Mandibular condyle displacements after orthognathic surgery-an overview of quantitative studies

Do Surgical Intervention Type and Baseline Condylar Position Affect Spatial Dimension Changes of the Temporomandibular Joint in the Surgical Correction of Skeletal Class II Deformities?

BACKGROUND

One of the key features of orthognathic surgery is altering temporomandibular joint (TMJ) condylar positions.

PURPOSE

This multivariate study aimed to identify surgical interventions and patient factors significantly associated with changes in TMJ spatial dimensions after the surgical correction of skeletal Class II deformities.

STUDY DESIGN, SETTING, SAMPLE

This is a retrospective cohort study including patients who had undergone an isolated bilateral sagittal split ramus osteotomy (BSSO) or a bimaxillary osteotomy (BMO) for mandibular advancement and a control sample of patients treated with the removal of odontogenic cysts in the mandibular posterior region. Excluded were those who presented with specific radiographic signs of TMJ osteoarthrosis, severe facial asymmetry, or deformity secondary to trauma.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

The primary predictors were condylar position at baseline (anterior, concentric, and posterior), time points (T0, preoperatively; T1, immediately after surgery; and T2, 1-year follow-up), and surgical intervention type (BSSO, BMO, and control group).

MAIN OUTCOME VARIABLES

The primary outcomes were changes in posterior spatial dimension (PSD), superior spatial dimension, and medial spatial dimension assessed by cone-beam computed tomography preoperatively, immediately after surgery, and at 1-year follow-up.

COVARIATES

Covariates included sex, age, and amount of mandibular advancement.

ANALYSES

Estimations of independent effects of primary predictors on outcome variables were made by applying generalized estimation equation models. The value of statistical significance was P < .05.

RESULTS

The study sample included 88 participants. The BSSO samples included 39 patients, and the BMO group included 22 patients; the control group comprised 27 subjects. The average age was 31.2 years; the majority were female (61.4%). Adjusted generalized estimation equation models yielded a significant time interaction between BSSO and spatial dimensions over time (PSD, P < .001). Key predictors of spatial dimension changes were the baseline posterior (PSD, P < .001) and the central condylar position (PSD, P < .001).

CONCLUSION AND RELEVANCE

This controlled study, for the first time, provides scientific evidence on the effects of surgical intervention type and baseline condylar position on spatial dimension changes in the TMJ. It shows a more favorable outcome in long-term spatial dimension changes for patients treated by a BMO procedure.

Pre- and Post-Operative Cone Beam Computed Tomography Assessment of the Temporomandibular Joint in Patients with Orthognathic Surgery

This study aimed to compare the pre- and post-operative temporomandibular joint (TMJ) condylar position in dentofacial deformity (DFD) patients who had orthognathic surgeries using cone beam computed tomography (CBCT). A retrospective study evaluating the pre- and post-operative CBCT for 79 DFD patients (equivalent to 158 TMJs) (mean age = 26.62 ± 9.5 years) with a bilateral sagittal split osteotomy with or without Le Fort I surgeries (n = 29 Class II DFD, n = 50 Class III DFD) was performed. This included the compartmental measurement of TMJ spaces, in addition to the measurement of intercondylar distances and angles. Condylar position centricity was assessed using the Pullinger and Hollender formula. Clinical data were analysed for DFD class, the type of surgery and post-operative CBCT timing. Pre- and post-operative measurements were compared statistically using a paired t-test, Wilcoxon signed-rank test, and Stuart-Maxwell test. TMJ condyles tended to relocate post-operatively in a posterosuperior position with internal rotation in Class II DFD and a superior position with internal rotation in Class III DFD. However, the overall changes were within <0.5 mm translation and <4° rotation and the number of concentrically positioned condyles (according to the Pullinger and Hollender formula) did not change significantly. Orthognathic surgery is associated with minor post-operative translational and rotational condylar positional changes in Class II and III DFDs.

An automated method for assessing condyle head changes in patients with skeletal class II malocclusion based on Cone-beam CT images

OBJECTIVES

Currently, there is no reliable automated measurement method to study the changes in the condylar process after orthognathic surgery. Therefore, this study proposes an automated method to measure condylar changes in patients with skeletal class II malocclusion following surgical-orthodontic treatment.

METHODS

Cone-beam CT (CBCT) scans from 48 patients were segmented using the nnU-Net network for automated maxillary and mandibular delineation. Regions unaffected by orthognathic surgery were selectively cropped. Automated registration yielded condylar displacement and volume calculations, each repeated three times for precision. Logistic regression and linear regression were used to analyse the correlation between condylar position changes at different time points.

