• Induction with administration of hypnotic.
• Administration of muscle relaxants. • Steady contact: anesthesia and surgeon—for
• Intubation (oral/nasal). estimating the duration of the surgery.
• Connecting respirator and respiratory • With the onset of the wound closure—
monitor. reduction-­removal of the anesthetics.
• Auscultation of both lungs. • At the end of the operation increase inspira-
• Fixation of the tube. tory oxygen concentration.
• Tube cuff pressure control. • Test the muscle relaxant lasting effect and
• If needed administer vasoactive drugs. eventual need for reversal or antagonists.

5.2.1 Critical Moments: Tubs 5.4.2 Extubation Criteria

Displacement/Disconnection
Accidental causes: • Sufficient spontaneous ventilation.
• Head-bearing change with release of the • Normal respiratory frequency.
external tube fixation. • TOF 100%—Muscle relaxation recovery.
• Intraoral manipulations with dislocation of the • Existing protective reflexes.
oro-tracheal tube. • Normal temperature.
• Stable circulation.
Throat after Intubation • No bleeding.
The throat can be tamponed to prevent blood
from flowing into the stomach or into the lungs. 5.4.3 Measures before Extubation

• Removal of all swabs and possible suction.

5.3 Maintenance: ITN Anesthesia • Nasal careful suction/continuity test.
• In wound secretion, blood and saliva, immedi-
• Continuation of ITN—preferably with target ate suction, bleeding control.
controlled total intravenous anesthesia. • If blood enters the stomach, it should be
• Administration of opioids as required. extracted perioperatively via a gastric tube to
• Repeat doses of relaxants if required. prevent postoperative vomiting.
• Normo-ventilation with a PEEP of approx.
5 cm H2O. 5.4.4 Extubation
• Measure blood loss.
• Maintain body temperature. • The extubation takes place—after operations
• Longer interventions. in the area of the respiratory tract—only when
–– Control of patients positioning. awake patient with sufficient protective
–– Continuous cuff pressure measurement. reflexes and unhindered passage of the breath-
–– Measure urinary output. ing air.
98 P.-M. Guardiola et al.

5.5 Documentation • Repetition of antibiotic administration after

>3 h surgical time.
All vital parameters, blood losses and measures • Prolongation of antibiotic therapy only in case
taken by the anesthesia staff and special events of pre-existing infection.
and complications, are carefully recorded in the
anesthesia protocol. A possible perioperative antibiotic regimen
can be as follows:
5.5.1 Anesthesia Protocol Antibiotics: Cefazolin and Metronidazole at
the initiation continuing postoperatively with
• Induction and intubation including occurring Amoxicillin-Clavulanic Acid
ITN problems as well as the laryngological
visual relations.
• Perioperative drugs and anesthetics.
Cefazolin 1.5 g i.v. single shot.
• Vital signs are displayed at least every 5 min.
+ Metronidazole 500 mg i.v.—intravenous
• Ventilation parameters every 20 min or in case
Single shot.
of changes.
• Fluids administered and estimated blood loss.

The documentation of special surgical mea- 6.1.1 Alternative Proposals

sures, in particular of For a possible postoperative antibiotic regime:
• Drains. Antibiotics: Aminopenicillin + Beta-lactam
• Specimens. antibiotics.
• Surgical Complications.

Ampicillin 2 g i.v. single shot.

6 Perioperative Phase: + Sulbactam 1 g i.v. single shot.
Prophylactic Measures
in CMF Surgery

6.1 Perioperative Prophylaxis 6.1.2 Alternative Proposals in Cases

with Antibiotics of Allergy
In case of allergy to beta lactams: clindamycin.
The aim of perioperative antibiotic prophylaxis is In case of allergy to beta lactams: clindamycin +
the prevention of postoperative wound infection aminoglycoside.
for patients undergoing maxillafacial In case of allergy to beta lactams: glycopeptides.
osteotomies. In the case of present risk factors, almost all
Execution: Task of the anesthetist. inpatients have an indication of perioperative
As a rule of thumb for perioperative antibiotic antibiotic prophylaxis during an operation.
prophylaxis in cranio-maxillary procedures:

• Antibiotic protection only for >2 h of 6.2 Perioperative Pain

surgery. Prophylaxis
• Antibiotic administration <24 h—time:
30–60 min before starting surgery. 6.2.1 Basic Pain Therapy
• For preparations with a standard dosing of
2×/d, single-shot prophylaxis is sufficient • Ibuprofen (NSAR).
even for longer procedures. • Metamizol.
10 Pre- and Peri-operative Care in Orthognathic Surgery - Anesthesiology and CMF-Surgery 99

6.2.2 Enhanced Pain Therapy Pain.

Peaks in intensity in the early postoperative Psychological stress.
period: Full urinary bladder.

• iv opioids in the recovery room 6.4.2 Prophylaxis: Reducing

Emetogenic Influence
6.2.3 Severe Pain Therapy With anamnestically known PONV [11].
Expected postoperative pain exacerbation can Prophylactic administration of 0.1 mg/kg
well be handled with: dexamethasone.
5-HT3-antagonist (Type: Ondansetron)
“Patient-controlled analgesia” Avoid low blood pressure.
• with opioids, such as Fentanyl or Avoid pain and stress.
Hydromorphin, Preferably administer non-opioid analgesics.
• Ketamin infusion.

7 Conclusion
6.3 Perioperative Prophylaxis
against Swelling Anesthesiologist and surgeon form a team and
coordinate optimally to maximize patient safety.
In contrast to the early postoperative pain, the The procedure corresponds to a fixed sequence,
postoperative facial swelling reaches the char- which should be more or less spread out depend-
acteristic maximum 48–72 h after surgery. ing on the anamnesis. On the day of the opera-
These symptoms can affect intensively the tion, the briefing and the time-out procedure
patient’s quality in the postoperative phase of fulfill the necessary communication in the team
well-being. for the maximum safety of the patient.
As a rule, the postoperative facial swelling
usually present for 2–3 weeks, which then sub-
sides down to some residual edema at 3–4 weeks References
post-surgery.
Perioperative swelling prophylaxis for the 1. Guidelines for the Provision of Anaesthetic Services
(GPAS). Guidance on the provision of anaesthetic ser-
operating area: vices for postoperative care. Chapter 4. London: The
0.1 mg/kg iv Dexamethasone before surgery and Royal College of Anaesthetists RCoA; 2019.
every 6–8 h after 2. Standards for basic anesthetic monitoring.
or, ASA. Committee on Standards and Practice
Parameters (CSPP), 2020.
125 mg iv Prednisolone (Prednisone) every 8 h. 3. American Society of Anesthesiologists–ASA. Practice
guidelines für postanaesthetic care. Anesthesiology.
2002;96(742)
6.4 Postoperative Nausea 4. Apfelbaum J, et al. Practice guidelines for
Management of the Difficult Airway Updated Report
and Vomiting: PONV by the American Society of Anesthesiologists Task
Prophylaxis Force on Management of the Difficult Airway.
Anesthesiology. 2013;118:1–20.
6.4.1 Influencing Factors 5. Larsen R. Anästhesie. München: Elsevier; Urban und
Fischer; 2013.
Opioids. 6. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical
Female gender. sign to predict difficult tracheal intubation: a prospec-
Nonsmoker status. tive study. Can Anaesth Soc J. 1985;32:429–33.
History of nausea and vomiting after anesthesia. 7. Samsoon GL, Young JR. Difficult tracheal intubation: a
retrospective study. Anaesthesia. 1987;42(5):487–90.
History of motion sickness.
Perioperatively low blood pressure.
100 P.-M. Guardiola et al.

8. Detsky ME, Jivraj N, Adhikari NK, Friedrich JO, 10. Dörges V, Bein B. Klinisches Management des
Pinto R, Simel DL, Wijeysundera DN, Scales Schwierigen Atemweges. Anasth Intesiv Notf. 2006
DC. Will this patient be difficult to intubate?: the Sep;41(9):564–75.
rational clinical examination systematic review. 11. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer
JAMA. 2019;321(5):493–503. N. A simplified risk score for predicting postopera-
9. Takenaka I. Mandibular protrusion test for predic- tive nausea and vomiting: conclusions from cross-­
tion of difficult mask ventilation. Anesthesiology. validations between two centers. Anesthesiology.
2001;94(5):935. 1999;91(3):693–700.
 Postoperative Care
in Orthognathic Surgery
11
Peter Kessler, Veronique C. M. L. Timmer,
and Nicolas Hardt

Contents
1  ostoperative Management
P 102
1.1 P ostoperative Instructions 102
1.2 F  or the Later Postoperative Phase 102
1.3 Postoperative Management in the Recovery Room 103
1.4 Controlling the Surgical Area in Orthognathic Surgery 103
1.5 Final Clinical Assessment 103
2  ostoperative Therapy of Postoperative Nausea and Vomiting (PONV)
P 105
2.1 On the Recovery 105
2.2 On the Ward 105
2.3 Postoperative Drug Thrombosis Prophylaxis 105
3  estart of a Pre-Existing Continuous Medication
R 105
3.1 Cardiovascular Medication 105
3.2 Antidiabetics in Diabetes Patients 105
3.3 Corticosteroid Medication 106
3.4 Postoperative Hydration and Oral Nutritional Supplementation 106
3.5 Dietary Structure 106
4  ound Care in Orthognathic Surgery
W 106
4.1 Postoperative Considerations 106
4.2 Intraoral Wound Treatment 106
5 Conclusion 106
Reference 106

Abstract
P. Kessler (*) · V. C. M. L. Timmer
Department of Cranio-Maxillofacial Surgery, Postoperative care of patients undergoing
Maastricht University Medical Center, Maastricht, orthognathic surgery requires special attention,
The Netherlands
e-mail: [email protected]; as surgical procedures are located in the airway
[email protected] entry zone and may compromise it. Special
N. Hardt (*) attention must be paid to postoperative bleed-
Kantonsspital Lucerne, Clinic and Policlinic of ing, swelling, and airway obstruction.
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 101
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_11
102 P. Kessler et al.

Postoperative pain management is absolutely 1.1 Postoperative Instructions

essential to make the patient feel safe. This is
even more important if the patient has received Essential information during sign-out procedure:
intermaxillary fixation after surgery.
• Relevant general medical diagnoses and
Keywords findings.
• Procedure(s) performed.
Postoperative patient management · Pain · • Intermaxillary situation, occlusion, fixation.
Medication · Recovery · Monitoring · Wound • Estimated/measured blood loss.
care · Diet · Mobilization • Postoperative pain medication.
• Continuation of antibiotic therapy, specify
dosage, and medication.
• Patient positioning.
1 Postoperative Management • Food intake and quality.
• Special measures in the wound area, e.g.,
Inpatient care is highly dependent on the type of cooling.
procedure, age, and condition of the patient. • Information to relatives.
General principles of medical management are
outlined below. Optional—usually noted in the anesthesia
Postoperative management is divided into protocol:
immediate postoperative observation and
­monitoring in the recovery ward and postopera- • Anesthetics used.
tive care in the normal ward. • Infusion amounts.
After extubation in the OR and ensuring safe • Fluid balance.
spontaneous breathing, the patient is trans- • Laboratory results.
ferred to the recovery ward for further observa-
tion. On the part of the OR team (anesthesia/
OMF surgeon), information and instructions 1.2 For the Later Postoperative
can be provided during the sign-out procedure Phase
in the OR, digitally and in the form of OR notes
and orders. • Food buildup.
Postoperative care instructions consider the • Removal of the urinary catheter.
impact of surgery and anesthesia on the patient’s • Gastric tube removal.
condition. Postoperative orders ensure that the • Laboratory checks.
findings and effects of the surgery are appropri- • Control of food intake.
ately addressed to ensure patient safety. • Postoperative X-ray control.
11 Postoperative Care in Orthognathic Surgery 103

• Medication management. • Respiratory rate.

• Expected discharge date. • Arterial O2 saturation by pulse oximetry.
• First outpatient follow-up.
–– If necessary: blood gas analysis.
–– Auscultatory lung findings.
1.3 Postoperative Management
in the Recovery Room 1.3.3 Cardiovascular Function
• Heart rate and pulse.
Postoperative management in recovery includes • Blood pressure.
immediate cardio-pulmonary monitoring, oxy- • ECG assessment.
gen saturation measurement, and respiratory con-
trol/assurance. 1.3.4 Neuromuscular Function
If necessary, laboratory parameters may be • Muscle strength assessment.
checked. Specifically, observation and monitor- • Relaxation surplus: Nerve Stimulator.
ing includes the following parameters: • Vigilance and orientation ability.
• State of consciousness
NotePostoperative recovery monitoring
1.3.5 Pain Level
includes three cardinal measures:
• Pain level: location and intensity of pain—
• Stabilization of the postoperative visual analog scale.
patient. • Effect of pain therapy.
• Timely detection and treatment of
complications.
• Initiation of postoperative treatment. 1.4 Controlling the Surgical Area
in Orthognathic Surgery

• Edema of the face.

1.3.1 Standard Basic Monitoring • Tongue swelling.
• Continuation of infusion therapy, temperature • Swallowing ability.
measurement. • Pressure dressing intact.
• Fluid balance, urine output. • Intraoral weeping.
• O2 insufflation—application of 2–4 l O2/min • IMF stability, occlusion, wafer.
on average.
• Documentation of vital signs. 1.5 Final Clinical Assessment

–– Balancing of drainage losses, if applied. After final clinical assessment and satisfactory
–– Laboratory results, if indicated. course without complications, the patient is
transferred to normal ward with further instruc-
1.3.2 Clinical Examination tions. The patient usually remains in the recovery
• Response to response. room for 3 h.
• Respiration—Breathing.
104 P. Kessler et al.

1.5.1 Example I: CMF-Surgery [1] 1.5.2 Example II: Orthognathic

Surgery (Adapted from [1])
Postoperative monitoring in the recovery
room Postoperative arrangement after transfer to
the ward using the example of
Surgical Procedure: BSSO and Le Fort I
monomaxillary surgery on the mandible:
osteotomy.
BSSO
Level of consciousness: responsive but
sleepy. Positioning of the patient
Vital signs: RR 105/65, P 100, R 16. Upper body/head elevated 30°.
In and outs: Medication.
IV: 1100 mL. Continuation of antibiotic therapy for at
Foley: 2200 mL. least 24 hours.
NG: 200 mL. Pain medication based on NSAIDs.
Labs: Hct: 29%. Repeat dexamethasone dose of 8 mg 10
PE: RRRs murmurs, gallops. and 20 hours after surgery.
Lungs: Bibasilar rales. Thermo-/Physical therapy.
Abdomen: BS × 4. Cooling of the wound area: cold packs
Head and neck: or cooling mask.
Moderate facial edema, pressure ban- Nutrition.
dage intact, Start feeding with water, tea and water-­
Minimal intraoral oozing, MMF stable. based ice cream.
Assessment: Build up nutrition—from the 2nd/third
Satisfactory postop results and day with soft food rich in protein and
progress. vitamins.
Postoperative care on the normal Special notes on postoperative
ward. therapy.
Physical postoperative antiedematous
• Patient positioning and mobilization. treatment to reduce swelling.
• Antibiotic regime. Regular intermittent application of ice
• Pain management. or chilled gel compresses to the surgical
• Antiedematous therapy. area—face-cheek-perioral—for the first
• PONV therapy—opening of IMF, wire 3 days after surgery, automatic cooling sys-
cutter. tems have proven their worth.
• Resumption of an existing permanent Sleeping for 1–2 weeks after surgery
medication. with the upper body/head elevated at a 30°
angle.
Antiedematous physical therapy. Application of special light compres-
Nutrition. sion bandages as directed by the surgeon.
Wound treatment.
Wound control.
Drainage removal.
Laboratory controls. Postoperative pain management: See Chap. 10.
X-ray controls. Regular evaluation of pain intensity (VAS)
Choice of medication: primarily according to
pain intensity.
11 Postoperative Care in Orthognathic Surgery 105

Choice of NSAIDs: According to type of sur- remember maximum doses, age reference, and
gery and any contraindications. Possible drug weight relation.
combination on recommendation of the pain For further information please consult
team. Chap. 10.

Note
2.3 Postoperative Drug
Chronic pain patients: Thrombosis Prophylaxis
Include pre-existing pain medication in
postoperative pain therapy on the ward. Thromboprophylaxis is part of perioperative
patient management for any procedure under
general anesthesia and is subject to strict recom-
mendations in every hospital.
For detailed planning of individual postoperative Low-molecular-weight heparins (LMWH) or
pain treatment, please consult Chap. 10. unfractionated heparins (UFH) have proven
themselves.

2 Postoperative Therapy 2.3.1 Indication

of Postoperative Nausea The risk of thrombosis should be assessed preop-
and Vomiting (PONV) eratively. History of family history of thrombosis
should be included in peri- and postoperative
The risk of PONV is generally 20–30%. The drug management. Gender, age, and weight and
risk of PONV should be taken very seriously, physical fitness play a major role. In addition to
especially after operations in which spontane- medicinal measures, physical aids are obligatory
ous or reflex opening of the mouth is restricted for thrombosis prophylaxis.
or impossible due to intermaxillary fixation.
Anesthetic and surgical procedures must be
adapted to this. For anesthetic procedures, 3 Restart of a Pre-Existing
intravenous methods have proven beneficial, Continuous Medication
as has the targeted administration of
antiemetics. 3.1 Cardiovascular Medication
During induction of anesthesia and postopera-
tively, dexamethasone is used not only as an anti- Stable circulatory conditions: Restart/continue
phlogistic but also as an antiemetic, e.g., in immediately postoperatively.
combination with serotonin (5-HT3) receptor Unstable circulatory conditions: dose reduc-
antagonists, such as ondansetron. tion or temporary pause and restart after cardiol-
Nausea and vomiting should be treated imme- ogy consult.
diately, as there is a high risk of recurrence.

3.2 Antidiabetics in Diabetes

2.1 On the Recovery Patients

10–20 mg Propofol i.v. fractionated by anesthesi- Restart in general after the onset of oral food
ologists—attention respiratory depression. intake.
Exceptions:
Metformin: restart 48 h postoperatively.
2.2 On the Ward Insulin: Measure basal insulin and blood glu-
cose, after first food intake initiation with insulin
Ondansetron i.v. or Dimenhydrinat. (histamine and correction according to schedule, thereafter
receptor antagonist). For dose information, please according to preoperative schedule.
106 P. Kessler et al.

3.3 Corticosteroid Medication • Patients should avoid disturbing the wound,

especially during the first 3–7 days.
For continuous therapy above the Cushing’s • Cleanliness of the mouth is essential for good
threshold dose: Dose adjustment postoperatively healing, as a clean wound heals better and faster.
depending on extent of surgery.
Below Cushing’s threshold dose: Continue
immediately postoperatively at the usual dose. 4.2 Intraoral Wound Treatment

4.2.1 Oral Hygiene

3.4 Postoperative Hydration • The mouth should be thoroughly cleaned after
and Oral Nutritional each meal and rinsed with warm salt water
Supplementation (half a teaspoon of salt in an 8 ounce glass of
warm water).
Fluid intake: Aim for neutral fluid balance to • Disinfectant mouth rinse 4–6 times daily until
motivate patients to drink early in the process. healing is complete and normal oral hygiene is
With trouble-free drinking, continue i.v. vol- possible again.
ume therapy only when medically indicated. • Patients should be encouraged to brush their
teeth three times a day. Use a small, soft pedi-
atric toothbrush.
3.5 Dietary Structure • Consumption of dairy products should be
avoided for the first 10 days.
Aim for early oral nutrition. • Alcohol and tobacco: Consumption of alcohol
Nutrition by gastric tube only, if oral nutrition and tobacco should also be avoided for the
currently is unforeseeable. first 2 weeks after surgery, as they promote
From day 2–3: soft protein- and vitamin-rich infection of the wound and delay healing.
diet. • Antibiotics and intraoral wounds: The need
for antibiotics for intraoral wounds should be
a clinical decision based on the type of
4 Wound Care in Orthognathic ­procedure and risk for infection, as well as the
Surgery patient’s immune status and health.
• Removal of drains from day 3 onward.
4.1 Postoperative Considerations • Suture removal of intraoral sutures on postop-
erative day 8.
• Minimizing bacterial colonization of intraoral
wounds during the early healing phase.
• Avoidance of trauma to the intraoral 5 Conclusion
wounds and immobilization of the wound
margins. Pre-, peri-, and postoperative care of the patient
• Intraoral wounds present challenges due to the are integral parts of the success of orthognathic
need to protect healing tissues when ingesting surgery. Not only medical professionals but also
solids of different textures and various types patients evaluate the treatment according to these
of fluids at different temperatures. In addition, criteria.
there is the presence of many types of micro-
organisms that can cause opportunistic
infections. Reference
• The primary goal of intraoral wound care is to
create optimal conditions for the natural heal- 1. Kwon PH, Laskin DM. Clinician’s manual of oral and
maxillofacial surgery. Quintessence Publishing; 2001.
ing processes of the wound to occur.
 Part III
Bilateral Ramus Split Osteotomies
(BSSO) - Surgical Principles
 Principles of the BSSO – Clinical
Aspects
12
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1 Transoral Approach to the BSSO—Line of Thoughts  110
2 Conclusion  111
References  111

Abstract analysis of the local conditions intraopera-

tively, but also the choice of instruments plays
The bilateral splitting osteotomy—BSSO—
a role.
according to Obwegeser–Dal Pont has become
The main goal of the step-shaped sagittal
the standard therapy worldwide for cutting the
splitting of the lower jaw with intraoral access
mandible in all forms of mandibular positional
was on the one hand to reduce the complica-
correction (Obwegeser Dtsch Zahn Mund
tion rate of previous techniques using extra-
Kieferheilk 23:1, 1955; DalPont Minerva chir
oral approaches, on the other hand to eliminate
1, 1958). The success of this technique
the problem of insufficient contact surfaces of
depends on anatomical conditions, but also on
the osteotomized bone segments and a reduc-
the technically correct execution. An exact
tion in the risk of inferior alveolar nerve
damage.

P. Kessler (*) · S. A. N. Lie Keywords

Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center,
Principles of BSSO · Bilateral sagittal
Maastricht, The Netherlands splitting osteotomy · Transoral approach ·
e-mail: [email protected]; [email protected] Access to the spaces · General rules in
N. Hardt (*) sagittal splitting · Obwegeser · Dal pont ·
Kantonsspital Lucerne, Clinic and Policlinic of Hunsuck · Epker
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 109
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_12
110 P. Kessler et al.

1 Transoral Approach • Creation of a sub periosteal access medially

to the BSSO—Line of Thoughts between ramus and pterygoid muscle (lingual
approach/lingual tunnel).
In principle, the surgical technique can be divided • Identification of the mandibular foramen and
into logical surgical steps (Figs. 12.1, 12.2, 12.3, the inferior alveolar nerve.
12.4): • Creation of a horizontal osteotomy above the
mandibular foramen with subsequent cutting
• Intraoral access at the front edge of the ascend- of the inner/lingual cortex of the ramus [1, 2]
ing mandible in the retromolar region by (Fig. 12.2).
mucosa incision. • Creating a lateral-vertical (buccal) osteotomy
with cutting of the cortex until cancellous
bone is reached [3]. Pay attention to a suffi-
cient osteotomy of the lower jaw margin
(Fig. 12.3).
• Connecting osteotomy line between the lin-
gual and buccal osteotomies and splitting of
the ramus into a medial (distal) and lateral
(proximal) segment (Fig. 12.4).
• After complete osteotomy and sufficient
mobilization of the split segments, the tooth-­
bearing mandibular segment is adjusted to the
maxilla according to the preoperative plan-
ning in the intended mandibulo-maxillary
position and intermaxillary fixation is applied.
Wafers/splints can be used, if needed.
• Depending on the initial diagnosis, the joint-­
bearing mandible part is now manually guided
Fig. 12.1 Principle of the bi-sagittal retro molar osteot-
omy according to Obwegeser–Dal Pont—BSSO [3, 4] into the articular fossa and held in position
©Copyright Keisuke Koyama 2020. All rights reserved until osteosynthesis is completed.
• Finally, the functionally stable osteosynthesis
of the segments is performed.

Fig. 12.2 Creating a

horizontal (lingual)
osteotomy line above the
mandibular foramen
with osteotomy of the
lingual cortex until
cancellous bone is
visible. Hunsuck-Epker
modification [2].
©Copyright Keisuke
Koyama 2020. All rights
reserved
12 Principles of the BSSO – Clinical Aspects 111

2 Conclusion

If the surgical steps for preparing the sagittal split

are carefully followed, splitting the mandible in
the mandibular angle region should not be a
problem. Note that the split on the lingual side
can take an arbitrary course.

References
1. Epker BN. Modification in the sagittal osteotomy of
the mandible. J Oral Surg. 1977;35:157–9.
2. Hunsuck EE. A modified intraoral sagittal splitting
Fig. 12.3 Lateral-vertical (buccal) osteotomy with cut- technic for correction of mandibular prognathism. J
ting through the cortex to the cancellous bone including Oral Surg. 1968;26(4):250–3.
the mandibular margin acc. Dal Pont [3] ©Copyright 3. DalPont GL. Osteotomia retromolare per la correzione
Keisuke Koyama 2020. All rights reserved della progenia. Minerva Chir. 1958;1
4. Obwegeser H. Zur Operationstechnik bei der Progenie
und anderen Unterkieferanomalien. Dtsch Zahn Mund
Kieferheilk. 1955;23:1.

Fig. 12.4 Application of the sagittal connecting osteot-

omy and splitting the mandibular ramus ©Copyright
Keisuke Koyama 2020. All rights reserved
 Relation of Cortical Versus
Cancellous Bone – The Crucial Ratio
13
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1 The Mandibular Canal: A Crucial Structure of Lower Resistance  114
2 Anatomical Variants of the MC: Canal Course  115
3 Conclusion  116
References  117

Abstract occur up to 87% and permanent lesions

between 3% and 39%. In order to reduce the
The sagittal ramus osteotomy has become the
risk of injury, the most precise knowledge of
standard procedure due to the large contact
the anatomical course of the IAN within the
area of the split bone segments and the associ-
osseous-mandibular structures is absolutely
ated optimal conditions for bone healing with
essential. The neurovascular bundle of the
sufficient bone overlap. However, due to the
IAN enters lingually through the mandibular
intrabony course of the inferior alveolar nerve
foramen into the mandibular canal. Depending
(IAN) throughout the whole length of the
on the split on the lingual side, the IAN will be
osteotomy this surgical technique is closely
more or less exposed to a risk of trauma.
associated with a potential injury of the
IAN. Thus, temporary postoperative lesions
Keywords

Anatomy of the mandible · Cortical bone ·

Cancellous bone · Sagittal split · Mandibular
P. Kessler (*) · S. A. N. Lie
Department of Cranio-Maxillofacial Surgery, canal · Third molar · Anatomical variations ·
Maastricht University Medical Center, Bad split
Maastricht, The Netherlands
e-mail: [email protected]; [email protected]
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 113
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_13
114 P. Kessler et al.

1 The Mandibular Canal: The MC is a canal that allows the inferior alve-
A Crucial Structure of Lower olar neurovascular bundle to traverse the mandi-
Resistance ble to supply the dentition, mandibular bone, and
soft tissue around the gingiva and lower lip.
The mandibular canal (MC), including the canal The MC is usually well separated from the
neurovascular structures, plays a key role in the surrounding cancellous bone by its denser bone
surgical implementation of osteotomies of the wall.
mandible, especially the bilateral sagittal split- Within the mandible from the proximal to
ting of the mandible—BSSO (Fig. 13.1). the distal end, the MC first runs medially along
The mean maximum diameter of the MC is the inner side of the lingual cortical bone (facies
2.52 mm. It contains neurovascular structures interna) and then turns successively at the level
such as the inferior alveolar nerve with a diame- of the third molar in a more caudal-lateral
ter of 1.84 mm, the inferior alveolar artery with a direction and runs in the anterior 2/3 thirds of
diameter of 0.42 mm, and the inferior alveolar the mandible close to the lateral (buccal) corti-
vein with a diameter of 0.58 mm [1]. cal bone (facies externa) to the exit of the IAN
on the buccal side at the mental foramen
• Location and topography of the mandibular (Fig. 13.2) [2].
canal
• In the posterior two-thirds, the mandibular
canal is closer to the inner surface of the
­mandible, and in the anterior third, it is closer
to its outer surface [2].
• Anatomical preparations of the sagittal split of
the mandible show that both an impacted third
molar (M3) and the IAN—which runs directly
under the M3—remain in the medial (distal)
segment during sagittal splitting (Fig. 13.3) [3].
• Course Variants of the MC and Branching
Patterns of the IAN

The MC is not a single canal, but an anatomi-

cal structure with multiple branches and varia-
tions. Thus, a second canal or an additional
retromolar canal may also be located in the cor-
pus mandibulae (Fig. 13.4) [5].
Basically, three intra-mandibular anatomical
variants of the MC canal course can be distin-
Fig. 13.1 The third branch—the inferior alveolar guished and classified [1].
nerve—of the trigeminal nerve (N.V) entering the man-
dible at the mandibular foramen ©Copyright Keisuke
Koyama 2020. All rights reserved
13 Relation of Cortical Versus Cancellous Bone – The Crucial Ratio 115

Fig. 13.2 Course of the IAN within the mandibular canal ©Copyright Keisuke Koyama 2020. All rights reserved

2 Anatomical Variants
of the MC: Canal Course

Type 1
The MC with the IAN is a single, large struc-
ture located in a bony canal and passing very
close to the root tips.
Type 2
The MC with the IAN passes closer to the
mandibular base and the main nerve has small
branches emerging from the canal which are con-
nected with the root tips.
Type 3
The MC with the IAN has a main branch of
the nerve innervating the posterior region of the
mandible, while a lower branch traverses the
mandible to the anterior region (Fig. 13.4).
Fig. 13.3 The impacted M3 and the underlying IAN
remain after sagittal split in the tooth-bearing distal segment
• Mandibular Canal and Sagittal Splitting—BSSO
©Copyright Keisuke Koyama 2020. All rights reserved.
116 P. Kessler et al.

a The canal derives its clinical significance from

the potential for injury to the neurovascular bun-
dle with the IAN in the sagittal splitting of the
mandible throughout the osteotomy site [6–8].
Potential cause of MC injury in BSSO is:

• Low cancellous bone thickness lateral to the

nerve canal to the buccal mandibular cortical
plate [7, 8].

Temporary postoperative lesions occur in up

to 87% and permanent lesions in 3% to 39%.
b

Note

Median bone thickness lateral to the nerve

canal to the buccal mandibular cortical
plate (CBCT).

• <4 mm immediately posterior to the

mental foramen
• Increased to <6 mm over the next
30 mm.
c
• Then decreased to <3 mm at the level of
the mandibular foramen.

3 Conclusion

Therefore, preoperative determination of the

exact location of the MC is indicated in orthogna-
thic surgery of the mandible by using cone-beam
tomography (CBCT). For detailed information
Fig. 13.4 Anatomical variations of the intra-mandibular see Part II.
course of the mandibular canal (MC) and the branching of
the IAN showing types a, b, and c of the mandibular canal
[4]. (a) IAN runs in a single MC (b) IAN of a single MC
with an accessory canal innervating the retromolar area
(c) IAN runs in a double MC. ©Copyright Keisuke
Koyama 2020. All rights reserved
13 Relation of Cortical Versus Cancellous Bone – The Crucial Ratio 117

References of mandibular canal detected by panoramic radiogra-

phy and CT: a systematic review and meta-analysis.
Dentomaxillofac Radiol. 2016;45(2):20150310.
1. Kamburoğlu K, Ozen T, Balcioglu HA, Kurt B,
6. Rich J, Golden BA, Phillips C. Systematic review of
Kutoglu T, Ozan H, Kilic C. The position of the man-
preoperative mandibular canal position as it relates to
dibular canal and histologic feature of the inferior
postoperative neurosensory disturbance following the
alveolar nerve. Clin Anat. 2010;23:34–42.
sagittal split ramus osteotomy. Int J Oral Maxillofac
2. Hollinshead WH. Anatomy for Surgeons for the head
Surg. 2014;43(9):1076–81.
and neck. Harper and Rowe; 1982.
7. Valdec S, Borm JM, Casparis S, Damerau G, Locher
3. Wolfe SA, Berkowitz S. Plastic surgery of the facial
M, Stadlinger B. Vestibular bone thickness of the
skeleton. Lippincott, Williams and Wilkins; 1989.
mandible in relation to the mandibular canal-a ret-
4. Carter RB, Keen MS. The intramandibular course
rospective CBCT-based study. Int J Implant Dent.
of the inferior alveolar nerve. Journal of Anatomy.
2019;5(1):37.
1971;108(3):433–40.
8. Hur SM, Kim H, Kim H. Topography and spatial fas-
5. Haas LF, Dutra K, Porporatti AL, Mezzomo LA, De
cicular arrangement of the human inferior alveolar
Luca CG, Flores-Mir C, et al. Anatomical variations
nerve. Clin Implant Dent Relat Res. 2013;15(1):88–95.
 Anatomical Reference Points –
Indispensable Aids
14
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1 Conclusion  120
Reference  120

Abstract Keywords

Anatomy of the mandible · Topography ·

The basis of a precise and uncomplicated sag-
Anatomical reference points in BSSO ·
ittal split is a controlled and systematic
Identification of the mandibular foramen ·
approach. Cornerstones of the orientation are
BSSO relevant clinical and topographic
topographical-anatomical points/landmarks,
anatomy
which should be surgically identified in every
case and at all times in order to be able to con-
stantly have orientation for the surgical
process.
This prevents disorientation and possible See Fig. 14.1.
complications caused by loss of control, which
the novice will throw off course. Step by step
and according to the rules the surgical process
must strictly be followed. It is divided into five
sections.

P. Kessler (*) · S. A. N. Lie

Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center,
Maastricht, The Netherlands
e-mail: [email protected]; [email protected]
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 119
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_14
120 P. Kessler et al.

Fig. 14.1 Anatomically– a

topographically important
landmarks in the area of the
preparation of the mandibular
sagittal split osteotomy [1] (a)
lingual aspect (b) lateral-buccal
aspect ©Copyright Keisuke
Koyama 2020. All rights reserved

1 Conclusion Reference

The complex anatomy consisting of different soft 1. Ferner H, Staubesand J. Sobotta/Becher Atlas der
Anatomie des Menschen. Urban & Schwarzenberg;
and hard tissues in the mandibular angle region 1972.
must be understood in order to identify the land-
marks required to gain the necessary orientation
intraoperatively to successfully split the
mandible.
 General Rules in Sagittal
Splitting – Five Steps
15
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1 Surgical Approach  122
2  ccess to the Lateral Side of the Ascending Ramus: Submasseteric
A
Space  123
3  ccess to the Medial Side of the Ascending Ramus: Pterygo-Mandibular
A
Space  123
4  reation of the Osteotomy Lines 
C 123
4.1 Upper Horizontal Osteotomy (Lingual Osteotomy)  123
4.2 Lower Vertical Osteotomy (Buccal Osteotomy)  124
4.3 Sagittal Connecting Osteotomy  124
5  eference Points for Osteosynthesis 
R 124
5.1 Bi-Cortical Screws  124
5.2 Mono-Cortical Screws and Miniplates  124
6 Conclusion  125
Further Reading  125

Abstract Five surgical steps can be distinguished, from

incision to osteosynthesis. Even the incision
The operation for sagittal splitting of the man-
can be decisive for obtaining a sufficient over-
dible is composed of a logical sequence of
view of the surgical area, which is located on
surgical steps that must be consistently fol-
both sides of the ascending mandibular
lowed during each splitting procedure in order
branch. The spaces between the masticatory
to operate successfully, with clarity and safely.
muscles and the mandible must be created
technically in such a way that the overview is
P. Kessler (*) · S. A. N. Lie
not impeded or even made impossible by
Department of Cranio-Maxillofacial Surgery, bleeding or remaining soft tissue attachments.
Maastricht University Medical Center, The identification of the vascular and nerve
Maastricht, The Netherlands bundle at the mandibular foramen must be
e-mail: [email protected]; [email protected]
ensured. Only then is the mandible split with
N. Hardt (*) usually three osteotomy lines lingually, buc-
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland
cally and the connection cut successful.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 121
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_15
122 P. Kessler et al.

Keywords retromolar region laterally in the sulcus between

the belly of the masseteric muscle somewhat lat-
Principles of the BSSO · Mucoperiosteal
erally of the external oblique line (linea obliqua
incision · Bilateral sagittal splitting oste-
externa) in anterior direction up to the level of the
otomy (BSSO) · Transoral approach · Access
first/second molar.
to the spaces · Anatomical reference points in
A pronounced lateral-vestibular incision of
BSSO · Identification of the mandibular
the mucosa in the retromolar and buccal vestibule
foramen · Systematic approach · BSSO
prevents injuries to the lingual nerve and pro-
relevant clinical and topographic anatomy ·
vides sufficient cuff tissue for subsequent muco-
Surgical steps · Creation of bone cuts ·
sal closure (Fig. 15.1). The buccal artery and vein
Mandibular canal · Avoidance of iatrogenic
cross the mucoperiosteal incision line and must
fractures · Avoidance of caudal mandibular
be coagulated (Spiessl 1974).
step formation · Instruments

Lead structure: External oblique line.

1 Surgical Approach

The mucosa-periosteal incision starts at the ven-

tral aspect of the coronoid process (crista tempo-
ralis of the muscular process) and runs in the

Fig. 15.1 View of the mandibular jaw from above with the relevant anatomical structures in order to create the incision
correctly. Incision line is marked in black ©Copyright Keisuke Koyama 2020. All rights reserved
15 General Rules in Sagittal Splitting – Five Steps 123

2 Access to the Lateral Side ning downward from the coronoid process strict
of the Ascending Ramus: subperiosteally to the retromolar region, where
Submasseteric Space the body of the mandible gets wider due to the
alveolar process.
Anterior Aspect of the Ascending Ramus
Gentle dissection of the soft tissues beginning in Pterygo-Mandibular Space
the retromolar region upwards to the tendon inser- Subfascial space between the lingual side of the
tion of the temporal muscle. The base of the coro- ascending ramus laterally and the medial ptery-
noid process must be thoroughly dissected from goid muscle (musculus pterygoideus medialis)
the tendinous attachment of the temporal muscle. medially. Pay attention not to harm the perios-
teal/perimuscular tissues, especially along the
Submasseteric Space edge of the internal oblique line (linea obliqua
Gentle approach to the space between the ascend- interna, sulcus mylohyoideus) in the retromolar
ing ramus medially and the masseteric muscle region.
laterally. Pay attention not to harm the periosteal/
perimuscular tissues. Landmarks

Landmarks • Internal oblique line (linea obliqua interna).

• Semilunar/mandibular notch (incisura
• Semilunar/mandibular notch (incisura semilu- semilunaris).
naris) cranially. • Lingula and the neurovascular bundle of the
• Base of the condylar process (processus con- IAN at the mandibular foramen.
dylaris) dorsally. • Posterior edge of the ascending ramus.
• Mandibular angle to the attachment of the
masseteric muscle at the masseteric tuberosity
latero-inferiorly (angulus mandibulae, tuber-
Lead structures: Semilunar notch—internal
ositas masseterica).
oblique line—lingula.

Lead structures: Semilunar notch—base

muscular process—base condylar process.
4 Creation of the Osteotomy Lines

4.1 Upper Horizontal Osteotomy

3 Access to the Medial Side (Lingual Osteotomy)
of the Ascending Ramus:
Pterygo-Mandibular Space Anterior Aspect of the Ascending Ramus
On the lingual side about 1 cm inferior to the
Anterior Aspect of the Ascending Ramus mandibular/semilunar notch and about 4–6 mm
Gentle dissection of the soft tissue attachments above the mandibular foramen parallel to the
on the lingual side of the ascending ramus begin- occlusal plane of the mandible.
124 P. Kessler et al.

Anterior-Posterior Length of the Osteotomy Leading Structures

The internal oblique line will be cut horizontally Reference Point: Bone Cut Medial to the Oblique
up to the mandibular sulcus which lies posteri- Line
orly to the mandibular foramen (acc. Hunsuck).
Cutting Length
From the intersection of the lingual-horizontal
Point of Orientation: About 1 cm Inferior to cut to the intersection of the vertical-buccal cut.
the Semilunar Notch Length is depending on the location of the afore-
Note: named osteotomies. Depth of the osteotomy
The outer surface of the ramus is kept in should not exceed 10 mm.
view to ensure the depth of the lingual
osteotomy.
One should take into account that the Point of orientation: Buccal cortex—oste-
inner cortical layer is concave and curved. otomy medially along the external oblique
line.

4.2 Lower Vertical Osteotomy

(Buccal Osteotomy)
5 Reference Points
for Osteosynthesis
Pre-Masseteric Space
Vertical osteotomy of the lateral cortex from the
5.1 Bi-Cortical Screws
pre-masseteric submandibular notch at the height
of the second molar (M2) reaching the anterior
Two/three screws at the superior border parallel
end of the external oblique line.
to the upper edge of the proximal segment. At
least one screw has to pass through the oblique
Caudo-Cranial Length of the Osteotomy
line (“Obliqua-screw”).
Depending on the shape of the mandibular body,
Alternatively two screws can be applied at the
it can be from convex to concave. The length of
superior border and a third screw at the base of the
the osteotomy and also the depth of the osteot-
jaw, about 6–8 mm above the lower edge of the
omy must correspond to these shapes and can be
mandible (“Base screw”). In this form of osteo-
shorter for convex shapes than for concave ones.
synthesis the three screws should be equidistant.
Screw size 2 mm, length depending on the
mandibular width.
Lead structures: second molar tooth on
buccal side.
5.2 Mono-Cortical Screws
and Miniplates
4.3 Sagittal Connecting
Osteotomy Standard is a 4-hole plate with a bar in different
design shapes, two screws posterior to the buccal
Retromolar Region split of 5 mm length, two screws anteriorly to the
Osteotomy starts at the anterior edge of the lin- split of 7 mm length. Plate position on or parallel
gual osteotomy and runs downward to the cranial to the oblique line.
end of the buccal osteotomy parallel to the buccal Screw size 2 mm, and plate profile accordingly.
cortex, but well inside along the cortico-­ Plate length depending on indication for sur-
cancellous border (about 5 mm medially). gery and mandibular advancement/setback.
15 General Rules in Sagittal Splitting – Five Steps 125

Further Reading
Focus on plates, screws, and instrumen-
tation (screw driver). Bell HW, Proffit WR, White RP. Surgical correction of
dentofacial deformities, vol. 1-3. Saunders; 1980.
Fonsecca RJ, Marciani RD, Turvey TA. Oral and maxil-
lofacial surgery, orthognathic surgery and craniofacial
surgery. Saunders; 2009.
6 Conclusion Michel C, Reuther J. Orthopädische Chirurgie. In:
Hausamen E, Machtens E, Reuther J, editors. Mund-,
Kiefer- und Gesichtschirurgie. Operationslehre und
The consecutive sequence of the five steps out- Atlas; Springer, 1995.
lined above greatly facilitates the procedure of Spiessl B. Osteosynthese bei sagittaler Osteotomie
sagittal splitting of the mandible and makes this nach Obwegeser/Dal Pont. In: Schuchardt K (Hrsg)
procedure, which can never be 100% controlled, Fortschritte der Kiefer- und Gesichts-Chirurgie, Bd
XVIII. Thieme, Stuttgart New York, 1974;S 145–8.
safe. Steinhäuser EW. Bone screws and plates in orthognathic
surgery. Int J Oral Surg. 1982;11:209–16.
 BSSO Relevant Clinical
and Topographic Anatomy
16
(Studies and Variations)

Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1 Topography of the Mandibular Foramen 125
2  opographic and Metric Relations on the Lingual Side of the Ascending
T
Mandibular Ramus 128
2.1 Position of the Anti-Lingula Opposite to the Lingula/Mandibular Foramen 128
2.2 Vertical and Horizontal Measurements Between the Mandibular Foramen
and the Borders 129
3 Topographic Determination of the Lingual Osteotomy 129
4  ingual Osteotomy Line and Cortex Fusion above the Mandibular
L
Foramen 130
5  he Neurovascular Bundle
T 131
5.1 Care of the Neurovascular Bundle 131
6  SSO and Vascular Structures in the Vicinity of the Lingual Aspect
B
of the Ascending Ramus 131
7 Variants of the Upper Horizontal Osteotomy (Lingual Osteotomy) 133
8 Variants of the Vertical Osteotomy (Buccal Osteotomy) 134
9 Variant of the Sagittal Osteotomy 135
10 Conclusion 135
References 135

Abstract

P. Kessler (*) · S. A. N. Lie Detailed knowledge of topographic condi-

Department of Cranio-Maxillofacial Surgery, tions is required for all surgical procedures.
Maastricht University Medical Center,
Maastricht, The Netherlands
Measurements and landmarks help to make
e-mail: [email protected]; [email protected] the preoperative planning first mentally one’s
N. Hardt (*)
own and then to implement it intraopera-
Kantonsspital Lucerne, Clinic and Policlinic of tively. In routine, these measurements will
Cranio-Maxillofacial Surgery, Lucerne, Switzerland not be necessary every time, but they can be

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 127
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_16
128 P. Kessler et al.

a useful aid for orientation and for gaining • The mandibular foramen—MF
confidence in the sagittal splitting of the • The lingula—La and
mandible.Measurement points and anatomi- • The mandibular sulcus—SuC
cal orientation aids serve to transfer the vir-
tual reality of computerized planning to the
surgical site.
2 Topographic and Metric
Keywords Relations on the Lingual Side
of the Ascending Mandibular
BSSO relevant clinical and topographic
Ramus
anatomy · Principles of the BSSO · Bilateral
sagittal splitting osteotomy · Transoral
2.1 Position of the Anti-Lingula
approach · Access to the spaces ·
Opposite to the Lingula/
Measurement · Anatomical landmarks ·
Mandibular Foramen
Anatomical reference points in BSSO ·
Identification of the mandibular foramen ·
Possible strategy, if the mandibular foramen is
Anatomical orientation · Surgical steps ·
difficult to find or after loss of orientation (e.g.
Obwegeser · Dal Pont · Hunsuck · Epker ·
bleeding): After dissection of the submasseteric
Creation of bone cuts · Short lingual oste-
space definition the anti-lingula on the lateral
otomy (SLO) · Mandibular canal · Surgical
side of the ascending ramus can be helpful as
variants
the first point of orientation for the topographic
position of the mandibular foramen (Fig. 16.2).
The relative position of the lingula in the lin-
1 Topography of the Mandibular gual side in relation to the position of the anti-­
Foramen (Fig. 16.1) lingula is posterior-inferiorly.
The mandibular sulcus and the channel
Anatomically important structures for orientation
entrance of the IAN are clearly below the level of
during the BSSO are
the anti-lingula.

Fig. 16.1 Topographic

anatomy of the
mandibular foramen and
lingual aspect of the
ascending mandibular
ramus. CM condyle of
the mandible, CP
coronoid process, SN
semilunar notch, SuC
sulcus colli, MF
mandibular foramen,
MHG mylohyoid
groove, La lingula.
©Copyright Keisuke
Koyama 2020. All rights
reserved
16 BSSO Relevant Clinical and Topographic Anatomy (Studies and Variations) 129

Fig. 16.3 Measures as indicating the distances between

the mandibular foramen/lingula and the surrounding bor-
ders of the mandible. ©Copyright Keisuke Koyama 2020.
All rights reserved

Fig. 16.2 Anatomical relationship of anti-lingula on the

3 Topographic Determination
latera/buccal side (a) to the mandibular foramen on the lin- of the Lingual Osteotomy
gual side (b) of the ascending ramus [1].©Copyright Keisuke
Koyama 2020. All rights reserved. Circle = Position of the The Point X is a safe and easy to find anatomical
anti-lingula—crossing point line A/B—C/D.
Square = Position superior border of the mandibular foramen
reference point to determine the vertical level of
(lingula)—crossing point line A/B—C/D. Triangle = Position the lingual bone cut in the BSSO. Point X indi-
inferior border of the mandibular foramen cates the deepest site in the concave structure of
the anterior aspect of the ascending ramus
2.2 Vertical and Horizontal (Fig. 16.4). The wider the mandibular ramus, the
Measurements Between closer to the mandibular foramen the horizontal
the Mandibular Foramen BSSO cut should be attempted.
and the Borders The horizontal plane defined by point X–X1–
X2 runs directly across the entrance point of the
The average distance between the mandibular neurovascular bundle of the IAN (Fig. 16.5). Any
foramen/the lingula and anterior border of the lingual osteotomy should be made at least 4 mm
ascending ramus measures 16.8–23.2 mm. The above this line.
distance to the posterior border of the ascending
ramus is 10.0–17.8 mm. The vertical distance to Note
the semilunar notch measures 14.1–25.2 mm, Ideally the horizontal osteotomy on the lin-
whereas the vertical distance between the lower gual side should not be more than 4 mm
border of the mandible to the lingula is 18.6– above the line Point X–X1–X2
42.5 mm (Fig. 16.3) [1].
130 P. Kessler et al.

4 Lingual Osteotomy Line

and Cortex Fusion above
the Mandibular Foramen

The ideal lingual osteotomy line is about 4 mm

above the mandibular foramen in the anterior,
cortico-cancellous part of the ascending ramus
which is a continuation of the inner oblique line
as described by (Fig. 16.6).

Note

The higher the osteotomy line is placed

above the lingula, the more difficult the
splitting

Fig. 16.4 Localization of point X at the deepest point of

the concave anterior edge of the ascending mandibular
ramus. ©Copyright Keisuke Koyama 2020. All rights
reserved

Fig. 16.6 Ideal position of the lingual osteotomy line ca.

4 mm above the lingula: La. CM condyle of the mandible,
CP coronoid process, SN semilunar notch, SuC sulcus
colli, CEC crista endocoronoidea, MF mandibular fora-
men, MHG mylohyoid groove. ©Copyright Keisuke
Koyama 2020. All rights reserved
Fig. 16.5 The line point X–X1–X2 runs directly above
the entrance of the mandibular canal. Point Z marks the
lingula. ©Copyright Keisuke Koyama 2020. All rights
reserved
16 BSSO Relevant Clinical and Topographic Anatomy (Studies and Variations) 131

5 The Neurovascular Bundle 6 BSSO and Vascular Structures

in the Vicinity of the Lingual
The neurovascular bundle can be injured at the Aspect of the Ascending Ramus
entry into the mandibular canal and within the
canal at any time by preparation of the lingual The maxillary artery is embedded in the deep
tunnel, performing of the lingual osteotomy, lobe of the parotid gland dorso-medially of the
splitting of the mandible, as well as after splitting neck of the condylar process. During its course
by rough manipulation and later during rigid several smaller arteries are branching off, includ-
osteosynthesis (Fig. 16.7). ing the inferior alveolar artery. The latter faces
downward, leaving the parotid gland to enter the
mandibular canal at the mandibular foramen and
5.1 Care of the Neurovascular to provide endosteal supply. Before the inferior
Bundle alveolar artery enters the mandibular foramen,
the vessel gives off two branches, the lingual and
The neurovascular entrance point should be visu- the mylohyoid arteries.
alized intraoperatively and the neurovascular The lingual branch follows the lingual nerve
bundle should be in the tooth bearing (distal) to supply the mucous membrane of the floor of
mandibular segment after splitting [1, 3]. the mouth. The mylohyoid branch runs in the

Fig. 16.7 Neurovascu-

lar structures of the
mandibular foramen.
IAN inferior alveolar
nerve—situated right
behind the lingula, IAA
inferior alveolar artery,
IAV inferior alveolar
veins. ©Copyright
Keisuke Koyama 2020.
All rights reserved
132 P. Kessler et al.

mylohyoid groove then ramifies on the undersur- carotid artery. The blood supply to the inner cortex
face of the mylohyoideus to vascularize the peri- is tiered, above and below the mylohyoid muscle.
osteum of the lower inner mandibular cortex. The blood flow through the mandibular perios-
These branches of the inferior alveolar artery teum could easily maintain a sufficient blood sup-
are supplemented in the floor of the mouth by the ply to the teeth of the mobile segment even when
deep lingual artery, a direct branch of the external the labial periosteum was degloved (Fig. 16.8) [2].

Fig. 16.8 The inner cortex and lingual periosteum of the gual view of the mandible (a) and in cross section in the
mandible and floor of the mouth are supplied by a three-­ area of parasymphysis (b). ©Copyright Keisuke Koyama
tiered distribution of vessels, best seen on an oblique lin- 2020. All rights reserved
16 BSSO Relevant Clinical and Topographic Anatomy (Studies and Variations) 133

7 Variants of the Upper Horizontal Transversal radiological distance measure-

Osteotomy (Lingual Osteotomy) ments of the ramus at the level of the mandibular
foramen show the greatest bone width in the
It corresponds to the anatomical—topographical anterior ramus region. The transverse bone dis-
findings that the flail—to dumbbell-shaped ramus tance values in the anterior ramus range from
cross-section in anterior-posterior extension has 3.0 mm (14%) to <7.0 mm (27.5%) [8]
a very variable transverse bone thickness, accom- The average anterior ramus thickness is
panied by an equally variable width of the can- 4.9 mm with a standard deviation of +/− 1 mm.
cellous bone layer (Fig. 16.9). In the area of the posterior ramus margin, the
This anatomical fact led to Hunsuck’s recom- average transverse width is approximately 50%
mendation to limit the lingual osteotomy to the of the anterior measurement with a correspond-
anterior cortico-cancellous area of the ascending ingly reduced cancellous bone layer.
ramus. The often bi-cortical sulcus colli (SuC) is In the median ramus section—at the level of
not suitable for controlled splitting of the the mandibular foramen—the bone width is only
mandible. about 1/3 of the average anterior bone width
accompanied by a very narrow layer of cancel-
lous bone. See Figs. 16.9 and 16.10.

Note
Transversal radiological bone distance
measurements in the region of the ascend-
ing ramus are not representative for a true
assessment of the existing cancellous/corti-
cal bone ratio

Fig. 16.9 Horizontal CT-scan of the right ascending

mandibular ramus above the lingula. 1 = masseteric
muscle

Fig. 16.10 Different a b

types of lingual
osteotomy. Shortening
of the lingual bone cut
will lead to less bone
overlap. (a) Bone cut
to the posterior end of
the ramus. Note the
bi-cortical sulcus colli
region. (b) Bone cut
on the anterior
cortico-­cancellous area
of the ascending ramus
as suggested by
Hunsuck. ©Copyright
Keisuke Koyama
2020. All rights
reserved
134 P. Kessler et al.

the length of the connecting osteotomy between

Note the lingual and buccal osteotomy line changes.
The width of the individual cancellous
bone layer in the middle and posterior Variations in length of the vertical oste-
ramus section—the presumptive splitting otomy [5]:
region—is significantly less than in the (a) a more buccal bone cut.
anterior part of the ascending ramus (b) central bone cut.
(c) lingual bone cut.

