J Oral Maxillofac Surg

60:996-1002, 2002

Treatment of Painful Temporomandibular

Joint Dysfunction With the Sagittal Split
Ramus Osteotomy
John 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 treat
patients with painful dysfunction of the temporomandibular joint.
Patients and Methods: Ten patients for whom nonsurgical management failed were found to have a
mandibular condyle positioned postero-superior within the glenoid fossa with reduced joint space on
corrected-axis tomograms. The sagittal split ramus osteotomy was used to reposition the proximal
segment 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 after
initial improvement. No patient developed a malocclusion. The long-term radiographic condyle-fossa
relationship tended to return to its preoperative position with no relapse of clinical symptoms, except
in the 1 patient.
Conclusion: The sagittal split ramus osteotomy with rigid fixation is another procedure that can be
used to treat painful temporomandibular joint dysfunction by changing the position of the mandibular
condyle in the glenoid fossa.
© 2002 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 60:996-1002, 2002

There are many nonsurgical and surgical modalities
for the treatment of temporomandibular joint (TMJ)
internal derangements. A conservative, nonsurgical
approach is initially indicated. If nonsurgical methods
fail, then often the procedure of choice for disc de-
rangements is controversial. Surgical options include
arthrocentesis, arthroscopic surgery, arthrotomy/ar-
throplasty, mandibular condylotomy, and/or orthog-
nathic surgery to correct skeletal jaw deformities.1
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
The mandibular condylotomy is a vertical ramus
osteotomy in which the proximal segment is allowed
to passively sag inferiorly and anteriorly, increasing
joint space to allow for the recapture of an anteriorly
displaced disc. The potential complications unique to
intracapsular procedures are avoided. Reports sub-
stantiating the modified condylotomy have been pub-
lished within the past 10 years by Nickerson and
Veaco,2 Nickerson,3,4 Hall et al,5 Hall,6,7 Werther et
al,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 usually
used for a varying amount of time.
Our practice has used the sagittal split ramus os-
teotomy (SSRO) as an alternative to the mandibular
condylotomy to treat patients with painful TMJ dys-
function. For these patients, nonsurgical treatment of
their internal derangement failed, and they have sig-
nificantly decreased joint space because of a condyle
that is positioned posterosuperiorly in the fossa as
shown by corrected-axis tomography. At times, the
mandibular condyle can be seen on tomography to be
touching the posterosuperior portion of the glenoid
fossa or the tympanic plate. As with the condylotomy,
this approach was chosen to avoid an intracapsular
procedure, yet provide better control and placement

