Payal Bsso Ppt-1

BILATERAL SAGITTAL SPLIT RAMUS OSTEOTOMY
(BSSO)
Prepared By: Dr. Mehta Payal

Guided By :Dr.Nimisha Desai
HOD,
(Dept of OMFS ,ksd)
Contents:
 Presurgical orthodontics.
 Diagnosis and treatment planning.
 Cephalometric analysis
 Model surgery
 BSSO
 History
 Indication and Contraindication
 Advantages and Disadvntages
 Surgical technique
 Complication
 Related articles.
 Conclusion
 Presurgical orthodontics
 Alignment and leveling
 Decompensation.
 Arch coordination
 Presurgical orthodontics objectives in the transverse plane
 Presurgical orthodontics objectives in the vertical plane

Alignment and leveling
• Dental crowding, spacing, and rotations should be
corrected before orthognathic surgery.
• If segmental osteotomy is planned we should provide
spaces between the roots, so we can tip the bracket

• Curve of spee should be flat (according to ideal
occlusion)
• A better result may be achieved by completing

leveling post surgically .
• In short face , when an increase in face height is
desired, lower incisors should not be depressed before
surgery. Maintenance of curve of spee is needed(3-
point landing).
• In normal or excessive face height, leveling by
intruding the incisors should be done before surgery.

Decompensation
• Compensations can be dental or skeletal, vertical,
transverse and/or sagittal.
• Presurgical orthodontic decompensation is

essential to enable the surgeon to make a
considerable amount of surgical correction

Decompensation
Arch coordination
• Arch coordination refers to coordinating the widths of
the dental arches.
• Coordination involves:-
– Arch expansion.
– Arch contraction.
– Occlusal plane leveling and alignment.

Presurgical orthodontics objectives in
the transverse plane
• The problem is the skeletal or dental
• Dental discrepancies are usually treated by means
of buccal tipping of the posterior teeth while
skeletal discrepancies are corrected by bodily
movement of the posterior teeth.
• the tipping should not exceed 4 to 6 mm total.
• Bodily movement of the posterior teeth should be
done by means of segmental osteotomy.
• Is the problem relative or absolute
• Articulation of the casts into a class I occlusion
allows the clinician to easily distinguish between
relative and absolute maxillary constriction.
• If the occlusion is proper when the casts are

brought into class I canine relationship the
discrepancy is relative; otherwise, if a crossbite
still exists, then the discrepancy is absolute.
• Absolute skeletal transverse discrepancy requires
planning for segmental osteotomy or surgically
assisted rapid palatal expansion (SARPE).
• SARPE technique is used in cases with a severe

 discrepancy or when the transverse defect of
the maxillary bone is an isolated
skeletal anomaly.
• Segmental maxillary osteotomy is used for

more modest defects (up to 7 mm).
Correction of maxillofacial deformities requires careful analysis
of the soft tissue with clinical examination and supporting
photographs, skeletal evaluation with standardized radiographs,
dental impressions, face-bow transfers, bite registrations, and
articulator-mounted models.
Clinical assessment should be directed specifically at evaluating

the relative position and size of each of the facial skeletal
elements, the degree of zygomatic projection, and the maxillary
and mandibular positions in space relative to each other and to
the cranial-orbital region.
The nasolabial angle, upper lip length, lip competency, labial-

mental sulcus, and cervicomental angle should be documented
Facial balance typically is assessed by dividing the face in
thirds.
Facial proportions
Profile analysis; angle of convexity
Additionally, in profile view the face should have a slight degree of convexity as
measured from the glabella to the subnasale to the menton. Excess facial convexity,
flatness, or concavity is felt to be less than ideal. However, facial proportions are only
idealized concepts and have changed over time
Lip line
At rest 2-4 mm of incisor show.
During smiling, whole length of incisor

is showing.
If there is excess of gingiva is showing,

it may referred as a gummy smile.
Any facial asymmetry should be noted along with the relationship
of the maxillary dental mid line to the mandibular dental mid line
and the dental mid lines to the facial mid line.
The degree of dental display on repose and smile also should be

recorded with the amount of gingival display.
The muscles of mastication and TMJ function should be assessed.
The intraoral examination should focus on the dental alignment

within each arch and relationship of the dental arches to each
other.
The periodontal status of the teeth and the patient's hygiene

should be evaluated
Among the steps in planning for orthognathic surgery,
preoperative cephalometric tracings are noteworthy and should
be performed with accuracy.
Tracings are usually performed on transparent acetate paper.
Tracing may aid in getting the pattern of facial profile changes.
Repositioning these patterns may determine the choice of the

type of osteotomy and provide an estimate of the amount of
bone which must be advanced, recessed or grafted.
In addition, cephalometric records are valuable in assessing the

postoperative changes and accurately measure resultant relapse.
Anatomic landmarks
Skeletal Analysis
COGS ANALYSIS;
CHARLES J. BURSTONE
 Charles J. Burstone (April 4, 1928
February 11, 2015)
 He was an American orthodontist who

was notable for his contributions to
biomechanics and force-systems in the
field of orthodontics.
 He wrote more than 200 articles in

scientific fields.
Harry L. Legan
Dr. Legan is an internationally
recognized orthodontic expert
on diagnosis and treatment
planning, obstructive sleep
apnea, orthognathic surgery,
biomechanics, and distraction
osteogenesis.
Burstone and Legan in their 1980 proposed a paper for constructed
horizontal line. This line is drawn through nasion at an angle of 7
degrees to the SN line.
They developed this line because of reliability issues with the SN

line when one can easily place the Sella point up/down which can
change the cephalometric measurements
 Charles J. Burstone et al (1978, 1980) developed an analysis

specially designed for patients requiring Orthognathic surgery.
 They used the landmarks and the measurements that can be altered by
common surgical procedures.
 This analysis is also called as Cephalometrics for Orthognathic