Follow-up examinations by CT showed that

8 Variants of the Vertical the bone cuts during a BSSO are often not placed
Osteotomy (Buccal Osteotomy) exactly as planned. The vertical buccal cut
reached the caudal cortex in all cases, but only
There are different variants of lateral vertical bone reached the lingual cortex (inferior border oste-
cut in the inferior rim area when performing a otomy) in 38% of the splits [7].
BSSO. These variations concern both the vertical For splitting the inferior mandibular border,
length of the osteotomy and the anterior-­posterior types b) and c) have proven to be the most suit-
or sagittal positioning of the osteotomy. able, as the inferior split of the mandibular mar-
We distinguish between short and long sagittal gin is technically the best option for a reliable
splits, whereby the starting point at the osteot- osteotomy of the buccal and lingual segments
omy of the lingual side is not changed. However, (Fig. 16.11) [4, 5].

a b c

Fig. 16.11 Different types of vertical buccal bone cuts [5] (a) without inferior border osteotomy, (b) with touching the
inferior border, (c) including inferior border osteotomy
16 BSSO Relevant Clinical and Topographic Anatomy (Studies and Variations) 135

Moving the vertical buccal osteotomy to a 10 Conclusion

region with a greater buccolingual volume and
more cancellous bone may facilitate the split- Taking into account the local anatomical condi-
ting process. On the other hand, shortening the tions and observing a consistent surgical tech-
sagittal splitting path to a region with less buc- nique, the sagittal split of the mandible is
colingual thickness and less cancellous bone achieved in a predictable manner. Anatomical
will increase the risk of uncontrolled mandibu- variations can be understood and specific situa-
lar fracture. tions can be addressed intraoperatively to avoid a
bad split of the mandible or unnecessary damage
to important structures.
9 Variant of the Sagittal
Osteotomy
References
The corticotomy and removal of the narrow
edge of the external oblique line up to the vis- 1. Aziz SR, Dorfman BJ, Ziccardi VB, Janal
ible border between cancellous bone and lat- M. Accuracy of using the antilingula as a sole deter-
minant of vertical ramus osteotomy position. J Oral
eral buccal cortex considerably facilitates the Maxillofac Surg. 2007;65(5):859–62.
marking and determination of depth of the 2. Beukes J, Reyneke JP, Damstra J. Unilateral sag-
buccal sagittal osteotomy lines (Fig. 16.12) [6, ittal split mandibular ramus osteotomy: indica-
9, 10] tions and geometry. Br J Oral Maxillofac Surg.
2016;54(2):219–23.
3. Bell WH, Levy BM. Revascularization and bone heal-
ing after anterior mandibular osteotomy. J Oral Surg.
1970;28:196–203.
4. Pilling E, Schneider M, Mai R, Eckelt U. Präoperative
Lagebestimmung des Canalis mandibulae vor sagit-
taler Ramusosteotomie des Unterkiefers. Mund
Kiefer Gesichtschir. 2004;8(1):18–23.
5. Dreiseidler T, Bergmann J, Zirk M, Rothamel D,
Zöller JE, Kreppel M. Three-dimensional fracture
pattern analysis of the Obwegeser and dal Pont bilat-
eral sagittal split osteotomy. Int J Oral Maxillofac
Surg. 2016;45(11):1452–8.
6. Houppermans PNWJ, Verweij JP, Mensink G, Gooris
PJJ, van Merkesteyn JPR. Influence of inferior border
cut on lingual fracture pattern during bilateral sagit-
tal split osteotomy with splitter and separators: A
prospective observational study. J Craniomaxillofac
Surg. 2016;44(10):1592–8.
7. Böckmann R, Schön P, Neuking K, Meyns J, Kessler
P, Eggeler G. In vitro comparison of the sagittal split
osteotomy with and without inferior border osteot-
omy. J Oral Maxillofac Surg. 2015;73(2):316–23.
8. Farhad BN, Daljit SG. Orthognathic surgery: princi-
ples, planning and practice. Wiley & Blackwell; 2011.
9. Spiessl B. Osteosynthese des Unterkiefers.
Rekonstruktive Chirurgie, Teil III. New York, Tokyo:
Fig. 16.12 Corticotomy of the edge of the external Springer,Berlin,Heidelberg; 1988.
oblique line up to the visible border between cancellous 10. Steinhäuser EW. Educational course on surgical
bone and lateral cortex. ©Copyright Keisuke Koyama methods in orthognathic surgery, vol. 8. Luzern,
2020.All rights reserved Switzerland; 1973. p. 4.
 Strategic Surgical Approach
and Technical Details
17
Peter Kessler and Nicolas Hardt

Contents
1  natomical Basis of Mandibular Bone Splitting 
A 138
1.1 Splitting Technique of the Ramus in the Borderline between Lateral Cortical
and Cancellous Bone  138
2  agittal Split Osteotomy of Mandible (BSSO)—Surgical Technique
S
Surgical Access  139
2.1 Intraoral Mucoperiosteal Incision  139
2.2 Exposure of the Ramus and the Buccal Region of the Second and
Third Molars  139
2.3 Anterior and Inferior Exposure of the Coronoid Process  140
2.4 Exposure of the Lateral Side of the Ramus (Sub-Masseteric Space)  140
2.5 Exposure/Dissection of the Lingual Side of the Ramus (Pterygomandibular
Space)  141
3  he Osteotomy Lines 
T 142
3.1 Horizontal Bone Cut—Horizontal Osteotomy  142
3.2 Vertical Bone Cut—Vertical Osteotomy  144
3.3 Sagittal Bone Cut—Sagittal Osteotomy  146
4  agittal Splitting 
S 148
4.1 P re-Angular Section  148
4.2 A  ngular and Supra-Angular Section  149
4.3 Mandibular Angle Beneath the Nerve Canal  150
4.4 Advanced Splitting  151
4.5 Splitting of the Mandibular Margin  151
4.6 Difficulties in Mandibular Splitting  152
4.7 After the Split  152
5 Conclusion  153
References  153

P. Kessler (*)
Maastricht University Medical Center,
Department of Cranio-Maxillofacial Surgery, N. Hardt (*)
Maastricht, The Netherlands Kantonsspital Lucerne, Clinic and Policlinic of
e-mail: [email protected] Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 137
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_17
138 P. Kessler and N. Hardt

Abstract Accordingly, the topography of the mandibu-

lar canal must be taken into account in the sagit-
The splitting technique, which has been modi-
tal splitting of the mandibular angle and ramus,
fied and perfected over decades, has largely
i.e., the splitting occurs strictly in the boundary
eliminated previous complications such as
zone between the lateral cortical bone layer, the
vascular bleeding, irregular osteotomy proce-
cancellous bone mass, and the mandibular canal.
dures, and unexpected fractures, as well as
Bone cross-sections mostly provided by cone-­
postoperative malpositioning of the mandibu-
beam CT data provide the guidelines for per-
lar condyles resulting in postoperative relapse.
forming an atraumatic osteotomy within the
There is still a residual surgical risk of tem- lateral aspect of the mandibular angle.
porary and sometimes unavoidable permanent In view of the risk of nerve injury, the lateral
an- or hypoesthesia of the lip and chin. This is margin is divided into a pre-angular (1), angular
due to the immediate proximity of the alveolar (2), and supra-angular (3) section (Fig. 17.1) [1,
neurovascular bundle to the osteotomy site, 10, 11].
which may result in a lesion of the nerve even There is minimal to no cancellous bone
with the utmost caution. between the wall of the nerve canal and lateral
cortex in the angular and supra-angular regions (c
Keywords and d) [1, 11].
In the angular and post-angular sections,
Anatomy of the mandible · Topography · there is generally only a small layer of cancel-
Anatomical reference points in BSSO · lous bone between the canal and the lateral cor-
Incision · Identification of the mandibular tex. In the pre-angular zone, the supply of
foramen · BSSO relevant clinical and cancellous bone is usually greater, but the course
topographic anatomy · Surgical approach · of the mandibular canal approaches the buccal
Lingula · Lingual tunnel · Osteotomy lines · cortical lamella, so the risk of injury to the infe-
Horizontal lingual osteotomy · Vertical buccal rior alveolar nerve (IAN) is also present here (a,
osteotomy · Sagittal osteotomy · Mandibular b) [1].
split · Sagittal split · Mandibular margin ·
Osteotomes · Spreader · Lindemann burr ·
Piezo surgery

1 Anatomical Basis of Mandibular

Bone Splitting

1.1 Splitting Technique

of the Ramus in the Borderline
between Lateral Cortical
and Cancellous Bone

The design of the bone cuts and the splitting behav-

ior of the ramus to be expected is based on the
knowledge of the ratio and relation of cancellous
bone mass between the mandibular nerve canal and
the lateral cortex in the pre-angular, angular, and Fig. 17.1 Relationship of the mandibular canal to the lat-
supra-angular regions of the mandible. The deci- eral cortex in the pre-angular (1), angular (2), and supra-­
angular (3) regions relevant for performing the mandibular
sive anatomical relationships can be excellently split (a, b, c, and d). ©Copyright Keisuke Koyama 2020.
depicted on three-dimensional X-ray images. All rights reserved
17 Strategic Surgical Approach and Technical Details 139

2 Sagittal Split Osteotomy molar and retromolar region—to facilitate subse-

of Mandible (BSSO)—Surgical quent suturing.
Technique Surgical Access In order not to lose bone contact when expos-
ing the edge of the ascending ramus, the incision
2.1 Intraoral Mucoperiosteal can also be performed in two sections [12].
Incision After careful incision the mucosa and perios-
teum are dissected laterally starting at the exter-
A mouth spreader/bite block on the contra-lateral nal oblique line and extending the dissection to
side ensures the maximum mouth opening. the lower mandibular border, and to the insertion
The oral mucosa is infiltrated buccally and lin- of the tendon of the masseteric muscle.
gually in the region of the mandibular angle with For a better overview, the incision can be
a local anesthetic containing a vasoconstrictive extended cranially to the end of the coronoid pro-
additive, e.g., epinephrine solution in a concen- cess (modification acc. to [10]).
tration of 1:100,000 for better intraoperative This is followed by subtle hemostasis and,
hemostasis and pain control. optionally, selective diathermy of the buccal
The cheek is stretched with two wound hooks artery, which crosses the ramus at the level of the
of matching length, e.g., Langenbeck hooks, in jaw angle.
cranio-lateral and bucco-caudal direction. Then a
continuous mucoperiosteal incision is made down
to the bone—beginning from the base of the coro- Note
noid process, then continued lateral of the external The incision should not be too lateral in the
oblique line of the ramus downwards to the man- proximal area to avoid injury to the bucci-
dibular vestibule and ending in the region between nator muscle and possible herniation of the
the first and second molar (Fig. 17.2). buccal fat pad.
It is advisable to leave 7–8 mm wide strip of (Corpus adiposum buccae).
the non-keratinized alveolar epithelium in the

Note
The pronounced lateral-vestibular place-
ment of the mucosal incision in the poste-
rior vestibule prevents injury to the lingual
nerve and provides sufficient cuff tissue for
subsequent wound closure.

2.2 Exposure of the Ramus

and the Buccal Region
of the Second and Third
Molars

Dissection of the periosteum begins along the

anterior border of the ramus and follows the exter-
Fig. 17.2 Preparing the surgical site in the lower jaw nal oblique line upwards to the base of the coro-
after insertion of the mouth spreader/mouth prop on the noid process and caudally to the mandibular
left. The extension of the mucoperiosteal incision extends vestibule, exposing the oblique line including the
from the anterior edge of the coronoid process (temporal retromolar region and the lateral crista buccinato-
crista of the coronoid process) to the vestibular crista buc-
cinatoria in the region of the first/second molar.©Copyright ria (Fig. 17.3).
Keisuke Koyama 2020. All rights reserved
140 P. Kessler and N. Hardt

Fig. 17.3 Subperiosteal exposition of the lateral-buccal Fig. 17.4 Exposure of the coronoid process with a
aspect of the mandibular ramus. ©Copyright Keisuke V-shaped rectangular retractor—dovetail retractor, which
Koyama 2020. All rights reserved is positioned and pushed up in the anterior and inferior
part of the coronoid process. ©Copyright Keisuke
Koyama 2020. All rights reserved

2.3 Anterior and Inferior

Exposure of the Coronoid act as a self-sustaining retractor of the abovemen-
Process tioned soft tissues.

After exposure of the anterior edge of the ramus,

two Langenbeck hooks are inserted into the upper Note
edge of the incision to retract the mucosa and The extensive elevation of the coronoid
visualize the insertion of the tendon of the tempo- tendon attachments improves the access to
ral muscle to the coronoid process. the lingual side of the ramus.

Note
A relatively small relief incision in the area 2.4 Exposure of the Lateral Side
of the tendon insertion of the temporal mus- of the Ramus (Sub-Masseteric
cle improves access to the coronoid process. Space)

Starting anteriorly in the region of the second

A blunt dissector is then used to detach the molar a subperiosteal space is created using a
tendinous attachments from the coronoid process blunt curved dissector in direction masseteric
in cranial direction. A dovetail hook (ramus muscle and inferior mandibular border, exposing
hook) is then placed on the exposed inferior edge the edge of the lower jaw and the jaw angle and
of the bone (crista temporalis of the coronoid retracting the masseteric muscle laterally. The
process) and the hook is pushed upwards manu- muscle attachment at the mandibular angle itself
ally to remove the muscle and tendon attach- is not detached to avoid unnecessary devascular-
ments of the temporal muscle until the coronoid ization of the proximal ramus.
notch is exposed (Fig. 17.4). The posterior margin of the ramus can be
A curved Kocher clamp/Zatinsky clamp/aortic exposed optionally, if a classical osteotomy
clamp is then attached to the coronoid process to according to Obwegeser is intended to protect the
17 Strategic Surgical Approach and Technical Details 141

Fig. 17.5 Exposure of the inferior mandibular rim,

curved channel retractor inserted. ©Copyright Keisuke
Koyama 2020. All rights reserved

delicate retromandibular structures with a curved

channel retractor (Fig. 17.5) .

Fig. 17.6 A blunt curved periosteal dissector is used to

create a strictly subperiosteal tunnel on the lingual side of
2.5 Exposure/Dissection the mandibular ramus to expose the medial surface of the
of the Lingual Side ramus. Tissue retraction with a clamp positioned at the
of the Ramus coronoid process. ©Copyright Keisuke Koyama 2020. All
(Pterygomandibular Space) rights reserved

To expose the lingual side of the ramus, a clamp The Hunsuck variant ends at a point immedi-
is first fixed to the coronoid process to secure the ately posterior to the neurovascular bundle. A
soft tissue position as explained above. narrow channel retractor is then placed in the
The dissection is performed below the level of subperiosteal tunnel to protect the medial vascu-
the sigmoid arch (incisura semilunaris), which is lar nerve bundle (Fig. 17.7) [4, 8, 9]
palpated with the blunt dissector.
After crossing the internal oblique line by
careful dissection, the dissector is guided Note
close to the bone—strictly in a subperiosteal Care should be taken to avoid damage to
plane—in dorsal direction and parallel to the the IAN, artery, and vein enclosed in a peri-
occlusal plane of the mandible to create a osteal fibrous bundle when dissecting the
space between the medial surface of the lingual tunnel.
ascending ramus and the neurovascular bundle Nevertheless, unpleasant venous bleed-
on the lingual side of the so-called lingual tun- ing may occur during preparation in the
nel. Notice that the ascending ramus is con- lingula area, but will stop after insertion of
cave here (Fig. 17.6). a channel retractor.
The pterygomandibular periosteal reflection
on the lingual side is then widened to a subperios-
teal tunnel and the medial bone surface is exposed In clinical practice, the channel retractor is
directly to the lingula and the mandibular foramen positioned approximately parallel to the mandib-
identifying the neurovascular bundle. ular occlusal plane at approximately a 45 ° angu-
Then the question is whether to use the lingual lation to the vertical.
osteotomy according to Obwegeser or Hunsuck, Excessive soft tissue retraction on the lingual
the short lingual osteotomy—SLO. side is unnecessary and can cause stretching of
In case of the Obwegeser variant the lingual the IAN as well as distortion or distension of the
dissection has to be continued to the posterior vessels over the sharp edge of the mandibular
edge of the ascending ramus. foramen (Fig. 17.8).
142 P. Kessler and N. Hardt

3 The Osteotomy Lines

Note
In practice, a clear access is achieved after The design of the bone cuts and the subsequent
inserting the narrow channel retractor and splitting of the mandibular ramus are based on
by pivoting the channel retractor 45° to the the knowledge of the ratio of cancellous bone to
vertical plane. cortical bone in the pre-angular, angular, and
The channel retractor then lies parallel supra-angular regions.
to the mandibular occlusal plane.
• Instruments suitable for a mandibular
osteotomy:
a b Drills in the following order: Lindemann
burr long—milling cutter/round burr—
Lindemann burr short.
• Oscillating saw for the sagittal bone cut.
• Piezoelectric bone surgery.

In principle, the sagittal osteotomy requires

three osteotomy lines to mark the borderline
between cortical and cancellous bone (Fig. 17.9):

(a) Horizontal bone cut—lingual cortex of the

Fig. 17.7 The correct position of the channel retractor ascending ramus.
with adequate soft tissue retraction is a prerequisite for (b) Vertical bone cut—lateral buccal cortex—
sufficient visualization and accessibility for the lingual mandibular body.
osteotomy and avoids injuries to the neurovascular bun- (c) Sagittal bone cut—oblique line—region of
dles. (a) Obwegeser, (b) Hunsuck. ©Copyright Keisuke
Koyama 2020. All rights reserved the ascending ramus.

3.1 Horizontal Bone Cut—

Horizontal Osteotomy

Before making the horizontal bone incision, it is

recommended that, e.g., a Seldin retractor be
inserted into the lingual subperiosteal tunnel
superior to the lingula and then rotated by 45° to
the vertical (Fig. 17.10). This will stretch the
periosteum in a tent-shaped manner in the area of
the foramen (see identification technique of the
mandibular foramen—Chap. 14).
For safe localization of the mandibular fora-
men at the tip of the lingual tunnel, it is recom-
mended to estimate the plane and length of the
planned osteotomy line with a blunt nerve probe,
which is placed in the foramen under direct visu-
alization (Fig. 17.11) [7]
After clear dissection of the surgical field, the
Fig. 17.8 Inserted channel retractor for visualization of first osteotomy is usually the horizontal bone cut
the lingual ramus side and the neurovascular bundle. Care on the lingual side.
should be taken that the neurovascular bundle is not dam- If burrs are used: The horizontal osteotomy
aged by the channel retractor due to excessive retraction.
©Copyright Keisuke Koyama 2020. All rights reserved through the lingual cortex to a depth equal to half
17 Strategic Surgical Approach and Technical Details 143

Fig. 17.9 Bone cuts for sagittal splitting of the mandible. ©Copyright Keisuke Koyama 2020. All rights reserved

According to Obwegeser the entire width/

length of the inner cortex of the ascending
Fig. 17.10 Seldin retractor ramus has to be cut as well as the inner cancel-
lous bone layer including the posterior edge of
the medio-lateral thickness of the ramus can be the ramus.
performed with the long Lindemann burr. The The Hunsuck technique commonly used
linguo-medial cortex cut is made approximately today for the short lingual osteotomy (SLO) is
1 cm below the mandibular notch, parallel to the in the same plane but ends somewhat cranially
occlusal surface of the lower row of teeth. Starting and distally of the mandibular foramen
point of the osteotomy: In or slightly above the (Fig. 17.12).
lingula (Fig. 17.11).
144 P. Kessler and N. Hardt

Fig. 17.11 Lateral view

of the nerve probe
placement in the
mandibular foramen and
the position of the burr.
©Copyright Keisuke
Koyama 2020. All rights
reserved

Note Note
The identification of the mandibular fora- If a protruding internal oblique line obstructs
men is crucial for the creation of the hori- the clear arrangement of the bone cuts, a
zontal osteotomy on the lingual side. pear- or round-shaped burr is used to make a
For the determination of the dis- groove in the internal oblique line to enable
tance between the foramen and the a correct horizontal bone section.
osteotomy line, see detailed technique
in Chap. 8.
3.2 Vertical Bone Cut—Vertical
Osteotomy
The horizontal osteotomy should be as low as
The vertical cut on the buccal side of the mandi-
possible, close to the lingula. In this region, there
ble lies in the region of the second molar or
is usually sufficient cancellous bone between the
slightly more anterior or posterior to the base of
cortical lamellae to facilitate separation/splitting
the masseteric muscle basically perpendicular to
(Fig. 17.13).
the occlusal surface and primarily affects the lat-
eral cortex [3]
The depth of the bone cut should just reach the
Note cancellous bone layer.
The closer the bone cut is located towards A buccal channel retractor is placed vertically
the mandibular notch, the lower the chance opposite the center of the second molar with its
that the sagittal split of the proximal ramus tip below the lower margin of the mandible to
is successful. protect the soft tissues of the cheek and the facial
(see detailed technique in Chap. 8). artery and vein crossing over the mandibular rim
in this region.
17 Strategic Surgical Approach and Technical Details 145

a b

Fig. 17.12 Horizontal bone cut directly above the man- or (b) behind the ascending ramus (Obwegeser) (c) Short
dibular foramen (lingula) and the inferiorly placed neuro- lingual osteotomy—SLO. ©Copyright Keisuke Koyama
vascular bundle. Note the two possible positions of the 2020. All rights reserved
channel retractor: (a) posteriorly to the lingula (Hunsuck)

A fissure drill or the long Lindemann burr is

then used to cut vertically and downward through Note
the thick outer cortical bone to a depth of about Due to the proximity of the inferior alveo-
2 mm until the vascularized cancellous bone lar nerve (IAN) to the buccal mandibular
becomes visible in the bone cut (Figs. 17.14, cortex in the area of the first molar, the
17.15A, B). anterior vertical osteotomy should be
Care should be taken to ensure that the oste- stopped as soon as a cancellous bone hem-
otomy is not made too deep into the cancellous orrhage occurs in the osteotomy channel
bone, since the mandibular canal and IAN are indicating that the buccal cortex has been
located near the lateral cortex. completely severed.
146 P. Kessler and N. Hardt

Likewise, the thick cortical edge of the lower

mandibular rim is completely cut until the can-
cellous bone layer is reached—to a depth of
2–3 mm.
The osteotomy of the basal mandibular mar-
gin ends shortly before the lingual cortex. This
measure is important and must be performed
with care. When adjusting the drill, care must be
taken not to overstretch the soft tissue of the
cheek (Figs. 17.14 and 17.15a, b) [2, 15]

Note
To check the completeness of the vertical
osteotomy, a fine, narrow osteotome should
be used to gently follow the bone incision.

Fig. 17.13 Removal of a protruding internal oblique line

with a burr in the preplanned horizontal osteotomy plane.
3.3 Sagittal Bone Cut—Sagittal
©Copyright Keisuke Koyama 2020. All rights reserved
Osteotomy

Both osteotomies, the lingual horizontal and ver-

tical buccal bone cuts, are connected by a third
osteotomy line. A round burr can be used to mark
the connecting line through a series of drill holes
in the sagittal plane parallel to the medial aspect
of the external oblique line. These holes are then
connected with a short drill to create a continu-
ous, straight sagittal connecting bone cut
(Fig. 17.16). The sagittal bone cut should be par-
allel to the sagittal plane of the ramus and the
depth of this osteotomy should not reach the
mandibular canal [13, 14]

Note
The corticotomy of the narrow edge of the
oblique external line up to the visible bor-
der between cortical and cancellous bone
Fig. 17.14 After insertion of a curved channel retractor,
the vertical osteotomy including the cortical mandibular considerably facilitates the marking and
margin (inset) is performed with the short or long placement of the sagittal bone cut.
Lindemann burr. ©Copyright Keisuke Koyama 2020. All
rights reserved

The direction and path for the subsequent sag-

As indicated in Fig. 17.14, the vertical cut is ittal splitting are thus determined. The two buc-
not made directly through the cortical bone, but cally and lingually inserted channel retractors
at an angle of 45° to the surface. provide firm support.
17 Strategic Surgical Approach and Technical Details 147

Fig. 17.15 After insertion of a curved channel retractor, short Lindemann burr (a) Alternatively Piezo surgery can
the vertical osteotomy is performed with the short or long be applied (b) ©Copyright Keisuke Koyama 2020. All
Lindemann burr. The mandibular margin is cut with the rights reserved
148 P. Kessler and N. Hardt

Fig. 17.16 Corticotomy of the edge of the oblique external line up to the visible border between cortical and cancel-
lous bone close to the lateral cortex [12, 14]. ©Copyright Keisuke Koyama 2020. All rights reserved

4 Sagittal Splitting Note

Correct transitions between the three oste-
• Splitting technique of the ramus in the border- otomy lines:
line between lateral cortex and cancellous The transition of the horizontal (lingual)
bone. cut and the transition of the vertical buccal
• Correct sequence of splitting with thin and cut in the sagittal osteotomy line should be
wide osteotomes/chisels. selectively deeply cut with a short burr and
• Modification Hunsuck instead of splitting the worked out to facilitate subsequent sagittal
posterior ramus margin—the short lingual splitting along the horizontal and vertical
osteotomy (SLO). sections with fine osteotomes.

Before the actual splitting begins, the proxi-

mal and distal transitions between the bone cuts 4.1 Pre-Angular Section
are separated with fine osteotomes. A narrow
osteotome with a finely tapered blade first com- The actual sagittal split osteotomy then begins in
pletes the transition from the sagittal to the verti- the pre-­angular section, where the cancellous layer
cal osteotomy with light hammer blows in an and the lateral cortex have approximately the same
inferior direction towards the mandibular margin width, and is performed with especially thin
as well as the transition from the sagittal to the Lambotte osteotomes of different widths: The stan-
horizontal osteotomy in the proximal region [13]. dard osteotomes have a width of 8, 10, and 12 mm.
17 Strategic Surgical Approach and Technical Details 149

Fig. 17.17 A chisel can be used to deepen the drill cuts.

©Copyright Keisuke Koyama 2020. All rights reserved Fig. 17.18 The osteotomes (1 and 2) are impacted alter-
nately for partial splitting of the lateral and medial cortex
The fine osteotomes—no. 8 or 10—are used to segments. ©Copyright Keisuke Koyama 2020. All rights
reserved
deepen the cortical drill cuts—starting at the inter-
section of the sagittal connecting osteotomy and the
vertical buccal osteotomy in the region of the first 4.2 Angular and Supra-Angular
and second molars, respectively. The medial and Section
lateral segments are then separated continuously
from pre- to post-angular (Figs. 17.17 and 17.18). Very thinly ground osteotomes or chisels—
Two Lambotte flat osteotomes alternate to straight or slightly curved—are used in the angu-
deepen the sagittal osteotomy gap. One osteo- lar and supra-angular sections, since there is little
tome is alternately loosened and re-inserted into or no cancellous bone between the wall of the
the gap parallel to the remaining osteotome— nerve canal and the lateral cortex.
behind the previously placed osteotome—for fur- Here, post-angular splitting is started directly
ther splitting and the medial and lateral segments at the lingual horizontal bone cut. A 5 mm osteo-
are separated progressively from anterior to pos- tome is placed at an angle. Basic direction: con-
terior - better visibility. necting line between the mandibular midline and
The remaining osteotome continuously deter- the external oblique line.
mines the direction of splitting by holding it The osteotome penetrates to the interface of
under tension while rotating it carefully so that the cortical bone under light, short hammer
the osteotomy gap is widened step by step and blows. After reaching this layer, the osteotome is
the splitting process is visually controlled, so that swiveled into the sagittal (parallel to the outer
the now free second osteotome can be safely reat- surface of the ascending ramus).
tached. Initially, the osteotomes should not be Gently into the depth, the bone is split either
guided too medially and too deep to exclude the to the posterior of the mandibular foramen [4,
possibility of transection of the alveolar neuro- 8] or including the posterior margin of the jaw
vascular bundle. [5, 9].
150 P. Kessler and N. Hardt

4.3 Mandibular Angle Beneath osteotomes with round wooden handles e.g., are
the Nerve Canal additionally inserted for further splitting.
These wide osteotomes are then used to
After identification of the nerve canal osteotomes slowly push the two segments apart and, by
are then guided angularly between the lateral cortex carefully twisting the osteotomes, achieve com-
and the spongy intramedullary bone in the sagittal plete inferior and posterior separation of the
plane of the mandible to the mandibular margin— last trajectory connections of the segments,
compacta to facilitate the separation of the mandib- while visualizing and protecting the neurovas-
ular margin. The neurovascular bundle must be safe cular bundle.
in the distal mandibular segment (Fig. 17.19). This procedure helps to avoid the “bad split”
After extensive splitting—up to well below the caused by incompletely osteotomized segments
alveolar canal—wide osteotomes, e.g., 12 mm at the inferior mandibular border.

Fig. 17.19 The cross-

sectional view demonstrates
the course of a complete
continuous lateral cortex split
to avoid splintering (Hunsuck
effect) and nerve injuries [12]
©Copyright Keisuke Koyama
2020. All rights reserved
17 Strategic Surgical Approach and Technical Details 151

4.4 Advanced Splitting

If the splitting of the buccal and lingual cortex

segment is largely advanced, a wider osteo-
tome—no. 10—that widens the osteotomy gap
and smaller osteotomes are used alternately as
indicated above.
The wider osteotome is left and immediately
behind it, smaller osteotomes continue the split-
ting at the mandibular angle/margin. The osteo-
tome should be directed towards the inner surface
of the cortex of the proximal fragment because of
the cutting blade of the instrument.

4.5 Splitting of the Mandibular

Margin
Fig.17.20 Splitting of the inferior mandibular margin.
A fine tapered curved sharp osteotome is then ©Copyright Keisuke Koyama 2020. All rights reserved
used to split the inferior mandibular rim—start-
ing from the lower part of the vertical osteotomy.
The osteotome is inserted between the par-
tially split bone segments in the area of the lower
vertical osteotomy. When separating the ­mandible
margin, the osteotome is pressed lightly against
the distal segment to direct the splitting pressure
against the inner surface of the proximal segment
(Fig. 17.20) [1, 15].
The osteotome is used in the area of the lower
vertical bone cut in partially split bone segments.
During the separation of the mandibular margin,
the osteotome is pressed slightly against the dis-
tal segment to direct the splitting pressure against
the inner surface of the proximal segment (Figs.
17.20 and 17.21) [1, 6, 13, 15].
Two osteotome technique: The rotation of the
wide osteotomes is slow but continuous—prefer-
ably anticlockwise on the right side and clock-
wise on the left side until the ramus fragments Fig. 17.21 Wide osteotomes inserted into the osteotomy
begin to split (Fig. 17.20). gap, which are rotated alternately for definitive division of
One osteotome technique: If only a single the two segments. ©Copyright Keisuke Koyama 2020. All
rights reserved
wide osteotome is used to spread the segments,
the osteotome must be inserted and rotated pro-
gressively from the anterior buccal cut beginning tor and spreader are popular instruments to use
to the linguo-medial end of the bone cut when the classic osteotomes do not fit well in
(Fig. 17.22). the hand (Figs. 17.22 and17.23). A combina-
Alternative splitting techniques often refer tion of spreader and osteotome is also
to the instrumentation used. The Smith separa- possible.
152 P. Kessler and N. Hardt

4.6 Difficulties in Mandibular

Note Splitting
• If bleeding due to vascular injury has
occurred as a result of the splitting, a If the separation of the proximal and distal seg-
folded hemostatic fleece is placed on the ments is difficult:
bleeding site and the two bone segments
are temporarily repositioned and com- • Use a 5 mm chisel/small osteotome to cut
pressed with a clamp. through the presumably resistant lower and
• Electrocautery should be avoided. angular cortical edge of the osteotomy in the
dorsal osteotomy region.
• With a thin chisel/osteotome in the area of the
buccal vertical osteotomy, the splitting of the
mandibular margin is repeated between the
buccal cortical plate and medullary bone in
order to separate remaining osseous
­connections mostly in the area of the mandib-
ular base.

Note
• If there is resistance to the separation of
the segments with the wide osteotomes,
it should be checked again whether the
separation of the cortical structures on all
sides has been completely successful.
• In case of recognizable splitting prob-
Fig. 17.22 Careful splitting using one osteotome and the
lems, it is better to stop the surgical pro-
Smith separator. ©Copyright Keisuke Koyama 2020. All
rights reserved cedure first and identify the problem.
• The problem should be diagnosed and
solved in order to avoid an “unfortunate
splitting.”
• If the jawbone is very cortical, force
must be used occasionally, then this
should preferably be done in the axial
direction of the instrument (osteotome)
without rotating it.

4.7 After the Split

After splitting the mandible, a wide osteotome is

inserted and rotated in the anterior region of the
sagittal osteotomy and the osteotome is rotated to
check the position of the neurovascular bundle,
the completeness of the osteotomy, and resistant,
Fig. 17.23 Careful splitting using the spreader and the
adherent tendon and muscle attachments.
Smith separator. ©Copyright Keisuke Koyama 2020. All Ideally, the IAN after splitting is either com-
rights reserved pletely in the medial distal segment or may be
17 Strategic Surgical Approach and Technical Details 153

Note
• The neurovascular bundle is to be visu-
alized. It should be in the distal segment
on the medial side.
• If the mandible is to be advanced, the
medial pterygoid muscle is detached
from the inferior mandibular border to
reduce the risk of relapse.
• If the mandible is to be set back, judi-
cious stripping of the pterygomasseteric
sling may be an important consideration
to prevent posterior displacement of the
condylar segment.
• The cortex of the mandibular margin
should be completely severed.
• For control purposes, the osteotomy gap
should be clearly expanded and a fine
Fig. 17.24 The osteotome is inserted into the osteotomy
gap and the gap is expanded by rotating it. ©Copyright osteotome should be used to gently test
Keisuke Koyama 2020. All rights reserved the complete cut of the cortical mandib-
ular margin.
more or less visible in the operation field or adher- • With an index finger placed on the ante-
ent to the lateral proximal segment (Fig. 17.24). rior edge of the proximal segment, the
If the nerve is partially located in the proximal distal tooth-bearing part of the mandible
segment, the nerve is carefully released from the is advanced gently to ensure that the
cancellous bone with the blunt dissector, e.g., split is complete and the mandibular
dissector acc. to Freer, to allow medial reposi- body can be mobilized without interfer-
tioning of the nerve. ence with the position of the proximal
If the alveolar neurovascular bundle is trapped segment/condyle.
in the mandibular canal of the proximal segment
and the planned segment movement is minimal, it
may be unnecessary to expose the nerve in the
proximal segment and release it from the sur-
rounding trabecula. 5 Conclusion
However, in the case of major segmental dis-
placements, repositioning of the nerve is inevita- The technique described here for splitting the
ble due to the nerve strain that might occur. Again mandible has proven itself in clinical practice
blunt dissectors must be used. worldwide and is also used with occasional varia-
If the neurovascular bundle is exposed within tions in terms of instruments. The splitting proce-
an incomplete split, the split is first completed dure itself must be well prepared to be
with fine osteotomes or chisels in the infra-nerval successful.
segment of the mandible and then the nerve is
repositioned. Utmost care is obligatory.
Occasionally, inferior detachment of soft tissue References
attachments of the pterygo-masseteric loop is
required to allow the proximal and distal bone frag- 1. Bell HW, Proffit WR, White RP. Surgical correction
of dentofacial deformities, vol. 1-3. Saunders; 1980.
ments to move independently and passively
2. Böckmann R, Schön P, Neuking K, Meyns J, Kessler
(Fig. 17.24). P, Eggeler G. In vitro comparison of the sagittal split
154 P. Kessler and N. Hardt

osteotomy with and without inferior border osteot- 9. Obwegeser H. Zur Operationstechnik bei der
omy. J Oral Maxillofac Surg. 2015;73(2):316–23. Progenie und anderen Unterkieferanomalien. Dtsch
3. Dal Pont G. L’osteotomia retromolare per la correzi- Zahn Mund Kieferheilk. 1955;23:1.
one della progenia. Minerva Chir. 1958:1. 10. Spiessl B. Gesicht und Gesichtsschädel in Naumann
4. Epker BN. Modifications in the sagittal osteotomy of HH: Gesicht- Kopf- und Hals-Chirurgie. Operations-­
the mandible. J Oral Surg. 1977;35(2):157–9. Manual in 3 Bänden. Orthopädische Operationen am
5. Epker BN, Stella JP, Fish LC. Dentofacial deformi- Kiefer , Bd.2/Teil 2. Thieme, Stuttgart 1974.
ties. Integrated orthodontic and surgical correction, 11. Spiessl B. New concepts in maxillofacial bone sur-
band 3. Mosby. 1998; gery. Berlin, Heidelberg: Springer; 1976.
6. Escobar V, Greenberg AM, Schwimmer 12. Spiessl B Osteosynthese des Unterkiefers.
A. Mandibular Osteotomies and Considerations Rekonstruktive Chirurgie, Teil III. Springer, Berlin,
for rigid ­internal fixation. In: Greenberg AM, Prein Heidelberg, New York, Tokyo, 1988.
J, editors. Craniomaxillofacial Reconstructive and 13. Steinhäuser EW, Janson I. Kieferorthopädische
Corrective Bone Surgery: Principles of internal fixa- Chirurgie Bd. I. Berlin, Chicago, London, Sao Paulo,
tion using AO/ASIF Technic. Springer; 2002. Tokyo: Quintessenz; 1988.
7. Ghali GE, Patel S. Avoiding surgical complications in 14. Steinhäuser EW. Educational course on surgi-
orthognathic surgery. In: Ghali GE, Woerner JE, Patel cal methods in orthognatic surgery, vol. 8. Luzern,
S, editors. Maxillofacial Surgery: Mandible (Third Switzerland; 1973. p. 4.
Edition). Livingstone: Churchill; 2017. 15. Wolford LM, Davis WM. The mandibular inferior
8. Hunsuck EE. A modified intraoral sagittal splitting border split: a modification in the sagittal split oste-
technic for correction of mandibular prognathism. J otomy. J Oral Maxillofac Surg. 1990;48:92–4.
Oral Surg. 1968;26(4):250–3.
 Intraoperative Hazards and Risks
18
Peter Kessler and Nicolas Hardt

Contents
1 Vascular Injuries 156
2  revention of Vascular Injuries in the Pterygomandibular Space
P 157
2.1 Inferior Alveolar Artery 157
2.2 Maxillary Artery 157
3  revention of Vascular Injuries in the Retromandibular Region
P 158
3.1 Retromandibular Vein/Retromandibular Venous Vascular Plexus 158
4 I ntraoperative Measures for Vascular Lesions 158
4.1 Inferior Alveolar Artery 158
4.2 Maxillary Artery 158
4.3 Facial Artery 159
5 Nerve Injuries 159
6 Paresthesia/Anesthesia 159
7 Damage to the IAN 159
7.1 In Detail, Intraoperative Injuries of the IAN Occur: 159
7.2 Injuries to the Inferior Alveolar Nerve Can Be Avoided by: 160
7.3 Treatment of IAN Injuries 160
7.3.1 Complete Transection of the Inferior Alveolar Nerve—IAN 160
8  amage to the Lingual Nerve
D 161
8.1 Injuries to the Lingual Nerve can be avoided by: 161
8.2 Treatment of Lingual Nerve Injuries 161
8.2.1 Complete Transection of the Lingual Nerve 161
9 Damage to the Facial Nerve 162
10 Split Patterns during BSSO 163

P. Kessler (*)
Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center,
Maastricht, The Netherlands
e-mail: [email protected]
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 155
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_18
156 P. Kessler and N. Hardt

10.1 Sagittal Split Variants 163

10.2 Bad Splits in BSSO 163
10.3 Danger Points: Bad Split 165
10.4 Avoidance of Bad Splits 166
11 Complications during and Immediately after Extubation 167
12 Conclusion 168
References 168

Abstract • Inferior alveolar artery.

• Intraossary course/mandibular and mental
Intraoperative risks/complications include foramina.
arterial and venous vessel injuries, direct and • Maxillary artery.
indirect nerve and soft tissue injuries and • Facial artery.
incomplete or irregular osteotomies (bad • Masseteric artery.
splits) (Kim J Korean Assoc Oral Maxillofac • Retromandibular vein.
Surg 431:3–15, 2017; van Merkesteyn et al.
Int J Oral and Maxillofacial Surg 166:665– Disturbing and sometimes even severe bleed-
670, 1987; Houppermans et al. J ings can occur as a result of injuries to larger arte-
Craniomaxillofac Surg 449:1170–1180, rial vessels, such as the maxillary artery in the
2016). For the sake of completeness, possible pterygomandibular fossa, the masseteric artery in
damage to neighboring teeth must also be the sigmoid region, and the facial artery at the
mentioned. lower edge of the mandible in the region of the
Intraoperative hazards and risks: submandibular notch. The inferior alveolar artery
can be disrupted in the pterygomandibular space
• Vascular injury. in the region of the lingula or in the sagittal fis-
• Nerve injury. sure after or while splitting the mandible.
• Undesirable fracture lines—bad split. Fierce maneuvers can also lead to rupture of
• Incorrect positioning of the proximal seg- venous vessels. Venous hemorrhages can be
ments/condyle attempted sublingually, e.g., after mandibular
split by excessive movement of the segments or
Keywords also through the retromandibular vein, but in
this case it is more likely that chisels and osteo-
General rules in sagittal splitting · BSSO tomes slip off. But also careless maneuvers
relevant clinical and topographic anatomy · with drills and saws can lead to unpleasant
Short lingual osteotomy · Mandibular canal · bleeding. The overall risk of intraoperative
Avoidance of iatrogenic fractures · Split bleeding when splitting the lower jaw is stated
patterns · Bad split · Vascular injury · at 9% [5, 10].
Bleeding · Nerve injury · Inferior alveolar Smaller vascular bleedings can be stopped by
nerve · Hazards in BSSO pressure tamponade with absorbable hemostatic
materials such as gauze strips impregnated with
thrombin or adrenaline or by electrocoagulation,
1 Vascular Injuries vascular occlusion or with vascular clips.
Bleeding from cancellous bone is stopped by
The vascular structures defined below are at applying pressure and bone wax, vascular bleed-
greatest risk of being injured during orthognathic ing in the osteotomy area—such as the inferior
procedures in the mandible: alveolar artery—is stopped by applying multiple-­
18 Intraoperative Hazards and Risks 157

folded, resorbable hemostats, such as surgical 2 Prevention of Vascular Injuries

Tabotamp™ or Surgicel™, e.g., as an adjunct in the Pterygomandibular Space
measure. Short-term readjustment of the split
bone segments and compression with a strong 2.1 Inferior Alveolar Artery
surgical clamp for a few minutes can also be
used. By careful and clear positioning of the horizon-
tal osteotomy line slightly superior of the lin-
Note gula with corresponding vertical safety distance
*Tabotamp™—An absorbable hemostatic between the lingula/neurovascular bundle and
agent that promotes platelet aggregation the horizontal osteotomy line on the lingual
and activates the intrinsic clotting cascade. side.
Tabotamp™ is in vitro bactericidal against By using special retractors to protect the soft
gram-positive and gram-­negative bacteria tissues and by careful positioning of the retrac-
as well as aerobic and anaerobic bacteria tors superior and posterior to the lingula.

2.2 Maxillary Artery

In the event of bleeding of large arterial ves- The maxillary artery runs directly under the peri-
sels that cannot be stopped immediately by vas- osteum in front of or behind the lateral pterygoid
cular ligation/obstruction, an emergency muscle and ascends through the two heads of the
embolization must be performed with the indica- lateral pterygoid muscle to the pterygopalatine
tion of a life-threatening and difficult-to-stop fossa (Fig. 18.1).
bleeding.
The extent of the intraoperative bleeding and
the possibility of further bleeding complications
varies from patient to patient. For this reason, it is
important to measure the relative blood loss dur-
ing the procedure continuously and patient
specifically. The controlled lowering of blood
­
pressure intraoperatively helps to prevent greater
blood loss.
Extensive surgery and a reduced body mass
index are associated with a relatively increased
intraoperative blood loss [23].

Note
Significant blood loss after sagittal splitting
of the ramus is usually the result of persis-
tent oozing bleeding from severed muscles,
such as the masseteric and/or medial ptery- Fig. 18.1 Course of the maxillary artery in the profound
goid muscles and inadequate intraoperative region of the face. The maxillary artery is marked red tri-
blood pressure control. angle at the crossing with the lateral pterygoid muscle.
Concomitant veins are marked with blue triangle. The
Minimal and strictly subperiosteal neurovascular bundle entering the mandibular canal is
detachment of muscles and periosteum marked with yellow triangle. The muscular (coronoid pro-
from the ramus reduces intraoperative and cess) and condylar processes is resected. ©Copyright
postoperative bleeding and swelling. Department Anatomy and Embryology Maastricht
University, 2021. All rights reserved
158 P. Kessler and N. Hardt

Surgical trauma/tearing/rupture of the maxil-

lary artery or its branches is usually the result of
a non-conforming approach to the planned oste-
otomy site on the lingual side of the ascending
mandibular ramus. Lack of exposure and visual-
ization of the relevant structures in this not always
clearly arranged region is the reason for loss of
orientation. The leading structure is the neurovas-
cular bundle of the inferior alveolar nerve, artery,
and vein.
The direct cause is a laceration of the perios-
teum/the pterygoid muscle and the associated
rupture of the maxillary artery or its branches
running under the periosteum.
Careful subperiosteal dissection along the
base of the muscular process (coronoid process) Fig. 18.2 The vascular environment of the region where
the BSSO is performed. Lateral sagittal section—retro-
to the posterior edge of the mandibular ramus and mandibular region and temporomandibular joint
subsequent careful widening of the lingual tunnel (resected). Retromandibular venous plexus is dissected
prevents injuries to the maxillary artery. (orange arrow). Mandibular canal is opened (blue arrow).
Facial artery and vein at the crossing point of the mandi-
ble (yellow arrow).©Copyright Department Anatomy and
Embryology Maastricht University, 2021. All rights
3 Prevention of Vascular Injuries reserved
in the Retromandibular Region
4 Intraoperative Measures
3.1 Retromandibular for Vascular Lesions
Vein/Retromandibular Venous
Vascular Plexus 4.1 Inferior Alveolar Artery

The posterior margin of the ascending mandibular Bleeding of the inferior alveolar artery and vein
ramus, which should be carefully prepared sub- can usually be easily stopped with the bipolar
periosteally, must be clearly visible and protected forceps.
if injury to the retromandibular venous vessels by CAVE: Lesion of the inferior alveolar nerve—
the drill/instruments is to be avoided. Careful han- possibly also of the lingual nerve—when bleed-
dling virtually eliminates the likelihood of retro- ing from the mandibular canal or tissue outside
mandibular bleeding. Under certain circumstances, the osteotomy area.
injuries to the retromolar vein can lead to life-
threatening bleeding (Fig. 18.2).
Therapy: Hemostasis via the surgical access 4.2 Maxillary Artery
route, if unavoidable also via an extraoral access.
The maxillary artery runs directly under the peri-
osteum in front of or behind the lateral pterygoid
Note muscle and ascends through the two heads of the
Profuse venous bleeding due to injury to the lateral pterygoid muscle to the pterygopalatine
retromandibular venous plexus is due to fossa (Rohen and Yokochi 1982, [6]).
“blind stripping” of the periosteum and the If the injured artery cannot be visualized directly,
muscles of the posterior margin of the ramus the bleeding site should be temporarily compressed
with gauzes. For serious bleeding digital pressure
18 Intraoperative Hazards and Risks 159

against the external or even common carotid artery Paresthesia/anesthesia of the IAN is caused by
can help to temporarily reduce excessive bleeding a direct injury or contusion in the area of the lin-
until the vessel is identified and vessel clips can be gula or by a split-related injury/contusion in the
applied. Alternatively, in case of a threatening area of the sagittal split.
bleeding a minimally invasive embolizing vascular Functional deficits of the facial nerve result
transcatheter closure may be considered. from a direct injury through instrumentation ret-
romandibular (rare) and of the lingual nerve
through pressure and stretching during mobili-
4.3 Facial Artery zation of the mandibular segments or during
osteosynthesis of the segments. The IAN can
Precise detachment of the periosteum at the edge also be injured during screw and/or plate
of the lower jaw in the area of the vertical oste- stabilization.
otomy, if possible without tearing the periosteum, An operating age > 40 years, additional
and the insertion of a protective, curved retractor intraoperative manipulations, wide segment
prevents injuries to the facial artery. displacements and excessive segment manipu-
Hemostasis through the surgical access, in lations as well as anatomical variations in the
extreme situations also through an extraoral course of the nerves can lead to an increased
access. There is an increased risk of inadvertently incidence of neurosensory deficits after the
injuring the mandibular branch of the facial nerve operation [5].
due to poor visibility by coagulation through the
transoral approach. The submandibular approach
and preparation of the facial artery and its liga- 7 Damage to the IAN
ture can be performed by extraoral submandibu-
lar access, while protecting the mandibular Surgical interventions of all kind are generally
branch of the facial nerve. associated with the risk of injury to neural struc-
tures. Injuries to the IAN can generally occur
during a BSSO, while splitting the mandible
5 Nerve Injuries (osteotomy), during segment mobilization or seg-
ment fixation (osteosynthesis).
• Inferior alveolar nerve—IAN.
Course in the mandibular canal/mandibular
foramen. 7.1 In Detail, Intraoperative
• Lingual nerve Injuries of the IAN Occur:
Lingual side /pterygomandibular space/floor
of the mouth. • During the dissection of the lingual pterygo-
• Facial nerve mandibular tunnel and when the lingual hori-
Retro- and submandibular part zontal osteotomy is performed.
• When performing the sagittal osteotomy, if
the osteotomy line is not strictly laterally
6 Paresthesia/Anesthesia placed (buccal mandibular cortex).
• If the vertical osteotomy line is applied, if the
After osteotomies in the mandible, the risk of bone cut is too deep or the basal mandibular
nerve injuries with long-term neurosensory defi- cortex is incised too deeply (inferior mandibu-
cits is higher than after upper jaw osteotomies. lar rim). The buccal vertical osteotomy should
The combination of a BSSO with genioplasty be terminated when bleeding from cancellous
increases the incidence of long-term neurosen- bone indicates that the buccal cortex has been
sory IAN deficits. completely cut.
160 P. Kessler and N. Hardt

7.2 Injuries to the Inferior 7.3 Treatment of IAN Injuries

Alveolar Nerve Can
Be Avoided by: 7.3.1 Complete Transection of the
Inferior Alveolar Nerve—IAN
• Strictly subperiosteal tunneling of the medial If a complete IAN transection occurs—e.g.,
side of the ascending ramus. during a mandibular advancement procedure—
• Avoidance of stretching of the nerve by the the distal nerve segment should be released
tissue retractor on the lingual side. from the mandibular canal to gain sufficient
• Rotating and oscillating instruments should length for the primary anastomosis of the nerve
exclusively and specifically be used for the (Fig. 18.3) [22].
separation of the cortical structures. The use of a surgical microscope is extremely
• Osteotomes must be guided during the split of difficult, so magnifying glasses with magnifying
the cortex on the lingual side. optics must be used for a direct nerve suture.
Strategy: If the IAN is completely transected
The incidence of complete nerve transection
in the area of the mandibular foramen during a
in orthognathic surgery is low. The incidence of a
BSSO at the level of the lingula:
complete transection of the IAN during a BSSO
The proximal segment of the mandible is
is reported as 1.3–7% [5, 25].
retracted laterally and the proximal nerve seg-
A neurosensory disturbance of the IAN
ment is carefully freed from the surrounding soft
occurs in most cases immediately after the
issue. The distal nerve segment is prepared from
BSSO. However, long-term deficits of the IAN
the distal mandible.
(not all of which are symptomatic) occur in
The IAN lies on the lingual side of the distal
10–15% of patients under 40 years of age. The
segment if the split is correct. Nerve continuity
overall risk of IAN deficits after BSSO was
can be restored by primary nerve anastomosis
estimated of about 33% [5].
using epineural sutures, usually 7–0 Prolene. The
In order to reduce IAN injuries, it is important
proximal nerve end is grasped first, as the distal
to evaluate the course of IAN preoperatively, if
possible with three-dimensional imaging (CBCT,
MSCT). At least an orthopantomogram must be
performed preoperatively, since several varia-
tions of the course of IAN through the mandible
are possible [1].

Note
Neurosensory disturbances of the inferior
alveolar nerve occur in the vast majority of
cases immediately after sagittal split oste-
otomy and cannot be entirely avoided.
Long-term deficits (not all of which are
symptomatic) occur in 10–15% of patients
younger than 40 years. Fig. 18.3 Complete transection of the IAN in the region
of the mandibular foramen during BSSO [5]
18 Intraoperative Hazards and Risks 161

nerve end allows more freedom of movement. At feel protruding screws. These screws should
least three circular sutures should be applied 6-0 be removed and replaced with shorter screws.
or even 5-0 Prolene can be used as well.

Note
8 Damage to the Lingual Nerve The placement of a flexible retractor
between the lingual mandibular cortex and
Osteotomy-related sensitivity disorders of the lingual soft tissues during bi-cortical screw
lingual nerve are not common. Immediate post- osteosynthesis is the best way to prevent
operative tongue paresthesia due to an alteration iatrogenic injury to the lingual nerve.
of the lingual nerve occurs in less than 10% of The use of bucco-laterally positioned
patients. mono-cortical osteosynthesis plates avoids
The risk of long-term lingual nerve deficits the abovementioned risk.
after BSSO ranges from 1% to 12% [5, 24, 25].

