Mandibular Orthognathic Procedures

1
MANDIBULAR
ORTHOGNATHIC
PROCEDURES
SUSMITHA.CHEBROLU
MOGP/SC/SEMINAR 4/27/2019 2:44:42 AM IIIyr PG OMFS
CONTENTS
 Introduction
 Surgical anatomy
 Classification
 Surgical procedures
 Ramus osteotomies
 Body osteotomies
 Symphysis osteotomies
 Soft tissue changes after mandibular orthognathic procedures
 Complications of mandibular orthognathic surgeries
 References
4/27/2019 2:44:42 AM MOGP/SC/SEMINAR 2

INTRODUCTION:-
 Orthognathic in Greek
 Orthos- straight ; Gnathos- jaw
 Orthognathic surgery refers to surgical procedures

designed to correct jaw deformities
 Orthognathic procedures are divided into three

categories:
 Maxillary surgery
 Mandibular surgery
 Bimaxillary procedures

 Indications to orthognathic surgery
 Impaired mastication
 Temperomandibular pain
 Dysfunction
 Sleep apnea
 Unaesthetic appearance

 Once growth has ceased, the combination of
orthognathic surgery with orthodontics, usually becomes
the only means of correcting severe dentofacial
deformities
 In severe malocclusion there are three possibilities for

correction:
 Growth modification
 Orthodontic treatment
 Orthognathic surgery in conjunction with orthodontics
to establish proper jaw relationship

 HISTORY
 Orthognathic surgery was originally developed in the
United States of America (Steinhäuser ).
 The first mandibular osteotomy is Hullihen´s procedure in

1849 used to correct anterior open bite & mandibular
dentoalveolar protrusion with an intraoral osteotomy.
 Osteotomy of the mandibular body for the correction of

mandibular horizontal excess was performed by Vilray
Blair.

 Berger (1897) described a condylar osteotomy for the
correction of prognathism.
 Limberg in 1925 first reported the subcondylar

osteotomy as an extraoral technique
 A variation of the vertical subcondylar osteotomy was

suggested by wassmund in 1927,which is similar to the
inverted –L-osteotomy.

 Hofer in 1936 demonstrated an anterior mandibular
alveolar osteotomy to advance anterior teeth in
correction of a mandibular dentoalveolar retrusion.
 In 1954, Caldwell and Letterman developed a vertical

ramus osteotomy technique,

 The greatest development in osteotomies of the vertical
ramus is the sagittal split osteotomy credited to
obwegeser in 1957. The major modifications in the
osteotomies design were first made by Dalpont in
1961.This was further discussed by Hunsuck in 1968 in
order to decrease the trauma to overlying soft tissues.
 Kent & Hinds in 1971 initially presented the use of single

tooth osteotomies of the mandible.

AIMS OF MANDIBULAR OSTEOTOMIES
Aesthetics
Function
Stability

PRINCIPLES IN TREATING MANDIBULAR DEFORMITIES
 Patient’s perception of the deformity and expectations
 Surgeon’s recognition of the deformity
 Complete physical examination, model surgery, cephalometric analysis
 Optimal treatment plan
 Counseling of the patient
 Informed consent

ANATOMICAL & PHYSIOLOGICAL CONSIDERATIONS OF
MANDIBULAR OSTEOTOMIES
Vascular
structures
Muscles Nerves

VASCULAR STRUCTURES
 Bell and Levy’s work {1970} demonstrated that blood
flow through the mandibular periosteum could easily
maintain a sufficient blood supply to the teeth of a
mobile segment, even when the labial periosteum was
degloved.
 subapical osteotomies need to be carefully planned to

ensure as large a vascular pedicle as possible.

