Mandibular Surgery

Technologic and Technical

Improvements
Alan S. Herford, DDS, MDa,*, Dale E. Stringer, DDSa,
Rahul Tandon, DMDb

KEYWORDS
 Orthognathic mandibular surgery  Virtual surgical planning  Distraction osteogenesis
 Temporary anchorage devices

KEY POINTS
 Technologic advances have always played a role in the progression of surgical craniofacial tech-
niques, helping to deliver the best possible outcomes in treating maxillomandibular relationships.
 Although traditional orthognathic surgery has relied on model surgery and fabrication of acrylic
occlusal splints, computer-aided manufactured surgical splints have helped to reduce and, in
some cases, eliminate the inherent human error that accompanies traditional model surgery.
 Improvements in fixation techniques have provided surgeons with more flexibility in surgical
sequencing, as well as allowing larger advancements with less chance of relapse, and improve-
ments in the postoperative period for the patient.
 Distraction osteogenesis can also be used to correct compromised airways such as those found in
patients with obstructive sleep apnea, and patients also benefit from elongation of the ramus such
as in hemifacial microsomia.
 Computed tomography has allowed clinicians (surgeons and orthodontists) to appropriately
analyze and manipulate images of the bony structures and overlying soft tissues in a way that
was not possible with the traditional two-dimensional techniques.
 Virtual surgical planning has improved the treatment of patients requiring orthognathic surgery, and
especially patients with significant facial asymmetries.

INTRODUCTION techniques have remained little changed, ad-

Technologic advances have always played a
role in the progression of surgical craniofacial
techniques, helping to deliver the best possible
outcome in correcting maxillomandibular rela-
tionships. Discrepancies between the 2 arches,
as well as facial asymmetries, continue to be
the primary reasons for performing orthognathic
vances in diagnostics and planning have made
such procedures more efficient. In the past,
surgeons and orthodontists used lateral cepha-
lometric radiographs to develop composite trac-
ings to help with planning possible treatment
outcomes. Studies in the 1970s showed that
data from digitized lateral films could be used
oralmaxsurgery.theclinics.com

to aid in describing possible postoperative soft

surgeries. Although many of the surgical

a
Department of Oral and Maxillofacial Surgery, Loma Linda University, 11092 Anderson Street, 3rd Floor,
Loma Linda, CA, USA; b Department of Oral and Maxillofacial Surgery, Parkland Memorial Hospital, University
of Texas Southwestern, Dallas, TX 75390, USA
* Corresponding author.
E-mail address: aherford@llu.edu

Oral Maxillofacial Surg Clin N Am 26 (2014) 487–521

http://dx.doi.org/10.1016/j.coms.2014.08.004
1042-3699/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
488 Herford et al
tissue changes.1 These methods involved the
use of sectioned photographs and freehand
alteration of the lateral cephalometric tracings.2
However, these methods had several disadvan-
tages, such as difficulty in physically manipu-
lating the photographs and human error in the
freehand alterations.3 However, the advent of
virtual surgical planning has provided better
methods for surgical planning, giving patients
the best possible outcome.
HISTORY OF ADVANCEMENTS
Nearly 56 years after its first description, the
sagittal split osteotomy (SSO) remains one of
the most commonly used procedures for
mandibular advancement and setback. As
described by Trauner and Obwegeser4 in 1957,
this procedure involved 3 distinct cuts: an obli-
que cut through the lateral cortex distal to the
second molar and directed toward the gonial
angle, a horizontal cut through the medial cortex
superior to the lingula, and a sagittal osteotomy
through the ramus between those cuts. The pro-
cedure had previously been done extraorally, but
this approach led to difficulties relating to the
small area of contact between the separated
bony segments. In addition, complications
involving open bite and pseudoarthrosis also
were common.5,6 It was Trauner and Obewe-
geser4 who introduced the intraoral option for
this technique, which is almost universally used
in current practice.
In 1961, Dal Pont7 described a modification of
the Obwegeser method, in which he introduced
the retromolar osteotomy. A vertical buccal cut
is made, which increases the area of bony over-
lap. As a result, the action of the masseter and
medial pterygoid decreased the displacement of
the proximal segments, increasing the uses for
this procedure. In the past, it was mainly used
for prognathism; however, this new modification
allowed it to be used for retrognathism and
open bite. This osteotomy began at the distal
aspect of the second molar, and extended from
the external oblique line to the inferior border of
the mandible.
Even with the advancements in the SSO, relapse
remained a significant concern for both surgeons
and patients. In 1977, Epker8 published his find-
ings on how to minimize, or even prevent, such re-
lapses.9 In his research, he suggested that in order
to decrease bleeding and edema, the surgeon
should stop periosteal stripping and blind dissec-
tion of the pterygomasseteric sling. He also stated
that placing a superior border intraosseous wire
with the proximal segment held inferior to the distal
segment helps to reposition the condyle in the
glenoid fossa.
Alternatives to the SSO were sought because it
led to an increased risk of injury to the inferior
neurovascular bundle.10 One alternative is the in-
traoral vertical ramus osteotomy (IVRO). In this
procedure the pterygomasseteric sling is re-
moved, allowing the proximal and distal seg-
ments to be pulled anteriorly and posteriorly,
respectively. Nevertheless, both segments re-
cover to their original positions once masticatory
balance is reestablished with jaw exercise.11
IVRO offers several advantages compared with
SSO; namely reduced operating time and de-
creased bleeding.12,13 However, there are disad-
vantages, including limitation to only cases of
mandibular prognathism and a longer period of
maxillomandibular fixation (MMF) after IVRO
compared with SSO.14,15 However, other clini-
cians use IVRO in asymmetry cases because of
limited bony interference.16
The total subapical mandibular osteotomy has
been rarely used, primarily because it is a difficult
osteotomy to perform. Making the transition from
the ramus split of the body horizontal osteotomy
was difficult and, in many instances, resulted in
fracturing of the osteotomy. Most patients who
benefitted from the total subapical were those
with class II division 2 low-angle malocclusion
that could not be corrected with orthodontics
alone. In an effort to reduce the difficulty and
morbidity of the surgery, we developed the C
modification of the total subapical osteotomy.
The procedure can be performed intraorally by us-
ing reciprocating and oscillating saws. Because
there is little tension from muscles, extensive sta-
bilization is not needed and relapse, if any, is min-
imal. It is also beneficial in a patient with excessive
chin projection that needs advancement, because
performing a chin reduction could leave the
mandible with a flat appearance. Although it is
rarely used, it can produce excellent esthetics for
patient with class II division 2 low-angle conditions
(Fig. 1).
TECHNOLOGIC AND TECHNICAL
IMPROVEMENTS
Over the last several decades, advances in tech-
nology have provided both surgeons and patients
with options for improving surgical outcomes,
both in preoperative diagnosis and planning,
and intraoperatively. More promising are the ad-
vances in software to plan three-dimensional
(3D) orthognathic surgery and use information
 Mandibular Surgery 489

