J Oral Maxillofac Surg

42578-588. 1984

Condylar Position Following

Mandibular Advancement:
Its Relationship to Relapse

LESLIE A. WILL, DMD, MSD,* DONALD R. JOONDEPH, DDS, MS,t

THOMAS H. HOHL, DDS, MSD,$ AND ROGER A. WEST, DMS§

Forty-one patients who elected to receive a bilateral sagittal osteotomy to

advance the mandible were examined clinically and radiographically to
assess condylar position preoperatively and at three specific times post-
operatively. Parameters designed to measure changes in condylar and
distal fragment position were located on tracings and digitized for statis-
tical analysis. Changes in distal fragment position included advancement
and clockwise rotation during the surgical interval and significant poste-
rior relapse with continued clockwide rotation during the period of max-
illomandibular fixation. A small amount of counterclockwise rotation as-
sociated with interocclusal splint removal was seen following fixation re-
lease. No significant condylar movement was seen during the surgical
interval. During the period of maxillomandibular fixation, both condyles
exhibited a significant superior movement, and the left condyle also
moved posteriorly. No changes in condylar position were noted following
release of fixation. The clinical significance of these condylar movements
is not clear. Despite minimal changes, 18 patients, six of whom had had
no preoperative symptoms and one of whom had exhibited reciprocal
clicking, complained of temporomandibular joint pain or noise postop-
eratively. This suggests that maintenance of condylar position during sur-
gery may not prevent temporomandibular joint dysfunction. In addition,
the observed 37% relapse in surgical advancement in the absence of sig-
nificant condylar distraction implies the interaction of other factors in the
relapse process.

The bilateral sagittal osteotomy to advance the

* Assistant Professor of Orthodontics, Assistant Professor of
Surgery, Loyola University of Chicago Medical Center. May-
wood, Illinois.
t Associate Professor and Chairman, University of Orthodon-
tics, University of Washington School of Dentistry, Seattle,
Washington.
$ Assistant Professor, Department of Oral and Maxillofacial
Surgery, University of Washington School of Dentistry. Seattle,
Washington.
§ Oral and Maxillofacial Surgery, NW Center for Corrective
Jaw Surgery, Seattle, Washington.
This reseach was supportd by the University of Washington
Orthodontic Memorial Fund. This article is based on research
submitted by the senior author in partial fulfillment of the re-
quirements for the Master of Science in Dentistry degree, De-
partment of Orthodontics, University of Washington. This ma-
terial was presented at the AAO/AAOMS Clinical Congress,
New Orleans, Louisiana January 28-30, 1983.
Address correspondence and reprint requests to Dr.Will: De-
partment of Orthodontics, Loyola University of Chicago School
of Dentistry. 2160 South First Avenue. Maywood, 1L 60153.
mandible has been used with increasing frequency
since its introduction to the English literature 25
years ago.’ Although technical modifications have
increased the reliability and stability of this proce-
dure,‘t3 postoperative relapse is the most commonly
mentioned complication.4 Postoperative instability
is seen in many patients and a wide range of post-
operative changes have been reported. Ive et al.”
found an average relapse of 30% during postoper-
ative maxillomandibular fixation while Reyes-Re-
tana Dah16 and Lake et a1.7 reported an average re-
lapse of 26% at the postoperative intervals of 10 and
42 months. respectively.
Although numerous etiologic factors have been
proposed, postoperative relapse still appears to
have many causes and show a great deal of indi-
vidual variation. Suggested contributing factors in-

