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Splitting the condyle — a method of removing the condyle in cases of fibrous ankytosis
Surgical Technique
Int. J. Oral Sltrg. 1979: 8: 398-401 (Key words; tlnkyfosis. join I, lem pOTomandibuJar: surger)'. oral}
Splitting the condyle - a method of removing the condyle in cases of fibrous ankylosis K. G. H. v. d. WAL AND N. P. J. B. SIEVERINK Department 0/ Oral and Maxilla-Facial Surgery, St. Radboud Hospital, Nijmegen, the Netherlands
A method used to remove a fibrous ankylosed condyle is discussed. To Overcome the complications of the conventional condylectomy, the risk of opening the neurocranium and laceration of the internal maxillary artery, the condyle is split in a latera-medial direction. Four patients have been operated upon successfully. ABSTRACT -
(Received jor publication 28 March, accepted 28 June 1978)
The only successful treatment of ankylosis of the temporomandibular joint (TMJ) is surgery. Non-operative treatment (brisement force, which refers to the forceful opening of the mouth) has no long-term value and is only indicated as a diagnostic aid. The most common techniques for the relief of ankylosis of the TMJ are: Condylectomy4,5 _ This method of treatment can seldom be performed and then only in cases of fibrous ankylosis. The condyle is so firmly fused with the glenoid fossa that attempts to remove this structure may lead to perforation of the roof of the glenoid fossa, which is paper-thin. In addition, laceration of the internal maxillary artery, lying directly medial to the condyle, may occur and is a serious complication2 ,3,7,8. Gap or interposition arthroplasty - In this method of treatment, which is often performed in cases of fibrous ankylosis and always in cases of osseous ankylosis, a
section of bone is removed from the original condylar neck. In cases of a combination of ankylosis of the TMJ and fusion of the coronoid process to the zygomatic arch, an ostectomy is performed in the ascending ramus 2 ,4,7,8. The created gap can be filled with various natural or artificial substances to prevent recurrence 1 ,2,4,7,8. Condylectomy is the method of choice. The function of a mandible with one condyle removed is generally adequate, and it is open to question whether any replacement, of either an autogenous or alloplastic nature is necessary5.
Material and methods Four patients with unilateral fibrous ankylosis have been treated during 1977-78 in which the new technique has been performed. In Table 1 a summary of the data of the four patien ts is given. The radiographs of all these patients show
0300-9785/79/050398-04$02.50/0 © 1979 Munksgaard, Copenhagen
SPLITTING OF CONDYLE IN ANKYLOSIS
399
Table 1. Patient data 2
Age of first examination Sex Involved side Etiology Duration Mouth opening Age at operation
4 years Male Left Unknown 4 years 16 mm 9 years
proliferative changes of the condyle and the glenoid fossa with narrowing of the joint space, these being the typical patll0logical radiographic changes of a fibrous ankylosis (Fig. 1). Because of the threatening Joss of the permanent dentition and the progression of the trismus we decided to treat these patients by means of a surgical intervention. Under general anesthesia the ankylosed condyle is exposed by a submandibular incision. This approach gives a better view of the ascending ramus and a larger operative field to extirpate the condyle and furthem10re the risk of damage to the facial nerve is less than in the preauricular ap-
Fig. 1. Tomograph of the fibrous ankylosed
condyle of patient 3.
Patients
5 years
Male Left Unknown 2 years 20 mm 12 years
3 22 years
Male Right Trauma 18 years 15 mm 22 years
4 5 years
Male Right Trauma 7 years 12 mm 12 years
proach. The condyle is exposed as far as possible. A bone cut is made ~uely in.,,;;;;a ~ ",~, ,.~'. dorsa-caudal direction from the sigmoid notch. The ankylosed condyle is split by using a fissure bur in latera-medial direction and divided in two parts by an elevator, analogous to removal of an impacted third molar (Figs. 2,3). The fragment with
Fig. 2. The condyle is split in two directions
(patient
3),
400
V. D.
WAL AND SIEVERINK
physiotherapeutic program to ensure continued mobilization of the mandible. After about 8 weeks, when the patient normally shows a correct and direct occlusion, the elastic traction and arch bars are removed. At this time an activator may be placed to stimulate the remaining growth.
