Unfavorable fractures in bilateral sagittal split osteotomy: a systematic review of classification and management strategies

Introduction:
Bilateral sagittal split osteotomy (BSSO) is widely used in orthognathic surgery due to its ability to precisely reposition the mandible, improving occlusal function and facial esthetics. Despite advancements, this procedure requires meticulous surgical skills, and carries the risk of complications, including unintended fractures known as “bad splits”. These complications can arise from anatomical variations, surgical technique, and the pre­sence of third molars. This systematic review aimed to present the classification of these fractures, challenges in their repair, management strategies, and types of stabilization used during BSSO procedures.

Material and methods:
A systematic review was conducted according to PRISMA guidelines, focusing on studies from the past 20 years. Articles were searched in databases, such as PubMed, Scopus, and Cochrane Library. Selected studies described management procedures, repair challenges, stabilization methods, and fracture patterns.

Results:
Various classification systems for unfavorable ramus fractures were developed, concentrating mainly on anatomical locations, but often lacked clinical guidelines. Effective strategies included the use of plates and screws for osteosynthesis. Reported incidence rates of fractures varied between the studies.

Conclusions:
Unfavorable ramus splits in BSSO procedures present significant challenges due to anatomical variability. Practical treatment guidelines in classification systems are essential for better outcomes. Effective strategies include osteosynthesis plates and screws. Further research is needed to enhance management strategies, understand risk factors, and improve pre-operative planning and stabilization methods. This will help reduce complications and achieve more predictable surgical results.