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Technique Guide Orthognathic Surgery

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Technique Guide Orthognathic Surgery Technique Guide Orthognathic Surgery Editor: Myron R. Tucker, DDS 1 Table of contents Table Table of contents Section I: Sagittal Ramus Osteotomy (BSSO or BSRO) for Advancement 3-12 Sagittal Ramus Osteotomy Multiple Modifications 3 Incision/Exposure 3 Superior/Medial, Osteotomy Cuts & Lateral/Vertical 4-5 Thin Ramus 5 Fixation 7-9 Technical Modifications for BSSO for Mandibular Setback 10-12 Section II: Transoral Vertical Ramus Osteotomy 13-15 Advantages/Considerations 13 Ramus Osteotomy Vertical Transoral Incision/Exposure 13-14 Osteotomies 14 Fixation 15 Recontouring proximal segment 15 Section III: Genioplasty 16-18 General Considerations 16 Incision/Exposure 16 Osteotomy 17 Fixation 18 Closure 18 Genioplasty Section IV: LeFort I Maxillary Osteotomy 19-27 Incision/Exposure 19 Osteotomies 19-24 Recontouring 22 Grafting 24 LeFort I Osteotomy Fixation 25-26 Closure 27 Technique guide: Orthognathic Surgery Table of contents 2 NL-SP-HSC-002NL-SP-HSC-002 - Sagittal - Sagittal Ramus, Ramus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and LeFortand LeFort I Osteotomy I Osteotomy Protocol Protocol SAGITTALSAGITTAL RAMUS RAMUS OSTEOTOMY OSTEOTOMY (BSSO (BSSO OR OR BSRO) BSRO) FOR FOR ADVANCEMENT ADVANCEMENT of contents Table NL-SP-HSC-002NL-SP-HSC-002Section - Sagittal - Sagittal I: Ramus, Ramus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and LeFortand LeFort I Osteotomy I Osteotomy Protocol Protocol • Multiple• Multiple modifications modifications SAGITTALSAGITTAL- RAMUS(Dalpont-Hunsuck- RAMUS(Dalpont-Hunsuck OSTEOTOMY OSTEOTOMY most most popular (BSSOpopular (BSSO OR OR BSRO) BSRO) FOR FOR ADVANCEMENT ADVANCEMENT Sagittaland andmost most widely Ramus widely used) used) Osteotomy - Dalpont- Dalpont modification modification with with lateral lateral cut vertically near first molar • Multiple• Multiple modificationscut modifications vertically near first molar - Hunsuck modification with - (Dalpont-Hunsuck- (Dalpont-HunsuckHunsuck modification most most popular with popular Sagittalposterior Ramus medial Osteotomy cut extending (BSSO or BSRO) for Advancement Sagittal Ramus Osteotomy and andposteriormost most widely medialwidely used) cutused) extending only to retrolingular depression • Multiple- Dalpont- Dalpontonly modifications tomodification retrolingular modification with depression with lateral lateral • Can• be used for correction of a wide -Can (Dalpont-Hunsuckcut be verticallycutused vertically for correction near near first most first molarof apopular molar wide varietyvariety of mandibular of mandibular deformities deformities - andHunsuck- mostHunsuck modificationwidely modification used) with with - Dalpontposteriorposterior modification medial medial cut extendingcut extendingwith lateral cutonly verticallyonly to retrolingular to retrolingular near firstdepression depression molar • Can • - Can be Hunsuck used be used for correctionformodification correction of a ofwide awith wide variety varietyposterior of mandibular of mandibular medial deformities cut deformities extending only to retrolingular depression • Can be used for correction of a wide INCISION INCISION variety DESIGN DESIGN of mandibular deformities • Mucosal• Mucosal incision incision made made 2 to 23 tocm 3 cm Transoral Vertical Ramus Osteotomy Vertical Transoral laterallateral to external to external oblique oblique ridge ridge - Through- Through mucosa mucosa only only • Pull medial edge of mucosa over INCISION INCISIONIncision• Pull DESIGN medial designDESIGN edge of mucosa over external oblique ridge • Mucosal• Mucosalexternal incision obliqueincision made ridge made 2 to 23 tocm 3 cm • • Mucosal incision made 2 to 3 cm lateralIncise• lateralIncise periosteumto external periosteumto external obliquedirectly obliquedirectly ridgeover ridgeover external lateral oblique to external ridge oblique ridge -externalThrough- Through oblique mucosa mucosaridge only only • Pull • -Pull medial Through medial edge edgemucosa of mucosa of mucosa only over over external• Pullexternal obliquemedial oblique ridgeedge ridge of mucosa over • Incise • externalIncise periosteum periosteum oblique directly directlyridge over over external• Inciseexternal oblique periosteum oblique ridge ridge directly over external oblique ridge Exposure of Anterior Ramus Genioplasty EXPOSUREEXPOSURE OF ANTERIOROF ANTERIOR RAMUS RAMUS • Expose•• ExposeExpose medial medialmedial