An intraoral approach to treatment of condylar hyperplasia or high condylar process fractures using the intraoral vertico-sagittal ramus osteotomy

Extracorporealization of the Mandibular Condyle: Effects on Viability and Function

Study Design

For certain condylar fractures, extracorporealization of the condylar segment may be performed via extra-oral vertical ramus osteotomy (EVRO) to facilitate reduction and fixation. This approach can similarly be used for condyle-sparing resection of osteochondromas of the condyle. Due to controversy regarding long-term health of the condyle after extracorporealization, we conducted a retrospective analysis of surgical outcomes.

Objective

For certain condylar fractures, extracorporealization of the condylar segment may be performed via extra-oral vertical ramus osteotomy (EVRO) to facilitate reduction and fixation. This approach can similarly be used for condyle-sparing resection of osteochondromas of the condyle. Due to controversy regarding long-term health of the condyle after extracorporealization, we investigated the viability of this technique through a retrospective analysis of outcomes.

Methods

Twenty-six patients were treated using EVRO with extracorporealization of the condyle for both condylar fractures (18 patients) and osteochondroma (8 patients). Of the 18 trauma patients, 4 were excluded due to limited follow-up. Clinical outcomes were measured, including occlusion, maximum interincisal opening (MIO), facial asymmetry, incidence of infection, and temporomandibular joint (TMJ) pain. Radiographic signs of condylar resorption were investigated, quantified, and categorized using panoramic imaging.

Results

Average follow-up was 15.9 months. Average maximum interincisal opening was 36.8 mm. Four patients demonstrated mild resorption and one patient demonstrated moderate resorption. Two cases of malocclusion were attributed to failed repairs of other concurrent facial fractures. Three patients reported TMJ pain.

Conclusions

Extracorporealization of the condylar segment with EVRO to facilitate open treatment of condylar fractures is a viable treatment option when more conventional approaches prove unsuccessful.

Simultaneous Condylar Reconstruction by Free Ramus Osteotomy Graft After Complete Condylectomy for Osteochondroma

ABSTRACT

Mandibular condyle osteochondromas cause morphologic and functional disturbances. Multiple options exist for reconstructing the condylar segment following complete condylectomy. In this series, we describe 3 cases of mandibular condyle osteochondroma treated with complete condylectomy, orthognathic surgery, and a novel free ramus osteotomy graft. This is the first report to reconstruct the temporomandibular joint using a free ramus graft. Through this single-staged approach we were able to avoid recurrence, preserve function, and restore facial balance without a separate donor site or an alloplastic implant.

Condyle Head Reimplantation Combined With Vascularized Free Flap for Mandibular Reconstruction

Due to the anatomic and functional complexity, reconstruction of the condylar process after mandibular tumor extirpation remains a surgical challenge. The aim of this study was to present the results and experience of condyle head reimplantation combined with vascularized free flap for mandibular reconstruction in our institution. In the current study, the authors evaluated the clinical features of condyle head reimplantation combined with vascularized free flap for mandibular reconstruction in 5 patients with benign mandibular intraosseous lesions from December 2013 to March 2015 in our institution. All patients showed nearly normal mouth opening, with minimal mandibular deviation and joint symptoms. The radiograph data showed that 4 patients had no obvious bone resorption of condyles while only 1 patient had prominent condyle resorption. All the condyles were cut above the condylar neck, with the biggest remaining condyle height being 2.8 cm and the smallest one being 1.1 cm. Moreover, the original vertical height of mandibular ramus was decreased by 2 to 3 mm during the surgery. In conclusion, this study revealed that combining the condyle reimplantation with vascularized free flap constitutes a reliable method in condylar reconstruction and a slight reduction of the vertical height of condyles may help to diminish unfavorable outcomes.