996
PRUITT ET AL
of both the proximal and distal segments. The selec-
tion criteria, treatment protocol, and retrospective
long-term results of this approach are described. The
rationale, advantages, and disadvantages are also dis-
cussed.
Patients and Methods
PATIENTS
A standardized history and physical examination
form is used in our practice to evaluate patients with
TMJ disorders or facial pain. If initial findings suggest
an internal derangement, then corrected-axis tomo-
grams are obtained to evaluate the osseous relation-
ships of the condyle within the glenoid fossa. The
sagittal bony anatomic relationships of the TMJ are
best examined with corrected-axis tomograms.17 If no
joint 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 performed
since 1990 in our practice if the following criteria
were met: 1) history and examination consistent with
an internal derangement of one or both TMJs; 2)
bilateral corrected-axis tomograms showing reduced
posterior and superior joint space of the affected
side(s); 3) inadequate clinical response to nonsteroi-
dal anti-inflammatory drugs, diet modifications, splint
therapy, and/or physical therapy for more than 3
months; and 4) pain and dysfunction resulting in
significant impairment of the patient’s diet and activ-
ities of daily living, and therefore motivation for the
patient to proceed to surgical treatment.
Twenty-six patients who met these criteria under-
went SSRO where at least 1 proximal segment was
deliberately repositioned to change the relationship
of the condyle to the glenoid fossa. Ten patients were
excluded from this report because a malocclusion
was surgically corrected, therefore requiring a change
in the position of both proximal and distal segments.
Two were excluded because of a previous history of
TMJ surgery: 1 patient had undergone arthroscopy
and discectomy, and 1 had undergone removal of a
Proplast-Teflon implant. Four patients could not be
reached for long-term follow-up. A chart review of
those 4 individuals revealed no instances of malocclu-
sion, and relief of symptoms were noted in their latest
progress notes. No concomitant maxillary osteoto-
mies were performed in this series.
Ten patients remained in the study series who had
clinical findings consistent with an internal derange-
ment of the TMJ (9 bilateral and 1 unilateral). The 9
patients with bilateral disease had simultaneous bilat-
eral osteotomies. One man was included, and the
average age at the time of surgery was 34.3 years
997
(range, 25 to 43 years). Two patients had a history of
mandible fractures that had been treated by closed
reduction in another practice. Both fracture patients
had required postreduction orthodontics to correct a
malocclusion. Six other patients had undergone pre-
vious routine orthodontic correction of a develop-
mental malocclusion. Average long-term follow-up
was 44.7 months (range, 31 to 83 months).
TECHNIQUE
Once the patient was under general anesthesia, the
mandible was manually positioned to seat the con-
dyles into the most retruded position, and the amount
of incisor overjet that could be achieved was noted.
SSROs were performed according to the techniques
described by Obwegeser and Trauner18 and Dal-
Pont.19 Once the ramus was successfully split, the
pterygomasseteric 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 was
removed from the vertical lateral cut, and approxi-
mately 1.5 to 2 mm was removed from the horizontal
medial cut, creating a gap to allow for the reposition-
ing of the condyle inferiorly and anteriorly. The
amount 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 inferior
vector. The osteotomy gaps were closed before the
proximal and distal segments were secured with a
modified Allis clamp.
Two 2.0-mm bicortical screws were placed along
the superior border. Intermaxillary fixation was re-
leased, and the occlusion and mandibular range of
motion were verified. The desired occlusal result was
shown if deliberate manual retropositioning of the
mandible to seat the condyle(s) could produce an
increased incisor overjet on the affected side com-
pared with what could be achieved preoperatively
under general anesthesia. The dental midlines would
remain unchanged during retropositioning if bilateral
procedures were done. With passive rotation of the
mandible through centric movements (no deliberate
retropositioning), the occlusion was stable and un-
