Int. J. Oral Maxillofac. Surg.

2018; 47: 1316–1321

https://doi.org/10.1016/j.ijom.2018.05.013, available online at https://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Comparison of osseous healing S. Rokutanda1,2, S. Yamada3,

S. Yanamoto1, K. Omori1,
Y. Fujimura4, Y. Morita4,
H. Rokutanda4, H. Kohara4,
after sagittal split ramus A. Fujishita4, T. Nakamura4,
T. Yoshimi4, N. Yoshida4,
M. Umeda1
osteotomy and intraoral vertical 1
Department of Clinical Oral Oncology,
Nagasaki University Graduate School of
Biomedical Sciences, Nagasaki City,

ramus osteotomy Nagasaki, Japan; 2Department of Oral and

Maxillofacial Surgery, Juko Memorial
Nagasaki Hospital, Nagasaki City, Nagasaki,
Japan; 3Department of Dentistry and Oral
Surgery, Shinshu University School of
S. Rokutanda, S. Yamada, S. Yanamoto, K. Omori, Y. Fujimura, Y. Morita, H. Medicine, Matsumoto City, Nagano, Japan;
4
Rokutanda, H. Kohara, A. Fujishita, T. Nakamura, T. Yoshimi, N. Yoshida, M. Umeda: Department of Orthodontics and Dentofacial
Orthopaedics, Nagasaki University Graduate
Comparison of osseous healing after sagittal split ramus osteotomy and intraoral School of Biomedical Sciences, Nagasaki
vertical ramus osteotomy. Int. J. Oral Maxillofac. Surg. 2018; 47: 1316–1321. ã 2018 City, Nagasaki, Japan
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Abstract. The sagittal split ramus osteotomy (SSRO) is generally associated with
greater postoperative stability than the intraoral vertical ramus osteotomy (IVRO);
however, it entails a risk of inferior alveolar nerve damage. In contrast, IVRO has
the disadvantages of slow postoperative osseous healing and projection of the
antegonial notch, but inferior alveolar nerve damage is believed to be less likely.
The purposes of this study were to compare the osseous healing processes
associated with SSRO and IVRO and to investigate changes in mandibular width
after IVRO in 29 patients undergoing mandibular setback. On computed
Key words: facial changes; intraoral vertical
tomography images, osseous healing was similar in patients undergoing SSRO and
ramus osteotomy; osseous healing; sagittal
IVRO at 1 year after surgery. Projection of the antegonial notch occurred after split ramus osteotomy.
IVRO, but returned to the preoperative state within 1 year. The results of the study
indicate that IVRO is equivalent to SSRO with regard to both bone healing and Accepted for publication
morphological recovery of the mandible. Available online 26 May 2018

The sagittal split ramus osteotomy
(SSRO) is a common orthognathic surgi-
cal procedure for patients with skeletal
mandibular prognathism. This mandibular
setback procedure can secure an extensive
contact area between the split segments1,2.
However, SSRO is also associated with a
high rate of mandibular nerve
paresthesia3–5.
In contrast, the intraoral vertical ramus
osteotomy (IVRO) is believed to have
several advantages, as it is a comparative-
ly easy surgical procedure and is associat-
ed with a low rate of mandibular nerve
paresthesia6. However, because the split
segments are not fixed, the contact area
between them is small, which makes
IVRO inferior to SSRO in terms of post-
operative stability and the postoperative
healing process and duration. Moreover,
problems involving protrusion of the prox-
imal segment can cause the mandibular
angle to protrude towards the buccal side.
Many studies have examined temporal
changes in the morphology of mandibular
ramus osteotomy sites during healing after
SSRO and IVRO1–3,7,8. However, there

