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Condylar Resorption
and Arthrosis of the Joints
Kieferorthopädie auf den Punkt gebracht
11. - 14. Oktober 2017
Wissenschaf...
©sylvainchamberland.com
Contemporary Findings on TMDs &
Clinical Management 1
• TMD: incidence in general population = 2 F...
©sylvainchamberland.com
Contemporary Findings on TMDs &
Clinical Management
• Sexual dismorphism M/F in the presence of oe...
©sylvainchamberland.com
Idiopathic Condylar Resorption in
Teenage Girls
• Most common TMD in adolescent (9F :1M)
• Begin d...
©sylvainchamberland.com
AICR: clinical characteristics
• Teenage female, age of onset 11 to 15 y
• High occlusal plane and...
©sylvainchamberland.com
According to L.M. WolfordAtlas Oral Maxfacial Surgery Clin N Am 19 (2011) 243-270
• 1369 consecuti...
©sylvainchamberland.com
AICR
• During active phase
✦ Discomfort at both TMJs, hyperactivity of masticatory muscles
✦ Activ...
©sylvainchamberland.com
Estrogen Role
• 17β-estradiol
✦ Down-regulation (↓ ) MMPs transcription
✦ ↓ cytokines and inflammat...
©sylvainchamberland.com
Cascade of Events Related to
Estrogen
• ↓Estrogen
✦ Inhibit fibrocartilage synthesis
✦ Promote cyto...
©sylvainchamberland.com
Is Estrogen Associated with Mandibular Condylar
Resorption? 

A Systematic Review
•Evidence was la...
©sylvainchamberland.com
Models of Degenerative TMJ Disease
•Direct mechanical trauma model
•Hypoxia reperfusion model
•Neu...
©sylvainchamberland.com
Mechanical Loading &
Joint Cartilage
• Mechanical load of TMJ : essential to maintain its mass and...
©sylvainchamberland.com
1. Bruxism-clenching
2. Disc displacement
3. Joint anatomy_Pre-existing condition
4. Macrotrauma
1...
©Sylvain Chamberland
Sequella of a mechanical stress to TMJ
Bone resorption
Mechanical stress
(compression or luxation)
Ph...
©sylvainchamberland.com
Pathophysiology Concept of the
Process of Cartilage breakdown
Tanaka E., Detamore M.S., Mercuri L....
©sylvainchamberland.com
Susceptibility to Condylar Resorption
• Strong female predilection
• Hormonal imbalance (↓estrogen...
©sylvainchamberland.com
Condylar Resorption Result of TMJ
Inflammation
•Inflammation = ∑ Joint compression + Systemic
overla...
©sylvainchamberland.com
Understanding TMJ
Arthritis
•OA changes observed in this study consisted of flattening of
the later...
©sylvainchamberland.com
Understanding TMJ
arthritis
•OA pathology has evolved from a disease of cartilage to a disease of ...
©sylvainchamberland.com
• Initial stage
✦ Flattening of anterior surface +
cortical thickening (sclerosis)in
loading area
...
©sylvainchamberland.com
• Advance stage
✦ Non reducing displaced disc
✓ Pain, limited open + cessation of a clicking
✓ DD ...
©sylvainchamberland.com
• Late stage
✦ Formation of osteophytes
✦ Impaction of synovial fluid
through un-corticated surface...
©sylvainchamberland.com
Normal Mandibular Growth
•Disc Displacement reducing or
non-reducing associated with
interruption ...
©sylvainchamberland.com
Disc Displacement or Joint
Degenaration?
•I have reasonable doubt that disc
displacement is at fau...
©sylvainchamberland.com
Sustained Inflammation Induces Degeneration 

of the Temporomandibular Joint
•The synovium in induc...
©sylvainchamberland.com
Deterioration of Mechanical Properties of
Discs in Chronically Inflamed TMJProperties of Discs in C...
©sylvainchamberland.com
Osteoarthritis of the Temporomandibular Joint
Organ and Its Relationship to Disc Displacement
•Dev...
©sylvainchamberland.com
Class II Subdivision Left
ArOu15-07-2014
ArOu24-11-2014
ArOu24-10-2016
10y 10m
11y 3m
13y 2m
©sylvainchamberland.com
•Class II correction was achieved with Cl II elastics up to june 2016 but relapse was noted at the...
©sylvainchamberland.com
What Can We Find Retrospectively?
•Shorter
condylar neck
on the left
ArOu15-07-2014
10y 10m
©sylvainchamberland.com
What Can We Find Retrospectively?
•At Debond
✦ Flattening of
both anterior
surface of the
condyles...
©sylvainchamberland.com
What Can We Find Retrospectively?
•Significant
Progressive
Condylar Resorption
•Normal jaw opening
...
©sylvainchamberland.com
©sylvainchamberland.com
Diagnostic of TMJ Degenerative
Changes
• Clinical history
• Noise (clicking, crepitus) present or ...
©sylvainchamberland.com
Diagnostic of TMJ degenerative
changes
• Difference RC/OC > 2 to 4 mm
✦ The functional shift is no...
©sylvainchamberland.com
Diagnostic of TMJ degenerative
changes
• Pain
✦ Arises from the soft tissues and masticatory muscl...
©sylvainchamberland.com
TMJ Rx Anatomy
•On a panogram, anterior surface is the lateral pole
Lateral
Pole
Articular
Surface...
©sylvainchamberland.com
Imaging Modalities Degenerative
Changes
• Panorexes (OPG):
• Readily available, 

