Technique Guide Orthognathic Surgery

Editor: Myron R. Tucker, DDS

1 Table of contents 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 Transoral Vertical Ramus Osteotomy 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 LeFort 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 Table of contents

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 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• externalMucosal incision obliqueincision made ridge made 2 to 23 tocm 3 cm • • Mucosal incision made 2 to 3 cm Inciselateral• Inciselateral 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 • periosteumperiosteumExpose medial medial ridgefrom from ridge ofanterior anteriorposterior of posterior ramus ramus • Create medial pocket above the body/anterior•• CreateCreatebody/anterior medialmedial ramus ramuspocket pocket area area above above the the inferior alveolar nerve using • Use • inferior inferiorUsenotched notched alveolar alveolarramus ramus retractor nerve nerve retractor using to using to periostealperiosteal elevator elevator elevate periostealelevate temporalis temporalis elevator muscle muscle and and I Osteotomy LeFort • Protect• IAN with retractor periosteum• ProtectProtectperiosteum 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 Table of contents 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 Transoral Vertical Ramus Osteotomy • 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 LeFort

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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, and LeFort and LeFort I Osteotomy I Osteotomy Protocol Protocol Table of contents • •If ramusIf ramus is extremely is extremely thin thin the themedial medial andand anterior anterior cuts cuts should should essentially essentially be a continuous straight cut THIN NL-SP-HSC-002 THIN RAMUSbe a RAMUS continuous - Sagittal straight Ramus, Osteotomy,cut Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol NL-SP-HSC-002• If• ramusIf - ramusSagittal is extremely isRamus, extremely Osteotomy, thin thinthe medialTransoralthe medial Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol and anteriorand anterior cuts cutsshould should essentially essentially be THIN a becontinuous aRAMUS continuous straight straight cut cut THIN RAMUS• If ramus is extremely thin the medial and anterior cuts should essentially • If ramus is extremely thin the medial Sagittal Ramus Osteotomy andThin anteriorbe ramus a continuous cuts should straight essentially cut be• a Ifcontinuous ramus is straightextremely cut thin the medial and anterior cuts should essentially be a continuous straight cut

LATERAL/VERTICALLATERAL/VERTICAL CUT CUT • •ExposeExpose the thelateral lateral mandible mandible Lateral/verticalanteriorlyanteriorly to the to theantegonial cut antegonial notch notch area area • •PlacePlace channel channel retractor retractor at inferior at inferior LATERAL/VERTICALLATERAL/VERTICAL• Expose the CUTlateral CUT mandible border of mandible Transoral Vertical Ramus Osteotomy • Expose•borderExpose the of lateral mandiblethe lateral mandible mandible • anteriorly to the antegonial notch area • anteriorlyUseanteriorlyUse of smaller ofto smallerthe to antegonialbitethe bite antegonialblock block notchor removal or notch arearemoval area • Placeof bite channel block may retractor improve at access inferior • Place•of Placebite channel block channel retractor may retractor improve at inferior at access inferior LATERAL/VERTICAL • border of mandible CUT • borderCutborderCut must of mustmandible ofextend mandible extend slightly slightly to medial to medial LATERAL/VERTICAL•• UseaspectExpose of ofsmaller the inferior lateralCUT bite border mandible block or removal • Use•aspect Useof smaller of inferiorsmaller bite blockbiteborder block or removal or removal • • ofanteriorly bite block to maythe antegonial improve notchaccess area • ofExposeCut biteofCut through biteblock the through block lateral may cortex maycorteximprove mandible only improve only toaccess avoid to access avoid anteriorly•• CutinjuryPlace must to tochannel the IAN extend antegonial retractor slightly notch at inferiorto area medial • Cut•injury mustCut tomust extend IAN extend slightly slightly to medial to medial • aspectborder of of inferior mandible border aspectPlaceaspect channelof inferior of inferior retractor border border at inferior border•• CutUse of through mandibleof smaller cortex bite blockonly toor avoidremoval • Cut• throughCut through cortex cortex only only to avoid to avoid • injuryof bite to block IAN may improve access injuryUseinjury of to smaller IAN to IAN bite block or removal of• biteCut block must may extend improve slightly access to medial • Cut mustaspect extend of inferior slightly border to medial aspect• Cut of inferiorthrough bordercortex only to avoid OSTEOTOMYOSTEOTOMYOsteotomy SEPARATION SEPARATION separation • Cut throughinjury tocortex IAN only to avoid • •GentleGentle osteotomy osteotomy separation separation at at injury• Gentle to IAN osteotomy separation at superiorsuperiorsuperior portion portionportion of osteotomy-obtain of of osteotomy-obtain osteotomy-obtain Genioplasty minimal mobility OSTEOTOMYOSTEOTOMY minimalminimal SEPARATION mobility SEPARATION mobility • • Use osteotome, wedge or spreader to • Gentle••Use GentleUse osteotome, osteotomy osteotome, osteotomy wedgeseparation wedgeseparation or spreader ator spreader at to to obtain separation at the anterior cut superior obtainsuperiorobtain portionseparation separation portion of osteotomy-obtainat of the osteotomy-obtain at anterior the anterior cut cut • •MOST MostMOST IMPORTANT important IMPORTANT ASPECTaspect ASPECT of OF OF OSTEOTOMYminimalminimal mobility mobility SEPARATION OSTEOTOMYOsteotomyOSTEOTOMY IS is TOtoIS TOinsureINSURE INSURE • Use• • Useosteotome, osteotome, wedge wedge or spreader or spreader to to OSTEOTOMY PROPERProperPROPERGentle SEPARATION INFERIOR osteotomyinferior INFERIOR borderBORDERseparation BORDER at obtainobtainsuperior separation separation portion at the at of anterior the osteotomy-obtain anterior cut cut • Gentle SEPARATIONSeparationSEPARATION osteotomy separation at • MOST• MOSTminimal IMPORTANT IMPORTANT mobility ASPECT ASPECT OF OF OSTEOTOMYsuperiorOSTEOTOMY portion IS of TO osteotomy-obtainIS INSURETO INSURE I Osteotomy LeFort minimal• Use mobility osteotome, wedge or spreader to PROPERPROPERobtain INFERIOR separation INFERIOR BORDER at theBORDER anterior cut • SEPARATIONUseSEPARATION osteotome, wedge or spreader to obtain• MOST separation IMPORTANT at the anterior ASPECT cut OF • MOSTOSTEOTOMY IMPORTANT IS ASPECT TO INSURE OF 4 4 OSTEOTOMYPROPER INFERIORIS TO INSURE BORDER SEPARATION TechniquePROPER guide: INFERIOR Orthognathic SurgeryBORDER SectionSEPARATION I: Sagittal Ramus Osteotomy 5 4 4

4 4 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 SEPARATION OF POSTERIOR ASPECT • SEPARATIONIn some cases, OFparticularly POSTERIOR young ASPECT Table of contents patients,• In somethe mandible cases, particularly will often young NL-SP-HSC-002NL-SP-HSC-002 - Sagittal - Sagittal Ramus, Ramus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and LeFort and LeFort I Osteotomy I Osteotomy Protocol Protocol “greenpatients, stick,” makingthe mandible complete will often separation“green difficult. stick,” making complete • NL-SP-HSC-002SEPARATIONNL-SP-HSC-002TheSEPARATION inferiorseparation - Sagittal -OF alveolarSagittal POSTERIOR Ramus,OFdifficult. Ramus, POSTERIOR nerve Osteotomy, Osteotomy, must ASPECT Transoral beASPECT Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and andLeFort LeFort I Osteotomy I Osteotomy Protocol Protocol identified.• • In• ThesomeIn inferior some cases,A curved cases, particularlyalveolar osteotomeparticularly nerve young mustis young be usedpatients, toidentified.Separation directpatients, the the mandible the posteriorA ofmandiblecurved posterior will aspectosteotome oftenwill often aspectof is SEPARATIONtheSEPARATION osteotomy“greenused“green stick,”to OF direct toward stick,” OFPOSTERIOR making POSTERIOR the making the posterior complete medial ASPECTcomplete ASPECT aspect of aspect• •separationInthe someof•In separation theosteotomysomeIn cases, somemandible difficult. cases, particularlydifficult.cases, toward particularly particularly the young medial young young Sagittal Ramus Osteotomy • Thepatients,•aspect patients, inferiorThepatients, theinferiorof thethealveolarmandible mandiblethe alveolar mandiblenerve will nervewill oftenmust often willmust be often be identified.“green “greenidentified.“green stick,” stick,” A stick,”curvedmaking A making curved makingosteotome complete completeosteotome complete is is usedseparation separation usedtoseparation direct to difficult. direct thedifficult. posterior difficult.the posterior aspect aspect of of • •theThe •Theosteotomy inferiorthe The inferiorosteotomy inferior alveolar toward alveolar toward alveolar nerve the nerve medial the must nerve medialmust be bemust be aspectidentified. identified.aspect identified.of the of A mandible the curved A mandiblecurved A curvedosteotome osteotome osteotome is is is used used toused direct to direct to the direct theposterior posterior the posterior aspect aspect of aspect of of the theosteotomythe osteotomy osteotomy toward toward thetoward themedial medial the medial ILLUSTRATIONaspect aspect aspectof OF the of POSTERIOR the mandibleof mandiblethe mandible CUT • ILLUSTRATIONOsteotome is used OF to POSTERIOR redirect CUT direction• Osteotome of osteotomy is used separation to redirect towarddirection the retrolingular of osteotomy depression separation toward the retrolingular depression ILLUSTRATIONILLUSTRATION OF POSTERIOR OF POSTERIOR CUT CUT Transoral Vertical Ramus Osteotomy • Osteotome• IllustrationOsteotome is used is of usedto posteriorredirect to redirect cut directiondirection of osteotomy of osteotomy separation separation ILLUSTRATIONILLUSTRATIONtoward• toward Osteotome the retrolingularOF the OFPOSTERIOR retrolingular POSTERIORis used depression to depression CUTredirect CUT • •Osteotome Osteotomedirection is used is ofused toosteotomy redirect to redirect separation direction directiontoward of osteotomyof the osteotomy retrolingular separation separation depression towardtoward the theretrolingular retrolingular depression depression

