Condylar positioning devices for orthognathic surgery: a 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 xation 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 scientic evidence to support the routine use of CPDs in orthognathic surgery. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:179-90)

In previous years, a great deal of attention has been paid to maintaining the preoperative condylar position during orthognathic surgery. Numerous condylar positioning methods have been reported and can be divided into manual/empirical methods,1 rigid retention,2-6 navigation,7-8 and sonographic monitoring.9 In 1986, Epker and Wylie10 suggested 3 reasons for accurately controlling the mandibular proximal segment: 1. to ensure the stability of the surgical result; 2. to reduce the adverse effects on the temporomandibular joint (TMJ); 3. to improve masticatory function. Ellis 11 conducted an excellent comprehensive review of the literature regarding the need for condylar positioning devices (CPDs) in 1994 and raised 2 important questions: 1. Do changes in condyle position with orthognathic surgery really matter? 2. Are CPDs effective? We conducted a review of the English-language medical literature from 1995 to 2007 to verify the actual
a

clinical usage of CPDs to prevent skeletal instability and contain the signs and/or symptoms of temporomandibular disorders (TMD) and a review from 1990 to 2007 to seek scientic evidence to support their use. SKELETAL STABILITY AND CPDS Many authors support the view that the skeletal relapse after rigidly xed bilateral sagittal split osteotomy (BSSO) might be reduced with the aid of positioning appliances.12 The relationship between condylar position and stability of mandibular advancement is well known. Distracting the condyle from the fossa during surgery causes an immediate skeletal relapse, and posterior repositioning of the condyle has been shown to induce condylar resorption, resulting in late relapse.13-15 The existence of a direct relationship between intraoperative malpositioning of the condyle-bearing fragment and the occurrence of relapse has likewise been frequently postulated in mandibular setback surgery. The degree of proximal segment rotation or the condyles being seated too far dorsally in the glenoid fossa during xation of the osteotomy segments are most likely responsible for late skeletal relapse.16-18 Based on published studies, it would seem prudent to keep the proximal segment as close to its preoperative position as possible during surgery, especially if rigid xation is to be used. Studies concerning skeletal stability are listed in Tables I-IV. In reviewing the materials and methods of these studies, we assumed that the condyle was repositioned manually unless specied otherwise. We found 12 studies analyzing skeletal stability after mandibular setback in 380 patients since 1995 (Table I).19-30 Repositioning was done manually in 10 studies. 179

Consultant in Maxillofacial Surgery. Associate Professor of Maxillofacial Surgery. c PhD researcher. d Professor and Chairman of Maxillofacial Surgery, Head of Department of Maxillofacial Surgery. Received for publication Sep 18, 2007; returned for revision Nov 15, 2007; accepted for publication Nov 21, 2007 1079-2104/$ - see front matter 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2007.11.027
b

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Table I. Skeletal stability after mandibular setback

Author(s) Costa et al.,19 Department of Maxillofacial Surgery, Udine, Italy. Year 2006 Patients 22 Positioning of the condyle Manual Follow-up (months) 12 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 xation used to stabilize the maxilla. The change in condylar angle after BSSO and xation with a titanium plate is greater than after BSSO and xation with a PLLA plate, but skeletal stability related to the occlusion is similar for the 2 procedures. The present results suggest a signicant difference between SSRO and IVRO in the time course of changes in the proximal segment including the condyle and distal segment. A signicant 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 xation 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 inuenced 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 signicant 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 xation was unable to prevent relapse. Technical renements 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.

