Vertical ramus osteotomy: an extraoral approach to the skull base

Numerous transmandibular approaches have been described for access to the distal internal carotid artery and to skull base lesions of the parapharyngeal space. The vertical ramus osteotomy can be performed with decreased morbidity, and provides several distinct advantages when compared to other approaches for these lesions. This is an extraoral approach, preventing oral contamination of the wound. It does not require the lip splitting incision often used in more anterior approaches, and provides better visibility than with transcondylar approaches. The osteotomy is readily repaired with rigid internal fixation using miniplates, without sacrifice of dentition. The vertical ramus osteotomy is made posterior to the inferior alveolar nerve, and allows for protection of the facial nerve with rotation of the proximal segment of the mandible. We discuss this technique and present our experience in four patients.