Releasing muscular, periosteal RELEASING MUSCULAR, PERIOSTEAL RELEASINGAnd tendonous MUSCULAR, attachement PERIOSTEAL AND TENDONOUS ATTACHEMENT AND TENDONOUS ATTACHEMENT • The J stripper• The Jis stripper an effective is an effective • The J stripper is an effective instrument to release muscular Genioplasty RELEASINGinstrumentRELEASINGinstrument MUSCULAR, to release MUSCULAR, to release muscular PERIOSTEAL muscular PERIOSTEAL ANDattachmentsAND TENDONOUS TENDONOUSattachments from ATTACHEMENT the ATTACHEMENTmedial from theaspect medial aspect attachments of the proximal from the segment medial aspect of• theThe• proximal TheJ stripper J stripper segment is an iseffective an effective RELEASINGRELEASINGof• the Retract MUSCULAR, proximal MUSCULAR, the segmentproximal PERIOSTEAL PERIOSTEAL segment and • Retractinstrument theinstrument proximal to release to segmentrelease muscular muscular and ANDAND •TENDONOUS TENDONOUSRetract insert the the proximalATTACHEMENT JATTACHEMENT stripper segment at the and antegonial insertattachments theattachments J stripper from atfrom the the medial the antegonial medial aspect aspect • •Theinsert The J notchstripper Jthe stripper J area stripper is an is effectivean at effective the antegonial notchof areatheof proximal the proximal segment segment • instrument•notch•instrument Push area to stripper release to release muscularposteriorly, muscular along the • PushRetract stripperRetract the posteriorly, proximal the proximal segment along segment andthe and • insertattachmentsPush attachmentsinsert theinferior stripper J thestripper from J border, fromstripperposteriorly, the at themedialthe aroundat medialantegonial the aspectalong antegonial theaspect the angle and inferiorofinferior the of border, theupproximal theproximal border, around posterior segment around segment the aspectangle the angle andof the and distal notchnotch area area I Osteotomy LeFort up the posterior segment aspect of the distal • •PushRetract•upRetractPush stripperthe the posterior stripper theproximal posteriorly, proximal posteriorly, aspect segment segment along of the andalong the distaland the segmentinferiorinsertsegmentinsert inferior the border, theJ stripper border,J stripper around at around the atthe theantegonial angle the antegonial angle and and upnotch thenotchup areaposterior the area posterior aspect aspect of the of distal the distal • •segmentPushPushsegment stripper stripper posteriorly, posteriorly, along along the the inferiorinferior border, border, around around the theangle angle and and up theup theposterior posterior aspect aspect of the of thedistal distal Technique guide: Orthognathic Surgery segmentsegment 6 Section I: Sagittal Ramus Osteotomy 5 5

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5 5 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol

NL-SP-HSC-002 NL-SP-HSC-002- Sagittal Ramus, - Osteotomy,Sagittal Ramus, Transoral Osteotomy, Vertical Transoral Ramus Osteotomy, Vertical Ramus Genioplasty, Osteotomy, and Genioplasty, LeFort I Osteotomy and LeFort Protocol I Osteotomy Protocol Table of contents

FIXATION FIXATION• Once maxillomandibularFIXATION fixation has • Oncebeen applied,maxillomandibular• Onceposition maxillomandibular the fixation proximal has fixation has beenfragment applied, into positionbeenthe appropriate applied, the proximal position the proximal fragmentposition. into fragmentthe appropriate into the appropriate Fixation position.- Condyle position. seated • Once-- maxillomandibularCondyleInferior seatedborder- Condyle alignment fixationseated • Passhasbeen- localInferior applied,anesthetic border- position needleInferior alignment through borderthe alignment Sagittal Ramus Osteotomy • Passskinproximal tolocal verify •anesthetic fragment Passproper local needlelocation into anesthetic throughthe for needle through fixation through the percutaneous skinappropriate to verify properskin position. to locationverify proper for location for trocar fixation- Condyle through seatedfixation the percutaneous through the percutaneous trocar- Inferior bordertrocar alignment • Pass local anesthetic needle through skin to verify proper location for fixation through the percutaneous trocar

DRILLING THROUGH TROCAR • DRILLINGAccess THROUGHDRILLING can be easily TROCAR THROUGH obtained to TROCAR Transoral Vertical Ramus Osteotomy • Accessapply fixation can be easilythrough obtained the proximal to Drilling through• Access trocar can be easily obtained to applysegment fixation applythrough fixation the proximal through the proximal • segmentAccess can besegment easily obtained to apply fixation through the proximal segment

In some cases use of a plate may involve combination of methods IN SOME CASES USE OF A PLATE MAY

for access Genioplasty ININVOLVE SOME CASES COMBINATIONIN SOME USE OFCASES A OFPLATE USE METHODS OFMAY A PLATE MAY INVOLVEFOR• ACCESS Posterior COMBINATIONINVOLVE aspect COMBINATION through OF METHODS the trocar OF METHODS FOR•• ACCESS PosteriorAccessFOR to aspect theACCESS anteriorthrough the area trocar can be • PosteriorAccessobtained to aspect •the transorally. Posterioranterior through area aspect the can trocar th berough the trocar • Accessobtained- Minimize to transorally. the• anteriorAccess retraction toarea the canto anterior expose be area can be obtained only- Minimize thetransorally. anteriorobtained retraction transorally.area to of expose the plate- Minimizeonly the anterior -retractionMinimize area to of expose retractionthe to expose onlyplate the anterioronly area the of anterior the area of the plate plate I Osteotomy LeFort

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Technique guide: Orthognathic Surgery Section I: Sagittal Ramus Osteotomy 7 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Table of contents

NL-SP-HSC-002NL-SP-HSC-002 - Sagittal - Sagittal Ramus, Ramus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and LeFort and LeFort I Osteotomy I Osteotomy Protocol Protocol

NL-SP-HSC-002NL-SP-HSC-002 FIXATION - Sagittal- Sagittal Ramus, OPTIONSRamus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and and LeFort LeFort I OsteotomyI Osteotomy Protocol Protocol • Lag Screw FIXATION FIXATION- OPTIONSGood OPTIONS bone approximation • Lag• -LagScrewTactile Screw sense of screw FIXATION FIXATIONFixation OPTIONS OPTIONS- Goodoptionstightening- Good bone bone approximation approximation -- TactilePossible- Tactile sense condyle sense of screw oftorquing screw or •• LagLag• Screw ScrewLag Screw tighteningcompressiontightening of IAN - - GoodGood bone bone approximation approximation Sagittal Ramus Osteotomy • - Good- Possible- bonePossible approximationcondyle condyle torquing torquing or or - - TactilePosition/bicorticalTactile sense sense of of screw screwscrew - Tactile- compressionLess sensecompression compression of of screw IAN of and IAN tightening tighteningtightening • -Position/bicortical • PossiblePosition/bicorticalpossible condyle less screw torquing torquingscrew or - - PossiblePossiblecompression-- LessInability- condyle Lesscondyle compression compressionto of verifytorquing IANtorquing and screw andor or • Position/bicorticalcompressioncompressionpossibleinterfacepossible of lessof on IAN IAN lesstorquingdistal screw torquing segment •• Position/bicorticalPosition/bicortical - Less- Inability -compressionInability screw screw to verify to verify and screw screw - - LessLesspossible compression interfacecompressioninterface less on torquing distal onand and distal segment segment -possible possibleInability less less to torquing verifytorquing screw - - InabilityInabilityinterface to to verifyon verify distal screw screw segment interfaceinterface on on distal distal segment segment FIXATION OPTIONS