578
WILLETAL.
elude the influence of the suprahyoid muscula-
ture ‘-12 inadequate periods of maxillomandib-
ular ‘fixation, l3 mtraosseous
’ wiring techniques,t4
tongue and perioral pressures,i5 insufficient bony
union,15,16 and condylar distraction.9~11-‘4~16~17
The problem of condylar distraction in particular
has been discussed by many authors. After ana-
lyzing 87 cases of mandibular advancement
formed in different institutions, Schendel and
Epkert8 concluded that “control of the proximal
segment was the single most important surgical as-
pect in determining the stability or relapse of the
advanced mandible.” Lake7 also found the position
of the proximal segment to be the predominant in-
fluence on postoperative stability. Wormsi warned
of the consequences of condylar distraction. “In
cases where the condyle is displaced . . . there is
obviously no possibility for spontaneous reposi-
tioning. . . . Nothing short of a reoperation should
be the remedy for a displaced condyle.”
Condylar position following surgical mandibular
advancement has been evaluated by only a limited
number of investigators. Freihofer and Petresvic*O
studied 38 patients who had bilateral sagittal oste-
otomies for mandibular advancement a mean of five
years postoperatively. Temporomandibular radio-
graphs (Schuller’s projection) and lateral cephalo-
grams were taken preoperatively, postoperatively,
and a minimum of two years following surgery. Al-
though ten of 26 condyles appeared to be positioned
anteriorly in the glenoid fossa, difference in projec-
tion angulation made direct comparision with pre-
operative films impossible. They did state, how-
ever, that four patients exhibited relapse that was
greater than 40% of the surgical advancement. In
two cases it was noted that condylar repositioning
during surgery had not been “satisfactory,”
though in one of these cases the amount of post-
operative relapse could not have been accounted for
by condylar distraction alone. The authors con-
cluded that “certainly the procedure leads quite
often to a slight change in position of the condyle
in the glenoid fossa. Nevertheless, no major disor-
ders have been found up to now.”
Kundert and Hadjianghelou*i studied 35 patients
who had received bilateral sagittal osteotomies, 14
of which were for mandibular advancement. Tem-
poromandibular tomograms, lateral oblique tem-
poromandibular films, and posteroanterior
films were taken prior to and two to five weeks
following surgery. The dimension of the temporo-
mandibular joint space was measured anteriorly,
posteriorly, and cranially at each time period to doc-
ument condylar changes during surgery. They noted
that in 75% of the condyles studied there was a
narrowing of the joint space concomitant with pos-
579
terior condylar displacement. Fifty per cent of the
condyles exhibited changes in axial inclination
as well.
Condylar displacement during surgery appears to
play an important role in the stability of mandibular
advancement. To adequately plan treatment and
monitor patients postoperatively, more data about
per- these changes are needed. The purpose of this in-
vestigation was twofold: first, to ascertain the fre-
quency, direction, and amount of condylar displace-
ment in patients receiving bilateral sagittal oste-
otomy for mandibular advancement; and second, to
determine whether a significant relationship exists
between observed alterations in condylar position
and other postoperative dental and skeletal
changes.
M a t e ri a l s a n d M e t h o d s
SAMPLE DATA
Subjects for this study consisted of 41 patients
aged 11 to 47 years (mean, 25 years) from the sur-
gical orthodontic clinic at the University of Wash-
ington who had elected to receive a bilateral sagittal
osteotomy for mandibular advancement. Patients
who had adjunctive procedures performed (e.g.,
genioplasty, maxillary surgical procedures) were
not included to minimize unrelated variables.
After presurgical orthodontic preparation, all pa-
tients were operated on by the same surgeon to min-
imize variations in surgical technique and patient
management. All patients received a modified bi-
lateral sagittal osteotomy with the amount of ad-
vancement determined by a prefabricated acrylic
occlusal splint. The advancement was stabilized by
intraosseous wires, which were fixed after manual
al-
manipulation of the proximal fragment into what
were felt by the surgeon to be the most posterior
and superior positions in the glenoid fossa. The in-
traosseous wires were placed on the superior
border of the ramus, farther anteriorly and inferi-
orly on the proximal fragment than the distal frag-
ment, so that when they were tightened, the con-
dyle would tend to be seated in the glenoid fossa.
The acrylic splint was maintained with maxilloman-
dibular fixation wires ligated to the orthodontic ap-
pliances for approximately six weeks and then with
elastics after release of fixation. A soft cervical
skull
collar was worn postoperatively until analysis of
two successive cephalometric radiographs no fur-
ther mandibular change.
RADIOGRAPHIC AND CLINICAL EXAMINATION
Each patient had a radiographic survey taken at
four specific times: t, = immediately preopera-
580
FIGURE 1. Tracing of submental vertex film with landmarks
used:
1. Lateral pole, left condyle
2. Medial pole, left condyle
3. Medial pole, right condyle
4. Lateral pole. right condyle
5. Frontal crest
6. Anterior limit, foramen magnum
7. Posterior limit. foramen magnum
8. Internal occipital protuberance
tively; t, = within one week postoperatively; t, =
within one week of fixation (six weeks) release; and
t, = at least six weeks following fixation release.
This survey included a submental vertex film, a lat-
eral cephalogram, and right and left temporoman-
dibular joint tomograms. A Quint@ cephalometer
(Quint X-Ray Company, Inc., Los Angeles, Ca) was
used to expose the submental vertex view and the
tomograms, while the lateral cephalograms were
obtained from either the surgical orthodontic clinic
or the referring orthodontist. The basilar film was
analyzed to determine the angle between the long
axis of each condyle and the midsagittal line (Fig.
1). The long axis of the condyle was defined as a
line connecting the medial- and lateral-most points
of the contour, and the midsagittal plane was con-
structed as a “best fit” line between the internal
