J Oral Maxillofac Surg

54:548-551. 1996

Modification of the Modified Condylotomy

H. DAVID HALL, DMD, MD*

Purpose: This article describes the results of modification of the condylotomy

procedure for treating painful internal derangements of the temporomandibular
joint.
Materials and Methods: Data on postoperative disc position, joint space,
and pain were evaluated in patients who underwent either the original modified
condylotomy or the newly modified procedure.
Results: Less anterior and inferior sag of the condyle was produced by the
new technique. Pain relief and disc reduction were about the same with both
procedures.
Conclusion: The new modifications make the operation quicker and easier,
while producing outcomes similar to those obtained with the original modified
procedure.

Magnetic resonance imaging (MRI) has demon-
strated spontaneous movement of the reducing dis-
placed disc after modified condylotomy in Wilkes
stage II, early stage III joints.‘.2 The disc sometimes
moves posteriorly and superiorly toward the 12 o’clock
position,2 accompanied by reciprocal condylar move-
ment, and becomes load bearing (reduced) approxi-
mately 70% of the time.‘” Before these MRI data, it
was assumed that disc reduction occurred because with
the original technique the condyle moved anteriorly
and inferiorly to a position beneath the displaced disc.
The realization that the disc and condyle can move
toward each other suggests that the condyle may not
need to move as far to effect disc reduction. Further-
more, pain is often relieved even when the disc is not
reduced, suggesting that unloading the retrodiscal or
other soft tissues by increasing joint space is the chief
reason pain is relieved. It is therefore possible that
a smaller amount of condylar movement may be as
effective as a larger amount for pain relief as well as
disc reduction. Thus, two modifications to the opera-
tion have been introduced that reduce both the anterior
and inferior movement of the condyle. A third unre-
lated change is further reduction of time in maxillo-
* Professor and Chairman, Department of Oral and Maxillofacial
Surgery, Vanderbilt University School of Medicine, Nashville, TN.
Address correspondence and reprint requests to Dr Hall: Depart-
ment of Oral and maxillofacial Surgery, Vanderbilt University
School of Medicine, 1623 The Vanderbilt Clinic, Nashville, TN
31232.
0 1996 American Association of Oral and Maxillofacial Surgeons
0278-2391/96/5405-0003$3.00/O
mandibular fixation (MMF), as suggested by Bell et
a1.4These modifications have simplified the procedure,
reduced operating time, and improved patient satisfac-
tion, but they do not seem to have changed outcomes.
Materials and Methods
Modifications to decrease movement of the condyle,
especially anterior movement, and to reduce the time
in MMF have been used in 190 consecutive patients
and 305 joints. Reducing (Wilkes stage II, early stage
III) and nom-educing (late stages III, IV) disc displace-
ments were verified by MRI in all joints before an
operation was performed. There may also have been
a few stage V joints, because perforations could not
be detected by MRI. Most of the joints were Wilkes
stage II or early stage III. The data on change in disc
position after surgery were derived from a subset of
55 consecutive joints with Wilkes stage II or early
stage III disease.’ Pain was evaluated before and after
modified condylotomy by asking 10 consecutive pa-
tients with 15 stage II and early stage III joints to fill
out a visual analog scale (VAS) consisting of a lo-cm
line with l-cm markings. Zero represented no pain,
and 10, the greatest amount of pain imaginable. These
estimates were compared with VAS estimates of pain
in 24 consecutive patients with 40 stage II and early
stage III joints and 19 consecutive patients with 27
early stage III, stage IV, and possibly stage V joints
on whom the same measurements had been performed
after modified condylotomy using the older surgical
technique. The increase in joint space after operation
was determined from tracings of the transcranial radio-