Surgery (COGS)
HORIZONTAL PLANE SUBSTITUTED S-N
PLANE:
Burstone CJ et al Cephalometrics for orthognathic

Horizontal plane 7º to SN plane surgery, J Oral Surg . 1978 Apr ; 36(4):269-77.
COGS ANALYSIS:
ANALYSIS
HARD TISSUE SOFT TISSUE

HARD TISSUE
ANALYSIS
CRANIAL HORIZONTAL VERTICAL

BASE SKELETAL SKELETAL
PROFILE
MAXILLA& VERTICAL DENTAL

DENTAL
MANDIBLE
1.
Ar-Ptm is the distance between Ar
and Ptm which is measured parallel to
HP
 Standard Value
MALES 37.1 ± 2.8 mm
FEMALES 32.8 ± 1.9 mm
Ar-Ptm indicates the position of

mandible in relation to posterior
surface of maxilla
2.
A few simple measurements should be made on the skeletal

profile to assess the amount of discrepancy in anteroposterior
direction.
It is called as Horizontal Skeletal Profile analysis because all the
measurements in this set of analysis are made parallel to HP
ANGLE OF SKELETAL CONVEXITY
 It is the angle formed between N-A andA-Pg
 Standard Value
MALES 3.9⁰ ± 6.4⁰
FEMALES 2.6⁰ ± 5.1⁰
A positive angle indicates convex profile while

negative angle indicates concave profile
A perpendicular to HP is droppedfrom
N (N perpendicular) and horizontal
distance parallel to HP is measured from
point A
 Standard Value
☺MALES 0 ± 3.7 mm
☺FEMALES -2 ±3.7 mm
This measurement describes the position

of apical base of maxilla in relation to
nasion
It is obtained by measuring the
distance between Point B and Nasion
perpendicular (N perpendicular)
 Standard Value
MALES -5.3 ± 6.7 mm
FEMALES -6.9± 4.3 mm
This measurement describes the

position of apical base of mandible in
relation to nasion
It is obtained by measuring the
distance between Pogonion and Nasion
perpendicular (N perpendicular to HP)
 Standard Value
MALES -4.3 ± 8.5 mm
FEMALES -6.5 ± 5.1 mm
This measurement describes the

position of mandibular chin in relation
to nasion
3.
A Vertical skeletal discrepancy may reflect ananterior, posterior or
complex dysplasia of the face .
Distance between N and ANS measured
perpendicular to HP gives us the Middle
third facial height.
 Standard Value
MALES 54.7 ± 3.2 mm
FEMALES 50 ± 2.4 mm
Any increase or decrease in this value

indicates increased or decreased middle
third facial height respectively
Distance between ANS and Gn
measured perpendicular to HP gives us the
Lower third facial height.
 Standard Value
MALES 68.6 ± 3.8 mm

indicates increased or decreased lower
third facial height respectively
Distance between PNS and HP
gives us the posterior maxillary
height.
 Standard Value
MALES 53.9 ± 1.7 mm
Any increase or decrease in this

value indicates increased or
decreased posterior maxillary
height respectively
4.
To obtain upper anterior dental height,
perpendicular distance from incisal edge of
upper incisor to palatal plane is measured
 Standard Value
MALES 30.5 + 2.1 mm
FEMALES 27.5 + 1.7 mm

indicates increased or decreased upper
anterior dental height respectively
To obtain lower anterior dental height,
perpendicular distance between incisal
edge of lower incisor to MP is measured
 Standard Value
MALES 45 ± 2.1 mm

anterior dental height respectively
To measure upper posterior dental height
a perpendicular line is dropped from the
tip of mesiobuccal cusp of upper first
molar to palatal plane
 Standard Value
MALES 26.2 ± 2.0 mm
FEMALES 23 ± 1.3 mm

indicates increased or decreased upper
posterior dental height respectively
To measure lower posterior dental height
a perpendicular line is dropped from the
mesiobuccal cusp of lower first molar to
MP
 Standard Value
MALES 35.8 + 2.6 mm

posterior dental height respectively.
5.
 ANS and PNS are projected on HP
Distance between these two points on

HP gives us total effective maxillary
length
 Standard Value
MALES 57.7 + 2.5 mm
Mandibular ramal length is the linear
distance between Articulare and Gonion.
 Standard Value
MALES 52 ± 4.2 mm
Variation in Ramal length can be a

causative factor for skeletal open bite or
deep bite
Mandibular body length is the linear
distance between Gonion and Pogonion
 Standard Value
MALES 83.7 ± 4.6 mm
 increase in length denotes skeletal class III
 decrease in length signifies skeletal class II

 This measurement describes the prominence
of chin in relation to mandibular apical base.
 It is obtained by measuring the distance b/w

point B and a perpendicular to mandibular plane
passing through Pg.
 Standard Value
MALES 8.9 ± 1.7 mm
This measurment represents the
relationship between the ramal plane and
mandibular plane
 Standard Value
MALES 119.1 ⁰ + 6.5 ⁰
FEMALES 112⁰ + 6.9 ⁰
 Gonial angle also contributes to skeletal

open bite or deep bite.
6.
OP is Occlusal Plane constructed from
buccal groove of first permanent molars
through a point 1 mm apical to the incisal
edge of the upper central incisors.
When incisors are not in proper overbite

relation, two OP are to be constructed,
upper and lower and mean to be taken.
 Standard Value
MALES 6.2 ⁰ ± 5.1 ⁰
FEMALES 7.1 ⁰ ± 2.5 ⁰
 An increased OP-HP angle may be associated

with skeletal open bite, lip incompetence and increased anterior facial height
An decreased OP-HP angle may be associated with skeletal deep bite,
decreased anterior facial height and lip redundancy.
This distance is obtained by measuring
the distance between projection of PointA
and Point B on OP .
 Standard Value
MALES - 1.1 + 2.0 mm
FEMALES - 0.4 + 2.5 mm
This distance gives us relationship

