J Oral Maxillofac 49:579-593.

Surg

1991

The Treatment of Temporomandibular Joint Internal Derangements Using a Modified Open Condylo tomy: A Preliminary

Report

L. GEORGE UPTON, DDS, MS,* AND STEVEN M. SULLIVAN,

DDSt

A modified open condylotomy was used to treat 44 patients who presented with painful temporomandibular joints, and in whom the clinical and arthrographic findings were indicative of disc displacement. A total of 64 joints (20 bilateral) were operated on. Postoperatively, the patients showed an overall improvement in their functional symptoms. Ninety-one percent of patients had improvement in clicking and popping, and 96% reported decrease in locking. Complaints related to pain and headache were improved 85% and 95%, respectively. The modified technique, as well as the anatomic basis for its use. are discussed.

my devised by Kostecka in 19282 and used the procedure to treat 21 patients in his original series. He reported marked improvement or complete relief of symptoms in 15 of these patients. The rationale for application of this procedure was his observation that in condylar neck fractures, where a history of prior joint symptoms was present, cure of the symptoms was effected by the accident.’ Campbell demonstrated 84% clinical improvement, with 32.2% of the patients being completely cured, by use of the Ward technique.3 Sada, in a series of 33 patients, and James, in his series of eight patients, claimed relief of symptoms in 83% and 66%, respectively.4,5 In 1973, Tasanen and von Konow evaluated the results of closed condylotomy for both idiopathic pain and dysfunction and traumatic pain and dysfunction of the TMJ in a series of 37 patients. Complete satisfaction was obtained in 23 of his patients.6 Banks and MacKenzie examined 119 patients clinically and radiographically and found that 91% were “cured” or improved by the surgery.’ It should be appreciated that Ward’s description was more related to generalized TMJ symptoms and did not address specifically internal derangements of the joint. These results indicate that condylotomy as a means of treating TMJ internal derangements is effective. Associated complications, which include bleeding, facial nerve palsy, auriculotemporal syndrome, and malocclusion, are reported to be small.

Temporomandibular joint (TMJ) internal derangements have been managed using a variety of nonsurgical and surgical techniques. The literature is replete with descriptions of these techniques, most of which have attained varying degrees of success. IV2It is the purpose of this article to discuss the use of a modified open condylotomy with condylar repositioning in the treatment of TMJs with internal derangements. Literature Review The literature is particularly sparse with regard to the use and long-term follow-up of condylotomy for the treatment of the internally deranged TMJ. Ward’ developed the technique of closed condylotomy as a modification of the closed ramus osteoto-

Received from the Department of Oral Medicine, Oral Pathology, Oral Surgery, University of Michigan School of Dentistry, Ann Arbor. * Professor. t Lecturer. Address correspondence and reprint requests to Dr Upton: Department of Oral Medicine, Oral Pathology, Oral Surgery, University of Michigan School of Dentistry, 1011 N University, Ann Arbor, MI 48109-1078. 0 1991 geons

American

Association

of Oral

and

Maxillofacial

Sur-

0278-2391/91/4908-0004$3.00/O

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UPTON AND SULLIVAN

Initially, the procedure was reported what technique-sensitive.‘-*

to be some-

Materials and Methods Forty-four patients (64 joints: 20 bilateral) were treated by condylotomy. Use of the procedure was confined to those patients with painful, clicking joints, most with a history of intermittent episodes of catching and brief periods of locking. Forty-three of these patients had preoperative arthrography to confirm disc displacement and reduction. One patient undergoing bilateral condylotomy did not have arthrography because she concurrently required a mandibular oblique osteotomy to correct her mandibular prognathism.Y SURGICAL

