Intra-oral condylotomyfor the treatment of temporomandibular joint derangement
Elliot Shevel Honeydew, Transvaal, S. Africa
E. Shevel: Intra-oral condylotomy for the treatment of temporomandibular joint derangement. Int. J. Oral Maxillofac. Surg. 1991; 20: 360-361. Abstract. Open condylotomy using Moose's intra-oral approach was performed on 46 patients suffering from anterior disc displacement. The results show that condylotomy is useful in the treatment of this disorder, but the technique used is not recommended due to the risk of dislocation of the condylar fragment.
Closed subcondylar condylotomy using a Gigli saw has been successfully used since 19541'2'7'9'10'11'12in the treatment of temporomandibular joint (TMJ) dysfunction, but there is a danger of serious post-operative complications due to possible damage to the facial and inferior alveolar nerves, and the internal maxillary and external carotid arteries ~'x°'H.The purpose of this paper is to show that anterior displacement of the disc can be successfully treated using intra-oral open condylotomy, with minimal risk of injury to vital structures, particularly the facial nerve. Material and methods
Unilateral condylotomy was performed on 46 patients with anterior disclolation of the articular disc, using the approach described by Moos~8 (Fig. 1). The patients were wired in occlusion for 7 days. The patients were grouped according to the findings at arthrography, which were either anterior displacement with reduction (28 patients), or anterior displacement without reduction (18 patients). The patients' ages ranged from 16 years to 35 years, and the sex distribution was 39 females and 7 males. The average age of the women was 22.4 yeats, and of the men 26.0 years. The operations were carried out in the period between November 1985 and April 1989, and the followup ranged from 18 months to 5 years. Results
On immediate post-operative examination none of the 46 patients showed any sign of facial nerve injury. One had paraesthesia of the lower lip. Longer term clinical evaluation (18
months to 5 years) was carried out on 32 of the 46 patients. These patients showed no signs of facial nerve damage, and they no longer had closed lock or painful joints; 4 had slight residual clicks which did not bother them. One patient had a 1.5 cm area of paraesthesia of the lower lip, and 2 had some residual anaesthesia on the inside of the cheek. All 32 had normal pain-free function and were satisfied with the results. The remaining 14 were unable to return for clinical evaluation, and were assessed according to their subjective verbal responses. Twelve of these reported that they regarded the operation as successful, in that they had normal function, and they no longer had limited opening, clicking, or pain. In 2 eases the operation failed. One had a recurrence of the same painful clicking which he had experienced pre-operatively, and one had severe limitation of opening, which was successfully treated elsewhere by prosthetic joint replacement.
Key words: condylotomy; TMJ dysfunction
Accepted for publication 31 July 1991
faces is decreased, allowing self-correction of the displaced meniscus in relation to the condylar head. Closed condylotomy has been used 1&9'1°'11'12since 1954 for treatment of TMJ-dysfunction, but has not become widely accepted because it appears to many surgeons to be a potentially hazardous procedure 1. BANKS & MAcKEz~ZIE~ carried out condylotomy on cadavers using Ward's technique, and demonstrated that the line of section often passes close to the main branches of the facial nerve and to the distal part of the external carotid artery. Further, the maxillary artery often lies immediately medial to the line of section, and the descending inferior alveolar artery is at risk if the flexible saw is too deep. With open condylotomy using Moose's approach (Fig. 1) the facial
Discussion
Some authors 1'3'4'6 maintain that treatment of anterior dislocation of the disc should be aimed at decompression of the joint. This is confirmed by the finding of BANKS & MACKENZIEI that postcondylotomy increase in joint space is directly proportional to improvement of symptoms. GUI~AI.NICldused high condylectomy to increase the joint space, but HARRIS5 pointed out that by using condylotomy, the joint space can be increased without damaging the synovial lining. The loading of the articular sur-
Fig. 1. Subcondylar osteotomy from the intra-oral approach. From Moose SM. Correction of abnormal mandibular protrusion by intra-oral operation. J Oral Surg 1945: 3: 304-10.
lntra-oral condylotomy nerve and external carotid artery are not endangered, and the maxillary and inferior alveolar arteries and inferior alveolar nerve are protected by a retractor during sectioning of the mandible. The occurrence of lower lip paraesthesia in one patient demonstrates, however, that there is still some danger of injury to the inferior alveolar nerve and artery during reflection and retraction of the periosteum from the medial surface of the mandibular ramus. Fracture-dislocation of the proximal fragment was an unforseen problem which occurred in 5 patients in this series. When the mandible is sectioned, the m o u t h is wide open, and the condylar head may lie anterior to the articular eminence. On closing, the condylar head is prevented from returning to the fossa, particularly in patients with a prominent articular eminence. In 4 of these patients, radiographs taken at operation revealed the displaced condyle, and the dislocation was reduced. In the 5th case, there were technical problems with the X-ray equipment, and the dislocation was not detected. The patient subsequently went to another surgeon complaining of severe limitation of opening, which was corrected by total joint replacement.
