BSSO Grybauskas PDF

sag itta I split
in detail
Simonas Grybauskas
George Deryabin
Bilateral
sagittal split
·steotomy
of th mandible
in detail.
Contents
Glossary of terms .
Glossary of abbreviations .
Preface........................................................................................................ II
Introduction IV
1. The injection of local anesthetics .
2. Incision and access to the medial ram us........................................................... 2
3. Subperiosteal dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4. The osteotomy line 14
5. Splitting the mandible 21
6. Controlling a bad or an unfavorable split 29
7. Adjusting the position of the bone fragments 47
8. Osteosynthesis of the mandible 58
9. Checking the occlusion 74
10. Grafting the osteotomy site 75
11. Suturing and finishing 77
12. Recovery from general anesthesia 78
Recommended reading 79
About the authors 86

Injection of
local anesthetics
To reduce the bleeding associated with incision and dissection, infiltrate the area with
a local anesthetic containing a vasoconstrictor 10 minutes before any incision is made.
•
It is best to perform this procedure before preparing the operating field; this allows at least
10-15 minutes for the local anesthetic to work. A 0.5% bupivacaine solution (or another
anesthetic agent) containing epinephrine (1:100,000) are reasonable options. Ten milliliters
of anesthetic solution per side is preferable and should be injected in the following manner:
submucosally, 2 ml into the area to be incised; subperiostally, 2 ml lateral to the anterior
border of the ascending ramus and 2 ml buccally around the area of the molars. Another 2 ml is
injected to block the inferior alveolar nerve (IAN). Finally, 2 ml is injected medial and lateral
to the retromolar area (Fig. 1.1).
Fig. 1.1. Areas to be infiltrated with anesthetic (marked in green).

Incision and access
to the medial ramus
The surgical procedure begins by inserting a mouth gauge between the teeth and
inserting a tongue retractor. At least three types of incision can be used to gain access
to the medial ramus: a "V-shaped" vestibular incision (Fig. 2.1 A,B), a vestibular "linear"
incision (Fig. 2.1 C,D), or a buccal "linear" incision (Fig. 2.1 E,F). The main features of these
incisions are described in Table 2-1.
Fig. 2.1 A,B. Outline of a 'V-shaped' vestibular incision (red and green lines).
2
C
Fig. 2.1 C,D. Outline of a vestibular 'linear' incision (red and green lines).
Fig. 2.1 E,F. Outline of a buccal 'linear' incision (red and green lines).
02. Incision and access to the medial ramus
Table 2-1.
Incisions used to gain access to the mandibular ramus and body for BSSO.
Type of incision 'V-shaped', long Linear, 5-10 mm from Linear in the cheek
upper extension. the mucogingival mucosa, 20 mm from
Incision made junction, 10-15 mm the mucogingival
down to the distal extension up from junction down to
margin of the lower the distal margin of the distal margin
second premolar. second molar, down of the first molar.
to the distal margin A shorter incision due
of lower first molar. to mobility of the flap.
Flap design Full thickness flap Full thickness flap Split the flap,
undermine the
submucosa,
and then cut the
periosteum close to
the mucogingival
junction.
Access to the inferior Higher resistance Medium resistance Less resistance from
part of the mandibular from the full from the full split thickness flap
body thickness flap thickness flap
Access to the Part of the buccinator Part of the buccinator Part of the buccinator
medial ram us of the muscle must be cut muscle must be cut muscle may be
mandible to gain access to the to gain access to the elevated without
medial ramus. medial ramus. cutting.
Bleeding Less Less More
Buccal nerve injury Minimal or no risk of Minimal or no risk of Possible buccal

buccal nerve injury buccal nerve injury nerve injury
Suturing The buccinator Part of the Suturing in two