Ueki et al.,20 Department of Oral and Maxillofacial Surgery, Kanazawa, Japan

2005

40

Manual

Not specied

Ueki et al.,21 Department of Oral and Maxillofacial Surgery, Kanazawa, Japan

2005

20

Manual (not specied)

12

Chou et al.,22 Department of Dentistry, Taipei , Taiwan Politi et al.,23 Department of Maxillofacial Surgery, Udine, Italy

2005 2004

64 17

Manual (not specied) Manual

12 12

Mobarak et al.,24 Department of Orthodontics, Oslo, Norway

2000

80

Manual

36

Kwon et al.,25 Oral and Maxillofacial Surgery, Osaka, Japan Marchetti et al.,26 Maxillofacial Surgery Department, Bologna, Italy Bailey et al.,27 Department of Orthodontics, Chapel Hill, USA

2000

25

Device

1999

15

Manual (not specied)

1998

35

Manual (not specied)

42

Harada and Enomoto,28 Oral and Maxillofacial Surgery, Tokyo, Japan Schatz and Tsimas,29 Department of Orthodontics and Pedodontics, Geneva, Switzerland Ingervall B, et al. University of Bern, Switzerland.30

1997

20

Device

12

1995

13

Manual (not specied)

12

1995

29

Manual (not specied)

14

Total

380

SSRO, Sagittal split ramus osteotomy; IVRO, intraoral vertical ramus osteotomy; PLLA, poly-L-lactic acid.

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Table II. Skeletal stability after mandibuar advancement

Author(s) Turvey et al.,31 Department of Oral and Maxillofacial Surgery, Chapel Hill, USA Year 2006 Patients 69 Positioning of the condyle Manual (not specied) Follow-up (months) 12 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 xed 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 signicant skeletal relapse in the mandible owing to condylar remodelling and/or resorption. Resorbable PLLA/PGA copolymer bicortical screw xation of a BSSO is a viable alternative to titanium screws for the xation of advancement BSSO. Although rigid xation is more stable than wire xation 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 xation is a more stable method than wire xation 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 signicant relapse in mandibular length, lower anterior face height, mandibular arc, lower incisor inclination, overbite, and overjet in each group, regardless of the type of xation. The potential was greater for relapse in patients stabilized with transosseous wiring.

Eggensperger et al.,32 Department of Craniomaxillofacial Surgery, Berne, Switzerland

2006

32

Manual (not specied)

144

Borstlap et al.,33 Department of Oral and Maxillofacial Surgery, Nijmegen, The Netherlands Arpornmaeklong et al.,34 Department of Oral and Maxillofacial Surgery, Melbourne, Australia

2004

222

Manual (gauzepacking instrument)

24

2004

29

Manual (not specied)

25

Ferretti and Reyneke,35 Department of Maxillofacial and Oral Surgery, Johannesburg, South Africa Dolce et al.,36 Department of Orthodontics, Gainesville, USA

2002

40

Device

12

2002

57

Manual

60

Pangrazio-Kulbersh et al.,37 Department of Orthodontics, Detroit, USA

2001

20

Manual (not specied)

12

Mobarak et al.,38 Department of Orthodontics, University of Oslo, Norway

2001

61

Manual

36

Dolce et al.,39 Department of Orthodontics, Gainesville, USA Keeling et al.,40 Department of Orthodontics, Gainesville, USA

2000

78

Manual

24

2000

64

Manual (not specied)

24

Berger et al.,41 University of Detroit, Detroit, USA

2000

28

Manual (not specied)

15

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Table II. Continued.

Author(s) Kallella et al.,42 Department of Oral and Maxillofacial Surgery, Helsinki, Finland Year 1998 Patients 25 Positioning of the condyle Manual Follow-up (months) 12 Conclusion SR-PLLA screws are considered to be comparable to other forms of rigid internal xation for xation 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 xation after surgical advancement of the mandible by BSSO did not signicantly differ from each other. Large surgical advancements in OSAS patients result in relatively stable repositioning of the maxilla and mandible over the long term.

