Professional Documents
Culture Documents
literature review
Fabio Costa, MD,a Massimo Robiony, MD,b Corrado Toro, MD,c Salvatore Sembronio, MD,c
Francesco Polini, MD,a and Massimo Politi, MD, DMD,d Udine, Italy
DEPARTMENT OF MAXILLOFACIAL SURGERY, UNIVERSITY OF UDINE
In the past few years, many devices have been proposed for preserving the preoperative position of the
mandibular condyle during bilateral sagittal split osteotomy. Accurate mandibular condyle repositioning is considered
important to obtain a stable skeletal and occlusal result, and to prevent the onset of temporomandibular disorders
(TMD). Condylar positioning devices (CPDs) have led to longer operating times, the need to keep intermaxillary
fixation as stable as possible during their application, and the need for precision in the construction of the splint or
intraoperative wax bite. This study reviews the literature concerning the use of CPDs in orthognathic surgery since
1990 and their application to prevent skeletal instability and contain TMD since 1995. From the studies reviewed, we
can conclude that there is no scientific evidence to support the routine use of CPDs in orthognathic surgery. (Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:179-90)
180
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Costa et al.
Follow-up
(months)
Author(s)
Year
Patients
2006
22
Manual
12
2005
40
Manual
Not specified
2005
20
12
2005
64
12
2004
17
Manual
12
2000
80
Manual
36
2000
25
Device
Marchetti et al.,26
Maxillofacial Surgery
Department, Bologna, Italy
Bailey et al.,27 Department of
Orthodontics, Chapel Hill,
USA
1999
15
1998
35
42
1997
20
Device
12
1995
13
12
1995
29
14
Total
Conclusion
Surgical correction of class III malocclusion
after combined maxillary and mandibular
procedures appears to be a fairly stable
procedure for maxillary advancements up
to 5 mm whatever the type of fixation
used to stabilize the maxilla.
The change in condylar angle after BSSO
and fixation with a titanium plate is
greater than after BSSO and fixation with
a PLLA plate, but skeletal stability
related to the occlusion is similar for the
2 procedures.
The present results suggest a significant
difference between SSRO and IVRO in
the time course of changes in the
proximal segment including the condyle
and distal segment.
A significant amount of relapse occurred
within 1 year after surgery.
Surgical correction of class III malocclusion
after combined maxillary and mandibular
procedures appears to be a fairly stable
procedure irrespective of the type of
fixation used to stabilize the mandible.
Clockwise rotation of the ascending ramus
at surgery with lengthening of the
elevator muscles, although evident in this
study and apparently responsible for the
early horizontal postoperative changes,
does not seem to be associated with
marked relapse.
Relapse of the mandible seems to be
influenced mainly by the amount and
direction of the surgical alteration of the
mandibular position
Stability of mandibular fragments depended
on the stability of the maxilla.
More than 90% of the patients showed no
clinically significant long-term changes,
which suggests that long-term changes
are less likely after class III than after
class II treatment.
Fixation of the bony segments with PLLA
screws after SSRO may be used
effectively in properly selected cases
Rigid internal fixation was unable to
prevent relapse. Technical refinements
should be investigated to improve the
stability of bilateral sagittal split
osteotomy.
The net effects on the labial fold and the
soft tissue of the chin were closely
correlated with those on their underlying
hard structures.
380
SSRO, Sagittal split ramus osteotomy; IVRO, intraoral vertical ramus osteotomy; PLLA, poly-L-lactic acid.
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Volume 106, Number 2
Year
Patients
Positioning of the
condyle
Follow-up
(months)
2006
69
12
Eggensperger et al.,32
Department of
Craniomaxillofacial Surgery,
Berne, Switzerland
2006
32
144
2004
222
24
Arpornmaeklong et al.,34
Department of Oral and
Maxillofacial Surgery,
Melbourne, Australia
2004
29
25
2002
40
Device
12
2002
57
Manual
60
Pangrazio-Kulbersh et al.,37
Department of Orthodontics,
Detroit, USA
2001
20
12
2001
61
Manual
36
2000
78
Manual
24
2000
64
24
2000
28
15
Conclusion
2-mm self-reinforced PLLDL (70/30) screws can
be used as effectively as 2-mm titanium
screws to stabilize the mandible after bilateral
sagittal osteotomies for mandibular
advancement.
Surgical displacement of the condyle in an
inferior and posterior direction may
compensate for early skeletal relapse.
Progressive condylar resorption seems to be
mainly responsible for long-term skeletal
relapse.
The sagittal split osteotomy fixed with
miniplates appeared to be a relatively safe and
reliable procedure, giving rise to a high
degree of patient satisfaction, despite the fact
that some occlusal relapse was seen.
The majority of patients undergoing bimaxillary
surgery for the correction of skeletal class II
malocclusions maintained a stable result. A
small number of patients suffered significant
skeletal relapse in the mandible owing to
condylar remodelling and/or resorption.
Resorbable PLLA/PGA copolymer bicortical
screw fixation of a BSSO is a viable
alternative to titanium screws for the fixation
of advancement BSSO.