0901-5027/01001316 + 06 ã 2018 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

have been no reports on how the healing
process differs depending on the surgical
procedure, although it is widely believed
that postoperative healing is better after
SSRO due to the large contact area be-
tween the segments. Previously, Al-Mor-
aissi and Ellis performed a meta-analysis
comparing mandibular setback after
SSRO and IVRO for skeletal mandibular
prognathism9. They reported no statisti-
cally significant difference between the
two procedures in terms of the horizontal
stability of the mandibular setback. For
vertical stability, they observed a tendency
towards retrogression with IVRO, al-
though the difference was not significant.
However, they did not explore differences
in the duration of osseous healing.
It is extremely important to investigate
differences in the duration of osseous
healing after different surgical procedures
and to determine whether the smaller con-
tact area between the segments in IVRO—
which is considered to be problematic—
delays osseous healing, and if so to what
extent. This knowledge will help the sur-
geon to select surgical procedures that
reduce the incidence of adverse events
such as inferior alveolar nerve hypoesthe-
sia.
Hence, the present study was performed
to compare the osseous healing processes
after SSRO and IVRO and to investigate
the changes in the distance between the
left and right mandibular angles due to
protrusion of the proximal segment after
IVRO.
Fig. 1. Categorization of callus formation. Phase 1: no callus-like tissue in any slices. Phase 2:
connectivity between segments due to callus-like tissue in some slices. Phase 3: connectivity
between segments due to callus-like tissue in all slices.
Osseous healing after ramus osteotomy
Materials and methods
This retrospective study was approved by
the Ethics Committee for Hospital and
Clinical Research of Nagasaki University
Graduate School of Biomedical Sciences.
Participants
The participants were patients diagnosed
with skeletal mandibular prognathism
from July 2012 to August 2016 at the
Department of Clinical Oral Oncology,
Unit of Translational Medicine, Nagasaki
University Graduate School of Biomedi-
cal Sciences. Twenty-nine patients who
had undergone only mandibular setback
with SSRO or IVRO were selected (19
female, 10 male; 58 sides). All partici-
pants provided informed consent, and all
procedures were performed by the same
surgeon. Patients who had also undergone
maxillary surgery were excluded. SSRO
was performed from July 2012 to Septem-
ber 2012; thereafter, until August 2016, all
patients underwent IVRO. Factors such as
the presence or absence of temporoman-
dibular symptoms were not considered
when selecting the surgical procedure.
Computed tomography (CT) was per-
formed before surgery, immediately after
surgery to check for complications, and at
1, 3, 6, and 12 months postoperative
(Aquilion 64; Canon Medical Systems
Corporation, Tochigi, Japan). CT was per-
formed with the mouth closed and with a
slice thickness of 3 mm.
1317
Assessment methods
The first assessment was the comparison
of callus formation at the ramus osteotomy
sites between patients who underwent
SSRO and those who underwent IVRO.
Two parallel slices were used as refer-
ences: a slice passing through the mandib-
ular foramen parallel to the occlusal plane
(upper slice) and a slice passing through
the mandibular first and second molar
furcations (lower slice). All of the slices
between these two planes were analyzed.
With regard to healing of the ramus osteot-
omy site, phase 1 was when a gap between
the sections was observed in all CT slices;
phase 2 was when the sections exhibited
connectivity as callus-like CT images in
some slices; and phase 3 was when callus-
like or normal bone-like CT images were
observed in all regions of the osteotomy
site in all slices (Fig. 1).
The second assessment was the change
in distance between the left and right
mandibular angles after IVRO. During
IVRO, the proximal section is placed lat-
eral to the distal section when the mandi-
ble is moved posteriorly. This gives rise to
a concern that the width of the frontal
aspect (front of the face) will increase
after the operation. Therefore, changes
in the distances between the left and right
mandibular angles before and after IVRO
were evaluated. A line was drawn passing
through the centre of the foramen magnum
from the mental spine on three-dimension-
al (3D) reconstructed CT images. Lines
were also drawn perpendicular to this from
the bottoms of the proximal segments on
their buccal sides, and changes in these
distances were measured (Fig. 2). To re-
duce protrusion of the mandibular angle
after IVRO, bone milling is sometimes
performed on the surgical margins of
the proximal and distal segments near
the mandibular notch and on the bottom
of the proximal segment. However, this
treatment was not performed in any of the
patients in this study.
The third assessment was the positional
relationship between the proximal and
distal segments after IVRO. When IVRO
was performed, the proximal segment was
guided to a position lateral to the distal
segment in all patients. However, depend-
ing on the case, the positional relationship
is not always maintained after IVRO. This
may have been relevant to the results of
the current study. Therefore, positional
relationships between the proximal and
distal segments after IVRO were exam-
ined.
The fourth assessment was postopera-
tive mandibular nerve hypoesthesia after
1318 Rokutanda et al.