The results show that anterior disc displacement can be successfully treated by open intra-oral condylotomy, without danger of injury to the facial nerve. The problem of dislocation of the proximal fragment has, however, led the author to abandon Moose's mesial approach in favour of a lateral intra-oral approach with the mandible wired in occlusion before the jaw is sectioned.
References
1. BANKSP, MACKENZIEI. Condylotomy. A clinical and experimental appraisal of a surgical technique. J Maxillofac Surg 1975: 3: 170-81. 2. CAMVBELLW. Clinical radiological investigations of the mandibular joints. Br J Radiol 1965: 38: 401-21. 3. CRAODOCKFW. A review of Costen's syndrome. Br Dent J 1951: 91: 199-204. 4. GURALNICK W. Treatment of organic temporomandibular joint disease (excluding arthritis). President's conference on the examination, diagnosis, and management of temporomandibular disorders. A.D.A., Chicago 1M- June, 1982. Published by Am Dental Assoc 18:129 32. 5. HARRISM. Medical versus surgical management of temporomandibular joint pain and dysfunction. Br J Oral Maxillofac Surg 1987: 25: 113-20.
361
6. HENNYFA, BALDRIDGEOL. Condylectomy for the consistently painful temporomandibular joint. J Oral Surg 1957: 15: 24~31. 7. JAMESR The surgical treatment of mandibular disorders. Ann R Coll Snrg 1971: 49: 310~8.
8. MOOSE SM. Surgical correction of mandibular prognathism by intra-oral subcondylar osteotomy. J Oral Surg 1964: 22: 197-202. 9. SADAV. Experience in surgical treatment of temporomandibular joint arthrosis by the Ward-technique. Transactions of the Congress of the First International Association of Oral Surgeons. 1967:265 7. 10. TASANEN A, LANBERG MA. Closed condylotomy in the treatment of recurrent dislocation of the mandibular condyle. Int J Oral Surg 1978: 7: 1-6. 11. TASANENA, YON KONOW MA. Closed condylotomy in the treatment of idiopathic and traumatic pain-dysfunction syndrome of the temporomandibular joint. Int J Oral Surg 1973: 2: 10~6. 12. WARD TG. Surgery of the mandibular joint. Ann R Coll Surg 1961: 28: 139-52. Address: Dr. Elliot Shevel P.O. Box 732 Honeydew 2040 South Africa
Elliot Shevel Honeydew, Transvaal, S. Africa
E. Shevel: Intra-oral condylotomy for the treatment of temporomandibular joint derangement. Int. J. Oral Maxillofac. Surg. 1991; 20: 360-361. Abstract. Open condylotomy using Moose's intra-oral approach was performed on 46 patients suffering from anterior disc displacement. The results show that condylotomy is useful in the treatment of this disorder, but the technique used is not recommended due to the risk of dislocation of the condylar fragment.
Closed subcondylar condylotomy using a Gigli saw has been successfully used since 19541'2'7'9'10'11'12in the treatment of temporomandibular joint (TMJ) dysfunction, but there is a danger of serious post-operative complications due to possible damage to the facial and inferior alveolar nerves, and the internal maxillary and external carotid arteries ~'x°'H.The purpose of this paper is to show that anterior displacement of the disc can be successfully treated using intra-oral open condylotomy, with minimal risk of injury to vital structures, particularly the facial nerve. Material and methods
Unilateral condylotomy was performed on 46 patients with anterior disclolation of the articular disc, using the approach described by Moos~8 (Fig. 1). The patients were wired in occlusion for 7 days. The patients were grouped according to the findings at arthrography, which were either anterior displacement with reduction (28 patients), or anterior displacement without reduction (18 patients). The patients' ages ranged from 16 years to 35 years, and the sex distribution was 39 females and 7 males. The average age of the women was 22.4 yeats, and of the men 26.0 years. The operations were carried out in the period between November 1985 and April 1989, and the followup ranged from 18 months to 5 years. Results
On immediate post-operative examination none of the 46 patients showed any sign of facial nerve injury. One had paraesthesia of the lower lip. Longer term clinical evaluation (18
months to 5 years) was carried out on 32 of the 46 patients. These patients showed no signs of facial nerve damage, and they no longer had closed lock or painful joints; 4 had slight residual clicks which did not bother them. One patient had a 1.5 cm area of paraesthesia of the lower lip, and 2 had some residual anaesthesia on the inside of the cheek. All 32 had normal pain-free function and were satisfied with the results. The remaining 14 were unable to return for clinical evaluation, and were assessed according to their subjective verbal responses. Twelve of these reported that they regarded the operation as successful, in that they had normal function, and they no longer had limited opening, clicking, or pain. In 2 eases the operation failed. One had a recurrence of the same painful clicking which he had experienced pre-operatively, and one had severe limitation of opening, which was successfully treated elsewhere by prosthetic joint replacement.
