Mandibular Condylectomy Revisited: Technical

ANESTHESIA/FACIAL PAIN
Mandibular Condylectomy Revisited:
Technical Notes Concerning the Use of an
Ultrasonic System
Sergio Olate, DDS, MS, PhD,* Alejandro Unibazo, DDS,y Andres Almeida, DDS,z
and M
arcio de Moraes, DDS, MS, PhDx
Condylar hyperplasia is a well-known pathologic entity with an established treatment protocol. Traditionally, saws and drills have been used in the condylar osteotomy. The use of ultrasonic systems has optimized
many procedures in the maxillofacial area; however, exploration of the use of this technique for condylectomy has been limited. Ultrasonic systems offer several advantages, such as a decrease in the risk of blood
vessel damage and clarity of the osteotomy. The present report addressed the scope of condylar osteotomy
using ultrasonic systems.
Ó 2013 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:1-4, 2013
Surgical Technique
Condylectomy is a routine surgical procedure for the
treatment of condylar hyperplasia and associated pathologic features.1 Traditionally, this technique has involved
a preauricular or endaural approach that facilitates visualization of the condylar head and condylar neck.1
The osteotomy is one of the more complex stages of
the surgical procedure; damage to neighboring vascular
structures, such as the maxillary artery, has been associated with surgical complications and considerable hemorrhaging during the condylar fracture or osteotomy.2
These complications primarily reflect the use of saws
and drills in osteotomy without visualization of the
entire surgical area.
Ultrasonic systems using cavitation technology are a
viable alternative for osteotomy, because these systems facilitate selective cutting of the bone but not
the soft tissues, thereby facilitating adequate and clean
visualization.3
The aim of the present report was to present the technical aspects of mandibular condylectomy performed in
5 consecutive cases using an ultrasonic system.
The surgical approach is conventional until the
condylar neck is reached. From that point, there is separation of the capsule and the entrance to the condylar
head. The tips used with our technique are shown
in Figure 1.
The cutting area should be selected from the
computed tomographic image, and the medial to lateral
and anteroposterior diameters are estimated. Subsequently, at the intraoperative stage, the cutting area is
selected, and the curved tip (0.3 mm thick, 1 mm
wide, and 1 cm long) is inserted perpendicularly
(Figs 2 and 3). During the active phase, the tip will
have black lines with 2-mm distances between them
to measure the osteotomy depth (Fig 4). The retraction
in the anterior and posterior sector of the surgical
approach requires neither total retraction nor the use
of retractors on the medial surface of the condylar neck.
Once the lateral sector of the osteotomy has been
marked and deeply penetrated by the tip, a slightly
*Assistant Professor, Division of Oral and Maxillofacial Surgery,
Address correspondence and reprint requests to Dr. Olate:
Universidad de La Frontera, Temuco, Chile; and Associated
Division of Oral and Maxillofacial Surgery, Universidad de La Frontera
Research, Center for Biomedical Research, Universidad Aut
onoma
Facultad de Odontologıa, Claro Solar No. 115, Temuco, Chile; e-mail:
de Chile, Temuco, Chile.
[email protected]
yClinical Professor, Division of Oral and Maxillofacial Surgery,
Received August 4 2013
Universidad de La Frontera, Temuco, Chile.
zClinical Professor, Division of Oral and Maxillofacial Surgery,
Ó 2013 American Association of Oral and Maxillofacial Surgeons
Universidad de La Frontera, Temuco, Chile.
0278-2391/13/01233-0$36.00/0
Accepted September 24 2013
xAssociated Professor, Division of Oral and Maxillofacial Surgery,
http://dx.doi.org/10.1016/j.joms.2013.09.040
State University of Campinas, Campinas, SP, Brazil.
1
2
MANDIBULAR CONDYLECTOMY
FIGURE 1. The tips used in the condylectomy technique.
