condylar resorption and arthrosis of the joint (dgkfo)

Condylar Resorption and Arthrosis of the Joints

Kieferorthopädie auf den Punkt gebracht 11. - 14. Oktober 2017

Wissenschaftliche Jahrestagung in Bonn Scientific Annual Meeting

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Revised as of October 2017

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Contemporary Findings on TMDs & Clinical Management 1

• TMD: incidence in general population = 2 F: 1 M

• TMD: incidence in patient population = 10 F: 1 H

• Age distribution: 18-45 y

• Hormonal influences may make an individual susceptible

✦ Estrogen & progesterone receptor are present in the TMJCurrent and future innovations in diagnostics and therapeutics of TMJ diseases , Temporomandibular disorders and orofacial pain: separating controversy from consensus, CFG vol 46, 2008, p 283-310Wadhwa S, and Kapila S. TMJ disorders: future innovations in diagnostics and Therapeutics. J Dent Educ. 2008, Aug;72(8):930-47

http://sylvainchamberland.com


Contemporary Findings on TMDs & Clinical Management

• Sexual dismorphism M/F in the presence of oestrogen receptors and age distribution of TMJD

• Evidence that sex-based determinants (estr., prog., relaxin) may make an individual susceptible to degenerative TMJ disease

✦ Association between facial pain associated with TMD and exogenous estrogen (HRT) or the use of oral contraceptive

✦ Pregnancy & menstrual cycle study suggest that in women who have TMD, high pain is associated with low levels of estradiol

Kapila S. p. 289, LeResche p.113-115, Monography #46, CFG series



Idiopathic Condylar Resorption in Teenage Girls

• Most common TMD in adolescent (9F :1M)

• Begin during pubertal growth phase (age range from 10 to 40)

★ Females hormones stimulates hyperplasia of the synovial tissues ➔produce chemical substrates that destroy the ligaments that normally stabilize the disc to the condyle➔ disc displace anteriorly (Larry Wolford)

• Affect condyles bilaterally and symmetrically

• Progressive mandibular retrusion followed by period of remission until the entire condylar head is resorbed

• Other reports say: No consistent or proven aetiology

✦ Disc luxation without reduction, general joint hypermobility

✦ Trauma, parafonctional activity, ↓estrogen



AICR: clinical characteristics• Teenage female, age of onset 11 to 15 y

• High occlusal plane and mandibular plane angle

• Predominant cl II skeletal & dental relationship with or without open bite

✦ Rarely occurs in hypodivergent or cl III patients

✓ This may contradict the “lack of oestrogen theory”

• TMJ symptoms: clicking, popping, TMJ pain, headaches, myofascial pain, earaches, tinnitus, vertigo; no other joint are involved



According to L.M. Wolford Atlas Oral Maxfacial Surgery Clin N Am 19 (2011) 243-270

• 1369 consecutives patients ranging from 8 to 76 y. referred for TMD

✦ F =78%; M = 22%

✦ 69% of the patients reported the onset during adolescence

✦ Therefore: TMD predominantly develop in teenage girls

• Thought:

✦ If occlusion would be at fault, it is likely that the ratio M/F would be more equal...



AICR• During active phase

✦ Discomfort at both TMJs, hyperactivity of masticatory muscles

✦ Activity often burn out in 6 months

• In remission

✦ Normal function of TMJs without significant pain or loss of jaw opening amplitude



Estrogen Role• 17β-estradiol

✦ Down-regulation (↓ ) MMPs transcription

✦ ↓ cytokines and inflammatory markers

✦ ↓ bone loss in women

• Ethinyl Estradiol (contraceptive pills or postmenopause hormonotherapy)

✦ Suppress production of naturally occurring 17β-estradiol

✦ ↑ osteoclast activity & ↑ inflammatory cytokines production

Gunson MJ, Arnett G.W. et al, Oral contraceptive pill use and abnormal menstrual cycles with severe condylar resorption: A case for low serum 17β-estradiol as a major factor in PCR, AJODO 2009; 136:772-9



Cascade of Events Related to Estrogen

• ↓Estrogen

✦ Inhibit fibrocartilage synthesis

✦ Promote cytokines production

✓ Matrix degradation enzymes MMP

✦ Bone loss

✓ Progressive mandibular retrusionArnett G.W. et al, Progressive mandibular retrusion-idiopathic condylar resorption. Part 1, AJODO 1996; 110:8-15



Is Estrogen Associated with Mandibular Condylar Resorption?

A Systematic Review•Evidence was lacking that estrogen deficiency contributes to mandibular condylar resorption

since this relationship was based on limited studies.

•Recommendations:

✦ Further investigations on serum estrogen concentrations in women with condylar resorption are needed.

✦ Future studies should focus on the effects of the different types of medication and diseases influencing estrogen concentrations,

✦ The utility of estrogen concentrations during preoperative screening, and the policies for managing orthognathic surgery patients with an estrogen deficiency.

✦ Are the mechanisms and risk factors that lead to idiopathic condylar resorption the same?

Nicolielo LFP, et al. Int . Oral Maxillofac Surg.doi.org/10.1016/j.ijom.2017.06.012 Coutesy Dr Louis Mercuri



Models of Degenerative TMJ Disease

•Direct mechanical trauma model

•Hypoxia reperfusion model

•Neurogenic inflammation model

Milan SB, Pathogenesis of degenerative temporomandibular joint arthritides, Odontology, September 2005, Volume 93, Issue 1, pp 7–15



Mechanical Loading & Joint Cartilage

• Mechanical load of TMJ : essential to maintain its mass and integrity

✦ Adaptation to normal muscular force and orthopaedic traction

✦ Dentofacial orthopaedic appliance : ↑proliferation & chondrocytes maturation

• Decreased loading→decreased of fibrocartilage

• If thinning layer of fibrocartilage: TMJ more prone to osteoarthrosis

Chen et al, Altered temporomandibular joint loading, monography #46, CFGS p. 451Wadhwa S. ,Kapila S., TMJ disorders: Future innovation in diagnostics and therapeutics, J. Dent. Educ. 2008, 72 (8), 930-947



1. Bruxism-clenching2. Disc displacement3. Joint anatomy_Pre-existing condition4. Macrotrauma

1. Female2. 14-24 years old3. Low estrogen (⬇)4. Systemic arthritis5. Corticosteroids6. Hyperprolactinemia7. Hyperparathyroidism8. Low Vit D/Calcium ⬇

Mandibular Retrusion

A. Bite treatment causes condylar displacement

B. Local influences

C. Systemic Influences

1. Seating direction2. Seating force3. Treatment devices4. General anesthesia5. Intermaxillary fixation6. Splints 7. Paramandibular connective tissue8. Unstable occlusion

Joint Remodelling

If A +B + C = aggressive resorption

Gunson MJ, Arnett G.W. et al, Oral contraceptive pill use and abnormal menstrual cycles with severe condylar resorption: A case for low serum 17β-estradiol as a major factor in PCR, AJODO 2009; 136:772-9


©Sylvain Chamberland

Sequella of a mechanical stress to TMJ

Bone resorption

Mechanical stress(compression or luxation)

