The Impact of Mandibular Anatomy on the Incidence of Bad Splits in Sagittal Split Ramus Osteotomy: A Retrospective Study

The Impact of Mandibular Anatomy on the Incidence of Bad Splits in Sagittal Split Ramus Osteotomy: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of Mandibular Anatomy on the Incidence of Bad Splits in Sagittal Split Ramus Osteotomy: A Retrospective Study Tuncer Akdogan, Huseyin Can Tukel This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7786845/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background The objective of this study was to conduct three-dimensional cone beam computed tomography (CBCT) analysis of posterior mandibular anatomy in order to investigate its potential correlation with the occurrence of bad splits during sagittal split ramus osteotomy (SSO). Materials and Methods A retrospective review was conducted on 56 patients (112 hemimandibles) who underwent bilateral SSO between 2016 and 2022. Distances between the mandibular canal and the borders of the mandible, along with anatomical landmarks, were measured. Sites with and without bad splits were compared using chi-square and Mann–Whitney U tests (p = 0.05). Intra- and inter-observer reliability were assessed via intraclass correlation coefficients. Results The overall incidence of bad split was 8.9% per site (10/112) and 14.3% per patient (8/56). Patient-related variables, including age, sex, skeletal deformity type (Class II vs. Class III), and the presence of impacted third molars, were not significantly associated with bad split (all P > 0.05). Among the morphometric parameters, the distance from the mandibular canal to the inferior cortical border at the mesial of the second molar (M2-inferior) was significantly greater in the bad-split group (P = 0.045). Other measurements, including ramal thickness, anteroposterior length, and canal position relative to buccal and inferior cortices, were not significantly different. Reliability analysis demonstrated good to excellent agreement for all the measurements. Conclusions A greater inferior mandibular border thickness at the mesial of the second molar appears to increase the risk of bad split during SSO. Routine preoperative CBCT evaluation and careful attention to inferior border osteotomy in this region may help reduce complications. Further prospective, standardized studies are needed to confirm these findings. Sagittal Split Ramus Osteotomy Bad Split Cone-Beam Computed Tomography Mandibular Anatomy Orthognathic Surgery Intraoperative Complications Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 BACKGROUND Sagittal split osteotomy (SSO) of the mandible is commonly performed in patients with dentofacial deformities to achieve proper occlusion and to create a balanced facial profile. Although this procedure has matured in time with modifications and is considered very versatile, various complications including bleeding, infection, hardware removal, nerve injury, condylar malpositioning, and bad splits, may occur [ 1 ]. A bad split refers to unfavourable or irregular fractures of the mandible that occur during SSO, and it is probably the most unwanted complication that may lead to other complications if not addressed properly [ 2 ]. Various studies have reported that the incidence of bad splits to range from 1% to 9.2% [ 3 , 4 ]. Bad splits can occur in various forms and locations in both proximal and distal segments [ 2 ]. A bad split can result in infection, delayed healing, malunion, and pseudoarthrosis. Additionally, postoperative instability, relapse, and mandibular dysfunction associated with temporomandibular disorders can be observed [ 5 , 6 ]. Many studies have suggested that bad splits can result from various factors, such as a lack of surgical experience, the surgical technique, the age of the patient, the presence of impacted third molars, and some anatomical deviations such as a high-riding lingula and a narrow ramus [ 7 ]. However, there is a paucity of literature regarding the anatomical factors of the mandible that may lead to bad splits, and most often the three-dimensional anatomy of the mandible in relation to SSO is overlooked. [ 3 ]. Thus, the objective of this study was to conduct a three-dimensional cone beam computed tomography (CBCT) analysis of posterior mandibular anatomy with regards to potential correlation between mandibles and a bad split. MATERIALS AND METHODS Patient Selection This retrospective study was conducted in the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cukurova University, including patients who underwent SSO from 2016–2022. A total of 138 patients who underwent sagittal split osteotomy (SSO) between 2016 and 2022 were retrospectively screened. Among these patients, 56 patients with available preoperative and postoperative cone-beam computed tomography (CBCT) scans were included in the study. Ethical approval was obtained from the Clinical Research Ethics Committee of Cukurova University (Meeting No. 125, dated September 16, 2022). All participants were informed about the study, and written informed consent was obtained prior to data collection. The participants were categorized by sex assigned at birth, following SAGER (Sex and Gender Equity in Research) guidelines, which recommend clear definitions for sex and gender classifications. Only binary categories of males and females were included, as no participants identified otherwise. This approach aligns with SAGER guidelines, which recommend explaining the rationale for selected sex categories. Among the 56 patients, 36 (64.3%) were female, and 20 (35.7%) were male. The inclusion criterion was the availability of preoperative and postoperative CBCT scans. The exclusion criteria included pathology or previous traumatic injury in the area, syndromes affecting skeletal development, or a history of revision SSO. Surgical Procedure The sagittal split osteotomy procedures for individuals who agreed to participate in this study were performed by three different surgeons following the same surgical protocol. The operation was performed under general anaesthesia using the techniques described by Trauner and Obwegeser[ 8 ] and modified by Hunsuck and Dal Pont[ 9 ]. The modified SSO technique, derived from the classic method of Trauner and Obwegeser, includes Dal Pont’s anteriorly positioned vertical osteotomy and Epker’s complete osteotomy of the inferior mandibular cortex. This approach was utilized to increase the surface area between bone segments, thereby optimizing rigid fixation and promoting enhanced postoperative healing. Acquisition of CBCT Images The CBCT records for all patients were obtained at the Faculty of Dentistry, Cukurova University. The records were obtained using a CBCT device (Planmeca Promax® 3D Mid, Helsinki, Finland). The tomography device operates at 90 kV and 10 Ma. It performs a 360° rotation around the patient, scanning a field of view (FOV) of 450 mm × 450 mm × 436 mm in approximately 27 seconds with an average slice thickness of 0.5 mm. The acquired data were stored in Digital Imaging and Communications in Medicine (DICOM) format. The patient’s DICOM data were transferred to the Planmeca Promax® 3D Mid (Helsinki, Finland) software for analysis. Measurements Evaluated on CBCT Images The landmarks and reference planes used in this study were established by utilizing various sources [ 10 , 11 ]. Y Plane: A vertical plane that is perpendicular to the ground (Fig. 1 ). X Plane: A horizontal plane that is parallel to the ground (Fig. 1 ). Mandibular Foramen: An anatomical structure located just above the center of the inner surface of the mandibular ramus, surrounded by bone at the beginning of the mandibular canal. Mandibular Sigmoid Notch: The deepest point of the concavity extending between the mandibular condyle and coronoid process. Mandibular Lingula: A bony prominence located on the medial side of the mandibular ramus above the mandibular foramen. Length Measurements LintoSig: Distance from the lingula mandible to the sigmoid notch (Fig. 2 .a). Rammedlat: Mediolateral thickness of the ramus at the level of the lingula mandible (Fig. 2 .b). M2toFor: Vertical distance from the distal of the mandibular second molar to the mandibular foramen (Fig. 2 .c). RanttoFor: Distance from the mandibular foramen to the anterior border of the ramus (Fig. 2 .d). -RanttoPost: Anteroposterior length of the ramus at the level of the mandibular foramen (Fig. 2 .d). The distance from the outer buccal cortical border to the mandibular canal was measured perpendicular to the Y plane (Fig. 3.a) at the mesial of the mandibular first molar (M1buccal), second molar (M2buccal), and distal of the mandibular second molar (M3buccal). The distance from the outer inferior cortical border to the mandibular canal was measured perpendicular to the X plane (Fig. 3.b) at the mesial of the mandibular first molar (M1inferior) and second molar (M2inferior), as well as the distal of the second molar (M3inferior). The thickness of the cancellous bone buccal to the mandibular canal (Fig. 3.c) was recorded at the mesial of the first molar (M1buccalcan) and second molar (M2buccalcan) and the distal of the second molar (M3buccalcan). The thickness of the cancellous bone inferior to the mandibular canal (Fig. 3.d) was measured at the mesial of the first molar (M1inferiorcan) and second molar (M2inferiorcan) and the distal of the second molar (M3inferiorcan). The thickness of the buccal cortical bone buccal to the