Results and discussion
Fig. 3. The condyle is divided into two parts. Note the use of an elevator to create the division (patient 3).
the fewest adhesions to the cranial base, most frequently the ventral part, can be easily removed with the use of an excavator, Ash 6, periosteal elevator and scissors. The operative field is thus larger and provides a better view for a free dissection of the remaining partes). By careful preparation the remaining part(s) may be removed without opening the mid-cranial fossa and without damage to the internal maxillary artery (Fig. 4). After inspection and careful removal of all bone fragments from the created gap, the defect is closed in layers and a drain is inserted. The mandible is immobilized for 1 week. After this period, neutral elastic traction is exerted on the incisor region and class II elastic on the operated side. The patient is put on a strict
The purpose of the present article is to suggest a method of removal of a fibrous ankylosed condyle. The method of choice in our opinion must be complete removal of the condyle. To overcome the problems of removal of a firmly fixed condyle we split this structure, analogous to the method that may be utilized to remove an impacted wisdom tooth. Disadvantages of a condylectomy performed in the conventional way are: 1. It is very difficult to extirpate in toto an enlarged condyle fused in all directions with the glenoid fossa 2,3,7,8. 2. Removal of the ankylosed condyle may open the mid-cranial fossa2 ,s,7,8. 3. The internal maxillary artery, lying directly medial to the condyle, is frequently damaged by the use of chisels or burs during the operative procedure2 ,5,7,8. In our opinion these problems may be resolved by splitting the condyle: 1. The part with the fewest adhesions may be removed easily, providing a better view. 2. A larger operative field is created to allow easier removal of the remaining parts. The free dissection can be performed utilizing small instruments such as the excavator, the Ash 6, the periosteal elevator and scissors, instead of heavier instruments such as the chisel, without the previously mentioned disadvantages. In the literature, as far as we know, splitting of a fibrous ankylosed condyle has
SPLITTING OF CONDYLE IN ANKYLOSIS
401
Fig. 4. The four sectiom, of the removed condyle of patient 2. Note the bone cut (arrow).
never been described. Our experience is limited with only four patients. However, we believe that, using this simple method of splitting the condyle in a latera-medial direction, more fibrous ankylosed condyles can be removed than by the more conventional techniques.
References 1. EL-MoFTY, S.: Surgical treatment of ankylosis of the temporomandibular joint. J. Oral
Surg. 1974: 32: 202-206. 2. F'REEDUS, M. S., ZITTER, W. D. & DOYLE, P. K.: Principles of treatment temporomandibular joint ankylosis. J. Oral Surg. 1975: 33: 757-765.
3. MrLLER, G. A., LANGLEY PAGE, H. & GRIFFrnI, C. R.: Temporomandibular joint ankylosis: review of the literature and report of two cases of bilateral involvement. J. Oral Surg. 1975: 33: 792-803.
4. POSWILLO, P.: Surgery of the temporomandibular joint. Oral Sci. Rev. 1974: 6: 87-117. 5. ROWE, N. L.: Surgery of the temporomandibular joint. Proc. R. Soc. Med. 1972: 65: 383-388. 6. ROWE, N. L. & KILLEY, H. C.: Fractures of the facial skeleton. Livingstone, Edinburgh and London, 1968, p. 162. 7. SILAGI, J. L. & SCHOW, C. E.: Temporomandibular joint arthroplasty. J. Oral Surg. 1970: 28: 920-926. 8. WALKER, R. Y.: Arthroplasty of the ankylosed temporomandibular joint. Trans. Int. Conf. Oral Sllrg. 1973: 4: 279-283.