TECHNIQUE

The patient is prepared and draped in the usual manner for a vertical ramus osteotomy. After the patient is anesthetized, the mandible is grasped and the condyle on the affected side brought downward and forward to the inferior aspect of the articular eminence. Upward pressure is then exerted and the condyle moved back into the glenoid fossa. Classically, this will result in the click being reproduced. The same maneuver is used subsequently in the surgical technique. The retromolar and anterior coronoid area is infiltrated with local anesthetic containing a vasoconstrictor. The standard retromolar incision for a vertical ramus osteotomy is then performed. Adequate exposure of the anterior coronoid for this operation, however, requires dissection to the coronoid tip. The lateral ramus is exposed from the inferior border to the sigmoid notch. Care is taken not to penetrate the periosteal envelope in the area of the sigmoid notch and also not to detach the insertion of the stylomandibular ligament along the posterior border of the ramus of the mandible (Fig I). It is important that direct visualization of the sigmoid notch is possible; thus, in some instances, it is necessary to remove a portion of the anterior coronoid process with a large round bur. Once exposure of the surgical site is achieved, a cut is made with an oscillating saw from the sigmoid notch to the angle of the mandible similar to a vertical ramus osteotomy . ” The variation from a standard osteotomy, however, is that the cut extends to the most anterior aspect of the sigmoid notch (Fig 2). This facilitates overlapping of the condylar segment and the distal segment. Once the cut is completed, tissue attachments on the medial aspect of the condylar segment are freed, except for the posterior attachments. Removal of the posterior attach-

Lateral Pterygoid Muscle Sphenomandibul Ligament Stylomandibular Ligament Medial Pterygoid Muscle

FIGURE 1. Diagram showing how maintanence of the stylomandibular ligament attachment minimizes condylar sag once the osteotomy is completed.

ments, especially the stylomandibular ligament, results in sagging of the condyle with hyperocclusion occurring on that side. In a bilateral case, the same procedure is done on the opposite side. The throat pack is then removed, the nasopharynx and hypopharynx are suctioned, and the patient is placed in maxillomandibular fixation. With the patient in maxillomandibular fixation, the surgical site is again inspected. At this time, a hemostat is used to grasp the forward extension of the condylar segment in the area of the sigmoid notch. A second instrument is used to stabilize the inferior aspect of the condylar segment to prevent rotation. The segment is then brought forward beneath the articular eminence, and then, with upward pressure, moved posteriorly. In those patients who classically have displaced discs that reduce (ie, history of clicking, popping, catching, and/or locking episodes) the surgeon can normally demonstrate a reproduceable click. This maneuver is carried out two or three times to determine precisely when the disc slips off the condyle. The maneuver is then repeated, but the condyle is left at the position just prior to occurrence of the click. The location of the condylar segment relative to the distal segment is then inspected in the area of the sigmoid notch. Normally, there is an overlap of approximately 2 mm. The surgical site is irrigated and closed with 3-O chromic sutures. Occasionally, it is not possible to reproduce the click when the condylar segment is manipulated. In this instance. it is necessary to rely solely upon the visual downward and forward overlap of the condylar segment of approximately 2 mm relative to the distal segment. The patient is left in maxillomandibular fixation

TMJ INTERNAL

DERANGEMENT:

TREATMENT

WITH CONDYLOTOMY

management of symptomatic TMJ internal derangements were reviewed. Data concerning the patient’s age, sex, and history of nonsurgical management, initiating event of symptoms, and types of symptoms (ie, headache, pain, popping, clicking, crepitus, locking), were analyzed. Pertinent clinical lindings, such as joint tenderness and pain, popping, reciprocal clicking, crepitus, deviation upon opening, and type of occlusion, were also included. The history and clinical and arthrographic examinations were all performed by one clinician (LGU). Fortyfour patients with an average follow-up of 33.8 months were included in this study. Results

FIGURE 2. Diagram (A) and radiograph (B) showing how the osteotomy is carried anteriorly in the sigmoid to facilitate manipulation of the condylar segment and allow overlap of the segments.

for approximately 3 weeks in a unilateral case followed by use of training elastics for another 3 weeks. In a bilateral case, the maxillomandibular fixation is maintained for 6 weeks, with 1 month of anterior training elastics. Following discontinuance of appliances, the patient is given physiotherapy instructions to facilitate normal mandibular motion. ANALYSIS

OF CASES

The records of patients who had undergone the modified open condylotomy procedure for surgical

