Condylar and disc positions after sagittal split ramus osteotomy

with and without Le Fort I osteotomy

Koichiro Ueki, DDS, PhD,a Kohei Marukawa, DDS, PhD,b Mayumi Shimada, DDS, PhD,c
Yukari Hashiba, DDS,d Kiyomasa Nakgawa, DDS, PhD,e and Etsuhide Yamamoto, DDS, PhD,f
Kanazawa, Japan
KANAZAWA UNIVERSITY

Purpose. The purpose of this study is to examine the changes in temporomandibular joint (TMJ) morphology and
clinical symptoms after sagittal split ramus osteotomy (SSRO) with and without a Le Fort I osteotomy.
Subjects and Methods. Of 45 Japanese patients with mandibular prognathism, 23 underwent SSRO and 22 underwent
SSRO in combination with a Le Fort I osteotomy. The TMJ symptoms and joint morphology, including disc tissue,
were assessed preoperatively and postoperatively by magnetic resonance imaging (MRI) and axial cephalography.
Results. There were significant differences between pre- and postoperative horizontal changes in the condylar long
axis on the right side in the group undergoing SSRO (sagittal split ramus osteotomy) alone. However, there were no
other significant differences in pre- and postoperative measurements in this group as compared with the group
receiving SSRO plus Le Fort I osteotomy, and the preoperative disc position could not be changed in either group.
Conclusion. These results suggest that SSRO, either with or without Le Fort I osteotomy, could not change the
preoperative disc position or correct anterior disc displacement, although these procedures did improve the symptoms
associated with TMJ dysfunction. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:342-8)

Since its introduction by Trauner and Obwegeser1 in deformities pointed out that SSRO could not correct
1957, the mandibular sagittal split ramus osteotomy anterior disc displacement (ADD).7 However, very few
(SSRO) has become one of the preferred surgical pro- of our patients had undergone SSRO with Le Fort I
cedures for the correction of various jaw deformities. osteotomy (as opposed to SSRO alone), so statistical
The Le Fort I osteotomy is another popular technique comparison between the 2 groups was not possible.
for the treatment of dentofacial deformities.2 The The purpose of the present study was to compare the
SSRO is frequently used in severe mandibular progn- changes in TMJ morphology and clinical symptoms
athism with maxillary deformity. When the mandibular after SSRO with and without a Le Fort I osteotomy and
setback amount is extremely large, or open bite is to assess the relationship between a change in condylar
present, a Le Fort I osteotomy is also used to maintain position and improvement in ADD.
skeletal and occlusal stability.3
Dentofacial deformity may be associated with vari- PATIENTS AND METHODS
ations in the temporomandibular joint (TMJ), including Patients
disc position.4-6 Magnetic resonance imaging (MRI) The 45 Japanese adults (13 men and 32 women) in
helps separate such deformities into 4 types on the basis this study presented with jaw deformities diagnosed as
of disc position and shape: 1) anteriorly displaced disc, mandibular prognathism with and without maxillary
2) anterior type, 3) fully covered type, and 4) posterior deformity. At the time of orthognathic surgery, the
type.4 Furthermore, our previous report regarding these patients ranged in age from 15 to 37 years, with a mean
age of 23.3 years (standard deviation 6.1 years).
Department of Oral and Maxillofacial Surgery, Graduate School of
Medicine, Kanazawa University. Surgery
a
Clinical fellow.
b
Of the 45 patients in this study, 23 (9 men and 14
Clinical fellow.
c
Clinical fellow. women, mean age 24.2 years, standard deviation 6.7
d
Graduate student. years) underwent bilateral SSRO. The other 22 patients
e
Associate professor. (4 men and 18 women, mean age 23.0, standard devi-
f
Chief professor. ation 6.5 years) underwent SSRO and a Le Fort I
Received for publication Mar 23, 2006; returned for revision Apr 18, osteotomy. Rigid fixation was achieved with miniplates
2006; accepted for publication May 25, 2006.
1079-2104/$ - see front matter and monocortical screws. After approximately 1 week
© 2007 Mosby, Inc. All rights reserved. of intermaxillary fixation, elastics were placed to main-
doi:10.1016/j.tripleo.2006.05.024 tain the ideal occlusion. All patients received orthodon-