ridge ridge ridgeof posterior of ofposterior posterior body/anterior body/anteriorbody/anterior ramus ramus ramus area area area • Use•• Use Usenotched notched ramus ramus ramus retractor retractor retractor to to to elevate temporalis muscle and EXPOSUREEXPOSURE elevateelevate OF ANTERIOROF temporalistemporalis ANTERIOR muscleRAMUS muscle RAMUS and and periosteum from anterior ramus • Expose • periosteumExposeperiosteum medial medial ridgefrom from ridge ofanterior anteriorposterior of posterior ramus ramus • Create medial pocket above the body/anterior•• Createbody/anteriorCreate medialmedial ramus ramuspocket pocket area area above above the the inferior alveolar nerve using • Use • inferior Useinferiornotched notched alveolar alveolarramus ramus retractor nerve nerve retractor using to using to periostealperiosteal elevator elevator elevate periostealelevate temporalis temporalis elevator muscle muscle and and LeFort I Osteotomy • Protect• IAN with retractor periosteum• ProtectperiosteumProtect fromIANIAN from with anteriorwith anterior retractor retractor ramus ramus • Create• Create medial medial pocket pocket above above the the inferiorinferior alveolar alveolar nerve nerve using using 2 2 periostealperiosteal elevator elevator • Protect• Protect IAN IAN with with retractor retractor Technique guide: Orthognathic Surgery Section I: Sagittal Ramus Osteotomy 3 2 2 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol of contents Table SUPERIOR/MEDIAL CUT • Protect medial tissue and IAN with NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol retractor SUPERIOR/MEDIAL CUT • Begin cutSUPERIOR/MEDIAL at 45• degreeProtect angle medial to CUT tissue and IAN with • medial cortex (moreProtectretractor angle medial if ramus tissue is and IAN with extremely thin)•Superior/medial retractorBegin cut at 45 degree cut angle to SUPERIOR/MEDIAL• Begin cut at 45 degree CUT angle to • Protectmedial cortex medial (more tissue angle and if ramusIAN is •medialProtect cortex medial (more tissue angle and if IAN ramus with is extremely thin) Sagittal Ramus Osteotomy extremelyretractorwith retractor thin) •• BeginBegin cut cut at at45 45 degree degree angle angle to to medialmedial cortex cortex (more (more angle angle if ramus if is extremelyramus is thin)extremely thin) SUPERIOR/MEDIAL CUT • Should extend into retrolingular Superior/medial cut depression SUPERIOR/MEDIAL CUT Ramus Osteotomy Vertical Transoral • After initiallySUPERIOR/MEDIAL outlining• Should saw extendextend cut, CUT place into into retrolingular retrolingular • saw to full depth Should ofdepression blade extend to cut into into retrolingular depression on medial•depression After aspect initiallyinitially of outlining outlining saw saw cut, cut,place place SUPERIOR/MEDIAL• CUT posterior ramus After areasaw initially toto full full outliningdepth depth of ofblade saw blade cut, to cut placeto intocut into •sawShould to full extend depth intoof blade retrolingular to cut into • Visualize and protect depression IAN on on medial medial aspect aspect of of depressiondepression on medial aspect of • Extend cut to lateral posterior cortex and ramus ramus area area •posteriorAfter initially ramus areaoutlining saw cut, place inferiorly, at full• depth, Visualize about and and1.5 protect cmprotect IAN IAN • Visualizesaw to fulland depth protect of IANblade to cut into • depressionExtend cut cut on to to mediallateral lateral aspectcortex cortex ofand and • Extend cut to lateral cortex and posteriorinferiorly, ramus at full area depth, about 1.5 cm inferiorly,inferiorly, at full at depth, full depth, about 1.5about cm 1.5 cm • Visualize and protect IAN • Extend cut to lateral cortex and inferiorly, at full depth, about 1.5 cm OSTEOTOMY CUTS • Should incorporateOsteotomy gentle curves cuts rather than OSTEOTOMYsharp• anglesShould incorporateCUTS gentle curves Genioplasty OSTEOTOMY• ratherShould CUTS thanincorporate sharp gentle angles curves • Shouldrather incorporate than sharp gentle angles curves OSTEOTOMYrather than CUTSsharp angles • Should incorporate gentle curves rather than sharp angles LeFort I Osteotomy 3 3 Technique guide: Orthognathic Surgery 3 4 Section I: Sagittal Ramus Osteotomy 3 NL-SP-HSC-002NL-SP-HSC-002 - Sagittal - Sagittal Ramus, Ramus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and andLeFort LeFort I Osteotomy I Osteotomy Protocol Protocol NL-SP-HSC-002 NL-SP-HSC-002 THIN THIN RAMUS - Sagittal RAMUS - Sagittal Ramus, Ramus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty,
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