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Bilateral low condylectomy of the mandible
Bilateral low condylectomy of the mandible Philip Worthington, M.D., D.D.S.,” UNIVERSITY
OF WASHINGTON
Seattle, Wash.
SCHOOL OF DENTISTRY
The operation of low condylectomy of the mandible is seldom performed bilaterally. The indications and consequences are reviewed, and a case is reported in which the adverse sequelae commonly attributed to this procedure were avoided over an 1l-year follow-up period.
T
he indications for bilateral low condylectomy of the mandible are few-and debatable-and this may account for the scant literature on the subject. Certainly it is a topic which has received limited attention, and this has diminished in the years since the introduction and popularity of the so-called “high condylectomy.“6 Possible indications might include certain cases of trauma and some cases of arthritis; rather recently, early bilateral condylectomy has been recommended’ for the prevention of mandibular prognathism, thus reviving the practice of Gonzalez-UlloazW4who introduced this operation for prognathism in 1950. It is probably fair to say that this latter indication is controversial. Opinions on condylectomy vary considerably. Thus, on the one hand, h-by7 states: “Removal of the entire condyle head with its muscular attachmentis a surgical catastrophe.” Elsewhere he says: “It has been demonstrated repeatedly through both animal research and clinical experience that the removal of the condyle head, including the attachment of the lateral pterygoid muscle, is an injurious and deforming procedure.” On the other hand, Silver and co-workersI give their opinion that “Condylectomy of the mandible . . . is an effective procedure for arthritis of the temporomandibular joint.” What of the results of condylectomy? Opinions seem to rest as often on preconceived ideas as on direct personal experience. However, the following beliefs are frequently expressed: (1) Unilateral condylectomy leads to hyperocclusion and deviation to the operated side on opening of the mouth. (2) Bilateral condylectomy leads inevitably to mandibular retrusion, anterior open-bite, and loss of masticatory efficiency. There seemsno doubt that thesedisadvantageouschangescan occur. The question is whether they need occur. Very few reports are available dealing with the re*Associate Professor, Deparhnent of Oral and Maxillofacial
204
Surgery.
suits of bilateral low condylectomy . Silver and his colleaguesperformed condylectomieson 100patients, and in eleven of these the operation was bilateral. Results were classedas good if patients later enjoyed free, painless movement and were able to take normal food; results were classed as poor if the patients showed mandibular retrusion and/or anterior open-bite. Of the eleven patients with bilateral condylectomy seven had good results and four had poor results. Silver and his associates12 concludedthat bilateral (low) condylectomy should be reserved for patients with rheumatoid arthritis or congenital fibrous ankylosis. The effects of condylectomy have been studied clinically in human patients and experimentally in animals by several workers, including Sarnat and Engel,‘O Jarabak and Stuteville,* Sarnat,” Skuble, Choukas, and Toto,13 and Poswillo.s Surprisingly, Poswillo was the first to study the effects of condylectomy in the adult animal. He showed that if condylectomy were performed during the growing period, then the growth and development of the jaws was disturbed. If the operation took place after the growth period, then there was always attempted condylar regeneration (in monkeys), but there was also an anterior open-bite deformity. CASE REPORT
A 29-year-oldwhite womanwasreferredwith a history of 5 months’pain, grating, andclicking in thejaw joints. The left joint was worse than the right. The patient was in good general health, and there was no sign of any generalized arthropathy . Examination showed restriction of movement in both temporomandibular joints, the left joint being tender on palpation. There was a click in the middle range of opening of the left side, but a continuous grating sound throughout the range of movement could be appreciated on both sides. Radiographs were relatively unimpressive beyond confirming restriction of movement. After conservative and palliative measures had been tried and had failed, the left joint was explored and erosion of the 0030-4220/80/030204+04$00.40/0
0
1980 ‘I-be C. V. Mosby Co.
Bilateral low condylectomy of mandible
Volume 49 Number 3
205
Fig. 1. Left condyle. The articular surface shows loss of fibrous tissue covering and fibrocartilage with osteoclastic resorption of the exposed subarticular bone.
Fig. 2. Right condyle showing similar superficial erosive changes
condyle head was found despite the unimpressive preoperative radiographs. The condyle was removed, and histologic examination confirmed that it was the site of osteoarthritis (Fig. I). The symptoms on the operated side disappeared. Some months later, however, the patient returned with a recurrence of symptoms on the right side and pleaded for that side to be operated on “in the same way.” Eventually the second condyle was removed and was found to be histologically similar to the first (Fig. 2). The jaws were immobilized by means of cast-silver cap splints for a total of 3 months, but toward the end of that time elastic intermaxillary traction was used at night only. It has now been 11 years, since the operation (Fig. 3).