A Comparative Review of Mandibular Orthognathic Surgeries with a Focus on Intraoral Vertico-sagittal Ramus Osteotomy

Severe dentofacial deformities require both orthodontics and surgical management to repair. Modern mandibular orthognathic surgery commonly uses sagittal split ramus osteotomy (SSRO) and intraoral vertical ramus osteotomy (IVRO) methods to treat patients. However, complications like neurosensory disturbances and temporomandibular joint disorders are common following both procedures. In 1992, Choung introduced the intraoral vertico-sagittal ramus osteotomy (IVSRO) which led to a decrease in postoperative complications. The 'straight' IVSRO or Choung’s type II osteotomy has a 'condylotomy' effect that reduces iatrogenic temporomandibular joint symptoms and treats preoperative temporomandibular joint symptoms. This osteotomy type is especially applicable for prognathism with excessive flaring of the ramus and with temporomandibular joint dysfunction. The 'L-shaped' IVSRO or Choung’s type I osteotomy is indicated for patients with condylar hyperplasia and high condylar process fractures.

Algorithm for the differential diagnosis of posterior open bites: two illustrative cases

PURPOSE

Posterior open bites can result from several causes: trauma, degenerative changes, tongue thrust habits, single-tooth ankylosis, multiple-tooth ankylosis, and/or condylar hyperplasia. Occasionally, posterior open bites are secondary to a combination of condylar hyperplasia and dental ankylosis, which can be difficult to diagnose and treat because of the large array of causative problems.

MATERIALS AND METHODS

This article presents 2 unusual cases of posterior open bite secondary to multiple etiologies in adolescent male patients. A useful method of algorithmic diagnosis, treatment, and protocol is presented that was used for these cases.

RESULTS

The 2 cases were successfully diagnosed and treated using the formulated algorithm for posterior open bites.

CONCLUSIONS

The algorithms presented facilitate the differential diagnosis of posterior open bites with ambiguous etiology.

Conservative management of unilateral condylar hyperplasia

OBJECTIVE

The purpose of this study was to eliminate orthodontic treatment in mild to moderate cases of condylar hyperplasia in its early stages by condylectomy.

PATIENTS AND METHODS

A total of five patients (two females and three males) aged between 17 and 40 years were treated with unilateral condylectomy of the involved side without orthodontic treatment. All patients underwent standardized clinical and radiological examination at initial consultation, before surgery, immediately after surgery, and follow-up. Objective and subjective evaluation of temporomandibular joint (TMJ) included maximal incisal opening, lateral excursions, correction of facial asymmetry, occlusal harmony, TMJ pain, and jaw function. Results were recorded at 5-year follow-up.

RESULTS

In all our cases, we achieved good mouth opening and near to normal occlusion. Good facial aesthetics was obtained after 3 months postoperative follow-up without secondary orthodontic treatment.

CONCLUSION

Thus, we conclude that treatment of mild to moderate cases of unilateral condylar hyperplasia during the inactive phase can be treated with condylectomy without orthodontic treatment, and it significantly improves long-term surgical outcomes.

Use of intraoral miniplates to control postoperative occlusion after high condylectomy for the treatment of condylar hyperplasia

Mandibular condylar hyperplasia is a rare disorder, characterized by unilateral mandibular overgrowth with overeruption of the dentition on the affected side. Although the etiology is unclear, multiple surgical techniques have been described to correct the associated mandibular bone, occlusal, and soft tissue deformities. Often a condylectomy, to arrest mandibular growth, is combined with various orthognathic procedures to restore occlusion and facial harmony. Here we report our technique of isolated high condylectomy with simultaneous intraoral placement of maxillary and mandibular miniplates. Each plate has an intraoral extension that allows our orthodontists to develop vertical force vectors to intrude the maxillary and mandibular molar segments. Using this combined surgical and orthodontic technique, we were able to postoperatively control the occlusal cant, restore the dental midline, improve facial aesthetics, and resolve the patient's contralateral temporomandibular joint dysfunction without concomitant orthognathic surgery. As a result of our findings, we are currently using, and would recommend, this technique for patients requiring surgical-orthodontic intervention for other conditions.

