Condylar Positioning Devices for Orthognathic Surgery

Condylar positioning devices for orthognathic surgery: aliterature reviewFabio 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, ItalyDEPARTMENT OF MAXILLOFACIAL SURGERY, UNIVERSITY OF UDINE

In the past few years, many devices have been proposed for preserving the preoperative position of themandibular condyle during bilateral sagittal split osteotomy. Accurate mandibular condyle repositioning is consideredimportant 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 intermaxillaryfixation as stable as possible during their application, and the need for precision in the construction of the splint orintraoperative wax bite. This study reviews the literature concerning the use of CPDs in orthognathic surgery since1990 and their application to prevent skeletal instability and contain TMD since 1995. From the studies reviewed, wecan conclude that there is no scientific evidence to support the routine use of CPDs in orthognathic surgery. (Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:179-90)
In previous years, a great deal of attention has beenpaid to maintaining the preoperative condylar positionduring orthognathic surgery. Numerous condylar posi-tioning methods have been reported and can be dividedinto manual/empirical methods,1 rigid retention,2-6 nav-igation,7-8 and sonographic monitoring.9

In 1986, Epker and Wylie10 suggested 3 reasons foraccurately controlling the mandibular proximal seg-ment:

1. to ensure the stability of the surgical result;2. to reduce the adverse effects on the temporoman-

dibular joint (TMJ);3. to improve masticatory function.

Ellis 11 conducted an excellent comprehensive reviewof the literature regarding the need for condylar posi-tioning devices (CPDs) in 1994 and raised 2 importantquestions:

1. Do changes in condyle position with orthognathicsurgery really matter?

2. Are CPDs effective?

We conducted a review of the English-language med-ical literature from 1995 to 2007 to verify the actual

aConsultant in Maxillofacial Surgery.bAssociate Professor of Maxillofacial Surgery.cPhD researcher.dProfessor and Chairman of Maxillofacial Surgery, Head of Depart-ment of Maxillofacial Surgery.Received for publication Sep 18, 2007; returned for revision Nov 15,2007; accepted for publication Nov 21, 20071079-2104/$ - see front matter© 2008 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2007.11.027
clinical usage of CPDs to prevent skeletal instabilityand contain the signs and/or symptoms of temporoman-dibular disorders (TMD) and a review from 1990 to2007 to seek scientific evidence to support their use.

SKELETAL STABILITY AND CPDSMany authors support the view that the skeletal re-

lapse after rigidly fixed bilateral sagittal split osteotomy(BSSO) might be reduced with the aid of positioningappliances.12

The relationship between condylar position and sta-bility of mandibular advancement is well known. Dis-tracting the condyle from the fossa during surgerycauses an immediate skeletal relapse, and posteriorrepositioning of the condyle has been shown to inducecondylar resorption, resulting in late relapse.13-15 Theexistence of a direct relationship between intraoperativemalpositioning of the condyle-bearing fragment and theoccurrence of relapse has likewise been frequently pos-tulated in mandibular setback surgery. The degree ofproximal segment rotation or the condyles being seatedtoo far dorsally in the glenoid fossa during fixation ofthe osteotomy segments are most likely responsible forlate skeletal relapse.16-18 Based on published studies, itwould seem prudent to keep the proximal segment asclose to its preoperative position as possible duringsurgery, especially if rigid fixation is to be used.

Studies concerning skeletal stability are listed inTables I-IV. In reviewing the materials and methods ofthese studies, we assumed that the condyle was repo-sitioned manually unless specified otherwise.

We found 12 studies analyzing skeletal stability aftermandibular setback in 380 patients since 1995 (Table
I).19-30 Repositioning was done manually in 10 studies.
179

OOOOE180 Costa et al. August 2008

Table I. Skeletal stability after mandibular setback

Author(s) Year PatientsPositioning of the

condyleFollow-up(months) Conclusion

Costa et al.,19 Department ofMaxillofacial Surgery,Udine, Italy.

2006 22 Manual 12 Surgical correction of class III malocclusionafter combined maxillary and mandibularprocedures appears to be a fairly stableprocedure for maxillary advancements upto 5 mm whatever the type of fixationused to stabilize the maxilla.

Ueki et al.,20 Department ofOral and MaxillofacialSurgery, Kanazawa, Japan

2005 40 Manual Not specified The change in condylar angle after BSSOand fixation with a titanium plate isgreater than after BSSO and fixation witha PLLA plate, but skeletal stabilityrelated to the occlusion is similar for the2 procedures.