Physical disruption of molecules and cellsCell deathProduction of free radicals

Impaired cellular functions

Ischemia, impeded regional blood flow

Release of inflammatory peptidesChange in viscosity synovial fluidDegradation of hyaluronic acid by free radicals

↑Matrix degradationInhibition of matrix synthesisDegradation of articular surface

Arnett G.W. et al, Progressive mandibular retrusion-idiopathic condylar resorption. Part 1, AJODO 1996; 110:8-15


Pathophysiology Concept of the Process of Cartilage breakdown

Tanaka E., Detamore M.S., Mercuri L.G. Degenerative disorders of the temporomandibular joint: Etiology, diagnosis and treatment, J Dent Res 2008; 87:296-307

Kapila S, Current and future innovations in diagnosis and therapeutics of TMJ diseases, Monograph 46, Craniofacial growth series 2008

• Loss of matrix molecules• Inability to sustain function• Degenerative joint disease

Hormones or other agents



Susceptibility to Condylar Resorption• Strong female predilection

• Hormonal imbalance (↓estrogen, ↓17β-estradiol)

• Nutritional status(↓ Vit D, ↓Omega-3)

• Bruxism and repetitive oral habits

✦ Free radical generation through sheer stress and increased metabolic demands

• Iatrogenic causes:

✦ Orthognathic surgery, intermaxillary fixation, improper occlusal splint.

✓ All condylar change or displacement through compression



Condylar Resorption Result of TMJ Inflammation

• Inflammation = ∑ Joint compression + Systemic overlay

• Systemic factor : illnesses, hormonal imbalance, age & gender

✦ Upmodulate systemic inflammation which upmodulate resorption

• Compression= ∑ Parafunction, condylar displacement, internal derangement, isolated macrotrauma

Arnett G.W., Gunson M.J., Risk Factors in the Initiation of Condylar Resorption, Semin Orthod 2013;19:81-88.



Understanding TMJ Arthritis

• OA changes observed in this study consisted of flattening of the lateral pole and bony projections in the anterior condylar surface, at initial diagnosis and significantly more marked at long-term diagnosis.

Cevidanes L. H. S., Gomes L. R., Jung B. T., Gomes M. R., Ruellas A. C.O., Goncalves J. R., Schilling J., Styner M., Nguyen T., Kapila S., Paniagua B. 3D superimposition and understanding temporomandibular joint arthritis, Orthod Craniofac Res 2015; 18(Suppl.1): 18–28

Cevidanes et al, Quantification of condylar resorption in temporomandibular joint osteoarthritis, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:110-117)Cevidanes et al, Condylar resorption in patients with TMD, monograph 46, Cranifacial Growth Series, 2008, p 147-157



Understanding TMJ arthritis

• OA pathology has evolved from a disease of cartilage to a disease of the entire joint and the multiple biological systems that interact with one another in this disease.

• The cross-talk that occurs between the components of the joint, which takes place over years, results in degradation of the articular cartilage and disk, bony changes, synovial proliferation, muscle and tendon weakness, and fatigue.

• The TMJ condyle is the site of numerous dynamic morphologic transformations in the initiation/progression of OA, which are not merely manifestations secondary to cartilage degradation. Thus, a strong rationale exists for therapeutic approaches that target bone resorption and formation and take into account the complex cross-talk between all of the joint tissues.

Cevidanes L. H. S., Gomes L. R., Jung B. T., Gomes M. R., Ruellas A. C.O., Goncalves J. R., Schilling J., Styner M., Nguyen T., Kapila S., Paniagua B. 3D superimposition and understanding temporomandibular joint arthritis Orthod Craniofac Res 2015; 18(Suppl.1): 18–28

Cevidanes et al, Quantification of condylar resorption in temporomandibular joint osteoarthritis, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:110-117)Cevidanes et al, Condylar resorption in patients with TMD, monograph 46, Cranifacial Growth Series, 2008, p 147-157



• Initial stage

✦ Flattening of anterior surface + cortical thickening (sclerosis)in loading area

✦ Early soft tissue change ( tissue thinning, ↓proteoglycans)

✦ Deformed condyle may favour anteriorly displaced disc

Hatcher D, CBCT (3D imaging): application for selected articular disorders and associated facial growth, monograph 46, Craniofacial Growth Series, 2008, p 125-145



• Advance stage

✦ Non reducing displaced disc

✓ Pain, limited open + cessation of a clicking

✓ DD may be a risk factor for onset of DJD, but it is likely the effect of degenerative change

✦ Erosive lesion progressing to be cavitation defects, flattening of articular surface + re-cortication




• Late stage

✦ Formation of osteophytes

✦ Impaction of synovial fluid through un-corticated surface → sub-chondral bone cyst




Normal Mandibular Growth

•Disc Displacement reducing or non-reducing associated with interruption in mandibular growth

•The earlier the onset and severity of DJD have a proportional relationship with the severity of md growth defect

•DJD is self-limiting process and despite progression, there is a point of remission and stability (no evolution.

•Signs and symptoms reduce to level associated with normal.




Disc Displacement or Joint Degenaration?

• I have reasonable doubt that disc displacement is at fault in the beginning (onset)

• I would say that there are some change in morphology, deformed condyle, related to some trauma or inflammation or osteoarthrosis that lead to disc displacement and then contribute to maintain inflammation that impaired normal growth

•Disc Displacement reducing or non-reducing associated with interruption in mandibular growth




Sustained Inflammation Induces Degeneration of the Temporomandibular Joint

• The synovium in induced inflammation group showed marked infiltration of mono-nucleated cells and accumulated sub-synovial adipose tissue.

• Both the disc and synovium had significantly higher iNOS and IL-1β mRNA expression than controls.

• Conclusion:

✦ These findings are consistent with our hypothesis that sustained TMJ inflammation may be a predisposing factor for structural abnormalities.

Wang XD, Kou XX, et al.Sustained inflammation induces degeneration of the temporomandibular joint. J Dent Res. 2012 May;91(5):499-505. doi: 10.1177/0022034512441946. Epub 2012 Mar 15.



Deterioration of Mechanical Properties of Discs in Chronically Inflamed TMJ

Properties of Discs in Chronically

•Effects of chronic inflammation on the biomechanical properties of TMJ discs in rats.

✦ The surfaces of the discs of inflamed TMJs became rough and porous due to the loss of the superficial gel-like stratum, with many collagen fibers exposed and degradation of the sub-superficial collagen fibrils.

✦ Results suggested that chronic inflammation of TMJ could lead to deterioration of mechanical properties and alteration of disc ultrastructure, which might contribute to TMJ disc displacement.

Wang XD, CUI SJ et al.Deterioration of mechanical properties of discs in chronically inflamed TMJ, J Dent Res. 2014 Nov;93(11):1170-6. doi: 10.1177/0022034514552825. Epub 2014 Sep 29.



Osteoarthritis of the Temporomandibular Joint Organ and Its Relationship to Disc Displacement

•Development of as well as recovery from disease appears to be intimately related to exceeding and supporting the adaptive capacity of the tissues that make up the joint organ.

• Loss of fibrocartilage and inflammation appear to be major pathobiologic processes,

✦ while serious doubts exist about the significance of disc position in joint pathology.

