Minimally invasive sagittal osteotomy-technical note.

This article describes a novel minimally invasive technique for bilateral sagittal split osteotomy (BSSO) that aims to reduce surgical trauma while maintaining bone overlap and rigid internal fixation for proper consolidation of the bone segments. The technique involves a small vestibular mucoperiosteal incision made on the lateral aspect of the mandible between the first and second molars, enabling a standard ramus split, surgical segment movement, and miniplate fixation. A retrospective evaluation of 67 consecutive patients who underwent BSSO using this protocol showed favorable split of the mandible with no unfavorable splits or non-union. Patients were discharged from hospital within an average of 17 h with minimal postoperative complications. This technique provides good surgical visualization with a very small incision and allows standard BSSO surgery without difficulty.

Does the type of sagittal split ramus osteotomy influence fixation strength? Evaluation of the mechanical behavior of two types of fixation used in three types of sagittal split ramus osteotomy.

PURPOSE: This study compared the mechanical behavior of two fixation techniques used in three sections representing the sagittal split ramus osteotomy (SSRO) in polyurethane replicas that were divided into groups, according to type of section, and sub-groups according to type of fixation, simulating 11-mm advancement and 6º clockwise mandibular rotation. METHODS: Loads were applied in two regions, aiming at progressive application and consequent strength value, measured in kilogram-force in displacements of 1, 3, 5, and 7 mm, from the load application tip. Shapiro-Wilk test was performed, followed by two-way analysis of variance (ANOVA-2 way), and Bonferroni's multiple comparison. RESULTS: The results showed no statistically significant difference in the type of section and type of fixation used when load was applied to the inter-incisor region. However, when load was applied to the first molar region, statistically significant difference was observed in 1-mm displacement, in which section described by Epker with two modifications showed greater strength, regardless of type of fixation used (p = 0.007). CONCLUSION: In the application of load in the inter-incisor region, there was no statistical difference between the type of osteotomy and the type of fixation used. When applying loads to molars, there was a difference for the type of osteotomy, where the Epker osteotomy with 2 modifications presented greater resistance, regardless of the type of fixation used.

Influence of the mandibular plane and magnitude of the movement in sagittal split ramus osteotomy: an in vitro study.

PURPOSE: The aim of this study was to evaluate fixation resistance in mandibular sagittal split ramus osteotomy in standardized polyurethane hemimandibles with two types of advancement (6 and 12 mm), with or without mandibular plane rotation, using a 2.0-mm plate/screw system. METHODS: Seven groups were evaluated using a vertical compressive load in the first molar region, and the applied force in Newtons was recorded in 1 mm, 5 mm, and 10 mm displacements, as well as the maximum force. RESULTS: There was a statistical intergroup difference and it was observed that increasing the advancement decreased fixation resistance with a single plate, and inserting an additional plate significantly increased osteosynthesis resistance. CONCLUSION: In the 12 mm advancements, clockwise rotation proved to be more resistant when fixed with only one plate. By contrast, counterclockwise rotation was significantly more resistant in stabilizing the mandibular sagittal ramus osteotomy when two plates were used.

Do lower third molars increase the risk of complications during mandibular sagittal split osteotomy? Systematic review and meta-analysis.

The aim of this systematic review was to investigate whether the presence of third molars (3Ms) during sagittal split osteotomy of the mandible increases the risk of complications. Searches were conducted using MEDLINE via PubMed, LILACS, Cochrane Central, Scopus, DOSS, and SIGLE via OpenGrey up to December 2020. Fifteen articles were included for evaluation and 14 in the meta-analysis, with a total of 3909 patients and 7651 sagittal split osteotomies (670 complications). Inferior alveolar nerve (IAN) exposure in the proximal segment was the most frequent complication (n = 409), followed by bad splits (n = 151). Meta-analysis revealed no significant increase in the incidence of 3M-related IAN exposure (P = 0.45), post-surgical infections (P = 0.15), osteosynthesis material removal (P = 0.37), or bad splits (P = 0.23). The presence of 3Ms was associated with a reduced risk of nerve disorder (P = 0.05) and favoured bad splits in the lingual plate (P = 0.005). The quality of evidence was very low, mainly due to non-randomized study designs, high risk of bias, inconsistency, and imprecision. This systematic review suggests that the removal of 3Ms before sagittal mandibular osteotomy does not reduce the incidence of complications. Thus, we recommend future better-designed studies with rigorous methodologies and adjustments for confounding factors.

