Int. J. Oral Maxillofac. Surg.

2001; 30: 443444

doi:10.1054/ijom.2001.0117, available online at http://www.idealibrary.com on
Technical note:
Orthognathic surgery
Intra-oral vertical ramus
osteotomy: a modied
technique for correction of
mandibular prognathism
Y. Manor, D. Blinder, S. Taicher: Intra-oral vertical ramus osteotomy: a modied
technique for correction of mandibular prognathism. Int. J. Oral Maxillofac. Surg.
2001; 30: 443444. 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 eld. A modied 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.
Moosr
8
and WiNs1\Nirx
12
intro-
duced the IVRO and additional modi-
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 eld.
The purpose of this article is to
describe a modied 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 39 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 modication
of the technique described by Eixr
and Woiron
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 rst
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
aorded 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 xation was
used for 6 weeks. Time for performing
the osteotomy ranged from 1020 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 WiNs1\Nirx
12
was modied by
Hrnr1 et al.
5
who introduced a
Stryker oscillating saw, a Bauer sigmoid
notch retractor, and a LeVasseur-Merrill
posterior border retractor. However,
these modications did not solve the
problem of limited visibility. M\io
et al.
7
further modied the technique by
0901-5027/01/050443+02 $35.00/0 2001 International Association of Oral and Maxillofacial Surgeons
changing the osteotomy directions on
the oscillating Stryker saw, rst superi-
orly and then inferiorly. This localized
the antilingula and reduced possible
injury to the inferior alveolar nerve.
The present technique uses the advan-
tages of M\io et al.
7
but with
improved retraction and visibility. Both
right and left Bauer retractors are
inserted at the operated area simul-
taneously, i.e., the same side Bauer
retractor is inserted into the sigmoid
notch area while the opposite side Bauer
retractor is inserted below the inferior
border of the pre-angular area of the
mandible. This method allows direct vis-
ibility of the osteotomy site throughout
the procedure, thus avoiding injury to
the nerves and vessels. Improved retrac-
tion prevents injury to the soft tissue and
decreases postoperative edema.
Our experience with 66 patients (132
sides) showed that the time required to
perform osteotomy ranged from
1020 min per side, which is similar to
the time reported by M\io et al.
7
.
There was no incidence of permanent
nerve injury to the inferior alveolar
nerve. The percentage of nerve injury in
the literature using various methods,
ranges from 014%
3,6,10,11,13
.
References
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osteotomy in the mandibular rami for
correction of prognathism. J Oral Surg
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193196.
Address:
Dr Yifat Manor
4 Popel Mordechai st. appt. 31
Rishon le Zion 75355
Israel
Fig. 1. Right side IVRO. The sigmoid notch Bauer retractor is inserted on both the right side
in the sigmoid notch and on the left side in the pre-angular area.
444 Manor et al.