Stegenga B. J Orofac Pain 2001. 15:193-205.Courtesy Dr Louis Mercuri



Class II Subdivision Left

ArOu15-07-2014

ArOu24-11-2014

ArOu24-10-2016

10y 10m

11y 3m

13y 2m



• Class II correction was achieved with Cl II elastics up to june 2016 but relapse was noted at the following rendez-vous

• Twin Force bite corrected were placed

✦ Came back within 3 weeks with pain. Removal of TFBC.

✦ Left disk luxation without reduction is noted with limited jaw opening. Pr: Ibuprofen 400mg 1 co q4hX 4jrs + 1 co q6h X 3 jrs

✦ Sent to physiotherapy. Came back with normal jaw opening 45 mm. No pain.

✦ New close lock, Pain at 32 mm jaw opening. More physio.

• Normal jaw opening at recall in January 2017 + some loss of OB

• Open bite noted in July 2017

ArOu24-10-2016 ArOu17-01-2017 ArOu03-07-2017

13y 2m 13y 4m 13y 10m



What Can We Find Retrospectively?

•Shorter condylar neck on the left

ArOu15-07-2014

10y 10m



What Can We Find Retrospectively?•At Debond

✦ Flattening of both anterior surface of the condyles

•This may explain

✦ Relapse of Cl II when the elastics were stopped

✦ DDWR on the leftArOu24-10-2016

13y 2m



What Can We Find Retrospectively?• Significant

Progressive Condylar Resorption

• Normal jaw opening but dull pain at the joint

• Referred to Oral Surgeon

✦ Refer to RhumatologistArOu03-07-2017

Juvenile Idiopathic Arthritis? Adolescent Internal CR?

13y 10m



Diagnostic of TMJ Degenerative Changes

• Clinical history

• Noise (clicking, crepitus) present or past

• Close lock, hypomobility present or past

• Anterior open-bite, or antero-lateralKa.Tu 1111

A-A.St-O.T 0711



Diagnostic of TMJ degenerative changes

• Difference RC/OC > 2 to 4 mm

✦ The functional shift is not the cause of the TMD, but rather the effect of degenerative change of the TMJ

✦ To reach a 2:1 odds ratio threshold for notable risk of association with degenerative changes, a slide > 5 mm would be necessary

Me.Po. 0610

Occ. Centrée (C.O.)

Rel. Centrée (C.R.)

Pullinger AG., Seligman DA., Quantification and validation of predictive values of occlusal variables in TMD using multifactorial analysis,J Prosthet Dent 2000; 83:66-75MacNamara JA, Seligman DA, Okeson JP, Occlusion, orthognathic treatment and temporomandibular disorders: A review, J Orofacial Pain, 1995; 9:73-90



Diagnostic of TMJ degenerative changes

• Pain

✦ Arises from the soft tissues and masticatory muscle around the affected joint

✦ Self-preservation reflex spasm (contraction) limiting movements in response to intra-articular injury, thus protecting it form further damage

• Facial deformity due to pathologic osteolysis decreasing the height of the condyle + its neck

Tanaka E, Detamore MS Mercuri LG, Degenerative disorders of the TMJ: Etiology, Diagnosis and Treatment, J Dent Res 2008 87: 296http://jdr.sagepub.com/content/87/4/296


http://jdr.sagepub.com/content/87/4/296


TMJ Rx Anatomy•On a panogram, anterior surface is the lateral pole

LateralPole

Articular Surface

Medial Pole

Goulet J-P. La topographie condylienne des ATM en radiographie panoramique. J Dent Québec 22: 375-79, 1995.



Imaging Modalities Degenerative Changes

• Panorexes (OPG):

• Readily available, easily performed, low cost

✦ ∆ TMJ shape

✓ Flattening of the anterior surface of the condyle

✓ ∆ size

✓ ∆ articular eminence shape

• Sensitivity 97%; specificity 45%

✓ Low specificity = Large number of false-positive

Me.Po. 0610

Jo.Ma. 0907

Ma.La.Br.La.0410

Al.Be. 0810

D.D.N.-R.

Shintaku WH et al, Imaging modalities to access bony tumors and hyperplastic reaction of the TMJ, JOMS 68:1911-1921, 2010



Imaging Modalities

• TMJ tomograms, mouth open Me.Po. 0610

A-A.St-O-T. 0711

MedialPole

LateralPole

Zenith ofarticular surface

Goulet J-P. La topographie condylienne des ATM en radiographie panoramique. J Dent Québec 22: 375-79, 1995.



Deformed Condyle• Anterosuperior tapering, anterior inferior

lipping, anterior flattening

• If growth ceased, deficits increased gradually during growth and it may take 2 years to measure an observable change

• Age of onset estimated: 12,5 y for boys et 10,5 y for girls

Dibbets J, Müller B, Krop F, and van der Weele L. Deformed Condyles and Craniofacial Growth: Findings of the Groningen Longitudinal Temporomandibular Disorder Study. Seminars in Orthodontics. 2013, Jun;19(2):71-80.

T0= 135 sujets; 12,5y43% male, 57% female



Deformed Condyle• Shorter PFH of 2,8 mm

• Reduced posterior alveolar height

✦ Mx of 1,2 mm post. & 2,3 mm ant.

✦ Md of 1,1 mm post. & 1,6 mm ant.

• Anterior open bite of 1,6 mm

• Shorter Sella-basion = -1,5 mm (Reduced vertical growth of the midface)

Dibbets J, Müller B, Krop F, and van der Weele L. Deformed Condyles and Craniofacial Growth: Findings of the Groningen Longitudinal Temporomandibular Disorder Study. Seminars in Orthodontics. 2013, Jun;19(2):71-80.

T0= 135 sujets; 12,5y



Deformed Condyle• More retrognathic md of 2,6°

• Larger Wits of 3,4 mm

• Shorter Md diagonal (ArPg): -4,5mm

• Antegonial notch shifted dorsally

✦ Massive done deposition in that area

• Partial Md growth arrest of some 50% its average growth potential. Dibbets J, Müller B, Krop F, and van der Weele L. Deformed Condyles and Craniofacial Growth: Findings of the Groningen Longitudinal Temporomandibular Disorder Study. Seminars in Orthodontics. 2013, Jun;19(2):71-80.

T20= 56 sujets; 31,9y



•Anterior openbite

•Retrognathic Md

✦ SNB ➘ 3°

•Arched antegonial notch

✦ Bone apposition

•Short Ramus (➘ condylar growth)

♂ 9a 8m ♂ 17a 5m

Tongue thrusting is not the cause of the open bite, but the consequence

Longitudinal observation of a patient



• Discrete deformed condyles at 11 y

• Flattening of anterosuperior surface of the condyles at 17 y

✦ Default or diminution of growth potential (OA?)

