minimally invasive intraoral condylectomy: proof of

YIJOM-3395; No of Pages 7

Case Series

TMJ Disorders

Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxxhttp://dx.doi.org/10.1016/j.ijom.2016.04.001, available online at http://www.sciencedirect.com

Minimally invasive intraoralcondylectomy: proof of conceptreportF. Hernandez-Alfaro, I. Mendez-Manjon, A. Valls-Ontanon, R. Guijarro-Martınez:Minimally invasive intraoral condylectomy: proof of concept report. Int. J. OralMaxillofac. Surg. 2016; xxx: xxx–xxx. # 2016 International Association of Oral andMaxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. A significant proportion of facial asymmetry cases are caused by abnormalgrowth of the mandibular condyles. Surgical management is generally based on acondylectomy performed through a pre-auricular transcutaneous access. However,this approach entails potential neurovascular, salivary, and aesthetic complications.In this study, a proof-of-concept evaluation was performed of a novel minimallyinvasive technique for condylectomy performed through an intraoral approach.Based on precise three-dimensional virtual planning to define intraoperativereferences, this technique provides an excellent access for total or partialcondylectomy through a limited intraoral incision. Piezoelectric surgery withcustomized attachments enables the safe, accurate execution of the condylectomy.In addition, experience gained in seven consecutive cases suggests that the need forcoronoidectomy can be obviated, surgical time is reduced to an average of 16.9 min,and postoperative morbidity is minimal. This alternative intraoral approach couldbecome the treatment of choice for most condylar hyperplastic conditions.

Please cite this article in press as: Hernandez-Alfaro F, et al. Minimally invasive intraoral co

Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.04.001

0901-5027/000001+07 # 2016 International Association of Oral and Maxillofacial Surge

F. Hernandez-Alfaro1,2,I. Mendez-Manjon1,2,A. Valls-Ontanon1,2,R. Guijarro-Martınez1,2

1Department of Oral and MaxillofacialSurgery, Universitat Internacional deCatalunya, Sant Cugat del Valles, Barcelona,Spain; 2Institute of Maxillofacial Surgery,Teknon Medical Centre, Barcelona, Spain

Key words: temporomandibular joint; condylarosteochondroma; condylar hyperplasia; endo-scope; intraoral; computer-assisted.

Accepted for publication 5 April 2016

Generically, condylar hyperplasia (CH)refers to any condition capable of enlarg-ing the mandibular condyle, thereby af-fecting the size and morphology of themandible, altering the occlusion, and in-directly affecting the maxilla.1 A symmet-ric or most often asymmetric dentofacialdeformity can develop as a result. Treat-ment entails temporomandibular joint(TMJ) surgery to address the underlyingpathological condition in the condyle andsubsequent or concomitant orthognathicsurgery to restore facial harmony andre-establish a functional occlusion.

The conventional approach to the man-dibular condyle consists of an extraoralaccess through a pre-auricular incision.2–8

This extraoral approach provides excellentvisualization of the condyle, condylarneck, and glenoid fossa. Moreover, addi-tional anatomical exposure can be gainedby temporal extension, zygomatic archsectioning, or combination with a subman-dibular approach.2,9,10 Due to the proxim-ity to vital anatomical structures, thisapproach entails a risk of neurovascularcomplications or salivary fistulae.5,11–15 Itis technically complex, time-consuming,

and requires a certain degree of surgicalexpertise. In addition, the use of an exter-nal transcutaneous incision can result inunaesthetic scarring.11,15

As an alternative to this extraoral ap-proach, an intraoral access to the condyleis possible.11,13,15,16 This intraoral approachminimizes the risk of facial nerve injury andsalivary fistulae, and visible facial scars areavoided completely.11,13,15–17 Hence, a rap-id postoperative recovery and high patientsatisfaction are to be expected. Despite theseadvantages, the popularity of this approach,as reported in the scientific literature, is

ndylectomy: proof of concept report, Int J

ons. Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijom.2016.04.001



2 Hernandez-Alfaro et al.


comparatively low. This is probably due tothe lack of a comprehensive description ofthe surgical technique and the absence ofprecise treatment planning criteria.