Blomqvist et al.,43 Department of Oral and Maxillofacial Surgery, Halmstad, Sweden

1997

60

Manual (not specied)

Nimkarn et al.,44 Department of Oral and Maxillofacial Surgery, Birmingham, USA Total

1995

19

Manual (not specied)

12

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
Author(s) Reyneke et al., Department of Maxillofacial and Oral Surgery, Johannesburg, South Africa
45

Year 2007

Patients 88

Position of the condyle Manual

Follow-up (months) 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 xation, 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 xation type is related to early B-point movement. The data conrm 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 classied as vertical maxillary excess in combination with mandibular deciency. 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 xation produced the best maxillary and mandibular stability. There is a difference in the way the proximal segments were manipulated between the 2 groups.

Iannetti et al.,46 Maxillofacial Surgery Department, Rome, Italy

2007

20

Manual (not specied)

24

Frey et al.,47 Department of Orthodontics, San Antonio, USA Emshoff et al.,48 Department of Oral and Maxillofacial Surgery, Innsbruck, Austria

2007

78

Manual

24

2003

26

Manual (not specied)

12

Swinnen et al.,49 Department of Orthodontics, Leuven, Belgium

2001

37

Manual (not specied)

12

Hoppenreijs et al.,50 Department of Oral and Maxillofacial Surgery, Arnhem, The Netherlands

1997

70

Manual (not specied)

69

Ayoub et al.,51 University of Glasgow, UK Total

1997

30 349

Manual

BSSO, Bilateral sagittal split osteotomy; RIF, rigid internal xation.

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Table IV. Skeletal stability in patients with a nonuniform skeletal pattern

Author(s) Landes and Ballon,52 Maxillofacial and Facial Plastic Frankfurt, Germany Year 2006 Patients 60 Positioning of the condyle Manual (not specied) Follow-up (months) 12 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, inuences of both factors were different between mandibular advancement and setback. Bioresorbable xation devices offer similar function to titanium in xation for orthognathic surgery and do not entail an increase in the clinical morbidities. The initial clinical ndings suggest that this form of bone xation is a viable alternative to standard metallic xation 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.

Eggensperger et al.,53 Department of Craniomaxillofacial Surgery, Berne, Switzerland

2004

60

Manual (not specied)

14

Cheung et al.,54 Oral and Maxillofacial Surgery, Hong Kong Edwards et al.,55 Oral and Maxillofacial Surgery Associates, New York, USA

2004

60

Manual (not specied)

24

2001

20

Manual

12

Donatsky et al.,56 Department of Oral and Maxillofacial Surgery, Glostrup, Denmark

1997

40

Manual (not specied)

Total

240

Only 2 studies reported using CPDs in a total of 45 patients (12% of all patients reviewed). Ueki et al.21 reported using a bent plate to deliberately create a step in the cortical bone between the anterior aspects of the proximal and distal segments to prevent any change in axial inclination involving either a medial, lateral, or inward rotation. This was not considered to be a CPD. Several authors23,29,30 have postulated that clockwise rotation of the proximal segment correlated with postoperative relapse. Ingervall et al.30 suggested that the technique used by individual surgeons in setting the condylar segment is probably important to the stability of the outcome of the procedure. As for the skeletal stability of mandibular advancement, we identied 14 studies involving 804 patients (Table II).31-44 Repositioning was done manually in 13 studies. Only 1 study, concerning 40 patients (5% of the patients reviewed), involved the use of CPDs. Mobarak et al.38 suggested that counterclockwise rotation of the ramus leads to instability because the subsequent altered muscle orientation tends to return the proximal segment to its original inclination; Eggensperger et al.32 found no correlation, however, between counterclockwise rotation of the proximal

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 xation. Berger et al.41 observed a signicant 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 identied 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 xation methods. However, they saw no patients with condylar resorption and, more importantly, they repositioned the proximal segment manually in their sample of patients.