mandibular canal (Fig. 3.e) was assessed at the mesial of the first molar (M1buccalcor), the second molar (M2buccalcor), and the distal of the second molar (M3buccalcor). The thickness of the cortical bone inferior to the mandibular canal (Fig. 3.f) was recorded at the mesial of the first molar (M1inferiorcor) and second molar (M2inferiorcor). Each parameter measured from the right and left sides of the patient was evaluated separately. Additionally, the surgical notes and postoperatively obtained CBCT images were reviewed to check for the presence of bad splits, and any instances of bad splits were recorded in the patient data (Figs. 4 , 5 ). To evaluate the reliability of the measurements, intra-observer agreement was assessed by having the same researcher repeat the measurements on images from 15 randomly selected patients after a 2-month interval, with intraclass correlation coefficient (ICC) values reported. Inter-observer agreement was assessed by a second researcher performing measurements on the same images, with the ICC values also reported. Interpretation of the ICC values followed Landis and Koch’s[ 12 ] established criteria: ICC < 0.20 (poor agreement), 0.21 to 0.40 (fair agreement), 0.41 to 0.60 (moderate agreement), 0.61 to 0.80 (good agreement), and 0.81 to 1.00 (excellent agreement). Statistical analysis The statistical analysis of the data was performed using the SPSS software (Statistical Package for the Social Sciences), version 25.0 (IBM Corp., Released 2010. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA). Categorical variables are summarized as frequencies and percentages, whereas continuous variables are presented as the means and standard deviations (where appropriate, medians and ranges are also reported as minimum and maximum values). Chi-square tests were used for the comparison of categorical variables. The Shapiro‒Wilk test was used to determine whether the parameters in the study followed a normal distribution. The Mann‒Whitney U test was used to analyse differences between the groups. Statistical significance was established at P < 0.050. RESULTS The study included 112 hemimandibles from 56 patients who underwent bilateral SSO. Both the right and left sides of each patient were included in the analysis. Of these, 36 (64.3%) were female, and 20 (35.7%) were male. The mean age of the patients was 23.9 years (± 6.1), with a median age of 22.5 years and an age range of 17 to 46 years. The mean postoperative follow-up period was 33.9 months (± 19.2), with a median of 40.5 months and a range of 6 to 72 months. Regarding the underlying skeletal deformities, 10 patients (17.9%) were diagnosed with Class II malocclusion, whereas 46 patients (82.1%) presented with Class III deformities. Impacted third molars were identified in 12 patients (10.7%). A total of 10 bad splits were observed, resulting in an incidence of 8.9% per site (10/112) and 14.3% per individual (8/56). Specifically, bilateral bad splits were detected in 2 patients, while 6 patients exhibited unilateral involvement. Tables 1 A and 1 B present the measurements of the morphological parameters from preoperative CBCT. Based on the reliability assessment, ICC values showed that most parameters had good (ICC 0.61 to 0.80) to excellent (ICC 0.81 to 1.00) agreement, with no values falling below the good agreement level. Differences Between Bad Split Groups and Measurements Evaluated on CBCT Images This study examined the differences between bad split findings and parameters in the patient group. No significant differences were found between the bad split groups and variables such as sex (P = 0.32), age (P = 0.43), or side of the bad split (P = 0.50). Moreover, no statistically significant correlation was established between the presence of impacted third molars (P = 0.93), the type of preoperative skeletal deformity (P = 0.49), and the incidence of bad splits (Table 2 ). In SSO regions where bad splits were detected, the distance between the inferior alveolar nerve and the inferior cortical border of the mandible in the mesial region of the second molar (M2Inferior) was significantly greater than that in patients without bad splits (P = 0.045). No significant differences were observed between the groups in terms of the other length parameters presented in Table 3 A, 3 B. DISCUSSION SSO is technically demanding, with potential intraoperative and postoperative complications such as bleeding, airway compromise, bad split, infection, bone necrosis, temporomandibular joint (TMJ) disorders, dysphagia, restricted mouth opening, and psychological impacts[ 4 ]. Among the intraoperative complications observed during sagittal split osteotomy, a bad split has been reported as the most common, as highlighted by Thiem et al.[ 13 ]. In response to this challenge, various studies have proposed novel modifications to conventional mandibular osteotomy techniques in an effort to minimize its occurrence[ 14 , 15 ]. Inadequately managed bad splits may result in postoperative issues, including infection, bone sequestration, delayed healing, and TMJ dysfunction[ 1 ]. Notably, the risk of a bad split has been shown to be closely linked to individual variations in mandibular morphology [ 16 ], underscoring the importance of preoperative anatomical assessment in reducing the likelihood of this complication. Therefore, this study aimed to analyse posterior mandibular anatomy in 3D and examine its relationship with bad split occurrence, with the goal of reducing the incidence of bad splits. Mensink et al.[ 17 ] reported the incidence of bad splits in 17 cases (2.0%) of 851 SSO sites performed across 427 patients from 1994 to 2011. Chrcanovic and Freire-Maia[ 3 ], in their review of 21 studies, reported incidence rates ranging from 0.21% to 22.72% across different sites. Balaji[ 18 ] reported bad splits in 27 cases (6.5%) of 416 SSO sites. Aarabi et al.[ 7 ] reported 14 bad splits (14.6%) among 96 SSO sites. A meta-analysis by Verweij et al.[ 19 ] included 18 retrospective and 3 prospective studies on bad splits, encompassing 8225 patients who underwent 16359 SSO procedures, with a total of 381 bad splits, yielding an overall incidence of 2.3% per site (range: 0.5% to 14.6%). Consistent with these findings, a total of 10 bad splits were observed in this study, resulting in an incidence of 8.9% per site (10/112) and 14.3% per individual (8/56). This relatively high incidence may be explained by the specific inclusion criteria of the present study, which enrolled only patients with both preoperative and postoperative cone-beam computed tomography (CBCT) scans. In routine clinical practice, postoperative CBCT imaging is not performed for all orthognathic surgery patients; it is commonly obtained in cases where a bad split is suspected. Therefore, the inclusion of only those patients with postoperative CBCT may have led to a selective concentration of suspected or confirmed bad split cases, consequently contributing to a higher observed rate compared to studies with broader or radiographically nonselective studies. Many factors including age, sex, the presence of impacted third molars, different surgical techniques and tools, surgical experience, and mandibular anatomy, may affect the risk of bad split. Mensink et al.[ 17 ] reported that 8 of the 17 bad splits in their study were associated with the presence of impacted third molars, suggesting a possible link. However, several studies and meta-analyses have indicated that the presence of impacted third molars during surgery does not affect the incidence of bad splits [ 20 , 21 , 22 ]. Accordingly, no significant relationship was found between third molar presence and bad split occurrence in the present study. Steenen et al.[ 20 ] reported no significant relationship between patient sex and the incidence of bad splits. However, a statistically significant correlation was observed between a higher mean age and an increased rate of bad splits. Similarly, Kriwalsky et al.[ 21 ] reported an association between older age and bad splits, with an average age of 35 years (range 21 to 60) for patients with bad splits compared to 25 years (range 17 to 45) for those without. They reported no significant correlation between bad splits and sex. In the present study, no associations were found between sex or age and bad split occurrence. Mensink et al.[ 17 ] and Jiang et al.[ 22 ] reported no statistically significant associations between bad split occurrence and factors such as patient age, sex, or preoperative skeletal relationship. These findings are consistent with the present study. Conversely, Kalabalık et al.[ 23 ] suggested that prognathic mandibles, characterized by reduced mediolateral width and a lower proportion of cancellous bone, may be more susceptible to bad splits. However, this conclusion was reached without statistical support. Although the majority of patients in this study presented with Class III skeletal deformities, and most bad splits (9 out of 10) occurred in Class III patients, this association did not reach statistical significance. Several studies have analysed various mandibular anatomical parameters between patients with bad splits and those without during the SSO procedure [ 1 , 7 , 11 ]. Aarabi et al. [ 7 ] reported that while the buccolingual thickness of the ramus at the level of the lingula was significantly thinner in patients with bad splits, no significant difference was observed between the groups in terms of the anteroposterior length of the ramus. Similar anatomical parameters were examined in the present study. Consistent with these findings, no correlation was found between the anteroposterior length of the ramus and bad splits. In contrast to Aarabi et al., no significant difference was observed in the buccolingual thickness of the ramus at the lingula level between the two groups in the present study. In their study, Wang et al.