Fig. 1. (A) The total subapical mandibular osteotomy. (B) The C modification of the total subapical mandibular
osteotomy. (C) Lateral cephalogram showing preoperative and postoperative results of total subapical osteot-
omy. (D) Preoperative and postoperative frontal views with subapical osteotomy. (E) Preoperative and postoper-
ative profile views following total subapical osteotomy. (F) Panoramic radiographs immediately postoperative
and at 6 months.
490 Herford et al
Fig. 1. (continued)
from multislice computed tomography (CT) or
cone beam computed tomography (CBCT) scans,
which allow virtual surgical planning.17–20 Tradi-
tional orthognathic surgery has relied on the
fabrication of acrylic intermaxillary occlusal splints
constructed on stone models that are mounted
on a semiadjustable dental articulator.21–24
Although this has been the standard, limitations
have been reported, with up to 5 mm of
malposition occurring in some cases.21 Com-
puter-aided design and computer-aided manu-
facturing surgical splints have been used to
reduce or eliminate the inherent error that
comes with traditional model surgery.
The development of CT and associated soft-
ware has provided surgeons with the ability to
treatment plan and perform craniofacial surgeries
with remarkable precision. The use of 3D surgical
planning has allowed surgeons to avoid many of
the limitations seen with the classic two-dimen-
sional (2D) approach, particularly the need to
amalgamate various data from multiple sour-
ces.20 Facial asymmetry, specifically, is now
more manageable for surgeons through 3D
 Mandibular Surgery 491

Fig. 2. (A) Patient with significant mandibular elongation and maxillomandibular cant. (B) Malocclusion with
open bite. (C) Preoperative position of mandible and maxilla. (D) Planned intermediate position. (E) Planned
final position. (F) Note the asymmetric genioplasty osteotomy as well as the significant discrepancies in vertical
length of both proximal segments. (G) Final splint and intermediate splint (piggyback) in place. The maxilla was
repositioned and fixated followed by the mandibular surgery. (H) The proximal segment was shorted on the
right and the removed bone was used as an interpositional graft on the chin. A MEDPOR implant was used
on the left to address the short proximal segment. (I) Postoperative facial appearance. (J) Postoperative
occlusion.
492

Fig. 3. (A) Preoperative view with significant facial symmetry. Virtual surgical planning aids in determining
whether any mandibular surgery will achieve the desired results. (B) Preoperative occlusion. (C) Preoperative
position. (D) Planned position of the mandible after only BSSO. (E) Note residual deformity after only BSSO.
(F) Planned position of mandible and maxilla after a BSSO and a Le Fort I osteotomy. (G) Note the improved sym-
metry compared with mandible surgery only (compare with part E). (H) Intraoperative view after only BSSO
showing significant fullness. (I) An intermediate splint is used to position the mandible and the segments are
fixated. (J) The maxillary surgery is performed last and it is fixated into place. Note the change in the yaw, which
compensates to our virtual planning. (K) Postoperative view. (L) Inferior view showing improved symmetry.
(M) Postoperative occlusal view. BSSO, bilateral sagittal split osteotomy.
 Mandibular Surgery 493

