Idiopathic condylar resorption and arthrosis of the joints

TMJ Pathologies
Idiopathic Condylar Resorption
Progressive Condylar Resorption
Internal Condylar Resorption of Adolescents
Reactive Arthritis
Rheumatoid Arthritis

www.slideshare.net/sylvainchamberland
www.sylvainchamberland.com
©Dr Sylvain Chamberland
Revised as of december 2012

Pre orthodontic
treatment
Anterior open bite
Severe Md retrognathism
Absence of articular clicking
Few if any TMJ symptoms

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

JoMa100907, 20 a 7m

Microrami
Flattening of the
superoanterior surface
of the condyle


Facial Asymmetry
Lateral open bite
Clicking of the left TMJ
Pain on palpation of the left
pre-auricular area

©Dr Sylvain Chamberland NaRo.01-02-06; 16 years

Right Hyperplasia ?

Left Hypoplasia ?

NaRo010206

Elongation of right condylar neck
Flattening of the anterior surface
of the left condyle
Antegonial notch: R ≠ L


Right Hyperplasia ?

Left Hypoplasia ?

NaRo010206
Or?
Undiagnosed condylar
fracture
Healing of the left
stumps, but loss of
ramus height & altered
condylar growth

ChLa150393
ChLa150393

Female 17 y
No more condylar head and neck
Microrami
Class II + anterior open bite
No previous ortho treatment

Adult
F. 33 y 5 m
Ask for a consult because her
occlusion has changed since her last
pregnancy
No previous orthodontic treatment

LyBo 180693

LyBo 180693

Microrami
No condyles!
Medical history
non contributive
(normal)

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

✦ Estrogen & progesterone receptor are present in the TMJ

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


Contemporary Findings on TMDs
& Clinical Management 2

Sexual dismorphism M/F in the presence of
oestrogen receptors
Evidence that estrogen is involved in TMD
✦ Association between facial pain and estrogen
replacement therapy or the use of oral
contraceptive
✦ High pain is associated with low levels of estradiol

✦ Elevated systemic levels of estrogen in women
with TMJ disease vs. those in normal controls
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
Affect condyles bilaterally and symmetrically
Progressive mandibular retrusion followed by period of
remission until the entire condylar head is resorbed
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
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
✦
opening amplitude


(adult)

Meniscal tissues and fossa may also undergo changes
affecting support of mandible and dentition

©Dr Sylvain Chamberland Arnett G.W. Et al, Progressive mandibular retrusion-idiopathic condylar resorption part 1 AJODO 1996; 110-8-15

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

1. Seating direction
2. Seating force
3. Treatment devices
4. General anesthesia A. Bite treatment causes
5. condylar displacement
6. Splints
7. Paramandibular connective tissue
8. Unstable occlusion

1. Bruxism-clenching
2. Disc displacement
B.
3. Joint anatomy
4. Macrotrauma
If A +B + C =
1. Female aggressive resorption
2. 14-24 years old
3. Low estrogen (⬇)
4. Systemic arthritis
C.
5. Corticosteroids
6. Hyperprolactinemia

Low Vit D/Calcium ⬇
7. Hyperparathyroidism
8.
Joint Remodelling Mandibular Retrusion
©Sylvain Chamberland

Condylar Resorption

In 2 words:
✦ Initial compression

✦ Overlaid systemic condition

G.W. Arnett, AAO meeting, Boston 2009

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

Estrogen Role
17β-estradiol
✦ Down-regulation (↓ ) MMPs transcription

✦ ↓

✦ ↓ bone loss in women

Ethinyl Estradiol (contraceptive pills or postmenopause hormonotherapy)
✦ Suppress production of naturally occurring 17β-estradiol

✦ ↑ osteoclast activity & ↑

Cascade of events related to
estrogen
↓Estrogen
✦

✦ Promote cytokines production
✓ Matrix degradation enzymes MMP

✦ Bone loss
✓ Progressive mandibular retrusion

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

Cascade of events related to
pregnancy
Prolactin
✦ Enhances cytokines production by
lymphocytes and macrophages
Increased levels of endogenous
corticosteroids is associated with
pregnancy
✦ Corticosteroid reported has causing joint
resorption (catabolic effect)


