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Technical Note TMJ Disorders
Modiﬁed trans-oral approach for mandibular condylectomy
M. Deng, X. Long, A. H. A. Cheng, Y. Cheng, H. Cai: Modiﬁed trans-oral approach for mandibular condylectomy. Int. J. Oral Maxillofac. Surg. 2009; 38: 374–377. # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Different approaches to the mandibular condyle have been described. In this paper, a modiﬁed trans-oral technique to access the mandibular condyle is described and illustrated. This technique was used in a small group of patients; the clinical outcomes are promising. The technique can be used in various temporomandibular joint (TMJ) operations, such as condylar resection, high condylectomy or tumor removal. It provides adequate intra-oral surgical access to the mandibular condyle and avoids complications from extra-oral approaches to the TMJ.
M. Deng1, X. Long1, A. H. A. Cheng2, Y. Cheng1, H. Cai1
1 Department of Oral & Maxillofacial Surgery, Key Lab for Oral Biomedical Engineering of Ministry of Education, School and Hospital of Stomatology, Wuhan University, Wuhan, Hubei Province 430079, PR China; 2Oral and Maxillofaical Surgery Unit, Royal Adelaide Hospital, Adelaide, Australia
Keywords: trans-oral approach; condylectomy. Accepted for publication 16 January 2009 Available online 17 March 2009
Mandibular condylectomy is widely used for treating temporomandibular condyle diseases. Extra-oral approaches, such as pre-auricular, posterior auricular and submandibular approaches3,7, are commonly used by clinicians. The intra-oral approach to the temporomandibular joint (TMJ) was ﬁrst reported by Sear in 19725. ELLER et al. also used this access for TMJ condylar osteochondroma resection in 19772. NICKERSON and VEACO described an intra-oral condylectomy technique using standard instrumentation for intra-oral vertical ramus osteomy in 19894. Intra-oral condylectomy avoids facial nerve injury and facial scarring. There are no descriptions of this technique in recent publications. The trans-oral approach to the TMJ is useful for accessing the condyle and potentially has lower morbidity than extra-oral approaches. The technique is easy to learn, based on experience from mandibular osteotomy.
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From September 2006 to June 2007, 6 patients underwent condylectomy using a trans-oral approach at Wuhan University. The clinical diagnoses included mandibular condylar osteochondroma (2 cases) and condylar hyperplasia (4 cases) (Table 1). All the diagnoses were supported by symptoms, physical examination, radiographic images and histopathology. All patients who partici-
pated in the study had good outcomes intra-operatively and postoperatively.
Case presentation and surgical technique
A 41-year-old woman presented with facial asymmetry and trismus in September 2006. The left side of her face was notably elongated. The mandibular mid-
Table 1. Patient details. Patient no. 1 2 3 4 5 6 Age (years) 25 15 21 24 22 41 Gender F M F M F F Diagnosis OC CH CH CH CH OC S, S, S, S, S, S, Complications MOL, MOL, MOL, MOL, MOL, MOL, MO MO MO AC, MO AC, MO MO MMO (mm) Pre-op post-op (m) 30 35 48 40 30 34 28 (3) no 35(3) 40 (8) 46(6) 42(6)
AC: angular cheilitis; CH: Condyle hyperplasia; m: month; MMO: maximum mouth opening; MO: malocclusion; MOL: mouth opening limitation; OC: osteochondroma; S: swelling.
# 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Modiﬁed trans-oral approach for mandibular condylectomy
Fig. 1. CT imaging showed the bony tumor on the left mandibular condyle.
