Condylar resorption and arthrosis of the joint (dgkfo)

Condylar Resorption
and Arthrosis of the Joints
Kieferorthopädie auf den Punkt gebracht
11. - 14. Oktober 2017
Wissenschaftliche Jahrestagung in Bonn
Scientiﬁc Annual Meeting
www.slideshare.net/sylvainchamberland
www.sylvainchamberland.com
Revised as of October 2017

©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

Contemporary Findings on TMDs &
Clinical Management
• Sexual dismorphism M/F in the presence of oestrogen  
receptors and age distribution of TMJD
• Evidence that sex-based determinants (estr., prog.,  
relaxin) may make an individual susceptible to  
degenerative TMJ disease
✦ Association between facial pain associated with TMD and exogenous
estrogen (HRT) or the use of oral contraceptive
✦ Pregnancy & menstrual cycle study suggest that in women who have TMD,
high pain is associated with low levels of estradiol
Kapila S. p. 289, LeResche p.113-115, Monography #46, CFG series

Idiopathic Condylar Resorption in
Teenage Girls
• Most common TMD in adolescent (9F :1M)
• Begin during pubertal growth phase (age range from 10 to 40)
★ Females hormones stimulates hyperplasia of the synovial tissues ➔produce chemical substrates that
destroy the ligaments that normally stabilize the disc to the condyle➔ disc displace anteriorly (Larry
Wolford)
• Affect condyles bilaterally and symmetrically
• Progressive mandibular retrusion followed by period of remission until the entire condylar head is
resorbed
• Other reports say: No consistent or proven aetiology
✦ Disc luxation without reduction, general joint hypermobility
✦ Trauma, parafonctional activity, ↓estrogen

AICR: clinical characteristics
• Teenage female, age of onset 11 to 15 y
• High occlusal plane and mandibular plane angle
• Predominant cl II skeletal & dental relationship  
with or without open bite
✦ Rarely occurs in hypodivergent or cl III patients
✓ This may contradict the “lack of oestrogen theory”
• TMJ symptoms: clicking, popping, TMJ pain, headaches, myofascial pain,
earaches, tinnitus, vertigo; no other joint are involved

According to L.M. 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
✦ Normal function of TMJs without signiﬁcant pain or loss of jaw
opening amplitude

Estrogen Role
• 17β-estradiol
✦ Down-regulation (↓ ) MMPs transcription
✦ ↓ cytokines and inﬂammatory markers
✦ ↓ bone loss in women
• Ethinyl Estradiol (contraceptive pills or postmenopause hormonotherapy)
✦ Suppress production of naturally occurring 17β-estradiol
✦ ↑ osteoclast activity & ↑ inﬂammatory cytokines production
Gunson MJ,Arnett G.W. et al, Oral contraceptive pill use and abnormal menstrual cycles with severe condylar resorption:A case for low serum 17β-estradiol as a major factor in PCR,AJODO 2009; 136:772-9

Cascade of Events Related to
Estrogen
• ↓Estrogen
✦ Inhibit ﬁbrocartilage synthesis
✦ Promote cytokines production
✓ Matrix degradation enzymes MMP
✦ Bone loss
✓ Progressive mandibular retrusion
Arnett G.W. et al, Progressive mandibular retrusion-idiopathic condylar resorption. Part 1,AJODO 1996; 110:8-15

Is Estrogen Associated with Mandibular Condylar
Resorption?  
A Systematic Review
•Evidence was lacking that estrogen deficiency contributes to mandibular condylar resorption
since this relationship was based on limited studies.
•Recommendations:
✦ Further investigations on serum estrogen concentrations in women with condylar resorption
are needed.
✦ Future studies should focus on the effects of the different types of medication and diseases
influencing estrogen concentrations,
✦ The utility of estrogen concentrations during preoperative screening, and the policies for
managing orthognathic surgery patients with an estrogen deficiency.
✦ Are the mechanisms and risk factors that lead to idiopathic condylar resorption the same?
Nicolielo LFP, et al. Int . Oral Maxillofac Surg.doi.org/10.1016/j.ijom.2017.06.012 Coutesy Dr Louis Mercuri

Models of Degenerative TMJ Disease
•Direct mechanical trauma model
•Hypoxia reperfusion model
•Neurogenic inﬂammation model
Milan SB, Pathogenesis of degenerative temporomandibular joint arthritides, Odontology, September 2005, Volume 93, Issue 1, pp 7–15

Mechanical Loading &
Joint Cartilage
• Mechanical load of TMJ : essential to maintain its mass and integrity
✦ Adaptation to normal muscular force and  
orthopaedic traction
✦ Dentofacial orthopaedic appliance : ↑proliferation &
chondrocytes maturation
• Decreased loading→decreased of ﬁbrocartilage
• If thinning layer of ﬁbrocartilage: TMJ more prone to osteoarthrosis
Chen et al,Altered temporomandibular joint loading, monography #46, CFGS p. 451
Wadhwa S. ,Kapila S.,TMJ disorders: Future innovation in diagnostics and therapeutics, J. Dent. Educ. 2008, 72 (8), 930-947

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

©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

Pathophysiology Concept of the
Process of Cartilage breakdown
Tanaka E., Detamore M.S., Mercuri L.G. Degenerative disorders of the temporomandibular joint: Etiology, diagnosis and treatment, J Dent
Res 2008; 87:296-307
Kapila S, Current and future innovations in diagnosis and therapeutics of TMJ
diseases, Monograph 46, Craniofacial growth series 2008
• Loss of matrix molecules
• Inability to sustain function
• Degenerative joint disease
Hormones or
other agents