[ 1 ] reported no significant relationship between bad split occurrence and various anatomical parameters, including the buccolingual thickness of the ramus at the lingula level and the anteroposterior length of the ramus at the same level. Furthermore, no association was observed with the distance from the mandibular foramen to the anterior border of the ramus, as well as the distance between the outer inferior cortical border of the mandible and the mandibular canal at the distal of the second molar. Telha et al.[ 11 ] found that a reduced distance between the mandibular canal and the buccal cortical border, as well as decreased cancellous bone thickness buccal to the mandibular canal, were significantly associated with an increased incidence of bad splits. In contrast, the present study found that neither of these parameters was related to bad split incidence. Additionally, Telha et al. reported no association between bad splits and other anatomical parameters, such as the anteroposterior length of the ramus at the mandibular foramen, the distance from the lingula to the sigmoid notch, the mediolateral thickness of the ramus at the lingula, and cortical bone thickness buccal to the mandibular canal. In line with this, the present study demonstrated no significant correlation between these parameters and the occurrence of bad splits. In distinction from these studies, we found that the distance between the inferior alveolar nerve and the inferior cortical border of the mandible in the region between the second and first molar was significantly greater in the bad split group. Similarly, Song and Kim, in their 2014 study, reported that the risk of bad splits increases when the inferior border osteotomy does not fully extend through the caudal cortex to the lingual cortex[ 24 ]. It is hypothesized that in the mandibles with increased bone thickness in this region where vertical osteotomies are carried out may have contributed to an incomplete extension of the osteotomy at the inferior border, hindering its full reach to the lingual cortex. It can be speculated that combined with a top-down splitting approach, an incomplete inferior cortical osteotomy may be a contributing factor to increased rate of bad splits found in our study. Houppermans et al. [ 25 ] reported that an inferior border cut extending through the lingual cortex does not necessarily result in greater predictability of a split in SSO. On the other hand, several studies have reported that extension of the inferior border osteotomy toward the lingual cortex may increase the risk of postoperative inferior border defects in mandibular advancements [ 26 , 27 , 28 ]. The present study is subject to several limitations. First, its retrospective and single-center design inherently constrains the external validity and generalizability of the findings. Moreover, as the surgical procedures were performed by multiple operators, a comprehensive evaluation of the potential effect of surgeon experience on clinical outcomes was not feasible. Additionally, within our clinical routine, postoperative CBCT imaging was not systematically performed for all orthognathic surgery patients. Therefore, future prospective studies are needed in which preoperative and postoperative CBCT scans are systematically obtained from all patients and where the precise location of osteotomies is determined and evaluated on these images. CONCLUSIONS This study investigated the effects of mandibular anatomy on the occurrence of bad splits associated with SSO, and several conclusions were drawn. The presence of an impacted third molar during surgery did not increase the risk of bad splits. Furthermore, in the bad split group, the bone between the mandibular canal and the inferior cortical border was thicker in the region of the vertical osteotomy line, positioned between the first and second molars. This increased thickness may result an incomplete inferior osteotomy, potentially contributing to bad split formation. Moreover, other parameters related to mandibular anatomy did not show a significant difference between the bad split and non-bad split groups. Finally, we believe that evaluating mandibular anatomy with CBCT in orthognathic surgery patients is important and may help reduce the incidence of bad splits. Abbreviations CBCT Cone beam computed tomography SSO Sagittal split ramus osteotomy SAGER Sex and gender equity in research FOV Field of view DICOM Digital Imaging and Communications in Medicine ICC Intraclass correlation coefficient TMJ Temporomandibular joint Declarations Ethics approval and consent to participate This retrospective study was approved by the Clinical Research Ethics Committee of Cukurova University (Meeting No. 125, dated September 16, 2022). Written informed consent was obtained from all participants prior to data collection. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Clinical trial number: not applicable. Consent for publication Written informed consent for publication was obtained from all participants included in the study. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available owing to patient confidentiality and institutional regulations but are available from the corresponding author upon reasonable request. Competing Interests The authors declare that they have no competing interests. Funding This study was supported by the Scientific Research Projects Coordination Unit of Cukurova University under project number TDH-2022-15476. Author contributions T.A. conceived and designed the study, collected the clinical data, performed the CBCT analyses, interpreted the data, drafted the manuscript, and approved the final version. H.C.T. contributed to the conception and design of the study, participated in data analysis and interpretation, critically revised the manuscript, and approved the final version. All the authors reviewed the manuscript. Acknowledgements The authors would like to thank the staff of the Department of Oral and Maxillofacial Surgery, Cukurova University, for their kind support and assistance during data collection and patient management. References Wang T, Han JJ, Oh HK, Park HJ, Jung S, Park YJ, Kook MS. Evaluation of mandibular anatomy associated with bad splits in sagittal split ramus osteotomy of mandible. J Craniofac Surg. 2016;27:500–4. https://doi.org/10.1097/SCS.0000000000002798 . Veras R, Kriwalsky M, Hoffmann S, Maurer P, Schubert J. Functional and radiographic long-term results after bad split in orthognathic surgery. Int J Oral Maxillofac Surg. 2008;37:606–11. https://doi.org/10.1016/j.ijom.2008.04.010 . Chrcanovic BR, Freire-Maia B. 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Modified mandibular inferior border sagittal split osteotomy reduces postoperative risk for developing inferior border defects. J Oral Maxillofac Surg. 2016;74. https://doi.org/10.1016/j.joms.2016.01.005 . :1062.e1-1062.e9. Verweij JP, Van Rijssel JG, Fiocco M, Mensink G, Gooris PJJ, Van Merkesteyn JPR. Are there risk factors for osseous mandibular inferior border defects after bilateral sagittal split osteotomy? J Cranio-Maxillofacial Surg. 2017;45:192–7. https://doi.org/10.1016/j.jcms.2016.12.015 . Tables Table 1A: Morphological evaluation findings of parameters on preoperative CBCT Mean±SD Med (Min–Max) M2toFor 10.1±3.9 10 (0-20.4) LintoSig 16.5±2.7 16.7 (10.9-22.0) RanttoFor 12.6±2.3 12.5 (8.4-20.1) Rammedlat 5.05±1.3 4.82 (2.43-8.84) RanttoPost 29.5±2.8 29.1 (22.7-38.4) M1 buccal 4.57±1.2 4.47 (1.65-7.6) M2 buccal 5.23±1.3 5.2 (1.79-8.41) M3 buccal 4.71±1.4 4.4 (1.6-8.16) M1 inferior 6.02±1.6 6 (2.4-12.0) M2 inferior 5.68±1.6 5.69 (2.4-10.47) M3 inferior 6.20±1.7 6.07 (2.4-12) SD: Standard Deviation, Med: Median, Min: Minimum, Max: Maximum Table 1B: Morphological evaluation findings of parameters on preoperative CBCT Mean±SD Med (Min–Max) M1 buccalcan 2.02±1.1 2 (0-5.34) M2 buccalcan 2.49±1.2 2.43 (0-5.64) M3 buccalcan 1.92±1.4 2 (0-5.6) M1 inferiorcan 2.53±1.4 2.52 (0-8.41) M2 inferiorcan 2.28±1.5 2.15 (0-6.81) M3 inferiorcan 3.01±1.8 3.04 (0-8.4) M1 buccalcor 2.59±0.5 2.43 (1.65-4.43) M2 buccalcor 2.71±0.5 2.8 (1.79-4.4) M3 buccalcor 2.80±0.5 2.8 (1.6-4.18) M1 inferiorcor 3.52±0.6 3.6 (2.4-5.44) M2 inferiorcor 3.42±0.6 3.36 (2.04-4.68) M3 inferiorcor 3.17±0.5 3.2 (1.65-4.56) SD: Standard Deviation, Med: Median, Min: Minimum, Max: Maximum .pf0 {} Table 2 is available in the Supplementary Files section. Table 3A: Differences Between Morphological Evaluation Findings on Preoperative CBCT and Bad Split Groups Without Bad Split (n=102) With Bad Split (n=10) p ‡ Mean±SD Mean±SD M2toFor 10.0±3.9 11.4±4.5 0.554 LintoSig 16.6±2.7 15.6±3.3 0.317 RanttoFor 12.7±2.3 11.7±1.7 0.247 Rammedlat 5.09±1.3 4.59±1.2 0.396 RanttPost 29.4±2.7 30.0±4.0 0.984 M1 buccal 4.56±1.2 4.68±1.4 0.907 M2 buccal 5.22±1.3 5.29±1.5 0.992 M3 buccal 4.68±1.4 5.0±1.4 0.627 M1 inferior 5.96±1.6 6.49±1.1 0.227 M2 inferior 5.59±1.6 6.52±1.0 0.045* M3 inferior 6.11±1.7 7.11±1.8 0.136 SD: Standard Deviation, *p<0.050, ‡: Mann‒Whitney U test Table 3B: Differences Between Morphological Evaluation Findings on Preoperative CBCT and Bad Split Groups Without Bad Split (n=102) With Bad Split (n=10) p ‡ Mean±SD Mean±SD M1 buccalcan 2.00±1.1 2.17±1.2 0.791 M2 buccalcan 2.48±1.3 2.61±1.2 0.890 M3 buccalcan 1.89±1.4 2.24±1.3 0.457 M1 inferiorcan 2.49±1.5 2.96±0.8 0.191 M2 inferiorcan 2.23±1.5 2.79±0.7 0.112 M3 inferiorcan 2.95±1.8 3.62±1.8 0.364 M1 buccalcor 2.59±0.4 2.52±0.4 0.785 M2 buccalcor 2.72±0.5 2.67±0.4 0.647 M3 buccalcor 2.80±0.5 2.76±0.4 0.881 M1 inferiorcor 3.52±0.6 3.53±0.4 0.931 M2 inferiorcor 3.39±0.6 3.72±0.5 0.090 M3 inferiorcor 3.13±0.5 3.50±0.6 0.100 SD: Standard Deviation, *p<0.050, ‡: Mann‒Whitney U test Additional Declarations No competing interests reported. Supplementary Files Table2.