ondylar resorption in orthognathic surgery

The role of intermaxillary fixation

Joppe P.B. Bouwman, MD, IIenricus C.J. erstens, DMD, BhD,

and Dirk B. Tuinzing, DMD, PhD, Amsterdam, The Netherlands
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, FREE UNIVERSITY HOSPITALIACTA

Condylar resorption that occurs after orthognathic surgery was investigated in a large sample of patients treated in
the Department of Oral and Maxillofacial Surgery of the Free University in Amsterdam, the Netherlands. The findings
correspond with previous publications on this subject. In a l-year follow-up study the role of intermaxillary fixation was
investigated radiologically. In a group of 158 patients prone to show occurrence of condyiar resorption, 24 (264%) of the 91
patients treated with intermaxillary fixation showed signs of condylar resorption. In the group of 67 patients treated without
intermaxillary fixation only eight (11.9%) of the patients showed signs of reduced volume of the condyle. Avoidence of
intermaxillary fixation seems to reduce the incidence of condylar resorption after orthognathic surgery in patients with a
mandibular deficiency with high mandibular plane angle. (QRAL SURG ORAL MED ORAL PATHOL 1994;78:138-41)

The occurrence of condylar resorption is an unpleas- Table 1. Incidence of condylar atrophy

ant feature that seems to make the outcome of January 1983 to January 1992
orthognathic surgery less predictable (Fig. 1). (n = 10251 Total Atrophy
After a number of case reports,?” Kerstens et a1.4
were the first to attempt to document the incidence of Mandibular prognatism 134 -
Mandibular prognatism with open 76 -
condylar resorption in a group of patients undergoing
bite
orthognathic surgery. More recently Moore et al5 Mandibular deficiency, 549 -
reported five cases with an extensive study of litera- low/normal mandibular plane
ture about potential contributing factors. The pa- angle
tients in the Kerstens et al. group, in which 5.5% of Relative mandibular deficiency 108 -
Absolute mandibular deficiency, 158 32
206 patients showed a condylar resorption, were all
high mandibular plane angle
treated with wire osteosyntheses and an intermaxil-
lary fixation period of 6 weeks. In the patients of
Moore et al. (condylar resorption in 1.2% of 421
cases) three of the five were treated with wire osteo- who have intermaxillary fixation after or orthog-
syntheses and a 6-week intermaxillary fixation period nathic surgery. In this study condylar resorption is
and two patients were treated with osteosyntheses, defined as the change of configuration or volume of
which made intermaxillary fixation unnecessary. As the condylar head in comparison with the preopera-
the potential negative effect of intermaxillary fixation tive condition.
is known from study of Glineburg et a1.,6 the role of
MATERIAL AND METHODS
intermaxillary fixation on the incidence of condylar
In the Department of Oral and Maxillofacial Sur-
resorption has been subject to investigation.
gery at the Free University/ACTA in Amsterdam,
The purpose of this study was to determine if there
The Netherlands, 1025 consecutive patients, surgi-
is a higher incidence of condylar resorption in patients
cally treated between January 1983 and January
1992 for a symmetric dentofacial deformity, were
Copyright 8 1994 by Mosby-Year Book, Inc subject to investigation. Patients treated by genio-
QO30-4220/94/$3.00+0 7/12/55961 plasty alone or treated for gross asymmetries or cleft
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Bouwman, Kerstens, and Tuinzing 139
Volume 78. Number 2

Fig. 2. Hypothetical construction of mandibular defi-

ciency with high or low mandibular plane angle.
Fig. 1. A, Volume of condyle postoperatively decreased,
compared with B, preoperative volume.
Table Ill. Incidence of condylar resorption
January 1983 to January 1992
Table II. Incidence of condylar atrophy: absolute
(n = 1025) Total Resorption
mandibular deficiency, high mandibular plane
angle Mandibular prognatism 134 -
Mandibular prognatism with open 16 -
Intermaxillary fixation n = 91 24 (26.4%) bite
Rigid. n = 67 8 (11.9%) Mandibular deficiency, 549 -
low/normal mandibular plane
angle
lip and palate were excluded. The distribution of the Relative mandibular deficiency 108 -
dentofacial deformities is shown in Tables I and II. Absolute mandibular deficiency, 158 32
Preoperative and postoperative surgical orthodon- high mandibular plane angle
tic treatment was performed in all patients by two
surgeons with negligible variations in surgical tech-
niqu e. The bilateral sagittal splitting technique segments of the sagittal splitting osteotomy was
according to Hunsuck was used for mandibular ad- achieved by upper border wiring. The segments were
vancement, whereas an intraoral vertical ramus os- im.mobilized after manual manipulation of the condy-
teotomy*, 9 was used to correct mandibular prog- lar fragment into the fossa. In cases of vertical ramus
natism. Maxillary surgery was used to prevent osteotomy, no intraosseous wires were used. Inter-
counterclockwise rotational movements of the man- maxillary fixation with archbars or orthodontic ap-
dibular plane during advancement of the mandi- pliances was supported by skeletal fixation for 4 to 6
ble 10-12 weeks.
From January 1983 to August 1988, fixation of the From August 1988 until January 1992, fixation of