Susceptibility to Condylar Resorption
• Strong female predilection
• Hormonal imbalance (↓estrogen, ↓17β-estradiol)
• Nutritional status(↓ Vit D, ↓Omega-3)
• Bruxism and repetitive oral habits
✦ Free radical generation through sheer stress and increased metabolic demands
• Iatrogenic causes:
✦ Orthognathic surgery, intermaxillary ﬁxation, improper occlusal splint.
✓ All condylar change or displacement through compression

Condylar Resorption Result of TMJ
Inflammation
•Inflammation = ∑ Joint compression + Systemic
overlay
•Systemic factor : illnesses, hormonal imbalance, age
& gender
✦ Upmodulate systemic inflammation which
upmodulate resorption
•Compression= ∑ Parafunction, condylar displacement,
internal derangement, isolated macrotrauma
Arnett G.W., Gunson M.J., Risk Factors in the Initiation of Condylar Resorption, Semin Orthod 2013;19:81-88.

Understanding TMJ
Arthritis
•OA changes observed in this study consisted of flattening of
the lateral pole and bony projections in the anterior
condylar surface, at initial diagnosis and significantly more
marked at long-term diagnosis.
Cevidanes L. H. S., Gomes L. R., Jung B. T., Gomes M. R., Ruellas A. C.O., Goncalves J. R., Schilling J., Styner M., Nguyen T., Kapila S., Paniagua B.  
3D superimposition and understanding temporomandibular joint arthritis, Orthod Craniofac Res 2015; 18(Suppl.1): 18–28
Cevidanes et al, Quantification of condylar resorption in temporomandibular joint osteoarthritis, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:110-117)
Cevidanes et al, Condylar resorption in patients with TMD, monograph 46, Cranifacial Growth Series, 2008, p 147-157

Understanding TMJ
arthritis
•OA pathology has evolved from a disease of cartilage to a disease of the entire joint and the
multiple biological systems that interact with one another in this disease.
•The cross-talk that occurs between the components of the joint, which takes place over years,
results in degradation of the articular cartilage and disk, bony changes, synovial proliferation,
muscle and tendon weakness, and fatigue.
•The TMJ condyle is the site of numerous dynamic morphologic transformations in the initiation/
progression of OA, which are not merely manifestations secondary to cartilage degradation.
Thus, a strong rationale exists for therapeutic approaches that target bone resorption and
formation and take into account the complex cross-talk between all of the joint tissues.
Cevidanes L. H. S., Gomes L. R., Jung B. T., Gomes M. R., Ruellas A. C.O., Goncalves J. R., Schilling J., Styner M., Nguyen T., Kapila S., Paniagua B.  
3D superimposition and understanding temporomandibular joint arthritis Orthod Craniofac Res 2015; 18(Suppl.1): 18–28
Cevidanes et al, Quantiﬁcation of condylar resorption in temporomandibular joint osteoarthritis, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:110-117)
Cevidanes et al, Condylar resorption in patients with TMD, monograph 46, Cranifacial Growth Series, 2008, p 147-157

• Initial stage
✦ Flattening of anterior surface +
cortical thickening (sclerosis)in
loading area
✦ Early soft tissue change ( tissue
thinning, ↓proteoglycans)
✦ Deformed condyle may favour
anteriorly displaced disc
Hatcher D, CBCT (3D imaging): application for selected articular disorders and associated
facial growth, monograph 46, Craniofacial Growth Series, 2008, p 125-145

• Advance stage
✦ Non reducing displaced disc
✓ Pain, limited open + cessation of a clicking
✓ DD may be a risk factor for onset of DJD,
but it is likely the effect of degenerative
change
✦ Erosive lesion progressing to be cavitation
defects, ﬂattening of articular surface + re-
cortication

• Late stage
✦ Formation of osteophytes
✦ Impaction of synovial ﬂuid
through un-corticated surface →
sub-chondral bone cyst

Normal Mandibular Growth
•Disc Displacement reducing or
non-reducing associated with
interruption in mandibular growth
•The earlier the onset and severity of
DJD have a proportional
relationship with the severity of md
growth defect
•DJD is self-limiting process and
despite progression, there is a point
of remission and stability (no
evolution.
•Signs and symptoms reduce to
level associated with normal.

Disc Displacement or Joint
Degenaration?
•I have reasonable doubt that disc
displacement is at fault in the beginning
(onset)
•I would say that there are some change in
morphology, deformed condyle, related to
some trauma or inﬂammation or
osteoarthrosis that lead to disc
displacement and then contribute to maintain
inﬂammation that impaired normal growth
•Disc Displacement reducing or non-reducing
associated with interruption in mandibular growth

Sustained Inflammation Induces Degeneration  
of the Temporomandibular Joint
•The synovium in induced inflammation group showed marked infiltration
of mono-nucleated cells and accumulated sub-synovial adipose tissue.
•Both the disc and synovium had significantly higher iNOS and IL-1β
mRNA expression than controls.
•Conclusion:
✦ These findings are consistent with our hypothesis that sustained TMJ
inflammation may be a predisposing factor for structural
abnormalities.
Wang XD, Kou XX, et al.Sustained inflammation induces degeneration of the temporomandibular joint. J Dent Res.
2012 May;91(5):499-505. doi: 10.1177/0022034512441946. Epub 2012 Mar 15.