There is no pain at all, and the patient has no other symptoms. The occlusion is undisturbed, and the mandible is not retruded (Fig. 4). The range of movement is adequate (Fig. 5). Radiographs show that there is no apparent condylar regeneration (although this has been seen in other cases). In this case there was no history of any preceding trauma to the jaws or joints and no signiticant pre-existing malocclusion. As is not uncommonly found, the severity of the symptoms and the operative findings, on the one hand, and the radiographic changes, on the other, did not correspond. The point of recording this case is to illustrate that the alleged evil consequences of bilateral low condylectomy do not nrcessarily follow. One can only speculate as to why
206 Worthingtorz
Oral Surg. March, 1980
Fig. 3. Results of bilateral condylectomy
Flg. 4. Patient with edge-to-edge bite maintained operation.
after
Fig. 5. Patient opening mouth nearly 30 mm. shortly after operation.
some patients escape these untoward sequelae. On the basis of considerations from orthognathic surgery and fracture management, it seems reasonable to suggest that the following factors might be important: (1) complete “looseness” of the parts at the time of fixation and (2) the duration of intermaxillary fixation and training with elastics. This case might
well be handled differently today, in view of the success of condylar replacement operations.j, I4 It highlights the difficulty of predicting which patient with excised condyles will develop complications, and it certainly illustrates that anterior open-bite and mandibular retrusion do not inevitably follow bilateral condylectomy . In such a case it is possible for the
Volume 49 Number 3 mandible to function well when slung in muscle below the skull, just as the hyoid bone functions when slung in muscle below the mandible. REFERENCES 1. Adler, E. A.: Early Condylectomy to Prevent Orthognatbism: A Preliminary Report, J. Oral Surg. 34: 702-706, 1976. 2. Gonzalez-Ulloa, M.: Temporomandibular Arthroplasty in the Treatment of Prognathism, Plast. Reconstr. Surg. 8: 136 149, 1951. 3. Gonzalez-Ulloa, M.: Important Details in the Treatment of Prognathism by Double Condylectomy, Plast. Reconstr. Surg. 9: 391-392, 19.52. 4. Gonzalez-Ulloa, M.: Late Results in the Treatment of Prognathism by Double Condylectomy, Plast. Reconstr. Surg. 18: 50-64, 1956. 5. Hartwell, S. W., and Hall, M. D.: Mandibular Condylectomy With Silicone Rubber Replacement, Plast. Reconstr. Surg. 53: 44@444, 1974. 6. Henny, F. A., and Baldridge, 0. L.: Condylectomy for the Persistently Painful TemporomandibularJoint, J. Oral Surg. 15: 24-31, 1957. 7. Irby, W. B.: Surgery of the Temporomandibular Joint. In Irby, W. B.: Current Advances in Oral Surgery, St. Louis, 1974, The C. V. Mosby Company. 8. Jarabak, J. R., and Stuteville, 0.: Bilateral Mandibular Condylar Resection (Abstr.), J. Dent. Res. 31: 509-510, 1952.
Bilateral low condylectomy oj’ mandible
207
9. Poswillo, D. E.: The Late Effects of Mandibular Condyiectomy, ORAL SURG. 33: 500-512, 1972. 10. Sarnat, B. G.: Facial and NeurocranialGrowth After Removal of the Condyle in the Maraca rhesus Monkey. Plast. Reconstr. Surg. 7: 364380, 1951. 11. Sarnat, B. G.: Facial and NeurocranialGrowth After Removal of the Mandibular Condyle in the Macaca rhesus Monkey, Am. J. Surg. 94: 19-30, 1957. 12. Silver, C. M., Simon, S. D., and Litchman, H. M.: Surgery of the Arthritic Temporomandibular Joint, Surg. Gynecol. Obstet. 136: 251-256, 1973. 13. Skuble, D. F., Choukas, N. C.. and Toto, P. D.: Craniomandibular Bone Changesin RhesusMonkeys Inducedby Condylectomy, J. Oral Surg. 28: 273-279, 1970. 14. Wukelich, S., Marshall, J., Walden, R., Bromberg, B., and Seldin, R.: Use of a Silastic Testicular Implant in Reconstruction of the Temporomandibular Joint of a 5-Year-Old Child, ORAL. SURG. 32: 4-9, 1971. Reprint requests to:
Dr. Philip Worthington Department of Oral and Maxillofacial Surgery, SB-24 School of Dentistry University of Washignton Seattle. Washington 98195
OF WASHINGTON
Seattle, Wash.