Estabilidad del tratamiento ortodóncico-quirúrgico de avance mandibular mediante osteotomía sagital bilateral de rama mandibular en pacientes clase II. Revisión narrativa / Stability of the orthodontic-surgical treatment of mandibular advancement through bilateral sagittal split osteotomy in class II patients. Narrative review

RESUMEN: Introducción: La anomalía esqueletal clase II posee un 16 a 22,5% de prevalencia mundial. Cuando estos pacientes se someten al avance mandibular mediante osteotomía sagital de rama mandibular pueden presentar un grado de inestabilidad postoperatoria evidenciándose como recidiva de éste. Objetivo: Describir la estabilidad del avance mandibular mediante osteotomía sagital bilateral de rama mandibular en pacientes clase II esqueletal. Material y método: Se realizó una búsqueda electrónica en las bases de datos PubMed, EBSCO, The Cochrane Library, Tripdatabase y Scopus mediante las palabras clave "mandibular stability", "skeletal stability", "mandibular advancement", "sagittal split osteotomy", "sagittal split ramus osteotomy", "class II", "class III" y "distraction osteogenesis", relacionadas entre sí con los términos booleanos AND, OR y NOT. También se incluyeron los términos MeSH "mandibular advancement" y "Sagittal Split Ramus Osteotomy". Paralelamente se realizó una búsqueda manual en las revistas AJODO, BJOMS, JOMS y EJO. Resultados y discusión: Se seleccionaron 29 artículos: 24 estudios observacionales analíticos, 2 revisiones sistemáticas y 3 ensayos clínicos aleatorizados. El avance mandibular mediante osteotomía sagital de rama mandibular es estable. No obstante, se debe tener en cuenta la existencia de múltiples factores pre e intraquirúrgicos que podrían generar recidiva del tratamiento.

ABSTRACT: Introduction: The class II skeletal anomaly has a 16-22,5% prevalence worldwide. When class II patients undergo mandibular advancement through Bilateral Sagittal Split Osteotomy (BSSO), they can present a postoperative instability, evidenced as a relapse. Objective: To describe the stability of mandibular advancement through BSSO in skeletal class II patients. Materials and method: An electronic search was performed in the databases PubMed, EBSCO, The Cochrane Library, Tripdatabase and Scopus using the keywords "mandibular stability", "skeletal stability", "mandibular advancement", "sagittal split osteotomy", "sagittal split ramus osteotomy", "class II", "class III" and "distraction osteogenesis", related to each other with the Boolean terms AND, OR and NOT. Also "mandibular advancement" and "Sagittal Split Ramus Osteotomy" MeSH terms were included. In parallel, a manual search in the journals AJODO, BJOMS, JOMS and EJO was performed. Results and discussion: 29 articles were selected: 24 analytic observational studies, 2 systematic reviews and 3 randomized clinical trials. Mandibular advancement through BSSO is stable. However, multiple pre and intraoperative factors that could cause a treatment relapse must be taken into account.

Which type of method shows the best mechanical behavior for internal fixation of bilateral sagittal split osteotomy in major advancements with clockwise rotation? Comparison of four methods.