Address: K. G. H. V. d. Wal St. Radboudziekenhuis Afd. mondziekten en kaakchirllrgie Geert Grooteplein Zuid no. 14 Nijmegen Holland
Int. J. Oral Sltrg. 1979: 8: 398-401 (Key words; tlnkyfosis. join I, lem pOTomandibuJar: surger)'. oral}
Splitting the condyle - a method of removing the condyle in cases of fibrous ankylosis K. G. H. v. d. WAL AND N. P. J. B. SIEVERINK Department 0/ Oral and Maxilla-Facial Surgery, St. Radboud Hospital, Nijmegen, the Netherlands
A method used to remove a fibrous ankylosed condyle is discussed. To Overcome the complications of the conventional condylectomy, the risk of opening the neurocranium and laceration of the internal maxillary artery, the condyle is split in a latera-medial direction. Four patients have been operated upon successfully. ABSTRACT -
(Received jor publication 28 March, accepted 28 June 1978)
The only successful treatment of ankylosis of the temporomandibular joint (TMJ) is surgery. Non-operative treatment (brisement force, which refers to the forceful opening of the mouth) has no long-term value and is only indicated as a diagnostic aid. The most common techniques for the relief of ankylosis of the TMJ are: Condylectomy4,5 _ This method of treatment can seldom be performed and then only in cases of fibrous ankylosis. The condyle is so firmly fused with the glenoid fossa that attempts to remove this structure may lead to perforation of the roof of the glenoid fossa, which is paper-thin. In addition, laceration of the internal maxillary artery, lying directly medial to the condyle, may occur and is a serious complication2 ,3,7,8. Gap or interposition arthroplasty - In this method of treatment, which is often performed in cases of fibrous ankylosis and always in cases of osseous ankylosis, a
section of bone is removed from the original condylar neck. In cases of a combination of ankylosis of the TMJ and fusion of the coronoid process to the zygomatic arch, an ostectomy is performed in the ascending ramus 2 ,4,7,8. The created gap can be filled with various natural or artificial substances to prevent recurrence 1 ,2,4,7,8. Condylectomy is the method of choice. The function of a mandible with one condyle removed is generally adequate, and it is open to question whether any replacement, of either an autogenous or alloplastic nature is necessary5.
Material and methods Four patients with unilateral fibrous ankylosis have been treated during 1977-78 in which the new technique has been performed. In Table 1 a summary of the data of the four patien ts is given. The radiographs of all these patients show
0300-9785/79/050398-04$02.50/0 © 1979 Munksgaard, Copenhagen
SPLITTING OF CONDYLE IN ANKYLOSIS
399
Table 1. Patient data 2
Age of first examination Sex Involved side Etiology Duration Mouth opening Age at operation
4 years Male Left Unknown 4 years 16 mm 9 years
proliferative changes of the condyle and the glenoid fossa with narrowing of the joint space, these being the typical patll0logical radiographic changes of a fibrous ankylosis (Fig. 1). Because of the threatening Joss of the permanent dentition and the progression of the trismus we decided to treat these patients by means of a surgical intervention. Under general anesthesia the ankylosed condyle is exposed by a submandibular incision. This approach gives a better view of the ascending ramus and a larger operative field to extirpate the condyle and furthem10re the risk of damage to the facial nerve is less than in the preauricular ap-
Fig. 1. Tomograph of the fibrous ankylosed
condyle of patient 3.
Patients
5 years
Male Left Unknown 2 years 20 mm 12 years
3 22 years
Male Right Trauma 18 years 15 mm 22 years
4 5 years
Male Right Trauma 7 years 12 mm 12 years
proach. The condyle is exposed as far as possible. A bone cut is made ~uely in.,,;;;;a ~ ",~, ,.~'. dorsa-caudal direction from the sigmoid notch. The ankylosed condyle is split by using a fissure bur in latera-medial direction and divided in two parts by an elevator, analogous to removal of an impacted third molar (Figs. 2,3). The fragment with
Fig. 2. The condyle is split in two directions
(patient
3),
400
V. D.
WAL AND SIEVERINK
physiotherapeutic program to ensure continued mobilization of the mandible. After about 8 weeks, when the patient normally shows a correct and direct occlusion, the elastic traction and arch bars are removed. At this time an activator may be placed to stimulate the remaining growth.
