How to Prevent Mandibular Lower

Border Notching After Bilateral Sagittal

Split Osteotomies for Major
Advancements: Analysis of 168
Osteotomies
Mirco Raffaini, MD, DDS, PhD,* Alice S. Magri, MD,y Veronica Giuntini, DDS, PhD,z
Michele Nieri, DDS,x Clarissa Pantani, MD,k and Marco Conti, MD, DDS#
Purpose: Mandibular ramus bilateral sagittal split osteotomy (BSSO) has been the most commonly used
technique in orthognathic surgery for mandibular advancement. However, a common complication of
BSSO has been the occurrence of visible and palpable osseous defects at the inferior border of the
mandible. The aim of the present study was to determine whether bone grafting of the osseous defect
at surgery would reduce the defect at 1 year postoperatively compared with no bone grafting.
Materials and Methods: The present retrospective cohort study evaluated patients who had under-
gone mandibular ramus BSSO for 10 mm or more of advancement. The primary predictor variable was
BSSO surgery with bone grafting of the defect (graft group [GG]) versus no bone graft (no graft group
[NGG]). The size of the mandibular ramus inferior border defect was the outcome variable considered
within the framework of a 1-year postoperative cone beam computed tomography (CBCT) analysis.
Gender, age, and the amount of advancement were also considered in the multilevel regression analyses.
Results: From January 2012 to November 2016, 84 patients (168 osteotomies) had undergone BSSO sur-
gery with 10 mm or more of mandibular advancement at the Facesurgery Center (Parma, Italy). Their mean
age was 27.4 years (range, 17 to 44 years). Of the 84 patients, 40 had undergone BSSO with bilateral bone
grafts (GG). The monocortical block of the iliac crest bone was used as the bone homograft. The final re-
sidual defect was measured at 1 year postoperatively on CBCT scans. The GG and NGG had presented with
a mean final defect of 0.7 mm (range, 0 to 4.5 mm) and 3.0 mm (range, 0 to 5.5 mm), respectively. Com-
plete absence of the defect was achieved in 72% of the osteotomies in the GG and 9% of the osteotomies in
the NGG.
Conclusions: The use of an iliac crest bone allograft block in the gap between 2 segments during
mandibular advancement of 10 mm or more substantially reduced the size and incidence of inferior border
defects.
Ó 2020 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 78:1620-1626, 2020

*Professor, Facesurgery Center, Parma, Italy.
yPrivate Practitioner, Facesurgery Center, Parma, Italy.
zResident, Department of Experimental and Clinical Medicine,
University of Florence, Florence, Italy.
xPhD Student, Department of Experimental and Clinical
Medicine, University of Florence, Florence, Italy.
kPrivate Practitioner, Facesurgery Center, Parma, Italy.
#PhD Student, Department of Experimental and Clinical
Medicine, University of Florence, Florence, Italy.
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Conti: MD,
DDS, Department of Experimental and Clinical Medicine, University
of Florence, Via Landucci 6, Florence 50136, Italy; e-mail: marco@
dottorconti.com
Received July 17 2019
Accepted April 23 2020
Ó 2020 American Association of Oral and Maxillofacial Surgeons
0278-2391/20/30442-0
https://doi.org/10.1016/j.joms.2020.04.036