Fig. 4. (A) Preoperative and postoperative frontal views following alteration of the occlusal plane. (B) Preoper-
ative and postoperative frontal smile views following alteration of the occlusal plane. (C) Profile view right side.
(D) Profile view left side. (E) Occlusal changes following surgery; note the closure of the anterior open bite. (F)
Occlusal view before and after surgery. (G) Preoperative and postoperative cephalograms.
494 Herford et al

Fig. 4. (continued)

Fig. 4. (continued)
virtual surgical planning, providing patients with a
better chance of a favorable outcome (Fig. 2).
The previous method, which relied on dental
models and 2D plain cephalograms, had several
drawbacks: technical limitations precluded the
ability to treatment plan complex surgical cases
in which the maxillary inclination plane had to
be manipulated beyond the occlusal plane.20
The use of the semiadjustable articulator can
lead to inclinations of the dental models that
differ from the natural Frankfurt horizontal plane
between 7 and 8 .25,26 The interocclusal splints
Mandibular Surgery 495
developed from this technique also were sub-
jected to inherent errors: if the centric position
of the condyle was not set properly, the patient
experienced discomfort in the temporomandib-
ular joint (TMJ) following the procedure.27 As a
result of many of these drawbacks, coupled
with the burgeoning technologic advances,
computer-driven techniques have rapidly gained
popularity.
CT has allowed clinicians (surgeons and ortho-
dontists) to appropriately analyze and mani-
pulate images of the bony structures and
496 Herford et al

overlying soft tissues in a way that was not
possible with the traditional 2D techniques. In
facial asymmetry cases, the anomalies within
the craniofacial structures can be viewed more
accurately.28–31 This accuracy can be traced to
the thin slices of the images (less than 1 mm),
which provides surgeons with more detailed
analysis of the anatomic structures. In addition,
the use of an optical scan on the dental casts
helps evaluate the occlusal relationship, allow-
ing surgeons to plan the treatment more accu-
rately (Fig. 3A–M). The 3D CT images
also help evaluate the predicted postsurgical
soft tissue changes, giving the patient a better
idea of what to expect.
Virtual surgical planning (VSP) has also im-
proved the accuracy of the genioplasty procedure
by constructing cutting guides that prevent injury
to the mental nerve and by duplicating the final po-
sition planned on the 3D model. The guide that fits
on the occlusal surface of mandibular teeth seems
to have the greatest accuracy; however, interposi-
tional guides can also be used. Although slightly
more time consuming, there is improved accuracy
and less risk to the nerve.
ALTERING THE POSTERIOR ASPECT OF THE
DISTAL SEGMENT IN THE SAGITTAL SPLIT
MANDIBULAR OSTEOTOMY
The use of maxillomandibular complex counter-
clockwise rotation to decrease the occlusal plane
is becoming increasingly popular to improve the
esthetic and functional results in both orthog-
nathic surgery (Fig. 4) and in patients with
obstructive sleep apnea (OSA). In many cases,
reducing the occlusal plane angle results in
lengthening the posterior aspect of the distal
segment of the SSO. Before using rigid fixation,
when closing an open bite deformity, the

Fig. 5. (A) Separation of lateral portion of BSSO. (B) Release of inferior alveolar nerve following bony cut,
and separation of the distal bony segments. Arrow indicates position of inferior alveolar nerve. (C) Continu-
ation of bony cuts with reciprocating saw. (D) Vertical cut on buccal plate. (E) Reconfiguration of distal seg-
ments following movement of mandible into correct position. (F) Plating of distal segments in correct
position.
 Mandibular Surgery 497

Fig. 6. (A) Preoperative and postoperative frontal views following alteration of the posterior aspect of the distal
segment. Note improvement in the vertical dimension. (B) Preoperative and postoperative frontal smile views
following alteration of the posterior aspect of the distal segment. (C) Preoperative and postoperative profile
views right side, following alteration of the posterior aspect of the distal segment. (D) Preoperative and postop-
erative profile views left side, following alteration of the posterior aspect of the distal segment. (E) Preoperative
and postoperative occlusal views following alteration of the posterior aspect of the distal segment. (F) Preoper-
ative and postoperative occlusal front views, following alteration of the posterior aspect of the distal segment.
(G) VSP of preoperative, intermediate, and final positions.

posterior maxilla was significantly impacted, pterygomaxillary sling, we found that the tension
which in many cases impaired the esthetic of closing the open bite was not only from the
outcome. Although traditionally it was thought pterygomaxillary sling but also from the spheno-
that relapse was caused by lengthening the mandibular ligament in its attachment near the
498 Herford et al