There were a total of 41 females and 3 males, with an average age of 31.8 years (range, 16 to 60) at the time of surgery. The initiating event that resulted in symptoms could not be identified in 50% of patients. A blow to the jaw was listed by 10 patients, 4 patients reported stress, and 3 indicated that symptoms began after a motor vehicle accident. The remaining 5 patients reported that their symptoms began after dental extraction, orthodontics, “whiplash” injury, or mastication of food. Thirtysix patients underwent presurgical bite appliance management for their TMJ pain. These had been worn an average of 10.8 months (range, 1 to 41 months). Patient’s response to bite appliance therapy was equivocal. Three reported that their symptoms became worse, 19 indicated that appliance therapy was of no value, 10 indicated that it relieved their symptoms to a minor degree, and only 4 patients indicated that it was of major help. Pain was present bilaterally in 20 patients, only on the right side in 11, and only on the left side in 7. The remainder had a past history of pain, but none at the time of examination. Bilateral clicking and popping were reported by 23 patients; in 10 patients they occurred on the right, and in 7 patients on the left. The remaining 4 did not complain of clicking or popping. Crepitus was present in 1 patient bilaterally, and in 3 patients on the right side and 2 patients on the left. Headaches were reported by only 7 patients. Clinical examination showed a class I occlusion in 3 1 patients, and a class II and class III malocclusion in 5 and 6 patients, respectively. The remaining 2 patients had combinations of class I and II occlusion. The TMJ examination demonstrated unilateral pain to palpation in 27 patients, and bilaterally in 13. A reciprocal click was found in 32 patients (18 bilateral), whereas only an opening pop was evident in 7 patients (2 bilateral). Crepitus and mandibular deviation were observed in 4 patients. The results of the preoperative arthrograms

UPTON AND SULLIVAN

showed that all 43 patients had internal derangements. Disc displacement was rated as being mild, moderate, or severe. The arthrographic examination demonstrated evidence of disc reduction on opening in all cases. Disc perforations were suggested arthrographically in nine TMJs. The modified condylotomy was performed unilaterally on 24 patients, with 20 patients undergoing the procedure for bilateral internal derangements. Intraoperative manual reduction of the displaced disc on the osteotomized condylar segment was accomplished in 55 operations. Sixteen patients had bilateral manual reduction of the disc and condyle; there were two bilateral cases in which the condyledisc complex could not be reduced (click reproduced). Two bilateral cases had unilateral reduction only. One unilateral case was not able to be reduced. Of all patients undergoing modified condylotomy on the TMJ, 91% exhibited reduction in clicking and popping, with 53% having major improvement, 25% moderate improvement, and 13% having mild improvement. Signs and symptoms of locking were improved in 96% of patients undergoing condylotomy, with 68% having a major improvement, 16% having a moderate improvement, and 12% having a mild improvement in their locking symptoms. Pain was reduced in 85%, with 55% reporting major improvement, 24.5% moderate improvement, and 5.5% mild improvement. Headaches were improved in 95% of patients, with 48.5% having a major improvement, 13% having a moderate improvement, and 33.5% having a mild improvement. Complications associated with the procedure included seven patients reporting slight ipsilateral hyperocclusion, one patient indicating that the pain had become worse, and one patient reporting a mass in the muscle on the operated side. Discussion Success in treating internal derangements of the TMJ generally has been high. Surgical techniques employed have included variations of disc repositioning, disc repair, contouring of the articular surfaces, discectomy with and without implants or grafts, condylotomy, high condylectomy, and arthroscopic surgery.‘1-‘3 Many authors have reported success rates with the various procedures that are significant enough to support the overall assessment that TMJ surgery is an effective modality in the treatment of internal derangements.“.” Although good results have been obtained, complications associated with the procedures have been reported. They include limitation in range of motion, intra-articular scarring, facial nerve deficit, de-