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Blomqvist et al.43 recognized that proper repositioning of the condyles is essential to preventing major relapse when the intermaxillary xation is released, emphasizing the role of rigid xation 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 xation improved stability after bimaxillary surgery. As they themselves said, however, whether this is primarily related to the fact that rigid xation 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 xation. 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 xation can inuence mandibular stability and recommended further studies to focus on the change in condylar position, not only anteroposteriorly but also mediolaterally, and to assess its inuence 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

was analyzed in patients with a nonuniform skeletal pattern.52-56 Here again, none of these studies reported on the use of CPDs. Overall, 38 studies were reviewed and the use of CPDs was described in only 3 of them. We might therefore argue that, in the last 12 years, the use of CPDs has not been considered to be crucial to skeletal stability. Even if suggested in the literature,51 the use of CPDs was not analyzed for preventing skeletal instability. Those clinicians who did study skeletal stability did not routinely use CPDs or if they did it was not mentioned in their methods. TEMPOROMANDIBULAR JOINT DYSFUNCTION IN ORTHOGNATHIC SURGERY AND CPDS Condylar remodeling has been thoroughly investigated in patients with postoperative TMJ problems.57 Because the placement of rigid internal xation devices can displace the condyles, it has been suggested that rigid xation can have a role in postoperative temporomandibular dysfunction.58 Surgery-related changes in condyle position can lead not only to early or late occlusal instability, but may also favor the onset of signs and symptoms of TMD. The results of our review of the English-language medical literature since 1995 on the incidence of TMD after mandibular orthognathic surgery with rigid xation are given in Table V.59-69 We found 11 studies involving 1,313 patients, but none of them mentioned any use of CPDs. Wolford et al.59 reported that patients with prior TMD undergoing orthognathic surgery, and mandibular advancement in particular, are likely to experience a signicant worsening of their TMD. They made the point that TMJs are fundamental to the stability of the results. They stressed that in the presence of a healthy joint the passive seating of the proximal segments deep in the fossa with the articular discs in a proper anatomic relationship provides predictable and stable outcomes. We can assume that the authors considered using CPDs to be clinically irrelevant, both for healthy TMJs and in cases of prior TMD, because they usually performed concomitant TMJ and orthognathic surgery.70 It is very difcult to assess the concomitant treatment of TMJ abnormalities and skeletal abnormalities, because the authors did not clearly discuss their criteria for surgery. The majority of the authors reported an overall benecial effect of orthognathic surgery on signs and symptoms of TMD.60,62-64,66 When rigid xation of the mandible was compared with wire osteosynthesis and maxillo-mandibular xation, no signicant differences were generally reported in terms of TMD.60,62,68 Using a randomized clinical trial design and the manual repositioning of the proximal mandibular segment, Nem-

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Table V. Incidence of TMD after mandibular orthognathic surgery with rigid xation
Author(s) Year Patients Device 25 No Follow-up (months) 12 Conclusion

Wolford et al.,59 Oral and Maxillofacial 2003 Surgery, Dallas, USA

Westermark et al.,60 Karolinska Hospital, Stockholm, Sweden

2001

386

No

Hu et al.,61 Department of Oral and Maxillofacial Surgery, Chengdu, China Nemeth et al.,62 Department of Prosthodontics and Periodontology, Faculty of Dentistry of Piracicaba

2000

22

No

2000

140

No

Panula et al.,63 Department of Oral and Maxillofacial Surgery, Vaasa Central Hospital, Finland

2000

60

No

Gaggl et al.,64 Clinical Department of 1999 Oral and Maxillofacial Surgery, Graz, Austria

25

No

Hoppenreijs et al.,65 Department of Oral and Maxillofacial Surgery, Arnhem, The Netherlands

1998

67

No

De Clercq et al.,66 Department of Surgery, Bruges, Belgium

1998

296

No

De Clercq et al.,67 Department of Surgery, Bruges, Belgium

1995

196

No

Feinerman and Piecuch,68 Department of Oral and Maxillofacial Surgery, Farmington, USA