Fig. 6. (continued)
 Mandibular Surgery 499

Fig. 6. (continued)
500 Herford et al

Fig. 7. (A) Preoperative and postoperative frontal views using alteration of distal aspect to correct horizontal
asymmetry. (B) Preoperative and postoperative frontal smile views using alteration of distal aspect to correct hor-
izontal asymmetry. (C) Profile views. (D) Oblique occlusal view. (E) Preoperative and postoperative cephalograms.
(F) VSP surgical plan with superimposition.

lingula. After cutting the portion of the distal frag-
ment of the SSO, the mandible more easily fits
into the splint and incorporates into our manipu-
lation of the occlusal plane, helping to obtain
improved esthetics. This cut can easily be
made with a reciprocating saw, by stopping short
of the inferior alveolar nerve and greensticking
the fracture or by releasing the nerve from its ca-
nal and making a complete bony cut (Fig. 5).
However, with the advancement of rigid internal
fixation (RIF; miniplates and bicortical screws)
concomitant superior repositioning of the maxilla

Fig. 7. (continued)
is not necessary. This technique can also be
used in correcting vertical asymmetries (Fig. 6)
and horizontal asymmetries (Fig. 7). The poste-
rior segment can then either be removed, or, if
there is some periosteal attachment, can be left
because we have found that this is not a
problem.
Mandibular Surgery 501
FIXATION
Mandibular advancements or setbacks in or-
thognathic surgery require a great deal of stabil-
ity of the osteotomized sites for postoperative
success. RIF of the mandible after such pro-
cedures was developed as an alternative to
traditional MMF techniques, including skeletal
502 Herford et al

Fig. 7. (continued)

Fig. 8. RIF with miniplates stabilized by monocortical screws.

 Mandibular Surgery 503

Fig. 9. (A) Preoperative and postoperative frontal views following use of DO on a syndromic patient. (B) Universal
mandibular distractor. (C) Surgical placement of universal mandibular distractor. (D) Preoperative and postoper-
ative profile views following DO. (E) Preoperative and postoperative cephalograms following DO. (F) Preopera-
tive and postoperative oblique occlusal views following DO.
504 Herford et al
Fig. 9. (continued)
wiring, which carried a high potential for relapse
caused by decreased stability. RIF involves
plates and screws to stabilize the forces placed
on bones as they function while healing; there
is no need to overlap the distal and proximal
segments, and gap can be created and filled in
with a bone graft. Development of RIF allows pa-
tients to function immediately after surgery,
improving their nutritional intake more rapidly
than with MMF.32
Advancements in RIF techniques have provided
surgeons with various options, 2 of which are bi-
cortical screws and miniplates (Fig. 8) with mono-
cortical screws. There are advantages and
disadvantages to both techniques: miniplates offer
easy access and manipulation of the proximal
segment, whereas bicortical screw fixation pro-
vides greater mechanical resistance.33 These
plates come in a variety of configurations that pro-
vides the surgeon with flexibility when performing
the fixation. Miniplates also allow for larger ad-
vancements and decrease the amount of mandib-
ular flaring that may occur with use of bicortical
screws.34 However, some surgeons opt for a
hybrid technique that uses miniplates with bicorti-
cal screws.33
Although RIF offers many advantages, there are
undesirable forces from soft tissues/muscles and
condylar positioning that can result in potential
relapse. Condylar changes and osseous complica-
tions have been noted and should be anticipated as
possible complications.35–37 The reasons for such
occurrences have been theorized, and include sur-
gical stimulation of disc displacement leading to
condylar resorption.38,39 Because of these draw-
backs, alternative methods, such as semirigid
fixation, were sought. First described as wire fixa-
tion, methods have expanded and there are now
other ways of attaining semirigid fixation using
nonrigid titanium plates.
DISTRACTION
As initially described by Iliazrov, distraction os-
teogenesis (DO) can be used to stretch bone
that has been osteotomized. In this technique,
the surgical space created by the osteotomy is
filled with bone. The use of distractors can be
subdivided to vertical lengthening and horizontal
lengthening,40 and has been used for large
advancements in syndromic patients and to
improve the airway of compromised patients
 Mandibular Surgery 505

Fig. 10. (A) Maxillary and mandibular distractors placed and advanced at equal rate post-operative day 5. (B) Pre-
operative and postoperative profile views following DO to treat OSA. (C) Postoperative frontal views with
occlusal opening following DO to treat OSA. (D) Preoperative and postoperative cephalograms using DO to treat
OSA. (E) Pre-operative polysomnogram. (F) Post-operative polysomnogram.
506 Herford et al
Fig. 10. (continued)
(Fig. 9). We propose using traditional SSO and
correcting half of the advancement at the time
of surgery and the rest at 1 mm/d. Correcting
the whole advancement by distraction only
may lead to proximal segment displacement
laterally.
Obstructive sleep apnea affects 2% to 4%
of the general population.41 Patients with
OSA may have craniofacial anomalies such
as mandibular hypoplasia and transverse dis-
crepancies.42 Untreated OSA can lead to
underlying salient but long-term effects on

