J Oral Maxillofac Surg60:996-1002, 2002

Treatment of Painful TemporomandibularJoint Dysfunction With the Sagittal Split

Ramus OsteotomyJohn W. Pruitt, DDS, MD,* John E. Moenning, DDS, MSD,†

Thomas H. Lapp, DDS, MS,‡ and David A. Bussard, DDS, MS§

Purpose: We describe a new indication for the sagittal split ramus osteotomy with rigid fixation to treatpatients with painful dysfunction of the temporomandibular joint.

Patients and Methods: Ten patients for whom nonsurgical management failed were found to have amandibular condyle positioned postero-superior within the glenoid fossa with reduced joint space oncorrected-axis tomograms. The sagittal split ramus osteotomy was used to reposition the proximalsegment and to increase joint space. Preoperative and long-term postoperative (average, 44.7 months)symptoms and tomographic findings were retrospectively compared.

Results: Significant pain relief occurred postoperatively in all patients. One patient had a relapse afterinitial improvement. No patient developed a malocclusion. The long-term radiographic condyle-fossarelationship tended to return to its preoperative position with no relapse of clinical symptoms, exceptin the 1 patient.

Conclusion: The sagittal split ramus osteotomy with rigid fixation is another procedure that can beused to treat painful temporomandibular joint dysfunction by changing the position of the mandibularcondyle in the glenoid fossa.© 2002 American Association of Oral and Maxillofacial SurgeonsJ Oral Maxillofac Surg 60:996-1002, 2002

There are many nonsurgical and surgical modalitiesfor the treatment of temporomandibular joint (TMJ)internal derangements. A conservative, nonsurgicalapproach is initially indicated. If nonsurgical methodsfail, then often the procedure of choice for disc de-rangements is controversial. Surgical options includearthrocentesis, arthroscopic surgery, arthrotomy/ar-throplasty, mandibular condylotomy, and/or orthog-nathic surgery to correct skeletal jaw deformities.1

The mandibular condylotomy is a vertical ramusosteotomy in which the proximal segment is allowedto passively sag inferiorly and anteriorly, increasingjoint space to allow for the recapture of an anteriorlydisplaced disc. The potential complications unique tointracapsular procedures are avoided. Reports sub-stantiating the modified condylotomy have been pub-lished within the past 10 years by Nickerson andVeaco,2 Nickerson,3,4 Hall et al,5 Hall,6,7 Werther etal,8 Bell et al,9,10 Shevel,11 Upton and Sullivan,12-14

Albury,15 and McKenna et al16 Postoperative inter-maxillary fixation and/or guiding elastics are usuallyused for a varying amount of time.

Our practice has used the sagittal split ramus os-teotomy (SSRO) as an alternative to the mandibularcondylotomy to treat patients with painful TMJ dys-function. For these patients, nonsurgical treatment oftheir internal derangement failed, and they have sig-nificantly decreased joint space because of a condylethat is positioned posterosuperiorly in the fossa asshown by corrected-axis tomography. At times, themandibular condyle can be seen on tomography to betouching the posterosuperior portion of the glenoidfossa or the tympanic plate. As with the condylotomy,this approach was chosen to avoid an intracapsularprocedure, yet provide better control and placement

Received from Indiana University School of Dentistry, Indianapolis,

IN.

*Clinical Assistant Professor, and Private Practice, Indiana Oral

and Maxillofacial Surgery Associates, Indianapolis, IN.

†Clinical Assistant Professor, and Private Practice, Indiana Oral

and Maxillofacial Surgery Associates, Indianapolis, IN.

‡Clinical Assistant Professor, and Private Practice, Indiana Oral

and Maxillofacial Surgery Associates, Indianapolis, IN.

§Clinical Assistant Professor, and Private Practice, Indiana Oral

and Maxillofacial Surgery Associates, Indianapolis, IN.

Address correspondence and reprint requests to Dr Pruitt: 1700

W Smith Valley Rd, Suite C-1, Greenwood, IN 46142; e-mail:

jpruitt@iomsa.com

© 2002 American Association of Oral and Maxillofacial Surgeons

0278-2391/02/6009-0006$35.00/0

doi:10.1053/joms.2002.34405

996

of both the proximal and distal segments. The selec-tion criteria, treatment protocol, and retrospectivelong-term results of this approach are described. Therationale, advantages, and disadvantages are also dis-cussed.