• Compensatory bone apposition at gonial angle

✦ Arched antegonial notch

♂ 11a 2m

♂ 17a 5m

Longitudinal Observation of a patient



•1-Condylar resorption

• 2- Left short ramus

• 3- Arched antegonial notch

• 4- Compensatory bone apposition at gonial angle

• 5- Decreased lateral mandibular growth of the affected side

♀36a

5



• Idem

•Tongue thrusting is a consequence and not a cause of the openbite

♀16a



Imaging Modalities• CBCT 3D

• Limited ability to evaluate active vs old chronic changes of arthritis and soft tissue changes

✦ Condyle assessment

✓ Specificity 100%

✓ Sensitivity 80%

✦ Dose effective & cost effective for evaluation of osseous abnormalities

N.R. 17-10-11

Mouth open

A-A.St-O-T. 16-08-01

Mouth closed



Imaging Modalities• Magnetic Resonance Imaging:

✦ Assess articular structure: cartilage, bone, ligaments, tendons, synovium, tendon sheats

✦ Allows for qualitative & quantitative evaluation for presence or status of synovitis and its sequelae

✓ bone marrow edema,synovial enhancement, synovial thickening, erosions,effusions, cartilage damage, articular disc involvement, and ligamentous involvement

• Gold Standard for evaluation of inflammatory arthritis

• Disk displacements & osteoarthritis = 30% of asymptomatics volunteers

• Difficult to consistently relate MRI findings (bone oedema, joint effusion, synovitis) to joint pain

• MRI sensitivity =78%; predictive value =54%

Reducing disc displacement

Non-reducing disc displacement

Non-reducing disc displacement

& Severe

Osteoarthrosis

Larheim TA et al, Clinical significance of changes in the bone marrow and intra-articular soft tissues of the temporomandibular joint, Sem Ortho 2012;18:30-43

Tanaka E, Detaore MS, Mercuri LG Degenerative disorders of the TMJ: etiology, diagnosis and treatment, J Dent Res 2008 87:296, fig1



Imaging Modalities• Bone scan Tc-99

✦ Assess bone activity

✓ Growing or degenerative

✦ Assess inflammatory status

✦ Insufficient specificity to assess state of stability/remission

Jo.Ma.Mean Maximum

Right 1,02 0,93april 2009Pre surg

Left 1,01 0,91

Right 1,3 1,73 november 2010

Post surgLeft 1,26 1,68

symmetric hypermetabolism in 2010



Additional diagnostic aid• Blood test mid-cycle

✦ Female

✓ Dosage of Estrogen & 17β-estradiol at start and mid-cycle, FSH, LH, Vit D

✦ Men

✓ DHEA-S, cortisol, Vit D, % free testosterone

✦ Level of rheumatoid factor, antinuclear antibodies and anti CCP

✦ Inflammatory status, protein C reactive



Management Options of TMJ • Medical Management

• Orthodontics only

• Arthrocentesis and/or Arthroscopic Surgery

• Orthodontics & Orthognathic Surgery ± disc repositioning

• Arthrotomy, condylar shave/disc repositioning

• Distraction

• Autogenous TMJ Reconstruction

• Alloplastic TMJ Replacement

• Nothing

Courtesy Dr Louis Mercuri



Pharmacotherapy Used to Control TMJ Arthritis

• Vit D and Ca Bone density

• C 500 mg and E 400 u Antioxidants

• Celebrex, 100 mg Anti-inflammatory, MMP, cytokine inhibitor

• Omega-3 fatty acid 2-4 G Potent antioxidant

• Doxycycline, 50-100 mg Anti-inflammatory, MMP, cytokine inhibitor

• Feldene, 10-20 mg Anti-inflammatory, MMP, cytokine inhibitor

• Simvastatin, 20 mg Anti-inflammatory, MMP, cytokine inhibitor

• Amitriptyline, 5-15 mg Antibruxism, mm relax

• Klonapin, 0.5-1 mg Antibruxism

• Tiagabine, 2-4 mg Antibruxism

• Botox injection, 36-48 u Antibruxism

• Simvistatin, 20 mg Autoimmune inhibitor

• 17-Estradiol, variable Potent anti-inflammatory

• Etanercept, 50 mg q week TNF- inhibitor

• Adalimumab, 40 mg q 2 weeks TNF- inhibitor

Arnett G.W., Gunson M.J., Risk Factors in the Initiation of Condylar Resorption, Semin Orthod 2013;19:81-88.



Pharmacotherapy 3

•Osteoarthritis ✦ Cytokines and/or MMPs inhibitors

✓ Doxycycline, Feldene, Simvistatin

✦ Free radical inhibitors

✓ Vit C, Vit E, fat acid omega 3

✦ Anabolic bone metabolism facilitator

✓ Vit D, Ca2+, 17β estradiol

✦ Parafonction inhibitors

✓ Amitriptyline, Tiagabine, Klonopin, Botox

•Auto-immune arthritides

✦ Auto-immune inhibitor

✓ Methotrexate, Enbrel, Simvistatin

•Gunson MJ, Arnett GW, Milam SB, Pathophysiology and Pharmacologic Control of Osseous Mandibular Condylar Resorption J Oral Maxillofac Surg 2011, october, •AAO meeting, Boston 2009

TNFα

What looks like such condyle?

There is no condyle! It's a stump



Prophylactic pharmacotherapy• If a patient fits the criteria suspicion of ICR or POCR

✦ 30 days pre-op and starting 14 days post op

✓ Calcium carbonate (CaCo) 500 mg/day + 1000 IU of Vit D3 (Vit D supplementation)

‣ Vitamin D supplementation (2000 IU/day) in patient with systemic lupus erythematous is recommendated because increased vitamin D levels seem to ameliorate inflammatory and hemostatic markers and show a tendency toward subsequent clinical improvement. Abou-Raya A et al The Effect of Vitamin D Supplementation on Inflammatory and Hemostatic Markers and Disease Activity in Patients with Systemic Lupus Erythematosus: A Randomized Placebo-controlled Trial J Rheumatol published 1 December 2012, 10.3899/jrheum.111594

✓ Celebrex 200mg id, (or bid if over 70kg)

Courtesy Dr Marco Caminiti, crescentoralsurgery.com


http://www.crescentoralsurgery.com


Prophylactic pharmacotherapy• If they are symptomatic post op

✦ Pain, occlusal change, sign of active resorption, limited opening

✓ Clodronate (clasteon) 2400mg OD for 30 days

✓ Get a rheumatologist consultation ASAP

✓ Internist md help to monitor the patient

Courtesy Dr Marco Caminiti, crescentoralsurgery.com


http://www.crescentoralsurgery.com


Principles for Management of TMJ Osteoarthritis

• Noninvasive management modalities

✦ Medications

✓ Nonsteroidal anti-inflammatory drugs (NSAIDs)

✓ Muscle relaxant

✦ Physiotherapy

✓ Active passive jaw movement, manual therapy, ∆ body posture

✦ Oral appliance (occlusal splint)

✓ Provide relief from muscle cocontraction/pain, decrease potential joint overloadMercuri LG, Osteoarthritis, Osteoarthrosis and Idiopathic Condylar Resorption, Oral Maxillofacial Surg Clin N Am 2008 May;20(2): 169-183