Mechanical Etiologic Factors
of Resorption
Traumatism
Parafonctional activity
Unstable occlusion
Altered TMJ loading
Increased friction into the joint


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→

osteoarthrosis
Wadhwa S. ,Kapila S., TMJ disorders: Future innovation in diagnostics and therapeutics, J. Dent. Educ. 2008, 72 (8), 930-947

Sequella of a mechanical stress to TMJ
Mechanical stress
(compression or luxation)
Physical disruption of molecules and cells
Cell death
Production of free radicals

Impaired cellular functions

Degradation of hyaluronic acid by free radicals

↑Matrix degradation
Inhibition of matrix synthesis Bone resorption
Degradation of articular surface
©Sylvain Chamberland Arnett G.W. et al, Progressive mandibular retrusion-idiopathic condylar resorption. Part 1, AJODO 1996; 110:8-15

Concept of the Process of Cartilage breakdown

Tanaka E., Detamore M.S., Mercuri L.G. Degenerative disorders of the

Osteophytes Pinch of articular interline

Geodes of resorption


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

Pathophysiology

Collagen
proteoglycans

Condylar Resorption

Root causes differentiate between diagnosis
✦ (Rh. Arthr., post-traumatic arthritis, ICR, auto-immune disease)

All bone loss involves common resorptive pathway
Loss of columnar organization

* *
Acellular areas
* Wadhwa S, Kapila S, JDE
vol 72 #8

Gunson MJ, Arnett GW, Milam SB., Pathophysiology and
pharmacologic control of osseous mandibular condylar resorption.
J Oral Maxillofac Surg. 2012 Aug;70(8):1918-34. Epub 2011 Oct 19

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

Pathophysiology
✦Cytokyne-activated osteoclasts promote the
recruitment and activity of osteoclasts that, in
turn, result in the secretion of enzymes that
are responsible for the breakdown of
hydroxyapatite and collagen

Gunson MJ, Arnett GW, Milam SB.,
Pathophysiology and pharmacologic
control of osseous mandibular
condylar resorption.
J Oral Maxillofac Surg. 2012 Aug;70(8):
1918-34. Epub 2011 Oct 19

Interleukine 6

TNF-α, IL-6 et RANKL
➡cytokines that activate catabolic Receptor Activator Nuclear Factor Kappa-beta Ligand
pathways of bone resorption
OsteoProteGerin

OPG
➡cytokine that inhibit bone Tumor necrosis factor-α

catabolism by binding to
RANKL


MMP = endopeptidases that
degrade extracellular matrix
molecules (collagen et elastin)

MMP require Zinc as a cofactor
for activity

TIMPs (tissue inhibitors of MMPs)
bind to MMPs and inhibit their
activity

Imbalance between MMPs and
TIMPs favour unregulated
degradation of tissue by MMP.


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:
✦

✓ All condylar change or displacement through compression

Role of posteriorly inclined
condylar neck 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):85-90

Sample: 11 patients having condylar
resorption selected in a sample of 240
patients who underwent orthognathic
surgery
Counterclockwise rotation of the proximal
segment (6,7°± 3,2°) was observed in all
patients


Explanation of the author

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.


J Oral Maxillofac Surg.2012, Aug;70(8):1951-9.

After moving the mandibule anteriorly and superioly
✦ Formation of a step at the buccal ostotomy site

✦ Counterclockwise rotation of the proximal segment to avoid
postoperative antegonial notch
✦ Condylar axis rotated inward affect sagittal condylar height
postoperatively (Park et al, JOMS 2012)

Other ref:
Hoppenreijis 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.