A minimally invasive surgical protocolfor intraoral condylectomy is describedherein. This novel technique is based onprecise three-dimensional (3D) treatmentplanning and piezoelectric surgical resectionof the condylar process using customizedattachments. A comprehensive analysis ofthe authors’ preliminary experience withseven consecutive cases is presented asa proof-of-concept demonstration of thefeasibility, efficiency, and safety of thistechnique.

Patients and methods

All patients with facial asymmetry due toabnormal condylar growth, who under-went condylectomy via an intraoral ap-proach at a specialized centre for thetreatment of dentofacial deformities, wereevaluated prospectively. The Declarationof Helsinki guidelines on medical protocoland ethics were followed at all stages oftreatment. The performance of this studydid not alter the ethically approved proto-col for the diagnosis and treatment offacial asymmetry at the study centre andhence was exempt from the requirementfor further ethical approval.

Diagnostic workup and treatment

planning

After a detailed interview and thoroughclinical assessment, the imaging protocol

Please cite this article in press as: Hernandez

Oral Maxillofac Surg (2016), http://dx.doi.o

Fig. 1. Three-dimensional skull model in maxim

for facial asymmetry at the study institu-tion was followed. This protocol includes:(1) technetium 99m (99mTc) scintigraphy,in order to investigate active condylargrowth, and (2) cone beam computed to-mography (CBCT) (i-CAT version 17–19;Imaging Sciences International, Hatfield,PA, USA) in maximum mouth openingposition, in order to evaluate the condylarmorphology and the translation in maxi-mum inter-incisal opening. The study cen-tre’s standardized scanning protocol fordentofacial deformity patients was used.This protocol comprises vertical (sittingupright) scanning in the ‘extended field’mode (field of view (FOV) 17 cm diame-ter and 22 cm height, scan time 7 s, voxelsize 0.4 mm) at 120 kV and 5 mA.Patients were instructed to sit uprightand position themselves in natural headposition (NHP).

Primary CBCT images were stored as576 DICOM (Digital Imaging and Com-munications in Medicine) data files. Thesewere segmented manually and processedusing third-party software (SimPlantPro OMS; Materialise Dental, Leuven,Belgium). A 3D skull model reconstruc-tion was obtained (Fig. 1). The prospectivelevel and orientation of the ostectomywere planned according to the underlyingdiagnosis and the adjacent anatomicalstructures, respectively (Fig. 2). A highcondylectomy was planned for an anatom-ically normal condyle, whereas a low con-dylectomy (at the junction of the condylarhead and neck and preserving the condylarneck) was planned for benign tumours.

-Alfaro F, et al. Minimally invasive intraoral co

rg/10.1016/j.ijom.2016.04.001

um mouth opening. Frontal (A), right profile (B

Scanning in maximum mouth openingenabled the surgeon to determine whetherthe amount of condylar translation in max-imum opening would be clearly sufficientto enable the planned resection throughan intraoral approach. In addition, theanatomical relationship to the coronoidprocess was evaluated in terms of poten-tial interference with the surgical access.

Surgical technique

Under general anaesthesia and nasotra-cheal intubation, maximum mouth open-ing was forced with a Molt mouth gagfitted with silicone tubing to avoid dentalinjuries.

A 2-cm vertical incision was madealong the anterior border of the ascendingmandibular ramus. This incision is similarto that used for a sagittal split osteotomy.Sub-periosteal dissection proceeded crani-ally towards the coronoid process and thendeeply towards the sigmoid notch. Thetemporalis tendon was dissected fromthe anterior, lateral, and medial borderof the ramus up to the level of the sigmoidnotch (Fig. 3). The superior temporalisattachment on the coronoid process abovethe level of the mandibular notch waspreserved completely. If required, a cor-onoidectomy was performed at this stageusing a piezoelectric microsaw (ImplantCenter 2; Satelec-Acteon Group, Tuttlin-gen, Germany).

The sub-periosteal dissection along thecondylar neck and head was continued upto the inferior joint space, such that the


), inferior (C), and left profile (D) views.


Minimally invasive intraoral condylectomy 3


Fig. 2. Treatment planning of the prospective level and orientation of the ostectomy. A low condylectomy (A), high condylectomy (B), andsuperimposition of both treatment plans (C) are shown. A low condylectomy (A) was performed in this patient.

disc was not disrupted. The same micro-saw was used to execute a condylectomyat the planned level and with the antici-pated angulation. A specific extra-longcustomized instrument with a short angu-lated tip was used for this purpose (Fig. 4).