between maxillary and mandibular apical
bases in relation to OP.
This angle is constructed by intersecting
a line passing through the tip of insical
edge through the root tip of upper incisor
and NF line.
 Standard Value
MALES 110 ± 4.70
FEMALES 112.50 ± 5.30
This angle gives us the inclination of

upper incisors in relation to palatal plane.
This angle is constructed by intersecting
a line joining the incisal edge of lower
incisor passing through its root tip and MP.
 Standard Value
MALES 95.9⁰ ± 5.2 ⁰
FEMALES 95.9⁰ ± 5.7 ⁰
This angle gives inclination of lower

incisors in relation to MP
SOFT
TISSUE
LIP
FACIAL POSITION
FORM & FORM
FACIAL
FORM
Facial
Convexity G-Sn/Sn- Sn-Gn-C Sn-Gn/C-
Angle G-Sn G-Pg M Gn
Angle
G-Sn-Pg
Facial Convexity Angle
G-Sn-Pg
Drop a line form Glabella ‘G’ to

Subnasale ‘Sn’ and a line Sn to soft tissue
pogonion ‘Pg’.
 Mean value : 12 ± 4⁰
 increased +ve value - convex profile
Increased -ve value - concave profile

(class3 skeletal and dental relationship)
MAXILLARY PROGNATHISM
G-Sn
Drop line perpendicular to horizontal
plane from Glabella. Measure the distance
from perpendicular line to Sn ( parallel to
HP)
 Mean value: 6 ± 3 mm
Describes the amount of maxillary

excess/deficiency in anteroposterior
dimension.
 +ve=maxillary prognathism.
 –ve=maxillary retrognathism.
MANDIBULAR PROGNATHISM
G-Pg
Drop a perpendicular line to HP from

Glabella. Measure the position of the
pogonion from this line parallel to HP.
 Mean value: 0 +/- 4
Increased –ve value indicate mandible is

retrognathic.
VERTICAL HEIGHT RATIO
G-Sn/Sn-M
Drop a perpendicular line to HP from

Glabella, to this line drop a perpendicular
line to Sn and M. Measure the distance
from G-Sn and Sn – Me ( all perpendicular
to HP )
The ratio of middle 3rd to lower 3rd

facial height measured perpendicular to
HP.
Ratio less than 1 = denotes

disproportionality and there is large lower
3rd face and vice versa.
Disadvantages - Further evaluation of

lower 3rd of face is needed.
LOWER VERTICAL HEIGHT DEPTH RATIO
Sn-Gn/C-Gn
Drop a line from Sn to Gn and C to Gn .

Measure the distance from Sn – Gn and C
–Gn .
 Mean value : 1.2 : 1
 If the ratio is more than 1 = short neck .
 Useful in determining the feasibility of

reducing / increasing the chin prominence.
LIP
POSITION
& FORM
Sn-
Ls to Li to Sn- INTER-
Cm-Sn-
Sn-Pg Pg
Si to Sn- StmS/ StmS- LABIAL
Ls Angle (Linear) linear Pg Sn- U1
GAP
StmI
NASOLABIAL ANGLE
Cm-Sn-Ls Angle
 Cm – Sn - Ls - NASOLABIALANGLE
Draw a line from Sn to Cm and drop a

line from Sn to Ls. Measure the angle
formed.
 Mean value : 102⁰ ± 8⁰
Important measurement in assessing the

anteroposterior maxillary dysplasias
ACUTE nasolabial angle = treated by
retracting the maxilla / maxillary incisors /
both.
OBTUSE nasolabial angle = suggests the
degree of maxillary hypoplasia and indicates
for maxillary advancement or orthodontic
proclination of maxillary incisors.
UPPER LIP PROTUSION
Ls to Sn-Pg (Linear)
Draw a line from Sn to soft tissue Pg,

the amount of lip Protrusion / Retrusion is
measured with perpendicular linear
distance from this line to the prominent
point of the lip.
 Standard value - 3±1mm
The abnormal values can be treated by

retracting or protracting the incisors ,
surgically or orthodontically advancing or
retracting the maxilla accordingly.
LOWER LIP PROTUSION
Li to Sn-Pg linear
Drop a line from Sn to Pg and the

amount of lip protrusion / retrusion is
measured with perpendicular linear
distance from this line to the most
prominent point of both lips .
 standard value - 2±1mm
By retracting / protracting the incisors

surgically / orthodontically advancing or
reducing the chin prominence , possible to
achieve desired lower lip.
MENTOLABIAL SULCUS DEPTH
Si to Sn-Pg
It is perpendicular distance

between deepest point on the
mentolabial sulcus to LiPg’line.
 Standard Value 4 ± 2 mm
is due to : TREATMENT
• Up righting the lower

1. Flared lower incisors. incisors.
2. Extruded upper incisors • Intruding the maxillary
impinging on lower lip. incisors,
3. Flaccid lip tone and
• Cheiloplasty to retract lower
abnormal morphology of lip —helps in reducing the
the lip itself . MLS.
4, Prominence of the chin also • Advancement genioplasty
contributes to deepened increases the deepening of
mento labial sulcus MLS.
• Reduction genioplasty
decreases the excess MLS
VERTICAL LIP CHIN RATIO
Sn-StmS/Sn-StmI
 To assess lower third of face
 Mean values : ( 1 : 2 )
Lower 3rd of the face ( Sn-Me ) can be

divided into three parts : length of the
upper lip ( distance from Sn to Stms )
should be approximately 1/3rd the total
and distance from Stmi to Me should be
2/3rd.
If the ratio becomes less than the normal