PURPOSE: The aim of the present study was to evaluate the four methods for bilateral sagittal osteotomy fixation. METHODS: In this study, 56 replicas of whole mandibles made of rigid polyurethane were used. After simulation of major advancement (11 mm) with clockwise rotation of the mandible (6o) in relation to the occlusal plane, the bone segments were fixed with plates and screws of the 2.0-mm system on both the right and left sides: group I, double "H" plate; group II, two mini-plates; group III, "hybrid technique"; and group IV, three bicortical screws in the "inverted L" pattern. The mandibles were submitted to load on the central incisors and right first molar. RESULTS: The mean value of group I was higher than those of groups IV and II in the displacement of 1 mm (F = 4.705; p = 0.010) with load on the incisor. The mean value of group III was higher than those of groups I and II in the displacement of 1 mm (F = 5.166; p = 0.007) and 3 mm (F = 5.166; p = 0.007). The mean value of group IV was higher than that of group II (F = 3.142; p = 0.044) with load on the molar. CONCLUSION: Therefore, after the analyses, the hybrid technique was the one that showed the best results.

Concepts, protocol, variations and current trends in surgery first orthognathic approach: a literature review

ABSTRACT In the current era of expedited orthodontics, among many clinicians, tertiary care hospitals and patients, surgery first orthognathic approach (SFOA) has gained popularity. The advantages of SFOA (face first approach) are the reduced overall treatment duration and the early improvement in facial esthetics. In SFOA, the absence of a presurgical phase allows surgery to be performed first, followed by comprehensive orthodontic treatment to achieve the desired occlusion. The basic concepts of surgery early, surgery last, SFOA and Sendai SFOA technique along with its variations are reviewed in the present article. The recent advancement in SFOA in the context of preoperative preparation, surgical procedures and post-surgical orthodontics with pertinent literature survey are also discussed.

RESUMO Na presente era da Ortodontia de resultados acelerados, a cirurgia ortognática com benefício antecipado (COBA) ganhou popularidade entre muitos clínicos, hospitais terciários e pacientes. A vantagem da COBA é a redução da duração total do tratamento, juntamente com a melhora precoce da estética facial. Na COBA, a ausência de uma fase pré-cirúrgica permite que a cirurgia seja realizada antes e, só então, venha o tratamento ortodôntico abrangente para se alcançar a oclusão desejada. Os conceitos básicos de cirurgia primeiro, cirurgia por último, COBA e a técnica COBA de Sendai, bem como suas variações, são aqui revistos. Também são discutidos no presente artigo, junto com a revisão da literatura pertinente, os recentes avanços da COBA no contexto do preparo pré-cirúrgico, dos procedimentos cirúrgicos e da Ortodontia pós-cirúrgica.

Análise biomecânica de diferentes tipos de fixação em osteotomia sagital do ramo após diferentes avanços e alterações do plano mandibular: um estudo com elementos finitos / Biomechanical analysis of different types of fixation in sagittal ramus osteotomy after different advances and changes in the mandibular plane: a study with finite elements

O objetivo deste trabalho foi avaliar, por meio de um estudo com análise em elementos finitos, as tensões de superfície presentes na cortical óssea mandibular e no material de síntese, assim como avaliar a resistência da fixação ao deslocamento após a osteotomia sagital do ramo mandibular (OSRM) quando da realização de diferentes avanços mandibulares com e sem alteração do plano mandibular. Foram obtidos modelos virtuais tridimensionais de uma mandíbula e planejados avanços de 6 e 12mm com avanço linear, assim como associados ao giro horário e anti-horário do plano mandibular. Cada conjunto foi, então, fixado com uma ou duas placas monocorticais do sistema 2.0 dispostas horizontalmente com 4 parafusos em cada placa. Ao todo, foram construídos 12 modelos que foram então submetidos a uma carga vertical linear na região de incisivos centrais em incrementos de 50N até o limite máximo de 500N. Os resultados demonstraram que os avanços de 12mm estão associados a maiores tensões nas corticais ósseas e no material se síntese. Também foi possível concluir que os modelos fixados com duas placas apresentaram valores menores de tensão no material de síntese em comparação aos modelos fixados com uma placa. A mudança do plano mandibular no sentido anti-horário nos avanços de 6 mm, fixados com 1 ou 2 placas, aumentou a tensão no material de síntese, o que não ocorreu nos avanços de 12 mm. Esses resultados podem auxiliar os cirurgiões na tomada de decisão clínica diária (AU).