342
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Volume 103, Number 3 Ueki et al. 343

Fig. 1. Measurements of axial cephalogram and measurements in the sagittal and coronal magnetic resonance images. a, Angle
of the condylar long axis in the horizontal plane. b, Coordinate of the condyle expressed as (x/X, y/Y) in the sagittal plane. c,
Angle of the condylar long axis in the coronal plane.

tic treatment before and after surgery. All were also in the closed resting position and then in its maximally
assessed with MRI 1 month before surgery and 6 open position. An initial axial localizer was introduced
months after surgery. Objective TMJ symptoms were to obtain exact midcondylar sections perpendicular and
recorded and evaluated. parallel to the long axis of each condyle. Images of the
bilateral orthogonal sagittal planes and coronal planes
Axial cephalographic assessment of the TMJs in the closed position were acquired first
Axial cephalography was used to assess the condylar with a repetition pulse (TR) of 2000 ms, echo times
long axis. The focus-to-film distance was 130 cm, the (TEs) of 20 ms, a 3-mm image slice thickness, and a
ear rod–to-film distance was set at 15 cm, the tube 10-cm field of view. Then images of the bilateral sag-
voltage was 80 kV, and the tube current was 50 mA. ittal planes of the TMJs in the open mouth position
The images of the apex in the ear rods were connected were obtained with a TR of 1000 ms and TEs of 20 ms.
by a line. Two more lines were then drawn through the Images of the midcondylar slices perpendicular and
lateral and medial poles of both condyles. The angles parallel to the long axis of each condyle were entered
between these 2 lines and the ear rod connecting line into a computer (PC9821Xa13; NEC, Tokyo, Japan)
defined the horizontal condylar angles. Change in the with a scanner (GT9500; Epson, Tokyo, Japan), and the
angle of the condylar long axis was evaluated from the coordinates of the highest points of the condyle were
difference between pre- and postoperative values determined with Scion Image software (Scion Corp.,
(Fig. 1). Frederick, MD).
In the sagittal images, the distance between the low-
MRI assessment est point of the articular eminence and the squamotym-
A detailed MRI assessment of each pair of TMJs was panic fissure was measured and the line designated X.
performed by a 1.5-Tesla MRI system (Signa Scanner; The distance from line X to the highest point of the
General Electric Medical Systems, Milwaukee, WI) glenoid fossa was measured and the line designated Y.
using bilateral 3-in dual surface coils with the jaw first The distance from line X to the highest point of the
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344 Ueki et al. March 2007

Fig. 2. Classification of disc position: a, anterior displacement; b, anterior type; c, fully covered type; d, posterior type. a, b, c,
and d were found in the sagittal images.