Note 8.2 Treatment of Lingual Nerve

Lingual sensory nerve disturbances are not Injuries
common.
Immediate postoperative tongue pares- 8.2.1 Complete Transection
thesia secondary to lingual nerve injury of the Lingual Nerve
probably occurs in less than 10% of patients. Two procedures exist:
Long-term deficit occurs in less than The direct nerve suture can be performed
1–12%. immediately after the nerve rupture is detected.
The nerve endings are carefully removed from
the surrounding soft tissue—about two centime-
ters proximally and distally—and adapted with
8.1 Injuries to the Lingual Nerve prolene 7x0 under suitable optical magnification.
can be avoided by: The nerve sheath must be grasped with the utmost
care, it is extremely vulnerable.
• Appropriate placement of the retromolar
Alternatively, there is the possibility of
mucosal incision.
delayed nerve suturing about 6 weeks postopera-
• Careful subperiosteal preparation of the lin-
tively. If the nerve endings cannot be adapted
gual tissues, especially in the area of the third
without problems, nerve interpositions, e.g., of
molar.
the sural or posterior auricular nerve, must be
• If bi-cortical screws are used: Due to the prox-
lifted to be inserted between the nerve stumps.
imity of the lingual nerve to the lingual man-
The delayed procedure has its justification in the
dibular cortex, penetration of bi-cortical
generally poor functional regeneration of this
screws should be avoided as this may increase
nerve (Fig. 18.4).
the risk of nerve injury.
The inserted nerve autograft can be wrapped
• If bi-cortical screws are used: Placement of a
with Axoguard® nerve protector as a tissue sepa-
retractor between the lingual cortex and
rator to prevent connective tissue from growing
­lingual soft tissues prevents iatrogenic injury
into the nerve anastomoses.
to the lingual nerve during placement of drill
To avoid the morbidity caused by lifting a neu-
holes for screw fixation.
ral autograft, neural allografts can also be used.
• After placement of bi-cortical screws, the lin-
gual cortex should be palpated with a finger to
162 P. Kessler and N. Hardt

a b

Fig. 18.4 (a) Nerve interposition for complete transection of the lingual nerve. (b) Protection of the interposition with
Axoguard® nerve protector [5]

9 Damage to the Facial Nerve Note

Facial paralysis or paresis secondary to
Complete facial paralysis or partial paresis as a facial nerve injury is extremely rare and
result of an injury to the facial nerve is extremely typically is associated with mandibular set-
rare and is typically associated with surgery on a back procedures.
setback of the lower jaw and usually resolves Facial nerve disturbances associated with
spontaneously. Although rare, facial nerve injury sagittal split osteotomies have resolved
leads to significant morbidity for the patient. spontaneously in all reported cases.
Facial nerve deficits after BSSO are reported
in the literature with an incidence of 0.1–1%
[5, 10].
Damage to the marginal branch of the facial Note
nerve: Injuries to the facial nerve can be avoided
The marginal branch can be injured by very by careful subperiosteal dissection and
careless instrumentation when the bucco-lateral avoidance of periosteal injuries to the pos-
bone cut is made. Injuries due to pressure, ten- terior margin of the ramus and by gentle
sion and stretching, but also direct trauma from tissue retraction. The same applies for the
drills or chisels cannot be excluded. Nerve adap- buccal osteotomy line.
tation is technically almost impossible and can
only be carried out via a submandibular approach.
18 Intraoperative Hazards and Risks 163

10 Split Patterns during BSSO the mandibular angle and corresponds to the clas-
sic osteotomy through the posterior margin (“true
10.1 Sagittal Split Variants Obwegeser”).
The LSS3 fracture line (32.5%) runs from the
In general, only 0.5% of sagittal splits follow inferior mandibular rim directly vertically through
exactly the osteotomy lines according to Obwegeser the lingual cortex and ends in the mandibular canal
and Dal Pont, while 40% follow the osteotomy in the region of the lingula (Figs. 18.5 and 18.6)
lines of the Hunsuck-Epker modification. The unfavorable splits occur mainly in the
After BSSO, different fracture patterns can be angular and supra-angular region (Fig. 18.7).
detected, especially in the lingual fracture line Experience has shown that regardless of the
(Fig. 18.5) [2, 4, 8, 9, 14, 19]. osteotomy technique used, only a minority of
The split pattern of type I was found in 60%, splits follow the fracture pattern indicated by
types II, III, and IV accounted for 11.2%, 16.2%, Obwegeser and Dal Pont.
and 5.0%, respectively, and type V for 7.5%. The vast majority of fracture lines follow the
Type VI represents a bad split. lingual side from the dorsal end of the lingual cut
According to the lingual split scale—Lingual to the caudal end of the buccal osteotomy rather
Split Scale (LSS) [14], in 51% of cases the frac- randomly [2, 3, 12, 19].
ture line (LSS1) runs from the inferior mandibular
rim (bucco-lateral bone cut end) in a vertical arc
through the lingual cortex and reaches the man- 10.2 Bad Splits in BSSO
dibular foramen (“true Hunsuck”). LSS1 runs dor-
sally of the mandibular canal. An unfavorable and unforeseen pattern of sagittal
The LSS2 fracture line (14%) runs from the split osteotomy is commonly referred to as “bad
inferior mandibular rim along the dorsal rim of split “ [7, 11, 13, 15].

Type I Type II Type III

Type IV Type V Type VI

Fig. 18.5 Variations of the course of the fracture line after bilateral sagittal split osteotomy on the lingual side of the
ramus (types I to VI) [14]
164 P. Kessler and N. Hardt

Fig. 18.6 Fracture patterns after sagittal split on the lin- row: Variants of bad splits on the lingual side. ©Copyright
gual side of the ramus. Upper row: Schematic drawing of Keisuke Koyama 2020. All rights reserved
the main types of lingual split LSS 1 to LSS 3 [14] Lower

Scheme 1-2-2 (39%) Scheme 1-1-2 (17.5%) Scheme 1-2-1 (11.5%)

Scheme 1-1-1 (10.5%) Scheme 1-2-3 (3%) Scheme 1-3-3 (3%)

Scheme 2-2-2 (1%) Scheme 1-3-1 (0.5%) Scheme 3-3-3 (0.5%)

Fig. 18.7 Lingual views after 3D reconstruction of nine more frequent split patterns and their percentage distribution
(based on 200 sagittal splits) [3]
18 Intraoperative Hazards and Risks 165

tical caudal osteotomies that did not split the

mandibular margin but ended in a buccal position
above the mandibular rim (P-0.001) [3].
This means that the horizontal lingual osteot-
omy should not cut too deeply and the bucco-­
lateral osteotomy should include the mandibular
margin to avoid undesirable fracture patterns
(Fig. 18.9).

10.3 Danger Points: Bad

Split

1. Horizontal lingual osteotomy performed too

high above the lingula or horizontal osteot-
omy incision too deep to the buccal cortex
–– wrong preparation with the burr/ultrasonic
osteotome,
2. Course of the sagittal connecting osteotomy
line on the external oblique line and not
median of the line.
–– wrong preparation with the burr/saw/ultra-
sonic osteotome,
3. Incomplete or omitted osteotomy of the infe-
rior mandibular margin/rim on the buccal
side.
Fig. 18.8 Iatrogenic bad fractures of the proximal seg- The risk of fracture of the buccal cortex is
ment (Types 1A-1F) and of the distal segment (Types 2A
particularly high if the osteotomy of both
und 2B) (postoperative—CBCT—Images) [20, 21]
bone segments at the inferior rim of the man-
dible is incomplete. An incomplete split
The incidence of a bad split BSSO ranges occurs, the buccal cortical bone breaks off,
from 2.3% [21] to 13.5%. The latter mainly and post-­osteotomy surgery is required, put-
affected the buccal surface of the proximal seg- ting the IAN at risk [3].
ment to a majority of 9% [3].
The most common iatrogenic and unwanted
bad splits affect the cortex of the proximal seg-
ment (type’s 1A-1F) and then the lingual cortex –– Incomplete preparation with the burr/
of the distal segment (types 2A and 2B) ultrasonic osteotome.
(Fig. 18.8) [21]. –– Incomplete osteotomy of the inferior
A significant correlation was found between rim of the mandible.
undesirable fracture patterns in the lateral buccal
segment and the course of splitting.
This is the case for horizontal sagittal osteoto- 4. Excessive, forced separation of the bone seg-
mies that ended in buccal position at the posterior ments with transverse bone loading by twist-
margin of the ramus (P-0.001) as well as for ver- ing/rotation using wide osteotomes when
166 P. Kessler and N. Hardt

Fig. 18.9 Example of a bad split in the angular and supra-angular region. View from the lateral side after 3D recon-
struction [3]

separating the proximal and distal segments with BSSO is controversially assessed with
(Fig. 18.10). regard to its influence on the splitting quality
–– wrong splitting technique/wrong instrument, [16–18].
5. Incomplete separation of the ramus posterior The removal of afunctional or impacted third
margin or the jaw angle with too early use of molars is generally recommended 6 months
wide osteotomes. before a BSSO.
–– wrong splitting technique/wrong instrument,
6. Use of chisels instead of finely ground
10.4 Avoidance of Bad Splits
osteotomes.
–– wrong instruments.
Precise and step-by-step procedure of the
splitting
The extraction of the third molar teeth nine,
six, or 3 months before BSSO or simultaneously • Horizontal lingual cut.
18 Intraoperative Hazards and Risks 167

Note
Working with the wide osteotome energeti-
cally and without feeling before complet-
ing all osteotomy steps leads to uncontrolled
force and fracture lines.
Control of the complete split with fine
osteotome. There must be no bony connec-
tions to be identified.
Fig. 18.10 Bad split on the left side with lingual split
line running upward to the semilunar notch. Additional
fixation plate. Compare with Fig. 18.6
11 Complications during
Horizontal-medial osteotomy (complete) with and Immediately after
fine osteotome (chisel) or Epker osteotome Extubation
(chisel)
• Vertical buccal cut. • Greatest danger of suffocation is if the removal of
the pharyngeal tamponade after extubation is for-
Vertical-buccal osteotomy (complete) with
gotten with the jaw in intermaxillary fixation.
fine osteotome (chisel), or Epker osteotome
• Great danger exists if no wire cutter is pro-
(chisel) for entry and then a straight osteotomy
vided when transporting the patient to the
• Sagittal Cut. recovery room, so that in an emergency (e.g.,
vomiting) the intermaxillary fixation can be
Gradual, systematic deepening of the supra-­
cut immediately.
IAN splitting zone, continuous splitting from dis-
• Great danger exists if there are fluctuations in
tal to proximal with fine straight osteotomes
blood pressure during the end of anesthesia
(chisels) not wider than 10 mm
leading to spontaneous bleeding from the
• Upon reaching the infra-IAN splitting zone. wound area.
• Danger exists if the patient suffers from suf-
Gradual splitting in constant alternation of
focation in the event of intermaxillary fixation
fine osteotome (progressive split = use of the
and swelling of the nasal airways.
chisel) and wide osteotome (gap expansion, don’t
• If the lower jaw is repositioned, in unfavorable
use chisels for this maneuver)
cases the tongue may be displaced dorsally
• Splitting of the mandibular margin/mandibu- and the upper respiratory tract may be
lar rim. obstructed, there is a risk of suffocation.
• Rare but dangerous are bleedings into the
Starting from the lower part of the bucco-­
tongue, which can lead to massive swelling of
vertical osteotomy with a curved osteotome/
the tongue with obstruction of the airways.
chisel (Epker chisel e.g.)
Massive swelling of the tongue can also occur
• After advanced splitting of the infra-IAN fis- spontaneously without bleeding.
sion zone.
Start of controlled rotation of the wide osteo- Note
tome to expand the osteotomy gap and further The surgeon in charge should be present in
splitting of the basal bony residual connections the OR until spontaneous breathing has sta-
with a fine osteotome after identification of the bilized and, if necessary, accompany the
mandibular canal under visual control. patient to the recovery room.
168 P. Kessler and N. Hardt

12 Conclusion 13. O'Ryan F, Poor DB. Completing sagittal split osteot-

omy of the mandible after fracture of the buccal plate.
J Oral Maxillofac Surg. 2004;62:1175–6.
There are no surgical interventions free of risks. 14. Plooij JM, Naphausen MTP, Maal TJJ, Xi T, Rangel
Good anatomical knowledge, good case analysis, FA, Swennnen G, de Koning M, Borstlap WA, Berge
good education, and training are the prerequisites S. 3D evaluation of the lingual fracture line after a
bilateral sagittal split osteotomy of the mandible. Int J
to recognize and avoid complications and also to Oral Maxillofac Surg. 2009;38:1244–9.
manage complications. 15. Posnick JC, Choi E, Liu S. Occurrence of a ‘bad’ split
and success of initial mandibular healing: a review of
524 sagittal ramus osteotomies in 262 patients. Int J
Oral Maxillofac Surg. 2016;45:1187–94.
References 16. Precious DS, Lung KE, Pynn BR. Goodday RH pres-
ence of impacted teeth as a determining factor of
1. Beukes J, Reyneke JP, Damstra J. Unilateral sag- unfavorable splits in 1256 sagittal-split osteotomies.
ittal split mandibular ramus osteotomy: indica- Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
tions and geometry. Br J Oral Maxillofac Surg. 1998;85:362–5.
2016;54(2):219–23. 17. Reyneke JP, Tsakiris P, Becker P. Age as a factor in
2. Böckmann R, Schön P, Neuking K, Meyns J, Kessler the complication rate after removal of unerupted/
P, Eggeler G. In vitro comparison of the sagittal split impacted third molars. At the time of mandibu-
osteotomy with and without inferior border osteot- lar sagittal split osteotomy. J Oral Maxillofac Surg.
omy. J Oral Maxillofac Surg. 2015;73(2):316–23. 2002;60:654–9.
3. Dreiseidler TJJ, Bergmann GHM, Zirk M, Rothamel 18. Schwartz HC. Simultaneous removal of third molars
D, Zöller J, Kreppel M. Three-dimensional fracture during sagittal split osteotomies: the case against. J
pattern analysis of the Obwegeser and Dal Pont bilat- Oral Maxillofac Surg. 2004;62:1147–9.
eral sagittal split osteotomy. Int J Oral Maxillofac 19. Song JM, Kim YD. Three-dimensional evaluation of
Surg. 2016;45(11):1452–8. lingual split line after bilateral sagittal split osteotomy
4. Epker BN. Modifications in the sagittal osteotomy of in asymmetric prognathism. J Korean Assoc Oral
the mandible. J Oral Surg. 1977;35(2):157–9. Maxillofac Surg. 2014;40:11–6.
5. Ghali GE, Patel S. Avoiding surgical complications in 20. Steenen SA, van Wijk AJ, Becking AG. Bad splits in
orthognathic surgery. In: Ghali GE, Woerner JE, Patel bilateral sagittal split osteotomy: systematic review
S, editors. Maxillofacial surgery: mandible. 3rd ed. and meta-analysis of reported risk factors. Int J Oral
Churchill Livingstone; 2017. Maxillofac Surg. 2016;45:971–9.
6. Hardt N, Kessler P. Surgical repair of craniofa- 21. Steenen SA, Becking AG. Bad splits in bilateral sagit-
cial fractures. In: Hardt N, Kessler P, et al., editors. tal split osteotomy: systematic review of fracture pat-
Craniofacial trauma. Diagnosis and management. terns. Int J Oral Maxillofac Surg. 2016;45:887–97.
Springer; 2010. 22. Stotland MA, Kawamoto HK. Plastic Surgery Secrets
7. Hönig JF. Maxillomandibuläre Plus. 2nd ed; 2010.
Umstellungsosteotomien. Steinkopff; 2013. 23. Thastum M, Andersen K, Rude K, Nørholt SE,
8. Houppermans PNWJ, Verweij JP, Mensink G, Peter Blomlöf J. Factors influencing intraoperative blood
JJ, Gooris JP, van Merkesteyn R. Influence of inferior loss in orthognathic surgery. Int J Oral Maxillofac
border cut on lingual fracture pattern during bilateral Surg. 2016;45:1070–3.
sagittal split osteotomy with splitter and separators: 24. van Merkesteyn JPR, Groot RH, van Leeuwaarden R.
a prospective observational study. J Craniomaxillofac Kroon FHM Intra-operative complications in sagittal
Surg. 2016;44(10):200. and vertical ramus osteotomies. Int J Oral Maxillofac
9. Hu J, Song Y, Wang D, Yuan H, Jiang H, Cheng Surg. 1987;16(6):665–70.
J. Patterns of lingual split and lateral bone cut end and
25. Verweij JP, Houppermans PN, Mensink GP, van
their associations with neurosensory disturbance after Merkesteyn JP. Risk factors for common compli-
bilateral sagittal split osteotomy. Int J Oral Maxillofac cations associated with bilateral sagittal split oste-
Surg. 2019;19(3):1311. otomy: a literature review and meta-analysis. J
10. Kim YK. Complications associated with orthogna- Craniomaxillofac Surg. 2016;44(9):1170–80.
thic surgery. J Korean Assoc Oral Maxillofac Surg.
2017;43(1):3–15.
11. Minde R, Schamsawary S. Mund-Kiefer-­
Gesichtschirurgie. Deutscher Ärzte-Verlag; 2008. Further Readings
12. Muto T, Takahashi M, Akizuki K. Evaluation of the
mandibular ramus fracture line after sagittal split ramus Rohen J, Yokochi C. Anatomie des Menschen/Kopf, Hals.
osteotomy using 3-dimensional computed tomogra- Schattauer: Rumpf-Band; 1982.
phy. J Oral Maxillofac Surg. 2012;70:e648–52.
 Surgical Tricks
19
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1  isplay of Important Anatomical Points and Structures in BSSO
D 170
1.1 Mucoperiosteal Incision in Relation to the Nerve Branches near the Ramus,
the Muscular and Vascular Structures 170
2 Preparation of the ­Masseterico-­mandibular and Pterygo-­Mandibular
Spaces 171
3 I dentification of the Mandibular Foramen and the Neurovascular
Bundle 173
4  reation of Bone Cuts in Preparation of the Sagittal Split
C
(SSRO/BSSO) 174
4.1 The Sagittal Osteotomy Line 174
5 Creation of the Horizontal Osteotomy Line 172
6 Creation of the Vertical/Buccal Osteotomy Line 176
7 Correct Transitions and Pre-splitting of the Osteotomy Sections 176
8  orrect Mandibular Split
C 177
8.1 Technique of the Pre-angular Split 177
8.2 Technique of Angular and Post-Angular Split 178
8.3 Avoidance of latrogenic Fractures during Splitting in the Proximal Segment:
Lingual Split 178
8.4 Avoidance of latrogenic Fractures during Splitting in the Angular Region
below the Mandibular Canal 179
9 Piezosurgical Splitting of the Inferior Mandibular Rim 180
10  voidance of Caudal-Basal Step formation in the Area of the Vertical
A
Split 181
11 Conclusion 182
References 182

P. Kessler (*) · S. A. N. Lie

Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center, N. Hardt (*)
Maastricht, The Netherlands Kantonsspital Lucerne, Clinic and Policlinic of
e-mail: [email protected]; [email protected] Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 169
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_19
170 P. Kessler et al.

Abstract However, avoid lateral vestibular overexten-

sion of the incision, which can result in injury to
Each surgical procedure becomes safer with
the buccinator muscle and possible herniation of
increasing experience, and each surgeon will
the buccal fat pad (corpus adiposum buccae) [1,
find his or her own style of successfully per-
2]. The scalpel blade should always be in contact
forming a sagittal split osteotomy of the man-
with underlying bone tissue to avoid straying into
dible. At the same time, you develop your
the layers of buccal soft tissue or even lingually
style, which may be alien to others. What is
located structures (Fig. 19.1).
routine to one is new to another. The reference
to surgical tricks and recommendations should
help to close this gap.
Note
Keywords Creation of the mucosal incision

Anatomy of the mandible · Approach · • Point of orientation: External oblique

Preparation for sagittal split · Lingula · line.
Osteotomy lines · Osteotomy of the mandible • Surgical access: Lateral to the external
· BSSO · Sagittal split ramus osteotomy oblique line.
(SSRO) · Osteotome • Cutting length: Continuous mucoperi-
osteal incision from the temporal/coro-
noid process to the crista buccinatoria in
1 Display of Important the region of the second molars.
Anatomical Points
and Structures in BSSO

1.1 Mucoperiosteal Incision Note

in Relation to the Nerve • Access to the sub-masseteric space.
Branches near the Ramus, Subfascial space between the lateral
the Muscular and Vascular surface of ascending mandibular ramus
Structures and fascia of the masseteric muscle.
• Surgical access: Anterior aspect of the
A vestibular placement of the mucosal incision in ramus.
the posterior mandibular vestibule and in the retro- External oblique line.
molar region, clearly lateral to the marginal peri- Coronoid process.
odontium, prevents injury to the lingual nerve, • Landmarks: Base of the condylar
which is located close to the ramus on the lingual process.
side, and provides sufficient cuff tissue during sub- Incisura semilunaris.
sequent wound closure. The buccal artery and vein Posterior aspect of the ascending ramus.
cross the muco-periosteal incision and must be Mandibular angle.
coagulated.
19 Surgical Tricks 171

Lingual n.
Buccal
n&a
Lingual mandibulae

Medial Pterygoid m

Temporalis

Superior constrictor m

Mylohyoid n
Crista temporalis
Pterygomandibular raphe

II Molar

Linea obliqua ext.

Buccinator m

Fig. 19.1 Muco-­periosteal incision (black-broken line). such as the lingual nerve to the medial border of the retro-
View of the retromolar region and the ascending ramus molar fossa. ©Copyright Keisuke Koyama 2020. All
and the relationships of the buccal nerve, artery, and vein rights reserved

2 Preparation of the ­Masseterico-­ The pterygo-mandibular periosteal deflection

mandibular and Pterygo-­ on the lingual side is then widened into a view-
Mandibular Spaces able subperiosteal tunnel and carried to the poste-
rior margin of the ramus or immediately posterior
Strictly subperiosteal preparation of the to the neurovascular bundle at the mandibular
masseterico-­mandibular and the pterygo-mandib- foramen. The medial bone surface is visualized
ular spaces with identification of the respective to the lingula and the neurovascular bundle can
anatomical lead structures (Fig. 19.2a, b; be identified (Fig. 19.4).
Fig. 19.3). Detachment of the neuro-vascular
bundle on the lingual side and preparation to the
posterior margin of the ramus.
172 P. Kessler et al.

a b

Fig. 19.2 (a) Preparation of the masseterico-mandibular space (b) Preparation of the ptergygo-mandibular space

Note
• Access to the pterygo-mandibular space.
Subfascial space between the medial
surface of ramus and fascia of the medial
pterygoid muscle.
1
• Surgical approach.
Base of the coronoid process.
• Landmarks.
Oblique external and internal line.
Semilunar notch.
2 Mandibular foramen.
Lingula.
Neuro-vascular bundle.
Base of the condylar process.
3
Posterior border of the ascending ramus
on the medial side.

Fig. 19.3 Frontal section: Topographic situation in the

pterygo-mandibular and masseterico-mandibular spaces.
Vascular structures in pterygomandibular region are encir- Note
cled: maxillary artery and vein 1 = lateral pterygoid mus- The more generous the detachment of the
cle, 2 = medial pterygoid muscle, 3 = masseteric muscle soft tissues on the lingual side—containing
©Copyright Department Anatomy and Embryology
the neuro-vascular bundle—the more
Maastricht University, 2021. All rights reserved
safely the vessels and nerves (maxillary
artery and inferior alveolar nerve) woven
into the tendon-muscle plate can be spared.
19 Surgical Tricks 173

Fig. 19.4 Two possible positions of the retractor on the lingual side ©Copyright Keisuke Koyama 2020. All rights
reserved

Prior to osteotomy, the retractor is then tilted

3 Identification of the Mandibular 45° to the opposite direction to protect the infe-
Foramen and the Neurovascular rior alveolar neurovascular bundle and create
Bundle space for the medial osteotomy [3].
The horizontal bone cut should be made as
A retractor (Seldin retractor, e.g.) is inserted low as possible, close to and above (approx.
superior to the lingula into the lingual subperios- 4–5 mm) the lingula. In this region, there is
teal tunnel and tilted 45° so that the periosteum is still enough cancellous bone between the
tented in the area of the foramen. external and internal cortices, which facilitates
Under direct visualization, the entrance to the the split.
foramen is identified and a blunt nerve probe is
placed in the foramen entrance. The nerve probe is
thus located at the upper edge of the foramen—cor-
responding to the position of the lingula (Fig. 19.5). Note
This procedure allows the bony distance The lingual osteotomy should be slightly
between the lingula and the lingually planned above the lingula—corresponding to the
osteotomy line to be estimated slightly above position of the inserted nerve probe.
this level.
174 P. Kessler et al.

Fig. 19.5 Lateral view

of the nerve probe
placement in the
mandibular foramen and
the determination of the
position of the
osteotomy line.
©Copyright Keisuke
Koyama 2020. All rights
reserved

4 Creation of Bone Cuts A corticotomy of the narrow edge of the exter-

in Preparation of the Sagittal nal oblique line to the visible boundary between
Split (SSRO/BSSO) cancellous bone and lateral cortex greatly facili-
tates the marking and creation of the sagittal
4.1 The Sagittal Osteotomy Line osteotomy line with a small Lindemann burr [1,
2, 4]. Direction and path for the subsequent sagit-
The sagittal osteotomy runs medially and along tal split are thus established (Fig. 19.6).
the external oblique line. The creation of the pre-
paratory drill holes for the sagittal osteotomy is
difficult because of the rigidity of the thick and
Note
oblique bone surface.
The width of the osteotomy facilitates
insertion and freedom of movement of the
Note osteotome and avoids pressure loading and
Creation of the sagittal osteotomy incision splintering of the ramus edge and allows a
good guidance of the osteotome for the
• Osteotomy about 5 mm medial and par- sagittal split.
allel to the externa oblique line
• Length: From the intersection point of
the lingual-­horizontal cut to the point of
intersection with the vertical-buccal cut.
19 Surgical Tricks 175

Fig. 19.6 Corticotomy of the edge of the external oblique line to the visible boundary between spongiosa and lateral
cortex ([1, 2, 4] ©Copyright Keisuke Koyama 2020. All rights reserved

5 Creation of the Horizontal

Osteotomy Line (Fig. 19.7)

Note
Creation of the upper horizontal osteotomy
incision
• Landmarks: about 10 mm inferior to the
semilunar notch, 4–5 mm above the
lingula.
• Position of the bone cut: horizontal and
parallel the occlusal plane of the
mandible.
• Length of the bone cut: Anterior margin
of the ramus—internal oblique line to a
point anterior to the posterior margin of
the ascending ramus, but posterior to the
Fig. 19.7 Position of the lingual osteotomy line: MF
CEC = crista endocoronoidea in the mandibular foramen, SuC sulcus colli, CEC crista endo-
region of the coronoid sulcus—modifi- coronoidea, La lingula ©Copyright Keisuke Koyama
cation according to Hunsuck. 2020. All rights reserved

Note
• Keep an eye on the outer surface of the
ramus to estimate the depth of the lin-
gual cut.
• Take into account that the inner cortical
layer is concave on the inside.
176 P. Kessler et al.

6 Creation of the Vertical/Buccal 7 Correct Transitions and Pre-

Osteotomy Line splitting of the Osteotomy Sections

After the horizontal, vertical, and sagittal bone

Note cuts have been made, the transitions from the
Creation of the lower vertical osteotomy horizontal to the sagittal cut as well as the transi-
section tion from the vertical to the sagittal bone cut—
• Landmarks: second molar buccal aspect the so-called Steinhäuser Points—should be
and end point of the external oblique line. prepared deeply with the incremental drill so that
• Osteotomy straight downward to the there is good guidance for the splitting direction
region of the submandibular notch of the fine osteotomes. Both the horizontal and
according to Dal Pont. vertical bone cuts should then be carefully pre-­
• Or oblique placement of the bone cut in split with fine osteotomes or chisels ([1, 2, 4]
direction to the attachment of the mas- (Fig. 19.8).
seteric muscle—short osteotomy.

Note
In addition to transecting the buccal cortex,
the inferior basal cortex is also transected
down to the cancellous bone layer.

a b

Fig. 19.8 (a) Careful and deep preparation of the con- Points) (b) Then careful beginning of the splitting proce-
necting points—marked with circles—of the three basic dure with fine chisels ©Copyright Keisuke Koyama 2020.
osteotomy lines: lingual—sagittal—buccal (Steinhäuser All rights reserved
19 Surgical Tricks 177

8 Correct Mandibular Split and including the jaw angle. This split region rep-
resents the “safe” zone in which the nerve or man-
8.1 Technique of the Pre-angular dibular canal can be injured the least (Fig. 19.9b).
Split

The mandibular canal runs in the pre-angular Note

region near the lingual margin. Between the buc- Be consistent!
cal cortex and the lateral canal wall there is a can- If you consequently stick to the inner
cellous bone layer which is as wide as the side of buccal cortical layer while splitting
adjacent lateral cortex (Fig. 19.9). the mandible the risk of injury to the IAN is
Split in the pre-angular section is successive minimal.
and takes into account the surface curvature up to

Fig. 19.9 Topography

of the pre-angular region a b
(a) The width of the
lateral cancellous layer
corresponds to the width
of the lateral cortex (b)
Successive splitting to
the inferior mandibular
rim ©Copyright Keisuke
Koyama 2020. All rights
reserved
178 P. Kessler et al.

8.2 Technique of Angular

and Post-Angular Split Note
Sagittal split in the angular region
In the angular and post-angular sections, there is After the split procedure has progressed
little to very little cancellous bone layer between to the point where the course of the man-
the canal wall and the lateral cortex. dibular canal is visible, one osteotome is
The most difficult part of the splitting is in the left cranial to the canal and a second osteo-
post-angular section. The split starts directly at tome is used to continue the osteotomy
the entrance to the lingual bone cut. along the outer cortex lateral to the canal to
Basic direction of the osteotome: Lingula the mandibular angle.
Junction line of mandibular midline—oblique The last bony connections are carefully
line (Fig. 19.10). detached by spreader movements with an
osteotome/spreader.

Note
Sagittal split in the post-angular section on
the lingual side 8.3 Avoidance of latrogenic
Fractures during Splitting
• Insert the chisel directly at the cranially in the Proximal Segment:
located lingual bone cut: Lingual Split
30° to the outer surface of the ascending
ramus (Fig. 19.10). Direction lingula. The horizontal lingual osteotomy should not run
The osteotome crosses the center of the too deep to the lateral cortex and not too high, but
anterior arch. should be made just above the mandibular
• After a penetration depth of about foramen.
15 mm, slowly pivot the chisel in an oral In the original Obwegeser technique, the pos-
direction. Under light, short hammer terior margin of the ascending ramus must be
blows, the osteotome penetrates to the included in the bone incision. Splitting is per-
interface of the cortical bone slightly formed with finely ground straight chisels of
above or in the lingula. 5 mm width.
• Then the chisel is swiveled in the sagit- For short split according to Hunsuck-Epker,
tal direction (parallel to the outer sur- the curved 5 mm Epker-chisel can serve well,
face of the ascending ramus). The with the curvature following the concave shape
posterior section is split cranially of the of the inner side of the ascending mandibular
mandibular angle. You can tell by the ramus.
tapping sound when you have come
through the bone.
19 Surgical Tricks 179

Fig. 19.10 Sagittal split

in the post-angular
section [5] ©Copyright
Keisuke Koyama 2020.
All rights reserved

8.4 Avoidance of latrogenic tome is pressed lightly against the distal seg-
Fractures during Splitting ment to direct the splitting pressure against the
in the Angular Region below inner surface of the proximal segment and the
the Mandibular Canal mandibular margin is pre-split (Figs. 19.11,
19.12).
To prevent undesirable fractures in the angular
region below the course of the mandibular
canal, the separation of the mandibular rim at Note
the vertical buccal cut should be completed. The sagittal split of the mandibular rim is
The osteotome is inserted horizontally performed before the splitting is completed
between the partially split bone segments in in the region of the mandibular angle below
the region of the lower vertical bone cut. When the mandibular canal.
separating the mandibular margin, the osteo-
180 P. Kessler et al.

a b

Fig. 19.11 Technique of the mandibular rim splitting (a) tome is pressed lightly against the distal segment to direct
First the area above the mandibular canal is widened until the splitting pressure against the inner surface of the prox-
the course of the IAN can be assumed (b) The osteotome imal segment ©Copyright Keisuke Koyama 2020. All
is inserted horizontally in the region of the lower vertical rights reserved
bone cut. When separating the mandibular rim, the osteo-

9 Piezosurgical Splitting
of the Inferior Mandibular Rim

Instead of the curved osteotome for splitting the

caudal mandibular rim, the inferior mandibular
rim can be split precisely, atraumatically and—
without the splitting pressure of the osteotome—
piezosurgically, thus increasing the certainty of a
proper segment split in the infranerval caudal
splitting area (Fig. 19.13) [6].

Fig. 19.12 After the split area can be controlled visually

the remaining bone bridges below the mandibular canal
can be separated to complete the split ©Copyright Keisuke
Koyama 2020. All rights reserved
19 Surgical Tricks 181

Fig. 19.13 Alternative piezosurgical splitting of the lateral and medial segment in the basal mandibular rim area, start-
ing from the inferior vertical osteotomy [6]. ©Copyright Keisuke Koyama 2020. All rights reserved

10 Avoidance of Caudal-Basal mandibular margin with undesirable step forma-

Step formation in the Area tion. This can happen if the basal osteotomy has cut
of the Vertical Split through the buccal to the lingual cortex. A precau-
tionary measure is to bevel the sharp osteotomy
One problem with vertical bone splitting in BSSO, margins (Fig. 19.14) [6]. Another alternative is an
especially with extensive mandibular advance- additional groove at the inferior rim as described
ment, is the bony defect (gap) created at the inferior extensively by Böckmann and Wolford [7, 8].
182 P. Kessler et al.

Fig. 19.14 (a) Without a

beveling (b)
Prophylactic beveling of
the inferior osteotomy
margins (c) The
Wolford-Böckmann
osteotomy at the lower
mandibular margin
©Copyright Keisuke
Koyama 2020. All rights
reserved

b c

11 Conclusion 5. Spiessl B.Chirurgie der Kiefer. In: Naumann HH

Kopf-und Hals-Chirurgie. Indikation, Technik, Fehler
und Gefahren. Operations-Manual. 3 Bdn. /Bd.2
There is no substitute for personal experience. This Thieme, Stuttgart 1974.
chapter is intended for the exchange of experience 6. Houppermans PNWJ, Verweij JP, Mensink G, Gooris
and to help identify unforeseeable difficulties in PJJ, van Merkesteyn JPR. Influence of inferior border
cut on lingual fracture pattern during bilateral sagittal
good time in order to avoid undesirable results. split osteotomy with splitter and separators: a prospec-
tive observational study. J Cranio-Maxillofac Surg.
2016;44(10):1592–8.
7. Böckmann R, Schön P, Neuking K, Meyns J, Kessler
References P, Eggeler G. In vitro comparison of the sagittal split
osteotomy with and without inferior border mosteot-
1. Steinhäuser EW, Janson J. Kieferorthopädische omy. J Oral Maxillofac Surg. 2015;73:316–23.
Chirurgie. Berlin, Chicago, Sao Paulo, Tokio: 8. Wolford LM, Davis WM. The mandibular inferior bor-
Quintessenz-Verlag; 1988. der split: a modification in the sagittal split osteotomy.
2. Steinhäuser EW. Educational course on surgical meth- J Oral Maxillofac Surg. 1990;48:92–4.
ods in orthognathic surgery. Luzern, Switzerland;
1973.
3. Ghali GE, Patel S. Avoiding Surgical Complications Further Reading
in Orthognathic Surgery. In: Ghali GE, Woerner JE,
Patel S, editors. Maxillofacial Surgery: Mandible. 3rd Rohen J, Yokochi C. Anatomie des Menschen/Kopf, Hals.
ed. London: Churchill-Livingstone; 2017. Schattauer: Rumpf-Band; 1982.
4. Bell WH, Proffit WR, White RP. Surgical correction
of dentofacial deformities, band, vol. 1–3. Saunders;
1980.
 Post-Surgical Complications
and Care
20
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1 I mmediate Complications after Orthognathic Surgery  184
1.1 Mechanical Airway Obstruction  184
1.2 Functional Respiratory Insufficiency  185
1.3 Bronchospasm  185
1.4 Tracheal Edema  185
1.5 Tachypnea and Shortness of Breath  185
1.6 Aspiration  185
1.7 Postoperative Nausea and Vomiting (PONV)  186
1.8 Reasons  186
2 Pain Management  186
2.1 Algorithms for Pain Therapy  187
2.2 Expected Pain Level  187
2.3 Pain Therapy on the Ward  187
2.4 Postoperative Pain Therapy—Pain Score and Basic Medication  187
2.4.1 Mild Pain (NRS 1–3)  187
2.4.2 Moderate Pain (NRS 4–6)  188
2.4.3 Severe Pain (NRS 7–10)  188
2.5 Postoperative Facial Swelling  188
2.6 Postoperative Fever  188
3 I ndirect Complications after Orthognathic Surgery  188
3.1 Wound Infections  189
3.2 Postoperative Soft Tissue Infections  189
3.3 Postoperative Bone Infections  189
3.4 Delayed Bone Union or Bone Non-union  189
3.5 Mandibular Relapse  190
3.6 Factors that Can Lead to a Relapse after Mandibular Split are  190
3.7 Mandibular Relapse and Rotation  190

P. Kessler (*) · S. A. N. Lie

Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center, N. Hardt (*)
Maastricht, The Netherlands Kantonsspital Lucerne, Clinic and Policlinic of
e-mail: [email protected]; [email protected] Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 183
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_20
184 P. Kessler et al.

3.8  andibular Relapse and Intersegmental Distance 

M 190
3.9 Malocclusion  191
3.10 Bone Necrosis  191
3.11 Prophylaxis  191
3.12 Pseudarthrosis  191
4 Conclusion  191
References  192

Abstract 2014; Soydan et al. Int J Oral Maxillofac Surg

44:1351–1354, 2015).
Postoperative complications can be divided
into immediate complications during the termi- Keywords
nation of the anesthesia and the first 3 h there-
after (emergence), as well as complications that Complications in BSSO · Early and late
can occur in the first 12–24 h after the end of complications · Airway obstruction · Bleeding
the operation, when the patient is usually on the · Edema · Aspiration · Infection · Pain ·
normal ward or at home. The most serious PONV · Instability of osteosynthesis ·
complications affect the functions of the lungs, Relapse · Bone healing · Bone necrosis ·
heart, and all forms of weaning disorders, in Pseudarthrosis
which the patient becomes a danger to himself/
herself (Van Merkesteyn et al. Int J Oral and
Maxillofacial Surg 16:665–670, 1987). 1 Immediate Complications
After orthognathic surgery various compli- after Orthognathic Surgery
cations can occur and cause serious situations.
To avoid postoperative respiratory complica- 1.1 Mechanical Airway
tions, all patients in this treatment group Obstruction
require critical and professional support in the
immediate postoperative phase. • Pharyngeal tamponades.
Complications related to the respiratory sys- • Residual fluids.
tem include airway obstruction, hypoventilation, • Epistaxis.
tachypnea, tracheal swelling, bronchospasm,
aspiration, and rarely spontaneous atelectasis or Pharyngeal tamponades, if forgotten, represent
even a pneumothorax (Ogle Oral Maxillofacial a life-threatening problem by suffocation, espe-
Surg Clin N Am 18:49–58, 2006). cially after rigid intermaxillary fixation. Surgical
It should not be forgotten that repositioning protocols, checklists, time-out procedures, and
of the lower jaw can lead to a narrowing of the memo-tapes on the patient/tube help to avoid this.
posterior airway. Especially in class III Any patient receiving a rigid intermaxillary fix-
patients, the preoperative assessment of the ation (IMF) must be provided with wire scissors for
airway space requires interdisciplinary coop- transport to the recovery department and for the
eration between surgeons and anesthesiolo- time thereafter, which must always remain within
gists to avoid unpleasant and almost reach of the patient to release the IMF in an emer-
unresolvable airway constrictions at the end of gency. The best protection is to avoid the rigid IMF.
a mandibular setback. In extreme situations, Residual fluids Have to be suctioned carefully
the planned mandibular setback must be after end of surgery and again during extubation.
reduced and, if necessary, solved by a bimax- Epistaxis Generally occurs due to damage of
illary intervention. Checklists will help to the Kiesselbach’s plexus in the anterior part of the
avoid these complications (Choi et al. nasal septum where branches from several arter-
Maxillofac Plast Reconstr Surg 36:185–191, ies, including branches of the ophthalmic, maxil-
20 Post-Surgical Complications and Care 185

lary, and facial arteries, anastomose to form a Nevertheless, acute bronchospasms can occur,
vascular plexus. To avoid this complication, the especially during induction, and should be treated
tracheal tube should be inserted into the nasal cav- immediately and methodically with medication
ity such that its bevel tip comes to the lateral side (glucocorticoids).
of the nostril. However, if the bleeding occurs on
insertion of the tube, the nasotracheal intubation
should be completed to chiefly protect the airway 1.4 Tracheal Edema
and also to tamponade the bleeding point. If bleed-
ing occurs after extubation, the nasal airway has to Respiratory insufficiency can also be caused by
be tamponaded with gauzes (Merocel™, e.g.). intubation due to damage to the vocal cords,
swelling of the trachea caused by incorrect tube
position and manipulation during intubation. The
1.2 Functional Respiratory commonly used nasal intubation can lead to
Insufficiency bleeding from the upper airways. Aspiration of
blood and secretions due to damage to the nasal
Functional respiratory abnormalities such as: mucosa can be the result.
Possible edema of the perioral soft tissues and
• Asthma. the floor of the mouth require careful airway
• Chronic obstructive pulmonary disease management. This swelling may not fully mani-
(COPD). fest until about 12 h postoperatively and may
• Pneumonia. continue to increase 48 h after surgery. Bleeding
into the floor of the mouth can also lead to critical
or other etiological factors related to abnormal- airway situations.
ities of the trachea or bronchi can cause breathing
disorders with hypo-oxygenation at the end of an
operation. But also anxiety, panic attacks, and a 1.5 Tachypnea and Shortness
drug overdose may be the reason for that. of Breath
The Esmarch maneuver, placement of a laryn-
geal tube (e.g., Guedel tube), and mask oxygen- Mostly painful and reinforced by IMF and/or
ation help to control the situation until a stable tight bandages that constrict the floor of the
breathing condition is reached again. If indicated, mouth or larynx. Also think of swelling of the
the patient must be re-intubated. tongue and, in the case of repositioning of the
Other rare but life-threatening respiratory lower jaw, constriction of the posterior airway.
complications should be mentioned for com- Shortness of breath and tachypnea can often
pleteness, but are not specifically associated with be resolved by adjusting bandages, opening
orthognathic surgery. intermaxillary fixation and appropriate pain
therapy.

1.3 Bronchospasm
1.6 Aspiration
Bronchospasm is often related to asthmatic dis-
eases, with obstruction of the airway. The key to an Aspiration dyspnea may occur as a result of
uncomplicated peri and postoperative course are extubation without adequate suction or incor-
the meticulous attention to detail in preoperative rect positioning after extubation, especially
assessment and the maintenance of anti-­swelling after severe intraoperative bleeding or severe
and bronchodilator management during the periop- secretion accumulation. Aspiration pneumonia
erative phase. Potential triggers should be identi- can occur as a complication when food, saliva
fied and avoided. Many routinely used anesthetics or nasal secretions enter the bronchial tree. The
have an alleviating effect on airway constriction. rate of aspiration pneumonia after orthognathic
186 P. Kessler et al.

interventions is about 0.01–0.03% (Kim et al. The first measure is to calm the patient. If this
2010, [1]). is not sufficient, the treatment of PONV consists
of mainly by using drugs from the antiemetic
Complication:
group such as serotonin receptor antagonists,
Aspiration
Symptoms  • Aspiration pneumonia: Dyspnea, dimenhydrinate, droperidol, glucocorticoids, or
cyanosis, rales, tachycardia, metoclopramide. If there is an increased risk of
 • Blood pressure drop, until PONV, an antiemetic is administered as a preven-
cardiac arrest, tive measure during the operation and anesthesia.
 • Cough.
Nitrous oxide should not belong to the selection
Reasons  • Vomiting in case of not observed
preop fasting, of anesthetic drugs. The intravenous anesthetic
 • Disorders of the gastrointestinal propofol is currently the least emetogenic general
passage with simultaneous anesthetic.
insufficiently existing protective
reflexes,
 • Extubation without suction of Complication: Nausea and Vomiting
the oral cavity, Symptoms  • Deep-set eyes,
 • Incorrect patient positioning  • Wide pupils,
after extubation.  • Dry, brittle tongue,
First measures  • Clear the airway and suction of  • Fear, pain, sweating,
the surgical field,  • Pale face,
 • Oxygen application by mask  • Feeling of pressure in the stomach,
ventilation, Reasons  • Anesthetic drugs side effects,
 • Airway support by intubation.  • Severe pain, hypotension,
 • Patient was not fasting,
 • Gastrointestinal atony,
 • Side effects of other medication,
1.7 Postoperative Nausea  • Elevated intracranial pressure.
and Vomiting (PONV) First  • Position of patient’s upper body high,
measures  • Emesis basin,
 • Substitution of saline solution and
PONV is a common, distressful, and debilitating electrolytes,
occurrence that many patients describe as the  • Antiemetics and sufficient pain
most distressing part of their anesthetic experi- medication,
ence. In a hospital-based surgery report, the inci-  • Check gastric tube for patency,
 • Prolongation of fasting.
dence of PONV is in 14% after general anesthesia
or IV sedation [2].

2 Pain Management
1.8 Reasons
Pain is uncomfortable and unnecessary, and its con-
Female gender, increased intravenous fluid trol must be a primary goal in postoperative care.
supplementation (overfilling), longer dura- Pain interferes with oxygenation, delays heal-
tion of anesthesia, and the use of nitrous ing, affects patient attitudes, and is a source of
oxide are factors that promote postoperative dissatisfaction with surgical and medical care.
nausea. Since there are no identifiable behavioral or clini-
Favoring factors for postoperative vomiting cal signs that can be reliably used to determine
are ethnic origin and individual disposition: the the actual degree of subjectively felt postopera-
risk of vomiting among non-Caucasians is 2.49 tive pain, it is best to trust patients’ assessment of
times higher than among Caucasians. Additional their own pain. Pain scores are reliable tools for
risk factors are obesity, age less than 16 years, this purpose.
additional surgical procedures, and the use of The pain experienced by different patients
opioids [1, 3]. during the same surgical procedure varies from
20 Post-Surgical Complications and Care 187

person to person, and responses to the same level Non-opioid analgesics are a heterogeneous
of pain are expressed differently by different peo- group of pharmaceuticals that all have in com-
ple. The best measure of adequate analgesia is mon their use in pain therapy. In addition, they
therefore the patients’ own perceptions. are used in the treatment to reduce fever. Some of
A scoring system should be used to assess the them inhibit platelet aggregation and may not be
level of pain and monitor the effectiveness of used in post-surgical pain therapy.
treatment. They mainly unfold their effect by inhibiting
cyclooxygenases, but they also have other central
effects in isolated cases. The respective side
2.1 Algorithms for Pain Therapy effects depend on the drug subgroup used. Above
all, non-steroidal anti-inflammatory drugs are
Postoperative pain can be managed well with often underestimated with regard to their risks for
patient-controlled analgesia techniques (PCA) the stomach and kidneys.
and modern pain therapy combinations.
Numerical rating scales (NRS) and pain scale Overview analgesics (exemplary)
diagrams have proven to be useful for assessing Low-potency High-potency
the severity of pain. In addition, the age of the NSAID opioids opioids
patient and his cognitive ability must be taken • Diclofenac. • Tramadol. • Morphine.
• Ibuprofen. • Tilidine/ • Oxycodone.
into account in the assessment.
• Paracetamol. naloxone. • Fentanyl.
Pain treatment is classified as either preven- • Metamizol. • Piritramide
tive or on demand. On-demand pain medications (PCA).
typically include either opioid or non-steroidal
anti-inflammatory drugs (NSAID) or use ket-
amine. On-demand drugs can be administered by
a clinician or by the patient using PCA. PCA has Note
been shown to provide slightly better pain control Immediate postoperative treatment with
and higher patient satisfaction compared to con- low-potency analgesics is generally not
ventional methods [4]. advisable, since intraoperatively, usually
high-­potency opioids are used.
A common “mistake” in pain therapy is
2.2 Expected Pain Level the implementation of an analgesic therapy
using only one opioid.
• Mild pain (NRS 1–3): non-opioid analgesics, In order to achieve effective and bal-
e.g., metamizole, ibuprofen, and paracetamol. anced analgesia, the (additional) adminis-
• Moderate to severe pain (NRS ≥4–10): Highly tration of a non-opioid analgesic and, if
potent opioid in combination with a non-­ necessary, a coanalgesic should be carried
opioid drugs. out in each treatment stage

2.3 Pain Therapy on the Ward

2.4 Postoperative Pain Therapy—
• Regular evaluation of pain intensity (NRS) at Pain Score and Basic
rest and under stress, e.g., movement of the Medication
lower jaw.
• Pain therapy primarily according to pain 2.4.1 Mild Pain (NRS 1–3)
intensity. Basic medication: Non-opioid analgesic—
• Pain therapy in consultation with the pain NSAID, e.g., ibuprofen.
team. Adaptation in case of insufficient effect:
188 P. Kessler et al.

Combination with low-potency opioid, e.g., 2.6 Postoperative Fever

tramadol, or combination with highly potent opi-
oid, e.g., oxycodone. Non-infectious causes of postoperative tempera-
ture rise can be different events. These can over-
2.4.2 Moderate Pain (NRS 4–6) lap, complement, and reinforce each other:
Basic medication: Primary low potent opioid, Temperature rise:
e.g., tramadol.
• Surgical trauma: Day 1–2.
Adaptation in case of insufficient effect:
• Drug fever: Day 1–8.
Combination with a non-opioid analgesic,
• Hematoma: Day 2–4.
e.g., ibuprofen.
• Rarely: Thromboembolism: Day 4–10.
2.4.3 Severe Pain (NRS 7–10) Infectious causes:
Basic medication: Primary highly potent opioid,
• Aspiration pneumonia: Day 1–2.
e.g., oxycodone.
• Various infections: pneumonia, urinary tract
Adaptation in case of insufficient effect:
infection: Day 3–8.
Combination with a non-opioid analgesic
• Wound infection with abscess formation: Day
such as ibuprofen.
5–10.
The World Health Organization (WHO) pub-
lishes stage schemes for pain therapy. The combi-
nation of different pain medications in one effect
group should be entrusted to experienced pain Note
specialists in order to avoid endangering the The “rule of 5W” for postoperative fever:
patient’s health by combining highly effective Wind → Lung (pneumonia).
medications. Especially the accumulation of side Water → Urinary tract (cystitis).
effects can lead to unexpected complications. Walking → Thrombosis/pulmonary
Pain is felt subjectively. A good preparation of embolism.
the patient for the postoperative phase, including the Wound → Wound infection.
expected pain, helps to reduce the use of pain medi- Watt → Myocardial infarction
cation. Rules of conduct also contribute to this.
After orthognathic surgery, mild to moderate pain
can be expected. Credible severe pain should be the
reason for excluding a surgical or infectious cause. 3 Indirect Complications after
The above recommendations are based on the Orthognathic Surgery
WHO stage scheme. It should not be forgotten that
after selection of the pain medications, the dosage These include (Kim et al. 2010, [1, 5])
must also be appropriate to the patient’s age and
• Soft tissue and/or bone infections.
weight, general state of health, and type of surgery.
• Neurological deficits due to intraoperative
nerve injury.
• Secondary occlusional or articular disorders,
2.5 Postoperative Facial Swelling mandibular relapse.
• Bone malunion due to incorrect or missing
Postoperative edematous facial swelling usually
bony stabilization.
persists for 2–3 weeks, which then subsides to
residual edema after 3–4 weeks after surgery.
This can persist for up to 6 months and occasion-
ally increase. Of course, cooling measures in the Note
operating area also help to prevent swelling. The overall rate of postoperative complica-
Pre and perioperative swelling prophylaxis tions after orthognathic surgery is between
based on glucocorticoids helps to reduce edema- 9.7% and 24.5%.
tous swelling. See also Chap. 2.
20 Post-Surgical Complications and Care 189

The individual surgical risks are distributed as infection, e.g., type I diabetes, must be
follows [1, 6]: identified.
Peri-implant infections are typically caused
• 50% Nerve injury and sensory disorders
by biofilm-forming microorganisms [9].
• 14% Temporomandibular joint disorders
Early Infections are usually caused by virulent
(TMJ dysfunction)
pathogens such as Staphylococcus aureus or
• 4–7% Infections
gram-negative bacteria, whereas delayed and late
• 4.5% Bone non-union in the mandibular split
infections are caused by low virulent pathogens
• 4% Mandibular relapse
such as coagulase-negative Staphylococci.
• 2.5% Fractures of osteosynthesis material
Among the pathogens of serious importance
• 2% Direct trauma to the IAN
are those which might be present in the biotome of
• 0,3% Nerve injury to the facial nerve.
the oral cavity of an individual for which there are
no effective antibiotics, if these pathogens are the
3.1 Wound Infections cause of an infection in an adjacent wound area.
“Difficult-to-treat”-pathogens [9]:
Postoperative infections such as soft tissue infec-
tions and/or osteomyelitis of the mandibular bone • Rifampicin-resistant gram-positive
are rare events. Aseptic working methods, less staphylococci.
traumatizing surgical techniques, a generally good • Ciprofloxacin-resistant gram-negative
blood supply of the operation field, usually young bacteria.
and healthy patients, and targeted intra- and post- • Enterococci.
operative prophylactic antibiotic shielding make • Fungi (Candida).
orthognathic surgery a safe surgical intervention.
The infection rate in osteotomies of the lower Patients who wish to undergo orthognathic
jaw is between 1 and 8% [1, 7, 8]. surgery must be prepared for the procedure with
the utmost care. This includes the restoration of
all carious defects, the removal of all suspected
3.2 Postoperative Soft Tissue pathological findings, and periodontal restoration
Infections prior to surgery. Only in this way can the risk of
infection be considered low [9, 10].
Soft tissue infections can usually be treated easily by
local measures—suture removal, wound spreading, 3.4 Delayed Bone Union or Bone
drainage—and antibiotic therapy after wound swab. Non-union

Delayed bony consolidation of an osteotomy can

3.3 Postoperative Bone Infections occur as a result of compromised healing of hard
and soft tissue.
Historically, the rate of wound infections with The risk of bone non-union is high when inad-
bone involvement was higher at the beginning equate segment fixation is performed with non-­
of rigid osteosynthesis than with wire ligatures. rigid materials such as wires, and when the
The enormous advancement of osteosynthesis anterior displacement of the distal segment is very
materials and technical procedures, the reduc- large, resulting in insufficient bone contact. This
tion of surgical time through improved preop- may be due to planning errors which must be
erative planning and targeted antibiotic support absolutely avoided with the planning options
make osteomyelitic infections a rare complica- available today.
tion. Nevertheless, basic surgical principles, Postoperative occlusal pre-contacts, an unbal-
such as the most economical denudation of the anced occlusion, and improperly designed splints
mandible, must be observed. Great importance may also interfere with the healing of bony seg-
is also attached to preoperative patient selec- ments, if the mandible is not sufficiently func-
tion, in which patients with an increased risk of tionally relieved.
190 P. Kessler et al.