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 Nov, 2025 Reviews received at journal 10 Nov, 2025 Reviewers agreed at journal 06 Nov, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers invited by journal 30 Oct, 2025 Editor invited by journal 15 Oct, 2025 Editor assigned by journal 15 Oct, 2025 Submission checks completed at journal 15 Oct, 2025 First submitted to journal 05 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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2","display":"","copyAsset":false,"role":"figure","size":529872,"visible":true,"origin":"","legend":"\u003cp\u003ea. Length between the lingula and the sigmoid notch in a 3D model b. Coronal section illustration of the mediolateral width of the ramus at the level of the lingula c. CBCT illustration of the vertical distance from the mandibular foramen to the distal region of the mandibular second molar d.\u003cstrong\u003e \u003c/strong\u003eAxial section illustration of the anteroposterior length of the ramus at the level of the mandibular foramen (green line) and the distance from the mandibular foramen to the anterior border of the ramus (red line).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7786845/v1/c1f75a5d32646c81fa8cf153.png"},{"id":95566742,"identity":"ced95907-76fb-448f-a742-e64bff9fd902","added_by":"auto","created_at":"2025-11-10 16:20:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":660790,"visible":true,"origin":"","legend":"\u003cp\u003ea. Distance between the mandibular canal and the outer buccal cortical border. b. Distance between the mandibular canal and the outer inferior cortical border. c. Thickness of the cancellous bone located buccal to the mandibular canal. d. Thickness of the cancellous bone located inferior to the mandibular canal. e. Thickness of the cortical bone located buccal to the mandibular canal. f. Thickness of the cortical bone located inferior to the mandibular canal.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7786845/v1/e4913432c6b56d2775807864.png"},{"id":95566743,"identity":"a4f878ba-10a4-4146-bda2-6740ec6d7ba3","added_by":"auto","created_at":"2025-11-10 16:20:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":509519,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative CBCT images showing the observed bad splits\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7786845/v1/739fe1a798b2f7530130d988.png"},{"id":95655493,"identity":"aad5f9ca-2c29-456e-aaad-9f4cb1df4a04","added_by":"auto","created_at":"2025-11-11 16:16:20","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":563193,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative CBCT images showing the observed bad splits\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7786845/v1/aae16f13e20ed19365419581.png"},{"id":95660226,"identity":"9aeec49c-3470-42a7-9d2e-4b65139ea6cf","added_by":"auto","created_at":"2025-11-11 16:31:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4026867,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7786845/v1/8551732d-4686-4d86-9c4c-46679c0d446e.pdf"},{"id":95566738,"identity":"09337a61-23b5-4ab0-be15-24747db0b3e9","added_by":"auto","created_at":"2025-11-10 16:20:01","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16066,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7786845/v1/bb0c7083f83b5417b47fe3b7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of Mandibular Anatomy on the Incidence of Bad Splits in Sagittal Split Ramus Osteotomy: A Retrospective Study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eSagittal split osteotomy (SSO) of the mandible is commonly performed in patients with dentofacial deformities to achieve proper occlusion and to create a balanced facial profile. Although this procedure has matured in time with modifications and is considered very versatile, various complications including bleeding, infection, hardware removal, nerve injury, condylar malpositioning, and bad splits, may occur [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA bad split refers to unfavourable or irregular fractures of the mandible that occur during SSO, and it is probably the most unwanted complication that may lead to other complications if not addressed properly [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Various studies have reported that the incidence of bad splits to range from 1% to 9.2% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Bad splits can occur in various forms and locations in both proximal and distal segments [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A bad split can result in infection, delayed healing, malunion, and pseudoarthrosis. Additionally, postoperative instability, relapse, and mandibular dysfunction associated with temporomandibular disorders can be observed [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Many studies have suggested that bad splits can result from various factors, such as a lack of surgical experience, the surgical technique, the age of the patient, the presence of impacted third molars, and some anatomical deviations such as a high-riding lingula and a narrow ramus [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, there is a paucity of literature regarding the anatomical factors of the mandible that may lead to bad splits, and most often the three-dimensional anatomy of the mandible in relation to SSO is overlooked. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThus, the objective of this study was to conduct a three-dimensional cone beam computed tomography (CBCT) analysis of posterior mandibular anatomy with regards to potential correlation between mandibles and a bad split.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatient Selection\u003c/h2\u003e\u003cp\u003e This retrospective study was conducted in the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cukurova University, including patients who underwent SSO from 2016\u0026ndash;2022. A total of 138 patients who underwent sagittal split osteotomy (SSO) between 2016 and 2022 were retrospectively screened. Among these patients, 56 patients with available preoperative and postoperative cone-beam computed tomography (CBCT) scans were included in the study. Ethical approval was obtained from the Clinical Research Ethics Committee of Cukurova University (Meeting No. 125, dated September 16, 2022). All participants were informed about the study, and written informed consent was obtained prior to data collection. The participants were categorized by sex assigned at birth, following SAGER (Sex and Gender Equity in Research) guidelines, which recommend clear definitions for sex and gender classifications. Only binary categories of males and females were included, as no participants identified otherwise. This approach aligns with SAGER guidelines, which recommend explaining the rationale for selected sex categories. Among the 56 patients, 36 (64.3%) were female, and 20 (35.7%) were male.\u003c/p\u003e\u003cp\u003eThe inclusion criterion was the availability of preoperative and postoperative CBCT scans. The exclusion criteria included pathology or previous traumatic injury in the area, syndromes affecting skeletal development, or a history of revision SSO.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical Procedure\u003c/h3\u003e\n\u003cp\u003eThe sagittal split osteotomy procedures for individuals who agreed to participate in this study were performed by three different surgeons following the same surgical protocol. The operation was performed under general anaesthesia using the techniques described by Trauner and Obwegeser[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and modified by Hunsuck and Dal Pont[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The modified SSO technique, derived from the classic method of Trauner and Obwegeser, includes Dal Pont\u0026rsquo;s anteriorly positioned vertical osteotomy and Epker\u0026rsquo;s complete osteotomy of the inferior mandibular cortex. This approach was utilized to increase the surface area between bone segments, thereby optimizing rigid fixation and promoting enhanced postoperative healing.\u003c/p\u003e\n\u003ch3\u003eAcquisition of CBCT Images\u003c/h3\u003e\n\u003cp\u003eThe CBCT records for all patients were obtained at the Faculty of Dentistry, Cukurova University. The records were obtained using a CBCT device (Planmeca Promax\u0026reg; 3D Mid, Helsinki, Finland). The tomography device operates at 90 kV and 10 Ma. It performs a 360\u0026deg; rotation around the patient, scanning a field of view (FOV) of 450 mm \u0026times; 450 mm \u0026times; 436 mm in approximately 27 seconds with an average slice thickness of 0.5 mm. The acquired data were stored in Digital Imaging and Communications in Medicine (DICOM) format. The patient\u0026rsquo;s DICOM data were transferred to the Planmeca Promax\u0026reg; 3D Mid (Helsinki, Finland) software for analysis.