Pharmacotherapy 1

Cytokine inhibitors
✦
every 2 weeks)
MMP inactivation
✦ Tetracyclines

Inhibition of prostanoids and leukotrienes
✦ Fatty acid Omega-3

✦ (medical
monitoring side effects)


Pharmacotherapy 2

Statins
✦ Reduce the risk of myocardial infarction by lowering
cholesterol levels and through
RANKL inhibitor: Denosumab
IL-6 receptor inhibitor: Tocilizumab



Pharmacotherapy 3

Osteoarthritis Auto-immune arthritides

✦ Cytokines and/or MMPs inhibitors ✦ Auto-immune inhibitor

✓ Doxycycline, Feldene, Simvistatin ✓ Methotrexate, Enbrel, Simvistatin

✦ Free radical inhibitors
TNFα
✓ Vit C, Vit E, fat acid omega 3

✦ Anabolic bone metabolism
facilitator

✓ Vit D, Ca2+, 17β estradiol

✦ Parafonction inhibitors

✓ Amitriptyline, Tiagabine,
Klonopin, Botox

Prophylactic
pharmacotherapy

✦ 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

subsequent clinical improvement.
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

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

Cevidanes et al, Condylar resorption in patients with TMD, monograph 46, Cranifacial Growth Series, 2008, p 147-157

Resorption
CBCT of TMJs (mouth open)
Extraction of volumes of interest

condylar morphology compared to non
symptomatic patients
TMDs patients = resorption of anterior
surface of the lateral pole + posterior

articular surface.

Initial stage:
★Flattening of anterior surface +
cortical thickening (sclerosis)in
loading area
★Possibility of reducing anteriorly
displaced disc
Advance stage:
Non reducing displaced disc
Pain, limited open + cessation
of a clicking
DD seems to be a risk factor
for onset of DJD
Erosive lesion progressing to be

articular surface + re-cortication
Late stages:
Formation of osteophytes

through un-corticated surface →
sub-chondral bone cyst

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

Initial stage
✦ Flattening of anterior surface + cortical
thickening (sclerosis)in loading area
✦ Possibility of reducing anteriorly
displaced disc

Hatcher D, CBCT (3D imaging): application for selected articular disorders and associated
©Dr Sylvain Chamberland 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 seems to be a risk factor for onset of DJD (or
the effect of degenerative change)

✦ Erosive lesion progressing to be

surface + re-cortication


Late stage
✦ Formation of osteophytes

✦
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.

Joint Hypermobility & TMD
Hirsch, C. John, M.T., Stang, A., Association
between generalized joint
hypermobility and signs and diagnoses of TMD
Eur. J Oral Sciences 2008; v.116 #6 525-530

N = 893; F = 56,7%; Mean age: F=39,9; M=41,2
Results:
✦ Hypermobile subjects (> 4 joints on the 0 à 9 scale)
✓ Higher risk for reproducible reciprocal TMJ clicking (OR = 1,68)

✓ Lower risk for limited mouth opening (<35 mm) (OR = 0,26)

✓ No association between hypermobility and myalgia/arthralgia


conditions
Degenerative joint disease
(Osteoarthritis/osteoarthrosis)
Post-traumatic arthritis
Infectious arthritis
Rheumatoid arthritis (adult and
juvenile)
Gouty arthritis
Psoriasis arthritis
Lupus erythematosus
Ankylosis spondylitis
Reiter's syndrome
Arthritis associated with ulcerative
©Dr Sylvain Chamberland colitis

Diagnostic of TMJ
degenerative changes
Clinical history
Noise (clicking, crepitus) present or past A-A.St-O.T 0711

Close lock, hypomobility present or past
Anterior open-bite, or antero-lateral
Ka.Tu 1111


Diagnostic of TMJ
Occ. Centrée (C.O.)