easily performed...
©sylvainchamberland.com
Imaging Modalities
• TMJ tomograms, 

mouth open
 Me.Po. 0610
A-A.St-O-T. 0711
Medial
Pole
Lateral...
©sylvainchamberland.com
Deformed Condyle
• Anterosuperior tapering, anterior inferior
lipping, anterior flattening
• If gro...
©sylvainchamberland.com
Deformed Condyle
• Shorter PFH of 2,8 mm
• Reduced posterior alveolar height
✦ Mx of 1,2 mm post. ...
©sylvainchamberland.com
Deformed Condyle
• More retrognathic md of 2,6°
• Larger Wits of 3,4 mm
• Shorter Md diagonal (ArP...
©sylvainchamberland.com
•Anterior openbite
•Retrognathic Md
✦ SNB ➘ 3°
•Arched antegonial
notch
✦ Bone apposition
•Short R...
©sylvainchamberland.com
•Discrete deformed condyles
at 11 y
•Flattening of anterosuperior
surface of the condyles at 17 y
...
©sylvainchamberland.com
•1-Condylar resorption
•2- Left short ramus
•3- Arched antegonial
notch
•4- Compensatory bone
appo...
©sylvainchamberland.com
•Idem
•Tongue thrusting is a
consequence and not a cause of
the openbite
♀16a
©sylvainchamberland.com
Imaging Modalities
• CBCT 3D
• Limited ability to evaluate active vs old chronic
changes of arthri...
©sylvainchamberland.com
Imaging Modalities
• Magnetic Resonance Imaging:
✦ Assess articular structure: cartilage, bone, li...
©sylvainchamberland.com
Imaging Modalities
• Bone scan Tc-99
✦ Assess bone activity
✓ Growing or degenerative
✦ Assess infl...
©sylvainchamberland.com
Additional diagnostic aid
• Blood test mid-cycle
✦ Female
✓ Dosage of Estrogen & 17β-estradiol at ...
©sylvainchamberland.com
Management Options of TMJ
• Medical Management
• Orthodontics only
• Arthrocentesis and/or
Arthros...
©sylvainchamberland.com
Pharmacotherapy Used to Control
TMJ Arthritis
•Vit D and Ca Bone density
•C 500 mg and E 400 u Ant...
©sylvainchamberland.com
Pharmacotherapy 3
•Osteoarthritis
✦ Cytokines and/or MMPs inhibitors
✓ Doxycycline, Feldene, Simvi...
©sylvainchamberland.com
Prophylactic pharmacotherapy
• If a patient fits the criteria suspicion of ICR or POCR
✦ 30 days pr...
©sylvainchamberland.com
Prophylactic pharmacotherapy
• If they are symptomatic post op
✦ Pain, occlusal change, sign of ac...
©sylvainchamberland.com
Principles for Management of TMJ
Osteoarthritis
• Noninvasive management modalities
✦ Medications
...
©sylvainchamberland.com
Principles for Management of TMJ
Osteoarthritis
• Minimally invasive modalities
✦ Arthrocentesis
✓...
©sylvainchamberland.com
Temporomandibular Lavage VS
Nonsurgical Treatment for TMD
•Reduction of pain in intervention group...
©sylvainchamberland.com
Principles for Management of TMJ
Osteoarthritis
• Moderately invasive approach
✦ Splint therapy
✦ ...
©sylvainchamberland.com
Case Presentation
©sylvainchamberland.com
•Class I
•Anterior openbite
•Mandibular incisor crowding
ChOlGa220514
©sylvainchamberland.com
•Skeletal Hyperdivergent
•Short ramus
©sylvainchamberland.com
•Concavity of right TMJ anterosuperior
surface, flattening on the left joint
•Condylar resorption o...
©sylvainchamberland.com
ChOlGa030914
Mx: 3 segments .020x.020 cnt. Tomas Pin SD 6 mm, Elinks E3 P-4