• Screws placed in line or inverted L Transoral Vertical Ramus Osteotomy FIXATIONFIXATION OPTIONS OPTIONS pattern •• ScrewsScrews• Screws placed placed placed in in line in line lineor invertedor or inverted inverted L L • Plates patternpattern L pattern- Long advancements • Plates• Plates • Plates- - LongWhen- Long advancements third advancements molars removed - Longduring advancements osteotomy FIXATIONFIXATION OPTIONS OPTIONS- When- When third third molars molars removed removed • - When third molars removed •• ScrewsScrews Combinationplaced placedduring in induring line lineosteotomy or osteotomyor inverted inverted L L during osteotomy patternpattern• Combination• Combination •• PlatesPlates• Combination - - LongLong advancements advancements - - WhenWhen third third molars molars removed removed duringduring osteotomy osteotomy •• CombinationCombination

FIXATION• Screws OPTIONS placed in line or inverted Genioplasty FIXATION •FIXATIONLScrews pattern OPTIONS placed OPTIONS in line or inverted L •• PlatesScrewspattern• Screws placed placed in line in lineor inverted or inverted L L • -patternPlates Longpattern advancements • -Plates • When-PlatesLong third advancements molars removed during-- Long When-osteotomyLong advancements third advancements molars removed - - • CombinationWhenduringWhen third osteotomy third molars molars removed removed • Combinationduringduring osteotomy osteotomy FIXATIONFIXATION• OPTIONS OPTIONSCombination• Combination •• ScrewsScrews placed placed in in line line or or inverted inverted L L I Osteotomy LeFort patternpattern •• PlatesPlates 7 - - LongLong advancements advancements 7 7 - - WhenWhen third third molars molars removed removed duringduring osteotomy osteotomy Technique guide: Orthognathic Surgery •• CombinationCombination 8 Section I: Sagittal Ramus Osteotomy

77 NL-SP-HSC-002NL-SP-HSC-002 - Sagittal - Sagittal Ramus, Ramus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and LeFort and LeFort I Osteotomy I Osteotomy Protocol Protocol Table of contents

FIXATION NL-SP-HSC-002 FIXATION OPTIONS - OPTIONSSagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol • Screws• Screws placed placed in line in orline inverted or inverted L L patternpattern • Plates• FixationPlates options FIXATION•- ScrewsLong- Long advancements OPTIONSplaced advancements in line or •- invertedScrewsWhen- When thirdplaced L thirdpattern molars in linemolars removed or inverted removed L Sagittal Ramus Osteotomy pattern • Platesduringduring osteotomy osteotomy • Plates • Combination• Combination- Long advancements - Long advancements - When third molars removed - When third molars removed during duringosteotomy osteotomy •• CombinationCombination

WOUNDWOUND CLOSURE CLOSURE Transoral Vertical Ramus Osteotomy • Proper• WoundProper lateral lateralclosure placement placement of mucosal of mucosal incisionincision provides provides easy easyaccess access during during • Proper lateral placement of mucosal closure.WOUNDclosure. CLOSURE incision provides easy access during • Proper lateral placement of mucosal closure.incision provides easy access during closure. Genioplasty LeFort I Osteotomy LeFort

Technique guide: Orthognathic Surgery 8 8 Section I: Sagittal Ramus Osteotomy 9 8 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol

TECHNICAL MODIFICATIONS FOR BSSO FOR MANDIBULAR SETBACK Table of contents

ANATOMIC CONSIDERATIONS FOR MANDIBULARTechnical SETBACKmodifications I for BSSO for mandibular setback • Determine pattern of ramus divergence - AnatomicU shape considerations shown to right for • U shaped mandible best suited for SSRO

Mandibular Setback I Sagittal Ramus Osteotomy • Determine pattern of ramus divergence - U shape shown to right • U shaped mandible best suited for SSRO

ANATOMIC CONSIDERATIONS FOR MANDIBULAR SETBACK I • Determine pattern of ramus divergence - V shape shown to right Transoral Vertical Ramus Osteotomy • V shaped mandibles best for TOVRO • Determine pattern of ramus divergence - V shape shown to right • V shaped mandibles best for TOVRO

ANATOMIC CONSIDERATIONS FOR MANDIBULAR SETBACK I • • DetermineDetermine pattern pattern of ramus of ramus divergencedivergence Genioplasty - -V vsV Uvs U • • UU shaped shaped mandible mandible best best suited suited for for SSRO-SSRO- shown shown to rightto right • • VV shaped shaped mandibles mandibles best best for TOVRO for TOVRO • • BestBest determined determined with withsubmental submental vertexvertex radiograph radiograph LeFort I Osteotomy LeFort

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Technique guide: Orthognathic Surgery 10 Section I: Sagittal Ramus Osteotomy NL-SP-HSC-002NL-SP-HSC-002 - Sagittal - Ramus, Sagittal Osteotomy,Ramus, Osteotomy, Transoral Transoral Vertical Ramus Vertical Osteotomy, Ramus Osteotomy, Genioplasty, Genioplasty, and LeFort and I OsteotomyLeFort I Osteotomy Protocol Protocol

NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol

ANATOMIC ANATOMIC CONSIDERATIONS CONSIDERATIONS FOR FOR Table of contents MANDIBULAR MANDIBULAR ANATOMIC SETBACK SETBACK CONSIDERATIONS I I FOR • V shaped• V MANDIBULAR shapedmandibles mandibles best SETBACK for best TOVRO forI TOVRO • V shaped mandibles best for TOVRO - NL-SP-HSC-002- - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Shown Shownto- rightShown to rightto right • Best• determinedBest• determinedBest withdetermined submental with with submental submental vertex vertexradiographvertex Anatomic radiograph radiograph considerations for • Angle• ofAngle ANATOMIC ramus• Angle ofMandibular divergenceramus of CONSIDERATIONSramus divergence divergence mostSetback most most I FOR MANDIBULAR SETBACK I importantimportant important• V shaped mandibles best for TOVRO

• V shaped mandibles best for TOVRO Sagittal Ramus Osteotomy - ShownShown toto right right • Best• Best determined determined with submental with submental vertex vertex radiograph radiograph • Angle• Angle of ramus of ramus divergence divergence most most important important

OSTEOTOMY DESIGN • Design of osteotomy identical to advancement OSTEOTOMYOSTEOTOMY DESIGN• Very DESIGN important to incorporate Osteotomy design Transoral Vertical Ramus Osteotomy • Design• Designof osteotomyHunsuck of osteotomy modification identical identical to to advancementadvancement • - DesignThis allows of osteotomy distal segment identical to to • Very• importantVeryOSTEOTOMY important toadvancement incorporatemove DESIGN to posteriorly incorporate without tissue impingement HunsuckHunsuck modification• Design• modificationVery of important osteotomy identical to incorporate to Hunsuck• ARROW modification - This- allowsadvancementThis distalallows segment distal segment to to • Very - important This allows to incorporate distal segment to move posteriorlyHunsuck movemove posteriorly modification posteriorly without without without tissue impingement tissue-tissueThis impingement impingement allows distal segment to • •ARROW ARROW• moveARROW posteriorly without tissue impingement • ARROW OSTEOTOMY DESIGN • Periosteal• Periosteal and muscle and attachmentsmuscle attachments must mustbe stripped be stripped from the frommedial the medial aspect of the proximal segment to aspect of the proximal segment to Genioplasty allow posterior movement of the distal allow segment posterior without tissue movement of the impingements distal segment without tissue OSTEOTOMYOSTEOTOMYOSTEOTOMY DESIGN DESIGNimpingements DESIGN • Periosteal• Periosteal and• Periosteal muscle and muscle attachmentsand muscle attachments attachments must bemust stripped bemust stripped from be stripped the from medial from the the medial medial aspect ofaspect the proximal aspectof the of proximal the segment proximal segment to segment to to allow posteriorallow posteriorallow movement posterior movement ofmovement the of ofthe the distal segment without tissue distal segmentdistal segment without without tissue tissue I Osteotomy LeFort impingements impingementsimpingements 10

Technique guide: Orthognathic Surgery Section I: Sagittal Ramus Osteotomy 11

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10 10 NL-SP-HSC-002NL-SP-HSC-002 - Sagittal - Sagittal Ramus, Ramus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and and LeFort LeFort I Osteotomy I Osteotomy Protocol Protocol

NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Table of contents

NL-SP-HSC-002FIXATIONFIXATION - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol • •OnceOnce maxillomandibular maxillomandibular fixation fixation has has FIXATIONbeenbeen applied, applied, position position the the proximal proximal fragmentfragment into into the the appropriate appropriate • Once maxillomandibular fixation has Fixationposition.position. FIXATIONbeen applied, position the proximal - -CondyleCondyle seated seated •• fragment OnceOnce maxillomandibular maxillomandibular into the appropriate fixation fixation has has - -InferiorInferior border border alignment alignment position.beenbeen applied, applied, position position the proximal the proximal fragment into the appropriate Sagittal Ramus Osteotomy fragment- Condyle into seated the appropriate InitiallyInitiallyposition. there there will will be bea significant a significant superior superior position.- Inferior border alignment borderborder discrepancy- discrepancyCondyle with seatedwith the the proximal proximal segment segment- wellCondyle well above above seated and and anterior anterior to theto the ramus ramus - Inferior border alignment Initiallyportion portion there- of Inferior theof will the distal bedistal border ase significantg sementgment alignment (arrow) superior(arrow) border discrepancy with the proximal segmentInitiallyInitially wellthere above will there be and awill significant anterior be a significantto superior the ramus portionbordersuperior discrepancyof the distal border withseg mentdiscrepancy the proximal (arrow) with the segment well above and anterior to the ramus proximal segment well above and portion of the distal segment (arrow) anterior to the ramus portion of the THISdistal THIS PROXIMAL PROXIMALsegment SEGMENT(arrow) SEGMENT POSITION POSITION CREATESCREATES SEVERAL SEVERAL PROBLEMS PROBLEMS • •Visibilty-difficultVisibilty-difficult to seeto see proximal proximal THISThis PROXIMALdistal proximaldistal segment segment SEGMENT forsegment forfixation fixation POSITION position Transoral Vertical Ramus Osteotomy CREATEScreates• •Positioning SEVERALPositioning several of PROBLEMS proximalof problems proximal segment- segment- THIS• PROXIMALVisibilty-difficultoftenoften over over rotatedSEGMENT rotated to posteriorly see posteriorly proximal POSITION • Visibilty-difficult to see proximal CREATESdistalelongated SEVERALelongated segment muscular formuscular PROBLEMS fixation sling sling distal segment for fixation •• •PositioningVisibilty-difficult•SoftSoft tissue tissue of attachment proximal attachment to see segment-lateral proximal lateral to to • often distalPositioningsecond secondover segment molar rotated molar of foroften proximal posteriorlyoftenfixation elevated elevated segmentoften creating creating • elongatedPositioningovertissuetissue rotated irritation muscular irritation of proximal posteriorly sling segment- • Softoftenelongated tissue over attachmentrotated muscular posteriorly lateral sling to • second elongatedSoft tissue molar muscular oftenattachment elevated sling lateralcreating to • tissueSoftsecond tissue irritation molar attachment often lateral elevated to creating secondtissue molar irritation often elevated creating tissue irritation MANAGEMENTMANAGEMENT OF OF PROXIMAL PROXIMAL SEGMENTSEGMENT RELATIONSHIP RELATIONSHIP Management• •RemoveRemove anterior anterior of proximalportion portion of proximalof proximal segmentsegmentsegment relationship to allowto allow setback setback MANAGEMENT OF PROXIMAL Genioplasty • •RemoveRemove superior superior portion portion of proximalof proximal SEGMENT• Remove RELATIONSHIP anterior portion of proximal MANAGEMENT• Removesegmentsegment anterior (externalOF (external PROXIMAL portion oblique oblique of proximalridge ridge area) area) segmentto to to allow setback SEGMENTsegment RELATIONSHIP to allow setback • Remove- -Improve superiorImprove visibility visibilityportion of proximal •• RemoveRemove superioranterior portion of proximal segment- -Prevent (externalPrevent over over obliquerotation rotation ofridge of area to segmentsegment (externalto allow setbackoblique ridge area) - Improveproximalproximal visibility segment segment • toRemove superior portion of proximal - Prevent- -ImproveImprove over soft rotation soft tissue tissue position of position segment- Improve (external visibility oblique ridge area) proximal segment to - Prevent over rotation of - Improve- Improve soft visibility tissue position proximal segment I Osteotomy LeFort -- ImprovePrevent oversoft tissuerotation position of 11 11 proximal segment - Improve soft tissue position

11 Technique guide: Orthognathic Surgery 11 12 Section I: Sagittal Ramus Osteotomy NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Table of contents TRANSORAL VERTICAL RAMUS AS ALTERNATIVE TECHNIQUE FOR MANDIBULAR SETBACK Section II:

TOVRO-AdvantagesNL-SP-HSC-002 - Sagittal IRamus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol TRANSORAL VERTICAL RAMUS AS ALTERNATIVE TECHNIQUE FOR MANDIBULAR SETBACK Transoral• Effective method for Verticaltreating Ramus Osteotomy mandibular excess • Minimal neurosensory risk •TOVRO-AdvantagesLong term stability I

Transoral vertical ramus as alternative technique Sagittal Ramus Osteotomy • Effective method for treating for mandibularmandibular excess setback • Minimal neurosensory risk TOVRO-Advantages• Long term stability I • Effective method for treating mandibular excess • Minimal neurosensory risk • Long term stability

ANATOMIC CONSIDERATIONS FOR MANDIBULAR SETBACK I • Determine pattern of ramus Transoral Vertical Ramus Osteotomy divergence ANATOMIC- V shown CONSIDERATIONS FOR Anatomic MANDIBULAR considerations SETBACK I for• mandibular•V shapedDetermine mandibles pattern setback better/ideal of ramus I for TOVROdivergence • Determine pattern of - V shown ramus divergence - • V Vshown shaped mandibles better/ideal for • V shapedTOVRO mandibles better/ideal for TOVRO

INCISION/EXPOSURE

Incision/Exposure• Initial incision identical to BSSO Genioplasty expose anterior aspect of ramus with • Initialnotched incision ramus retractor identical to BSSO INCISION/EXPOSURE• exposePlace channel anterior retractor aspect in ofsigmoid ramus with notched•notchInitial ramus incision retractor identical to BSSO • • PlaceUseexpose reciprocatingchannel anterior retractor saw aspect to create of in ramus sigmoid and with notchosteotomynotched to ramus separate retractor coronoid • Use•process reciprocatingPlace channel retractor saw to in create sigmoid and - osteotomynotchProvides to separate better visibility coronoid process

- Removes pull of temporalis I Osteotomy LeFort - • ProvidesUse reciprocating better visibility saw to create and muscle - Removesosteotomy pull to separate of temporalis coronoid muscle process - 12 Provides better visibility - Removes pull of temporalis muscle

Technique guide: Orthognathic Surgery Section II: Transoral Vertical Ramus Osteotomy 13 12 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol

EXPOSURE OF LATERAL RAMUS Table of contents NL-SP-HSC-002• Remove bite- Sagittal block, Ramus, allow Osteotomy, mouth Transoralto Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol close NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol • Place on Bauer retractor in the EXPOSUREsigmoid notch OF LATERAL RAMUS • Place• Remove a second bite Bauer block, retractor allow mouth at the to EXPOSURE OF LATERAL RAMUS Exposureinferiorclose border of lateral near the ramusangle • Remove bite block, allow mouth to • Surgeon• Place retractson Bauer tissue retractor with in large the toe • Remove bite block, allow mouth closeout retractorsigmoid notch • Placeto close on Bauer retractor in the • Place a second Bauer retractor at the Sagittal Ramus Osteotomy •sigmoid Placeinferior notchon Bauerborder nearretractor the angle in the • Place•sigmoidSurgeon a second notch retracts Bauer tissueretractor with at largethe toe •inferior Placeout border retractora second near Bauerthe angle retractor at the • Surgeoninferior retracts border tissue near with the large angle toe •out Surgeon retractor retracts tissue with large toe out retractor

OSTEOTOMY CUT • Oscillating saw (105 degree) used to create osteotomy from sigmoid notch to the inferior border, slightly anterior OSTEOTOMYOsteotomyto angle area. cutCUT Transoral Vertical Ramus Osteotomy • •Oscillating-OscillatingBehind saw sawIAN/Lingula (105 degree) degree) used used to OSTEOTOMY to createcreate CUT osteotomy osteotomy from from sigmoid sigmoid notch • to the inferior border, slightly anterior Oscillatingnotch to saw the (105 inferior degree) border, used to createto osteotomy angle area. from sigmoid notch slightly anterior to angle area. to the inferior- Behind border, IAN/Lingula slightly anterior - Behind IAN/Lingula to angle area. - Behind IAN/Lingula

OSTEOTOMY• Cut vertically CUT from midportion of • Cutramus vertically to inferior from midportion border of ramus to inferior border Genioplasty • Return saw to mid portion of ramus • Return saw to mid portion of ramus and OSTEOTOMY and cut superiorly CUT to sigmoid notch cut• superiorlyCut vertically to sigmoid from midportion notch of ramus to inferior border OSTEOTOMY CUT • Return saw to mid portion of ramus and • Cut verticallycut superiorly from to midportion sigmoid notch of ramus to inferior border • Return saw to mid portion of ramus and cut superiorly to sigmoid notch LeFort I Osteotomy LeFort