muscle remains buccinator muscle layers is mandatory.
well attached to needs to be sutured. The lower part
the "V" part of Suturing of the of the buccinator
the gingival flap. mucosa in one layer muscle needs to be
Since the sutures is not sufficient since sutured with care
placed in the the sutures placed since it is not brought
keratinized gingiva in non-keratinized back to the original
are usually strong, mucosa do not position upon closure
the muscle does not guarantee full of the mucosa I flap.
require additional repositioning of the
suturing and is buccinator muscle.
repositioned
automatically.
4
The Vestibular "V-shaped" incision (Fig. 2.1 A,B) and access through a full thickness flap.
1. A toe-in retractor is used to stretch the buccal mucosa. A No.15 blade and/or a monopolar
coagulator, preferably a Colorado needle, are used to dissect all soft tissue layers.
2. The incision starts at the distal margin of the lower second molar and continues along
the vestibule to the medial margin of the lower second premolar. The incision is made
through all tissue layers and the periosteum.
3. Next. a second connecting incision is made from the distal margin of the lower second
molar at an angle of 45 degrees into the buccal mucosa.
4. Once the periosteum in the molar and retromolar areas is elevated buccally, the upper
part of the buccinator muscle is cut to access the anterior border of the ramus.
5. The anterior border is stripped to provide access to the medial ram us.
6. Once the osteotomy and osteosynthesis are completed, the wound is closed in a single layer.
Vestibular "linear" incision (Fig. 2.1 C,D) and access through a full thickness flap.
1. A toe-in retractor is used to stretch the buccal mucosa. A No.15 blade and/or a monopolar
coagulator, preferably a Colorado needle, are used to dissect all soft tissue layers.
2. The anterior border of the ramus is palpated, and the incision is made starting 10-15 mm distal
to the second molar and runs along the vestibule down to the distal margin of the lower first
molar. The incision is made through the mucosa. the buccinator muscle, and the periosteum.
3. The periosteum is elevated buccally in the area of the first and second molars. and the
inferior border of the mandible is stripped. This frees the flap and eliminates the need for
a long upper extension of the incision.
4. The anterior border is stripped to gain access to the medial ramus.
5. Once the osteotomy and osteosynthesis are finished, the wound is closed in two
layers. Several deep mattress sutures are placed in the buccinator muscle and interrupted
sutures are placed in the mucosa.
"Linear" buccal incision (Fig. 2.1 E,F) and access through a split flap.
1. Two toe-in retractors are used to stretch the buccal mucosa along the incision line (see the
marked incision line in Fig. 2.2). A No.15 blade and bipolar coagulator (or a monopolar
coagulator alone). preferably a Colorado needle, are used for soft tissue dissection (Fig. 2.3).
5
02. Incision and access to the medial ramus
2. The linear incision starts in the buccal mucosa at the level of the maxillary occlusal plane
and continues down to the medial margin of the lower first molar. The incision is made
through the mucosa and submucosa at a distance of about 20 mm from the mucogingival
junction. The underlying buccinator muscle is then exposed (Fig. 2.4).
3. It is important to hold the incision line open with retractors and to lift the medial margin of
the flap with anatomical tweezers to keep the flap under tension. The mucosal flap is widely
undermined with a No.15 blade or monopolar coagulator to expose the upper and lower
parts of the buccinator muscle.
4. Only the lower part of the buccinator muscle is cut (from the distal margin of the second
molar to the medial margin of the first molar) at about 5-10 mm from its insertion point to
facilitate further repositioning and suturing. The upper part of the buccinator is left intact and
is easily elevated since it is separated from the mucosa! flap (Fig. 2.5).
5. The anterior border is stripped to provide access to the medial ramus.
6. When the osteotomy and osteosynthesis are finished, the wound is closed in two layers. First,
the lower part of the buccinator muscle is sutured with care (Fig. 2.6), followed by the second layer
of mucosa (Fig. 2.7). It is mandatory that the wound is closed in two layers. since closure of the
mucosal flap alone does not guarantee the return of the buccinator muscle to its original position.
All three types of incision have advantages and disadvantages. The choice is a matter of personal
preference. The crucial aspect of the incision and suturing procedure is the preservation of the
buccinator muscle (or its complete reconstruction in cases when it must be cut). Failure to
reconstruct the buccinator muscle may lead to permanent perioral soft tissue sag.
Fig. 2.2. lntraoral view of a buccal 'linear' Fig. 2.3. A Colorado needle is used to
incision with toe-in retractors in place. undermine the mucosal flap up to the vestibule.
Fig. 2.4. The mucosal flap is retracted to Fig. 2.5. The periosteum (green arrow) and
gain access to the external oblique ridge. the buccinator muscle (blue arrows) are
cut along the external oblique ridge.
Fig. 2.6. Sutured buccinator muscle Fig. 2.7. Sutured buccal mucosa.
and periosteum.
7
Subperiosteal
l[I) dissection
Subperiosteal dissection should be adequate when performing corticotomies with full protection
of soft tissues. However, one should avoid excessive exposure, which may lead to the
detachment of muscle fibers from the proximal bone fragments or ligaments from distal
fragment, which results in soft tissue sag and unnecessary pockets that may allow hematoma
formation (Fig. 3.1).
1. Insert a periosteal elevator into the area of the second molar to primarily reflect the flap.
Use another periosteal elevator to expose the lateral surface of the mandible in the area
of the molars. Use two periosteal elevators together to ensure that you remain below the
periosteum at all times during the dissection.
2. Place the toe-out retractor under the periosteal flap. This allows one to maintain constant
tension in the flap and facilitates further dissection (Fig. 3.2).
3. Using the curved end of the periosteal elevator, expose the lower border or the mandible
in the area of the molars. Strip the inferior and, if possible, part of the lingual surface of the
lower border in the area of the first and second molars.
4. Expose the anterior border of the ramus, both lingually and buccally, to a depth of a few
millimeters. The buccinator muscle should be elevated with a periosteal elevator. If a vestibular
V-shaped or linear incision is used, the upper part of the buccinator muscle must be cut.
5. Use the ascending ramus retractor to strip the temporal muscle attachments from the
anterior border of the ramus. Make sure to access the area above the point of greatest
concavity in the anterior border of the ascending ram us (Fig. 3.3).
6. Place the clamp on the anterior border of the ramus at the base of the coronoid process
to retract the flap upward (Fig. 3.4 A).
7. Begin to expose the medial aspect of the anterior ram us by inserting the periosteal elevator
under the periosteum (at the point of greatest concavity in the anterior border of the ram us)
to a depth of 5-8 mm to tension the flap (Fig. 3.4 A and 3.4 B).
::--
'JaSA
Fig. 3.1. Areas of subperiosteal dissection (red).
Fig. 3.2. Subperiosteal dissection with Fig. 3.3. Subperiosteal dissection with the
exposure of the external oblique ridge and anterior border of the ramus stripped and
inferior border in the area of the molars. the buccinator muscle elevated.
9
03. Subperiosteal dissection
Fig. 3.4 A. The retractor
I
on the anterior border
is replaced with a clamp
followed by initial
penetration of the
medial ramus with
a periosteal elevator.
Fig. 3.4 B. Determining the approximate location of the lingula with reference to the point
of greatest concavity on the anterior border of the ascending ramus.
10
8. While holding the first elevator in place, swipe the second elevator (which is placed next
to the first one) and swipe it down to the second molar. Work at a depth of 5-8 millimeters to
avoid any unintentional injury to the periosteum or the IAN. This will release the tension on
the flap in the area of the first periosteal elevator and will prevent laceration of the periosteum
or the medial flap during the procedure (Fig. 3.5).
9. Check the mobility of the flap by gliding the elevator under the periosteum. If the flap is
not free enough, expose the retromolar area of the mandible (Fig. 3.6).
10. Once the flap is free of tension, use the curved end of the periosteal elevator to penetrate
the medial aspect of the ram us above the lingula. Most of the time, the lingula is positioned at
the level of greatest concavity at the border of the anterior ram us or on a line extending across
the lower occlusal plane. Once the level of lingula has been approximately located on the
anterior border, the periosteum must be elevated above this point (backwards and upwards).
The periosteal elevator should be in contact with the bone surface at all times. All movements
need to be performed carefully with little surgical force. If any obstacle prevents the elevator
from smoothly advancing posteriorly and to the necessary depth (both backward and upward),
consider changing the vector of the elevator to a more upward and backward direction.
11. While holding the periosteal elevator in place, use a blunt or ball-ended nerve retractor
to identify the exact position of the lingula. It may be difficult to locate at first due to the inward
Fig. 3.5. A second periosteal elevator is Fig. 3.6. A curved periosteal elevator
swiped down the periosteum to release is advanced posteriorly and superiorly
tension from the flap. to retract the flap.
11
03. Subperiosteal dissection
angulation of the ram us and/or the thick anterior border. The initial identification of the lingula
mandibulae and the mandibular foramen is tactile in such cases. After identification, the
anterior border of the ramus may be marked to keep the landmark clear during the
subsequent steps (Fig. 3.7 A,B).
12. If steps 7 to 11 are performed correctly, one should obtain a "tent effect", in which the
periosteal elevator reflects the entire soft tissue flap and exposes the medial surface of the
ramus and the soft tissue cone entering the bone at the lingula site. However, if the medial
flap is not raised sufficiently, the periosteal elevator may tear the periosteum and the "tent
effect" is not achieved. This causes the soft tissue to drop back to the bone around the tip of
the elevator and makes visualization of the medial ramus difficult. Occasionally, fatty tissue
may herniate through the periosteum, bleed, and block the lingual view (Fig. 3.8).
13. Sometimes, visibility and access need to be improved to avoid errors. This is the case
when one encounters a thick anterior border or a concave and medially inclined ramus. A No.6
round or oval bur is then used to trim the medial part of the anterior ramus back by 5-10 mm
at the level of lingula (previously marked with a sterile pencil or a bur). Once the view of the
medial aspect has been improved, the position of the lingula can be determined (Fig. 3.9 A,B).
14. Carefully swipe the periosteal elevator back and down to the newly-exposed lingula and
then rotate it downward to protect the soft tissue cone entering the mandibular foramen.
At this stage, the medial ramus can be exposed for corticotomy (Fig. 3.10).
Fig. 3.7 A,B. If unsure about the location of the lingula and IAN, use a nerve retractor
to blindly identify the mandibular foramen.
12
Fig. 3.8. "Tenting" effect with no Fig. 3.9 A. A 6 mm bur is used to trim the
herniation of the soft tissues. medial edge of the anterior border to improve
visibility and access to the medial ramus.
Fig. 3.9 B. A channel is created to a depth Fig. 3.10. The periosteal elevator is rotated
of 10 mm. Cancellous bone can be seen and laid down to protect the JAN from
in the deepest part of the channel. damage by the rotary instruments.
The osteotomy line
The ideal corticotomy line would be one that originates right above the mandibular lingula and
runs forward along the medial surface of the ram us parallel to the occlusa\ plane and onto the
anterior ridge at the base of the coronoid process. At a distance of 2-4 mm from the lateral
cortex of the ramus, it should then follow a curve and bend along the external oblique line,
maintaining a distance of at least 2-3 mm from the lateral cortex. At the level of the second
molar, the external oblique line continues downward. whereas the corticotomy line should
be extended higher and parallel to the gingival line (but no closer than 2 mm to the teeth).
Between the first and second molars. the line should make a 90 degree turn and run down to
the base of the mandible, extending to the lingual surface of the lower border (Fig. 4.1 A,B).
The corticotomy is most easily performed with a reciprocating saw. Long blades are not
needed since the average distance from the anterior border to the lingula is only 12-18 mm,
depending on the patient and type of deformity. A thin non-bending blade with a working
length of 15 mm is sufficient for performing all cortical cuts to the lower jaw.
Begin by performing a medial ramus corticotomy:
• Placement and the length of the cut. The cut should be made at the level of the lingula, either
at a right angle to the posterior border or inferiorly inclined; it should not run superiorly towards
the condyle. The cut starts at the anterior border of the ramus and ends right above the lingula or
just in front of it, depending on the relationship between the mandibular foramen and the lingula.
• The depth of the cut. Close to the lingula, only a corticotomy should be performed; however,
a corticotomy and a cut through the medul\ary bone to the lateral cortex should be performed
at the anterior border, leaving 2-4 mm of the lateral cortex intact. Usually, cortical bone is
already missing from the medial aspect of the ramus because it was removed with the bur
prior to corticotomy to improve visibility and access to the medial ram us.
• Corticotomy technique. Corticotomy begins with the tip of the saw above the lingula. Care must
be taken to complete a full corticotomy at the lingula before the body of the saw touches the rest of
the ram us. This makes it easier to control both the length and depth of the cut. The saw is inclined
at an angle of 0-30 degrees inferiorly to the bone surface to facilitate the osteotomy (Fig. 4.2 A-D).
Next, proceed with the anterior cut:
• Placement and the length of the cut. The cut starts from the end of medial corticotomy
(about 2-3 mm medially from the lateral surface of the rarnus), continues along the external
oblique ridge parallel to the teeth, and ends between the first and the second molars.
14
Fig.4.1
A. The corticotomy lines that typically provide a favorable split (marked in red):
1, a medial cut; 2, an anterior cut; 3, a buccal cut; 4, an inferior cut.
B. A favorable split.
• The depth of the cut depends on the position of the IAN. In most cases, the depth of the
cut is 8-12 mm. In patients with a high-running IAN, only a corticotomy can be performed.
• Corticotomy technique. Try to avoid sharp angles when connecting the medial and anterior
cuts. The osteotomy is made through the cortical bone and into the medullary bone. The
blade is then reversed and the corticotomy is rechecked from the bottom to the top and
then connected with the medial cut. During the lower anterior portion of the cut, the saw
should be inclined outward to enable the blade to stay close to the lateral cortex; however,
it should be inclined inward during the upper anterior portion of the cut to connect with
the medial cut. In cases with a concave ramus, the inclination of the saw should follow the
surface of the lateral cortex to avoid a bicortical cut and a bad split. The more lateral the
osteotomy line is placed, the thinner the resulting proximal fragment. Although this means
that the probability of the nerve crossing between the split fragments is lower, the chances
of achieving an unfavorable long split or a bad split are higher (Fig. 4.3 A-E).
Finish with buccal and inferior corticotomies of the mandibular body.
• Placement and length of the cut. The buccal cut runs vertically in a line between the first
and second molars, beginning from the lower border and ending at the anterior cut. In cases
where the premolars have been extracted and the molars medialized, it is preferable to
perform the vertical cut in the area of the middle of the second molars.
• The depth of the cut may vary depending on the thickness of the lateral and inferior cortices,
which are measured by preoperative CT. Full buccal and inferior corticotomies must be performed.
15
04. The osteotomy line
Fig. 4.2. A medial cut.

A. The cut starts with the tip of the saw above the lingula.
B. When the cortex is fully cut, the saw is rotated parallel to the ram us and downward.
C,D. Once the medial cortex is cut, the osteotomy line is extended
downwards a few millimeters.
16
A B
Fig. 4.3. The anterior cut.

A. The cut starts at the point at which
the medial cut was finished, but not
less than 2 mm from the lateral cortex.
The saw is inclined medially at the top of
anterior cut and laterally at the bottom
of the cut. The anterior cut finishes
between the first and second molars.
B. The saw is reversed and the osteotomy
revisited in the same fashion, connecting
again with the medial cut.
C. Schematic cross-sectional view of the
mandible showing the position of the cut.
Note the depth and the inclination of the cut.
C
Fig. 4.3 D. Complete anterior cut. E. Note the placement of the anterior cut (yellow arrow)
with respect to the external oblique line (dotted line indicated by black arrow).
• Corticotomy technique. To access the lower border, all of the retractors must be removed.
The exception is the inferior border retractor, which must be kept in place because it enables
optimum exposure of the lower border of the mandible with the mouth closed and allows
sufficient access to ensure that the reciprocating saw can be used at a 90 degree angle.
The corticotomy begins at the lower border, before the buccal cut is made. Typically, the cut
is 3-5 mm deep, depending on the thickness of the inferior cortex and the position of the
JAN. Once the inferior border has been cut, the buccal cortex is cut in an upward direction
until the cut reaches the anterior cut between the first and second molars. The inferior cut
is performed before the buccal cut since it is easier to control the depth of the inferior cut
when the buccal cortex is intact: the buccal cortex is thicker than the lingual cortex, which
prevents the surgeon from making the inferior cut too deep and injuring the IAN. However,
if the buccal cut is made before the inferior cut, care must be taken when completing the
latter. Once the inferior border is completely cut, the blade may advance too deep since the
thin lingual cortex will not provide adequate resistance. The buccal and inferior corticotomy
lines should be angled slightly obliquely and posteriorly to facilitate the split (Fig. 4.4 A,B).
18
"l.~R J,,~R
5-6mm
2-3mm
A B
JoSA
C D
Fig. 4.4.
A,B. The depth of the cut may be 5-6 mm or 2-3 mm depending
on the position of the IAN: the ideal depth in most cases is 4 mm.
C. The angle of the buccal cut.
D. Cross-sectional view of the mandible showing the inferior and buccal
corticotomy lines. Note the depth and inclination of the cut.
19
I
E
Fig. 4.4.
E. The 4 mm-long cutting saw is fully embedded in the inferior border,
indicating a sufficient depth of cut.
F. The buccal corticotomy is complete and is connected to the anterior cut.
After completing the corticotomy on one side, the same procedure is performed on the
opposite side prior to splitting. It is more condyle-friendly and convenient to perform all
corticotomies on a stable mandible prior to splitting.
20
Splitting
the mandible [IJ
It is important that the mandible is maintained in a stable position during splitting.
A medium-sized mouth gauge is placed between the teeth and a tongue retractor is inserted.
Although a clamp can be placed on the anterior border, clamping tends to impart too much
tension on the soft tissue flap once the inferior border retractor is inserted in the area of the
molars.
1. Begin the splitting procedure with a 12 mm chisel inclined lingually and tap along the upper
part of the anterior corticotomy to initiate the split. Next, incline the chisel buccally and tap
along the lower part of the anterior cut. If the anterior osteotomy gap does not open, redefine
the corticotomies. To avoid a bad split or damage to the IAN, DO NOT try to separate the
segments completely at this stage (Fig. 5.1).
Fig. 5.1.
A 6 mm or12 mm
osteotome is inclined
lingually and used to tap
along the upper part of
the anterior cut to open
the osteotomy gap.
21
05. Splitting the mandible
2. Insert a larger 12 mm osteotome into the anterior osteotomy line and continue to separate
the fragments (Fig. 5.2 A,B).
3. Split the lower border by inserting a 6 mm osteotome into the bottom of the buccal
corticotomy line and apply torque to open the lateral cortex outward. Apply pressure into
the anterior corticotomy by gently rotating the 12 mm osteotome. It is important to place a
channel retractor at the inferior border to support the mandible to avoid distracting the TMJ
or injuring the perimandibular soft tissue envelope (Fig. 5.3).
4. Next, rotate and press down on the 6 mm osteotome to separate the distal part of the
proximal bone fragment, making sure that the lower border is split even or more bone mass
stays on the proximal fragment. Complete the osteotomy using two 12-14 mm chisels: place
them in the anterior cut and in the inferior cut and rotate them in opposite directions (Fig. 5.4).
Maintain control of both osteotomes and do not advance them any deeper until the IAN has
been clearly identified.
Fig. 5.2 A,B.

