Idiopathic condylar resorption and arthrosis of the joints

©Dr Sylvain Chamberland

TMJ PathologiesIdiopathic Condylar Resorption

Progressive Condylar ResorptionInternal Condylar Resorption of Adolescents

Reactive ArthritisRheumatoid Arthritis

www.slideshare.net/sylvainchamberlandwww.sylvainchamberland.com

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


Lateral open bite

Clicking of the left TMJ

Pain on palpation of the left pre-auricular area

Facial Asymmetry

NaRo.01-02-06; 16 years


Elongation of right condylar neck

Flattening of the anterior surfaceof the left condyle

Antegonial notch: R ≠ L

NaRo010206

Right Hyperplasia ?

Left Hypoplasia ?


Or?

Undiagnosed condylar fracture

Healing of the left stumps, but loss of ramus height & altered condylar growth

NaRo010206

Right Hyperplasia ?

Left Hypoplasia ?


Female 17 y

No more condylar head and neck

Microrami

Class II + anterior open bite

No previous ortho treatment

ChLa150393

ChLa150393


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


Microrami

No condyles!

Medical history non contributive (normal)

LyBo 180693


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

Contemporary Findings on TMDs & Clinical Management 1

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 283-310Wadhwa S, and Kapila S. TMJ disorders: future innovations in diagnostics and Therapeutics. J Dent Educ. 2008, Aug;72(8):930-47


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

Contemporary Findings on TMDs & Clinical Management 2

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


Idiopathic condylar resorption in teenage girlsMost 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. WolfordAtlas 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

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

(adult)

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

©Sylvain Chamberland

1. Bruxism-clenching2. Disc displacement3. Joint anatomy4. 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.

C.

1. Seating direction2. Seating force3. Treatment devices4. General anesthesia5.6. 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


Condylar Resorption

In 2 words:

✦ Initial compression

✦ Overlaid systemic condition

G.W. Arnett, AAO meeting, Boston 2009


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 & ↑

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

✦

✦ 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→

osteoarthrosisWadhwa 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

Bone resorption

Mechanical stress(compression or luxation)

Physical disruption of molecules and cellsCell deathProduction of free radicals

Impaired cellular functions

Degradation of hyaluronic acid by free radicals

↑Matrix degradationInhibition of matrix synthesisDegradation of articular surface



Concept of the Process of Cartilage breakdown

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


Pinch of articular interline

Geodes of resorption

Osteophytes

Pathophysiology

Collagen proteoglycans

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


Condylar Resorption

Root causes differentiate between diagnosis

✦ (Rh. Arthr., post-traumatic arthritis, ICR, auto-immune disease)

All bone loss involves common resorptive pathway

* **Acellular areas

Loss of columnar organization

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

Wadhwa S, Kapila S, JDE vol 72 #8

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

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

✦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


Interleukine 6

Tumor necrosis factor-α

Receptor Activator Nuclear Factor Kappa-beta Ligand

OsteoProteGerin

TNF-α, IL-6 et RANKL ➡cytokines that activate catabolic

pathways of bone resorption

OPG ➡cytokine that inhibit bone

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 neckSample: 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

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


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.


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.

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)

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


Pharmacotherapy 2

Statins

✦ Reduce the risk of myocardial infarction by lowering cholesterol levels and through

RANKL inhibitor: Denosumab

IL-6 receptor inhibitor: Tocilizumab

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


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

Osseous Mandibular Condylar Resorption J Oral Maxillofac Surg 2011, october,

TNFα


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


ResorptionCBCT 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.

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

★Possibility of reducing anteriorly displaced disc

Advance stage:Non reducing displaced disc

Pain, limited open + cessation of a clickingDD seems to be a risk factor for onset of DJD

Erosive lesion progressing to be

articular surface + re-corticationLate 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, 2008, p 125-145


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 (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

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

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


conditionsDegenerative joint disease (Osteoarthritis/osteoarthrosis)Post-traumatic arthritis

Infectious arthritisRheumatoid arthritis (adult and juvenile)Gouty arthritisPsoriasis arthritisLupus erythematosusAnkylosis spondylitisReiter's syndromeArthritis associated with ulcerative colitis


Diagnostic of TMJ degenerative changes

Clinical history

Noise (clicking, crepitus) present or past

Close lock, hypomobility present or past

Anterior open-bite, or antero-lateral

Ka.Tu 1111

A-A.St-O.T 0711



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.)