\u003c/p\u003e\n\u003ch3\u003eMeasurements Evaluated on CBCT Images\u003c/h3\u003e\n\u003cp\u003eThe landmarks and reference planes used in this study were established by utilizing various sources [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eY Plane: A vertical plane that is perpendicular to the ground (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eX Plane: A horizontal plane that is parallel to the ground (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMandibular Foramen: An anatomical structure located just above the center of the inner surface of the mandibular ramus, surrounded by bone at the beginning of the mandibular canal.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMandibular Sigmoid Notch: The deepest point of the concavity extending between the mandibular condyle and coronoid process.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMandibular Lingula: A bony prominence located on the medial side of the mandibular ramus above the mandibular foramen.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLength Measurements\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eLintoSig: Distance from the lingula mandible to the sigmoid notch (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.a).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eRammedlat: Mediolateral thickness of the ramus at the level of the lingula mandible (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.b).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eM2toFor: Vertical distance from the distal of the mandibular second molar to the mandibular foramen (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.c).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eRanttoFor: Distance from the mandibular foramen to the anterior border of the ramus (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.d).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e-RanttoPost: Anteroposterior length of the ramus at the level of the mandibular foramen (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.d).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe distance from the outer buccal cortical border to the mandibular canal was measured perpendicular to the Y plane (Fig.\u0026nbsp;3.a) at the mesial of the mandibular first molar (M1buccal), second molar (M2buccal), and distal of the mandibular second molar (M3buccal).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe distance from the outer inferior cortical border to the mandibular canal was measured perpendicular to the X plane (Fig.\u0026nbsp;3.b) at the mesial of the mandibular first molar (M1inferior) and second molar (M2inferior), as well as the distal of the second molar (M3inferior).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe thickness of the cancellous bone buccal to the mandibular canal (Fig.\u0026nbsp;3.c) was recorded at the mesial of the first molar (M1buccalcan) and second molar (M2buccalcan) and the distal of the second molar (M3buccalcan).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe thickness of the cancellous bone inferior to the mandibular canal (Fig.\u0026nbsp;3.d) was measured at the mesial of the first molar (M1inferiorcan) and second molar (M2inferiorcan) and the distal of the second molar (M3inferiorcan).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe thickness of the buccal cortical bone buccal to the mandibular canal (Fig.\u0026nbsp;3.e) was assessed at the mesial of the first molar (M1buccalcor), the second molar (M2buccalcor), and the distal of the second molar (M3buccalcor).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe thickness of the cortical bone inferior to the mandibular canal (Fig.\u0026nbsp;3.f) was recorded at the mesial of the first molar (M1inferiorcor) and second molar (M2inferiorcor).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eEach parameter measured from the right and left sides of the patient was evaluated separately. Additionally, the surgical notes and postoperatively obtained CBCT images were reviewed to check for the presence of bad splits, and any instances of bad splits were recorded in the patient data (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e, \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo evaluate the reliability of the measurements, intra-observer agreement was assessed by having the same researcher repeat the measurements on images from 15 randomly selected patients after a 2-month interval, with intraclass correlation coefficient (ICC) values reported. Inter-observer agreement was assessed by a second researcher performing measurements on the same images, with the ICC values also reported. Interpretation of the ICC values followed Landis and Koch\u0026rsquo;s[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] established criteria: ICC\u0026thinsp;\u0026lt;\u0026thinsp;0.20 (poor agreement), 0.21 to 0.40 (fair agreement), 0.41 to 0.60 (moderate agreement), 0.61 to 0.80 (good agreement), and 0.81 to 1.00 (excellent agreement).\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe statistical analysis of the data was performed using the SPSS software (Statistical Package for the Social Sciences), version 25.0 (IBM Corp., Released 2010. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA). Categorical variables are summarized as frequencies and percentages, whereas continuous variables are presented as the means and standard deviations (where appropriate, medians and ranges are also reported as minimum and maximum values). Chi-square tests were used for the comparison of categorical variables. The Shapiro‒Wilk test was used to determine whether the parameters in the study followed a normal distribution. The Mann‒Whitney U test was used to analyse differences between the groups. Statistical significance was established at P\u0026thinsp;\u0026lt;\u0026thinsp;0.050.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe study included 112 hemimandibles from 56 patients who underwent bilateral SSO. Both the right and left sides of each patient were included in the analysis. Of these, 36 (64.3%) were female, and 20 (35.7%) were male. The mean age of the patients was 23.9 years (\u0026plusmn;\u0026thinsp;6.1), with a median age of 22.5 years and an age range of 17 to 46 years. The mean postoperative follow-up period was 33.9 months (\u0026plusmn;\u0026thinsp;19.2), with a median of 40.5 months and a range of 6 to 72 months. Regarding the underlying skeletal deformities, 10 patients (17.9%) were diagnosed with Class II malocclusion, whereas 46 patients (82.1%) presented with Class III deformities. Impacted third molars were identified in 12 patients (10.7%). A total of 10 bad splits were observed, resulting in an incidence of 8.9% per site (10/112) and 14.3% per individual (8/56). Specifically, bilateral bad splits were detected in 2 patients, while 6 patients exhibited unilateral involvement. Tables\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA and \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eB present the measurements of the morphological parameters from preoperative CBCT. Based on the reliability assessment, ICC values showed that most parameters had good (ICC 0.61 to 0.80) to excellent (ICC 0.81 to 1.00) agreement, with no values falling below the good agreement level.\u003c/p\u003e\n\u003ch3\u003eDifferences Between Bad Split Groups and Measurements Evaluated on CBCT Images\u003c/h3\u003e\n\u003cp\u003eThis study examined the differences between bad split findings and parameters in the patient group. No significant differences were found between the bad split groups and variables such as sex (P\u0026thinsp;=\u0026thinsp;0.32), age (P\u0026thinsp;=\u0026thinsp;0.43), or side of the bad split (P\u0026thinsp;=\u0026thinsp;0.50). Moreover, no statistically significant correlation was established between the presence of impacted third molars (P\u0026thinsp;=\u0026thinsp;0.93), the type of preoperative skeletal deformity (P\u0026thinsp;=\u0026thinsp;0.49), and the incidence of bad splits (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). In SSO regions where bad splits were detected, the distance between the inferior alveolar nerve and the inferior cortical border of the mandible in the mesial region of the second molar (M2Inferior) was significantly greater than that in patients without bad splits (P\u0026thinsp;=\u0026thinsp;0.045). No significant differences were observed between the groups in terms of the other length parameters presented in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eA, \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eB.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSSO is technically demanding, with potential intraoperative and postoperative complications such as bleeding, airway compromise, bad split, infection, bone necrosis, temporomandibular joint (TMJ) disorders, dysphagia, restricted mouth opening, and psychological impacts[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Among the intraoperative complications observed during sagittal split osteotomy, a bad split has been reported as the most common, as highlighted by Thiem et al.