Fig. 2. The incision was made from the buccal mucosa of the mandibular second molar to the level of the maxilla occlusion.
line was deviated 5 mm to the right. CT imaging showed a large bony tumor of the left mandibular condyle (Fig. 1). The patient was otherwise ﬁt and well for surgery. The procedure was performed under general anesthesia. Using a standard mouth prop, the patient was placed with maximum mouth opening. A buccal incision was made from the level of the mandibular second molar to the level of the maxillary teeth (Fig. 2). Buccal and lingual mucoperiosteal ﬂaps were elevated. Dissection of the temporalis tendon from the anterior, lateral and medial border of the ramus was carried up to the level of the mandibular notch. The superior temporalis attachment on the coronoid process above the level of mandibular notch was preserved completely. Two large malleable retractors were placed laterally and medially to protect the buccal and lingual soft tissue. The coronoid process was osteotomized at the level of the mandibular notch (Fig. 3) using a drill, reciprocating saw and osteotome. It was then displaced upward and retracted to expose the condyle. Subperiosteal dissection along the condylar neck and head was carried out until the mandibular condyle was fully exposed. Small malleable retractors were inserted to protect the soft tissue medially and laterally. The condylectomy cut was made with a drill, reciprocating saw and osteotome (Fig. 4). The TMJ capsule and lateral pterygoid muscle was dissected off the condylar head and neck. The whole TMJ pathology was removed (Fig. 5). The remaining portion of the condyle was reshaped and smoothed. After haemostasis was achieved, the coronoid process was reduced and ﬁxated with wire (Fig. 6). The incision was sutured with 3-0 sutures and a small penrose drain was placed in the surgical site. The same technique was applied to the other ﬁve patients in the study.
Fig. 3. The coronoid process was cut at the level of the sigmoid notch (C: coronoid process; M: temporolias muscle; arrow shows the resection line).
Four patients with condylar hyperplasia had high condylectomies through a trans-oral approach. Two patients with condylar osteochondroma underwent total condylectomy and removal of the tumors. For this group of patients, common postoperative complications such as swelling and pain at the surgical site, angular cheilitis, trismus, and minor malocclusion were noted. Intraoperative complications, such as bleeding from maxillary or inferior alveolar arteries and injury of the inferior alveolar or lingual nerve, can be avoided through careful dissection and meticulous soft tissue retraction. Infection of the sur-
Deng et al.
gical site can be avoided with prophylactic antibiotic therapy pre- and post-operatively. Malocclusion was unavoidable, but it can be managed effectively with inter-maxillary traction or orthodontic treatment. Five of the six patients attended the follow-up appointments. Swelling, pain and angular cheilitis resolved within one month postoperatively. Trismus was common in all patients at the 3-month but not the 6-month follow-up (Table 1). No other complications were found during the follow-up period. Schon et al. suggested endoscopy assisted open treatment of condylar fractures of the mandible in 20026. Special instruments and endoscope were necessary to ﬁxate the condylar fracture intraorally. The surgical access was designed for condylar neck and subcondylar fracture. The technique described in this paper enables access to the head of the condyle and has several advantages. The temporalis attachment to the coronoid process was preserved before osteotomizing the coronoid process, therefore, the coronoid process and the temporalis attachment can be re-established anatomically postoperatively. The condylectomy was conﬁned to the lower joint space without damage to the joint capsule and ligament and therefore ﬁbro-osseous ankylosis of the TMJ was less likely. Inter-maxillary ﬁxation was not used postoperatively to encourage immediate mandibular function. The surgical trauma to the TMJ and masticatory system can be minimized, which reduces long-term complications1,7. The trans-oral approach to assess the mandibular condyle is more technically demanding than the extra-oral approach and requires the operator to have previous experience in intra-oral osteotomy. The condyle is far from the intra-oral incision, compared with extra-oral approaches, so exposing the lesion is more challenging. With maximum mouth opening and the coronoid process retracted superiorly, the surgical ﬁeld can be optimized but a longer surgical time is to be expected initially. A larger study group and longer term follow-up will be needed to assess the long-term effect of this technique.
Fig. 4. The lesion was resected from the condyle (O: osteochondroma; C: condyle; arrow shows the resection line).
Fig. 5. The lesion was removed (O: osteochondroma).