condyle was measured and the line designated y. Fi- point of the posterior band is greater than 180°
nally, the distance between the lowest point of the (Fig. 2).
articular eminence and the highest point of the condyle
parallel to line X was measured and the line designated Statistical analysis
x. The coordinate of the highest point of condyle was Data were compared between groups with the Mann-
expressed as (x/X, y/Y). The change in condylar posi- Whitney U test and between pre- and postoperative
tion was evaluated from the changes in the coordinates values with the Wilcoxon signed ranks test using the
(postoperative value minus preoperative value). Stat View version 4.5 software program (Abacus Con-
The angle between the condylar long axis and the cepts, Berkeley, CA). The frequencies of data were
Frankfurt horizontal (FH) plane was measured in the compared within groups using the chi-squared test and
coronal images. The change in the angle of the condylar the Stat View software program. The differences were
long axis was evaluated from the difference between considered significant at P ⬍ .05.
preoperative and postoperative values (Fig. 1).
In the sagittal plane images, the center point was RESULTS
determined to be the midpoint of the anteroposterior After surgery there were no instances of wound
length of the condyle on the line between the lowest infection or dehiscence, bone instability, nonunion, or
point of articular eminence and the squamotympanic long-term malocclusion. The mean amount of setback
fissure. The lowest point of the articular eminence was was 6.5 ⫾ 3.3 mm on the right side and 6.8 ⫾ 3.0 mm
considered to be 0° and the squamotympanic fissure on the left side in the SSRO group and 6.4 ⫾ 3.0 mm
became 180°. on the right side and 6.3 ⫾ 3.1 mm on the left side in
the group that had undergone SSRO with a LeFort I
Definitions osteotomy. These figures did not differ significantly
All joint discs were classified according to following from the results of the statistical analysis, indicating
definitions, as described in our previous report.4 that the comparison study between the groups was
1. Anterior displacement: The entire disc is anteroin- valid.
ferior to the most anterior point on the contour of the
condyle. Condylar position and angle
2. Anterior type: The center of the intermediate zone is There was no significant difference between pre- and
between 0° and 90°, and the most posterior point of postoperative condylar position (X and Y coordinates)
the posterior band is posterosuperior to the most or the angle of the condylar long axis on coronal images
anterior point on the contour of the condyle and less on both sides after SSRO. However, the postoperative
than 180°. angle of the condylar long axis on axial cephalography
3. Fully covered type: The most anterior point of the was larger than the preoperative angle on the right side
anterior band is less than 0°, and the most posterior after SSRO (P ⫽ .0001); there was no significant
point of the posterior band is greater than 180°. difference on the left side.
4. Posterior type: The most anterior point of the ante- There was no significant difference between pre- and
rior band is more than 0°, and the most posterior postoperative condylar position (X and Y coordinates)
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Volume 103, Number 3 Ueki et al. 345

Table I. Changes in the highest condylar point and condylar longaxis

In coronal image In axial image
x/X-coordinate y/Y-coordinate (degree) (degree)
Average SD Average SD Average SD Average SD
SSRO Right side Preoperation 0.56 0.06 0.71 0.15 9.38 9.94 12.21 5.13
Postoperation 0.57 0.07 0.74 0.13 8.51 10.80 16.52 4.69
P value NS NS NS .0001
Left side Preoperation 0.55 0.06 0.73 0.13 11.81 12.57 12.97 5.57
Postoperation 0.56 0.06 0.73 0.13 12.76 15.20 15.43 5.47
P value NS NS NS NS
Condylar point in sagittal image The angle of condylar long axis
In coronal image In axial image
X-coordinate Y-coordinate (degree) (degree)
Average SD Average SD Average SD Average SD
SSRO ⫹ Le Fort I Right side Preoperation 0.59 0.08 0.72 0.10 10.29 10.74 12.06 7.18
Postoperation 0.58 0.08 0.73 0.11 10.30 11.51 15.15 6.50
P value NS NS NS NS
Left side Preoperation 0.59 0.08 0.75 0.10 10.05 12.60 10.60 7.21
Postoperation 0.57 0.07 0.73 0.13 10.31 11.19 11.59 7.62
P value NS NS NS NS