Md: 2 segments .020x....
©sylvainchamberland.com
•Improvement of lip seal
•Counterclockwise rotation of
occlusal plane
•Bimax protusion:
✦ I decide...
©sylvainchamberland.com
•Intrusion of Mx and Md buccal
segment
•Counterclockwise rotation of
mandibular plane
©sylvainchamberland.com
ChOlGa310315
ChOlGa120515ChOlGa220615
ChOlGa140915
©sylvainchamberland.com
•FMA decrease 0,5°
•ANS-Me decrease 5,5 mm
•/1-MP decrease 99° to 87°
ChOlGa13-07-1216
©sylvainchamberland.com
•Significant intrusion
✦ Mx + Md molars
•Retraction of 1/ & /1
©sylvainchamberland.com
Outcome
•Tx time 117 weeks
ChOlGa13-10-1216
©sylvainchamberland.com
ChOlGa13-10-1216
©sylvainchamberland.com
Initial May 2014 Pre genio July. 2016
ChOlGa13-07-1216 ChOlGa13-10-1216
Final Oct. 2016
ChOlGa22-0...
©sylvainchamberland.com
©sylvainchamberland.com
Current Surgical Approach
•Wolford L.M., Arnett G.W. & Gunson M., Posnick J.C., Kaban L,
✦ Bimaxil...
©sylvainchamberland.com
Caution During Surgery
•Avoid to posteriorly incline proximal segment
(counterclockwise rotation)
...
©sylvainchamberland.com
Rigid Fixation & Proximal Segment
• Condylar torquing during fixation
• Posteriorization of the con...
©sylvainchamberland.com
Rigid Fixation & Proximal Segment
• Rigid fixations (screw RIF):
✦ No possible adjustment between p...
©sylvainchamberland.com
Maximize teeth in contact
• Control surgical compression
✦ Means that posterior teeth must be in c...
©sylvainchamberland.com
Consequences of postop
Openbite
•Control surgical compression
✦ Means that posterior teeth must be...
©sylvainchamberland.com
Why I don't like Posterior Openbite
after Orthognathic Surgery?
• Lack of posterior occlusion may
...
©sylvainchamberland.com
Disc Repositioning
Does it really work?
•Removal of hypertrophied bilaminar & synovial tissue
•Rep...
©sylvainchamberland.com
Disc Repositioning
Does it really work?
•Situations where disc repositioning with Mitek anchor has...
©sylvainchamberland.com
Disc Repositioning
3-Dimensional Quantitative Findings
•Patient without DD
✦ Condylar translationa...
©sylvainchamberland.com
©sylvainchamberland.com
Principles for Management of TMJ
Osteoarthritis
• Invasive surgical modalities
✦ Ortho treatment a...
©sylvainchamberland.com
• Ortho surgical treatment (years 1993-1995)
• Bimax surgery: clockwise rotation:
✦ Le Fort 1, BSS...
©sylvainchamberland.com
• Ortho treatment only, exo 4 Pm1
• Genioplasty only
• Note the possibility of posterior intrusion...
©sylvainchamberland.com
• No condyle before
• No condyle after
• But stable occlusion
LyBo93/ pre-ortho
LyBo97/ 2 years po...
©sylvainchamberland.com
Common denominator
• Hormonal aetiology probable
• Condyles were completely resorbed
©sylvainchamberland.com
Case
Presentation
•Had a bike accident at 10-11 y.
•Consult at 12-13.
Recommended to wait until 18...
©sylvainchamberland.com
•Class II div 1
•Vertical maxillary excess
•Anterior open bite
•Constricted maxilla
SaLa 22-10-13 ...
©sylvainchamberland.com
Pre op
SaLa060714 preop
Pre op
Post op
SaLa161214 post op
Surgeon: Dr Jean-Philipe Fréchette
©sylvainchamberland.com
• Mandible :
✦ Forward 9 mm
✦ Left Laterodeviation 1 mm
• Menton :
✦ Forward 4 mm
✦ Right Impactio...
©sylvainchamberland.com
Outcome
SaLa070415
Follow up at 2 y
©sylvainchamberland.com
Cascapedia
Gaspésie
©sylvainchamberland.com
Principles for Management of TMJ
Osteoarthritis
• Invasive surgical approach
✦ Autogenous hemiarth...
©sylvainchamberland.com
Autogenous
Hemiarthroplasty
•♀, 28 y.
•All conservatives tx were done: AINS,
myorelaxant Botox, ph...
©sylvainchamberland.com
©sylvainchamberland.com
• A limitation of jaw opening & unstable occlusion was noted postop
• Finishing with occlusal toot...
©sylvainchamberland.com
• Note flattening of the anterior
surface of the condylar head
La.Va.0107/ 14 a 3 m/ pré-ortho
• Pr...
©Dr Sylvain Chamberland
Initial
Pre surgery
End of ortho
2 y post ortho
• Retrospectively, would it be legitimate to extra...
©sylvainchamberland.com
Male Patient
• Cl II div 1. Md Laterodeviation to right
• COCR functional shift AP
• Bilateral con...
©sylvainchamberland.com
• Parafonction: clenching
• Rheumato: no systemic disorder
✦ Complete blood, sedimentation, protei...
©sylvainchamberland.com
Treatment Plan
• Occlusal splint therapy: 6 months
• Tx ortho
• June 2008 (pre-op): Scinti positiv...
©sylvainchamberland.com
• Functional Cl I
LuBo261007 préchir
LuBo161208 19a 6 m
Le Fort 1
OSMB
Genio
Surgeon: Dr Michel Fo...
©sylvainchamberland.com
• PCR Progressive 

postsurgical condylar

resorption
• Cant of the mandibular 

incisor occlusal ...
©sylvainchamberland.com
• Decreased ramus height:
condylar head & neck
• Pre existing condition: Active
during tx
LuBo0702...
©sylvainchamberland.com
•Post op
✦ Class I occlusion
✦ No condylar change
JoMa.10-09-07; 20 a 7 m
JoMa100907, 20 a 7m
•Bas...
©sylvainchamberland.com
•Follow up at 2 years
✦ Progressive bite opening noted 3
months post op
✦ Flattening of left condy...
©sylvainchamberland.com
Common Denominator
• They had condyles presurgery
• Inflammatory activity pre surgically in one cas...
©sylvainchamberland.com
•Pre surgery
JoMa 170913
JoMa.11-02-14; 2 sem post op
•2 weeks post surgery
✦Le Fort 1 superior re...
©sylvainchamberland.com
•Mx Impaction + counterclockwise rotation of occlusal
plane
•Increase chin-throat projection
JoMa0...
©sylvainchamberland.com
©sylvainchamberland.com
• Previous ortho treatment with bionator and fixed appliances (Oct
2008- Nov 2010)
• CRCO functiona...
©sylvainchamberland.com
•Left: Short condylar neck + flattening of the anterior surface
•Right: normal growth
•Left antegon...
©sylvainchamberland.com
•Slight cant of the occlusal plane in frontal view can be noted
✦ Sequela of lack of vertical grow...
©sylvainchamberland.com
•BSSO + Genio
•Note lack of vertical dentoalveolar height
in the left mandibular body, related to ...
©sylvainchamberland.com
Trauma
• Fall in a gym at age 11
• Kicking on the right side of the face
• Blockage + DD without r...
©sylvainchamberland.com
• Functional occlusion
• Right TMJ
✦ ??± similar???
MaPiBe290604, 15 a 1 m
©sylvainchamberland.com
• Left anterolateral openbite
✦ This open bite has manifested itself within 6 months post ortho
Ma...
©sylvainchamberland.com
• Progression during the following year
• Antegonial notch: adaptation to 

lack of right condylar...
©sylvainchamberland.com
• Follow up
✦ 6½ years post ortho
✓ Cortical layer appears normal
MaPiBe040112, 22 a 7 m
©sylvainchamberland.com
Principles for Management of TMJ
Osteoarthritis
• Salvage procedures— Total joint replacement
✦ Au...
A case to make you humble
©Dr Sylvain Chamberland
NaRo.01-05-11; 21 ans
Unilateral condylar resorption→ Controlateral open bite
NaRo.01-02-06; 16 an...
©Dr Sylvain Chamberland
• Pre retreatment