( ½ ) -- vertical reduction genioplasty is
recommended.
MAXILLARY INCISOR EXPOSURE
StmS- U1
It is obtained by measuring the distance

between tip of upper central incisor and
Stms.
 Standard Value -2 ± 2 mm
Increased incisor exposure may be due

to vertical maxillary excess or short upper
lip .
Decreased incisor exposure may be due

to vertical maxillary deficiency or larger
upper lip.
INTER-LABIALGAP
 It is the distance between Stms and Stmi
 Standard Value - 2 ±2 mm
Patients with vertical maxillary excess

tend to have large interlabial gap and lip
incompetence
Patients with vertical maxillary

deficiency tend to have no Inter labial gap
and Lip redundancy.
(Model surgery)
To initiate analytical model surgery, maxillary and mandibular impressions are
taken and stone casts poured.
These are subsequently mounted with a face-bow transfer onto an anatomic

articulator.
Landmarks, horizontal and vertical reference marks are made directly on the
casts to quantify the amount, the direction and extent of jaw movement.
Segmental cuts (Mock Surgery) are then performed on the casts to mimic the
cuts that will be made during surgery.
The casts are then remounted according to the prescribed movements determined
in the treatment plan.
Subsequently, surgical guide splint is fabricated, which is critical for the accurate
intraoperative positioning of the maxilla and/or mandible. Splint fabrication
can use self-cure or light-cure acrylic
Surgical guide splint fabrication
Splints and Stabilization
 The splint should be thin 2mm thickness with adequate strength.
 Splint stays in place during initial healing ( 3 to 4 weeks).
 It should be trimmed to allow good access to the teeth for hygiene

and permit lateral movements during jaw function.
 It should remain in place until the stabilizing wires also are replaced
with lighter and more flexible archwires
The final stage of the surgical planning process is transferring
surgical plan to operation room. Surgical splints are used to place
the osteotomized jaw bone segments into a desired position.
This approach, however, has drawback for accurate simulation of

real bony movement based on 2D radiographic evaluation and
dental models.
The limitations are directed to landmark identification and

overlapping of anatomic structures, especially for patients with
facial asymmetry .
Further, it is impossible to simulate different surgeries with a

single model. Once the model is cut, it is impossible to undo it
The advent of virtual surgical planning has recently called into
question the efficacy and accuracy of traditional analytical model
surgery which is time consuming and imprecise .
Currently three-dimensional imaging and computer simulation are

used for planning office-based procedures.
The system allows cephalometric analysis, can be used to perform

virtual surgery and establish a definitive and objective treatment
plan for correction of facial deformity, thus improving the
accuracy and reliability of diagnosis and treatment.
Moreover, unlike conventional model surgery on dental casts, this

technology allows to virtually perform multiple simulations of
different osteotomies and skeletal movements in order to evaluate
multiple surgical plans .
Three-dimensional imaging
3D cephalometric analysis
Computer-aided design and manufacturing (CAD/CAM)
technique, Virtual surgery
Surgical splints milled on polymethyl methacrylate
More recently, the concept of an occlusal-based
“orthognathic positioning system” has been introduced
The orthognathic positioning system has the
possibility to eliminate the inaccuracies commonly
associated with traditional orthognathic surgery planning
and to simplify the execution by eliminating surgical steps
such as intraoperative measuring, determining the condylar
position, the use of bulky intermediate splints, and the use
of intermaxillary wire fixation.
The system attempts precise translation of the virtual plan

to the operating field, bridging the gap between virtual and
actual surgery
Maxillary positioning guides firmly attached to splint with
bone footplates placed over previously drilled landmarks
Mandibular positioning guide held in place by
temporary screws before skeletal fixation
Genioplasty positioning guides in place after osteotomy
and repositioning of skeletal segment
Classification of Mandibular procedures
Ramus procedures Body procedures Genioplasty

Subapical body procedures
• Condylotomy(subcondylar osteotomy)
• Condylectomy
Anterior
• Saggital split osteotomy • Anterior to mental foramen
• Kole
• Vertical subsigmoid Step osteotomy/ ostectomy
• Combined
• Inverted ‘L’ midline symphyseal with midline
• ‘C’ or arching osteotomy • Posterior to mental foramen symphyseal
• Postcondylar grafts Y- ostectomy 2 Posterior
rectangular ostectomy 3 Total
Trapezoid ostectomy Inverted
‘V’ ostectomy
• Mandibuloplasty
PRINCIPLES IN TREATING MANDIBULAR
DEFORMITIES
• Patient’s perception of the deformity and expectations

• Surgeon’s recognition of the deformity
• Complete physical examination, model surgery,
cephalometric analysis
• Optimal treatment plan
• Counseling of the patient
• Informed consent
 COMMONLY USED • RARELY USED
Historical review…..
Schuchartd’s osteotomy Trauner & Obwegeser’s osteotomy
First described in 1942 by Schuchardt in

German literature
Evolution of the Sagittal Split Ramus Osteotomy of the mandible
❖ Obwegeser & Trauner technique (1957)
❖ DalPont modification (1961)
❖ Hunsuck modification (1968)
❖ Bell & Schendel (1977), Epker modification

(1977)
 Bell and Schendel established the biologic basis of
BSSO, by showing that with minimal detachment
of the pterygomassetric sling, intraosseous
ischemia and necrosis of the proximal segment
were significantly reduced.
Bell W, Schendel S. Biological basis for the sagittal split operation. J oral Surg
1977 ;35 : 362 -369
Epker published his modifications-
1977 – confirm the biological
criteria
 He stressed the importance of carrying the
lateral vertical osteotomy completely through
the inferior cortex for ease of splitting”
 The masseter was not reflected from the
lateral surface of the ramus
 The medial dissection was carried only to the
lingula
 No attempt was made to carry the dissection
to the posterior border of the mandible
• This research suggested to us that
– Study material favored the extension of the sagittal
osteotomy cut into the first molar area.
• Reasons :
– The buccal cortical plate is thicker
– Total mandibular width is thicker
– Distance between the inner aspect of the buccal
cortical plate and mandibular canal is consistently
greater in this area
– Third molar area is the least favourable area for cuts to
be made
– First molar and second bicuspid area – most favourable
area for extension of sagittal osteotomy
Rajchel J, Ellis E, Fonseca R: The anatomical location of the