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 Me.Po. 0610

✦ To reach a 2:1 odds ratio threshold Rel. Centrée (C.R.)

for notable risk of association with
degenerative changes, a slide > 5 mm
would be necessary
J Prosthet Dent 2000; 83:66-75
MacNamara JA, Seligman DA, Okeson JP, Occlusion, orthognathic treatment and temporomandibular disorders: A review,
J Orofacial Pain, 1995; 9:73-90

Diagnostic of TMJ
Pain
✦ Arises from the soft tissues and masticatory muscle
around the affected joint
✦
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: 296
©Dr Sylvain Chamberland http://jdr.sagepub.com/content/87/4/296

Shintaku WH et al, Imaging modalities

Imaging Modalities
to access bony tumors and
hyperplastic reaction of the TMJ,
JOMS 68:1911-1921, 2010

Panorexes: D.D.N.-R.

✦ ∆ TMJ shape
Al.Be. 0810 Jo.Ma. 0907
✓ Flattening of the anterior surface of the condyle

✓ ∆ size
Me.Po. 0610

✓ ∆ articular eminence shape

✓
©Dr Sylvain Chamberland Ma.La.Br.La.0410

Imaging Modalities

TMJ tomograms,
mouth open Me.Po. 0610

©Dr Sylvain Chamberland A-A.St-O-T. 0711

Imaging Modalities
Mouth closed

CBCT 3D mouth open
✦ Condyle assessment
✓
A-A.St-O-T. 16-08-01
✓
Mouth open
✦ Dose effective & cost effective
for evaluation of osseous
abnormalities

N.R. 17-10-11


Imaging Modalities
Magnetic resonance imaging:
✦ Useful for soft tissue (disc) Reducing disc
displacement

✦ Less useful for osseous degenerative changes

Non-reducing
disc displacement

Disk displacements & osteoarthritis = 30% of
asymptomatics volunteers Non-reducing
disc displacement
&
Severe
Osteoarthrosis
(bone oedema, joint effusion, synovitis) to
Tanaka E, Detaore MS, Mercuri LG Degenerative disorders of the
joint pain
©Dr Sylvain Chamberland MRI sensitivity =78%; predictive value =54% bone marrow and intra-articular soft tissues of the
temporomandibular joint, Sem Ortho 2012;18:30-43

Imaging Modalities
Mean Maximum
Jo.Ma.

Bone scan Tc-99 Right 1,02 0,93
april 2009
p
✦ Assess bone activity Left 1,01 0,91
Pre surg

✓ Growing or degenerative
Right 1,3 1,73 november
✦ 2010
Left 1,26 1,68 Post surg

symmetric hypermetabolism in 2010


Additional diagnostic aid
Blood test mid-cycle
✦ Female
✓ Dosage de Estrogen & 17β-estradiol at debut and mid-cycle, FSH, LH,Vit D

✦ Men
✓

✦ Level of rheumatoid factor, antinuclear antibodies and anti CCP

✦


Principles for management of
TMJ osteoarthritis
Noninvasive management modalities
✦ Medications
✓

✓ Muscle relaxant

✦ Physiotherapy
✓ ∆ body posture

✦ Oral appliance (occlusal splint)
✓
Mercuri LG, Osteoarthritis, Osteoarthrosis and Idiopathic Condylar Resorption, Oral Maxillofacial Surg Clin N Am 2008 May;20(2): 169-183

TMJ osteoarthritis
Minimally invasive modalities
✦
✓

✦ Arthrocentesis
✓ ↓ 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, 2009
Guo C, Shi Z, Revington P, Arthrocenthesis and lavage for treating temporomandibular joint disorders, Cochrane database of systematic reviews 2009, Issue 4. Art.No.:CD004973
Shi Z, Guo C, Awad M. Hyaluronate for the temporomandibular joint, Cochrane database of systematic reviews 2003, Issue 1. Art.No.: CD002970

Minimally invasive modalitie
vs corticosteroid, after 6 months
✦ Reported pain (mm on VAS),

✦ Pain on palpation of the affected TMJ

✦ Pain on palpation of contralateral TMJ

✦ Pain on palpation of masticatory muscle

✦ None of the mean differences between

©Dr Sylvain Chamberland Hyaluronate for temporomandibular joint disorders (Review). Cochrane Database of Systematic Reviews 2003. 2003;(1):