occipital protuberance, the posterior limit of the fo-
ramen magnum, the anterior limit of the foramen
magnum, and the frontal crest. The perpendicular
distance from the midsagittal plane to the center of
the condylar axis was also measured to determine
CONDYLARPOSITIONAFTER MANDIBULARADVANCEMENT
the depth of cut for the tomograms, which were
then exposed with the patient’s head rotated to po-
sition the long axis of the condyle parallel with the
patient’s mandible manually positioned by the ex-
aminer.
A clinical examination was carried out at the time
of the first and last radiographic surveys. The oc-
clusion was examined to determine molar, canine,
and incisor relationships, midline deviation, con-
tacts on excursions, and deviation on opening. A
history of temporomandibular joint symptoms was
taken, the joints were clinically examined for noise
on movement, and the muscles were palpated for
tenderness.
Thirty-four patients completed the four radio-
graphic surveys. Partial records were included on
seven additional patients who had three sets of ra-
diographs taken but were unavailable six weeks fol-
lowing release of fixation.
DATA ANALYSIS
All films were traced on O.Ol-cm acetate by the
same examiner. The submental vertex films were
traced in the manner previously described. The lat-
eral cephalograms were traced and landmarks
located according to Little22 (Fig. 2). Gonion,
menton, pogonion, and B point were transferred
from the initial tracing to subsequent tracings of the
same individual using ramall and sympysea123 con-
tours to minimize error in their identification. Com-
posite tracings were made for each time interval
investigated (t,-tz, t,-t,, t,-t,. t,-t,). The tracings
were superimposed using the ethmoid triad,24 na-
sion, the posterior cranial fossa,ll and the soft tissue
contour of the upper face as references. The center
of the condyle (CC) was located on the film in which
it was most evident and transferred to successive
films during superimposition, insuring constancy of
its position. This permitted quantification of prox-
imal fragment movement by measuring linear
changes between points CC and gonion (Go).
Tomograms were traced and superimposed to
measure superoinferior and anteroposterior move-
ments of the condyle and inclination of the condyle
in a sagittal plane. Inclination of the proximal con-
dyle and distal fragment were referred to as either
clockwise, with the anterior portion moving inferi-
orly, or counterclockwise, with the anterior portion
moving superiorly. The preoperative films were
traced, outlining the contours of the condyle and
glenoid fossa and anatomic detail in the cranial
base. Two arbitrary points were located along the
neck of the condylar process as an axis and a cross
T Reidel RA: Personal communication.
WILL ET AL.
of perpendicular lines was constructed through the
more superior point. Two additional points were ar-
bitrarily marked in the cranial base. (Fig. 3) Sub-
sequent tomograms were similarly traced and su-
perimposed on the initial tracing in two steps. The
condylar tracings were first superimposed by a
“best fit” method, and the two points of the axis
were transferred. The cranial bases were then su-
perimposed using anatomic detail for registration.
The cross constructed through the superior con-
dylar point was transferred to indicate its original
position. The two cranial base points were also
transferred to enable angular measurements be-
tween the line they formed and the condylar axis
(Fig. 3).
STATISTICAL ANALYSIS
The cephalogram and tomogram superimposi-
tions and the submental vertex tracings were digi-
tized using a Tektronix@ tablet (Tektronix, Inc.,
Beaverton, Ore.). Twenty-one parameters were se-
lected and measured from the coordinates of the
landmarks digitized. The changes in each paramter,
as well as the mean, range, and standard deviation
of each change, were calculated for each of the four
time periods using Student’s t test. Those differ-
ences that had a P value less than or equal to 0.05
were considered significant, a P value of 0.01. very
FIGURE 2. Tracing of cephalogram with landmarks used:
1. Sella 9. Pogonion
2. Nasion 10. B point
3. Porion II. Apex, mandibular incisor
4. Orbitale 12. Incisal edge, mandibular incisor
5. Center of condyle 13. Incisal edge, maxillary incision
6. Articulare 14. Apex, maxillary incisor
7. Gonion
8. Menton
581
FIGURE 3. Top left, tracing of left tomogram. which includes
condylar contour with axis points and cross for reference, con-
tour of glenoid fossa, cranial base detail. and cranial base ref-
erence points (solid lines). Top right. superimposed left tomo-
gram tracing showing condylar axis points, cranial base points,
and cross from initial tracing, and glenoid fossa. condylar con-
tours, and cranial base details from subsequent tracing (dotted
lines).
FIGURE 4. Bottom reft und right, superimpositions of left and
right condylar contours using perpendicular cross as reference
to show successive movements of condyles: t,, solid line; tz,
broken line; t,. dotted line; t,, dotted and broken line.
significant, and a P value of 0.001, highly signifi-
cant.
Pearson’s r correlation test was performed on
each change in each parameter at each time in-
terval, comparing changes in pairs in a round robin
fashion. A correlation with an r value greater than
or equal to 0.800 was designated strong, between
0.600 and 0.800, moderate, and less than or equal
to 0.600, weak.
Tracing error was determined by tracing each of
three films four times and digitizing each tracing.
Digitizing error was also determined by digitizing
one tracing from each film four times. The overall
meaurement error for the data used in this study
was the sum of both tracing and digitizing error, and
was found to be 1.06 mm for linear measurements,
1.00” for angles based on three digitized locations,
and 1.61” for angles based on four digitized points.
Measurement error is that portion of the standard
deviation that can be attributed to nonbiologic vari-
ation, and in no way affects the validity of the mean
value. Error due to measurement does affect indi-
vidual values, but the sum of all such individual
errors is normally distributed with a mean zero, and
as such does not influence the mean value.
582 CONDYLAR POSITION AFTER MANDIBULAR ADVANCEMENT