RESULTS

The Dice score for the automated segmentation of the condyle was 0.971. The intraclass correlation coefficients (ICCs) for all repeated measurements ranged from 0.93 to 1.00. The results of the automated measurement showed that 83.33% of patients exhibited condylar resorption occurring six months or more after surgery. Logistic regression and linear regression indicated a positive correlation between counterclockwise rotation in the pitch plane and condylar resorption (P < .01). And a positive correlation between the rotational angles in both three planes and changes in the condylar volume at six months after surgery (P ≤ .04).

CONCLUSIONS

This study's automated method for measuring condylar changes shows excellent repeatability. Skeletal class II malocclusion patients may experience condylar resorption after bimaxillary orthognathic surgery, and this is correlated with counterclockwise rotation in the sagittal plane.

ADVANCES IN KNOWLEDGE

This study proposes an innovative multi-step registration method based on CBCT, and establishes an automated approach for quantitatively measuring condyle changes post-orthognathic surgery. This method opens up new possibilities for studying condylar morphology.

Three-Dimensional Changes of Condylar Position After Bimaxillary Surgery to Correct Skeletal III Malocclusion: Cone Beam Computed Tomography Voxel-Based Superimposition Analysis

BACKGROUND

The stability of the condylar position within the first 3 months after orthognathic surgery in patients with skeletal Class III malocclusion is crucial for subsequent orthodontic treatment.

PURPOSE

The purpose was to compare condylar positional changes 3 months after bimaxillary surgery to correct skeletal Class III deformities, utilizing the conventional two-dimensional combined with cone beam computed tomography voxel-based superimposition analysis.

STUDY DESIGN, SETTING, SAMPLE

This retrospective cohort study included skeletal Class III patients undergoing bimaxillary orthognathic surgery at Khon Kaen University, Thailand, in 2020. Exclusion criteria were patients with temporomandibular disorder symptoms, facial asymmetry prior to the surgery, or surgical complications.

EXPOSURE VARIABLE

The exposure variable was the timing, both preoperatively and 3 months postoperatively. This 3-month postoperative time point was chosen because complete healing of the bimaxillary surgery is expected by then, without any potential influence of condylar changes resulting from subsequent orthodontic treatment.

MAIN OUTCOME VARIABLES

The outcome variables are condylar position measurement, joint space (mm), and axial condylar angle (degrees).

COVARIATES

Demographics (age, sex) and surgical details (direction and amount of movement) were collected as covariates.

ANALYSES

Statistical analysis of condylar positional changes and correlations was performed using paired t-test and linear correlation (P value < .05), respectively.

RESULTS

The sample included 11 subjects (22 condyles), with a mean age of 24 ± 5.24 years. Both two-dimensional measurements and voxel-based three-dimensional superimposition showed significant changes in condylar position 3 months after bimaxillary surgery: inferior (0.45 ± 0.26 mm, P < .001), posterior (0.46 ± 0.39 mm, P = .003), lateral (0.38 ± 0.42 mm, P = .01) displacement, and inward rotation (5.21 ± 2.54°, P < .001). No significant correlation was found between jaw movement distance and condylar changes.

CONCLUSION AND RELEVANCE

To our knowledge, this is the first study to report measures of condylar changes at 3 months, when complete healing of the osteotomies would be expected, using Le Fort I osteotomy for maxillary advancement combined with bilateral sagittal split ramus osteotomy for mandibular setback. These changes are small in magnitude and may be of little relevance to patient care.

The Evaluation of Condylar Position Change in the Asymmetric Mandible Following Sagittal Split Osteotomy

BACKGROUND

The change of condyle position following orthognathic surgery affects the stability of treatments. This study aims to assess the correlation between the amount of condyles' position change and the severity of mandibular asymmetry following BSSO.

MATERIALS AND METHODS

This is a cross-sectional study. Subjects with asymmetric mandibular prognathism following BSSO were studied. Subjects were classified into 2 groups: group 1, subjects had mandibular asymmetry without occlusal cant and underwent BSSO. Group 2, subjects had mandibular asymmetry with occlusal cant and underwent BSSO+ Lefort I osteotomy. The condyle position was evaluated using cone-beam computer tomography (CBCT). Pearson's correlation test was used to assess any correlation between the condyle changes and the change in the mandible in sagittal and anterior-posterior directions.

RESULTS

A total of 44 subjects were studied. In group 1, the condyle tilted outward in the deviated condyle and inward in the non-deviated condyle immediately after osteotomy. After 12 months, both condyles showed a rotation relative to the original position. In group 2, the condyles of the deviated sides and non-deviated sides moved inferiorly after surgery (condylar sagging), which was more significant in the non-deviated sides. The condyle rotation was similar to group 1. The severity of asymmetry and occlusal cant correlate with the condylar position change in the two groups.