Although rigid fixation is more stable than wire
fixation for maintaining the skeletal
advancement after a BSSO, the incisor
changes made the resultant occlusions of the 2
groups indistinguishable.
Total mandibular alveolar osteotomy is the
treatment of choice for the correction of
severe dentoalveolar retrusive class II
malocclusion for which an alteration of the
mentolabial sulcus is desirable.
High-angle patients were associated with both a
higher frequency and a greater magnitude of
horizontal relapse. The high rate of late
relapse observed among high-angle cases
indicates that condylar morphologic changes
might occur with a greater frequency than
previously thought.
Rigid fixation is a more stable method than wire
fixation for maintaining mandibular
advancement after SSRO.
2 years after surgery, mandibular symphasis was
unchanged in the rigid group, whereas 26% of
the wire group had sagittal relapse. However,
the overjet and molar discrepancy had
relapsed similarly in the 2 groups.
There was a statistically significant relapse in
mandibular length, lower anterior face height,
mandibular arc, lower incisor inclination,
overbite, and overjet in each group, regardless
of the type of fixation. The potential was
greater for relapse in patients stabilized with
transosseous wiring.
182
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Costa et al.
Positioning of the
condyle
Follow-up
(months)
Year
Patients
1998
25
Manual
12
1997
60
1995
19
12
Conclusion
SR-PLLA screws are considered to be
comparable to other forms of rigid internal
fixation for fixation of bilateral splitting
osteotomies after mandibular advancement, as
far as skeletal stability is concerned.
This prospective dual-center study indicates that
the two different methods of internal rigid
fixation after surgical advancement of the
mandible by BSSO did not significantly differ
from each other.
Large surgical advancements in OSAS patients
result in relatively stable repositioning of the
maxilla and mandible over the long term.
804
PGA, polyglycolic acid; BSSO, bilateral sagittal split osteotomy; SSRO, sagittal split ramus osteotomy; SR, self-reinforced; PLLDL, Polylactate
mixture of the L- and D-isomers; OSAS, obstructive sleep apnea syndrome.
Table III. Skeletal stability after orthognathic surgery for open bile deformities
Position of the
condyle
Follow-up
(months)
Author(s)
Year
Patients
45
2007
88
Manual
2007
20
Manual (not
specified)
24
2007
78
Manual
24
2003
26
Manual (not
specified)
12
2001
37
Manual (not
specified)
12
Hoppenreijs et al.,50
Department of Oral and
Maxillofacial Surgery,
Arnhem, The Netherlands
1997
70
Manual (not
specified)
69
1997
30
Manual
349
13,9
Conclusion
The long-term skeletal stability of clockwise rotation
and counterclockwise rotation of the
maxillomandibular complex (MMC) compares
favorably with the postoperative skeletal stability
of conventional treatment when the rotation of the
MMC takes place around a point at the condyle.
In class III patients with anterior open bite treated
with mono- or bimaxillary surgery and rigid
internal fixation, the maxilla was demonstrated to
be stable, whereas there was a moderate rate of
mandibular relapse dependent on the amount of
surgical alteration.
Surgically closing the mandibular plane angulation is
associated with late horizontal and vertical
relapse, whereas fixation type is related to early
B-point movement.
The data confirm the concept that the bimaxillary
approach of Le Fort I impaction and BSSO
advancement using the described technique of
RIF is a stable procedure in the treatment of open
bite patients classified as vertical maxillary excess
in combination with mandibular deficiency.
Open bite patients, treated by posterior Le Fort I
impaction and anterior extrusion, with or without
an additional BSSO, 1 year after surgery, exhibit
relatively good clinical dental and skeletal
stability.
It can be concluded that patients with anterior open
bites, treated with a Le Fort I osteotomy in 1
piece or in multisegments, with or without BSSO,
exhibited good skeletal stability of the maxilla.
Rigid internal fixation produced the best maxillary
and mandibular stability.
There is a difference in the way the proximal
segments were manipulated between the 2 groups.
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Volume 106, Number 2
Year
Patients
Positioning of the
condyle
Follow-up
(months)
2006
60
12
2004
60
14
2004
60
24
2001
20
Manual
12
1997
40
Total
Conclusion
Resorbable materials permitted clinically faster
occlusal and condylar settling than standard
titanium osteosyntheses, because bone
segments showed slight clinical mobility up to
6 weeks postoperatively.
Skeletal relapse was affected by magnitude of
surgical movement and different facial patterns
according to the mandibulonasal plane angle;
however, influences of both factors were
different between mandibular advancement and
setback.
Bioresorbable fixation devices offer similar
function to titanium in fixation for
orthognathic surgery and do not entail an
increase in the clinical morbidities.
The initial clinical findings suggest that this form
of bone fixation is a viable alternative to
standard metallic fixation techniques for
certain maxillomandibular deformities in
which excessive bony movements are not
performed.
The TIOPS computerized cephalometric
orthognathic program is useful in orthognathic
surgical simulation, planning, and prediction
and in postoperative evaluation of surgical
precision and stability.