mandibular canal: its relationship to the sagittal split ramus
osteotomy; Int J Adult Orthognath Surg 1986; 1: 37-47
Wolford SSRO modification
• Advocated bringing the vertical cut farther forward.
Position screws in preference to Lag
screws????
as a means of preventing possible nerve compression

and condylar displacement.
In 1990 Wolford introduced the concept of the inferior

border split
Smith’s et al studies - 1991
• I study – study concerned the level of fusion of
the buccal and lingual cortical plates in the area
above the lingula
• II study – concerned the thickness of the

buccal cortical plate
Mandibular Ramus Anatomy as It Relates to the Medial Osteotomy of
the Sagittal Split Ramus Osteotomy
Smith B, Rajchel J, Waite D, et al: JOMS 1991;49:112
.
✓Their research indicated that the fusion of cortical plates frequently occurs very
near the superior tip of the lingula and posterior to the lingula.
• What did there first research indicate ?
– Fusion of cortical plates frequently occurs very near the
superior tip of the lingula and posterior to the lingula
– mean length of horizontal cut should be 18mm.
• What did the second study tell?

– Confirmed that the buccal plate is thickest at the lateral
oblique ridge, very favourable for screw placement
Mercier studies*
• The posterior ramus had more cortical bone and less medullary
bone than the anterior ramus.
• Wolford stated that at the superior edge of lingula distance

between the buccal and lingual cortical plate increases while
superior to this region plates may be fused together
*Mercier P: The inner osseous architecture and sagittal splitting of the

ascending ramus of the mandible. J Maxillofac Surg 1:171, 1973
Cortical plate thickness in the retromolar area :
Relationship to rigid fixation of the SSRO
Section A : At the distal root of the second

molar
Section B : At the distal root of the third molar
Section C : just behind the third molar tooth
and just posterior to the posterior border of the
ramus
Location of section through the second molar and retromolar areas for thickness
of the cortical bone available for rigid fixation
Comparison of the mean thickness(mm) of the lingual
cortical plate at the superior border and 5mm above the
inferior border of the mandible*
(p < .001) (p < .001) (p < .001)
*Smith BR, Rajchel JL, Waite DE, Read L : Mandibular anatomy as it relates to rigid
fixation of the sagittal split ramus osteotomy JOMS 49: 22, 1991
PRINCIPLE
• Natural plane of cleavage between buccal &
lingual cortical plates of the ramus used to develop
sagittal split separating the proximal (condylar)
fragment from distal (dentoalveolar) fragment.
INDICATION CONTRAINDICATION
• Mandibular retrusion • Severe decreased
• Mandibular prognathism posterior mandibular
• Minor mandibular body height
asymmetry • Thin medio-lateral
• Cleft osteotomies[bimax width of ramus.
procedures] • Severe ramus
• Compensatory hypoplasia
repositioning of occlusal • Severe asymmetries
plane
➢ADVANTAGES
 Greater flexibility in repositioning the distal
segment.
 Better cancellous bone contact which enhances
healing.
 No external scar and injury to mar. mand nerve.
 Min. alteration in the position of the condyles and
the muscles of mastication.
 Maintain the angle of mandible in original position
even in large advancements
➢DISADVANTAGES
 Risk of injury to IAN is greater
Surgical technique
Surgical technique:
 Step 1: Infiltration of soft tissue with a
vasoconstrictor
 Step 2: Soft tissue incision.

Step 3: Buccal
subperiosteal dissection.
Step 4: Superior subperiosteal dissection.
Step 5: Medial subperiosteal dissection
& exposure of lingula.
 Step 6: Identification of the lingula.
Step 7: Medial Ramus Osteotomy
Step 8: Vertical Section Of The Osteotomy
Step 9: Removing the notched ramus retractor and placing
a channel retractor.
Step 10: Buccal osteotomy of the mandibular body.
Vertical cut
Step 8: Vertical Section Of
The Osteotomy.
Vertical cut joined
by the horizontal
cut
Step 10: Buccal Osteotomy of mandibular body.
Step 9: channel retractor placed at

inferior border of mandible
Step 11: Lavage.
Step 12: Defining the osteotomy cut with an
osteotome.
Step 13: Splitting the mandible.
Step 14: Completion of the split.
osteotomes used to
split
SPREADER
Used To Split The

Cortex
Step 15: Stripping The
Pterygomassetric Sling.
Step 16: Stripping the medial pterygoid muscle and stylomandibular
ligament.
Step 17: Removal of impacted third molars.

Step 18: Smoothing contact areas
of bone segments.
Step 19: Noting the position of IAN

bundle.
Step 20: Noting the position of
third molar.
Step 21: Mobilization of the distal
segment.
Step 22: Selective odontoplasty
Step 23: Removal of bone from the
proximal segment(in setback cases)
Step 24: Condylar
positioning.
Step 25: splint placed and secured with E-chains.
Splint placed Splint placed and secured wit E-chains

Step 26: Rigid fixation.
Step 27: Removal of
MMF & checking of
occlusion.
Step 28: Closure.
Step 29: Placing
elastics.
Osteosynthesis
• Post- operative fixation of the
osteotomised segments was once a great
challenge
• Initially,
No fixation of the fragments
Healing- intermaxillary splinting of the
teeth
• Introduction of wires for fixation

• Initially the use of three 2.7 mm “lag”
screws on each side was advocated
• Concern
• Compression may cause increased nerve
damage
• Displacement of the condyles, with
subsequent temporomandibular joint
dysfunction
• The position screw or bicortical screw
This technique permits maintenance of the gaps
between the proximal and distal fragments, with no
compression of the two segments together
• Osteosynthesis with miniplates