CONCLUSION

The severity of mandibular asymmetry correlates with the amount of condyles' position change immediately after BSSO. However, the condyles tend to return to their original position 12 months later.

Evaluating changes in the condylar head after orthognathic surgery with or without articular disc repositioning: a systematic review

Failures in orthognathic surgery are associated with different factors, including those related to untreated or undiagnosed preoperative temporomandibular joint (TMJ) disorders. This systematic review aimed to assess potential alterations in the condylar head following orthognathic surgery. A systematic search for randomised controlled trials and retrospective studies was performed. For inclusion in the review, studies had to meet the following eligibility criteria according to the PICO framework: Patients: patients with orthognathic deformity and temporomandibular dysfunction (or temporomandibular osteoarthritis); Intervention: patients submitted to orthognathic surgery concomitantly with TMJ disjunction; Control: patients undergoing only orthognathic surgery with or without presurgical data; and Outcome: changes in temporomandibular joint position and volume. Nine studies met all the inclusion criteria and were selected for qualitative analysis. The results of this review show that simultaneous articular disc repositioning and orthognathic surgery provide better results in patients with preoperatively diagnosed condylar osteoarthritic changes. In conclusion, condylar remodelling (resorption/deposition) and its extent are determined by the direction of condylar displacement during surgery. Other factors such as age are also associated with the development of condylar resorption.

[Mandibular condyle localization in orthognathic surgery based on mandibular movement trajectory and its preliminary accuracy verification]

OBJECTIVE

To establish and assess the precision of pre-surgical condyle position planning using mandibular movement trajectory data for orthognathic surgery.

METHODS

Skull data from large-field cone beam computed tomography (CBCT) and dental oral scan data were imported into IVSPlan 1.0.25 software for 3D reconstruction and fusion, creating 3D models of the maxilla and mandible. Trajectory data of mandibular movement were collected using a mandibular motion recorder, and the data were integrated with the jaw models within the software. Subsequently, three-dimensional trajectories of the condyle were obtained through matrix transformations, rendering them visually accessible. A senior oral and maxillofacial surgeon with experience in both diagnosis and treatment of temporomandibular joint disease and orthognathic surgery selected the appropriate condyle position using the condyle movement trajectory interface. During surgical design, the mobile mandibular proximal segment was positioned accordingly. Routine orthognathic surgical planning was completed by determining the location of the mandibular distal segment, which was based on occlusal relationships with maxilla and facial aesthetics. A virtual mandible model was created by integrating data from the proximal and distal segment bone. Subsequently, a solid model was generated through rapid prototyping. The titanium plate was pre-shaped on the mandibular model, and the screw hole positions were determined to design a condylar positioning guide device. In accordance with the surgical plan, orthognathic surgery was performed, involving mandibular bilateral sagittal split ramus osteotomy (SSRO). The distal segment of the mandible was correctly aligned intermaxillary, while the proximal bone segment was positioned using the condylar positioning guide device and the pre-shaped titanium plate. The accuracy of this procedure was assessed in a study involving 10 patients with skeletal class Ⅱ malocclusion. Preoperative condyle location planning and intraoperative positioning were executed using the aforementioned techniques. CBCT data were collected both before the surgery and 2 weeks after the procedure, and the root mean square (RMS) distance between the preope-rative design position and the actual postoperative condyle position was analyzed.

RESULTS

The RMS of the condyle surface distance measured was (1.59±0.36) mm (95%CI: 1.35-1.70 mm). This value was found to be significantly less than 2 mm threshold recommended by the expert consensus (P < 0.05).

CONCLUSION

The mandibular trajectory may play a guiding role in determining the position of the mandibular proximal segment including the condyle in the orthognathic surgery. Through the use of a condylar positioning guide device and pre-shaped titanium plates, the condyle positioning can be personalized and customized with clinically acceptable accuracy.

Early and 1-year postsurgical stability and its factors in patients with complicated skeletal Class Ⅲ malocclusion treated by conventional and surgery-first approach: A prospective cohort study

INTRODUCTION

This study aimed to compare postsurgical stability between conventional (CSA) and surgery-first (SFA) approaches and investigate its prognostic factors in patients with a skeletal Class Ⅲ extraction.