Results
The subjects were aged 17 to 54 years
(mean 26.7 years) at the time of surgery.
The setback range was 2.0 to 9.0 mm
(mean 6.5 mm) with SSRO and 0 to
13.0 mm (mean 6.8 mm) with IVRO (Ta-
ble 1).

Osseous healing process between the

segments at the osteotomy site
In the SSRO group, gaps or contact between
the margins was observed between all areas
of the proximal and distal segments imme-
diately after surgery. At 1 month postoper-
ative, some patients exhibited a small
amount of callus-like tissue. At 3 months
postoperative, callus-like tissue appeared
from the spongy bone of the margins of
Fig. 2. Method of measuring changes in mandibular width. A line was drawn passing through both segments, some connectivity was ob-
the centre of the foramen magnum from the mental spine. Then, lines were drawn perpendicular served between the segments, and the gaps
to this from the bottom of the proximal segments on their buccal sides, and changes in these between the segments had shrunk. At 6
distances were measured. months postoperative, callus-like tissue
had expanded towards the centre of the
Table 1. Demographic and clinical characteristics of the study patients. gaps, and connectivity between the seg-
Setback Proximal segment ments was observed in almost all areas.
amount with respect to distal At 1 year postoperative, spongy bone-like
(mm) segment after IVRO trabeculae were observed in the spongy
Case Sex Age at time of operation (years) Surgical method
bone areas of the margins of both segments,
Right Left Left side Right side
and cortical bone-like tissue was observed
1 M 42 SSRO 8.0 8.0 – – in the cortical bone areas.
2 F 21 SSRO 8.0 5.0 – – In the IVRO group, protrusion of the
3 F 22 SSRO 6.0 3.5 – –
proximal segment due to contact between
4 F 23 SSRO 7.0 9.0 – –
5 F 18 SSRO 3.0 6.0 – – the tops of the segments at the mandibular
6 F 36 SSRO 8.0 7.0 – – notch was observed immediately after the
7 F 22 SSRO 9.0 9.0 – – operation. At 1 month postoperative, the
8 F 21 SSRO 2.0 5.0 – – protrusion had decreased compared to that
9 M 45 IVRO 5.0 5.0 Lateral Posterior immediately after surgery, and many
10 M 19 IVRO 7.5 9.5 Lateral Lateral patients exhibited a small amount of cal-
11 M 23 IVRO 5.0 5.0 Posterior Lateral lus-like tissue due to overlapping of the
12 F 26 IVRO 10.5 6.5 Lateral Lateral proximal and distal segments. At 3 months
13 F 24 IVRO 3.0 3.0 Medial Medial postoperative, the callus-like tissue had
14 F 21 IVRO 7.0 4.0 Lateral Lateral
15 M 21 IVRO 9.0 6.0 Posterior Lateral
expanded, with gaps narrowing or almost
16 F 28 IVRO 12.0 12.0 Lateral Lateral complete contact between the segments.
17 M 20 IVRO 11.0 11.0 Lateral Lateral In some cases, the gaps were filled with
18 F 20 IVRO 8.0 8.0 Medial Lateral callus-like tissue. At 6 months postopera-
19 F 17 IVRO 4.0 3.0 Lateral Lateral tive, most of the gaps were filled with
20 M 47 IVRO 6.5 6.5 Lateral Lateral callus-like tissue. At 1 year postoperative,
21 F 18 IVRO 13.0 13.0 Posterior Lateral the callus-like tissue had acquired a den-
22 M 17 IVRO 6.0 6.0 Posterior Lateral sity similar to that of connective bone
23 M 42 IVRO 1.0 3.0 Posterior Posterior tissue, although in many cases the cortical
24 F 19 IVRO 9.0 9.0 Lateral Lateral
bone between the segments had not been
25 F 18 IVRO 8.0 10.0 Lateral Lateral
26 M 54 IVRO 6.0 2.0 Lateral Lateral completely replaced with spongy bone.
27 F 18 IVRO 7.5 7.5 Lateral Lateral Thus, callus formation in both the
28 F 24 IVRO 3.0 0 Lateral Posterior SSRO group and the IVRO group was
29 F 50 IVRO 7.0 5.0 Lateral Posterior in the phase 1 state (no connectivity be-
F, female; IVRO, intraoral vertical ramus osteotomy; M, male; SSRO, sagittal split ramus tween segments) immediately after sur-
osteotomy. gery. At 1 month postoperative, both
groups were in phase 2, in which a small
SSRO and IVRO. Postoperative mandibu- of the time9. Mandibular nerve hypoesthe- amount of callus-like tissue was observed
lar nerve hypoesthesia is almost never as- sia was assessed at the same time as CT was at the margins of the segments, and most
sociated with IVRO, but reportedly occurs performed, to investigate whether hypoal- patients exhibited some bone connectivi-
in conjunction with SSRO more than 90% gesia was associated with SSRO. ty. At 3 months postoperative, the extent
 Osseous healing after ramus osteotomy 1319