SCHOOL OF DENTISTRY
The operation of low condylectomy of the mandible is seldom performed bilaterally. The indications and consequences are reviewed, and a case is reported in which the adverse sequelae commonly attributed to this procedure were avoided over an 1l-year follow-up period.
T
he indications for bilateral low condylectomy of the mandible are few-and debatable-and this may account for the scant literature on the subject. Certainly it is a topic which has received limited attention, and this has diminished in the years since the introduction and popularity of the so-called “high condylectomy.“6 Possible indications might include certain cases of trauma and some cases of arthritis; rather recently, early bilateral condylectomy has been recommended’ for the prevention of mandibular prognathism, thus reviving the practice of Gonzalez-UlloazW4who introduced this operation for prognathism in 1950. It is probably fair to say that this latter indication is controversial. Opinions on condylectomy vary considerably. Thus, on the one hand, h-by7 states: “Removal of the entire condyle head with its muscular attachmentis a surgical catastrophe.” Elsewhere he says: “It has been demonstrated repeatedly through both animal research and clinical experience that the removal of the condyle head, including the attachment of the lateral pterygoid muscle, is an injurious and deforming procedure.” On the other hand, Silver and co-workersI give their opinion that “Condylectomy of the mandible . . . is an effective procedure for arthritis of the temporomandibular joint.” What of the results of condylectomy? Opinions seem to rest as often on preconceived ideas as on direct personal experience. However, the following beliefs are frequently expressed: (1) Unilateral condylectomy leads to hyperocclusion and deviation to the operated side on opening of the mouth. (2) Bilateral condylectomy leads inevitably to mandibular retrusion, anterior open-bite, and loss of masticatory efficiency. There seemsno doubt that thesedisadvantageouschangescan occur. The question is whether they need occur. Very few reports are available dealing with the re*Associate Professor, Deparhnent of Oral and Maxillofacial
204
Surgery.
suits of bilateral low condylectomy . Silver and his colleaguesperformed condylectomieson 100patients, and in eleven of these the operation was bilateral. Results were classedas good if patients later enjoyed free, painless movement and were able to take normal food; results were classed as poor if the patients showed mandibular retrusion and/or anterior open-bite. Of the eleven patients with bilateral condylectomy seven had good results and four had poor results. Silver and his associates12 concludedthat bilateral (low) condylectomy should be reserved for patients with rheumatoid arthritis or congenital fibrous ankylosis. The effects of condylectomy have been studied clinically in human patients and experimentally in animals by several workers, including Sarnat and Engel,‘O Jarabak and Stuteville,* Sarnat,” Skuble, Choukas, and Toto,13 and Poswillo.s Surprisingly, Poswillo was the first to study the effects of condylectomy in the adult animal. He showed that if condylectomy were performed during the growing period, then the growth and development of the jaws was disturbed. If the operation took place after the growth period, then there was always attempted condylar regeneration (in monkeys), but there was also an anterior open-bite deformity. CASE REPORT
A 29-year-oldwhite womanwasreferredwith a history of 5 months’pain, grating, andclicking in thejaw joints. The left joint was worse than the right. The patient was in good general health, and there was no sign of any generalized arthropathy . Examination showed restriction of movement in both temporomandibular joints, the left joint being tender on palpation. There was a click in the middle range of opening of the left side, but a continuous grating sound throughout the range of movement could be appreciated on both sides. Radiographs were relatively unimpressive beyond confirming restriction of movement. After conservative and palliative measures had been tried and had failed, the left joint was explored and erosion of the 0030-4220/80/030204+04$00.40/0
0
1980 ‘I-be C. V. Mosby Co.
Bilateral low condylectomy of mandible
Volume 49 Number 3
205
Fig. 1. Left condyle. The articular surface shows loss of fibrous tissue covering and fibrocartilage with osteoclastic resorption of the exposed subarticular bone.
Fig. 2. Right condyle showing similar superficial erosive changes
condyle head was found despite the unimpressive preoperative radiographs. The condyle was removed, and histologic examination confirmed that it was the site of osteoarthritis (Fig. I). The symptoms on the operated side disappeared. Some months later, however, the patient returned with a recurrence of symptoms on the right side and pleaded for that side to be operated on “in the same way.” Eventually the second condyle was removed and was found to be histologically similar to the first (Fig. 2). The jaws were immobilized by means of cast-silver cap splints for a total of 3 months, but toward the end of that time elastic intermaxillary traction was used at night only. It has now been 11 years, since the operation (Fig. 3).