changed. Tight intermaxillary elastics were then
placed 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 patients
remained in tight elastic intermaxillary fixation (with
no mandibular movement) for approximately 5 to 7
days, followed by loosening of the elastics. After the
first week, the liquid diet was advanced to a nonchew
diet with light training elastics for 5 to 6 weeks post-
operatively. At that point the patients were encour-
998
aged to maximize their mandibular range of motion
through the resumption of a normal diet and occa-
sionally tongue-blade exercises.
DATA COLLECTION
Patients were mailed a retrospective questionnaire
requesting their assessment of preoperative and post-
operative symptoms. Subjects were asked to rate the
intensity of their headaches, neck pain, jaw pain, ear
pain, “pain while chewing,” and “pain when opening
mouth widely” using a numeric scale with choices
ranging between 0 (none) and 5 (excruciating). Sub-
jects were also requested to rate the frequency of
mandibular locking, frequency of tooth clenching and
grinding, 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 returned
at a long-term follow-up appointment where bilateral
corrected-axis tomograms were taken, mandibular
range of motion, occlusion, joint noises, and other
TMJ symptoms were evaluated by the surgeon.
All bilateral tomograms were taken with the same
machine. Each individual patient’s position and image
slices were repeated at the preoperative, immediate
postoperative, and long-term postoperative appoint-
ments. The cortical outlines of the glenoid fossa and
condyle were traced on acetate sheets by an author
(J.W.P.). The fossa outlines were overlaid, and the
postoperative positions of the condyles were com-
pared with their initial location in both a vertical and
a horizontal dimension. The superiormost point on
the head of the condyle was used as the vertical
reference, and the anteriormost point was used as the
horizontal reference. The change in position was
measured in millimeters, with positive values repre-
senting a superior (cranial) vertical direction and an
anterior (forward) horizontal direction.
Results
Maximum incisal opening increased an average of
5.3 ⫾ 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 preoperative
joint noises, and 1 patient developed clicking when
her opening increased 25 mm postoperatively. There
were 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 had
symptom relief during the initial 3 months of postop-
erative follow-up; however, at 83 months reported all
TREATMENT OF TMD WITH SSRO
Table 1. AVERAGE PAIN RATINGS (0 to 5)
Symptom Preoperative Postoperative
Headaches 3.45 1.27
Jaw pain 2.18 1.18
Ear pain 2.91 0.91
Pain when chewing 3.27 0.82
Pain when opening 3.27 1.00
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 consistent
with a chronic closed-lock (nonreducing disc dis-
placement).
The immediate postoperative condyle position was
an average of ⫹0.8 ⫾ 1.0 mm anterior (range, ⫺0.5
to ⫹ 3.0 mm) and ⫺1.1 ⫾ 0.8 mm inferior (range, 0
to ⫺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 ⫺1.5
mm). Only 1 condyle was not successfully brought
anterior and inferior, and this was the same patient
mentioned earlier whose pain and dysfunction wors-
ened. The 83-month postoperative position of this
side was, in fact, posterior and superior to its original
position.
Discussion
Use of the SSRO for the treatment of TMJ internal
derangements is based on the same concept as the
condylotomy procedure. The premise behind condy-
lotomy is that repositioning the condyle is a more
effective treatment for disc displacements than repo-
sitioning the disc. A posterior position of the condyle
within 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 is
displaced 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 joint
structures. Surgically repositioning the condyle ante-
riorly and inferiorly while maintaining the occlusion
will increase joint space, or “decompress” the joint.
This may result in disc reduction and/or unloading of
the retrodiscal tissues, and thus allow these structures
(ie, disc, retrodiscal tissue, and bony surfaces) to heal
and repair. For nonsurgical treatment, Farrar22 intro-
duced the concept of the anterior repositioning splint
to “capture” the displaced disc and unload the joint.
Unfortunately, the splint offers limited usefulness dur-
PRUITT ET AL 999