TMJ osteoarthritis

Moderately invasive approach
✦ Splint therapy

✦ Nonsurgical orthodontic treatment
✓ Use of TAD for the vertical changes instead of surgery


TMJ osteoarthritis
Invasive surgical modalities
✦ Ortho treatment and orthognathic surgery (mono or bimax)
✓ Clockwise rotation

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

✦ Autogenous hemiarthroplasty
✓

‣ Orthopaedic literature show long-term poor experience with hemiarthroplasty

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

TMJ osteoarthritis

Salvage procedures— Total joint replacement
✦ Autogenous total joint replacements: Costochondral graft
✓

✓


TMJ osteoarthritis
Salvage procedures— Total joint replacement
✦ Alloplastic total joint replacements:
✓ Biomet

✓

‣ 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


Case 1


RCIA

17 ans
1. Female

Estrogen ⬇
2. 14-24 years old
ChLa150393 ChLa010695/ surgeon: Dr Denis Gagnon 3.
4. Systemic arthritis
5. Corticosteroid

Ortho surgical treatment
6. Hyperprolactinemy

Vit D/Calcium ⬇
7. Hyperparathyroidism
8.

Bimax surgery, clockwise
rotation:
✦ Le Fort 1, BSSO, genio
ChLa150393 ChLa-10695
Tomo Chantal


Case 2


Resorption post pregnancy

LyBo 180693 LyBo 190396/ ~1 an post ortho
LyBo 0997/ ~2 ans post ortho

Ortho treatment only, exo 4 Pm1
Genioplasty only
Note the possibility of posterior
intrusion


LyBo93/ pre-ortho

No condyle before
No condyle after
But stable occlusion

LyBo97/ 2 years post-ortho

Case 3


F. 30 years
Ortho Tx at adolescence
Progressive anterior openbite
developed during the past 5
years
Menses: regular, contraceptive
ceased 1½ year ago
Occasional TMJ pain
Investigation rheumato = normal
Invisalign since 12 months...
Courtesy: Dr Dany Morais

Bimaxillary surgery: clockwise rotation
✦ Le Fort 1, BSSO

There is no more condyle to resorb, it should be stable!
Esthetic and functional outcome...may be questionable.
Courtesy: Dr Dany Morais

Common denominator

Hormonal aetiology probable
Condyles were completely resorbed


Differential Diagnosis
Juvenile rheumatoid arthritis
✦ Bilateral resorption

✦ Short ramus
ElCr 2010
✦ Lack of condylar growth

©Dr Sylvain Chamberland Courtesy Dre Claudia Giambastini ElCr 2007

Adjunct treatment
Advancement genioplasty to improve lip function at repose &
aesthetics of the chin
Favour bone remodelling and apposition at the buccal aspect of
the incisors roots
Reassessment during treatment and in adulthood

Bone apposition
site
ElCr 2011-post
©Dr Sylvain Chamberland genio Courtesy Dr Dany Morais ElCr 2011-post genio

Progress late 2011

apposition labial
Bone apposition to incisors
site roots
ElCr 2011-post genio

Reassessment during treatment
A new genioplasty can be done
Uprigthing of lower incisors could be achieved (root mvt)??

©Dr Sylvain Chamberland Courtesy Dr Claudia GIambastini

La.Va.0109, end of ortho
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.0107/ 14 a 3 m/ pré-ortho
La.Va.0311/ 2 ans post ortho

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 La.Va.0408/ pre-surg
Tc99 presurg & pre ortho

2 years post ortho
✦ Remodelling +++

La.Va.0311/2 y post tx
Surgeon: Dr Patrick Giroux


Initial
Pre surgery
End of ortho
Retrospectively, would it be legitimate to extract 2 1st Pm
2 y post ortho
However, does not mean that the outcome would have
been any better?

LuBo070706 preortho; en RC

LuBo.17a.1 m.

