The temporomandibular joints (TMJs) are the foundation and support for jaw position, function, occlusion, and facial balance necessary for quality treatment outcomes in dentistry, orthodontics, and orthognathic surgery. If the TMJs are not stable and healthy (non-pathological), treatment outcomes in these dental disciplines may be unsatisfactory relative to function, esthetics, occlusal and skeletal stability, and pain.
There are many temporomandibular joint disorders that can affect the TMJ adversely. The most common of these conditions include: 1. 2. 3. 4. 5. 6. Articular disc dislocation; Reactive arthritis; Adolescent internal condylar resorption; Condylar hyperplasia; Osteochondroma or osteoma; and End-stage TMJ pathology. These conditions often are associated with dentofacial deformities, malocclusion, TMJ pain, headaches, myofascial pain, TMJ and jaw functional impairment, ear symptoms, sleep apnea, etc.
Patients with these conditions may benefit from corrective surgical intervention. This chapter will discuss the most common TMJ pathologies and present the orthodontic and surgical management considerations to correct the specific TMJ conditions and associated jaw deformities to obtain predictable outcomes. Improvements in TMJ diagnostics and surgical procedures have contributed to improved treatment and rehabilitation of the pathological, dysfunctional and painful TMJ disorders.
Research has demonstrated that TMJ and orthognathic surgery can be performed safely and predictably at the same operation, but it does necessitate the correct diagnosis and treatment plan, as well as requires the surgeon to have expertise in both TMJ and orthognathic surgery. 159 Common TMJ Disorders There are many temporomandibular joint (TMJ) conditions that can cause pain, TMJ and jaw dysfunction and disability. The most common of these conditions include: 1. 2. 3. 4. 5. 6.
Articular disc dislocation; Reactive arthritis; Adolescent internal condylar resorption (AICR); Condylar hyperplasia; Osteochondroma or osteoma; and End-stage TMJ pathology (e. g. , connective tissue/ autoimmune diseases, advanced reactive arthritis and osteoarthritis, multiply operated joints, failed alloplastic TMJ implants, absence of the joint, traumatic injuries and ankylosis). These conditions often are associated with dentofacial deformities, malocclusion, TMJ pain, headaches, myofascial pain, TMJ and jaw functional impairment, ear symptoms and sleep apnea.
Patients with these conditions may benefit from corrective surgical intervention. The difficulty for many clinicians may lie in identifying the presence of a TMJ condition, diagnosing the specific TMJ pathology and selecting the proper treatment for that condition. This chapter will discuss the most common TMJ pathologies and present the orthodontic and surgical management considerations to correct the specific TMJ conditions and associated jaw deformities. WHY CONSIDER TMJ SURGERY?
The TMJs are the foundation and support for jaw position, function, occlusion and facial balance necessary for quality treatment outcomes in dentistry, orthodontics and orthognathic surgery. If the TMJs are not stable and healthy (non-pathological), treatment outcomes for patients may be unsatisfactory relative to function, esthetics, occlusal and skeletal stability, and pain. Contrary to popular belief, orthognathic surgery to correct a malocclusion and jaw deformity will not “fix” or eliminate co-existing TMJ pathology and symptoms.
Our studies (Fuselier et al., 1998; Wolford et al. , 2003; Goncalves et al. , 2008) and other studies (Arnett and Tamborello, 1990; Kerstens et al. , 1990; Moore et al. , 1991; Crawford et al. , 1994; DeClercq et al. , 1994) demonstrate that performing only orthognathic surgery on patients with co-existing TMJ pathology can result in unsatisfactory treatment outcomes. 160 Wolford et al. The above listed TMJ conditions, when occurring with or without dentofacial deformities, can be treated predictably by performing the appropriate TMJ and orthognathic surgical procedures at one operation.
These TMJ conditions also can be treated by performing the TMJ and orthognathic surgery at separate operations, but the TMJ surgery should be done at the first operation for best quality outcomes. Patient history as well as clinical, radiographic, dental model, MRI and/or CT scan evaluations and when indicated laboratory tests are very important for accurate diagnosis of the TMJ pathology and treatment planning. With appropriate selection and execution of the surgical procedures and proper postsurgical management, good outcomes usually can be achieved.
Our research studies (Fuselier et al., 1998; Wolford et al. , 2003) evaluated 25 consecutive patients with jaw deformities and anteriorly displaced discs treated with orthognathic surgery only. All but one patient had the mandible advanced. Pre-surgery, 36% of the patients had pain or discomfort. At an average of 2. 2 years post-surgery, 84% of the patients had TMJ-related pain, with a 70% increase in pain severity. In addition, 25% of the patients developed anterior open bites from condylar resorption. New onset/aggravation of TMJ symptoms occurred at an average of 14 months post-surgery.
