CASE REPORT

Severe Class II malocclusion with facial

asymmetry treated with intraoral
vertico-sagittal ramus osteotomy
and LeFort I osteotomy
Shingo Kuroda,a Kaoru Murakami,b Yasuko Morishige,b and Teruko Takano-Yamamotoc
Tokushima, Okayama, and Sendai, Japan

In this article, we report the successful treatment of a patient, aged 19 years 11 months, who had a severe
Class II malocclusion and facial asymmetry. A combination of intraoral vertical-sagittal ramus osteotomy
(IVSRO), intraoral vertical ramus osteotomy (IVRO), and LeFort I osteotomy was used for mandibular
advancement and maxillary impaction. The patient had a convex profile because of a retrognathic mandible.
She also had severe mandibular deviation and vertical maxillary excess with a canted occlusal plane. A deep
overbite of 8.0 mm and an excessive overjet of 10.0 mm were observed. After 16 months of presurgical
orthodontic treatment, IVRO in the left ramus and IVSRO in the right ramus were performed with maxillary
impaction by LeFort I osteotomy. The mandible was advanced 6.0 mm on the right side, and the maxilla was
impacted 4.0 mm at ANS, 2.0 mm at the right first molar, and 5.0 mm at the left first molar. The total active
treatment time was 35 months. Both occlusion and facial appearance were significantly improved by the
surgical-orthodontic treatment. Occlusion was stable after a year of retention. There were no functional
problems during or after treatment. Our results suggest that IVSRO and IVRO combined with LeFort I
osteotomy in a patient with severe mandibular retrusion with facial asymmetry might be useful to improve
occlusion and facial esthetics. (Am J Orthod Dentofacial Orthop 2009;135:809-19)

S
evere Class II malocclusion in adults has been
treated by orthodontics alone (camouflage) or
orthognathic surgery to reposition the mandible
or the maxilla.1 Camouflage treatment is not a compro-
mise, but orthognathic surgery is performed if the
patient has a severe Class II malocclusion caused by
mandibular retrusion, because orthognathic surgery can
provide significant skeletal improvement.1,2 In addi-
tion, orthognathic surgery provides more esthetic treat-
ment results than orthodontic camouflage treatment in a
patient with facial asymmetry.
For orthognathic surgery of the mandible, 2
methods are commonly used: sagittal split ramus
a
Associate professor, Department of Orthodontics and Dentofacial Orthope-
dics, The University of Tokushima Graduate School of Oral Sciences, To-
kushima, Japan.
b
Postdoctoral fellow, Department of Orthodontics and Dentofacial Orthope-
dics, Okayama University Graduate School of Medicine, Dentistry and Phar-
maceutical Sciences, Okayama, Japan.
c
Professor and chair, Division of Orthodontics and Dentofacial Orthopedics,
Tohoku University Graduate School of Dentistry, Sendai, Japan.
Reprint requests to: Teruko Takano-Yamamoto, Division of Orthodontics and
Dentofacial Orthopedics, Tohoku University Graduate School of Dentistry, 4-1
Seiryo-machi, Aobaku, Sendai, Japan, 980-8574; e-mail, t-yamamo@
mail.tains.tohoku.ac.jp.
Submitted, June 2006; revised and accepted, November 2006.
0889-5406/$36.00
Copyright © 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.11.026
osteotomy (SSRO) and intraoral vertical ramus os-
teotomy (IVRO). SSRO is a commonly performed
mandibular surgery for setback or advancement; this
method usually provides a stable treatment result be-
cause of rigid fixation.1-5 IVRO is mainly used to set
back the mandible.6-9 In addition, recent reports have
shown satisfactory outcomes in patients with temporo-
mandibular disorder (TMD) treated by IVRO.6,9-11
However, IVRO is unsuitable for mandibular advance-
ment. In 1992, Choung12 introduced an alternative
method for orthognathic surgery—intraoral vertical-
sagittal ramus osteotomy (IVSRO). This method in-
cludes the useful characteristics of both SSRO and
IVRO. However, few case reports describe mandibular
advancement with IVSRO in severe Class II patients.
Severe skeletal Class III patients with facial asym-
metry have sometimes been treated by using unilateral
SSRO and IVRO, because significant flaring of the
proximal ramus segment occurred to correct the man-
dibular deviation.13,14 In Class II patients, the greater
the rotational component of the asymmetric mandibular
advancement, the more the distal segment of the man-
dible on the most severe Class II side rotates laterally,
and this also results in flaring of the overlying proximal
segment of the mandible.15 In such cases, IVSRO
809
810 Kuroda et al
Fig 1. Pretreatment facial and intraoral photographs.
might be suitable, but there are few reports of IVSRO
in patients with skeletal Class II mandibular deviation.
This case report demonstrates the usefulness of
combination treatment of unilateral IVSRO, IVRO, and
LeFort I osteotomy in a patient with a severe Class II
malocclusion with facial asymmetry.
DIAGNOSIS AND ETIOLOGY
A young woman, aged 19 years 11 months, came to
the outpatient clinic of our university hospital in
Okayama, Japan (Figs 1-4). Her chief complaints were
facial asymmetry and deep overbite. A convex profile
due to a retrognathic mandible was noted. An acute
nasolabial angle, decreased lower facial height, and
circumoral muscle strain on lip closure were observed.
She had facial asymmetry with mandibular deviation to
the right and excessive gingival display. A severe deep
overbite with an overjet of 10.0 mm and an overbite of
American Journal of Orthodontics and Dentofacial Orthopedics
June 2009
8.0 mm were observed. The mandibular dental arch was
significantly constricted with a V-shape and a scissors-
bite of the premolars bilaterally. There was mild crowd-
ing in the mandibular incisors. The maxillary left second
premolar was rotated 180°. The maxillary dental midline
almost coincided with the facial midline, but the mandib-
ular midline was shifted 3.0 mm toward the right.
Cephalometric analysis, when compared with the
Japanese norm, showed a skeletal Class II relationship
(ANB, 7.5°) with mandibular retrusion (SNB, 70.0°)
(Figs 3 and 4; Table).16 Both mandibular body length
and ramus height were short (Ar-Go, 41.5 mm; Go-Me,
61.6 mm). The mandibular plane angle was steep, and
the gonial angle was large (MP/FH, 36.5°; Go.A,
140.5°). The maxillary incisors were lingually inclined
(U1-NF, 110.0°). The mandibular incisors were not
inclined labially but were significantly extruded (L1-MP,
89.0°; L1/MP, 48.5 mm). The molar relationships were
American Journal of Orthodontics and Dentofacial Orthopedics Kuroda et al 811
Volume 135, Number 6

Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment radiographs: A, lateral cephalogram; B, posteroanteror cephalogram;

C, panoramic radiograph.
812 Kuroda et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2009

Fig 4. Pretreatment cephalometric tracing: A, tracing (solid line) was superimposed with a mean
profilogram (dotted line); B, tracing of posteroanterior cephalogram.

Table. Cephalometric summary

Variable Mean (women) SD Pretreatment Postactive treatment 1 year postretention

Angular (°)
ANB 2.8 2.44 7.5 7.0 8.5
SNA 80.8 3.61 77.5 79.0 79.5
SNB 77.9 4.54 70.0 72.0 71.0
MP-FH 30.5 3.60 36.5 36.0 37.5
Gonial A. 122.1 5.29 140.5 135.5 138.0
U1-FH 112.3 8.26 110.5 106.0 101.5
U1-NF 115.0 6.99 110.0 103.5 98.0
L1-MP 93.4 6.77 89.0 93.0 93.5
Interincisal A. 123.6 10.64 122.0 119.0 127.0
Occlusal pl. A. 16.9 4.40 24.0 29.5 28.5
Linear (mm)
S-N 67.9 3.65 68.2 68.2 68.2
N-Me 125.8 5.04 124.2 121.0 121.5
N/NF 56.0 2.53 53.0 49.0 49.8
Me/NF 68.6 3.71 66.5 68.8 68.5
Go-Me 71.4 4.14 61.6 65.0 65.0
Ar-Me 106.6 5.74 95.8 98.0 98.0
Ar-Go 47.3 3.33 41.5 40.4 37.4
Overjet 3.1 1.07 10.0 3.8 4.4
Overbite 3.3 1.89 8.0 2.4 4.3
U1/NF 31.0 2.34 34.5 34.5 35.0
U6/NF 24.6 2.00 20.5 20.5 20.5
L1/MP 44.2 2.68 48.5 43.0 44.0
L6/MP 32.9 2.50 32.5 32.5 32.5

