Conylar Sag

CONDYLAR SAG
DEFINATION
• 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
TYPES
• CENTRAL
1.Bilateral
2.Unilateral
• PERIPHERAL
TYPE 1
TYPE 2
a.Unilateral
b.Bilateral
Central condylar sag
when the condyle is positioned inferiorly in the glenoid fossa and

makes no contact with any part of the fossa
After removal of the IMF and in the absence of intracapsular edema or
hemarthrosis, the condyle will move superiorly causing a malocclusion
INTRAOPERATIVELY DIAGNOSED
Condylar sag produces repeatable patterns of malocclusion after
removal of the IMF, which can be used to diagnose the condition and
identify the offending condyle.
Diagnosis made by observing the
following clinical signs.
BILATERAL UNILATERAL
class II occlusion (bilaterally) class II dental relationship on offending side; and if

the mandible is moved until the midlines coincide, the
overjet is corrected and the correct occlusion can be
re-established
Dental midlines are correct; Mandibular dental midline is towards offending side
Anterior openbite; -
overjet is increased overjet is increased (more on the offending side);

PERIPRHERAL TYPE 1
• Occurs when the condyle is positioned inferiorly with peripheral
contact with the fossa (lateral, medial, posterior,
• or anterior), while the IMF is in position and the teeth are in
occlusion.
• Delayed occlusal relapse occurs as a result of condylar resorption or
change in its shape
• This type of sag cannot be diagnosed intraoperatively because there
is contact between condyle and glenoid fossa that supports the
occlusion.
• Late relapse from condylar resorption may result in a malocclusion
Peripheral condylar sag (type II)
when the condyle is positioned correctly in the fossa while IMF is in

position and teeth are in occlusion; however, the incorrect placement
of rigid fixation causes flexural stress in the proximal segment . Once
the IMF is removed, the tension in the proximal segment is released
and the condyle moves either laterally or medially and slides inferiorly
resulting posterior open bite.
Post open bite =change in vertical position of condyle
UNILATERAL/BILATERAL
Bilateral peripheral condylar sag Unilateral peripheral condylar sag
Dental midlines are correct and a Dental midline of the mandible is towards the
opposite side;
Anterior crossbite or an edge-to-edge incisal edge-to-edge incisor relationship with a tendency

relationship to crossbite on the offending side
Dental class III relationship
Bilateral posterior openbites. There is a posterior openbite on the offending side;

and when the mandible is moved to correct the
dental midlines, the incisal relationship remains
edge-to-edge or in crossbite with canines and
molars tending to a class III relationship.
Condylar positioning technique
• A hole is drilled anteriorly in the proximal segment close to the inferior border to
engage a condylar-positioning instrument.
• After splitting, any bony interference in the medullary aspect of the proximal and distal
segments is removed to allow free movement between the two segments during
condylar positioning.
• The proximal segment is pushed posteriorly and slightly inferiorly with the positioning
instrument, while light extraoral digital pressure is applied to the angle of the mandible
pushing superiorly and slightly anteriorly
• Controlled force, combined with an awareness of the anatomic relationship of the
condyle, meniscus, and glenoid fossa enable the surgeon to achieve the best possible
condylar position.
• At this stage a holding wire to pull the proximal segment posteriorly and the distal
segment anteriorly is carefully tightened
• Care is taken to avoid distracting of the condyle out of the fossa. This could deceive the
surgeon into thinking that a correct occlusion had been achieved.
• The occlusion is deemed to be correct when it corresponds to that achieved during
• This step is followed by the transbuccal insertion of three bicortical screws in an
inverted-L or straight-line configuration.
• Again, care is taken that the screws merely maintain the condylar position and do not
compress the segments together.
• The occlusion is carefully inspected before removal of the IMF to identify any occlusal
alterations that may have occurred during the placement of rigid fixation . After
removal of the IMF, the mandible is opened and closed, and the condyles gently
translated out of the fossae by pulling the mandible anteriorly and moving it to the
left and right.
• This procedure is repeated after a minute and then, with light digital pressure on the
chin, the mandible is rotated until first occlusal contact, and the occlusion is then
checked.
• The temptation to force the teeth into occlusion by increasing the digital pressure
must be resisted. It should be kept in mind that only a light force is necessary to
If a malocclusion is noted, it is diagnosed by the clinical signs already
listed.
The IMF is replaced and the screws on the offending side are removed
and replaced after a repetition of the condylar seating procedure (if a
bilateral sag occurs both condyles are reseated).
Light 3-ounce, 0.25-in. training elastics are placed at operation and the
patients are seen 1-week postoperatively when the occlusion is
checked again.
If a malocclusion is found at this stage and condylar sag is a likely
diagnosis, the patient is informed and is seen 4 days later.
By this time most of the postoperative swelling and intra-articular
edema or hemarthrosis has resolved and a definitive diagnosis can be
made.
If it is indicated, the patient has a further operation
REASONS FOR INCORRECT
CONYLAR POSITIONING
• Incorrect vector during condylar positioning
• Incorrect direction of the holding wire or bone clamp
• An incomplete or green-stick split which prevents condylar seating
• muscular, ligamentous or periosteal interference
• Intra-articular hemorrhage or edema Flexing the proximal segment
whilst placing rigid fixation. The stress in the segment is released once
the IMF is removed
Condylar Sag in VRO
• DIAGNOSIS:
• Ater MMF apply pressure at angle if proximal segment can be pushed
upward more than 2-3 mm conylar sag is present.
• Treatment option;
• Fixation to hold the proximal fragment in more superior position
• Options
• 1.5mm L shaped plate
• Screws
• Screw/wire technique
Screw and wire technique
• Drill hole at inferior border of proximal segment
• Drill hole at 45 degree angle in distal segment
• Distance superior to proximal segment should be equal to the
distance estimated to elevate the proximal segment
• 2.0 screw placed in distal segment ans 26 g wire in proximal segment
ans tied with screw

Conylar Sag

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CONDYLAR SAG

when the condyle is positioned inferiorly in the glenoid fossa and

class II occlusion (bilaterally) class II dental relationship on offending side; and if

overjet is increased overjet is increased (more on the offending side);

when the condyle is positioned correctly in the fossa while IMF is in

Anterior crossbite or an edge-to-edge incisal edge-to-edge incisor relationship with a tendency

Dental class III relationship

Bilateral posterior openbites. There is a posterior openbite on the offending side;

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