T a ble 1. Su m m ary of M e a n S k ele t al Changes (m m)

Time Interval

t,-12 tz-t, ti-t4 t1-h

Anterior facial height +3.91 2 1.8 +0.48 2 1.5 -1.06 2 I.2 +3.21 i I.6
P < 0.001 NS P < 0.0 0 1 P < 0.0 0 1

Genial arc length +0.98 t 3.3 -2.38 2 2.1 -0.17 k 2.4 - 1.42 i- 3.Y
NS P < 0.001 NS P <O.Ol

Gonial angle +7.51 + 4.8 +3.18 k 1.8 -0.28 k 2.1 + 10.00 2 5.6
P < 0.001 P < 0.001 NS P < 0.0 0 1

Overbite -2.73 5 I.9 -0.02 -+ 0.82 +0.09 5 1.0 -2.51 -t 2.3

P < 0.001 NS NS P < 0.0 0 1

Ovejet -5.88 + 2.4 -0.04 k 0.7 -0.57 t 1.1 -6.15 2 3.5

P < 0.001 NS P < 0.01 P < 0.001

SNB angle +3.59 k I.4 -0.83 + 0.9 -0.53 ? 0.7 +3.20 r I.3
P < 0.001 P < 0.001 P < 0.001 P < 0.001

SN-Mandibular plane angle +2.44 -t 7.8 +2.90 -t 1.3 -0.85 5 I.6 +4.47 ? Z.7
P < 0.001 P < 0.001 P < 0.01 P < 0.001

Posterior facial height -0.17 k 4.2 -2.52 !I 3.4 -0.31 ? 3.4 -2.68 2 5.0
NS P < 0.001 NS P < 0.01

Vertical postion of +4.49 t 1.4 +0.29 + 1.9 -0.98 k I.8 13.64 2 2.1
anterior mandible* P < 0.001 NS P < 0.01 P < 0.001

Horizontal position of +5.54 2 5.0 -2.49 -’ 6.0 + 1.26 2 5.3 +4.69 2 7.0
anterior mandible* P < 0.001 P < 0.05 NS P < 0.0 0 1

* Negative value indicates superior movement.

t Negative value indicates posterior movement.

R e sults counterclockwise inclination of the left condyle and

MEAN CHANGES
Surgical Changes. As the mandible was surgi-
cally advanced (x = 5.5 mm), it was rotated in a
clockwise direction, producing significant (P <
0.001) increases in gonial angle and anterior facial
height and significant (P < 0.001) decreases in
ovetjet and overbite. These changes were reflected
by significant (P < 0.001) increases in the SNB and
mandibular plane angles (Table 1).
There was no significant rotation or change in the
anteroposterior position of the condyles. Although
there were tendencies for counterclockwise incli-
nation and inferior movement of both condyles,
these were not statistically significant (Table 2.
Fig. 4).
Counterclockwise inclination and posterior
movement of the right condyle, when they oc-
curred, were significantly correlated (Y = 0.589, P
< 0.001). Correlations were also noted between
increases in the gonial angle (r = 0.415, P = 0.009)
and the mandibular plane angle (Y = 0.426, P =
0.007).
Fixation Changes. Movements observed during
fixation were clockwise inclination of the distal
fragment of the mandible and superior movement
of the proximal fragment. These changes were re-
flected in significant (P < 0.001) decreases in pos-
terior facial height, gonial arc. and SNB angle, and
significant (P < 0.001) increases in the gonial and
mandibular plane angles (Table 1). Horizontal re-
lapse as measured by the horizontal position of the
anterior mandible was significantly correlated with
surgical horizontal advancement (Y = - 0.4 1, P <
0.05). Vertical changes in the position of the ante-
rior mandible during the surgical and fixation inter-
vals were also correlated with each other (Y =
-0.58, P < 0.001). However, horizontal and ver-
tical changes were not related significantly. The de-
crease in posterior facial height was correlated with
both the posterior relapse of the anterior mandible
WILL ET AL

T a bl e 2. Su m m ary of M e a n C ondylar Changes (m m)

Time Interval

1,-f: tz-t, (1-h ‘1-h

Superoinferior movement. +0.74 2 2.5 - 1.69 2 2.4 -0.05 & 2.3 - .85 i 2.9
left Condyle* NS P < .OOl NS YS

Superoinferior movement, +0.35 2 2.4 ~ 1.18 * 3.2 -0.53 f 2.19 - .98 IT 1.x
right condyle* NS P < 0.05 NS P <: 0.01

Anteroposterior movement, -0.20 2 2.3 -0.89 2 2.1 +0.38 ? 2.1 -.7x 2 2.0
left condylet NS P < 0.05 NS P < 0.05

Anteroposterior movement, +0.22 t 3.0 -0.31 -’ 2.4 -0.23 h 2.6 - ,3112 3.0
right condylet NS NS NS NS