Key words: condylotomy; TMJ dysfunction
Accepted for publication 31 July 1991
faces is decreased, allowing self-correction of the displaced meniscus in relation to the condylar head. Closed condylotomy has been used 1&9'1°'11'12since 1954 for treatment of TMJ-dysfunction, but has not become widely accepted because it appears to many surgeons to be a potentially hazardous procedure 1. BANKS & MAcKEz~ZIE~ carried out condylotomy on cadavers using Ward's technique, and demonstrated that the line of section often passes close to the main branches of the facial nerve and to the distal part of the external carotid artery. Further, the maxillary artery often lies immediately medial to the line of section, and the descending inferior alveolar artery is at risk if the flexible saw is too deep. With open condylotomy using Moose's approach (Fig. 1) the facial
Discussion
Some authors 1'3'4'6 maintain that treatment of anterior dislocation of the disc should be aimed at decompression of the joint. This is confirmed by the finding of BANKS & MACKENZIEI that postcondylotomy increase in joint space is directly proportional to improvement of symptoms. GUI~AI.NICldused high condylectomy to increase the joint space, but HARRIS5 pointed out that by using condylotomy, the joint space can be increased without damaging the synovial lining. The loading of the articular sur-
Fig. 1. Subcondylar osteotomy from the intra-oral approach. From Moose SM. Correction of abnormal mandibular protrusion by intra-oral operation. J Oral Surg 1945: 3: 304-10.
lntra-oral condylotomy nerve and external carotid artery are not endangered, and the maxillary and inferior alveolar arteries and inferior alveolar nerve are protected by a retractor during sectioning of the mandible. The occurrence of lower lip paraesthesia in one patient demonstrates, however, that there is still some danger of injury to the inferior alveolar nerve and artery during reflection and retraction of the periosteum from the medial surface of the mandibular ramus. Fracture-dislocation of the proximal fragment was an unforseen problem which occurred in 5 patients in this series. When the mandible is sectioned, the m o u t h is wide open, and the condylar head may lie anterior to the articular eminence. On closing, the condylar head is prevented from returning to the fossa, particularly in patients with a prominent articular eminence. In 4 of these patients, radiographs taken at operation revealed the displaced condyle, and the dislocation was reduced. In the 5th case, there were technical problems with the X-ray equipment, and the dislocation was not detected. The patient subsequently went to another surgeon complaining of severe limitation of opening, which was corrected by total joint replacement.
The results show that anterior disc displacement can be successfully treated by open intra-oral condylotomy, without danger of injury to the facial nerve. The problem of dislocation of the proximal fragment has, however, led the author to abandon Moose's mesial approach in favour of a lateral intra-oral approach with the mandible wired in occlusion before the jaw is sectioned.
References
1. BANKSP, MACKENZIEI. Condylotomy. A clinical and experimental appraisal of a surgical technique. J Maxillofac Surg 1975: 3: 170-81. 2. CAMVBELLW. Clinical radiological investigations of the mandibular joints. Br J Radiol 1965: 38: 401-21. 3. CRAODOCKFW. A review of Costen's syndrome. Br Dent J 1951: 91: 199-204. 4. GURALNICK W. Treatment of organic temporomandibular joint disease (excluding arthritis). President's conference on the examination, diagnosis, and management of temporomandibular disorders. A.D.A., Chicago 1M- June, 1982. Published by Am Dental Assoc 18:129 32. 5. HARRISM. Medical versus surgical management of temporomandibular joint pain and dysfunction. Br J Oral Maxillofac Surg 1987: 25: 113-20.
361
6. HENNYFA, BALDRIDGEOL. Condylectomy for the consistently painful temporomandibular joint. J Oral Surg 1957: 15: 24~31. 7. JAMESR The surgical treatment of mandibular disorders. Ann R Coll Snrg 1971: 49: 310~8.
8. MOOSE SM. Surgical correction of mandibular prognathism by intra-oral subcondylar osteotomy. J Oral Surg 1964: 22: 197-202. 9. SADAV. Experience in surgical treatment of temporomandibular joint arthrosis by the Ward-technique. Transactions of the Congress of the First International Association of Oral Surgeons. 1967:265 7. 10. TASANEN A, LANBERG MA. Closed condylotomy in the treatment of recurrent dislocation of the mandibular condyle. Int J Oral Surg 1978: 7: 1-6. 11. TASANENA, YON KONOW MA. Closed condylotomy in the treatment of idiopathic and traumatic pain-dysfunction syndrome of the temporomandibular joint. Int J Oral Surg 1973: 2: 10~6. 12. WARD TG. Surgery of the mandibular joint. Ann R Coll Surg 1961: 28: 139-52. Address: Dr. Elliot Shevel P.O. Box 732 Honeydew 2040 South Africa