 The proximal segment of the vertical sub sigmoid osteotomy
maintains its blood supply through the temperomandibular
joint capsule and the attachment of the lateral pterygoid
muscle.
 We should minimize the periosteal and muscle attachment

stripping on the medial surface of the proximal fragment with
either the C or L osteotomy or any of their variations.
 The greater distance from the apices of the teeth not only
minimizes direct pulpal injury but increases the vascular
pedicle to the mobile segment as well

 NERVES
 In most cases in orthognathic surgery avoiding injury to
marginal mandibular branch of facial nerve is achieved
because soft tissue anatomy in patients undergoing the
surgery has not been disturbed by disease or trauma.
 The course of the inferior alveolar nerve into the vertical
ramus and then through the body of the mandible makes
it extremely susceptible to damage from almost every
mandibular surgical procedure.
 Main goal – “To minimize the trauma because its
avoidance is impossible”
4/27/2019
MOGP/SC/SEMINAR 2:44:42 AM 15
Accuracy of Using the Antilingula as a Sole Determinant of Vertical Ramus Osteotomy
Position . J Oral Maxillofac Surg, 2007
 The position of the lingula is

posterior-inferior relative to
the position of the
antilingula
 Any osteotomies performed
at a measurement of 5 mm
posterior to the antilingula
(at the level of the
antilingula)- no risk of
damaging the neurovascular
bundle
 Position of IAN at second
molar Int. J. Oral Maxillofac. Surg, 2008
 Bone thickness from

mandibular canal to buccal
plate- 7.2 +/- 1.47 mm

Tsuji et al, Int. J. Oral Maxillofac. Surg, 2005
Classification of the position of the mandibular canal within the bone.

(a)Separate type, bone marrow space evident;
(b) contact type, outer surface of the canal and inner surface of buccal cortical bone in
contact;
(c) fusion type, outer cortical plate of the canal not evident.
 MUSCLES
Orthognathic surgery affects muscles in primarily two
ways:
 It changes the length of a muscle or it changes the
direction of muscle function.
 The muscles commonly discussed in orthognathic surgery
of the mandible have been the muscles of mastication
and the suprahyoid group of muscles .

CLASSIFICATION
MANDUBULAR ORTHOGNATHIC PROCEDURES
RAMUS SUB APICAL BODY HORIZONTAL

OSTEOTOMIES OSTEOTOMIES OSTEOTOMIES OSTEOTOMY OF
CHIN
VERTICAL RAMUS ANTERIOR SUB APICAL
OSTEOTOMY OSTEOTOMIES
POSTERIOR SUB APICAL

INVERTED “L” &
OSTEOTOMIES
“C” OSTEOTOMY
SAGGITAL SPLIT
TOTAL SUB APICAL
OSTEOTOMY
OSTEOTOMIES 4/27/2019
2:44:42 AM 20
MOGP/SC/SEMINAR
 Bilateral Saggital Split Osteotomy
 First described in 1942 by Schuchardt
 Most widely used surgical procedure for correcting mal- positioned

mandible
 Procedure of choice for mandibular advancement and mandibular
setback
 Highly cosmetic procedure
 Done intraorally

HISTORY:- Bilateral Sagittal Split Osteotomy
1957 – Trauner & Obwegeser 1961 – Dal pont 1968 – Hunsuck

Bilateral Sagittal Split Osteotomy
 In 1977 - Epker
 Horizontal cut upto entrance of inf. Alveolar canal
 Vertical cut - between the first and second molars, completely through
the inferior border
 Minimal stripping of masseter muscle &

limited medial dissection

 Bell and Schendel established the biological basis
for BSSO
 Minimal detachment of the pterygomassetric
sling there is decreased intra- osseous
ischemia, and necrosis of the proximal segment
 1976, Spiessel advocated rigid internal fixation of

BSSO to promote primary healing, restore early
function, and attenuate relapse

 Indications
 Mandibular deficiency
 Advancements beyond 10- 12 mm, extra oral approach should be considered
 Mandibular prognathism
 Large setbacks of more than 7 -8 mm, IVRO/ inverted L osteotomy should be
considered
 Mandibular asymmetry

Surgical Procedure

 ADVANTAGES  DISADVANTSGES
 Broad bony overlap of

osteotomised segments.
 Requires additional maxillary
 Minimal alteration of natural surgery for most dentofacial

position of muscles of deformities
mastication
 Minimal alteration in position of
TMJ
 Short operating time and low
complication rate