neurocognitive function and cardiovascular
physiology.43 Treatment options for OSA include
both surgical and nonsurgical intervention.
Nonsurgical options include continuous positive
airway pressure therapy, pharmacologic therapy,
weight loss, and altering the sleep posture. Sur-
gical options include uvulopalatopharyngoplasty,
tonsillectomy, and mandibular osteotomy with
advancement. Unlike traditional orthognathic
surgery used for large advancements of the
jaw, DO may have less relapse and can be
used to correct such anatomic discrepancies.
DO has been performed on patients requiring
advancements of 10 mm or more, because bilat-
eral sagittal split osteotomies are generally
limited to 6-mm advancements before an
increased chance of relapse occurs.44–46 In addi-
tion, the distraction method can lead to greater
advancements, more stability, and can be per-
formed without using a graft (Fig. 10).47 Studies
are needed to show the long-term stability of
DO compared with traditional SSO.
The reported lower rate of relapse with DO
compared with bilateral SSOs may be caused
by the gradual stretching of the soft tissues,
decreased periosteal stripping, and placement of
the osteotomy site behind the pterygomasseteric
muscular sling.48,49 DO has proved to be the treat-
ment of choice for large advancements in cor-
recting and improving aesthetic and functional
problems related to mandibular hypoplasia, espe-
cially in adolescent patients (Fig. 11). Patients
requiring larger advancements who have TMJ
dysfunction may benefit from slow advancement
of the jaw, which may place less force on the
condyle.
GENIOPLASTY
By using VSP, the path of the inferior alveolar
nerve can be accurately shown and surgical
Fig. 11. Postoperative panorex showing placement of distractor.
Mandibular Surgery 507
cutting guides can be made to optimize distance
from the nerve and produce symmetry of the os-
teotomy (guides: Fig. 12). In addition, guides can
also be produced and repositioned and hold the
chin while the chin plate is secured. Asymmetries
can be addressed with cutting and repositioning
guides (graft: Fig. 13).
CORRECTING MANDIBULAR VERTICAL
ASYMMETRY AT THE MANDIBULAR BODY
The use of the surgical titanium mesh was devel-
oped in 1968 by Dr. Frank Morgan, a dentist, who
collaborated with Dr. Phillip Boyne. They de-
signed a tray mesh that included a contoured
mandibular angle. This tray was used for recon-
struction of the mandible for defects caused by
trauma and tumor resection. We expanded its
use in orthognathic surgery for the vertically
asymmetric mandible and published a series of
5 patients in 2009.50 Although other methods
have been used, such as autogenous augmenta-
tion, unpredictable bone resorption and as-
sociated donor site morbidity occurs. Other
alloplastic implants, such as silicone and porous
polyethylene, are options but may have a higher
risk of postoperative infection compared with
the titanium mesh tray. The mesh tray is placed
after fixation of the mandibular osteotomy and,
because minimal forces are placed on it, it can
be secured with 2 to 3 screws or wires. Fibrous
tissue ingrowth prevents long-term migration
problems (Fig. 14).
TEMPORARY ANCHORAGE DEVICES
During mandibular osteotomies designed to
move the segmented bone forwards or back-
wards, vector control remains an important factor
in determining the planned movement. In tradi-
tional methods, such as DO, the accuracy of
508 Herford et al

Fig. 12. (A) VSP genioplasty guides hole marking, osteotomy marking, and positioning. (B) Hole-marking guide
positioned. (C) Screws inserted through marking guide. (D) Osteotomy made. (E) Final positioning guide with
plate positioned and stabilized.
 Mandibular Surgery 509

Fig. 13. (A) VSP can be used as a genioplasty bone graft template. (B) Placement of genioplasty guide for bone
graft placement. (C) Osteotomized segments are stabilized with plates and screws. (D) Interpositional graft is
placed.

this vector movement may be limited. Many op-
tions exist regarding ways to improve vector con-
trol: elastomeric chain, surgical acrylic resin, and
a wire splint.51,52 Temporary anchorage devices
(TADs) (Fig. 15), which are used in orthodontics
and act to supplement orthodontic anchorage,
can also be used surgically for patients with In-
visalign braces during orthognathic surgery,
avoiding the need to place orthodontic appli-
ances, Ivy loops, or arch bars at the time of
surgery.
TADs can be placed at the mucogingival junc-
tion between the teeth by using VSP/CT-guided
splints or navigation, avoiding injury to the roots
(see Fig. 15A). We have also used VSP/CT
guides to place TADs for the IVRO/condylotomy
procedure.
VIRTUAL SURGICAL PLANNING
Before discussing the use of VSP in orthognathic
surgery, other uses should be mentioned, in-
cluding surgical treatment planning of resection
of pathologic lesions (Fig. 16). The ability to plan
for large surgical resections involving both benign
and malignant disorders can provide both
510 Herford et al

Fig. 14. (A) Preoperative and postoperative lateral cephalograms. (B) Postoperative panorex showing placement
of mesh tray. (C) Preoperative and postoperative frontal views. (D) Preoperative and postoperative profile views.
(E) Preoperative and postoperative oblique occlusal views.

