Orthognatic Surgery. Techniques, Tips, Tricks & Traps

PART 1 THE BILATERAL SAGITTAL SPLIT MANDIBULAR RAMUS OSTEOTOMY

■ SURGICAL APPROACH

• Step 1. Infiltrate the area of the intendid soft tissue dissection with a vasoconstrictor
• Step 2. Soft tissue incision
• Step 3. Buccal subperiosteal dissection
• Step 4. Superior subperiosteal dissection
• Step 5. Medial subperiosteal dissection
• Step 6. Identifi cation of the lingula 34

■ PERFORMING THE OSTEOTOMY

• Step 7. Medial ramus osteotomy
• Step 8. Vertical vertical ramus osteotomy
• Step 9. Prepare for the vertical buccal osteotomy
• Step 10. Buccal osteotomy of the mandibular body
• Step 11. Drill the holes for the placement of a holding wire
• Step 12. Drill a purchase hole for the condylar positioner* and place reference marks perpendicular to the vertical osteotomy line

■ SPLITTING THE RAMUS OF THE MANDIBLE

• Step 13. Define the osteotomy cut with an osteotome
  • Splitting the mandible
• Step 14. Starting the split
• Step 15. Completion of the split
  • The bad split

1. Fracture of the buccal cortex of the body of the mandible

2. Fracture of the buccal cortex involving the body and ramus of the mandible, and continues to the coronoid process

3. The vertical osteotomy on the medial aspect of the mandibular ramus fractures anterior to the inferior alveolar foramen

4. Fracturing the segment of bone distal to the second molar

• Step 16. Stripping the pterygo-masseteric sling
• Step 17. Stripping the medial pterygoid muscle and stylomandibular ligament for setback procedures
• Step 18. Removal of impacted third molars

■ PREPARATION FOR REPOSITIONING THE DISTAL SEGMENT

• Step 19. Contour contact areas of the bone segments
• Step 20. Placement of a holding wire (018”)
• Step 21. Note the position of the inferior alveolar neurovascular bundle
• Step 22. Note the position of the third molar tooth (socket)
• Step 23. Lavage
• Step 24. Splitting the opposite side
• Step 25. Mobilize the distal segment
• Step 26. Selective odontoplasty and placement of a intermaxillary fixation
• Step 27. Removal of bone for mandibular setback procedures

■ PROXIMAL SEGMENT REPOSITIONING

• Step 28. Condylar positioning

■ PLACEMENT OF RIGID FIXATION

• Step 29. Tightening the holding wire
• Step 30. Placement of the trocar
• Step 31. Placement of rigid fixation. Bicortical screws
• Step 31. Plate fixation
• Step 32. Remove the intermaxillary fi xation and check the occlusion

■ EVALUATION OF POST FIXATION OCCLUSION

Step 33. Intra operative diagnosis of an incorrect occlusion

• A. Incorrect condylar positioning (condilar sag)
  • 1. Central condilar sag
    • 1.1. Bilateral central condylar sag
    • 1.2. Unilateral central condylar sag left side
    • 1.3. Unilateral condylar sag right side
  • 2. Peripheral condylar sag type I
  • 3. Peripheral condylar sag type II
    • 3.1. Bilateral peripheral condylar sag
    • 3.2. Unilateral peripheral condylar sag right
    • 3.3. Unilateral peripheral condylar sag left
• B. Mobility at the osteotomy site
• C. Movement of the occlusion during placement of rigid fixation
• D. Maloclusion as a result of a poorly fitted final surgical splint

■ COMPLETE THE PROCEDURE

• Step 5. Place intra- and extra-oral sutures
• Step 6. Place elastics – 4Oz, 1/4”
• Step 7. Place a pressure dressing 95

PART 2 THE LEFORT I MAXILLARY OSTEOTOMY

■ SURGICAL APPROACH

• Step 1. Infi ltrate the soft tissue with a vasoconstrictor
• Step 2. Mucosal incision
• Step 3. Complete the soft tissue incision through the muscle and periosteum onto bone
• Step 4. Subperiosteal dissection
• Step 5. Intraoral reference marks & extraoral measurements

■ PERFORMING THE OSTEOTOMY

• Step 6. Anterior buccal osteotomy
• Step 7. Posterior buccal osteotomy
• Step 8. Connect the anterior and posterior osteotomies
• Step 9. Prepare for buttress wires
• Step 10. Separate the tuberosity from the pterygoid plates
• Step 11. Complete and refi ne the posterior maxillary osteotomy
• Step 12. Lateral nasal wall osteotomy
• Step 13. Complete the soft tissue incision on the contralateral side and perform the osteotomies on the opposite side
• Step 14. Place a maxillary positioning wire
• Step 15. Complete the subperiosteal nasal spine dissection
• Step 16. Septal cartilage and vomer osteotomy

■ MAXILLARY DOWN FRACTURE

• Step 17. Maxillary down fracture

■ FAILURE TO EFFECT MAXILLARY DOWN FRACTURE

• Step 18. Redefine the osteotomies
• Step 19. Mobilize the maxilla
• Step 20. Exposure of the posterior maxilla
• Step 21. Check the level of the fracture
• Step 22. Trim the lateral nasal wall
• Step 23. Refine the osteotomy at the posterior maxilla