Angle Class II on both sides. In the anteroposterior
cephalogram, the occlusal plane was canted, and the
mandible deviated 7.0 mm to the right of the facial
midline.
The patient had no significant symptoms of TMD,
and normal jaw movements during mastication were
observed on a 6 degrees of freedom jaw-movement
recording system (Gnathohexagraph, version 1.31, Ono
Sokki, Kanagawa, Japan). An occlusal force of 585 N
and an occlusal contact area of 17.1 mm2 were calcu-
lated on an occlusal-force recording system (Dental
Prescale & Occluzer, Fuji Film, Tokyo, Japan).
TREATMENT OBJECTIVES
The patient was diagnosed as having an Angle
Class II malocclusion, with a skeletal Class II jaw-base
relationship caused by mandibular retrusion and defi-
ciency, and facial asymmetry. The treatment objectives
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 6
Fig 5. Posttreatment facial and intraoral photographs.
were to (1) correct the deep overbite and establish ideal
overjet and overbite, (2) achieve an acceptable occlu-
sion with a good functional Class I occlusion, (3)
correct the mandibular deviation and the canted occlu-
sal plane with facial asymmetry, and (4) correct the
gummy smile.
Since the cause of the deep overbite and the retrog-
nathic profile was suggested to have been retroposition
and a small mandible, we planned to advance and rotate
the mandible with a combination of IVSRO and IVRO.
LeFort I osteotomy was also planned to correct the
canted occlusal plane and excessive gingival display
caused by the vertical maxillary excess.
TREATMENT ALTERNATIVES
Several procedures were explored to achieve ideal
overjet and overbite. Although extraction treatment
without orthognathic surgery was considered an effec-
Kuroda et al 813
tive treatment method to improve the malocclusion
without prolonged hospitalization and higher medical
costs with maximal invasion, this plan would not
correct the skeletal disharmony (facial asymmetry,
retrognathic mandible, maxillary vertical excess with
canted occlusal plane.) Therefore, we chose surgical-
orthodontic treatment with 2-jaw surgery.
For mandibular advancement surgery, SSRO is the
most common procedure and usually provides a stable
treatment result. However, the patient had facial asym-
metry, and rotational movement of the mandible was
required. Therefore, we planned a combination treatment
of unilateral IVSRO, IVRO, and LeFort I osteotomy.
TREATMENT PROGRESS
Before the start of orthodontic treatment, an
occlusal splint was placed in the maxilla to identify
a stable mandibular position. Then, 0.018-in slot
814 Kuroda et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2009

Fig 6. Posttreatment dental casts.

Fig 7. Posttreatment radiographs: A, lateral cephalogram; B, posteroanterior cephalogram;

C, panoramic radiograph.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 6
Fig 8. Pretreatment (solid line) and posttreatment (dotted line) cephalometric tracings, superim-
posed on A, sella-nasion plane at sella; B, anterior palatal counter; C, mandibular plane at menton.
Fig 9. Pretreatment (solid line) and posttreatment (dot-
ted line) posteroanterior cephalometric tracings, super-
imposed on ZL-ZR line.
preadjusted edgewise appliances were placed on both
arches, and leveling and alignment with nickel-
titanium archwires were started. A bi-helix appliance
was also placed between the mandibular first molars
to upright the lingually inclined molars. Six months
after placement of the bi-helix appliance, the man-
dibular molars were significantly uprighted. The
Kuroda et al 815
maxillary right second premolar was aligned to
maintain 180° of rotation.
After 16 months of presurgical orthodontic treat-
ment, IVRO in the left ramus and IVSRO in the right
ramus were performed with maxillary impaction by
LeFort I osteotomy. The mandible was advanced 5.0
mm at the right first molar. The maxilla was impacted
4.0 mm at ANS, 2.0 mm at the right first molar, and 5.0
mm at the left first molar.
The preadjusted edgewise appliances were replaced
19 months after orthognathic surgery. After removal of
the edgewise appliances, a wraparound retainer and a
lingual bonded retainer were placed in the maxillary
and mandibular arches for retention. The total active
treatment time was 35 months. A mandibular border
osteotomy to advance the chin was recommended to
improve the profile, but the patient declined further
surgery. One year after retention, the occlusion was
almost stable in spite of a slight backward mandibular
movement and an increase in overbite.
TREATMENT RESULTS
The posttreatment records show that both skeletal
disharmony and malocclusion were significantly im-
proved, and jaw movements during mastication were in
the normal range without signs or symptoms of TMD
(Figs 5-9). The facial photographs showed a significant
improvement of facial asymmetry. The excessive gin-
gival display was also improved with maxillary impac-
816 Kuroda et al
Fig 10. One-year postretention facial and intraoral photographs.
tion. A Class I occlusion with normal overjet and
overbite was achieved. Posttreatment cephalometric
evaluation showed an increased SNB angle (72.0°), but
the skeletal jaw base relationship was still Class II
(ANB, 7.0°) (Table). The maxilla was impacted 4.0
mm at ANS, 2.0 mm at the maxillary right first molar,
and 5.0 mm at the left first molar. The mandible was
advanced 5.0 mm at the right first molar and 3.4 mm at
pogonion, and there was no undesirable clockwise
rotation of the mandible (Figs 7-9, Table). Facial
asymmetry with mandibular deviation was improved
significantly on the posteroanterior cephalogram. Jaw
movement during mastication was normal on a 6
degrees of freedom jaw-movement recording system.
After a year of retention, the occlusion was stable,
and good facial esthetics were also maintained (Fig 10).
Cephalometric analysis showed a 1.0° decrease in the
American Journal of Orthodontics and Dentofacial Orthopedics
June 2009
SNB angle and a 1.0 mm elongation of the mandibular
incisors (Figs 11 and 12; Table).
DISCUSSION
As a result of surgical-orthodontic treatment, both
occlusion and facial appearance were improved signif-
icantly. LeFort I osteotomy effectively improved the
excessive gingival display and the canted occlusal
plane. Pogonion was advanced 3.4 mm by mandibular
advancement surgery, and the facial profile was im-
proved. Advancement genioplasty was recommended
to improve the facial profile more, but the patient
declined further surgery. In general, Japanese layper-
sons prefer a retrognathic facial appearance rather than
a prognathic profile.17,18 Therefore, she might have
been more satisfied with her profile after surgery.
American Journal of Orthodontics and Dentofacial Orthopedics Kuroda et al 817
Volume 135, Number 6

