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British Journal of Oral and Maxillofacial Surgery 54 (2016) 638–642

High oblique sagittal split osteotomy of the mandible:

assessment of the positions of the mandibular condyles after
orthognathic surgery based on cone-beam tomography
R. Kuehle a , M. Berger a , D. Saure b , J. Hoffmann a , R. Seeberger a,∗
a Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
b Institute of Medical Biometrics and Informatics University of Heidelberg, Germany

Accepted 20 March 2016

Available online 3 April 2016

Abstract

High oblique sagittal split osteotomy is an orthognathic technique to move the mandible. Our aim was to evaluate changes in the position of the
condyle in the glenoid fossa and its angulation before and after high oblique sagittal split osteotomy (HSSO). Fifty patients (32 women and 18
men, mean age 26.3 (SD 7.4) years) had cone-beam computed tomographyic (CT) scans before operation, immediately postoperatively, and
before removal of the osteosynthesis nine months postoperatively. The images were analysed to look for changes in the sagittal, coronal, and
axial positions of the condyles. Twenty-four patients with class II malocclusion had a mean (SD) mandibular advancement of 6.51 (2.41) mm,
and 26 patients with class III malocclusion had a mean (SD) mandibular setback of 4.16 (2.77) mm. The joint space increased significantly
(p < 0.05) relative to baseline immediately postoperatively, but there was no significant increase at the nine-month follow-up. The changes in
position in the sagittal, coronal, and axial planes were comparable. Despite there being a short proximal joint-bearing segment, the results
indicate that this technique allows free-hand condylar positioning into the fossa safely without any clinically relevant dislocations.
© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Orthognathic surgery; Cranio-mandibular-joint; Bilateral sagittal split osteotomy; Mandibular condyle position

Introduction extensive bony contact was vital to achieve stable results.

There have been many innovations in orthognatic surgery
since Obwegeser introduced the bilateral sagittal split
osteotomy (BSSO) in 1959.1 Since then there have been sev-
eral modifications to the standard BSSO technique, including
those introduced by Hunsuck in 1968 and by Epker in 1977.2,3
To date, this method remains the most commonly used tech-
nique by most maxillofacial surgeons during orthognathic
surgery of the mandible, but it was developed at a time
when ridged osteosynthesis was unavailable, and therefore
∗ Corresponding author at: Department of Oral and Maxillofacial
Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120
Heidelberg, Germany.
E-mail address: robin.seeberger@me.com (R. Seeberger).
However, effects on the course of the inferior alveolar nerve
in the body of the mandible, and consequent numbness of the
lower lip and chin, were and remain a major drawback. The
reported risk of permanent numbness of the lower lip after
BSSO varies between 11.7% and 24%.4–7
The current availability of stable, ridged osteosynthesis
has led to the development of transoral short osteotomy tech-
niques that involve the ascending ramus of the mandible
and so avoid damage to the inferior alveolar nerve. The so-
called high sagittal split osteotomy (HSSO) was described
in this journal by Seeberger et al. in 2013.8 Compared
with the BSSO, injuries to the lower alveolar nerve are
less common with HSSO, the exposed bony surface is
smaller, and the osteotomy is completed without the risk of a
“bad split”.6,7,9