■ REFINE THE OSTEOTOMY

• Step 24. Reduce the palatal aspect (nasal floor) of the septum
• Step 25. Contour the piriform rim
• Step 26. Feed positioning wires through the drilled holes

■ INTERMAXILLARY FIXATION

• Step 27. Place the splint and apply intermaxillary fixation
• Step 28. Check the nasal septum position

■ MAXILLARY REPOSITIONING

• Step 29. Reposition the maxilla
• Step 30. Turbinectomy (if necessary)
• Step 31. Nasal mucosa suturing
• Step 32. Tighten the buttress wires
• Step 33. Rigid fixation placement

■ SEGMENTAL MAXILLARY SURGERY

• • 1. Interdental osteotomies
  • 2. Nasal floor (palatal) osteotomy
  • 3. Closing interdental spaces
  • 4. Fixation and stabilization after segmental osteotomies

■ EVALUATE THE OCCLUSION

• Step 34. Remove the intermaxillary fi xation and carefully check the occlusion

■ POST-PROCEDURAL SUTURING

• Step 35. Place a cinch and nasal septum suture
• Step 36. Submucosal suturing
• Step 37. Mucosal suturing

■ PROCEDURE COMPLETION

• Step 38. Placing elastics or intermaxillary fixation
• Step 39. Apply a pressure dressing
• Step 40. Extubation

PART 3 THE SLIDING GENIOPLASTY

■ SURGICAL APPROACH

• Step 1. Infiltration of the soft tissue with a vasoconstrictor
• Step 2. Mucosal incision
• Step 3. Submucosal incision
• Step 4. Mucoperiosteal dissection
• Step 5. Mark reference points
• Step 6. Mark the design of the osteotomy

■ PERFORMING THE OSTEOTOMY

• Step 7. Osteotomy of the chin

■ MOBILIZING THE CHIN SEGMENT

• Step 8. Mobilisation of the chin
• Step 9. Engage the positioning wire
• Step 10. Reduction of soft tissue tension
• Step 11. Refinement of the osteotomy

■ ANTEROPOSTERIOR AUGMENTATION OF THE CHIN

• Step 12. Repositioning the chin segment

■ INTERNAL RIGID FIXATION OF THE CHIN SEGMENT

• Step 13. Tri-cortical fixation
• Step 14. Placement of the tricortical screwss

■ BONE PLATE FIXATION

• Step 15. Bone plate fixation as an alternative to screw fixation

■ ANTEROPOSTERIOR REDUCTION OF THE CHIN

• Step 16. Antero-posterior reduction of chin prominence

■ VERTICAL AUGMENTATION OF THE CHIN

• Step 17. Down graft of the chin segment

■ VERTICAL REDUCTION OF THE CHIN

• Step 18. Vertical reduction of the chin

■ CORRECTION OF CHIN ASYMMETRY

• Step 19. Correction of asymmetry of the chin

■ CORRECTION OF TRANSVERS CHIN DEFORMITIES

• Step 20. Changing the width of the chin
  • 1. Altering the posterior dimension of the chin
    • Widening (increasing the posterior width
    • Narrowing (decreasing the posterior width
  • 2. Altering the anterior dimension of the chin
    • Widening (increasing the anterior dimension and squareness of the chin)
    • Narrowing (decreasing the anterior width and squareness of the chin)

■ COMPLETION OF THE PROCEDURE

• Step 21. Suture the submucosal tissue
• Step 22. Suture the mucosa
• Step 23. Place a pressure dressing

This needs not only manual skills but technical know-how. There is the saying, if you want to become a guru, you have to learn with a guru. Johan Reyneke is a guru in orthognathic surgery in our times and not everyone has the opportunity to study and observe with him. In his passion for the profession and with his experience after more than many thousands of orthognathic surgical cases, he has put together an exceptional manual on the technique of mandibular sagittal ramus osteotomy. The book not only describes every surgical step thoroughly and is perfectly illustrated, but also provides the reader with suggestions and tricks how to avoid and how to deal with complications.

 

The secret of success in any venture in life is based on structured, strategic actions. This is well demonstrated by the actions of the military leaders in the ancient Rome or CEOs of a fl ourishing company, or the clinical and technical approach of a brilliant surgeon. It is therefore not without reasons that the father of modern orthognathic surgery, Hugo Obwegeser came up with his 61 Principles of Treatment Planning or Ralph Millard wrote his book on Principlization of Plastic Surgery. In surgery it all starts with a clear treatment plan. We are currently privileged to have Access to exquisite 3D data of our patients which may distracted the surgeon and tempt him or her not to study the patient clinically in-depth anymore. All this information is only rewarding if you can transform it successfully into a safe step to step manoeuvre intraoperatively.

And this needs not only manual skills but technical know-how. There is the saying, if you want to become a guru, you have to learn with a guru. Johan Reyneke is a guru in orthognathic surgery in our times and not everyone has the opportunity to study and observe with him. In his passion for the profession and with his experience after more than many thousands of orthognathic surgical cases, he has put together an exceptional manual on the technique of mandibular sagittal ramus osteotomy. The book not only describes every surgical step thoroughly and is perfectly illustrated, but also provides the reader with suggestions and tricks how to avoid and how to deal with complications.

In this regard the manual should not only be a must in every trainee´s library of departments specialized in corrections of dysgnathia but it defi nitely also has interesting aspects for already practising surgeons.