Deterioration of Mechanical Properties of
Discs in Chronically Inflamed 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.

Osteoarthritis of the Temporomandibular Joint
Organ and Its Relationship to Disc Displacement
•Development of as well as recovery from disease appears to be
intimately related to exceeding and supporting the adaptive
capacity of the tissues that make up the joint organ.
•Loss of fibrocartilage and inflammation appear to be major
pathobiologic processes,
✦ while serious doubts exist about the significance of disc position in
joint pathology.
Stegenga B. J Orofac Pain 2001. 15:193-205.
Courtesy Dr Louis Mercuri

Class II Subdivision Left
ArOu15-07-2014
ArOu24-11-2014
ArOu24-10-2016
10y 10m
11y 3m
13y 2m

•Class II correction was achieved with Cl II elastics up to june 2016 but relapse was noted at the following rendez-vous
•Twin Force bite corrected were placed
✦ Came back within 3 weeks with pain. Removal of TFBC.
✦ Left disk luxation without reduction is noted with limited jaw opening. Pr: Ibuprofen 400mg 1 co q4hX 4jrs + 1 co
q6h X 3 jrs
✦ Sent to physiotherapy. Came back with normal jaw opening 45 mm. No pain.
✦ New close lock, Pain at 32 mm jaw opening. More physio.
•Normal jaw opening at recall in January 2017 + some loss of OB
•Open bite noted in July 2017
ArOu24-10-2016 ArOu17-01-2017 ArOu03-07-2017
13y 2m 13y 4m 13y 10m

What Can We Find Retrospectively?
•Shorter
condylar neck
on the left
ArOu15-07-2014
10y 10m

•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

•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

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

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

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

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.

Imaging Modalities Degenerative
Changes
• Panorexes (OPG):
• Readily available,  
easily performed, low cost
✦ ∆ TMJ shape
✓ Flattening of the anterior  
surface of the condyle
✓ ∆ size
✓ ∆ articular eminence shape
• Sensitivity 97%; speciﬁcity 45%
✓ Low speciﬁcity = Large number of false-positive
Me.Po. 0610
Jo.Ma. 0907
Ma.La.Br.La.0410
Al.Be. 0810
D.D.N.-R.
Shintaku WH et al, Imaging modalities
to access bony tumors and hyperplastic
reaction of the TMJ, JOMS
68:1911-1921, 2010

Imaging Modalities
• TMJ tomograms,  
mouth open  Me.Po. 0610
A-A.St-O-T. 0711
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.

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

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)
T0= 135 sujets; 12,5y

Deformed Condyle
• More retrognathic md of 2,6°
• Larger Wits of 3,4 mm
• Shorter Md diagonal (ArPg): -4,5mm
• Antegonial notch shifted dorsally
✦ Massive done deposition in that area
• Partial Md growth arrest of some 50% its average growth potential.
T20= 56 sujets; 31,9y

•Anterior openbite
•Retrognathic Md
✦ SNB ➘ 3°
•Arched antegonial
notch
✦ Bone apposition
•Short Ramus  
(➘ condylar growth)
♂ 9a 8m ♂ 17a 5m
Tongue thrusting is not the cause
of the open bite, but the
consequence
Longitudinal observation
of a patient

•Discrete deformed condyles
at 11 y
•Flattening of anterosuperior
surface of the condyles at 17 y
✦ Default or diminution of
growth potential (OA?)
•Compensatory bone
apposition at gonial angle
✦ Arched antegonial notch
♂ 11a 2m
♂ 17a 5m
Longitudinal Observation
of a patient

•1-Condylar resorption
•2- Left short ramus
•3- Arched antegonial
notch
•4- Compensatory bone
•5- Decreased lateral
mandibular growth of the
affected side
♀36a
5

•Idem
•Tongue thrusting is a
consequence and not a cause of
the openbite
♀16a

Imaging Modalities
• CBCT 3D
• Limited ability to evaluate active vs old chronic
changes of arthritis and soft tissue changes
✦ Condyle assessment
✓ Speciﬁcity 100%
✓ Sensitivity 80%
✦ Dose effective & cost effective for  
evaluation of osseous abnormalities
N.R. 17-10-11
Mouth open
A-A.St-O-T. 16-08-01
Mouth closed

Imaging Modalities
• Magnetic Resonance Imaging:
✦ Assess articular structure: cartilage, bone, ligaments, tendons, synovium, tendon sheats
✦ Allows for qualitative & quantitative evaluation for presence or status of synovitis and its sequelae
✓ bone marrow edema,synovial enhancement, synovial thickening, erosions,effusions, cartilage
damage, articular disc involvement, and ligamentous involvement
• Gold Standard for evaluation of inflammatory arthritis
• Disk displacements & osteoarthritis = 30% of asymptomatics volunteers
• Difficult to consistently relate MRI findings (bone oedema, joint effusion,
synovitis) to joint pain
• MRI sensitivity =78%; predictive value =54%
Reducing disc
displacement
Non-reducing
disc displacement
Non-reducing
disc displacement
&
Severe 
Osteoarthrosis
Larheim TA et al, Clinical significance of changes in the
bone marrow and intra-articular soft tissues of the
temporomandibular joint, Sem Ortho 2012;18:30-43
Tanaka E, Detaore MS, Mercuri LG Degenerative disorders of the
TMJ: etiology, diagnosis and treatment, J Dent Res 2008 87:296, fig1