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



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


Imaging Modalities degenerative changes

Panorexes:

✦ ∆ TMJ shape

✓ Flattening of the anterior surface of the condyle

✓ ∆ size

✓ ∆ articular eminence shape

✓

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


Imaging Modalities

CBCT 3D mouth open

✦ Condyle assessment

✓

✓

✦ Dose effective & cost effectivefor evaluation of osseous abnormalities

N.R. 17-10-11

Mouth open

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

Mouth closed


Imaging ModalitiesMagnetic resonance imaging:

✦ Useful for soft tissue (disc)

✦ Less useful for osseous degenerative changes

Disk displacements & osteoarthritis = 30% of asymptomatics volunteers

(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

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


Imaging Modalities

Bone scan Tc-99

✦ Assess bone activity

✓ Growing or degenerative

✦

Jo.Ma.Mean Maximum

Right

Left

Right

Left

1,02 0,93april 2009

1,01 0,91

p Pre surg

1,3 1,73 november 2010

1,26 1,68

2010

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



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, 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


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

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



Moderately invasive approach

✦ Splint therapy

✦ Nonsurgical orthodontic treatment

✓ Use of TAD for the vertical changes instead of surgery



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



Salvage procedures— Total joint replacement

✦ Autogenous total joint replacements: Costochondral graft

✓

✓



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


Ortho surgical treatment

Bimax surgery, clockwise rotation:

✦ Le Fort 1, BSSO, genio

ChLa150393

17 ans

ChLa010695/ surgeon: Dr Denis Gagnon

Tomo Chantal ChLa150393 ChLa-10695

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

RCIA


Case 2


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


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 DiagnosisJuvenile rheumatoid arthritis

✦ Bilateral resorption

✦ Short ramus

✦ Lack of condylar growthElCr 2010

ElCr 2007Courtesy Dre Claudia Giambastini


Adjunct treatmentAdvancement 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 genio ElCr 2011-post genioCourtesy Dr Dany Morais


Progress late 2011

Reassessment during treatment

A new genioplasty can be done

Uprigthing of lower incisors could be achieved (root mvt)??

Bone apposition site

ElCr 2011-post genio

Courtesy Dr Claudia GIambastini

apposition labial to incisors

roots


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


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


Initial

Pre surgery

End of ortho

2 y post orthoRetrospectively, would it be legitimate to extract 2 1st Pm

However, does not mean that the outcome would have been any better?


Cl II div 1. Md Laterodeviation to right

COCR functional shift AP

Bilateral condylar resorption (R>L)

✦ 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

LuBo070211; 2 ans post ortho

LuBo070706 preortho


Investigation in Rheumato: negative

Scinti Tc99: normal pre surgically

Tx plan: SARPE, Le Fort 1, BSSO, genio

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

JoMa100907, 20 a 7m


Bone scan normal preop

Condyle looked normal at debonding

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

Chir: Dr Michel Fortin


Bite reopening was observed 3 months after debonding

Fact Rh = n; 17β-oest. = n (fev2010)

Scinti Tc 99 positive in October 2010

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

Note root resorption of lower molars

condyle

2 year post ortho


Progressive Md retrusion

Relative stability between 2011-2010

Note upper molar extrusion

Note condylar resorption


Common DenominatorThey 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. ArnettProgressive 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


According to G. W. ArnettProgressive 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


According to G. W. ArnettAAO 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?

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


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)

KaTu031105, 15 a 1 m Courtesy Dr Maryse Gendron


Post ortho: fairly acceptable occlusion

Except slight right lateral openbite

No Xray taken at debonding

KaTu160107, 16 a 4 m


Left condylar resorption in November 07

Probably in remission in may 10

KaTu161107, 17 a 1 m

KaTu030510, 19 a 7 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

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

Vi.Pr.120312; 15 y 6 m


neck

Flatness of the anterior surface of the left condyle

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

Vi.Pr.120312; 15 y 6 m


CBCT

Normal condylar head and neck

Shorten condylar neck

Flatten condylar head


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


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

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


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 unilateralAll possible exams were done


CBCTLong 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. WolfordAtlas 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)