• Minimally invasive modalities

✦ Arthrocentesis

✓ Infiltration hyaluronic acid (Synvisc) or corticosteroid

✓ Viscosupplementation: restore the lubricating properties of synovial fluid

✓ Washing the particles of the inflammatory response, ↓ intra-articular pressure

Nitzan D.W., Arthrocentesis-Incentives for using this minimally invasive approach for TMD, Oral Maxillo Surg Clin N Am 18 (2006)311-328 Richie Wai Kit Yeung et al, Short-term therapeutic outcome of intra-articular high molecular weight hyaluronic acid injection for nonreducing disc displacement of the temporomandibular joint, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102: 453-61)Xing Long, et al, A Randomized Controlled Trial of Superior and Inferior Temporomandibular Joint Space Injection With Hyaluronic Acid in Treatment of Anterior Disc Displacement Without Reduction, J Oral Maxillofac Surg 67:357-361, 2009Guo C, Shi Z, Revington P, Arthrocenthesis and lavage for treating temporomandibular joint disorders, Cochrane database of systematic reviews 2009, Issue 4. Art.No.:CD004973Shi Z, Guo C, Awad M. Hyaluronate for the temporomandibular joint, Cochrane database of systematic reviews 2003, Issue 1. Art.No.: CD002970

Courtoisie Dr Jean-Philipe Fréchette



Temporomandibular Lavage VS Nonsurgical Treatment for TMD

•Reduction of pain in intervention group at 6 months

•No difference in mouth opening at 6 months and 3 months

•Given high risk of bias in 3 studies + statistical and clinical heterogeneity

✦ TMJ lavage should be recommended with caution because lack of strong evidence to support its use

✦ Nonsurgical treatment may offer similar results, without risk of complicationBouchard C, Goulet JP, El-Ouazzani M, Turgeon AF. Temporomandibular Lavage Versus Nonsurgical Treatments for Temporomandibular Disorders: A Systematic Review and Meta-Analysis. J Oral Maxillofac Surg. 2017 Jul;75(7):1352-1362. doi: 10.1016/j.joms.2016.12.027. Epub 2017 Jan 4




• Moderately invasive approach

✦ Splint therapy

✦ Nonsurgical orthodontic treatment

✓ Use of TAD for the vertical changes instead of surgery



Case Presentation



•Class I

•Anterior openbite

•Mandibular incisor crowding

ChOlGa220514



•Skeletal Hyperdivergent

•Short ramus



• Concavity of right TMJ anterosuperior surface, flattening on the left joint

• Condylar resorption or arthrosis

• Patient at risk…



ChOlGa030914

Mx: 3 segments .020x.020 cnt. Tomas Pin SD 6 mm, Elinks E3 P-4Md: 2 segments .020x.020 cnt. Tomas Pin EP 6 mm, Hamac elastic

ChOlGa221014

Mx: 3 segments .020x.025niti. ∆ E3 P-4.Md: ∆ Hamac

7 weeks later



• Improvement of lip seal

•Counterclockwise rotation of occlusal plane

•Bimax protusion:

✦ I decided to extract all 5s

January 2015

May 2014

January 2015May 2014 March 2015



• Intrusion of Mx and Md buccal segment

•Counterclockwise rotation of mandibular plane



ChOlGa310315

ChOlGa120515ChOlGa220615

ChOlGa140915



•FMA decrease 0,5°

•ANS-Me decrease 5,5 mm

• /1-MP decrease 99° to 87°

ChOlGa13-07-1216



•Significant intrusion

✦ Mx + Md molars

•Retraction of 1/ & /1



Outcome•Tx time 117 weeks

ChOlGa13-10-1216



ChOlGa13-10-1216



Initial May 2014 Pre genio July. 2016ChOlGa13-07-1216 ChOlGa13-10-1216

Final Oct. 2016ChOlGa22-05-1214



Current Surgical Approach•Wolford L.M., Arnett G.W. & Gunson M., Posnick J.C., Kaban L,

✦ Bimaxillary Osteotomy (Le Fort 1 + BSSO + genio prn)+ counterclockwise rotation

✓ Wolford L.M.

‣ Disc repositionning + mitek ligature

✓ Arnett G.W. & Gunson M.

‣ Cocktail of drugs

✓ Kaban L.

‣ Occlusal splint, myorelaxant, AINS, follow up with bone scan and no rx change for 2 years before surgery



Caution During Surgery•Avoid to posteriorly incline proximal segment

(counterclockwise rotation)

✦ When the condylar neck is posteriorly inclined (per-op), the anatomically less dense, preoperatively unloaded anterior-superior surface of the condyle is subjected to increased loading following surgery due to an increase in soft tissue tension and rotation of the condyle.

Hwang SJ, Haers Pe, and Sailer HF. The role of a posteriorly inlcined condylar neck in condylar resorption after orthognathic surgery. J Craniomaxillafac Surg 2000; 28 (2):85-90Hoppenreijis T et al. Condylar remodelling and resorption after Le Fort I and bimaxillary 0steot0mies in patients with anterior open bite A clinical and radiol0gical study. Int J. of Oral & Maxillo Surgery. 1998;27(2):81-91.Moore K et al. The Contributing Role of Condylar Resorption to Skeletal Relapse Folio wing Mandibular Advancement Surgery- Report of Five Cases. JOMS. 1991, Mar;49(5):448-460.Park SB, Yang YM, Kim YI, Cho BH, Jung YH, and Hwang DS. Effect of bimaxillary surgery on adaptive condylar head remodeling: metric analysis and image interpretation using cone-beam computed tomography volume superimposition. J Oral Maxillofac Surg.2012, Aug;70(8):1951-9.

MUSCLE FORCES



Rigid Fixation & Proximal Segment• Condylar torquing during fixation

• Posteriorization of the condyle in the fossa

✦ Could favour anterior disc displacement, a disc compression or an hypomobility (protective muscular spasm)

• Dysfunctional remodelling in susceptible patients

Arnett GW, Progressive mandibular retrusion-idiopathic condylar resorption. Part II, AJODO, 1996, 110:117-127



Rigid Fixation & Proximal Segment• Rigid fixations (screw RIF):

✦ No possible adjustment between proximal and distal segments

• Wire fixated osteotomies

✦ Possible adjustment in the early stage of healing

• Ellis: experimentation on animal models confirm these observation

Arnett GW, Progressive mandibular retrusion-idiopathic condylar resorption. Part II, AJODO, 1996, 110:117-127



Maximize teeth in contact• Control surgical compression

✦ Means that posterior teeth must be in contact post-op.

• Neutral rigid fixation

• Early mobilization

• Class II elastics

• Cocktail of drugs (pills medicines)

Arnett GW, AAO meeting Boston 2009



Consequences of postop Openbite

•Control surgical compression

✦ Means that posterior teeth must be in contact post-op.

✦ It is not "having a post-op posterior open bite”

Ma-EMa 18-3-14

Arnett GW, AAO meeting Boston 2009



Why I don't like Posterior Openbite after Orthognathic Surgery?

• Lack of posterior occlusion may increase pressure at the condyle and cause non-physiologic remodelling or condylar resorption

Jam-packedScrewed Setting occlusion

Pressure

The bite openSlight progressive

retrusion

Condyle resorb



Disc Repositioning Does it really work?