581

generative changes of the articular surfaces, implant fragmentation with subsequent foreign-body giant cell reaction, recurrent pain with dysfunction. and malocclusion.6*14-22 Techniques to reestablish a more anatomically correct disc-condyle relationship have been devised and are based on the premise that the displaced disc causes mechanical obstruction of the condylar path of movement and compression of retrodiscal tissues by an anterior-posteriorly malpositioned disccondyle complex, thus resulting in pain and dysfunction. Joint noise and degenerative changes may also accompany these tindings.“3.‘4 Surgical manipulation of joint structures invariably results in scar formation that can ultimately lead to limitation of functional movements. This may be a result of capsular fibrosis, tethering of the retrodiscal tissues, or postoperative muscle splinting secondary to surgical pain. Preexisting conditions can result in additive effects, causing decreased range of motion, including adaptive functional shortening of muscles due to chronic myositis. 14-‘* Alloplastic TMJ implant materials have recently come under increased scrutiny because of the possible association with accelerated degenerative changes of the articular surfaces and potential for foreign-body giant cell reactions. Although alloplastic implants have been used successfully, they may be a source of reconstructive failure.20,21 Disc repositioning procedures when used for displaced discs have been shown to be effective, but are also subject to effects of scarring and its sequelae. As progressive disc changes occur, this alternative becomes less desirable. Nonsurgical techniques of disc-condyle reduction, such as altering the occlusion through equilibration, fixed and removable appliances (ie, crowns, bridges, bite splints), and orthodontics, have been advocated. Changing the condylar relationship with regard to an altered disc position can result in reduction of the displaced disc and effectively resolve the patient’s symptoms. However, when disc reduction is not possible, or is refractory to reduction by nonsurgical means, surgical repositioning may be a consideration if the patient’s symptoms and functional deficits result in disability.“*‘3 Early clicks have the best prognosis. The small amount of displacement allows a seating of the condyle onto the articular disc, with a minimum of downward and forward repositioning of the condyle on the slope of the artitular eminence. Late opening clicks may require the condyle to be repositioned too far forward to be functionally acceptable. The condylotomy procedure has several inherent advantages when one considers the local joint anat-

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TMJ INTERNAL

omy and the disc-condyle dynamics. The basis for condylotomy becomes apparent when proper patient selection has taken place. The procedure circumvents the potential for capsule fibrosis, facial nerve deficit, and articular adhesions. Although maxillomandibular fixation is required, postoperative range of motion appears to be better in the long term compared with open joint procedures. The reduction of the condyle onto the disc as a result of the osteotomy may provide relief of pain through shortening of the lateral pterygoid muscle and increasing the joint space. Additionally, compression of retrodiscal tissues by the condyle is eliminated

DERANGEMENT:

TREATMENT

WITH CONDYLOTOMY

once the proper disc-condyle relationship has been reestablished. Disc reduction and stabilization also contribute to the elimination of popping and clicking with functional movements. lq3-’ Immediate postoperative panoramic radiographs consistently showed increased joint space, but, more importantly, additional radiographs later in the postoperative follow-up period demonstrated that the joint space still appeared to be increased over preoperative images (Fig 3). Because of obvious limitations with panoramic radiographs, we did not specifically evaluate and attempt to quantify joint space changes. Long-term radiographic evalu-

FIGURE 3. A, The 13month postoperative radiograph shows partial maintenance of the increased joint space that is noted immediately postoperatively (B) when compared with the preoperative radiograph (0.

JAMES W. NICKERSON

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ation by Banks and McKenzie demonstrated that the maintenance of increased joint space correlated well with the patients who reported a cure of their symptoms, which included popping, clicking, and pain. It was also noted that the new condylar position was stable, and minimal long-term changes were noted.’ When specific symptoms such as pain with function, clicking, and headaches were evaluated in previous series, rates of improvement of 88% to 100% were noted. These results closely parallel the findings in this series.1*3-7*25 Surgeons have a variety of alternatives at their disposal to manage internal derangements of the TMJ. This article presents additional evidence that the open condylotomy is another alternative in indicated patients for management of this condition. References 1. Ward TG: Surgery of the mandibular joint. Ann R Co11Surg 28: 139, 1961 2. Kostecka F: Surgical correction of protrusion of the lower and upper jaws. J Am Dent Assoc 15:362, 1928 3. Campbell W: Clinical radiological investigators of the mandibular joints. Br J Radio1 38401, 1965 4. Sada V: Experience in surgical treatment of temporomandibular joint arthritis by the Ward Technique. Transactions of the Congress of the First International Association of Oral Surgeons, 1967, pp 265-267 5. James P: The surgical treatment of mandibular joint disorders. Ann R Co11 Surg Engl 49:310, 1971 6. Tasanen A, Von Konow L: Closed condylotomy in the treatment of idiopathic and traumatic pain dysfunction syndrome of the temporomandibular joint. Int J Oral Surg 2: 102, 1973 7. Banks P, MacKenzie I: A clinical experimental appraisal of a surgical technique. Condylotomy. Proc R Sot Med 68601, 1975 8. Buckerlield JP: The applied anatomy of closed condylotomy. Br J Oral Surg 15:245, 1977