Patients and Methods

PATIENTS

A standardized history and physical examinationform is used in our practice to evaluate patients withTMJ disorders or facial pain. If initial findings suggestan internal derangement, then corrected-axis tomo-grams are obtained to evaluate the osseous relation-ships of the condyle within the glenoid fossa. Thesagittal bony anatomic relationships of the TMJ arebest examined with corrected-axis tomograms.17 If nojoint space anomaly or condylar malposition is iden-tified, then magnetic resonance imaging (MRI) is ob-tained to view the disc.

Condylar repositioning surgery has been performedsince 1990 in our practice if the following criteriawere met: 1) history and examination consistent withan internal derangement of one or both TMJs; 2)bilateral corrected-axis tomograms showing reducedposterior and superior joint space of the affectedside(s); 3) inadequate clinical response to nonsteroi-dal anti-inflammatory drugs, diet modifications, splinttherapy, and/or physical therapy for more than 3months; and 4) pain and dysfunction resulting insignificant impairment of the patient’s diet and activ-ities of daily living, and therefore motivation for thepatient to proceed to surgical treatment.

Twenty-six patients who met these criteria under-went SSRO where at least 1 proximal segment wasdeliberately repositioned to change the relationshipof the condyle to the glenoid fossa. Ten patients wereexcluded from this report because a malocclusionwas surgically corrected, therefore requiring a changein the position of both proximal and distal segments.Two were excluded because of a previous history ofTMJ surgery: 1 patient had undergone arthroscopyand discectomy, and 1 had undergone removal of aProplast-Teflon implant. Four patients could not bereached for long-term follow-up. A chart review ofthose 4 individuals revealed no instances of malocclu-sion, and relief of symptoms were noted in their latestprogress notes. No concomitant maxillary osteoto-mies were performed in this series.

Ten patients remained in the study series who hadclinical findings consistent with an internal derange-ment of the TMJ (9 bilateral and 1 unilateral). The 9patients with bilateral disease had simultaneous bilat-eral osteotomies. One man was included, and theaverage age at the time of surgery was 34.3 years

(range, 25 to 43 years). Two patients had a history ofmandible fractures that had been treated by closedreduction in another practice. Both fracture patientshad required postreduction orthodontics to correct amalocclusion. Six other patients had undergone pre-vious routine orthodontic correction of a develop-mental malocclusion. Average long-term follow-upwas 44.7 months (range, 31 to 83 months).

TECHNIQUE

Once the patient was under general anesthesia, themandible was manually positioned to seat the con-dyles into the most retruded position, and the amountof incisor overjet that could be achieved was noted.SSROs were performed according to the techniquesdescribed by Obwegeser and Trauner18 and Dal-Pont.19 Once the ramus was successfully split, thepterygomasseteric sling was stripped from the infe-rior border of the proximal segment. The preopera-tive occlusion was reestablished with wire intermax-illary fixation. Usually 2 to 3 mm of bone wasremoved from the vertical lateral cut, and approxi-mately 1.5 to 2 mm was removed from the horizontalmedial cut, creating a gap to allow for the reposition-ing of the condyle inferiorly and anteriorly. Theamount of bone to be removed was judged by exam-ining the preoperative corrected-axis tomograms.Generally, our goal was to produce greater decom-pression in the anterior vector than in the inferiorvector. The osteotomy gaps were closed before theproximal and distal segments were secured with amodified Allis clamp.

Two 2.0-mm bicortical screws were placed alongthe superior border. Intermaxillary fixation was re-leased, and the occlusion and mandibular range ofmotion were verified. The desired occlusal result wasshown if deliberate manual retropositioning of themandible to seat the condyle(s) could produce anincreased incisor overjet on the affected side com-pared with what could be achieved preoperativelyunder general anesthesia. The dental midlines wouldremain unchanged during retropositioning if bilateralprocedures were done. With passive rotation of themandible through centric movements (no deliberateretropositioning), the occlusion was stable and un-changed. Tight intermaxillary elastics were thenplaced before the patient emerged from anesthesia.

