Sixty Years of Innovation in Biomechanical Orthognathic Surgery: The State of the Art and Future Directions

Abstract

Craniofacial surgery is proposed and performed for a variety of reasons, ranging from congenital or acquired malformations to emotional disorders and parafunctions of the masticatory, respiratory, auditory, and visual systems. Surgery of the mandible and its orthostatic repositioning is the most common of these corrections of craniofacial anomalies. Throughout the history of these procedures, various techniques have been proposed and perfected, but always with a high rate of minor and major complications. The recurrence rate of mandibular malposition is high, as is the temporary loss of facial sensitivity and motor skills. These outcomes are often related to the choice of surgical technique rather than the skill of the surgeon, which is considered to be one of the most important factors in the final outcome. Surgical techniques involving direct manipulation of the vascular-nervous bundles, such as bilateral sagittal split osteotomy, clearly present the possibility of major or minor complications. In this study, an orthognathic surgical technique, performed by the same team for over 40 years and now available through a 20-year postoperative patient follow-up study, is presented with a literature review relating it to biomechanical concepts and bone remodeling to analyze the evolution of orthognathic surgery since it became common practice to correct maxillofacial discrepancies. In this review, we also present a case report in which previous orthodontic treatment prepared a patient for surgical correction of mandibular bone discrepancy without the need for combined maxillary and/or genioplasty, and we describe the most commonly used techniques today, as well as their advantages and disadvantages. The combination of established concepts together promotes favorable stability of mandibular osteotomies, functional anatomical positioning of the temporomandibular joint, reduced risk of injury to the mandibular vasculo-nervous bundle, and good aesthetics with positive patient acceptance and no relapse, thus these are the objectives for proposing innovative treatments that combine the technologies available today.

Biomechanics of a Novel 3D Mandibular Osteotomy Design

“…There have been no significant innovations since that time. Suggestions for improving established techniques are mostly based on professional experience and adapting surgical procedures to individual patient needs [14].…”

“…A favorable osteotomy can eliminate the need for plates and screws for bone fixation, with excellent short-and medium-term benefits for the patient and surgeon [14].…”

“…The method described here can also be used to train surgeons in maxillofacial surgery residencies to perform other conventional techniques, such as the bilateral sagittal split, the bilateral horizontal cut, the intraoral and/or extraoral vertical cut, and the extraoral inverted "L" osteotomy [14,21].…”