• Pre surgery
NaRo18112014
NaRo300414
©Dr Sylvain Chamberland
Initial Pré op Post op
©sylvainchamberland.com
•Initial et pre op
©sylvainchamberland.com
3D Surgical Planning
•Left elongation
•Right impaction
•Advancement 3 mm
•Left laterodeviation of ...
©sylvainchamberland.com
3D Surgical Planning
•Advancement 5,8 mm at
tip of incisors
©sylvainchamberland.com
•SNA increase 3°
•SNB increase 4 °
•Occlusal change 15,7° to 14, 6°
©sylvainchamberland.com
•Autogenous graft: piece of resected
ramus

•Costochondral graft
©Dr Sylvain Chamberland
©sylvainchamberland.com
•17 days postop
NaRo020215
©sylvainchamberland.com
1 m. post op 4 m. post op 9 m. post op
©sylvainchamberland.com
•Happy ending
NaRo120515
Follow up 5 mois (Oct15)
Amplitude 33 mm
©sylvainchamberland.com
2006 2009 2011
2014 2014 2015
©sylvainchamberland.com
©Dr Sylvain Chamberland
Case 6
©sylvainchamberland.com
• At 13 until 15 years old (may 04-June 06)
✦ Ortho tx: HG + Fixed app.
✦ Began oral contraceptive...
©sylvainchamberland.com
• Severe resorption in right TMJ, moderate in the left
• Note: her sister was recently diagnose of...
©sylvainchamberland.com
Bone scan Tc99
• Increased uptake in right
• Ratio right/left mean 0,79
• Ratio right/left maximum...
©sylvainchamberland.com
Medical & dental history
• MRI: DD w/o reduction left TMJ, DD W/R right. Both TMJ flattened + degen...
©sylvainchamberland.com
Tx Plan
• Genioplasty early into ortho treatment
• Total joint replacement
✦ Alloplastic
✦ Autogen...
©Dr Sylvain Chamberland
ArLa300812
ArLa280113
At 4 months: Genioplasty
©sylvainchamberland.com
• Resumed post surgical orthodontic care
ArLa080713
©sylvainchamberland.com
• Pre-surgery and graft
©sylvainchamberland.com
• Post surgery and graft
©sylvainchamberland.com
• Follow up rx 3 months post surgery
©Dr Sylvain Chamberland
Perioste 2-3 mm cartilage
©Dr Sylvain Chamberland
Fixation chain, costal graft is thin
Bone remodeling...
©Dr Sylvain Chamberland
©sylvainchamberland.com
•Classe I
•Asymptomatic
•Opening amplitude 29 mm
ArLa 280114
©sylvainchamberland.com
ArLa070715 2y postop
Jaw opening amplitude 30 mm
©sylvainchamberland.com
•Follow up 4 y post op. Very stable occlusion
•Coronoïd process likely limit jaw opening
ArLa07071...
©sylvainchamberland.com
Autogenous Tissue
•Advantages
✦ Available
✦ Adaptable?
✦ Heals?
✦ Predictable growth?
✦ Less expen...
©sylvainchamberland.com
Importance of vascularity
•Receptor site
✦ Must support revascularization and promote osteogenesis...
©sylvainchamberland.com
Importance of vascularity
•Despite screw/plate fixation, micromotion of these free grafts will
inva...
©sylvainchamberland.com
©sylvainchamberland.com
Principles for Management of
TMJ Osteoarthritis
• Salvage procedures— Total joint replacement
✦ Al...
Adult
Severe left condylar resorption
©sylvainchamberland.com
•Is it because of occlusion?

Of disk?
•Vertical growth has stopped around 10-12 y in left TMJ
✦ L...
©sylvainchamberland.com
•1-Condylar resorption
•2- left short ramus
•3- Arched left antegonial
notch
•4- Compensatory bone...
©sylvainchamberland.com
•Class III subdivision right
•Dentoalveolar compensation:
✦ Mx right constriction, left
expansion
...
©sylvainchamberland.com
•Tx plan
✦ Sarpe
✦ Bimaxillary jaw surgery
✦ Total joint replacement of left TMJ
©sylvainchamberland.com
Pre Surgery
•Mx dentoalveolar compensation are
corrected
ElKsa020215
©sylvainchamberland.com
•Note bone apposition at the left gonial angle and the arched
antegonial notched
©sylvainchamberland.com
3D Surgical Planning
©sylvainchamberland.com
Marking guide
Biomet Custom Joint Prothesis
©sylvainchamberland.com
Capsule articulaire et
disque
Guide de coupe du
condyle
Gabarit de coupe
©sylvainchamberland.com
1 month Post op
•Jaw opening amplitude 13 mm
•Temporal branche of VII nerve: Grade IV à V: moderat...
©sylvainchamberland.com
•Facial symmetry and class I occlusion achieved
ElKsa230615 37 a 8 m
©sylvainchamberland.com
•Counteclockwise rotation of occlusal plane
©sylvainchamberland.com
©sylvainchamberland.com
Alloplastic Replacement
•Advantages
✦ No donor site
✦ Conform to given anatomy
✦ Early physiothera...
©sylvainchamberland.com
•No sensitive or motrice loss of the eye, the eyebrow and forehead. Revovery 100%
•Resemblance to ...
©sylvainchamberland.com
Follow up at 2 y post surgery
ElKsa200317 39 a 5 m
Jaw opening= 44 mm
No deviation on opening
No p...
©sylvainchamberland.com
Commun denominator commun
•TMJ trauma: ischemia
•Disk displacement without reduction
•Adolescent 1...
©sylvainchamberland.com
Final Thoughts
•Facial asymmetry commonly involves TMJ pathology or disorders.
•Therefore, the TMJ...
©sylvainchamberland.com
Final Thoughts
•In conclusion, it is essential that TMJ osteoarthritis be presented as the patholo...
Merci
Merci
©sylvainchamberland.com
•drsylchamberland@videotron.ca
•sylvainchamberland.com
•418-847-1115
•Please like my FaceBook page...
©Dr Sylvain Chamberland
Condylar
Resorption
and Arthrosis of
the Joints
www.slideshare.net/sylvainchamberland
www.sylvainc...
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Condylar resorption and arthrosis of the joint (dgkfo)