All patients received bilateral corrected-axis tomo-grams and orthopantomograms on the day of dis-charge to confirm condylar position. The patientsremained in tight elastic intermaxillary fixation (withno mandibular movement) for approximately 5 to 7days, followed by loosening of the elastics. After thefirst week, the liquid diet was advanced to a nonchewdiet with light training elastics for 5 to 6 weeks post-operatively. At that point the patients were encour-

PRUITT ET AL 997

aged to maximize their mandibular range of motionthrough the resumption of a normal diet and occa-sionally tongue-blade exercises.

DATA COLLECTION

Patients were mailed a retrospective questionnairerequesting their assessment of preoperative and post-operative symptoms. Subjects were asked to rate theintensity of their headaches, neck pain, jaw pain, earpain, “pain while chewing,” and “pain when openingmouth widely” using a numeric scale with choicesranging between 0 (none) and 5 (excruciating). Sub-jects were also requested to rate the frequency ofmandibular locking, frequency of tooth clenching andgrinding, and the frequency with which their symp-toms hindered daily activities on the following scale:0, never; 1, rarely; 2, monthly; 3, weekly; 4, daily; 5,multiple times a day. The questionnaire was returnedat a long-term follow-up appointment where bilateralcorrected-axis tomograms were taken, mandibularrange of motion, occlusion, joint noises, and otherTMJ symptoms were evaluated by the surgeon.

All bilateral tomograms were taken with the samemachine. Each individual patient’s position and imageslices were repeated at the preoperative, immediatepostoperative, and long-term postoperative appoint-ments. The cortical outlines of the glenoid fossa andcondyle were traced on acetate sheets by an author(J.W.P.). The fossa outlines were overlaid, and thepostoperative positions of the condyles were com-pared with their initial location in both a vertical anda horizontal dimension. The superiormost point onthe head of the condyle was used as the verticalreference, and the anteriormost point was used as thehorizontal reference. The change in position wasmeasured in millimeters, with positive values repre-senting a superior (cranial) vertical direction and ananterior (forward) horizontal direction.

Results

Maximum incisal opening increased an average of5.3 � 10.8 mm from the preoperative average (range,�7 to �26 mm). Preoperatively, there were 6 pa-tients with joint clicking/popping, and postopera-tively there were 3. Two of the 3 had preoperativejoint noises, and 1 patient developed clicking whenher opening increased 25 mm postoperatively. Therewere no changes in the occlusion that required treat-ment for any patient.

Postoperative pain scores and frequency of dys-function scores were lower in every patient except 1,which would be considered a treatment failure (Ta-bles 1 and 2). Chart review revealed that 1 patient hadsymptom relief during the initial 3 months of postop-erative follow-up; however, at 83 months reported all

symptoms had worsened to a score of 5 (excruciat-ing). Clinical findings at the long-term follow-up ap-pointment of this particular patient were consistentwith a chronic closed-lock (nonreducing disc dis-placement).

The immediate postoperative condyle position wasan average of �0.8 � 1.0 mm anterior (range, �0.5to � 3.0 mm) and �1.1 � 0.8 mm inferior (range, 0to �2.0 mm) to its preoperative location (Figs 1, 2).Tomograms taken at the long-term evaluation re-vealed the condylar position to be an average of�0.2 � 0.5 mm anterior (range, �1.0 to �1.0 mm)and �0.2 � 0.6 mm inferior (range, �1.0 to �1.5mm). Only 1 condyle was not successfully broughtanterior and inferior, and this was the same patientmentioned earlier whose pain and dysfunction wors-ened. The 83-month postoperative position of thisside was, in fact, posterior and superior to its originalposition.

Discussion

Use of the SSRO for the treatment of TMJ internalderangements is based on the same concept as thecondylotomy procedure. The premise behind condy-lotomy is that repositioning the condyle is a moreeffective treatment for disc displacements than repo-sitioning the disc. A posterior position of the condylewithin the glenoid fossa can be associated with inter-nal derangements.20,21 To these authors, it is not ra-tional to reposition an anteriorly displaced disc into a“tight” joint, that is, one in which the condyle isdisplaced posterosuperior within the glenoid fossa.Rather than pursue disc repositioning procedures (eg,plication), we believe it is sometimes more appropri-ate to alter the spatial relationships of the bony jointstructures. Surgically repositioning the condyle ante-riorly and inferiorly while maintaining the occlusionwill increase joint space, or “decompress” the joint.This may result in disc reduction and/or unloading ofthe retrodiscal tissues, and thus allow these structures(ie, disc, retrodiscal tissue, and bony surfaces) to healand repair. For nonsurgical treatment, Farrar22 intro-duced the concept of the anterior repositioning splintto “capture” the displaced disc and unload the joint.Unfortunately, the splint offers limited usefulness dur-