• 4- holed plate with 2screws on each side of the
osteotomy cut
• Resorbable screws
• Obvious advantage of resorbable fixation is to
obviate the need for future hardware removal
• 4 screws have to be placed on each side of the
mandible
WHAT IS A COMPLICATION
?
“Complication refers to an unintended

consequence of the surgery that causes harm to
the patient, occurring either intraoperatively or
early or late postoperatively”.
Steel BJ, Cope MR. Unusual and rare complications of orthognathic surgery: a literature review. Journal
of Oral and Maxillofacial Surgery. 2012 Jul 31;70(7):1678-91.
• Surgical relapse to varying degree can
occur after mandibular surgery
• Complications in orthognathic surgery
• Pre-operative phase
• Intra-operative phase
• Post-operative phase
PRE-OPERATIVE PHASE
• Limitations on surgical movement- failure to
eliminate dental compensations
• Molar root fenestrations, transverse surgical relapse-
Failure to manage transverse discrepancy
• Immpossibilility in achieving class I cusp relation,
overjet and over bite- failure to indentify and
manage tooth size discrepancies
• Root damage during osteotomies- failure to
properly level and achieve root divergence in
segmental cases
• Psychological preparation of the patient
INTRA-OPERATIVE PHASE
• Attributed to improper surgical technique and/or
failure to appreciate patient’s anatomy
• Unanticipated intra-op complications are not unheard
of and can be categorised into:
• Unfavourable osteotomy splits
• Nerve injury
• Bleeding
• Proximal segment malpositioning
• Miscellenaeous
Complications of Sagittal
Split Ramus Osteotomy
• Unfavorable osteotomy split
• Incidence- 18%
Abort the procedure
& perform after healing
Bad split
Correct the split &
Complete the procedure
Unfavorable splits
The incidence of unfavorable splits after a BSSO is between 3% and 20%.
Proximal segment (lateral) fractures
1. Small proximal fragment
2. Large proximal fragment
Distal segment (medial) fractures
1. Splits short of the lingula
2. Medial splits up the condyle
3. Distal segment splits (Behind the second
molar)
Proximal Segment
Fracture
• Also called “Buccal plate fracture”
• Most frequent
• Presence of impacted 3rd molar
• Recent removal of 3rd molar
• Age of thepatient
• Incomplete transection of the
inferior border
• Surgeon’s experience
• Fracture of distal segment occurred
more often in young people with
impacted 3rd molars
Distal Segment Fractures
 Splits short of the lingula

Failure to ensure that the bone cut dips into the fossa behind the
lingula
 Medial splits up the condyle

when starting the medial bone cut several millimeters superior to
the lingula or angling the cut in an oblique fashion toward the condylar
neck
 Distal segment splits (behind the second molar)

 Retained third molars
 Excessive prying of the segments along the
Ascending ramus before the lateral cut is ensured
 A fracture behind the second molar is difficult to
Manage
Prevention:
- Proper corticotomy (slow and careful).
- Place bur/saw blade parallel to mandibular occlusal plane for
medial ramus cut.
- Avoid placing too high medial cortical cut.
Management:
- Aggressive rigid fixation
- Reconstruction plates
- If bad splits on both sides, better
return to original position
Steel BJ, Cope MR. Unusual and rare complications of orthognathic surgery: a literature review. Journal of Oral
and
Maxillofacial Surgery. 2012 Jul 31;70(7):1678-91.
Unfavourable Osteotomies In
Mandible Leads To :
CONDYLAR NECK Occurs when horizontal osteotomy is misdirected

FRACTURES : posteriorly and superiorly.
BUCCAL PLATE Occurs when vertical osteotomy at inferior border is

FRACTURES: incomplete and sagital split is attempted.
Occurs when mandibular 3rd molars have not

LINGUAL PLATE been extracted before the surgery.
FRACTURE:
KABAN, L. B. TEXT BOOK OF COMPLICATIONS IN ORAL AND MAXILLOFACIAL SURGERY. ELSEVIER 1ST Ed
Morris DE, Lo LJ, Margulis A. Pitfalls in orthognathic surgery: avoidance and management of complications.
Clinics in
plastic surgery. 2007 Jul 31;34(3):e17-29.
MALOCLUSION:
- Uncommon (Common).
Causes: - Inadequate mobilization.
- Bony interferences and instability.
- Failure of fixation systems.
Prevention:
-Avoid abnormal forces on repositioned jaws while
extubation.
- Delay IMF and elastics.
Management: - If minimal - Class II& III dental elastics.

Steel BJ, Cope MR. Unusual and rare complications of orthognathic surgery: a literature review. Journal of
Oral and Maxillofacial Surgery. 2012 Jul 31;70(7):1678-91.
Morris DE, Lo LJ, Margulis A. Pitfalls in orthognathic surgery: avoidance and management of complications. Clinics in
plastic
surgery. 2007 Jul 31;34(3):e17-29.
OPEN BITE:
Causes: - Incorrect placement of fragments.
- Failure of rigid fixation.
- Occlusal shifts during fixation.
- Central condylar sag.
Management: - Minor discrepancies Aggressive Orthodontics

- Discrepancies < 3mm Vertical elastics
- Severe discrepancies Surgery
plastic surgery. 2007 Jul 31;34(3):e17-29.
VASCULAR COMPROMISE:
- Transient and due to reduced blood
supply to the osteotomized segments.
Causes:
- Excessive stripping of the periosteum.
- Loss of fixation and instability.
- Poor flap design.
Prevention: - Expose only necessary portion of mandible and chin.

