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Int. J. Oral Maxillofac. Surg. 2009; 38:

Int. J. Oral Maxillofac. Surg. 2009; 38:

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Technical NoteTMJ Disorders
Modified trans-oral approach formandibular condylectomy
 M. Deng, X. Long, A. H. A. Cheng, Y. Cheng, H. Cai: Modified trans-oral approach for mandibular condylectomy. Int. J. Oral Maxillofac. Surg. 2009; 38: 374–377.
#
2009 International Association of Oral and Maxillofacial Surgeons. Published byElsevier Ltd. All rights reserved.
M. Deng
1
, X.Long
1
,A. H. A. Cheng
2
, Y. Cheng
1
, H. Cai
1
1
Department of Oral & Maxillofacial Surgery,Key Lab for Oral Biomedical Engineering ofMinistry of Education, School and Hospital ofStomatology, Wuhan University, Wuhan,Hubei Province 430079, PR China;
2
Oral andMaxillofaical Surgery Unit, Royal AdelaideHospital, Adelaide, Australia
 Abstract.
Differentapproachestothemandibularcondylehavebeendescribed.Inthis paper,amodifiedtrans-oraltechniquetoaccessthemandibularcondyleisdescribed and illustrated. This technique was used in a small group of patients; the clinicaloutcomes are promising. The technique can be used in various temporomandibular  joint (TMJ) operations, such as condylar resection, high condylectomy or tumor removal. It provides adequate intra-oral surgical access to the mandibular condyleand avoids complications from extra-oral approaches to the TMJ.
Keywords: trans-oral approach; condylectomy.Accepted for publication 16 January 2009Available online 17 March 2009
Mandibular condylectomy is widely used for treating temporomandibular condylediseases. Extra-oral approaches, such as pre-auricular, posterior aur icular ansubmandibular approaches
, are com-monly used by clinicians. The intra-oralapproach to the temporomandibular joint(TMJ)was first reported by Sear in1972
5
. E
LLER 
et al. also used this accessfor TMJ cond ylar osteochondroma resec-tion in 1977
2
. N
ICKERSON
and V
EACO
described an intra-oral condylectomytechnique using standard instrumentationfor intra-oral vertical ramus osteomy in1989
4
. Intra-oral condylectomy avoidsfacial nerve injury and facial scarring.There are no descriptions of this techni-que in recent publications. The trans-oralapproach to the TMJ is useful for acces-sing the condyle and potentially haslower morbidity than extra-oralapproaches. The technique is easy tolearn, based on experience from mandib-ular osteotomy.From September 2006 to June 2007, 6 patients underwent condylectomy using atrans-oral approach at Wuhan University.The clinical diagnoses included mandib-ular condylar osteochondroma (2 cases)and condylar hyperplasia (4 cases)(Table 1). All the diagnoses were sup- ported by symptoms, physical examina-tion, radiographic images anhistopathology. All patients who partici- pated in the study had good outcomesintra-operatively and postoperatively.
Case presentation and surgicaltechnique
A 41-year-old woman presented withfacial asymmetry and trismus in Septem- ber 2006. The left side of her face wasnotably elongated. The mandibular mid-
 Int. J. Oral Maxillofac. Surg. 2009; 38: 374–381?
available online at http://www.sciencedirect.com
Table 1
. Patient details.Patientno.Age(years) Gender Diagnosis ComplicationsMMO (mm)Pre-op post-op (m)1 25 F OC S, MOL, MO 30 28 (3)2 15 M CH S, MOL, MO 35 no3 21 F CH S, MOL, MO 48 35(3)4 24 M CH S, MOL, AC, MO 40 40 (8)5 22 F CH S, MOL, AC, MO 30 46(6)6 41 F OC S, MOL, MO 34 42(6)AC: angular cheilitis; CH: Condyle hyperplasia; m: month; MMO: maximum mouth opening;MO: malocclusion; MOL: mouth opening limitation; OC: osteochondroma; S: swelling.
0901-5027/040374+08 $36.00/0
#
2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 
line was deviated 5 mm to the right. CTimaging showed a large bony tumor of theleft mandibular condyle (Fig. 1). The patient was otherwise fit and well fosurgery. The procedure was performed under general anesthesia. Using a standard mouth prop, the patient was placed withmaximum mouth opening. A buccal inci-sion was made from the level of the man-dibular second molar to the level of themaxillary teeth (Fig. 2). Buccal and lin-gual mucoperiosteal flaps were elevated.Dissection of the temporalis tendon fromthe anterior, lateral and medial border of theramus was carried up tothe level of themandibularnotch.Thesuperiortemporalisattachment on the coronoid process abovethe level of mandibular notch was pre-served completely. Two large malleableretractors were placed laterally and medi-ally to protect the buccal and lingual softtissue. The coronoid process was osteoto-mized at the level of the mandibular notch(Fig. 3) using a drill, reciprocating sawand osteotome. It was then displaceupward and retracted to expose the con-dyle. Subperiosteal dissection along thecondylar neck and head was carried outuntil the mandibular condyle was fullyexposed. Small malleable retractors wereinserted to protect the soft tissue mediallyand laterally. The condylectomy cut wasmade with a drill, reciprocating saw and osteotome (Fig. 4). The TMJ capsule and lateral pterygoid muscle was dissected off the condylar head and neck. The wholeTMJ pathology was removed (Fig. 5). Theremaining portion of the condyle wasreshapedandsmoothed.Afterhaemostasiswas achieved, the coronoid process wasreducedand fixatedwith wire (Fig. 6).Theincisionwassuturedwith3-0suturesandasmall penrose drain was placed in thesurgical site. The same technique wasapplied to the other five patients in thestudy.
Discussion
Four patients with condylar hyperplasiahad high condylectomies through atrans-oral approach. Two patients withcondylar osteochondroma underwent totalcondylectomy and removal of the tumors.For this group of patients, common post-operative complications such as swellingand pain at the surgical site, angular chei-litis, trismus, and minor malocclusionwere noted. Intraoperative complications,suchasbleedingfrommaxillaryorinferior alveolar arteries and injury of the inferior alveolar or lingual nerve, can be avoided through careful dissection and meticuloussoft tissue retraction. Infection of the sur-
 Modified trans-oral approach for mandibular condylectomy
375
 Fig. 1
. CT imaging showed the bony tumor on the left mandibular condyle.
 Fig. 2
. The incision was made from the buccal mucosa of the mandibular second molar to thelevel of the maxilla occlusion.
 Fig. 3
. The coronoid process was cut at the level of the sigmoid notch (C: coronoid process; M:temporolias muscle; arrow shows the resection line).
 