Ueki et al.,21 Department ofOral and MaxillofacialSurgery, Kanazawa, Japan

2005 20 Manual (not specified) 12 The present results suggest a significantdifference between SSRO and IVRO inthe time course of changes in theproximal segment including the condyleand distal segment.

Chou et al.,22 Department ofDentistry, Taipei , Taiwan

2005 64 Manual (not specified) 12 A significant amount of relapse occurredwithin 1 year after surgery.

Politi et al.,23 Department ofMaxillofacial Surgery,Udine, Italy

2004 17 Manual 12 Surgical correction of class III malocclusionafter combined maxillary and mandibularprocedures appears to be a fairly stableprocedure irrespective of the type offixation used to stabilize the mandible.

Mobarak et al.,24 Departmentof Orthodontics, Oslo,Norway

2000 80 Manual 36 Clockwise rotation of the ascending ramusat surgery with lengthening of theelevator muscles, although evident in thisstudy and apparently responsible for theearly horizontal postoperative changes,does not seem to be associated withmarked relapse.

Kwon et al.,25 Oral andMaxillofacial Surgery,Osaka, Japan

2000 25 Device 6 Relapse of the mandible seems to beinfluenced mainly by the amount anddirection of the surgical alteration of themandibular position

Marchetti et al.,26

Maxillofacial SurgeryDepartment, Bologna, Italy

1999 15 Manual (not specified) Stability of mandibular fragments dependedon the stability of the maxilla.

Bailey et al.,27 Department ofOrthodontics, Chapel Hill,USA

1998 35 Manual (not specified) 42 More than 90% of the patients showed noclinically significant long-term changes,which suggests that long-term changesare less likely after class III than afterclass II treatment.

Harada and Enomoto,28 Oraland Maxillofacial Surgery,Tokyo, Japan

1997 20 Device 12 Fixation of the bony segments with PLLAscrews after SSRO may be usedeffectively in properly selected cases

Schatz and Tsimas,29

Department of Orthodonticsand Pedodontics, Geneva,Switzerland

1995 13 Manual (not specified) 12 Rigid internal fixation was unable toprevent relapse. Technical refinementsshould be investigated to improve thestability of bilateral sagittal splitosteotomy.

Ingervall B, et al. Universityof Bern, Switzerland.30

1995 29 Manual (not specified) 14 The net effects on the labial fold and thesoft tissue of the chin were closelycorrelated with those on their underlyinghard structures.

Total 380

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

OOOOEVolume 106, Number 2 Costa et al. 181

Table II. Skeletal stability after mandibuar advancement



Turvey et al.,31 Department ofOral and MaxillofacialSurgery, Chapel Hill, USA

2006 69 Manual (not specified) 12 2-mm self-reinforced PLLDL (70/30) screws canbe used as effectively as 2-mm titaniumscrews to stabilize the mandible after bilateralsagittal osteotomies for mandibularadvancement.

Eggensperger et al.,32

Department ofCraniomaxillofacial Surgery,Berne, Switzerland

2006 32 Manual (not specified) 144 Surgical displacement of the condyle in aninferior and posterior direction maycompensate for early skeletal relapse.Progressive condylar resorption seems to bemainly responsible for long-term skeletalrelapse.

Borstlap et al.,33 Departmentof Oral and MaxillofacialSurgery, Nijmegen, TheNetherlands

2004 222 Manual (gauze-packing instrument)

24 The sagittal split osteotomy fixed withminiplates appeared to be a relatively safe andreliable procedure, giving rise to a highdegree of patient satisfaction, despite the factthat some occlusal relapse was seen.

Arpornmaeklong et al.,34

Department of Oral andMaxillofacial Surgery,Melbourne, Australia

2004 29 Manual (not specified) 25 The majority of patients undergoing bimaxillarysurgery for the correction of skeletal class IImalocclusions maintained a stable result. Asmall number of patients suffered significantskeletal relapse in the mandible owing tocondylar remodelling and/or resorption.

Ferretti and Reyneke,35

Department of Maxillofacialand Oral Surgery,Johannesburg, South Africa

2002 40 Device 12 Resorbable PLLA/PGA copolymer bicorticalscrew fixation of a BSSO is a viablealternative to titanium screws for the fixationof advancement BSSO.

Dolce et al.,36 Department ofOrthodontics, Gainesville,USA

2002 57 Manual 60 Although rigid fixation is more stable than wirefixation for maintaining the skeletaladvancement after a BSSO, the incisorchanges made the resultant occlusions of the 2groups indistinguishable.