- Periosteum stripping should be limited.
plastic
surgery. 2007 Jul 31;34(3):e17-29.
NERVE INJURY:
In Mandible - IAN is at risk and gets
damaged anywhere from pterygomandibular
space to the vertical osteotomy cut anteriorly
- Allodynia and traumatic neuroma of IAN occurs.
Morris DE, Lo LJ, Margulis A. Pitfalls in orthognathic surgery: avoidance and management of complications. Clinics in plastic surgery.
2007 Jul 31;34(3):e17-29
Steel BJ, Cope MR. Unusual and rare complications of orthognathic surgery: a literature review. Journal of Oral and Maxillofacial
Surgery. 2012 Jul 31;70(7):1678-91.
Causes: - Incorrect separation of soft tissues
- Lack of profound knowledge of anatomy
Prevention: -Care should be taken while splitting of

osteotomised segments in cases of incomplete
osteotomy cuts.
- Careful, gradual and controlled splitting under
direct vision
Management: - Exploration and decompression
- Repair nerve with standard techniques
Morris DE, Lo LJ, Margulis A. Pitfalls in orthognathic surgery: avoidance and management of
complications. Clinics in plastic surgery. 2007 Jul 31;34(3):e17-29.
Steel BJ, Cope MR. Unusual and rare complications of orthognathic surgery: a literature review. Journal of
Oral and Maxillofacial
Surgery. 2012 Jul 31;70(7):1678-91.
NERVE INJURY
Inferior Alveolar Nerve Function After Mandibular
Osteotomies
A. Westermark A, Bystedt H, Von Konow L
Br J Oral Maxillofac Surg (1998) 36,425428
The incidence of neurosensory deficiency was

 (39%) after sagittal split ramus osteotomy.
HEMORRHAGE:
In mandible - Due to injury to inferior alveolar, facial arteries,
retromandibular vein and pterygoid venous plexus.
- May lead to formation of hematoma.
• Incidence decreased from 38% in

1972 to 1% in 2005
• Most common sources

• Retromandibular vein
• Facial artery and vein
Prevention - Stay within the periosteal envelope.
- Hypotensive anaesthesia.
- Elevated head position.
- Careful sub periosteal dissection.
- For medial ramus, start dissection anteriorly
and proceed in postero-superior direction.
Management: - Ligation.
- Vascular clips or bipolar cautery.
- Dense packing.
Last resort: - Ligation of ECA.
- Catheterization with embolism.
Morris DE, Lo LJ, Margulis A. Pitfalls in orthognathic surgery: avoidance and management of complications. Clinics in plastic surgery.
2007 Jul 31;34(3):e17-29.
Sousa CS, Turrini RN. Complications in orthognathic surgery: a comprehensive review. Journal of Oral and Maxillofacial Surgery, Medicine,
and Pathology. 2012 May 31;24(2):67-74.
PROXIMAL SEGMENT MALPOSITIONING
• Counterclockwise rotation and condylar

distraction are frequent positional changes in
proximal segment
• MINOR DIFFICULTIES
• Herniation of buccal fatpad
• Difficulty in incision closure
• Breaking of bur
• Condylar Position:
• Failure to seat condyle in fossa rotation of

segment or Condylar torque or condylar sag….
– Lead to:
• Skeletal relapse,
• Malocclusion,
• Hypomobility or condylar head resorption..
✓ Positioning appliances
Relapse
- Cause is multifactorial
- Relapse is expected with mandibular advancements greater

than 7 mm
- Van Sickels - decrease in skeletal relapse when a 1- to 2-week

period of skeletal fixation was used with patients who
had advancements of 7mm or more.
- suprahyoid myotomies and orthodontic overcorrection.
- Suprahyoid myotomies - undergoing large mandibular

advancements and whose mandibular advancement is
accompanied by a large counterclockwise rotational
movement (i.e., patients with a steep mandibular plane
angle).
Ninety-two dried Thai
mandibles with known sexes
and ages were selected from
the collection at the
Department of Anatomy,
Faculty of Medicine Siriraj
Hospital, Mahidol University.
A lingula (arrow) is located on the internal surface of the ascending ramus

of the mandible. The inferior alveolar nerve and blood vessels (arrowhead)
pass lateral to the lingula and through the mandibular foramen into the
mandibular canal.
Shape of the Lingula
The most common shape was
the truncated type (46.2%)
and the least common was
the assimilated type (4.3%). A
bilateral shape (71.7%) was
found more often than a
unilateral one (28.3%). Each
type of lingula was more often
bilateral rather than unilateral Diagram showing four shapes of the lingula:
except for the assimilated type (a) truncated, (b) triangular, (c) nodular, and
and sometimes there were (d) assimilated
different shapes in one
mandible. Lingulae were found
bilaterally as truncated in 68
sides (51.5%), triangular in 36
sides (27.3%), nodular in 26
sides (19.7%), and
assimilated in two sides
(1.5%).
In conclusion, the present study provides the mean
height of the lingula was 8.2 mm(B). The mean
width of the mandibular foramen was 4.76 mm. The
lingula was located an average of 20.6 mm from the
anterior border of the mandibular ramus(a), 16.6
mm from the mandibular notch(c), the distance from
the lingual to the posterior border of the ramus(b)
was18.06 mm and 29.7 mm from the distal surface
of the mandibular second molar(A). In the majority of
mandibles studied,the lingula was located above the
occlusal plane.This finding may assist surgeons to localize
the lingula and avoid intraoperative complications.
(ORAL SURG ORAL MED ORAL PATHOL 1988;65:32-
4)
Twelve measurements were obtained from

each of 317 hemisected dried human
mandibles. These were made available by
the Department of Anatomy and Cellular
Biology, Tufts University School of Medicine
and Dental Medicine.
Narrowest antero posterior Nearest distance to the mandibular

ramal dimension. foramen from the narrowest
anteroposterior ramal dimension.
This study is of interest since it is the first time that the
gonial angle has been used in predicting the position of
the mandibular foramen
• The more obtuse gonial angle represents an expanded
growth potential of the mandible, while
• A less obtuse gonial angle indicates a lower growth
potential of this bone.
The results of this