surgeons and patients with detailed knowledge
necessary to perform the most effective treatment.
It is, therefore, important that the surgeon be fully
aware of the extended uses of VSP when consid-
ering treatment options for a variety of maxillofa-
cial procedures.
Mandible First or Maxilla First
Sequencing with either maxillary movement
first or mandibular movement first in VSP was
discussed earlier. Some early indications
suggested that, in a patient with a short ramus,
our splint became disproportionately large and
the mandibular projection was not matching
our treatment plan, which would require addi-
tional chin projection. This problem was espe-
cially apparent in Le Fort III/Le Fort I high-angle
cases in which there were 2 maxillary move-
ments before mandibular movement, resulting
in a chin procedure being necessary to obtain
the prediction result (Fig. 17).
For class III low-angle cases, which jaw is oper-
ated first does not seem important, but it does in
 Mandibular Surgery 511

Fig. 14. (continued)

512 Herford et al

Fig. 14. (continued)


Fig. 14. (continued)
class II short ramus cases. The reason was that the
mandibular surgery needed to be accurately done
or the maxillary position would become flawed
(Fig. 18).
A common reason why surgeons prefer per-
forming the maxillary surgery first is because of
the possibility of a bad split on the mandible,
leading to inadequate position of the maxilla.
However, with the advancement of the trocar
technique and plates and screws, even bad splits
can be fixated to obtain an accurate relationship
of the maxilla and mandible. Additional studies
are needed to determine the accuracy of oper-
ating on the mandible first or the maxilla first.
For patients who are treatment planned for
maxilla and mandible surgery, it is helpful to
plan on operating on the jaw with the largest
discrepancy or midline deviation first. This
method allows the surgeon to evaluate the soft
tissue changes at the time of the surgery, and to
Mandibular Surgery 513
convert the surgical plan to a single-jaw surgery
if necessary.
SUMMARY
The ability of surgeons to use advanced tech-
niques can significantly improve both surgical
outcome and patient satisfaction. Surgical evolu-
tion in mandibular orthognathic surgery is no
exception, because advancements have aided
both surgical planning and technique. It is
important for clinicians to be aware of the
historical progression of improvements in this
technique, and appreciate the technologic
advancements as they are happening. Com-
puter-driven surgical planning is becoming in-
creasingly popular, providing surgeons and
patients with the ability to adjust to intraopera-
tive and postoperative variations. By using these
514 Herford et al

Fig. 15. (A) VSP showing guide for TAD placement. (B) VSP showing anchorage device spacing analysis. (C)
Preoperative and postoperative occlusal views of TAD placement.

Fig. 16. (A) VSP use for planned resection preoperatively. (B) VSP use for planned resection postoperatively.
 515

Fig. 17. (A) VSP planning with occlusal plane at 7 degrees and no genioplasty. Postoperative cephalometric with
resultant occlusal plane at 12 degrees and chin had to be added to obtain mandibular projection to match VSP.
(B) Preoperative and postoperative frontal views following movement of the maxilla first and mandible second,
which necessitated a genioplasty. (C) Preoperative and postoperative profile views. (D) Preoperative and postop-
erative oblique occlusal view. (E) Preoperative and postoperative cephalometric views.
516 Herford et al

Fig. 17. (continued)

 Mandibular Surgery 517

Fig. 17. (continued)

518 Herford et al

Fig. 18. (A) Preoperative view. (B) Preoperative profile view. (C) Occlusal view. (D) Preoperative position of the
maxilla and mandible. (E) Intermediate position of the maxilla. (F) Final planned position. (G) Maxillary surgery
performed first. (H) Sagittal split fixated with mesh and screws. (I) Sagittal split fixated with mesh and screws. (J)
Advancement of inferior border of mandible. (K) Postoperative final result. (L) Postoperative final profile view.
(M) Postoperative occlusal view.

