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Condylar positioning devices for orthognathic surgery: a

literature review
Fabio Costa, MD,a Massimo Robiony, MD,b Corrado Toro, MD,c Salvatore Sembronio, MD,c
Francesco Polini, MD,a and Massimo Politi, MD, DMD,d Udine, Italy
DEPARTMENT OF MAXILLOFACIAL SURGERY, UNIVERSITY OF UDINE

In the past few years, many devices have been proposed for preserving the preoperative position of the
mandibular condyle during bilateral sagittal split osteotomy. Accurate mandibular condyle repositioning is considered
important to obtain a stable skeletal and occlusal result, and to prevent the onset of temporomandibular disorders
(TMD). Condylar positioning devices (CPDs) have led to longer operating times, the need to keep intermaxillary
fixation as stable as possible during their application, and the need for precision in the construction of the splint or
intraoperative wax bite. This study reviews the literature concerning the use of CPDs in orthognathic surgery since
1990 and their application to prevent skeletal instability and contain TMD since 1995. From the studies reviewed, we
can conclude that there is no 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 been


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

Consultant in Maxillofacial Surgery.


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

clinical usage of CPDs to prevent skeletal instability


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

180

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Costa et al.

Table I. Skeletal stability after mandibular setback


Positioning of the
condyle

Follow-up
(months)

Author(s)

Year

Patients

Costa et al.,19 Department of


Maxillofacial Surgery,
Udine, Italy.

2006

22

Manual

12

Ueki et al.,20 Department of


Oral and Maxillofacial
Surgery, Kanazawa, Japan

2005

40

Manual

Not specified

Ueki et al.,21 Department of


Oral and Maxillofacial
Surgery, Kanazawa, Japan

2005

20

Manual (not specified)

12

Chou et al.,22 Department of


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

2005

64

Manual (not specified)

12

2004

17

Manual

12

Mobarak et al.,24 Department


of Orthodontics, Oslo,
Norway

2000

80

Manual

36

Kwon et al.,25 Oral and


Maxillofacial Surgery,
Osaka, Japan

2000

25

Device

Marchetti et al.,26
Maxillofacial Surgery
Department, Bologna, Italy
Bailey et al.,27 Department of
Orthodontics, Chapel Hill,
USA

1999

15

Manual (not specified)

1998

35

Manual (not specified)

42

Harada and Enomoto,28 Oral


and Maxillofacial Surgery,
Tokyo, Japan
Schatz and Tsimas,29
Department of Orthodontics
and Pedodontics, Geneva,
Switzerland

1997

20

Device

12

1995

13

Manual (not specified)

12

1995

29

Manual (not specified)

14

Ingervall B, et al. University


of Bern, Switzerland.30

Total

Conclusion
Surgical correction of class III malocclusion
after combined maxillary and mandibular
procedures appears to be a fairly stable
procedure for maxillary advancements up
to 5 mm whatever the type of fixation
used to stabilize the maxilla.
The change in condylar angle after BSSO
and fixation with a titanium plate is
greater than after BSSO and fixation with
a PLLA plate, but skeletal stability
related to the occlusion is similar for the
2 procedures.
The present results suggest a significant
difference between SSRO and IVRO in
the time course of changes in the
proximal segment including the condyle
and distal segment.
A significant amount of relapse occurred
within 1 year after surgery.
Surgical correction of class III malocclusion
after combined maxillary and mandibular
procedures appears to be a fairly stable
procedure irrespective of the type of
fixation used to stabilize the mandible.
Clockwise rotation of the ascending ramus
at surgery with lengthening of the
elevator muscles, although evident in this
study and apparently responsible for the
early horizontal postoperative changes,
does not seem to be associated with
marked relapse.
Relapse of the mandible seems to be
influenced mainly by the amount and
direction of the surgical alteration of the
mandibular position
Stability of mandibular fragments depended
on the stability of the maxilla.
More than 90% of the patients showed no
clinically significant long-term changes,
which suggests that long-term changes
are less likely after class III than after
class II treatment.
Fixation of the bony segments with PLLA
screws after SSRO may be used
effectively in properly selected cases
Rigid internal fixation was unable to
prevent relapse. Technical refinements
should be investigated to improve the
stability of bilateral sagittal split
osteotomy.
The net effects on the labial fold and the
soft tissue of the chin were closely
correlated with those on their underlying
hard structures.

