Condylar sag

Condylar sag as a complication of orthognathic surgery

1. CONDYLAR SAG Dept. of Oral & Maxillofacial Surgery, VSPM’s DCRC, Nagpur

2. Introduction Definition Incidence of Condylar Sag Risk factors Condylar Sag & IVRO Types Intra-operative diagnosis Prevention of C ondylar sag- IVRO, BSSO, Lefort -I Osteotomy Articles at a glance Conclusion CONTENTS

3. INTRODUCTION Malocclusion after orthognathic surgeries (BSSO, IVRO, lefort I osteotomy) may be the result of failure of rigid fixation at the osteotomy site, occlusal shifts during fixation or improper condylar position.

4. Condylar sag is most challenging to diagnose and treat correctly. The most troublesome sequelae are skeletal instability and anteroinferior condyle displacement (sag) with resultant unpredictability of the postoperative mandibular position. The term condylar sag was coined by Hall et al. in 1975 . They described the influence of the condylar position on postoperative occlusal stability following the release of IMF. Hall HD, Chase DC, Payor LG. Evaluation and refinement of the intraoral vertical subcondylarosteotomy . J Oral Surg1975;33:333-41 . INTRODUCTION

5. Condylar sag can be defined as an immediate or late change in position of the condyle in the glenoid fossa after surgical establishment of a preplanned occlusion and rigid fixation of the bone fragments, leading to a change in the occlusion. Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292 DEFINITION

6. Complications following Orthognathic surgery ranges from 9.7-24.5 % Neural deficit- most common – 50.42% TMJ Dysfunction- 13.64% Hemorrhage-9.09%

7. Incorrect vector during condylar positioning; A n incomplete or green-stick split that prevents condylar seating; Muscular , ligamentous, or periosteal interference ; I ntra-articular hemorrhage or edema and flexing the proximal segment while placing rigid fixation. Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292 RISK FACTORS

8. Condylar sag after IVRO has clinical significance and is associated with improved mandibular function. Removal of masseter & medial pterygoid attachment Condylar luxation ( lateral pterygoid muscle pulling the condyle forward) Condylar sag typically occurs when the masseter and medial pterygoid attachment to the proximal segment are removed. Therefore, the condylar luxation may be related to the lateral pterygoid muscle pulling the condyle forward.

9. 2 postulates Medial and forward displacement of the mandibular disk- by the upper head of the lateral pterygoid muscle. After sectioning - the mandibular condyle is displaced in the same direction as the disk - by the pull of the lower head of the lateral pterygoid muscle.

10. TYPES Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292

11. CENTRAL CONDYLAR SAG Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292

12. PERIPHERAL CONDYLAR SAG - i Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292

13. PERIPHERAL CONDYLAR SAG - Ii Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292

14. INTRA-OPERATIVE DIAGNOSIS OF CONDYLAR SAG Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292

15. Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292 CENTRAL CONDYLAR SAG

16. Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292 CENTRAL CONDYLAR SAG

17. Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292 PERIPHERAL CONDYLAR SAG - Ii

18. Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292 PERIPHERAL CONDYLAR SAG - Ii

19. quired to assure condylar seating. As noted, procedures that result in lengthening of the soft tissue envelope of the ramus, such as vertical lengthening of the maxillomandibular complex, can result in condylar sag.

20. Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292 CONDYLAR SAG – LEFORT-I OSTEOTOMY

21. Meticulous examination of the occlusion and an understanding of the occlusal changes secondary to condylar sag can reliably identify condylar sag intraoperatively . The use of suitable corrective measures during the primary operation can substantially reduce the postoperative complication rate of condylar sag. CONCLUSION

22. REFERENCES Massimo Politi et al, Intraoperative Awakening of the Patient During Orthognathic Surgery: A Method to Prevent the Condylar Sag, J Oral Maxillofac Surg 65:109-114, 2007 Arnett G Wiliam , A redefinition of bilateral sagittal osteotomy advancement relapse, American Journal of Orthodontics and Dentofacial Orthopedics 1993;104:506-15 Kensuke Yamauchi et all, Condylar luxation following bilateral intraoral vertical ramus osteotomy,Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:747-51 Eckerdal 0, Sund G. Astrand P: Skeletal remodeling in the temporomandibular joint after oblique sliding osteotomy of the mandibular rami. Int J Oral Maxillofac Surg 15:233, 1986 Kenneth S Rotskoff et al, correction of condylar displacement following IVRO,JOMS, 49, 366-372, 1991 Hall HD, Chase DC, Payor LG. Evaluation and refinement of the intra-oral vertical subcondylar osteotomy . Oral Surg 1975;33:333–341 . Johan. P. Reyneke , C. Ferretti , Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy ,British Journal of Oral and Maxillofacial Surgery (2002) 40, 285–292

23. THANK YOU…..