Results and discussion
Fig. 3. The condyle is divided into two parts. Note the use of an elevator to create the division (patient 3).
the fewest adhesions to the cranial base, most frequently the ventral part, can be easily removed with the use of an excavator, Ash 6, periosteal elevator and scissors. The operative field is thus larger and provides a better view for a free dissection of the remaining partes). By careful preparation the remaining part(s) may be removed without opening the mid-cranial fossa and without damage to the internal maxillary artery (Fig. 4). After inspection and careful removal of all bone fragments from the created gap, the defect is closed in layers and a drain is inserted. The mandible is immobilized for 1 week. After this period, neutral elastic traction is exerted on the incisor region and class II elastic on the operated side. The patient is put on a strict
The purpose of the present article is to suggest a method of removal of a fibrous ankylosed condyle. The method of choice in our opinion must be complete removal of the condyle. To overcome the problems of removal of a firmly fixed condyle we split this structure, analogous to the method that may be utilized to remove an impacted wisdom tooth. Disadvantages of a condylectomy performed in the conventional way are: 1. It is very difficult to extirpate in toto an enlarged condyle fused in all directions with the glenoid fossa 2,3,7,8. 2. Removal of the ankylosed condyle may open the mid-cranial fossa2 ,s,7,8. 3. The internal maxillary artery, lying directly medial to the condyle, is frequently damaged by the use of chisels or burs during the operative procedure2 ,5,7,8. In our opinion these problems may be resolved by splitting the condyle: 1. The part with the fewest adhesions may be removed easily, providing a better view. 2. A larger operative field is created to allow easier removal of the remaining parts. The free dissection can be performed utilizing small instruments such as the excavator, the Ash 6, the periosteal elevator and scissors, instead of heavier instruments such as the chisel, without the previously mentioned disadvantages. In the literature, as far as we know, splitting of a fibrous ankylosed condyle has
SPLITTING OF CONDYLE IN ANKYLOSIS
401
Fig. 4. The four sectiom, of the removed condyle of patient 2. Note the bone cut (arrow).
never been described. Our experience is limited with only four patients. However, we believe that, using this simple method of splitting the condyle in a latera-medial direction, more fibrous ankylosed condyles can be removed than by the more conventional techniques.
References 1. EL-MoFTY, S.: Surgical treatment of ankylosis of the temporomandibular joint. J. Oral
Surg. 1974: 32: 202-206. 2. F'REEDUS, M. S., ZITTER, W. D. & DOYLE, P. K.: Principles of treatment temporomandibular joint ankylosis. J. Oral Surg. 1975: 33: 757-765.
3. MrLLER, G. A., LANGLEY PAGE, H. & GRIFFrnI, C. R.: Temporomandibular joint ankylosis: review of the literature and report of two cases of bilateral involvement. J. Oral Surg. 1975: 33: 792-803.
4. POSWILLO, P.: Surgery of the temporomandibular joint. Oral Sci. Rev. 1974: 6: 87-117. 5. ROWE, N. L.: Surgery of the temporomandibular joint. Proc. R. Soc. Med. 1972: 65: 383-388. 6. ROWE, N. L. & KILLEY, H. C.: Fractures of the facial skeleton. Livingstone, Edinburgh and London, 1968, p. 162. 7. SILAGI, J. L. & SCHOW, C. E.: Temporomandibular joint arthroplasty. J. Oral Surg. 1970: 28: 920-926. 8. WALKER, R. Y.: Arthroplasty of the ankylosed temporomandibular joint. Trans. Int. Conf. Oral Sllrg. 1973: 4: 279-283.
Address: K. G. H. V. d. Wal St. Radboudziekenhuis Afd. mondziekten en kaakchirllrgie Geert Grooteplein Zuid no. 14 Nijmegen Holland