Int. J. Oral Maxillofac. Surg.

2009; 38: 374–381

?available online at http://www.sciencedirect.com

Technical Note
TMJ Disorders

Modified trans-oral approach for M. Deng1, X. Long1,

A. H. A. Cheng2, Y. Cheng1, H. Cai1
1
Department of Oral & Maxillofacial Surgery,

mandibular condylectomy
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
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 Keywords: trans-oral approach; condylectomy.
joint (TMJ) operations, such as condylar resection, high condylectomy or tumor
removal. It provides adequate intra-oral surgical access to the mandibular condyle Accepted for publication 16 January 2009
and avoids complications from extra-oral approaches to the TMJ. Available online 17 March 2009

Mandibular condylectomy is widely used From September 2006 to June 2007, 6 pated in the study had good outcomes
for treating temporomandibular condyle patients underwent condylectomy using a intra-operatively and postoperatively.
diseases. Extra-oral approaches, such as trans-oral approach at Wuhan University.
pre-auricular, posterior auricular and The clinical diagnoses included mandib-
Case presentation and surgical
submandibular approaches3,7, are com- ular condylar osteochondroma (2 cases)
technique
monly used by clinicians. The intra-oral and condylar hyperplasia (4 cases)
approach to the temporomandibular joint (Table 1). All the diagnoses were sup- A 41-year-old woman presented with
(TMJ) was first reported by Sear in ported by symptoms, physical examina- facial asymmetry and trismus in Septem-
19725. ELLER et al. also used this access tion, radiographic images and ber 2006. The left side of her face was
for TMJ condylar osteochondroma resec- histopathology. All patients who partici- notably elongated. The mandibular mid-
tion in 19772. NICKERSON and VEACO
described an intra-oral condylectomy
technique using standard instrumentation Table 1. Patient details.
for intra-oral vertical ramus osteomy in Patient Age
19894. Intra-oral condylectomy avoids MMO (mm)
no. (years) Gender Diagnosis Complications
facial nerve injury and facial scarring. Pre-op post-op (m)
There are no descriptions of this techni-
1 25 F OC S, MOL, MO 30 28 (3)
que in recent publications. The trans-oral 2 15 M CH S, MOL, MO 35 no
approach to the TMJ is useful for acces- 3 21 F CH S, MOL, MO 48 35(3)
sing the condyle and potentially has 4 24 M CH S, MOL, AC, MO 40 40 (8)
lower morbidity than extra-oral 5 22 F CH S, MOL, AC, MO 30 46(6)
approaches. The technique is easy to 6 41 F OC S, MOL, MO 34 42(6)
learn, based on experience from mandib- AC: angular cheilitis; CH: Condyle hyperplasia; m: month; MMO: maximum mouth opening;
ular osteotomy. MO: malocclusion; MOL: mouth opening limitation; OC: osteochondroma; S: swelling.

0901-5027/040374 + 08 $36.00/0 # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Modified trans-oral approach for mandibular condylectomy 375

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 inci-
sion was made from the level of the man-
dibular second molar to the level of the
maxillary teeth (Fig. 2). Buccal and lin-
gual 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 pre-
Fig. 1. CT imaging showed the bony tumor on the left mandibular condyle. served completely. Two large malleable
retractors were placed laterally and medi-
ally to protect the buccal and lingual soft
tissue. The coronoid process was osteoto-
mized 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 con-
dyle. 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
Fig. 2. The incision was made from the buccal mucosa of the mandibular second molar to the the condylar head and neck. The whole
level of the maxilla occlusion. 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.

Discussion
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 post-
operative complications such as swelling
and pain at the surgical site, angular chei-
litis, 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
Fig. 3. The coronoid process was cut at the level of the sigmoid notch (C: coronoid process; M: through careful dissection and meticulous
temporolias muscle; arrow shows the resection line). soft tissue retraction. Infection of the sur-
376 Deng et al.

gical site can be avoided with prophylactic

antibiotic therapy pre- and post-opera-
tively. 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 com-
mon in all patients at the 3-month but not
the 6-month follow-up (Table 1). No other
complications were found during the fol-
low-up period.
Schon et al. suggested endoscopy
assisted open treatment of condylar frac-
tures of the mandible in 20026. Special
instruments and endoscope were neces-
sary to fixate the condylar fracture intra-
orally. The surgical access was designed
Fig. 4. The lesion was resected from the condyle (O: osteochondroma; C: condyle; arrow shows
for condylar neck and subcondylar frac-
the resection line).
ture. The technique described in this paper
enables access to the head of the condyle
and has several advantages. The tempor-
alis 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 postopera-
tively. The condylectomy was confined to
the lower joint space without damage to
the joint capsule and ligament and there-
fore fibro-osseous ankylosis of the TMJ
was less likely. Inter-maxillary fixation
was not used postoperatively to encourage
immediate mandibular function. The sur-
gical 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
Fig. 5. The lesion was removed (O: osteochondroma). 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.

References
1. David A KEITH. Complications of tempor-
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 Modified trans-oral approach for mandibular condylectomy 377

3. Kreutiger KL. Surgery of the tempor-
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7. Vallerand WP, Dolwick MF. Compli- Hubei Province 430079
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E-mail: longxing_china@hotmail.com
Address:
Xing Long doi:10.1016/j.ijom.2009.01.020
Department of Oral & Maxillofacial Surgery
Key Lab for Oral Biomedical

Technical Note
Reconstructive Surgery

A novel modification of a bone K.

Y.
K.
Tominaga1, I. Yoshioka1,
Yamashita2, M. Habu1,
Iwanaga1, A. Khanal1,
Nishikawa1
repositioning device and a new T.
1
Department of Oral and Maxillofacial
Surgery, Division of Maxillofacial Diagnostic
and Surgical Science, Kyushu Dental College,

technique for reestablishing Kitakyushu, Japan; 2Department of Oral and

Maxillofacial Surgery, Division of Oral and
Maxillofacial Reconstructive Surgery, Kyushu

facial contours after mandibular Dental College, Kitakyushu, Japan

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
Keywords: bone positioning; mandibular resec-
simple method for determining the contour of the reconstructed mandible to regain tion; sagittal split ramus osteotomy.
the original shape and form. The advantage of this technique is its simplicity and
flexibility compared with other methods of bone positioning during mandibular Accepted for publication 9 February 2009
segmental surgery. Available online 9 March 2009

For surgery in the mandible, precise posi- tional reconstruction of the mandible. Var- tions. The authors described a simple
tioning of the resected or split bone is often ious positioning devices1,2,8 have been method for bone segment positioning9 that
needed. 3-dimensional positioning of the developed to maintain bone position, but consists of a combination of bone plates and
mandibular stumps is mandatory for func- they are complex or have limited indica- a flexible tube filled with acrylic polymer,