548
H. DAVID HALL
FIGURE 1. Diagram showing direction of movement of condyle
with original technique and current modification.
graphs of 10 joints in which the original technique had
been used’ and an additional 10 joints in which the
current technique was used. A single measurement was
made, representing an approximation of the vertical
change in condylar position. Although transcranial ra-
diographs do not provide precise indications of the
amount of joint space, they are capable of showing
gross changes and were uniformly consistent with the
gross changes demonstrated by MRI tomograms.
TECHNIQUE
The first modification reduces the anterior compo-
nent of movement of the condyle (Fig 1) by eliminating
trimming and overlap of the proximal segment or re-
moval of bone from the proximal segment before for-
mation of a butt joint.’ With the new technique, the butt
joint created by the osteotomy is maintained without
further modification (Fig 2). The principal component
of movement of the proximal segment in this instance
is inferior.
The second modification is reduction of condylar
sag. The amount of condylar sag is a function of the
laxity of the soft tissues attached to the proximal seg-
ment, including the medial pterygoid muscle. One way
549
to estimate laxity of these tissues is to place the sharp
end of a #9 periosteal elevator in the marrow space of
the proximal segment and move the segment inferiorly
and superiorly. Another way to estimate laxity and
condylar sag is to view the amount of sag of the proxi-
mal segment before any muscle is reflected. This can
be achieved by using a large, upward curved Obweg-
eser retractor to retract the soft tissues from the inferior
border of the mandible near the angle. The amount of
sag is represented by the difference in height between
the tip of the proximal segment and the inferior border.
Usually the distal 5 to 6 mm (about 20%) of the
medial pterygoid muscle is detached from the segment,
rather than the 50% to 60% described for the original
technique.’ In some instances, especially in late-stage
disease, there is sufficient laxity of the soft tissues to
permit a 2- to 3-mm sag of the proximal segment with-
out detaching any medial pterygoid muscle. An osteot-
omy too near the posterior border of the vertical ramus
leaves a smaller mass of muscle attached to the proxi-
mal segment and also may result in more sag. In such
instances, little or no muscle need be stripped from the
tip of the proximal segment, depending on how much
sag is desired. Conversely, if there is little or no move-
ment of the proximal segment, and the attached tissues
have less than the usual compliance, up to 15 mm of
muscle may be detached if moderate or marked sag is
desired.
The third modification is a reduction in the length
of time MMF is maintained from 3 weeks to 8 to 10
days. When MMF is removed, light elastic traction is
initiated, as previously recommended.’ The traction is
FIGURE 2. Panoramic radiographs of the right mandible showing
the osteotomy. The condylar segment forms a butt joint and “sags”
slightly.
550
FIGURE 3. Transcranial radiograph showing typical increase in
joint space using the current modifications. The increase in joint
space is mild, and the major vector of condylar movement
maintained for an additional 4.5 weeks, after which
the arch bars are removed, and chewing is resumed.
Results
Joint space increased by a mean of approximately
1.5 mm with the current technique compared with a
mean of 3.5 mm using the original method. The
amount of sag varied, but rarely was as great as with
the original technique. A typical amount of sag is illus-
trated in Fig 3. There were no complications in healing
with the reduced time in MMF. Pain relief with the
current modifications was similar to that obtained by
the older technique in both early and late-stage joints
(Fig 4). The rate of disc reduction was 85% for the
55 stage II, early stage III joints treated by the new
technique, compared with 72% in a prior series of 43
stage II, early stage III joints” using the older tech-
nique.
Discussion
The elimination of bone trimming and overlap of
the segments, or formation of a butt joint, has simpli-
fied the procedure and shortened surgery time, thereby
reducing operating room and anesthesia costs. The typ-
ical operating time, determined by review of 32 op-
MODIFICATION OF MODIFIED CONDYLOTOMY
erating room records, is approximately 90 minutes for
a bilateral case and includes arch bar placement. The
smaller increase in joint space with the current modifi-
cation should also lessen the difference between centric
occlusion and centric relation. Whether less joint space
will also reduce the already low incidence of anterior
open bite or retrusion of the mandible after surgery is
not yet known.
The rate of disc reduction with the current technique
was slightly higher than with the original. Because
there is generally less reciprocal movement between
the disc and condyle with the new technique, it was
expected that if there were any differences, the new
method would result in less frequent disc reduction.
Because no effort was made to assure comparable pop-
ulations of patients, the difference is likely explained
by use of the two techniques in different populations
of patients. It is anticipated that subsequent data will
show either that there is no difference between the two
techniques in rate of disc reduction or, if there is, that
it is a clinically insignificant amount.
Some internal derangements may be better treated
with the original modified condylotomy technique.
Greater condylar displacement may improve disc re-
duction when the amount of displacement seen in the
sagittal plane on MRI is great or when little or no
is vertical.
reciprocal disc movement is anticipated at surgery.
Poor movement of the disc after condylotomy seems
to be related to more advanced stages of degeneration.