1995

66

No

Onizawa et al.,69 Department of Stomatology, University of Tsukuba, Japan Total

1995

30

No

Patients with preexisting TMJ dysfunction undergoing orthognathic surgery, particularly mandibular advancement, are likely to have signicant worsening of the TMJ dysfunction after surgery. 24 Preoperatively 43% and postoperatively 28% of the patients reported subjective symptoms of TMD. This difference indicates an overall benecial effect of orthognathic surgery on TMD signs and symptoms. Sagittal ramus osteotomy was less effective than vertical ramus osteotomy in relieving TMD symptoms when performed on similar diagnoses. 6 Intraoral oblique ramus osteotomy with MMF appears to be more favorable to the TMJ than the sagittal split ramus osteotomy with RIF. 24 The long-term (2 years) effects of wire and rigid internal xation methods on the signs and symptoms of temporomandibular disorders do not differ. Earlier concerns about increased risk of TMDs with rigid xation were not supported by these results. 48 Functional status can be signicantly improved and pain levels reduced with orthognathic treatment. The risk of new TMD is extremely low. No association, however, could be shown between TMD and the specic type or magnitude of dentofacial deformity. 3 Improvement of the disc position was achieved by repositioning of the condylar-disc complex during orthognathic surgery in angle class II patients. Clinical and magnetic resonance imaging ndings regarding the TMJ in class II patients correlated signicantly both preoperatively and postoperatively. 69 RIF in bimaxillary osteotomies resulted in condylar remodeling in 30% and progressive condylar resorption in 19% of the patients. Condylar changes were not signicantly different after using either miniplate osteosynthesis or positional screws in BSSO procedures. 12 There was a subjective improvement in TMJ function in 40% of the patients and a worsening in 11%; masticatory function was improved in 41% and worsened in 7% of the patients. 6 Fewer TMJ symptoms were found postoperatively than preoperatively in the group as a whole. In the normal/ low-angle group, there was a decrease in TMJ symptoms. In the high-angle group, however, more TMJ symptoms were seen postoperatively. Rigid 36 There were no demonstrable long-term differences between Nonrigid 71 rigid and nonrigid xation methods with respect to mandibular vertical opening, crepitance, and TMJ pain. Masticatory muscle pain and temporomandibular joint clicking improved with rigid xation and worsened with nonrigid xation. 6 Alterations of TMJ symptoms after orthognathic surgery do not always result from the correction of malocclusion.

1,313

TMJ, Temporomandibular joint; TMD, temporomandibular disorder; MMF, maxillomandibular xation; RIF, rigid internal xation.

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eth et al.62 found no signicant differences in TMD signs or symptoms comparing rigid xation and wire xation. They postulated that the reasons earlier studies may have found that rigid xation procedures could increase the risk of TMD were related to their retrospective design and/or smaller numbers of patients. They also claimed that the risks of TMD with rigid xation were higher in the past, because the procedure is fairly technique sensitive, so the risks of TMD have probably decreased as surgeons have become more experienced. Several authors60,66,67 thought that specic dentofacial deformities, e.g., the high-angle group, coincide with a higher likelihood of developing new TMJ symptoms after bimaxillary surgery, but this is attributed more to a greater loading of the mandibular condyle creating a deeper bite pattern than to any intraoperative change in the position of the mandibular condyle. Although authors generally agree that a change in condylar position during orthognathic surgery can exacerbate the signs and symptoms of TMD, our review fails to support this conviction. Moreover, all of the studies reviewed that consider the inuence of orthognathic surgery on TMJ function did not mention any use of CPDs. CPDS: SCIENTIFIC EVIDENCE TO SUPPORT THEIR CLINICAL USE Many clinicians are concerned that rigid internal xation can induce great changes in the position of the condyle. Although the use of CPDs seems reasonable, no critical assessment of their use is currently available. CPDs have meant longer operating times, the need to keep the intermaxillary xation as stable as possible during their use, the need for precision in the fashioning of the splint or intraoperative wax bite. The most widely used method for repositioning the condylar fragment after a mandibular osteotomy is to put it in the glenoid cavity,1 and the quality of the procedure depends largely on the operators experience. So the best way to understand the real clinical advantages of using CPDs is to compare their use with the traditional or empirical methods for repositioning the condyle in the fossa during orthognathic surgery. Reviewing the English-language literature from 1990, we found only 6 papers comparing the use of CPDs with traditional methods (Table VI).71-76 Rotskoff et al.76 evaluated condylar position in 20 patients before and 1 day after mandibular advancements. Ten of the patients underwent condylar repositioning using a device: They were better able to place the condyle in the preoperative position with the aid of the positioning device, but the device was unable to prevent the rotation of the mandibular ramus. This