380

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

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Costa et al. 181

Table II. Skeletal stability after mandibuar advancement


Author(s)

Year

Patients

Positioning of the
condyle

Follow-up
(months)

Turvey et al.,31 Department of


Oral and Maxillofacial
Surgery, Chapel Hill, USA

2006

69

Manual (not specified)

12

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

2006

32

Manual (not specified)

144

Borstlap et al.,33 Department


of Oral and Maxillofacial
Surgery, Nijmegen, The
Netherlands

2004

222

Manual (gauzepacking instrument)

24

Arpornmaeklong et al.,34
Department of Oral and
Maxillofacial Surgery,
Melbourne, Australia

2004

29

Manual (not specified)

25

Ferretti and Reyneke,35


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

2002

40

Device

12

2002

57

Manual

60

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

2001

20

Manual (not specified)

12

Mobarak et al.,38 Department


of Orthodontics, University
of Oslo, Norway

2001

61

Manual

36

Dolce et al.,39 Department of


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

2000

78

Manual

24

2000

64

Manual (not specified)

24

2000

28

Manual (not specified)

15

Berger et al.,41 University of


Detroit, Detroit, USA

Conclusion
2-mm self-reinforced PLLDL (70/30) screws can
be used as effectively as 2-mm titanium
screws to stabilize the mandible after bilateral
sagittal osteotomies for mandibular
advancement.
Surgical displacement of the condyle in an
inferior and posterior direction may
compensate for early skeletal relapse.
Progressive condylar resorption seems to be
mainly responsible for long-term skeletal
relapse.
The sagittal split osteotomy fixed with
miniplates appeared to be a relatively safe and
reliable procedure, giving rise to a high
degree of patient satisfaction, despite the fact
that some occlusal relapse was seen.
The majority of patients undergoing bimaxillary
surgery for the correction of skeletal class II
malocclusions maintained a stable result. A
small number of patients suffered significant
skeletal relapse in the mandible owing to
condylar remodelling and/or resorption.
Resorbable PLLA/PGA copolymer bicortical
screw fixation of a BSSO is a viable
alternative to titanium screws for the fixation
of advancement BSSO.
Although rigid fixation is more stable than wire
fixation for maintaining the skeletal
advancement after a BSSO, the incisor
changes made the resultant occlusions of the 2
groups indistinguishable.
Total mandibular alveolar osteotomy is the
treatment of choice for the correction of
severe dentoalveolar retrusive class II
malocclusion for which an alteration of the
mentolabial sulcus is desirable.
High-angle patients were associated with both a
higher frequency and a greater magnitude of
horizontal relapse. The high rate of late
relapse observed among high-angle cases
indicates that condylar morphologic changes
might occur with a greater frequency than
previously thought.
Rigid fixation is a more stable method than wire
fixation for maintaining mandibular
advancement after SSRO.
2 years after surgery, mandibular symphasis was
unchanged in the rigid group, whereas 26% of
the wire group had sagittal relapse. However,
the overjet and molar discrepancy had
relapsed similarly in the 2 groups.
There was a statistically significant relapse in
mandibular length, lower anterior face height,
mandibular arc, lower incisor inclination,
overbite, and overjet in each group, regardless
of the type of fixation. The potential was
greater for relapse in patients stabilized with
transosseous wiring.

182

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Costa et al.

Table II. Continued.


Author(s)

Positioning of the
condyle

Follow-up
(months)

Year

Patients

Kallella et al.,42 Department


of Oral and Maxillofacial
Surgery, Helsinki, Finland

1998

25

Manual

12

Blomqvist et al.,43 Department


of Oral and Maxillofacial
Surgery, Halmstad, Sweden

1997

60

Manual (not specified)

Nimkarn et al.,44 Department


of Oral and Maxillofacial
Surgery, Birmingham, USA
Total

1995

19

Manual (not specified)

12

Conclusion
SR-PLLA screws are considered to be
comparable to other forms of rigid internal
fixation for fixation of bilateral splitting
osteotomies after mandibular advancement, as
far as skeletal stability is concerned.
This prospective dual-center study indicates that
the two different methods of internal rigid
fixation after surgical advancement of the
mandible by BSSO did not significantly differ
from each other.
Large surgical advancements in OSAS patients
result in relatively stable repositioning of the
maxilla and mandible over the long term.