Table 2. AVERAGE FREQUENCY OF SYMPTOMS

Symptom Preoperative Postoperative

Jaw locking 2.73 0.73

Clenching and grinding 3.55 2.27
Hindrance 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.

ing mastication, which is when the joint is under

maximum function.
Staz23 and Ward et al24 originally described the
condylotomy, using a percutaneous Gigli saw, after
noting that joint clicking and dysfunction were rarely
found after condylar fractures. Subsequently both the
open or closed condylotomy have been reported by
numerous authors for both internal derangements
and osteoarthritis of the TMJ with favorable relief of

FIGURE 2. Corrected-axis tomograms of right temporomandibular

joint preoperatively (A) and postoperatively (B) after repositioning.

pain and dysfunction.2-16,25-32 The technique for the

FIGURE 1. Corrected-axis tomograms of left temporomandibular joint
preoperatively (A) and postoperatively (B) after repositioning.
modified condylotomy is essentially the same as that
for the intraoral vertical ramus osteotomy. Time in
intermaxillary fixation generally ranges between 8
days6 to 3 weeks.2
MRI has shown complete disc recapture in 79% and
partial disc recapture in 15% of 80 joints with dis-
placed, reducible discs after modified condylotomy.8
New condylar bone formation has been reported in
90% of joints radiographed 5 to 72 months postoper-
atively by Nickerson and Veaco.2 The recortication of
the articular surfaces of osteoarthritic joints after con-
dylotomy has been described by several authors.5,32,33
Malocclusion due to excessive condylar sag has been
the 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 patients
needed minor occlusal equilibration in the posterior
quadrant of the side of the condylotomy, and 1 pa-
tient underwent further orthognathic surgery. Nick-
erson4 considers a discrepancy between centric rela-
1000
tion and centric occlusion to be an expected outcome
of condylotomy. Certainly minor centric relation–
centric occlusion discrepancies may be of little clini-
cal significance, but this is difficult to quantify. Hall et
al prospectively evaluated the occlusion in patients
who had modified condylotomies for reducing35 and
nonreducing36 disc displacements. Cephalometric
and study model evaluations by an orthodontist 1 year
postoperatively showed minor changes in the incisor
relationships in some patients. None developed an
open bite, and all who returned for follow-up had a
stable occlusion.
Limiting the amount of medial pterygoid muscle
stripping during condylotomy has been suggested as a
way to prevent excessive condylar displacement and
a resulting midline shift and/or malocclusion.4,6,14
Nickerson4 advised that “surgeons should minimize
the use of simultaneous bilateral condylotomy” be-
cause of the increased likelihood of maintaining the
original occlusion. Even if apertognathia does not
develop, there is the risk that vertical ramus height
may shorten, leading to an increased mandibular
plane angle, extrusion of the incisors, and possibly
intrusion of the molars.4
Another potential complication of the modified
condylotomy is a palpable or visible deformity of the
ramus if the inferior aspect of the proximal segment is
displaced too far laterally. There may also be exces-
sive axial and coronal rotation of the condyle when
the proximal segment is laterally positioned. Hall’s6
recommendation to create a butt joint between the
osteotomy segments would help prevent these com-
plications. He also reported an interosseous wiring
technique37 to reduce the chance of inappropriate
postoperative condylar sag and/or medial displace-
ment of the proximal segment after condylotomy.
An advantage of repositioning the condyle using
the 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 the
proximal segment positioning is probably superior
with 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 reduces
the time the patient is in tight intermaxillary fixation
to 5 to 7 days. The benefits of early mobilization
include improved range of motion and enhanced nu-
trition. Careful technique will prevent unwanted con-
dylar rotation in the axial or coronal planes. Bony
interferences should be removed between the over-
lapping proximal and distal segments, and bicortical
screws should be placed in a manner that does not
torque the proximal segment. The primary disadvan-
TREATMENT OF TMD WITH SSRO
tage of the SSRO compared with the intraoral vertical
ramus osteotomy is the potentially higher incidence
of trigeminal nerve paresthesia.38 Costs may be higher
with the SSRO because of the bicortical screws and
possibly longer operating room time.
While all patients had favorable symptom relief
during the immediate postoperative period, condylar
cortical outlines measured at long-term follow-up con-
sistently relapsed from their immediate postoperative
positions, sometimes to their original locations. This
may be true segment relapse or settling, or more
likely cortical remodeling and/or hypertrophy, which
has been seen with modified condylotomy.5,32,33
Both the modified condylotomy and SSRO avoid the
complications unique to intracapsular surgery: facial
nerve injury, otologic injury, intra-articular scarring/
fibrosis, trismus, ankylosis, cutaneous scarring, and
disturbing the synovium. Both procedures require
less than 1 week of tight intermaxillary fixation and
only training elastics thereafter.
The clinical success of modified condylotomy and
SSRO may be related to the reestablishment of the
disc between the articulating surfaces of the condyle
and fossa, although it is now recognized that normal
disc position is not required for asymptomatic TMJ
function. Disc displacement is seen on MRI among
30% to 40% of joints in asymptomatic popula-
tions.39,40 Increasing joint space with a splint has been
shown to relieve symptoms despite a failure to
achieve normal disc position (“recapture the disc”) on
MRI.41
The success of condylar repositioning may also
result from unloading of the highly innervated retro-
discal tissues. The auriculotemporal nerve has a close
anatomic relationship with the condyle, TMJ capsule,
and lateral pterygoid muscle.42 Histologic studies
have shown that the nerve fibers from the auriculo-
temporal nerve can become displaced and impinged
between the articular fossa and condyle.43 Pain relief
after condylar repositioning may be due to the elimi-
nation of direct bony contact between the condyle
and glenoid fossa and/or tympanic plate. It may also
relieve nerve irritation, inflammation, or entrapment.
Loughner et al44 found the posterior trunk of the
mandibular nerve, which includes the auriculotempo-
ral nerve, entrapped within the lateral pterygoid mus-
cle in 3 of 52 joint dissections. Condylar repositioning
would be expected to shorten the lateral pterygoid
muscle, and thereby reduce any contributory pain
that 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 of
internal derangement, nor can we comment on how
PRUITT ET AL
this procedure affects disc position. The rating system
used by the patients was not objective, and patients
may have been reluctant to report candidly. There
also are the biases of the treating physicians’ record-
ing and interpretation of the data. The small number
of subjects involved precluded any meaningful statis-
tical analysis.
The SSRO with rigid fixation may offer 2 potential
advantages over the modified condylotomy for treat-
ment of painful TMJ dysfunction: 1) less chance of
postoperative 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 the
occlusion intraoperatively, and 2) surgeons’ experi-
ence with the SSRO may be greater.
The SSRO may be a better procedure when there is
a greater risk of postoperative malocclusion, such as
when bilateral procedures are necessary or if there is
an unstable preoperative occlusion.
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