There is no pain at all, and the patient has no other symptoms. The occlusion is undisturbed, and the mandible is not retruded (Fig. 4). The range of movement is adequate (Fig. 5). Radiographs show that there is no apparent condylar regeneration (although this has been seen in other cases). In this case there was no history of any preceding trauma to the jaws or joints and no signiticant pre-existing malocclusion. As is not uncommonly found, the severity of the symptoms and the operative findings, on the one hand, and the radiographic changes, on the other, did not correspond. The point of recording this case is to illustrate that the alleged evil consequences of bilateral low condylectomy do not nrcessarily follow. One can only speculate as to why
206 Worthingtorz
Oral Surg. March, 1980
Fig. 3. Results of bilateral condylectomy
Flg. 4. Patient with edge-to-edge bite maintained operation.
after
Fig. 5. Patient opening mouth nearly 30 mm. shortly after operation.
some patients escape these untoward sequelae. On the basis of considerations from orthognathic surgery and fracture management, it seems reasonable to suggest that the following factors might be important: (1) complete “looseness” of the parts at the time of fixation and (2) the duration of intermaxillary fixation and training with elastics. This case might
well be handled differently today, in view of the success of condylar replacement operations.j, I4 It highlights the difficulty of predicting which patient with excised condyles will develop complications, and it certainly illustrates that anterior open-bite and mandibular retrusion do not inevitably follow bilateral condylectomy . In such a case it is possible for the
Volume 49 Number 3 mandible to function well when slung in muscle below the skull, just as the hyoid bone functions when slung in muscle below the mandible. REFERENCES 1. Adler, E. A.: Early Condylectomy to Prevent Orthognatbism: A Preliminary Report, J. Oral Surg. 34: 702-706, 1976. 2. Gonzalez-Ulloa, M.: Temporomandibular Arthroplasty in the Treatment of Prognathism, Plast. Reconstr. Surg. 8: 136 149, 1951. 3. Gonzalez-Ulloa, M.: Important Details in the Treatment of Prognathism by Double Condylectomy, Plast. Reconstr. Surg. 9: 391-392, 19.52. 4. Gonzalez-Ulloa, M.: Late Results in the Treatment of Prognathism by Double Condylectomy, Plast. Reconstr. Surg. 18: 50-64, 1956. 5. Hartwell, S. W., and Hall, M. D.: Mandibular Condylectomy With Silicone Rubber Replacement, Plast. Reconstr. Surg. 53: 44@444, 1974. 6. Henny, F. A., and Baldridge, 0. L.: Condylectomy for the Persistently Painful TemporomandibularJoint, J. Oral Surg. 15: 24-31, 1957. 7. Irby, W. B.: Surgery of the Temporomandibular Joint. In Irby, W. B.: Current Advances in Oral Surgery, St. Louis, 1974, The C. V. Mosby Company. 8. Jarabak, J. R., and Stuteville, 0.: Bilateral Mandibular Condylar Resection (Abstr.), J. Dent. Res. 31: 509-510, 1952.
Bilateral low condylectomy oj’ mandible
207
9. Poswillo, D. E.: The Late Effects of Mandibular Condyiectomy, ORAL SURG. 33: 500-512, 1972. 10. Sarnat, B. G.: Facial and NeurocranialGrowth After Removal of the Condyle in the Maraca rhesus Monkey. Plast. Reconstr. Surg. 7: 364380, 1951. 11. Sarnat, B. G.: Facial and NeurocranialGrowth After Removal of the Mandibular Condyle in the Macaca rhesus Monkey, Am. J. Surg. 94: 19-30, 1957. 12. Silver, C. M., Simon, S. D., and Litchman, H. M.: Surgery of the Arthritic Temporomandibular Joint, Surg. Gynecol. Obstet. 136: 251-256, 1973. 13. Skuble, D. F., Choukas, N. C.. and Toto, P. D.: Craniomandibular Bone Changesin RhesusMonkeys Inducedby Condylectomy, J. Oral Surg. 28: 273-279, 1970. 14. Wukelich, S., Marshall, J., Walden, R., Bromberg, B., and Seldin, R.: Use of a Silastic Testicular Implant in Reconstruction of the Temporomandibular Joint of a 5-Year-Old Child, ORAL. SURG. 32: 4-9, 1971. Reprint requests to:
Dr. Philip Worthington Department of Oral and Maxillofacial Surgery, SB-24 School of Dentistry University of Washignton Seattle. Washington 98195