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
Position of the
condyle

Follow-up
(months)

Author(s)

Year

Patients

45

Reyneke et al., Department of


Maxillofacial and Oral
Surgery, Johannesburg, South
Africa

2007

88

Manual

Iannetti et al.,46 Maxillofacial


Surgery Department, Rome,
Italy

2007

20

Manual (not
specified)

24

Frey et al.,47 Department of


Orthodontics, San Antonio,
USA

2007

78

Manual

24

Emshoff et al.,48 Department of


Oral and Maxillofacial
Surgery, Innsbruck, Austria

2003

26

Manual (not
specified)

12

Swinnen et al.,49 Department of


Orthodontics, Leuven,
Belgium

2001

37

Manual (not
specified)

12

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

1997

70

Manual (not
specified)

69

Ayoub et al.,51 University of


Glasgow, UK
Total

1997

30

Manual

349

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

13,9

Conclusion
The long-term skeletal stability of clockwise rotation
and counterclockwise rotation of the
maxillomandibular complex (MMC) compares
favorably with the postoperative skeletal stability
of conventional treatment when the rotation of the
MMC takes place around a point at the condyle.
In class III patients with anterior open bite treated
with mono- or bimaxillary surgery and rigid
internal fixation, the maxilla was demonstrated to
be stable, whereas there was a moderate rate of
mandibular relapse dependent on the amount of
surgical alteration.
Surgically closing the mandibular plane angulation is
associated with late horizontal and vertical
relapse, whereas fixation type is related to early
B-point movement.
The data confirm the concept that the bimaxillary
approach of Le Fort I impaction and BSSO
advancement using the described technique of
RIF is a stable procedure in the treatment of open
bite patients classified as vertical maxillary excess
in combination with mandibular deficiency.
Open bite patients, treated by posterior Le Fort I
impaction and anterior extrusion, with or without
an additional BSSO, 1 year after surgery, exhibit
relatively good clinical dental and skeletal
stability.
It can be concluded that patients with anterior open
bites, treated with a Le Fort I osteotomy in 1
piece or in multisegments, with or without BSSO,
exhibited good skeletal stability of the maxilla.
Rigid internal fixation produced the best maxillary
and mandibular stability.
There is a difference in the way the proximal
segments were manipulated between the 2 groups.

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Costa et al. 183

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


Author(s)

Year

Patients

Positioning of the
condyle

Follow-up
(months)

Landes and Ballon,52


Maxillofacial and Facial Plastic
Frankfurt, Germany

2006

60

Manual (not specified)

12

Eggensperger et al.,53 Department


of Craniomaxillofacial Surgery,
Berne, Switzerland

2004

60

Manual (not specified)

14

Cheung et al.,54 Oral and


Maxillofacial Surgery, Hong
Kong

2004

60

Manual (not specified)

24

Edwards et al.,55 Oral and


Maxillofacial Surgery
Associates, New York, USA

2001

20

Manual

12

Donatsky et al.,56 Department of


Oral and Maxillofacial Surgery,
Glostrup, Denmark

1997

40

Manual (not specified)

Total

Conclusion
Resorbable materials permitted clinically faster
occlusal and condylar settling than standard
titanium osteosyntheses, because bone
segments showed slight clinical mobility up to
6 weeks postoperatively.
Skeletal relapse was affected by magnitude of
surgical movement and different facial patterns
according to the mandibulonasal plane angle;
however, influences of both factors were
different between mandibular advancement and
setback.
Bioresorbable fixation devices offer similar
function to titanium in fixation for
orthognathic surgery and do not entail an
increase in the clinical morbidities.
The initial clinical findings suggest that this form
of bone fixation is a viable alternative to
standard metallic fixation techniques for
certain maxillomandibular deformities in
which excessive bony movements are not
performed.
The TIOPS computerized cephalometric
orthognathic program is useful in orthognathic
surgical simulation, planning, and prediction
and in postoperative evaluation of surgical
precision and stability.

240

Only 2 studies reported using CPDs in a total of 45


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

segment during surgery and skeletal relapse. Arpornmaeklong et al.34 concluded that maxillomandibular
correction of class II malocclusion was stable in the
majority of patients, whereas a few exhibited significant skeletal relapse regardless of any simultaneous
use of rigid internal fixation.
Berger et al.41 observed a significant relapse in the
vertical height of the posterior mandible (Co-Go) in
both the rigid and the transosseous wiring groups of
their series, but they identified no relapse in the condylion-gnathion and condylionB point distances, postulating that remodeling took place in the gonial angle
with only a minimal change or remodeling in the condylar head of the mandible. They suggested that readjusting the skeleton-jaw relationship induces remodeling changes in the gonial angle, reducing the effective
posterior face height.
Kallella et al.42 claimed that changes in condylar
position and anatomic structures, together with technical errors, could explain the marked variability in the
direction and rate of skeletal relapse between patients
with comparable advancements and fixation methods.
However, they saw no patients with condylar resorption
and, more importantly, they repositioned the proximal
segment manually in their sample of patients.