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Publié le

To understand the pathophysiology of the arthrosis that lead to
condylar resorption.
To understand systemic, local and occlusal factors that may lead to condylar resorption.
To know the diagnostic test that are recommended.
To know how to adapt the treatment plan (surgical or nonsurgical) to patients with condylar resorption.
Case report of bilateral costochondral graft and alloplastic custom fit total joint replacement.

Publié dans : Santé & Médecine
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Condylar resorption and arthrosis of the joint (dgkfo)

  1. 1. Condylar Resorption and Arthrosis of the Joints Kieferorthopädie auf den Punkt gebracht 11. - 14. Oktober 2017 Wissenschaftliche Jahrestagung in Bonn Scientific Annual Meeting www.slideshare.net/sylvainchamberland www.sylvainchamberland.com Revised as of October 2017
  2. 2. ©sylvainchamberland.com 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 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
  3. 3. ©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
  4. 4. ©sylvainchamberland.com 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
  5. 5. ©sylvainchamberland.com 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
  6. 6. ©sylvainchamberland.com 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...
  7. 7. ©sylvainchamberland.com 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
  8. 8. ©sylvainchamberland.com 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
  9. 9. ©sylvainchamberland.com Cascade of Events Related to Estrogen • ↓Estrogen ✦ Inhibit fibrocartilage synthesis ✦ 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
  10. 10. ©sylvainchamberland.com 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
  11. 11. ©sylvainchamberland.com 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
  12. 12. ©sylvainchamberland.com 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. 451 Wadhwa S. ,Kapila S.,TMJ disorders: Future innovation in diagnostics and therapeutics, J. Dent. Educ. 2008, 72 (8), 930-947
  13. 13. ©sylvainchamberland.com 1. Bruxism-clenching 2. Disc displacement 3. Joint anatomy_Pre-existing condition 4. Macrotrauma 1. Female 2. 14-24 years old 3. Low estrogen (➡) 4. Systemic arthritis 5. Corticosteroids 6. Hyperprolactinemia 7. Hyperparathyroidism 8. LowVit D/Calcium ➡ Mandibular Retrusion A. Bite treatment causes condylar displacement B. Local influences C. Systemic Influences 1. Seating direction 2. Seating force 3. Treatment devices 4. General anesthesia 5. Intermaxillary fixation 6. Splints 7. Paramandibular connective tissue 8. 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
  14. 14. ©Sylvain Chamberland Sequella of a mechanical stress to TMJ Bone resorption Mechanical stress (compression or luxation) Physical disruption of molecules and cells Cell death Production of free radicals Impaired cellular functions Ischemia, impeded regional blood flow Release of inflammatory peptides Change in viscosity synovial fluid Degradation of hyaluronic acid by free radicals ↑Matrix degradation Inhibition of matrix synthesis Degradation of articular surface Arnett G.W. et al, Progressive mandibular retrusion-idiopathic condylar resorption. Part 1,AJODO 1996; 110:8-15
  15. 15. ©sylvainchamberland.com 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
  16. 16. ©sylvainchamberland.com 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
  17. 17. ©sylvainchamberland.com 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.
  18. 18. ©sylvainchamberland.com 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
  19. 19. ©sylvainchamberland.com 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
  20. 20. ©sylvainchamberland.com • 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
  21. 21. ©sylvainchamberland.com • 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 Hatcher D, CBCT (3D imaging): application for selected articular disorders and associated facial growth, monograph 46, Craniofacial Growth Series, 2008, p 125-145
  22. 22. ©sylvainchamberland.com • Late stage ✦ Formation of osteophytes ✦ Impaction of synovial fluid 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
  23. 23. ©sylvainchamberland.com 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. Hatcher D, CBCT (3D imaging): application for selected articular disorders and associated facial growth, monograph 46, Craniofacial Growth Series, 2008, p 125-145
  24. 24. ©sylvainchamberland.com 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 Hatcher D, CBCT (3D imaging): application for selected articular disorders and associated facial growth, monograph 46, Craniofacial Growth Series, 2008, p 125-145
  25. 25. ©sylvainchamberland.com 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.
  26. 26. ©sylvainchamberland.com Deterioration of Mechanical Properties of Discs in Chronically Inflamed TMJProperties 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.
  27. 27. ©sylvainchamberland.com 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
  28. 28. ©sylvainchamberland.com Class II Subdivision Left ArOu15-07-2014 ArOu24-11-2014 ArOu24-10-2016 10y 10m 11y 3m 13y 2m
  29. 29. ©sylvainchamberland.com •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
  30. 30. ©sylvainchamberland.com What Can We Find Retrospectively? •Shorter condylar neck on the left ArOu15-07-2014 10y 10m
  31. 31. ©sylvainchamberland.com 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