240
segment during surgery and skeletal relapse. Arpornmaeklong et al.34 concluded that maxillomandibular
correction of class II malocclusion was stable in the
majority of patients, whereas a few exhibited significant skeletal relapse regardless of any simultaneous
use of rigid internal fixation.
Berger et al.41 observed a significant relapse in the
vertical height of the posterior mandible (Co-Go) in
both the rigid and the transosseous wiring groups of
their series, but they identified no relapse in the condylion-gnathion and condylionB point distances, postulating that remodeling took place in the gonial angle
with only a minimal change or remodeling in the condylar head of the mandible. They suggested that readjusting the skeleton-jaw relationship induces remodeling changes in the gonial angle, reducing the effective
posterior face height.
Kallella et al.42 claimed that changes in condylar
position and anatomic structures, together with technical errors, could explain the marked variability in the
direction and rate of skeletal relapse between patients
with comparable advancements and fixation methods.
However, they saw no patients with condylar resorption
and, more importantly, they repositioned the proximal
segment manually in their sample of patients.
184
Costa et al.
Blomqvist et al.43 recognized that proper repositioning of the condyles is essential to preventing major
relapse when the intermaxillary fixation is released,
emphasizing the role of rigid fixation to control the
occlusion postoperatively; here again, there is no mention of any use of CPDs.
Table III shows the 7 studies reviewed concerning
skeletal stability after orthognathic surgery for open
bite deformities; none of these studies reported using
CPDs.45-51
Frey et al.47 said that the role of condylar distraction
from the glenoid fossa and failure to control the proximal segment during surgery deserve further investigation but that they always rely on manual repositioning.
Emshoff et al.48 agreed that distraction of the
condyles medially or inferiorly can cause mandibular
relapse. They did not report on any use of CPDs,
however, and pre- and postoperative radiographs of
the TMJ with the teeth in occlusion were obtained
from the 26 patients studied, and none of them required reoperation. They also showed that using rigid
fixation improved stability after bimaxillary surgery.
As they themselves said, however, whether this is
primarily related to the fact that rigid fixation may
better control the rotation between the proximal and
distal segment, maintain the condyle-fossa relationship during the healing phase, or allow the surgeon to
check the condylar position at surgery remains unknown.
Ayoub et al51 evaluated stability after bimaxillary
osteotomy to correct class II skeletal deformities in 2
groups of patients: one treated at Canniesburn Hospital
and the other at Ann Arbor Michigan University Hospital. The surgical technique used at both centers was
the same, except that condyles were pushed more posteriorly in the Canniesburn cases than in the Michigan
cases. The authors found a difference in the way the
proximal segments were handled in the 2 groups, i.e., in
the Canniesburn cases the proximal and distal segments
were held together with a bone clamp to close the
osteotomy gap between the distal and proximal segments at the time of fixation. The authors postulated
that closing the gap between the bony segments may
have torqued the condyles, causing a compression that
led to remodeling changes and relapse. They concluded
that improper placement of the proximal segment and
displacement of the condyles during sagittal split fixation can influence mandibular stability and recommended further studies to focus on the change in condylar position, not only anteroposteriorly but also
mediolaterally, and to assess its influence on mandibular stability. They also said it would be useful to
investigate the usage of CPDs.
Table IV lists 5 studies in which skeletal stability
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Volume 106, Number 2
Table V. Incidence of TMD after mandibular orthognathic surgery with rigid fixation
Author(s)
25
No
2001
386
No
2000
22
No
2000
140
No
2000
60
No
25
No
1998
67
No
1998
296
No
1995
196
No
1995
66
No
1995
30
No
Follow-up
(months)
Conclusion
12
1,313
TMJ, Temporomandibular joint; TMD, temporomandibular disorder; MMF, maxillomandibular fixation; RIF, rigid internal fixation.
186
Costa et al.
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Volume 106, Number 2
Table VI. Studies comparing the use of CPDs with traditional methods
Author(s)
Year
Condylar device
CPD
Control
Follow-up
patients group Type of surgery (months)
20
29
28 class II
21 class III
20
29
28 class II
21 class III
23
18
18 class II
23 class III
15
15
30 class III
Conclusion
35
outcome than the manual positioning technique in either mandibular advancement or setback surgery in
terms of TMJ function.
The second paper71 examined whether using CPDs
instead of manual positioning had a favorable influence
on skeletal stability in 49 patients who had undergone
BSSO or bimaxillary surgery. Neither in advancement
nor in setback surgery did using the positioning device
result in a better outcome. The authors concluded that
using the positioning appliances did not improve skeletal stability and that, concerning TMJ function, the
manual positioning technique enabled equally stable
results to be obtained in advancement as well as in
setback surgery.
Two other publications that discuss the accuracy of
condylar repositioning during orthognathic surgery are
not included in Table VI, because they did not compare
the use of CPDs with the traditional method. Landes77
compared dynamic proximal segment positioning by
intraoperative sonography with the splint and plate
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Costa et al.
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Reprint requests:
Dr. F. Costa
Clinica di Chirurgia Maxillo-Facciale
Azienda Ospedaliero Universitaria
P.le S. Maria della Misericordia
33100 Udine
Italy
maxil2@med.uniud.it