A 6 mm or 12 mm
buccally inclined
osteotome is tapped
into the lower part
of the anterior cut
to open the
osteotomy gap.
22
Fig. 5.3.
A 6 mm osteotome
is inserted into the
inferior cut and the
two osteotomes are
rotated in opposite
directions.
Fig. 5.4.
Once the bone
fragments have
separated, the
upper osteotome
can be replaced
with a Smith
ramus separator.
Use the Smith ram us separator only when the osteotomy has been completed rather than to
complete the osteotomy. Although in most cases of the latter it will not do any harm, it may
in some cases influence the direction of the lingual wall fracture and may negatively affect
the TMJ by forcing the condylar head laterally (Fig. 5.5).
Always ensure that the split line runs along the lower border for about 10-15 mm before
turning onto the lingual surface of the mandible. Maintaining a portion of lower border on
the distal fragment can prevent the formation of a notch in the lower border in the late
postoperative period. Also, make sure that the neurovascular bundle is intact.
If it becomes obvious that the neurovascular bundle is still attached to the proximal segment,
it should be carefully released using a blunt Howart's dissector or a piezo device, especially
in cases that will require a large advancement after the split is completed (Fig. 5.6 A,B).
23
Fig. 5.5.
The bone fragments
are separated,
a pterygomasseteric
sling seen at the
bottom of the split.
Fig. 5.6.
A. The IAN (running
from the proximal to
the distal fragment).
B. The IAN is freed
from the cancellous
bone with a piezo
saw and a Howart's
dissector.
24
The technique: the nerve canal is identified by probing with a nerve retractor from the back
and from the front ends. After the canal has been identified, perform an additional bone
cut 3-4 mm above the canal and at a 45 degree angle to the internal bone surface. The cut
should be 2-3 mm in depth along the entire length of the canal and made using a piezo
device or a saw.
The area around the Jingula (where the IAN is located inside the cortical bone ring) is critical.
Therefore, a full corticotomy must be performed above and anterior to the ring. A ~6 mm wide
chisel is placed in the new osteotomy line and rotated. The thin fragment of bone along the
entire canal will then separate and expose the IAN (Fig. 5.7 A-G).
~J~
. I
8
JoSA
A
Fig. 5.7 A,B. The procedure used to free the IAN from the canal.
An additional osteotomy must be performed along the yellow and red lines.
Fig. 5.7 C.
If the osteotomy is performed
along the yellow line alone, an
~J) incomplete exposure will be achieved.

The bone fragment that is likely to
separate under these conditions is
indicated in blue.
I
\
C
D E
Fig. 5.7 D,E.

An additional osteotomy will be needed (yellow line) to free the IAN from the bone ring.
-J ~ ;
j
l
F G
Fig. 5.7 F,G.

The bone ring is separated and the IAN is ready to be freed from the canal.
Failure to cut the cortical bone above or through the bone ring around the lingula will
expose the nerve along the entire length of the canal (apart from in the lingula area, where
the nerve remains inside the bone ring) (Fig. 5.7A-G). Direct dissection of the canal without
performing an additional osteotomy is not recommended (even if piezo surgery is used) due
to the high risk of canal penetration and nerve injury, particularly when working in the deep
posterior areas around the lingula.
The IAN should be freed even in cases requiring only small symmetrical advancements
(e.g., 4-6 mm). Nerve release is not traumatic if performed meticulously by making
additional cuts in the proximal bone fragment. Indeed, it is no more traumatic than the
BSSO procedure itself if performed as described. Once the nerve is free from the canal,
bone irregularities and spikes should be trimmed off anterior to the crossing point to avoid
mechanical damage to the nerve during repositioning of the fragment.
Fig. 5.8
A. A schematic
representation of an
ideal or favorable
short split.
B. All major muscles
and ligaments remain
attached to the proximal
fragments according to
the following split pattern:
1, the temporal muscle;
2, the masseter muscle;
3, the medial pterygoid
muscle;
4, the lateral pterygoid
muscle;
A 5, the sphenomandibular
ligament;
4 6, the stylomandibular
ligament; and
7, the capsular ligament.
27
An "ideal" or a "good" split has four distinctive characteristics (Fig. 5.8 A,B):
1. The proximal bone fragment contains part of the mandibular ramus along with the condyle.
coronoid process, buccal plate of the mandibular body, and inferior body of the mandible.
2. The distal part of the tooth-bearing bone fragment ends up at the lingual or just behind
it (short split).
3. The tooth-bearing (distal) bone fragment is free from (or has few) muscle attachments.
4. The neurovascular bundle is attached to the distal fragment and there is no (or a minimal
amount of) bone behind it.
When splitting of the mandible is complete, pull on the tooth-bearing fragment while holding
the proximal fragment firmly with a clamp to stretch the muscle slings and pacify the distal
fragment. Stripping the medial pterygoid muscle fibers may facilitate this (Fig. 5.9 A,B).
Next, perform maxillomandibular fixation (MMF) through a splint.
Fig. 5.9.
A. A blunt curved elevator is used to dissect the muscles from
the medial inferior surface of the distal fragment.
B. Possible medial pterygoid muscle attachments are indicated by black arrows.
28
Controlling a bad
or an unfavorable split
A bad or unfavorable split may occur both because of poor technique with respect to the
•
splitting procedure, or when the corticotomy is performed improperly.
The main clinical difference between a bad split and a developing bad split, or between
a bad split and an unfavorable split, is that unfavorable and developing bad splits are
"reversible" or "manageable", whereas a truly bad split is not. If managed correctly,
unfavorable splits and developing bad splits may not affect the outcome of the osteotomy.
If a developing bad split is recognized during surgery, a bad split can be prevented.
A developing bad split is a situation in which the two jaw fragments are still connected, but
will proceed into a bad split if the process is continued without appropriate management
(Fig. 6.1 A-C).
A bad split is a full split on one side of the mandible with at least one of the following outcomes:
a) the condyle stays attached to the tooth-bearing fragment; b) there is a comminuted fracture
with a free condylar fragment; c) there is a full fracture of the buccal cortex of the proximal
fragment; or d) the full thickness of the lower border of the mandible stays attached to the
tooth-bearing fragment (Fig. 6.2 A-0).
Accordingly, an unfavorable split is a full split on one side of the mandible that has the
following features:
a) the condyle stays attached to the proximal fragment (correct); b) the lower border of
the mandible stays attached to the proximal fragment (correct); and c) one of the following
is present: a long split pattern in the ramus extending back to the po\terior border OR a
short split pattern of the ramus that does not reach the mandibular forar:ien OR a fracture
of the distal fragment through the wisdom tooth OR a high lingual split of the distal frag-
ment (Fig. 6.3 A-C).
The most common mistakes and appropriate management strategies are listed in Table 6-1.
29
06. Controlling a bad or an unfavorable split
Fig. 6.1.
Development of
a bad split.
A. The buccal plate
is about to separate
from the condyle,
which remains
attached to the
distal fragment.
B. A developing
bad split.
C. The condylar
fragment is
recaptured to the
proximal fragment
and the osteotomy
A is salvaged.
30
Fig.6.2.
Examples of
bad splits.
A. A condylar split:
sagittal fracture of
the buccal plate
with the coronoid
process and a part
of condyle.
B. A comminuted
fracture with a free
condylar fragment.
C. A buccal plate
fracture with or with-
out the coronoid
process.
D. A lower border
A buccal split.
I 31
Fig.6.3.
Examples of
unfavorable splits.
A. A long split.
B. A too short split.
C. A fracture of
the distal fragment
through the
retromolar area.
32
Table 6-1.
Common types of unfavorable splits and appropriate management strategies.
Long split Long medial cut Remove or separate Perform medial ramus
(distal fragment Fig. 6.4A-D the bone from osteotomy 0-1 mm
! includes the medial the posterior above the lingula
cortex from the part of the distal and do not extend it
anterior border to the fragment, behind posteriorly. Medial cut
posterior border) the neurovascular should not be deep
bundle. in the area of lingula,
only to the depth of
the cortex.
Too short split Medial cut too short The /AN should Medial ramus
(fracture of the Fig. 6.SA-E be carefully dissected osteotomy should
medial ramus from the proximal be made right above
cortex anterior segment after or through the lingula.
to the lingu/a; performing an Full corticotomy is
the lingula stays additional osteotomy mandatory in the
attached to the from the inner side of area of lingula to
proximal segment, the proximal fragment avoid a split that is
and /AN is using a piezo device, too short.
crossing between especially in the
fragments) case of a large
advancement.
Fracture of the Upper part of anterior Complete the Remove third

distal fragment cut not deep enough osteotomy in the molars at least 4
through the or anterior cut not retromolar area months (preferably
retromo/ar area connected to the and medial ramus. 6 months) before
or wisdom tooth medial cut. Once fixation surgery. If healing is
Wisdom tooth of the fragments complicated, allow
present and medial is complete, 8-9 months.
cut not deep enough. replace and fix Care should be taken
Fig. 6.6A-D the free/separated while splitting the
bone fragment in mandible in this area.
the appropriate
position (preferably)
of or leave it floating
if it has muscle
attachments.
High lingual Inferior cut too deep Free the IAN from Keep the inferior cut
split line Fig. 6.7 A,B the canal. Make sure as deep as 3-4 mm.
that the fracture line The depth of the
does not extend to cut must take into
the alveolar process account the thickness
across one of the of the cortical bone at
molars. Graft the the base of the man-
osteotomy site to dible relative to the
avoid notching. position of the IAN.
A B
Fig. 6.4. Management of an unfavorable long split.