Fig. 3. Sub-periosteal dissection. The temporalismedial borders of the ramus up to the level ofsuperior temporalis attachment on the coronoid p

Fig. 4. Extra-long piezoelectric surgery instrum

This device enables the surgeon to reachthe condylar neck from an intraoral accesscomfortably while minimizing the softtissue dissection and allowing a steadyexecution of the ostectomy. The articularcapsule and lateral pterygoid muscle were


rg/10.1016/j.ijom.2016.04.001

tendon is dissected off the anterior, lateral, and the sigmoid notch, with preservation of therocess above the level of the mandibular notch.

ent.

dissected off the condylar head and neck.At this point, stabilization of the condylarfragment with a temporary screw and wirecan facilitate the soft tissue dissection(Fig. 5). After intraoral delivery of theosteotomized fragment, a tension-free wa-tertight soft tissue closure was performedwith resorbable 4–0 polyglactin (Vicryl;Ethicon, Somerville, NJ, USA) (Fig. 6).No drainage tubes were left in place.

Endoscopic assistance may be usedthroughout the surgical intervention toimprove illumination and visualizationof the surgical field.

Patients were discharged from the hos-pital the following day. Average postop-erative pain was evaluated on a visualanalogue scale (VAS), with a range of 0(no pain) to 10 (worst pain imaginable).Active physiotherapy was started 3–4 daysafter surgery to accelerate functional re-covery and prevent joint ankylosis.

A complete case example is shown inFig. 7.

Results

From August 2014 to January 2016, sevenpatients underwent an intraoral condylect-omy at the study centre due to progressivefacial asymmetry. The patient demograph-ic characteristics, clinical findings, surgi-cal procedure, pathology results, andpostoperative pain levels are summarizedin Table 1. Active condylar growth wasdetected in all cases. The affected jointwas on the left side in all patients exceptone. The underlying cause of the abnormalcondylar growth was Wolford CH type 1in two cases and CH type 2 in the otherfive.1

Chronologically, the first two caseswere operated on under endoscopic assis-tance, and a coronoidectomy was per-formed in both. In the remaining cases,direct illumination of the surgical fieldwith a headlight was deemed sufficient,and resection of the coronoid process was







Fig. 5. Temporary stabilization of the condylar fragment with a screw and wire.

Table 1. Patient demographic characteristics, clinical findings, surgical procedure, pathology res

PatientAge,years Sex Clinical findings

Affectedside Coronoidectomy

Endoassi

1 29 F Progressive facial asymmetryChin deviation to the rightIpsilateral and anterior open bite,contralateral crossbiteNormal mouth opening

Left Yes Y

2 25 M Progressive facial asymmetryChin deviation to the rightIpsilateral open biteNormal mouth opening

Left Yes Y

3 32 F Progressive facial asymmetryChin deviation to the rightIpsilateral open bite,contralateral crossbiteNormal mouth opening

Left No N


Left No N


Left No N

6 28 F Progressive facial asymmetryChin deviation to the leftContralateral crossbiteNormal mouth opening

Right No N

7 38 F Progressive facial asymmetryChin deviation to the rightIpsilateral open bite,contralateral crossbiteNormal mouth opening

Left No N

Postop., postoperative; VAS, visual analogue scale (range 0–10); F, female; M, male; CH 1, chyperplasia type 2 (osteochondroma).

obviated. The average duration of surgeryfrom incision to last suture was 16.9 min(range 14–25 min). A progressive reduc-tion in the operation time was observedchronologically from case 1 to case 7.

Postoperative swelling was minimal inall cases. No other complications oc-curred. The average postsurgical pain onthe VAS was 1 (range 0–2). The facialasymmetry was improved markedly im-mediately after surgery, and a normal,painless maximum mouth opening couldbe achieved within 48 h with active phys-iotherapy.