Imaging Modalities
• Bone scan Tc-99
✦ Assess bone activity
✓ Growing or degenerative
✦ Assess inflammatory status
✦ Insufficient specificity to assess  
state of stability/remission
Jo.Ma.
Mean Maximum
Right 1,02 0,93
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

Additional diagnostic aid
• Blood test mid-cycle
✦ Female
✓ Dosage of Estrogen & 17β-estradiol at start and mid-cycle, FSH, LH, Vit D
✦ Men
✓ DHEA-S, cortisol, Vit D, % free testosterone
✦ Level of rheumatoid factor, antinuclear antibodies and anti CCP
✦ Inﬂammatory status, protein C reactive

Management Options of TMJ
• Medical Management
• Orthodontics only
• Arthrocentesis and/or
Arthroscopic Surgery
• Orthodontics & Orthognathic
Surgery ± disc repositioning
• Arthrotomy, condylar shave/
disc repositioning
• Distraction
• Autogenous TMJ
Reconstruction
• Alloplastic TMJ Replacement
• Nothing

Pharmacotherapy Used to Control
TMJ Arthritis
•Vit D and Ca Bone density
•C 500 mg and E 400 u Antioxidants
•Celebrex, 100 mg Anti-inflammatory, MMP, cytokine inhibitor
•Omega-3 fatty acid 2-4 G Potent antioxidant
•Doxycycline, 50-100 mg Anti-inflammatory, MMP, cytokine inhibitor
•Feldene, 10-20 mg Anti-inflammatory, MMP, cytokine inhibitor
•Simvastatin, 20 mg Anti-inflammatory, MMP, cytokine inhibitor
•Amitriptyline, 5-15 mg Antibruxism, mm relax
•Klonapin, 0.5-1 mg Antibruxism
•Tiagabine, 2-4 mg Antibruxism
•Botox injection, 36-48 u Antibruxism
•Simvistatin, 20 mg Autoimmune inhibitor
•17-Estradiol, variable Potent anti-inflammatory
•Etanercept, 50 mg q week TNF- inhibitor
•Adalimumab, 40 mg q 2 weeks TNF- inhibitor
Arnett G.W., Gunson M.J., Risk Factors in the Initiation of Condylar Resorption, Semin Orthod 2013;19:81-88.

Pharmacotherapy 3
•Osteoarthritis
✦ Cytokines and/or MMPs inhibitors
✓ Doxycycline, Feldene, Simvistatin
✦ Free radical inhibitors
✓ Vit C, Vit E, fat acid omega 3
✦ Anabolic bone metabolism facilitator
✓ Vit D, Ca2+, 17β estradiol
✦ Parafonction inhibitors
✓ Amitriptyline, Tiagabine, Klonopin,
Botox
•Auto-immune arthritides
✦ Auto-immune inhibitor
✓ Methotrexate, Enbrel, Simvistatin
•Gunson MJ,Arnett GW, Milam SB, Pathophysiology and Pharmacologic Control of
Osseous Mandibular Condylar Resorption J Oral Maxillofac Surg 2011, october,
•AAO meeting, Boston 2009
TNFα
What looks like
such condyle?
There is no condyle!
It's a stump

Prophylactic pharmacotherapy
• If a patient fits the criteria suspicion of ICR or POCR
✦ 30 days pre-op and starting 14 days post op
✓ Calcium carbonate (CaCo) 500 mg/day + 1000 IU of Vit D3
(Vit D supplementation)
‣ Vitamin D supplementation (2000 IU/day) in patient with systemic lupus erythematous is recommendated because increased vitamin
D levels seem to ameliorate inflammatory and hemostatic markers and show a tendency toward subsequent clinical improvement.  
Abou-Raya A et al The Effect of Vitamin D Supplementation on Inflammatory and Hemostatic Markers and Disease Activity in Patients with Systemic Lupus Erythematosus: A Randomized Placebo-controlled Trial J Rheumatol
published 1 December 2012, 10.3899/jrheum.111594
✓ Celebrex 200mg id, (or bid if over 70kg)
Courtesy Dr Marco Caminiti, crescentoralsurgery.com

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

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

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

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

Osteoarthritis
• Moderately invasive approach
✦ Splint therapy
✦ Nonsurgical orthodontic treatment
✓ Use of TAD for the vertical changes instead of surgery

Case Presentation

•Class I
•Anterior openbite
•Mandibular incisor crowding
ChOlGa220514

•Skeletal Hyperdivergent
•Short ramus

•Concavity of right TMJ anterosuperior
surface, ﬂattening on the left joint
•Condylar resorption or arthrosis
•Patient at risk…

ChOlGa030914
Mx: 3 segments .020x.020 cnt. Tomas Pin SD 6 mm, Elinks E3 P-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

•Improvement of lip seal
•Counterclockwise rotation of
occlusal plane
•Bimax protusion:
✦ I decided to extract all 5s
January 2015
May 2014
January 2015May 2014 March 2015

•Intrusion of Mx and Md buccal
segment
•Counterclockwise rotation of
mandibular plane

ChOlGa310315
ChOlGa120515ChOlGa220615
ChOlGa140915

•FMA decrease 0,5°
•ANS-Me decrease 5,5 mm
•/1-MP decrease 99° to 87°
ChOlGa13-07-1216