• Removal of hypertrophied bilaminar & synovial tissue

• Repositioning & stabilization of the articular disc to the condyle with the Mitek anchor

• Bimaxillary surgery + counterclockwise rotation

✦ Le Fort 1

✦ BSSO + genio prn

• 91% success rate

Goçalves, João Roberto, Daniel Serra Cassano, Luciano Rezende, and Larry M Wolford. "Disc Repositioning: Does It Really Work?" Oral Maxillofac Surg Clin North Am 27, no. 1 (2015): doi:10.1016/j.coms.2014.09.007 Wolford LM, Concomitant TMJ and orthognathic surgery. JOMS 61: 1198-1204, 2003 Wolford LM Dhameja A, Planning for Combined TMJ Arthroplasty and Orthognathic SurgeryAtlas Oral Maxfacial Surgery Clin N Am 19 (2011) 243-270



Disc Repositioning Does it really work?

• Situations where disc repositioning with Mitek anchor has high success rate

✦ Disc repositioning at the onset of displacement within 4 years of displacement provides the greatest predictability of outcome.

✦ Adolescent internal condylar resorption patients who are treated within the first 4 years of disease onset

✦ No significant intracapsular inflammation, especially in the bilaminar tissues

✦ Good remaining anatomy of the disc.

✓ Young patients with Intact well-shaped disc

Goçalves, João Roberto, Daniel Serra Cassano, Luciano Rezende, and Larry M Wolford. "Disc Repositioning: Does It Really Work?" Oral Maxillofac Surg Clin North Am 27, no. 1 (2015): doi:10.1016/j.coms.2014.09.007 Wolford LM, Concomitant TMJ and orthognathic surgery. JOMS 61: 1198-1204, 2003 Wolford LM Dhameja A, Planning for Combined TMJ Arthroplasty and Orthognathic SurgeryAtlas Oral Maxfacial Surgery Clin N Am 19 (2011) 243-270



Disc Repositioning 3-Dimensional Quantitative Findings

• Patient without DD

✦ Condylar translational displacement of at least 1,5 mm in posterior, superior or mediolateral direction

✦ 1 y post MMA,

• Patient with DD ➜ Mitek Disc repositioning

✦ Condylar displacement anterior, inferior and mediolateral

✦ Bone apposition in anterior surface Goçalves, João Roberto, Daniel Serra Cassano, Luciano Rezende, and Larry M Wolford. "Disc Repositioning: Does It Really Work?" Oral Maxillofac Surg Clin North Am 27, no. 1 (2015): doi:10.1016/j.coms.2014.09.007 Goncalves JR, Wolford LM, Cassano DS, et al. Temporomandibular joint condylar changes following maxillomandibular advancement and articular disc repositioning. J Oral Maxillofac Surg 2013;71(10):1759.e1–15;

MMA only, Patient without DD

MMA -Drep, Patient with DD




• Invasive surgical modalities

✦ Ortho treatment and orthognathic surgery (mono or bimax)

✓ Clockwise rotation

✓ Counterclockwise rotation (Arnett, Wolford, Posnick), disk repositioning



• Ortho surgical treatment (years 1993-1995)

• Bimax surgery: clockwise rotation:

✦ Le Fort 1, BSSO, genio

•Nowadays it would be

✦ Counterclockwise rotation of occlusal plane & posterior elongation

ChLa150393

17 ans

ChLa010695/ surgeon: Dr Denis Gagnon

1. Female2. 14-24 years old3. Estrogen ⬇4. Systemic arthritis5. Corticosteroid6. Hyperprolactinemy7. Hyperparathyroidism8. Vit D/Calcium ⬇

RCIA

Tomo Chantal ChLa150393ChLa-10695



• Ortho treatment only, exo 4 Pm1

• Genioplasty only

• Note the possibility of posterior intrusion

LyBo 180693 LyBo 190396/ ~1 an post ortho

LyBo 0997/ ~2 ans post ortho

Resorption post pregnancy



• No condyle before

• No condyle after

• But stable occlusion

LyBo93/ pre-ortho

LyBo97/ 2 years post-ortho

Hormonal imbalance during pregnancy?



Common denominator

• Hormonal aetiology probable

• Condyles were completely resorbed



Case Presentation

•Had a bike accident at 10-11 y.

•Consult at 12-13. Recommended to wait until 18y

SaLa 12-07-01 8 a

SaLa 22-10-13 20 a 4 m



•Class II div 1

•Vertical maxillary excess

•Anterior open bite

•Constricted maxilla

SaLa 22-10-13 20 a 4 m



Pre opSaLa060714 preop

Pre op

Post opSaLa161214 post op

Surgeon: Dr Jean-Philipe Fréchette



• Mandible :

✦ Forward 9 mm

✦ Left Laterodeviation 1 mm

• Menton :

✦ Forward 4 mm

✦ Right Impaction: 2 mm

✦ Laterodeviation to the right 4 mm

• Maxilla :

✦ Forward 6 mm

✦ Left Laterodeviation 2 m

✦ 5 mm Anterior Impaction & 2 mm posterior

✦ Correction of occlusal plane

✦ Segmentation 17 à 14, 13 à 23 et 24 à 27



Outcome

SaLa070415

Follow up at 2 y


©sylvainchamberland.comCascapedia Gaspésie




• Invasive surgical approach

✦ Autogenous hemiarthroplasty

✓ Vascularized local temporalis muscle flap or alloplastic materials

‣ Orthopaedic literature show long-term poor experience with hemiarthroplasty in low- and high-inflammatory arthritic disease,

‣ It would seem logical that using this method in management of TMJ arthritic disease might only lead to the same outcome



Autogenous Hemiarthroplasty

•♀, 28 y.

•All conservatives tx were done: AINS, myorelaxant Botox, physio

•Chronique pain right TMJ. Amplitude 28 mm

•MRI confirm disk perforation.

•Surgery A.H at 32 y.

• Follow up: Pain free. Amplitude 37 mm

Perforated disk Discectomie

Flap is insertedTemporal flap



• A limitation of jaw opening & unstable occlusion was noted postop

• Finishing with occlusal tooth equilibration & elastics

• Parafonction persisting (bruxism & sygmatism)

• Progressive open bite noted in retention: the surgeon is advised

La.Va.0109, end of ortho

La.Va.0311/ 2 ans post orthoLa.Va.0107/ 14 a 3 m/ pré-ortho



• Note flattening of the anterior surface of the condylar head

La.Va.0107/ 14 a 3 m/ pré-ortho

• Pre orthognathic surgery ✦ Remodelling noted in the right condyle

• Should have done bone scan Tc99 presurg & pre ortho

• 2 years post ortho ✦ Remodelling +++

Surgeon: Dr Patrick Giroux

La.Va.0408/ pre-surg

La.Va.0311/2 y post tx


©Dr Sylvain Chamberland

Initial

Pre surgery

End of ortho

2 y post ortho• Retrospectively, would it be legitimate to extract 2 1st Pm

and do camouflage?• However, does not mean that the outcome would have been

any better?


Male Patient

• Cl II div 1. Md Laterodeviation to right

• COCR functional shift AP

• Bilateral condylar resorption (R>L)

• Pain in right TMJ when eating, difficulty to open.

✦ Disc displacement with reduction in the right

LuBo070706 preortho; en RC

LuBo.17a.1 m.

LuBo070706 preortho



• Parafonction: clenching

• Rheumato: no systemic disorder

✦ Complete blood, sedimentation, protein C reactive = normal

✦ Antinuclear factor normal, Rheumatoid factor negative

• November 2006: Scinti = negative pretreatment

• October 2007: Scinti = positive right TMJ, negative in left (the orthodontist was never told!)