y Bouwman, Kerstens, and Tuinzirtg
le IV, Incidence of condylar resorption: absolute mandibular deficiency, high mandibular plane angle
Male/Female
Total n= 1.58 151143
Intermaxillary fixation II=91 9182
Rigid n = 67 6161
the segments of the sagittal splitting osteotomy was
achieved by transbuccal-placed position screws(three
on both sides) on the upper border. The segmentswere
fixed after manual manipulation of the condylar
fragment in the fossa.After Le Fort I osteotomy, the
maxilla was fixed with two titanium/plates parana-
sely and two wire osteosyntheseson the zygomatic
buttress.
Intermaxillary fixation was taken out directly after
surgery. Fixation was applied for 6 weeksonly in cases
when the vertical ramus osteotomy was performed.
Radiographic survey (standard cephalograms and
panoramic radiographs) was done preoperatively (T-
1). Postoperatively (T-2) and at least 1 year postop-
eratively (T-3) by two investigators (J.P.R.B. and
H.C.J.K.) who were not the surgeons.
When radiographic evidence of changes in condy-
lar shapeand volume could be observed,tracings were
made. The contour and position of the condyle in the
T- 1) T-2, and T-3 radiographs were examined.
The radiographs taken 1 year after surgery (T-3)
demonstrated a change of shape and volume of the
condyle in 32 (3%) patients.
All patients were treated for the samekind of dent-
ofacial deformity, mandibular deficiency with high
mandibular plane angle, and all but eight had bimax-
illary surgery (n = 158).
Of the 32 patients with condylar resorption, there
were 14 patients with osteoarthrotic changes on the
preoperative radiographs (T- 1) after finishing orth-
odontic treatment.
Because all cases of condylar resorption were
clearly in the group of mandibular deficiency with
high mandibular plane angle, this group was investi-
gated further. Of the 158 patients in this group (mean
mandibular plane angle, 44.1 degrees;range, 35 to 55
degrees), 9 1 had intermaxillary fixation for 6 weeks,
and 67 were allowed and encouraged to function im-
mediately after surgery; the number of cases with
condylar resorption were 24 (26.4%) and 8 (11.9%),
respectively (Tables III and IV). Statistical evalua-
.--,-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
August J 994
Age in Condylal Mandibular
years resorption plane angle
17-46 32 35-55 degrees
mean 44.1 degrees
19-46 24 (26.4%) mean 46.7 degrees
mean 26
17-45 8 (11.9%) mean 44.7 degrees
mean 28
tion (Fisher test) revealed that these numbers were
significant (p = 0.039).
DlSCUSSlON
The growth pattern of the mandible seemsto play
an important role as it influences the morphology of
the face.t33l4 A more anterior-directed or a more
posterior-directed growth pattern, tends to develop a
type of mandibular deficiency with a low mandibular
plane angle or a kind of mandibular deficiency with
a high mandibular plane angle, respectively (Fig. 2).
In casesof mandibular deficiency with a low man-
dibular plane angle the condyle (<30 degrees) gener-
ally shows a good volume of the condylar head radio-
logically. However, in casesof mandibular deficiency
with a high mandibular plane angle (>35 degrees)the
condyles appear radiologically smaller and more
fragile. l5 This latter group is the kind of deformity in
which condylar resorption is seen. This resorption
might occur spontaneously’6 after orthodontic treat-
ment and after orthognathic surgery as is shown in
this study.
In addition to predisposing factors, such as, osteo-
myelitis, osteolysis, rheumatoid arthritis, renal os-
teodystrophy, age seemsto be a contributing factor in
the occurrence of condylar resorption. Because the
majority of patients who undergo orthognathic sur-
gery are between 17 and 46 years of age, no firm
statement can be made about this factor. And al-
though hormones seem to play a part in condylar
changes and all patients with affected temporoman-
dibular joints were female,t7 no conclusion can be
made about this factor either.
Changes of loading of the condylar head is of im-
portance. This occurs when the position of the condyle
is changed as a result of autorotation of the mandible
or by clockwise rotational movement of the condylar
fragment after sagittal splitting osteotomy.18-21 These
unfavorable changes are generally not preventable in
the surgical correction of this kind of deformity
becauseof the anatomic situation.
Increased loading occurs in cases with major ad-
vancement or when counterclockwise rotation of the
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 78, Number 2
mandibular plane occurs during surgical advance-
ment of the mandible. By performing bimaxillary
surgery, counterclockwise rotation movement is pre-
vented and the distance of forward movement is
reduced. This bimaxillary surgery complicates the
recording of the effect of mandibular advancement as
a combination of linear and rotational movements
occurs, sometimes further complicated by genioplas-
ties.
Further investigation is required to determine the
effect of the almount of advancement of the mandible
on the onset of condylar resorption. Decreased load-
ing rnight be :a contributing factor because condylar
resorptions are seen when orthodontic functional ap-
pliances are used for a protracted length of time.22 As
shown in this study the period of intermaxillary fix-
ation influences the temporomandibular joint in a
negative way, in addition it probably deprives the
condyle form (ofits essential “nutrition” and function.
It was difficult to quantify major changes in the
volume of the condylar head, and it was equally as
difficult to obtain complete objectivity because the
investigators were aware of the method of fixation.
Therefore the outcome has to be interpreted with
care.
Although a surgical technique that obviates the
need for intermaxillary fixation appears to reduce the
incidence of condylar resorption, it does certainly not
eliminate the incidence completely.
Female patients who require correction of a man-
dibular defici’ency with a high mandibular plane an-
gle therefore have to be informed about the phenom-
ena of condylar resorption and its consequences to
stability and the profile from an esthetic point of view.
Further investigation with MRI imaging23 or dig-
ital substraction radiography24 is necessary to predict
more precisely which patients are target to condylar
resorption after orthognathic surgery.
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Reprint requests.
Joppe P.B. Bouwman
Kennemer Gasthuis
Lokatie E.G.
Aideling Kaakchirurgie
Postbus 417
2000 AK Haarlem
The Netherlands