A. Completed split.
B. The posterior part of the distal fragment is separated and the split
is converted into a short split.
C,D. A medial fracture line running back to the posterior border; a short and shallow
medial cut would have resulted in a fracture along the dotted red line.
34
A JoSA
B JoSA
Fig. 6.5.
A. An unfavorable split because the medial cut was too short.
B. The sections of bone that need to be removed to free the IAN from
the canal are shown in green.
35
. 06. Controlling a bad or an unfavorable split
Fig. 6.5.
C. The medial cut
must extend back to
the lingula and the
cortex must be
completely cut.
D. An additional
osteotomy above
the JAN (red dotted
line) must be
performed.
E. The IAN can then
be removed from
the canal.
36
'~~
I / ~
'<. -··-, , ~ 'JaSA

A
Fig. 6.6.
A. An unfavorable split due to a fracture of the distal fragment through the
retromolar area. The red dotted lines delineate the unfavorable fracture lines.
B. The impacted wisdom tooth needs to be cut with a bur at the required
depth to ensure that it fractures.
C. The wisdom tooth is visible in the distal fragment.
D. The removed wisdom tooth.
37
Fig. 6.7.
A. An unfavorable split due to a high lingual wall fracture.
B. The lingual split line is running too high. As a result, the proximal fragment captures the JAN.
Table 6-2.
Common types of developing bad splits and appropriate management strategies.
Incomplete Angulation of the Use piezo surgery to A medial ramus

fracture of the upward medial cut perform a vertical cut in corticotomy should be
medial cortex Fig.6.SA-H the medial cortex behind performed at a right
extending back the canal from inside the angle to the posterior
to the posterior osteotomy gap. This will border, or inferiorly
border and upward convert the long split Into inclined. It should not
towards the condyle a short split. be upward.
A green stick buccal Buccal or Redefine the buccal Perform the full
plate fracture, either inferior cut not osteotomy and corticotomy of the
alone or with the deep enough recapture the lower border and
coronoid process Fig. 6.9A,B lower border by the buccal plate.
performing an If the gap does
additional lingual not open by at least
Cut along the canal. 2-3 mm, stop the
If needed, plate the procedure and
green stick fracture redefine all the
before recapturing. osteotomies.
Developing lower Inferior border cut Redefine inferior border Cut entire inferior
border buccal split not deep enough cut. In case of a long border cortex.
split across the posterior Evaluate its
border, remove bone thickness with the
from the posterior part help of CT before
of the distal fragment. the operation.
38
Bad splits and unfavorable splits are still categorized as complete splits; however, unfavorable
splits can be converted to a short split, regardless of their pattern. The procedure can then
be completed successfully. By contrast, a bad split is a severe complication that typically
requires osteosynthesis before either proceeding with or aborting the procedure. In the
unfortunate case of a buccal plate fracture, the buccal plate needs to be plated first and
the osteotomy revisited later. Fortunately, the lower border often remains on the distal
fragment and be recaptured and fixed to the proximal fragment. Occasionally, however, it
can be lost and an antegonial notch may form. In unfortunate cases of condylar or com minuted
fractures, we advise that the surgeon continues with the osteotomies after all of the fracture
lines have been plated. The surgeon needs to be sure that no additional non-reduced
fracture lines remain. If there is any doubt about the fracture pattern, or if the reduction is
not satisfactory, we recommend that the osteotomy be postponed for 6 months.
A developing bad split is an unfavorable run of the fracture line, often resulting from surgery
at the wrong location, or inadequate or excessive depth or length of the cuts. The surgeon
does not usually foresee the split pattern that will result from a procedure performed on the
lingual side. A developing bad split may be converted to an unfavorable split if the condyle
stays attached to the proximal fragment or, unfortunately, into a bad split if the condyle remains
attached to the distal fragment. Moreover, a developing bad split may (and should) be guided
into a short split, provided the surgeon takes the necessary actions, including making ad-
ditional cuts from inside the osteotomy gap and applying guiding forces (Fig 6.8 A-H). It is
imperative that this potentially dangerous situation is identified before a bad split occurs; a
few extra minutes spent guiding the split may save the extra hour needed to fix a bad split.
If the split continues even after the appropriate intervention, a developing bad split may still
be possible. In this case, the surgeons should not rush; instead, they should carefully inspect
the bottom section of the split. The split line, having passed 10-15 mm posterior to the buccal
and inferior cuts along the inferior border, must turn lingually and upwards to reach the
mandibular canal. If this is the case. the split may be continued by using two 12 mm osteotomes
to apply a rotational outward force on the proximal fragment. If the inferior split continues
posteriorly along the lower border and does not incline lingually and upwards, care should
be taken to stop at this point and guide the split before it converts into a long or bad split.
A piezo or reciprocating saw can be used to perform an oblique inferior corticotomy on the
distal fragment from inside the osteotomy gap. The cut should be made in the area where
the lingual fracture occurs in an ideal split. The inferior cut may be continued upward and
posteriorly, immediately behind the nerve canal (as far as it can be seen) (Fig. 6.10 A,B).
A blunt 6 mm curved osteotome is then inserted into the inferior cut and pushed inward to
fracture the lingual wall and push the posterior lower part of the distal fragment laterally.
In this way, the split is converted into a short split and an adverse outcome prevented.
In the case of a developing bad split of the buccal plate, or when the fracture line runs
posteriorly along the inferior border and turns buccally rather than lingually, care should be
taken to stop the procedure before the split is completed. A full split of this pattern would
result in the inferior border remaining attached to the distal fragment; the muscle and ligament
attachments would then impede the mobilization and passive fixation of the distal fragment.
39
If a buccal plate green stick fracture is noticed, it can be plated before proceeding with the
split. The other option is to deepen the inferior cut and use a 6 mm osteotome to cut the
lower border of the mandible on the lingual side. The purpose of this is to guide the fracture
line lingually and keep the inferior border attached to the proximal fragment.
C D
Fig. 6.8.
A. A developing bad split occurs because of the angulation of the upward medial cut.
8. If continued, this cut can proceed to a bad split.
C. An additional inferior cut allows the surgeon to perform a lingual split of the distal fragment.
D. Recapture of the condylar fragment.
40
Fig. 6.8.
E. An additional inferior cut.
F. A lingual split of the distal
fragment.
Fig. 6.8.
G. A salvaged osteotomy converted into a short split.
H. This split can be avoided by making a medial cut (indicated by the red line).
The cut should be made at the level of the lingula and should not extend behind it.
41
5-6mm
Fig. 6.9.
A. A green stick buccal plate fracture, either alone or with the coronoid process.
A developing lower border buccal split.
8. The depth of the lower cut is increased to 5-6 mm (if the position of IAN permits),
and the lower border of the proximal fragment is recaptured.
42
Table 6-3.
Types of bad splits and appropriate management strategies.
A complete Angulation Plate the fracture and abort The angle of the
fracture of the of the upward the procedure, or reduce medial cut should
medial ramus medial cut and plate the separated be normal, or inferiorly
running to the Fig. 6.11 buccal cortex to the man- inclined toward the
incisura (notch); dible. Next, redefine the posterior border.
the condyle medial cut to separate the It should not be
remains attached proximal fragment angled upward.
to the distal (with the condyle and
fragment. coronoid process) from
the distal fragment.
Comminuted Upward medial Endoscopic examination Cuts must be performed

fracture with a free cut angled will help to define the correctly (correct length
condylar fragment towards the pattern of the fracture. and angulation). Avoid
condyle. Open vs. closed reduction excessive force during
Application should be considered splitting. If excessive
of excessive force after endoscopic or force is needed, stop
during splitting. intraoperative x-ray and recheck the
Fig. 6.12 examination. corticotomies carefully.
Full fracture of the Insufficient inferior Reduce the fracture by Cut the inferior border
buccal cortex border and buccal repositioning the free frag- cortex completely.
of the proximal cuts. Lateral cortex ment and then plate it to Perform a preoperative
fragment left too thin the proximal fragment using CT to evaluate the
because of a at least one plate. Redefine thickness of the
deep medial cut. the buccal and inferior cuts inferior border cortex.
Excessive force and continue with the Avoid applying
applied during osteotomy. Remove bone excessive force during
splitting. from the posterior part of splitting. If excessive
Fig. 6.10 A-G the distal fragment behind force is needed, stop
the neurovascular bundle. and recheck the
Release the medial ptery- corticotomies carefully.
goid muscle attachments
from the lingual side of the
inferior border on the distal
fragment using a "J stripper".
A lower border Inferior border cut Check the passiveness Cut the entire inferior
buccal split not deep enough of the distal fragment. If border cortex.
Fig. 6.13 A,B the distal fragment is not Perform a preoperative
passive, use bone rongeurs CT to evaluate the
to remove the lower border thickness of the
and repeat the stripping inferior border cortex.
procedure. Take care not
to remove too much of the
lower border as this may
affect the contour of the
lower Jaw, particularly in
cases of clockwise rotation.
43
5-6mm
A B
Fig. 6.10.
A. A complete buccal plate fracture including the coronoid process.
B. Revisiting the inferior corticotomy cut.
C,D. Plating the fracture.
44
F
Fig. 6.10.
E. The inferior cutting line is indicated.
A new split in the distal fragment is
performed and the condylar fragment
is separated from the distal fragment.
F. The inferior cut is revisited and the
lower border is recaptured by creating
a new split line on the distal fragment.
G. Converting a bad split into
a favorable split.
I 45
Fig. 6.11. An example of a bad split. Fig. 6.12. An example of a bad split.
A complete fracture of the medial ram us A com minuted fracture with a free
running to the incisura notch. condylar fragment.
Fig. 6.13. An example of a bad split.