Fig 11. One-year postretention: A, lateral cephalogram; B, posteroanteror cephalogram; C, panoramic

radiograph.

Fig 12. Posttreatment (solid line) and 1-year postretention (dotted line) cephalometric tracings, superim-
posed on A, sella-nasion plane at sella; B, anterior palatal contour; C, mandibular plane at menton.

For mandibular orthognathic surgery, SSRO is the IVRO has been used for mandibular setback.6-9 Re-
most common procedure and usually provides a stable cently, IVRO has received renewed attention since it is
treatment result for both setback and advancement.1-5 less invasive during and after surgery: ie, less bleeding
818 Kuroda et al
during surgery and less neurosensory disturbance after
the procedure.19-21 In addition, IVRO has been used for
patients with symptoms of TMD.6,9,10 However, IVRO
is not suitable for mandibular advancement, because it
is difficult to achieve an adequate bone contact area
between the proximal and distal segments after man-
dibular advancement. Choung12 introduced IVSRO in
1992; it includes the useful characteristics of both
SSRO and IVRO. IVSRO provides larger contact areas
between the proximal and distal segments than IVRO;
therefore, IVSRO allows the distal segments to move
posteriorly, anteriorly, superiorly, or rotationally.
IVSRO has some advantages compared with SSRO:
lower medical costs, shorter surgical duration, minimal
condylar displacement, and less injury or compression
of the neurovascular bundle.11,22 In addition, some
reports showed that IVSRO was effective in treating
TMD patients.22-25
In this patient, rotation of the mandible was re-
quired to correct facial asymmetry with midline devi-
ation. The greater the rotational component of the
asymmetric mandibular advancement, the more the
distal segment of the mandible on the most Class II side
rotates laterally, and this results in variable flaring of
the overlying proximal segment of the mandible.15 If
the proximal and distal mandibular ramus segments are
approximated with rigid fixation to correct the flaring of
the proximal segment of the mandible, the condyle will
be distracted or displaced laterally, or the distal man-
dible will be forced somewhat in the medial direction.15
In such cases, SSRO is sometimes unsuitable, because
rigid fixation or flaring of the proximal and distal
mandibular ramus segments might distract the condyle
or move the distal mandible medially. Therefore, we
selected a combination of unilateral IVSRO and IVRO
for this patient. As a result of these procedures, facial
asymmetry with mandibular deviation was significantly
improved, and both condylar and jaw movement during
mastication were also kept in the normal range, with no
TMD symptoms after surgery. Therefore, we suggest
that IVSRO is suitable for treatment of patients with
Class II mandibular deficiency and mandibular devia-
tion. In addition, IVSRO might be useful for mandib-
ular advancement in TMD patients.
However, we had some concerns about IVSRO,
such as destabilization of the distal segment immedi-
ately after surgery, rehabilitation time of several
months, and loading of the dentition during intermax-
illary fixation. In addition, IVSRO is unsuitable for
more than 5 mm of mandibular advancement. Recently,
distraction osteogenesis (DO) has been widely used to
lengthen the maxilla or the mandible.26-29 More than 10
mm of mandibular lengthening can be achieved by DO.
American Journal of Orthodontics and Dentofacial Orthopedics
June 2009
Then, we must decide which method is better for a
patient to advance the mandible—SSRO, IVSRO, or
DO—according to the clinical characteristics of each
situation.
In previous reports, mandibular advancement sur-