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In response to this challenge, various studies have proposed novel modifications to conventional mandibular osteotomy techniques in an effort to minimize its occurrence[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Inadequately managed bad splits may result in postoperative issues, including infection, bone sequestration, delayed healing, and TMJ dysfunction[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Notably, the risk of a bad split has been shown to be closely linked to individual variations in mandibular morphology [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], underscoring the importance of preoperative anatomical assessment in reducing the likelihood of this complication.\u003c/p\u003e\u003cp\u003eTherefore, this study aimed to analyse posterior mandibular anatomy in 3D and examine its relationship with bad split occurrence, with the goal of reducing the incidence of bad splits.\u003c/p\u003e\u003cp\u003eMensink et al.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] reported the incidence of bad splits in 17 cases (2.0%) of 851 SSO sites performed across 427 patients from 1994 to 2011. Chrcanovic and Freire-Maia[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], in their review of 21 studies, reported incidence rates ranging from 0.21% to 22.72% across different sites. Balaji[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported bad splits in 27 cases (6.5%) of 416 SSO sites. Aarabi et al.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported 14 bad splits (14.6%) among 96 SSO sites. A meta-analysis by Verweij et al.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] included 18 retrospective and 3 prospective studies on bad splits, encompassing 8225 patients who underwent 16359 SSO procedures, with a total of 381 bad splits, yielding an overall incidence of 2.3% per site (range: 0.5% to 14.6%). Consistent with these findings, a total of 10 bad splits were observed in this study, resulting in an incidence of 8.9% per site (10/112) and 14.3% per individual (8/56). This relatively high incidence may be explained by the specific inclusion criteria of the present study, which enrolled only patients with both preoperative and postoperative cone-beam computed tomography (CBCT) scans. In routine clinical practice, postoperative CBCT imaging is not performed for all orthognathic surgery patients; it is commonly obtained in cases where a bad split is suspected. Therefore, the inclusion of only those patients with postoperative CBCT may have led to a selective concentration of suspected or confirmed bad split cases, consequently contributing to a higher observed rate compared to studies with broader or radiographically nonselective studies.\u003c/p\u003e\u003cp\u003eMany factors including age, sex, the presence of impacted third molars, different surgical techniques and tools, surgical experience, and mandibular anatomy, may affect the risk of bad split. Mensink et al.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] reported that 8 of the 17 bad splits in their study were associated with the presence of impacted third molars, suggesting a possible link. However, several studies and meta-analyses have indicated that the presence of impacted third molars during surgery does not affect the incidence of bad splits [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Accordingly, no significant relationship was found between third molar presence and bad split occurrence in the present study.\u003c/p\u003e\u003cp\u003eSteenen et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported no significant relationship between patient sex and the incidence of bad splits. However, a statistically significant correlation was observed between a higher mean age and an increased rate of bad splits. Similarly, Kriwalsky et al.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] reported an association between older age and bad splits, with an average age of 35 years (range 21 to 60) for patients with bad splits compared to 25 years (range 17 to 45) for those without. They reported no significant correlation between bad splits and sex. In the present study, no associations were found between sex or age and bad split occurrence.\u003c/p\u003e\u003cp\u003eMensink et al.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and Jiang et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported no statistically significant associations between bad split occurrence and factors such as patient age, sex, or preoperative skeletal relationship. These findings are consistent with the present study. Conversely, Kalabalık et al.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] suggested that prognathic mandibles, characterized by reduced mediolateral width and a lower proportion of cancellous bone, may be more susceptible to bad splits. However, this conclusion was reached without statistical support. Although the majority of patients in this study presented with Class III skeletal deformities, and most bad splits (9 out of 10) occurred in Class III patients, this association did not reach statistical significance.\u003c/p\u003e\u003cp\u003eSeveral studies have analysed various mandibular anatomical parameters between patients with bad splits and those without during the SSO procedure [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAarabi et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported that while the buccolingual thickness of the ramus at the level of the lingula was significantly thinner in patients with bad splits, no significant difference was observed between the groups in terms of the anteroposterior length of the ramus. Similar anatomical parameters were examined in the present study. Consistent with these findings, no correlation was found between the anteroposterior length of the ramus and bad splits. In contrast to Aarabi et al., no significant difference was observed in the buccolingual thickness of the ramus at the lingula level between the two groups in the present study.\u003c/p\u003e\u003cp\u003eIn their study, Wang et al.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] reported no significant relationship between bad split occurrence and various anatomical parameters, including the buccolingual thickness of the ramus at the lingula level and the anteroposterior length of the ramus at the same level. Furthermore, no association was observed with the distance from the mandibular foramen to the anterior border of the ramus, as well as the distance between the outer inferior cortical border of the mandible and the mandibular canal at the distal of the second molar.\u003c/p\u003e\u003cp\u003eTelha et al.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] found that a reduced distance between the mandibular canal and the buccal cortical border, as well as decreased cancellous bone thickness buccal to the mandibular canal, were significantly associated with an increased incidence of bad splits. In contrast, the present study found that neither of these parameters was related to bad split incidence. Additionally, Telha et al. reported no association between bad splits and other anatomical parameters, such as the anteroposterior length of the ramus at the mandibular foramen, the distance from the lingula to the sigmoid notch, the mediolateral thickness of the ramus at the lingula, and cortical bone thickness buccal to the mandibular canal. In line with this, the present study demonstrated no significant correlation between these parameters and the occurrence of bad splits.\u003c/p\u003e\u003cp\u003eIn distinction from these studies, we found that the distance between the inferior alveolar nerve and the inferior cortical border of the mandible in the region between the second and first molar was significantly greater in the bad split group. Similarly, Song and Kim, in their 2014 study, reported that the risk of bad splits increases when the inferior border osteotomy does not fully extend through the caudal cortex to the lingual cortex[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. It is hypothesized that in the mandibles with increased bone thickness in this region where vertical osteotomies are carried out may have contributed to an incomplete extension of the osteotomy at the inferior border, hindering its full reach to the lingual cortex. It can be speculated that combined with a top-down splitting approach, an incomplete inferior cortical osteotomy may be a contributing factor to increased rate of bad splits found in our study. Houppermans et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] reported that an inferior border cut extending through the lingual cortex does not necessarily result in greater predictability of a split in SSO. On the other hand, several studies have reported that extension of the inferior border osteotomy toward the lingual cortex may increase the risk of postoperative inferior border defects in mandibular advancements [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe present study is subject to several limitations. First, its retrospective and single-center design inherently constrains the external validity and generalizability of the findings. Moreover, as the surgical procedures were performed by multiple operators, a comprehensive evaluation of the potential effect of surgeon experience on clinical outcomes was not feasible. Additionally, within our clinical routine, postoperative CBCT imaging was not systematically performed for all orthognathic surgery patients. Therefore, future prospective studies are needed in which preoperative and postoperative CBCT scans are systematically obtained from all patients and where the precise location of osteotomies is determined and evaluated on these images.