  32. 32. ©sylvainchamberland.com What Can We Find Retrospectively? •Significant Progressive Condylar Resorption •Normal jaw opening but dull pain at the joint •Referred to Oral Surgeon ✦ Refer to Rhumatologist ArOu03-07-2017 Juvenile Idiopathic Arthritis? Adolescent Internal CR? 13y 10m
  33. 33. ©sylvainchamberland.com
  34. 34. ©sylvainchamberland.com 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
  35. 35. ©sylvainchamberland.com 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; 83:66-75 MacNamara JA, Seligman DA, Okeson JP, Occlusion, orthognathic treatment and temporomandibular disorders:A review, 
 J Orofacial Pain, 1995; 9:73-90
  36. 36. ©sylvainchamberland.com 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: 296 http://jdr.sagepub.com/content/87/4/296
  37. 37. ©sylvainchamberland.com TMJ Rx Anatomy •On a panogram, anterior surface is the lateral pole Lateral Pole Articular Surface Medial Pole Goulet J-P. La topographie condylienne des ATM en radiographie panoramique.  J Dent Québec 22: 375-79, 1995.
  38. 38. ©sylvainchamberland.com 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
  39. 39. ©sylvainchamberland.com Imaging Modalities • TMJ tomograms, 
 mouth open
 Me.Po. 0610 A-A.St-O-T. 0711 Medial Pole Lateral Pole Zenith of
 articular surface Goulet J-P. La topographie condylienne des ATM en radiographie panoramique.  J Dent Québec 22: 375-79, 1995.
  40. 40. ©sylvainchamberland.com 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; 12,5y 43% male, 57% female
  41. 41. ©sylvainchamberland.com 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
  42. 42. ©sylvainchamberland.com 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
  43. 43. ©sylvainchamberland.com •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
  44. 44. ©sylvainchamberland.com •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
  45. 45. ©sylvainchamberland.com •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
  46. 46. ©sylvainchamberland.com •Idem •Tongue thrusting is a consequence and not a cause of the openbite ♀16a
  47. 47. ©sylvainchamberland.com 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
  48. 48. ©sylvainchamberland.com 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
  49. 49. ©sylvainchamberland.com 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 0,93 april 2009 Pre surg Left 1,01 0,91 Right 1,3 1,73 november 2010 Post surgLeft 1,26 1,68 symmetric hypermetabolism in 2010
  50. 50. ©sylvainchamberland.com 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
  51. 51. ©sylvainchamberland.com 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
  52. 52. ©sylvainchamberland.com 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.
  53. 53. ©sylvainchamberland.com 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
  54. 54. ©sylvainchamberland.com 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
  55. 55. ©sylvainchamberland.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
  56. 56. ©sylvainchamberland.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 overload Mercuri LG, Osteoarthritis, Osteoarthrosis and Idiopathic Condylar Resorption, Oral Maxillofacial Surg Clin N Am 2008 May;20(2): 169-183
  57. 57. ©sylvainchamberland.com Principles for Management of TMJ Osteoarthritis • 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 KitYeung 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 Courtoisie Dr Jean-Philipe Fréchette
  58. 58. ©sylvainchamberland.com 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 complication Bouchard C, Goulet JP, El-Ouazzani M, Turgeon AF. Temporomandibular Lavage Versus Nonsurgical Treatments for Temporomandibular Disorders: A Systema Meta-Analysis. J Oral Maxillofac Surg. 2017 Jul;75(7):1352-1362. doi: 10.1016/j.joms.2016.12.027. Epub 2017 Jan 4
  59. 59. ©sylvainchamberland.com Principles for Management of TMJ Osteoarthritis • Moderately invasive approach ✦ Splint therapy ✦ Nonsurgical orthodontic treatment ✓ Use of TAD for the vertical changes instead of surgery
  60. 60. ©sylvainchamberland.com Case Presentation
  61. 61. ©sylvainchamberland.com •Class I •Anterior openbite •Mandibular incisor crowding ChOlGa220514
  62. 62. ©sylvainchamberland.com •Skeletal Hyperdivergent •Short ramus
  63. 63. ©sylvainchamberland.com •Concavity of right TMJ anterosuperior surface, flattening on the left joint •Condylar resorption or arthrosis •Patient at risk…
  64. 64. ©sylvainchamberland.com ChOlGa030914 Mx: 3 segments .020x.020 cnt. Tomas Pin SD 6 mm, Elinks E3 P-4
 Md: 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
  65. 65. ©sylvainchamberland.com •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
  66. 66. ©sylvainchamberland.com •Intrusion of Mx and Md buccal segment •Counterclockwise rotation of mandibular plane
  67. 67. ©sylvainchamberland.com ChOlGa310315 ChOlGa120515ChOlGa220615 ChOlGa140915
  68. 68. ©sylvainchamberland.com •FMA decrease 0,5° •ANS-Me decrease 5,5 mm •/1-MP decrease 99° to 87° ChOlGa13-07-1216
  69. 69. ©sylvainchamberland.com •Significant intrusion ✦ Mx + Md molars •Retraction of 1/ & /1
  70. 70. ©sylvainchamberland.com Outcome •Tx time 117 weeks ChOlGa13-10-1216
  71. 71. ©sylvainchamberland.com ChOlGa13-10-1216
  72. 72. ©sylvainchamberland.com Initial May 2014 Pre genio July. 2016 ChOlGa13-07-1216 ChOlGa13-10-1216 Final Oct. 2016 ChOlGa22-05-1214
  73. 73. ©sylvainchamberland.com
  74. 74. ©sylvainchamberland.com 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
  75. 75. ©sylvainchamberland.com 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):85-90
 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. MUSCLE FORCES