METHODS

Twenty and 19 patients treated with LeFort I osteotomy and bilateral sagittal split ramus osteotomy (BSSRO) with premolar extraction were enrolled in SFA and CSA groups, respectively. Serial cone-beam computed tomography images obtained before surgery, immediately after surgery (T1), 3 months after surgery, and 12 months after surgery were used for 3-dimensional quantitative analysis. The condyle was segmented for analyzing volumetric changes. Repeated measures analysis of variance, independent t test, and chi-square test were used to compare time-course and intergroup differences. Pearson and Kendall correlation and multivariate linear regression analyses were used to explore prognostic factors affecting skeletal stability.

RESULTS

In both CSA and SFA, postsurgical relapse mainly occurred in the mandible sagittal and vertical dimensions and during the first 3 months after surgery. Stability in SFA was significantly less than that in CSA. Intraoperatively, inferolateral condylar displacement with proximal segment inwards, clockwise rotation, and return movements after surgery were observed regardless of the treatment approach. The condylar volume remained stable over time. Multivariate regression analysis showed that posterior vertical dimension (VD) at T1 (-1.63 mm), surgical amount of mandibular setback (-10.33 mm), surgical condylar downwards displacement (-1.28 mm), and anterior overjet at T1 (6.43 mm) were the most important predictors of early mandibular relapse (r2 = 0.593).

CONCLUSIONS

The risk of early relapse could be reduced by controlling the anterior, middle, and posterior constraints provided by the prediction model.

Condylar positional changes and remodeling following bimaxillary anterior segment osteotomy with and without Le Fort I osteotomy: a three-dimensional comparative analysis

OBJECTIVE

To evaluate 3D condylar displacement and long-term remodeling following the correction of bimaxillary protrusion by anterior segment osteotomy (ASO) with and without Le Fort I surgery.

MATERIALS AND METHOD

This retrospective study included 32 adults with bimaxillary protrusion who underwent ASO alone (group 1) or with concomitant Le Fort I osteotomy (group 2). Subject's computed tomography scans at basic (T0), immediate postoperatively (T1), and at 1 year or more follow-up (T2) were collected. The condyle displacement was measured at superior-inferior, lateromedially, and anteroposterior surfaces, while condyle remodeling was measured at the superior, lateral, anterior, medial, and posterior surfaces. All 3D analyses were performed using 3D Slicer software (4.11.2).

RESULTS

At T1, 52.7%, 86.7%, and 94.4% of condyles in group 1 were displaced inferiorly, laterally, and posteriorly, respectively, as well as 75%, 89.2%, and 53.5% of condyles in group 2, which had not fully returned to the original preoperative positions at T2. Condylar remodeling was observed in both groups at T2, and no significant difference was found in the overall condylar volume between T1 and T2 in both groups. Patients in group 2 exhibited significant bone resorption at both lateral and anterior surfaces compared to group 1 (P = 0.000 and 0.01, respectively).

CONCLUSION

This study's results demonstrated that ASO is associated with a degree of condylar changes even if the posterior mandible is not osteomized. The positional changes vary between bimaxillary ASO alone and those with simultaneous Le Fort I osteotomy. However, both groups' condyle volume remained stable at the long-term follow-up.

Modeling the effect of bilateral sagittal split osteotomy on posterior, superior and medial space dimensions of the temporomandibular joint: a retrospective controlled cohort study

BACKGROUND

To model the effect of isolated bilateral sagittal split osteotomy (BSSO) on changes in posterior (PSD), superior (SSD), and medial space dimensions (MSD) of the temporomandibular joint.

METHODS

Using a retrospective cohort study design, pre- and postoperative (immediately after surgery; 1 year follow-up) cone-beam computed tomography measurements of 36 patients who had undergone BSSO for mandibular advancement were compared with a control group of 25 subjects from whom a mandibular odontogenic cyst was removed under general anesthesia. Generalized estimation equation (GEE) models were used to examine the independent effects of study group, preoperative condylar position, and time points on PSD, SSD, and MSD adjusting for covariates (age, sex, and mandibular advancement).

RESULTS

No significant differences were found regarding changes in PSD (p = 0.144), SSD (p = 0.607), or MSD (p = 0.565) between the BSSO and control groups. However, the preoperative posterior condylar position showed significant effects on PSD (p < 0.001) and MSD (p = 0.043), while the preoperative central condylar position demonstrated a significant effect on PSD (p < 0.001).

CONCLUSION

The data suggest that preoperative posterior condylar position is a significant effect modifier of PSD and MSD over time in this cohort.

