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Int. J. Oral Maxillofac. Surg. 2001; 30: 443–444 doi:10.1054/ijom.2001.0117, available online at http://www.idealibrary.com on Technical note: Orthognathic surgery Intra-oral vertical ramus osteotomy: a modified technique for correction of mandibular prognathism Y. Manor, D. Blinder, S. Taicher: Intra-oral vertical ramus osteotomy: a modified technique for correction of mandibular prognathism. Int. J. Oral Maxillofac. Surg. 2001; 30: 443–444. 2001 International Association of Oral and Maxillofacial Surgeons Abstract. Intra-oral vertical ramus osteotomy is a useful procedure for correction of mandibular prognathism. However, a major disadvantage is poor visibility of the operating field. A modified technique that improves visibility without higher morbidity is described. Yifat Manor 1 , Danielle Blinder 2 , Shlomo Taicher 1,2 1 Department of Oral and Maxillofacial Surgery, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Israel 2 Department of Oral and Maxillofacial Surgery, The Chaim Sheba Medical Center, Tel Hashomer, Israel Key words: intra-oral vertical ramus osteotomy; intra-oral subsigmoid osteotomy. Accepted for publication 1 April 2001 Intra-oral vertical ramus osteotomy (IVRO) is a useful procedure for cor- rection of mandibular prognathism. Initially, this procedure was performed extra-orally 1,6 with the advantage of good visibility. The disadvantage was an external scar and potential of facial nerve injury. M 8 and W 12 intro- duced the IVRO and additional modifi- cations have been subsequently described 4,5,7,9 . Major advantages of IVRO are the avoidance of a facial scar and of potential injury to the mandibu- lar branch of the facial nerve and to the inferior alveolar nerve. The major dis- advantage is the relatively poor visibility of the operating field. The purpose of this article is to describe a modified technique that improves visibility for performing IVRO. Patients and technique From 1987 to 1999, 66 patients under- went IVRO in our department. Most patients had bilateral IVRO (98%). Half of the patients had IVRO and genio- plasty and the rest had only IVRO. The procedure was used for mandibular set- back of 3–9 mm (60 patients) and to correct the mandibular asymmetry (six patients). Follow-up was from 6 months to 2 years. The method used was a modification of the technique described by E and W 2 . A mucosal incision was made along the anterior border of the mandibular ramus, from the base of the coronoid and laterally into the buccal vestibule of the mandible to the first molar tooth area. Dissection was carried out along the anterior border of the ramus to expose the coronoid process and laterally to expose the sigmoid notch and the inferior and posterior borders of the ramus. Fiberoptic lit Bauer retractors for both sides (W. Lorenz 01-0166DA, 01-0167DA, left and right, respectively) were placed in the sigmoid notch and in the pre-angular area (Fig. 1). This enabled retraction of the buccal and vestibular mucosa laterally and afforded excellent visibility of the anti- lingula area and posterior border of the mandible. An oscillating saw angled at 105 was used to perform the osteotomy cut pos- terior to the antilingula prominence, and directed superiorly to the sigmoid notch and inferiorly to the mandibular angle. After the contralateral osteotomy was performed intermaxillary fixation was used for 6 weeks. Time for performing the osteotomy ranged from 10–20 min per side. Discussion IVRO is considered a useful procedure for correction of mandibular prognath- ism, since an external scar and the possi- bility of loss of sensation are avoided. The initial method of IVRO described by W 12 was modified by H et al. 5 who introduced a Stryker oscillating saw, a Bauer sigmoid notch retractor, and a LeVasseur-Merrill posterior border retractor. However, these modifications did not solve the problem of limited visibility. M et al. 7 further modified the technique by 0901-5027/01/050443+02 $35.00/0 2001 International Association of Oral and Maxillofacial Surgeons
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Int. J. Oral Maxillofac. Surg. 2001; 30: 443–444doi:10.1054/ijom.2001.0117, available online at http://www.idealibrary.com on
Technical note:Orthognathic surgery
Intra-oral vertical ramusosteotomy: a modifiedtechnique for correction ofmandibular prognathismY. Manor, D. Blinder, S. Taicher: Intra-oral vertical ramus osteotomy: a modifiedtechnique for correction of mandibular prognathism. Int. J. Oral Maxillofac. Surg.2001; 30: 443–444. � 2001 International Association of Oral and MaxillofacialSurgeons
Abstract. Intra-oral vertical ramus osteotomy is a useful procedure for correctionof mandibular prognathism. However, a major disadvantage is poor visibility ofthe operating field. A modified technique that improves visibility without highermorbidity is described.
Yifat Manor1, Danielle Blinder2,Shlomo Taicher1,2
1Department of Oral and Maxillofacial Surgery,The Maurice and Gabriela GoldschlegerSchool of Dental Medicine, Tel Aviv University,Israel2Department of Oral and Maxillofacial Surgery,The Chaim Sheba Medical Center, TelHashomer, Israel
Key words: intra-oral vertical ramusosteotomy; intra-oral subsigmoid osteotomy.
Accepted for publication 1 April 2001
Intra-oral vertical ramus osteotomy(IVRO) is a useful procedure for cor-rection of mandibular prognathism.Initially, this procedure was performedextra-orally1,6 with the advantage ofgood visibility. The disadvantage was anexternal scar and potential of facialnerve injury.
M8 and W12 intro-duced the IVRO and additional modifi-cations have been subsequentlydescribed4,5,7,9. Major advantages ofIVRO are the avoidance of a facial scarand of potential injury to the mandibu-lar branch of the facial nerve and to theinferior alveolar nerve. The major dis-advantage is the relatively poor visibilityof the operating field.