Olate et al. Mandibular Condylectomy. J Oral Maxillofac Surg 2013.
more generous retraction can be made in the anterior
sector and released in the posterior sector (Fig 4), allowing the tip to penetrate the anterior sector of the
condyle. The same procedure is subsequently performed in the posterior area.
Thus, the osteotomy has been completed up to the
medial sector of the condylar neck. A second tip
(1 mm thick, 2 mm wide, and 1.8 cm long) is then
used to cut the condylar segment along the medial
side to separate (Fig 5) or mobilize (Fig 6) the superior
aspect of the condyle. A chisel is not required at any
stage of the osteotomy, because the medial cortical
bone of the condylar segment will automatically
retract when the tip is placed. Medial and superior
dissection of the condyle will be necessary, and the
segment can be extracted using a Kelly clamp, detaching any sector that was not previously completely
FIGURE 2. Position of the tip in the initial step, perpendicular to the
lateral side of the condyle in the left temporomandibular joint.
FIGURE 3. Left temporomandibular joint, inferior view. Initial osteotomy using a tip (0.2 mm thick, 1 cm long, and 1 mm wide) on
the lateral, posterior, and anterior surfaces of the condyle. The lines
on the tip surface are separated by 2 mm. Retraction can be seen in
anterior and superior area of the approach.
Olate et al. Mandibular Condylectomy. J Oral Maxillofac Surg
2013.
Olate et al. Mandibular Condylectomy. J Oral Maxillofac Surg
2013.
3
OLATE ET AL
FIGURE 4. Left temporomandibular joint, inferior view. Osteotomy
in anterior area of the condyle with adequate retraction for introduction of the tip. Note, the error-free lineal cut introduced on the lateral
side. Retraction can be seen in anterior and superior area of the
approach, with minor retraction in the posterior area.
Olate et al. Mandibular Condylectomy. J Oral Maxillofac Surg
2013.
detached from the soft tissue. The condylar fragment
showed a clean and straight cut without irregularities
on the cut surface (Fig 7).
FIGURE 5. Position of the second tip in the final step on the left
condyle, once the lateral, anterior, and posterior osteotomy has
been performed.
Olate et al. Mandibular Condylectomy. J Oral Maxillofac Surg
2013.
FIGURE 6. Left temporomandibular joint, inferior view. The second
tip used in the condyle osteotomy (1 mm thick and 1.8 mm long) was
placed in the medial cortical bone to mobilize the superior segment
of the condyle; the absence of adjacent tissue damage can be
observed. Retraction can be seen in the anterior and superior
area of the approach, with minor retraction in the posterior area
(for better visualization only).
Olate et al. Mandibular Condylectomy. J Oral Maxillofac Surg
2013.
Discussion
One of the major complications of the osteotomy for
high condylar fractures has been the proximity of the
maxillary artery and other vascular elements of the
temporomandibular joint. As many as 10 vascular elements can be present in the different sectors.4 Vascular
complications demand local control of hemorrhage,
ligation of the maxillary artery, ligation of the external
carotid artery, or endovascular embolization.5
Conventionally, condylar osteotomy has been performed using a saw, drill, or chisel.6 However, the use
of these tools can damage the vessels or soft tissue on
the medial side. Although dissection of the soft tissue
on the condylar head is necessary, the use of a piezoelectric ultrasonic system will offer better control of
bleeding and relatively minor soft tissue damage
compared with the other traditional osteotomy tools.
4
FIGURE 7. Final condylar osteotomy. The cut area shows lineal
and straight cuts without irregularities. The condylar neck, which
also shows this lineal cut, contacts the temporomandibular joint disk.
MANDIBULAR CONDYLECTOMY
The increased operating time has been indicated in
other studies as a disadvantage of the system8; however, in 5 cases in which we used this technique, the
duration of the osteotomy was 8 to 15 minutes, a trivial
period in the entire surgery. In addition, unlike saws
and drill bits, the osteotomy performed with ultrasonic systems does not create necrosis in the residual
bone,9 which could lead to improved postoperative
bone repair and reduced patient symptoms.