Cl II div 1. Md Laterodeviation to right
COCR functional shift AP
LuBo070706 preortho
Bilateral condylar resorption (R>L)

✦ Disc displacement with reduction in the right


LuBo070706 préortho
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!)

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


Le Fort 1
OSMB
Genio
LuBo261007 préchir

LuBo161208 19a 6 m

Functional Cl I

Surgeon: Dr Michel Fortin


LuBo070211 21a 8 m

PCR Progressive
postsurgical condylar
resorption
Cant of the mandibular
incisor occlusal plane to the left LuBo070211


LuBo070706 preortho

LuBo070211; 2 ans post ortho

Decreased ramus height:
condylar head & neck


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

JoMa100907, 20 a 7m

Investigation in Rheumato: negative
Scinti Tc99: normal pre surgically
Tx plan: SARPE, Le Fort 1, BSSO, genio


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

Bone scan normal preop Chir: Dr Michel Fortin

Condyle looked normal at debonding


2 year post ortho

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

Bite reopening was observed 3
months after debonding
Fact Rh = n; 17β-oest. = n Note root resorption of lower
(fev2010) molars
Scinti Tc 99 positive in
October 2010 condyle

Progressive Md retrusion
Relative stability between 2011-2010
Note upper molar extrusion
Note condylar resorption


Common Denominator
They had condyles presurgery

Progressive condylar resorption postsurgery
What happened during or after surgery?
✦

✦ They all had stiffness during jaw opening?

✦ Hypomobility?

✦ Counterclockwise rotation of the proximal segment

According to G. W. Arnett
Progressive mandibular retrusion-idiopathic condylar resorption. Part II, AJODO, 1996, 110:117-127

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


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

✦ No possible adjustment between proximal and
distal segments

✦ Possible adjustment in the early stage of healing

these observation


AAO meeting Boston 2009

Control surgical compression

Early mobilization
Class II elastics
Cocktail of drugs (pills medicines)


Risk factor of surgical TMJ
compression
Post surgical visit
✦ Contact anteriorly

✦ Slight posterior open bite

Occlusal load is distributed between the
condyles and incisor contact during use
of intermaxillary elastics to close the
posterior openbite


Why I don't like posterior
openbite after orthognathic
surgery?
Pressure Condyle resorb

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

Screwed Setting Jam-packed Slight progressive
occlusion retrusion The bite open

KaTu031105, 15 a 1 m Courtesy Dr Maryse Gendron

Preortho: had previous blockages in both side
Ortho tx limited to mx arch only
Joint hypermobility: luxation knee, ankle, synd. fémoroplatellaire
Had disc displacement without reduction (16 mm of opening)


KaTu160107, 16 a 4 m

Post ortho: fairly acceptable occlusion
Except slight right lateral openbite
No Xray taken at debonding


KaTu161107, 17 a 1 m

Left condylar resorption in November 07
Probably in remission in may 10

©Dr Sylvain Chamberland KaTu030510, 19 a 7 m

KaTu031111, 21 a 1 m

May 2011
✦ MRI: degeneration of the left disc

✦ Scinti Tc99= No metabolic activity (it’s normal)

Condylar resorption in remission
Wear an occlusal splint

KaTu031111, 21 a 1 m

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

©Dr Sylvain Chamberland Vi.Pr.120312; 15 y 6 m

neck
Flatness of the anterior
surface of the left condyle
Vi.Pr.120312; 15 y 6 m
Increased left antegonial
notching
2 levels of occlusal plane &
lower mandibular border

Vi.Pr.120312; 15 y 6 m

Normal right condylar growth
Progressive left condylar
resorption
➡ Anterolateral bite opening


CBCT

Normal condylar head and Shorten condylar neck
neck
Flatten condylar head


MaPiBe240203, 13 a 9 m

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


MaPiBe290604, 15 a 1 m

Functional occlusion
Right TMJ
✦ ??± similar???