Table 1. AVERAGE PAIN RATINGS (0 to 5)

Symptom Preoperative Postoperative

Headaches 3.45 1.27Jaw pain 2.18 1.18Ear pain 2.91 0.91Pain when chewing 3.27 0.82Pain when opening 3.27 1.00

998 TREATMENT OF TMD WITH SSRO

ing mastication, which is when the joint is undermaximum function.

Staz23 and Ward et al24 originally described thecondylotomy, using a percutaneous Gigli saw, afternoting that joint clicking and dysfunction were rarelyfound after condylar fractures. Subsequently both theopen or closed condylotomy have been reported bynumerous authors for both internal derangementsand osteoarthritis of the TMJ with favorable relief of

pain and dysfunction.2-16,25-32 The technique for themodified condylotomy is essentially the same as thatfor the intraoral vertical ramus osteotomy. Time inintermaxillary fixation generally ranges between 8days6 to 3 weeks.2

MRI has shown complete disc recapture in 79% andpartial disc recapture in 15% of 80 joints with dis-placed, reducible discs after modified condylotomy.8

New condylar bone formation has been reported in90% of joints radiographed 5 to 72 months postoper-atively by Nickerson and Veaco.2 The recortication ofthe articular surfaces of osteoarthritic joints after con-dylotomy has been described by several authors.5,32,33

Malocclusion due to excessive condylar sag has beenthe most significant complication of condylotomy,especially if no intermaxillary fixation is used.34 Al-bury15 reported that 11 (22%) of his 63 patients re-ported a worsened bite postoperatively. Ten patientsneeded minor occlusal equilibration in the posteriorquadrant of the side of the condylotomy, and 1 pa-tient underwent further orthognathic surgery. Nick-erson4 considers a discrepancy between centric rela-

FIGURE 1. Corrected-axis tomograms of left temporomandibular jointpreoperatively (A) and postoperatively (B) after repositioning.

FIGURE 2. Corrected-axis tomograms of right temporomandibularjoint preoperatively (A) and postoperatively (B) after repositioning.

Table 2. AVERAGE FREQUENCY OF SYMPTOMS

Symptom Preoperative Postoperative

Jaw locking 2.73 0.73Clenching and grinding 3.55 2.27Hindrance of daily

activities 2.64 0.55

NOTE. Scale is 0, never; 1, rarely; 2, monthly; 3, weekly; 4, daily; 5,multiple times a day.

PRUITT ET AL 999

tion and centric occlusion to be an expected outcomeof condylotomy. Certainly minor centric relation–centric occlusion discrepancies may be of little clini-cal significance, but this is difficult to quantify. Hall etal prospectively evaluated the occlusion in patientswho had modified condylotomies for reducing35 andnonreducing36 disc displacements. Cephalometricand study model evaluations by an orthodontist 1 yearpostoperatively showed minor changes in the incisorrelationships in some patients. None developed anopen bite, and all who returned for follow-up had astable occlusion.

Limiting the amount of medial pterygoid musclestripping during condylotomy has been suggested as away to prevent excessive condylar displacement anda resulting midline shift and/or malocclusion.4,6,14

Nickerson4 advised that “surgeons should minimizethe use of simultaneous bilateral condylotomy” be-cause of the increased likelihood of maintaining theoriginal occlusion. Even if apertognathia does notdevelop, there is the risk that vertical ramus heightmay shorten, leading to an increased mandibularplane angle, extrusion of the incisors, and possiblyintrusion of the molars.4

Another potential complication of the modifiedcondylotomy is a palpable or visible deformity of theramus if the inferior aspect of the proximal segment isdisplaced too far laterally. There may also be exces-sive axial and coronal rotation of the condyle whenthe proximal segment is laterally positioned. Hall’s6

recommendation to create a butt joint between theosteotomy segments would help prevent these com-plications. He also reported an interosseous wiringtechnique37 to reduce the chance of inappropriatepostoperative condylar sag and/or medial displace-ment of the proximal segment after condylotomy.