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Technique guide: Orthognathic Surgery 14 Section II: Transoral Vertical Ramus Osteotomy 13 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 AFTER COMPLETION OF OSTEOTOMY Table of contents • Strip muscular and periosteal attachment from inferior portion of AFTERmedial COMPLETION aspect of proximal OF OSTEOTOMY segment • •ApplyStrip maxillomandibular muscular and periosteal fixation andattachment evaluate proximal from inferior segment portion of relationshipmedialAfter aspect completion of proximal of segmentosteotomy • • RemoveApply bony maxillomandibular interference (usually fixation at and• evaluateStrip muscular proximal andsegment periosteal

the sigmoid notch area) to achieve Sagittal Ramus Osteotomy relationship attachment from inferior portion of passive overlap • Remove medial bony aspect interference of proximal (usually segmentat the• sigmoidApply maxillomandibularnotch area) to achieve fixation passive and overlap evaluate proximal segment relationship • Remove bony interference (usually at the sigmoid notch area) to achieve passive overlap

FIXATION • After recontouring/interference removal FIXATIONin lateral ramus area, passively position Transoral Vertical Ramus Osteotomy •condylarAfterFixation recontouring/insegment, condyleterference seated removal • Insertin lateralpercutaneous ramus area, trocar passively position • After recontouring/interference removal • Fixatecondylar with threesegment, lag condyleor bicortical seated screws • Insert in percutaneous lateral ramus trocar area, passively position • Fixate condylar with three segment, lag or bicortical condyle screws seated • Insert percutaneous trocar • Fixate with three lag or bicortical screws

RECONTOURINGRecontouring PROXIMAL proximal segment SEGMENTRECONTOURING PROXIMAL Genioplasty SEGMENT• If the• anatomy If the anatomy of the proximal of the proximal •segmentIf thesegment anatomyproduces producesof excessive the proximal excessive lateral lateral projectionsegment projection at produces the angle, at excessive the the angle, inferior lateral the inferior portionprojection portionof the at proximal theof theangle, proximalsegment the inferior segment shouldportion beshould recontouredof the be proximal recontoured segment • Woundshould• Woundcloser be recontoured is closer identical is identicalto sagittal to sagittal •osteotomyWound osteotomy closer is identical to sagittal osteotomy LeFort I Osteotomy LeFort

14 14 Technique guide: Orthognathic Surgery Section II: Transoral Vertical Ramus Osteotomy 15 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Table of contents

GENIOPLASTYNL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Section III: GENERAL CONSIDERATIONS GENIOPLASTY NL-SP-HSC-002NL-SP-HSC-002Genioplasty• Dramatic - Sagittal - Sagittalfacial Ramus, changes Ramus, Osteotomy, Osteotomy, can be Transoral made Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and LeFortand LeFort I Osteotomy I Osteotomy Protocol Protocol with relatively minor surgery GENERAL• Morphology CONSIDERATIONS of bony chin and GENIOPLASTYGENIOPLASTY • Dramaticoverlying facialsoft tissue changes must can be be made General considerations

withconsidered relatively minor surgery Sagittal Ramus Osteotomy GENERAL•GENERAL• MorphologyDramatic- CONSIDERATIONSRelatively CONSIDERATIONS facialof bony flat changes chin anatomy and can to be made • overlying•DramaticwithDramatic relativelyanterior facialsoft facial tissue mandiblechanges minor changes must can usually besurgery can be made be made • consideredwithMorphologywith relativelyproduces relatively minorof most bonyminor surgery aesthetic chinsurgery and • •Morphologyoverlying-MorphologyRelativelyresults softof bony of tissueflat bony chin anatomy chinmust and and tobe overlyingconsideredoverlyinganterior soft soft tissue mandible tissue must must usually be be considered- Relativelyconsideredproduces flat most anatomyaesthetic to - results- anteriorRelativelyRelatively mandible flat flatanatomy usually anatomy to to anterioranterior mandible mandible usually usually produces most aesthetic producesproduces most most aesthetic aesthetic results SURGICAL EXPOSUREresultsresults • Mucosal incision should be made at

least 1 cm facial to the depth of Transoral Vertical Ramus Osteotomy SURGICALanterior EXPOSURE mucosal vestibule • Mucosal incision should be made at least 1 cm facial to the depth of SURGICALSURGICALSurgicalanterior EXPOSURE mucosal exposureEXPOSURE vestibule • • • MucosalMucosalMucosal incision incision incision should should be made be be made made at at at leastleast 1 cm 1 facialcm facial to the to depththe depth of of least 1 cm facial to the depth of anterioranterior mucosal mucosal vestibule vestibule anterior mucosal vestibule

SURGICAL EXPOSURE • Blunt dissection to identify, retract Genioplasty and protect the mental nerves SURGICAL EXPOSURE • Blunt dissection to identify, retract • Blunt dissection to identify, retract and protect the mental nerves and protect the mental nerves SURGICALSURGICAL EXPOSURE EXPOSURE • •BluntBlunt dissection dissection to identify, to identify, retract retract and andprotect protect the mentalthe mental nerves nerves LeFort I Osteotomy LeFort

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Technique guide: Orthognathic Surgery 15 16 Section III: Genioplasty

15 15 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Table of contents SURGICAL EXPOSURE NL-SP-HSC-002 - Sagittal Ramus, Osteotomy,• Scissor Transoraldissection Vertical through Ramus mentalis Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol muscle attachments exposing NL-SP-HSC-002 - Sagittal Ramus, Osteotomy,periosteum Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol • Periosteum incised with scalpel NL-SP-HSC-002SURGICAL - Sagittal EXPOSURE Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol •SurgicalScissor dissectionexposure through (cont.) mentalis SURGICALmuscle EXPOSURE attachments exposing • Scissor dissection through mentalis SURGICAL• EXPOSUREperiosteumScissor dissection through mentalis muscle attachments exposing • Scissor• Periosteummuscle dissection attachments through incised mentalis with exposing scalpel Sagittal Ramus Osteotomy muscle periosteumperiosteum attachments exposing periosteum• PeriosteumPeriosteum incised incised with with scalpel scalpel • Periosteum incised with scalpel

SURGICAL EXPOSURE • Periosteum incised with scalpel Transoral Vertical Ramus Osteotomy SURGICAL EXPOSURE SURGICAL• EXPOSUREPeriosteum incised with scalpel • Periosteum incised with scalpel SURGICAL• Periosteum EXPOSURE incised with scalpel • Periosteum incised with scalpel

SURGICAL EXPOSURE • Anterior mandible exposed • Mental nerve identified, retracted and protected

• Anterior mandible exposed Genioplasty SURGICAL• EXPOSUREMental nerve identified, retracted • Anterior and mandible protected exposed •SURGICALMental nerve EXPOSURE identified, retracted and protected• Anterior mandible exposed SURGICAL• Mental EXPOSURE nerve identified, retracted and • protectedAnterior mandible16 exposed • Mental nerve identified, retracted and protected LeFort I Osteotomy LeFort

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Technique guide: Orthognathic Surgery 16 Section III: Genioplasty 17

16 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Table of contents

NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol OSTOEOTOMY NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol • Mark midline • Osteotomy extending posteriorly to OSTOEOTOMYNL-SP-HSC-002 - Sagittal Ramus, Osteotomy,inferior Transoral border Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol • • Mark midlineOSTOEOTOMY Adequate room below mental Ostoeotomy foramen to insure that inferior extent • Osteotomy• extendingMark midline posteriorly to of intrabony canal is not violated inferiorOSTOEOTOMY border•• OsteotomyMark midline extending •posteriorlyDrill hole toin superior aspect of chin • Adequate room•• inferiorMarkOsteotomy below midline bordermental extending segment, posteriorly pass wire. to This will allow • for easy manipulation of segment Sagittal Ramus Osteotomy foramen to• insureAdequateOsteotomyinferior that inferior borderroom extending belowextent posteriorly mental to of intrabony• canal forameninferiorAdequate is not border to violated insureroom that below inferior mental extent • of intrabony canal is not violated Drill hole in• superiorAdequateforamen aspect roomto insureof below chin that mental inferior extent segment, pass• Drillwire. hole This in will superior allow aspect of chin foramenof intrabony to insure canal that isinferior not violated extent for easy manipulationsegment,of intrabony of pass segment canal wire. is Thisnot violated will allow • forDrill easy hole manipulation in superior of segmentaspect of chin • Drillsegment, hole in pass superior wire. aspect This of will chin allow segment, pass wire. This will allow for easy manipulationOSTEOTOMY of segment FIXATION for easy manipulation• of Countersinksegment bone in area of screw placement • Advance segment to desired position • Make sure posterior aspects of inferior segment are symmetrical