A. A lower border buccal split.
B. The upper arrow points to a red line, which indicates an additional osteotomy.
All excess tissue behind that line is recaptured and fixed to the proximal fragment.
The lower arrow indicates the lower border, which remains on the distal fragment
and needs to be stripped of muscle attachments on the lingual side.
Fig. 6.13 C,D. Inferior and lingual views of the buccal split and its management.
46
Adjusting the bone
fragments
Once the bilateral osteotomy of the mandible is complete and the distal fragment is mobilized,
a passive relationship between the fragments has to be achieved. MMF is performed by tying
the lower and upper dental arches using a final or intermediate splint. Once the proximal bone
fragment is positioned, there may be a point of contact with the distal fragment or there may
be a gap between them, depending on the surgical plan (correction of yaw through trans-
lation or rotation around the incisors in the axial plane, or correction of cant through rotation
around the incisors in the frontal plane), the vector, and the amount of surgical repositioning
required. A point of contact between the fragments is not a prerequisite for adequate bone
healing, but stable fixation is necessary. However, to achieve stability, we recommend that
at least one passive point of contact is achieved to lock the framework in the transverse
dimension; this point may be either bone contact or hardware that firmly connects the
fragments together. Failure to create a stable framework may lead to a transverse shift of
the posterior part of the jaw once the osteosynthesis is complete and the MMF is released
(Fig. 7.1).
If there is premature contact between the proximal and distal fragments before the desired
3D position is achieved, a rongeur, piezo, or bur may be used to trim and pacify the bone
segments. It is important to protect the alveolar neurovascular bundle while trimming the
bone (Fig. 7.2 A,B).
Fig. 7.1.
Osteosynthesis
performed with
mini-plates and
positional bicortical
screws to stabilize
the framework in the
horizontal plane.
07. Adjusting the bone fragments
"JoSA
B
Fig. 7.2 A,B.

Protecting the IAN and smoothing an irregular bone surface to avoid premature bone contact.
It is critical that premature bone contacts are managed before proceeding to osteosynthesis
(Table 7-1). The most common problems encountered when adjusting the mandibular
fragments and appropriate management strategies are listed in Table 7.2.
Table 7-1.
Potential negative outcomes resulting from unmanaged premature bone interfaces.
1. Failure to seat the condyle into the glenoid fossa may result in the following outcomes (Fig. 7.3 A-D):
a) In cases requiring lower jaw surgery or a bimaxillary "maxilla first" surgery, malocclusion may
occur after recovery from general anesthesia (GA). Upon recovery from GA, the muscles will
attempt to return the displaced condyle to the physiological position. This will shift the entire jaw.
The bite will probably open on the contralateral side.
b) In the case of bimaxillary "mandible first" surgery, a good occlusion with a canted occlusal
plane may occur. Once the plated mandible (with one of the condyles undersealed) is released
from MMF and the upper jaw is down-fractured and fixed onto the lower jaw, the condyles will be
seated and the jaws will acquire a cant.
2. Condylar torque or condylar displacement due to compression of the fragments at the site of
osteosynthesis may result in the following (Fig. 7.4 A-D):
a) Malocclusion after recovery and prolonged TMD symptoms;

b) Progressive condylar resorption with unilateral or bilateral mandibular retrusion.
3. Transversal asymmetry at the genial angles due to unfavorable flaring of the fragment
with good occlusion (Fig. 7.5)
4. IAN injury due to sharp bony edges and/or compression.
48
Fig. 7.3. The mechanism underlying condylar sag and immediate mandibular
retrusion after recovery.
A. Initial position of the mandible.
B. B550 complete and jaws put into MMF. Note the sagging of the condyle
and the proximal fragment under general anesthesia (GA).
C. Osteosynthesis completed in the sagged position (incorrect).
D. After recovery from GA, the muscles pull the condyle back into the fossa,
thereby generating a Class II open bite.
49
Fig. 7.4. The process of condylar torque and displacement.

A. Long split pattern of the lower jaw.
B. An advanced distal fragment flares out from the proximal fragments.
Pressure on the proximal fragments displaces the condyles due to posterior bone contact.
C,D. Condylar displacement scheme (viewed from above).
--- Fig. 7.5. Transverse

asymmetry at the gonial
angles due to flaring
of the left proximal
fragment.
50
Table 7-2.
Management of premature collision between mandibular fragments.
Regardless of the type of surgical repositioning, the initial steps are usually the same:
1. Keep the exact plan for surgical repositioning of the distal and proximal fragments firmly in mind.
Perform a 3D simulation of, or at least try to imagine, the anticipated interrelationship between the proximal
and the distal fragments on either side in the transverse, sagittal, and vertical planes (Fig. 7.6 A,B).
2. Check the passivity of the proximal fragment in the seated condyle position. As a general rule,
the proximal fragment should feel passive; however, this may sometimes be the case for the
following reasons:
a) Condylar sag during GA;
b) The proximal fragment is distracted by the distal fragment. Once the proximal fragment is seated and its
position has been adjusted both vertically and transversally, collision of the bone fragments may occur.
In some cases, the passivity of the proximal fragment may be limited by the downward pull of the
distal fragment due to insufficient mobilization. If proximal fragment is not passive enough to be
repositioned to the planned position, remove the MMF, recheck the osteotomy, and redo the
stripping and mobilization of the distal fragment.
3. Seat the condyle and check passiveness again. In many cases, a remarkable change in the passiveness
may be noticed after removal of a premature bone contact that prevents it from good adaptation.
Fig. 7.6. A 3D simulation of the surgical plan depicting the desired position of the bone
fragments during surgery.
A. The preoperative position.
B. The planned position of the fragments after surgery.
Correcting yaw (rotation around the central incisors in the horizontal plane)
The collision points between the distal and proximal bone fragments dictate the amount by which
the proximal fragments will flare. Premature bone contacts are usually caused by either advancing
or rotating the parabola-shaped distal fragment. The distal posterior part of the distal fragment
is the widest, and pushes one or both of the proximal fragments outward during advancement,
rotation, or translation (Fig. 7.7A). The resulting flaring may be either anticipated or unlikely,
depending on the initial clinical situation and jaw symmetry. Changing the yaw can correct an
asymmetry of the gonial angles; however, it can also create asymmetry (Fig. 7.7 8-G).
51
Fig. 7.7 A. Flaring of the

proximal fragments during
advancement of the distal
fragment.
Fig. 7.7.
B. The initial position of the fragments in an asymmetric case.
C. Ideal position of the distal fragment resulting in a symmetrical distribution
of the proximal fragments (correct).
D. Right yaw of the distal fragment (incorrect).
E. The right gonial angle is flared more than the left gonial angle.
52
Fig. 7.7.
F. Left yaw of the distal fragment (incorrect).
G. The left gonial angle is projected more than the right gonial angle.
Symmetrical advancement
In contrast to the vast majority of asymmetrical cases, flaring of the proximal fragments in symmet-
rical cases is usually unintentional. Usually, this type of flaring indicates a premature bone contact
that must be removed. However, in some asymmetrical cases, for example, hemimandibular hypo-
plasia patients, intentional surgical flaring on the shorter side can help to increase the gonial angle
projection, normalize the vertical inclination of the ram us, and reduce asymmetry. A 3D simulation
may provide clues as to whether or by how much the premature bone contact needs to be trimmed.
Symmetrical mandibular setback
In cases of a mandibular setback, there is clearly an excess of bone that has to be removed.
Common practice is to cut off the anterior part of the proximal fragment and do nothing to
the posterior parts of the distal fragment. It is assumed that the widest part of the parabola is
set back and therefore "narrows," causing the proximal fragments to rotate inward. However,
in patients with a parallel nonconverging ramus, there may be a need to trim the proximal
fragments around the lingula and to remove any premature contact resulting in a kick-out
of the proximal fragments. Usually, the lower border on the lingual side of the proximal
fragment needs to be trimmed to achieve a passive fit between the fragments (Fig. 7.8 A,B).
Clockwise rotation
When a clockwise (CW) rotation is planned, the premature points of contact usually occur
the level of the lingula. Therefore, bone needs to be trimmed from the inner side of the
proximal fragment and from the top of the distal fragment. CW rotation of the distal fragment
means that it is impossible to place a bicortical screw to stabilize the framework in the
transverse plane. Therefore, a second additional plate may be needed to achieve a more
stable osteosynthesis, particularly in cases of "mandible first" bimaxillary surgery (Fig. 7.9).
53
Fig. 7.8. Setback of the distal fragment.

A. Red arrows indicate the sites at which the proximal and distal fragments
need to be shortened to avoid bone collisions.
B. The most frequent point of collision is the inferior border.
Fig. 7.9.
Clockwise rotation of the
distal fragment results in a
large divergence between
the anterior borders of the
proximal and distal
fragments.
Counterclockwise rotation
In cases of counterclockwise (CCW) rotation, bone collisions are very rare. Usually, there is a
gap between the fragments rather than a point of contact. CCW rotations cause the widest
part of the lower jaw to move downward and forward. Therefore, the lower face becomes
wider and the proximal fragments rotate outward in the frontal plane; however, no collision
occurs. In such cases, it is beneficial to create a point of contact if it is absent. Also, an additional
positional bicortical screw may be used after plate fixation has been accomplished.
54
Correction of cant (rotation around central incisors in the frontal plane)
Correcting the cant is one of the most challenging clinical situations in terms of achieving
the final position of the proximal fragments. Pure correction of the cant should result in the
distal fragment rotating in the frontal plane as follows: the higher side moves down (usually
causing premature contact with the upper part of distal fragment), whereas the lower side is
moved up and contacts the bottom part of the proximal fragment. These two areas usually
need adjustment before proceeding with osteosynthesis.
JoSA
Fig. 7.10.
The most common points of premature bone contact between the bone fragments. Distal
fragment: A1 - the lower border in cases where it remains on this fragment; A2 - the pos-
terior aspect behind the IAN in cases of long splits; A3 - lateral part of the anterior border
in case of cant correction or clockwise rotation. Proximal fragment: 81 - the lower border
in case of mandibular setback; 82 - the posterior segment, particularly in cases where the
split is too short; 83 - medial part of the anterior border in cases of clockwise rotation.
55
Table 7-3.
Common sites of bone collision and appropriate management strategies.
Symmetrical Small to moderate outward Locate the premature bony

advancement rotation of the proximal contact and trim it. It is usually
fragments. in area A2. (Fig. 7.10).
Reason: the advanced
parabolic distal fragment
pushes the proximal Use piezo or back-biting
fragments outward. rongeurs to remove bone from
The longer the split, the behind the mandibular canal.
greater the flaring.
The greater the convergence
of the left and right rami, the
greater the flaring.
Asymmetrical Kick-out of the Determine whether premature contact kicks