http://dx.doi.org/10.1016/j.bjoms.2016.03.017
0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 R. Kuehle et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 638–642
One major drawback of a short osteotomy, however,
involves concerns about bony healing and the condylar posi-
tion as a result of the reduced bony contact and poor handling
of the short proximal segment. We present a clinical evalu-
ation of HSSO, which we made by evaluating the position
of the proximal segment with cone-beam computed tomo-
graphy (CT). Condylar positioning devices were omitted to
simplify the technique, as the reliability of cone-beam CT
for the evaluation of condylar changes has been described
previously.10,11
Patients and Methods
Orthognathic operations were followed by examination of a
consecutive, retrospective, cone-beam CT analysis, as all our
orthognathic patients have routine cone-beam CT scans. We
included 32 women and 18 men, mean age 26.3 (SD 7.4) years
with skeletal class II (n = 24) or class III (n = 26) malocclu-
sion. All patients had HSSO to reposition the mandible during
bimaxillary surgery. Patients with a history of orthognathic
surgery to the jaws, trauma to the mandibular joint, degen-
erative joint disease, or large anatomical deviations were
excluded from the study. Data were collected after informed
consent had been obtained from all patients, together with
approval from the ethics committee of the University Hospital
of Heidelberg (S-131/2009).
Each HSSO was done as described by Seeberger et al.
in 2013 and as shown in Fig. 1.8,12 After positioning of
the distal (tooth-bearing) segment of the mandible into a
regular class I occlusion, the proximal (condyle bearing) seg-
ment was positioned free-hand without positioning devices.
Fig. 1. The high oblique sagittal split osteotomy starts above the entry of the
inferior alveolar nerve (orange) and ends within the ascending mandibular
ramus without touching the course of the nerve. The proximal joint-bearing
segments are shown in green.
639
Osteosynthesis was achieved using titanium miniplates
(Modus 2.0; Medartis, Basel, Switzerland) that were fixed
in place with four monocortical screws for each segment.
Orthodontic treatment was restarted 2–4 weeks postopera-
tively. The osteosynthesis material was removed nine months
postoperatively (250 (73) days).
Each patient had three cone-beam CT scans with a
Gallileos Comfort plus system (Sirona Dental Systems
GmbH, Bensheim, Germany). The specifications of the cone-
beam CT machine included a spherical volume with a
diameter of 15.4 cm, edge length of 0.125 mm for each voxel,
tube voltage of 98 kV, amperage of 3–6 mA tube current, and
scanning time of 14 seconds. The first scan was done two
weeks preoperatively, and during this scan the positions of
the patient’s occlusion and joint were fixed with an initial
centric splint. The second scan was done 2–4 days postop-
eratively to evaluate the results. During this scan patients were
fixed in the final occlusion splint. The third and final scan was
done nine months postoperatively and after completion of the
orthodontic treatment to control ossification before removal
of the osteosynthesis. All patients stood upright, and were
adjusted to the Frankfort horizontal plane (FH) during the
scans.
Cone-beam CT data were analysed using Galaxis 3-
dimensional imaging software (Sirona Dental Systems),
which allows various reconstructive options (for example,
multiplanar and 3-dimensional reconstructions). Cone-beam
CT scans were examined in a standard pattern beginning with
the definition of reference points and corresponding planes
to allow reliable measurements of the condylar angulations.
These points and planes included the most cranial points of
the glenoid fossa in the coronal plane, the FH in the sagittal
plane, and a multiplanar reconstructed line from the lower
nasal spine to the most anterior part of the foramen magnum
in the axial plane.
The angles of the proximal (condyle-bearing) segments
were measured in the sagittal, coronal, and axial planes. The
values of the three cone-beam CT images were then ana-
lysed for changes in the angulations from the preoperative
to the postoperative positions, and at the long-term follow
up. Fig. 2 shows the optimal measurements for the coronal
plane. The position of the head of the mandible was calcu-
lated according to the method modified by Kim et al.10 In
a central sagittal condylar reconstruction, the cranial, ante-
rior, and posterior joint spaces were measured as shown in
Fig. 3. The mandibular sagittal shifts were calculated using
a sagittal reconstruction of the ascending mandibular ramus.
Postoperatively, the clearly visible edges of the osteotomy
(Fig. 4) allowed exact measurements of the magnitudes of
mandibular advancements and setbacks.
Statistical analyses were made with the help of SPSS soft-
ware (version 16.0, SPSS Inc, Chicago, IL, USA). Given
the exploratory nature of this study, no adjustments were
made for multiple testing. Probabilities of less than 0.05 were
accepted as significant. An analysis of variance (ANOVA)
was used to detect differences in the primary endpoint of
640 R. Kuehle et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 638–642
Fig. 2. The method for measuring the angulations of the joints in the coronal
plane. Supporting lines are shown in yellow, and measurements of angula-
tions in orange.
Fig. 3. The condyle in a central sagittal reconstruction. The cranial, anterior,
and posterior joint spaces were measured as shown. (Yellow and orange
indicate supporting lines to measure the joint space in the three areas.).
Fig. 4. The edges of the osteotomy are clearly visible after mandibular set-
back (red arrows). This allows precise measurement of the movements. (Blue
and purple indicate supporting lines.).
the study. The significance of pairwise comparisons were
assessed the post hoc Tukey honest significant difference
(HSD) test.
Results
The mean (SD) sagittal mandibular advancement after HSSO
among the 24 patients with class II malocclusion was 6.51
(2.41) mm and the mean (SD) mandibular setback among
the 26 patients with class III malocclusion was 4.16 (2.77)
mm. According to the patients’ records, there were no pre-
vious signs of abnormalities of the temporomandibular joint
(TMJ). The patients had no signs of severe pain or TMJ-
related dysfunction.
In the class II group of patients with initial mandibular
retrognathia, the measured changes in joint space indicated
near-equal reductions on the left and right sides.
After a nine-month follow-up the joint spaces had
increased again in all dimensions, and in particular the ante-
rior space had changed little when the preoperative and
follow-up measurements were compared. In an ANOVA
to evaluate intergroup differences, there were significant
changes in the posterior right, cranial left, and posterior left
joint space changes (p < 0.05). Nevertheless, no significant
changes were found with the post hoc Tukey HSD test in
either the postoperative evaluation or the follow-up when
compared with the preoperative joint spaces. When multi-
planar changes in the positions of the joint were evaluated,
the angulation of the left sagittal plane was high, with a mean
(SD) of -4.0 (2.4)◦ . There were no significant differences
between the preoperative and postoperative or follow-up eval-
uations according to an ANOVA or post hoc Tukey HSD test.
The results for the class II patients are shown in Table 1.
Among the class III patients with initial mandibular
prognathia, measurements also indicated near-equal initial
reductions in the joint spaces on the left and right sides. After
a nine-month follow-up, the joint spaces were again approx-
imated in all dimensions, particularly the cranial dimension.
In class III patients, an ANOVA inter-group evaluation and
post hoc Tukey HSD test showed significant changes in the
posterior space during the postoperative evaluation. Never-
theless, there were no significant changes in the follow-up
post hoc test, which served as an expression of approxima-
tion and adjustment of the joint spaces in all dimensions. In an
evaluation of the multiplanar changes of positions of joints,
the angulation of the left sagittal plane was high with a mean
value of -2.9 (1.8)◦ . None of the values changed significantly
from the preoperative to the postoperative or follow-up eval-
uations according to either the ANOVA or the post hoc Tukey
HSD test. The results for the class III patients are shown in
Table 2.
When we described the assessed data, we noted a slight
increase in the joint space immediately postoperatively.
However, the follow-up values were similar to the primary
measurements. In addition there was a tendency towards
 R. Kuehle et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 638–642 641

