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TECHNICAL STRATEGY

Lingual Short Split: A Bilateral Sagittal Split

Osteotomy Technique Modification
Eduardo Sant’Ana, DDS, PhD, Denis Pimenta e Souza, DDS, PhD,y
Astrid Buysse Temprano, DDS, PhD,y Elio H. Shinohara, DDS, PhD,z
and Paulo Esteves Pinto Faria, DDS, PhD§
Hunsuck,7 Gallo et al,8 Epker,9 and Wolford et al10 proposed
Abstract: The technique of sagittal split osteotomy of the man- previous modifications such as an anterior extension, to improve
dibular ramus is an established technique that has been evolving bone contact, surgical approach, intraoperative manipulation, and
over the years, with significant improvements regarding stability, synthesis between the distal and proximal bone segments. Wolford
better bone contact between the segments, and possibilities of and Davis Jr proposed another modification in 1990,11 modifying
osteosynthesis. However, paresthesia is common in the postopera- the type of osteotomy at the base of the jaw leading to a good
tory, sometimes permanent, and undesirable fractures in the sub- stability and minimize complications.
condylar region can occur leading to longer operative time and The changes proposed above were made mainly in the proximal
area, differentiating osteotomies over the base of the jaw and its
extraoral scars. The short lingual split technique is an easy tech-
design in the molar region, but none, however, was modified in the
nique that simplifies the horizontal osteotomy of the ramus and portion of the ascending branch, directly below the alveolar nerve
decreases the risk of undesirable fractures with a neurosensitive aiming a faster and less surgical trauma procedure.
recovery of patients in a much shorter time because of minor trauma The purpose of this article is to describe a new surgical modi-
and nerve manipulation during the execution. fication, making the procedure technically simpler, with lower risks
of undesirable fractures and likely minimize the manipulation of the
inferior alveolar neurovascular bundle.
Key Words: Bilateral sagittal split osteotomy, orthognathic
surgery
TECHNICAL DESCRIPTION
(J Craniofac Surg 2017;00: 00–00) The short lingual split technique modification was initially
described for patients with narrow jaw with a thick cortical bone

W ithin the orthognathic surgery, sagittal technique of the

mandibular ramus is enshrined in the scientific literature.
The osteotomy is indicated for patients who have facial deformities
and thin medullar bone, with potential risk of undesirable subcon-
dylar fractures during the handling and the opening with forceps and
the Smith separators.
and problems in the temporomandibular joint (TMJ), with good The surgical procedure follows the common steps of the con-
results in both indications.1 However, some problems are still ventional surgical technique, described in literature,5– 13 with muco-
reported as condylar absorption,2 displacement of the segments,3 sal incision over the external oblique line, mucoperiosteal
inferior alveolar nerve damage, lingual nerve injury, undesirable detachment to the mandibular basal across buccal surface, from
displacement of the condyle, unfavorable fracture, infection, airway the ramus region until we reach the mental nerve. It is held also the
compromise, postoperative relapse, and disc displacement.1 Minor carefully mucoperiosteal detachment in the lingual region of the
changes occurred over the years, always aiming to minimize any mandibular ramus, identifying the mandibular lingula and inferior
problems, accidents, complications, and limitations of previous alveolar neurovascular bundle (Fig. 1A), but without manipulating
techniques presented. The contraindications for this type of tech- it. From this point on, we propose a modification, as the technique
nique are: the presence of unerupted mandibular second molars; originally describes the horizontal osteotomy 0.5 cm above the
a severely narrow anteroposterior or mediolateral dimension of nerve/lingual. Our proposal is the low horizontal osteotomy per-
the ramus with no medullary bone between the buccal and formed with drill 4.0 to 5.0 mm in diameter, weakening the cortical
lingual cortices; and severe mandibular asymmetry.4 Since the first area until we reach the most fragile region located below the
article published by Trauner and Obwegeser5 in 1957, Dal Pont,6 mandibular lingula (Fig. 1B), and then the osteotomy starts with
a short saw over the cortical bone (Fig. 1C and Fig. 2A). We
performed a sagittal osteotomy with a surgical saw until we reach
From the Department of Surgery, Stomaology, Pathology and Radiology, the distal face of the first molar (Fig. 1D) and the downward vertical
Bauru Dental School, University of Sao Paulo, FOB/USP, Bauru;
yPrivate Practice; zDepartment of Oral Surgery and Integrated Clinic, mandibular osteotomy to the mandibular basal (Fig. 1E), perpen-
Araçatuba Dental School, University of the State of Sao Paulo, FOA/ dicular to the sagittal, such as described by Hunsuck7 (Fig. 2B). At
UNESP; and §Department of Oral & Maxillofacial Surgery, University this part, an osteotomy at the inferior border with 2- to 3-mm depth
of Ribeirao Preto (UNAERP), Ribeirao Preto, Brazil. into the lingual cortical will unite the vertical osteotomy (Fig. 1F) as
Received February 20, 2017. described by Wolford et al.10 Carefully, we open the sagittal
Accepted for publication March 23, 2017. osteotomy with chisels (Fig. 1G), without traumatizing the inferior
Address correspondence and reprint requests to Paulo Esteves Pinto Faria, alveolar nerve, separating the 2 bone fragments (Fig. 1H), proximal
DDS, PhD, Av. Costábile Romano, 2201, Ribeirão Preto, SP, CEP and distal. To the mandible set back movement, a vertical osteot-
14096-900, Brazil; E-mail: p.faria@me.com omy (Fig. 1I) is performed to adapt the new position of the
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD mandible.
ISSN: 1049-2275 The difference of this new technique is that the sagittal fracture
DOI: 10.1097/SCS.0000000000003839 in the mandibular lingual region would have a horizontal, inferior,