The aim of the present paper was to evaluate, via a finite element analysis, the tensions on the cortical bone and the plating system, as to evaluate mandibular resistance after the sagittal split ramus osteotomy with different mandibular advancements and mandibular plane movements. 3D mandibular models were obtained and a 6mm and 12mm advancement was planned associated with linear, clockwise or counter clockwise rotation of the mandibular plane angle. Each model was then fixed with one or two plates of the 2.0mm system and held with 4 monocortical screws at each side. A total of 12 models were built and they were subjected to a vertical load in the incisors region ranging from 50N to 500N in 50N increments. Results have shown that the 12mm advancement was associated with a higher tension in the cortical bone and plate surface. It was also concluded that the models fixed with 2 plates presented lower values of tension on the plates in comparison with the models fixed with a single plate. Counter clockwise rotation of the mandibular plane angle in the 6mm advancement, fixed with 1 or 2 plates, brought more tension to the plates, which did not occur in the 12mm advancements. These results may aid surgeons with decision making on a daily basis (AU).

Mechanical evaluation of the use of conventional and locking miniplate/screw systems used in sagittal split ramus osteotomy.

OBJECTIVES: The aim of this study was to compare the mechanical resistance of four different osteosyntheses modeled in two different sagittal split ramus osteotomy (SSRO) designs and to determine the linear loading in a universal testing machine. MATERIALS AND METHODS: An in vitro experiment was conducted with 40 polyurethane hemimandibles. The samples were divided into two groups based on osteotomy design; Group I, right angles between osteotomies and Group II, no right angles between osteotomies. In each group, the hemimandibles were distributed into four subgroups according to the osteosynthesis method, using one 4-hole 2.0 mm conventional or locking plate, with or without one bicortical screw with a length of 12.0 mm (hybrid technique). Each subgroup contained five samples and was subjected to a linear loading test in a universal testing machine. RESULTS: The peak load and peak displacement were compared for statistical significance using PASW Statistics 18.0 (IBM Co., USA). In general, there was no difference between the peak load and peak displacement related to osteotomy design. However, when the subgroups were compared, the osteotomy without right angles offered higher mechanical resistance when one conventional or locking 2.0 mm plate was used. One locking plate with one bicortical screw showed higher mechanical resistance (162.72±42.55 N), and these results were statistically significantly compared to one conventional plate with monocortical screws (P=0.016) and one locking plate with monocortical screws (P=0.012). The difference in peak displacement was not statistically significant based on osteotomy design or internal fixation system configuration. CONCLUSION: The placement of one bicortical screw in the distal region promoted better stabilization of SSRO. The osteotomy design did not influence the mechanical behavior of SSRO when the hybrid technique was applied.

Mechanical evaluation of six techniques for stable fixation of the sagittal split osteotomy after counterclockwise mandibular advancement.

We have evaluated the resistance to displacement of six stable methods of fixation of a sagittal split ramus osteotomy (SSRO) in the mandibular advancement with counterclockwise rotation. We tested 60 synthetic hemimandibles in six groups of 10 each: Group I - fixation with a straight four-hole 2.0mm miniplate; Group II - a straight six-hole 2.0mm miniplate; Group III - two straight 2.0mm four-hole miniplates; Group IV - an eight-hole 2.0mm (grid plate); Group V - a 2.0mm four-hole straight miniplate and 2.0×12mm bicortical screw; and Group VI - a straight four-hole 2.0mm locking miniplate. We applied a linear force in the region between the canine and the first premolar using a universal testing machine (EMIC- DL2000) with a loading cell of 10 KN. The loads at 1, 3, and 5mm displacement were recorded (N) and the data transmitted from the load cell to a computer. Results were analysed using analysis of variance (ANOVA) (p<0.001) and the Tukey post-test for comparison of the significance of the differences between the groups. For the three degrees of displacement, fixation with two straight 2.0mm plates and with the grid plate gave higher load values.

Analysis of Mandibular Test Specimens Used to Assess a Bone Fixation System.