Table 1
Changes in joint spaces and condylar angulation directly postoperatively and at a 9- month follow-up among patients in the class II group.
Variables Mean (SD) Mean (SD) p value Postoperative Follow-up
postoperative follow-up values (ANOVA) p value p value
values (Tukey HSD) (Tukey HSD)
Joint space anterior right (mm) -0.52 (0.31) 0.03 (0.31) 0.196 0.239 0.994
Joint space cranial right (mm) -0.29 (0.39) 0.78 (0.39) 0.023 0.736 0.119
Joint space posterior right (mm) -0.43 (0.37) 0.88 (0.37) 0.003 0.501 0.052
Joint space anterior left (mm) -0.49 (0.33) 0.03 (0.33) 0.209 0.292 0.995
Joint space cranial left (mm) -0.25 (0.37) 0.68 (0.37) 0.043 0.769 0.170
Joint space posterior left (mm) -0.33 (0.45) 0.78 (0.45) 0.049 0.743 0.194
Sagittal angulation right (◦ ) -3.1 (2.9) -1.4 (2.9) 0.572 0.542 0.877
Coronal angulation right (◦ ) -1.6 (1.6) -1.3 (1.6) 0.584 0.592 0.708
Axial angulation right (◦ ) -0.05 (2.2) -0.82 (2.2) 0.874 0.864 0.976
Sagittal angulation left (◦ ) -3.8 (2.4) -4.0 (2.4) 0.172 0.255 0.215
Coronal angulation left (◦ ) -0.95 (1.8) 0.03 (1.8) 0.822 0.855 1.00
Axial angulation left (◦ ) -1.3 (3.5) 0.44 (3.5) 0.937 0.933 0.992

Table 2
Changes in joint spaces and condylar angulation directly postoperatively and at a 9-month follow-up among patients in the class III group.
Variables Mean (SD) Mean (SD) p value Postoperative Follow-up
postoperative follow-up values (ANOVA) p value p value
values (Tukey HSD) (Tukey HSD)
Joint space anterior right (mm) -0.29 (0.25) 0.10 (0.25) 0.280 0.492 0.911
Joint space cranial right (mm) -0.85 (0.29) -0.01 (0.29) 0.006 0.013 0.999
Joint space posterior right (mm) -0.97 (0.25) .023 (0.25) 0.000 0.001 0.628
Joint space anterior left (mm) -0.52 (0.22) -0.07 (0.22) 0.044 0.055 0.949
Joint space cranial left (mm) -0.65 (0.22) 0.36 (0.22) 0.000 0.011 0.236
Joint space posterior left (mm) -0.52 (0.24) 0.19 (0.25) 0.012 0.084 0.707
Sagittal angulation right (◦ ) -2.9 (1.8) -2.3 (1.8) 0.243 0.248 0.417
Coronal angulation right (◦ ) 1.0 (1.6) 0.98 (1.6) 0.763 0.791 0.809
Axial angulation right (◦ ) -0.05 (2.2) -0.8 (2.2) 0.918 1.00 0.928
Sagittal angulation left (◦ ) -1.6 (1.8) -1.4 (1.8) 0.605 0.629 0.696
Coronal angulation left (◦ ) -0.53 (1.3) -1.1 (1.3) 0.700 0.915 0.676
Axial angulation left (◦ ) -1.1 (2.3) -2.0 (2.3) 0.679 0.884 0.654