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study investigated the effects of mandibular anatomy on the occurrence of bad splits associated with SSO, and several conclusions were drawn. The presence of an impacted third molar during surgery did not increase the risk of bad splits. Furthermore, in the bad split group, the bone between the mandibular canal and the inferior cortical border was thicker in the region of the vertical osteotomy line, positioned between the first and second molars. This increased thickness may result an incomplete inferior osteotomy, potentially contributing to bad split formation. Moreover, other parameters related to mandibular anatomy did not show a significant difference between the bad split and non-bad split groups. Finally, we believe that evaluating mandibular anatomy with CBCT in orthognathic surgery patients is important and may help reduce the incidence of bad splits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCBCT Cone beam computed tomography\u003c/p\u003e\u003cp\u003eSSO Sagittal split ramus osteotomy\u003c/p\u003e\u003cp\u003eSAGER Sex and gender equity in research\u003c/p\u003e\u003cp\u003eFOV Field of view\u003c/p\u003e\u003cp\u003eDICOM Digital Imaging and Communications in Medicine\u003c/p\u003e\u003cp\u003eICC Intraclass correlation coefficient\u003c/p\u003e\u003cp\u003eTMJ Temporomandibular joint\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Clinical Research Ethics Committee of Cukurova University (Meeting No. 125, dated September 16, 2022). Written informed consent was obtained from all participants prior to data collection. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available owing to patient confidentiality and institutional regulations but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Scientific Research Projects Coordination Unit of Cukurova University under project number TDH-2022-15476.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT.A. conceived and designed the study, collected the clinical data, performed the CBCT analyses, interpreted the data, drafted the manuscript, and approved the final version.\u003c/p\u003e\n\u003cp\u003eH.C.T. contributed to the conception and design of the study, participated in data analysis and interpretation, critically revised the manuscript, and approved the final version.\u0026nbsp;All the authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the staff of the Department of Oral and Maxillofacial Surgery, Cukurova University, for their kind support and assistance during data collection and patient management.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWang T, Han JJ, Oh HK, Park HJ, Jung S, Park YJ, Kook MS. 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J Cranio-Maxillofacial Surg. 2017;45:192\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jcms.2016.12.015\u003c/span\u003e\u003cspan address=\"10.1016/j.jcms.2016.12.015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1A:\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Morphological\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eevaluation findings of parameters on preoperative\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;CBCT\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMed (Min\u0026ndash;Max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM2toFor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e10.1\u0026plusmn;3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e10 (0-20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eLintoSig\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e16.5\u0026plusmn;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e16.7 (10.9-22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eRanttoFor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e12.6\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e12.5 (8.4-20.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eRammedlat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e5.05\u0026plusmn;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e4.82 (2.43-8.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eRanttoPost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e29.5\u0026plusmn;2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e29.1 (22.7-38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM1 buccal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e4.57\u0026plusmn;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e4.47 (1.65-7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM2 buccal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e5.23\u0026plusmn;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e5.2 (1.79-8.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM3 buccal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e4.71\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e4.4 (1.6-8.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM1 inferior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e6.02\u0026plusmn;1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e6 (2.4-12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM2 inferior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e5.68\u0026plusmn;1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e5.69 (2.4-10.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM3 inferior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e6.20\u0026plusmn;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e6.07 (2.4-12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eSD: Standard Deviation, Med: Median, Min: Minimum, Max: Maximum\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1B:\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Morphological\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eevaluation findings of parameters on preoperative\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;CBCT\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMed (Min\u0026ndash;Max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM1 buccalcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.02\u0026plusmn;1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2 (0-5.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM2 buccalcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.49\u0026plusmn;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.43 (0-5.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM3 buccalcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e1.92\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2 (0-5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM1 inferiorcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.53\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.52 (0-8.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM2 inferiorcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.28\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.15 (0-6.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM3 inferiorcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e3.01\u0026plusmn;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e3.04 (0-8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM1 buccalcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.59\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.43 (1.65-4.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM2 buccalcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.71\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.8 (1.79-4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM3 buccalcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.80\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e2.8 (1.6-4.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM1 inferiorcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e3.52\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e3.6 (2.4-5.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM2 inferiorcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e3.42\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e3.36 (2.04-4.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4099%;\"\u003e\n \u003cp\u003eM3 inferiorcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e3.17\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.7951%;\"\u003e\n \u003cp\u003e3.2 (1.65-4.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eSD: Standard Deviation, Med: Median, Min: Minimum, Max: Maximum\u003c/em\u003e\u003c/p\u003e\n\u003cstyle\u003e\n .pf0 {}\n\u003c/style\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 is available in the Supplementary Files section.