•Signiﬁcant intrusion
✦ Mx + Md molars
•Retraction of 1/ & /1

Outcome
•Tx time 117 weeks
ChOlGa13-10-1216

ChOlGa13-10-1216

Initial May 2014 Pre genio July. 2016
ChOlGa13-07-1216 ChOlGa13-10-1216
Final Oct. 2016
ChOlGa22-05-1214

Current Surgical Approach
•Wolford L.M., Arnett G.W. & Gunson M., Posnick J.C., Kaban L,
✦ Bimaxillary Osteotomy (Le Fort 1 + BSSO + genio prn)+ counterclockwise rotation
✓ Wolford L.M.
‣ Disc repositionning + mitek ligature
✓ Arnett G.W. & Gunson M.
‣ Cocktail of drugs
✓ Kaban L.
‣ Occlusal splint, myorelaxant, AINS, follow up with bone scan and no rx change for 2 years
before surgery

Caution During Surgery
•Avoid to posteriorly incline proximal segment
(counterclockwise rotation)
✦ When the condylar neck is posteriorly inclined (per-op),
the anatomically less dense, preoperatively unloaded
anterior-superior surface of the condyle is subjected to
increased loading following surgery due to an increase
in soft tissue tension and rotation of the condyle.
Hwang SJ, Haers Pe, and Sailer HF.The role of a posteriorly inlcined condylar neck in condylar resorption after orthognathic surgery. J
Craniomaxillafac Surg 2000; 28 (2):85-90 
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

Rigid Fixation & Proximal Segment
• Condylar torquing during ﬁxation
• Posteriorization of the condyle in the fossa
✦ Could favour anterior disc displacement, a disc
compression or an hypomobility (protective
muscular spasm)
• Dysfunctional remodelling in susceptible patients
Arnett GW, Progressive mandibular retrusion-idiopathic condylar resorption. Part II, AJODO, 1996, 110:117-127

Rigid Fixation & Proximal Segment
• Rigid fixations (screw RIF):
✦ No possible adjustment between proximal and
distal segments
• Wire fixated osteotomies
✦ Possible adjustment in the early stage of
healing
• Ellis: experimentation on animal models confirm
these observation
Arnett GW, Progressive mandibular retrusion-idiopathic condylar resorption. Part II, AJODO, 1996, 110:117-127

Maximize teeth in contact
• Control surgical compression
✦ Means that posterior teeth must be in contact post-op.
• Neutral rigid ﬁxation
• Early mobilization
• Class II elastics
• Cocktail of drugs (pills medicines)
Arnett GW, AAO meeting Boston 2009

Consequences of postop
Openbite
•Control surgical compression
✦ Means that posterior teeth must be in contact post-
op.
✦ It is not "having a post-op posterior open bite”
Ma-EMa 18-3-14
Arnett GW, AAO meeting Boston 2009

Why I don't like Posterior Openbite
after Orthognathic Surgery?
• Lack of posterior occlusion may
increase pressure at the condyle
and cause non-physiologic
remodelling or condylar resorption
Jam-packedScrewed Setting  
occlusion
Pressure
The bite open
Slight progressive  
retrusion
Condyle resorb

Disc Repositioning
Does it really work?
•Removal of hypertrophied bilaminar & synovial tissue
•Repositioning & stabilization of the articular disc to
the condyle with the Mitek anchor
•Bimaxillary surgery + counterclockwise rotation
✦ Le Fort 1
✦ BSSO + genio prn
•91% success rate
Goçalves, João Roberto, Daniel Serra Cassano, Luciano Rezende, and Larry M Wolford. "Disc Repositioning: Does It Really Work?" Oral Maxillofac
Surg Clin North Am 27, no. 1 (2015): doi:10.1016/j.coms.2014.09.007
Wolford LM, Concomitant TMJ and orthognathic surgery. JOMS 61: 1198-1204, 2003
Wolford LM Dhameja A, Planning for Combined TMJ Arthroplasty and Orthognathic SurgeryAtlas Oral Maxfacial Surgery Clin N Am 19 (2011) 243-270

Disc Repositioning
Does it really work?
•Situations where disc repositioning with Mitek anchor has high
success rate
✦ Disc repositioning at the onset of displacement within 4 years of
displacement provides the greatest predictability of outcome.
✦ Adolescent internal condylar resorption patients who are treated
within the first 4 years of disease onset
✦ No significant intracapsular inflammation, especially in the
bilaminar tissues
✦ Good remaining anatomy of the disc.
✓ Young patients with Intact well-shaped disc
Wolford LM, Concomitant TMJ and orthognathic surgery. JOMS 61: 1198-1204, 2003
Wolford LM Dhameja A, Planning for Combined TMJ Arthroplasty and Orthognathic SurgeryAtlas Oral Maxfacial Surgery Clin N Am 19 (2011) 243-270

Disc Repositioning
3-Dimensional Quantitative Findings
•Patient without DD
✦ Condylar translational displacement of at least 1,5
mm in posterior, superior or mediolateral direction
✦ 1 y post MMA,
•Patient with DD ➜ Mitek Disc repositioning
✦ Condylar displacement anterior, inferior and
mediolateral
✦ Bone apposition in anterior surface
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

Osteoarthritis
• Invasive surgical modalities
✦ Ortho treatment and orthognathic surgery (mono or bimax)
✓ Clockwise rotation
✓ Counterclockwise rotation (Arnett, Wolford, Posnick), disk
repositioning