Pangrazio-Kulbersh et al.,37

Department of Orthodontics,Detroit, USA

2001 20 Manual (not specified) 12 Total mandibular alveolar osteotomy is thetreatment of choice for the correction ofsevere dentoalveolar retrusive class IImalocclusion for which an alteration of thementolabial sulcus is desirable.

Mobarak et al.,38 Departmentof Orthodontics, Universityof Oslo, Norway

2001 61 Manual 36 High-angle patients were associated with both ahigher frequency and a greater magnitude ofhorizontal relapse. The high rate of laterelapse observed among high-angle casesindicates that condylar morphologic changesmight occur with a greater frequency thanpreviously thought.

Dolce et al.,39 Department ofOrthodontics, Gainesville,USA

2000 78 Manual 24 Rigid fixation is a more stable method than wirefixation for maintaining mandibularadvancement after SSRO.

Keeling et al.,40 Departmentof Orthodontics, Gainesville,USA

2000 64 Manual (not specified) 24 2 years after surgery, mandibular symphasis wasunchanged in the rigid group, whereas 26% ofthe wire group had sagittal relapse. However,the overjet and molar discrepancy hadrelapsed similarly in the 2 groups.

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

2000 28 Manual (not specified) 15 There was a statistically significant relapse inmandibular length, lower anterior face height,mandibular arc, lower incisor inclination,overbite, and overjet in each group, regardlessof the type of fixation. The potential wasgreater for relapse in patients stabilized with
transosseous wiring.


Table II. Continued.



Kallella et al.,42 Departmentof Oral and MaxillofacialSurgery, Helsinki, Finland

1998 25 Manual 12 SR-PLLA screws are considered to becomparable to other forms of rigid internalfixation for fixation of bilateral splittingosteotomies after mandibular advancement, asfar as skeletal stability is concerned.

Blomqvist et al.,43 Departmentof Oral and MaxillofacialSurgery, Halmstad, Sweden

1997 60 Manual (not specified) 6 This prospective dual-center study indicates thatthe two different methods of internal rigidfixation after surgical advancement of themandible by BSSO did not significantly differfrom each other.

Nimkarn et al.,44 Departmentof Oral and MaxillofacialSurgery, Birmingham, USA

1995 19 Manual (not specified) 12 Large surgical advancements in OSAS patientsresult in relatively stable repositioning of themaxilla and mandible over the long term.

Total 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) Year PatientsPosition of the


Reyneke et al.,45 Department ofMaxillofacial and OralSurgery, Johannesburg, SouthAfrica

2007 88 Manual 13,9 The long-term skeletal stability of clockwise rotationand counterclockwise rotation of themaxillomandibular complex (MMC) comparesfavorably with the postoperative skeletal stabilityof conventional treatment when the rotation of theMMC takes place around a point at the condyle.

Iannetti et al.,46 MaxillofacialSurgery Department, Rome,Italy

2007 20 Manual (notspecified)

24 In class III patients with anterior open bite treatedwith mono- or bimaxillary surgery and rigidinternal fixation, the maxilla was demonstrated tobe stable, whereas there was a moderate rate ofmandibular relapse dependent on the amount ofsurgical alteration.

Frey et al.,47 Department ofOrthodontics, San Antonio,USA

2007 78 Manual 24 Surgically closing the mandibular plane angulation isassociated with late horizontal and verticalrelapse, whereas fixation type is related to earlyB-point movement.

Emshoff et al.,48 Department ofOral and MaxillofacialSurgery, Innsbruck, Austria


12 The data confirm the concept that the bimaxillaryapproach of “Le Fort I impaction and BSSOadvancement” using the described technique ofRIF is a stable procedure in the treatment of openbite patients classified as vertical maxillary excessin combination with mandibular deficiency.

Swinnen et al.,49 Department ofOrthodontics, Leuven,Belgium


12 Open bite patients, treated by posterior Le Fort Iimpaction and anterior extrusion, with or withoutan additional BSSO, 1 year after surgery, exhibitrelatively good clinical dental and skeletalstability.

Hoppenreijs et al.,50

Department of Oral andMaxillofacial Surgery,Arnhem, The Netherlands


69 It can be concluded that patients with anterior openbites, treated with a Le Fort I osteotomy in 1piece or in multisegments, with or without BSSO,exhibited good skeletal stability of the maxilla.Rigid internal fixation produced the best maxillaryand mandibular stability.

Ayoub et al.,51 University ofGlasgow, UK

1997 30 Manual 6 There is a difference in the way the proximalsegments were manipulated between the 2 groups.

Total 349

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


Only 2 studies reported using CPDs in a total of 45patients (12% of all patients reviewed).