A delayed bone healing of osteotomized seg- upper and lower jaw, insufficient orthodontic
ments may also occur in patients with systemic preparation for surgery.
disease, which in turn may interfere with wound • Changes in tooth position, loss of teeth.
healing. This must be avoided by careful anam-
nesis and patient selection. Large mandibular advancements of more than
7 mm can lead to an increased risk of relapse. To
prevent this, increased attention should be paid to
3.5 Mandibular Relapse
• TMJ positioning.
Relapse and changes of occlusion after orthogna- • Avoidance of rotational mandibular
thic surgery in the mandible are mostly the result movements.
of [1, 11, 12]. • Adequate osteosynthetic stabilization with
two parallel placed 2.0 mm plates, if
• Improperly performed segmental fixation at necessary.
the osteotomy sites. • Extended intermaxillary fixation with elastics
• Insufficient occlusal stability during for 1–2 weeks.
osteosynthesis. • Suprahyoid myotomy/Botox-injections.
• Deficits in rigidity of osteosynthetic plates • Orthodontic overcorrection to anticipate a
with insufficient bending strength. slight relapse.
• Occlusal displacements during fixation.
• Incorrect positioning of the condyles.
3.7 Mandibular Relapse
and Rotation
3.6 Factors that Can Lead to
a Relapse after Mandibular The stability of the surgical result obtained by
Split are BSSO decreases as counterclockwise rotation of
the distal segment increases. This is true even
• Muscle-related physiological effects on the with mandibular setback corrections. This is
jaw position despite correct mandibular presumably due to a muscular-neurophysiologi-
positioning. cal imbalance between the muscle groups that
• Changes in the physiological balance of the close the jaw and those that open the mouth.
pterygo-masseteric muscular loop. The The relapse tendency also increases, if the
changes in muscle insertion (length) and func- proximal segment, which was previously rotated
tion (contractability) tend to cranialize the clockwise, is activated counterclockwise after the
proximal segment. Changes in position of the operation [13–15].
horizontal branch of the mandible could result
in leverage changes of muscle contractability.
Note
• Increased muscular tension in the suprahyoidal
Postoperative relapse can be prevented by
muscles can produce an open bite, especially
minimizing rotation of the proximal
during mandibular anti-clockwise rotation and
segment
advancement with insufficient stabilization.
Changes in the mandibular plane.
• Asymmetric mandibular position between the
left and right side. 3.8 Mandibular Relapse
• Incorrect positioning of the temporomandibu- and Intersegmental Distance
lar joint/joints.
• Excessive segment inclination. The occurrence of intersegmental interferences
• Insufficient segment fixation, improperly pro- between the distal and the two proximal seg-
duced splints. ments after BSSO is unavoidable. Interference
• Orthodontic misalignment of the dentitions of between bony segments, combined with rigid
20 Post-Surgical Complications and Care 191

segment fixation, can force changes in the posi- 3.10 Bone Necrosis
tion of the condyles, leading to positional relapse
of the mandible, condylar resorption and, caus- Bone necrosis of the ascending ramus may occur
ally, to the loss of the targeted result. as a result of local ischemia following excessive
See also Chap. 9. soft tissue ablation and hematoma formation,
The application of osteosynthesis in the distal such as after complete buccal and lingual denu-
segment posterior to the last molar, interposition dation. There is also an increased risk in exces-
of a bone graft in a wide segment gap to prevent sive manipulations of the proximal segment
changes of position and a functionally stable plate during joint positioning and osteosynthesis.
osteosynthesis without compression is advisable. Especially when using the transbuccal approach
for screw fixation an uncontrolled soft tissue
stripping on the buccal side can happen. This
3.9 Malocclusion maneuver also increases the risk of hematoma
formation between bone and cheek soft tissues.
Postoperative occlusion disorders after BSSO can
manifest clinically as frontal or lateral or combined
fronto-lateral open bite and/or lateral mandibular 3.11 Prophylaxis
shifting. Mandibular misalignment in the frontal
plane may result from occlusal interferences. The best prophylaxis is the careful handling of
Anterior and lateral open bite: the covering soft tissues. However, an economi-
cal exposure that provides sufficient visibility is
• Inadequate osteosynthetic fixation. sometimes difficult to achieve. In very rare
• Posterior open bite during fixation due to extreme cases it may be necessary to remove
insufficient splint. necrotic bone areas, often together with the
• Insufficient orthodontic presurgical treatment, osteosynthesis material.
e.g., imbalance of curve of Spee.
• Insufficient anterior overbite, missing curve of
Spee. 3.12 Pseudarthrosis
• Too early functional load by chewing.
Pseudarthrosis is rare and usually caused by
Lateral mandibular displacement:
infection and instability in the osteotomy area
• Different sagittal mandibular repositioning due to inadequate stabilization. Even a too early
with right/left disbalance. onset of excessive mastication can lead to pseud-
• Symmetric sagittal mandibular repositioning arthrosis due to premature material loosening
with loss of the midline. despite sufficient osteosynthesis.
• Twisting of the proximal segment(s). Therapy: Adequate osteosynthesis and IMF.
• Inadequate transverse width between mandi-
ble and maxilla.
4 Conclusion
Treatment of mild postoperative malocclusion:
• Vertical traction with elastics when there is no Any surgical procedure presents a challenge to
anterior-posterior disharmony for 2–3 weeks. the patient’s biology, which must allow the iatro-
• In case of anterior-posterior discrepancies genically inflicted wound to heal. The surgeon,
reenter, explore the situation and correct the through his careful and cautious approach, must
discrepancy. ensure that the conditions for recovery are ideal.
The special feature of orthognathic surgery is the
combination of soft tissue and bone tissue sur-
Note
gery in the region of the oral cavity, which is
The use of vertical forces by elastics can
always potentially at risk of infection, with tran-
have detrimental effects on teeth
soral access. The risks of the procedures lie
192 P. Kessler et al.

between the known risks of orthopedic and oral 7. Davis CM, Gregoire CE, Steeves TW, Demsey
surgery. The desire for early mandibular move- A. Prevalence of surgical site infections following
orthognathic surgery: a retrospective cohort analysis.
ment and keeping the airway open must also be J Oral Maxillofac Surg. 2016;74:1199–206.
given much consideration [16–19]. 8. Posnick JC, Choi E, Liu S. Occurrence of a ‘bad’ split
After unsatisfactory experiences with various and success of initial mandibular healing: a review of
osteotomy techniques, the bilateral sagittal split 524 sagittal ramus osteotomies in 262 patients. Int J
Oral Maxillofac Surg. 2016;45:1187–94.
according to Obwegeser–Dal Pont, as refined by 9. Kleber C, Schaser KD, Trampuz
Hunsuck and Epker, has prevailed since the A. Komplikationsmanagement bei infizierter
1950s and is considered the standard procedure Osteosynthese : Therapiealgorithmus bei periim-
for relocating the mandible to correct the jaw plantären Infektionen [Complication management of
infected osteosynthesis: therapy algorithm for peri-
position. In addition to the technique of splitting, implant infections]. Chirurg. 2015;86(10):925–34.
the intraoral approach has since become firmly 10. Trampuz A, Zimmerli W. Diagnosis and treatment of
established. The technique is elegant, but it infections associated with fracture-fixation devices.
always presents even the experienced surgeon Injury. 2006;37(Suppl 2):S59–66.
11. Lee JH, Lee IW, Seo BM. Clinical analysis of early
with the challenge of adjusting this technique reoperation cases after orthognathic surgery. J Korean
individually, which can be associated with com- Assoc Oral Maxillofac Surg. 2010;36:28–38.
plications. The increasing demand for facial cor- 12. Van Sickels JE, Richardson DA. Stability of orthog-
rections for aesthetic indications puts pressure on nathic surgery: a review of rigid fixation. Br J Oral
Maxillofac Surg. 1996;34(4):279–85.
the surgeon to perform the operation flawlessly. 13. Han JJ, Yang HJ, Lee SJ, Hwang SJ. Relapse after
However, this can never be guaranteed, as unex- SSRO for mandibular setback movement in relation
pected events can always occur in the course of a to the amount of mandibular setback and intraopera-
split jaw, mainly due to the fact that in the end the tive clockwise rotation of the proximal segment. J
Craniomaxillofac Surg. 2014;42(6):811–5.
fracture of the lower jaw occurs spontaneously. 14. Proffit WR, Phillips C, Dann C 4th, Turvey
TA. Stability after surgical-orthodontic correc-
tion of skeletal class III malocclusion. I. mandibu-
References lar setback. Int J Adult Orthodon Orthognath Surg.
1991;6(1):7–18.
15. Yang HJ, Hwang SJ. Bone mineral density and
1. Kim YK. Complications associated with orthogna- mandibular advancement as contributing factors for
thic surgery. J Korean Assoc Oral Maxillofac Surg. postoperative relapse after orthognathic surgery in
2017;43(1):3–15. patients with preoperative idiopathic condylar resorp-
2. Chye EP, Young IG, Osborne GA, et al. Outcomes tion: a prospective study with preliminary 1-year fol-
after same-day oral surgery: a review of 1180 case low-­up. Oral Surg Oral Med Oral Pathol Oral Radiol.
at a major teaching hospital. J Oral Maxillofac Surg. 2015;120(2):112–8.
1993;51:846. 16. Choi SK, Yoon JE, Cho JW, Kim JW, Kim SJ, Kim
3. Phillips C, Brookes CD, Rich J, Arbon J, Turvey MR. Changes of the airway space and the position of
TA. Postoperative nausea and vomiting following hyoid bone after mandibular set back surgery using
orthognathic surgery. Int J Oral Maxillofac Surg. bilateral sagittal split ramus osteotomy technique.
2015;44:745–51. Maxillofac Plast Reconstr Surg. 2014;36:185–91.
4. Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier 17. Ogle OE. Postoperative care of oral and maxillofacial
M. Validation of the critical-care pain observation tool surgery patients. Oral Maxillofacial Surg Clin N Am.
in adult patients. Am J Crit Care. 2006;15(4):420–7. 2006;18:49–58.
5. Jędrzejewski M, Smektała T, Sporniak-Tutak K, 18. Soydan SS, Bayram B, Akdeniz BS, Kayhan Z, Uckan
Olszewski R. Preoperative, intraoperative, and postop- S. Changes in difficult airway predictors following
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6. Te Veldhuis EC, Te Veldhuis AH, Bramer WM, 19. Van Merkesteyn JPR, Groot RH, van Leeuwaarden R,
Wolvius EB, Koudstaal MJ. The effect of orthogna- Kroon FH. Intra-operative complications in sagittal
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 Part IV
Mandibular Deficiency - Surgical
Technique - BSSO
 Indications for Mandibular
Advancement
21
Peter Kessler and Suen An Nynke Lie

Contents
1  orphological and Dental Criteria 
M 196
1.1 Skeletal Relation—Possible Conditions  199
1.2 Dentobasal Relation—Possible Conditions  199
2 Cephalometry in Skeletal Mandibular Retrognathia:  199
3 Indications  200
4 Conclusion  200
Reference  200

Abstract upper jaw fronts as well as compensatory pro-

truded lower incisors (class II/1). Furthermore,
The word retrognathism—class II dysgnathia, it must be differentiated whether the respec-
mandibular retrognathism—is derived from tive class II is a forward displacement of the
Latin retro (“backward”) and the Greek word maxilla or a horizontal or combined horizontal
γνάθος (gnáthos, “jaw”). Clinical symptoms and vertical growth deficit in the mandible. A
can be very diverse. They include negative combination of both symptoms is possible.
anterior steps in the dentition, a volumetri- Mandibular retrognathism can be treated at
cally small lower third of the face up to the different ages and stages of development. In
receding chin in conjunction with a symmetri- most cases, pure orthodontic treatment with
cal or asymmetrical mandibular growth defi- functional orthodontic appliances is sufficient.
ciency of various degrees. A narrow upper jaw However, if growth induction by orthodontics
with crowding and retrusion of the central/ is insufficient or when the growth deficit is too
lateral incisors is typical in class II/2 dys- pronounced, different surgical means can be
gnathias, but also compensatory extraverted used. Common to all these means of treatment
is that they are perceived as esthetically posi-
P. Kessler (*) · S. A. N. Lie tive by the patients. Often, in combination
Department of Cranio-Maxillofacial Surgery, with mandibular advancement, there is also a
Maastricht University Medical Center, need/possibility for correction of the chin
Maastricht, The Netherlands position (genioplasty)
e-mail: [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 195
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_21
196 P. Kessler and S. A. N. Lie

Keywords 1 Morphological and Dental

Criteria
Class II relation/malocclusion · Mandibular
retrognathism · Mandibular retrognathia · Dental class II is the most common form of treat-
Maxillary protrusion · Dental crowding · ment in orthodontics and orthognathic surgery. It
Tongue function · Indications for mandibular is precisely for this reason that assessment, plan-
advancement · Sagittal splitting · BSSO · ning, and treatment require attention, circum-
Mandibular advancement · Special surgical spection, and experience, since this form of
aspects · Mandibular segment osteotomy · dysgnathia can occur in all conceivable combina-
Modifications and surgical alternatives · tions and configurations.
Distraction osteogenesis · Genioplasty The morphological characteristics of mandib-
ular retrognathism are responsible for a typical
patient appearance, which is judged subjectively
The typical patient with a class II malocclusion,
as less disturbing than a mandibular prognathia.
proclination, or crowding of the mandibular ante-
Patients with class II position of the lower jaw are
rior teeth, and a moderate-to-low mandibular
less dissatisfied with their appearance since the
plane angle is a planning and treatment chal-
receding mandibular position can be compen-
lenge. The following points must be considered
sated by conscious or unconscious protrusion of
before or at the start of treatment, because class II
the mandible. In contrast, in cases of pronounced
patients have a smaller effective mandibular base
mandibular retrognathism or even mandibular
length:
micrognathia, the three-dimensional loss of vol-
ume in the lower third of the face is perceived as
• Crowding—extraction of teeth or decompen-
very disturbing.
sation without extraction: extraction versus
The extraoral facial profile is often harmoni-
non-extraction cases.
ous, with a negative lip line with the lower lip
• Is there an asymmetry of the number of teeth
receding dorsally and a pronounced lip red may
in the upper and lower jaw.
be present. A pronounced retracted sublabial fold
• Tongue function and lip habits—forced lip
is noticeable in forms of dentoalveolar retrogna-
closure.
thia, whereby the nose position, and also the chin
• Presence of wisdom teeth.
position, can be correct.
• In case of a deep bite: is the correction in one
In a fully developed class II mandibular ret-
jaw (mandible) sufficient? How is the vertical
rognathia the receding of the lower jaw, chin, and
problem approached: Segment or bimaxillary
lower lip can be seen in both lateral and en-face
correction.
views. Nevertheless, mild forms are often per-
• A large pretreatment mandibular plane angle
ceived by patients as not very disturbing
leads to unfavorable results.
(Fig. 21.1). Pronounced forms, however, lead to
The initial task in most patients with mandibu- increased suffering, since a “receding” chin
lar deficiency is to eliminate dental compensation causes the esthetically significant chin promi-
by retrusion of the lower front and protrusion of nence to disappear, resulting in a very disturbing
the upper front as well as by bucco-lingual cor- transitionless chin-neck area.
rection of the inclination of the posterior teeth, in Intraorally, in addition to a class II occlusion
the maxilla to the vestibular side, in the lower jaw in the first molar region, an enlarged positive den-
to lingual. If extreme vertical overbite is present tal anterior overjet is usually noticeable, which
at the same time, additional orthodontic means may be pronounced by lingual tilting of the lower
are necessary to successfully level the occlusion. and labial tilting of the upper front teeth
These remarks are intended to make it clear that, (Fig. 21.2).
especially in class II malocclusion, interdisci- On the other hand, the clinical situation of a
plinary contact and cooperation with the ortho- class II jaw relationship can be camouflaged by a
dontist are crucial for success [1] palatal tilting of the upper and labial tilting of the
21 Indications for Mandibular Advancement 197

Fig. 21.1 Lower facial third: Typical facial appearance in Class II occlusion with mandibular deficiency

Fig. 21.2 Bite relation of the patient in Fig. 21.1 with positive dental anterior overjet

lower front teeth. The anterior tooth relationship caused by the sagittal underdevelopment of the
also depends on the individual activity of the lip tooth-bearing alveolar process. Often there may
muscles. A narrow frontal overbite position can also be non-development of teeth in the premolar
therefore also be present with a class II occlusion region, which should not be overlooked.
findings in the molar region. The clinical image of mandibular retrogna-
However, there may also be a dental compen- thism in non-syndromal cases can be assigned to
sation with protrusion position of the mandibular a dentoalveolar or skeletal class II with cause in
and retrusion position of the upper front teeth and the mandible only.
thus a reduction of the overjet. In addition to the Clinical, radiological, and technical analyses
characteristic class II occlusion, the dentoalveo- (cephalometry), especially in the sagittal plane,
lar relation often shows crowding of the lower are used to determine which diagnosis is appli-
anterior and posterior teeth. This protrusion is cable. These analyses must provide information
198 P. Kessler and S. A. N. Lie

about the position and size of the mandibular and lead to rotational moments—mostly anti-
skeletal structures with respect to the degree of clockwise—in the correction of the mandibular
mandibular retrognathism within the respective malposition, which must be observed without
facial growth pattern and clarify the extent of fail while avoiding relapse or transverse
dentoalveolar and/or skeletal involvement in disharmony.
class II occlusion. The distinction between an orthognathic, ret-
Special attention must be paid to the overall rognathic, and retrognathic-elongated facial type
length of the face and the relative proportion of helps to avoid errors in planning and can occa-
the lower third of the face in order not to overlook
a vertical excess of growth in the middle and
lower third of the face, which often requires
bimaxillary correction (Fig. 21.4).
If patients complain of a gummy smile, extra
attention has to be paid, if the malocclusion can
be solved in a mono-maxillary surgical approach
to the mandible.
In cephalometric analysis the simple class
II cases show a jaw base harmony except for
the mandibular retrognathism (SNB-angle).
The sagittal interbasal relation (ANB-angle) is
found to be increased (enlarged positive
ANB-angle).
If the pogonion prominence is in harmony
with the face, it indicates an alveolar mandibular
underdevelopment. If the position of the pogo-
nion is also in disharmony—sagittal retroposi-
tioning of the pogonion—the situation fulfills the
criteria of a skeletal mandibular retrognathism
(Fig. 21.3).
Vertical and mostly transversal disharmonies Fig. 21.3 Typical cephalometry for class II occlusion
or discrepancies may be present in the planning with mandibular retrognathism. ©Copyright Keisuke
of the procedure, which complicate planning Koyama 2020. All rights reserved

Fig. 21.4 Lower facial third: Typical facial appearance in class II occlusion with mandibular deficiency and vertical
overgrowth of the maxilla. Retrognathic elongated facial type with forced lip closure
21 Indications for Mandibular Advancement 199

sionally lead to the decision to recommend 1.2 Dentobasal Relation—

bimaxillary correction in the case of retrognathic Possible Conditions
facial type with vertical elongation (dolichofacial
type, long face). • Dental compensation, protrusion of lower
Special attention must be paid to the relation- anterior teeth in case of retruded or normally
ship of the mandibular base to the skull base positioned upper anterior teeth.
plane (ML-NSL) to avoid errors that may lead to • Retroclined upper front teeth and retrusion
an acceptable functional but unsatisfactory and elongation of the lower front teeth (class
esthetic result. II division 2, class II/2).
The position of the chin (pogonion-gnathion) • Deep bite with reduced height of the lower
requires special attention in order to achieve a third of the face and small vertical interbasal
good esthetic result. angle ML-NL.
• Deep bite with extruded lower front teeth, pro-
truded upper front teeth, and harmonious
Note
facial height.
In class II jaw relations the dysgnathic jaw
• Combination forms with exclusively retro-
position must made clear to patients.
clined central incisors with vertically harmo-
• Dental compensation is a common clini- nious jaw relation.
cal finding in class II dysgnathias.
• The indication for correction can be
functional and/or esthetic. Note
• In planning, attention must be paid to The dentoalveolar relation with character-
the vertical sagittal position of the man- istic retrognathic mandibular base realign-
dibular base—ML-NSL—and the posi- ment may include all known tooth
tion of the pogonion. misalignments in the sagittal, vertical, and
transverse directions.

1.1 Skeletal Relation—Possible

Conditions
2 Cephalometry in Skeletal
• Disharmonious profile of the face. Mandibular Retrognathia:
• Lower lip incompetence and retrusion.
• Flattened sublabial fold. • SNB and SNPg reduced.
• Receding chin. • SNA harmonious.
• Open mouth posture with balanced, reduced, • ANB enlarged.
or increased vertical face height. • ML-NL can show all variants.
• Fibrillary muscle twitches in the chin area—m. • Transversal dysharmonies with a narrowed
mentalis—with compulsive lip/mouth closure. upper jaw base.
• Voluminous lip red area of the lower lip.
• Class II relation in the molar region, increased For completeness it must be mentioned that
overjet with protruded upper front teeth (class mandibular retrognathia can also occur in combina-
II division 1, class II/1). tion with maxillary retrognathia. On the other hand,
• In adults, dental compensation without pro- mandibular retrognathia can also occur in maxillary
nounced sagittal overjet. prognathia or can be relatively masked by maxillary
• Protrusion position of the upper incisors. prognathia and an orthognathic mandible.
200 P. Kessler and S. A. N. Lie

3 Indications deficiency or skeletal mandibular retrognathia is

also the domain of combined orthodontic and
A class II mandibular growth deficiency must be surgical treatment. During the assessment and
regarded as risk factor for functional disorders of cephalometric measurement in class II patients,
the stomatognathic system: the maxilla must never be disregarded in order to
exclude incorrect treatment.
• Speech development.
• Speech disorders.
• Mouth breathing. Reference
• Disturbed chewing function.
• TMJ dysfunctions. 1. Vaden JL, Williams RA, Goforth RL. Class II cor-
rection. Extraction or nonextraction? Am J Orthod
• Impossibility of prosthetic-implantological Dentofac Orthop. 2018;154(6):860–76.
rehabilitation, especially at an advanced age.

4 Conclusion

The dentoalveolar class II relation is the domain

of orthodontics in growth age starting with the
eruption of permanent teeth. But mandibular
 Sagittal Split and Mandibular
Advancement
22
Peter Kessler and Suen An Nynke Lie

Contents
1 Mandibular Advancement: BSSO 203
2  ombination of Osteotomies
C 214
2.1 S egment Osteotomies 214
3 The Chin 214
4 Conclusion 214
References 214

Abstract prevalent with today’s surgical correction of

the jaw bases.
Corrections of mandibular position are the
Nevertheless, segment osteotomies can
domain of bilateral sagittal splitting osteot-
play a role, especially in extreme Class II/2
omy—BSSO. The Obwegeser-Dal Pont tech-
occlusal situations, to impact severely verti-
nique is considered the overall standard
cally exaggerated anterior segments and also
technique for mandibular advancement.
to modify them in anteroposterior inclina-
The importance of alveolar segmental oste-
tion. Negative occlusal curves (curve of
otomies has greatly decreased due to the dif-
Spee) can also be corrected by raising the
ferentiated orthodontic treatment options. The
anterior segment. Segment osteotomies can
known risks of alveolar segmental osteoto-
be combined with corrections of the mandib-
mies—loss of bone, teeth, fractures, and long-
ular base.
term damage to adjacent teeth—are not

P. Kessler (*) · S. A. N. Lie

Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center,
Maastricht, The Netherlands
e-mail: [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 201
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_22
202 P. Kessler and S. A. N. Lie

Keywords described by Dal Pont [3]. The main argument is

the largest possible bone attachment area
Mandibular retrognathism · Indications for between the distal and proximal bone segments
mandibular advancement · Sagittal splitting · (Fig. 22.1).
BSSO - SSRO · Mandibular advancement · However, with the establishment of distraction
Segmental osteotomy · Special surgical osteoneogenesis as an additional therapeutic option
aspects · Short lingual osteotomy—SLO · in cranio-maxillofacial (CMF) surgery, osteotomy
Modifications and surgical alternatives · techniques have experienced a renaissance. There
Distraction osteogenesis will always be patients with a class II mandibular
deficiency in whom the desired result in the sagittal
direction cannot be achieved during the course of
The total mandibular alveolar process osteot- orthodontic treatment in the growth age. If the
omy, as described by MacIntosh [1], has never transverse mandibular width in the molar region is
been able to assert itself, because of the known favorable, these cases can alternatively be treated
risks especially for the inferior alveolar nerve with Intermolar Mandibular Distraction
similar to the stepwise osteotomy in the jaw Osteoneogenesis (IMDO). See Chap. 24.
body according to Pichler and Berg [2] for In class II patients with extreme vertical
advancement of the mandible. growth excess or in the anterior segment of both
Correction of the mandibular deficiency is the the mandible and maxilla, segmental osteotomies
domain of bilateral sagittal split osteotomy as may still be necessary.

a b

Fig. 22.1 Sagittal splitting according to Dal Pont: (a) SLO according to Hunsuck (b) Osteotomy on the lingual side
according to Obwegeser ©Copyright Keisuke Koyama 2020. All rights reserved
22 Sagittal Split and Mandibular Advancement 203

1 Mandibular Advancement: BSSO In the case of a class II retrognathism, the

lower jaw must be shifted forward—mandibular
Chapter 17 describes the surgical procedure of advancement—in order to achieve a regular den-
the sagittal split in detail. tal occlusion in class I. Depending on the splitting
Of all the techniques and variations described technique, there will be a greater or lesser overlap
in literature, two are still used regularly today: of bone. The two most common osteotomy tech-
The osteotomy in the area of the jaw angle and in niques used are SSRO/BSSO and IVRO. Even
the area of the ascending mandibular ramus. with a short lingual osteotomy (SLO) accord-
The main method, which is used in many ing to Hunsuck and Epker, an overlap must be
places in the mandibular angle area, is the sag- assured [6, 7, 9].
ittal splitting, which was originally published by If the SLO is applied the placement of the buc-
Obwegeser [4] in the ascending branch clearly cal osteotomy is absolutely relevant to achieve
above the jaw angle. a good bone overlap between the proximal and
In 1958, Dal Pont then placed the buccal cut in distal segments. The buccal vertical osteotomy
the horizontal mandibular body at the level of the should deliberately be placed at the height of the
second molar, resulting in extremely wide bone second molar region or even further anteriorly
contact surfaces after sagittal splitting (Fig. 22.2) (Fig. 22.2). Impacted third molars should have
[3]. The masseteric muscle remains on the proximal been removed at least 6 months before surgery.
segment, which is important for its blood supply. Chapter 17 describes the surgical approach in
Sagittal mandibular splitting, especially in the detail:
Dal Pont modification, is the standard procedure Under nasal intubation anesthesia and after
today (SSRO/BSSO/SLO). Many suggestions for infiltration of the lingual and buccal jaw angle
modifying this successful method have been pub- region with local anesthetics containing vasocon-
lished. These modifications deal with the creation strictors, the mucosal incision is made slightly
of osteotomy lines, the instruments for tissue lateral to the external oblique line from the dis-
retraction, splitting, and especially the fixation of tal aspect of the second premolar to the ascend-
the fragments. Only the most important ones are ing mandible, but without cutting through the
mentioned here [5–8]. bucco-­ temporal fascia. To guarantee this the
scalpel should always maintain a perpendicular

a b

Fig. 22.2 (a) Obwegeser–Dal Pont procedure for mandibular advancement (Hunsuck–Epker modification) (b)
Osteosynthesis using a 4-hole mini plate with bar (2.0 mm) ©Copyright Keisuke Koyama 2020. All rights reserved
204 P. Kessler and S. A. N. Lie

position towards the bony surface from the point optional procedure to ensure that the tunnel is
where the external oblique line starts at the lateral prepared at the correct level.
aspect of the ascending ramus. Now a specially formed ramus clamp can be
This avoids prolapse of the cheek fat body. inserted, e.g., Satinsky clamp or DeBakey aor-
The periosteum can now be easily pushed away tic clamp, above the lingual tunnel at the origin
from the mandibular body to the jaw angle by of the coronoid process to replace the notched
blunt dissection until the distal insertion of the ramus hook. Clamps are easier to handle to retain
masseteric muscle in the region of the mandib- and protect the soft tissues cranially and lingually
ular angle is reached. The masseteric muscle (Fig. 22.3a, b).
must not be detached. A useful instrument for Next, the more or less prominent edge above
this preparation is the Minnesota retractor. the lingula, which represents an offshoot of the
The periosteum should be injured as little as mylohyoid line/internal oblique line, can be
possible. The attachment of the coronoid pro- ablated with a round burr. Especially in class
cess is dissected, whereby the connective tis- II mandibles this bone excess at the entrance to
sue attachment of the temporal muscle fibers the lingual tunnel is only rarely there. In most
should be dissected meticulously. Care is taken cases is due to the mandibular growth defi-
not to completely detach the periosteum on the ciency the coronoid process thin. The view to
lateral side, so as not to endanger the blood the dorsal edge of the ascending ramus is usu-
supply to the proximal fragment carrying the ally good.
joint. A notched ramus hook is used to retain Before the lingual osteotomy is performed, a
the soft tissues from the muscular/coronoid channel retractor, which can surround the poste-
process. rior edge, is inserted to prevent injury to the lin-
The fibrous periosteum is now carefully gually located nerves and vessels. A blunt, 90°
detached lingually at the level of the base of the curved nerve hook can be used for reliable iden-
muscular/coronoid process caudally towards the tification of the lingula before the channel retrac-
point where the alveolar process is bulging out to tor is inserted. The channel retractor should lie in
the lingual aspect—undercut. Be sure to remain contact with the lingual side of the ascending
in the subperiosteal plane to avoid disrupting the mandibular branch in such a way that it is turned
soft tissue layers on the lingual side with the risks 45° caudally.
of bleeding and injuring the lingual nerve. After Anatomically the channel retractor is posi-
having achieved this a horizontal tunnel is made tioned in the sulcus colli groove behind the crista
to the posterior edge of the ascending ramus endocoronoidea. In this position, the lingula as
above the lingula. entrance port for the neurovascular bundle is pro-
The lingula with the nerve and vessel exit tected and at the same time the lingual soft tis-
remains caudally of the periosteal tunnel. For sues are kept out (Fig. 22.4).
safe orientation the incisura semilunaris can now The lingual bone cut is made with the long
be identified with a blunt curved elevator, raspa- Lindemann burr at a depth of 1.5–2 mm as
tory or dissector according to Freer. This is an described by Hunsuck and Epker (SLO). Caution
22 Sagittal Split and Mandibular Advancement 205

a b

Fig. 22.3 (a) The surgical site is sufficiently prepared for a safe osteotomy. Osteotomy line is indicated. (b) Safe
approach to the retromolar region for splitting the mandible ©Copyright Keisuke Koyama 2020. All rights reserved

Fig. 22.4 Channel retractor placement on the lingual side for protection of the soft tissues and the IAN, clinical situa-
tion for safe access ©Copyright Keisuke Koyama 2020. All rights reserved
206 P. Kessler and S. A. N. Lie

Fig. 22.5 The lingual

osteotomy should run
parallel to the occlusion
of the lower jaw. Nerve
probe as guiding tool
©Copyright Keisuke
Koyama 2020. All rights
reserved

is required in the middle part of the ascending

ramus, where the bone can be very thin; it is
essential to avoid separating the condylar process
from the proximal segment. The inclination of
the Lindemann burr is decisive.
It is recommended to align the drilling plane
parallel to the occlusal plane of the mandible and
if possible parallel to the lingual retractor which
can be used as a guiding tool (Figs. 22.5, 22.6,
22.7).
As second osteotomy the buccal cortical cut is
made, which is usually placed in the region of the
second molar or even anteriorly as classical Dal
Pont osteotomy. Here, the cortical bone should
be completely cut through to ensure easy
splitting.
A connection between the two cortical inci-
sions is then marked with an excavator drill,
which is completed with a short Lindemann or
fissure burr. This bone cut can also be made with-
out predrilling in soft bone types and should
safely cut through the cortex along the internal
aspect of the buccal cortex. The two cortical cuts
can also be connected directly with the saw.
Special attention must be paid to the complete
osteotomy with the drill at the transition of the
Fig. 22.6 Channel retractor placement for protection of
horizontal and buccal osteotomy to the connect- the IAN and as guiding tool for the lingual osteotomy
ing line (Figs. 22.8, 22.9). No cortical bridges ©Copyright Keisuke Koyama 2020. All rights reserved
22 Sagittal Split and Mandibular Advancement 207

Fig. 22.7 (a) Short a

lingual osteotomy—
SLO—on the lingual
side according to
Hunsuck–Epker (b)
CBCT horizontal scan:
on the right mandibular
side only the SLO can
be applied ©Copyright
Keisuke Koyama 2020.
All rights reserved

must remain here. It is also recommended to weakened the bone here with a 5 mm Epker osteo-
carefully weaken the solid mandibular base at the tome or a straight chisel it is easier to continue
lower edge of the buccal osteotomy as recom- with the splitting procedure in an ascending man-
mended by Böckman et al. and Wolford and ner from the buccal osteotomy to the lingual.
Davis [5, 8] (Fig. 22.8). After the buccal edge of the lower jaw is also
To avoid problems during the sagittal split it is protected towards the cheek by a channel retractor
advisable to start the osteotomy on the lingual side we then split the mandible with thin, slightly later-
at the lingual cut where solid cortical bone struc- ally bent chisels (5 mm Epker osteotome) first to
tures prevail. When using the Epker osteotome one about the middle, then if possible towards the cau-
feels the resistance of the bone against splitting dal end of the osteotomy (Figs. 22.10, 22.11).
which suddenly recedes after having reached the This depends on the form of the mandible at
groove inferiorly of the condylar process (sulcus the buccal osteotomy site: The lateral side of the
colli) where the SLO usually ends. After having mandible can be straight but is mostly curved
208 P. Kessler and S. A. N. Lie

During this process keep an eye on what is hap-

pening at the lingual osteotomy side.

While the osteotomy gap is widened, it is usu-

ally possible to identify the course of the man-
dibular canal. This lies mostly in the distal
tooth-bearing segment. If this is successful, the
osteotome can also be inserted deeper under the
protection of the IAN in order to split bony con-
nections below the course of the canal. Depending
on the form of the mandible also straight chisels
can be used. The tooth-bearing distal segment is
now gently mobilized and freely movable. The
osteotomized jaw can be relocated anteriorly
against little resistance.
Detaching the masseterico-pterygoidal
muscle loop is not recommended in mandibu-
lar advancement, but soft tissues/fibrous/mus-
cular attachments at the lower border of the
distal segment have to be removed for suffi-
cient mobilization. This maneuver, which can
be carried out with a strongly curved dissector,
removes the remaining attachment of the
medial pterygoid muscle from the tooth-bear-
Fig. 22.8 Sagittal split completed with the burr ing distal segment, but not from the proximal
segment. This segment is now only fixed to the
which makes chiseling more difficult. suprahyoidal muscles and the muscles of the
Alternatively straight 5 mm chisels can be used to floor of the mouth and tongue and can be
deepen the buccal osteotomy in a vertical and moved ventrally against little resistance.
slightly dorsal direction to create a gap between The instruments used to split the jaw angle, or
the cortical buccal plate and the remaining man- the ascending ramus of the lower jaw, are chosen
dibular body. Make sure that the solid lower man- differently by each surgeon (Figs. 22.13, 22.14,
dibular rim is fully osteotomized (Figs. 22.11, 22.15). After making the connecting osteotomy
22.12). between the lingual and buccal osteotomy, chis-
Straight 10 mm chisels can be used to deepen els and osteotomes are preferred. The order of the
the connecting osteotomy line. While doing so instruments mentioned seems to be more in keep-
experienced surgeons learn to differentiate ing with habit.
between “harder” and “softer” bone substance Freihofer [10] recommended laterally curved
which provides valuable information for the later chisels that can slide along the buccal cortex to
splitting. Then wide osteotomes can be used with deepen the connecting incision. In many opera-
the help of the spreader to widen the gap and tion theaters this instrument is called Epker
finally break the remaining bony connections. osteotome.
The splitting itself can be performed with straight
As mentioned above osteotomes (size 8, 10, and 12) or a bone spreader
It is advisable to start the splitting procedure or a combination of both. Which instrument is used
from anterior to posterior, which means from the also has to do with the length of the connecting oste-
buccal osteotomy towards the lingual osteotomy. otomy line (Figs. 22.13, 22.14, 22.15).
22 Sagittal Split and Mandibular Advancement 209

Fig. 22.9 Sagittal split completed with the saw

In the classic situation of sagittal splitting If the connecting osteotomy line between the
according to Dal Pont [3] the spreader can be lingual and buccal osteotomy is short, chisels
inserted close to the buccal osteotomy from and osteotomes are more likely to be used, as
above and anteriorly, and then the osteotomes can the spreader is less able to expand compact
be used to complete the splitting first buccally bone. In this case, more energy is required for
and then lingually after identification of the splitting.
course of the IAN. The Figs. 22.17 and 22.18 illustrate possible
The split can also be performed by a combi- lingual splits in theory and reality.
nation of spreader and the Smith separator Wire loops of 0.4 or 0.5 mm thick steel wire
which is inserted in the buccal osteotomy. are used for intermaxillary fixation. These are
Spreader and Smith separator have to be acti- looped over existing Kobayashi ligature hooks,
vated simultaneously to split the mandible crimpable hooks, or IMF screws (Figs. 22.19,
(Figs. 22.15, 22.16). 22.20). In any case, a safe and stable IMF must
210 P. Kessler and S. A. N. Lie

Fig. 22.10 Weakening the inferior mandibular rim for safe splitting ©Copyright Keisuke Koyama 2020. All rights
reserved

be ensured to avoid displacement of the occlu-

sion during osteosynthesis.
Even with symmetrical initial conditions, dis-
turbing influences on the proximal segment—flar-
ing, rotation, dislocation—must be expected [11].

• If rotational movements are added to the

sagittal movement of the mandible, this can
lead to a forced displacement of the
temporomandibular joint (proximal seg-
­
ment), mostly on the contralateral side of the
asymmetry.
• If the mandible is shifted for correction of
asymmetry without rotation, the ipsilateral
proximal segment can be affected.

Both movements can lead to temporomandib-

ular joint diseases and functional restrictions of
the lower jaw movements.
A special chapter is devoted to the procedures
for asymmetrically shaped mandibles in detail.
Fig. 22.11 Careful osteotomy along the inner side of the
buccal cortex with the 5 mm chisel ©Copyright Keisuke
Koyama 2020. All rights reserved
22 Sagittal Split and Mandibular Advancement 211

Fig. 22.12 Inferior

mandibular rim osteotomy
with special attention to
split the mandible as
described by Böckmann et
al. and Wolford and Davis
[5, 8] ©Copyright Keisuke
Koyama 2020. All rights
reserved

Fig. 22.14 Careful splitting using one osteotome and the

Fig. 22.13 Careful splitting using two osteotomes Smith separator ©Copyright Keisuke Koyama 2020. All
©Copyright Keisuke Koyama 2020. All rights reserved rights reserved
212 P. Kessler and S. A. N. Lie

Fig. 22.15 Careful splitting using the spreader and the

Smith separator ©Copyright Keisuke Koyama 2020. All
rights reserved

Fig. 22.16 Clinical situation: Sagittal split using the spreader and the Smith separator, identification of the IAN
22 Sagittal Split and Mandibular Advancement 213

Fig. 22.17 Two possible variants of the lingual split ©Copyright Keisuke Koyama 2020. All rights reserved

Fig. 22.18 BSSO: Focus on the lingual split which conforms to the schematic drawings of Fig. 22.17

Fig. 22.19 Preparing for IMF with crimpable hooks, per-

fect midline

Fig. 22.20 IMF and rigid osteosynthesis with 2.0 mm

4-hole miniplate with bar
214 P. Kessler and S. A. N. Lie

separate chapter to the possibilities of chin reloca-

Note tion. The techniques described there can be com-
The three moments of BSSO where nerve bined with BSSO and mandibular advancement.
damage can occur are:
• Preparation of the lingual tunnel
• Splitting the lower jaw
4 Conclusion
• Crushing or direct nerve injury during
The BSSO as a splitting technique in the man-
osteosynthesis, especially when com-
dibular angle region must be understood in order
pression or positional screws are used
to apply it successfully. The pictorial and graphic
representation points out the decisive steps of this
outstanding technique.

2 Combination of Osteotomies
References
2.1 Segment Osteotomies
1. MacIntosh RB. Total mandibular alveolar osteotomy.
In class II occlusal positions, there may be an Encouraging experiences with an infrequently indi-
extreme extrusion of the mandibular front, which cated procedure. J Maxillofac Surg. 1974;
2. Pichler H, Berg A. Kieferosteotomie als
cannot always be sufficiently levelled preopera- Korrekturverfahren bei hochgradiger Fehlokklusion
tively by levelling the Spee curve. und äusserer Entstellung im Kieferbereich. Fortschr
In some cases there is an indication to correct Zahnheilk. 1933;IX:1. Teil
the mandibular misalignment before orthodontic 3. DalPont G. L’ osteotomia retromolare per la correzi-
one della progenia. Minerva Chir. 1958:1.
treatment (surgery first). In the classic approach, 4. Obwegeser H. Zur Operationstechnik bei der
a combination of BSSO and anterior segment Progenie und anderen Unterkieferanomalien. Dtsch
osteotomy can be performed, whereby the ante- Zahn Mund Kieferheilk. 1955;23:1.
rior segment is impacted first and then the BSSO 5. Böckmann R, Schön P, Neuking K, Meyns J,
Kessler P, Eggeler G. In vitro comparison of the
is performed as described above. sagittal split osteotomy with and without infe-
Also, the final fixation of the anterior segment rior border osteotomy. J Oral Maxillofac Surg.
should only be performed at the end of the entire 2015;73(2):316–23.
procedure to ensure that the occlusion is set as 6. Epker BN. Modification in the sagittal osteotomy of
the mandible. J Oral Surg. 1977;35:157–9.
planned preoperatively. The combination of both 7. Epker B, Fish L. The surgical orthodontic correc-
osteotomies is technically difficult and lengthy. tion of mandibular deficiency. Part I. Am J Orthod.
Particular attention must be paid to ensuring ade- 1983;84:408. Part II Am J Orthodont 1983; 84, 491
quate perfusion of the anterior segment through 8. Wolford LM, Davis WM. The mandibular infe-
rior border split: a modification in the sagittal split
the lingual soft tissue attachment. ramus osteotomy associated with the presence or
absence of third molars. J Oral Maxillofac Surg.
2001;59(8):92–4.
3 The Chin 9. Hunsuck EE. A modified intraoral sagittal splitting
technic for correction of mandibular prognathism. J
Oral Surg. 1968;26(4):250–3.
Another typical combination osteotomy in con- 10. Freihofer HP. Proleme der Behandlung der
junction with advancement of the mandible is the Progenie durch sagittale Spaltung der aufsteigen-
chin osteotomy. The positioning of the chin can den Unterkieferäste. Schweiz Mschr Zahnheilk.
1976;86:679.
have a decisive influence on facial aesthetics and 11. Severt TR, Proffit WF. The prevalence of facial asym-
contribute more to the overall aesthetic assess- metry in the dentofacial deformities population at the
ment of the surgical result than mandibular University of North Carolina. Int J Adult Orthodon
advancement. For this reason, we have devoted a Orthoganthic Surg. 1997;12:171–6.
 Special Surgical Aspects
in Mandibular
23
Advancement - Flaring

Peter Kessler and Suen An Nynke Lie

Contents
1 Anatomical Surgical Background  215
2 Modifications and Surgical Alternatives  217
3 Conclusion  217
Reference  218

Abstract Keywords

Due to the parabolic shape of the mandibular Mandibular split · BSSO · Mandibular
base, mandibular advancement by BSSO can advancement · Mandibular anatomy ·
lead to lateral or medial dislocation, or rota- Rotational movement · Osteosynthesis ·
tion about a vertical or also horizontal axis by Flaring · TMJ · 3D planning
the temporomandibular joint (TMJ) in the
proximal segment, depending on the replace-
ment distance and the fracture behavior in the
region of the mandibular split. Combinations 1 Anatomical Surgical
of all three movements are possible, and they Background
can occur unilaterally or bilaterally. Careful
preoperative 3D planning provides valuable After advancement of the mandible and adjusting
information to address this fact. the occlusion, the mandible is usually stabilized
with functionally stable 2.0 mm osteosynthesis
plates. For detailed description see Osteosynthesis
for Sagittal Splitting. These plates must be long and
strong enough to bridge the sagittal gap between
the proximal and distal segments. If the long Dal
Pont split leads to a wide bony overlap, which is
P. Kessler (*) · S. A. N. Lie desirable because of healing, and if the advance-
Department of Cranio-Maxillofacial Surgery, ment of the distal segment is approximately
Maastricht University Medical Center, 5–7 mm or more, the forward movement will inevi-
Maastricht, The Netherlands tably impact the proximal segments due to the
e-mail: [email protected]; [email protected]
parabolic form of the mandibular base (Fig. 23.1).
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 215
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_23
216 P. Kessler and S. A. N. Lie

Fig. 23.1 The long bone overlap in the Dal Pont split may lead to rotational effects on the proximal segment: flaring.
©Copyright Keisuke Koyama 2020. All rights reserved

Rigid screw fixation is more difficult because correction of the excess bone in the gap area of
the mandibular forward displacement can result the distal segment is sufficient to adjust the two
in an unfavorable position for screw fixation in segments so that the bone overlap is still suffi-
the distal segment. Preference should be given to cient to ensure direct bone regeneration.
plate osteosynthesis. Depending on the width and size of this
lingual bone surplus, either the bone forceps
(Liston forceps) or the burr must be used for
Note
this maneuver. All surrounding soft tissues
• The base of the mandible has the shape
must be carefully protected and the distal
of a parabola.
mandibular segment must be manually stabi-
• If the mandible is split according to Dal
lized to allow a safe procedure. In 3D plan-
Pont in the region of the jaw angle, i.e.,
ning, the problem of flaring can be well
at the base of the parabola, rotation of
represented and, if necessary, corrected by
the TMJ-bearing proximal segments
adjusting the buccal osteotomy depending on
will occur when the mandible is moved
the planned advancement. The actual course
forward and the split mandibular seg-
of the split as well as the width of the con-
ments are superimposed.
necting osteotomy line, the so-called third
• This effect, known as flaring, depends
osteotomy, also plays a role in the evaluation
on the length of the overlay in the split
of flaring.
region, the transverse width of the man-
Transfacial-transbuccal approaches to the sur-
dible in the region of the gonion angle,
gical site in orthognathic surgery should be
and the advancement distance.
avoided. The use of angulated drill handpieces
allows preparation and osteosynthetic stabiliza-
tion of the proximal segment while bypassing a
To avoid this, a correction must be made to transbuccal approach. The angulated handpieces
relieve the TMJ. In most situations, a moderate can also be used for manual screw fixation.
23 Special Surgical Aspects in Mandibular Advancement - Flaring 217

The TMJ should be pushed gently into the ments of the distal tooth-bearing mandibular seg-
fossa articularis when the lower jaw is ment in relation to the proximal mandibular
repositioned. segment (TMJ) and provides very useful infor-
After the split and sufficient mobilization of mation when selecting the appropriate splitting
the segments, the proximal segments can be technique and defining the position of the buccal
pushed back- and upward under manual-digital osteotomy.
control preauricularly to prevent unintentional In addition, individually manufactured osteo-
dislocation of the TMJ during osteosynthesis or synthesis plates can transmit the preoperatively
while positioning the mandible in intermaxillary determined optimal surgical solution to the oper-
fixation. ating room. Laser-melted titanium plates are
In class II cases with large mandibular extremely hard and guarantee form and function
advancement, the temporomandibular joint stability at low volume.
should be set in the position that corresponds to Ultimately, stable osteosynthesis could also be
slight sagittal overcorrection. This means that dispensed with in order to give the proximal seg-
gentle forces should act on the TMJ during the ment more freedom to rotate back into a func-
osteosynthetic stabilization when correcting class tionally physiological position. However, this
II mandibles. requires a long IMF, which in turn requires inten-
The pre-fixation of the TMJ is certainly sen- sive cooperation of the patient [1].
sible for functional reasons, but clinically it does This, however, means that the decisive advan-
not meet the expectations placed on it, since the tage of rigid internal fixation, namely the ability
guaranteed precision and stability are not suffi- to dispense with a long-term IMF, is abandoned.
cient and the technical solution limits the over- Further, instability of the proximal segment can
view. This is a classic indication for 3D planning lead to unwanted cranial rotation of the proximal
in order to recognize the risk of flaring preopera- segment due to muscle contraction, which can
tively, to search for alternative solutions and to hardly be corrected at a later stage.
judge them virtually. Real alternatives are the vertical osteotomy in
the area of the ascending mandibular, which is
described in Part VII. The oblique, inverted L-
Note and C-shaped osteotomy can be considered. A
• Flaring with negative effects on the second alternative to mandibular advancement is
function of TMJ should be avoided. horizontal mandibular distraction. Both alterna-
• 3D planning enables the preoperative tives are discussed in separate chapters.
detection and correction of this
problem.
• Intraoperative corrections are techni- 3 Conclusion
cally not easy to perform, their effect
can hardly be verified. SSRO/BSSO with a short lingual osteotomy—
SLO—acc. to Hunsuck/Epker is the standard tech-
nique in correction of symmetric/asymmetric
mandibular retrognathism. Use 3D planning to
2 Modifications and Surgical avoid negative effects on the TMJ structures due to
Alternatives flaring and excessive TMJ rotation. Asymmetric
mandibular retrognathism is challenging and needs
Computer-based planning is of great help when more attention during planning and surgery.
planning symmetrical or asymmetrical advance- The mandibular split technique by means of
ment operations in mandibular retrognathism, as BSSO per se and the shape of the mandibular
it clearly shows the sagittal and rotational move- base must be placed in relation to the TMJ when-
218 P. Kessler and S. A. N. Lie

ever the mandible is replaced. 3D planning pro- Reference

vides a significant contribution to avoid
intraoperative problems in functional terms, but 1. Ohba S, Nakao N, Kawasaki T, Miura K, Minamizato
also with a view to a stable result and a non-­ T, Koga T, et al. Skeletal stability after sagittal spit
ramus osteotomy with physiological positioning
compromised TMJ function. As a safe technique, in patients with skeletal mandibula prognathism
the advantages of the BSSO outweigh any possi- and facial asymmetry. Br J Oral Maxillofac Surg.
ble consequences or technique-related functional 2016;54:920–6.
limitations.
 Intermolar Mandibular Distraction
Osteogenesis IMDO
24
Suen An Nynke Lie and Peter Kessler

Contents
1 I ndication 220
1.1 I ndications for Intermolar Osteotomy and DOG are 220
2 Surgical Procedure 221
3 Surgical Steps: 221
4 Distraction/Treatment Protocol: 222
5 The Clinical Treatment Phase 222
6 Radiological Follow-Up: 222
7  linical Follow-Up
C 224
7.1 A dvantages and Disadvantages of IMDO Treatment 225
8 Conclusion 225
References 225

Abstract upper airway obstruction secondary to micro-

gnathia. In infants extraoral appliances and in
Lengthening the human mandible by distrac-
young adults intraoral distraction devices are
tion osteogenesis (DOG) has become an
used.
accepted treatment to correct severe mandibu-
lar hypoplasia (Kessler et al. Mund Kiefer As described in this chapter, there is a very
Gesichtschir 4(3):178–182, 2000a; Wiltfang different genetic distribution of growth pat-
et.al. Br J Oral Maxillofac Surg 40:473–479, terns in the viscerocranium. In some regions,
2002). Mandibular distraction osteogenesis is class II jaw relations predominate up to 60%
especially used for neonates and infants with of all treatment cases, while in Asian countries
class III or relative class III jaw relations are
more common. The success of distraction
S. A. N. Lie · P. Kessler (*) treatments, especially in newborns and
Department of Cranio-Maxillofacial Surgery, patients with syndromal growth disorders
Maastricht University Medical Center Maastricht,
Maastricht, The Netherlands
e-mail: [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 219
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_24
220 S. A. N. Lie and P. Kessler

affecting the jaws, has led to DOG also being 1 Indication

used in classic orthodontic treatments (Kessler
et al. Mund Kiefer Gesichtschir 4(6):373–376, Orthodontic treatment starts when the first pre-
2000b; Breik et al. Int J Oral Maxillofac Surg molars erupt at an average age of 10–12 years.
45(6):769–782, 2016). Patient cooperation and sufficient growth are pre-
The structure that stays behind in growth in requisites for success [1–3].
the mandible is usually the lower jaw body.
For special indications or treatment courses,
intermolar osteotomy and DOG treatment in 1.1 Indications for Intermolar
the mandible represents an additional surgical Osteotomy and DOG are
treatment option during growth (Garcia-Piña
and Coceancig Int J Oral Maxillofac Surg • Class II/1 or class II/2 occlusion (Fig. 24.1).
481:118, 2019). • Lack of growth of the mandible during orth-
odontic treatment.
Keywords • Treatment with functional appliances is not
effective.
Class II relation · Mandibular retrognathism ·
• Lack of patient compliance at young age.
Mandibular retrognathia · Indications for
• Desire to complete the treatment successfully
mandibular advancement · Mandibular
and quickly.
advancement · Special surgical aspects ·
Modifications and surgical alternatives · Root
It is not recommended to perform an early
damage · Distraction osteogenesis—DOG ·
mandibular DOG if the maxillary/midface com-
Intermolar osteotomy · IMDO · Pubertal
plex is also retrusive. In this case a bimaxillary
growth spurt · Patient satisfaction
advancement at a later age is indicated.

a b

Fig. 24.1 Cephalometric analysis before distraction treatment (a) class II/1 occlusion (b) Desired mandibular advance-
ment distal to the first mandibular molar
24 Intermolar Mandibular Distraction Osteogenesis IMDO 221

Fig. 24.2 Distractor placement in the molar region of the lower jaw. Osteotomy between first and second molar.
©Copyright Keisuke Koyama 2020. All rights reserved

2 Surgical Procedure • Incision 5-8 mm buccal of the mucogingival

border from the premolar region to the base of
The young patients are carefully prepared for the the masseteric muscle.
operation, and it is emphasized that after the • Subperiosteal preparation with preparation of
operation the active distraction phase requires the the inferior mandibula rim.
intensive cooperation of the patient. If possible, a • Identification of the mental foramen.
small gap should be created orthodontically • Mark the vertical osteotomy line between the
between the distal radix of the first mandibular first and second molar with a fine fissure drill.
molar and the mesial radix of the second molar. • Fitting of the distractor and temporary fixation
This is where the transverse interradicular oste- with at least 2 screws ventral and dorsal to the
otomy is performed (Fig. 24.2) [2]. osteotomy line.
The patients must be aware that two opera- • Buccal cortical osteotomy with the fine
tions are necessary: Insertion and removal of the Lindemann drill or with the piezo technique.
distractor, usually under general anesthesia. • Deepening the osteotomy in between the radi-
Different distractors can be selected depending ces with the 5 mm chisel.
on the size of the mandible. The distraction is uni- • Cranial, lateral, and caudal osteotomy of the
directional; care must be taken to ensure that the mandibular canal.
distraction vector is aligned as parallel as possible • Cautious osteotomy of the lingual cortex with
to the occlusal plane. If there is a deep bite with a a chisel or piezo. The lingual mucosa must not
traumatic palatal bite, a slightly divergent direction be harmed.
of the distractor is preferred. The distractor must be • Mobilizing the osteotomized jaw segments
able to provide sufficient distraction length. with the osteotome while protecting the struc-
tures in the mandibular canal.
• Identical procedure on the opposite side.
3 Surgical Steps: • Positioning of the distractor under vector
control.
General anesthesia with nasal intubation. • Definitive fixation of the distractors.
• Activation of the distractors to check function.
• Weight-adapted local anesthesia with vaso- • Hemostasis, wound irrigation with saline, and
constriction in oral mucosa in the molar region wound closure with Vicryl 4x0.
of the mandible.
222 S. A. N. Lie and P. Kessler

• Ensure a convenient port for the distraction • Consolidation period after active distraction
arms of the distractors, which are usually approximately 8–12 weeks, then distractor
located in the cover fold. removal.
• Continuing orthodontic treatment.