Twelve patients (48%) required TMJ surgery and repeat orthognathic surgery. Nine additional patients (36%) required long-term medications and/or splint therapy for pain control. These studies clearly demonstrate the problems associated with performing orthognathic surgery only on patients with co-existing TMJ disc dislocations. Goncalves and coworkers (2008) evaluated 72 patients (59 females, 13 males) with an average age of 30 years (range, 15 to 60 years) who had double-jaw orthognathic surgery with counter-clockwise rotation of the maxillo-mandibular complex.
The patients were divided into three groups. Group 1 (G1; n = 21) with healthy TMJs (Fig. 1) received orthognathic surgery only; Group 2 (G2; n = 35) with bilateral articular disc dislocation (Fig. 2) received articular disc repositioning with the Mitek anchor technique concomitantly with orthognathic surgery; and Group 3 (G3; n = 16) with bilateral articular disc dislocation received orthognathic surgery only. Average post surgical follow-up was 31 months.
At surgery, the occlusal plane angle decreased significantly in all three groups G1 (-6. 3 ± 5. 0o), G2 (-9. 6 ± 4. 8o), and G3 (-7. 1 ± 4. 8o). The maxillomandibular complex advanced and rotated counter-clockwise similarly in all three groups, with advancement at menton in G1 (12. 4 ± 161 Common TMJ Disorders 5. 5 mm), G2 (13. 5 ± 4. 3 mm), and G3 (13. 6 ± 5. 0 mm); Point B in G1 (9. 5 ± 4. 9 mm), G2 (10. 2 ± 3. 7 mm), and G3 (10. 8 ± 3. 7 mm); and lower incisor edge in G1 (7. 1 ± 4. 6 mm), G2 (6. 6 ± 3. 2 mm), and G3 (7. 9 ± 3. 0 mm).
Post-surgery, the occlusal plane angle increased in G3 (37% relapse) while G1 and G2 remained stable. Mandibular post-surgical changes demonstrated a significant anteroposterior relapse in G3 at menton (28%), Point B (28%), and lower incisor edge (34%) while G1 and G2 remained stable. This study clearly demonstrated that maxillomandibular advancement with counter-clockwise rotation of the occlusal plane is a stable procedure for patients with healthy TMJs and for patients with simultaneous TMJ disc repositioning using the Mitek anchor technique.
Patients with preoperative TMJ articular disc displacement who underwent double-jaw surgery and no TMJ intervention experienced significant relapse. Figure 1. MRI of a TMJ shows good A-P position of the articular disc as well as good shape of the disc, condyle and eminence. On opening, the disc remains in good position as the condyle demonstrates good translation (C = condyle, arrows denote the disc). TMJ surgery (e. g. , disc repositioning, arthroplasties, high condylectomies) can alter the position of the mandible and the occlusion significantly.
Therefore, the surgical sequencing for performing TMJ and orthognathic surgery at one operation or divided into two operations (the TMJ and orthognathic procedures performed separately) is important to achieve good outcomes and includes TMJ surgery first, followed by mandibular ramus sagittal split osteotomies with rigid fixation and then, if indicated, maxillary osteotomies with rigid fixation. With the mandibular osteotomies being performed after the TMJ surgery, the mandible will be positioned into its predetermined position regardless of the amount of mandibular displacement resulting from the TMJ surgery.
The jaws are not wired together post-surgery because rigid fixation (bone plates and screws) is used to stabilize the maxillary and mandibular osteotomies. Light vertical elastics (3. 5 oz) with a slight Class III vector 162 Wolford et al. usually are used post-surgery to control the occlusion and minimize the TMJ intercapsular edema. Closely monitoring and managing the occlusion in the post-surgery period, as well as controlling the parafunctional habits (i. e. , clenching, bruxism), are very important to provide high quality outcomes.
When end-stage TMJ pathology requires reconstruction with total joint prostheses, then the mandible can be advanced, counterclockwise rotated if indicated, and asymmetries corrected with customfitted total joint prostheses without requiring additional mandibular osteotomies. BENEFITS OF ONE-STAGE TMJ AND ORTHOGNATHIC SURGERY The benefits of one-stage TMJ and orthognathic surgery include: 1. It requires one operation and general anesthetic; 2. It balances the occlusion, TMJs, jaws and neuromuscular structures at the same time; and 3. It decreases overall treatment time.
Our research studies (Wolford et al. , 1994, 1995, 2002, 2003; Wolford, 1997; Wolford and Karras, 1997; Wolford and Cardenas, 1999; Mehra and Wolford, 2000; Downie et al. , 2001; Garcia-Morales et al. , 2001; Freitas et al. , 2002; Mehra and Wolford, 2002; Morales-Ryan et al. , 2002) have shown that simultaneous surgical correction of TMJ pathology and co-existing dentofacial deformities performed in one operation provides high quality treatment outcomes for patients relative to function, esthetics, elimination or significant reduction in pain, and patient satisfaction.