Fig. 18. (continued)
capabilities, clinicians are now able to give pa-
tients the best possible outcomes.
REFERENCES
1. Schendel SA, Eisenfeld J, Bell WH, et al. Superior
repositioning of the maxilla: stability and soft
tissue osseous relations. Am J Orthod 1976;70:
663.
2. Laney TJ, Kuhn BS. Computer imaging in orthog-
nathic and facial cosmetic surgery. Oral Maxillofac
Surg Clin North Am 1990;2(4):659–68.
3. Proffit WR, Epker BN. In: Bell WH, Proffit WR,
White RP, et al, editors. Surgical correction of den-
tofacial deformities. Philadelphia: WB Saunders;
1980. p. 556–81.
4. Trauner R, Obwegeser H. The surgical correction
of mandibular prognathism and retrognathia with
Mandibular Surgery 519
consideration of genioplasty. Oral Surg Oral Med
Oral Pathol 1957;10:677.
5. Puricelli E. A new technique for mandibular osteot-
omy. Head Face Med 2007;3:15.
6. Obwegeser H. The indications for surgical correc-
tion of mandibular deformity by the sagittal splitting
technique. Br J Oral Surg 1964;1:157.
7. Dal Pont G. Retromolar osteotomy for the correc-
tion of prognathism. J Oral Surg 1961;19:42.
8. Epker BN. Modifications in the sagittal osteotomy
of the mandible. J Oral Surg 1977;35:157.
9. Epker BN, Wolford LM, Fish LC. Mandibular
deficiency syndrome: surgical consideration for
mandibular advancement. Oral Surg Oral Med
Oral Pathol 1978;45:349.
10. Ghali GE, Sikes JW. Intraoral vertical ramus
osteotomy as the preferred treatment for mandib-
ular prognathism. J Oral Maxillofac Surg 2000;58:
313–5.
520 Herford et al
11. Ohba S, Tasaki H, Tobita T, et al. Assessment of
skeletal stability of intraoral vertical ramus osteo-
tomy with one-day maxillary-mandibular fixation
followed by early jaw exercise. J Craniomaxillofac
Surg 2013;41:586–92.
12. Bell WH, Yamaguchi Y. Condyle position and
mobility before and after intraoral vertical ramus
osteotomies and neuromuscular rehabilitation. Int
J Adult Orthodon Orthognath Surg 1991;6:97–104.
13. Westemark A, Bystedt H, Von Know L. Inferior alve-
olar nerve function after mandibular osteotomies.
Br J Oral Maxillofac Surg 1998;36:425–8.
14. Ayoub AF, Millett DT, Hasan S. Evaluation of
skeletal stability following surgical correction of
mandibular prognathism. Br J Oral Maxillofac
Surg 2000;38:305–11.
15. Chen CM, Lai SS, Wang CH, et al. The stability of
intraoral vertical ramus osteotomy and factors
related to skeletal relapse. Aesthetic Plast Surg
2011;25:192–7.
16. Ueki K, Marukawa K, Shimoda M, et al. Maxillary
stability following LeFort I osteotomy in combina-
tion with sagittal split ramus osteotomy and intrao-
ral vertical ramus osteotomy: a comparative study
between titanium miniplate and poly L-lactic acid
plate. J Oral Maxillofac Surg 2006;64:74–80.
17. Cevidanes LH, Bailey IJ, Tucker GR Jr, et al. Super-
imposition of 3D cone-beam CT models of orthog-
nathic surgery patients. Dentomaxillofac Radiol
2005;34:369.
18. Cevidanes LH, Styner MA, Profitt WR. Image anal-
ysis and superimposition of 3-dimensional cone-
beam computer tomography models. Am J Orthod
Dentofacial Orthop 2006;129:611.
19. Cevideanes LH, Bailey IJ, Tucker SF, et al. Three-
dimensional cone-beam computed tomography
for assessment of mandibular changes after or-
thognathic surgery. Am J Orthod Dentofacial Or-
thop 2007;131:44.
20. Zinser MJ, Sailer HE, Ritter L, et al. A paradigm shift in
orthognathic surgery? A comparison of navigation,
computer-aided designed/computer aided manu-
factured splints, and “classic” intermaxillary splints
to surgical transfer of virtual orthognathic planning.
J Oral Maxillofac Surg 2013;71:2151.e1–21.
21. Ellis E III. Accuracy of model surgery: evaluation of
an old technique and introduction of a new one.
J Oral Maxillofac Surg 1990;48:1161.
22. Dai J, Dong Y, Xin P, et al. A novel method to deter-
mine the potential rotational axis of the mandible
during virtual three-dimensional orthognathic sur-
gery. J Craniofac Surg 2013;24:2014–7.
23. Lemoine JJ, Xia JJ, Gateno J, et al. Radiographic
analysis for jaw motion normalization. J Oral Maxil-
lofac Surg 2005;63:961–7.
24. Lindauer SJ, Sabol G, Isaacson RJ, et al. Condylar
movement and mandibular rotation during jaw
opening. Am J Orthod Dentofacial Orthop 1995;
107:573–7.
25. Ellis E III, Tharanon W, Gambrell K. Accuracy of
face-bow transfer: effect on surgical prediction
and postsurgical result. J Oral Maxillofac Surg
1992;50:562.
26. Zizelmann C, Hammer B, Gellrich NC, et al. An
evaluation of face-bow transfer for the planning
of orthognathic surgery. J Oral Maxillofac Surg
2012;70:1944.
27. Cascone P, Di Paolo C, Leonardi R, et al. Temporo-
mandibular disorders and orthognathic surgery.
J Craniofac Surg 2008;19:687.
28. Cavalanti MG, Vannier MW. Quantitative analysis of
spiral computed tomography for craniofacial clin-
ical applications. Dentomaxillofac Radiol 1998;27:
344–50.
29. Kawamata A, Ariji Y, Langlais RP. Three dimen-
sional computed tomography imaging in dentistry.
Dent Clin North Am 2000;44:395–410.
30. Hsu SS, Gateno J, Bell RB, et al. Accuracy of a
computer-aided surgical simulation protocol for or-
thognathic surgery: a prospective multicenter
study. J Oral Maxillofac Surg 2013;71:128–42.
31. Gateno J, Xia J, Teichgraeber JF, et al. The pre-
cision of computer-generated surgical splints.
J Oral maxillofac Surg 2003;61:814–7.
32. Swift JQ. Mandibular advancement. Atlas
Oral Maxillofac Surg Clin North Am 1993;1(1):
17–27.
33. Sato FR, Asprino L, Moreira RW, et al. Comparison
of postoperative stability of three rigid internal fixa-
tion techniques after sagittal split ramus osteotomy
for mandibular advancement. J Craniomaxillofac
Surg 2014;42(5):e224–9.
34. Shetty V, Freymiller E, McBrearty D, et al. Exper-
imental analysis of functional stability of sagittal
split osteotomies secured by miniplates and
position screw. J Oral Maxillofac Surg 1996;54:
1317–24.
35. Chung IH, Yoo CK, Lee EK, et al. Postoperative
stability after sagittal split ramus osteotomies for
a mandibular setback with monocortical plate fixa-
tion or bicortical screw fixation. J Oral Maxillofac
Surg 2008;66(3):446–52.
36. Herford AS, Hoffman R, Demirdji S, et al.
A comparison of synovial fluid pressure after im-
mediate versus gradual mandibular advancement
in the miniature pig. J Oral Maxillofac Surg 2005;
63(6):775–85.
37. Kim YI, Cho BH, Jung YH, et al. Cone-beam
computerized tomography evaluation of con-
dylar changes and stability following two-jaw
surgery: Le Fort I osteotomy and mandibular set-
back surgery with rigid fixation. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2011;111(6):
681–7.