4 Distraction/Treatment
Protocol: 5 The Clinical Treatment Phase

• Start of the active treatment phase 1 week Like any distraction treatment, intermolar DOG
postoperatively. is a dynamic procedure that requires regular
• Activation of the distractor once a day by 0.5 radiological and clinical monitoring, mainly by
mm. the orthodontist (Figs. 24.3, 24.4 and 24.5) [4, 5].
• If there is no midline deviation, symmetrical
activation on both sides.
• Duration of the active treatment phase depends 6 Radiological Follow-Up:
on the growth deficit of the mandible.
• Stop activation when cusps and molars are in See Figs. 24.3, 24.4.
class I relation.

a b

c d

Fig. 24.3 Panoramic X-rays: (a) Before intermolar oste- cal axis tilt of the distractors (c) End of active distraction
otomy and application of distractors. Note the small dia- treatment and removal of activation rods for more patient
stema between the first and second molars of the mandible comfort (d) Bone consolidation 10 weeks after end of dis-
(b) Control after distractor placement. Note the symmetri- tractor activation (e) After removal of the distractors
24 Intermolar Mandibular Distraction Osteogenesis IMDO 223

Fig. 24.4 Lateral skull X-ray before and after treatment with intermolar osteotomy and DOG
224 S. A. N. Lie and P. Kessler

7 Clinical Follow-Up

See Fig. 24.5.

Fig. 24.5 Photographic documentation of two patients: traumatic deep bite before and after end of combined orth-
(a) 12-year-old patient with class II/2 occlusion before odontic and distraction treatment. Notice the treatment-
and after end of combined orthodontic and DOG treat- related development of the lower third of the face in both
ment (b)12-year-old patient with class II/1 occlusion and cases
24 Intermolar Mandibular Distraction Osteogenesis IMDO 225

7.1 Advantages and 8 Conclusion

Disadvantages of
IMDO Treatment Satisfactory results can be achieved with inter-
molar osteotomy and DOG. Despite the risk of
Advantages: tooth damaging during the intermolar osteotomy,
a major advantage in terms of patient satisfaction
• Treatment at early age.
is due to the fact that the entire orthodontic and
• Stimulation of self-healing potential by apply-
orthognathic treatment can be completed in a
ing DOG on all tissues.
manageable period of time during the pubertal
• Dynamic treatment process can be beneficial
growth spurt. The esthetic benefit of harmonizing
for TMJ adaptation.
the facial features at this sensitive age should not
• Positive effects on the posterior airway space.
be underestimated in the positive assessment.
• Improvement on the position of the cervical
spine.
• Increasing width of the mandible and creating
space.
References
1. Breik O, Tivey D, Umpathysivam K, Anderson
Disadvantages: P. Mandibular distraction osteogenesis for the man-
agement of upper airway obstruction in children
• Second intervention for distractor removal is with micrognathia: a systematic review. Int J Oral
needed. Maxillofac Surg. 2016;45(6):769–82.
• Risk of wound infection through distractor 2. Garcia-Piña J, Coceancig P. Inter-molar mandibular
port. distraction osteogenesis (IMDO), why and when to do
it. Int J Oral Maxillofac Surg. 2019;48(Suppl 1):118.
• Root damage of neighboring teeth during 3. Kessler P, Wiltfang J, Merten HA, Neukam
osteotomy (Fig. 24.6). FW. Distraktionsostogenese der Mandibula bei kra-
niofazialen Fehlbildungen. Mund Kiefer Gesichtschir.
2000a;4(3):178–82.
4. Kessler P, Wiltfang J, Teschner M, Girod B, Neukam
FW. Computergestützte Simulationsmöglichkeiten
in der orthopädischen Chirurgie. Mund Kiefer
Gesichtschir. 2000b;4(6):373–6.
5. Wiltfang J, Hirschfelder U, Neukam FW, Kessler
P. Long-term results of distraction osteogenesis of
the maxilla and midface. Br J Oral Maxillofac Surg.
2002;40(6):473–9.

Fig. 24.6 Postoperative X-ray documentation of an unin-

tentional root tip amputation in the second molar in the
left mandible after intermolar osteotomy and distraction
treatment. Consolidation of the root stump with resorption
of the root fragment
 Retromolar Mandibular
Distraction Osteogenesis RMDO
25
Suen An Nynke Lie and Peter Kessler

Contents
1 Indication  228
2 Surgical Procedure  228
3 Surgical Steps:  229
4 Distraction Protocol:  230
5  he Clinical Treatment Phase 
T 230
5.1 Advantages and Disadvantages of RMDO Treatment  232
6 Conclusion  232
References  232

Abstract Keywords

Lengthening the human mandible by distraction Class II relation · Mandibular retrognathism ·

osteogenesis (DOG) has become an accepted Indications for mandibular advancement ·
treatment alternative in selected cases to correct Sagittal splitting · BSSO · Mandibular
mandibular hypoplasia (Kessler Mund Kiefer advancement · Special surgical aspects ·
Gesichtschir 4(3):178–182, 2000a). Modifications and surgical alternatives ·
Mandibular DOG is especially used for neo- Distraction osteogenesis—DOG · Retromolar
nates and infants with upper airway obstruction osteotomy · Soft tissue deficit
secondary to micrognathia. In infants extraoral
appliances and in young adults intraoral dis- As described in this chapter, there are genetically
traction devices are preferred determined differences in the regional occur-
rence of growth patterns in the viscerocranium.
In some regions, class II jaw relations predomi-
S. A. N. Lie · P. Kessler (*) nate up to 60% of all treatment cases, while in
Department of Cranio-Maxillofacial Surgery, Asian countries class III or relative class III jaw
Maastricht University Medical Center, Maastricht, relations are more common. The success of dis-
The Netherlands traction treatments, especially in newborns and
e-mail: [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 227
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_25
228 S. A. N. Lie and P. Kessler

a c

Fig. 25.1 Clinical and radiological situation before treat- tissue conditions (b) Class II/1 malocclusion (c) Lateral
ment: (a) Clinical picture of a patient with mandibular cephalogram displaying a hypoplastic mandible
deficiency and unfavorable submandibular/submental soft

patients with syndromal growth disorders affect- It is not recommended to perform a RMDO, if
ing the jaws, has led to DOG also being used in the maxillary/midface complex is also retrusive.
classic orthognathic surgery [1, 4, 5, 7]. In this case a bimaxillary advancement is
The structure that stays behind in growth in indicated.
the mandible is usually the lower jaw body. For
special indications or treatment courses, retromo-
lar mandibular distraction osteogenesis treat- 2 Surgical Procedure
ment—RMDO—represents an additional
surgical treatment option (Fig. 25.1). The patients are carefully prepared for the oper-
ation and it is emphasized that after the opera-
tion the active distraction phase requires the
1 Indication intensive cooperation of the patient. RMDO like
any distraction procedure is a dynamic treat-
• Class II/1 or class II/2 malocclusion (Fig. 25.1). ment versus the static treatment in BSSO by
• Short mandible. osteosynthesis [2].
• Insufficient length of the suprahyoid soft tis- The patients must be aware that two opera-
sues (geniohyoid muscle). tions are necessary: Insertion and removal of
• Increased risk of relapse with the use of a the distractor, usually under general
BSSO. anesthesia.
25 Retromolar Mandibular Distraction Osteogenesis: RMDO 229

Fig. 25.2 Distractor placement in the retromolar region Fig. 25.3 Distractor activated. Distraction gap opens dis-
of the lower jaw. Osteotomy distal of the second molar tal of the second molar. ©Copyright Keisuke Koyama
©Copyright Keisuke Koyama 2020. All rights reserved 2020. All rights reserved

In adults stable distractors must be selected 3 Surgical Steps:

adapted to the size of the mandible. The distrac-
tion is unidirectional; care must be taken to General anesthesia with nasal intubation
ensure that the distraction vector is aligned as
parallel as possible to the occlusal plane and in • Local infiltration anesthesia with vasocon-
parallel to each other (Figs. 25.2 and 25.3). striction in oral mucosa in the lateral molar
If there is a deep bite with a traumatic palatal region of the mandible.
bite, a slightly divergent direction of the distrac- • Incision 5–8 mm buccal of the mucogingival
tor is preferred. The distractor must be able to border from the premolar region to the retro-
provide sufficient distraction length. molar region, comparable to the BSSO
approach.
230 S. A. N. Lie and P. Kessler

• Subperiosteal preparation with preparation of • If there is no midline deviation, symmetrical

the inferior mandibula rim. activation on both sides.
• Identification of the mental foramen. • Duration of the active treatment phase depends
• Mark the vertical osteotomy line distal of the on the growth deficit of the mandible.
second molar with a fine fissure drill. • Stop activation when cusps and molars are in
• Fitting of the distractor and temporary fixation class I relation with overcorrection.
with at least two screws ventral and dorsal to • Consolidation period after active distraction
the osteotomy line. approximately 12 weeks, then distractor
• Buccal cortical osteotomy with the fine removal.
Lindemann drill or with piezosurgery. • Continuing orthodontic treatment.
• Deepening the osteotomy in with the 5 mm
chisel.
• Cranial, lateral, and caudal osteotomy of the 5 The Clinical Treatment Phase
mandibular canal.
• Cautious osteotomy of the lingual cortex with a Like any distraction treatment, RMDO is a
chisel or piezo. The lingual mucosa must not be dynamic procedure that requires regular radio-
harmed. logical and clinical monitoring, mainly by the
• Mobilizing the osteotomized jaw segments surgeon (Fig. 25.5).
with the osteotome while protecting the struc- Distraction treatment not only rebuilds bone
tures in the mandibular canal. but also stimulates redevelopment of soft tissue
• Identical procedure on the opposite side. (Fig. 25.4). The gradual lengthening of muscles,
• Positioning of the distractor under vector tendons, and connective tissue in general reduces
control. the risk of recurrence.
• Definitive fixation of the distractors. An advantage of mandibular distraction is that
• Activation of the distractors to check function. even after the active distraction phase is com-
• Hemostasis, wound irrigation with saline, and pleted, treatment can be restarted after a break.
wound closure with Vicryl 4x0. This time window is about 6 weeks. This may be
• Ensure a convenient port for the activation necessary if one notices a relapse/settling of the
rods of the distractors, which are usually mandibular position during follow-up. This con-
located in the vestibular fold. cept is called floating bone concept [3, 6].
The clinical case illustrated here is intended to
demonstrate that RMDO should only be used in
4 Distraction Protocol: selected cases (Figs. 25.1, 25.4, 25.5). The stan-
dard class II treatment is the BSSO with man-
• Start of the active treatment phase 1 week dibular advancement (Fig. 25.6).
postoperatively.
• Activation of the distractor twice a day by
0.5 mm (2 x 0.5 mm).
25 Retromolar Mandibular Distraction Osteogenesis: RMDO 231

Fig. 25.4 Result after

finishing treatment. Note
the redevelopment of the
submandibular soft
tissues

Fig. 25.6 Clinical picture of a patient with II jaw posi-

tion with standard proportions not requiring RMDO/DOG

Fig. 25.5 Assessment of mandibular advancement by

lateral cephalogram during active distraction treatment.
Note the parallel position of the distractors
232 S. A. N. Lie and P. Kessler

5.1 Advantages and cifically where significant post-development of

Disadvantages of RMDO the mandible and its surrounding soft tissues are
Treatment a priority.

Advantages:
References
• Stimulation of self-healing potential by apply-
ing DOG on all tissues. 1. Breik O, Tivey D, Umpathysivam K, Anderson
• Dynamic treatment process can be beneficial P. Mandibular distraction osteogenesis for the man-
for TMJ adaptation. agement of upper airway obstruction in children
• Positive effects on the posterior airway space. with micrognathia: a systematic review. Int J Oral
Maxillofac Surg. 2016;45(6):769–82.
• Improvement on the position of the cervical 2. Baas EM, Pijpe J, De Lange J. Long term stability of
spine. mandibula advancement procedures: bilateral sagittal
• Increasing width of the mandible and creating split osteotomy versus distraction osteogenesis. Int J
space. Oral Maxillofac Surg. 2012;41(2):137–41.
3. Hoffmeister B, Marks C, Wolff K. Floating bone con-
cept in mandibular distraction. Int J Oral Maxillofac
Disadvantages: Surg. 1999;28(1):90.
4. Kessler P, Wiltfang J, Merten HA, Neukam
• Second intervention for distractor removal is FW. Distraktionsostogenese der Mandibula bei kra-
needed. niofazialen Fehlbildungen. Mund Kiefer Gesichtschir.
• Risk of wound infection through distractor port/ 2000a;4(3):178–82.
activation rod. 5. Kessler P, Wiltfang J, Teschner M, Girod B, Neukam
FW. Computergestützte simulationsmöglichkeiten
• Root damage of neighboring teeth during in der orthopädischen chirurgie. Mund Kiefer
osteotomy. Gesichtschir. 2000b;4(6):373–6.
• Limited indication. 6. Politi M, Sembronio S, Robiony M, Costa F. The
floating bone technique of the vertical ramus in hemi-
facial microsomia: case report. Int J Adult Orthodon
Orthgnath Surg. 2002;17(3):223–9.
6 Conclusion 7. Wiltfang J, Hirschfelder U, Neukam FW, Kessler
P. Long-term results of distraction osteogenesis of
the maxilla and midface. Br J Oral Maxillofac Surg.
In the surgical treatment of the retrognathic 2002;40(6):473–9.
mandible, DOG—RMDO—represents an alter-
native treatment method that can be used spe-
 Part V
Mandibular Excess -
Surgical Technique - BSSO
 Indications for Mandibular
Setback
26
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1 Conclusion 237
References 237

Abstract both symptoms. Prognathism can be treated at

different ages and stages of development.
The word prognathism—class III dysgnathia,
Depending on this, different therapeutic means
mandibular prognathism, class III malocclu-
can be used, often only with the support of
sion—is derived from Greek πρό (pro, “for-
orthognathic surgery. Common to all these
ward”) and γνάθος (gnáthos, “jaw”). Clinical
means of treatment is that they are visible to the
symptoms can be very diverse. They include
patient’s social environment. Non-treatment
anterior cross- and headbites, unilateral or
may remain a limitation in daily life (Severt and
bilateral crossbites of various degrees, upper
Proffit Int J Adult Orthodon Orthoganthic Surg
jaw crowding, but also incomplete upper jaw
12:171–176, 1997).
dentitions, compensatory extraverted upper jaw
Skeletal class III malocclusion is a wide-
fronts, as well as compensated inverted lower
spread, mostly genetically determined maloc-
incisors. Furthermore, it must be differentiated
clusion that can be explained by a growth
whether the respective class III is a forward dis-
excess in the mandible and/or growth deficit in
placement of the mandible or a backward dis-
the maxilla/midface. A concave facial profile
placement of the maxilla or a combination of
with protruding chin is the result. The preva-
lence of class III malocclusion varies greatly
both among and within populations, and the
highest prevalence has been observed in
P. Kessler (*) · S. A. N. Lie Southeast Asian populations. In pronounced
Department of Cranio-Maxillofacial Surgery, form, biting off food is impossible and the
Maastricht University Medical Center, functional range of the temporomandibular
Maastricht, The Netherlands
e-mail: [email protected]; [email protected]
joints is limited. This is the functional indica-
tion for therapy. The only true option for cor-
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of
rection in skeletal class III is surgical. In
Cranio-Maxillofacial Surgery, Lucerne, Switzerland addition to the BSSO, the inverted L osteot-

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 235
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_26
236 P. Kessler et al.

omy and the intraoral vertical ramus osteot- mandibular prognathism within the respective
omy (IVRO) can also be used (Bell et al. facial growth pattern and clarify the extent of
Surgical correction of dentofacial deformities dentoalveolar and/or skeletal involvement in
2:890–895, 1980). class III malocclusion (Fig. 26.2).
In cephalometric analysis the simple class III
Keywords cases show a jaw base harmony except for the
mandibular prognathism (SNB-angle). The sagit-
Class III relation · Class III malocclusion ·
tal interbasal relation (ANB-angle) is found to be
Mandibular prognathism · Maxillary/midface
reduced (negative ANB-angle). If the pogonion
retrusion · Indications for mandibular setback
prominence is in harmony with the face, it indi-
· Sagittal splitting · BSSO · Mandibular
cates an alveolar mandibular overdevelopment. If
setback · Special surgical aspects in mandibu-
the position of the pogonion is also in dishar-
lar setback · Mandibular segment osteotomy ·
mony—sagittal forward displacement of the pogo-
Modifications and surgical alternatives ·
nion—the situation fulfills the criteria of a skeletal
Inverted Vertical Ramus Osteotomy - IVRO ·
mandibular prognathism (Fig. 26.3) [1, 2].
Inverted L osteotomy
Vertical and transversal disharmonies or dis-
crepancies may be present in the planning of the
The morphological characteristics of a mandibu- procedure, which complicate planning and lead
lar prognathism are responsible for a typical to horizontal and vertical rotational moments in
patient appearance, which is judged objectively the correction of the malocclusion, which must
and subjectively very differently. Patients with be observed without fail while avoiding relapse.
class III position of the lower jaw are often dis- The more subjective aesthetic distinction between
satisfied with their appearance. At the same time, an orthognathic, retrognathic, and prognathic
if the lower face height is enlarged, a prominent facial type helps to avoid errors in planning and
chin position can be disturbing (Fig. 26.1). can occasionally lead to the decision to recom-
The clinical image of mandibular prognathism mend bimaxillary correction in the case of a
can be assigned to a dentoalveolar or skeletal prognathic facial type even without skeletal dis-
class III with cause in the mandible or maxilla or harmony in the maxilla and midface [1, 2].
a combination of both. Clinical, radiological, and Special attention must be paid to the relation-
technical analyses (cephalometry), especially in ship of the mandibular base to the skull base
the sagittal plane, are used to determine which plane (ML-NSL) to avoid errors that may lead to
diagnosis is applicable [1, 2]. an acceptable functional but unsatisfactory aes-
These analyses must provide information thetic result. The position of the chin (pogonion-
about the position and size of the mandibular gnathion) requires special attention in order to
skeletal structures with respect to the degree of achieve a satisfactory aesthetic result.

Fig. 26.1 Typical facial appearance in class III malocclusion with mandibular overgrowth
26 Indications for Mandibular Setback 237

Fig. 26.2 Malocclusion of the patient in Fig. 26.1 with negative dental overjet, anterior and lateral right crossbite

1 Conclusion

The diagnosis of mandibular prognathism is usu-

ally clear. The assessment of whether it is a pure
mandibular prognathism or a combination with
maxillary or midface hypoplasia results from the
analysis of cephalometry. The resulting correc-
tion must take into account aesthetic aspects and
desires.

References
Fig. 26.3 3D imaging of the skeletal class III relation of
the patient in Fig. 26.1 1. Bell WH, Hall HD, White RP. Surgical ramus oste-
otomy. In: Surgical correction of dentofacial deformi-
ties. 2. Saunders, Philadelphia, 1980; 890–895.
Note 2. Severt TR, Proffit WF. The prevalence of facial asym-
metry in the dentofacial deformities population at the
• Class III patients often desire correction University of North Carolina. Int J Adult Orthodon
for aesthetic reasons. Orthoganthic Surg. 1997;12:171–6.
• The indication for correction can be
functional or aesthetic or both.
• In planning, special attention must be
paid to the vertical sagittal position of the
mandibular base—ML-NSL—and the
position of the pogonion - SNB, ANB.
 Sagittal Split and Mandibular
Setback
27
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1 Mandibular Setback: BSSO  240
2 Conclusions  244
References  244

Abstract Keywords

Surgical treatment of class III malocclusion in Class III relation · Class III malocclusion ·
most cases involves mandibular setback. Mandibular prognathism · Indications for
After bilateral sagittal split osteotomy (BSSO), mandibular setback · Sagittal splitting ·
mandibular setback, vertical and horizontal BSSO - SSRO - IVRO - Inverted L osteotomy ·
rotation is possible. In addition to the standard Mandibular setback · Special surgical aspects in
method of BSSO, segmental osteotomies, mandibular setback · Mandibular segment
intraoral vertical ramus osteotomy (IVRO), osteotomies · Modifications and surgical
and inverted L osteotomy can be used. alternatives

The importance of alveolar segmental osteoto-

mies has greatly decreased due to the differenti-
ated orthodontic treatment options. The known
risks of alveolar segmental osteotomies—loss of
P. Kessler (*) · S. A. N. Lie
bone, teeth, fractures, and long-term damage to
Department of Cranio-Maxillofacial Surgery, adjacent teeth—are not prevalent with today’s
Maastricht University Medical Center, surgical correction of the jaw bases.
Maastricht, The Netherlands However there will always be patients in
e-mail: [email protected]; [email protected]
whom orthodontic therapy cannot be performed
N. Hardt (*) for various reasons (number of teeth, age of the
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland
patient, costs, and patient compliance). For these

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 239
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_27
240 P. Kessler et al.

patients, the segmental osteotomy of alveolar muscle remains on the proximal segment, which
ridge sections may be an alternative therapy. This is important for its blood supply.
also applies to those findings in which the extent Sagittal split ramus osteotomy (SSRO) and/
of correction cannot be resolved by standard or bilateral sagittal split osteotomy (BSSO),
combined orthodontic-­surgical treatment alone. especially in the Dal Pont modification, are the
standard procedures today. Many suggestions
for modifying this successful method have been
1 Mandibular Setback: BSSO published. These modifications deal with the
creation of osteotomy lines, the instruments for
As described in Part I, there are numerous meth- tissue retraction, splitting, and especially the
ods of mandibular setback. Of the techniques fixation of the fragments. Only the most impor-
described there, two are still used regularly today: tant ones are mentioned here [1–4]. Figs. 27.1
The osteotomy in the area of the jaw angle and in and 27.2 describe the access to the mandibular
the area of the ascending mandibular ramus. angle.
The main method, which is used in many In the case of a class III mandibular progna-
places in the mandibular angle area, is the sagittal thism, the lower jaw must be shifted back-
splitting in the ascending ramus clearly above the ward—mandibular setback—in order to achieve
jaw angle. a regular dental occlusion in class I. Regardless
In 1958, Dal Pont then placed the buccal cut in of the splitting technique, there will be an over-
the horizontal mandible at the level of the second lap of bone segments or bone has to be removed.
molar, resulting in extremely wide bone contact The two most common osteotomy techniques
surfaces after sagittal splitting. The masseteric used are SSRO/BSSO and IVRO. Even with a
short lingual osteotomy (SLO) according to

a b

Fig. 27.1 Incision (a) The scalpel is inclined at 45° towards the external oblique line (b) S-shaped incision in the
retro−/para mandibular region
27 Sagittal Split and Mandibular Setback 241

a b

Fig. 27.2 (a) Blunt dissection of the buccal pocket without bleeding (b) Surgical site prepared for sagittal splitting. All
protecting instruments in place

Epker, bony interference/overlap cannot be ply to the fragment carrying the joint (proximal
ruled out [3, 5]. segment).
In principle, however, it is irrelevant whether A notched ramus hook is used to retain the
the buccal osteotomy is required at the height of soft tissues from the muscular/coronoid process.
the second molar region or further back. Impacted The periosteum is now carefully detached lin-
third molars should have been removed at least gually at the level of the base of the muscular/
6 months before surgery. coronoid process and a tunnel is made to the pos-
In detail: Under nasal intubation anesthesia terior edge of the ascending ramus. The lingula
and after infiltration of the lingual and buccal jaw with the nerve and vessel exit remains caudally of
angle region with local anesthetics containing the periosteal tunnel.
vasoconstrictors, the mucosal incision is made The incisura semilunaris is now identified
slightly lateral to the external oblique line from with a blunt curved elevator, raspatory, or dissec-
the distal aspect of the second premolar to the tor according to Freer. Now a specially formed
ascending mandibular ramus, but without cutting ramus clamp is inserted, e.g., Satinsky vascular
through the bucco-temporal fascia. This avoids clamp or DeBakey aortic clamp, which retains
prolapse of the cheek fat body. The periosteum and protects the soft tissues cranially and lin-
can now be easily pushed away from the mandib- gually (Figs. 27.3 and 27.4).
ular body to the jaw angle by blunt dissection. Next, the more or less prominent edge above
A useful instrument for this preparation is the the lingula, which represents an offshoot of the
Minnesota retractor. The periosteum should be mylohyoid line/internal oblique line, can be
injured as little as possible. The attachment of the ablated with a round burr. In class III cases this
coronoid process is dissected, whereby the con- line can be very prominent. This allows a good
nective tissue attachment of the temporal muscle view to the dorsal edge of the ascending ramus.
should be detached meticulously. Care is taken Before the lingual osteotomy is performed, a
not to completely detach the periosteum on the channel retractor, which surrounds the posterior
lateral side, so as not to endanger the blood sup- edge, is inserted to prevent injury to the lingually
242 P. Kessler et al.

a b

Fig. 27.3 (a) Lindemann-burr in correct position on the lingual side. (b) Lingual osteotomy

located nerves and vessels (Figs. 27.3, 27.4 and

27.5).
A blunt, 90° curved nerve hook can be used
for reliable identification of the lingula before the
channel retractor is inserted. The channel retrac-
tor should lie in contact with the lingual side of
the ascending mandibular ramus in such a way
that it is turned 45° caudally. In this position, the
lingula is protected and at the same time the lin-
gual soft tissues are kept out (Fig. 27.5). The
inclination of the Lindemann is decisive. It is rec-
ommended to align the drilling plane parallel to
the occlusal plane of the mandible (Fig. 27.3).
The short lingual osteotomy is made with the
long Lindemann burr at a depth of 1.5–2 mm as
described by Epker (SLO) [1, 3]. Caution is
required in the middle part of the ascending man-
dibular ramus, where the bone can be very thin; it
is essential to avoid separating the condylar pro-
cess from the proximal segment.
Now the buccal cortical bone cut is made,
Fig. 27.4 Satinsky-DeBakey clamp in correct position. which is usually placed in the region of the sec-
Connecting osteotomy can be performed before the verti- ond molar or distally (short osteotomy). Here, the
cal buccal osteotomy acc. to Dal Pont cortical bone should be completely cut through to
27 Sagittal Split and Mandibular Setback 243

Fig. 27.5 Channel retractor (Dumbach retractor) placed

on the lingual side to open the lingual tunnel
Fig. 27.6 Mandibular split with spreader and Smith
separator

ensure easy splitting. A connection between the

two cortical incisions is now marked with an on the form of the mandible also straight chisels
excavator drill, which is then completed with a and osteotomes can be used.
short Lindemann or fissure burr. This bone cut After bilateral osteotomy the tooth-bearing distal
can also be made without predrilling in soft bone segment is now gently mobilized and freely mov-
types and should safely cut through the cortex able. The osteotomized jaw can be relocated dor-
along the internal aspect of the buccal cortex. The sally against little resistance. Detaching the
two cortical cuts can also be connected directly masseterico-pterygoidal muscle loop is not recom-
with the saw. mended. Excess bone on the bucco-lateral side of the
Special attention must be paid to the complete proximal segment should be removed if necessary.
osteotomy with the drill at the transition of the The instruments used to split the jaw angle, or
horizontal and buccal osteotomy to the connect- the ascending branch of the lower jaw, are chosen
ing line. No cortical bridges must remain here. It differently by each surgeon. After making the
is also recommended to carefully weaken the connecting osteotomy between the lingual and
very solid mandibular base at the lower edge of buccal osteotomy, chisels and osteotomes are
the buccal osteotomy. preferred. The order of the instruments men-
After the buccal edge of the lower jaw is also tioned seems to be more in keeping with habit.
protected buccally by a channel retractor we then Freihofer [6] recommended laterally curved
split the mandible with thin, slightly laterally chisels that can slide along the buccal cortex to
bent chisels to about the middle. Then wide deepen the connecting osteotomy. In many oper-
osteotomes can be used with the help of the ation theaters this instrument is called Epker
spreader to widen the gap and finally break the osteotome. The splitting itself can be performed
remaining bony connection (Fig. 27.6). with straight osteotomes or a bone spreader or a
While the osteotomy gap is widened, it is usu- combination of both. Which instrument is used
ally possible to identify the course of the man- also has to do with the length of the connecting
dibular canal. This lies mostly in the distal osteotomy line.
tooth-bearing segment. If this is successful, the In the classic situation of sagittal splitting
osteotome can also be inserted deeper under the according to Dal Pont, the spreader can be
protection of the IAN in order to split bony con- inserted close to the buccal osteotomy from
nections below the course of the canal. Depending above and anteriorly, and then the osteotomes can
244 P. Kessler et al.

be used to complete the splitting first buccally 2 Conclusions

and then lingually after identification of the
course of the IAN. The correction of mandibular prognathism is the
If a short connecting osteotomy between the domain of the bilateral sagittal split osteotomy—
lingual and buccal osteotomy is required, chisels BSSO. No surgical technique can be applied
and osteotomes are more likely to be used, as the more universally. The characteristics of this tech-
spreader is less able to expand compact bone. In nique must be understood in order to safely apply
this case, more energy is required for splitting. the technique. Even with the most careful
Wire loops of 0.4 or 0.5 mm thick steel wire are approach, the mandibular split remains a sponta-
used for intermaxillary fixation. These are looped neous fracture that can permanently damage the
over existing Kobayashi ligature hooks, crimpable function of the IAN.
hooks, or IMF screws. In any case, a safe and sta-
ble IMF must be ensured to avoid displacement of
the occlusion during osteosynthesis. Laterally, References
overlapping of cortical bone may occur. Excess
bone should be removed. 1. Epker BN. Vascular considerations in orthognathic
surgery. I. Mandibular osteotomies. Oral Surg Oral
With symmetrical initial conditions, less dis- Med Oral Pathol. 1984;57(5):467–72.
turbing influences on the proximal segment can 2. Böckmann R, Schön P, Neuking K, Meyns J, Kessler
be expected than with asymmetrical ones with P, Eggeler G. In vitro comparison of the sagittal split
horizontal deviation of the mandible. If rota- osteotomy with and without inferior border osteotomy.
J Oral Maxillofac Surg. 2015;73(2):316–23.
tional and translational movements are added to 3. Epker BN. Modification in the sagittal osteotomy of
the sagittal movement of the mandible, this can the mandible. J Oral Surg. 1977;35:157–9.
lead to an in- and/or outward displacement of the 4. Wolford LM, Davis WM. The mandibular inferior bor-
temporomandibular condyle (proximal segment). der split: a modification in the sagittal split ramus oste-
otomy associated with the presence or absence of third
This can lead to temporomandibular joint dys- molars. J Oral Maxillofac Surg. 2001;59(8):92–4.
function and functional restrictions of the lower 5. Hunsuck EE. A modified intraoral sagittal splitting
jaw movements. Part VI describes the procedure technic for correction of mandibular prognathism. J
for asymmetrically shaped mandibles. Oral Surg. 1968;26(4):250–3.
6. Freihofer HP. Probleme der Behandlung der
Progenie durch sagittale Spaltung der aufsteigen-
den Unterkieferäste. Schweiz Mschr Zahnheilk.
Note 1976;86:679.
The three moments of BSSO where nerve
damage can occur are:
• Preparation of the lingual tunnel.
• Splitting the lower jaw.
• Crushing or direct nerve injury during
osteosynthesis, especially when com-
pression or positional screws are used.
 Special Surgical Aspects
in Mandibular Setback
28
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1 Conclusions  246

Abstract Modifications and surgical alternatives ·

Intraoral vertical ramus osteotomy—IVRO ·
Mandibular repositioning can lead to interfer-
Inverted L osteotomy · Temporomandibular
ence between the proximal and distal man-
joint—TMJ
dibular segments depending on the
displacement distance and the shape of the
After repositioning the mandible and adjusting
mandible. These interferences must be recog-
the occlusion, the mandible is usually stabilized
nized and corrected to avoid temporomandib-
with functionally stable 2.0 mm osteosynthesis
ular joint displacements.
plates. The bone overlap laterally caused by the
repositioning should but does not always have
Keywords
to be removed. This decision depends, among
Class III relation · Class III malocclusion · other things, on the posterior dislocation dis-
Mandibular prognathism · Maxillary retru- tance of the mandible. If the bone overlap leads
sion · Indications for mandibular setback · to a dislocation of the proximal segment sup-
Sagittal splitting · BSSO · Mandibular porting the temporomandibular joint (TMJ), a
setback · Special surgical aspects in mandibu- correction must be performed to relieve the
lar setback · Mandibular segment osteotomy · TMJ. In most situations, a moderate correction
of the excess bone is sufficient to adapt the two
segments in such a way that the bone gap is not
too large when the mandible is repositioned
P. Kessler (*) · S. A. N. Lie (Fig. 28.1).
Department of Cranio-Maxillofacial Surgery, Gaps of up to 5 mm can be accepted. If the dis-
Maastricht University Medical Center, tance in the area of the mandibular split is too
Maastricht, The Netherlands
e-mail: [email protected]; [email protected]
large, slight internal rotation of both proximal
segments can lead to a satisfactory relation of the
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of
split segments, so that a safe osseous regeneration
Cranio-Maxillofacial Surgery, Lucerne, Switzerland can be guaranteed without damaging the TMJ.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 245
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_28
246 P. Kessler et al.

a b

Fig. 28.1 (a) Grasping the proximal segment for reduction of bone overlap (b) Perfect adaptation of both segments
before osteosynthesis

If possible, transfacial access to the surgical site sion. This means that no forces should act on the
in orthognathic surgery should be avoided. The TMJ during osteosynthesis when correcting class
use of angulated drill hand pieces allows osteosyn- III mandibles.
thesis of the proximal segment while bypassing a A pre-fixation of the lateral segment with the
transbuccal approach. The angulated hand pieces help of an osteosynthesis plate, which must be
can also be used for manual screw fixation. guided from the lateral mandibular segment to a
The TMJ should not be pushed deeply into suitable fixation point on the upper jaw, has become
the articular fossa when the lower jaw is reposi- superfluous in the age of digital planning and the
tioned. After the split and sufficient mobilization possibility of using individualized implants.
of the segments, the proximal segments can be
grasped transorally with the Kocher clamp and
carefully mobilized under manual-digital control 1 Conclusions
preauricularly to prevent unintentional disloca-
tion of the TMJ during the surgery or while posi- Three-dimensional planning of orthognathic pro-
tioning the mandible in intermaxillary fixation. cedures facilitates the choice of surgical tech-
In class III cases the TMJ should be set in the nique and a realistic approach. This helps to
position that corresponds to the habitual occlu- avoid intra- and postoperative problems.
 Mandibular Excess – Modifications
and Surgical Alternatives
29
Peter Kessler, Nicolas Hardt, and Suen An Nynke Lie

Contents
1 Conclusion  248
References  248

Abstract Keywords

Alternatives to BSSO are osteotomies in the Class III relation · Class III malocclusion ·
region of the ascending mandibular branch. Mandibular prognathism · Maxillary retru-
The intraoral vertical ramus osteotomy sion · Indications for mandibular setback ·
(IVRO) and the inverted L osteotomy are Sagittal splitting · BSSO - SSRO ·
alternative procedures for mandibular setback Mandibular setback · Special surgical aspects
(Yamauchi et al. Oral Surg Oral Med Oral in mandibular setback · Mandibular segment
Pathol Oral Radiol Endod 104:747–751, 2007; osteotomy · Modifications and surgical
Jung et al, Br J Oral Maxillofac Surg 52:866– alternatives · Intraoral vertical ramus oste-
867, 2014). otomy—IVRO · Inverted L-osteotomy

Computer-based planning is of great help when

planning symmetrical or asymmetrical setback
operations in mandibular prognathism, as it
clearly shows the sagittal and rotational move-
ments of the distal tooth-bearing mandibular seg-
ment in relation to the proximal mandibular
P. Kessler (*) · S. A. N. Lie segment (TMJ) and provides very useful infor-
Department of Cranio-Maxillofacial Surgery, mation when selecting the appropriate splitting
Maastricht University Medical Center,
Maastricht, The Netherlands
technique.
e-mail: [email protected]; [email protected] In addition, individually manufactured osteo-
N. Hardt (*)
synthesis plates can transmit the preoperatively
Kantonsspital Lucerne, Clinic and Policlinic of determined optimal surgical solution to the oper-
Cranio-Maxillofacial Surgery, Lucerne, Switzerland ating room.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 247
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_29
248 P. Kessler et al.

Alternatively, a functionally stable osteosyn- 1 Conclusion

thesis can be deliberately avoided in order to give
the proximal segment (TMJ) more freedom to The establishment of alternative splitting pro-
rotate back into a functionally physiological cedures resulted from the development in
position when the intraoral vertical ramus oste- orthognathic surgery per se. The procedures of
otomy (IVRO) is applied (see: Part VII) [1, 2]. vertical mandibular splitting are older than the
However, this requires a long-lasting inter- BSSO and are the result of the BSSO, which
maxillary fixation (IMF), which in turn requires sometimes cannot be applied perfectly.
intensive cooperation from the patient [3]. This, Nevertheless, the BSSO remains the procedure
however, means that the decisive advantage of of first choice in mandibular orthognathic
rigid internal fixation avoid is abandoned. surgery.

References
Note
• SSRO/BSSO with short lingual osteot- 1. Yamauchi K, Takenobu T, Takahashi T. Condylar luxa-
omy—SLO—acc. to Epker is the stan- tion following bilateral intraoral vertical ramus oste-
dard technique in correction of otomy. Oral Surg Oral Med Oral Pathol Oral Radiol
symmetric/asymmetric mandibular Endod. 2007;104:747–51.
2. Jung HD, Kim SY, Park HS, Jung YS. Modification
prognathism. of intraoral vertical ramus osteotomy. Br J Oral
• Use 3D planning to avoid negative Maxillofac Surg. 2014;52:866–7.
effects on the TMJ structures due to 3. Ohba S, Nakao N, Kawasaki T, Miura K, Minamizato
excessive TMJ rotation/dislocation. T, Koga T, Yoshida N, Asahina I. Skeletal stability
after sagittal spit ramus osteotomy with physiological
• Asymmetric mandibular prognathism is positioning in patients with skeletal mandibula prog-
challenging and needs more attention nathism and facial asymmetry. Br J Oral Maxillofac
during planning and surgery. Surg. 2016;54:920–6.
 Part VI
Asymmetries, Vertical and Horizontal
Rotation, Mandibular Flaring - Surgical
Techniques
 Introduction - Asymmetries,
Vertical and Horizontal Rotation,
30
Mandibular Flaring - Surgical
Techniques

Peter Kessler and Kensuke Yamauchi

Contents
1 Conclusion  252
References  252

Abstract The frequency of facial asymmetries is high

because a complete symmetry of the right and
No face is absolutely symmetrical. Therefore,
left half of the face can rarely be found. A dis-
because of the dentition conditions in the
tinction is made between structural and physi-
upper jaw and the result of the orthodontic
ological asymmetries and genetically
pretreatment, the sagittal forward or backward
determined or acquired asymmetries (trauma).
displacement of the lower jaw always includes
The cause of an asymmetry of the jaws can be
a rotational component. Vertical growth differ-
in the upper or lower jaw, in both jaws, or also
ences in the area of the mandibular corpus
in the area of the skull base. In addition to a
must be taken into account. Rotation of the
bony cause, changes in the number of teeth,
distal mandibular segment can lead to unfa-
tooth loss, and other dental causes could also
vorable positional changes of the proximal
be possible. In addition to asymmetries that are
segment. Three-dimensional complexities can
skeletal or dental in origin, there are a variety
be predicted well using three-dimensional
of asymmetries that can be caused by volume
planning tools. If necessary, the surgical tech-
differences in the surrounding soft tissues or
nique must be adapted and supplemented by
even by space-consuming processes.
additional procedures to obtain a functionally
and esthetically satisfactory result.
Keywords

P. Kessler (*) Vertical and horizontal mandibular rotation ·

Department of Cranio-Maxillofacial Surgery, Sagittal split · Mandibular rotation · Special
Maastricht University Medical Center, surgical aspects · Hazards and support
Maastricht, The Netherlands
e-mail: [email protected] measures · Surgical modifications ·
Alternatives · Inverted vertical ramus
K. Yamauchi
Department of Oral & Maxillofacial Surgery, Tohoku osteotomy—IVRO · Temporo-mandibular
University Sendai, Sendai, Miyagi, Japan joint—TMJ · Flaring

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 251
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
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252 P. Kessler and K. Yamauchi

a b c

Fig. 30.1 a–c adapted from Reichenbach 1952 (a)sym- are indicating the vector of deficiency or overgrowth lead-
metrical form of the mandible, (b) mandibular asymmetry ing to a rotational component. ©Copyright Keisuke
due to hypoplasia on the right, (c) mandibular asymmetry Koyama 2020. All rights reserved
due to hyperplasia/hypertrophy on the right side. Arrows

In the case of asymmetries that only affect the From what has been said it can be deduced that
mandible or are only determined by asymmetric there can be corresponding deviations that have
mandibular growth or form, unilateral condylar their cause in unilateral growth deficits up to struc-
hyper- or hypoplasia must be mentioned as a spe- tural growth deficits, as for example presented in
cial case, as these disorders can be related to the Pruzansky classification. Hypodontia and anky-
autonomous growth disorders. losis of teeth or groups of teeth may be present [2].
A clinically relevant classification of condylar Genetically caused syndromic changes affect-
hyperplasia or mandibular asymmetry with uni- ing the development and growth of the mandible
lateral involvement was published by [1]. Three and/or the TMJ (first pharyngeal arch) are not
categories are distinguished: explicitly discussed here. Nevertheless, d­ iagnostics,
The hemimandibular hyperplasia, the hemi- analysis, planning, and therapeutic options can be
mandibular elongation, and a mixed form of applied to these patients in most cases.
both first mentioned deviations. Hemimandibular
hyperplasia is described as a vertical growth
excess in the ascending branch of the jaw or 1 Conclusion
condyle, with the lower jaw showing downward
tilting with an ipsilateral open bite, since the The evaluation of facial asymmetry requires clin-
growth rate does not allow for dental compensa- ical and radiological findings. Different types of
tion. A cross bite on the opposite side or chin excess or deficient growth can lead to three-­
deviation is not observed.This is also seen with dimensional asymmetries.
hemimandibular elongation: Cross bite on the
opposite, unaffected side of the jaw, midline
shift dental and skeletal. The third form is a References
hybrid of excessive unilateral vertical and hori-
zontal growth (Fig. 30.1). 1. Obwegeser HL, Makek MS. Hemimandibular hyper-
plasia—hemimandibular elongation. J Maxillofac
Since no diagnostic or therapeutic standard has Surg. 1986;14(4):183–208.
yet been defined for these growth-related man- 2. Pruzansky S. Not all dwarfed mandibles are alike.
dibular asymmetries, all mandibular asymmetries Birth Defects. 1969;1:120–9.
must be analyzed with extreme caution in order to
find the right therapeutic timing and approach.
 Diagnosis in Mandibular
Asymmetries, Vertical
31
and Horizontal Rotation

Peter Kessler and Kensuke Yamauchi

Contents
1 Photographic and Clinical Analysis  253
2 The Further Clinical Analysis Must Comprise  254
3 Radiological Diagnosis  254
4 The Further Radiological Analysis Must Comprise  255
5 Conclusion  255
References  255

Abstract Keywords

The following elements must be considered

Facial asymmetry · Vertical and horizontal
when assessing hemi- or bilateral mandibular
mandibular rotation · Sagittal split—BSSO ·
asymmetry morphologically:
Mandibular rotation · Surgical alternatives ·
• Mandible length. Inverted vertical ramus osteotomy—IVRO ·
• Lower jaw shape and size. Temporomandibular joint—TMJ · Flaring
• Volume of the mandible/hemimandibles.

1 Photographic and Clinical

Analysis

P. Kessler (*) The bipupillary, bizygomatic, bigonial, and men-

Department of Cranio-Maxillofacial Surgery, tal planes and the stomion must be marked. These
Maastricht University Medical Center, planes are placed in relation to a center line
Maastricht, The Netherlands
e-mail: [email protected]
through the median of the face—facial midline—
and to each other to detect deviations from paral-
K. Yamauchi
Department of Oral & Maxillofacial Surgery, Tohoku
lelism and transverse deviations from the midline
University Sendai, Sendai, Miyagi, Japan (Fig. 31.1).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 253
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
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254 P. Kessler and K. Yamauchi

3 Radiological Diagnosis

Panoramic and anterior-posterior two-­dimensional

radiographs are only useful for screening, but not
for the quantitative evaluation, classification, and
diagnosis of patients with hemimandibular asym-
metry affecting the face [1].

• Quantification of asymmetry is essential for

the evaluation of the degree of deformity.
• Quantification is essential for objectification
of the deviation and planning.
• Quantification enables a classification of
severity.
• Quantification is essential for objective moni-
toring and follow-up.

The only objective data collection option for

planning a correction of facial asymmetries is
provided by radiological procedures that gener-
ate three-dimensional data sets and images:
Fig. 31.1 Patient with mild mandibular hyperplasia on
CBCT, MSCT, and MRI. For the purposes of
the right and deviation of the chin point
orthognathic surgery, DICOM (Digital Imaging
and Communications in Medicine) data sets of
2 The Further Clinical Analysis the -CBCT are perfectly sufficient. They are
Must Comprise required for the computer-based planning of sur-
gical correction.
• Bite position: Class I, II, or III in combination In almost all forms of mandibular hyper- or
with transverse/transverse-vertical deviation. hypoplasia, changes in volume or size in the area
• Cross bite ipsi- or contralaterally. of the condylar heads are noticeable. Particularly
• Lingual/buccal tilting of teeth (premolars, in the case of enlarged condyles, any doubt about
molars). the presence of autonomic growth disturbances
• Frontal and/or lateral open bite. in the collum-condylar region should be excluded
• Dental midline deviation. before surgical correction [1].
• Skeletal midline deviation. This means that further radiological proce-
• Midline deviation of the chin. dures such as SPECT (Single-Photon Emission
• Participation/involvement of the maxilla: size, Tomography) may be required to rule out active
form, skull-related position. growth in the condylar region.
• Involvement of the midface (hemifacial asym- If this is not possible, serial dental casts and
metry possible). photographic documentation of the face as
• Participation of the orbit/−s (hemifacial non-­invasive procedures are the only way to
growth disturbance). document changes in facial asymmetry over
• Deviation of the nose. time [1, 2].
31 Diagnosis in Mandibular Asymmetries, Vertical and Horizontal Rotation 255

4 The Further Radiological correct planning in general. In the time before the
Analysis Must Comprise introduction of these techniques, planning based
on 2D X-ray images in two or more planes, patient
• Panoramic X-ray: Evaluation only. photographs, and plaster models was the standard.
(a) Shape and size of the condyles. These methods never allowed for exact planning.
(b) Length of the condylar process. Therefore, documentation, analysis, and planning
(c) Dental and/or skeletal midline deviation. with 3D techniques are an indispensable prerequi-
• CBCT: Measurement [3]. site for surgical therapy today [1, 3].
(a) Mark the SN-plane and C-point: deepest
point of the semilunar/sigmoid notch.
(b) Mark Superior Condyle: most cranial
point of the condyle. 5 Conclusion
(c) Draw parallels between SN-plane
and Superior Condyle and C-point: height Even comprehensive diagnostics cannot always
of the condyle measured between paral- assign the cause of facial asymmetry, or asym-
lels through Superior Condyle and metry in the mandibular region, to a growth
C-point. excess or growth deficit. Nevertheless, asymme-
(d) C-Gonion axis: height of the ascending tries must be carefully considered during
ramus (estimation). planning.
(e) Gonion-Menton/Gnathion axis: length of
the mandibular body (estimation).
(f) Midline axis through N (Nasion)–ANS References
(anterior nasal spine)–Sym (mandibular
symphysis above the mental tubercle): 1. Nolte JW, Karssemakers LH, Grootendorst DC,
Tuinzing DB, Becking AG. Panoramic imaging is not
frontal facial asymmetry.
suitable for quantitative evaluation, classification, and
(g) Mandibular angle defined by Ar follow up in unilateral condylar hyperplasia. Br J Oral
(Articulare) -Gonion axis and Gonion- Maxillofac Surg. 2015;53(5):446–50.
Menton/Gnathion axis. 2. Karssemakers LH, Raijmakers PG, Nolte JW, Tuinzing
DB, Becking AG. Interobserver variation of single-­
photon emission computed tomography bone scans
Based on 3D analysis, further planes and vol- in patients evaluated for unilateral condylar hyperac-
umes can be calculated [3]. The volume of the tivity. Oral Surg Oral Med Oral Pathol Oral Radiol.
condylar process, the ascending ramus, and the 2013;115(3):399–405.
3. Nolte JW, Verhoeven TJ, Schreurs R, Bergé
mandibular body can be assessed per side and
SJ, Karssemakers LH, Becking AG, Maal TJ.
compared. 3-Dimensional CBCT analysis of mandibular
Three-dimensional planning with the help of asymmetry in unilateral condylar hyperplasia. J
suitable computer programs is the prerequisite for Craniomaxillofac Surg. 2016;44(12):1970–6.
 Surgical Correction in Mandibular
Asymmetry
32
Kensuke Yamauchi and Peter Kessler

Contents
1 Chin osteotomies and Corrections of the Mandibular Rim 258
2 Osteotomies in the Mandibular Angle 259
3 Unilateral Sagittal Split Osteotomies—USSO 259
4 Mandibular Asymmetry in Prognathism 260
5 Mandibular Asymmetry in orthognathism 261
6 Bilateral Sagittal Split Osteotomies—BSSO 261
7 Rotation and Side Shift of the TMJ 262
8 Flaring 263
9 Osteotomies in the Ascending Ramus—IVRO 265
9.1 Surgical Technique 265
10 Postoperative Management 271
11 Which Criteria Are Decisive in the Choice of Surgical Technique? 271
12 Conclusion 272
References 272

Abstract

A suitable therapy must pursue two goals:

• Correction of asymmetry.
• Elimination of the progressive component of
K. Yamauchi
Department of Oral & Maxillofacial Surgery, Tohoku the disease.
University Sendai, Sendai, Miyagi, Japan
P. Kessler (*)
Department of Cranio-Maxillofacial Surgery, Keywords
Maastricht University Medical Center, Maastricht,
The Netherlands Vertical and horizontal mandibular rotation ·
e-mail: [email protected]
Sagittal split - Unilateral and bilateral sagittal
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 257
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_32
258 K. Yamauchi and P. Kessler

split osteotomy USSO/BSSO - Sagittal split The choice of the osteotomy site will therefore
ramus osteotomy SSRO · Mandibular rotation depend essentially on the severity of the facial
· Special surgical aspects · Surgical modifica- asymmetry and the corresponding laterognathia,
tions · Alternatives · Chin osteotomy · which is usually associated with an occlusion
Inverted vertical ramus osteotomy—IVRO · disorder. The main methods affecting the mandi-
Temporomandibular joint—TMJ · Flaring ble are described here.