condylar centralisation by the spatial approximations. We
found no significant differences in the evaluations of the
multiplanar condylar positions when we compared the pre-
operative and follow-up values. None of the three condylar
angulation dimensions had changed significantly immedi-
ately postoperatively or at the nine-month follow-up for
removal of the osteosynthesis material.
Discussion
The cause of relapse after orthognathic surgery remains
highly controversial. The potential causes of relapse are not
fully clear, and published factors range from the extent of
movement of the jaw, to the type of osteosynthesis used, to
incorrect positioning of the condyle.11,13–15 Malpositioning
of the condyle during operation leads to direct malocclusion
when the intermaxillary fixation is opened. It is possi-
ble to correct this error during operation by releasing the
osteosynthesis and repositioning the proximal segment, but
the surgeon must have the knowledge and skill to realise when
such correction is needed. The HSSO, as described by See-
berger et al, seems to be susceptible to malpositioning of the
condyle because it involves short proximal segments.8,12 The
lack of supportive positioning devices in HSSO underscores
the effectiveness of the technique for avoiding damage to the
inferior alveolar nerve while providing stable results and a
lack of appreciable changes in the positions of joints.
We used cone-beam CT scans to obtain follow-up mea-
surements of changes in position, as all orthognathic patients
at our clinic routinely have these scans for planning and
control of treatment. Cone-beam CT is a 3-dimensional imag-
ing technique associated with low exposure to radiation,
and is widely used for planning craniomaxillofacial surgery,
orthodontics and diagnostics.9–12 The technique provides
accurate images of bony structures, and allows for precise
measurements of distances and angles. Although magnetic
resonance imaging is a standard procedure for abnormalities
of the TMJ, it cannot provide highly accurate measure-
ments of bony structures. Cone-beam CT is therefore optimal
for evaluating the postoperative position of the mandibular
condyle after HSSO.11,13–16
The TMJ has a complex, curved anatomy, and so the def-
inition of reference points is crucial when measurements
are made. Although points such as the nasal spine or FH
plane can be clearly identified, small deviations caused by
642 R. Kuehle et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 638–642
the voxel size (0.125 mm) or variables of reconstruction data
always remain. These small but measurable postoperative dif-
ferences in joint spaces and angulations are minimal and tend
to decrease during the follow-up. For example, in both groups
of patients in the present study the joint spaces decreased
immediately postoperatively, and there were no significant
differences between class II and class III patients. In an eval-
uation of the follow-up data before removal of osteosynthesis,
there were no significant changes in any positions of the joint
spaces. These follow-up values approximated the preopera-
tive values after nine months of consolidation. We assumed
that remodelling effects directed the condyles to almost the
same positions that they were in preoperatively.
To date, we have seen no relapses in the patients stud-
ied. All patients presented with proper occlusions at the time
of removal of the miniplate. When we evaluated the joint
angulations in multiplanar data reconstructions, we were
particularly curious about changes in the sagittal position.
Because this technique provides two angular faces, we were
not concerned about lateral shifting or tilting of the condyles
in the axial or coronal plane, or both. However, the creation of
an opening rotation as a result of the short oblique osteotomy
might place stress on the sagittal plane, particularly in patients
with class II malocclusion. The results, however, did not dif-
fer significantly at either the postoperative or follow-up time
point. Given the possible error associated with this technique,
the anatomic complexity, and the voxel size (0.125 mm),
minor changes in the joint space can be assumed to be not
clinically relevant, particularly as we found no significant
changes in condylar angulation.17,18 In addition, the position
of the condyle within the fossa tended to approximate after
the operation, which further supports the lack of importance
of minor changes in the joint space.
In conclusion, the HSSO seems to be a safe, orthognathic
technique for positioning of joints. Although the proximal
(joint-bearing) segment after osteotomy is short and small,
our results indicate that free-hand positioning of the joints
into the fossa can be achieved safely, with no dislocation
of the condyle after osteosynthesis. The immediate post-
operative changes in joint spaces approximated during the
consolidation phase, and there were no appreciable changes
between the evaluations, which underscores the accuracy of
positioning in the absence of supportive devices.
Conflict of Interest
We have no conflict of interest.
Ethics statement/confirmation of patient permission
Data were collected after obtaining patients’ informed con-
sent and approval from the ethics committee of the University
Hospital of Heidelberg (S-131/2009).
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