advancement proximal fragment. the fragment out to the desired transverse
Reason: the side that Is position after the condyle has been seated. If
more advanced pushes the the flare is too large, identify any contacts and
proximal fragment laterally. begin to gradually reduce them.
There is no (or only
minimal) bone contact Usually, contact occurs in the A2 and 83
at the bottom of the areas on the affected side, and in the A1 and
proximal fragment on the 81 areas on the contralateral side.
contralateral side which Management of collision in A2 and 83 areas:
is advanced less. - Use piezo or back-biting rongeurs to remove
bone from behind the lingula in area A2;
- Use a bur to remove excess bone
in area 83;
- If this is not enough in extreme cases with
large asymmetry, then infraction of the distal
fragment at the site of the wisdom tooth can
be achieved by performing an osteotomy with
a bur or a saw.
Management of collisions in the
A1 and 81 areas:
- Trim the 81 area with a bur;
- Cut the A1 area with back-biting rongeurs
(Fig. 7.10).
Setback Bone overlap and inward Usually, there are two areas
rotation of the proximal that should be trimmed:
fragments. I. Any excess bone on the anterior part
Reason: backward of the proximal fragment needs to be
movement of the distal cut and area 81 trimmed
fragment and relative II. Area 82 needs to be trimmed with a bur.
narrowing of the distal Area A2 does not usually interfere; however,
fragment during the setback. if this is the case, it should be removed with
back-biting rongeurs (Fig. 7.10).
56
Table 7-3. (Cont.)
Common sites of bone collision and appropriate management strategies.
Surgical management
Clockwise Kick-out of the proximal Usually, the point of collision is in area

rotation fragment. 82 and/or 83, which correspond to areas
Reason: bony interference A2 and A3, respectively. Trim areas 82 and
at the level of lingula. 83 with a bur. Provide protection by inserting
a lingual spatula into the osteotomy gap
(Fig. 7.10).
Counterclockwise Kick-outs due to fragment A gap rather than a collision is more often
rotation collisions are rare. observed when performing counterclockwise
rotations of the distal fragment.
Rotation in the Premature contacts at the Most often the areas of first bone contact
frontal plane bottom part of the proximal are located in the following areas:
(correction of an fragment on the lower side, Lower side: A1 and 81;
occlusal cant) and at the top part of the Higher side: A3 and 83.
fragment on the higher side. Trimming these zones aids passive positioning
Reason: rotation of the distal of the fragments (Fig. 7.10).
fragment in the frontal plane.
57
Osteosynthesis
• of the mandible
Once the distal fragment is free and passive, it is attached to the upper jaw using a splint
(Fig. 8.1). The key to surgical success is a precise connection between the proximal and
distal fragments. Preferably, the proximal fragments should be plated in their original position,
with no anteroposterior rotation, flaring, or torque. Flaring and torque can be controlled
by selectively trimming the points of contact between the fragments. Common mistakes
involve upward/downward rotation of the proximal fragment: once the distal fragment is
surgically repositioned by means of MMF, the reference points are gone and it is a matter of
guessing the vertical level at which the proximal fragment needs to be plated (the surgeon
must also consider whether should it be rotated upward counterclockwise, or downward
clockwise). Some experts claim that there is no difference; however, the importance of the
anteroposterior (A-P) position is often underappreciated (Fig. 8.2). Fixation of the proximal
fragment in its original A-P position is the key to long-term stability because this position
maintains the preoperative hinge axis and musculoskeletal balance.
Rotation downwards or upwards can result in long-term changes in the position of the mandible,
including protrusion or retrusion. Moreover, for a bimaxillary "mandible first" surgery, the ver-
tical position of the proximal fragments during plating may have a crucial effect on the A-P
position of the osteotomized maxilla, and even on the inclination of the occlusal plane.
Plates or screws can be used for osteosynthesis of the mandible. It is the surgical technique
and degree of passivity, rather than the type of fixation, which are important. Plate fixation
is more passive than screw fixation; however, in experienced hands, both methods work
equally well as long as the fixation method does not influence the vertical and the transversal
position of the proximal fragments. There are a few prerequisites for a successful result:
Fig. 8.1. Dental arches wired into a splint

(bi maxillary mandible first surgery).
58
Fig.8.2.
Asymmetric advancement
with rotation provides no clue
as to the vertical level at which
the proximal fragment needs
to be fixed.
-No CW or CCW rotation of the proximal fragment
The proximal fragments must be fixed at the same preoperative position in the sagittal plane.
The position of the proximal fragment has a major influence on the stability of the entire system
and the final occlusion. Posterior (downward) rotation of the proximal fragment followed by
fixation may have a tendency towards Class Ill occlusion, whereas anterior (upward) rotation of
the proximal fragment has a tendency toward Class II occlusion at long-term follow-up.
If a straight advancement or setback is planned, it is quite easy to predict the final and correct
position of the proximal fragments. Usually, the lower border of the mandible is the key
to successful osteosynthesis. However, if a CW or CCW rotation along with advancement or
setback of the distal fragment is planned, the lower border of the jaw should not be used as a
reference. Instead, 3D simulations may better reveal the correct interrelationship between the
fragments. For CW rotations, the proximal fragment should be fixed in a lower position relative
to the distal fragment. By contrast, for CCW rotations, the proximal fragments should be fixed
higher relative to the distal fragment. The position of the plates, therefore, needs to be estimated
before fixing the first screw; otherwise, a plate fixed to the proximal fragment in an extremely
high or low position adversely affects the position of the entire proximal fragment (Fig. 8.3 A,B).
When an occlusal cant has to be surgically corrected in the frontal plane, understanding the
interrelationship between the fragments is more difficult. If the higher side of the distal frag-
ment is brought down, the proximal fragment should be fixed relatively higher. Conversely,
if the lower side is brought up, the proximal fragment should be fixed relatively lower
(Fig. 8.4 A,B). It is obvious that these solutions, in combination with the asymmetric
CCW advancement plan, make it very difficult to appreciate the vertical interrelation-
ship between the fragments unless a 3D simulation is performed.
In cases in which the mandible is operated on first and the maxilla second, incorrectly positioning
the proximal fragments may change the hinge axis and closing pathway of the lower jaw and intro-
duce projection errors of the entire maxillomandibular complex. Moreover, if the proximal fragments
are rotated in opposite directions in the sagittal plane relative to their preoperative position, the
hinge axis may become asymmetric, resulting in an occlusal cant of the upper and lower occlusal
planes when the maxillomandibular complex is closed to the necessary facial height (Fig. 8.4 C-G).
59
08. Osteosynthesis of the mandible
Fig. 8.3. Initial positioning of the osteosynthesis plate fixation for CCW (left) and CW (right)
rotation of the distal fragment.
A. Incorrect: the plate is fixed too high on the proximal fragment in the left image; therefore, the
proximal fragment will have to be pushed down from its original position. The plate in the right image
is fixed too low. Therefore, the proximal fragment will have to be lifted up from its original position
to enable the placement of two screws in the front end of the plate to secure the distal fragment.
B. Correct: the location of plates was estimated such that they would not induce a change in
the vertical level of the proximal fragments once connected to the distal fragment.
In general, maintaining the correct position of the proximal fragments throughout surgery is
critical in cases of a "mandible first" operation, in which the upper jaw is cut and fixed to the
operated lower jaw and subsequently autorotated to achieve the necessary height. The
truth is, during a virtual treatment simulation, the initial hinge axis of the lower jaw and the
opening/closing pathways of an unoperated jaw (with unaltered anatomy) are considered to
be known parameters. However, once the lower jaw is osteotomized and the body shortened
or lengthened, or the proximal fragments are rotated CW or CCW, changes in the position of
the proximal fragments affect the biomechanics of the lower jaw. If this is the case, the hinge
axis changes its position, and the maxillomandibular complex (comprising the operated lower
jaw and the osteotomized floating upper jaw) may close at unpredicted A-P locations. If the
proximal fragments happen to rotate upward or CCW, the maxilla will not reach its planned
position in the A-P plane following surgery. Alternatively, a late backward displacement of
the entire lower jaw may occur. resulting in Class II occlusion. By contrast, if the proximal
fragments are rotated downward or CW, the maxilla may be too far forward of its planned A-P
position, whereas a late forward displacement of the lower jaw or a tendency towards a Class
Ill occlusion may occur regardless of the degree of preoperative occlusion (Fig. 8.5 A-C).
60
Fig. 8.4. Unwanted changes in the hinge axis when correcting a mandibular cant:
A,B. The right side of the distal fragment is repositioned downward due to correction of
the cant. The proximal fragment remains in its original position. The left side of the distal
fragment is repositioned upward. The proximal fragment remains in its original position.
C. The jaw closing vector of the proximal fragment is unchanged when the proximal
fragment is in its original position (correct).
D. Closing vector of the right side of the jaw becomes more horizontal due
to posterior rotation of the proximal fragment (incorrect).
61
Fig. 8.4. Unwanted changes in the hinge