Inclination, left condyle!: -2.42 + 10.2 -2.14 * 8.7 -3.12 ? 7.2 -6.50 _’ 7.2
NS NS NS P < 0.001

Inclination. right condyle# -1.23 ? 9.5 - I.51 -c 7.8 + 1.20 -c 9.3 ~ 1.60 2 7.9
NS NS NS NS

Rotation, left condyle(i -1.51 f 13.6 +2.03 2 9.8 + 1.97 + 6.1 +2.81 2 10.6
NS NS NS NS

Rotation. right condyleEj -0.04 2 8.4 -0.46 ? 9.6 -0.06 t 8.0 + I.lX + 7.0
NS NS NS NS

* Negative value indicates superior movement.

t Negative value indicates posterior movement.
$ Negative value indicates counterclockwise movement.
P Negative value indicates anteromedial rotation.

0.001) and the increase in the man-

(r = 0 . 8 1 , P < intervals for anteroposterior and superoinferior
dibular plane angle (u = 0.33, P < 0.05). The in- condylar movements (Table 3). Correlations were
crease in the mandibular plane angle was also re- also noted between the superior and posterior
lated to the decrease in the gonial arc (Y = 0.600. movements of the left condyle (r = 0.401, P <
P < 0.001). O.Ol), the counterclockwise and posterior move-
Both condyles moved superiorly to a significantly ments of both condyles (left condyle, r = 0.775, P
extent during fixation (left condyle, P < 0.001; right < 0.001; right condyle, r = 0.583, P < 0.001). and
condyle, P < 0.05), and their movements were sig- the counterclockwise movement of the left condyle
nificantly related (r = 0.431; P < 0.01). The left and the increase in mandibular plane angle (r =
condyle also exhibited significant (P < 0.05) pos- 0.437, P < 0.01). There were no relationships noted
terior movement (Table 2, Fig. 4). No significant between surgical or fixation condylar movements
dental changes were observed. With the exception and vertical or horizontal changes in anterior man-
of posterior movement of the right condyle, there dible position.
were significant correlations noted between the Postfixation Changes. When the acrylic occlu-
amount of change during the surgical and fixation sal splint was removed, the mandible rotated in a

T a bl e 3. C o rr e l a t i o n s Between C ondylar Move m ents D u ri n g S u r g i c a l a nd Fix a tion Therapy

Sample Correlation Probability V)

size (n) Coefficient (r)

Superoinferior movement. 41 -0.35 co.03

left condyle
Anteroposterior movement, 41 -0.49 <0.005
left condyle
Superoinferior movement. 41 - 0.55 <O.OOl
right condyle
Anteroposterior movement, 41 -0.09 >o.s
right condyle
584 CONDYLAR POSITION AFTER MANDIBULAR ADVANCEMENT

counterclockwise direction, with significant (P < RELATION OF CONDYLAR MOVEMENT TO

