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Inverted-L Osteotomy

Indications
Small or large setbacks
Asymmetries
Mandibular
advancements
Ramus lengthening
Thin ramus mediolaterally
Severe decrease in
posterior mandibular
body height

Contraindications
Abnormal posterior
location of the mandibular
foramena
Mandibular advancement
without grafting

Advantages
Can correct mandibular prognathism or
asymmetries
Coronoid process and temporalis muscle
remain basically in originally position
Can setback mandible greater distance
Can lengthen ramus or advance the
mandible when used with bone or
synthetic bone for grafting
May be able to use rigid skeletal fixation

Disadvantages
Usually requires bone or synthetic bone
grafting for significant ramus lengthening
or mandibular advancement
Healing time may be increased compared
to other technique because of poor
approximation of the segments when
grafts are not used

INTRAORAL SURGICAL TECHNIQUE


The inverted-L osteotomy is a blend of the IVRO and
SSRO techniques
The medial exposure and dissection are done as for SSRO.
The nerve is identified as it enters the mandibular foramen
medially.
With the medial soft tissues protected, the horizontal
osteotomy is completed just superior to the foramen with
either a reciprocating saw or a Lindemann bur.
The bicortical horizontal osteotomy should be completed
first, as close as possible to the mandibular foramen to
minimize the chance of coronoid fracture, which would
convert the inverted L into an IVRO with coronoidotomy.
Exposure of the lateral ramus and completion of the inferior
vertical osteotomy are exactly the same as for the IVRO.

It is important to keep the medial osteotomy as close as possible to the mandibular


foramen to avoid creating a coronoid fracture.

Rigid fixation of the segments is performed with


the patient in MMF.
One or two percutaneous bone plates are used to
secure the segments.
As with SSRO, care in seating the condyle
properly is essential. The plate is secured initially
only to the condylar segment, where it can be
used as a lever arm to assist in condylar seating.
Then screws are placed in the distal segment to
maintain the gap.
Autogenous bone graft is then contoured to the
appropriate dimension and secured snugly in
position.

If a second bone plate is used, it is then adapted and


secured. Use of closed suction drains is strongly
recommended to prevent hematoma formation following
the soft tissue dissection and bone graft.
Depending on the quality of the rigid fixation, the patient
is maintained in MMF for 5 to 14 days after surgery.
Elastic traction is used to guide the occlusion and
resist soft tissue relapse for the next 4 to 5 weeks
while initial bone healing occurs.
If mandibular setback is performed, bony interference is
eliminated to achieve passive segment approximation
before placement of rigid fixation.
Wound closure and care after surgery are the same as
for IVRO or SSRO.