• Ortho surgical treatment (years 1993-1995)
• Bimax surgery: clockwise rotation:
✦ Le Fort 1, BSSO, genio
•Nowadays it would be
✦ Counterclockwise rotation of occlusal plane
& posterior elongation
ChLa150393
17 ans
ChLa010695/ surgeon: Dr Denis Gagnon
1. 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

• Ortho treatment only, exo 4 Pm1
• Genioplasty only
• Note the possibility of posterior intrusion
LyBo 180693 LyBo 190396/ ~1 an post ortho
LyBo 0997/ ~2 ans post ortho
Resorption post pregnancy

• No condyle before
• No condyle after
• But stable occlusion
LyBo93/ pre-ortho
LyBo97/ 2 years post-ortho
Hormonal imbalance
during pregnancy?

Common denominator
• Hormonal aetiology probable
• Condyles were completely resorbed

Case
Presentation
•Had a bike accident at 10-11 y.
•Consult at 12-13.
Recommended to wait until 18y
SaLa 12-07-01 8 a
SaLa 22-10-13 20 a 4 m

•Class II div 1
•Vertical maxillary excess
•Anterior open bite
•Constricted maxilla
SaLa 22-10-13 20 a 4 m

Pre op
SaLa060714 preop
Pre op
Post op
SaLa161214 post op
Surgeon: Dr Jean-Philipe Fréchette

• Mandible :
✦ Forward 9 mm
✦ Left Laterodeviation 1 mm
• Menton :
✦ Forward 4 mm
✦ Right Impaction: 2 mm
✦ Laterodeviation to the right 4 mm
• Maxilla :
✦ Forward 6 mm
✦ Left Laterodeviation 2 m
✦ 5 mm Anterior Impaction & 2 mm
posterior
✦ Correction of occlusal plane
✦ Segmentation 17 à 14, 13 à 23 et 24 à
27

Outcome
SaLa070415
Follow up at 2 y

Cascapedia
Gaspésie

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

Autogenous
Hemiarthroplasty
•♀, 28 y.
•All conservatives tx were done: AINS,
myorelaxant Botox, physio
•Chronique pain right TMJ. Amplitude 28
mm
•MRI conﬁrm disk perforation.
•Surgery A.H at 32 y.
•Follow up: Pain free. Amplitude 37 mm
Perforated disk Discectomie
Flap is insertedTemporal ﬂap

• A limitation of jaw opening & unstable occlusion was noted postop
• Finishing with occlusal tooth equilibration & elastics
• Parafonction persisting (bruxism & sygmatism)
• Progressive open bite noted in retention: the surgeon is advised
La.Va.0109, end of ortho
La.Va.0311/ 2 ans post orthoLa.Va.0107/ 14 a 3 m/ pré-ortho

• Note ﬂattening of the anterior
surface of the condylar head
La.Va.0107/ 14 a 3 m/ pré-ortho
• Pre orthognathic surgery
✦ Remodelling noted in the right condyle
• Should have done bone scan
Tc99 presurg & pre ortho
• 2 years post ortho
✦ Remodelling +++
Surgeon: Dr Patrick Giroux
La.Va.0408/ pre-surg
La.Va.0311/2 y post tx

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

Male Patient
• Cl II div 1. Md Laterodeviation to right
• COCR functional shift AP
• Bilateral condylar resorption (R>L)
• Pain in right TMJ when eating, difﬁculty to open.
✦ Disc displacement with reduction in the right
LuBo070706 preortho; en RC
LuBo.17a.1 m.
LuBo070706 preortho

• Parafonction: clenching
• Rheumato: no systemic disorder
✦ Complete blood, sedimentation, protein C reactive =
normal
✦ Antinuclear factor normal, Rheumatoid factor negative
• November 2006: Scinti = negative pretreatment
• October 2007: Scinti = positive right TMJ, negative in left (the
orthodontist was never told!)
LuBo070706 préortho

Treatment Plan
• Occlusal splint therapy: 6 months
• Tx ortho
• June 2008 (pre-op): Scinti positive in right TMJ,  
negative in left . The orthodontist was never told!
• Surgery plan
✦ Le Fort 1: Posterior impaction
✦ Md: autorotation; genio only

• Functional Cl I
LuBo261007 préchir
LuBo161208 19a 6 m
Le Fort 1
OSMB
Genio
Surgeon: Dr Michel Fortin

• PCR Progressive  
postsurgical condylar 
resorption
• Cant of the mandibular  
incisor occlusal plane to the left
LuBo070211 21a 8 m
LuBo070211

• Decreased ramus height:
condylar head & neck
• Pre existing condition: Active
during tx
LuBo070211; 2 ans post ortho
LuBo070706 preortho

•Post op
✦ Class I occlusion
✦ No condylar change
JoMa.10-09-07; 20 a 7 m
JoMa100907, 20 a 7m
•Baseline
✦ Rhumato: negatif
✦ Bone scan: normal
JoMa.28-10-09; 22 a 8 m
JoMa.28-10-09; 22 a 8 m Chir: Dr Michel Fortin

•Follow up at 2 years
✦ Progressive bite opening noted 3
months post op
✦ Flattening of left condyle
•Fact Rh = n; 17β-oest. = n (feb 2010)
•Scinti Tc 99 positive in octobre 2010
JoMa.24-11-11; 24 a 9 m