OSTEOTOMY FIXATIONOsteotomy fixation• Secure with 2 or 3 bicortical screws Transoral Vertical Ramus Osteotomy • CountersinkOSTEOTOMY bone in area FIXATION of screw • Plates can also be used. placement •• CountersinkCountersink bone bone in area in area of screw of screw • placement AdvanceOSTEOTOMY segmentplacement to desired FIXATION position • •• Advance segment to desired position Make sure• posteriorAdvanceCountersink aspects segment bone of toin desiredarea of screwposition inferior segment•• MakeplacementMake are suresymmetrical sure posterior posterior aspects aspects of of • Secure with• 2 inferiorAdvanceorinferior 3 bicortical segment segmentsegment screws are to aresymmetricaldesired symmetrical position • • Plates can •also• SecureMakeSecure be used. sure with with posterior 2 or 2 3or bicortical 3aspects bicortical ofscrews screws •• PlatesinferiorPlates can cansegment also also be are used.be symmetrical used. • Secure with 2 or 3 CLOSUREbicortical screws • • Plates can also be used. Two or three layer closure - Periosteum - Muscle - Mucosa Closure

• Two or three layer closure Genioplasty CLOSURE - Periosteum - Muscle • Two orCLOSURE three layer closure - Mucosa - Periosteum• Two or three layer closure - CLOSUREMuscle - Periosteum - Mucosa• Two- or Musclethree layer17 closure - MucosaPeriosteum - Muscle

- Mucosa I Osteotomy LeFort

17 Technique guide: Orthognathic Surgery 18 17 Section III: Genioplasty

17 NL-SP-HSC-002NL-SP-HSC-002 - Sagittal - Ramus,Sagittal Ramus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and and LeFort LeFort I OsteotomyI Osteotomy ProtocolProtocol

LEFORTLEFORT I MAXILLARY I MAXILLARY OSTEOTOMY OSTEOTOMY Table of contents

INCISION/EXPOSURE INCISION/EXPOSURESection• Short incision IV: with wide pedicle base • ShortNL-SP-HSC-002NL-SP-HSC-002 incision -with Sagittal - Sagittal wide Ramus, Ramus, pedicle Osteotomy, Osteotomy, base Transoral Transoral Vertical Vertical Ramus Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and and LeFort LeFort I Osteotomy I Osteotomy Protocol Protocol

LEFORTLEFORTLeFort I MAXILLARY I MAXILLARY I Maxillary OSTEOTOMY OSTEOTOMY Osteotomy

INCISION/EXPOSUREINCISION/EXPOSURE Sagittal Ramus Osteotomy • •Short incision with wide pedicle base Incision/exposureShort incision with wide pedicle base • Short incision with wide pedicle base

EXPOSURE • Generous exposure of anterior EXPOSURE maxilla and lateral maxillary wall • Generous exposure- Pterygoid of anterior plate should be maxillaExposure and lateralvisualized maxillary wall Transoral Vertical Ramus Osteotomy - • PterygoidGenerous- Nasal plate exposure mucosa should elevated of be anterior from EXPOSUREEXPOSURE maxillapiriform and lateral rim, lateral maxillary nasal wall •visualized•GenerousGenerous exposure exposure of ofanterior anterior - Nasal- Pterygoid mucosawall and plate elevated nasal should floor. from be maxillamaxillaProtected and and lateral lateral with maxillary retractormaxillary wall wall piriform visualized- - rim,PterygoidPterygoid lateral plate plate nasal should should be be wall- Nasal and visualized nasalmucosavisualized floor. elevated from Protected piriform- - Nasal withNasal rim, mucosa retractor mucosa lateral elevated elevated nasal from from wall andpiriformpiriform nasal rim, rim,floor. lateral lateral nasal nasal Protectedwallwall andwith and nasal nasalretractor floor. floor. ProtectedProtected with with retractor retractor

OSTEOTOMIES •OsteotomiesOsteotomy cut from buttress to • piriformOsteotomy rim cuttingcut from from buttress outside in.to Genioplasty OSTEOTOMIES piriform- Posterior rim cutting cut as low from into outside in. pterygoid maxillary junction • OsteotomyOSTEOTOMIES OSTEOTOMIES- Posterior cut from cutbuttress as low to into as possible piriform • •rimOsteotomypterygoidOsteotomy cutting cut from maxillary cut from from outside buttress buttress junction in. to to - Anterior cut through piriform - Posterior piriformaspiriform possible cutrim rim ascutting cuttinglow frominto from outside outside in. in. - Anterior- rim- Posterior and cut anterior through cut as portionlow piriform into of pterygoid maxillaryPosterior cut junction as low into rimlateral andpterygoidpterygoid anterior nasal maxillary wall maxillary portion junction junction of as possible lateralas nasal aspossible possible wall - Anterior- - AnteriorcutAnterior through cut cut through piriform through piriform piriform LeFort I Osteotomy LeFort rim and anteriorrimrim and and anterior portion anterior portion of portion of of lateral nasallaterallateral wall nasal nasal wall wall 18

Technique guide: Orthognathic Surgery 18Section18 IV: Lefort I Maxillary Osteotomy 19 18 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol

OSTEOTOMIES

NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Table of contents • Complete cut to posterior aspect of maxilla by cutting from inside the sinus outward OSTEOTOMIES NL-SP-HSC-002• Complete - Sagittal cut Ramus,to posterior Osteotomy, aspect Transoral of Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol maxilla by cutting from inside the Osteotomiessinus outward (cont.) OSTEOTOMIES • • Complete cut to posterior aspect of

Complete cut to posterior aspect of Sagittal Ramus Osteotomy maxillamaxilla by cuttingby cutting from from inside inside the the sinussinus outward outward

OSTEOTOMIES-Interdental cuts • Complete interdental cuts before downfracturingOsteotomies maxilla. - Interdental cuts - This allows cuts to be made Transoral Vertical Ramus Osteotomy OSTEOTOMIES-Interdental• Completeon stable interdental maxilla. cuts cuts before • Completedownfracturing• interdentalSaw more maxilla.cuts efficient before downfracturing- This• allowsTechnically maxilla. cuts to easier be made - onThis stable allows maxilla. cuts to be made OSTEOTOMIES-Interdental• Sawon more stable efficient maxilla. cuts • •Complete Technically interdental• Saw easier more cuts efficient before downfracturing• Technically maxilla. easier - This allows cuts to be made on stable maxilla. • Saw more efficient • Technically easier

Osteotomies OSTEOTOMIES Genioplasty • Use• doubleUse double guarded guarded osteotome osteotome or or mayo mayo scissors scissors to divide to divideinferior inferior portion portion of septum of septum from nasal from crest nasal of crest OSTEOTOMIESmaxilla of maxilla • Use double guarded osteotome or mayo scissors to divide inferior portion of septum from nasal crest of OSTEOTOMIESmaxilla

• Use double guarded osteotome or I Osteotomy LeFort mayo scissors to divide inferior portion of septum from nasal crest of maxilla 19

Technique guide: Orthognathic Surgery 20 Section IV: Lefort I Maxillary Osteotomy 19

19 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Table of contents

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 OSTEOTOMIES • Curved osteotome used to divide OSTEOTOMIESpterygoid-maxillary junction OSTEOTOMIES• Curved osteotome used to divide • Curvedpterygoid-maxillary osteotome used junction to divide

pterygoid-maxillary junction Sagittal Ramus Osteotomy Osteotomies (cont.) • Curved osteotome used to divide pterygoid-maxillary junction

OSTEOTOMIES

• Single guarded osteotome used to Transoral Vertical Ramus Osteotomy OSTEOTOMIESdivide lateral nasal wall. • Single- Can guarded extend osteotomeosteotome used to OSTEOTOMIES• Single guarded osteotome used to dividecompletely lateral nasal through wall. posterior • Singledivide guardedlateral nasal osteotome wall. used to - aspect of wall divide- Can lateralCan extend extend nasal osteotome wall.osteotome completelycompletely• Transects through through descending posteriorposterior - Can extendpalatine osteotome vessel aspectcompletelyaspect of ofwall wall through posterior • Transectsaspect• descending ofTransects wall descending palatine •vesselTransectspalatine vessel descending palatine vessel

OSTEOTOMIES Genioplasty • Downfracture maxilla. You should OSTEOTOMIES• beDownfracture able to do this withmaxilla. digital You should pressurebe able to do this with digital OSTEOTOMIES• Downfracture maxilla. You should • Elevatepressure remaining nasal mucosa from • Downfracturebe able to do this maxilla. with digital You should • pressurenasalElevate floor remaining and crest of nasalmaxilla mucosa while from bedownfracturing able to do this with digital • pressureElevatenasal floorremaining and nasal crest mucosa of maxilla from while • Elevatenasaldownfracturing floor remaining and crest nasal of maxilla mucosa while from nasaldownfracturing floor and crest of maxilla while downfracturing I Osteotomy LeFort

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Technique guide: Orthognathic Surgery 20 Section IV: Lefort I Maxillary Osteotomy 21 20 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol

OSTEOTOMIES

• Place Tessier mobilizers on posterior Table of contents NL-SP-HSC-002aspect of maxilla - Sagittal and Ramus, complete Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol separation from pterygoid plate area. NL-SP-HSC-002OSTEOTOMIESYou - Sagittalshould Ramus,be able Osteotomy,to move maxilla Transoral at Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol least• 1.5Place cm Tessier in any mobilizersdirection on posterior - aspectObtainNL-SP-HSC-002 of hemostasismaxilla - Sagittal and withRamus,complete cautery Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol OSTEOTOMIES - OsteotomiesseparationPlace entire from moist (cont.)pterygoid sponge plate area. • Place TessierYoubehind shouldOSTEOTOMIES mobilizers each be sideable ofonto maxillamove posterior maxilla in at •least Place 1.5• cm TessierPlace in any Tessier mobilizers direction mobilizers on on posteriorposterior aspect of areamaxilla of pterygoid-maxillary aspectand completeof maxilla and complete aspect of maxilla and complete Sagittal Ramus Osteotomy separationseparation -fromObtain pterseparation ygoidhemostasis from plate pter with area.ygoid cautery plate area. You should separation- bePlace ableYou entireto shouldfrom move moist bepterygoid ablemaxilla sponge to move atplate maxilla area. at You shouldleast 1.5be cm able in any to directionmove maxilla at least 1.5 cm inbehind any direction each side of maxilla in leastarea 1.5 of cm- pterygoid-maxillary inObtain any hemostasis direction with cautery - Obtain hemostasis- Place with entire cauterymoist sponge - Obtainseparation hemostasis with cautery - Place entire moistbehind sponge each side of maxilla in - Place entirearea moist of pterygoid-maxillary sponge behind behind each eachsideseparation ofside maxilla of maxilla in in area ofarea pterygoid-maxillary of pterygoid-maxillary separation separation RECONTOURING • Recontour, remove interferences from superior aspect of maxilla.

EspeciallyRecontouring important in the following Transoral Vertical Ramus Osteotomy RECONTOURING areas RECONTOURING • • Recontour, remove interferences - Recontour,Nasal •crest Recontour,remove of maxilla interferences remove interferences - fromLateralfrom superior superiornasalfrom aspect superiorwall aspect toof aspect includemaxilla. of of maxilla. maxilla. EspeciallymostEspecially posterior importantEspecially important aspect important in the infollowing in the the followingfollowing areasareas areas - Posterior, lateral- Nasal aspect crest ofof maxilla RECONTOURING -- NasalNasal crest crest ofof maxilla maxillary sinus- Lateral nasal wall to include • Recontour, -- removeLateralLateral interferencesnasal nasalmost wall posterior toto include includeaspect from superior most mostaspect posterior posterior- ofPosterior, maxilla. aspect lateral aspect of Especially - -important Posterior,Posterior, in lateral maxillarylateral the following aspectaspect sinus of of areas maxillarymaxillary sinussinus - Nasal crest of maxilla - Lateral nasal wall to include most posterior aspect RECONTOURING - OsteotomiesPosterior, lateral aspect of Genioplasty • RECONTOURING Save bonemaxillary dust harvested sinus during recontouring• Save • bone Save dust bone dustharvested harvested during recontouring - Canrecontouring be used for grafting RECONTOURING - Can be used- Can for be usedgrafting for grafting segmental defectssegmental defects • Save bonesegmental dust harvested defects during - Large quantity- Largeof bone quantity can ofbe bone can be recontouring- Large quantity of bone can be saved saved - savedCan be used for grafting segmental defects - Large quantity of bone can be saved I Osteotomy LeFort RECONTOURING • Save bone dust harvested during recontouring21 21 - Can be used for grafting segmental defects Technique guide: Orthognathic Surgery - Large quantity of bone can be 22 Section IV: Lefort I Maxillary Osteotomy 21 saved

21 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Table of contents

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 COMPLETE SEGMENTAL OSTEOTOMIES • Connect anterior interdental cuts by COMPLETEmaking SEGMENTAL an osteotomy OSTEOTOMIES in a tangential • Connect anterior interdental cuts by COMPLETEfashion SEGMENTAL across the palate OSTEOTOMIES making an osteotomy in a tangential • fashionConnect across anterior the interdental palate cuts by

making an osteotomy in a tangential Sagittal Ramus Osteotomy Completefashion across segmental the palate osteotomies • Connect anterior interdental cuts by making an osteotomy in a tangential fashion across the palate

COMPLETE SEGMENTAL OSTEOTOMIES • Complete segmental cuts by making Transoral Vertical Ramus Osteotomy COMPLETEparasagittal SEGMENTAL cuts in palate OSTEOTOMIES •• CompleteComplete segmental segmental cuts cuts by making by making COMPLETE- SEGMENTALShould use parasagittal OSTEOTOMIES cuts even parasagittalparasagittal cuts cuts in palate in palate • Completefor segmental 2 piece maxilla cuts by making - Should use parasagittal cuts even parasagittal- Should- Bone cutsuse thinnest inparasagittal palate laterally whilecuts evensoft for 2 piece maxilla for- Should2tissue piece is use maxillathickest parasagittal cuts even - Bone thinnest laterally while soft - Bonefor thinnest 2• pieceMinimizes maxilla laterally risk whileof soft tissue is thickest tissue- Bone is thinnestthickestperforation laterally while soft • Minimizes risk of • Minimizestissue• riskis Tissuethickest of perforation more elastic for perforation • Tissue more• Minimizeselasticexpansio forn risk expansion of • Tissue more elastic for perforation expansion • Tissue more elastic for expansion

COMPLETE SEGMENTAL OSTEOTOMIES Genioplasty • Begin seating individual segments in COMPLETE• splintBegin SEGMENTAL seating individual OSTEOTOMIES segments • Beginin splint seating individual segments in COMPLETE• Remove SEGMENTAL small interferences OSTEOTOMIES with 701 bur • splintRemove small interferences with • Beginto complete seating positioning individual ofsegments segments in in • Remove small interferences with 701 bur splintsplint701 bur to complete positioning of to complete positioning of segments in • segments in splint splintRemove small interferences with 701 bur to complete positioning of segments in splint LeFort I Osteotomy LeFort

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22 Technique guide: Orthognathic Surgery Section IV: Lefort I Maxillary Osteotomy 23 22 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 COMPLETE SEGMENTAL OSTEOTOMIES • In cases where there is a significant amount of mucosa in the space to be NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol COMPLETE SEGMENTALclosed, itNL-SP-HSC-002 may be OSTEOTOMIES necessary - Sagittal Ramus,to incise Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol mucosa along crest of ridge to facilitate

• In cases where there is a significant Table of contents close approximation of segments to amount of mucosa in the space to be COMPLETEcomplete SEGMENTAL spaceCOMPLETE closure SEGMENTAL OSTEOTOMIES OSTEOTOMIES closed, •it mayIn cases be necessarywhere• In there cases to is where incise a significant there is a significant mucosaNL-SP-HSC-002 along crest - Sagittalof ridgeamount Ramus, to of facilitateOsteotomy,mucosa in Transoralthe space Vertical to be Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol amount of mucosaclosed, in it the may space be necessary to be to incise close approximationclosed, it may of mucosabesegments necessary along tocrest to inciseof ridge to facilitate complete spacemucosa closure along closecrest approximation of ridge to facilitate of segments to COMPLETEclose approximation SEGMENTALcomplete of space segments OSTEOTOMIES closure to Complete segmental osteotomies complete• In cases space where closure there is a significant amount(cont.) of mucosa in the space to be Sagittal Ramus Osteotomy closed,• In cases it may where be necessary there tois incisea significant mucosa amount along of crest mucosa of ridge in tothe facilitate space to be close closed, approximation it may be of necessarysegments to to incise complete space closure mucosa along crest of ridge to GRAFTING OF SEGMENTALfacilitate close SITES approximation of • Defects createdsegments by segmentalization to complete space closure should be grafted. Sources include: - FreezeGRAFTING dried banked OF SEGMENTAL bone SITES • - Bone dustDefects harvested created from by segmentalization should be grafted. Sources include: GRAFTING OF SEGMENTALrecontouring SITES- afterFreeze downfracture dried banked bone GRAFTING OF SEGMENTAL- Bone SITESdust harvested from

• Defects created by segmentalization Transoral Vertical Ramus Osteotomy • DefectsGrafting created ofby segmental segmentalizationrecontouring sites after downfracture should be grafted.should be Sourcesgrafted. Sourcesinclude: include: • Defects created by segmentalization - Freeze- dried banked bone GRAFTING Freezeshould OF SEGMENTAL dried be grafted. banked Sources SITESbone include: - Bone• dust-Defects Bone -harvested Freeze created dust driedharvested by from segmentalization banked from bone recontouringshould recontouring- Bone beafter grafted. dust downfracture after harvested Sources downfracture include: from - recontouringFreeze dried banked after downfracturebone - Bone dust harvested from recontouring after downfracture TURBINATES ANDTURBINATES SEPTUM AND SEPTUM • In casesTurbinates of significant• In cases and superior of septumsignificant superior repositioning• In casesor repositioningwhen of significantnasal or when superior nasal obstruction is apparent, turbinectomy obstruction repositioning is apparent, turbinectomy or when nasal may be required may be required obstruction- Openis apparent, nasal mucosa turbinectomy - Open nasal mucosa

may be required Genioplasty TURBINATES -AND Open SEPTUM nasal mucosa TURBINATES• ANDIn cases SEPTUM of significant superior • TURBINATESrepositioning AND or when SEPTUM nasal In cases ofobstruction significant is superiorapparent, turbinectomy repositioning• orIn whencases of nasal significant superior may repositioningbe required or when nasal obstruction is -apparent,obstructionOpen nasal turbinectomyis apparent, mucosa turbinectomy may be requiredmay be required - Open nasal- mucosaOpen nasal mucosa