1620
RAFFAINI ET AL
Mandibular bilateral ramus sagittal split osteotomy
(BSSO) has been commonly used in orthognathic sur-
gery for mandibular repositioning.1 BSSO provides
the best bony interface to improve healing and allows
for the simplest adaption of rigid fixation. This tech-
nique was first introduced by Trauner and Obwe-
geser2-4 in 1955 and was later refined by Dal Pont,5
Hunsuck,6 Epker,7 and Wolford and Davis8 to reduce
the frequency of perioperative and postoperative com-
plications and disadvantages.
Various perioperative and postoperative complica-
tions have continued to be associated with BSSO,
including postoperative vascular hemorrhage, tempo-
romandibular joint problems, nerve damage, infec-
tion, bone necrosis, periodontal disease, a bad split,
and consequent failure.9 Another complication of
BSSO is notching, which, although usually less debili-
tating, can cause a visible and palpable persisting
osseous defect of the mandibular inferior border.10
Notching, if large, produces an interruption of the nat-
ural flow of the jawline, leaving a noticeable and unes-
thetic bony defect that can cause patient
dissatisfaction, although the masseter muscle and par-
amandibular soft tissues can mask some of
the defect.11
As previously reported, the performance of BSSO us-
ing the method of Dal Pont,5 Hunsuck,6 or Epker,7 the
risk factors for mandibular inferior border defects
include older patient age, increased mandibular
advancement, significant counter clockwise rotation
of the occlusal plane, malpositioning of the proximal
segment pattern of a lingual fracture, the presence of
third molars, the occurrence of bad splits, the pres-
ence of thin mandibles, and the presence of a deep an-
tegonial notch.12
The esthetic flaw can be corrected by secondary
reconstruction using bone grafts, bone products, al-
loplastic implants, and/or lipofilling. Only in rare
and severe cases, will it be necessary to redo major
surgery. These secondary procedures not only cause
patient discomfort but also unpleasing esthetic re-
sults and/or iatrogenic damage.13-15 Many
techniques, such as bone grafts and modified
osteotomy techniques, have been applied to
prevent and decrease the incidence of mandibular
lower border defects.16
The purpose of the present study was to evaluate
the conformation of the inferior border after mandib-
ular advancement in patients who had and had not
received a bone graft (graft group [GG] and no graft
group [NGG], respectively). Our hypothesis was that
bone grafting would reduce the incidence of inferior
border defects after BSSO, in accordance with the
report by Epker.7 The specific aim of the present study
was to measure the amount of inferior border defects
in the GG compared with the NGG.
1621
Materials and Methods
The present retrospective cohort study was con-
ducted to evaluate 2 different treatment methods for
the management of the inferior border defect associ-
ated with the Epker7 modification of mandibular
ramus BSSO: grafting of the bony defect versus no
bone grafting. The mandibular inferior border defect
size was the outcome variable and was evaluated at
1 year postoperatively using cone-beam computed to-
mography (CBCT) analysis. Gender, age, and amount
of advancement were also considered in the multilevel
regression analyses.
The patient inclusion criteria for the present study
were as follows: 1) nonsmoking; 2) third molars
removed before surgery; 3) performance of BSSO
with symmetric or slightly asymmetric advancement
in conjunction with bimaxillary orthognathic surgery;
4) preoperative CBCT scans available; and 5) 1-year
postoperative CBCT scans available. The exclusion
criteria were as follows: 1) the presence of a syn-
drome; 2) surgery necessary after trauma; 3) unfavor-
able sagittal splits occurring during the surgical
procedure; 4) the presence of moderate to severe
mandibular asymmetry; 5) no preoperative or 1-year
postoperative CBCT scans available; and 6) preexist-
ing medical conditions such as diabetes, kidney disor-
ders, dysthyroidism, metabolic deficiency, or
immunocompromised conditions.
To reposition the mandible, mandibular advance-
ment, a part of bimaxillary surgery, was performed
first17 (mandible-first protocol), with the correction
consisting of symmetric mandibular advancements
and concomitant Le Fort I osteotomy. Mandibular
ramus BSSRO in accordance with the method reported
by Epker7 was performed. As described in a previous
report,18 throughout the splitting procedures, sur-
geons should be especially careful to maintain the
integrity of the inferior alveolar nerve.
An intermediate splint, manufactured using com-
puter aided design/computer aided manufacturing
technology, was used to reposition the tooth-bearing
segment. Virtual surgery was simulated (FAB Nemo-
tech, Madrid, Spain) using the mandible-first
protocol.19,20
For rigid fixation, either a double 4-hole straight tita-
nium miniplate (2.0-mm BSSO plate; OSA System, Os-
teoMed, Dallas, TX) or a single 4-hole straight
titanium miniplate was placed on the oblique ridge.
In either case, the proximal and distal segments
were stabilized with 4 monocortical screws. The sin-
gle titanium miniplate, however, was used with 1 bi-
cortical (positional, not lag) screw, which was
placed in between the proximal segment (posterior
to the last tooth and superior to the inferior alveolar