The purpose of this article is todescribe a modified technique thatimproves visibility for performingIVRO.
Patients and technique
From 1987 to 1999, 66 patients under-went IVRO in our department. Mostpatients had bilateral IVRO (98%). Half
0901-5027/01/050443+02 $35.00/0
of the patients had IVRO and genio-plasty and the rest had only IVRO. Theprocedure was used for mandibular set-back of 3–9 mm (60 patients) and tocorrect the mandibular asymmetry (sixpatients). Follow-up was from 6 monthsto 2 years.
The method used was a modificationof the technique described by Eand W2. A mucosal incision wasmade along the anterior border of themandibular ramus, from the base of thecoronoid and laterally into the buccalvestibule of the mandible to the firstmolar tooth area. Dissection wascarried out along the anterior borderof the ramus to expose the coronoidprocess and laterally to expose thesigmoid notch and the inferior andposterior borders of the ramus.Fiberoptic lit Bauer retractors forboth sides (W. Lorenz 01-0166DA,01-0167DA, left and right, respectively)were placed in the sigmoid notch andin the pre-angular area (Fig. 1). Thisenabled retraction of the buccal andvestibular mucosa laterally andafforded excellent visibility of the anti-
� 2001 International A
lingula area and posterior border of themandible.
An oscillating saw angled at 105� wasused to perform the osteotomy cut pos-terior to the antilingula prominence, anddirected superiorly to the sigmoid notchand inferiorly to the mandibular angle.After the contralateral osteotomy wasperformed intermaxillary fixation wasused for 6 weeks. Time for performingthe osteotomy ranged from 10–20 minper side.
Discussion
IVRO is considered a useful procedurefor correction of mandibular prognath-ism, since an external scar and the possi-bility of loss of sensation are avoided.
The initial method of IVRO describedby W12 was modified byH et al.5 who introduced aStryker oscillating saw, a Bauer sigmoidnotch retractor, and a LeVasseur-Merrillposterior border retractor. However,these modifications did not solve theproblem of limited visibility. Met al.7 further modified the technique by
ssociation of Oral and Maxillofacial Surgeons
444 Manor et al.
changing the osteotomy directions onthe oscillating Stryker saw, first superi-orly and then inferiorly. This localizedthe antilingula and reduced possibleinjury to the inferior alveolar nerve.
The present technique uses the advan-tages of M et al.7 but withimproved retraction and visibility. Bothright and left Bauer retractors areinserted at the operated area simul-taneously, i.e., the same side Bauerretractor is inserted into the sigmoidnotch area while the opposite side Bauerretractor is inserted below the inferiorborder of the pre-angular area of themandible. This method allows direct vis-ibility of the osteotomy site throughoutthe procedure, thus avoiding injury tothe nerves and vessels. Improved retrac-tion prevents injury to the soft tissue anddecreases postoperative edema.
Our experience with 66 patients (132sides) showed that the time required to
perform osteotomy ranged from10–20 min per side, which is similar tothe time reported by M et al.7.There was no incidence of permanentnerve injury to the inferior alveolarnerve. The percentage of nerve injury inthe literature using various methods,ranges from 0–14%3,6,10,11,13.
References
1. C JB, L GS. Verticalosteotomy in the mandibular rami forcorrection of prognathism. J Oral Surg1954: 12: 185–202.
2. E BF, W LM. DentofacialDeformities: Surgical OrthodonticCorrection. London: C.V. MosbyCompany 1980.
3. H HD, C DC, P LE.Evaluation and refinement of theintraoral vertical subcondylar osteotomy.J Oral Surg 1975: 33: 333–341.
4. H HD, MK SJ. Further refine-ment and evaluation of intraoral verticalramus osteotomy. J Oral Maxillofac Surg1987: 45: 684–688.
5. H JM, K JN, H EC.Correction of prognathism by anintraoral vertical subcondylar osteotomy.J Oral Surg 1970: 28: 651–653.
6. L AA. Treatment of open bite bymeans of plastic oblique osteotomy of theascending rami of the mandible. DentCosmos 0000: 67: 1191–1197.
7. M JV, M M, M S,S W. Modified technique for com-pleting the intraoral vertical osteotomy.J Oral Maxillofac Surg 1982: 40: 167–168.
8. M SM. Surgical correction ofmandibular prognathism by intraoralsubcondylar osteotomy. Br J Oral Surg1964: 22: 197–201.
9. P MG, L JA, M DE.Mandibular prognathism. Clin Plast Surg1989: 16: 677–685.
10. T K. Extraoral and intraoralvertical subcondylar ramus osteotomy forcorrection of mandibular prognathism.Int J Oral Maxillofac Surg 1987: 16:671–677.
11. T DB, G RB. Compli-cations related to the intraoral verticalramus osteotomy. Int J Oral Surg 1985:14: 319–324.
12. W RP. Subcondylar osteotomyof the mandible and the intra-oral approach. Br J Oral Surg 1968: 6:134–136.
13. Z HS, P C, T BC.Long term sensory deficits followingtransoral vertical ramus and sagittalsplit osteotomies for mandibular progna-thism. J Oral Maxillofac Surg 1986: 44:193–196.
Address:Dr Yifat Manor4 Popel Mordechai st. appt. 31Rishon le Zion 75355Israel
Fig. 1. Right side IVRO. The sigmoid notch Bauer retractor is inserted on both the right sidein the sigmoid notch and on the left side in the pre-angular area.