Orthodontic treatment to prepare forsubsequent orthognathic surgery was ini-tiated between 1 and 2 weeks after sur-gery. To date, four patients haveundergone orthognathic surgery. The tim-ing of surgery was scheduled according toa ‘surgery late’ protocol (conventional fullorthodontic preparation) in three cases and


ults, and postoperative pain level.

scopicstance

Durationof surgery

(min)Pathological

findings

Postop.pain

(VAS)

es 25 CH 2 1

es 19 CH 2 2

o 16 CH 1 0

o 14 CH1 0

o 15 CH 2 2

o 15 CH 2 0

o 14 CH 2 2

ondylar hyperplasia type 1; CH 2, condylar






Fig. 7. Facial and pathology images of the patient shown in Figs 1–6. (A) and (B) are preoperatianalysis, which was compatible with condylar osteochondroma. (E) and (F) show the patient at

Fig. 6. Wound closure.

a ‘surgery early’ protocol in one.18 Norecurrence of facial asymmetry has beenobserved over an average follow-up of 8.7months (range 2–16 months).

Discussion

In 2013, Wolford proposed a classificationsystem for CH covering all conditions thatlead to excessive growth and enlargementof the mandibular condyle and which aretherefore potential causes of alterations inthe bony architecture of the mandible,malocclusion, and dentofacial deformity.1

This classification is comprehensive butsimple and reflects well the clinical andimaging characteristics, occurrence rate,natural progression, histological particula-rities, and recommended treatment. Inbrief, CH type 1 refers to accelerated


ve images. (C) and (D) show the pathological 3 weeks after surgery.




and prolonged ‘normal’ growth, CH type 2corresponds to osteochondroma, CH type3 includes other types of benign condylartumours, and CH type 4 comprises malig-nant condylar tumours.

At the authors’ institution, the treatmentprotocol for facial asymmetry due to CHincludes interruption of abnormal condylargrowth with a condylectomy and second-stage correction of facial asymmetry withorthognathic surgery. If the patient hascompleted growth and systemic conditionsallow, first-stage surgery is performed assoon as the diagnosis of excessive condylargrowth is established. Although it is to beexpected that the sooner the condylargrowth is normalized the less facial defor-mity will develop and thus the easier sec-ondary corrective orthognathic surgery willbe, in adolescents it seems reasonable towait for complete contralateral mandibulargrowth.

The conventional and most commonsurgical approach to the mandibular con-dyle is through a pre-auricular incision.2–8

This approach provides ample exposureof the TMJ hard and soft tissue compo-nents and can easily be extended to allowadditional exposure of the adjacent ana-tomical structures.2,9,10 However, visibleunaesthetic facial scars, paresis of thetemporal and zygomatic branches of thefacial nerve, and salivary fistulae are sig-nificant potential complications.5,11–15 Asan alternative, access to the mandibularcondyle from an intraoral approach ispossible due to condylar translation inmaximum mouth opening. This approachminimizes the incidence of neurovascularand salivary complications, avoids thecreation of facial scars, and preservesthe integrity of the articular capsule, there-by reducing the risk of fibro-osseousTMJ ankylosis.11,13,15,16 Moreover, takinginto account that osteochondromas growanteromedially in most cases,8,13 anintraoral approach provides a more directpath to the tumour with less tissue dissec-tion.11,13 Overall, these advantages resultin minimal patient morbidity.11,13,15,16

The intraoral route to the mandibularcondyle can be contextualized within thecurrent trend for minimally invasive proce-dures that enable expedited postoperativerecovery, and the preferential use of naturalorifices for surgical access. It represents themaxillofacial counterpart to the so-calledNOTES (natural orifice transluminal endo-scopic surgery) in gastrointestinal surgeryand interventional gastroenterology. Thisemerging field in which a scar-less accessto the peritoneal cavity is gained via ahollow viscus (mouth, stomach, colon,anus, vagina, urethra, or cystic cavities)



has already been used for a variety ofdiagnostic explorations of the peritonealcavity, as well as complex organ resec-tions.19 Potential advantages include thelower anaesthesia requirements, faster re-covery and shorter hospital stay, and avoid-ance of the potential complications ofexternal wounds (including unaestheticscars and infections).20

In this proof-of-concept evaluation ofthe feasibility of intraoral condylectomy,endoscopic assistance was used in onlytwo cases. Although the spatial orientationand perception of depth can be somewhatdifficult in inexperienced hands, the use ofan endoscope improves illumination of thesurgical field, provides a magnified visu-alization of the TMJ for the whole surgicalteam, and may be a useful adjunct, espe-cially for young surgeons. Nevertheless,direct visualization from the surgeon’sintraoral viewpoint is sufficient for a safeand accurate execution of the procedure.