0.01) decreases in anterior facial height, overjet. AMOUNT OF RELAPSE DURING FIXATION
and mandibular plane angle, and a significant (P <
0.001) increase in the SNB angle. There was no Those groups demonstrating the least and
significant change in the gonial angle or gonial arc greatest amounts of mandibular posterior relapse
(Table 1). No significant condylar movement was during fixation, as measured by changes in SNB
noted (Table 2, Fig. 4). angle, were also examined separately regarding
Net Changes. The distal fragment of the man- condylar movement. Patients who showed the least
dible showed a significant net advancement of 4.69 amount of mandibular relapse (0 degrees, n = 6)
mm (P < O.OOl), with significant (P < 0.001) in- showed only slight counterclockwise inclination of
creases in the SNB angle and decrease in overjet. the proximal fragment during surgery: after fixation
The anterior portion of the distal fragment also release, counterclockwise inclination continued. In
dropped, as reflected by significant (P < 0.001) in- contrast, the group that relapsed 1.8 degrees or
creases in anterior facial height and vertical position more (n = 6) during fixation showed significantly
of the anterior mandible, and a significant (P < more counterclockwise inclination during surgery
0.001) decrease in overbite. The proximal fragment (P < 0.05), with clockwise inclination of the prox-
showed a net superior movement with significant imal fragment (P < 0.04) following fixation release.
(P < 0.01) decreases in posterior facial height and
gonial arc. This anterior lengthening and posterior RELATION OF CONDYLAR MOVEMENT TO
shortening in vertical dimension resulted in signifi- INCREASES IN ANTERIOR FACIAL HEIGHT
cant (P < 0.001) increases in the mandibular plane
angle and gonial angle (Table 1). Groups showing the greatest and least amount of
The right condyle demonstrated signiticant (P < increase in anterior facial height during surgery
0.01) superior movement, while the left condyle were compared with each other, with a group con-
showed significant counterclockwise inclination (P sisting of patients who had average increases, and
< 0.001) and posterior movement (P < 0.05; Table with all other subjects to test for differences in con-
2, Fig. 4). dylar movement. No significant differences were
Clockwise inclination of the right condyle was observed.
correlated with its posterior movement (Y = 0.46,
P < 0.01). Significant relationships were also noted TEMPOROMANDIBULAR JOINT FUNCTION
between the counterclockwise inclination of the left
condyle and increases in the gonial angle (r = 0.59, Information regarding temporomandibular joint
P < O.OOl), mandibular plane angle (v = 0.57, P < function was obtained in two portions of the clinical
O.OOl), and anterior facial height (Y = 0.49, P < examination. First, patients were asked whether
O.Ol), and increases in overbite (Y = 0.47, P < 0.01) they had noticed any pain. noises, or limitation of
and overjet (r = 0.38, P < 0.05). Superior move- motion in their temporomandibular joints. Preop-
ment of the left condyle, though not significant in eratively, 19 patients reported pain, clicking, pop-
the entire sample, was significantly correlated with ping, or locking of their joints, while 18 reported
superior movement of the right condyle (r = 0.62, these symptoms 12 weeks after sugery. There was
P < 0.001) and posterior movement of the left con- considerable overlap between the two groups.
dyle (r = 0.67, P < 0.001). However, six patients who had preoperative symp-
toms had none postoperatively, and six patients
RELATION OF CONDYLAR MOVEMENT TO
who had no symptoms preoperatively reported
symptoms following surgery.
AMOUNT OF SURGICAL ADVANCEMENT
The patients were also examined for muscle ten-
derness to palpation and joint noise on movement.
Those patients who demonstrated the least and Thirteen patients were found to have muscle ten-
greatest surgical increases in SNB angle were iso- derness or joint noise preoperatively, while seven
lated and examined separately for significant con- experienced these symptoms postoperatively. Only
dylar movement during all time intervals. Each three patients had these symptoms both pre- and
group was compared with all remaining patients and postoperatively. Although the group of patients
a group of patients who exhibited average in- found to have these symptoms on examination was,
creases. The two groups of extremes were also in general, the same group who reported joint noise
compared with each other. No clinically significant or pain, more joint symptoms were reported than
differences in condylar movement were noted. could be elicited on examination. However, two pa-
WlLL ET AL.
tients who reported no joint symptoms were found
to have noises on examination.
Dis c ussion
Contrary to what was expected from the litera-
ture, very little condylar movement as observed in
this study. Despite possible tissue tension, intracap-
sular edema, and manipulation of the fragments,
condylar movement during the surgical interval av-
eraged less than 1 mm. The greatest mean net con-
dylar movement in any direction was also less than
1 mm. Although the changes observed were small,
the movements were statistically significant. During
fixation, both condyles moved superiorly. with the
change in the left condyle being greater and at a
higher level of significance. The superior movement
in the right condyle was also significant throughout
the study. Posterior movement of the left condyle
was significant during fixation and during the entire
observation period. The left condyle also showed
significant net counterclockwise inclination. This
pattern of change is consistent with what might be
expected from masticatory muscle pull in the im-
mediate postoperative period and during fixation.
As the anterior portion of the distal fragment re-
lapses posteriorly and inferiorly, perhaps due to su-
prahyoid muscle forces, the posterior portion is
pulled anteriorly and superiorly by the internal pter-
ygoid muscle, resulting in clockwise rotation of the
distal fragment. As the portion of the distal frag-
ment bearing the intraosseous wire moves antero-
superiorly, it causes posterior movement and coun-
terclockwise inclination of the condyle (Fig. 5).
The observed superior changes may well be the
combined result of masticatory muscle function,
cervical collar pressure, and resolution of postop-
erative intracapsular edema. Maxillary and mandib-
ular superimposition of cephalograms of 23 cases
revealed that either the upper or lower second
molar was intruded in 19 of these cases, while the
remaining four showed maintenance of vertical