 Osteosynthesis :-
 Post- operative fixation of the osteotomised segments

was once a great challenge
 Initially, No fixation of the fragments

Healing- intermaxillary splinting of the teeth

 Major breakthrough- development of “stable compression
osteosynthesis”- Spiessl in 1974
 Initially the use of three 2.7 mm “lag” screws on each side

was used
 DIS ADV:-Compression may cause increased nerve damage

Displacement of the condyles, with subsequent temporomandibular joint
dysfunction

 Position screw or bicortical screw
It permits maintenance of the gaps between the
proximal and distal fragments, with no
compression of the two segments together
 Osteosynthesis with miniplates

 4- holed plate with 2screws on each side of the
osteotomy cut are used
 Resorbable screws
 Advantage of resorbable fixation is to obviate the
need for future hardware removal
 4 screws have to be placed on each side of the
mandible

 INTRAORAL VERTICAL
RAMUS OSTEOTOMIES
 1st described by Caldwell and
Letterman in 1954 as a extra oral
approach
 Introduced by Moose in 1964- intra-

oral technique performed from
lingual aspect
 Wistanley, 1968- performing the

technique from the lateral aspect of
the mandible

Indications Contraindications
 Horizontal mandibular excess  Advancement of the distal
 Mandibular asymmetry segment
 Minor occlusal discrepancy  Recent condylar fractures
after isolated Le Fort I

osteotomy
 Patients with significant TMJ

complaints

ADVANTAGES DISADVANTSGES
 Less chance of damaging the  Unless segments are wired, it may

be difficult to control the position
IAN bundle
of the condyle
 Found to have curable effects in
 Healing time - increased
pts with pre-op TMD
 Less incidence of condylar sag  Difficult to use rigid fixation intra

orally
 MMF - 4 to 8 weeks

Vertical Ramus Osteotomy
IVRO Technique
A straight-line incision to expose the ramus

Proximal extent of the mandibular foramen - 10 mm from the posterior ramus.

Standard thickness (1 mm) oscillating saw blades

A 7-mm length.
B 12-mm length

(A) is the standard pattern used for setback of up to 4 mm.
(B) setback of 5 mm or more , the inferior osteotomy cut - angled anteriorly
Maximal preservation of the medial pterygoid muscle attachment on the

condylar segments

parallel to the mandibular occlusal divergent from the mandibular occlusal plane,
plane yields a straight, the angled inferior osteotomy - more easily cut
vertical ramus osteotomy

Comparison between SSRO and
VRO
SSRO VRO
OSTEOTOMY PA Saggital split Latero medial cut
Open procedure Blind procedure
Along IAN Rear to IAN
Frequent exposure of IAN No exposure of IAN
BONE HEALING Contact on marrow to marrow Contact on cortex to cortex
BONE FIXATION Rigid internal fixation No fixation
CONDYLAR HEAD Original position New equilibrated position
POST OP IMF None or shorter period Required
PROGNOSIS Weakely dependent on PT Strongly dependent on PT

These are designs in the vertical
ramus that include both the
condyle and coronoid in the same
segment
Most commonly done via an extra-

oral approach

 Inverted-L Osteotomy
Indications
 Small / large setbacks
 Asymmetries
 Mandibular advancements
 Ramus lengthening Contraindications

 Abnormal posterior location of
 Severe decrease in posterior the mandibular foramen
mandibular body height
 Mandibular advancement without
grafting
Inverted-L Osteotomy
Advantages
 Can correct mandibular prognathism or asymmetries
 Coronoid process and temporalis muscle – remain in original position
 setback mandible greater distance
 lengthen ramus/ advance - bone grafting
 rigid skeletal fixation

Inverted-L Osteotomy
Disadvantages
 Bone or synthetic bone grafting - significant ramus lengthening /
mandibular advancement
 Healing time - increased compared to other technique
because of poor approximation of the segments when grafts are not
used