Ueki et al.21 reported using a bent plate to deliber-ately create a step in the cortical bone between theanterior aspects of the proximal and distal segments toprevent any change in axial inclination involving eithera medial, lateral, or inward rotation. This was notconsidered to be a CPD. Several authors23,29,30 havepostulated that clockwise rotation of the proximal seg-ment correlated with postoperative relapse. Ingervall etal.30 suggested that the technique used by individualsurgeons in setting the condylar segment is probablyimportant to the stability of the outcome of the proce-dure.

As for the skeletal stability of mandibular advance-ment, we identified 14 studies involving 804 patients(Table II).31-44 Repositioning was done manually in 13studies. Only 1 study, concerning 40 patients (5% of thepatients reviewed), involved the use of CPDs.

Mobarak et al.38 suggested that counterclockwiserotation of the ramus leads to instability because thesubsequent altered muscle orientation tends to returnthe proximal segment to its original inclination; Eg-gensperger et al.32 found no correlation, however,

Table IV. Skeletal stability in patients with a nonunifo

Author(s) Year PatientsPositioning

condy

Landes and Ballon,52

Maxillofacial and Facial PlasticFrankfurt, Germany

2006 60 Manual (not

Eggensperger et al.,53 Departmentof Craniomaxillofacial Surgery,Berne, Switzerland

2004 60 Manual (not

Cheung et al.,54 Oral andMaxillofacial Surgery, HongKong

2004 60 Manual (not

Edwards et al.,55 Oral andMaxillofacial SurgeryAssociates, New York, USA

2001 20 Manual

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

1997 40 Manual (not

Total 240

between counterclockwise rotation of the proximal

segment during surgery and skeletal relapse. Arporn-maeklong et al.34 concluded that maxillomandibularcorrection of class II malocclusion was stable in themajority of patients, whereas a few exhibited signif-icant skeletal relapse regardless of any simultaneoususe of rigid internal fixation.

Berger et al.41 observed a significant relapse in thevertical height of the posterior mandible (Co-Go) inboth the rigid and the transosseous wiring groups oftheir series, but they identified no relapse in the con-dylion-gnathion and condylion–B point distances, pos-tulating that remodeling took place in the gonial anglewith only a minimal change or remodeling in the con-dylar head of the mandible. They suggested that read-justing the skeleton-jaw relationship induces remodel-ing changes in the gonial angle, reducing the effectiveposterior face height.

Kallella et al.42 claimed that changes in condylarposition and anatomic structures, together with techni-cal errors, could explain the marked variability in thedirection and rate of skeletal relapse between patientswith comparable advancements and fixation methods.However, they saw no patients with condylar resorptionand, more importantly, they repositioned the proximal

eletal patternFollow-up(months) Conclusion

d) 12 Resorbable materials permitted clinically fasterocclusal and condylar settling than standardtitanium osteosyntheses, because bonesegments showed slight clinical mobility up to6 weeks postoperatively.

d) 14 Skeletal relapse was affected by magnitude ofsurgical movement and different facial patternsaccording to the mandibulonasal plane angle;however, influences of both factors weredifferent between mandibular advancement andsetback.

d) 24 Bioresorbable fixation devices offer similarfunction to titanium in fixation fororthognathic surgery and do not entail anincrease in the clinical morbidities.

12 The initial clinical findings suggest that this formof bone fixation is a viable alternative tostandard metallic fixation techniques forcertain maxillomandibular deformities inwhich excessive bony movements are notperformed.

d) The TIOPS computerized cephalometricorthognathic program is useful in orthognathicsurgical simulation, planning, and predictionand in postoperative evaluation of surgicalprecision and stability.

rm skof the

le

specifie

specifie

specifie

specifie

segment manually in their sample of patients.


Blomqvist et al.43 recognized that proper reposition-ing of the condyles is essential to preventing majorrelapse when the intermaxillary fixation is released,emphasizing the role of rigid fixation to control theocclusion postoperatively; here again, there is no men-tion of any use of CPDs.

Table III shows the 7 studies reviewed concerningskeletal stability after orthognathic surgery for openbite deformities; none of these studies reported usingCPDs.45-51

Frey et al.47 said that the role of condylar distractionfrom the glenoid fossa and failure to control the prox-imal segment during surgery deserve further investiga-tion but that they always rely on manual repositioning.