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 3A:\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Differences Between Morphological Evaluation Findings on Preoperative CBCT and Bad Split Groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWithout Bad Split\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=102)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWith Bad Split\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM2toFor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e10.0\u0026plusmn;3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e11.4\u0026plusmn;4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0.554\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eLintoSig\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e16.6\u0026plusmn;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e15.6\u0026plusmn;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.317\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eRanttoFor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e12.7\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e11.7\u0026plusmn;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.247\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eRammedlat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e5.09\u0026plusmn;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e4.59\u0026plusmn;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.396\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eRanttPost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e29.4\u0026plusmn;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e30.0\u0026plusmn;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.984\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM1 buccal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e4.56\u0026plusmn;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e4.68\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.907\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM2 buccal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e5.22\u0026plusmn;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e5.29\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.992\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM3 buccal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e4.68\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e5.0\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.627\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM1 inferior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e5.96\u0026plusmn;1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e6.49\u0026plusmn;1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.227\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM2 inferior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e5.59\u0026plusmn;1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e6.52\u0026plusmn;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM3 inferior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e6.11\u0026plusmn;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e7.11\u0026plusmn;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eSD: Standard Deviation, *p\u0026lt;0.050,\u003c/em\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003cem\u003e\u0026Dagger;:\u0026nbsp;\u003c/em\u003e\u003cem\u003eMann‒Whitney U test\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 3B:\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Differences Between Morphological Evaluation Findings on Preoperative CBCT and Bad Split Groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWithout Bad Split\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=102)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWith Bad Split\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM1 buccalcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e2.00\u0026plusmn;1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2.17\u0026plusmn;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.791\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM2 buccalcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e2.48\u0026plusmn;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2.61\u0026plusmn;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM3 buccalcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e1.89\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2.24\u0026plusmn;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.457\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM1 inferiorcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e2.49\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2.96\u0026plusmn;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.191\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM2 inferiorcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e2.23\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2.79\u0026plusmn;0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM3 inferiorcan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e2.95\u0026plusmn;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e3.62\u0026plusmn;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.364\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM1 buccalcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e2.59\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2.52\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.785\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM2 buccalcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e2.72\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2.67\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.647\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM3 buccalcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e2.80\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2.76\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.881\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM1 inferiorcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e3.52\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e3.53\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.931\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM2 inferiorcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e3.39\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e3.72\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eM3 inferiorcor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e3.13\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e3.50\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eSD: Standard Deviation, *p\u0026lt;0.050, \u0026Dagger;:\u0026nbsp;\u003c/em\u003e\u003cem\u003eMann‒Whitney U test\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sagittal Split Ramus Osteotomy, Bad Split, Cone-Beam Computed Tomography, Mandibular Anatomy, Orthognathic Surgery, Intraoperative Complications","lastPublishedDoi":"10.21203/rs.3.rs-7786845/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7786845/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe objective of this study was to conduct three-dimensional cone beam computed tomography (CBCT) analysis of posterior mandibular anatomy in order to investigate its potential correlation with the occurrence of bad splits during sagittal split ramus osteotomy (SSO).\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e\u003cp\u003eA retrospective review was conducted on 56 patients (112 hemimandibles) who underwent bilateral SSO between 2016 and 2022. Distances between the mandibular canal and the borders of the mandible, along with anatomical landmarks, were measured. Sites with and without bad splits were compared using chi-square and Mann\u0026ndash;Whitney U tests (p\u0026thinsp;=\u0026thinsp;0.05). Intra- and inter-observer reliability were assessed via intraclass correlation coefficients.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe overall incidence of bad split was 8.9% per site (10/112) and 14.3% per patient (8/56). Patient-related variables, including age, sex, skeletal deformity type (Class II vs. Class III), and the presence of impacted third molars, were not significantly associated with bad split (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Among the morphometric parameters, the distance from the mandibular canal to the inferior cortical border at the mesial of the second molar (M2-inferior) was significantly greater in the bad-split group (P\u0026thinsp;=\u0026thinsp;0.045). Other measurements, including ramal thickness, anteroposterior length, and canal position relative to buccal and inferior cortices, were not significantly different. Reliability analysis demonstrated good to excellent agreement for all the measurements.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eA greater inferior mandibular border thickness at the mesial of the second molar appears to increase the risk of bad split during SSO. Routine preoperative CBCT evaluation and careful attention to inferior border osteotomy in this region may help reduce complications. Further prospective, standardized studies are needed to confirm these findings.\u003c/p\u003e","manuscriptTitle":"The Impact of Mandibular Anatomy on the Incidence of Bad Splits in Sagittal Split Ramus Osteotomy: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 16:19:57","doi":"10.21203/rs.3.rs-7786845/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-16T17:09:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-10T07:06:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304653991600884436681728979446905655038","date":"2025-11-06T09:12:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108477372820503858730098453755626269261","date":"2025-10-30T09:29:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-30T07:39:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-16T01:45:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-15T13:46:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-15T13:44:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-10-05T21:35:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2aa12990-f1e9-4225-a28e-f1d82aad7762","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:19:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 16:19:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7786845","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7786845","identity":"rs-7786845","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}