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

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


MaPiBe190207, 17 a 9 m

MaPiBe140308, 18 a 9 m

Progression during the following year


MaPiBe040112, 22 a 7 m

Follow up
✦ 6½ years post ortho
✓ Cortical layer appears normal


NaRo010206 NaRo.01-02-06; 16 ans

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

NaRo.01-05-11; 21 ans

Unilateral condylar resorption→ Controlateral open bite

CBCT
Long right condylar neck
Short left condylar neck
Anterosuperior resorption

Patient N.R.

Common Denominator

Impact to the TMJ : ischemia
Disc displacement without reduction
Adolescent 14-18 years old
Non functional remodelling →resorption


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

Disc repositioning & ligature
Bimaxillary osteotomy &
counterclockwise rotation
✦ Le Fort 1

✦ BSSO + genio prn

91% success rate (stability)


AAO meeting Boston 2009

Bimaxillary osteotomy
✦ Counterclockwise rotation MxMd

✦ Cocktail of drugs


Alternative to surgical ortho tx

AnGr 0609, 14a 4 m

Class II div 1
Hyperdivergent
Anterior open bite
Tx exo ⅘ & microimplants


AnGr 131009

Microimplants Mx

Microimplants Md
AnGr 071209

Note posterior openbite
& anterior deep bite
AnGr 080310


AnGr 0911, 16a 10 m

Clockwise rotation
Few if any molar
extrusion
Surgery avoided


Progressive
condylar
resorption post
JuBo260404
surgically

Aggressive
development in 1 y

✦ Rheumato: Ø
JuBo3101005
Stabilization the
following year

Recall at 5 years

✦ Dental
compensation JuBo0801106
noted

✓ Tx limited Md

JuBo020511

TAD and posterior intrusion

JuBo250511

Selective intrusion of
buccal segment
JuBo231111

JuBo310512

TAD and posterior intrusion

JuBo250511

At debonding, positive overbite achieved

JuBo220812


JuBo250511 JuBo220812

Comparison tracing shows
✦ Posterior intrusion

✦ Counterclockwise rotation of Md

✦ Positive overbite is obtained


JuBo250511 JuBo220812 JuBo081112

✦ Post genioplasty

JuBo250511

JuBo250511 JuBo081112 JuBo081112


JuBo020511

JuBo220812


MaLaBrLa041110

MaLaBrLa041110
F. Rhum. Ø; Oestradiol < normal en 2009,
Pregnancy 2010-11
Investigation Rheumato: Ø in November 2011

Blood test non contributive

TAD MaLaBrLa141211

✦ Intrusion of buccal segment

✦ Positive overbite obtained

©Dr Sylvain Chamberland MaLaBrLa160812

MaLaBrLa041110

MaLaBrLa041110

Class I occlusion is achieved
MaLaBrLa160812 Positive overbite maintained

MaLaBrLa081112

MaLaBrLa041110

MaLaBrLa041110 MaLaBrLa081112

Dentoalveolar protrusion is reduced


Case 4


AA.St.Tr. 130711, 22ans

Class I, anterior open bite
Md deviation to the right (midline to right)
Normal facial proportion Symptoms began at age 19

Started contraceptive pills at 19 or 19½

Concavity on the superior surface of the right condyle
Flatness of the anterior surface of the left condyle
Rheumato: Ø
17β-estradiol: 84 pmol/L début cycle (n=180-550)
<73 pmol/L mid cycle (n= 110-1470)
ANF: positive, moucheté, titre1:80 (normal)
Scinti Tc99: Slight increased intake left TMJ
Blood test: normal
Rh factor: negative

Rheumato: Ø
17β-estradiol: 84 pmol/L début cycle (n=180-550)
<73 pmol/L mid cycle (n= 110-1470)
ANF: positive, moucheté, titre1:80 (normal)
Scinti Tc99: Slight increased intake left TMJ
Blood test: normal
Rh factor: negative


Tx Plan

Intrude maxillary buccal segment
Intrude & mesialize mandibular buccal segments
Rotate the maxillary occlusal plane