 Inverted-L Osteotomy
keep the medial osteotomy as close as possible to the mandibular foramen -

avoid creating a coronoid fracture.
TRAUNER and OBWEGESER in 1957
Blend of VRO and BSSRO
Medial exposure and dissection are done as for
SSRO
Nerve identified as it enters mandibular
foramen medially.
Bicortical horizontal osteotomy cut –superior
to the foramen
Exposure of lateral ramus and completion of

inferior vertical osteotomy same as VRO
Rigid fixation is performed with patients in
MMF
Suction drains to be placed
MMF -5 to 14 days after surgery
Elastic traction -guide the occlusion and resist
soft tissue relapse -4-5 weeks

 Vertical Sub Sigmoid Or Ramus Osteotomy
British Journal of Oral and Maxillofacial Surgery 2013
 The vertical ramus osteotomy can be used to advance

the mandible and vertically lengthen the ramus.

 “C” osteotomy
Modification of the inverted “L” osteotomy devised by
Caldwell et al.(1968)
Indication :-
Mandibular advancement in patient with a high
mandibular plane angle
 Less risk of condylar sag compared with VRO

 Temporalis and pterygoid remain attached to condylar
segment
 The basic techniques for C & L are same, with only

modification being inferior horizontal cut in the C osteotomy
 Forms of C osteotomy

 Blair -1907-as an extra oral procedure
 Dingman –combination of extraoral and intra
oral access
 Now contemplated only as an intraoral
procedure.

Indications
 Mandibular setback
 Mandibular prognathism with ramus procedure.
 Mandibular prognathism where long body in relation to
ramus
 Anterior open bite closure
 Curve of spee reduction
 Progenia correction
 In class III-anterior body osteotomy –wedge of bone
removed and set back

Body osteotomy

Body osteotomy
56
Pitfalls
 Anatomic discrepancies leading to reduction in bone to
bone contact
 Segment control
 Torquing of the proximal segments is the classic problem
 Root anatomy is variable
 Difficult to perform osteotomy in the premolar region
when trying to skrit the mental nerve and root of the 1st
premolar

 Anterior sub apical osteotomy
 Indications
 Correction of non skeletal open bite / bimaxillary protrusion
 Level the plane of occlusion
 Up righting the anterior teeth to a more normal angulation

SURGICAL TECHNIQUE:-
 Extraction of premolars to obtain space for posterior movements
 Incision-in lower lip approx 15 mm from vestibule- premolar to premolar.
 Anterior mandible degloved upto inferior border
 Vertical bone cuts-passing through premolars
 Inferior horizontal cut must be made perpendicular to bone connecting vertical cut
at inferior extent.
 Segment mobilized by gentle prying at osteotomy sites.
 Preformed surgical splint should be used to guide the segment in its predetermine
position.
 Segment secured by transosseous wires /
semirigid fixation

• Complications :-
 Loss of bone or teeth in osteotomised segment.(lingual
tissues not protected-decrease in blood supply)
 Bone cuts placed close to the teeth-loss of vitality and

periodontal defects
 Mental nerve paresthesia-directly related to the amount

of trauma

 Posterior sub apical osteotomy
Indications
 Correction of supra eruption of posterior mandibular
teeth
 Ankylosis of one or more posterior teeth
 Abnormal buccal or lingual positioning of teeth when
orthodontics is not feasible

Posterior sub apical osteotomy

 Total sub apical osteotomy
Indications
Malocclusion due to mandibular dento alveolar deformity
Occlusal discrepancies without associated esthetic

changes
Substitute for orthodontic leveling (occasionally)
Increased height of mandible
Leveling of occlusal plane

Total sub apical osteotomy

 Facial features often form a basis for stereotyping of
personality charecteristics
 Chin is most prominent facial feature
 Chin deformities can manifest in 3 dimensions but

majority are in the horizontal direction

Procedures
 Horizontal osteotomy with advancement
 Horizontal osteotomy with AP reduction
 Double sliding horizontal osteotomy
 Vertical reduction genioplasty
 Vertical augmentation

A) Horizontal osteotomy with advancement
 Incision extending from canine to canine.
 Periosteum should be left intact on the inf border to maintain soft

tissue support and blood supply.
 Osteotomy is made 5mm below the canine root & 10-15mm above the
inferior border.
 After completion the osteotomised segment is advanced to the desired
position and stabilized by uni-cortical or bi-cortical plates.