1 Chin osteotomies
It is important to make a distinction between and Corrections
asymmetry and cause of asymmetry or, if neces- of the Mandibular Rim
sary, to combine them in the analysis. An expec-
tative behavior can lead to a strong worsening of Mandibular asymmetry without occlusion disor-
the asymmetry, which is accordingly more dif- der: correction by genioplasty with lateral dis-
ficult to correct. Since an end to autonomous placement and vertical correction (Fig. 32.1).
growth cannot be predicted, interventions on the Possible additional corrections at the lower mar-
temporomandibular joint (TMJ) may also be gin of the mandible. Augmentation with tissue
necessary or their combination with classical transplants—bone, cartilage—is possible, also
elements of orthognathic surgery. Interventions the implantation of allogenic implants up to
on the condyle are not described here [1–6]. patient-specific implants.
Especially in cases of laterognathism, which Part IX discusses the technique of genioplasty
can be localized in the entire viscerocranium, the in detail. In addition to the possibilities described
choice of the site for the osteotomy is difficult there, the lateral chin displacement must be men-
and requires great care and experience. The indi- tioned in laterognathism and mandibular
cation for corrective osteotomy also depends to a asymmetry.
great extent on the etiology of the lateral devia-
tion of the corresponding parts of the facial
skeleton.
The general rule for the selection of the oste-
otomy site or the osteotomy sites is that the
more asymmetric the face is, i.e., the more pro-
nounced the lateral shift is, the more osteoto-
mies are required to restore facial symmetry
and occlusion. For example, a lateral displace-
ment of the chin can be corrected without alter-
ing the occlusion by simply shifting the chin
margin.
On the other hand, asymmetry caused by mal-
formation of the joint and ascending ramus requires
osteotomies on the affected and unaffected side. In
most cases, osteotomies must also be performed in
the upper jaw to achieve facial symmetry. On this
basis, harmonious occlusion is easier to achieve.
The same applies to the overdevelopment/exces-
sive growth of a joint or an entire side of the man- Fig. 32.1 Genioplasty. Shifting the chin point to correct
dible, which can usually also only be corrected by a mandibular midline deviation. ©Copyright Keisuke
multiple osteotomies [7]. Koyama 2020. All rights reserved
32 Surgical Correction in Mandibular Asymmetry 259

2 Osteotomies in the Mandibular 3 Unilateral Sagittal Split

Angle Osteotomies—USSO

Mandibular osteotomies to correct laterogna- When planning the operation, the focus must be
thism can be performed unilaterally in the region on the midline of the face, the midline of the rows
of the temporomandibular joint, the ascending of teeth, and the chin (Menton = Me). The greater
mandibular ramus or the jaw angle as well as the horizontal deviation of the mandible, the
bilaterally, using various surgical techniques. more dislocation/rotation of the proximal seg-
Distraction treatment may also be indicated. ment/TMJ on the side facing away from the
Standard procedures are the BSSO/USSO (bilat- asymmetry can be expected, as the dorsal dis-
eral/unilateral sagittal split osteotomy) and sec- placement of the distal segment (mandible) is
ondarily IVRO, the inverted ramus osteotomy. greater (Figs. 32.2 and 32.3).

a b

Fig. 32.2 (a) SSRO (sagittal split ramus osteotomy) on the left for correction of a mild mandibular asymmetry with (b)
setback of the mandible on the left side. ©Copyright Keisuke Koyama 2020. All rights reserved
260 K. Yamauchi and P. Kessler

a b

Fig. 32.3 (a) SSRO for correction of a mild mandibular asymmetry with (b) setback of the mandible on the left side
and simultaneous chin correction. ©Copyright Keisuke Koyama 2020. All rights reserved

4 Mandibular Asymmetry
in Prognathism

The greater the horizontal deviation of the man-

dible, the more dislocation of the proximal seg-
ment on the side facing away from the asymmetry
can be expected, as the posterior displacement of
the distal mandibular segment is greater and must
be included in the correction of the asymmetry
(Fig. 32.4).
The rotational adaptability in the TMJ com-
plex consisting of condyle and fossa is limited
and amounts to only a few degrees (changes in
the Bennett angle). Depending on the selected
osteotomy technique, flaring may occur on the
affected side.

Fig. 32.4 SSRO for correction of mandibular asymmetry

with rotation of the mandible on the left side. Risk of joint
rotation due to dislocation of the proximal segment. Risk
of flaring. ©Copyright Keisuke Koyama 2020. All rights
reserved
32 Surgical Correction in Mandibular Asymmetry 261

5 Mandibular Asymmetry the center line of the chin. This may still be dis-
in orthognathism placed after the occlusion has been set, so that a
genioplasty may also be required (Figs. 32.5 and
Due to the fact that the rotational component is 32.6).
largely eliminated, bilateral osteotomy is usually
required in laterognathic cases with transverse
displacement of the mandible. In transverse den-
tal orthognathia, a chin correction is often suffi-
cient, possibly in combination with a correction
of the mandibular base.

6 Bilateral Sagittal Split

Osteotomies—BSSO

A bilateral osteotomy in the area of the ascending

ramus or the mandibular angle is not only used to
correct mandibular pro- or retrognathism, but
may also be indicated in the presence of laterog-
nathism. The surgical technique is the same as
described in the Parts III, IV, and V extensively.
If the mandible is displaced laterally at the
same time, it is important to note that on the lon-
ger side of the mandible the overlapping buccal
cortical bone must be shortened (Fig. 32.6).
Fig. 32.6 BSSO and correction of mandibular asymme-
When adjusting the occlusion, it is important to try including genioplasty. ©Copyright Keisuke Koyama
observe the center line of the face and thus also 2020. All rights reserved

a b

Fig. 32.5 (a) BSSO and correction of mandibular asymmetry with (b) buccal cortical ostectomy on the hyperplastic
left side. ©Copyright Keisuke Koyama 2020. All rights reserved
262 K. Yamauchi and P. Kessler

Of course other types of osteotomy in the 7 Rotation and Side Shift

ascending ramus, such as the intraoral vertical of the TMJ
(IVRO) or oblique ramus osteotomy, can also be
used. The disadvantage of this method, however, The rotational movements of the temporoman-
is that the overlapping bone surfaces, especially dibular joint head can be anticipated by comput-
on the shorter mandibular side, are small, which erized planning, but not specified exactly in every
delays the bony consolidation of the fragments. case. In addition to rotational movements, lateral
In the presence of a laterognathism with man- displacements or canting of the ascending man-
dibular retrognathia, as in condylar hypoplasia dibular ramus (proximal segment) can also lead
e.g., the advancement of the shorter mandibular to displacement/tilting of the TMJ (Fig. 32.7).
side can be used to correct the midline at the A further complicating factor is that rigid
same time. osteosynthesis may fix the proximal mandibular
Depending on the degree of retrognathism an segment in a functionally unfavorable position. If
advancement can be necessary on both sides. On the condylar head cannot be seated in a physio-
the shorter mandibular side a Dal Pont osteotomy logically ideal position, abnormal movement of
with a long bone overlap is indicated. On the the condyle in the fossa will result. This can lead
opposite side a short SSO should be preferred to to temporomandibular joint disorders, TMJ
avoid negative rotational effects on the TMJ. resorption, and relapse.

Fig. 32.7 The long overlap in mandibular split according undesirable pivot points with dislocation effects on the
to Dal Pont can lead to a rotational component on the TMJ. ©Copyright Keisuke Koyama 2020. All rights
TMJ—proximal segment—depending on the direction of reserved
mandibular rotation in the distal segment. Circled in blue
32 Surgical Correction in Mandibular Asymmetry 263

Rotational influences on the temporoman-

dibular joint can be displayed well with the
help of 3D planning. To reduce negative influ-
ences on the TMJ, a suitable splitting technique
must then be simulated and implemented, if
necessary, to protect the joints. With the help of
CAD/CAM manufactured splints and possibly
patient-­specific implants (plates and screws),
the planning can be transferred to the OR, even
without navigation or intraoperative radiologi-
cal control.
What cannot be predicted, however, is how the
mandible will break in the sagittal splitting pro-
cedure. This must be checked and corrected
intraoperatively, if splints or osteosynthesis
plates do not fit properly. Negative influences on
the TMJ by rotation or dislocation increase the
risk of a skeletal recurrence [8].

8 Flaring

When IVRO is used in setback surgery, there is a

greater overlap of the proximal and distal seg-
ments, since this type of osteotomy does not
allow for any variation. This means that unfavor-
Fig. 32.8 Consequences of mandibular body rotation
able effects can also be exerted on the TMJ in the (distal segment) to both sides with dislocation of the prox-
IVRO. In addition, stripping the pterygo-­ imal segment and TMJ rotation in SSRO. Compare Fig.
masseteric muscle loop releases the proximal 32.8 with Fig. 32.17 IVRO. ©Copyright Keisuke Koyama
segment from its muscularly determined position 2020. All rights reserved
and thus exposes the distal segment to move-
ments caused by surgery and displacement, This maneuver is delicate and can lead to an
which can lead to serious dislocations in the TMJ increased risk of injury to the surrounding soft
(Figs. 32.8 and 32.17). tissues, including the lingual and inferior alveolar
In the SSRO, the pterygo-masseteric muscle nerves. Bone healing in the split region may also
loop, which is not detached, provides additional be at risk if the procedure is too radical and/or the
stability for the TMJ against rotational influ- osteosynthetic stabilization is insufficient.
ences. However, when using the SSRO, a long In the case of an asymmetrical mandible shape
split similar to the Dal Pont variant can also cause or asymmetrical horizontal mandibular position,
interference between the proximal and distal the use of the IVRO can lead to less interference
segments. than the SSRO technique.
If this is recognized intraoperatively, a verti- The SSRO is the standard technique also from
cal fracture of the lingually overlapping bone the point of view of osteosynthetic stabilization,
segment on the distal segment—mandibular which is easier to perform with an SSRO than
body—may be necessary after splitting in order with the IVRO. A short bone overlap should be
to exclude disturbing rotational influences on attempted to avoid the risk of dislocation or even
the position of the proximal segment (Fig. 32.9). luxation of the TMJ (Fig. 32.10).
264 K. Yamauchi and P. Kessler

a b c

Fig. 32.9 Long bone overlap and possible osteotomy— cates osteotomy/fracture for correction of flaring (c)
dotted line—to avoid flaring or rotation/dislocation of the Medial rotation of the proximal segment will result in an
proximal segment (a) Illustration rotational effects on the outward rotation of the TMJ. ©Copyright Keisuke
TMJ (b) Lateral rotation of the proximal segment will Koyama 2020. All rights reserved
result in an inward rotation of the TMJ. Dotted line indi-
32 Surgical Correction in Mandibular Asymmetry 265

Fig. 32.10 Short bone overlap with oblique buccal osteotomy as alternative to the Dal Pont procedure to avoid or
reduce long bone overlap. ©Copyright Keisuke Koyama 2020. All rights reserved

9 Osteotomies in the Ascending is positioned to be able to close the wound with

Ramus—IVRO intermaxillary fixation at the end of operation. The
periosteum is incised and reflected from the lateral
9.1 Surgical Technique surface of the mandible only, extending from sig-
moid notch to the antegonial notch [9–11].
As described in Part V the mucosal incision is posi- At the anterior portion of the ramus and tem-
tioned over the external oblique line and extended poralis tendon is stripped off the coronoid process
from the level of the occlusal plane anteriorly and to identify clearly the anterior aspect of the sig-
inferiorly approximately about 3 cm. This incision moid notch even at the level of maxillary occlusal
266 K. Yamauchi and P. Kessler

plane height. Channel retractors are positioned in After confirming the starting point, the oste-
the sigmoid notch/posterior rim of the ascending otomy is completed by using an angulated
mandibular ramus and the antegonial notch, then ­oscillating saw from the sigmoid to the antego-
almost whole lateral surface of the ramus can be nial notches.
seen by reflecting with the retractors. Care has to be taken at the anterior and poste-
The initial point of the osteotomy is located rior edge to prevent the injury to the maxillary
just posterior to the opening of the mandibular and facial artery by poor protection with the
foramen and the antilingula prominence is the retractors. So the surgeon has to check the rela-
orientation point at lateral surface of the ramus tionship between osteotomy line and the retrac-
(Fig. 32.11). See also Part III BSSO Relevant tors to protect the soft tissue around the notches.
Clinical and Topographic Anatomy. Ultrasonic bone cutting device such as Piezo sur-
However, some cases with flat surface do not gery also helps to decrease the risk of damage the
provide sufficient prominence. The initial point is soft tissues.
planned at 7 or 8 mm anteriorly from the poste- After completing the osteotomy, the proximal
rior border of the ramus (Fig. 32.12). segment is mobilized and displaced laterally to
check the completeness of the osteotomy. To
mobilize the proximal segment, only minimal
periosteum is dissected off in the region of
the medial pterygoid muscle (Fig. 32.13).
Depending on the rotational movement, the prox-
imal and distal segments may overlap or not.
At the contralateral side a short SSRO should
be preferred for rigid osteosynthesis. Which side

Fig. 32.11 Construction of the antilingula to determine

the vertical osteotomy. ©Copyright Keisuke Koyama
2020. All rights reserved

Fig. 32.12 Ideal vertical osteotomy line about 7-8 mm

anterior to the posterior border of the ascending ramus, Fig. 32.13 Mobilization of the proximal segment and
but dorsally from the antilingula. ©Copyright Keisuke dissection of the medial pterygoid muscle. ©Copyright
Koyama 2020. All rights reserved Keisuke Koyama 2020. All rights reserved
32 Surgical Correction in Mandibular Asymmetry 267

can be treated with IVRO and which side with a in IVRO may block the backward movement to
conventional SSRO is determined by the preop- acquire the desired occlusion by interference at
erative planning. In addition to rotation effects, a the coronoid process. Then a coronoidotomy is
lateral displacement of the mandible may also be needed to acquire adequate space and mobility
necessary. This movement and the antero-­ of the distal segment. In some cases, a lateral
posterior displacement determine the choice of flaring of proximal segment is observed, and
osteotomy technique in order to avoid larger bone bone at the inferior rim of the proximal segment
diastases. has to be removed by reduction with the recipro-
In IVRO the condylar proximal segment is cating saw [12].
usually left floating without being stabilized by The medial aspect of the proximal segment
osteosynthesis. Nevertheless, rigid fixation with must sometimes be trimmed with a burr or saw to
a horizontally oriented osteosynthesis plate is facilitate passive adaptation of proximal and dis-
possible, although the spontaneous adjustment of tal segment (Fig. 32.15a, b).
the TMJ is lost (Fig. 32.14). Figures 32.16 and 32.17 refer again to the
The mandible is repositioned to the planned problem of lateral flaring during horizontal man-
occlusion following intermaxillary fixation with dibular movements to correct midline shifts. The
wires or elastics. In a case with severe mandibu- pivot point can be identified during 3D planning
lar prognathism with setback, the distal segment so that the appropriate splitting technique can be
applied/selected to avoid damaging the TMJ by
dislocation or rotation. Several strategies are
displayed.
Figure 32.18 depicts BSSO in the correction
of mandibular asymmetry. If a classic BSSO is
performed and the rotation leads to significant
displacements of the proximal segment, the lin-
gually protruding bone of the distal segment
should be shortened or fractured to allow passive
alignment of the segments. This measure is not
necessary in every case and depends on the
course of the fracture after splitting.
To prevent the condylar luxation or sagging
after surgery, the inferior part of proximal seg-
ment is sutured to the periosteum of the sur-
rounding tissues in the retromolar region to tract
the proximal segment anteriorly to the inferior
part of the distal segment (Fig. 32.19). For this
purpose a drill hole has to be made in the base of
the proximal segment. After checking the rela-
tionship of segments, wound closure is done fol-
lowed by the insertion of drain tube. For detailed
Fig. 32.14 Horizontal osteosynthesis after IVRO with
2.0 mm 4-hole miniplate with bar. ©Copyright Keisuke description see Part V.
Koyama 2020. All rights reserved
268 K. Yamauchi and P. Kessler

a b

Fig. 32.15 (a) Coronoidotomy and backward movement of the distal segment (b) Correction of interfering bone edges
and lateral superimposition of proximal and distal segment. ©Copyright Keisuke Koyama 2020. All rights reserved
32 Surgical Correction in Mandibular Asymmetry 269

Fig. 32.16 IVRO on

the right side with no
flare-out and flare-out
rotations to the left and Pivot
right, respectively. No point
segment interference, if
the pivot point lies in the
region of the osteotomy
and the rotation of the
mandible does not lead
to segment interference.
If pivotal rotation leads
to lateral dislocation of
the distal segment and Non-flare out
inward rotation of the Pivot point at mandibular ramus on the affected side
proximal segment,
correction may be
necessary to avoid TMJ
rotation/luxation.
©Copyright Keisuke
Koyama 2020. All rights
reserved

Flare out after IVRO

Strategy
Additional bone cutting

Inferior bone cutting Notch bone trimming

270 K. Yamauchi and P. Kessler

Fig. 32.17 Rotation of

the mandible to the left
with segment
interference in
BSSO. Risk of
dislocation of the TMJ
on the right side. Two
strategies are offered:
(a) IVRO as alternative
to BSSO or (b) positive
alignment with fracture
of the overlapping
lingual segment.
©Copyright Keisuke
Koyama 2020. All rights
reserved

a b
32 Surgical Correction in Mandibular Asymmetry 271

a b

Fig. 32.18 (a) Rotation to the left with segment interfer- truding bone of the distal segment is corrected in its axial
ence is more pronounced when a BSSO is performed (b) alignment. ©Copyright Keisuke Koyama 2020. All rights
Passive alignment of the proximal segment with correc- reserved
tion of TMJ position is only possible, if the lingually pro-

that the bite is closed again. This is achieved

mainly by elastics in the anterior tooth region.
The elastics are changed with the relation-
ship of the occlusion and mandibular move-
ment during the first postoperative month. The
exceptions to the use of full-time training elas-
tic therapy are the periods when elastics are
removed to facilitate eating, tooth brushing,
and exercising mouth opening. After occlusion
is stabilized and the elastics are reduced to one
per each side, the application of elastics is
based on individual needs with postoperative
orthodontic treatment.
Fig. 32.19 Suturing of the proximal segment.
©Copyright Keisuke Koyama 2020. All rights reserved

11 Which Criteria Are Decisive

10 Postoperative Management in the Choice of Surgical
Technique?
If no osteosynthesis is applied on the IVRO side,
intermaxillary fixation is maintained for 7 days The USSO/BSSO has a wider bony attachment
with/without interocclusal splint. After removing surface than the IVRO:
the IMF, light vertical training elastics are placed
bilaterally. Without bilateral osteosynthesis the • Rigid fixation allows mouth opening immedi-
pulling direction must correspond to the midline. ately after the operation.
You have to keep an eye that no open bite occurs. • Postoperative healing is faster with rigid
In such a case, the elastics must be positioned so osteosynthesis.
272 K. Yamauchi and P. Kessler

In IVRO the bony contact is comparatively planning confidently identifies this and may force
narrow or missing: adjustment of the surgical approach.

• Rigid osteosynthesis is difficult.

• Long postoperative intermaxillary fixation is References
required.
• Simple surgical technique. 1. Delaire J, Gaillard A, Tulasne JF. La place de la con-
• Shorter operation time. dylectomie dans le traitement des hypercondylies.
Rev Stomatol Chir Maxillofac. 1983;84(1):11–8.
• Low risk of damage to the inferior alveolar 2. von Eiselsberg F. Über schiefen Biss in Folge
nerve. Arthritis eines Unterkieferköpfchens. Arch Klin Chir.
1906;79:587–92.
The main advantage of IVRO is that it reduces 3. Gruca M, Meisels E. Asymmetry of the mandible from
unilateral hypertrophy. Ann Surg. 1926;83:755–67.
postoperative temporomandibular joint prob- 4. Nolte JW, Karssemakers LH, Grootendorst DC,
lems. Instead of intraoperative rigid fixation with Tuinzing DB, Becking AG. Panoramic imaging is not
rigid condylar positioning, IVRO allows func- suitable for quantitative evaluation, classification, and
tional and gradual repositioning of the mandibu- follow up in unilateral condylar hyperplasia. Br J Oral
Maxillofac Surg. 2015;53(5):446–50.
lar condyles with postoperative physiotherapy 5. Nolte JW, Verhoeven TJ, Schreurs R, Bergé
with controlled mouth opening. Stable bony heal- SJ, Karssemakers LH, Becking AG, Maal TJ.
ing depends on patient compliance [12]. 3-Dimensional CBCT analysis of mandibular
asymmetry in unilateral condylar hyperplasia. J
Craniomaxillofac Surg. 2016;44(12):1970–6.
6. Steinhäuser EW, Rudzki-Janson
12 Conclusion IM. Kieferorthopädische Chirurgie—Eine inter-
disziplinäre Aufgabe—Band II. Berlin: Quintessenz;
When correcting vertical and horizontal asym- 1994.
7. Bell WH, Hall HD, White RP. Surgical ramus oste-
metries of the mandible, alternative techniques otomy. In: Surgical correction of dentofacial deformi-
can be used if the distal segment is more dis- ties. 2. Sanders, Philadelphia, 1980; 890–895.
placed in order to avoid functionally harmful 8. Severt TR, Proffit W. The prevalence of facial asym-
influences on the proximal segment and the metry in the dentofacial deformities population at the
University of North Carolina. Int J Adult Orthodon
TMJ. The IVRO is a common technique with dif- Orthognath Surg. 1997;12:171–6.
ferent technical challenges than BSSO. 9. Jung HD, Kim SY, Park HS, Jung YS. Modification
Often patients wish to correct facial asymme- of intraoral vertical ramus osteotomy. Br J Oral
try even before they think about the necessary Maxillofac Surg. 2014;52:866–7.
10. Yamauchi K, Takenobu T, Takahashi T. Condylar lux-
orthodontic pretreatment. In the case of strong ation following bilateral intraoral vertical ramus oste-
asymmetries, aesthetics is the guiding factor. otomy. Oral Surg Oral Med Oral Pathol Oral Radiol
Often the correction of the lower jaw alone will Endod. 2007;104:747–51.
not be sufficient. Correction of the chin position 11. Yamauchi K, Takahashi T, Kaneuji T, Nogami S,
Miyamoto I, Lethaus B. Pivot technique combined
can be of great advantage and contribute a lot to with mandibular backward distraction osteogenesis
the elimination of an asymmetry. The upper jaw for the patient with high risk for relapse. J Craniofac
must not be disregarded in the analyses, since the Surg. 2012;23(3):658–60.
majority of all corrections to eliminate facial 12. Ueki K, Marukawa K, Shimada M, Yoshida K, Hashiba
Y, Shimizu C, Nakagawa K, Alam S, Yamamoto
asymmetries must be bimaxillary. Rotational E. Condylar and disc positions after intraoral vertical
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ment of the TMJ. Computer-aided preoperative omy. Int J Oral Maxillofac Surg. 2007;36(3):207–13.
 Part VII
Mandibular Excess: class III Setback/
Surgical Technique-IVRO
 Indications for Mandibular
Setback/Advancement Using IVRO
33
or Inverted L Osteotomy

Kensuke Yamauchi and Peter Kessler

Contents
1 Conclusion  276
References  276

Abstract otomy can be applied on the side facing the

rotation.
Vertical splitting of the ascending mandibular
branch is an old procedure. This technique is
Keywords
suitable when the mandible is to be reposi-
tioned, especially in class III correction, man- Class III · Bird-face deformity · Orthognathic
dibular prognathism. This technique is no · Mandibular setback · Vertical osteotomy and
longer recommended for mandibular advance- mandibular setback · Mandibular setback–
ment. In regions with predominantly progna- IVRO–BSSO–inverted L osteotomy · Special
thic jaw types, this technique is popular surgical aspects in mandibular setback ·
because it can be performed quickly and is Modifications and surgical alternatives
gentle on the tissue. Advantages of the BSSO,
such as sufficient bone overlay, are eliminated.
The stability of osteosynthetic stabilization
cannot be compared with the possibilities of In the introduction to Parts V and VI, the most
the BSSO. Even in the case of strong horizon- important indications for mandibular reposition-
tal rotational movement, a vertical ramus oste- ing or repositioning with correction of asymme-
try have already been described in detail. In this
chapter, we will discuss alternative methods of
K. Yamauchi (*) mandibular osteotomy, which can be used espe-
Department of Oral & Maxillofacial Surgery, Tohoku cially in cases of mandibular setback surgery.
University Sendai, Sendai, Miyagi, Japan
The clinical criteria and planning preparation
P. Kessler (*) correspond to the procedures described in the
Department of Cranio-Maxillofacial Surgery,
above chapters. 3D planning is of even greater
Maastricht University Medical Center,
Maastricht, The Netherlands importance here, since IVRO and inverted L oste-
e-mail: [email protected] otomy must be seen as alternatives to standard

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 275
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_33
276 K. Yamauchi and P. Kessler

sagittal splitting surgery and do not have the However, procedures to idealize facial propor-
same status as SSRO or BSSO [1–3]. tions must be performed in accordance with the
IVRO and inverted L osteotomy are especially patient’s wishes and expectations in addition to
popular in the Asian population, since the man- clinical analysis. After weighing the risks and pos-
dibular repositioning—often in combination with sibilities, the decision to correct the mandible can
maxillary advancement—contributes to the ide- be made in favor of IVRO or inverted L osteotomy
alization of the face with enhancement of the in the case of a class III mandibular relationship.
midface prominence and simultaneous reduction Severe class II jaw relations with a bird-face
of the mandibular or chin prominence. In princi- deformity, high Frankfurt-mandibular plane
ple, both techniques are technically simpler than angle, and reduced posterior facial height pose
the splitting procedures described in detail in the another exceptional indication for vertical ramus
previous chapters. In addition, the use of osteo- osteotomies, if a BSSO cannot be applied. An
synthesis is often unnecessary, which makes the inverted L osteotomy can facilitate mandibular
procedure both temporally and logistically advancement and ramus lengthening [3].
attractive.
Patients with class III position of the lower jaw
are often dissatisfied with their appearance. At the 1 Conclusion
same time, if the lower face height is enlarged, a
prominent chin position can be disturbing. Vertical osteotomies in the ascending mandibular
The clinical image of mandibular prognathism ramus are suitable for repositioning the mandible
can be assigned to a dento-alveolar or skeletal and correcting the ramus length.
class III with cause in the mandible or maxilla or
a combination of both. Clinical, radiological, and
technical analyses (cephalometry), especially in References
the sagittal plane, are used to determine which
1. Caldwell JB, Hayward JR, Lister RL. Correction of
diagnosis is applicable. mandibular retrognathia by vertical L osteotomy: a
These analyses must provide information new technique. J Oral Surg. 1968;26:259–64.
about the position and size of the mandibular 2. Dattilo DJ, Braun TW, Sotereanos GC. The inverted L
skeletal structures with respect to the degree of osteotomy for treatment of skeletal open-bite deformi-
ties. J Oral Maxillofac Surg. 1985;43:440–3.
mandibular prognathism within the respective 3. Greaney L, Bhamrah G, Sneddon K, Collyer
facial growth pattern and clarify the extent of J. Reinventing the wheel: a modern perspective on the
dento-alveolar and/or skeletal involvement in bilateral inverted ‘L’ osteotomy. Int J Oral Maxillofac
class III occlusion (Parts V and VI). Surg. 2015;44:1325–9.
 Vertical Ramus Osteotomy and
Mandibular Setback
34
Kensuke Yamauchi and Peter Kessler

Contents
1 Conclusion  278
References  278

Abstract otomy can be applied on the side facing the

rotation.
Vertical splitting of the ascending mandibular
branch is an old procedure. This technique is
Keywords
suitable when the mandible is to be reposi-
tioned, especially in class III correction, man- Class II · Bird-face deformity · Orthognathic
dibular prognathism. This technique is no surgery · Mandibular setback · Vertical
longer recommended for mandibular advance- osteotomy and mandibular setback ·
ment. In regions with predominantly progna- Mandibular setback–IVRO–BSSO–inverted
thic jaw types, this technique is popular L osteotomy · Special surgical aspects in
because it can be performed quickly and is mandibular setback · Modifications and
gentle on the tissue. Advantages of the BSSO, surgical alternatives
such as sufficient bone overlay, are eliminated.
The stability of osteosynthetic stabilization
cannot be compared with the possibilities of
the BSSO. Even in the case of strong horizon- In the introduction to Parts V and VI, the most
tal rotational movement, a vertical ramus oste- important indications for mandibular reposition-
ing or repositioning with correction of asymme-
try have already been described in detail. In this
chapter, we will discuss alternative methods of
K. Yamauchi (*)
Department of Oral & Maxillofacial Surgery, Tohoku mandibular osteotomy, which can be used espe-
University Sendai, Sendai, Miyagi, Japan cially in cases of mandibular setback surgery.
P. Kessler (*) The clinical criteria and planning preparation
Department of Cranio-Maxillofacial Surgery, correspond to the procedures described in the
Maastricht University Medical Center, above chapters. 3D planning is of even greater
Maastricht, The Netherlands importance here, since IVRO and inverted L oste-
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 277
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_34
278 K. Yamauchi and P. Kessler

otomy must be seen as alternatives to standard However, procedures to idealize facial propor-
sagittal splitting surgery and do not have the tions must be performed in accordance with the
same status as SSRO or BSSO [1–3]. patient’s wishes and expectations in addition to
IVRO and inverted L osteotomy are especially clinical analysis. After weighing the risks and
popular in the Asian population, since the man- possibilities, the decision to correct the mandible
dibular repositioning—often in combination with can be made in favor of IVRO or inverted L oste-
maxillary advancement—contributes to the ide- otomy in the case of a class III mandibular
alization of the face with enhancement of the relationship.
midface prominence and simultaneous reduction Severe class II jaw relations with a bird-face
of the mandibular or chin prominence. In princi- deformity, high Frankfurt-mandibular plane
ple, both techniques are technically simpler than angle, and reduced posterior facial height pose
the splitting procedures described in detail in the another exceptional indication for vertical ramus
previous chapters. In addition, the use of osteo- osteotomies, if a BSSO cannot be applied. An
synthesis is often unnecessary, which makes the inverted L osteotomy can facilitate mandibular
procedure both temporally and logistically advancement and ramus lengthening [3].
attractive.
Patients with class III position of the lower
jaw are often dissatisfied with their appearance. 1 Conclusion
At the same time, if the lower face height is
enlarged, a prominent chin position can be Vertical osteotomies in the ascending mandibular
disturbing. ramus are suitable for repositioning the mandible
The clinical image of mandibular prognathism and correcting the ramus length.
can be assigned to a dento-alveolar or skeletal
class III with cause in the mandible or maxilla or
a combination of both. Clinical, radiological, and References
technical analyses (cephalometry), especially in
the sagittal plane, are used to determine which 1. Caldwell JB, Hayward JR, Lister RL. Correction of
mandibular retrognathia by vertical L osteotomy: a
diagnosis is applicable.
new technique. J Oral Surg. 1968;26:259–64.
These analyses must provide information 2. Dattilo DJ, Braun TW, Sotereanos GC. The inverted L
about the position and size of the mandibular osteotomy for treatment of skeletal open-bite deformi-
skeletal structures with respect to the degree of ties. J Oral Maxillofac Surg. 1985;43:440–3.
3. Greaney L, Bhamrah G, Sneddon K, Collyer
mandibular prognathism within the respective
J. Reinventing the wheel: a modern perspective on the
facial growth pattern and clarify the extent of bilateral inverted ‘L’ osteotomy. Int J Oral Maxillofac
dento-alveolar and/or skeletal involvement in Surg. 2015;44:1325–9.
class III occlusion (Parts V and VI).
 The Inverted L Osteotomy
35
Kensuke Yamauchi and Peter Kessler

Contents
1 Advantages  280
2 Disadvantages  281
3 Conclusion  282
References  282

Abstract Mandibular advancement · Modifications and

surgical alternatives
The inverted L-osteotomy represents a variant
of vertical osteotomies in the ascending man-
dibular branch. Attention must be paid to the
The third clinically relevant possibility to frac-
function of the temporal muscle. Inverted L
ture the mandible in a controlled manner is the
and vertical ramus osteotomy can also be used
Inverted L Osteotomy (Fig. 35.1).
when anatomic reasons prohibit BSSO. A lon-
If the problem of the IVRO in the area of the
ger period of intermaxillary fixation must be
coronoid process is to be expected, then this pro-
accepted.
cedure offers itself, whereby here elements of the
classical BSSO/SSRO and the IVRO merge.
Keywords
The main indication for the inverted L osteot-
Vertical osteotomy and mandibular setback · omy, however, is when the cancellous bone sup-
IVRO–inverted L osteotomy · Special ply between the compact osseous lamellae in the
surgical aspects in mandibular setback · region of the mandibular angle is so low that con-
ventional splitting of the mandible would result
K. Yamauchi (*)
in a bad fracture.
Department of Oral & Maxillofacial Surgery, Tohoku The horizontal osteotomy below the coronoid
University Sendai, Sendai, Miyagi, Japan is at the same level as the lingual osteotomy of
P. Kessler (*) the Hunsuck-Epker variant of BSSO/
Department of Cranio-Maxillofacial Surgery, SSRO. However, it is an osteotomy and not a
Maastricht University Medical Center, split, the bone is completely passed through [1,
Maastricht, The Netherlands
e-mail: [email protected]
2]. The combination of the vertical osteotomy is

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 279
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_35
280 K. Yamauchi and P. Kessler

Fig. 35.1 Ideal inverted

L osteotomy.
©Copyright Keisuke
Koyama 2020. All rights
reserved

Fig. 35.2 Horizontal and vertical osteotomy with the oscillating saw. Piezosurgery can be applied ©Copyright Keisuke
Koyama 2020. All rights reserved

again borrowed from IVRO and, like IVRO, is 1 Advantages

performed dorsal to the lingula/antilingula of the
ascending ramus (Fig. 35.2). The inverted L oste- • Technically simple, quick to perform.
otomy on one side can be combined with an • Ideal in compact bone, where splitting is
SSRO on the contralateral side [3]. impossible.
35 The Inverted L Osteotomy 281

• In mandibular asymmetry with relevant verti- cases where inverted L osteotomy replaces the
cal displacement. SSRO/BSSO (Fig. 35.3a–c).
• Theoretically more bone overlap than with • Cranial displacement of distal segment
IVRO, but significantly less than with both impossible.
BSSO/SSRO.
• Risk of injury to IAN. Another indication for inverted L osteotomy
can be found in mandibular asymmetries where a
relevant vertical correction to the caudal is
2 Disadvantages required (Fig. 35.3b).
Pronounced bird-face deformities can be
• Increased risk of a bad fracture in the area of treated by vertical ramus osteotomies with fur-
the semilunar notch. ther mandibular advancement and lengthening of
• Mobilization of the segments more difficult the ascending mandibular branch, although pro-
due to more bony interference. longed postoperative intermaxillary fixation must
• Osteosynthesis is recommended, especially in be accepted [4].

a b

Fig. 35.3 (a) Osteosynthesis with the angulated burr/ sis is recommended for optimal bone healing. ©Copyright
screwdriver (b) Vertical osteosynthesis with bone interpo- Keisuke Koyama 2020. All rights reserved
sition in major vertical correction (c) Stable osteosynthe-
282 K. Yamauchi and P. Kessler

Then the coronoid process with the temporal often not applied. The functional influxes of the
muscle attached will not block caudal dislocation masticatory muscles must be taken into account,
to the distal segment [5]. and intermaxillary fixation plays an important
The surgical procedure from incision to role in postoperative management.
wound closure corresponds to the procedure in
the preceding chapters. In the case of compact
bone structure and thin bone layers, stable osteo- References
synthesis is recommended to optimally support
bony healing (Fig. 35.3c). 1. Dattilo DJ, Braun TW, Sotereanos GC. The inverted L
osteotomy for treatment of skeletal open-bite deformi-
ties. J Oral Maxillofac Surg. 1985;43:440–3.
2. DiStefano JF, Spilka C. Inverted L osteotomy for cor-
3 Conclusion rection of mandibular prognathism after relapse. J
Oral Surg. 1978;36:147–9.
Inverted L osteotomy can be considered as an 3. McMillan B, Jones R, Ward-Booth P, Goss
alternative osteotomy technique. It is also suit- A. Technique for intraoral inverted “L” osteotomy. Br
J Oral Maxillofac Surg. 1999;37:324–6.
able for mandibular advancement with 4. Greaney L, Bhamrah G, Sneddon K, Collyer
limitations. J. Reinventing the wheel: a modern perspective on the
Inverted L and vertical ramus osteotomy are bilateral inverted ‘L’ osteotomy. Int J Oral Maxillofac
alternatives when BSSO cannot be performed. Surg. 2015;44:1325–9.
5. Muto T, Akizuki K, Tsuchida N, Sato Y. Modified
Furthermore, the vertical osteotomies are suit- intraoral inverted-“L” osteotomy: a technique for
able for mandibular repositioning. The procedure good visibility, greater bony overlap and rigid fixation.
is quick to perform and rigid osteosynthesis is J Oral Maxillofac Surg. 2008;66:1309–15.
 Part VIII
Alveolar Segment Osteotomies
 Types of Segmental Alveolar
Osteotomies in the Mandible
36
Peter Kessler and Nicolas Hardt

Contents
1 Anterior Subapical Segmental Osteotomy 286
2 Posterior Subapical Osteotomy 286
3 Variants of an Anterior Segment Osteotomy 286
4 Conclusion 286
References 286

Abstract
deformities are as follows: Excess vertical
Class II division I malocclusions are the most growth in the anterior dentoalveolar process
common dentofacial deformities seen in clini- of the mandible, some types of mandibular
cal practice. Combined orthodontic and surgi- vertical alveolar deficiency and anterior open
cal treatment in cases of severe class II bite, relapse after BSSO, cases of condylar
dentofacial deformities (class II division I agenesis and hypoplasia, lateral open bite,
malocclusion/class II division II malocclu- mandibular dental arch asymmetry, and nega-
sion) is a routine procedure in these orthodon- tive curve of Spee (Köle. Oral Surgery, Oral
tic patients (Bell et al., American Journal of Medicine, and Oral Pathology 12(3):277–288,
Orthodontics. 85:1–20, 1984). 1959; MacIntosh RB Journal of Maxillofacial
Surgery. 2:210-218, 1974).
Some indications for segment osteotomies However, the aim will always be to avoid
in combination with correction of class II segmental osteotomies by means of suitable
orthodontic pretreatment, since the techniques
P. Kessler (*) of relocating the entire mandible are safer and
Department of Cranio-Maxillofacial Surgery, involve fewer risks. Nevertheless, there are sit-
Maastricht University Medical Center, uations in which the performance of a segmen-
Maastricht, The Netherlands
e-mail: [email protected] tal osteotomy is indicated, either in combination
with a BSSO or as a stand-alone procedure.
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of Segmental osteotomies can be performed in the
Cranio-Maxillofacial Surgery, Lucerne, Switzerland anterior mandibular region, but also laterally.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 285
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_36
286 P. Kessler and N. Hardt

Keywords 3 Variants of an Anterior Segment

Alveolar osteotomies · Segmental osteotomy Osteotomy
· Dentoalveolar retrusion · Anterior deep
bite - Class II malocclusion · Dentoalveolar • Lateral mandibular body step osteotomy/
protrusion · Correction of open bite · ostectomy.
Posterior subapical osteotomy · Anterior body The lateral step osteotomy/ostectomy of
osteotomy · BSSO the mandible is a variant of the anterior seg-
mental block osteotomy to reposition the ante-
rior section of the mandible, e.g., for posterior
1 Anterior Subapical Segmental or superior repositioning [4, 5]
Osteotomy • Anterior body osteotomy (Straight vertical
osteotomy).
Anterior subapical segmental osteotomies in the A vertical osteotomy with ostectomy pri-
mandible involve vertical and horizontal separation marily to reposition the anterior mandibular
and mobilization of the alveolar mandibular seg- segment.
ment ideally between the first premolars and canines.
The subapical osteotomized segment is then
repositioned: 4 Conclusion

• Either superiorly to correct an open bite. Segmental osteotomies can be applied in the
• Inferiorly with ostectomy of a horizontal bone upper as well as in the lower jaw. Anterior and
segment. lateral segmental osteotomies are discerned.
• Posteriorly with ostectomy of a vertical alveo-
lar bone segment or as a combined movement.
References
Dentoalveolar segment relocation—down-
1. Bell WH, Jacobs JD, Legan HL. Treatment of class
wards and backwards—is associated with bone II deep bite by orthodontic and surgical means. Am J
removal; alveolar segment relocation—upwards Orthod. 1984;85(1):1–20.
and forwards—is associated with bone interposi- 2. Köle H. Surgical operations on the alveolar ridge to
tion inferiorly or distally. correct occlusal abnormalities. Oral Surg Oral Med
Oral Pathol. 1959;12(3):277–88.
Segmental anterior mandibular osteotomies 3. MacIntosh RB. Total mandibular alveolar osteotomy:
may be combined with the anterior maxillary encouraging experiences with an infrequently indi-
osteotomies in cases with bimaxillary alveolar cated procedure. J Maxillofac Surg. 1974;2(4):210–8.
protrusion [1–3]. 4. Fonsecca RJ, Marciani, RD, Turvey TA. Oral and
maxillofacial surgery, Bd 1 Saunders/Elesevier, 2009.
5. Harris M, Reynolds IR. Fundamentals of orthognatic
surgery. Saunders; 1991.
2 Posterior Subapical Osteotomy

The posterior subapical osteotomy is performed

to correct super-eruption of posterior mandibular
teeth or in case of ankylosis of impacted posterior
teeth.
 Indications for Segmental
Osteotomies in the Mandible
37
Peter Kessler and Nicolas Hardt

Contents
1 Anterior Subapical Osteotomy  287
2 Conclusion  288
References  288

Abstract Keywords

Mandibular subapical segmental osteotomies Segmental osteotomies · Mandibular osteoto-

are not the most common choices to treat mies · Dysgnathia · BSSO · Alveolar protru-
patients with dentofacial deformity. However, sion · Open bite
especially the anterior subapical osteotomy is
a very versatile technique that allows the oste-
otomized segment to be moved in different 1 Anterior Subapical Osteotomy
directions. The surgical technique can also be
applied with other dysgnathias and in combi- It is possible to set the anterior segment back-
nation with a BSSO. ward, forward, upward, and downward, depend-
ing on the need. Also, this type of osteotomy may
be performed along with a bilateral sagittal split
osteotomy (BSSO).
According to Bell et al. [1, 2], the mandibular
anterior subapical osteotomy may be indicated to
level the occlusion, produce anteroposterior
P. Kessler (*)
changes of the osteotomized segment, correct
Department of Cranio-Maxillofacial Surgery, crowding in the lower anterior arch, correct ante-
Maastricht University Medical Center, rior dentoalveolar asymmetries, alter the axial
Maastricht, The Netherlands inclination of the anterior teeth, reduce overall
e-mail: [email protected]
treatment time, and improve treatment stability.
N. Hardt (*) Anterior subapical osteotomy is indicated
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland
when there is a skeletal class I relation but a

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 287
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_37
288 P. Kessler and N. Hardt

deformity in the frontal mandibular segment can- 5. Asymmetries of the anterior mandibular den-
not be corrected by orthodontic treatment. tal arch.
6. Vertical height/volume deficits in the anterior
1. Alveolar protrusion of the mandibular front mandibular segment may be associated with
segment with possibly negative overjet ankylosing teeth or oligo/hypodontia.
(mandibulo-­alveolar protrusion) in contrast
to a true mandibular prognathism, the jaw
base is normally developed. The maldevelop- 2 Conclusion
ment is limited to the frontal alveolar process
and teeth (dentoalveolar localization). The There are specific indications in which segmental
protrusion of the mandibular front is often osteotomy in the anterior mandibular region in
associated with a protrusion of the maxillary particular may be indicated. If orthodontic cor-
front (bimaxillary alveolar protrusion). rection is impossible or unsuccessful, relocation
2. Alveolar elevation of the anterior bone seg- of a defined jaw segment can help. Especially the
ment and teeth as a concomitant symptom of vertical component may be affected.
mandibular prognathism. Anterior elevation
of the anterior mandibular segment is a fairly
regular occurrence in mandibular progna- References
thism and alveolar protrusion in the maxilla
(pronounced curve of Spee with elevation of 1. Bell WH, Proffit WR, White RP. Surgical correction of
dentofacial deformities. Philadelphia: WB Saunders;
the mandibular front).
1980.
3. Marked anteroposterior discrepancy of the ante- 2. Bell WH, Jacobs JD, Legan HL. Treatment of class
rior bone segment and teeth (­ mandibulo-­alveolar II deep bite by orthodontic and surgical means. Am J
retrusion) in class II division II malocclusion . Orthod. 1984;85(1):1–20.
4. Vertical alveolar bone deficit in the anterior man-
dibular segment in certain types of anterior open
bite (vertical mandibulo-alveolar deficiency).
 Preoperative Planning
and Preparation for Surgery in
38
Segmental Mandibular
Osteotomies

Peter Kessler and Nicolas Hardt

Contents
1 Preparation for Operation  290
2 Profile Changes  290
3 Conclusion  291
References  291

Abstract Planning requirements:

The surgical preparations require the same • Dental casts and profile photos.
care as for other orthognathic procedures. • Dental status.
Particular attention must be paid to the subapi- • Routine radiographs: panoramic radiography,
cal bone supply for creating an osteotomy. if indicated cone-beam CT (CBCT).
Evaluation of:
Keywords
• Chin region/bone strength in the region of the
Segmental osteotomies · Mandibular osteoto-
mandibular symphysis: mental spine/cortical
mies · Dysgnathia · BSSO · Alveolar protru-
bone structure in the mental region/position of
sion · Open bite · Preoperative planning
the mental foramina.
• Assessment of contour of the chin and anterior
alveolar process, the root tip region and the
P. Kessler (*)
interdental septa 35–45.
Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center, • Analysis of the lateral projection of the facial
Maastricht, The Netherlands skeleton on the lateral cephalogram or CBCT,
e-mail: [email protected] cephalometry (Fig. 38.1).
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 289
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_38
290 P. Kessler and N. Hardt

rected model. Preoperatively, individually made

dental wire-arches can be prepared.
If posterior teeth are missing, the splint can
serve as a prosthesis splint which is temporarily
used even after the surgery. The anterior arch of
the splint is stiffened with self-curing acrylic at the
end of surgery to stabilize the segment on the ves-
tibular and lingual side. With this type of fixation,
intermaxillary immobilization is not required.
If the anterior teeth are elongated, only the
affected segment from the alveolar process is
osteotomized and shortened accordingly.
If preoperative extractions are performed for
orthodontic tooth movements, it must be ensured
that a 3 mm wide interdental space remains to
allow the vertical osteotomy to be performed
without damaging the roots. Interdental space
can also be created orthodontically without
extracting teeth.
If the anterior teeth are positioned too low, the
Fig. 38.1 Graphic-cephalometric surgery planning—lat- mandibular segment is elevated and supported
eral cephalogram of a case with bi-alveolar protrusion and with a bone graft. Here, too, the segment is
dental class II relation with large overjet. Lower jaw base
and ascending ramus are normally developed. ©Copyright adjusted using an occlusal splint and the segment
Keisuke Koyama 2020. All rights reserved is then fixed using arch-wires supported by self-­
curing acrylics as described above.
In general, segments are also fixed at their
1 Preparation for Operation base with mini plates of 1.5 mm and short screws
in such a way that the bone segment has maxi-
• Planning mum stability. Nevertheless, the greatest care
• Simulation by means of model operation must be taken in segmental osteotomies when
• Production of surgical splints making and adjusting the occlusal splints [1, 2].

Simple plaster models are sufficient. The cor-

rection of the inverted overbite or anterior step, 2 Profile Changes
for example, is done by retro positioning the pro-
and extruded lower jaw segment by one premolar In an anterior subapical segmental osteotomy of
width. On the plaster model, the corresponding the mandible, the lower lip follows a skeletal
premolar is erased on each side and the segment retro-positioning of approximately 75% at the
including the anterior teeth is cut out approxi- level of the lip, and a forward movement of the
mately at right angles. alveolar process segment of 60%.
The three cut surfaces must be such that a har- If the chin position remains unchanged, the
moniously shaped dental arch with normal ante- labio-mental fold is simultaneously reinforced or
rior overbite is created when the fragment is flattened. A change in the vertical height of the
adjusted. An occlusal splint is made on the cor- face is impossible.
38 Preoperative Planning and Preparation for Surgery in Segmental Mandibular Osteotomies 291

3 Conclusion References

The planning and preparation of a segmental 1. Bell WH, Proffit WR, White RP. Surgical correction of
dentofacial deformities. Philadelphia: WB Saunders;
osteotomy requires thoroughness to be performed 1980.
successfully at all. This has to do primarily with 2. Bell WH, Jacobs JD, Legan HL. Treatment of class
the limited space available around the segment to II deep bite by orthodontic and surgical means. Am J
be lifted. Orthod. 1984;85(1):1–20.
 Anatomical, Surgical,
and Technical Aspects
39
Peter Kessler and Nicolas Hardt

Contents
1  ecisive Anatomical Reference Points 
D 294
1.1 Reference Points  294
1.1.1 For the Mucosal Incision  294
1.1.2 For Access to the Osteotomy  294
1.1.3 For Vertical or Horizontal Ostectomy  294
1.2 Surgical Aspects  294
1.3 Technical Aspects  294
1.3.1 Rotating Instruments: Burrs  294
1.3.2 Piezo-Surgery  294
1.3.3 Segment Fixation  295
2  urgical Approach: Detailed Surgical Steps 
S 295
2.1 Anterior Segment Osteotomy  295
2.2 Detailed Surgical Steps  295
2.2.1 Step 1: Intraoral Mucosal Incision  295
2.2.2 Step 2: Segment Osteotomy  297
2.2.3 Step 3: Segment Mobilization  297
2.2.4 Step 4: Setting the Segment and Intraoral Fixation  298
2.2.5 Step 5: Wound Closure  299
2.3 Technical Variants  299
2.3.1 Downward and Posterior Movement  299
2.3.2 Vertical Segment Movement  300
2.3.3 Upward Movement  300
2.3.4 Forward Movement  300
2.3.5 Optional Variants and Combinations  301
3 Conclusion  302
References  302

P. Kessler (*) Abstract

Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center, The success of a segmental osteotomy depends
Maastricht, The Netherlands on the surgical approach, which must be fully
e-mail: [email protected]
thought out from the initial incision to the
N. Hardt (*) suture to be successful. This has to do with
Kantonsspital Lucerne, Clinic and Policlinic of
segmental perfusion and the limited displace-
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 293
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_39
294 P. Kessler and N. Hardt

ment ability of the segment in the mandibular

arch. Only well-considered surgical steps Note
guarantee success. • Subapical osteotomies need careful
planning to ensure a vascular pedicle as
Keywords large as possible.
• The blood flow through the mandibular
Segmental osteotomies · Mandibular osteoto-
periosteum could easily maintain a suf-
mies · Dysgnathia · BSSO · Alveolar protru-
ficient blood supply to the teeth of an
sion · Open bite · Preoperative planning ·
osteotomized segment, even when the
Surgical access · Incision · Osteosynthesis
labial periosteum was degloved.
• The greater distance from the apices of
the teeth not only minimizes direct
pulpal injury but increases the vascular
1 Decisive Anatomical Reference pedicle to the mobile segment.
Points

1.1 Reference Points • If the segmental osteotomy is performed pos-

terior to the mental foramen, the mental nerve
1.1.1 For the Mucosal Incision may cross the osteotomy field. The vascular
Gingival margin. nerve bundle must be visualized and released
Labial attachment of the lip ligament. from its bone canal; otherwise there is a risk of
permanent damage to the nerve.
1.1.2 For Access to the Osteotomy • Segment fixation as stable as possible.
Aponeurosis of the following muscles and
structures:
Mentalis muscle, levator labii muscle and 1.3 Technical Aspects
depressor anguli oris muscle as well as:
Mental foramen and lower edge of the man- 1.3.1 Rotating Instruments: Burrs
dible in the chin region. The degree of mechanical processing of the jaw-
bone when the osteotomies are applied depends
1.1.3 For Vertical or Horizontal on the geometry and shape of the rotating instru-
Ostectomy ments (spherical, conical, cylindrical), the instru-
Extraction sockets of premolars; mental foramen; ment diameter, the roughness of the surface
alveolar protuberances; interdental and interal- structure of the instruments: diamond-coated,
veolar space. saw-tooth structure (cross-toothed, spiral-­
toothed) and the speed of rotation.
High rotational speed and strong contact pres-
1.2 Surgical Aspects sure of the rotating instruments lead to more or
less pronounced bone necrosis and increase sig-
• Operation simulation as exact and detailed as nificantly at higher rotational speeds and increas-
possible. ing osteotomy depth.
• Surgical access as clear as possible.
• Bone cuts/osteotomies as simple as possible. 1.3.2 Piezo-Surgery
• Existing tooth gaps in the premolar region can Piezo-surgery in segmental osteotomies allows
be closed surgically by placing the osteotomy/ highly precise, uncomplicated interdental verti-
ostectomy deliberately in the region of the cal separation of alveolar bone without damaging
tooth gap. the neighboring teeth and the connecting hori-
39 Anatomical, Surgical, and Technical Aspects 295

zontal incisions with the least possible bone loss 2.2 Detailed Surgical Steps
and guarantees superior protection of soft tissue
(nerves/vessels/mucosa). 2.2.1 Step 1: Intraoral Mucosal
This is associated with a significantly Incision
reduced bone trauma in the area of the osteoto- • Expose the surgical area from the first molar
mies and a micromorphologically and histolog- on the left to the first molar on the right—from
ically verified significant improvement in bone 6–6.
healing and a better hemodynamic microcircu- • Mobilization of soft tissues subperiosteal to
lation of the tissues of the surgical site [1, 2]. beyond the lower jaw margin.
See Chap. 16.

1.3.3 Segment Fixation Intraoral Muco-Periosteal Incision

The osteotomized alveolar segment is fixed in The labial mucosa and vestibule are infiltrated
position either by an intra-mandibular arch-wire with local anesthetics containing vasoconstric-
splint with and without prior segmentation, tive additives, e.g., a solution of epinephrine
which is reinforced with self-curing plastic dur- 1:100,000. After tensioning the lower lip and
ing surgery. exposing the vestibule with Langenbeck retrac-
or tors and drying the mucosa, the incision is marked
Fixed by an orthodontically ligated orthodontic with a sterile skin marker.
arch-wire, which is reinforced with self-curing The mucosa is then incised parabolically from
resins during the operation, supplemented by an 6–6, distal to the planned vertical bone cuts.
intraoperatively integrated lingual-occlusal splint. The apex of the incision parabola lies in the
in combination with median region of the labial mucosa (Fig. 39.1).
Mini-plate osteosynthesis bridging the osteot- This incision design prevents suture dehis-
omy gap with 1.5 mm plates and self-tapping cence later on. After cutting through the mucosa
cortical screws. and submucosa, the terminal branches of the
mental nerve are localized in the submucosal tis-
sues in an atraumatic, blunt manner.
2 Surgical Approach: Detailed Then, below the mobilized mucosa-­submucosa
Surgical Steps cuff, the chin musculature is severed sharply

2.1 Anterior Segment Osteotomy

The anterior segment osteotomy is performed

after pre-surgical orthodontic gap formation to
safely protect adjacent tooth roots and the mental
nerve, preferably between the canine and first
premolars.
The osteotomy is placed horizontally subapi-
cally about 6–8 mm - minimum 5 mm - below the
root apices and ends about 2–3 mm before the
mental foramen. Then the horizontal osteotomy
is connected to the vertical osteotomies in the
area of the extracted first premolars.
If extraction is not planned, the anterior seg-
ment can be positioned cranially to close an ante-
Fig. 39.1 Parabolic incision line from the first molar on
rior open bite. A bone graft should be integrated the left to the first molar on the right. ©Copyright Keisuke
into the horizontal gap. Koyama 2020. All rights reserved
296 P. Kessler and N. Hardt

down to the bone—approximately halfway men to form a tunnel, and the periosteal conus is
between the gingival margin and the lower limit carefully incised and the nerve is prepared freely
of the mandible—and the periosteum is incised so that the risk of injury is minimized and the
repeatedly at the same location (Figs. 39.2 and access is considerably widened so that the nerve
39.3). can be better protected.
A smooth, atraumatic detachment of the
Mucoperiosteal Dissection adhering periosteal-tendinous tissue of the men-
The mental nerve is visualized by elevation of the talis muscle is best achieved with a sharp-edged,
periosteum in distal direction. The periosteum is not too wide dissector.
then elevated below, above, and behind the fora- The lateral mimic muscles of the oral fissure
can be levered off smoothly, so that it is recom-
mended to start with subperiosteal detachment
there first at the height of the mental foramen, and
then subperiosteally detach the adherent attach-
ment of the mental muscle (mental tubercula) up
to the alveoli of the incisors without tearing.
An elevator is then used to lift the anterior soft
tissue package to below the edge of the mandible
and a chin retractor is inserted to hold the flap and
support the mandible.
If additional reduction of the chin is planned,
the soft tissues must be mobilized beyond the
edge of the lower jaw.
Clear exposure of the labial bone surface—
including the mental foramina—is always neces-
sary. Since the position of the tooth roots are
Fig. 39.2 The mucosa incision runs halfway between the clearly visible, the height of the root tips can be
inner vermillion border and the mucogingival junction. determined easily; transverse osteotomy is per-
©Copyright Keisuke Koyama 2020. All rights reserved
formed about 6–8 mm below.