Emshoff et al.48 agreed that distraction of thecondyles medially or inferiorly can cause mandibularrelapse. They did not report on any use of CPDs,however, and pre- and postoperative radiographs ofthe TMJ with the teeth in occlusion were obtainedfrom the 26 patients studied, and none of them re-quired reoperation. They also showed that using rigidfixation improved stability after bimaxillary surgery.As they themselves said, however, whether this isprimarily related to the fact that rigid fixation maybetter control the rotation between the proximal anddistal segment, maintain the condyle-fossa relation-ship during the healing phase, or allow the surgeon tocheck the condylar position at surgery remains un-known.

Ayoub et al51 evaluated stability after bimaxillaryosteotomy to correct class II skeletal deformities in 2groups of patients: one treated at Canniesburn Hospitaland the other at Ann Arbor Michigan University Hos-pital. The surgical technique used at both centers wasthe same, except that condyles were pushed more pos-teriorly in the Canniesburn cases than in the Michigancases. The authors found a difference in the way theproximal segments were handled in the 2 groups, i.e., inthe Canniesburn cases the proximal and distal segmentswere held together with a bone clamp to close theosteotomy gap between the distal and proximal seg-ments at the time of fixation. The authors postulatedthat closing the gap between the bony segments mayhave torqued the condyles, causing a compression thatled to remodeling changes and relapse. They concludedthat improper placement of the proximal segment anddisplacement of the condyles during sagittal split fixa-tion can influence mandibular stability and recom-mended further studies to focus on the change in con-dylar position, not only anteroposteriorly but alsomediolaterally, and to assess its influence on mandib-ular stability. They also said it would be useful toinvestigate the usage of CPDs.

Table IV lists 5 studies in which skeletal stability

was analyzed in patients with a nonuniform skeletalpattern.52-56 Here again, none of these studies reportedon the use of CPDs.

Overall, 38 studies were reviewed and the use ofCPDs was described in only 3 of them. We mighttherefore argue that, in the last 12 years, the use ofCPDs has not been considered to be crucial to skeletalstability. Even if suggested in the literature,51 the use ofCPDs was not analyzed for preventing skeletal insta-bility. Those clinicians who did study skeletal stabilitydid not routinely use CPDs or if they did it was notmentioned in their methods.

TEMPOROMANDIBULAR JOINTDYSFUNCTION IN ORTHOGNATHICSURGERY AND CPDS

Condylar remodeling has been thoroughly investi-gated in patients with postoperative TMJ problems.57

Because the placement of rigid internal fixation devicescan displace the condyles, it has been suggested thatrigid fixation can have a role in postoperative temporo-mandibular dysfunction.58 Surgery-related changes incondyle position can lead not only to early or lateocclusal instability, but may also favor the onset ofsigns and symptoms of TMD. The results of our reviewof the English-language medical literature since 1995on the incidence of TMD after mandibular orthognathicsurgery with rigid fixation are given in Table V.59-69

We found 11 studies involving 1,313 patients, butnone of them mentioned any use of CPDs.

Wolford et al.59 reported that patients with priorTMD undergoing orthognathic surgery, and mandibularadvancement in particular, are likely to experience asignificant worsening of their TMD. They made thepoint that TMJs are fundamental to the stability of theresults. They stressed that in the presence of a healthyjoint the passive seating of the proximal segments deepin the fossa with the articular discs in a proper anatomicrelationship provides predictable and stable outcomes.We can assume that the authors considered using CPDsto be clinically irrelevant, both for healthy TMJs and incases of prior TMD, because they usually performedconcomitant TMJ and orthognathic surgery.70 It is verydifficult to assess the concomitant treatment of TMJabnormalities and skeletal abnormalities, because theauthors did not clearly discuss their criteria for surgery.

The majority of the authors reported an overall ben-eficial effect of orthognathic surgery on signs andsymptoms of TMD.60,62-64,66 When rigid fixation of themandible was compared with wire osteosynthesis andmaxillo-mandibular fixation, no significant differenceswere generally reported in terms of TMD.60,62,68 Usinga randomized clinical trial design and the manual re-
positioning of the proximal mandibular segment, Nem-


Table V. Incidence of TMD after mandibular orthognathic surgery with rigid fixation

Author(s) Year Patients DeviceFollow-up(months) Conclusion

Wolford et al.,59 Oral and MaxillofacialSurgery, Dallas, USA

2003 25 No 12 Patients with preexisting TMJ dysfunction undergoingorthognathic surgery, particularly mandibularadvancement, are likely to have significant worsening ofthe TMJ dysfunction after surgery.

Westermark et al.,60 KarolinskaHospital, Stockholm, Sweden

2001 386 No 24 Preoperatively 43% and postoperatively 28% of the patientsreported subjective symptoms of TMD. This differenceindicates an overall beneficial effect of orthognathicsurgery on TMD signs and symptoms. Sagittal ramusosteotomy was less effective than vertical ramusosteotomy in relieving TMD symptoms when performedon similar diagnoses.