gery with SSRO was clinically stable, because of rigid
fixation.1-5 However, 30% of the patients treated with
LeFort I osteotomy and mandibular advancement with
SSRO had horizontal relapse of more than 2 mm at
pogonion 2 years after surgery.2 In our patient, the
mandible moved backward 1.2 mm at pogonion at 2
years postsurgery. It was reported that a tendency
toward backward movement of the mandible after
mandibular advancement with IVSRO was slightly
stronger than that after SSRO.30 Therefore, we suggest
that some overcorrection might be required to treat
mandibular advancement with IVSRO.
CONCLUSIONS
We treated an adult with severe mandibular retru-
sion and facial asymmetry using IVSRO and IVRO
combined with LeFort I osteotomy. After treatment,
both skeletal disharmony and malocclusion were sig-
nificantly improved, and jaw movements during mas-
tication remained in the normal range with no TMD
signs or symptoms. Therefore, we suggest that IVSRO
and IVRO combined with LeFort I osteotomy in a
patient with severe mandibular retrusion with facial
asymmetry might be useful to improve occlusion and
facial esthetics. However, some overcorrection might
be recommended to treat mandibular advancement with
IVSRO.
We thank Akira Sasaki and Akiyoshi Nishiyama,
Department of Oral and Maxillofacial Surgery and
Biopathology, Okayama University Graduate School of
Medicine, Dentistry and Pharmaceutical Sciences, for
their valuable suggestions and support in the surgical
procedures.
REFERENCES
1. Proffit WR, Phillips C, Douvartzidis N. A comparison of
outcomes of orthodontic and surgical-orthodontic treatment of
Class II malocclusion in adults. Am J Orthod Dentofacial Orthop
1992;101:556-65.
2. Mihalik CA, Proffit WR, Phillips C. Long-term follow-up of
Class II adults treated with orthodontic camouflage: a compari-
son with orthognathic surgery outcomes. Am J Orthod Dentofa-
cial Orthop 2003;123:266-78.
3. Dermaut LR, De Smit AA. Effects of sagittal split advancement
osteotomy on facial profiles. Eur J Orthod 1989;11:366-74.
4. Blomqvist JE, Isaksson S. Skeletal stability after mandibular
advancement: a comparison of two rigid internal fixation tech-
niques. J Oral Maxillofac Surg 1994;52:1133-7.
5. Busby BR, Bailey LJ, Proffit WR, Phillips C, White RP Jr.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 6
Long-term stability of surgical Class III treatment: a study of
5-year postsurgical results. Int J Adult Orthod Orthognath Surg
2002;17:159-70.
6. Kuroda S, Sugawara Y, Yamashita K, Mano T, Takano-
Yamamoto T. Skeletal Class III oligodontia patient treated with
titanium screw anchorage and orthognathic surgery. Am J Orthod
Dentofacial Orthop 2005;127:730-8.
7. Lew KK, Loh FC, Yeo JF, Loh HS. Evaluation of soft tissue
profile following intraoral ramus osteotomy in Chinese adults
with mandibular prognathism. Int J Adult Orthod Orthognath
Surg 1990;5:189-97.
8. Tornes K, Wisth PJ. Stability after vertical subcondylar ramus
osteotomy for correction of mandibular prognathism. Int J Oral
Maxillofac Surg 1988;17:242-8.
9. Bell WH. Correction of mandibular prognathism by mandibular
setback and advancement genioplasty. Int J Oral Surg 1981;10:
221-9.
10. Bell WH, Yamaguchi Y, Poor MR. Treatment of temporoman-
dibular joint dysfunction by intraoral vertical ramus osteotomy.
Int J Adult Orthod Orthognath Surg 1990;5:9-27.
11. Ueki K, Marukawa K, Nakagawa K, Yamamoto E. Condylar and
temporomandibular joint disc positions after mandibular osteot-
omy for prognathism. J Oral Maxillofac Surg 2002;60:1424-32.
12. Choung PH. A new osteotomy for the correction of mandibular
prognathism: techniques and rationale of the intraoral vertico-