B) Horizontal osteotomy with AP reduction
 Reduce the proximal tips of the mobilised segments
along the inf border and avoid palpable wings.

3) Vertical reduction genioplasty
 Indicated in excess chin height
 Approximately 3-5mm of vertical height can be reduced.
 Procedure is same but wedge osteotomy is performed.

4) Vertical augmentation
 Indicated to increase lower facial height.
 It is accomplished by interpositioning grafting or
alloplastic materials b/w segments

5)Double Sliding Horizontal Osteotomy
 Indication- severe chin
deficiency
 Surgical technique involved-
creation of a stepped
intermediate wafer between
the inferior fragment and
mandible.
 Inferior fragment also
advanced to provide bony
contact between upper and
lower fragments.
6) Propellar Genioplasty
Large cants in chin
First osteotomy-superior osteotomy-parallel to
occlusal plane
Second osteotomy-parallel to lower border of
 chin
Traingular segment rotated 180°while muscle
attachment maintained

7) Saggital Splilt Genioplasty
Sagittal Split Genioplasty: A New Technique . J Oral Maxillofac Surg, 2010
The osteotomy is begun below and slightly

posterior to the mental foramen on either the
right or the left side of the mandible. The
reciprocating saw blade is used and is oriented
almost vertically and in the sagittal plane
The cut starts approximately 6 mm below the

mental foramen and exits at the inferior
border. The saw is carried forward in this plane
until the area mesial to the cuspid tooth is
reached. At this point the saw blade is rotated
into a horizontal position as the remainder of
the cut is completed in the usual manner as
shown. This results in a sagittal split of the
lateral one third to two thirds of the inferior
chin segment

8)Transverse Reduction Genioplasty
Transverse Reduction Genioplasty to Reduce Width of the
Chin-J Oral Maxillofac Surg, 2010
 Horizontal osteotomy was performed 5

mm below the mental foramina to avoid
injury to the inferior alveolar nerve
 Two vertical osteotomies were performed
according to the previously marked lines,
and the mobilized central segment was
removed
 Distal segments were positioned medially
and fixed together and were then fixed to
the upper bone segment by miniplates
and screws

9) Chin Sheild Genioplasty
Chin shield osteotomy – a new genioplasty technique avoiding a deep mento-labial

fold in order to increase the labial competence . Int. J. Oral Maxillofac. Surg, 2009

10) M- Shaped Genioplasty
M- shaped genioplasty: new surgical technique for vertical and saggital

chin augmentation: 3 case reports
J Oral Maxillofac Surg, 2012

Soft Tissue Changes associated with Skeletal
Repositioning
 Mandibular Advancement
 Frontal Changes
 Increasing the lower anterior facial height
 Reduces lip eversion
 Reduces mentolabial fold (Lower lip rolls back)
• Profile changes
• Chin prominence
• Decreases lower lip vermlion exposure
• Increases lip fullness
• Decreases mentolabial fold
Mandibular Setback
 Frontal Changes
 Decreases chin prominence
 Makes upper lip vermilion more prominent
 Decreases lower 1/3rd of face
 Profile Changes
 Decreases mandibular antero-posterior prominence
 Reduces lower lip vermilion exposure
 Reduces chin throat length

Soft tissue changes
 Superior mandibular repositioning
Lower lip becomes shorter
Protrusive
Smaller in area
 Inferior mandibular repositioning

Lower lip becomes longer with increased area

 Surgical relapse to varying degree can occur
after mandibular surgery
 Complications in orthognathic surgery