axis when correcting a mandibular cant:
E. The jaw closing vector of the left
proximal fragment is unchanged when
the proximal fragment is in its original
position (correct).
F. The jaw closing vector becomes
more vertical when the left proximal
fragment is rotated upward into a more
"beautiful" position (incorrect).
G. Differential changes in the jaw closing
vectors of the proximal fragments can
cause asymmetric jaw opening and
closing after surgery.
Therefore, the proximal fragments must be kept in their exact positions to prevent such
adverse consequences. This is not always feasible, for example, in cases with large
maxillary impactions in which the lower jaw has to autorotate, or in cases with large CW
rotations. In such cases. one should use a maxilla first protocol to avoid errors in positioning
the proximal fragments (Fig. 8.6 A,F).
-Adjustment of the transversal position of the proximal fragments
With the condyles correctly seated and the vertical position of the proximal fragments adjusted,
the final steps need to be performed. The proximal fragment is rotated in the frontal plane
to meet the distal fragment in the anticipated position (according to the 30 simulation).
If the fragment is prevented from reaching the desired position by a collision point, any bony
interferences need to be reduced and the entire positioning process repeated. The anterior
part of the proximal fragment is rotated inward or outward according to the plan. Once this
has been achieved, it is the time to proceed with the osteosynthesis.
62
c.o:::
• •10 I • -10 I
:1J.:; r1t:..
. ,;~ ,., " ;,,. . JS ~H
13.9 :6.1 • B.9 .: 6.~
v~·~ . .::·!-.
"'6 -~: : 5.6 _. -I 2.6 ~ .•5 6 .14
-." - rt~.:.~,
. -111:1; _:/,
: •0.9
~ 0 I .JI .t
. ..
~ ., f
]
1).\ ·-:: ~
Original position Anterior rotation
• -10 I
Lo9
\
• 0 I 41 _i
I~ t)
.. r
Large anteriorrotation Posterior rotation
Fig. 8.5. Influence of the vertical positioning of the proximal fragment on the final anteroposterior
position of the jaws in a case of bimaxillary surgery using a "mandible first" approach.
A. Four different positions of the proximal fragment.
- Initial plate fixation to the proximal fragment
A two-tailed instrument is placed on the lower part of the anterior edge of the proximal fragment,
and then pushed back to pre-seat the condyle and examine the size of the osteotomy gap. After
the intended position of the plate on the proximal and distal fragments is marked. the proximal
fragment can be released. A plate of adequate length should be chosen for the osteosynthesis.
A clamp is then placed on the upper border of the proximal fragment, which is then gently
lifted up. The first hole is drilled while holding a short toe-out retractor at a right angle to the
proximal fragment. The plate is bent as follows to enable a better fit with the anatomy of the
proximal fragment: an inferior twist of the most posterior segment of the plate is performed
first, followed by an inward bend at the second ring hole. The front end of the plate does
not usually require bending.
63
Fig. 8.6. The position of proximal fragments normally changes in cases in which the facial
height is significantly altered.
A. Maxillary impaction is planned, along with osteotomy and autorotation of the mandible.
B. Left: repositioned maxilla (maxilla first protocol) showing sufficient space for splint
production. Right: repositioned mandible (mandible first protocol) showing collision
and overlap of the upper and lower dental arches.
C. Opening of the lower jaw around an imaginary hinge axis to create adequate
space for the intermediate splint.
65
Fig. 8.6. The position of proximal fragments normally changes in cases in which the facial
height is significantly altered.
D. Different outcomes resulting from proximal fragment fixation: large anterior rotation
(left), anterior rotation (center), and the original position (right).
E. Simulation of Le Fort I osteotomy and MMF. Large anterior rotation of the proximal
fragments (left), anterior rotation (center), and the original position (right).
F. Simulation of maxillomandibular autorotation around an altered hinge axis: greater
anterior rotation of the proximal fragment yields more deficient anteroposterior projection
of the maxilla and a more convex facial profile with respect to an arbitrary vertical reference
line (black line). Large anterior rotation of the proximal fragments (left), anterior rotation
(center), and the original position (right).
The plate is pre-fixed by placing a screw into the second ring hole, taking care to correct the
position of the plate. Then, the clamp is pushed down to the planned position to approximate
the proximal fragment, and the position of the plate is corrected by rotating it around the
screw in the second ring hole using forceps. Once the position is satisfactory, the clamp is
lifted up again and a second hole is drilled into the most distal hole of the plate.
66
A second screw is inserted and both are tightened. A notch is then made in the top of the
proximal fragment to facilitate an anterior downward push during the condyle positioning
procedure. A two-tailed instrument is placed on the lower part of the anterior border of the
proximal fragment to pre-seat the condyle, and the osteotomy site is checked for premature
collisions and balancing of the proximal fragment. If there is no collision in the desired position,
the anterior end of the plate is adjusted to the surface of the distal fragment using in-site plate
bending forceps while holding the proximal fragment in the pre-seated position (Fig. 8.7 A-E).
Fig. 8.7. Single vector seating of the condyle (incorrect).

A. Condylar sag with dental arches fixed in occlusion during general anesthesia.
B. Single vector seating of the proximal fragment upward and backward.
C. Fixation of a plate while the condyle is seated posteriorly.
D. Once the maxillomandibular fixation is released and the patient recovers from general
anesthesia, the mandible acquires a musculoskeletally-stable position and there is
an anterior occlusal shift.
E. Posterior pressure on the proximal fragment, or postoperative traction to control Class Ill
occlusion, may cause immediate or late anterior disc displacement (red arrows).
67
- Tri-vector seating of the condyles
The purpose of surgery is to bring the distal fragment to a precise Class I occlusion while
leaving the proximal fragments to acquire a musculoskeletally-stable position. Furthermore,
the condylar heads have to appear in the upfront position within the fossae. Thus, it is possible
that the centric occlusion and centric relation will coincide after the patient recovers (provided
there is no disc displacement). The surgeon uses a two-tailed instrument to push the anterior
part of the proximal fragment down while using his or her other hand to bring the gonial angle
up. Once the condyle is seated in the fossa, the surgeon simulates forward movement of the
jaw by bringing the entire proximal fragment forward (Fig. 8.8). The surgeon should feel the
condylar head and disc sliding over the eminence. The condyle is then repositioned in the
fossa. This movement is repeated several times to feel the depth of the fossa and to determine
the most anterior and superior points at which the condyle begins descending down the
eminence. This completes the procedure of tri-vector seating of the condyle. With the condylar
head in this position, the fragment should be stabilized and fixed to the distal fragment. Do
not apply extreme force at this stage since forceful compression of the proximal fragment may
result in damage to the soft tissue components of the TMJ (Fig. 8.9 A-G).
Fig. 8.8. During surgery, the position of the proximal fragments must match the 30 simulation.
This ensures that no mistakes are made that result in an alteration of the hinge axis.
Fig. 8.9. The sequence of osteosynthesis.

A. The proximal fragment is gently lifted up and a pre-bent plate
is fixed using a proximal screw.
B. Once the position of the plate is checked and readjusted, a second screw
is placed in the proximal fragment.
68
Fig. 8.9 C. A notch is made in the upper border of the proximal fragment to enable better control
during condylar seating. D. The distal part of the plate is bent to adapt to the bone surface.
Fig. 8.9. The sequence of osteosynthesis.

E. Positioning and seating of the proximal
fragment. A two-tailed instrument is placed
into the notch to control the fragment.
F. The gonial angle is pushed up while the
notch is pushed down to seat the condyle
into the upper-most and front-most positions,
then the proximal fragment is advanced to
feel the slope of the articular eminence.
G. Two screws are inserted into the distal
fragment by the assisting surgeon while
the proximal fragment is held in place.
69
-Passive fixation without compression of the fragments
The last two screws are inserted into the distal fragment while it is held in a passive position.
Tightening the last two screws should play no role in the final position of the proximal fragment.
The second plate is necessary in cases of large CCW advancement, or in cases of moderate ad-
vancement in which the mandible is operated on first. Also, in cases of large CW advancement,
the distal and proximal fragments overlap slightly at the site of osteosynthesis. Poor access to the
proximal fragment once it has been fixed with the first plate means that the second plate can be
fixed through a trocar (Fig. 8.10). An angled screwdriver is also an option for fixation. In cases of
asymmetry, and when there is no contact point between the fragments, an additional bicortical
positional screw should be placed on each side to transversally stabilize the framework of the
newly constructed mandible. Double plates provide better control over the position of the proximal
fragment in the sagittal plane; however, they may not fit well enough to maintain the transverse
dimensions. Therefore, the distal fragment may shift transversally and affect the position of the
gonial angles. The use of positional bicortical screws may eliminate this problem (Fig. 8.11 A-D).
Fig. 8.10.
The second plate
can be fixed through
a trocar if needed.
Fig. 8.11. Fixation of an asymmetrically advanced mandible.

A. Simulation of the split.
B. The more advanced right side is fixed with two plates, whereas the less advanced
left side is fixed with a single plate.
70
C
Fig. 8.11. Fixation of an asymmetrically advanced mandible.

C. An additional bicortical screw is placed on the right side and two additional screws
are placed on the left side to provide transverse stability to the framework.
D. lntraoperative view.
Some surgeons use only positional bicortical screws. Although this makes the procedure faster,
the screw may displace or torque the condyle (Fig. 8.12 A). Moreover, to accommodate a
bicortical positional screw, the upper margin of the proximal fragment must be positioned close
to the upper margin of the distal fragment. Therefore, the proximal fragment may need to be
rotated upward or downward to make screw fixation feasible (Fig. 8.12 B). Consequently, this
method of osteosynthesis would interfere with both the surgical plan and the position of the
proximal fragments; therefore, it is not the preferred option. Moreover, intentional CW or CCW
changes in the position of the proximal fragment are not recommended due to subsequent
alterations to the hinge axis, which influences the opening and closing pathway of the man-
dible. This makes particular sense when the mandible is operated on first (Fig. 8.12 C).
Fig. 8.12 A. There is a danger of condylar torque and displacement only if bicortical
screws are used as lag-screws rather than positional screws. B. CW-rotated distal
fragment triggers incorrect upward rotation of the proximal fragment.
Fig. 8.12 C. Correct position of the proximal fragments during CCW (left) and CW (right)
rotation of the distal fragment. Red arrows indicate incorrect adjustments, which are often
made by clinicians who choose screw fixation as the preferred method.
The surgical techniques, along with the advantages and disadvantages of these two types
of mandibular fixation, are shown in Table 8-1.
Table 8-1.
Fixation types and the surgical sequence for BSSO.
. ..
Plates 1. Twist the plate at the first screw- 1. Friendly to the 1. Not rigid enough
hole and bend the plate across the condyles - lower in the transversal
second screw-hole. chance to produce dimension for large
condylar torque. advancement cases
2. Fix the plate to the proximal when long plates
fragment with one screw at first. 2. If malocclusion is are used.
observed after the
3. Adjust the proximal fragment surgery proximal 2. Longer operating
and check the position of the plate; fragment may be time.
if necessary, rotate the plate up or readjusted easily
down. Consider the space that may by removing the 3. Requires
be needed to place a second plate screws from the additional bicortical
below the first plate. distal fragment and screw fixation when
replacing them In a there is no point of
4. Gently lift the proximal fragment new position. contact between
to insert the second screw. the fragments.
5. Drill a notch into the proximal

fragment for the condylar
seating instrument.
72
Table 8-1. (Cont.)
Fixation types and the sequence of surgical steps for BSSO.
/ ,:. , ... ';\:{
Disadvantages "" '
Plates 6. Perform condylar seating by 3. Plates serve as a

pressing the anterior part of the "tent" and protect
proximal fragment down and the bone graft from
angle of the mandible up. the soft tissue
invagination and the
7. If necessary adjust the shape of formation of a notch
the plate with a plate bender. in the lower border of
the mandible in cases
8. Ask an assisting surgeon to of big advancements.
drill and insert another two screws.
9. Place a second plate if it is

needed.
10. In cases of moderate to big

advancement, asymmetries
of CCW rotations, consider
placement of additional positional
bicortical screws to stabilize the
framework in the transversal
dimension.
Positional 1. Apply a trocar. More rigid fixation 1. Very rigid fixation is