According to G. W. ArnettAAO meeting Boston 2009

Bimaxillary osteotomy

✦ Counterclockwise rotation MxMd

✦ Cocktail of drugs


Case 1


Alternative to surgical ortho tx

Class II div 1

Hyperdivergent

Anterior open bite

Tx exo ⅘ & microimplants

AnGr 0609, 14a 4 m


Microimplants Mx

Microimplants Md

Note posterior openbite& anterior deep bite

AnGr 131009

AnGr 071209

AnGr 080310


Clockwise rotation

Few if any molar extrusion

Surgery avoided

AnGr 0911, 16a 10 m


Case 2


Progressive condylar resorption post surgically

Aggressive development in 1 y

✦ Rheumato: Ø

Stabilization the following year

Recall at 5 years

✦ Dental compensation noted

✓ Tx limited Md

JuBo020511

JuBo0801106

JuBo3101005

JuBo260404


TAD and posterior intrusion

Selective intrusion of buccal segment

JuBo231111

JuBo250511

JuBo310512


TAD and posterior intrusion

At debonding, positive overbite achieved

JuBo250511

JuBo220812


Comparison tracing shows

✦ Posterior intrusion

✦ Counterclockwise rotation of Md

✦ Positive overbite is obtained

JuBo220812JuBo250511


✦ Post genioplastyJuBo220812JuBo250511 JuBo081112

JuBo081112 JuBo081112

JuBo250511

JuBo250511


JuBo020511

JuBo220812


Case 3


TAD

✦ Intrusion of buccal segment

✦ Positive overbite obtained

MaLaBrLa141211

MaLaBrLa041110

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

Blood test non contributive

MaLaBrLa160812

MaLaBrLa041110


Class I occlusion is achieved

Positive overbite maintained

MaLaBrLa041110

MaLaBrLa160812

MaLaBrLa081112

MaLaBrLa041110


Dentoalveolar protrusion is reduced

MaLaBrLa081112MaLaBrLa041110

MaLaBrLa041110


Case 4


Class I, anterior open bite

Md deviation to the right (midline to right)

Normal facial proportion

AA.St.Tr. 130711, 22ans

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: Ø17β-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 TMJBlood test: normalRh factor: negative


Rheumato: Ø17β-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 TMJBlood test: normalRh factor: negative


Tx Plan

Intrude maxillary buccal segment

Intrude & mesialize mandibular buccal segments

Rotate the maxillary occlusal plane


MechanotherapyBond 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


Mx: posterosuprerior vector of traction

Posterior open bite is obtained & positive anterior OB

AA St-O 211111

AA St-O 150212

AA St-O 100512


Mx: Midline correction

AA St-O 100512

AA St-O 130812

AA St-O 100912


TPA help derotate 6’s/

LLA help helped to avoid expansionAA St-O 150212

AA St-O 100512

AA St-O 211111


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 changedistal to molar may demonstrate molar intrusion


Tx time: 66 weeks

AA St-O 271112, 14 days post debonding

AA.St.Tr. 130711, 22ans


Stability...

Time will tell

Initial


Case 5


Notable CO/CR discrepancy

After 4 months of splint therapy

MePo 030610

MePo 030610

MePo 021110



Cl I open bite

Bimaxillary protrusion

Lower lip is prominent

Slightly long LAFH


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

the buccal segment

MePo310512

MePo310112


At 60 weeks into tx

Class I relationship & positive OB is achieved

MePo310512

MePo310112

MePo040912


At 105 weeks into tx

MePo310512MePo310112MePo040912

MePo071112

MePo021012

At 100 weeks into tx


If superimposition is accurate

✦ 1/ retraction and extrusion

✦ Slight increase of FMA

Progress MePo040912

Initial

Progress 0512


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

MePo040912


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


Medical & dental historyMRI in 2007

✦ Left:

✓ DD without reduction

✓ Degenerative changes

✦ Right

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

✓ Degenerative changes

Occlusal splint therapy initiated. (

✦ Helped to reduce pain slightly (~ 35%)

ArLa 19092007


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

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

Left

1,67 1,43 Sept 2011

2,12 2,35

2011


Splint therapy since fall 2007

Since March 2011

✦ Naproxen 500 mg bid

✦ Ran pantotrazole 40mg 1co le matin

✦ Cyclobenzaprine 10mg 1co hs

Picture with the splint will be added. ArLa240912


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


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 colleaguesThank you for your attention


Thank you Dr Wilson and Dr Tompson

Dear colleaguesThank you for your attention

Health & Medicine

Idiopathic condylar resorption and arthrosis of the joints