1. David A KEITH. Complications of temporomandibular joint surgery. Oral Maxillofac Surg Clin N Am 2003: 15: 187–194. 2. Eller DJ, Blackemore JR, Stein M, Byers S. Transoral resection of a condylar osteochondroma: report of case. J Oral Surg 1977: 35: 409–413.
Fig. 6. The coronoid process was reduced and ﬁxated with wire (arrow shows the wire).
Modiﬁed trans-oral approach for mandibular condylectomy
3. Kreutiger KL. Surgery of the temporomandibular joint. Surgical anatomy and surgical incisions. Oral Surg Oral Med Oral Pathol 1984: 58: 637–646. 4. Nickerson JW, Veaco NS. Condylotomy in surgery of the temporomandibular joint. Oral Maxillofacial Surg Clin N Am 1989: 2: 303–327. 5. Sear AJ. Intra-oral condylectomy applied to unilateral condylar hyperplasia. Br J Oral Surg 1972 Nov: 10: 143–153. 6. Schon R, Gutwald R, Schramm A, Gellrich N-C, Schmelzeisen R. Endoscopy-assisted open treatment of condylar fractures of the mandible:extraoral vs intraoral approach. Int J oral Maxillofac Surg 2002: 31: 237–243. 7. Vallerand WP, Dolwick MF. Complications of temporomandibular joint surgery. Oral Maxillofac Surg Clin N Am 1990: 2: 481–488. Address: Xing Long Department of Oral & Maxillofacial Surgery Key Lab for Oral Biomedical Engineering of Ministry of Education School and Hospital of Stomatology Wuhan University Wuhan Hubei Province 430079 PR China Tel: +86 27 87686216 Fax: +86 27 87873260 E-mail: firstname.lastname@example.org
Technical Note Reconstructive Surgery
A novel modiﬁcation of a bone repositioning device and a new technique for reestablishing facial contours after mandibular resection surgery
K. Tominaga, I. Yoshioka, Y. Yamashita, M. Habu, K. Iwanaga, A. Khanal, T. Nishikawa: A novel modiﬁcation of a bone repositioning device and a new technique for reestablishing facial contours after mandibular resection surgery. Int. J. Oral Maxillofac. Surg. 2009; 38: 377–381. # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. A novel modiﬁcation of a bone repositioning device previously published by the same authors is introduced. A ﬂexible tube to deﬁne the intersegmental bony relationship is ﬁlled with light-cured resin. It solidiﬁes following exposure to strong visible light for about 1 min. This technique can be used for bone positioning after mandibular resection surgery and during positioning of the proximal segment after sagittal split ramus osteotomy. The authors also propose a simple method for determining the contour of the reconstructed mandible to regain the original shape and form. The advantage of this technique is its simplicity and ﬂexibility compared with other methods of bone positioning during mandibular segmental surgery.
K. Y. K. T.
Tominaga1, I. Yoshioka1, Yamashita2, M. Habu1, Iwanaga1, A. Khanal1, Nishikawa1
1 Department of Oral and Maxillofacial Surgery, Division of Maxillofacial Diagnostic and Surgical Science, Kyushu Dental College, Kitakyushu, Japan; 2Department of Oral and Maxillofacial Surgery, Division of Oral and Maxillofacial Reconstructive Surgery, Kyushu Dental College, Kitakyushu, Japan
Keywords: bone positioning; mandibular resection; sagittal split ramus osteotomy. Accepted for publication 9 February 2009 Available online 9 March 2009
For surgery in the mandible, precise positioning of the resected or split bone is often needed. 3-dimensional positioning of the mandibular stumps is mandatory for func-
tional reconstruction of the mandible. Various positioning devices1,2,8 have been developed to maintain bone position, but they are complex or have limited indica-
tions. The authors described a simple method for bone segment positioning9 that consists of a combination of bone plates and a ﬂexible tube ﬁlled with acrylic polymer,