LuBo070706 préortho



Treatment Plan• Occlusal splint therapy: 6 months

• Tx ortho

• June 2008 (pre-op): Scinti positive in right TMJ, negative in left . The orthodontist was never told!

• Surgery plan

✦ Le Fort 1: Posterior impaction

✦ Md: autorotation; genio only



• Functional Cl I

LuBo261007 préchir

LuBo161208 19a 6 m

Le Fort 1OSMBGenio

Surgeon: Dr Michel Fortin



• PCR Progressive postsurgical condylarresorption

• Cant of the mandibular incisor occlusal plane to the left

LuBo070211 21a 8 m

LuBo070211



• Decreased ramus height: condylar head & neck

• Pre existing condition: Active during tx

LuBo070211; 2 ans post ortho

LuBo070706 preortho



•Post op

✦ Class I occlusion

✦ No condylar change

JoMa.10-09-07; 20 a 7 m

JoMa100907, 20 a 7m

•Baseline

✦ Rhumato: negatif

✦ Bone scan: normal

JoMa.28-10-09; 22 a 8 m

JoMa.28-10-09; 22 a 8 m Chir: Dr Michel Fortin



•Follow up at 2 years

✦ Progressive bite opening noted 3 months post op

✦ Flattening of left condyle

•Fact Rh = n; 17β-oest. = n (feb 2010)

•Scinti Tc 99 positive in octobre 2010

JoMa.24-11-11; 24 a 9 m



Common Denominator• They had condyles presurgery

• Inflammatory activity pre surgically in one case

• Progressive condylar resorption postsurgery

• What happened during or after surgery?

✦ They all had rigid internal fixation?

✦ They all had stiffness during jaw opening?

✦ Hypomobility?

✦ Counterclockwise rotation of the proximal segment



•Pre surgery

JoMa 170913

JoMa.11-02-14; 2 sem post op

•2 weeks post surgery

✦Le Fort 1 superior repositionning

✦BSSO counterclockwise rotation + Genio

Chirurgien: Dr Carl Bouchard



•Mx Impaction + counterclockwise rotation of occlusal plane

• Increase chin-throat projection

JoMa020914



• Previous ortho treatment with bionator and fixed appliances (Oct 2008- Nov 2010)

• CRCO functional slide of 4 mm

• Pain was reported shortly after the bionator was placed

• Notes were made Nov08, Dec08, Jan09, June09

Vi.Pr.120312; 15 y 6 m



• Left: Short condylar neck + flattening of the anterior surface

• Right: normal growth

• Left antegonial notch gauche more arched than right side

✦ Compensatory bone apposition at gonial angle

• 2 levels of occlusal plane and mandibular inferior border

• Left progressive condylar resorption

➡ Controlateral anterior openbite



•Slight cant of the occlusal plane in frontal view can be noted

✦ Sequela of lack of vertical growth of the left condyle



•BSSO + Genio

•Note lack of vertical dentoalveolar height in the left mandibular body, related to lack of condylar growth



Trauma• Fall in a gym at age 11

• Kicking on the right side of the face

• Blockage + DD without reduction

• Physiotherapy

• Show at 13 years old for ortho tx

• Standard tx, exo 3 Pm, intermaxillary elastics prn

MaPiBe240203, 13 a 9 m

Arched antegonial notch



• Functional occlusion

• Right TMJ

✦ ??± similar???

MaPiBe290604, 15 a 1 m



• Left anterolateral openbite

✦ This open bite has manifested itself within 6 months post ortho

MaPiBe151204, 15 a 6 m MaPiBe190207, 17 a 9 m



• Progression during the following year

• Antegonial notch: adaptation to lack of right condylar growth

MaPiBe190207, 17 a 9 m

MaPiBe140308, 18 a 9 m



• Follow up

✦ 6½ years post ortho

✓ Cortical layer appears normal

MaPiBe040112, 22 a 7 m




• Salvage procedures— Total joint replacement

✦ Autogenous total joint replacements: Costochondral graft

✓ Fairly good prognostic if it is low-inflammatory arthritis

✓ Caution in patient with high-inflammatory arthritis (RA, auto-immune, etc)


A case to make you humble


NaRo.01-05-11; 21 ans

Unilateral condylar resorption→ Controlateral open bite

NaRo.01-02-06; 16 ansNaRo010206

Undiagnosed fracture of the left condyle Normal growth to the right, affected (↓)to the left

NaRo.01-04-08; 18 ans

Progressive condylar resorption unilateral All possible exams were done


• Pre retreatment

• Pre surgery

NaRo18112014

NaRo300414


Initial Pré op Post op


• Initial et pre op



3D Surgical Planning•Left elongation

•Right impaction

•Advancement 3 mm

•Left laterodeviation of 1 mm

•Rotation 3° at the midline



3D Surgical Planning

•Advancement 5,8 mm at tip of incisors



•SNA increase 3°

•SNB increase 4 °

•Occlusal change 15,7° to 14, 6°



•Autogenous graft: piece of resected ramus

•Costochondral graft



•17 days postop

NaRo020215



1 m. post op 4 m. post op 9 m. post op



•Happy ending

NaRo120515

Follow up 5 mois (Oct15)

Amplitude 33 mm



2006 2009 2011

2014 2014 2015



Case 6


• At 13 until 15 years old (may 04-June 06)

✦ Ortho tx: HG + Fixed app.

✦ Began oral contraceptive when she was 14-15

• TMJ consultation begins in 2007

ArLa 30082012



• Severe resorption in right TMJ, moderate in the left

• Note: her sister was recently diagnose of rheumatoid arthritis

Mouth closed

Mouth open



Bone scan Tc99• Increased uptake in right

• Ratio right/left mean 0,79

• Ratio right/left maximum 0,61

• Increased bone metabolism in the left joint revealing condylar resorption

• Right condyle seem in remission

Ar.La.Mean

Maximum

Right 1,67 1,43 Sept 2011

Left 2,12 2,35



Medical & dental history• MRI: DD w/o reduction left TMJ, DD W/R right. Both TMJ flattened + degenerative changes

• Splint therapy since fall 2007

• Since March 2011

✦ Naproxen 500 mg bid

✦ Ran pantotrazole 40mg 1co le matin

✦ Cyclobenzaprine 10mg 1co hs

ArLa240912

ArLa 19092007



Tx Plan• Genioplasty early into ortho treatment

• Total joint replacement

✦ Alloplastic

✦ Autogenous (costochondral)

✓ Audience: discuss why one would be choose over the other?

• Bimax surgery advancement + counterclokwise rotation + another genioplasty prn

-13

82

101

74

42

100

11186

18

40

22

115

108

-1

5

3

2-3

12

6

80

45

8

Lower Arch: Right Left Change Changes:

X Y

Rot

ALD mx at ANS 3.6 2.5Incisors mx at A 3.6 2.51st Molar mx at 1 crown 3.6 2.5Extraction mx at PNS 3.6 2.5Expansion mx at 6 crown 3.6 2.5Stripping md6 Left ost. 8.9 5.3 4.3E-Space genioplasty 8.1 -0.0

md at 1 crown 8.2 1.3Net Change

Dr. Sylvain Chamberland

Quick Ceph® Studio

Name: Ariane LabelleBirth: 15/09/1991 Status: Traitement1Gender: Féminin Record: 30/08/2012Case: Age: 20Année 11mo

Disclaimer: This presentation is a SIMULATION ONLY and is not intended to be a guarantee of the actual orthodontic or surgical results.