Table 2. Osseous healing in sagittal split ramus osteotomy and intraoral vertical ramus osteotomy groups.
Osseous healing Immediately 1 month 3 months 6 months 1 year
phase after surgery postoperative postoperative postoperative postoperative
SSRO Phase 1 (%) 100 – – – –
Phase 2 – 100 100 – –
Phase 3 – – – 100 100
IVRO Phase 1 (%) 100 12 – – –
Phase 2 – 88 90 12 –
Phase 3 – – 10 88 100
SSRO, sagittal split ramus osteotomy; IVRO, intraoral vertical ramus osteotomy.

of partial connectivity between the seg-
ments had increased in both groups.
While most patients were still in the
phase 2 state, some patients in the IVRO
group had reached phase 3. At 6 months
postoperative, patients in both groups
were in phase 3, in which connectivity
due to callus-like tissue was observed
between the segments, although some
patients in the IVRO group who exhibited
large gaps due to protrusion of the proxi-
mal segments were still in phase 2. At
1 year postoperative, all patients in both
groups were in phase 3. These results
indicate that the duration of osseous heal-
ing did not differ between the SSRO and
IVRO groups (Table 2).
Positional relationships and changes in
mandibular width after surgery in the
IVRO group
When IVRO was performed, the proximal
segment was guided to a position lateral to
the distal segment in all patients. In 30 of
the 42 sides (72%), the segment remained
lateral in position, while it moved to a
posterior position in nine sides (21%) and
to a medial position in three sides (7%).
The distance from the bottom of the
proximal segment in each group to a line
passing through the centre of the foramen
magnum and the mental spine was mea-
sured. Data for the difference in distance
(mean  standard deviation values in
millimetres) are presented in Fig. 3,
along with the results of the Mann–Whit-
ney U-test. In all cases, the unilateral
distance immediately after surgery was
greater than the preoperative measure-
ment (difference 4.7  4.3 mm). This
difference reduced over time, and the
difference was 0.5  3.0 mm at 1 year
postoperative.