An advantage of repositioning the condyle usingthe SSRO with rigid fixation is the ability to intraop-eratively verify the patient’s occlusion, range of mo-tion, and any joint noises before completing the pro-cedure and awakening the patient. Accuracy of theproximal segment positioning is probably superiorwith screw fixation compared with interosseous wir-ing. None of the patients in this small series devel-oped a postoperative malocclusion, even when bilat-eral osteotomies were performed (9 of 10 patients).

The use of rigid fixation in this technique reducesthe time the patient is in tight intermaxillary fixationto 5 to 7 days. The benefits of early mobilizationinclude improved range of motion and enhanced nu-trition. Careful technique will prevent unwanted con-dylar rotation in the axial or coronal planes. Bonyinterferences should be removed between the over-lapping proximal and distal segments, and bicorticalscrews should be placed in a manner that does nottorque the proximal segment. The primary disadvan-

tage of the SSRO compared with the intraoral verticalramus osteotomy is the potentially higher incidenceof trigeminal nerve paresthesia.38 Costs may be higherwith the SSRO because of the bicortical screws andpossibly longer operating room time.

While all patients had favorable symptom reliefduring the immediate postoperative period, condylarcortical outlines measured at long-term follow-up con-sistently relapsed from their immediate postoperativepositions, sometimes to their original locations. Thismay be true segment relapse or settling, or morelikely cortical remodeling and/or hypertrophy, whichhas been seen with modified condylotomy.5,32,33

Both the modified condylotomy and SSRO avoid thecomplications unique to intracapsular surgery: facialnerve injury, otologic injury, intra-articular scarring/fibrosis, trismus, ankylosis, cutaneous scarring, anddisturbing the synovium. Both procedures requireless than 1 week of tight intermaxillary fixation andonly training elastics thereafter.

The clinical success of modified condylotomy andSSRO may be related to the reestablishment of thedisc between the articulating surfaces of the condyleand fossa, although it is now recognized that normaldisc position is not required for asymptomatic TMJfunction. Disc displacement is seen on MRI among30% to 40% of joints in asymptomatic popula-tions.39,40 Increasing joint space with a splint has beenshown to relieve symptoms despite a failure toachieve normal disc position (“recapture the disc”) onMRI.41

The success of condylar repositioning may alsoresult from unloading of the highly innervated retro-discal tissues. The auriculotemporal nerve has a closeanatomic relationship with the condyle, TMJ capsule,and lateral pterygoid muscle.42 Histologic studieshave shown that the nerve fibers from the auriculo-temporal nerve can become displaced and impingedbetween the articular fossa and condyle.43 Pain reliefafter condylar repositioning may be due to the elimi-nation of direct bony contact between the condyleand glenoid fossa and/or tympanic plate. It may alsorelieve nerve irritation, inflammation, or entrapment.Loughner et al44 found the posterior trunk of themandibular nerve, which includes the auriculotempo-ral nerve, entrapped within the lateral pterygoid mus-cle in 3 of 52 joint dissections. Condylar repositioningwould be expected to shorten the lateral pterygoidmuscle, and thereby reduce any contributory painthat may arise from auriculotemporal nerve entrap-ment within this muscle.

Limitations of this case series include its retrospec-tive design, less-than-ideal records, and lack of a con-trol group. Without disc imaging by MRI or arthrog-raphy, we cannot make a definitive diagnosis ofinternal derangement, nor can we comment on how

1000 TREATMENT OF TMD WITH SSRO

this procedure affects disc position. The rating systemused by the patients was not objective, and patientsmay have been reluctant to report candidly. Therealso are the biases of the treating physicians’ record-ing and interpretation of the data. The small numberof subjects involved precluded any meaningful statis-tical analysis.

The SSRO with rigid fixation may offer 2 potentialadvantages over the modified condylotomy for treat-ment of painful TMJ dysfunction: 1) less chance ofpostoperative malocclusion because of better 3-di-mensional control and stabilization of condylar posi-tion, elimination of postoperative condylar displace-ment with rigid fixation, and the ability to verify theocclusion intraoperatively, and 2) surgeons’ experi-ence with the SSRO may be greater.

The SSRO may be a better procedure when there isa greater risk of postoperative malocclusion, such aswhen bilateral procedures are necessary or if there isan unstable preoperative occlusion.

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