Minimally Invasive Surgery of the Mandible

The mandible is operated first in most cases, except when custom patient-specific implants for the Le Fort I osteotomy are used. When sagittal osteotomy is carried out, a proper cortex cut reaching the bone marrow of the sagittal osteotomy including lingual cortex, mandibular ramus and lateral oblique ridge of the body, and buccal cortex including the inferior basal border avoids a bad-split fracture. When chiseling, the osteotomes should not be inserted more than 5 mm in order to avoid inferior alveolar nerve damage. Separation of both segments is carried out under direct visualization of proper separation of the two segments and inferior alveolar nerve preservation. Interferences between the distal and proximal bony segments should be checked for proper condyle settlement. Proper seating of the condyles into the uppermost anterior part of the fossa should be ensured with a bidirectional maneuver. Rigid internal fixation using a hybrid technique (a mini-plate fixed with four monocortical screws and a retromolar bicortical screw) is recommended, since it provides enough stability while allowing proper condyle accommodation to the glenoid fossa. Finally, suspension of the platysma of the upper aspect of the submandibular space to the uppermost mandibular periosteum can be performed to improve the jawline contour.