  76. 76. ©sylvainchamberland.com 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
  77. 77. ©sylvainchamberland.com 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
  78. 78. ©sylvainchamberland.com 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
  79. 79. ©sylvainchamberland.com 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
  80. 80. ©sylvainchamberland.com 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 open Slight progressive 
 retrusion Condyle resorb
  81. 81. ©sylvainchamberland.com 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
  82. 82. ©sylvainchamberland.com 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
  83. 83. ©sylvainchamberland.com 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
  84. 84. ©sylvainchamberland.com
  85. 85. ©sylvainchamberland.com Principles for Management of TMJ Osteoarthritis • Invasive surgical modalities ✦ Ortho treatment and orthognathic surgery (mono or bimax) ✓ Clockwise rotation ✓ Counterclockwise rotation (Arnett, Wolford, Posnick), disk repositioning
  86. 86. ©sylvainchamberland.com • 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. Female 2. 14-24 years old 3. Estrogen ➡ 4. Systemic arthritis 5. Corticosteroid 6. Hyperprolactinemy 7. Hyperparathyroidism 8. Vit D/Calcium ➡ RCIA Tomo ChantalChLa150393 ChLa-10695
  87. 87. ©sylvainchamberland.com • 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
  88. 88. ©sylvainchamberland.com • No condyle before • No condyle after • But stable occlusion LyBo93/ pre-ortho LyBo97/ 2 years post-ortho Hormonal imbalance during pregnancy?
  89. 89. ©sylvainchamberland.com Common denominator • Hormonal aetiology probable • Condyles were completely resorbed
  90. 90. ©sylvainchamberland.com 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
  91. 91. ©sylvainchamberland.com •Class II div 1 •Vertical maxillary excess •Anterior open bite •Constricted maxilla SaLa 22-10-13 20 a 4 m
  92. 92. ©sylvainchamberland.com Pre op SaLa060714 preop Pre op Post op SaLa161214 post op Surgeon: Dr Jean-Philipe Fréchette
  93. 93. ©sylvainchamberland.com • 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
  94. 94. ©sylvainchamberland.com Outcome SaLa070415 Follow up at 2 y
  95. 95. ©sylvainchamberland.com Cascapedia Gaspésie
  96. 96. ©sylvainchamberland.com Principles for Management of TMJ Osteoarthritis • 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
  97. 97. ©sylvainchamberland.com 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
  98. 98. ©sylvainchamberland.com
  99. 99. ©sylvainchamberland.com • 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
  100. 100. ©sylvainchamberland.com • 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
  101. 101. ©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?
  102. 102. ©sylvainchamberland.com 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
  103. 103. ©sylvainchamberland.com • 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
  104. 104. ©sylvainchamberland.com 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
  105. 105. ©sylvainchamberland.com • Functional Cl I LuBo261007 préchir LuBo161208 19a 6 m Le Fort 1 OSMB Genio Surgeon: Dr Michel Fortin
  106. 106. ©sylvainchamberland.com • PCR Progressive 
 postsurgical condylar
 resorption • Cant of the mandibular 
 incisor occlusal plane to the left LuBo070211 21a 8 m LuBo070211
  107. 107. ©sylvainchamberland.com • Decreased ramus height: condylar head & neck • Pre existing condition: Active during tx LuBo070211; 2 ans post ortho LuBo070706 preortho
  108. 108. ©sylvainchamberland.com •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
  109. 109. ©sylvainchamberland.com •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
  110. 110. ©sylvainchamberland.com 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
  111. 111. ©sylvainchamberland.com •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
  112. 112. ©sylvainchamberland.com •Mx Impaction + counterclockwise rotation of occlusal plane •Increase chin-throat projection JoMa020914
  113. 113. ©sylvainchamberland.com
  114. 114. ©sylvainchamberland.com • 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
  115. 115. ©sylvainchamberland.com •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
  116. 116. ©sylvainchamberland.com •Slight cant of the occlusal plane in frontal view can be noted ✦ Sequela of lack of vertical growth of the left condyle
  117. 117. ©sylvainchamberland.com •BSSO + Genio •Note lack of vertical dentoalveolar height in the left mandibular body, related to lack of condylar growth
  118. 118. ©sylvainchamberland.com 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
  119. 119. ©sylvainchamberland.com • Functional occlusion • Right TMJ ✦ ??± similar??? MaPiBe290604, 15 a 1 m
  120. 120. ©sylvainchamberland.com • Left anterolateral openbite ✦ This open bite has manifested itself within 6 months post ortho MaPiBe151204, 15 a 6 m MaPiBe190207, 17 a 9 m
  121. 121. ©sylvainchamberland.com • Progression during the following year • Antegonial notch: adaptation to 
 lack of right condylar growth MaPiBe190207, 17 a 9 m MaPiBe140308, 18 a 9 m
  122. 122. ©sylvainchamberland.com • Follow up ✦ 6½ years post ortho ✓ Cortical layer appears normal MaPiBe040112, 22 a 7 m
  123. 123. ©sylvainchamberland.com Principles for Management of TMJ Osteoarthritis • 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)
  124. 124. A case to make you humble
  125. 125. ©Dr Sylvain Chamberland 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
  126. 126. ©Dr Sylvain Chamberland • Pre retreatment
 