Thus, one clue to predicting poor disc movement is
significant disc degeneration and deformity as deter-
mined by MPIs. Conversely, the current modification,
with less inferior and anterior condylar movement,
may be better for earlier-stage disease when good re-
ciprocal disc movement can be anticipated or when
10
6 7.5
-
6.7
6
.E
h
4
2
-
aI-
Before 2 mos. after
Operation Operation
FIGURE 4. Pain levels before and 2 months after modified condy-
lotomy using original and current techniques. Measurements made
from visual analog scales for reducing (RAD) or nonreducing
(NRAD) anterior displacement. There is no apparent difference be-
tween techniques or stage of joint disease.
HOWARD A. ISRAEL
there is a nonreducing disc and the only surgical goal
is to unload the retrodiscal tissuesbecausedisc reduc-
tion is not a possibility. Joints with medial displace-
ment of the disc typically have diminished space in
the lateral part of the joint, as seenin the coronal plane
on MRI, and also may benefit from the new technique.
In such cases,a butt joint usually results in slight me-
dial rotation of the distal tip of the condylar segment
in the coronal plane, probably because of contraction
of the medial pterygoid muscle. This movement tends
to differentially create greater space in the lateral part
of the joint.2 Joints with lateral disc displacement,how-
ever, often have diminished space in the medial por-
tion. Overlap of the proximal segment on the lateral
aspect of the ramus rotates the condyle in the coronal
plane, tending to create more space in the medial part
of the joint. More uniform joint space should result in
more even distribution of joint loads.
The current modifications simplify the modified
J Oral Maxillofac Surg
54551-552, 1996
Discussion
Modification of the Modified Condylotomy
Howard A. Israel
Columbia University, New York, New York
The author of this article describesmodificationsin the
techniqueandpostoperativemanagementof patientsunder-
going condylotomy assurgicaltreatmentfor both reducing
and nonreducinginternalderangements of the temporoman-
dibular joint. Although there are severalweaknesses in the
study design,the investigatorshouldstill be commendedfor
his work, which I believe will stimulatescientific contro-
versy and debate.One of the flaws in this study is the use
of two variablesin the modifiedprocedure,namelydecreased
condylar movement(by eliminationof bone removal from
the proximal segment)andthe reducedtime in maxilloman-
dibular fixation. By using two variables, the questionof
which oneof these,if not both,hadaneffect on the postsurgi-
cal results is raised. The accuracy of using transcranial radio-
graphsto determinejoint spacecan alsobe questioned.Al-
though the author comparesthe differencesin joint space
betweenthe standardcondylotomy and the modifiedproce-
dure,he doesnot indicatewhetherthesedifferencesare sta-
tistically significant.Another questionraisedby this investi-
gation is why only 10 consecutivepatientswere evaluated
for pain before andafter the modifiedcondylotomy, because
the study population included 190 patients who underwent
the procedure.Despitesomeof thesecomments,I am con-
vinced that the condylotomy procedure (conventional-or
modified) is effective Blthoughperhapsnot for the reasons
stated.I believe we can learnmuchaboutthe theoreticaland
551
condylotomy and make the operation easier and
quicker to perform. The reduction of time in MMF to
8 to 10 days hasbeen welcomed by patients and allows
them to resume jaw movement sooner. These modifi-
cations do not seem to affect the outcomes adversely
and thus are recommended.
References
1. Hall HD, Nickerson w Jr, McKenna SJ: Modified condylotomy
for treatment of the painful temporomandibular joint with a
reducing disc. J Oral Maxillofacial Surg 51:133, 1993
2. Werther JR, Hall HD, Gibbs SJ: Type of disc displacement and
change in disc position after modified condylotomy in 80
symptomatic T-M joints. Oral Surg Oral Med Oral Path01
79:668, 1995
3. Nickerson JW Jr: The role of condylotomy in the management
of temporomandibular joint disorders, in Worthington P, Ev-
ans JR (eds): Controversies in Oral and Maxillofacial Sur-
gery. Philadelphia, PA, Saunders, 1994, p 348
4. Bell WH, Yamaguchi Y, Poor MR: Treatment of temporoman-
dibular joint dysfunction by intraoral vertical ramus osteot-
omy. Int J Adult Orthodon Orthognath Surg 5:9, 1990
scientific basis for the management of temporomandibular
disordersby carefully scrutinizing the condylotomy proce-
dure and its proposedscientificrationale.
As surgeons, we are well aware that there are many times
that we becomeproponentsof surgicaltechniquesthat are
effective in alleviating symptoms,but we really do not know
why theseprocedureswork. In the field of temporomandibu-
lar disorders(TMD), arthroscopy,arthrocentesis, andcondy-
lotomy are examples.Certainly, we are obligatedto explain
the rationale and theoretical basisfor treatmentto our pa-
tients and colleagues.However, it is extremely important
that we do not makethe mistakeof allowing the successof
the surgicalprocedureto becomethe validation of our pro-
posedtheories.
The condylotomy procedure,as well as other treatments
designedto reducea displaceddisc,areexampleswherenew
scientificknowledgehasclearly shownthat the rationalefor
the effectivenessof thesetechniquesneedsto looked at in
a new light. Current trends in the managementof patients
with TMD, including patientswith internal derangements,
have emphasizedthe restorationof function, the reduction
of inflammation,and the decreasein joint loading, rather
than manipulationof grossanatomic relationships.“’The
rationale for thesechangesin TMD managementis based
on recentdevelopmentsin the scientific literature that have
shownthe following:
1. Disc displacementis extremely commonin asymptom-
atic populations,being presentin approximately 30%
to 40% of joints basedon MR13,4and autopsystudies.’