The aim of this study was to assess through biomechanical testing if different synthetic materials used to fabricate test specimens have a different biomechanical behavior in comparison with other materials when simulating in vitro load resistance of a fixation method established for sagittal split ramus osteotomy (SSRO). Thirty synthetic and standardized human hemimandible replicas with SSRO were divided into three groups of 10 samples each. Group A-ABS plastic; Group B-polyamide; and Group C-polyurethane. These were fixated with three bicortical position screws (16 mm in length, 2.0-mm system) in an inverted l pattern using perforation guide and 5-mm advancement. Each sample was submitted to linear vertical load, and load strength values were recorded at 1, 3, 5, 7, and 10 mm of displacement. The means and standard deviation were compared using the analysis of variance (p < 0.05) and the Tukey test. A tendency for lower values was observed in Group B in comparison with Groups A and C. At 3 and 5 mm of displacement, a difference between Groups A and C was found in comparison with Group B (p < 0.05). At 7 and 10 mm of displacement, a difference was found among the three groups, in which Group C showed the highest values and Group B the lowest (p < 0.05). Taking into consideration the results obtained and the behavior of each material used as a substrate, significant differences occurred among the materials when compared among them.

An in vitro comparison between two different designs of sagittal split ramus osteotomy.

OBJECTIVES: To evaluate the influence of the type of osteotomy in the inferior aspect of the mandible on the mechanical performance. MATERIALS AND METHODS: The study was performed on 20 polyurethane hemimandibles. A sagittal split ramus osteotomy (SSRO) was designed in 10 hemimandibles (group 1) with a vertical osteotomy in the buccal side (second molar level) and final osteotomy was performed horizontally on the lingual aspect, while the mandible body osteotomy was finalized as a straight osteotomy in the basilar area, perpendicular to the body. For group 2, the same osteotomy technique was used, but an oblique osteotomy was done in the basilar aspect of the mandibular body, forming continuity with the sagittal cut in the basilar area. Using a surgical guide, osteosynthesis was performed with bicortical screws using an inverted L scheme. In both groups vertical compression tests were performed with a linear load of 1 mm/min on the central fossa of the first molar and tests were done with models made from photoelastic resin. Data were analyzed using Student's t-test, establishing a statistical significance when P <0.05. RESULTS: A statistical difference was not observed in the maximum displacements obtained in the two osteotomies (P <0.05). In the extensiometric analysis, statistically significant differences were identified only in the middle screw of the fixation. The photoelastic resin models showed force dissipation towards the inferior aspect of the mandible in both SSRO models. CONCLUSION: We found that osteotomy of the inferior aspect did not influence the mechanical performance for osteosynthesis with an inverted L system.

Aparelho Herbst X osteotomia sagital mandibular bilateral no tratamento do Padrão II, Classe II, divisão 1 em adultos - relato de casos / Herbst appliance X mandibular sagittal split osteotomy in adult Class II, division 1 treatment - case reports

Indivíduos adultos de Padrão II com deficiência mandibular e má oclusão de Classe II, divisão 1 possuem duas opções de tratamento: preparo ortodôntico com vistas à cirurgia de avanço mandibular ou aparelhos protratores mandibulares. O objetivo deste estudo foi analisar os efeitos de duas modalidades terapêuticas no tratamento da má oclusão de Classe II com deficiência mandibular. Dois indivíduos distintos com má oclusão de Classe II, divisão 1 e deficiência mandibular sagital foram tratados após o surto de crescimento. O primeiro indivíduo utilizou o aparelho Herbst como opção terapêutica e o outro foi tratado com osteotomia mandibular sagital bilateral. Foram avaliados os resultados cefalométricos, oclusão e face desses indivíduos. A correção da Classe II para uma oclusão normal tratada com sobressaliência horizontal e vertical corretas ocorreu tanto no caso tratado com aparelho Herbst quanto no associado à cirurgia de avanço mandibular. Assim, conclui-se que o aparelho Herbst pode ser uma alternativa para correção da má oclusão em casos limítrofes do Padrão II deficiência mandibular, Classe II, divisão 1, em adultos.