184

Costa et al.

Blomqvist et al.43 recognized that proper repositioning of the condyles is essential to preventing major
relapse when the intermaxillary fixation is released,
emphasizing the role of rigid fixation to control the
occlusion postoperatively; here again, there is no mention of any use of CPDs.
Table III shows the 7 studies reviewed concerning
skeletal stability after orthognathic surgery for open
bite deformities; none of these studies reported using
CPDs.45-51
Frey et al.47 said that the role of condylar distraction
from the glenoid fossa and failure to control the proximal segment during surgery deserve further investigation but that they always rely on manual repositioning.
Emshoff et al.48 agreed that distraction of the
condyles medially or inferiorly can cause mandibular
relapse. They did not report on any use of CPDs,
however, and pre- and postoperative radiographs of
the TMJ with the teeth in occlusion were obtained
from the 26 patients studied, and none of them required reoperation. They also showed that using rigid
fixation improved stability after bimaxillary surgery.
As they themselves said, however, whether this is
primarily related to the fact that rigid fixation may
better control the rotation between the proximal and
distal segment, maintain the condyle-fossa relationship during the healing phase, or allow the surgeon to
check the condylar position at surgery remains unknown.
Ayoub et al51 evaluated stability after bimaxillary
osteotomy to correct class II skeletal deformities in 2
groups of patients: one treated at Canniesburn Hospital
and the other at Ann Arbor Michigan University Hospital. The surgical technique used at both centers was
the same, except that condyles were pushed more posteriorly in the Canniesburn cases than in the Michigan
cases. The authors found a difference in the way the
proximal segments were handled in the 2 groups, i.e., in
the Canniesburn cases the proximal and distal segments
were held together with a bone clamp to close the
osteotomy gap between the distal and proximal segments at the time of fixation. The authors postulated
that closing the gap between the bony segments may
have torqued the condyles, causing a compression that
led to remodeling changes and relapse. They concluded
that improper placement of the proximal segment and
displacement of the condyles during sagittal split fixation can influence mandibular stability and recommended further studies to focus on the change in condylar position, not only anteroposteriorly but also
mediolaterally, and to assess its influence on mandibular stability. They also said it would be useful to
investigate the usage of CPDs.
Table IV lists 5 studies in which skeletal stability

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August 2008

was analyzed in patients with a nonuniform skeletal


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

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Volume 106, Number 2

Costa et al. 185

Table V. Incidence of TMD after mandibular orthognathic surgery with rigid fixation
Author(s)

Year Patients Device

Wolford et al.,59 Oral and Maxillofacial 2003


Surgery, Dallas, USA

25

No

Westermark et al.,60 Karolinska


Hospital, Stockholm, Sweden

2001

386

No

Hu et al.,61 Department of Oral and


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

2000

22

No

2000

140

No

2000

60

No

Gaggl et al.,64 Clinical Department of


1999
Oral and Maxillofacial Surgery, Graz,
Austria

25

No

Hoppenreijs et al.,65 Department of


Oral and Maxillofacial Surgery,
Arnhem, The Netherlands

1998

67

No

De Clercq et al.,66 Department of


Surgery, Bruges, Belgium

1998

296

No

De Clercq et al.,67 Department of


Surgery, Bruges, Belgium

1995

196

No

Feinerman and Piecuch,68 Department


of Oral and Maxillofacial Surgery,
Farmington, USA

1995

66

No

Onizawa et al.,69 Department of


Stomatology, University of Tsukuba,
Japan
Total

1995

30

No

Panula et al.,63 Department of Oral and


Maxillofacial Surgery, Vaasa Central
Hospital, Finland

Follow-up
(months)

Conclusion

12

Patients with preexisting TMJ dysfunction undergoing


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

1,313

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

186

Costa et al.