nerve) and the lingual cortex of the distal segment.21
1622
Once rigid fixation had been achieved, the bone
gaps between the proximal and distal segments of
the lower border of the mandible were measured us-
ing a caliper. Of the 84 patients who had undergone
BSSO, 40 received bilateral bone grafts. The primary
variable was the use of the homologous iliac crest
bone graft, which was first sculpted and then firmly
positioned under the fixation plate or plates, without
any direct fixation. For the monocortical iliac crest
block, the cortical bone was placed firmly in between
the mandibular cortical segments, while the cancel-
lous bone was directed lingually.
During the preoperative and postoperative follow-
up (1 week, 6 weeks, 6 months, 1 year) examinations,
all the patients underwent panoramic radiography and
facial photograph documentation. In addition, all the
patients had undergone preoperative and 1-year post-
operative CBCT scans to complete the follow-
up protocol.
Radiological configuration of inferior border profile
was assessed using the 1-year postoperative CBCT
scan. Osirix software (Pixmeo Sarl, Bernex,
Switzerland) was used to draw a line tangent to the
mandibular inferior border distally and proximally to
the lateral vertical osteotomy line. The point of the
bone defect farther from the tangent line was deemed
the postoperative defect measurement. Two of us
(M.A. and C.M.) performed the measurements inde-
pendently of each another.
All procedures were performed in accordance with
the ethical standards of the 1964 Declaration of Hel-
sinki and those of our institution.
STATISTICAL ANALYSIS
A descriptive statistics analysis was performed, with
the following variables of interest: age, gender, amount
of advancement, and size of the residual defect. To
compare imbalances between the 2 groups, a t test
was used for age, the Fisher exact test for gender,
and a mixed effects model with the patient as a
random effect for mandibular advancement.
A 2-level model (the 2 levels were patient and site)
was applied to the data. Multilevel models are statisti-
cal models with parameters that vary at more than 1
level. These models can be seen as generalizations of
linear models (in particular, linear regression). Multi-
level models were particularly suitable for the present
investigation, because the participants’ data were orga-
nized at more than 1 level (ie, nested data), the multi-
level models adjusted for clustered correlated
observations. In our study, the analysis units were
the sites (at a lower level), which were nested within
patients (at a higher level).
The outcome variable was the residual defect in mil-
limeters, and the predictor variables were graft (GG vs
MANDIBULAR LOWER BORDER NOTCHING PREVENTION
NGG), age, gender (male vs female), and amount of
advancement in millimeters. A linear regression
2-level model was applied to the data. The interaction
graft*advancement was tested and added to the model
if significant. For the absence of notching (complete
absence vs residual defect), a logistic multilevel model
similar to the previous model was applied to the data.
A significance level of 5% was considered. Multilevel
modeling software was used (MLwiN, version 2.26;
University of Bristol, Bristol, UK).
Results
BSSO according to Epker7 was performed in 84 pa-
tients (168 osteotomies) who required bilateral sym-
metric or mildly asymmetric mandibular
advancement of 10 mm or more at the Facesurgery
Center (Parma, Italy). From January 2012 to December
2014, BSSO advancement was performed without a
bone graft, and from January 2015 to December
2017, BSSO advancement was performed in conjunc-
tion with bilateral bone graft placement.
Of the 84 patients, 40 had undergone BSSO with
bone grafting (GG) and 44 had undergone BSSO
without bone grafting (NGG). The mean patient age
was 27.4 years (range, 17 to 44 years). The mean
advancement amount was 12.2 mm (range, 10 to
15 mm) for the GG and 12.5 mm (range, 10 to
14.5 mm) for the NGG. No significant differences
were found between the 2 groups with respect to
age, gender, or advancement (Table 1). No bone graft
infections occurred.
The residual final defect was measured on the 1-year
postoperative CBCT scans (Figs 1-3). The GG
presented with a mean final defect of 0.7 mm (range
0 to 4.5 mm), and NGG showed an average final
defect of 3.0 mm (range, 0 to 5.5 mm). The
complete absence of the defect was achieved in 72%
of the osteotomies in the GG and 9% of the
osteotomies in the NGG (Table 2).
Regarding the residual defect, in the 2-level model,
the interaction term (graft*advancement) was not sig-
nificant. All explicative variables were statistically sig-
nificant. The best results (small residual defects) were
obtained in the GG, male gender, younger age, and
smaller advancement amount (Table 3). Specifically,
the GG had a smaller residual defect than that of the
NGG of 2.3 mm (95% confidence interval [CI], 1.8 to
2.8 mm; P < .0001). Also, each additional year of age
led to an increase in the residual defect of 0.06 mm
(95% CI, 0.03 to 0.09 mm; P = .0005). In addition,
male patients had a smaller residual defect than that
of the female patients by 0.8 mm (95% CI, 0.3 to
1.3 mm; P = .0015). Finally, each additional 1 mm of
mandibular advancement at surgery led to an increase
in the residual defect of 0.1 mm (95% CI, 0.02 to 0.2;
RAFFAINI ET AL 1623