Fig. 3. Changes in the distance from the bottom of the proximal segment to the midline. Difference in the distance from the bottom of the ramus to
the midline compared to that before surgery, and the results of the Mann–Whitney U-test: (A) all cases (n = 42); (B) cases in which the proximal
segment remained positioned laterally (n = 30); (C) cases in which the proximal segment was positioned posteriorly (n = 9); (D) cases in which the
proximal segment was positioned medially (n = 3).
1320 Rokutanda et al.
When the proximal segment was posi-
tioned laterally, the unilateral distance
immediately after surgery was greater than
the preoperative measurement by
5.5  3.9 mm. This difference reduced
over time, and the mean was
1.0  2.9 mm at 1 year postoperative.
When the proximal segment was posi-
tioned posteriorly, the unilateral distance
immediately after surgery was greater than
the preoperative measurement by
4.3  2.1 mm. The difference reduced
over time, and the mean was
0.3  1.0 mm at 1 year postoperative.
When the proximal segment was posi-
tioned medially, the unilateral distance
immediately after surgery was less than
the preoperative measurement by a mean
of -4.2  1.7 mm. This difference de-
creased over time, and the mean was
-8.3  2.2 mm at 6 months postoperative.
In other words, at 6 months after surgery,
the bottom of the proximal segment was a
mean distance of 8.3 mm closer to a line
connecting the centre of the foramen mag-
num and the mental spine than it was
before surgery, and the left–right distance
between the mandibular angles had de-
creased by a mean of 16.6 mm. Neverthe-
less, the anterior portions of the osteotomy
site had maintained their morphology, and
no changes to the face were observed.
The results of the Mann–Whitney U-test
showed that in all cases in which the
proximal segment was positioned laterally
or posteriorly, significant differences in
width were apparent up to 6 months after
surgery, but that there was no significant
difference in width at 1 year after surgery.
It was not viable to perform a statistical
analysis of the cases in which the proximal
segment was positioned medially, because
the number of cases was too small.
Postoperative mandibular nerve
hypoesthesia after SSRO and IVRO
In the current study, mandibular nerve
hypoesthesia was not observed immedi-
ately after surgery or later in the IVRO
group. However, in the SSRO group, four
of the eight patients exhibited mandibular
nerve hypoesthesia, which remained
1 year after surgery.
Discussion
Many studies have examined chronologi-
cal changes in the healing morphology of
mandibular ramus osteotomy sites follow-
ing SSRO and IVRO1–3,7. However, there
have been no reports on how the healing
process differs depending on the surgical
method utilized, although many believe
that postoperative healing is better after
SSRO due to the large contact area be-
tween the segments. It is extremely im-
portant to investigate differences in the
duration of osseous healing associated
with different surgical methods. In partic-
ular, it is important to determine whether
the small contact area between the seg-
ments in IVRO—which some see as prob-
lematic—delays osseous healing and to
what extent, and also to examine the de-
gree of aberrant elevation of the proximal
segments and how this changes. Such
research will help the surgeon to select
surgical methods that reduce the incidence
of adverse events such as inferior alveolar
nerve hypoesthesia.
In the current study, osseous healing
processes after SSRO and IVRO were
compared and found to be largely similar.
At 6 months postoperative, callus-like tis-
sue had filled the gaps between the seg-
ments in all patients in the SSRO group
and most of those in the IVRO group. At
1 year postoperative, the segments were
connected by cortical bone-like tissue in
both groups. For elderly patients, osseous
healing was slightly slower in the IVRO
group than in the SSRO group, while for
younger patients, healing tended to be
faster in the IVRO group. In any case,
the results indicate that the duration of
osseous healing does not differ substan-
tially between SSRO and IVRO.
Post-IVRO protrusion of the mandibular
angle due to protrusion of the proximal
segment is considered one of the major
problems associated with IVRO. Jung
et al. examined changes in mandibular
width after IVRO10. While they observed
significant differences in cephalometric
radiographs during the first postoperative
year, they did not observe any significant
differences in soft tissue at 3 months post-
operative. They suggested that mandibular
angle protrusion after IVRO should not be
seen as a problem. However, they used
cephalometric radiographs to evaluate bone
changes. Overlap in radiographs is thought
to make it difficult to accurately measure
position. Further, Jung et al. used regular
frontal photographs (photographs of the
front of the face) to evaluate changes in
the width of the soft tissue10, which also
raises questions about accuracy. In the pres-
ent study, radiographic CT images were
used to measure changes in the left–right
width of the mandibular angles before and
after IVRO. The results showed that the
distance from the bottom of the proximal
segment to the midline was approximately
the same 1 year postoperative as it was
before the surgery. This indicates that while
a slight increase in width may persist, there
is no need to consider how the face may be
affected by mandibular angle protrusion
due to protrusion of the proximal segments.
Postoperative mandibular nerve
hypoesthesia is likely to occur at a high
rate in SSRO, as previously reported,
whereas it did not occur in IVRO in the
current study. Thus, the risk of mandibular
nerve hypoesthesia should be given care-
ful consideration when deciding between
IVRO and SSRO. Moreover, either SSRO
or IVRO can be considered in young
patients, because mandibular nerve
hypoesthesia can be expected to improve.
In elderly patients, however, performing
SSRO may cause mandibular nerve
hypoesthesia that persists for a long time
or even permanently, so IVRO is consid-
ered the better choice9. That said, there is
no established age threshold at which
IVRO should be prioritized, which is
something that warrants further study.
One limitation of the current study is
that it was only a preliminary investigation
involving a small number of patients. Ad-
ditional research using longer follow-up
periods and more cases is needed.
In conclusion, the results of the present
study suggest that the processes of osseous
healing associated with SSRO and IVRO
are similar. Furthermore, changes in the
width of the mandible after IVRO do not
appear to be significant enough to merit
consideration when deciding between the
two surgical procedures.
Funding
Research expenses were paid by the uni-
versity.
Competing interests
None.
Ethical approval
This study was approved by the Ethics
Committee for Hospital and Clinical Re-
search of Nagasaki University Graduate
School of Biomedical Sciences (approval
number 16020826).
Patient consent
Not required.
References
1. Jönsson E, Svartz K, Welander U. Sagittal
split technique. III. Postoperative rest con-
ditions. A radiographic follow-up study. Int J
Oral Surg 1979;8:89–94.