9. Upton LG, Sullivan SM: Modified condylotomies for management of mandibular prognathism and TMJ internal derangement. J Clin Orthod 24:697, 1990 10. Bell WH, Profitt WR, White Jr RP: Surgical Correction of Dentofacial Deformities, vol II. Philadelphia, PA, Saunders, 1980,pp 891-894 11. Merrill RG: Historical perspectives and comparisons of TMJ surgery for internal disk derangements and arthropathy. J Craniomand Pratt 4:74, 1986 12. McCarty WL, Farrar WB: Surgery for internal derangements of the temporomandibular joint. J Prosthet Dent 42:191. 1979 13. Ohnishi M: Arthroscopy of the human temporomandibular joint. J Jpn Stomatol Sot 42:207, 1975 14. Gallagher DM, Wolford LM: Comparison of Silastic and Proplast implants in the temporomandibular joint after condylectomy for osteoarthritis. J Oral Maxillofac Surg 40:627. 1982 15. Moloney F: Internal derangements of the temporomandibular joint. IV. Disc repair surgery. Aust Dent J 3 1:192, 1986 16. Walker RV. Kalamchi S: A surgical technique for management of internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 45:299, 1987 17. Solberg WK: Temporomandibular disorders; Functional and radiological considerations. Br Dent J 160:1%, 1986 18. Feinberg SE, Smilck MS: Lateral capsular ligament reconstruction in temporomandibular joint surgery. J Oral Maxillofac Surg 46:6, 1988 19. Dolwick MF, Aufdemorte LM: Comparison of silastic and proplast implants in the temporomandibular joint arthroplasty. Oral Surg 59:449, 1985 20. Rooney TP, Haug RH, Indresano AT: Rapid condylar degeneration after glenoid fossa prosthesis insertion. J Oral Maxillofac Surg 46:240, 1988 21. Acton C, Hoffman G, McKenna H, et al: Silicone-induced foreign-body reaction after temporomandibular joint arthroplasty. Case report. Aust Dent J 34:228, 1989 22. Tasanen A, Jokinen J: Closed condylotomy in the treatment of osteoarthritis of the temporomandibular joint. Int J Oral Surg 10:230, 1981 23. Farrar WB: Differentiation of temporomandibular joint dysfunction to simplify surgery. J Prosthet Dent 28:629, 1972 24. Mercuri LG. Campbell RL, Shamaskin RG: Intra-articular meniscus dysfunction surgery. Oral Surg 54:613, 1982 25. Nickerson J, Veaco NS: Condylotomy in surgery of the temporomandibular joint. Oral Maxillofac Surg Clin North Am I:?. 1989

.I OralMaxillofacSvrg 49583-584.1991

Discussion The Treatment of Temporomandibular Joint Internal Derangements Using a Modified Open Condylotomy: A Preliminary Report James Vanderbilt

W. Nicker-son Jr, DMD University,

Nashville

This report suggests a new method to reestablish condylar-disc position in patients with disc displacement. The study is on a sample of patients with objectively defined anterior displacement with reduction (ADR). The effects on locking, pain, and headache are presented in terms of “major,” “moderate,” and “mild” improvement. None of these terms, however, are defined. If “ma-

jor improvement in clicking and popping” means “no popping” then 53% (34) of the 64 patients would have the disc in a superior or normal position; however, nine joints were resistant to manipulative reduction as assessed at surgery, although the authors only accounted for seven of them. Assuming their operative assessment that nine discs were not reduced is correct, and that absence of clicking after condylotomy otherwise equates to achieving a reduced disc, then they restored the disc to a loadbearing position in 25 joints (39%). My own success noted in a sample of 64 joints, biased toward identifying failure and studied with follow-up arthrography, was 72% at a mean of 2.6 +- 1.9 years (range, 7 weeks to 6.3 years) after modified condylotomy.’ Unfortunately, there were no objective data on maximal interincisal opening or follow-up with osseous or disc