 Pre-operative phase
 Intra-operative phase
 Post-operative phase

PRE-OPERATIVE PHASE
 Limitations on surgical movement- failure to eliminate
dental compensations
 Molar root fenestrations, transverse surgical relapse-
Failure to manage transverse discrepancy
 Immpossibilility in achieving class I cusp relation, overjet
and over bite- failure to indentify and manage tooth size
discrepancies
 Root damage during osteotomies- failure to properly
level and achieve root divergence in segmental cases
 Psychological preparation of the patient
INTRA-OPERATIVE PHASE
 Can be categorised into
 Unfavourable osteotomy splits
 Nerve injury
 Bleeding
 Proximal segment malpositioning
 Miscellenaeous

 Sagittal Split Ramus Osteotomy
1) UNFAVORABLE OSTEOTOMY SPLIT
 Incidence- 18%
Proximal segment fracture
Bad split • Also called “Buccal plate fracture”
• Most frequent
• Presence of impacted 3rd molar
• Recent removal of 3rd molar
Abort the Correct the split &

Fracture of coronoid process
procedure Complete the • Occurs when the horizontal cut is placed
too high where the ramus is thin
& perform after procedure
• Fracture of distal segments
healing • Inferior border remains attached to distal
segment

2) NERVE INJURY
 Damage can occur at many points
 When nerve was transected- usually in 3rd molar
region or anterior to it
 Higher incidence of neurosensory disturbance
with bicortical screws than monocortical screws

3) BLEEDING
 Incidence decreased from 38% in 1972 to 1% in 2005
 Most common sources
 Maxillary artery and its branches (massetric and
inferior alveolar artery)
 Retromandibular vein
 Facial artery and vein
4)PROXIMAL SEGMENT MAL-POSITIONING
5) MINOR DIFFICULTIES
 Herniation of buccal fat pad
 Difficulty in incision closure
 Breaking of bur

 Vertical Ramus Osteotomy
1) UNFAVOURABLE OSTEOTOMY
Inadvertent subcondylar osteotomy
 More likely in
Prognathic mandible with high mandibular plane angle and ill- defined gonial
angle
2) NERVE INJURY
 Incidence ranges from 0%- 14%

 Less incidence when compared to SSO
 Can occur in 2 phases

 If osteotomy is close to mandibular foramen
 Medial displacement of the proximal segment compressing and tearing the
nerve

3) BLEEDING
 Common source- maxillary artery and its
branches
4) PROXIMAL SEGMENT MALPOSITIONING

 Control of proximal segment- major
disadvantage
 May be displaced antero- medially, anteriorly
towards articular eminence or can be displaced
medially and inferiorly

 Sub- Apical Osteotomies
 Nerve injury
 Damage to teeth roots
 Non- vitality of teeth
 Mal-positioning of mobilised segments
 Inadequate trimming, inadequate bone removal
 Difficulty in stabilisation

 Genioplasty
1) UNFAVOURABLE OSTEOTOMY
 Inadvertent # of body and ramus
 Damage to teeth roots
2) NERVE INJURY
 Mental nerve is commonly injured
 incision, reflection and retraction, osteotomies, plating or
closure
3) BLEEDING
Damage to lingual soft tissues
Injury to genioglossus, geniohyoid muscles
Laceration of sublingual and submental arteries

 POST-OPERATIVE PHASE
EARLY POSTOP
 Excessive swelling
Genioplasty
Neurological
 Haemorrhage & dysfunction
Haematoma Chin asymmetry
 Neurological dysfunction Uneven mentalis
 Mandibular dysfunction muscle contraction
 Hypomobility, reduction in Chin ptosis
bite force, TMJ
dysfunction
 Relapse

 LATE POST-OP
 Long term neurological dysfunction

 TMJ dysfunction
 Dental and periodontal problems

 CONDYLAR SAG
 Immediate or late caudal movement of condyle in the
glenoid fossa after surgical establishment of the
preplanned occlusion and bone fragments leading to
change in the occlusion
 Types –
 Central:
 Peripheral