Chondroma in temporomandibular region--case report and therapeutic considerations

PURPOSE

Chondromas are benign tumors composed of mature hyaline cartilage. These tumors are quite common in the bones of the hands and feet but extremely rare in jaw bones, and few such cases are reported in the literature. The aim of the present study was to carry out a literature review and present a clinical case of a patient with a chondroma in the right mandibular condyle treated with excision of the tumor.

CONCLUSIONS

The importance of early diagnosis and treatment in order to impede or minimize any lasting effects is discussed.

Condylar hyperplasia and facial asymmetry: report of five cases

Condylar hyperplasia of mandible is overdevelopment of condyle, unilaterally or bilaterally, leading to facial asymmetry, mandibular deviation, malocclusion and articular dysfunction. This is a series of five such patients managed at our centre.

The "antilingula"--fact or fiction?

PURPOSE

The "antilingula" is a term that is only used in oral and maxillofacial surgery publications. It is not found in anatomy texts. This paper examines the origin of the term "antilingula" and explores the literature to determine why there is a bony lump on the lateral surface of the mandible.

METHODS

The English literature was searched for references to this bony lump on the lateral surface of the mandible to find its origin and intent. Discussion with anatomists about the "antilingula" were undertaken to determine their understanding of it.

RESULTS

Oral and Maxillofacial surgeons began using this bony prominence as a guide to the position of the entrance of the inferior alveolar nerve on the medial surface of the mandible in the 1950s. Beginning in 1976, many descriptions of ramus osteotomies refer to the "antilingula" and recommend it as a guide for making bone cuts safely without injuring the inferior alveolar nerve. However, research studies that have been performed reveal no evidence that the "antilingula" has any relationship to the entrance of the inferior alveolar nerve. Discussions with anatomists suggest it is a bony response to the muscles and tendons that insert in that area rather than having a relationship to the entrance of the inferior alveolar nerve.

CONCLUSION

The use of the "antilingula" for marking the location of ramus osteotomies is illogical.

Free-grafting of mandibular condyle fractures: clinical outcomes in 10 consecutive patients

"Free-grafting" of the superior segment, either alone or in combination with a posterior ramus osteotomy, is occasionally required when managing displaced condylar neck fractures. This allows ideal reduction and fixation, but carries the risk of proximal segment resorption, possibly requiring secondary reconstruction. The purpose of this study was to evaluate the clinical and radiographic outcomes of this technique in all patients who underwent this procedure during a seven-year period at a tertiary care centre. Ten patients who had undergone 11 free graft procedures were included in the study. Three patients required secondary costochondral reconstruction due to advanced resorption of the free-grafted condylar segment, this occurring from 3 to 9 months following the initial trauma surgery. All but one of the remaining patients exhibited varying degrees of condylar resorption/flattening radiographically, occurring within the first year only. However, no occlusal changes occurred in this group either objectively or subjectively during this year or during the subsequent follow-up period. The mean inter-incisal opening was 47mm (range 40-56). With the exception of one patient that had a non-painful reciprocal click of the treated side, no patients demonstrated either objective or subjective signs of TMJ pathology. No patients reported dietary limitations, and all reported satisfaction with treatment to date. Based on objective and subjective evaluation, free grafting of the fractured condylar segment in this patient population had a 70% success rate. All failures occurred within 9 months and required secondary costochondral reconstruction.

Comparison of the clinical outcomes of patients having sounds in the temporomandibular joint with skeletal mandibular deformities treated by vertico-sagittal ramus osteotomy or vertical ramus osteotomy

OBJECTIVE

This article describes the effects of the intraoral vertico-sagittal ramus osteotomy (IVSRO) procedure on the jaw of patients with temporomandibular joint (TMJ) disorders.

STUDY DESIGN

IVSRO was performed on 15 patients (30 sides) who had mandibular protrusion or asymmetry with TMJ dysfunction. IVRO was performed on another 15 patients (30 sides). All of the 30 patients had sounds in the TMJ uni- or bilaterally. The relative positions of the condyle and disc and the range of motion of the condyles were determined by magnetic resonance imaging (MRI) before and 12 months after the operations.