2. Shepherd JP. Changes in the mandibular
ramus following osteotomy—a long-term
review. Br J Oral Surg 1980;18:189–201.
3. Vijayaraghavan K, Richardson A, Whitlock
RI. Post-operative relapse following sagittal
split osteotomy. Br J Oral Surg
1974;12:63–9.
4. Walter Jr JM, Gregg JM. Analysis of post-
surgical neurologic alteration in the trigemi-
nal nerve. J Oral Surg 1979;37:410–4.
5. Zaytoun Jr HS, Phillips C, Terry BC. Long-
term neurosensory deficits following trans-
oral vertical ramus and sagittal split osteo-
tomies for mandibular prognathism. J Oral
Maxillofac Surg 1986;44:193–6.
6. Bell WH. . Surgical correction of dentofa-
cial deformities, First edition, Volume II.
Philadelphia: WB Saunders; 1980. p. 890–5.
Osseous healing after ramus osteotomy 1321
7. Komori E, Aigase K, Sugisaki M, Tanabe H. Address:
Cause of early skeletal relapse after mandib- Satoshi Rokutanda
ular setback. Am J Orthod Dentofac Orthop Department of Clinical Oral Oncology
1989;95:29–36. Nagasaki University Graduate School of Bio-
8. Reitzik M. Skeletal and dental changes after medical Sciences
surgical correction of mandibular progna- 1-7-1 Sakamoto
thism. J Oral Surg 1980;38:109–16. Nagasaki City
9. Al-Moraissi EA, Ellis 3rd E. Is there a
Nagasaki 852-8588
Japan
difference in stability or neurosensory func-
Tel: +81 95 819 7698; Fax: +81 95 819 7700
tion between bilateral sagittal split ramus
E-mail: satoshi6@nagasaki-u.ac.jp
osteotomy and intraoral vertical ramus
osteotomy for mandibular setback? J Oral
Maxillofac Surg 2015;73:1360–71.
10. Jung YS, Kim SY, Park SY, Choi YD, Park
HS. Changes of transverse mandibular width
after intraoral vertical ramus osteotomy.
Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2010;110:25–31.