or the angle of the condylar long axis on coronal images patients reported trismus. Symptoms were improved by
and axial images on both sides after SSRO with Le Fort surgery in 80% of patients who underwent SSRO only
I osteotomy. and in 75% of patients who underwent SSRO with Le
In bilateral pre- and postoperative condylar position Fort I osteotomy; however, no statistically significant
(X and Y coordinates), bilateral pre- and postoperative difference was found between the 2 groups (Table IV).
angle of the condylar long axis in a frontal image, and
the results of axial cephalography (Table I), there were DISCUSSION
no significant differences between those who under- Signs and symptoms of TMJ dysfunction have pre-
went SSRO alone and those who also underwent os- viously been studied in patients with dentofacial defor-
teotomy. mities. Laskin et al.8 reported that 14% (range, 0% to
Further, with regard to changes in the X and Y 75%) of their patients had TMJ symptoms before or-
coordinates (postoperative value minus preoperative thognathic surgery. Kerstens et al.9 reported that 16.2%
value), there was no significant difference between the of 480 patients with dentofacial deformities had TMJ
2 groups (Table II). symptoms before surgery. White and Dolwick10 re-
ported that 49.3% of their patients showed some degree
Disc position of TMJ dysfunction preoperatively. However, Link and
The anterior type was dominant in the SSRO group; Nickerson11 found a very high incidence (97%) of
however, the fully covered type was dominant in the internal TMJ derangements in an orthognathic surgery
SSRO with Le Fort I osteotomy group. The distribution population. Fernandez Sanroman et al.12 found that the
of disc classification was significant (P ⫽ .0010). incidence of disc displacement was 11.1% for the class
Joints preoperatively classified as anterior type, fully I anterior open-bite group and 10% for the class III
covered type, or posterior type showed no postopera- group. When the class II group was studied, ADD was
tive changes in either group. diagnosed in 15 of the 28 joints (53.6%). Schellhas et
Preoperative anterior disc displacement with reduc- al.5 studied 100 patients with a retrognathic facial skel-
tion (ADDwR) and without reduction (ADDwoR) did eton, examining the TMJs with MRI for signs of mod-
not change postoperatively in either group (Tables III erate to severe pathology. In short, a class II dentofacial
and IV). deformity is reportedly strongly associated with mod-
erate to severe TMJ pathology or an ADD. In our
TMJ symptoms previous study, the incidence of disc displacement was
The TMJ symptoms most frequently reported preop- 18.2% in the class III symmetry group and 56.8% in the
eratively were abnormal sounds (clicking and crepitus) class III asymmetry group.4 These results suggest that
and slight pain upon opening the mouth; none of the asymmetry increases the occurrence of TMJ dysfunc-
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346 Ueki et al. March 2007

Table II. Difference between pre- and postoperative highest condylar point
Condylar point in sagittal image The angle of condylar long axis
In coronal image In axial image
x/X-coordinate y/Y-coordinate (degree) (degree)
Average SD Average SD Average SD Average SD
SSRO Right side ⫺0.56 0.06 ⫺0.71 0.15 ⫺9.38 9.94 ⫺12.21 5.13
Left side ⫺0.55 0.06 ⫺0.73 0.13 ⫺11.81 12.57 ⫺12.97 5.57
SSRO ⫹ Le Fort I Right side ⫺0.57 0.07 ⫺0.74 0.13 ⫺8.86 10.92 ⫺16.49 4.80
Left side ⫺0.56 0.06 ⫺0.73 0.13 ⫺13.64 14.95 ⫺15.08 5.33

Table III. Changes in disc tissue seen in sagittal images

Disc position
classification Joints Symptomatic joints
Preoperatively Postoperatively Preoperatively Postoperatively
SSRO Anterior displacement
With reduction 3 3 2 0
Without reduction 1 1 1 0
Normal
Anterior type 25 25 8 2
Posterior type 6 6 0 0
Fully covered type 11 11 4 1
SSRO Le Fort I Anterior displacement
With reduction 1 * 1 * 1 1
Without reduction 0 0 0 0
Normal
Anterior type 9 9 3 1
Posterior type 10 10 1 0
Fully covered type 24 24 3 0

* P ⫽ .0010.

Table IV. The rate of improvement anterior disc displacement seen in sagittal images and TMJ symptoms
Procedure Number of joints Symptomatic joints preoperatively Joints improved postoperatively Rate of improvement (%)
SSRO 46 15 12 80
SSRO ⫹ LeFort I 44 8 6 75
Procedure Number of joints Joints with ADD preoperatively Joints improved postoperatively Rate of improvement (%)
SSRO 46 7 0 0
SSRO ⫹ LeFort I 44 1 0 0