Hu et al.,61 Department of Oral andMaxillofacial Surgery, Chengdu,China

2000 22 No 6 Intraoral oblique ramus osteotomy with MMF appears to bemore favorable to the TMJ than the sagittal split ramusosteotomy with RIF.

Nemeth et al.,62 Department ofProsthodontics and Periodontology,Faculty of Dentistry of Piracicaba

2000 140 No 24 The long-term (2 years) effects of wire and rigid internalfixation methods on the signs and symptoms oftemporomandibular disorders do not differ. Earlierconcerns about increased risk of TMDs with rigidfixation were not supported by these results.

Panula et al.,63 Department of Oral andMaxillofacial Surgery, Vaasa CentralHospital, Finland

2000 60 No 48 Functional status can be significantly improved and painlevels reduced with orthognathic treatment. The risk ofnew TMD is extremely low. No association, however,could be shown between TMD and the specific type ormagnitude of dentofacial deformity.

Gaggl et al.,64 Clinical Department ofOral and Maxillofacial Surgery, Graz,Austria

1999 25 No 3 Improvement of the disc position was achieved byrepositioning of the condylar-disc complex duringorthognathic surgery in angle class II patients. Clinicaland magnetic resonance imaging findings regarding theTMJ in class II patients correlated significantly bothpreoperatively and postoperatively.

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

1998 67 No 69 RIF in bimaxillary osteotomies resulted in condylarremodeling in 30% and progressive condylar resorptionin 19% of the patients. Condylar changes were notsignificantly different after using either miniplateosteosynthesis or positional screws in BSSO procedures.

De Clercq et al.,66 Department ofSurgery, Bruges, Belgium

1998 296 No 12 There was a subjective improvement in TMJ function in40% of the patients and a worsening in 11%; masticatoryfunction was improved in 41% and worsened in 7% ofthe patients.

De Clercq et al.,67 Department ofSurgery, Bruges, Belgium

1995 196 No 6 Fewer TMJ symptoms were found postoperatively thanpreoperatively 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 symptomswere seen postoperatively.

Feinerman and Piecuch,68 Departmentof Oral and Maxillofacial Surgery,Farmington, USA

1995 66 No Rigid 36Nonrigid 71

There were no demonstrable long-term differences betweenrigid and nonrigid fixation methods with respect tomandibular vertical opening, crepitance, and TMJ pain.Masticatory muscle pain and temporomandibular jointclicking improved with rigid fixation and worsened withnonrigid fixation.

Onizawa et al.,69 Department ofStomatology, University of Tsukuba,Japan

1995 30 No 6 Alterations of TMJ symptoms after orthognathic surgery donot always result from the correction of malocclusion.

Total 1,313

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


eth et al.62 found no significant differences in TMDsigns or symptoms comparing rigid fixation and wirefixation. They postulated that the reasons earlier studiesmay have found that rigid fixation procedures couldincrease the risk of TMD were related to their retro-spective design and/or smaller numbers of patients.They also claimed that the risks of TMD with rigidfixation were higher in the past, because the procedureis fairly technique sensitive, so the risks of TMD haveprobably decreased as surgeons have become moreexperienced. Several authors60,66,67 thought that spe-cific dentofacial deformities, e.g., the high-angle group,coincide with a higher likelihood of developing newTMJ symptoms after bimaxillary surgery, but this isattributed more to a greater loading of the mandibularcondyle creating a deeper bite pattern than to anyintraoperative change in the position of the mandibularcondyle.

Although authors generally agree that a change incondylar position during orthognathic surgery can ex-acerbate the signs and symptoms of TMD, our reviewfails to support this conviction. Moreover, all of thestudies reviewed that consider the influence of orthog-nathic surgery on TMJ function did not mention anyuse of CPDs.

CPDS: SCIENTIFIC EVIDENCE TO SUPPORTTHEIR CLINICAL USE

Many clinicians are concerned that rigid internalfixation can induce great changes in the position of thecondyle. Although the use of CPDs seems reasonable,no critical assessment of their use is currently available.CPDs have meant longer operating times, the need tokeep the intermaxillary fixation as stable as possibleduring their use, the need for precision in the fashioningof the splint or intraoperative wax bite. The mostwidely used method for repositioning the condylar frag-ment after a mandibular osteotomy is to put it in theglenoid cavity,1 and the quality of the procedure de-pends largely on the operator’s experience. So the bestway to understand the real clinical advantages of usingCPDs is to compare their use with the traditional orempirical methods for repositioning the condyle in thefossa during orthognathic surgery.