23 I Osteotomy LeFort

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Technique guide: Orthognathic Surgery 24 Section IV: Lefort I Maxillary Osteotomy

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23 NL-SP-HSC-002NL-SP-HSC-002 - Sagittal - Sagittal Ramus, Ramus, Osteotomy, Osteotomy, Transoral Transoral Vertical Vertical Ramus Osteotomy, Osteotomy, Genioplasty, Genioplasty, and and LeFort LeFort I Osteotomy I Osteotomy Protocol Protocol Table of contents

TURBINATESNL-SP-HSC-002TURBINATES -AND Sagittal AND SEPTUM Ramus, SEPTUM Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol • Dissect• Dissect nasal nasal mucosa mucosa from from septum septum - - ResectResect as asnecessary necessary - Suture mucosa TURBINATES- Suture AND mucosa SEPTUM • Dissect nasal mucosa from septum

Turbinates- Resect and as necessaryseptum (cont.) Sagittal Ramus Osteotomy - Suture mucosa • Dissect nasal mucosa from septum - Resect as necessary - Suture mucosa

FIXATION/STABALIZATION • Apply firm maxillomandibular Transoral Vertical Ramus Osteotomy FIXATION/STABALIZATIONFixation/Stabalizationfixation • Apply• Rotate firm maxillomandibular maxillomandibular complex FIXATION/STABALIZATION• Apply firm maxillomandibular fixationsuperiorly, seating condyles • Applyfixation firm maxillomandibular • • Remove interferences as necessary to Rotatefixation maxillomandibular complex • achieveRotate appropriate maxillomandibular vertical complex superiorly,• seating condyles dimensionRotatesuperiorly, maxillomandibular seating condyles complex • Remove• superiorly,Remove interferences interferencesseating condyles as necessary as necessary to to achieve• Removeachieve appropriate interferences appropriate vertical as verticalnecessary to dimension achievedimension appropriate vertical dimension

FIXATION/STABALIZATION Genioplasty • PLATES • PLATES- Most common fixation - Mosttechnique common fixation technique FIXATION/STABALIZATIONFIXATION/STABALIZATION - Usually- Usually use use 4 4plates plates • PLATES• PLATES - -MostMost common common fixation fixation techniquetechnique - -UsuallyUsually use use 4 plates4 plates LeFort I Osteotomy LeFort

24 Technique guide: Orthognathic Surgery Section IV: Lefort I Maxillary Osteotomy 25

24 24 NL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol

FIXATION/STABALIZATIONNL-SP-HSC-002 - Sagittal Ramus, Osteotomy, Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol • PLATES

NL-SP-HSC-002- - SagittalIn segmental Ramus, Osteotomy, cases may Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol Table of contents FIXATION/STABALIZATIONinclude all segments in • PLATESfixation although not usually necessary- In segmental to incorporate cases may FIXATION/STABALIZATIONanteriorinclude segment all segments in • PLATES fixation although not usually - In segmentalnecessary cases to incorporate may includeanterior all segments segment in fixation although not usually Fixation/Stabalizationnecessary to incorporate (cont.) Sagittal Ramus Osteotomy anterior segment • PLATES - In segmental cases may include all segments in fixation although not usually necessary to incorporate anterior segment FIXATION/STABALIZATION • SCREWS - In some cases, the direction of FIXATION/STABALIZATIONmaxillary movement results in • SCREWSbone overlap that allows Transoral Vertical Ramus Osteotomy • SCREWSfixation- In some with cases, 6 or 8 the screws. direction of FIXATION/STABALIZATION - In somemaxillary cases, movement the direction results of in • SCREWS maxillary bone overlap movement that allows results in - Inbone somefixation overlap cases, with thethat 6 directionor allows 8 screws. of maxillaryfixation movementwith 6 or results8 screws. in bone overlap that allows fixation with 6 or 8 screws.

FIXATION/STABALIZATION • COMBINATION of plates and screws Genioplasty - Useful when there is end to end • COMBINATION of plates and screws FIXATION/STABALIZATIONbone contact in some areas and - Useful when there is end to end • bone overlap or grafting in COMBINATION bone contact ofin platessome andareas screws and other- Useful areas when there is end to end FIXATION/STABALIZATION bone overlap or grafting in otherbone areas contact in some areas and • COMBINATIONbone overlap of plates or andgrafting screws in - Usefulother when areas there is end to end bone contact in some areas and I Osteotomy LeFort bone overlap or grafting in other areas

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Technique guide: Orthognathic Surgery 26 Section IV: Lefort I Maxillary Osteotomy 25

25 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 CLOSURE • Alar base cinch suturing is required to help prevent unesthestic widening of the alar base

CLOSURE - Grasp nasal alar base soft Table of contents • Alar basetissue/musculature cinch suturing is requiredwith NL-SP-HSC-002to help - Sagittal preventforceps Ramus, unesthestic Osteotomy, widening Transoral Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol of the- alarPlace base long resorbing 2-0 PDS - Graspsuture nasal alar base soft tissue/musculature with forceps CLOSUREClosure - Place long resorbing 2-0 PDS • Alar basesuture cinch suturing is required • Alarto helpbase prevent cinch unesthestic suturing widening is required to ofhelp the alarprevent base unesthestic widening of the- alarGrasp base nasal alar base soft Sagittal Ramus Osteotomy - Grasp tissue/musculaturenasal alar base with soft tissue/musculatureforceps with forceps - Place long resorbing 2-0 PDS CLOSURE - Place longsuture resorbing 2-0 PDS suture • Begin tightening the suture while examining the alar base to evaluate alar base width. CLOSURE• Secure suture • Begin tightening the suture while examining the alar base to evaluate • Beginalar tighteningbase width. the suture while •examiningSecure suture the alar base to evaluate

alar base width. Transoral Vertical Ramus Osteotomy CLOSURE• Secure suture • Begin tightening the suture while examining the alar base to evaluate alar base width. • Secure suture

CLOSURE • Mucosal closure is usually • Mucosalaccomplished closure in ais V-Y usually fashion to accomplishedavoid thinning in of a the V-Y upper fashion lip to CLOSUREavoid thinning- Begin by of using the uppera single lipprong NL-SP-HSC-002 •- - SagittalBeginMucosal Ramus, byskin closure using hook Osteotomy, is to ausually singleform Transoral a verticalprong Vertical Ramus Osteotomy, Genioplasty, and LeFort I Osteotomy Protocol accomplished in a V-Y fashion to skin hookleg ofto the form closure a vertical avoid thinning of the upper lip leg of- theBegin closure by using a single prong skin hook to form a vertical Genioplasty CLOSURE leg of the closure CLOSURE • Closure is completed with chromic 26 • Mucosal closure is usually suture inaccomplished using a horizontal in a V-Y mattressfashion to closure.avoid thinning of the upper lip - Begin by using a single prong 26 • Closure isskin completed hook to form with a vertical chromic suture inleg using of the a closure horizontal mattress closure. LeFort I Osteotomy LeFort

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Technique guide: Orthognathic Surgery Section IV: Lefort I Maxillary Osteotomy 27

The opinions expressed come from third parties and are not those of Stryker. Individual results may vary and not all patients will receive the same post-operative activity level.

9410-400-057 Rev. None 27 This manual is designed to provide an introductory overview to basic surgical techniques for the most commonly performed orthognathic surgical procedures. The techniques demonstrated are examples of the author’s primary techniques for performing these surgical procedures. Modifications should be made based on the patient’s clinical presentation and anatomy, the surgeon’s experience and preferences regarding instrumentation, osteotomy design and fixation techniques.

The opinions expressed come from third parties and are not those of Stryker. Individual results may vary andnot all patients will receive the same post-operative activity level.

Craniomaxillofacial

The information presented in this brochure is intended to demonstrate a Stryker product. Always refer to the package Stryker Craniomaxillofacial insert, product label and/or user instructions before using any Stryker product. Products may not be available in all Kalamazoo, MI 49002 USA markets. Product availability is subject to the regulatory or medical practices that govern individual markets. t: 269 389 5346, f: 877 648 7114 Please contact your Stryker representative if you have questions about the availability of Stryker products in your area. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following toll free: 800 962 6558 trademarks or service marks: Stryker. All other trademarks are trademarks of their respective owners or holders. stryker.com Literature Number: MAX-PR-2_Rev. None_28309. stryker.com/cmf UnDe/PS Copyright © 2020 Stryker Printed in USA

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