study place the MF
just posterior to the
middle of the
ramus.
Angle between posterior ramal

border and inferior mandibular
border (gonial angle).
Mediolateral Position Of Mandibular
Canal –
Rajchel’s study
 What is the mediolateral position of the mandibular
canal as it courses from the mandibular foramen to
mental foramen ?.
 What is the safe position for the placement of the
lateral cortical cut ?.
 This research suggested to us that
◦ Study material favored the extension of
the sagittal osteotomy cut into the first
molar area.
 Reasons :
◦ The buccal cortical plate is thicker
◦ Total mandibular width is thicker
◦ Distance between the inner aspect of the
buccal cortical plate and mandibular canal
is consistently greater in this area
◦ Third molar area is the least favourable
area for cuts to be made
◦ First molar and second bicuspid area –
most favourable area for extension of
sagittal osteotomy
Rajchel J, Ellis E, Fonseca R: The anatomical location of the mandibular
canal: its relationship to the sagittal split ramus osteotomy; Int J Adult
Orthognath Surg 1986; 1: 37-47
 I study – study concerned the level of
fusion of the buccal and lingual cortical
plates in the area above the lingula
 II study – concerned the

thickness of the buccal cortical
plate
A B C
.
✓Their research indicated that the fusion of cortical
plates frequently occurs very near the superior tip of
the lingula and posterior to the lingula.
Cortical plate thickness in the
retromolar area : Relationship to
rigid fixation of the SSRO
Section A : At the
distal root of the
second molar
Section B : At the
distal root of the third
molar
Section C : just behind
the third molar tooth
and just posterior to
the posterior border of
the ramus
Location of section through the second molar and retromolar
areas for thickness
of the cortical bone available for rigid fixation
 What did there first research indicate ?
◦ Fusion of cortical plates frequently occurs
very near the superior tip of the lingula and
posterior to the lingula
◦ Mean length of horizontal cut should be
18mm and it should be 5mm above the
lingula.
 What did the second study tell?
◦ Cortical bone thickness was measured, at the
external oblique ridge and 5 mm above the
inferior border. The buccal and lingual
cortices were found to be significantly
thicker at the external oblique ridge than at
the inferior border. This suggests that there
may be an advantage in terms of stability to
placement of internal fixation screws at the
superior border.
Comparison of the mean thickness(mm) of the
lingual cortical plate at the superior border and
5mm above the inferior border of the mandible*
(p < .001) (p < .001) (p < .001)

• The position of the
lingula is posterior-
inferior relative to the
position of the
antilingula
• Any osteotomies
performed at a
measurement of 5 mm
posterior to the
antilingula (at the
level of the
antilingula)- no risk of
damaging the
neurovascular bundle
Accuracy of Using the Antilingula as a Sole Determinant
of Vertical Ramus
Osteotomy Position . J Oral Maxillofac Surg, 2007
Conclusion
 Surgical orthodontic treatment combined with

bilateral sagittal split osteotomy with semi-rigid
fixation can be effective for correcting the facial
profile and esthetic and occlusion in skeletal Class
III and class II malocclusion cases.
 Quick healing due to a good bony interface.
 good access with intraoral approach, so no extra

oral scar after surgery.
THANK YOU:

Payal Bsso Ppt-1

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BILATERAL SAGITTAL SPLIT RAMUS OSTEOTOMY

Prepared By: Dr. Mehta Payal

 Alignment and leveling

 Presurgical orthodontics objectives in the transverse plane

 Presurgical orthodontics objectives in the vertical plane

• Dental crowding, spacing, and rotations should be

corrected before orthognathic surgery.

• If segmental osteotomy is planned we should provide

spaces between the roots, so we can tip the bracket

• A better result may be achieved by completing

surgery. Maintenance of curve of spee is needed(3-

• In normal or excessive face height, leveling by

intruding the incisors should be done before surgery.

• Compensations can be dental or skeletal, vertical,

transverse and/or sagittal.

• Presurgical orthodontic decompensation is

considerable amount of surgical correction

the dental arches.

– Occlusal plane leveling and alignment.

• If the occlusion is proper when the casts are

• SARPE technique is used in cases with a severe

• Segmental maxillary osteotomy is used for

Clinical assessment should be directed specifically at evaluating

The nasolabial angle, upper lip length, lip competency, labial-

At rest 2-4 mm of incisor show.

During smiling, whole length of incisor

If there is excess of gingiva is showing,

The degree of dental display on repose and smile also should be

The muscles of mastication and TMJ function should be assessed.

The intraoral examination should focus on the dental alignment

The periodontal status of the teeth and the patient's hygiene

Tracings are usually performed on transparent acetate paper.

Tracing may aid in getting the pattern of facial profile changes.

Repositioning these patterns may determine the choice of the

In addition, cephalometric records are valuable in assessing the

 He was an American orthodontist who

 He wrote more than 200 articles in

They developed this line because of reliability issues with the SN

 Charles J. Burstone et al (1978, 1980) developed an analysis

 This analysis is also called as Cephalometrics for Orthognathic

Burstone CJ et al Cephalometrics for orthognathic

HARD TISSUE SOFT TISSUE

CRANIAL HORIZONTAL VERTICAL

MAXILLA& VERTICAL DENTAL

Ar-Ptm indicates the position of

A few simple measurements should be made on the skeletal

 It is the angle formed between N-A andA-Pg

A positive angle indicates convex profile while

This measurement describes the position

This measurement describes the

This measurement describes the

Any increase or decrease in this value

Any increase or decrease in this value

Any increase or decrease in this

Any increase or decrease in this value

Any increase or decrease in this value

Any increase or decrease in this value

Any increase or decrease in this value

Distance between these two points on

Variation in Ramal length can be a

 increase in length denotes skeletal class III

 decrease in length signifies skeletal class II

 It is obtained by measuring the distance b/w

 Gonial angle also contributes to skeletal