The key issue in determining whether amandibular condylectomy is feasiblethrough an intraoral access is the degreeof condylar translation with mouth open-ing. To this effect, CBCT scanning of thepatient in maximum mouth opening wasperformed. It may be argued that condylarmovement can be simulated with treat-ment planning software, but the authorsbelieve that virtual simulation of condylarrotation and translation is too inaccurateunless sequential scanning at differentdegrees of mouth opening is performed;however, this practice would be contra-indicated ethically.

Additional benefits of 3D virtual plan-ning for the intraoral condylectomy includethe determination of the prospective leveland orientation of the ostectomy and thepotential need for a concomitant coronoi-dectomy. Regarding the former, it must benoted that, in comparison to other surgicalprocedures in which 3D planning involvesthe fabrication of CAD/CAM surgicalguides or splints, the authors’ virtual plan-ning protocol for intraoral condylectomydoes not result in the production of any typeof surgical guide. Therefore, the intraoper-ative design of the condylectomy is notexact but approximate. However, virtualsimulation of the level and orientation ofthe bone cut according to the underlyingdiagnosis and adjacent anatomical struc-tures helps the surgeon to anticipate eachsituation individually and precisely.

Although at the beginning of theauthors’ learning curve an additional cor-onoidectomy was performed, experiencehas shown that resection of the coronoidprocess may be unnecessary. As corrobo-rated with CBCT imaging in maximum


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mouth opening, full condylar translationprovides an adequate obstacle-free routeto the condyle without interference fromthe coronoid in most cases. Furthermore,the anteromedial location of most osteo-chondromas8,13 implies excellent expo-sure of the tumour without the need forcoronoidectomy. Increasing surgical ex-perience and the avoidance of coronoi-dectomy enabled the operative time tobe reduced to an average of 16.9 min.Together with a minimally invasive surgi-cal technique, the reduced theatre timewas probably responsible for the patients’rapid and uneventful recovery and the lowlevels of postoperative pain.

It is a general perception that the type ofcondylectomy should be individualizedaccording to the underlying diagnosis.While CH types 3 and 4 call for an indi-vidualized treatment plan according totumour size and histology, most authorsagree that the proliferative zone in CHtype 1 can be eliminated adequately witha high condylectomy.1 In CH type 2, therecommended height of the condylectomycontinues to be the subject of debate. Areview of the scientific literature foundthat most osteochondromas were managedwith a total condylectomy,8 but propo-nents of a more conservative approachrefer to the benign nature of the lesionand avoiding TMJ reconstruction to justifya low condylectomy. In a retrospectivecohort study of 37 osteochondroma caseswith postoperative follow-up averaging 48months (range 12–288 months), no recur-rence occurred after a low condylect-omy.21 The surgical protocol developedby Wolford included ipsilateral reshapingof the condylar neck with disc reposition-ing and contralateral disc repositioning –when displaced – via a pre-auricular ac-cess, and concomitant orthognathic sur-gery.21 In the present study, the selectedlevel of resection for the two CH type 2cases was a low condylectomy. No addi-tional TMJ procedures were performed.Ongoing follow-up will confirm whetherthe positive results obtained are main-tained in the longer term.

In conclusion, compared to the conven-tional pre-auricular access, an intraoral ap-proach to the mandibular condyle has thepotential to minimize the incidence of neu-rovascular and salivary complications,avoid creating facial scars and openingthe articular capsule, and reduce patientmorbidity. A minimally invasive protocolfor intraoral condylectomy based on pre-cise 3D treatment planning, a reduced inci-sion, and customized piezoelectric surgicalinstruments has been described herein. Theresults of the proof-of-concept evaluation





suggest that this technique allows reliableand accurate condylar resection and is tech-nically simple and fast, and that patientmorbidity is minimal. This alternative ap-proach could become the treatment ofchoice for most condylar hyperplastic con-ditions.

Funding

None.

Competing interests

None.

Ethical approval

Exempt.

Patient consent

Patient consent was obtained to publishthe clinical photographs.

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Address:Raquel Guijarro-MartınezInstitute of Maxillofacial SurgeryTeknon Medical CentreVilana 12D-185Barcelona 08022SpainTel: +34 933 933 185; Fax: +34 933 933 085E-mail: [email protected]


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