SAGITTAL SPLIT RAMUS OSTEOTOMY

ANATOMIC CONSIDERATIONS IN

REVIEW OF SURGICAL TECHNIQUES

Perthes ( 1924) 1st surgeon to perform a saggital osteotomy of the mandibular ramus

Trauner & Obwegeser (1957)

saggital splitting of the mandibular ramus

transoral approach

Kazanjian & Converse (1959)

beveling the horizantal osteotomy - extra oral aproach

Schuchardts (1961)

greater step & overlap of the repositioned segments

Dal Pont (1961)

changed the lateral cortical osteotomy from horizantal to vertical adjacent to3rd molar region
- Increasing the bony contact
- masseter & medial pterygoid to remain in preoperative position

Hunsuck (1968)

terminated the medial cortical osteotomy posterior to mandibular foramen

SAGGITAL SPLIT RAMUS OSTEOTOMY

Easily adaptable to correct a wide variety of mandibular anamolies. Transoral approach simplifies surgical technique. Eliminates external scar. No risk to facial nerve. Produces a large area of bone contact. Eliminates need for bone grafting.

KNOWLEDGE OF ANATOMY
Paramount to carry out SSRO
Safely
Efficiently With confidence

POSITION OF MANDIBULAR FORAMEN & CANAL

4.9MM (Lingula to occlusal plane)

8.3MM (Lingula to foramen)

NEUROVASCULAR BUNDLE ENTERS FORAMEN BELOW OCCLUSAL PLANE

MEAN AP WIDTH OF RAMUS

30.5mm
19.7mm

Mandibular foramen is 2/3rd of the ramus from the anterior border

DEPT OF SIGMOID NOTCH & FORAMEN

21.8mm

22.4mm

ANATOMIC CONSIDERATION IN RELATION TO VERTICAL CUT

Distance of mandibular canal to inferior border

Anterior to mandibular foramen - 18.5mm Third molar region 1st & 2nd molar region - 10.5mm - 7.4mm

MEDIOLATERAL POSITION OF MANDIBULAR CANAL

Horizontal medullary width :

1st molar region 4.05mm 2nd molar region 3.61mm 3rd molar region 1.72mm

POSITION OF LATERAL CORTICAL CUT

In the 1st & 2nd molar region. In the 3rd molar region.

ANATMOIC CONSIERATION IN RELATION TO ADJOINING CUT

Superior edge of the mandibular canal to the cortical surface :

2nd molar region 6.9mm 3rd molar region 10.9m Anterior border of ramus 13.9mm

ANATOMIC CONSIDERATION IN RELATION TO HORIZANTAL CUT

POSITION OF CORTICAL FUSION

Anterior ramus
notch.

near the depth of sigmoid

Mid to Posterior ramus halfway from lingula

to sigmoid notch.
Cortices fuse at progressive levels above the tip of the lingula

Medial osteotomy should be placed through the superior aspect of lingula to facilitate a less problematic split and should stop at lingual fossa About 18m beyond which the cortices fuse

IDENTIFYING THE LINGULA

Visualization of the lingula can be improved by reduction of a convex internal oblique ridge using a large trimming bone

Coronoid notch is at most 1mm below the lingula.

So if lingula is not visualized the coronoid notch would be an acceptable land mark - 1mm above the coronoid notch

OUTER CORTICAL PLATE THICKNESS (guide to rigid internal fixation)

Rigid internal fixation Michelet et al 1973 miniplate fixation Spiessl 1976 lag screw fixation
Advantages of RIF Prevents relapse Increased comfort to pts Early jaw mobilisation Return to function

OUTER CORTICAL PLATE THICKNESS (guide to rigid internal fixation)

Cortical thickness in the retromolar region

THICKNESS OF BUCCAL CORTICAL PLATE

Ideal position of rigid internal fixation - superior border or external oblique ridge.
Also helps in tension banding & prevents tendency for post-op increase in gonial angle.

THE BAD SPLIT

FRACTURE OF THE BUCCAL CORTEX OF THE BODY OF THE MANDIBLE Early diagnosis

FRACTURE OF THE BUCCAL CORTEX OF THE BODY OF THE MANDIBLE Late diagnosis

Fracture of the buccal cortex involving the body & ramus of the mandible Early diagnosis Late diagnosis

Fracture of the vertical osteotomy on the medial aspect of the mandibular ramus anterior to the inferior alveolar foramen Early diagnosis Late diagnosis

Fracture of the retromolar segment of the mandible distal to the 2nd molar Early diagnosis Late diagnosis

CONDYLAR SAG
CENTARL CONDYLAR SAG
DURING MAXILLOMANDIBULAR FIXATION AFTER REMOVAL OF MAXILLOMANDIBULAR FIXATION

PERIPHERAL CONDYLAR SAG

DURING MAXILLOMANDIBULAR FIXATION AFTER REMOVAL OF MAXILLOMANDIBULAR FIXATION

PREVENTION OF CONDYLAR SAG