Three different approaches to address unfavorable buccal plate fractures during sagittal split osteotomies: a case series

The bilateral sagittal split osteotomy (BSSO) of the mandible is a widely used technique for correcting dentofacial deformities. A well-known complication is the “bad split,” which can lead to both short- and long-term consequences. This case series illustrates three different strategies for the type 1E buccal bad splits commonly encountered during BSSO. All patients initially received fixation of the fractured segments. The first case continued with the sagittal ramus osteotomy after fixation. The second case involved fixation followed by a second-stage Le Fort I osteotomy only after orthodontic adjustments. The third case used fixation and in a second procedure underwent an intraoral vertical ramus osteotomy (IVRO). Postoperative follow-up included clinical evaluations and imaging to monitor recovery and functional outcomes. Recognition of a type 1E buccal plate fracture and deciding on the appropriate next step—ranging from fixation to staged surgical intervention—is important for minimizing complications and achieving favorable clinical outcomes. • Bad splits occur in 0.5–5.5% of bilateral sagittal split osteotomies • Three strategies for type 1E buccal plate fractures are presented • Fixation with BSSO continuation was successful in selected cases • Le Fort I osteotomy and IVRO serve as staged surgical alternatives • A framework for intraoperative bad split decision-making is proposed