screws Shorter operating less friendly to the
2. Perform condylar seating by time. condyles if they are
pressing the anterior part of the unintentionally
proximal fragment down and the torqued.
angle of the mandible up.
2. Necessity to rotate
3. Ask an assisting surgeon proximal fragments up
to drill and Insert bicortical to accommodate
positional screws. bicortical screws
Beware of compressing may result in:
the proximal fragment and
subsequent condyle torque! • inaccuracies if a
mandible first proto-
col is used for CCW
advancement
. reduced projection
of gonial angles in
case of CW rotation
· posteriorized
condyles due to
CW rotation of the
proximal fragments
73
Checking
• the occlusion
When the osteosynthesis of the mandible is complete, release the MMF, remove the splint,
and check the occlusion by applying a tri-vector seating force to the mandible. A few extra
minutes may be needed for the mandible to acquire a neutral position. One of the main
criteria for a correct position is the coincidence of the upper and lower midlines. Perform a
forced protrusion test by pushing the gonial angles forward to verify the symmetry of the
anterior movement. Sliding of the condylar heads and discs over the eminences can be
effectively determined this way. If the forced protrusion test is negative or asymmetrical,
care should be taken to redetermine the occlusion by means of tri-vector seating (Fig. 9.1).
If the occlusion is incorrect, remove the fixation and correct the position of the proximal
fragments. Then, perform the osteosynthesis again using the same splint and protocol.
Fig. 9.1. Tri-vector testing of the occlusion: place the thumbs on the chin and push it down.
At the same time, the fingers gently lift the gonial angles and seat the condyles into the
fossa. The little fingers thrust the jaw forward gently. Lateral movements and
protrusion are also checked.
74.
Grafting
the osteotomy site II
It is preferable to fill any gaps larger than 10 mm with autogenous bone or with osteo-
conductive bone substitutes to accelerate and improve bone healing. As a general rule,
a certain amount of bone can be collected from the osteotomy sites during the operation.
These bone particles can either be used alone or they can be mixed with collagen and bone
substitutes to achieve a semi-solid implant before grafting. Patients with a thin soft tissue
envelope will benefit from grafting because they are more prone to formation of antegonial
notches due to bone remodeling at the osteotomy sites (Fig. 10.1). Grafting a lower jaw
osteotomy gap in the area of the inferior cut is advisable when there is a full thickness gap
as this will prevent notching (Fig. 10.2 A-C).
Fig. 10.1. Antegonial notching in a patient with thin skin 1 year after large BSSO
advancement surgery without grafting. Notching results from remodeling
of the lower border of the mandible.
75
10. Grafting the osteotomy site
Fig. 10.2. Plate removal at the

patient's request.
A. The osteotomy site is re-entered
9 months after the initial surgery
and the plate is exposed.
B. Full integration of the non-resorbable
hydroxyapatite that was used during
the BSSO procedure.
C. No loss of volume or notching
is observed on the CT scan.
76
Suturing
and finishing
•
The intraoral wounds should be sutured in two layers. First, place interrupted resorbable
sutures into the buccinator muscles and then close the mucosa with an interrupted
resorbable suture. A running suture is also an option; however, they tend to shrink the
length of the wound. Suction drains are not needed in most cases. Place light vertical
elastics when the throat pack is removed. A cooling mask is applied for 1-2 days and
pressure bandage is applied for 3-4 days. Note that if the pressure bandage is too
tight, it may push the lower jaw back by 1-2 mm; however, do not worry too much as the
occlusion will rebound immediately when the pressure bandage is removed.
Recovery from
II general anesthesia
The surgeon may want to wait for the patient to wake up from GA before checking the occlusion.
The anesthesiologist should not use a mouth gauge, not even the rubber ones used to
facilitate the intraoral suction of saliva and blood before extubation, as the patient may
accidentally bite into the gauge upon recovery. This can change the position of the
fragments and cause an occlusal shift.
Once spontaneous breathing and muscle tone are restored, the true occlusion can be assessed.
If the surgery has been successful, the patient usually bites into a perfect Class I occlusion, with no
open bite in the posterior aspects and with the upper and lower midlines coinciding.
Once the surgery is over. there are almost no opportunities for major adjustments to the
occlusion unless the surgeon decides to perform the surgery again. However, nonsurgical
correction is possible in cases of slight malocclusion.
If the lower jaw was fixed with a single plate, there will be a small degree of mobility in the sagittal
plane at the osteotomy site. In such cases, slight nonsurgical corrections can be made during
the first few days after surgery. Fixation with two plates, or with one plate and a bicortical screw,
makes the construction more rigid and defects are impossible to correct non-surgically.
There are only two types of nonsurgical jaw molding options that can be performed within
the first days of surgery:
1. Pressing the gonial angle up (extraorally) on one side while pressing the anterior front
teeth down (intraorally). This increases the gonial angle; therefore, the length of the man-
dible on the corrected side increases. This closes a posterior open bite (if there was one)
and shifts the midline to the contralateral side. This method should only be used in cases
of a posterior open bite; otherwise, it may produce premature contact at the molars and an
anterior open bite when the midlines coincide.
2. Pressing the chin up (extraorally) and the molars down (intraorally). This reduces the
gonial angle; therefore, the length of the mandible on the corrected side decreases. This
maneuver opens the bite posteriorly and shifts the midline to the corrected side. This method
should only be used in cases of posterior premature contact at the molars or an anterior
open bite with the midline shifted to the contralateral side. Otherwise, although any attempt
to correct the midline to the ipsilateral side may be successful, it can also open the bite
posteriorly, which is quite difficult to manage.
78
Recommended reading
Fundamentals of orthognathic surgery:
1. Arnett GW, McLaughlin RP. Facial and Dental Planning for Orthodontists and Oral Surgeons.
St Louis: Mosby, 2004.
2. Epker BN, Wolford LM. Dentofacial Deformities: Surgical Orthodontic Correction. Mosby, 1980 Jan.
3. Ellis E, Zide M. Surgical Approaches to the Facial Sceleton. 2 edition. Philadelphia,
Lippincott Williams & Wilkins; 2005 Dec.
4. Fonseca RJ. Oral and Maxillofacial Surgery: Orthognathic surgery, esthetic surgery, cleft and
craniofacial surgery. Saunders/Elsevier, 2009.
5. Harris M, Hunt N. Fundamentals of Orthognathic Surgery. Imperial College Press, 2008 Jun.
6. Obwegeser HL. Mandibular growth anomalies - terminology - aetiology - diagnosis - treatment.
Berlin: Springer-Verlag; 2001.
7. Obwegeser HL. Orthognathic surgery and a tale of how three procedures came to be:
a letter to the next generations of surgeons. Clin Plast Surg 2007, 34:331-355
8. Proffit WR, White RP, Sarver DM. Contemporary treatment of dentofacial deformity. Mosby, 2003.
9. Reyneke JP. Essentials of Orthognathic Surgery. 2 nd ed. Chicago, Quintessence, 2010.
10. Ronchi P. Orthodontic-surgical treatment of dentofacial anomalies: an integrated esthetic-functional
approach. Quintessenza, 2005.
11. Sarver DM. Esthetic Orthodontic and Orthognathic Surgery. St Louis: Mosby, 1998.
Surgical techniques and postoperative stability issues:
12. Agbaje JO, Sun Y, De Munter S, Schepers S, Vrielinck L, Lambrichts I, Politis C. CBCT-based
predictability of attachment of the neurovascular bundle to the proximal segment of the mandible
during sagittal split osteotomy. Int J Oral Maxillofac Surg. 2013 Mar:42(3):308-15.
13. Angle AD, Rebellato J, Sheats RD. Transverse displacement of the proximal segment after
bilateral sagittal split osteotomy advancement and its effect on relapse. J Oral Maxillofac Surg.
2007 Jan; 65(1):50-9.
14. Brasileiro BF, Grempel RG, Ambrosano GM, Passeri LA. An in vitro evaluation of rigid internal
fixation techniques for sagittal split ramus osteotomies: advancement surgery. J Oral Maxillofac Surg.
2009 Apr;67(4):809-17.
15. Arnett GW. A redefinition of bilateral sagittal osteotomy (BSO) advancement relapse.
Am J Orthod Dentofacial Orthop 1993;104:506-515.
16. Bailey L', Cevidanes LH, Proffit WR. Stability and predictability of orthognathic surgery.
Am J Orthod Dentofacial Orthop. 2004 Sep:126(3):273-7.
17. Becktor JP, Rebellato J, Sollenius 0, et al. Transverse Displacement of the Proximal Segment After
Bilateral Sagittal Osteotomy: A Comparison of Lag Screw Fixation Versus Mini plates With
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81

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sag itta I split

1. The injection of local anesthetics .

2. Incision and access to the medial ram us........................................................... 2

4. The osteotomy line 14

5. Splitting the mandible 21

6. Controlling a bad or an unfavorable split 29

7. Adjusting the position of the bone fragments 47

8. Osteosynthesis of the mandible 58

9. Checking the occlusion 74

10. Grafting the osteotomy site 75

11. Suturing and finishing 77

12. Recovery from general anesthesia 78

About the authors 86

Fig. 1.1. Areas to be infiltrated with anesthetic (marked in green).

Bleeding Less Less More

Buccal nerve injury Minimal or no risk of Minimal or no risk of Possible buccal

Suturing The buccinator Part of the Suturing in two

4. The anterior border is stripped to gain access to the medial ramus.

5. The anterior border is stripped to provide access to the medial ramus.

Fig. 3.1. Areas of subperiosteal dissection (red).

Fig. 3.4 A. The retractor

Begin by performing a medial ramus corticotomy:

Next, proceed with the anterior cut:

Finish with buccal and inferior corticotomies of the mandibular body.

Fig. 4.2. A medial cut.

Fig. 4.3. The anterior cut.

Fig. 5.2 A,B.

~J) incomplete exposure will be achieved.

Fig. 5.7 D,E.

Fig. 5.7 F,G.

Next, perform maxillomandibular fixation (MMF) through a splint.

Fracture of the Upper part of anterior Complete the Remove third

Fig. 6.4. Management of an unfavorable long split.

'<. -··-, , ~ 'JaSA

Incomplete Angulation of the Use piezo surgery to A medial ramus

Comminuted Upward medial Endoscopic examination Cuts must be performed

Fig. 6.13. An example of a bad split.

Fig. 7.2 A,B.

a) Malocclusion after recovery and prolonged TMD symptoms;

4. IAN injury due to sharp bony edges and/or compression.

Fig. 7.4. The process of condylar torque and displacement.

--- Fig. 7.5. Transverse

Fig. 7.7 A. Flaring of the

Symmetrical mandibular setback

Fig. 7.8. Setback of the distal fragment.

Symmetrical Small to moderate outward Locate the premature bony

Asymmetrical Kick-out of the Determine whether premature contact kicks

Clockwise Kick-out of the proximal Usually, the point of collision is in area

Fig. 8.1. Dental arches wired into a splint

-No CW or CCW rotation of the proximal fragment

Fig. 8.4. Unwanted changes in the hinge

-Adjustment of the transversal position of the proximal fragments

Original position Anterior rotation

Large anteriorrotation Posterior rotation

- Initial plate fixation to the proximal fragment

Fig. 8.7. Single vector seating of the condyle (incorrect).

- Tri-vector seating of the condyles

Fig. 8.9. The sequence of osteosynthesis.

Fig. 8.9. The sequence of osteosynthesis.

-Passive fixation without compression of the fragments

Fig. 8.11. Fixation of an asymmetrically advanced mandible.

Fig. 8.11. Fixation of an asymmetrically advanced mandible.

5. Drill a notch into the proximal