Common Denominator
• They had condyles presurgery
• Inﬂammatory activity pre surgically in one case
• Progressive condylar resorption postsurgery
• What happened during or after surgery?
✦ They all had rigid internal ﬁxation?
✦ They all had stiffness during jaw opening?
✦ Hypomobility?
✦ Counterclockwise rotation of the proximal segment

•Pre surgery
JoMa 170913
JoMa.11-02-14; 2 sem post op
•2 weeks post surgery
✦Le Fort 1 superior repositionning
✦BSSO counterclockwise rotation + Genio
Chirurgien: Dr Carl Bouchard

•Mx Impaction + counterclockwise rotation of occlusal
plane
•Increase chin-throat projection
JoMa020914

• Previous ortho treatment with bionator and ﬁxed appliances (Oct
2008- Nov 2010)
• CRCO functional slide of 4 mm
• Pain was reported shortly after the bionator was placed
• Notes were made Nov08, Dec08, Jan09, June09
Vi.Pr.120312; 15 y 6 m

•Left: Short condylar neck + ﬂattening of the anterior surface
•Right: normal growth
•Left antegonial notch gauche more arched than right side
✦ Compensatory bone apposition at gonial angle
•2 levels of occlusal plane and mandibular inferior border
•Left progressive condylar resorption
➡ Controlateral anterior openbite

•Slight cant of the occlusal plane in frontal view can be noted
✦ Sequela of lack of vertical growth of the left condyle

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

Trauma
• Fall in a gym at age 11
• Kicking on the right side of the face
• Blockage + DD without reduction
• Physiotherapy
• Show at 13 years old for ortho tx
• Standard tx, exo 3 Pm, intermaxillary elastics prn
MaPiBe240203, 13 a 9 m
Arched antegonial notch

• Functional occlusion
• Right TMJ
✦ ??± similar???
MaPiBe290604, 15 a 1 m

• Left anterolateral openbite
✦ This open bite has manifested itself within 6 months post ortho
MaPiBe151204, 15 a 6 m MaPiBe190207, 17 a 9 m

• Progression during the following year
• Antegonial notch: adaptation to  
lack of right condylar growth
MaPiBe190207, 17 a 9 m
MaPiBe140308, 18 a 9 m

• Follow up
✦ 6½ years post ortho
✓ Cortical layer appears normal
MaPiBe040112, 22 a 7 m

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)

NaRo.01-05-11; 21 ans
Unilateral condylar resorption→ Controlateral open bite
NaRo.01-02-06; 16 ansNaRo010206
Undiagnosed fracture of the left condyle
Normal growth to the right, affected (↓)to the left
NaRo.01-04-08; 18 ans
Progressive condylar resorption unilateral
All possible exams were done

• Pre retreatment 
 
 
 
 
 
• Pre surgery
NaRo18112014
NaRo300414

Initial Pré op Post op

•Initial et pre op

3D Surgical Planning
•Left elongation
•Right impaction
•Advancement 3 mm
•Left laterodeviation of 1
mm
•Rotation 3° at the
midline

•Advancement 5,8 mm at
tip of incisors

•SNA increase 3°
•SNB increase 4 °
•Occlusal change 15,7° to 14, 6°

•Autogenous graft: piece of resected
ramus 
•Costochondral graft

•17 days postop
NaRo020215

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

•Happy ending
NaRo120515
Follow up 5 mois (Oct15)
Amplitude 33 mm

2006 2009 2011
2014 2014 2015

Case 6

• At 13 until 15 years old (may 04-June 06)
✦ Ortho tx: HG + Fixed app.
✦ Began oral contraceptive when she was 14-15
• TMJ consultation begins in 2007
ArLa 30082012

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

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

Medical & dental history
• MRI: DD w/o reduction left TMJ, DD W/R right. Both TMJ ﬂattened + degenerative changes
• Splint therapy since fall 2007 
 
 
• Since March 2011
✦ Naproxen 500 mg bid
✦ Ran pantotrazole 40mg 1co le matin
✦ Cyclobenzaprine 10mg 1co hs
ArLa240912
ArLa 19092007

Tx Plan
• Genioplasty early into ortho treatment
• Total joint replacement
✦ Alloplastic
✦ Autogenous (costochondral)
✓ Audience: discuss why one would be choose over the other?
• Bimax surgery advancement + counterclokwise rotation + another
genioplasty prn
-13
82
101
74
42
100
11186
18
40
22
115
108
-1
5
3
2
-3
12
6
80
45
8
Lower Arch:


Right Left Change


Changes:


X

Y

Rot

ALD mx at ANS 3.6 2.5
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.

ArLa300812
ArLa280113
At 4 months: Genioplasty

• Resumed post surgical orthodontic care
ArLa080713

• Pre-surgery and graft

• Post surgery and graft

• Follow up rx 3 months post surgery

Perioste 2-3 mm cartilage

Fixation chain, costal graft is thin
Bone remodeling...