could be seen as a study to compare the CPDs ability to maintain the preoperative position, but no advantages in terms of skeletal stability or TMJ function were reported. Helm and Stepke75 evaluated 30 prognathic patients treated with bimaxillary osteotomies, recording their joint motion with an axiograph: only 1 patient had a pathologic shortening of the joint track length. They concluded that the Luhr device is effective in securing condyle position and consequently also TMJ function. The problem with this particular study is that there were no control subjects, so it is difcult to assess the benet of the CPD. Renzi et al.74 compared the clinical and radiographic ndings at 1 year in 2 groups of 15 patients each who had bimaxillary surgery to correct dental-skeletal class III malocclusions: CPDs were used in one group and manual repositioning in the other. No relapses or postoperative TMD were observed in any of the 30 patients. The authors concluded that CPDs are not necessary in patients with dental-skeletal class III malocclusions without any preoperative TMD. They recommended using CPDs only in the case of TMD, although their sample of patients cannot support such a recommendation, because none of them had TMD. Landes and Sterz73 performed bimaxillary surgery in a study group of 23 patients with intraoperative joint positioning using a splint and CPD. Eighteen bimaxillary-operated controls had conventional plates inserted according to their habitual occlusion. The study group had signicantly less postoperative dysfunction than the control group, with a lower prevalence of disc dislocation, more limited postoperative changes in condylar translation, and 8% skeletal relapses as opposed to 22% in the controls. The most interesting papers, in our opinion, are those published recently by Geressen at al.71-72 The rst72 examined whether using CPD in BSSO affords greater long-term benets in terms of TMJ function than the manual positioning technique. Joint function was analyzed using axiography and clinical examination in 49 patients who underwent BSSO or bimaxillary osteotomy: in 10 of 28 patients with mandibular advancement and 10 of 21 with mandibular setback, the Luhr positioning device was used intraoperatively to reproduce the condylar position. In mandibular advancement cases, the manually positioned group showed signicantly fewer signs of TMD, whereas there were slight advantages in axiographically measured joint track lengths for the patients operated with positioning devices. After mandibular setback surgery, clinical analysis and axiography showed comparable results in the 2 groups. The authors concluded that using a positioning device did not assure a better long-term functional

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Table VI. Studies comparing the use of CPDs with traditional methods
Author(s) Gerressen et al.,71 Department of Oral, Maxillofacial, and Plastic Facial Surgery, Aachen, Germany Gerressen et al.,72 Department of Oral, Maxillofacial and Plastic Facial Surgery, Aachen, Germany Year Condylar device CPD Control Follow-up patients group Type of surgery (months) 20 29 28 class II 21 class III 35 Conclusion

2007 Positioning plates (Leibinger)

2006 Positioning plates (Leibinger)

20

29

28 class II 21 class III

Landes and Sterz,73 Maxillofacial and Plastic Facial Surgery, Frankfurt, Germany Renzi et al.,74 Maxillofacial Surgery Department, Rome, Italy

2003 Positioning plates (Leibinger)

23

18

18 class II 23 class III

2003 Positioning plates (Leibinger)

15

15

30 class III

Helm and Stepke,75 Department 1997 Positioning plates 30 30 class III of Maxillofacial Surgery, (Luhr-device) Frankfurt, Germany Rotskoff K, et al.,76 St. Marys 1991 Positioning 10 10 20 class II Health Center and device Dentofacial Deformities and Orofacial Pain Center, St Louis, USA Total 141 112 with manual CPDs CPD, Condylar positioning device.