Thus, optimization of the condylectomy technique
is essential in the surgical approach10 and the use of
endoscopy technique.11 Perhaps, the endoscopic use
of ultrasonic systems could be proposed as a new possibility for further optimizing the outcomes of this surgery. Moreover, the surgical conditions observed using
this technique have demonstrated the efficiency and
safety of the ultrasonic system.
Olate et al. Mandibular Condylectomy. J Oral Maxillofac Surg
2013.
References
Thus, we examined the use of an ultrasonic device,
the Piezotome Solo (SatelecÒ, Action Group, Merignac,
France), at 50 Hz/60 Hz, with an ultrasonic frequency of
28 kHz minimum (28kHz permit this use only on mineralized tissue without activation in non mineralized
tissue), using a D1 program with 90-mL/minute irrigation flow rates for better potency. Titanium tips
(Fig 1) were used for the osteotomy, with movement
from 60 to 120 mm. The cavitation phenomenon produced by the ultrasonic device allows the cutting of
only the mineralized tissue and not soft tissue.3,7
Osteotomy with ultrasonic systems has been reported as successful in other procedures.3 The use
of this system in condylar surgery has great advantages, including 1) visual clarity and control of the osteotomy, 2) decreased rigor of tissue separation and
detachment, 3) increased access to the medial cortex
without requiring the use of chisels or a saw, 4) a
reduced need for external irrigation, because an
intrinsic physiologic solution is supplied with the system, 5) adequate visualization owing to the irrigation
and cleaning of the osteotomy, and 6) a reduced risk
of damage to the soft tissues and vascular structures.
1. Villanueva-Alcojol L, Monje F, Gonzalez-Garcıa R: Hyperplasia of
the mandibular condyle: Clinical, histopathologic, and treatment considerations in a series of 36 patients. J Oral Maxillofac
Surg 69:447, 2011
2. Keith D: Complications of temporomandibular joint surgery.
Oral Maxillofac Surg Clin North Am 15:187, 2003
3. Labanca M, Azzola F, Vinci R, Rodella L: Piezoelectric surgery:
Twenty years of use. Br J Oral Maxillofac Surg 46:265, 2008
4. Cuccia AM, Caradonna C, Caradonna D, et al: The arterial blood
supply of the temporomandibular joint: An anatomical study and
clinical implications. Img Sci Dent 43:37, 2013
5. Yeo M, Goh T, Nallanthamby V, et al: Maxillary artery injury associated with subcondylar mandible fractures: A novel treatment
algorithm. Craniomaxillofac Trauma Reconstr 5:83, 2012
6. Wolford LM, Mehra P, Reiche-Fischel O, et al: Efficacy of high
condylectomy for management of condylar hyperplasia. Am J
Orthod Dentofacial Orthop 121:136, 2002
7. Eggers G, Klein J, Blank J, Hassfeld S: Piezosurgery: An ultrasound device for cutting bone and its use and limitations in
maxillofacial surgery. Br J Oral Maxillofac Surg 42:451, 2004
8. Nocini PF, Turra M, Valsecchi S, et al: Microvascular free bone flap
harvest with piezosurgery. J Oral Maxillofac Surg 69:1485, 2011
9. G€
ulnahar Y, H€
useyin K€
osger H: Tutar Y: A comparison of piezosurgery and conventional surgery by heat shock protein 70
expression. Int J Oral Maxillofac Surg 42:508, 2013
10. Deng M, Long X, Cheng AHA, et al: Modified transoral approach
for mandibular condylectomy. Int J Oral Maxillofac Surg 38:374,
2009
11. Troulis M, Williams B, Kaban L: Endoscopic mandibular condylectomy and reconstruction: Early clinical results. J Oral Maxillofac Surg 62:460, 2004