Bilateral sagittal split osteotomy buccal cut classification. Indications: pros and cons

Bilateral sagittal split osteotomy (BSSO) and its numerous modifications remain the cornerstone of mandibular orthognathic surgery. Despite extensive literature describing individual techniques, we know of no comprehensive comparison of their properties, indications, and clinical outcomes. This review proposes a novel classification of the BSSO technique based on the position of the buccal cut relative to the mandibular notch and angle: pre-notch, post-notch, and post-gonial. Their technical characteristics and clinical implications are described and compared, providing a straightforward guide to the optimal approach in each scenario. A narrative review of key publications on BSSO techniques was conducted and combined with the authors' clinical experience. Using this foundation, an original classification was formulated, organising established osteotomy designs according to the position of the buccal cut relative to the mandibular notch. Pre-notch approaches provide broad bony contact and stable outcomes for standard procedures with a thick soft tissue; post-notch techniques reduce inferior border notching and help protect the inferior alveolar nerve, and are therefore indicated for large mandibular movements and thin soft tissues; post-gonial strategies facilitate ramus lengthening and the correction of complex vertical asymmetry. The proposed classification offers a simple, clinically oriented framework that aligns existing BSSO modifications with surgical objectives, and supports more precise and individualised treatment planning.