Reviewing the English-language literature from1990, we found only 6 papers comparing the use ofCPDs with traditional methods (Table VI).71-76

Rotskoff et al.76 evaluated condylar position in 20patients before and 1 day after mandibular advance-ments. Ten of the patients underwent condylar reposi-tioning using a device: They were better able to placethe condyle in the preoperative position with the aid ofthe 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 CPD’s abilityto maintain the preoperative position, but no advan-tages in terms of skeletal stability or TMJ function werereported.

Helm and Stepke75 evaluated 30 prognathic patientstreated with bimaxillary osteotomies, recording theirjoint motion with an axiograph: only 1 patient had apathologic shortening of the joint track length. Theyconcluded that the Luhr device is effective in securingcondyle position and consequently also TMJ function.The problem with this particular study is that there wereno control subjects, so it is difficult to assess the benefitof the CPD.

Renzi et al.74 compared the clinical and radiographicfindings at 1 year in 2 groups of 15 patients each whohad bimaxillary surgery to correct dental-skeletal classIII malocclusions: CPDs were used in one group andmanual repositioning in the other. No relapses or post-operative TMD were observed in any of the 30 patients.The authors concluded that CPDs are not necessary inpatients with dental-skeletal class III malocclusionswithout any preoperative TMD. They recommendedusing CPDs only in the case of TMD, although theirsample of patients cannot support such a recommenda-tion, because none of them had TMD.

Landes and Sterz73 performed bimaxillary surgery ina study group of 23 patients with intraoperative jointpositioning using a splint and CPD. Eighteen bimaxil-lary-operated controls had conventional plates insertedaccording to their habitual occlusion. The study grouphad significantly less postoperative dysfunction thanthe control group, with a lower prevalence of discdislocation, more limited postoperative changes in con-dylar translation, and 8% skeletal relapses as opposedto 22% in the controls.

The most interesting papers, in our opinion, are thosepublished recently by Geressen at al.71-72 The first72

examined whether using CPD in BSSO affords greaterlong-term benefits in terms of TMJ function than themanual positioning technique. Joint function was ana-lyzed using axiography and clinical examination in 49patients who underwent BSSO or bimaxillary osteot-omy: in 10 of 28 patients with mandibular advancementand 10 of 21 with mandibular setback, the Luhr posi-tioning device was used intraoperatively to reproducethe condylar position. In mandibular advancementcases, the manually positioned group showed signifi-cantly fewer signs of TMD, whereas there were slightadvantages in axiographically measured joint tracklengths for the patients operated with positioning de-vices. After mandibular setback surgery, clinical anal-ysis and axiography showed comparable results in the 2groups. The authors concluded that using a positioning
device did not assure a better long-term functional


outcome than the manual positioning technique in ei-ther mandibular advancement or setback surgery interms of TMJ function.

The second paper71 examined whether using CPDsinstead of manual positioning had a favorable influenceon skeletal stability in 49 patients who had undergoneBSSO or bimaxillary surgery. Neither in advancementnor in setback surgery did using the positioning deviceresult in a better outcome. The authors concluded thatusing the positioning appliances did not improve skel-etal stability and that, concerning TMJ function, themanual positioning technique enabled equally stableresults to be obtained in advancement as well as insetback surgery.

Two other publications that discuss the accuracy ofcondylar repositioning during orthognathic surgery arenot included in Table VI, because they did not comparethe use of CPDs with the traditional method. Landes77

compared dynamic proximal segment positioning by

Table VI. Studies comparing the use of CPDs with tra

Author(s) Year Condylar deviceCPD

patient

Gerressen et al.,71 Departmentof Oral, Maxillofacial, andPlastic Facial Surgery,Aachen, Germany

2007 Positioning plates(Leibinger)

20

Gerressen et al.,72 Departmentof Oral, Maxillofacial andPlastic Facial Surgery,Aachen, Germany


20

Landes and Sterz,73

Maxillofacial and PlasticFacial Surgery, Frankfurt,Germany


23

Renzi et al.,74 MaxillofacialSurgery Department, Rome,Italy


15

Helm and Stepke,75 Departmentof Maxillofacial Surgery,Frankfurt, Germany

1997 Positioning plates(Luhr-device)

30

Rotskoff K, et al.,76 St. Mary’sHealth Center andDentofacial Deformities andOrofacial Pain Center, StLouis, USA

1991 Positioningdevice

10

Total 141withCPD

CPD, Condylar positioning device.