 Central condylar sag-. The condyle is positioned inferiorly in the
glenoid fossa with no contact with bone, while the teeth are in occlusion
and rigid fixation is placed (A). After removal of IMF the condyle moves
superiorly leading to immediate relapse (B).
 Bilateral condylar sag
 Overjet increased
 Anterior open bite
 Class II malocclusion
 Unilateral condylar sag
 Mandibular dental midline towards offending side
 Overjet increased
 Class II dental relationship on the offending side
 Overjet corrected and the correct occlusion reestablished if
mandible is moved until midlines coincide

Central condylar sag
Unilateral
Bilateral

 Peripheral condylar sag-
 A) Type I- condyle positioned inferiorly with some fossa contact with MMF
in position and rigid fixation
 Provides physical support to occlusion
 Post operative resorption or change in condylar shape will lead to late
relapse.
 Difficult to diagnose intra-operatively
B) Type II- condyle positioned correctly in the fossa with MMF in position.
 With the placement of rigid fixation-torquing force is applied to
condyle and ramus of mandible.
 Tension on ramus released when MMF removed-condyle will move
either laterally or medially and slide inferiorly

Peripheral condylar sag
Type I
Peripheral condylar sag

Type II
Bilateral Unilateral
REFERENCES
 Maxillofacial Surgery-Peter Ward Booth
 Principles Of Oral And Maxillofacial Surgery- Peterson
 Oral And Maxillofacial Surgery-Fonseca
 Essentials Of Orthognathic Surgery-Reyneke
 Chin shield osteotomy – a new genioplasty technique avoiding

a deep mento-labial fold in order to increase the labial
competence Int. J. Oral Maxillofac. Surg, 2009
REFERENCES
 Transverse Reduction Genioplasty to Reduce Width of the Chin J Oral
Maxillofac Surg, 2010
 Sagittal Split Genioplasty: A New Technique J Oral Maxillofac Surg, 2010
 M- shaped genioplasty: new surgical technique for vertical and saggital
chin augmentation: 3 case reports J Oral Maxillofac Surg, 2012

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1

4/27/2019 2:44:42 AM MOGP/SC/SEMINAR 2

 Orthognathic surgery refers to surgical procedures

 Orthognathic procedures are divided into three

4/27/2019 2:44:42 AM MOGP/SC/SEMINAR 3

4/27/2019 2:44:42 AM MOGP/SC/SEMINAR 4

 In severe malocclusion there are three possibilities for

4/27/2019 2:44:42 AM MOGP/SC/SEMINAR 5

 The first mandibular osteotomy is Hullihen´s procedure in

 Osteotomy of the mandibular body for the correction of

4/27/2019 2:44:42 AM MOGP/SC/SEMINAR 6

 Limberg in 1925 first reported the subcondylar

 A variation of the vertical subcondylar osteotomy was

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 In 1954, Caldwell and Letterman developed a vertical

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 Kent & Hinds in 1971 initially presented the use of single

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 Patient’s perception of the deformity and expectations

 Surgeon’s recognition of the deformity

 Complete physical examination, model surgery, cephalometric analysis

 Optimal treatment plan

 Counseling of the patient

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 subapical osteotomies need to be carefully planned to

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 We should minimize the periosteal and muscle attachment

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 The position of the lingula is

 Bone thickness from

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Classification of the position of the mandibular canal within the bone.

 It changes the length of a muscle or it changes the

direction of muscle function.

 The muscles commonly discussed in orthognathic surgery

of the mandible have been the muscles of mastication

and the suprahyoid group of muscles .

RAMUS SUB APICAL BODY HORIZONTAL

POSTERIOR SUB APICAL

 First described in 1942 by Schuchardt

 Most widely used surgical procedure for correcting mal- positioned

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 Horizontal cut upto entrance of inf. Alveolar canal

 Minimal stripping of masseter muscle &

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 1976, Spiessel advocated rigid internal fixation of

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 Broad bony overlap of

 Minimal alteration of natural surgery for most dentofacial

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 Post- operative fixation of the osteotomised segments

 Initially, No fixation of the fragments

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 Initially the use of three 2.7 mm “lag” screws on each side

 DIS ADV:-Compression may cause increased nerve damage

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 Osteosynthesis with miniplates

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 Introduced by Moose in 1964- intra-