Table 1. STATISTICAL DESCRIPTIVE ANALYSIS AND COMPARISONS OF AGE, GENDER, NUMBER OF ADVANCEMENTS
(OSTEOTOMIES), AND ADVANCEMENT AMOUNT

Variable GG (n = 40) NGG (n = 44) P Value

Age (yr) 27.4  8.0 27.5  7.8 .986*

Female gender 20 (50) 22 (50) 1.0y
Defect sides (n) 80 88 NA
Advancement (mm) 12.2  1.3 12.5  1.5 .280z
Data presented as mean  standard deviation or n (%).
Abbreviations: GG, graft group; NA, not applicable; NGG, no graft group.
* t Test.
y Fisher exact test.
z Mixed effect model using patient as random effect and group as fixed effect.
Raffaini et al. Mandibular Lower Border Notching Prevention. J Oral Maxillofac Surg 2020.

P = .0164; Table 3). Similarly, in the logistic 2-level Discussion

model regarding the absence of notching, best results
(more frequent absence of notching) were obtained in The purpose of the present study was to compare
the GG, male gender, younger age, and smaller the incidence of osseous defects of the mandibular
advancement (Table 4, Fig 4).

FIGURE 1. Cone-beam computed tomography scan at 1 year post-
operatively of a 32-year-old woman who had undergone 11.5 mm
of mandibular advancement without a bone graft. The residual gap
was 3.5 mm.
Raffaini et al. Mandibular Lower Border Notching Prevention. J
Oral Maxillofac Surg 2020.
FIGURE 2. Cone-beam computed tomography scan at 1 year post-
operatively of a 21-year-old woman who had undergone 13 mm of
mandibular advancement without a bone graft. The residual gap
was 1.1 mm.
Raffaini et al. Mandibular Lower Border Notching Prevention. J
Oral Maxillofac Surg 2020.
1624 MANDIBULAR LOWER BORDER NOTCHING PREVENTION

associated with BSSO, including defects of the mandib-

FIGURE 3. Cone-beam computed tomography scan at 1 year post-
operatively of a 33-year-old man who had undergone 14.5 mm of
mandibular advancement with a bone graft. No residual gap was
found.
Raffaini et al. Mandibular Lower Border Notching Prevention. J
Oral Maxillofac Surg 2020.
inferior border after BSSO with or without an iliac
crest bone allograft block. The results of the present
study have indicated that grafting of the osseous de-
fects created by BSSO results in a significant reduction
in the size of the defect compared with no grafting at
1 year postoperatively.
The refined BSSO technique reported by Hunsuck6
and Epker7 became an effective treatment of skeletal
Class II and III imbalances, resulting in stable out-
comes in the short- and long-term. However, various
postoperative complications have continued to be
ular inferior border. The incidence of mandibular infe-
rior border defects reported in several studies have
varied from 5 to 54.5%.10,12,13,16 The discrepancy in
the reported rates has resulted from the differences
in the amount of mandibular advancement and the
size of the defects. However, various local and sys-
temic factors also have significant effects on bone heal-
ing.22-24
In BSSO, osteotomy, advancement, and fixation of
the mandible to the new position can impair the
normal healing process, which can result in delayed
healing or a defect at the healing site. The Dal Pont,5
Hunsuck,6 and Epker7 techniques rely on the split os-
teotomy to divide the mandibular inferior border. The
mandibular inferior border, after being fractured, will
remain attached to the proximal segment, thus
creating a vertical defect of the lingual aspect of the
distal segment. Consequently, notching after major
advancement will create a significant esthetic defect.
It has been demonstrated that age (range, 17 to
44 years) plays a significant role in healing at the os-
teotomy site. An age-related decrease in the number
of osteogenic progenitor cells has been reported in
different animal models.25,26 In the present study, pa-
tients without mandibular defects were younger than
were the patients with such defects. This finding is
in line with the reported data, which found that, in
younger patients, the healing process was faster and
the associated complications were fewer.27 Bone
homografts have been largely used in various surgical
techniques to increase the amount of mandibular
and maxillary bone. Postoperative bone measure-
ments have demonstrated stable volumetric
results.28,29
In 2018, Cifentes et al16 placed a particulate allograft
and collagen membrane in the gap between bone seg-
ments to reduce the incidence of postoperative resid-
ual inferior border defects after mandibular