RESULTS

Sounds such as clicking improved in 92% (24/26) of the joints in the IVSRO group, and in 83% (20/24) of the joints in the IVRO group 12 months after the operation. The positional relationship between the condyle and disc on the MR images improved in 82% (9/11) of the joints with reduction of the anterior disc displacement; in 60% (3/5) of the joints without reduction of the anterior disc displacement in the IVSRO group; in 75% (9/12) of the joints with reduction of the anterior disc displacement; and in 40% (2/5) of the joints without reduction of the anterior disc displacement in the IVRO group. Immediately after the operation, the condyle was displaced anterio-inferiorly in all joints in both groups, but gradually returned to close to the preoperative position. There were no significant differences between the 2 groups regarding the extent of shift of the condylar head at 2 weeks and 12 months after the operation.

CONCLUSION

The clinical outcomes of the IVSRO procedure are similar to those of the IVRO procedure. Therefore, IVSRO may be a suitable procedure for patients having TMJ dysfunction with skeletal mandibular deformities, particularly when an IVRO is unsuitable.

Condylar reconstruction by oblique sliding vertical–ramus osteotomy

INTRODUCTION

The posterior border of the mandibular ramus can be used as a pedicled graft for reconstruction of the condyle. This article describes a technique that is better in certain situations than the use of other autogenous grafts or alloplastic materials.

PATIENTS AND METHODS

Three adult patients, two with osteochondroma and one with hyperplasia were treated by condylectomy and simultaneous reconstruction with the pedicled posterior mandibular border. A meticulous oblique osteotomy and reinsertion of the lateral pterygoid muscle was performed.

RESULTS

In all three cases an immediate mouth opening with stable occlusion was achieved. The interincisal opening was more than 40 mm after 3 weeks, with a deviation no greater than 4mm towards the affected side. All excursive movements were present in all directions, and correction of the facial asymmetry was achieved. There was no T.M.J. pain and all patients expressed satisfaction during the follow-up of 56 months (average). An adequate remodelling of the neocondyle without resorption as well as a stable occlusion was observed in every case.

CONCLUSION

Reconstruction of the condyle by sliding vertical-oblique ramus osteotomy provides, in cases of condylar tumours, excellent functional and cosmetic results.

Open reduction of condylar neck fractures with exposure of the facial nerve

OBJECTIVE

The purpose of this study was to evaluate the clinical and radiologic results in patients whose condylar neck fractures were reduced and stabilized through use of a standard preauricular approach involving systematic exposure of the facial nerve.

STUDY DESIGN

We performed open reductions of high condylar neck fractures with exposure of the facial nerve in a prospective series of 34 patients. In this article, we describe clinical and radiologic results in 25 patients with follow-up longer than 6 months.

RESULTS

Immediate postoperative radiographs showed excellent reduction of the fractures in 24 patients. The postoperative course was uneventful in most patients. The incidence of complications was low; there were 5 patients with temporary facial nerve palsies, 3 patients with plate fractures or screw loosenings, 5 patients with transitory auricular hypoesthesia, 1 patient with inadequate reduction, and 1 patient with limited mouth opening.

CONCLUSIONS

The results of this study showed that accurate reduction and rigid fixation of high condylar neck fractures were possible through use of an approach in which the facial nerve was exposed.

Evaluation of condylar neck fracture plating techniques

The purpose of this study was to compare the biomechanical stability of four different plating techniques used to fix condylar neck fractures and to decide which fixation systems are strong enough to withstand the functional load. Ten recently acquired formalin-fixed cadaver mandibles were used for this study. Each of the four sets of osteotomized condylar processes was fixed by one of four different fixation systems. The mandibles were then held in an angle vice so that the mandibles were oriented to simulate actual masticatory force loading on the temporomandibular joint and were loaded with an Instron loading machine. Data demonstrated that a two-miniplate system applied to the anterior and posterior regions of the condylar neck was more stable than single-plate repairs using either mini-dynamic compression plates or 2.4 mm plates. The two-miniplate-fixation technique is indicated in cases of condylar neck fracture to achieve early mobility of the jaw and stability of the fracture site.