tion with an ADD. The incidence ratio of ADD in the in the group that underwent SSRO with Le Fort I
deviated side was higher than in the nondeviated side. osteotomy. This suggested that the patients with severe
However, in this study, mandibular prognathism prognathism had TMJ with the fully covered type of
with asymmetry was not involved in analysis of frontal disc. The joints and their disc tissue adapt to the indi-
cephalogram, so the patients with TMJ symptoms were vidual skeletal morphology in these cases. Occlusion
very few. In particular, the patients who underwent and skeletal discrepancies can lead to morphologic
SSRO with Le Fort I osteotomy had fewer TMJ symp- changes in the structure of the TMJ; we proved this
toms. As to disc position, TMJ with ADD was also using a rigid body spring theory model.6 Correlation
infrequent. However, anterior disc displacement does between classification and stress angulation indicated
not always cause TMJ symptoms. that the stress direction of the anterior displaced or
Furthermore, the anterior type was dominant in the anterior-type disc was more anterior to the condyle. On
SSRO group, and the fully covered type was dominant the other hand, the stress directions of the fully covered
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Volume 103, Number 3 Ueki et al. 347

and posterior types had a tendency to be more superior can open their mouths wide without a condylar protru-
to the condyle. In other words, disc position and mor- sive movement because they have longer mandibles.
phology were related to stress distribution. Therefore condylar movement after SSRO with and
Regarding the TMJ clicking sound, not all patients without Le Fort I osteotomy was also comparatively
with clicking sounds have ADD with reduction; nor do limited in class III patients. In sum, significant changes
all patients with clicking sounds have a deviation in the of condylar and disc position were not found in this
form of the articular surfaces.13 In our study, patients study. Westesson et al.22 found that the mean horizontal
with the anterior type, fully covered type, and posterior condylar angle was most acute in joints with a normal
type of disc can also experience the clicking sound. In superior disc position (mean 21.2°) and less so in joints
such cases, when the condyle moved beyond the ante- with disc displacement (29.7° disc displacement with-
rior hypertrophic part of the disc, the sound occurred. out reduction) and/or degenerative joint disease (36.5°).
This may be characteristic in mandibular prognathism Fernandez Sanroman et al.12 found that the mean hor-
and of the nondeviated side in mandibular asymmetry. izontal condylar angle in the class II group was signif-
Orthognathic surgery such as SSRO may cause icantly larger than that in the control group and that the
changes in condylar position; therefore, the position of larger condylar angle can be an etiologic factor for disc
the condyle must be monitored. However, the disc- displacement and degenerative joint disease. Our pre-
condyle relationship is a more important parameter in vious study also showed a mean horizontal condylar
assessing changes in TMJ morphology and symptoms. angle for the class III symmetry group of 12.0° on the
Many researchers, using different radiographic meth- right and 11.8° on the left.4 These reports indicate that
ods, have studied the movements of the condyle that if the skeletal pattern is changed, TMJ morphology,
occur in patients who undergo orthognathic surgery. including that of the condylar long axis, also will be
Freihofer and Petresevic,14 in a radiographic study of modified. In short, changes in occlusion and skeletal
38 patients who underwent SSRO for mandibular ad- structure may induce a change in the condylar long
vancement, showed that 10 of 26 condyles appeared to axis. In the present study, the horizontal dimension of
be positioned anteriorly in the glenoid fossa. Similarly, the condylar long axis increased significantly on the
Will et al.15 found that both condyles were positioned right side; this increase tended to be greater on the left
posteriorly in 41 patients who underwent SSRO to side in the SSRO group and in both sides in the group
advance the mandible. However, in their study of 15 undergoing SSRO plus Le Fort I osteotomy. The post-
patients, Hackney et al.16 found no correlation between operative change in the condylar long axis may play a
the amount of mandibular advancement and changes in very important role to the change of TMJ symptons.23
condylar position or mandibular shape. In SSRO, rigid In conclusion, these results suggest that SSRO either
fixation of the mandible may result in a greater change with or without Le Fort I osteotomy cannot alter the
in the position of the condyle and a higher incidence of preoperative disc position, including anterior disc dis-
TMJ dysfunction compared with nonrigid fixation.17 placement, although these procedures can improve the
Although many studies report a reduction of TMJ symptoms of TMJ dysfunction.
symptoms after SSRO for advancement,18,19 few spe-
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