•Classe I
•Asymptomatic
•Opening amplitude 29 mm
ArLa 280114

ArLa070715 2y postop
Jaw opening amplitude 30 mm

•Follow up 4 y post op. Very stable occlusion
•Coronoïd process likely limit jaw opening
ArLa070715 2y
Jaw opening amplitude 27-28 mm
ArLa230817 4y postop

Autogenous Tissue
•Advantages
✦ Available
✦ Adaptable?
✦ Heals?
✦ Predictable growth?
✦ Less expensive?
•Disadvantages
✦ Second surgical site
✦ Longer surgery
✦ Morbidity at the donor site
✦ Difﬁcult to adapt
✦ Require jaw immobility 4-6 weeks
✦ Delay physiotherapy
✦ Unpredictable cartilage growth
✦ Ankylosis
✦ Relapse with repositional 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

Importance of vascularity
•Receptor site
✦ Must support revascularization and promote osteogenesis,
✦ Provide stable ﬁxation to allow incorporation of the donor bone.
•Capillaries can penetrate a maximum thickness of 180 – 220 microns
(µm) of tissue
•Micromotion of these free grafts will likely occur, with the early
mandibular function resulting in shear movements of the graft that may
lead to poor vascularization, nonunion, and/or potential failure
Mercuri L., Swift J.Q., Considerations for the Use of Alloplastic Temporomandibular Joint Replacement in the Growing Patient J Oral Maxillofac Surg 67:1979-1990, 2009
Mercuri LG: The Use of Alloplastic Prostheses for Temporomandibular Joint Reconstruction J Oral Maxillofac Surg 58:70, 2000

Importance of vascularity
•Despite screw/plate ﬁxation, micromotion of these free grafts will
invariably occur, with the early mandibular function resulting in
shear movements of the graft, leading to poor vascularization,
nonunion,and/or potential failure
• Therefore
✦ Immobilization is necessary for vascularisation of the grafted
bone
✦ This may lead to hypomobility or ankylosis
Mercuri LG: The Use of Alloplastic Prostheses for Temporomandibular Joint Reconstruction J Oral Maxillofac Surg 58:70, 2000

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"

Adult
Severe left condylar resorption

•Is it because of occlusion? 
Of disk?
•Vertical growth has stopped around 10-12 y in left TMJ
✦ Look at antegonial notch…
•Probable traumatisme?
ElKsa190913, 36y

•1-Condylar resorption
•2- left short ramus
•3- Arched left antegonial
notch
•4- Compensatory bone
•5- Decrease lateral
growth of the mandibule
on the affected side
♀36a
5

•Class III subdivision right
•Dentoalveolar compensation:
✦ Mx right constriction, left
expansion
ElKsa190913 36a

•Tx plan
✦ Sarpe
✦ Bimaxillary jaw surgery
✦ Total joint replacement of left TMJ

Pre Surgery
•Mx dentoalveolar compensation are
corrected
ElKsa020215

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

Marking guide
Biomet Custom Joint Prothesis

Capsule articulaire et
disque
Guide de coupe du
condyle
Gabarit de coupe

1 month Post op
•Jaw opening amplitude 13 mm
•Temporal branche of VII nerve: Grade IV à V: moderately to severe dysfunction
•Eye: Grade II. mild dysfunction
•Mouth: Grade III: moderate dysfunction, slightly weak with maximum effort
ElKsa080415
House-Brackmann
Classiﬁcation of
Facial Function

•Facial symmetry and class I occlusion achieved
ElKsa230615 37 a 8 m

•Counteclockwise rotation of occlusal plane

Alloplastic Replacement
•Advantages
✦ No donor site
✦ Conform to given anatomy
✦ Early physiotherapy
✦ No susceptibility to
systemic disease
•Disadvantages
✦ Expensive
✦ Sensitivity
✦ Longevity
✦ Only adults?

•No sensitive or motrice loss of the eye, the eyebrow and forehead. Revovery 100%
•Resemblance to her photo at 10 y
•New start in her life…She is pregnant at 38 y
Initial Follow up 3 mois 10 ans
Amplitude 43 mm

Follow up at 2 y post surgery
ElKsa200317 39 a 5 m
Jaw opening= 44 mm
No deviation on opening
No pain
No sensibility loss

Commun denominator commun
•TMJ trauma: ischemia
•Disk displacement without reduction
•Adolescent 12-18 y
•Dysfunctional remodeling→resorption

Final Thoughts
•Facial asymmetry commonly involves TMJ pathology or disorders.
•Therefore, the TMJs should always be evaluated (whether symptomatic or asymptomatic) to
determine if the TMJs are the etiologic factor, a problem that developed because of facial
asymmetry, a coexisting pretreatment condition, or that the joints are normal and healthy.
•Progressive worsening facial asymmetry usually indicates that TMJ pathology is present with one
condyle either resorbing or growing.
✦ Wolford L.M., Mandibular Asymmetry: Temporomandibular Joint Degeneration , Chap. 82, p.
696-725

Final Thoughts
•In conclusion, it is essential that TMJ osteoarthritis be presented as the pathologic entity it is in the
same terms as our colleagues discuss osteoarthritis in orthopaedic circles.
•To not do this only exacerbates the problem that everyone dealing with this entity —patients,
clinicians, insurance carriers, and so forth — has with TMJ osteoarthritis, because they do not
consider it as the orthopaedic (medical) pathology that it is, but rather a purely dental TMJ
problem.
• Mercuri L.G., Oral Max Surg Clin N Am 20 (2008) 169-183

•drsylchamberland@videotron.ca
•sylvainchamberland.com
•418-847-1115
•Please like my FaceBook page  
www.facebook.com/drsylvainchamberland

Condylar
Resorption
and Arthrosis of
the Joints
www.slideshare.net/sylvainchamberland
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Revised as of November 2015

Condylar resorption and arthrosis of the joint (dgkfo)

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