molar position. These observed changes would ac-
comodate the superior movement of the condyles
beyond their original position.
Though precise causes for the disparity between
left and right condylar movements can not be iden-
tified. the differences were not totally unexpected.
At the time of intraosseous wiring, the right condyle
was more easily seated than was the left, since both
were positioned by the same person standing at the
patient’s right. Additionally, the side on which the
osteotomies were first completed would theoreti-
cally have had a longer time before positioning
during which to develop intracapsular edema,
585
MASSETER
INTERNAL PTERYG OID
SUPRAHYOIDS
FIGURE 5. Directions of force exerted by mandibular depres-
sors and elevators and their influence on mandibular proximal
and distal fragments.
which also could have led to differences in condylar
displacement.
No significant mean rotations of the condyle
about a vertical axis were observed in any of the
time periods studied. The methods used may not
have been sufficiently sensitive to detect any
changes, but if this were true, they would probably
not have been clinically significant changes.
The mean changes in position of the distal man-
dibular fragment were similar to those described by
Ive et al.“, and Lake et al.7 During surgery, the man-
dible was advanced and rotated in a clockwise di-
rection, with an increase in the anterior facial height
and decrease in overjet and overbite. During fixa-
tion, there was posterior movement of the distal
fragment, with further clockwise rotation. This is
consistent with Ive’$ description of mandibular re-
lapse during fixation. With fixation release and
splint removal, there was autorotation of the man-
dible in a counterclockwise direction, with no
change in the relationship between proximal and
distal fragments. This is evident in the lack of sig-
nificant change in the gonial angle. Although these
mean changes were significant for the entire
sample, it is important to note that a high degree of
individual variation existed.
The significant correlation between the amount
of surgical advancement and the amount of relapse
during fixation is in agreement with Lake’s7 obser-
vations, but is inconsistent with Ive’s’ report that
no such association exists. This finding, as well as
the significant relationships between condylar
586
FIGURE 6. Increase in moment arm of the masseter muscle
due to counterclockwise inclination of the mandibular proximal
fragment.
movements during surgery and during tixation, sug-
gest that much of the postoperative change occured
during fixation, when the dentition can compen-
sate for skeletal changes.
Groups demonstrating the greatest and least
amount of mandibular relapse during fixation were
compared for condylar movements. Although the
groups were small, the significant relationship may
give an indication of a trend that existed within the
entire group. Individuals who experienced the most
relapse during fixation exhibited more counter-
clockwise inclination of the condyle during surgery.
This may be due to the change in biomechanics
brought about by the change in position of the prox-
imal fragment, as discussed by Finn2? “If the prox-
imal segment rotates from its presurgical spatial ori-
entation, the insertions of the jaw adductors will be
altered dramatically with simultaneous changes in
jaw biomechanics.” This purely biomechanical ex-
planation does not deal with the more complex as-
pects of muscle physiology such as length-tension
relationships, motor unit recruitment, or other
changes in neuromuscular control following sur-
gery, but is does illustrate that proximal fragment
inclination may be quite important in relapse
(Fig. 6).
Following fixation release, individuals who ex-
perienced the greatest amount of mandibular re-
lapse demonstrated clockwise condylar inclination.
This is in contrast to the continued counterclock-
wise movement observed in patients who relapsed
the least. With healing at the osteotomy site, the
CONDYLAR POSITION AFTER MANDIBULAR ADVANCEMENT
proximal and distal fragments moved together, as
evidenced by the lack of change of the genial angle
following release of fixation. When little or no re-
lapse occurred, as in the group that exhibited the
least change during fixation, counterclockwise au-
torotation of the mandible after removal of the oc-
clusal splint was the only change noted in condylar
position. However, when individuals who relapsed
the most during fixation continued to relapse fol-
lowing fixation release, the clockwise movement of
the relapsing mandible was greater than the coun-
terclockwise autorotation, and a net clockwise ro-
tation was seen. The lack of plasticity noted in the
mandible after six weeks of healing was in contrast
to the plasticity seen by Reitzik26, who subjected
healing monkey mandibles to deforming forces. He
found that complete healing of the osteotomy site
in these primates required 20 weeks, and extrapo-
lated this to 25 weeks for humans. Perhaps the
forces operating in our study were smaller, so that
significant deformation did not occur; however,
plasticity of the osteotomy site during the osseous
healing period can not be ignored as a factor in long-
term relapse.
Despite the minimal condylar movements seen,
net postoperative relapse of the distal fragment was
2.49 mm, or approximately 37% of the advance-
ment. Thus, in this sample, condylar distraction
was only a minor factor in the constellation of phe-
nomena that contribute to relapse. This is in con-
trast to the conclusions of Schendel and Epker18
and Lake et al.’ that condylar or proximal fragment
position was the single most important influence on
the stability of the advanced mandible. Clearly,
other factors must be examined in greater depth.
Plasticity of the osteotomy site may contribute to
relapse, though this did not appear to be an influ-
ence in the short follow-up period employed in the
present study. Suprahyoid muscle pull is frequently
mentioned as a cause of postoperative relapse.
Wessberg et a1.,27 analyzed the cephalograms from
16 patients, eight of whom had had suprahyoid my-
otomies in conjunction with mandibular advance-
ment using the bilateral sagittal osteotomy. Similar
percentages of postoperative relapse were noted in
the two groups, indicating that myotomy does not
ensure postoperative stability. Finn25 has described
the role masticatory muscles play in relapse fol-
lowing mandibular advancement using the sagittal
osteotomy, as previously discussed. The complex
area of muscle physiology may yield valuable in-
formation regarding relapse following mandibular