The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017 1
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Faria et al The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017

FIGURE 2. (A) Schematic drawing showing the region located below the
mandibular lingula to start the horizontal osteotomy. (B) Schematic drawing
showing the sagittal osteotomy trajectory till the distal face of the first molar. (C)
Schematic drawing showing the sagittal fracture in the mandibular lingual
region presenting a horizontal, inferior, and parallel trajectory to the entrance of
the inferior alveolar bundle.

in the superior direction or the subcondylar region, as most

weakness will occur lingually and inferiorly, toward the mandib-
ular basal.
After the planned mandibular movement, the osteosynthesis
FIGURE 1. (A) Photography showing the mucoperiosteal detachment in the
(Fig. 1J) is done as usual with interjaw block with steel wire and
lingual region of the mandibular ramus, identifying the mandibular lingula and the occlusal splint in position. The proximal bone fragment is
inferior alveolar neurovascular bundle. (B) Photography showing the low brought into position with the aid of condyle positioner instrument
horizontal osteotomy performed with drill 4.0–5.0 mm in diameter, weakening and bone fixation is performed bilaterally. Then the interjaw
the cortical area until reach the most fragile region located below the
mandibular lingual. (C) Photography showing the osteotomy beginning with a
block is removed and the occlusion obtained intraoperatively is
short saw over the cortical bone. (D) Photography showing the sagittal tested. The mandibular surgery is finalized with homeostasis and
osteotomy performed with a surgical saw until reach the distal face of the first mucoperiosteal suture.
molar. (E) Photography showing the vertical mandibular osteotomy in the
mandibular inferior border with 2–3 mm depth into the lingual cortical. (F)
Photography showing the union of the lingual osteotomy and the vertical DISCUSSION
osteotomy. (G) Photography showing the opening of the sagittal osteotomy The lingual short split modification is a promising technique, with
with chisels. (H) Photography showing the split of the 2 bone fragments. (I)
Photography showing the vertical osteotomy to reduce the distal fragment to fit potential for decreasing the inferior alveolar neurovascular bundle
in the new mandible position. (J) Photography showing the osteosynthesis manipulation and probably better prognosis regarding recovery of
procedure using the hybrid technique. paresthesia, so it is common in cases of mandibular orthognathic
surgery.
This technique has been used in our service without occur bad
split, reducing the transoperative time and facilitating the fixation of
and parallel trajectory to the entrance of the inferior alveolar the mandible using the hybrid fixation technique.14 The modifi-
bundle (Fig. 2C), and not posterior and superior like in the origi- cations in the horizontal, sagittal, and lingual osteotomy, which are
nal technique, so that the nerve would be free after the osteotomy, reduced and allow an osteotomy that runs down when placing the
without tension, with little manipulation, and the mandibular chisel and the Smith retractor, seen to be the most fragile region,
basal preserved, maintaining the pterigomasseteric muscle inser- decreasing the possibility of undesirable fractures to the neck of the
tion, helping preserve the Condyle position.13 Others benefit condyle, accident that may occur in the conventional technique3,6,13
would be decreasing the risks of undesirable fractures and that can lead to extraoral surgical approaches and delays

2 # 2017 Mutaz B. Habal, MD

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017 Lingual Short Split

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