Note
• Deep vestibular mucosal/submucosal
incision in the area of the planned seg-
mental osteotomy.
• Sharp cutting of the chin muscles up to
the periosteum.
• Periosteal incision and subperiosteal
elevation of the vestibular mucosa.
• Elevation of the submucosal periosteum
in distal direction with presentation of
the mental nerve.
• Tunneling preparation of the gingival
mucosa in the area of the vertical inter-
dental osteotomies while preserving the
soft tissues for later saliva-tight gingival
Fig. 39.3 Incision of the muscular tissues of the orbicu-
wound closure in the interdental osteot-
laris oris and mental muscle. ©Copyright Keisuke omy area.
Koyama 2020. All rights reserved
39 Anatomical, Surgical, and Technical Aspects 297

2.2.2 Step 2: Segment Osteotomy

• The interdental bone cuts with burr and Note
micro-saw • Mark vertical osteotomy lines with a
• or piezo-surgery and small osteotomes. fine fissure drill.
• In the case of planned segment reposi-
It is essential to study the patient’s tomograms tioning with tooth extraction, the area to
carefully before performing the osteotomies. be osteotomized is also marked.
First, usually a premolar is extracted on both • Mark the horizontal connecting osteot-
sides and the alveolar walls are gently removed. omy line with a minimum distance of
The initial horizontal osteotomy runs about 6–8 mm to the root tips of the teeth of
6–8 mm below the apices of the anterior teeth of the segment.
the planned alveolar segment. The position of the • Completing the osteotomies with fine
tooth roots determines the position of the hori- fissure drills, alternatively fine oscillat-
zontal osteotomy. Danger points of an incorrect ing saws and chisels or piezo-surgical
subapical osteotomy are injuries to the adjacent cutting.
roots and root tips and injuries to the mental
nerve.
Fine drill holes are made in the cortical bone
along the osteotomy line which has been marked
with a sterile pencil.
The horizontal and vertical osteotomies are
first pre-cut along the cortical perforations with a
fissure drill, alternatively with a sagittal oscillat-
ing micro-saw.
The completion of the horizontal and vertical
osteotomies—including the alveolar bone on the
lingual side—is initially performed with fine fis-
sure drills or oscillating saws and, advanta-
geously on the lingual side, atraumatically with
piezo-surgery.
If no teeth are to be extracted, the buccal cut
can initially only be made through the outer cor-
Fig. 39.4 Principle design of vertical and horizontal
tex with a fine split drill or oscillating saw. bone cuts for anterior mandibular segment osteotomy.
After very limited loosening the lingual muco- ©Copyright Keisuke Koyama 2020. All rights reserved
periosteum vertically from above—using a thin
periosteal elevator—the separation of the lingual 2.2.3 Step 3: Segment Mobilization
cortex is performed advantageously by Mobilization of the Segment with Small
piezo-surgery. Osteotomes
Horizontal and/or vertical alveolar ostecto- The osteotomized segment is then mobilized
mies/corrections are necessary if the segment is with narrow 3–5 mm osteotomes and small lever
repositioned or lowered (Fig. 39.4). movements.
298 P. Kessler and N. Hardt

The fragment can be lifted by the muscle and Rigid Segment Fixation
mucosa of the lingual side and tilt. A very narrow The final fixation of the secured alveolar segment is
pear-shaped burr is used for its further processing then performed by rigid osteosynthesis with 1.5 mm
of the segment. The aim is to shape the cut sur- miniplates and self-tapping cortical screws.
faces according to the model template. After 2 weeks, the splint is removed to pre-
In order to achieve a normal overbite, the seg- vent gingivitis on the lingual side, and since a
ment must either be shifted back, lowered, raised, rigid wire-arch bandage enforced by self-cur-
or rotated. If this results in a horizontal gap open ing plastic is applied labially, the splint can be
to the front or a continuous vertical gap already dispensed with after this short time.
(Fig. 39.5), this gap is filled with a regional bone If the bone segment is still too mobile or the
graft from the lower edge of the chin. intermaxillary relation can lead to a masticatory
overload, the fixation splint must be re-implanted.
2.2.4 Step 4: Setting the Segment This should no longer be necessary after a maxi-
and Intraoral Fixation mum of 6 weeks.
Occlusion-Related Setting of the
Osteotomized Segment
After the osteotomized and sufficiently mobi-
lized segment has been precisely adjusted to the
occlusion, the preplanned occlusion is secured
intraoperatively. This is done either with an Note
applied mono-maxillary dental/occlusal splint • Setting the front block to the planned
which should cover the lingual side of the man- position.
dibular teeth and include them for stabilization. • Segment stabilization with preopera-
The segment is secured by the mono-­maxillary tively fabricated occlusal-lingual splint
splint which is connected and fixed by wire liga- enforced with self-curing plastic.
tures and self-curing plastic. The fragment is now • Definitive positionally stable fixation
firmly locked in its new position (Fig. 39.6). An using osteosynthesis plates and mono-­
intermaxillary immobilization is not necessary. cortical screws.

Fig. 39.5 Frontal segment osteotomy: mandible before and after anterior relocation. The resulting bone gaps are in
turn filled with bone grafts. ©Copyright Keisuke Koyama 2020. All rights reserved
39 Anatomical, Surgical, and Technical Aspects 299

Fig. 39.6 Anterior mandibular segment fixed with an occlusal splint and wires. The osteotomy gap is filled with bone
graft. ©Copyright Keisuke Koyama 2020. All rights reserved

manipulation during splinting, the mucosal suture

would be torn open again. Thus, the wound
remains covered with a saline compress during
splinting. The wound and oral cavity are then
thoroughly cleaned with a saline lavage under
constant suction.
The wound is closed in two layers: periosteum
and muscles are attached to the bone/periosteum
with Vicryl mattress sutures 4 × 0. This succeeds
well laterally, while possible periosteal incisions
are required in the midline area, as the mental
aponeurosis is difficult to pull up. The mucosa is
sutured with interrupted Vicryl 4 × 0 and 5 × 0
continuously (Fig. 39.7).

2.3 Technical Variants

Fig. 39.7 Wound closure in layers. ©Copyright Keisuke
Koyama 2020. All rights reserved
2.3.1 Downward and Posterior
2.2.5 Step 5: Wound Closure Movement
The two premolars should be carefully extracted
• Two-layer wound closure.
and the interdental bone accurately removed/
• Periosteum and musculature with Vicryl 4 × 0
ostectomized to create sufficient space for distal
and mattress sutures.
repositioning (Fig. 39.8).
• Mucosa continuous—Vicryl 4 × 0 and 5 × 0.

For practical reasons, the wound is not closed

until the segment fixation is complete. Due to the
300 P. Kessler and N. Hardt

Fig. 39.8 Posterior relocation and lowering of the anterior segment (horizontal/vertical bone cut) ©Copyright Keisuke
Koyama 2020. All rights reserved

1 and 2 
Horizontal and vertical double osteoto-
mies and vertical interseptal and alveolar
ostectomy in the residual extraction socket
3. Subapical horizontal ostectomy
4.  
Bone sculpturing after mobilization of the
segment on the lingual side.

2.3.2 Vertical Segment Movement

For exclusively vertical movements—without
extractions—it is imperative that there is suffi-
cient space between the roots of the teeth adja-
cent to the vertical osteotomies. The orthodontist
should prepare the patient with a sufficient inter-
dental space for later osteotomy.
Sometimes the mobilized segment cannot be
satisfactorily positioned. In this case, all cortical
osteotomy margins, especially in the angular
Fig. 39.9 Transplantation of cortical symphyseal bone
region, must be carefully controlled and interfer- into the subapical gap [3]. The arrows in the upper jaw
ing bone tips must be removed with a well-­ indicate orthodontic corrections. ©Copyright Keisuke
cooled, narrow drill (bone sculpturing). Koyama 2020. All rights reserved

2.3.3 Upward Movement physeal bone chips from the chin, especially
The segment osteotomy is performed as described when the segment is moved vertically to close
and the bone defect in the subapical region result- an anterior open bite (Fig. 39.9). Bone replace-
ing from the upward movement is filled with can- ment material can be used as well.
cellous bone chips. In a simultaneous sagittal
split osteotomy, buccal bone can be used to fill 2.3.4 Forward Movement
the subapical gap. Occasionally, a forward segment movement is
Alternatively, the subapical bone gap can be necessary to correct a class II division I with a
closed by grafting the gap with cortical sym- deep bite and large overjet.
39 Anatomical, Surgical, and Technical Aspects 301

The segment may include one or more of the bone chips from the iliac crest, e.g., and covered
premolars. This requires mobilization of the with a buccal mucosa flap.
mental nerve from its canal by removing the
lateral cortical bone to the vertical osteotomy 2.3.5 Optional Variants
with a drill, cutting two parallel grooves start- and Combinations
ing at the upper and lower end of the mental Correction of bimaxillary protrusion and anterior
foramen. open bite by anterior maxillary and mandibular
The intervening bone is carefully removed subapical ostectomies (Fig. 39.10).
with a trimmer, and the exposed neurovascular Correction of mandibular deficiency by man-
bundle is displaced gently from the canal. During dibular subapical osteotomy and sagittal split
this procedure the contents of the nerve canal can ramus osteotomies and orthodontic treatment
be protected with the Ash filling instrument (Fig. 39.11).
inserted into the canal. Correction of anterior open bite with exces-
Once the alveolar segment has been mobilized sive chin height by subapical osteotomy and
anteriorly and fixed with a splint, the residual transplantation of the symphysis bone in the bone
vertical gaps are filled with cortico-cancellous gap (Fig. 39.12).

a b

Fig. 39.10 (a) Dental, skeletal, and facial features asso- reduce facial convexity. Arrows indicate planned direc-
ciated with bimaxillary protrusion and anterior open bite tional movements. ©Copyright Keisuke Koyama 2020.
(b) Maxillary and mandibular subapical dentoalveolar All rights reserved
segment osteotomies to close anterior open bite and
302 P. Kessler and N. Hardt

a b c

Fig. 39.11 (a) Pretreatment: Typical dental, skeletal, and of misaligned teeth by orthodontic means (c) Post-­surgery:
facial features associated with mandibular deficiency—class Mandibular subapical osteotomy to partially level mandibu-
II division l malocclusion—with mandible in centric rela- lar occlusal plane, mandible surgically advanced into class I
tion (b) Pre-surgery: Maxillary second premolars and man- occlusion by bilateral sagittal split ramus osteotomy.
dibular first premolar teeth are extracted to allow correction ©Copyright Keisuke Koyama 2020. All rights reserved

a b c

Fig. 39.12 (a) Pretreatment: Typical dental, skeletal, and (c) Post-surgery: Mandibular subapical osteotomy to par-
facial features associated with severe anterior open bite— tially level mandibular occlusal plane. Resected bone is
class I occlusion—with mandible in centric relation. (b) sculptured to proper dimensions to facilitate its placement
Presurgery: Maxillary second premolars and mandibular into bony gap created by closure of open bite. Anterior
first premolar teeth are extracted to allow correction of mandibular segment fixed by an interocclusal splint and
malaligned teeth by orthodontic means. Reposition of the the mandibular arch wire. ©Copyright Keisuke Koyama
osteomized segment in the planned position and resection 2020. All rights reserved
of the inferior aspect of the chin for bone a­ ugmentation.

3 Conclusion References

Segmental osteotomies are complementary pro- 1. Möhlhenrich SC, Modabber A, Steiner T, Mitchell
DA, Hölzle F. Heat generation and drill wear during
cedures in orthognathic surgery. In addition to dental implant site preparation: systematic review. Br
the limited options for segment shifting, segment J Oral Maxillofac Surg. 2015;53(8):679–89.
stabilization also requires prudence and experi- 2. Siegel SC, Fraunhofer JA. Irrigating solution and
ence. 3D planning can help with this. Splints and pressure effects on tooth sectioning with surgical burs.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
the patient’s cooperation are required to achieve 1999;87(5):552–6.
primary healing. 3. Köle H. Surgical operations on the alveolar ridge to
correct occlusal abnormalities. Oral Surg Oral Med
Oral Pathol. 1959;12(3):277–88.
 Lateral Mandibular Step
Osteotomy/Ostectomy, Posterior
40
Subapical Osteotomy and Anterior
Body Osteotomy

Peter Kessler and Nicolas Hardt

Contents
1 Lateral Mandibular Step Osteotomy/Ostectomy 304
1.1 Detailed Surgical Steps 304
1.1.1 Step 1: Mucoperiosteal Incision 304
1.1.2 Step 2: Osteotomy (Fig. 40.1) 305
1.1.3 Step 3: Setting the Segment and Fixation (Fig. 40.1) 305
2  osterior Subapical Osteotomy
P 305
2.1 Indications 305
2.2 Detailed Surgical Steps 305
2.2.1 Step 1: Mucoperiosteal Incision 305
2.2.2 Step 2: Osteotomy 305
2.2.3 Step 3: Stabilization 305
3  nterior Body Osteotomy (Straight Vertical Osteotomy)
A 305
3.1 Detailed Surgical Steps 305
3.1.1 Step 1 305
3.1.2 Step 2 306
3.1.3 Step 3 306
3.1.4 Step 4 306
3.1.5 Step 5 307
3.1.6 Step 6 307
3.1.7 Step 7 307
4 Conclusion 307
References 307

Abstract
P. Kessler (*)
Department of Cranio-Maxillofacial Surgery, The principle of the lateral mandibular body
Maastricht University Medical Center,
Maastricht, The Netherlands
step osteotomy/ostectomy and the anterior
e-mail: [email protected] vertical body osteotomy are variants of ante-
N. Hardt (*)
rior segment osteotomy for mandibular prog-
Kantonsspital Lucerne, Clinic and Policlinic of nathism but can also be used to reposition the
Cranio-Maxillofacial Surgery, Lucerne, Switzerland anterior segment of the mandible backward or

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 303
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_40
304 P. Kessler and N. Hardt

vertically. This procedure is reserved for spe- The method is indicated in cases of:
cial indications and individual treatment situa- 1. Mandibular anterior open bite.
tions and is not one of the first-choice forms of 2. Excessive mandibular sagittal growth.
therapy. Posterior subapical osteotomy/ostec- 3. Asymmetries of the mandibular dental arch.
tomy is also reserved for specific indications. 4. Mandibular retrognathia.

Keywords
1.1 Detailed Surgical Steps
Segment osteotomies · Lateral mandibular
step osteotomy · Vertical osteotomy ·
1.1.1 Step 1: Mucoperiosteal Incision
Ostectomy · Mandibular osteotomies ·
Dysgnathia · BSSO · Alveolar protrusion - • After extraction of the first/second premo-
Mandibular prognathism · Open bite · Deep lars, a transoral circum-vestibular incision is
bite · Preoperative planning · Surgical access made distal to the second molar, and the
· Incision · Osteosynthesis bone of the mandibular body is then exposed
subperiosteally only in the region of the
canines/premolars up to the inferior man-
1 Lateral Mandibular Step dibular rim in order to keep the soft tissues
Osteotomy/Ostectomy attached and not to compromise blood circu-
lation of the mandible.
In most cases this is a procedure with osteoto- • The soft tissue flap should be extended to
mies in the region of the second premolar. The behind the second premolar to provide ade-
step-shaped bone cut avoids displacement of the quate access to the prospective osteotomy area
mental nerve in the osteotomy area (Fig. 40.1). and thus avoid unnecessary soft tissue trauma.

Fig. 40.1 Principle of lateral mandibular body step osteotomy/ostectomy as a variant of an anterior segment osteotomy
for correction of mandibular prognathism [1]. ©Copyright Keisuke Koyama 2020. All rights reserved
40 Lateral Mandibular Step Osteotomy/Ostectomy, Posterior Subapical Osteotomy and Anterior... 305

1.1.2 Step 2: Osteotomy (Fig. 40.1) 2.2 Detailed Surgical Steps

• After adequate exposure of the mental nerve 2.2.1 Step 1: Mucoperiosteal Incision
and the subapical premolar region, a horizon- The transoral incision begins at the front edge of
tal osteotomy is performed 5 mm below the the ascending mandibular ramus and extends to
premolar apices and above the foramen. the canine region.
• Two vertical osteotomies are then made in the In the area of the intended osteotomy, the ves-
extracted first/second premolar region and the tibular incision is made marginally, starting one
interdental bone segment is removed. tooth width behind the intended posterior, respec-
• To preserve the inferior alveolar neurovascu- tively anterior osteotomy.
lar bundle, the anterior vertical alveolar oste- The periosteal attachment is detached, but
otomy in front of the foramen is extended the inferior border of the mandible is left
caudally to the edge of the mandible—corre- untouched to preserve soft tissue contour and
sponding to a step osteotomy—and a second not to compromise blood supply, the neurovas-
anterior vertical osteotomy is placed parallel cular bundle is identified, and the horizontal
and mesial to it. The width of this bone seg- incision is carefully extended into the anterior
ment corresponds to the width of the interden- premolar region.
tal bone segment.
2.2.2 Step 2: Osteotomy
1.1.3 Step 3: Setting the Segment The horizontal osteotomy is performed subapi-
and Fixation (Fig. 40.1) cally, about 5 mm from the root tips. Special
attention must be paid to the course and integrity
• After mobilization, the anterior segment is of the mandibular canal and its contents.
positioned posteriorly, thereby closing the The horizontal osteotomy is connected to
defect of the extraction socket. Care must be two vertical osteotomies posterior to the last
taken to ensure sufficient bone contact in order molar and in front of the first/second premo-
to avoid periodontal problems later on. lar. The interdental and horizontal bone inci-
• If no extraction is planned, the anterior seg- sions should be made carefully with a fine
ment is positioned cranially, closing the open chisel or better with the piezo device to avoid
bite. injury to the roots. After mobilization of the
• After securing the segment position with segment, the posterior segment can be
monomaxillary splinting, rigid segment fixa- repositioned.
tion must be performed with miniplates and
self-tapping bone screws where appropriate 2.2.3 Step 3: Stabilization
(1.5/2.0 mm miniplates and self-tapping corti- The mobilized and splinted segment is definitely
cal screws) [2]. stabilized with mono-cortical 1.5 mm miniplates.

2 Posterior Subapical Osteotomy 3 Anterior Body Osteotomy

(Straight Vertical Osteotomy)
2.1 Indications
3.1 Detailed Surgical Steps
• Correction of super-eruption of teeth in the
posterior mandible. 3.1.1 Step 1
• Ankylosis of premolars and/or molars. Bilateral circum-vestibular incision with preser-
• Abnormal transverse position of the posterior vation of the attached gingiva in the area of the
teeth/alveolar process tilting, if orthodontic first or second premolar, depending on the
treatment is not possible or not successful. intended extraction (Fig.40.2).
306 P. Kessler and N. Hardt

Fig. 40.2 Incision line ©Copyright Keisuke Koyama Fig. 40.4 Identification of the mandibular canal
2020. All rights reserved ©Copyright Keisuke Koyama 2020. All rights reserved

Fig. 40.5 Vertical osteotomy ©Copyright Keisuke

Fig. 40.3 Extraction of premolars ©Copyright Keisuke Koyama 2020. All rights reserved
Koyama 2020. All rights reserved

3.1.4 Step 4
3.1.2 Step 2 After the inferior alveolar nerve is identified and
Extraction of premolars before performing oste- mobilized, two parallel vertical osteotomy lines
otomies in the region where the resection is are created with a fine drill marked on the cortical
planned (Fig. 40.3). bone surface, then the lingual mucoperiosteum is
detached from the bone with a fine dissector and
3.1.3 Step 3 the osteotomy is performed with a saw/drill/
Removal of the lateral cortex above the terminal piezosurgery (Fig. 40.5).
end of the nerve (piezosurgery) and identification
and mobilization of the inferior alveolar nerve
(Fig. 40.4).
40 Lateral Mandibular Step Osteotomy/Ostectomy, Posterior Subapical Osteotomy and Anterior... 307

3.1.5 Step 5 3.1.6 Step 6

After completion of the two osteotomies, the After bilateral resection, the anterior segment is
bone segment is removed (Fig. 40.6). placed in the pre-planned posterior mandibulo-­
maxillary position. Mandibulo-maxillary fixation
is achieved with a prefabricated surgical splint
and using intermaxillary ligatures.

3.1.7 Step 7
Rigid internal fixation is usually achieved with
two straight 2.0 mm miniplates above and below
the mandibular canal/mental foramen (Fig. 40.7).

4 Conclusion

Excessive mandibular growth in three-­

dimensional space, but also deficient vertical
mandibular growth—open bite, but also espe-
cially sagittal mandibular growth deficits can be
Fig. 40.6 Ostectomy of mandibular segment ©Copyright
an indication for supplementary segmental oste-
Keisuke Koyama 2020. All rights reserved
otomies of the mandible. Pronounced asymme-
tries can also be improved in the bite relation by
segment osteotomies. Combinations with other
osteotomy procedures are possible.
Osteosynthetic stabilization is challenging
and may not always meet the definition of rigid
osteosynthesis. The dentition plays an important
role in segmental osteotomies, as osteotomies
have to be placed in interdental spaces.

References
1. Fonsecca RJ, Marciani RD, Turvey TA. Oral and max-
illofacial surgery, vol. 1. Saunders/Elsevier; 2009.
2. Shafer DM, Assael LA. Rigid internal fixation of man-
dibular segmental osteotomies. Atlas Oral Maxillofac
Fig. 40.7 Rigid internal fixation with two 2.0 mm osteo- Surg Clin North Am. 1993;1:41–51.
synthesis plates ©Copyright Keisuke Koyama 2020. All
rights reserved
 Intraoperative Risks in Segment
Osteotomies: Danger Points
41
and Errors

Peter Kessler and Nicolas Hardt

Contents
1 Vascularization of the Segment  310
2 Injury of the Mental Nerve  310
3 Injuries to Teeth, Periodontium, and Alveolar Ridge  310
4 Injury of Adjacent Tooth Roots  310
5 Injuries Due to Osteosynthesis Screws  310
6 I njury of Periodontium and Alveolar Crest  310
6.1 Thermal Damage  311
6.2 Insufficient Wound Closure with Dehiscence  311
6.3 Insufficient Segment Stabilization  311
7 Conclusion  311
References  311

Abstract mies present a particular challenge because they

must be performed in an anatomically limited
The risks of surgery are defined by the anatomy,
space, but at the same time the greatest attention
the surgical intervention, and the chance of suc-
must be paid to perfusion of the osteotomized
cess, among other factors. Segmental osteoto-
segment. The segmental stability that can be
achieved may not always be satisfactory.

P. Kessler (*) Keywords

Department of Cranio-Maxillofacial Surgery,
Maastricht University Medical Center, Segment osteotomies · Mandibular osteoto-
Maastricht, The Netherlands mies · Preoperative planning · Surgical access
e-mail: [email protected] · Incision · Osteosynthesis · Mental foramen ·
N. Hardt (*) Mental nerve · Tooth damage · Infection ·
Kantonsspital Lucerne, Clinic and Policlinic of Wound dehiscence
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 309
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_41
310 P. Kessler and N. Hardt

1 Vascularization of the Segment 4 Injury of Adjacent Tooth Roots

The vascularization of the osteotomized segment/ Injuries to adjacent tooth roots can occur due to
segments is performed exclusively through the lin- the bone cut during vertical and horizontal oste-
gual soft tissue attachment. This implies that intra- otomy as well as due to osteosynthesis screws
operative injuries to the lingual soft tissue attachment during segment fixation. If osteotomies are per-
during surgery must be strictly avoided [1]. formed in close vicinity to the roots of neigh-
Soft tissue trauma to the lingual mucosa, as boring teeth or resection of root tips occurs,
well as injury and denudation of the lingual peri- pulp necrosis with discoloration of the teeth
osteal stalk, results in delayed revascularization may occur, resulting in endodontic treatment.
and compromises bone healing. Tooth root injuries due to surgery [2].
• Injury rate through segmental osteotomies
Note approx. 4–12%.
• Muscle stripping of the adherent mus- • Temporary loss of sensitivity for 6–12 months.
cles should be kept to a minimum, since • Direct damage to the roots of teeth heals in
segmental vascularization occurs by the about 90% of cases.
inserting muscles on the lingual side.
• Excessive soft tissue trauma can lead to
Note
devitalization of the segment.
The vascular supply of teeth in the segment
• It is also advisable to segment the alveo-
requires that the horizontal osteotomy be
lar process of a jaw into only a few
placed ≥5 mm from the root tips of the
major segments, as multiple segmenta-
teeth in the segment.
tion reduces blood supply.

5 Injuries Due to Osteosynthesis

2 Injury of the Mental Nerve
Screws
The mental nerve should be carefully protected
The contact rate between osteosynthesis screws
during the operation. Injuries to the mental nerve
and tooth roots in segmental osteotomies is 12%.
during segmental and chin osteotomies can
Postoperatively, however, pulp necrosis, devital-
result in up to 5% in long-term dysfunction and
ization of the teeth, or pain related to the screw
pain.
injury are rarely observed. If the tooth root is
immediately pierced or the root canal is perfo-
rated, the tooth may be lost.
3 Injuries to Teeth, Periodontium,
and Alveolar Ridge
6 Injury of Periodontium
Note and Alveolar Crest
• Loss of teeth in osteotomized segment
due to loss of lingual tissue attachment, The alveolar ridge and the periodontium of teeth
decrease in blood supply. neighboring the vertical osteotomy must be pro-
• Bone cuts placed close to the teeth— tected. If these structures are injured during the
loss of vitality and periodontal defects. operation, deep periodontal pockets may form.
• Tooth root injuries caused by osteosyn- Ankylosis or loss of teeth may result.
thesis screws. Intensive irrigation of the drilling and cutting
instruments minimizes thermal bone damage.
41 Intraoperative Risks in Segment Osteotomies: Danger Points and Errors 311

Whenever an alveolar bone defect develops, a ment displacement due to fibrous pseudarthrosis
bone graft should be considered for the defect. (pseudarthrosis formation—malunion) or non-­
union (delayed bone healing) of the osteotomized
segments.
6.1 Thermal Damage

High-speed drilling and high contact pressure 7 Conclusion

combined with insufficient water cooling can
cause bone necrosis with increasing osteotomy The risks of damage to adjacent tooth structures,
depth. insufficient segmental blood supply, and insuffi-
cient stability are realistic and must be discussed
in detail with the patient. Alternative treatments
6.2 Insufficient Wound Closure should always be considered.
with Dehiscence

Incorrect wound closure can lead to wound dehis- References

cence, hematoma formation, soft tissue and bone
infection, and bone/tooth loss—an undesirable 1. Bell WH, Proffit WR, White RP. Surgical correction of
dentofacial deformities. Philadelphia: WB Saunders;
postoperative outcome.
1980.
2. Young Kyun K. Complications associated with orthog-
nathic surgery. J Korean Assoc Oral Maxillofac Surg.
2017;43(1):3–15.
6.3 Insufficient Segment
Stabilization

Good segment immobilization and fixation are

necessary to prevent segment instability and seg-
 Tricks and Typical Mistakes
42
Peter Kessler and Nicolas Hardt

Contents
1 Intraoperative Tricks  313
2 Intraoperative Errors  314
3 Management After Surgery  314
4 Limitations and Contraindications  314
5 Conclusion  314
References  315

Abstract Keywords

Segment osteotomies can present challenges Segment osteotomies · Mandibular osteoto-

to even the most experienced surgeon because mies · Tips and tricks · Incision · Nerve
the surgical margin of maneuver is limited. injuries · Tissue traumatization · Segment
Tips and tricks help to recognize and treat stability
unexpected problems intraoperatively. The
limits of the method must be known and
adhered to.
1 Intraoperative Tricks

P. Kessler (*) • Labial extension of the parabolic vestibular

Department of Cranio-Maxillofacial Surgery, mucosa incision—infra-submucous prepara-
Maastricht University Medical Center, tion up to the periosteum—two layers.
Maastricht, The Netherlands
e-mail: [email protected] • Segment position control with occlusal splint
and temporary securing of the segment.
N. Hardt (*)
Kantonsspital Lucerne, Clinic and Policlinic of • Two-layer wound closure: first muscle and
Cranio-Maxillofacial Surgery, Lucerne, Switzerland periosteum then mucosa.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 313
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_42
314 P. Kessler and N. Hardt

• Before wound closure: thorough mechanical 4 Limitations and Contraindications

cleaning of the wound with saline and con-
stant suction. All segmental osteotomies share some potential
• Wound closure only after definitive stabiliza- complications, which may be mild, moderate, or
tion of the segment. severe [1].

• Mild complications include periodontal

2 Intraoperative Errors defects, pulp necrosis, infection, and delayed
union.
• Intraoral access/incision not wide enough. • Moderate complications may include infec-
• Thus missing overlook and unnecessary soft tion, delayed union, and malunion.
tissue traumatization. • Severe complications include nonunion and
• Crushing of soft tissues, resulting in edema, tooth and/or bone loss.
hematoma, and postoperative pain.
• Tearing/detachment of the periosteum result- Because the mandible presents a thick cortical
ing in delayed or compromised wound bone, the blood supply may be threatened after
healing. soft tissue detachment. Therefore, osteotomies
• Exaggerated denudation thereby increased that involve small segments of bone, with one or
risk of devitalization of the fragment ends. two teeth mobilized, should be discouraged.
• Too high speed and too little cooling during Also, because the soft tissue pedicle
drilling causing bone necrosis. attached to the mobilized segment is the exclu-
• Mental/inferior alveolar nerve injuries— sive blood supply, the more it is mobilized or
directly related to the size of surgical trauma. manipulated surgically and the further it is
repositioned, the greater the potential for
detachment of the pedicle and thus compro-
3 Management After Surgery mise of its vasculature.
The anterior subapical osteotomy is mostly
After segmental mandibular osteotomy, an exter- contraindicated when the anterior mandible is
nal tight pressure dressing is applied to prevent short in height. In some cases the apices of the
the formation of hematomas in the surgical site anterior teeth, especially the canines, are close to
and to limit the mobility of the lip and chin region the inferior border of the mandible, impeding
in the first days of healing. This allows the soft performance of the osteotomy. Even if enough
tissues to be reattached to the bony base. space is available to complete the osteotomy, at
A 1 in. (2.5 cm) elastic tape is cut and folded least 1 cm of basilar bone should remain to ensure
butterfly-­wise so that there is no adhesive in the the integrity of the mandible.
center section. Two of these tapes each are placed
in front of and under the chin.
If patient hygiene requires the tapes to be 5 Conclusion
changed, the adhesive tapes can be removed
without touching the skin over the surgical site, Segment osteotomies represent an addition to
which facilitates their removal or replacement. the possibilities of performing corrections in the
42 Tricks and Typical Mistakes 315

area of the alveolar process that have not been appearance of the face. Technically, segmental
successful orthodontically or cannot be success- osteotomies are challenging and carry typical
ful because the anatomical conditions do not risks that are significantly different from those of
allow it. In rare cases, segmental osteotomies mandibular relocation in toto.
may be indicated as the sole surgical
correction.
The basic methods in orthognathic surgery References
concern the relocation of the complete jaws [2].
Partial or segmental osteotomies help where, due 1. Epker BN, Fish LC. Dentofacial deformities: inte-
to unfavorable local anatomical, genetic, or tech- grated orthodontic and surgical correction. St. Louis:
C.V. Mosby; 1986.
nical possibilities, there is no other option than to 2. Kashani H, Rasmusson L. Osteotomies in orthog-
improve occlusion by partial osteotomy. From an nathic surgery. In: Motamedi M, editor. A textbook
esthetic point of view, segmental osteotomies of advanced oral and maxillofacial surgery, vol. 3.
often include too small volumes to affect the London: Intech; 2016.
 Part IX
Chin Osteotomies
 Indications for Chin Osteotomy/
Genioplasty and Standard
43
Procedures

Peter Kessler and Nicolas Hardt

Contents
1  tandard Procedures in Genioplasty 
S 320
1.1 Horizontal Osteotomy for Chin Advancement  320
1.2 Horizontal Osteotomy for Chin Repositioning  320
1.3 Horizontal Sliding Osteotomy  321
1.4 Double Sliding Chin Osteotomy to Reduce Chin Height  321
1.5 Slanted Osteotomy for Chin Advancement  322
1.6 Transverse Narrowing/Widening Genioplasty  322
2 Genioplasty and Facial Profile Changes  323
3 Preoperative Planning  323
4 Conclusion  324
References  324

Abstract Generally, surgeons use the standard slid-

The chin is one of the most important units of ing osteotomy with anteroposterior displace-
facial structures responsible for the overall ment, which is used to correct both the
appearance and esthetics of the face. Chin retrusive and protrusive chin. There are many
osteotomies are routine esthetic procedures to modifications, such as curved osteotomy,
create a harmonious appearance of the face in M-shaped osteotomy, transverse reduction
terms of shape, position, and size. osteotomy, and others. Mandibular anatomy is
highly variable, as are the patient’s esthetic
requirements. Therefore, the solution should
P. Kessler (*)
Department of Cranio-Maxillofacial Surgery, be individualized in each clinical case, includ-
Maastricht University Medical Center, ing the position of the chin.
Maastricht, The Netherlands The 3D technologies with simulation of the
e-mail: [email protected]
covering soft tissue are suitable for simulating
N. Hardt (*) the desired result.
Kantonsspital Lucerne, Clinic and Policlinic of
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 319
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_43
320 P. Kessler and N. Hardt

Keywords wrinkle between chin and lip skin is

disturbing.
Chin · Progenia · Retrogenia · Receding chin
• In extremely protruding and square formed or
· Preoperative 3D planning · Standard
pointed chins.
procedures · Facial profile changes -
• In excessive vertical triangular growth—often
Transgender surgery · Surgical techniques ·
related to vertical excess in the lower third of
Genioplasty · Chin osteotomy · Intraoperative
the face.
risks and tricks · Postoperative complications
• In mandibular prognathism, if the mandibular
setback does not lead to an esthetically bal-
anced face.
• Exostotic humps.
• Asymmetric chin hyperplasia.
Note
• The facial appearance forms the basis
for the typological characteristics and
1 Standard Procedures
personality of a human being.
in Genioplasty
• The chin is one of the most prominent
elements of the face.
Corrections of the form or position of the chin can
• Chin deformities manifest themselves
be achieved by various surgical techniques leading
three-dimensionally, but the majority is
to a three-dimensional positional change of the
related to horizontal deviations.
chin point in the sagittal, vertical, and transverse
dimension. Genioplasties can be combined with
all kind of orthognathic surgical interventions in
Chin osteotomy was first described by Hofer in the mandible, the maxilla, or both [3, 4].
1942 [1]. Genioplasty also carries risks: esthetic Most often horizontal chin osteotomies are
deformation and asymmetry, step-like shape of used for the sagittal correction in anterior or pos-
the mandibular contour depending on the chin terior direction (Fig. 43.1).
dimension and distance of displacement, notch-
ing of the mandibular body, and worsening of
the labiomental fold after advancement genio- 1.1 Horizontal Osteotomy
plasty. In order to avoid abovementioned disad- for Chin Advancement
vantages, numerous modifications have been
developed [2]. See Fig. 43.1.
Facial profiles in the lower facial third can be
classified as of normal proportion, or as pro-genic
with a horizontal excess in volume and size, or as 1.2 Horizontal Osteotomy
retro-genic with a sagittal setback and decreased for Chin Repositioning
volume. The anterior vertical height if increased
is regarded as disturbing. Surgically same procedure as for chin advance-
Surgical correction is indicated, if: ment with reduction of tips or overlapping bone
steps of the mobilized chin segment to ensure a
• The chin is receding or even micro-genic as an smooth transition to the mandibular margin to
independent anomaly without malocclusion. avoid palpable steps.
• In mandibular advancement or correction of
mandibular asymmetry the basic surgical cor- Note
rection is not esthetically satisfactory. Increase of the anterior vertical height of
• In the case of a very pronounced chin-lip fur- the lower jaw.
row, e.g., as a result of a deep bite, where the
43 Indications for Chin Osteotomy/Genioplasty and Standard Procedures 321

a b

Fig. 43.1 (a) Horizontal osteotomy with chin advance- chin advancement. Vertical line to mark the center line.
ment: Double creation of a horizontal osteotomy line for (b) Osteosynthesis
ostectomy of a segment, shortening of the chin height and

a b

Fig. 43.2 Horizontal sliding osteotomy of the chin with elongation, osteosynthesis, and interposition of bone sub-
vertical elongation (a) Marking the center lines and the stitute material
horizontal osteotomy (b) Intraoperative view with vertical

1.3 Horizontal Sliding Osteotomy 1.4 Double Sliding Chin

Osteotomy to Reduce Chin
The sliding osteotomy is performed either to extend Height
or to reduce the chin height (Figs. 43.2 and 43.3).
In the case of a sliding osteotomy with vertical In the double sliding chin osteotomy, a bone
extension, the chin is moved downwards and pos- strip is removed to vertically reduce the chin
sibly forward. The downward movement of the chin height and an anterior or posterior reduction of
segment is associated with the formation of a gap. the segment can be performed in conjunction
If the vertical defect is larger than 5 mm, aug- with the vertical shortening (Fig. 43.3).
mentation of the gap with autogenous bone or
bone replacement material must be considered to
ensure a perfect contour.
322 P. Kessler and N. Hardt

a b

Fig. 43.3 Double Sliding Osteotomy to reduce chin height. (a) The bone strip marked red is resected (b) Miniplate
stabilization ©Copyright Keisuke Koyama 2020. All rights reserved

result, the muscle attachments are also shifted

upwards and forward, thus relaxing the entire
perioral region. The contour of the chin deter-
mined by the soft tissue is not changed.

1.6 Transverse Narrowing/

Widening Genioplasty

Vertical osteotomies/ostectomies can be added to a

horizontal chin osteotomy for transverse, but also
sagittal chin deformities. This allows the chin to be
widened or narrowed (Fig. 43.5). Reduction or
Fig. 43.4 Diagram of the oblique/slanted osteotomy for augmentation genioplasty requires combined work
chin advancement ©Copyright Keisuke Koyama 2020.
All rights reserved
in the horizontal, sagittal and transverse planes so
as to obtain a harmonious result.
The transversal dimension of the chin can
1.5 Slanted Osteotomy for Chin
be changed by segmenting the symphyseal
Advancement
region. In case of widening, additional bone
grafts or alloplastic materials (resorbable or
In an oblique chin osteotomy, a forward displace-
non-­resorbable blocks) are integrated into the
ment is performed with simultaneous rotation of
median gap.
the chin segment upwards (Fig. 43.4) [5].
If reduction of the transverse dimension of the
The advantage is that a maximum forward and
chin is planned, two parallel vertical osteotomies
upward displacement of the chin apex is possible.
are performed laterally of the midline and a bone
An essential element of this technique is that the
segment is removed.
muscles remain attached to the bony chin. As a
43 Indications for Chin Osteotomy/Genioplasty and Standard Procedures 323

Fig. 43.5 (a) Reduction of the transverse width of the chin (b) Widening of the transverse dimension of the chin
©Copyright Keisuke Koyama 2020. All rights reserved

2 Genioplasty and Facial Profile gery) are associated with a shortening or

Changes lengthening of the soft tissue relief of the lower
face of 90% of the skeletal displacements.
Profile changes after chin osteotomies are highly 3D planning programs with soft tissue simula-
dependent on the surgical method, the bony base, tion are an enormous help in the preoperative
and the soft tissue volume of the chin region. assessment of the perceptible changes in the
Profile predictions prior to chin plastic surgery facial profile in the chin region. Thus, changes in
should therefore—with appropriate education of the position of the chin are among the most
the patient—only be understood as guidelines. esthetically effective visible changes in the pro-
Displacements of the bony chin after horizon- file of the face.
tal osteotomy lead to a 90% reduction of the vis-
ible soft tissue pogonion when the segment is
repositioned and to an augmentation of the chin 3 Preoperative Planning
soft tissue by approximately 75% of the bony dis-
placement distance after forward displacement. Genioplasty requires careful preoperative plan-
At the same time, the labiomental fold is flat- ning based primarily on two- and three-­
tened or reinforced. dimensional cephalometry and its analysis.
Chin displacements with simultaneous ostec- Simulation can be performed based on CBCT
tomy or bone interposition (sandwich plastic sur- images and facial photos, 3D reconstruction of
324 P. Kessler and N. Hardt

bones and soft tissues of the face. The virtual References

planning based on specialized medical software
programs creates the possibility of 3D printing of 1. Hofer O. Die operative Behandlung der alveo-
anatomic models and surgical guides as well as lären Retraktion des Unterkiefers und ihre
Anwendungsmöglichkeit für Prognathie und
prefabrication of osteosynthesis plates for Mikrogenie. Dtsch Zahn Mund Kieferheilk.
fixation. 1942;9:142–4.
2. Haggerty CJ, Laughlin RM. Operative atlas of oral
and maxillofacial surgery. Wiley-Blackwell; 2015.
3. Bell WH, Proffit WR, White RP. Surgical correction
4 Conclusion of dentofacial deformities, band 1–3. Saunders; 1980.
4. Kelly JP. Mandibular osteotomies. In: Keith DA, edi-
Changing the position of the chin is an essential tor. Atlas of oral and maxillofacial surgery. Saunders;
part of corrective orthognathic surgery, but it 1992.
5. Joos U, Delaire J, Scheibe B, Schilli W. Funktionelle
belongs to facial esthetic surgery. The technique Aspekte der Kinnplastik. Fortschr Kiefer Gesichtschir.
is simple and varied. 1981;26:86.
 Principle Surgical Technique
44
Peter Kessler and Nicolas Hardt

Contents
1 Anatomical Reference Points  325
2 Technical Notes  326
3  orizontal Chin Osteotomy 
H 327
3.1 Stepwise Surgical Approach  327
3.2 Fixation Technique  330
4  hin Wing Osteotomy 
C 330
4.1 S urgical Principle  330
4.2 S  tepwise Surgical Approach  331
5 Conclusion  331
References  331

Abstract Keywords

Genioplasty can be performed so that the chin Genioplasty · Chin osteotomy · Horizontal
can be relocated as a whole or divided. The chin osteotomy · Sliding chin osteotomy ·
inclination of the osteotomy line can be Chin wing osteotomy
adjusted to the chin displacement. The chin
wing osteotomy is a lateral extension of the
genioplasty.
1 Anatomical Reference Points

• Labial insertion of the frenulum of the lower

P. Kessler (*)
Department of Cranio-Maxillofacial Surgery, lip.
Maastricht University Medical Center, • Mental foramen with mental nerve.
Maastricht, The Netherlands • Alveolar yokes.
e-mail: [email protected] • Base of the mandible.
N. Hardt (*) • Digastric fossa.
Kantonsspital Lucerne, Clinic and Policlinic of • Mental protuberance.
Cranio-Maxillofacial Surgery, Lucerne, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 325
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_44
326 P. Kessler and N. Hardt

2 Technical Notes
Note
• Three main neural branches emerge Prior to the osteotomy of the chin (genioplasty),
from the mental foramen (Fig. 44.1). the midline of the chin and mandible should be
• One branch innervates the mental skin marked after exposure of the chin area. This step
area. is important for controlled midline shifts
• The two other branches innervate the (Fig. 44.2).
skin of the lower lip area, the vestibular
mucosa and the gingiva to posterior of
the second premolar.

Fig. 44.1 Branching pattern and intrabony and extrabony

course of the mental nerve. A angular branch, M medial
branch, ILm inferior labial medial, Ill inferior labial lat-
eral, ICN incisive nerve [1, 2]

Pre-op Post-op
a

Fig. 44.2 (a) The center line of the mandible and the cen- ment of the osteotomized chin segment. (b) Horizontal
ter line of the chin and the horizontal osteotomy line osteotomy line about 5 mm below the root apices of the
should be marked as reference points/lines using a drill or front teeth. ©Copyright Keisuke Koyama 2020. All rights
fine saw. This marking avoids intraoperative misalign- reserved
44 Principle Surgical Technique 327

Fig. 44.2 continued

3 Horizontal Chin Osteotomy

3.1 Stepwise Surgical Approach

Step 1: Mucosal Incision and Mucoperiosteal

Dissection
The labial mucosa and the vestibule are infiltrated
with a local anesthetic containing vasoconstric-
tive additives before incision. After retraction of
the lower lip and exposure of the vestibule with
Langenbeck hooks and drying of the mucosa, the
incision is color-marked.
Fig. 44.3 Anatomical variations of the horizontal posi-
Subsequently, the mucosa is cut parabolically
tion of the mental foramen. Blue: mental incisive canal
from element 35–45. The apex of the incision (MIC), red: mental canal, yellow: mandibular canal (acc
parabola lies in the median area of the labial [3, 4]). (a) Possible positions of the mental foramen in
mucosa. This incision guide prevents subsequent horizontal plane. (b) Average location of the mental fora-
men in the Caucasian population. ©Copyright Keisuke
suture dehiscence. After cutting through the
Koyama 2020. All rights reserved
mucosa and submucosa, the mental foramina and
the mental nerves are identified and dissected
bluntly (Figs. 44.1 and 44.3).
Note
The periosteum is then incised below, above,
• Exposition of the surgical field to the
and behind the foramen and lifted slightly under
first molars on both sides.
traction so that the periosteal conus can be care-
• Preparation of the mental foramina on
fully incised along the course of the nerve and the
bilaterally.
mental nerve can be prepared freely in order to
• Exposition of the mental nerve.
minimize the risk of injury on the one hand and to
better protect the nerve on the other hand due to the
considerably wider access and better overview.
328 P. Kessler and N. Hardt

Then, below the mobilized mucosal-­

submucosal cuff, the chin muscles are cut sharply
down to the bone approximately halfway between
the marginal gingiva and the inferior rim of the
lower jaw. The periosteum is incised in the same
place.
A smooth, atraumatic detachment of the adher-
ent tendon tissue of the mental muscle especially at
the mental protuberances is best achieved with a
sharp-edged, not too wide dissector.
The mimic muscles of the oral fissure insert
laterally and can be levered off smoothly, so that
it is recommended to start with the subperiosteal Fig. 44.4 Nerve loop of the mental nerve in the mental
dissection here first (height: mental foramen) and canal. The region marked “c” marks the most common
position of the mental foramen (acc [3, 4]). Blue = inci-
then subperiosteally detach the adherent attach- sive canal; red = mental canal (the opening of the man-
ment of the mental muscle (mental tubercle/pro- dibular canal); yellow = mandibular canal. ©Copyright
tuberances) up to the alveoli of the central Keisuke Koyama 2020. All rights reserved
incisors without tearing the periosteum.
An elevator is then used to lift the periosteum below the apices and laterally to the edge of the
to the edge of the inferior border of the man- lower jaw (Figs. 44.2 and 44.4).
dibular rim. The inferior periosteum attachment Laterally of the canines the osteotomy should
of the soft tissues of the chin should be left as be 4–5 mm below the mental foramen to avoid
untouched as possible to preserve the soft tissue injury to the nerve bundle.
contour and not to compromise the chin seg- The nerve canal itself lies up to 4–5 mm below
ment blood flow. the mental foramen. The lateral end of the oste-
otomy is determined by the shape of the chin [1].

Note
• Subperiosteal mobilization of the soft Note
tissues in the chin region takes place up • The osteotomy line should be 5–10 mm
to the inferior edge of the lower jaw. below the apices of the front teeth.
• The inferior periosteal attachment of the • 5 mm below the apices of the canines.
soft tissues of the chin should remain • 4–5 mm below the mental foramen.
unaffected as far as possible. • 10–15 mm above the lower mandibular
• Also maintain a 5 × 10 mm field of the edge.
periosteal attachment in the center of the
chin symphysis to ensure soft tissue
attachment and blood supply.

Note
It is important that the osteotomy runs
Step 2: Osteotomy 4–5 mm below the visible mental foramen
For the subsequent osteotomy, the center line so that no injury to the anterior loop of the
should be marked crosswise as a reference point mental nerve occurs while the mental nerve
with a small Lindemann drill (Fig. 44.2). ascends within the canal before leaving the
The position of the root tips determines the foramen.
position and course of the horizontal osteotomy.
The osteotomy runs about 5–10 mm horizontally
44 Principle Surgical Technique 329

Fine cortical drill holes are made along the If a reduction of the vertical height is planned,
color-marked osteotomy line. The horizontal line a parallel osteotomy is performed and the mobi-
is then pre-cut along the cortical perforations lized bone segment is removed.
with a hard-metal fissure drill, alternatively an
oscillating saw can be used. Step 3: Chin Segment Adjustment
The completion of the horizontal osteotomy— Before the chin segment is adjusted to the exact
including the lingual cortical bone—is initially median, vertical, transverse, and sagittal position,
performed with fine Lindemann burrs or the excess bone is removed and the osteotomy mar-
oscillating saw. Fine osteotomes can be helpful. gins are smoothed and contoured.
Of course, the piezo technique is ideal for a
maximally atraumatic procedure, especially on Step 4: Chin Segment Fixation
the lingual side of the chin region to avoid bleed- The chin segment is secured with pre-bent osteo-
ing from the floor of the mouth. synthesis plates or individually bent mini plates
(Fig. 44.5). Especially in the case of vertical chin
elongation and laterally displaced segments to
Note compensate for an existing asymmetry, the osteo-
The more parallel the osteotomy line is synthesis should be sufficiently stable.
made to the occlusal and the mandibular If necessary, bone chips may also be added to
plane, the easier it is to relocate the chin cover the terraced step between the mandible and
segment. the advanced chinpoint.

Step 5: Osteosynthesis of the Chin Segment

If the vertical dimension of the chin is to be Prefabricated plates with horizontal steps of 3, 5,
increased, the osteotomy gap can be augmented 7, and 10 mm are available for chin forward and
with bone or bone replacement material. backward displacements.

Fig. 44.5 Genioplasty with a preformed and individually adapted osteosynthesis plate. ©Copyright Keisuke Koyama
2020. All rights reserved
330 P. Kessler and N. Hardt

3.2 Fixation Technique gin and covers the entire mandibular base from
jaw angle to jaw angle (Fig. 44.6).
Positioning of the mobilized chin segment. This operation allows a sagittal, vertical, as
Adaptation of the plate. Drill the screw holes well as transversal repositioning of the mandibu-
with the drill bit and insert short screws. To better lar base in all three planes and has the additional
determine the definitive position of the chin, it is advantage that with the position correction of the
advisable to start at one of the two bone seg- entire mandibular base, the jaw angles can also
ments, so that the plate can be used to control the be influenced in their position [5].
chin to the mandible or vice versa to fix the chin Depending on the anatomy, variations have
segment to the plate pre-fixed to the mandible in been described. The mini chin wing is a variant
a controlled manner. of the chin wing osteotomy that ends before the
mandibular angle. Its design extends from the
Step 6: Wound Closure chin region to the horizontal branch of the man-
After fixation is complete, a two-layer wound dible as in a traditional genioplasty. However,
closure is performed. It is important to ensure the the posterior cut ends in the submandibular
anatomically exact position of the mental mus- notch. It corresponds to a posteriorly extended
cles. For the readaptation of the mentalis aponeu- genioplasty. Its advantage is the possibility to be
rosis, the periosteum and muscles are sutured to combined with a bilateral sagittal split osteot-
the bone periosteum with Vicryl 4 × 0 mattress omy (BSSO).
sutures. This is successful laterally, while possi- There are no contraindications to the real-
ble periosteal incisions are required in the mid- ization of a mini chin wing. Contrarily to the
line region, since the mentalis aponeurosis is traditional chin wing, a very low positioned
difficult to raise. inferior alveolar nerve (IAN) is not a contrain-
Only then is the mucosa readapted with single dication to the short version of the chin wing
button sutures (Vicryl 4 × 0) and finally sutured osteotomy [6].
continuously with Vicryl 5 × 0.

Note
• 2-layer wound closure.
• Periosteum and musculature Vicryl
4 × 0 with mattress sutures.
• Mucosa readaptation with single button
sutures Vicryl 4 × 0, then continuously
with Vicryl 5 × 0.