sagittal ramus osteotomy. J Craniomaxillofac Surg 1992;20:
153-62.
13. Lai W, Yamada K, Hanada K, Ali IM, Takagi R, Kobayashi T,
et al. Postoperative mandibular stability after orthognathic sur-
gery in patients with mandibular protrusion and mandibular
deviation. Int J Adult Orthod Orthognath Surg 2002;17:13-22.
14. Oba Y, Nagashima Y, Moriyama K. Evaluation of a combination
of intraoral vertical ramus osteotomy and sagittal split ramus
osteotomy in three cases with asymmetric mandible. Jpn J Jaw
Deform 2005;15:28-40.
15. Epker BN, Stella JP, Fish LC. Dentofacial deformities: asym-
metric Class II dentofacial deformities. 2nd ed. St Louis: Mosby;
1996. p. 1959-2028.
16. Wada K, Matsushita K, Shimazaki S, Miwa Y, Hasuike Y, Susami
R. An evaluation of a new case analysis of a lateral cephalometric
roentgenogram. J Kanazawa Med Univ 1981;6:60-70.
17. Mantzikos T. Esthetic soft tissue profile preferences among the
Japanese population. Am J Orthod Dentofacial Orthop 1998;
114:1-7.
18. Ioi H, Nakata S, Nakasima A, Counts A. Effect of facial
convexity on antero-posterior lip positions of the most favored
Japanese facial profiles. Angle Orthod 2005;75:326-32.
Kuroda et al 819
19. Ueki K, Marukawa K, Shimada M, Nakagawa K, Yamamoto E.
The assessment of blood loss in orthognathic surgery for prog-
nathia. J Oral Maxillofac Surg 2005;63:350-4.
20. Al-Bishri A, Barghash Z, Rosenquist J, Sunzel B. Neurosensory
disturbance after sagittal split and intraoral vertical ramus osteot-
omy: as reported in questionnaires and patients’ records. Int
J Oral Maxillofac Surg 2005;34:247-51.
21. Westermark A, Bystedt H, von Konow L. Inferior alveolar nerve
function after mandibular osteotomies. Br J Oral Maxillofac Surg
1998;36:425-8.
22. Choung PH, Nam IW. An intraoral approach to treatment of
condylar hyperplasia or high condylar process fractures using the
intraoral vertico-sagittal ramus osteotomy. J Oral Maxillofac
Surg 1998;56:563-70.
23. Choi YS, Yun KI, Kim SG. Long-term results of different
condylotomy designs for the management of temporomandibular
joint disorders. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2002;93:132-7.
24. Fujimura K, Segami N, Sato J, Kanayama K, Nishimura M,
Demura N. Advantages of intraoral verticosagittal ramus osteot-
omy in skeletofacial deformity patients with temporomandibular
joint disorders. J Oral Maxillofac Surg 2004;62:1246-52.
25. Fujimura K, Segami N, Sato J, Kaneyama K, Nishimura M.
Comparison of the clinical outcomes of patients having sounds in
the temporomandibular joint with skeletal mandibular deformi-
ties treated by vertico-sagittal ramus osteotomy or vertical ramus
osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2005;99:24-9.
26. McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH.
Lengthening the human mandible by gradual distraction. Plast
Reconstr Surg 1992;89:1-8.
27. Polley JW, Figueroa AA. Distraction osteogenesis: its applica-
tion in severe mandibular deformities in hemifacial microsomia.
J Craniofac Surg 1997;8:422-30.
28. Kofod T, Norholt SE, Pedersen TK, Jensen J. Unilateral man-
dibular ramus elongation by intraoral distraction osteogenesis. J
Craniofac Surg 2005;16:247-54.
29. Kuroda S, Araki Y, Oya S, Mishima K, Sugahara T, Takano-
Yamamoto T. Maxillary distraction osteogenesis to treat maxil-
lary hypoplasia: comparison of an internal and an external
system. Am J Orthod Dentofacial Orthop 2005;127:493-8.
30. Ito M, Yamada I, Furuki Y, Yamauchi K, Mitsugi M. Postsur-
gical stability of mandible of mandibular advancement by in-
traoral vertico-sagittal ramus osteotomy and sagittal split ramus
osteotomy. J Chu-Sikoku Orthod Soc 2002;14:51-6.