eth et al.62 found no significant differences in TMD


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

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August 2008

could be seen as a study to compare the CPDs ability


to maintain the preoperative position, but no advantages in terms of skeletal stability or TMJ function were
reported.
Helm and Stepke75 evaluated 30 prognathic patients
treated with bimaxillary osteotomies, recording their
joint motion with an axiograph: only 1 patient had a
pathologic shortening of the joint track length. They
concluded that the Luhr device is effective in securing
condyle position and consequently also TMJ function.
The problem with this particular study is that there were
no control subjects, so it is difficult to assess the benefit
of the CPD.
Renzi et al.74 compared the clinical and radiographic
findings at 1 year in 2 groups of 15 patients each who
had bimaxillary surgery to correct dental-skeletal class
III malocclusions: CPDs were used in one group and
manual repositioning in the other. No relapses or postoperative TMD were observed in any of the 30 patients.
The authors concluded that CPDs are not necessary in
patients with dental-skeletal class III malocclusions
without any preoperative TMD. They recommended
using CPDs only in the case of TMD, although their
sample of patients cannot support such a recommendation, because none of them had TMD.
Landes and Sterz73 performed bimaxillary surgery in
a study group of 23 patients with intraoperative joint
positioning using a splint and CPD. Eighteen bimaxillary-operated controls had conventional plates inserted
according to their habitual occlusion. The study group
had significantly less postoperative dysfunction than
the control group, with a lower prevalence of disc
dislocation, more limited postoperative changes in condylar translation, and 8% skeletal relapses as opposed
to 22% in the controls.
The most interesting papers, in our opinion, are those
published recently by Geressen at al.71-72 The first72
examined whether using CPD in BSSO affords greater
long-term benefits in terms of TMJ function than the
manual positioning technique. Joint function was analyzed using axiography and clinical examination in 49
patients who underwent BSSO or bimaxillary osteotomy: in 10 of 28 patients with mandibular advancement
and 10 of 21 with mandibular setback, the Luhr positioning device was used intraoperatively to reproduce
the condylar position. In mandibular advancement
cases, the manually positioned group showed significantly fewer signs of TMD, whereas there were slight
advantages in axiographically measured joint track
lengths for the patients operated with positioning devices. After mandibular setback surgery, clinical analysis and axiography showed comparable results in the 2
groups. The authors concluded that using a positioning
device did not assure a better long-term functional

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Costa et al. 187

Table VI. Studies comparing the use of CPDs with traditional methods
Author(s)

Year

Condylar device

CPD
Control
Follow-up
patients group Type of surgery (months)

Gerressen et al.,71 Department


of Oral, Maxillofacial, and
Plastic Facial Surgery,
Aachen, Germany
Gerressen et al.,72 Department
of Oral, Maxillofacial and
Plastic Facial Surgery,
Aachen, Germany

2007 Positioning plates


(Leibinger)

20

29

28 class II
21 class III

2006 Positioning plates


(Leibinger)

20

29

28 class II
21 class III

Landes and Sterz,73


Maxillofacial and Plastic
Facial Surgery, Frankfurt,
Germany

2003 Positioning plates


(Leibinger)

23

18

18 class II
23 class III

Renzi et al.,74 Maxillofacial


Surgery Department, Rome,
Italy

2003 Positioning plates


(Leibinger)

15

15

30 class III

Helm and Stepke,75 Department 1997 Positioning plates


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

Conclusion

35

The use of positioning


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

CPD, Condylar positioning device.

outcome than the manual positioning technique in either mandibular advancement or setback surgery in
terms of TMJ function.
The second paper71 examined whether using CPDs
instead of manual positioning had a favorable influence
on skeletal stability in 49 patients who had undergone
BSSO or bimaxillary surgery. Neither in advancement
nor in setback surgery did using the positioning device
result in a better outcome. The authors concluded that
using the positioning appliances did not improve skeletal stability and that, concerning TMJ function, the
manual positioning technique enabled equally stable
results to be obtained in advancement as well as in
setback surgery.
Two other publications that discuss the accuracy of
condylar repositioning during orthognathic surgery are
not included in Table VI, because they did not compare
the use of CPDs with the traditional method. Landes77
compared dynamic proximal segment positioning by
intraoperative sonography with the splint and plate

technique discussed in the earlier paper. Sonographic


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

188

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August 2008

Costa et al.

tive group) the computer-assisted system was used to


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

ening.78,79 From the studies published to date, we


conclude that there is no scientific evidence to support
the routine use of CPDs in orthognathic surgery.
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Reprint requests:
Dr. F. Costa
Clinica di Chirurgia Maxillo-Facciale
Azienda Ospedaliero Universitaria
P.le S. Maria della Misericordia
33100 Udine
Italy
maxil2@med.uniud.it