ArLa300812

ArLa280113

At 4 months: Genioplasty


• Resumed post surgical orthodontic care

ArLa080713



• Pre-surgery and graft



• Post surgery and graft



• Follow up rx 3 months post surgery



Perioste 2-3 mm cartilage


Fixation chain, costal graft is thin

Bone remodeling...


• Classe I

• Asymptomatic

• Opening amplitude 29 mm

ArLa 280114



ArLa070715 2y postop

Jaw opening amplitude 30 mm



•Follow up 4 y post op. Very stable occlusion

•Coronoïd process likely limit jaw opening

ArLa070715 2y

Jaw opening amplitude 27-28 mm

ArLa230817 4y postop



Autogenous Tissue•Advantages

✦ Available

✦ Adaptable?

✦ Heals?

✦ Predictable growth?

✦ Less expensive?

•Disadvantages

✦ Second surgical site

✦ Longer surgery

✦ Morbidity at the donor site

✦ Difficult to adapt

✦ Require jaw immobility 4-6 weeks

✦ Delay physiotherapy

✦ Unpredictable cartilage growth

✦ Ankylosis

✦ Relapse with repositional loadingMercuri L., Swift J.Q., Considerations for the Use of Alloplastic Temporomandibular Joint Replacement in the Growing Patient J Oral Maxillofac Surg 67:1979-1990, 2009



Importance of vascularity•Receptor site

✦ Must support revascularization and promote osteogenesis,

✦ Provide stable fixation to allow incorporation of the donor bone.

•Capillaries can penetrate a maximum thickness of 180 – 220 microns (µm) of tissue

•Micromotion of these free grafts will likely occur, with the early mandibular function resulting in shear movements of the graft that may lead to poor vascularization, nonunion, and/or potential failure

Mercuri L., Swift J.Q., Considerations for the Use of Alloplastic Temporomandibular Joint Replacement in the Growing Patient J Oral Maxillofac Surg 67:1979-1990, 2009 Mercuri LG: The Use of Alloplastic Prostheses for Temporomandibular Joint Reconstruction J Oral Maxillofac Surg 58:70, 2000



Importance of vascularity•Despite screw/plate fixation, micromotion of these free grafts will

invariably occur, with the early mandibular function resulting in shear movements of the graft, leading to poor vascularization, nonunion,and/or potential failure

• Therefore

✦ Immobilization is necessary for vascularisation of the grafted bone

✦ This may lead to hypomobility or ankylosisMercuri LG: The Use of Alloplastic Prostheses for Temporomandibular Joint Reconstruction J Oral Maxillofac Surg 58:70, 2000





• Salvage procedures— Total joint replacement

✦ Alloplastic total joint replacements:

✓ Biomet

✓ Patients-fitted TJR_TMJ Concepts

‣ Louis Mercuri: "Based on these data (14 years follow-up) and a paper we are presently working on with 19-22 years follow-up of the TMJ Concepts custom device, we believe that "custom" TMJ TJR devices will have at least 15-25 years longevity, or more since they have not shown any polyethylene wear-related osteolysis. The forces placed on these joint replacements are no where near those placed on orthopaedic joints as well"


AdultSevere left condylar resorption


• Is it because of occlusion?Of disk?

• Vertical growth has stopped around 10-12 y in left TMJ

✦ Look at antegonial notch…

• Probable traumatisme?

ElKsa190913, 36y



•1-Condylar resorption

• 2- left short ramus

• 3- Arched left antegonial notch

• 4- Compensatory bone apposition at gonial angle

• 5- Decrease lateral growth of the mandibule on the affected side

♀36a

5



•Class III subdivision right

•Dentoalveolar compensation:

✦ Mx right constriction, left expansion

ElKsa190913 36a



•Tx plan

✦ Sarpe

✦ Bimaxillary jaw surgery

✦ Total joint replacement of left TMJ



Pre Surgery

•Mx dentoalveolar compensation are corrected

ElKsa020215



•Note bone apposition at the left gonial angle and the arched antegonial notched



3D Surgical Planning



Marking guide

Biomet Custom Joint Prothesis



Capsule articulaire et disque

Guide de coupe du condyle

Gabarit de coupe



1 month Post op

•Jaw opening amplitude 13 mm

•Temporal branche of VII nerve: Grade IV à V: moderately to severe dysfunction

•Eye: Grade II. mild dysfunction

•Mouth: Grade III: moderate dysfunction, slightly weak with maximum effort

ElKsa080415

House-Brackmann Classification of Facial Function



•Facial symmetry and class I occlusion achieved

ElKsa230615 37 a 8 m



•Counteclockwise rotation of occlusal plane



Alloplastic Replacement•Advantages

✦ No donor site

✦ Conform to given anatomy

✦ Early physiotherapy

✦ No susceptibility to systemic disease

•Disadvantages

✦ Expensive

✦ Sensitivity

✦ Longevity

✦ Only adults?




• No sensitive or motrice loss of the eye, the eyebrow and forehead. Revovery 100%

• Resemblance to her photo at 10 y

• New start in her life…She is pregnant at 38 y

Initial Follow up 3 mois 10 ans

Amplitude 43 mm



Follow up at 2 y post surgery

ElKsa200317 39 a 5 m

Jaw opening= 44 mm No deviation on opening No pain No sensibility loss



Commun denominator commun

•TMJ trauma: ischemia

•Disk displacement without reduction

•Adolescent 12-18 y

•Dysfunctional remodeling→resorption



Final Thoughts•Facial asymmetry commonly involves TMJ pathology or disorders.

• Therefore, the TMJs should always be evaluated (whether symptomatic or asymptomatic) to determine if the TMJs are the etiologic factor, a problem that developed because of facial asymmetry, a coexisting pretreatment condition, or that the joints are normal and healthy.

•Progressive worsening facial asymmetry usually indicates that TMJ pathology is present with one condyle either resorbing or growing.

✦ Wolford L.M., Mandibular Asymmetry: Temporomandibular Joint Degeneration , Chap. 82, p.696-725



Final Thoughts

• In conclusion, it is essential that TMJ osteoarthritis be presented as the pathologic entity it is in the same terms as our colleagues discuss osteoarthritis in orthopaedic circles.

• To not do this only exacerbates the problem that everyone dealing with this entity —patients, clinicians, insurance carriers, and so forth — has with TMJ osteoarthritis, because they do not consider it as the orthopaedic (medical) pathology that it is, but rather a purely dental TMJ problem.

• Mercuri L.G., Oral Max Surg Clin N Am 20 (2008) 169-183


MerciMerci


•[email protected]

• sylvainchamberland.com

•418-847-1115

•Please like my FaceBook page www.facebook.com/drsylvainchamberland


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Condylar Resorption

and Arthrosis of the Joints

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Revised as of November 2015

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condylar resorption and arthrosis of the joint (dgkfo)

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