Condylar resorption following mandibular advancement or bimaxillary osteotomies: A systematic review of systematic reviews

Several systematic reviews have been published on the effects of mandibular surgery on condylar remodeling without reaching a consensus. The purpose of this systematic review of systematic reviews was to assess the impact of mandibular advancement or bimaxillary surgeries on condylar resorption. A literature search, using several electronic databases, was carried out by two reviewers independently. Article preselection was based on titles and abstracts, and final article selection based on full-text analysis of preselected studies. After final study selection, the quality of studies was assessed using the AMSTAR 2 tool. A decision algorithm was subsequently established to choose the best body of evidence. From an initial yield of 1'848 articles, 23 systematic reviews were identified for further analysis, with ten studies being included in the final selection. Despite the generally low quality of the reviews, certain associations could be made: young patients, female patients, and those with a high mandibular plane angle are more prone to condylar resorption following mandibular advancement osteotomies, especially if anterior rotation of the mandible is performed during surgery. Patients undergoing bimaxillary surgery also appear to have a higher risk of developing condylar resorption. In conclusion, these results confirm the multi-factorial nature of condylar resorption, stressing the need for well-controlled prospective studies with long-term follow-up to clearly identify potential risk factors associated with orthognathic surgery.

Evaluation of the Mandibular Condyle Morphologic Relation before and after Orthognathic Surgery in Class II and III Malocclusion Patients Using Cone Beam Computed Tomography

Simple Summary

In individuals with severe malocclusions, orthognathic surgery seeks to rebalance the relationships between the jaws by providing a stable occlusion, a healthy muscle balance, and the functioning of the temporomandibular joint. Cone beam computed tomography may be used to determine the position of the mandibular condyle in the glenoid fossa. This study aimed to assess how the position of the mandibular condyle varies in class II and III malocclusions before and after bimaxillary orthognathic surgery. Before and after orthognathic surgery, 56 TMJs from 28 patients were studied. Following surgery, both class II and class III patients experienced changes in the anterior joint space, posterior joint space, condyle position, and condyle angle. The preliminary findings are promising for determining changes in condyle position and joint spaces that might guide oral and maxillofacial surgeons to address a debilitating clinical affliction.

Abstract

This study aimed at evaluating the mandibular condyle position changes before and after bimaxillary orthognathic surgery in class II and III malocclusion patients. CBCT scans from patients who underwent bimaxillary orthognathic surgery were analyzed: Le Fort I osteotomy and bilateral sagittal split osteotomy (BSSO). Both condyles were independently assessed for their largest anterior and posterior joint spaces, smallest medial joint spaces, and condyle angles concerning the transverse line. In the sagittal plane, the minimum size of the anterior and posterior joint spaces was measured. In the coronal plane, the smallest medial joint space was measured. The position of the condyle within the glenoid fossa was determined before and after surgery. A total of 56 TMJs from 28 patients were studied. Following orthognathic surgery, the anterior and posterior space in class II increased. Postoperatively, the anterior joint space in class III decreased. In 42.85% of malocclusion class II patients and 57.14% of malocclusion class III patients, the pre-and post-surgical position of the condyle changed, the condyle was anteriorly positioned (42.85%) in class II patients and centrically positioned (71.4%) in class III patients. Significant changes in the joint space, condylar position, and condyle angle were found in the class II and class III subjects.

A Biomechanical Analysis of Muscle Force Changes After Bilateral Sagittal Split Osteotomy

A basic procedure affecting maxillofacial geometry is the bilateral sagittal split osteotomy. During the surgery, the bony segments are placed in a new position that provides the correct occlusion. Changes in the geometry of the mandible will affect the surrounding structures and will have a significant impact on the functioning of the masticatory system. As a result of the displacement of the bone segment, the biomechanical conditions change, i.e., the load and the position of the muscles. The primary aim of this study was to determine the changes in the values of the muscular forces caused by mandible geometry alteration. The study considered the translation and rotation of the distal segment, as well as rotations of the proximal segments in three axes. Calculations were performed for the unilateral, static loading of a model based on rigid body mechanics. Muscles were modeled as spring elements, and a novel approach was used to determine muscle stiffness. In addition, an attempt was made, based on the results obtained for single displacements separately, to determine the changes in muscle forces for geometries with complex displacements. Based on the analysis of the results, it was shown that changes in the geometry of the mandibular bone associated with the bilateral sagittal split osteotomy will have a significant effect on the values of the masticatory muscle forces. Displacement of the distal segment has the greatest effect from -21.69 to 26.11%, while the proximal segment rotations affected muscle force values to a less extent, rarely exceeding 1%. For Yaw and Pitch rotations, the opposite effect of changes within one muscle is noticed. Changes in muscle forces for complex geometry changes can be determined with a high degree of accuracy by the appropriate summation of results obtained for simple cases.