4 Chin Wing Osteotomy

4.1 Surgical Principle

Fig. 44.6 Principle of chin wing osteotomy. ©Copyright
Keisuke Koyama 2020. All rights reserved
The chin wing osteotomy is performed tran-
sorally as an esthetic correction and contour
enhancement of the entire mandibular lower mar-
44 Principle Surgical Technique 331

4.2 Stepwise Surgical Approach

Note
Step 1: Mucoperiosteal Incision The osteotomy cannot be performed if the
The intraoral incision corresponds to the frontal mandibular canal runs close to the buccal
incision in genioplasty. The mental foramen and cortical bone, because the osteotomy will
nerve is dissected at the foramen so that it can be split the buccal cortex in a beveled angula-
safely protected. tion from above the mandibular canal to
The mucosal incision is continued approxi- inferior and would inevitably cut the
mately 10 mm above the deepest point of the oral nerve.
vestibule to the jaw angle and directed towards
the mandible.
The periosteum is dissected from the cortex to is challenging as the osteotomized bone segment
the level where the chin wing osteotomy is is fragile. Great care must be taken when attach-
planned. It is important that the periosteum is not ing plates and screws.
further detached caudally in order not to compro-
mise the blood perfusion.
The caudal masseter attachments are also 5 Conclusion
bluntly detached from the masseteric
tuberosity. Genioplasty is a simple, varied, and effective
The lingual periosteum and the muscle attach- technique to redefine the chin position. Changing
ments are left untouched to maintain vasculariza- the chin position changes the esthetics of the
tion of the osteotomized segment. face. The combination with all other osteotomy
techniques of the facial skeleton makes the chin
Step 2: Osteotomy osteotomy a very versatile technique.
First, the horizontal chin osteotomy is performed.
The horizontal bicortical osteotomy is best per-
formed piezo-surgically. References
Approximately 10 mm before the mental
1. Hu KS, Yun HS, Hur MS, Kwon HJ, Abe S, Kim
foramen, the horizontal bicortical osteotomy is HJ. Branching patterns and intraosseous course
transferred to a more vertically oriented mono- of the mental nerve. J Oral Maxillofac Surg.
cortical osteotomy. The further monocortical 2007;65(11):2288–94.
osteotomy runs latero-caudally from superior 2. Kieser J, Kieser D, Hauman T. The course and distri-
bution of the inferior alveolar nerve. J Craniofac Surg.
to inferior to the jaw angle to avoid any IAN 2005;16(1):6–9.
injury. 3. Juodzbalys G, Wang HL, Sabalys G. Anatomy of man-
The monocortical osteotomy can also be per- dibular vital structures. Part II: mandibular incisive
formed with a microsaw or a thin burr. Special canal, mental foramen and associated neurovascular
bundles in relation with dental Implantology. J Oral
care must be taken when performing the osteot- Maxillofac Res. 2010a;1(1):e3.
omy near the mental foramen. 4. Juodzbalys G, Wang HL, Sabalys G. Anatomy of
mandibular vital structures. Part I: mandibular canal
Before performing this osteotomy, it is neces- and inferior alveolar neurovascular bundle in rela-
sary to carefully identify the location of the man- tion with dental implantology. J Oral Maxillofac Res.
dibular canal by CBCT examination. 2010b;1(1):e2.
After the complete osteotomy of the mandibular 5. Triaca A, Brusco D, Guijarro-Martinez R. Chin wing
osteotomy for the correction of hyper-divergent skel-
base, mobilization should be performed very care- etal class III deformity: technical modification. Br J
fully to avoid fracturing the basal mandibular Oral Maxillofac Surg. 2015;53:775–7.
segment. 6. Cordier G, Sigaux N, Carlier A, Ibrahim B, Cresseaux
The most dangerous place for fracture is in the P. Mini wing osteotmy: avariant o chin wing oste-
otomy. J Stomatol Oral and Maxillofac Surg.
area around the mental foramen. Osteosynthesis 2020;121(3):282–5.
 Intraoperative Risks: Danger
Points—Postoperative
45
Complications

Peter Kessler and Nicolas Hardt

Contents
1 Nerve Injuries  333
2 Intraoperative Tricks  334
3  ostoperative Complications 
P 334
3.1 E arly Postoperative Complications  334
3.2 Late Complications  334
4 Conclusion  334
References  335

Abstract Keywords

During the genioplasty procedure, the mental Genioplasty · Incision and preparation ·
nerve is at risk of injury. Careful subperiosteal Nerve injury · Hematoma · Mandibular
dissection, retraction, and protection of the nerve osteotomy · Esthetics - Transgender surgery ·
during the osteotomy helps to prevent injuries to Wound dehiscence
the nerve (Bell et al. Surgical correction of den-
tofacial deformities, Band 1–3. Saunders, 1980;
Joos et al. Fortschr Kiefer Gesichtschir 26:86,
1981; Fonsecca et al. Oral and maxillofacial sur- 1 Nerve Injuries
gery, Saunders, 2009; Hofer. Dtsch Zahn Mund
Kieferheilk 9:142–144, 1942). • Injuries to the superficial mucosal distal fibers
of the mental nerve often occur during the
mucosal incision.
P. Kessler (*) • The long-term incidence of sensory loss of the
Department of Cranio-Maxillofacial Surgery, mental nerve due to intraoperative alteration/
Maastricht University Medical Center,
Maastricht, The Netherlands
ablation/injury is approximately 20%.
e-mail: [email protected] • Especially during chin wing surgery injuries
N. Hardt (*)
of the mental and inferior alveolar nerve due
Kantonsspital Lucerne, Clinic and Policlinic of to preparation and dissection at the mental
Cranio-Maxillofacial Surgery, Lucerne, Switzerland foramen and the course of the alveolar canal

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 333
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_45
334 P. Kessler and N. Hardt

can happen. Not only the neural structures but • Rigid segment/chin fixation is achieved using
also the vascular content of the mandibular microplates and screws.
canal can be hurt.
• Injuries to the marginal mandibular branch of
the facial nerve but also the facial artery can 3 Postoperative Complications
happen during the chin wing osteotomy.
3.1 Early Postoperative
Complications
Note
Nerve damage is possible due to: • Excessive soft tissue swelling.
• Incision. • Bleeding and hematoma.
• Periosteal dissection. • Damage to the lingual soft tissues.
• Nerve retraction. • Injury of the genioglossus and geniohyoid
• Osteotomy. muscles.
• Application of osteosynthesis. • Laceration of the sublingual and submental
• Wound closure. arteries with hematoma of the floor of the
mouth—risk of airway obstruction due to
hematoma of the floor of the mouth and bleed-
ing into the tongue.
2 Intraoperative Tricks

• Prepare a wide, tension-free approach for the

3.2 Late Complications
chin osteotomy.
• Clear exposure of the anterior and lateral man-
• Chin asymmetry.
dibula to assess the extent and location of the
• Unequal, asymmetrical contractions of the
chin deformity and to determine the position
mental muscle.
of the mental foramen.
• Chin ptosis with “dropping chin” phenome-
• Atraumatic surgery to avoid severe postopera-
non due to sagging of the mental muscle.
tive edema of the lip and wound edges result-
ing in dehiscence of sutures and infection of
the surgical site.
4 Conclusion
• If the osteotomy is to be placed distally of the
mental foramen, the periosteum around the
Various techniques for chin displacement exist.
mental nerve should be sharply dissected, thus
The technique itself is simple, the risks are
relieving the nerve to reduce the risk of nerve
well manageable. With careful execution of
compression or avulsion.
genioplasty, osteotomy of the chin is low-risk,
• It is important that the chin osteotomy be
circumscribed surgery. The chin position must
placed 5 mm below the mental foramen to pre-
be taken into account in every orthognathic
vent injury to the anterior loop of the mental
surgical procedure. The chin position must not
nerve as it ascends within the mandible chan-
be neglected from an esthetic point of view
nel before leaving the foramen.
[1–4].
45 Intraoperative Risks: Danger Points—Postoperative Complications 335

References 3. Fonsecca RI, Marciani RD, Turvey TA. Oral and max-
illofacial surgery. Saunders; 2009.
4. Hofer O. Die operative Behandlung der alveo-
1. Bell WH, Proffit WR, White RP. Surgical correction
lären Retraktion des Unterkiefers und ihre
of dentofacial deformities, Band 1–3. Saunders; 1980.
Anwendungsmöglichkeit für Prognathie und
2. Joos U, Delaire J, Scheibe B. Schilli W Funktionelle
Mikrogenie. Dtsch Zahn Mund Kieferheilk.
Aspekte der Kinnplastik. Fortschr Kiefer Gesichtschir.
1942;9:142–4.
1981;26:86.
 Part X
The Temporomandibular Joint
 Introduction
46
Barbara Gerber and Nadeem Saeed

Contents
1 Definition of TMD  340
2 Conclusion  340
References  340

Abstract Operations on the upper and lower jaw, as

well as corrections of malocclusions, have an
The temporomandibular joint is a diarthrodial, impact on the temporomandibular joints. The
bicondylar-type joint and unique in its rota- temporomandibular joint shows a high degree
tional and translational movements; due to this of adaptability over the course of a lifetime
it is known as a gingliomyoarthrodial joint. but can also be damaged under certain circum-
The internal fibrocartilage disc is attached to stances. In addition, there are systemic dis-
the condyle by ligaments that permit rotation eases that affect the temporomandibular joint.
during translational movements. The disc is The assessment of the temporomandibular
thought to have several roles to include distri- joint from a structural and functional point of
bution of joint loads, joint stability in chewing, view is an essential part of diagnosis before
facilitating lubrication and nourishment of the treatment, but it also needs to be checked after
joint surfaces and promoting growth of the the completion of orthodontic and orthogna-
condyle. Therefore, any change in the condyle/ thic treatment.
disc relationship could potentially lead to joint
dysfunction and instability. Keywords

TMJ · TMD · Diagnosis in temporomandibu-

B. Gerber (*)
Oxford University Hospitals, Oxfordshire, UK
lar joint disorders · Classification of TMD ·
e-mail: [email protected] TMD clinical assessment · Management
N. Saeed
strategies · At-risk groups · Occlusion ·
Oxford University Hospitals, Oxfordshire, UK Controversy
Great Ormond Street Hospital for Children,
London, UK
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 339
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_46
340 B. Gerber and N. Saeed

In order to discuss the impact of orthognathic etiology of this condition has remained a subject
surgery on the temporomandibular joint (TMJ) of much debate and controversy. It is likely mul-
and any pre-existing or subsequent dysfunction, tifactorial in nature from a biopsychosocial
it is necessary to define what dysfunction of the model with initiating, predisposing, and perpetu-
TMJ encompasses. Temporomandibular dys- ating factors [1]. Its reported incidence is 3–4%
functions (TMD) have a variety of different per annum (OPPERA study) with increasing
nomenclatures in the literature as well as numer- prevalence in adults, peaking in the second and
ous definitions. This contributes to, and high- third decades until age 45 years [2]. Hence, it is
lights, the complexity of this topic and to the likely that TMD will be encountered in patients
potential difficulty in devising management strat- who are undergoing orthognathic surgery (OGS).
egies to treat this condition.

2 Conclusion
1 Definition of TMD
The assessment of TMJ function and TMD is part
TMD is a collective term used to describe a wide-­ of the preclinical assessment of all combined
ranging condition that involves a variety of signs orthodontic-orthognathic treatments. The special
and symptoms of the TMJ and its related structures anatomy and role of the TMJ must be regarded.
[1]. Most common signs and symptoms include:

• Myalgia. References
• Headaches.
• Facial/neck pain. 1. Durham J, Newton-John TR, Zakrzewska
JM. Temporomandibular disorders. BMJ.
• Otalgia in the absence of aural disease.
2015;350:1154.
• Joint noises. 2. Slade GD, Ohrbach R, Greenspan JD, Fillingim RB,
• Limitation of mouth opening. Bair E, Sanders AE, Dubner R, Diatchenko L, Meloto
CB, Smith S, Maixner W. Painful temporomandibular
Additionally, there may be evidence of para- disorder: decade of discovery from OPPERA studies.
J Dent Res. 2016;95(10):1084–92.
functional habits, deviation of mouth opening
and tenderness in the masticatory muscles. The
 Diagnosis and Classification
47
Barbara Gerber and Nadeem Saeed

Contents
1 Diagnosis and Classification  341
2 Conclusion  342
References  342

Abstract Keywords

In order to diagnose and characterize TMD, TMJ · TMD · Diagnosis in temporomandibu-

many indexes have been devised as stan- lar joint disorders · Classification of TMD ·
dardized tools for clinical applications; one Wilkes classification · Disk dislocation
of the earliest was described by Helkimo
(Sven Tandlak Tidskr. 1974;67(2):101–21).
Subsequent indexes were developed for clin- 1 Diagnosis and Classification
ical research and this led to the RDC/TMD
(Research Diagnostic Criteria for TMD); The Wilkes classification is a commonly used
this has been further developed to the DC/ clinical and radiographic index that not only
TMD with a more clinical application includes TMD severity but also stages of TMJ
(Schiffman E, Ohrbach R. J Am Dent Assoc. internal derangement and disk-fossa relations.
2016;147(6):438–45). This classification is often used to guide treat-
ment (Fig. 47.1).
Internal derangement (ID) includes clinical
B. Gerber (*) and radiologic disk displacement and can often
Oxford University Hospitals NHS Foundation Trust, be associated with TMD symptomatology. It is
Oxfordshire, UK
likely that TMJ ID is related to multiple factors
e-mail: [email protected]
including macro- and microtrauma but also
N. Saeed
systemic factors including hormonal, nutri-
Oxford University Hospitals, Oxfordshire, UK
tional, and autoimmune variables. It is known
Great Ormond Street Hospital for Children,
that MRI findings do not always correlate with
London, UK
e-mail: [email protected] clinical symptomology [1] and therefore there

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 341
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_47
342 B. Gerber and N. Saeed

• Stage I: TMJ early opening click/no pain/no radiographic disc displacement

• Stage II: Joint sounds/pain with intermittent locking/episodes of pain/radiological disc displacement with reduction
• Stage III: As stage II, but with radiological disc displacement without reduction/multiple painful episodes/
restricted mobility
• Stage IV: Non-reducing anterior disc displacement/chronic and increasing functional
disturbance/arthritic changes
• Stage V: Disc perforation or non-reducing disc displacement/osteoarthritis/grating, grinding
symptoms/pain/restricted mobility/limited function

Fig. 47.1 Wilkes classification—adapted

must be elements of TMJ adaptation to account 2 Conclusion

for this.
The TMJ articular surfaces have great poten- TMJ disease can coexist with jaw deformity and
tial for physiological adaptation to numerous undiagnosed or untreated disease can lead to
functional procedures. During the course of a unpredictable results with unfavorable outcomes
lifetime, progressive remodeling maintains a in both functional and aesthetic terms. Decisions
constant balance between shape and function. about the timing of intervention for TMJ disease
If the joint is exposed to nonphysiological in patients undergoing orthognathic treatment are
effects, then the adaptive ability can be over- dependent on the severity and onset of the disease
come, and can lead to permanent damage to the process. Some dentofacial deformities are a result
articular surfaces and potential condylar resorp- of TMJ disorders such as idiopathic condylar
tion. This total adaptive capacity can also be resorption or severe degenerative joint diseases.
affected under normal conditions when it is
weakened due to aging or numerous systemic
disorders [2]. References
This adaption is supported anecdotally by the
multitude of orthognathic procedures performed 1. Kircos LT, Orthendahl DA, Mark AS, Arakawa
with only a small number of patients that present M. Magnetic resonance imaging of the TMJ disc in
asymptomatic volunteers. J Oral Maxillofac Surg.
postoperatively with TMD and TMJ pathology. It 1987;45(10):852–4.
is this ability of the TMJ that allows us to alter its 2. Ivkovic N, Racic M. Structural and functional dis-
position often without detrimental effects. orders of the temporomandibular joint (internal dis-
However, there are still a cohort of patients that orders). In: Almasri MA, Kummoona R, editors.
Maxillofacial surgery and craniofacial deformity–
succumb to TMD and some of its more patho- practices and updates. IntechOpen; 2018.
logical effects, i.e., idiopathic condylar resorp-
tion (ICR).
 Clinical Assessment
48
Barbara Gerber and Nadeem Saeed

Contents
1 Imaging 343
2 Conclusion 344
Reference 344

Abstract of medical comorbidities and nutritional sta-

tus should also be standard practice.
It is standard that all patients requesting
orthognathic treatment are subject to a thor-
Keywords
ough clinical examination as well as a perti-
nent history, symptom evaluation, treatment TMJ · TMD · Diagnosis in temporomandibu-
history, and outcome expectations. Included in lar joint disorders · Classification of TMD ·
this should be a TMJ history and examination, TMD clinical assessment · TMJ imaging
being mindful that certain dentofacial defor-
mities can be related to a high risk of obstruc-
tive sleep apnea, and that these deformities The clinical examination should include evalua-
may be as a result of a pre-existing TMJ dis- tion of the TMJ status and function, noting any
ease process. Further screening should option- positive findings to include:
ally be provided to include Stop-Bang scoring
and an Epworth sleepiness scale. Assessment • TMJ clicking/crepitus.
• Tenderness in the muscles of mastication.
• Deviation in mouth opening.
• Inter-incisal distance (if considered limited).
B. Gerber (*)
Oxford University Hospitals, Oxfordshire, UK
e-mail: [email protected]
N. Saeed
1 Imaging
Oxford University Hospitals, Oxfordshire, UK
• OPT/Lateral Cephalogram.
Great Ormond Street Hospital for Children,
London, UK • CBCT/CT.
e-mail: [email protected] • MRI +/− contrast.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 343
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_48
344 B. Gerber and N. Saeed

Included in every workup for orthognathic 2 Conclusion

surgery are panoramic and cephalometric radio-
graphs and dental study models (see: Chap. 7). A thorough clinical assessment related to TMJ
Plain radiographs may highlight significant morphology and function is indicated in all orth-
TMJ abnormalities that can guide the clinician to odontic and especially orthognathic treatments.
consider further detailed imaging in the form of
a CT for bony pathology. In addition, the oro-
pharyngeal and nasal airway can also be evalu- Reference
ated if necessary from these scans. Significant
clinical symptoms of ID may warrant additional 1. Kumar R, Pallagatti S, Sheikh S, Mittal A, Gupta D,
MRI with or without contrast. This can help in Gupta S. Correlation between clinical findings of
temporomandibular disorders and MRI. Open Dent J.
quantifying the degree of synovitis, disk mor- 2015;9:273–81.
phology, position, and effusions. MRI has shown
to have a high sensitivity and specificity to clini-
cal symptoms [1].
 Management Strategies
49
Barbara Gerber and Nadeem Saeed

Contents
1 TMJ Disease Prior to Commencement of Orthognathic Surgery  345
2 At-Risk Groups  348
3 Orthognathic Surgery Effects on TMD  349
4 TMD in the Postoperative Patient  350
5 Conclusion  351
References  351

Abstract Angle Orthod. 2003; 73:109–115; McNamara

et al. J Orofac Pain. 1995; 9:73–90).
As with all patients once a diagnosis of the
dentofacial deformity has been made, then
Keywords
treatment can proceed as per any other orthog-
nathic strategy. The treatment of concomitant TMJ · TMD · Diagnosis in temporomandibu-
TMD should follow strategies aimed at the lar joint disorders · Classification of TMD ·
degree of TMD as per the Wilkes classifica- TMD clinical assessment · Wilkes classifica-
tion. Often TMD treatment occurs alongside tion · Management strategies · At-risk groups
presurgical orthodontics. Although controver- · Occlusion
sial, there has been no clear evidence that
orthodontic treatment nor the preceding mal-
occlusion induces TMD (Sim et al. Korean J 1 TMJ Disease Prior
Orthod. 2019;49(3):181-187; Egermark et al. to Commencement
of Orthognathic Surgery

These patients should have a well-documented

B. Gerber (*) · N. Saeed
Oxford University Hospitals, Oxford University NHS TMJ history and examination performed and treat-
Foundation Trust, London, UK ment guided by their initial Wilkes staging [1].
e-mail: [email protected]; Nad.Saeed@
ouh.nhs.uk

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 345
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_49
346 B. Gerber and N. Saeed

• Wilkes I and II. pain scores in those that didn’t have simultaneous
• Nonoperative modalities: physiotherapy, med- disc surgery [3]. This was noted particularly in
ical management (analgesia, muscle relax- those that had large mandibular advancements
ants), jaw exercises, soft diet (when required). and long-standing (> 4 years) pre-existing TMD.
• Wilkes III and IV. However, as we know that there will be some
• Initial nonoperative management, if unrespon- degree of TMJ repositioning after orthognathic
sive, then arthroscopy (lysis and lavage) prior surgery, it might be prudent to wait and assess
to definitive surgery. any persistence of TMD ID postoperatively. It
• Wilkes V. has been shown that in certain groups,
• Combined TMJ replacement and orthognathic ­orthognathic surgery alone has improved TMD
surgery. The TMJ complex is not stable ­symptomatology [4, 5].
enough to withstand orthognathic surgery If necessary, TMJ arthroscopy with disc
alone. repositioning and plication can be performed as
a stand-alone procedure, to avoid open TMJ
It has been shown that arthroscopic treatment surgery, once full recovery from orthognathic
of Wilkes II–IV patients to be more than 80% surgery has been achieved. A simple flow dia-
successful and hence recommended as a simple gram and treatment algorithm for patients with
intervention. For those that have no improvement dentofacial deformity and TMD symptoms has
in their symptoms it has been advocated by been proposed by Nale [6]. Essentially this pro-
Wolford and Dhameja [2] that simultaneous disk tocol suggests treatment of painful TMD is
repositioning and orthognathic surgery be per- completed and stabilized prior to OGS (orthog-
formed. They reported good results with this nathic surgery) or in severe disease concomi-
approach as have other studies, with increased tant surgeries undertaken (Fig. 49.1).

Fig. 49.1 Wilkes V TMJ with condylar resorption, sleep bilateral TMJ replacement. Pre- and post-lateral cephalo-
disordered breathing, poor facial aesthetics. Treated with grams confirming airway changes, overjet change, lateral
combined counterclockwise Le Fort I osteotomy and and frontal facial views
49 Management Strategies 347

Fig. 49.1 (continued)

348 B. Gerber and N. Saeed

Fig. 49.1 (continued)

2 At-Risk Groups terior face height, and posteriorly inclined

condylar neck [8].
There are a subset of patients that should be cau- TMJ condylar resorption can also occur de
tiously considered before the commencement of novo without any preceding surgery, and the
orthognathic surgery. They are known to have the cause of this can be related to local, systemic, or
potential for adverse outcomes if careful assess- idiopathic causes. The resorptive process is via
ment and planning is not performed (Fig. 49.2). cytokine-activated osteoblasts which promote
It has been well documented that female osteoclast activity. This results in an enzymatic
patients with a high Frankfurt-Mandibular plane breakdown of hydroxyapatite and collagen [9].
angle who have a class II skeletal relationship are Certain individuals may be predisposed to con-
at a higher risk of developing idiopathic condylar dylar resorption due to a multitude of factors.
resorption (ICR) postoperatively and hence These can include gender, nutritional status,
relapse. They should be closely counselled about genetics, oral habits, and parafunction. As men-
this risk if a mandibular procedure is considered tioned once the TMJ adaptive capacity is over-
or alternative osteotomies recommended [7]. come then resorption or destruction of the
Much research has gone into understanding the articular structures can ensue.
etiology of this phenomenon with postulations It has also been suggested that those patients
around an estrogen-mediated process. Other con- with pre-existing TMD that require counterclock-
tributing factors have included a diminished pos- wise rotation of the maxillomandibular complex
49 Management Strategies 349

• ICR +/- TMD – female, Class II, large mandibular advancements, high angle

• Bilateral TMJ ID - cephalometric analysis has highlighted that such patients tend to have a short ramus, clockwise
rotation of mandible, and retrognathic mandible (38)
• Counter-clockwise rotation movements in pre-existing TMD patients

Fig. 49.2 At-risk groups

are at risk of persistent and likely worsening Numerous studies have reported an overall
TMD. This is due to the stretch on the pterygo-­ improvement with OGS with both setback ([14–
masseteric muscles and stretch of the soft tissues. 17]) and advancement procedures via a sagittal
This movement theoretically increases the TMJ split osteotomy (SSO) [18] with relatively low
loading. In this instance, addressing the TMD incidence of asymptomatic patients developing
prior to surgery would be advantageous and can TMD postoperatively [19].
provide a more stable outcome [10]. This surgical It has been shown that disc position improves
move has been shown to be as stable as conven- after mandibular advancement in class II patients
tional treatment that doesn’t alter the occlusal as well as reducing excessive translation [20].
plane. Also noted that in class II patients that underwent
OGS have better quality of life scores and a
reduction in chronic and articular pain when not
3 Orthognathic Surgery Effects associated with a psychosocial input [21]. This
on TMD too is noted in the class III patient having had a
SSO procedure [22].
The effects of OGS on the TMD has been fre- Combined orthodontic and orthognathic treat-
quently debated in the literature, and studies ment has generally been shown to have a positive
both advocating its beneficial effect and delete- treatment outcome with respect to TMD pain,
rious effects have been published. During having a frequency similar to a control group [4].
orthognathic surgery, the condylar position is Of note different osteotomy procedures and
important to avoid relapse or subsequent maloc- types of fixation have an effect on the condylar
clusion upon waking. Some surgeons have even position and hence the potential to produce post-
advocated waking the patient intraoperatively to operative changes [7]. The commonest types of
make sure the condyle is seated correctly and to mandibular osteotomy are the sagittal split oste-
avoid sag [11]. otomy (SSO) and intraoral vertical ramus osteot-
It has also been suggested that certain orthog- omy (IVRO). It is likely that IVRO for setback
nathic surgical movements can potentiate postop- procedures are better to reduce the risk of TMD
erative TMD due to the torque placed on the as the condyle takes a more anterior-inferior
potentially newly positioned condyle. Condylar position resulting from the lateral pull of the lat-
shape is not uniform, and 3D volumetric analysis eral pterygoid. This allows an increased joint
demonstrates that different skeletal relationships space and recapture of an anteriorly displaced
have different condylar morphologies [12]. The disc (see: Mandibular Prognathism—Class III
relevance of whether this contributes to TMD is Setback—Surgical Technique—IVRO).
unknown and certainly it is understood that the However, the drawback of the IVRO is the
condylar position is altered after orthognathic need for a period of IMF and potential for long-­
surgery. The most noticeable change is in the term hypomobility of the joint. Overall numer-
early postoperative period (6 months) with a slow ous studies have demonstrated a low incidence
move to a position close to the preoperative sta- of hypomobility and recovery up to 90–98% of
tus; however, it never fully returns to this original the premorbid mouth opening [18]. In terms of
position [13]. fixation, there’s some evidence to support the
350 B. Gerber and N. Saeed

use of monocortical plate fixation over bicorti- that prolonged immobility of the TMJ can induce
cal screws in the SSO [23] but that lag screws stiffness and may induce TMD and long-term
should be avoided due to their increase on lat- hypomobility. The initial reduced mouth opening
eral torque of the condyles. The miniplate is after orthognathic surgery is transient, and with
more forgiving than positional bicortical screws encouragement the premorbid status can be
for condylar seating (see: Osteosynthesis for achieved [18].
Sagittal Splitting). If patients go on to develop intractable TMD
ID (Wilkes III), then they should be treated as
per any other TMJ patient. This would include
4 TMD in the Postoperative arthroscopy (lysis and lavage) and consideration
Patient for Level 3 arthroscopy (disc repositioning and
plication) or open TMJ surgery. Open surgery
In most cases, like TMD in the preoperative prior to 6 months is not recommended as there
patient, treatment should be guided by the sever- will be ongoing adaption and the potential to
ity and degree of TMD as per the Wilkes classifi- worsen rather than relieve symptoms (Fig. 49.3).
cation. Time must be given for the effects of OGS Careful consideration must be given to the late
to settle and any planned surgical intervention postoperative patient that presents with a Wilkes
should allow recovery time. As always, nonoper- V TMJ secondary to ICR. These patients will
ative measures should initially be instituted for need a full workup and clear discussion about the
symptom control. expectations of future treatment. It is likely that
Intermaxillary fixation should be avoided in they will have developed a change in occlusion,
the immediate postoperative period as it’s known asymmetry, and possibly facial aesthetics.

Fig. 49.3 Patient referred post BSSO advancement with with restricted opening (15 mm) and degeneration at the
bicortical screw fixation, and open disc plication only time of referral treated with Right Total TMJ replacement
3 months post-surgery due to TMJ pain. Fibrous ankylosis restoring opening to 40 mm and pain reduction
49 Management Strategies 351

Avoidance of future mandibular osteotomy pro- 10. Al-Moraissi EA, Wolford LM. Does temporomandib-
cedures has been advocated but thought must ular joint pathology with or without surgical manage-
ment affect the stability of counterclockwise rotation
also be given to TMJ replacement with an allo- of the Maxillomandibular complex in orthognathic
plastic joint. This allows a stable TMJ base if fur- surgery? A systematic review and meta-analysis. J
ther orthognathic treatment is needed and desired. Oral Maxillofac Surg. 2017;75(4):805–21.
11. Politi M, Toro C, Costa F, Polini F, Robiony
M. Intraoperative awakening of the patient during
orthognathic surgery: a method to prevent the condy-
5 Conclusion lar sag. J Oral Maxillofac Surg. 2007;65(1):109–14.
12. Santander P, Quast A, Olbrisch C, Rose M, Moser N,
The Wilkes classification helps to decide on adju- Schliephake H, Meyer-Marcotty P. Comprehensive
3D analysis of condylar morphology in adults with
vant therapies and risks related to the TMJ and different skeletal patterns–a cross-sectional study.
helps to select the best fitting therapy in orthog- Head Face Med. 2020;16(1):33.
nathic surgery. 13. Ma RH, Li G, Yin S, Sun Y, Li ZL, Ma XC. Quantitative
assessment of condyle positional changes before and
after orthognathic surgery based on fused 3D images
from cone beam computed tomography. Clin Oral
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23. Ureturk EU, Apaydin A. Does fixation method affect 25. McNamara JA Jr, Seligman DA, Okeson JP. Occlusion,
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 Controversy
50
Barbara Gerber and Nadeem Saeed

Contents
1 Occlusion, Orthodontics, and TMD  353
2 Orthognathic surgery as a Treatment of TMD  354
3 Conclusions  354
References  354

Abstract 1 Occlusion, Orthodontics,

and TMD
The controversial topic of the association
between malocclusion and TMD has been
Many such studies discuss occlusion as a static
extensively discussed in the literature, often
phenomenon in relationship to TMD; however, as
with contradictory results. The use of incon-
TMD is now accepted to be a multifactorial pro-
sistent terminology, within studies, makes this
cess, this binary relationship is unlikely to exist.
a difficult subject to compare.
Occlusion is most likely a complex pathway
including a dynamic process of adaptation and a
Keywords
somatosensory process [1].
TMJ · TMD · Diagnosis in temporomandibu- Longitudinal studies of adolescents with a
lar joint disorders · Classification of TMD · variety of malocclusions have not shown an
TMD clinical assessment · Management increase in the prevalence of TMD [2] and long-­
strategies · At-risk groups · Occlusion · standing malocclusion and occlusal interferences
Controversy have likely been subject to an adaptive process.
The overriding consensus view is that malocclu-
sion doesn’t contribute to TMD [1, 3, 4].
That said, low levels of evidence have impli-
B. Gerber (*) · N. Saeed
cated some occlusal factors associated with TMD,
Oxford University Hospitals, Oxford University NHS including an overjet of >4 mm, unilateral posterior
Foundation Trust, London, UK crossbite and retruded contact position, and inter-
e-mail: [email protected]; Nad.Saeed@ cuspidal position slides of greater than 1.75 mm.
ouh.nhs.uk

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 353
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9_50
354 B. Gerber and N. Saeed

However, no single occlusal factor was able to dif- this ability which allows most orthognathic sur-
ferentiate between TMD and healthy patients [5]. gery to have little impact on long-term TMJ
Some proponents suggest the use of therapies health. In patients with mild TMD (Wilkes I/II),
aimed at adjusting the occlusion in order to treat this should be treated conservatively prior to
TMD, with some even advocating permanent orthognathic surgery. Moderate (Wilkes III) or
occlusal adjustment. A Cochrane review showed severe TMJ disease (Wilkes IV/V), or in patients
there is no clear evidence that this contributes to with persistent issues, should be counselled as to
the reduction or prevention of TMD [6]. In gen- the potential worsening of symptoms or offered
eral, the literature suggests that occlusal equili- concomitant open surgery or joint replacement.
bration or irreversible adjustment should not be In moderate disease, the vast majority will settle
used as a tool to treat TMD [7]. and a wait-and-see policy should be adopted.
The role of orthodontic treatment has been It should be noted that any individual propen-
cited as prevention, cure, and induction of sity to develop TMD either as a pre-, intra-, or
TMD. The rationale behind these concepts were postoperative phenomenon will very much
presumed to come from the idea that achieve- depend on a myriad of variables and the underly-
ment of an ideal occlusal harmony or by reposi- ing biopsychosocial model of TMD must not be
tioning the condyles in their optimal position, forgotten.
reduced the risk of TMD. However, opponents to Orthognathic surgery and its relationship to
this view considered orthodontics as a trigger for the TMJ and TMD will continue to be a much
TMD [1]. It seems that overall orthodontic ther- investigated area, and ultimately the treatment of
apy has a neutral effect on TMD, neither as a TMD due to this will always be via multiple
cure nor as a prompt. In a literature review, it treatment strategies.
seems regardless of the type of orthodontic treat-
ment plan used, including those with premolar
extractions, none were associated with TMD [8]. References
1. Michelotti A, Rongo R, D’Antò BR. Occlusion,
2 Orthognathic surgery orthodontics, and temporomandibular disorders: cut-
as a Treatment of TMD ting edge of the current evidence. World Fed Orthod.
2020;9:15–8.
2. Olliver SJ, Broadbent JM, Thomson WM. Occlusal
There is very limited evidence to support orthog- features and TMJ clicking: a 30-year evaluation form
nathic surgery as a treatment strategy for TMD as a cohort study. J Dent Res. 2020;99(11):1245–51.
nearly all studies concentrate on the effects of 3. De Kanter RJAM, Battistuzzi PGFCM, Truin
GJ. Temporomandibular disorders: “occlusion” mat-
surgery on TMD. ters! Pain Res Manag. 2018;2018:8746858.
As most TMD symptoms (80–90%) can be 4. Manfredini D, Lombardo L, Siciliani
treated effectively by simple measures, the use of G. Temporomandibular disorders and dental occlu-
orthognathic surgery as a treatment for TMD sion. A systematic review of association studies: end
of an era? J Oral Rehabil. 2017;44(11):908–23.
should be limited to those patients with a severely 5. Al-Ani Z. Occlusion and temporomandibular disor-
degenerative joint that require combined open ders: a long-standing controversy in dentistry. Prim
surgery or joint replacement and orthognathic Dent J. 2020;9(1):43–8.
surgery. 6. Koh H, Robinson PG. Occlusal adjustment for treating
and preventing temporomandibular joint disorders. J
To advocate OGS as treatment for TMD only, Oral Rehabil. 2004;31(4):287–92.
without concerns of a dentofacial disharmony 7. Tsukiyama Y, Baba K, Clark GT. An evidence-based
would seem unwise. assessment of occlusal adjustment as a treatment
for temporomandibular disorders. J Prosthet Dent.
2001;86(1):57–66.
8. Leite RA, Rodrigues JF, Sakima MT, Sakima
3 Conclusions T. Relationship between temporomandibular disorders
and orthodontic treatment: a literature review. Dental
The temporomandibular joint is known to be an Press J Orthod. 2013;18(1):150–7.
adaptive joint in terms of its capability to with-
stand anatomical and physiological changes. It is
 Index

A linguo-medial osteotomy, 29
Accurate orthognathic planning mandibular body osteotomy, 30
dental examination, 49–50 proximal and distal bone surfaces, 28
face examination of, 43–47 sagittal connecting osteotomy, 111
facial midline, 44, 45 sagittal split variants, 163, 164
frontal position, 46, 47 stepwise osteotomy, 30, 31
lower facial third, 43, 44 surgical principle, 28–29
natural head position, 42 transoral approach, 110
photo documentation, 42–47 Body osteotomies, 24
relaxed soft tissues, 47 Bone healing, 85
Adjacent tooth roots, 310 Bone necrosis, 191
Alternative splitting techniques, 151 Bronchospasm, 185
Alveolar nerve, 85 Buccal osteotomy, 55–56, 124, 167, 207
Alveolar segmental osteotomies, 239
Anterior body osteotomy, 286
bilateral vestibular incision, 305 C
extraction of premolars, 306 Cancellous bone, 156
incision line, 306 Centering genioplasty, 36
mandibular canal, 306 Cephalometric analysis, 65, 220
ostectomy of mandibular segment, 307 Chin advancement, 322
rigid internal fixation, 307 Chin augmentation genioplasty, 35
vertical osteotomy, 306 Chin displacements, 323
Anterior mandibulotomy, 32–33 Chin osteotomies, 24, 36, 258
Anterior segment osteotomy, 295 centering genioplasty, 36
Anterior subapical osteotomy, 33–34, 286–288 chin advancement, 322
Arcing osteotomy, 7 cranio-facial skeletal deficiencies, 34
Aspiration dyspnea, 185 double sliding chin osteotomy, 321
Asymmetric dysgnathia, 18–19 esthetic deformation, 320
Asymmetric skeletal growth disorders, 19 facial profile changes, 323
Axoguard® nerve protector, 162 horizontal sliding genioplasty, 35
horizontal osteotomy, 35, 36, 320–321
jumping genioplasty, 36
B macrogenia, 34
Bicortical compression, 79 microgenia, 34
Bicortical positioning screw osteosynthesis, 76–77, 79 oblique/slanted osteotomy, 35–36, 322
Bilateral osteotomies, 261–262 preoperative planning, 323–324
Bilateral sagittal split osteotomy (BSSO), 29–30, 163, principal surgical techniques, 35–36
287 retrogenia, 34
bad splits, 163–167 sagittal setback, 320
bi-sagittal retromolar osteotomy, 110 sliding osteotomy, 321
horizontal mandibular distraction osteogenesis, 31, 110 surgical correction, 320
indications, 28 two-tiered/tandem genioplasty, 36
lateral-vertical (buccal) osteotomy, 111 variants and alternatives, 36

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature 355
Switzerland AG 2024
P. Kessler et al. (eds.), Illustrated Manual of Orthognathic Surgery,
https://doi.org/10.1007/978-3-031-06978-9
356 Index

Chin reduction genioplasty, 35 I

Chin repositioning, 320–321 Ideal inverted-L osteotomy, 280
Chin-wing-osteotomy, 36 Idiopathic condylar resorption (ICR), 342
Class III occlusion, 236 Inferior alveolar artery, 157
Computer-based planning, 217, 247 Inferior alveolar nerve (IAN), 55, 145, 159
Condylar hyperplasia, 252 Intermaxillary fixation (IMF), 74, 213
Condylar proximal segment, 267 Intermolar mandibular distraction osteogenesis (IMDO),
Condylar torque, 82 31, 202
Cone-beam computed tomography (CBCT), 53–55 advantages, 225
Conventional miniplate osteosynthesis, 78 cephalometric analysis, 220
Conventional osteosynthesis plates, 78–79 clinical follow-up, 224–225
C-osteotomy, 7, 8 clinical treatment phase, 222
Cranio-maxillofacial (CMF)-surgery, 104 disadvantages, 225
distraction protocol, 222
lateral skull view, 223
D operation steps, 221–222
DeBakey aortic clamp, 204, 241 orthodontic treatment, 220
Dehiscence, 311 panoramic X-rays, 222
Dentoalveolar dysgnathia, 19 photographic documentation, 224
Double sliding chin-osteotomy, 321–322 postoperative x-ray documentation, 225
Dumbach retractor, 243 radiological follow-up, 222–224
Dysgnathias surgical procedure, 221
asymmetric skeletal growth disorders, 19 Internal derangement (ID), 341
dento-alveolar dysgnathias, 19 Intraoperative risks
facial growth patterns, 20, 21 adjacent tooth roots, 310
sagittal, vertical and transversal, 18 injury of mental nerve, 310
skeletal dysgnathia, 18 vascularization of segment, 310
surgical classification of, 19 Intraoral muco-periosteal incision, 295
types and typical forms, 21 Intraoral vertical ramus osteotomy (IVRO), 248, 349
Inverted L-osteotomy, 8, 275–278
advantages, 280–281
E classical BSSO/SSRO, 279
Epker osteotome, 207 disadvantages, 281–282
Extended stepped osteotomy, 11 horizontal osteotomy, 279, 280
vertical ramus osteotomies, 278, 281

F
Facial nerve, 159 J
Fibrous periosteum, 204 Jumping genioplasty, 36
Forward movement, 300–301
Frankfurt-mandibular plane angle, 276, 278
French osteotome, 167 K
Frontal segment osteotomy, 298 Kiesselbach's plexus, 184
Functional respiratory abnormalities, 185 Kocher clam, 246

G L
General anesthesia, 221 Lambotte flat osteotomes, 149
Genioplasty, 320–323 Langenbeck hooks, 139, 140, 327
Graphic-cephalometric surgery planning, 290 Langenbeck retractors, 295
Lateral cephalometric X-ray, 52–53
Lateral mandibular step osteotomy, 286
H indications, 304–305
Hemimandibular hyperplasia, 252 intraoral mucoperiosteal incision, 304
Horizontal chin osteotomy, 331 osteotomy, 305
Horizontal mandibular distraction osteogenesis, 31 segment and fixation, 305
Horizontal osteosynthesis, 267 Laterognathism, 258
Horizontal osteotomy, 35, 36, 175–176, 305, 320, 321 Lindemann burr, 147, 174, 206, 242, 329
Horizontal sliding genioplasty, 35 Lingual nerve, 159
Hunsuck technique, 143 Lingual osteotomy, 123–124, 204, 206, 207, 242
Index 357

Low-molecular-weight heparins (LMWH), 105 lingual osteotomy, 242, 244

masseterico-pterygoidal muscle loop, 243
Minnesota retractor, 241
M osteosynthesis plate, 246
Macrogenia, 34 osteotomy gap, 243
Mandibular advancement proximal segment, 244
class II malocclusion, 196 sagittal mandibular splitting, 240
Dal Pont split, 216 Satinsky-DeBakey clamp, 242
lingual bone surplus, 216 Satinsky vascular clamp, 241
mandibular deficiency, 196 spreader and Smith separator, 243
modifications and surgical alternatives, 217 class III occlusion, 236
morphological and dental criteria class III position, 236
cephalometric analysis, 198 sagittal interbasal relation, 236
class II jaw relationship, 196 segmental osteotomy techniques, 240
class II mandibular retrognathia, 196 3D cephalometric analysis, 237
class II occlusion, 197, 198 vertical and transversal disharmonies, 236
dental compensation, 197 Mandibulo-maxillary fixation, 307
dentobasal relation, 199 Marked anteroposterior discrepancy, 288
extraoral facial profile, 196 Masseterico-pterygoidal muscle loop, 208
mandibular base, 199 Maxillary artery, 157–158
mandibular retrognathism, 196, 198 Medial osteotomy, 167
pogonion prominence, 198 Medial pterygoid muscle, 266
skeletal mandibular retrognathia, 199 Microgenia, 34
transversal disharmonies, 198 Minnesota retractor, 241
osteosynthetic stabilization, 217 Monocortical mini plate-osteosynthesis, 79
rigid screw fixation, 216 Mucoperiosteal dissection, 296, 327, 328
skeletal mandibular retrognathia, 199, 200 Mucoperiosteal incision, 331
transfacial-transbuccal approaches, 216 Mucosal incision, 296, 327, 328
Mandibular asymmetry, 252 Multi-slice computed tomography (MSCT), 55
BSSO, 261–262
chin osteotomies, 258
clinical analysis, 253–254 N
condylar luxation, 267 Nerve injuries, 333–334
flaring, 263–265 damage to facial nerve, 162–163
IVRO, 265–272 damage to lingual nerve, 161
orthognathism, 261 inferior alveolar nerve, 160
osteotomies, 259 intraoperative injuries, 159
postoperative management, 271 paresthesia/anesthesia, 159
prognathism, 260 treatment of lingual nerve injuries, 161
proximal segment, 263, 271 Non-opioid analgesics, 187
radiological analysis, 255 Numerical rating scales (NRS), 187
radiological diagnosis, 254
rotation and mandibular side, 262–263
SSRO/BSSO, 271 O
TMJ rotation, 263 Oblique retromolar osteotomy, 13–14
unilateral osteotomies, 259, 260 Obwegeser's sagittal splitting technique, 11
Mandibular deficiency, 202 One osteotome technique, 151
Mandibular excess, 248 Open sagittal split osteosynthesis plate, 79
Mandibular osteotomies, 24, 259 Orthognathic procedures, 24
Mandibular retrognathia, 34 Orthognathic surgery
Mandibular setback clinical parameters for, 68
BSSO operation day, 70
angulated handpieces, 246 personal remarks, 69
bone gap, 245 postoperative care
buccal cortical incision, 242 cardiovascular function, 103
buccal osteotomy, 241 clinical assessment, 103–105
channel retractor, 242, 243 controlling surgical area, 103
DeBakey aortic clamp, 241 measurement of temperature, 103
incisura semilunaris, 241 monomaxillary surgery, 104
Lindemann-burr, 242 neuromuscular function, 103
358 Index

Orthognathic surgery (Cont.) postoperative facial swelling, 188

pain level, 103 residual fluids, 184
PONV, 105 respiratory insufficiency, 185
postoperative instructions, 102 tachypnea and shortness of breath, 185
pre-existing continuous medication, 105–106 indirect complications
recovery room, 103 bone necrosis, 191
sign-out procedure, 102 bone non-union, 189–190
wound care, 106 delayed bone union, 189–190
pre- and perioperative medication, 70–71 individual surgical risks, 189
preoperative phase intersegmental distance, 190–191
anesthesia procedure, 90, 91, 96–98 malocclusion, 191
CMF-surgery, 91, 92 mandibular relapse, 190–191
documentation, 98 mandibular split, 190
Mallampati classification, 93 postoperative bone infections, 189
mandibular protrusion test, 95 postoperative soft tissue infections, 189
patient positioning, 95–96 prophylaxis, 191
prophylactic measures in CMF-surgery, 98–99 pseudarthrosis, 191
skeletal dysgnathias, 93 wound infections, 189
third contact, 70 Preoperative planning, 289
week before surgery, 70 Prophylaxis, 191
Osteosynthesis techniques, 75, 310 Pseudarthrosis, 191
Osteotomies Pterygo-mandibular fossa, 156
chin osteotomies, 24 Pure retrogenia, 34
mandibular deformities, 24
ramus osteotomies, 24
segmental osteotomies, 24 R
surgical correction, 24 Radiological imaging
Osteotomized segment, 298 buccal osteotomy, 55–56
CBCT, 53–55
lateral cephalometric X-ray, 52–53
P MSCT, 55
Panoramic X-ray, 52, 222 panoramic X-ray, 52
Parabolic incision, 295 region of mandibular angle, 56–57
Paresthesia/anesthesia, 159 Ramus osteotomies, 24
Patient-controlled analgesia techniques (PCA), 187 Residual fluids, 184
Periodontium and alveolar crest, 310–311 Respiratory insufficiency, 185
Periosteum, 327 Retrogenia, 34
Pharyngeal tamponades, 184 Retrognathism, 30
Piezo-surgery, 294 Retromandibular vein, 158
Posterior subapical osteotomy, 34, 286 Retromandibular venous vascular plexus, 158
horizontal osteotomy, 305 Retromolar mandibular distraction osteogenesis (RMDO)
indications, 305 advantages, 232
intraoral mucoperiosteal incision, 305 clinical and radiological situation, 228
stabilization, 305 clinical treatment phase, 230–232
Postoperative bone infections, 189 disadvantages, 232
Postoperative nausea and vomiting (PONV), 99, 105, distraction gap, 229
186 distraction protocol, 230
Postoperative soft tissue infections, 189 distraction treatment, 230
Post-surgical complications distractor placement, 229
immediate complications indication, 228
algorithms for pain therapy, 187 operation steps, 229–230
aspiration dyspnea, 185 submandibular soft tissues, 231
bronchospasm, 185 surgical procedure, 228–229
epistaxis, 184 Retromolar osteotomy, 12
functional respiratory abnormalities, 185 Rigid bicortical compression screw osteosynthesis,
pain management, 186–188 75–76
pharyngeal tamponades, 184 Rigid internal fixation (RIF), 75
PONV, 186 Rigid monocortical miniplate osteosynthesis, 78
postoperative fever, 188 Rigid osteosynthesis, 75–77, 210
postoperative pain therapy, 187–188 Rigid segment fixation, 298
Index 359

Rotating instruments, 294 Segment mobilization, 297–298

Segment osteotomy, 24, 214, 297
anterior subapical osteotomy, 33–34
S intraoperative errors, 314
Sagittal connecting osteotomy, 124 limitations and contraindications, 314
Sagittal ramus osteotomy, 9 management after surgery, 314
Sagittal retromolar osteotomy, 11, 12 posterior subapical osteotomy, 34
Sagittal-skeletal dysgnathia, 19 Segment stabilization, 311
Sagittal split osteotomy (SSO), 9, 10, 29, 349 Seldin retractor, 143
Sagittal splitting, 215 Short lingual osteotomy (SLO), 240
ascending ramus, 123 Skeletal dysgnathia, 18, 93
bicortical positioning screw osteosynthesis, 76–77 Skeletal mandibular retrognathia, 199, 200
bi-cortical screws, 124 Slanted osteotomy, 322
buccal osteotomy, 124, 208 Sleep disordered breathing, 346
caudo-cranial length, 124 Smaller vascular bleedings, 156
class II retrognathism, 203 Smith separator, 152, 209, 211, 212
crimpable hooks, 213 Soft tissue analysis
Dal Pont modification, 203 cephalometric analysis, 62
distal tooth-bearing segment, 208 clinical examination, 62
inferior mandibular rim, 210 E-line, 61
intermaxillary fixation, 74, 209, 210 H-line, 61
lateral-vestibular incision, 122 mandibular prognathism, 63
lingual osteotomy, 123–124, 206, 207 mandibular retrognathism, 62–64
lingual split, 213 maxillary prognathism, 63–64
mandibular deficiency, 202 maxillary protrusion, 63
masseterico-pterygoidal muscle loop, 208 maxillary retrognathism, 63
mono-cortical screws and miniplates, 124–125 planning, 62–64
mucosa-periosteal incision, 122 S-line, 61
nasal intubation anesthesia, 203 Stable osteosynthesis, 217
osteosynthesis, 75 Staphylococcus aureus, 189
alveolar nerve, 85 Steinhäuser points, 176
bone healing, 85 Stepwise osteotomy, 30, 31
closed sagittal split plates, 79, 80 Surgical approach
conventional osteosynthesis plates, 78–79 anterior segment osteotomy, 295
open sagittal split osteosynthesis plate, 79 avoidance of caudal-basal step formation, 181–182
removal of, 85 avoidance of iatrogenic fractures, 178–180
revascularization of bone segments, 85, 86 branching pattern, 326
rigid monocortical miniplate osteosynthesis, 78 chin wing–osteotomy
pterygo-mandibular space, 123 horizontal chin osteotomy, 331
rigid internal fixation, 75 mucoperiosteal incision, 331
rigid osteosynthesis, 75–77, 213 principle of, 330
central condylar sag, 83 controlled midline shifts, 326
intercondylar distance, 82–85 correct mandibular split, 177–180
interfering factors, 82 correct transitions and pre-splitting, 176–177
peripheral condylar sag, 83–85 creation of bone cuts, 174–175
postoperative changes, 81 horizontal chin osteotomy, 175–176
rotation of condyle, 82 chin segment adjustment, 329
temporomandibular joint, 81 chin segment fixation, 329
sagittal connecting osteotomy, 124 fixation technique, 330
segment osteotomies, 214 horizontal osteotomy, 329
segment positioning mental foramen, 327
BSSO and bicortical screw fixation, 80–81 mucoperiosteal dissection, 327, 328
inter-segmental distance, 80 mucosal incision, 327, 328
temporo-mandibular dysfunction, 81 nerve loop, 328
Smith separator, 209, 211, 212 osteotomy, 328
submasseteric space, 123 wound closure, 330
sulcus colli groove, 204 incision of muscular tissues, 296
wire-osteosynthesis, 74 intraoral fixation, 298–299
Satinsky clamp, 204, 241 intraoral muco-periosteal incision, 295
Segment fixation, 295 lingual osteotomy, 175
360 Index

Surgical approach (Cont.) orthodontics, 353–354

mandibular bone splitting, 138 orthognathic surgery, 354
mandibular foramen, 173–174 Temporomandibular joint (TMJ), 346
mandibular rim splitting, 180 adverse outcomes, 348, 349
mucoperiosteal dissection, 296 clinical examination, 343
mucoperiosteal incision, 170–173 commencement of orthognathic surgery, 345–348
mucosa incision, 296 dentofacial deformity, 346
neurovascular bundle, 173 imaging, 343–344
osteotomy lines orthognathic surgery effects, 349–350
horizontal bone cut, 142–145 postoperative patient, 350–351
sagittal bone cut, 142, 146 Wilkes classification, 341, 342, 346
vertical bone cut, 142, 144–146 Thermal damage, 311
piezo surgical splitting, 180–181 3D cephalometric analysis, 65, 237
pterygomandibular region, 172 3D imaging and planning, 64–66
retractor on lingual side, 173 3D virtual planning, 64
sagittal splitting, 178, 179 Tooth root injuries, 310
advanced splitting, 151 Tracheal edema, 185
alveolar neurovascular bundle, 153 Transverse interradicular osteotomy, 221
angular and supra-angular section, 149 True vertical line (TVL) analysis, 61
anterior and inferior exposure, 140 2D cephalometric analysis
difficulties in mandibular splitting, 152 marking of anatomical landmarks and planes, 60
horizontal osteotomy, 148 measuring skeletal relations, 61
inferior mandibular margin, 151 tracing, 60
intraoral muco-periosteal incision, 139 Two osteotome technique, 151
mandibular angle beneath, 150 Two-tiered/tandem genioplasty, 36
mandibular margin, 151–152 Typical cephalomety, 198
medial distal segment, 152
neurovascular bundle, 153
osteotomy gap, 153 U
pre-angular section, 148–149 Unfractionated heparins (UFH), 105
pterygo-mandibular space, 141–142 Unilateral osteotomies, 259, 260
ramus and the buccal region, 139–140 Upward movement, 300
sub-masseteric space, 140–141
segment mobilization, 297–298
segment osteotomy, 297 V
vertical/buccal osteotomy line, 176 Vascular injuries
wound closure, 299 definition, 156
Surgicel™, 157 facial artery, 159
Symmetric dysgnathias, 18 inferior alveolar artery, 158
intraoperative bleeding, 157
maxillary artery, 158–159
T prevention of, 158
Tabotamp™, 157 pterygomandibular space, 156–158
Technical variants Vertical alveolar bone deficit, 288
anterior segment, 300 Vertical osteotomies, 6, 7, 32, 217, 306, 322
downward and posterior movement, 299–300 Vertical segment movement, 300
forward movement, 300–301 Viscerocranium, 227, 258
optional variants and combinations, 301–302
upward movement, 300
vertical segment movement, 300 W
Temporomandibular dysfunctions (TMD) Wilkes classification, 341, 342
definition of, 340 Wire-osteosynthesis, 74
occlusion, 353–354 Wound care, 106, 299, 311, 330