The use of positioning appliances does not lead to an improvement in skeletal stability. From 6 to The use of a positioning 120 device did not provide a better functional outcome in the long term in either mandibular advancement or setback surgery. 24 The study group exhibited less postoperative dysfunction than the control group and 8% skeletal relapses versus 22% in the control group. 12 The use of CPDs can be avoided in patients with dental-skeletal class III without presurgical temporomandibular dysfunction. Not The Luhr device is effective in reported securing condyle position and therefore TMJ function. 1 day A signicant improvement was observed in the vertical and horizontal condylar position in the group in which a CPD was used.

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 inuence 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

technique discussed in the earlier paper. Sonographic placement enabled a dynamic intraoperative monitoring of the condylar position and took an average of 5 min, as opposed to the 25 min needed for conventional positioning. The author concluded that postoperative reduction of condylar translation and recovery, dysfunction, and disc dislocation were comparable with the 2 methods at 1-year follow-up, but that the new technique enabled intraoperative real-time monitoring and dynamic correction and it proved safe, easier, and faster than conventional plate positioning. Judging from this article, clinicians might be able to save 20 minutes of operating time if they became expert with intraoperative sonography, without any signicant clinical advantage for patients. Bettega et al.8 published the rst interesting paper on the clinical advantages of a computer-assisted system for replacing the condyle over the traditional method. Eleven patients underwent condylar repositioning using the empirical repositioning method, in 10 patients (ac-

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tive group) the computer-assisted system was used to replace the condyle in its sagittal preoperative position, and in another 10 (graft group) the computer-assisted system was used to place the condyle in all 3 directions. The authors found that they needed to ll the osteotomy gap with a bone graft more frequently in the last group. They reported 5 patients in the empirical group not having the expected postoperative occlusion, 5 had evidence of clinical relapse at 1 year, 5 had worse TMD, and only 63.37% of the patients mandibular motion had been recovered at 6 months. All of the patients in the active group had the expected occlusion, and only 1 had a mild relapse and TMD symptoms, but the mean mandibular motion recovered was only 62.65% at 6 months. All of the patients in the graft group had a good occlusion and no relapse or TMD, and they had recovered 77.58% of their mandibular motion at 6 months. The authors concluded that the quality of sagittal repositioning is the main factor contributing to a good occlusion and bone stability, whereas functional results depend more on limiting condylar torque. Intraoperative surgical navigation seems to be precise, but the method is elaborate; it requires extra incisions and equipment and the adaptation of diode reectors, and this probably explains why there is only 1 publication8 regarding this method. Taken together, in the 6 studies we reviewed, 141 patients with CPDs were compared with 112 patients treated using conventional manual repositioning. Three studies supported the use of CPDs,73-76 but only 173 supported their application to improve clinical outcome concerning TMJ function and skeletal stability. One study,74 which was limited to class III malocclusions, supported the use of CPDs only in the case of TMD. Two studies did not support the use of CPDs, because they failed to improve skeletal stability or TMJ function, irrespective of the skeletal deformities treated. CONCLUSIONS Very little was changed since Ellis11 published his outstanding, comprehensive review on the use of CPDs in orthognathic surgery. From the studies we reviewed, we conclude that since 1995 both skeletal/occlusal stability and TMJ function after orthognathic surgery have continued to be investigated substantially without considering the use of CPDs. Most authors rely on manual repositioning after sagittal split osteotomy to obtain the best mandibular proximal segment relationship with the condylar fossa. Because manual repositioning of the proximal segment continues to be the method of choice, we think it is best to opt for more simple and inexpensive methods for intraoperatively identifying a malpositioned condyle, such as intraoperative patient awak-

ening.78,79 From the studies published to date, we conclude that there is no scientic evidence to support the routine use of CPDs in orthognathic surgery.
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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