 
 
 
 
 • Pre surgery NaRo18112014 NaRo300414
  127. 127. ©Dr Sylvain Chamberland Initial Pré op Post op
  128. 128. ©sylvainchamberland.com •Initial et pre op
  129. 129. ©sylvainchamberland.com 3D Surgical Planning •Left elongation •Right impaction •Advancement 3 mm •Left laterodeviation of 1 mm •Rotation 3° at the midline
  130. 130. ©sylvainchamberland.com 3D Surgical Planning •Advancement 5,8 mm at tip of incisors
  131. 131. ©sylvainchamberland.com •SNA increase 3° •SNB increase 4 ° •Occlusal change 15,7° to 14, 6°
  132. 132. ©sylvainchamberland.com •Autogenous graft: piece of resected ramus
 •Costochondral graft
  133. 133. ©Dr Sylvain Chamberland
  134. 134. ©sylvainchamberland.com •17 days postop NaRo020215
  135. 135. ©sylvainchamberland.com 1 m. post op 4 m. post op 9 m. post op
  136. 136. ©sylvainchamberland.com •Happy ending NaRo120515 Follow up 5 mois (Oct15) Amplitude 33 mm
  137. 137. ©sylvainchamberland.com 2006 2009 2011 2014 2014 2015
  138. 138. ©sylvainchamberland.com
  139. 139. ©Dr Sylvain Chamberland Case 6
  140. 140. ©sylvainchamberland.com • 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
  141. 141. ©sylvainchamberland.com • Severe resorption in right TMJ, moderate in the left • Note: her sister was recently diagnose of rheumatoid arthritis Mouth closed Mouth open
  142. 142. ©sylvainchamberland.com 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 Maxi mum Right 1,67 1,43 Sept 2011 Left 2,12 2,35
  143. 143. ©sylvainchamberland.com 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
  144. 144. ©sylvainchamberland.com 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 2.5 Incisors mx at A 3.6 2.5 1st Molar mx at 1 crown 3.6 2.5 Extraction mx at PNS 3.6 2.5 Expansion mx at 6 crown 3.6 2.5 Stripping md6 Left ost. 8.9 5.3 4.3 E-Space genioplasty 8.1 -0.0 md at 1 crown 8.2 1.3 Net Change Disclaimer: This presentation is a SIMULATION ONLY and is not intended to be a guarantee of the actual orthodontic or surgical results.
  145. 145. ©Dr Sylvain Chamberland ArLa300812 ArLa280113 At 4 months: Genioplasty
  146. 146. ©sylvainchamberland.com • Resumed post surgical orthodontic care ArLa080713
  147. 147. ©sylvainchamberland.com • Pre-surgery and graft
  148. 148. ©sylvainchamberland.com • Post surgery and graft
  149. 149. ©sylvainchamberland.com • Follow up rx 3 months post surgery
  150. 150. ©Dr Sylvain Chamberland Perioste 2-3 mm cartilage
  151. 151. ©Dr Sylvain Chamberland Fixation chain, costal graft is thin Bone remodeling...
  152. 152. ©Dr Sylvain Chamberland
  153. 153. ©sylvainchamberland.com •Classe I •Asymptomatic •Opening amplitude 29 mm ArLa 280114
  154. 154. ©sylvainchamberland.com ArLa070715 2y postop Jaw opening amplitude 30 mm
  155. 155. ©sylvainchamberland.com •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
  156. 156. ©sylvainchamberland.com 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 loading 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
  157. 157. ©sylvainchamberland.com 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
  158. 158. ©sylvainchamberland.com 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 ankylosis Mercuri LG: The Use of Alloplastic Prostheses for Temporomandibular Joint Reconstruction J Oral Maxillofac Surg 58:70, 2000 Courtesy Dr Louis Mercuri
  159. 159. ©sylvainchamberland.com
  160. 160. ©sylvainchamberland.com Principles for Management of TMJ Osteoarthritis • 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"
  161. 161. Adult Severe left condylar resorption
  162. 162. ©sylvainchamberland.com •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
  163. 163. ©sylvainchamberland.com •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
  164. 164. ©sylvainchamberland.com •Class III subdivision right •Dentoalveolar compensation: ✦ Mx right constriction, left expansion ElKsa190913 36a
  165. 165. ©sylvainchamberland.com •Tx plan ✦ Sarpe ✦ Bimaxillary jaw surgery ✦ Total joint replacement of left TMJ
  166. 166. ©sylvainchamberland.com Pre Surgery •Mx dentoalveolar compensation are corrected ElKsa020215
  167. 167. ©sylvainchamberland.com •Note bone apposition at the left gonial angle and the arched antegonial notched
  168. 168. ©sylvainchamberland.com 3D Surgical Planning
  169. 169. ©sylvainchamberland.com Marking guide Biomet Custom Joint Prothesis
  170. 170. ©sylvainchamberland.com Capsule articulaire et disque Guide de coupe du condyle Gabarit de coupe
  171. 171. ©sylvainchamberland.com 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
  172. 172. ©sylvainchamberland.com •Facial symmetry and class I occlusion achieved ElKsa230615 37 a 8 m
  173. 173. ©sylvainchamberland.com •Counteclockwise rotation of occlusal plane
  174. 174. ©sylvainchamberland.com
  175. 175. ©sylvainchamberland.com Alloplastic Replacement •Advantages ✦ No donor site ✦ Conform to given anatomy ✦ Early physiotherapy ✦ No susceptibility to systemic disease •Disadvantages ✦ Expensive ✦ Sensitivity ✦ Longevity ✦ Only adults? Courtesy Dr Louis Mercuri
  176. 176. ©sylvainchamberland.com •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
  177. 177. ©sylvainchamberland.com 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
  178. 178. ©sylvainchamberland.com Commun denominator commun •TMJ trauma: ischemia •Disk displacement without reduction •Adolescent 12-18 y •Dysfunctional remodeling→resorption
  179. 179. ©sylvainchamberland.com 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
  180. 180. ©sylvainchamberland.com 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
  181. 181. Merci Merci
  182. 182. ©sylvainchamberland.com •drsylchamberland@videotron.ca •sylvainchamberland.com •418-847-1115 •Please like my FaceBook page 
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  183. 183. ©Dr Sylvain Chamberland Condylar Resorption and Arthrosis of the Joints www.slideshare.net/sylvainchamberland www.sylvainchamberland.com Revised as of November 2015

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