surgery but needs much more experimental and
clinical investigation.
Temporomandibular joint symptoms were a fre-
quent complaint before (56% of sample) and after
WILL ET AL.
(53% of sample) surgery. Some patients who had
joint symptoms before surgery had none after, and
vice versa. Despite minor changes in condylar po-
sition, 18 patients complained of symptoms post-
operatively, six of whom had had no previous com-
plaints. This emphasized that such symptoms may
not be related solely to joint space and condylar
position, and that other etiologies should be consid-
ered. It was admittedly difficult to evaluate the im-
portance of complaints six weeks after fixation re-
lease. Most patients were still wearing their oc-
clusal splint and maxillomandibular elastics on a
part-time basis and had not yet resumed their post-
operative orthodontic treatment. Postoperative
analysis of the occlusion revealed that contacts
were generally uneven, and mandibular movements
were often restricted. Transient temporomandibular
joint symptoms could well be provoked by these
occlusal disturbances, as well as by postoperative
muscle soreness and changes in muscle function
and mandibular length brought about by surgery.
Kiyak et al.28 administered a questionnaire to 55
orthognathic surgery patients nine months postop-
eratively, and reported that 73% had experienced a
reduction of temporomandibular joint popping and
clicking since surgery, while 23% reported an in-
crease. Although subjects in the present study were
not asked to judge whether their symptoms had in-
creased or decreased since surgery, the relatively
high number of patients reporting symptoms post-
operatively suggests that many of these distur-
bances are transient. These patients will be moni-
tored over the next several years to more clearly
define the long-term incidence of temporomandi-
bular joint problems.
The clinical implication of the tendency for pos-
terosuperior condylar movement can be seen in pa-
tients who present with reciprocal clicking of the
temporomandibular joints following fixation re-
lease. This sign is consistent with an anteriorly dis-
placed meniscus, which may occur with posterior
condylar displacement. Since condylar movement
appears to continue in a posterosuperior direction
following fixation release, it is doubtful that this
disc dysfunction will resolve spontaneously during
the immediate postoperative course.
Changes indicative of condylar remodeling, such
as alterations in condylar shape or the appearance
of double cortical contours, were not seen in the
present study. Condylar remodeling has often been
observed in animal experimentation29-31 and in clin-
ical studies32 where functional stresses to the tem-
poromandibular joint have been altered or in-
creased. Double cortical contours reflecting appo-
sition have been observed by several authors
investigating temporomandibular joint changes fol-
587
lowing mandibular surgery. Hollender and RidelP3
found double contours in 30 of 36 joints that were
repositioned anteriorly and inferiorly following
oblique sliding osteotomy for mandibular protru-
sion, but they noted that no changes were seen until
six months following surgery, and that the two con-
tours were not distinguishable until 18 months after
surgery. Edlund also noted double contours in 37
of 86 condyles, but only after one to two years fol-
lowing mandibular retropositioning. It appears that
longer observation periods would be necessary to
determine the presence of double cortical contours.
In contrast, McNamara3i observed double con-
tours in juvenile Rhesus monkeys following only 13
weeks of anterior mandibular posturing. Although
this change took place very rapidly, it is consistent
with the concept of the greater adaptability of
growing animals. Histologic and experimental
studies have confirmed that the potential for con-
dylar growth, and thus adaptation to changes in
function, decreases with age. Wright,35 who exam-
ined 56 human condyles aged one day to 17 years
at autopsy, observed that the growth rate of the
condyle diminishes after 12 to 13 years of age as
evidenced by a decreasing cellularity of the growth
cartilage. Zimmerman’s 36 findings in the Macaca
mulatta were similar. As a result, fewer and less
rapid remodeling changes could be expected in the
present sample, because all patients were past their
major period of growth.
The direction of condylar movement observed in
the present study may also explain why no double
cortical contours were noted. The appearance of
two cortices on the condyle is a radiographic sign
of bony apposition, which would occur following
anterior or inferior repositioning of the condyle.
With the tendency toward posterior and superior
condylar movement in the present group, resorptive
rather than appositional changes would be ex-
pected.
It is apparent that the condylar movements ob-
served in this group of patients were infrequent and
of small magnitude. It is difficult to assess the clin-
ical importance of such small changes. While they
may be compensated for by the dental occlusion,
these condylar movements may be associated with
alterations in muscle function that have more wide-
spread implications for function and stability. The
effects of mandibular repositioning on the neuro-
muscular complex are poorly understood, and fur-
ther studies are needed to address this problem.
The results of this study show condylar move-
ments after surgical mandibular advancement of
less frequency and amount than those commonly
reported in the literature. With such accurate re-
positioning, relapse is still a common postoperative
588 CONDYLAR POSITION AFTER MANDIBULAR
occurrence, emphasizing the multifactorial nature
of this phenomenon.
Clockwise mandibular rotation concomitant with
relapse during fixation was associated with coun-
terclockwise inclination of the proximal fragment
and posterosuperior movement of the condyle.
Postoperative masticatory muscle activity may
have played a significant role in these changes.
Many factors influencing postoperative stability
still need investigation. The process of neuromus-
cular adaptation to altered skeletal relations must
be examined, particularly as it relates to skeletal
relapse. Long-term follow up is needed to evaluate
functional changes brought about by surgery, such
as remodeling and chronic disturbances of the tem-
poromandibular joint. The implications of the small
changes in condylar position seen in this study for
long-term stability and health of the temporoman-
dibular apparatus should also be assessed.
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