Two treatment options are available for adult patients with skeletal Class II malocclusion caused by mandibular deficiency: combined mandibular advancement surgery and orthodontic treatment or mandibular advancement appliance. This study aimed to analyze the effects of two therapeutic modalities of Class II malocclusion treatment with mandibular deficiency. Two distinct individuals with Class II malocclusion division 1 and mandibular deficiency were treated after growth spurt. The first individual used the Herbst appliance as a therapeutic option and the second individual was treated with bilateral sagittal osteotomy. The cephalometric, occlusion and face results were evaluated for both individuals. Correction of Class II malocclusion was observed on both Herbst and surgery patients resulting on a normal occlusal relationship with normal overjet and overbite. Therefore it was concluded that Herbst appliance can be used to treat borderline skeletal Class II in adult patients.

Evaluación de la anatomía mandibular relacionada con la osteotomía sagital de la rama / Evaluation of mandibular anatomy related to sagittal split ramus osteotomy

La osteotomía sagital de la rama mandibular (SSRO) es una de las técnicas quirúrgicas más frecuentes para corregir las deformidades de la mandíbula. Con el fin de prevenir problemas anatómicos y quirúrgicos, los cirujanos requieren una mayor investigación sobre las estructuras anatómicas relacionadas con la SSRO. El objetivo de este estudio fue investigar las posiciones de la antilingula (AL), la entrada al nervio alveolar inferior (NAI) en la mandíbula y otros puntos de referencia anatómicos en relación con la língula mandibular (L). Fueron estudiadas 70 hemimandíbulas secas. La AL y los demás puntos de referencia y, la posición correspondiente de la L se marcaron en la cara medial y lateral de la rama mandibular respectivamente. Fueron medidas las distancias de la AL, NAI y L en los planos anterior-posterior y superior-inferior con un caliper, y se estableció su relación geométrica. Los resultados mostraron que la AL era perceptible en el 100 por ciento de las caras laterales mandibulares. La mayoría de las ALs se encuentran anterior a la L, con una distancia media de 0,66+/-2,43mm y 0,92+/-2,56 mm y, 4,23+/-2,97 mm y 3,62 +/- 3,14 mm superior a ella (lados derecho-izquierdo respectivamente) (ambos con un valor de p <0,001). Valores similares se observaron en relación con el NAI. No se encontraron diferencias significativas entre los lados derecho e izquierdo, para la mayoría de los parámetros. Los parámetros estudiados pueden asistir a los cirujanos maxilofaciales a determinar la proximidad anatómica del NAI, y reducir al mínimo el riesgo de dañar el nervio y vasos sanguíneos. No recomendamos el uso de la AL como única referencia anatómica cuando se realiza un procedimiento de SSRO.

Sagittal split ramus osteotomy (SSRO) of the mandible is one of the most common surgical techniques to correct mandibular deformities. In order to prevent many surgical anatomical problems, surgeons have found that further investigation of the anatomical structures related to SSRO is needed. This study aims to investigate positions of the antilingula (AL), inferior alveolar nerve (IAN) and other anatomic landmarks in relation to the lingula of dried mandibles. 70 Chilean dried hemimandibles were studied. The AL, others landmarks and the corresponding position of the L were marked on the internal and external aspect of the mandibular ramus respectively. The distances from the AL, IAN and L were measured in the anterior­posterior and the superior­inferior planes using a digital caliper and geometric relationship was established. The results showed the AL was discernible in 100 percent of lateral mandibular rami studied. The most of the AL was found anteriorly to the L with a mean distance of 0.66+/-2.43mm and 0.92+/-2.56mm, and 4.23 +/- 2.97mm and 3.62+/-3.14mm superiorly (right-left sides respectively) (both with p value <0.001). Similar values were seen in relation with IAN. No significant differences were found between the right and left sides, for the majority of parameters. The studied parameters will assist clinicians to determine the anatomical proximity to the IAN, and, minimize the risk of damaging nerver and vessels. We do not recommend the use of antilingula as only anatomical landmark when performing a SSRO procedure.