Table 2. DESCRIPTIVE STATISTICS STRATIFIED BY NOTCHING

Notching (n; %)
P Value (Multilevel Logistic
Variable Yes No Regression)

Total sample 102 (61) 66 (39) NA

Group < .0001
NGG 80 (91) 8 (9)
GG 22 (28) 58 (72)
Gender .0142
Female 58 (69) 26 (31)
Male 44 (52) 40 (48)

Abbreviations: GG, graft group; NA, not applicable; NGG, no graft group.
Raffaini et al. Mandibular Lower Border Notching Prevention. J Oral Maxillofac Surg 2020.
RAFFAINI ET AL 1625

Table 3. MULTILEVEL LINEAR REGRESSION MODEL

FOR RESIDUAL DEFECT

Predictor Estimate 95% CI P Value

Group (GG vs NGG) 2.3 2.8 to 1.8 <.0001

Age 0.06 0.03 to 0.09 .0005
Gender (male vs female) 0.8 1.3 to 0.3 .0015
Amount of advancement 0.1 0.02 to 0.2 .0164
A 2-level model, with patient and site as the levels, was
applied to the data; the outcome variable was the residual
defect and the explicative variables were graft (GG vs FIGURE 4. Graphic comparison of the possibility of complete
NGG), age, gender (male vs female), and mandibular closure of the lateral osseous defect between the proximal and distal
advancement amount. segments after bilateral sagittal split osteotomy with 10-mm or
Abbreviations: CI, confidence interval; GG, graft group; greater advancement in a 27-year-old patient with and without
NGG, no graft group. bone grafting. Blue line indicates bone grafting group (GG); and
orange line, no bone grafting group (NGG).
Raffaini et al. Mandibular Lower Border Notching Prevention. J
Oral Maxillofac Surg 2020. Raffaini et al. Mandibular Lower Border Notching Prevention. J
Oral Maxillofac Surg 2020.

advancement of greater than 10 mm (mean advance-
ment, 8.2 mm on the right and 9.2 mm on the left).
The final residual defects decreased from 54.5 to
1.3%. In our study, the advancement was more than
10 mm, and the final residual defect was measured
on the 1-year postoperative CBCT scans. As described
in previous studies, mandibular inferior border defects
will increase in parallel with increasing mandibular
advancement (P < .01).14 Moreover, the possibility of
the complete absence of the defect has been strictly
connected with the amount of advancement (P < .01).
The homologous bone graft technique is straightfor-
ward and quick to perform. Also, the precise fit of
cortical bone in between the mandibular cortical seg-
ments improves the bone scaffold and reduces the pos-
sibility of soft tissue invasion. The costs of a
homologous bone grafting are low ($300 to $500),
and no morbidity has been associated with the
donor site.
The comparison between the GG and NGG showed
that the use of a bone graft should be strongly recom-
mended for cases with advancement of 10 to 15.5 mm.
The GG had a mean final defect of 0.7 mm (range, 0 to
4.5 mm), and the NGG had an average final defect of
3.0 mm (range, 0 to 5.5 mm). The defect was not pre-
sent in 72% of the GG and 9% of the NGG. Moreover,
the defects in the GG were inconspicuous compared
with those in the NGG (control group). The statistical
analysis showed an important reduction in the final
defect in the group with bone homograft in patients
with similar factors (ie, age, gender, advancement
amount) (Table 4). In the NGG, fibrotic tissue invaded
the osteotomy gap more quickly than the osseous tis-
sue. The precise fit of the bone block graft can
improve stability, reduce the possibility of micromo-
tion between mandibular segments, prevent incom-
plete ossification at the site of osteosynthesis, and
avoid fibrotic tissue migration into the gap.30,31
In conclusion, the use of an iliac crest bone allograft
block in the lateral osseous gap between the proximal
and distal segments in mandibular BSSO advancement
of greater than 1 mm significantly reduced the size of
the inferior border defects at 1 year postoperatively.
Moreover, this procedure is straightforward and quick
to perform, with low costs and the absence
of mobility.

Table 4. MULTILEVEL LOGISTIC REGRESSION MODEL Acknowledgments

FOR ABSENCE OF NOTCHING
Our sincere thanks to Dr Franchi for his insightful comments.
Predictor OR 95% CI P Value
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