38. Kerstens HC, Tuinzing DB, Golding RP, et al.
Condylar atrophy and osteoarthrosis after bimaxil-
lary surgery. Oral Surg Oral Med Oral Pathol
1990;69:274–80.
39. Arnett GW, Tamborello JA, Rathbone JA. Temporo-
mandibular joint ramifications of orthognathic sur-
gery. In: Bell WH, editor. Modern practice in
orthognathic and reconstructive surgery, vol. 1.
Philadelphia: WB Saunders; 1992. p. 523–93.
40. Gonzalez M, Egbert M, Guerrero CA, et al. Vertical
and horizontal mandibular lengthening of the
ramus and body. Atlas Oral Maxillofac Surg Clin
North Am 2008;16:215–36.
41. Strollo PJ Jr, Rogers RM. Obstructive sleep apnea.
N Engl J Med 1996;334:99–104.
42. Nie P, Zhu M, Lu XF, et al. Bone-anchored maxillary
expansion and bilateral interoral mandibular dis-
traction osteogenesis in adult with severe obstruc-
tive sleep apnea syndrome. J Craniofac Surg 2013;
24:949–52.
43. Lipton AJ, Gozal D. Treatment of obstructive sleep
apnea in children: do we really know how? Sleep
Med Rev 2003;7:61–80.
44. Van Sickels JE, Serafin BL. Preface. Atlas Oral
Maxillofac Surg Clin North Am 2008;16:147–58.
45. Mobarak KA, Espeland L, Krogstad O, et al. Man-
dibular advancement surgery in high-angle and
low-angle class II patients: different long-term skel-
etal responses. Am J Orthod Dentofacial Orthop
2001;119:368.
Mandibular Surgery 521
46. McDonald WR. Stability of mandibular length-
ening: comparison of moderate and large ad-
vancements. Oral Maxillofac Surg Clin North Am
1990;2:729.
47. Gaur A, Singh G, Mishra M, et al. Distraction osteo-
genesis for management of obstructive sleep ap-
nea secondary to TMJ ankylosis. Natl J Maxillofac
Surg 2013;4(1):104–6.
48. Al-Mahdi AH, Al-Jumaily HA. Clinical evaluation
of distraction osteogenesis in the treatment of
mandibular hypoplasia. J Craniofac Surg 2013;
24(1):e50–7.
49. van Strijen PJ, Breuning KH, Becking AG, et al.
Stability after distraction osteogenesis to lengthen
the mandible: results in 50 patients. J Oral Maxil-
lofac Surg 2004;62:304–7.
50. Stringer D, Brown B. Correction of mandibular
asymmetry using angled titanium mesh. J Oral
Maxillofac Surg 2009;67:1619–27.
51. Aizenbud D, Hazan-Molina H, Cohen M, et al.
Combined orthodontic temporary anchorage
devices and surgical management of the
alveolar ridge augmentation using distraction
osteogenesis. J Oral Maxillofac Surg 2012;70:
1815–26.
52. Posnick JC, Fantuzzo JJ, Orchin JD. Deliberate
operative rotation of the maxillo-mandibular com-
plex to alter the A-point to B-point relationship for
enhanced facial esthetics. J Oral Maxillofac Surg
2006;64:1687–95.