gicalsitecanbe avoidedwith prophylacticantibiotic therapy pre- and post-opera-tively. Malocclusion was unavoidable, but it can be managed effectively withinter-maxillary traction or orthodontictreatment.Five of the six patients attended thefollow-up appointments. Swelling, painand angular cheilitis resolved within onemonth postoperatively. Trismus was com-mon in all patients at the 3-month but notthe 6-month follow-up (Table 1). No other complications were found during the fol-low-up period.Schon et al. suggested endoscopyassisted open treatment of condylar frac-tures of the mandible in 2002
6
. Specialinstruments and endoscope were neces-sary to fixate the condylar fracture intra-orally. The surgical access was designed for condylar neck and subcondylar frac-ture. The technique described in this paper enables access to the head of the condyleand has several advantages. The tempor-alis attachment to the coronoid processwas preserved before osteotomizing thecoronoid process, therefore, the coronoid  process and the temporalis attachment can be re-established anatomically postopera-tively. The condylectomy was confined tothe lower joint space without damage tothe joint capsule and ligament and there-fore fibro-osseous ankylosis of the TMJwas less likely. Inter-maxillary fixationwas not used postoperatively to encourageimmediate mandibular function. The sur-gical trauma to the TMJ and masticatorysystem can be minimized,which reduceslong-term complications
.The trans-oral approach to assess themandibular condyle is more technicallydemanding than the extra-oral approachand requires the operator to have previousexperience in intra-oral osteotomy. Thecondyle is far from the intra-oral incision,compared with extra-oral approaches, soexposing the lesion is more challenging.With maximum mouth opening and thecoronoid process retracted superiorly, thesurgical field can be optimized but alonger surgical time is to be expected initially. A larger study group and longer term follow-up will be needed to assessthe long-term effect of this technique.
References
1.
David
A K 
EITH
. Complications of tempor-omandibularjointsurgery.OralMaxillofacSurg Clin N Am 2003:
15
: 187–194.2.
Eller
DJ,
Blackemore
JR,
Stein
M,
Byers
S. Transoral resection of a condylar osteochondroma: report of case. J OralSurg 1977:
35
: 409–413.
376
Deng et al.
 Fig. 4
. The lesionwas resected from the condyle(O: osteochondroma; C:condyle;arrow showsthe resection line).
 Fig. 5
. The lesion was removed (O: osteochondroma).
 Fig. 6 
. The coronoid process was reduced and fixated with wire (arrow shows the wire).

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