intraoperative sonography with the splint and plate

technique discussed in the earlier paper. Sonographicplacement enabled a dynamic intraoperative monitor-ing of the condylar position and took an average of 5min, as opposed to the 25 min needed for conventionalpositioning. The author concluded that postoperativereduction of condylar translation and recovery, dys-function, and disc dislocation were comparable with the2 methods at 1-year follow-up, but that the new tech-nique enabled intraoperative real-time monitoring anddynamic correction and it proved safe, easier, and fasterthan conventional plate positioning. Judging from thisarticle, clinicians might be able to save 20 minutes ofoperating time if they became expert with intraopera-tive sonography, without any significant clinical advan-tage for patients.

Bettega et al.8 published the first interesting paper onthe clinical advantages of a computer-assisted systemfor replacing the condyle over the traditional method.Eleven patients underwent condylar repositioning using

al methodstrolup Type of surgery

Follow-up(months) Conclusion

9 28 class II21 class III

35 The use of positioningappliances does not lead toan improvement in skeletalstability.


From 6 to120

The use of a positioningdevice did not provide abetter functional outcome inthe long term in eithermandibular advancement orsetback surgery.


24 The study group exhibited lesspostoperative dysfunctionthan the control group and8% skeletal relapses versus22% in the control group.

5 30 class III 12 The use of CPDs can beavoided in patients withdental-skeletal class IIIwithout presurgicaltemporomandibulardysfunction.

- 30 class III Notreported

The Luhr device is effective insecuring condyle positionand therefore TMJ function.

0 20 class II 1 day A significant improvement wasobserved in the vertical andhorizontal condylar positionin the group in which aCPD was used.

anual

dition

sCongro

2

2

1

1

1

s

112m

the empirical repositioning method, in 10 patients (ac-


tive group) the computer-assisted system was used toreplace the condyle in its sagittal preoperative position,and in another 10 (graft group) the computer-assistedsystem was used to place the condyle in all 3 directions.The authors found that they needed to fill the osteotomygap with a bone graft more frequently in the last group.They reported 5 patients in the “empirical group” nothaving the expected postoperative occlusion, 5 hadevidence of clinical relapse at 1 year, 5 had worseTMD, and only 63.37% of the patients’ mandibularmotion had been recovered at 6 months. All of thepatients in the “active group” had the expected occlu-sion, and only 1 had a mild relapse and TMD symp-toms, but the mean mandibular motion recovered wasonly 62.65% at 6 months. All of the patients in the“graft group” had a good occlusion and no relapse orTMD, and they had recovered 77.58% of their mandib-ular motion at 6 months. The authors concluded that thequality of sagittal repositioning is the main factor con-tributing to a good occlusion and bone stability,whereas functional results depend more on limitingcondylar torque.

Intraoperative surgical navigation seems to be pre-cise, but the method is elaborate; it requires extraincisions and equipment and the adaptation of diodereflectors, and this probably explains why there is only1 publication8 regarding this method.

Taken together, in the 6 studies we reviewed, 141patients with CPDs were compared with 112 patientstreated using conventional manual repositioning. Threestudies supported the use of CPDs,73-76 but only 173

supported their application to improve clinical outcomeconcerning TMJ function and skeletal stability.

One study,74 which was limited to class III maloc-clusions, supported the use of CPDs only in the case ofTMD. Two studies did not support the use of CPDs,because they failed to improve skeletal stability or TMJfunction, irrespective of the skeletal deformities treated.

CONCLUSIONSVery little was changed since Ellis11 published his

outstanding, comprehensive review on the use of CPDsin orthognathic surgery. From the studies we reviewed,we conclude that since 1995 both skeletal/occlusal sta-bility and TMJ function after orthognathic surgery havecontinued to be investigated substantially without con-sidering the use of CPDs. Most authors rely on manualrepositioning after sagittal split osteotomy to obtain thebest mandibular proximal segment relationship with thecondylar fossa. Because manual repositioning of theproximal segment continues to be the method of choice,we think it is best to opt for more simple and inexpen-sive methods for intraoperatively identifying a malpo-
sitioned condyle, such as intraoperative patient awak-
ening.78,79 From the studies published to date, weconclude that there is no scientific evidence to supportthe routine use of CPDs in orthognathic surgery.

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Reprint requests:

Dr. F. CostaClinica di Chirurgia Maxillo-FaccialeAzienda Ospedaliero UniversitariaP.le S. Maria della Misericordia33100 UdineItaly
[email protected]
mailto:[email protected]

Condylar Positioning Devices for Orthognathic Surgery

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