Mechanotherapy
Bond md arch + Mx occlusal splint for 3 months
Bond Mx arch at 3 months or so
TAD between /6-7 + LLA 32x32SS + E-link

AA St-O 211111


AA St-O 211111

Mx: posterosuprerior vector of traction

AA St-O 150212

Posterior open bite is obtained & positive anterior OB

AA St-O 100512


AA St-O 100512

Mx: Midline correction

AA St-O 130812

AA St-O 100912


AA St-O 211111

TPA help derotate 6’s/
AA St-O 150212

LLA help helped to avoid expansion

AA St-O 100512


Md forward rotation occurred
/1-MP change from 88° to 95°


Monitor root resorption
If superimpositions are accurate
✦ lower dentition intrude & advance

✦ Mx dentition:
✓ no posterior intrusion, no anterior extrusion

Bone level change
distal to molar may
demonstrate molar
intrusion


AA.St.Tr. 130711, 22ans

Tx time: 66 weeks

AA St-O 271112, 14 days post debonding


Initial

Stability...
Time will tell


Case 5


MePo 030610

Notable CO/CR discrepancy

MePo 030610

After 4 months of splint therapy

MePo 021110


Cl I open bite
Bimaxillary protrusion
Lower lip is prominent
Slightly long LAFH


MePo310112

TAD inserted un January between 6-7/ (not the best
place!)

the buccal segment

MePo310512


MePo310112

MePo310512

At 60 weeks into tx
Class I relationship & positive OB is achieved

MePo040912


MePo040912
MePo310112
MePo310512

At 100 weeks into tx

MePo021012

At 105 weeks into tx

MePo071112


Initial

Progress 0512

If superimposition is accurate
✦ 1/ retraction and extrusion

✦ Slight increase of FMA

Progress MePo040912


MePo040912

Superimposition show
✦ Mx molar intrusion & slight incisor extrusion
✓ Similar to differential mx impaction

✦ Md molar protraction. Lower incisor AP is maintained

Smile display is acceptable


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

Mouth closed

Mouth open

Severe resorption in right TMJ, moderate in the left
Note: her sister was recently diagnose of rheumatoid
arthritis


Medical & dental history
MRI in 2007
✦ Left:
✓ DD without reduction

✓ Degenerative changes

✦ Right ArLa 19092007

✓ DD with reduction + possibility of perforation (Surgeon: Early click noted on opening)

✓ Degenerative changes

Occlusal splint therapy initiated. (
✦ Helped to reduce pain slightly (~ 35%)

Current exam
MRI 2011
✦
osteophytes, bone signal: "hypointense". DD with reduction
✦
normal. DD NR
Blood test
✦ ANF negative, Rh factor normal, sedimentation normal

✦ Estogen: result pending

Bone scan Tc99
Maxi
Mean
Ar.La. mum
Increased uptake in right
Right 1,67 1,43 Sept
Ratio right/left mean 0,79 2011
Left 2,12 2,35
Ratio right/left maximum 0,61
Increased bone metabolism in the left joint revealing
condylar resorption
Right condyle seem in remission


Splint therapy since fall 2007

Picture with the splint will be added.
ArLa240912

Since March 2011
✦ Naproxen 500 mg bid

✦ Ran pantotrazole 40mg 1co le matin

✦ Cyclobenzaprine 10mg 1co hs


Tx Plan
82
74
100 8

80

86 111

-1

Genioplasty early into ortho treatment
18
52
-3
115
3
12
40
108
42
6

Total joint replacement
45
-13
101

22

✦ Alloplastic

✦ Autogenous (costochondral)
✓ Audience: discuss why one would be choose over the other?

Bimax surgery advancement + counterclokwise
rotation + another genioplasty prn


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

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


Thank you
Dr Wiltshire
Dear colleagues
Thank you for your attention


Thank you
Dr Wilson and Dr Tompson
Dear colleagues
Thank you for your attention


Idiopathic condylar resorption and arthrosis of the joints

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