Equivalent results also can be achieved by separating the TMJ and orthognathic surgical procedures into two operations; the TMJ surgery must be performed first, with at least six months before performing the orthognathic surgery procedures. ARTICULAR DISC DISLOCATION The most common TMJ pathology is an anterior and/or medial displaced disc (Fig. 2). This condition can initiate a cascade of events leading to arthritis and TMJ-related symptoms (Nickerson and Boring, 1989).
Simultaneous surgical treatment would include repositioning the TMJ disc into a normal anatomical, functional position and stabilizing it using the Mitek anchor (Mitek Surgical Products Inc. , Westwood, MA) 163 Common TMJ Disorders Figure 2. MRI of a TMJ shows a significantly anterior displaced articular disc (C = condyle, arrow denotes the disc). technique (Wolford et al. , 1995, 2002; Wolford, 1997; Wolford and Cardenas, 1999; Downie et al. , 2001; Mehra and Wolford, 2001) and then performing the indicated orthognathic surgery.
The Mitek anchor technique uses a bone anchor that is placed into the lateral aspect of the posterior head of the condyle and the anchor will subsequently osseointegrate. Two 0-Ethibond sutures (Ethicon Inc. , Somerville, NJ) are attached to the anchor and are used as artificial ligaments to secure and stabilize the disc to the condylar head (Fig. 3). Our study (Wolford et al. , 2002) using this treatment protocol on 70 patients showed that pre-surgery, 80% of the patients had preoperative TMJ pain, but at longest follow-up, 60% had complete relief of pain and an additional 33% had significant reduction in pain.
All but one patient had stable orthognathic surgery outcomes. Using the criteria of incisal opening greater than 35 mm, stable skeletal and occlusal relationships and significant reduction in pain, the success rate was 91%. The success rate was significantly better (95%) if the TMJ discs were repositioned surgically within the first four years of onset of the TMJ dysfunction. After four years, the progression of irreversible TMJ degenerative changes may result in a lower success rate.
Another of our studies (Downie et al., 2001) evaluated 88 different patients with simultaneous TMJ disc repositioning with the Mitek anchor and orthognathic surgery that likewise demonstrated a very similar statistically significant decrease in TMJ pain and headaches, while improving jaw function and providing stable occlusal and skeletal results.
Patients with systemic conditions that affect joints (e. g. , rheumatoid arthritis, psoriatic arthritis, Sjogren’s syndrome, scleroderma, ankylosing spondylitis, lupus), previously operated TMJs, or with multiple other joint involvement, generally will not do well with the Mitek anchor technique or 164.
Wolford et al. Figure 3. A: In the use of the Mitek anchor to stabilize the articular disc, the joint first is exposed and the excessive bilaminar tissue excised. To mobilize the disc, the anterior attachment of the disc to the articular eminence is released so the disc can be positioned over the condyle passively. B and C: The Mitek Mini Anchor (insert) has an eyelet that will support two 0-Ethibond sutures that can function as artificial ligaments. The anchor is inserted into the posterior head of the condyle lateral to the mid-sagittal plane and 5 to 8 mm below the top.
One suture is placed in a mattress fashion through the medial aspect of the posterior part of the posterior band. The other suture is placed more lateral through the posterior band. D: Cross-sectional sagittal view shows the Mitek anchor positioned in the condyle with the artificial ligaments attached to the disc to stabilize it to the condylar head. attempts to use autogenous tissues to reconstruct the TMJs. TMJ total joint prostheses may be indicated for TMJ reconstruction with these pathological conditions.
Case 1 This 41-year-old female presented with bilateral TMJ anteriorly displaced articular discs (confirmed by MRI; Fig. 6) and a Class II skeletal and occlusal dentofacial deformity (Figs. 4A and C; 5A-C; 7A). Shehad moderate to severe TMJ pain, headaches and myofascial pain as 165 Common TMJ Disorders Figure 4. Case 1. A and C: A 41-year-old female is seen with bilaterally displaced articular discs, TMJ dysfunction and severe TMJ pain and headaches. The mandible is retruded significantly with a high occlusal plane angle and associated facial morphology.
B and D: The patient is seen three years postsurgery following bilateral TMJ articular disc repositioning with Mitek anchors and simultaneous double-jaw orthognathic surgery. Figure 5. Case 1. A-C: The pre-surgical occlusion demonstrates an anterior open bite and Class II occlusal relationship. D-F: The Class I occlusion achieved by the surgery remained stable three years post-surgery. well as clicking in the TMJs and difficult eating. Following orthodontic preparation, surgery was performed in one operation including: 1.
Bilateral TMJ disc repositioning with Mitek anchors; 2. Mandibular counter-clockwise advancement of 20 mm at pogonion; and 3. Multiple maxillary osteotomies to downgraft the posterior aspect and upright the incisors (Fig. 7B). 166 Wolford et al. Figure 6. Case 1. A: MRI of a TMJ shows a significantly anterior displaced articular disc (arrows). B: On opening, the disc remains anteriorly displaced and non-reducing with degenerative changes (C = condyle; arrows denote the disc).
The patient was evaluated three years post-surgery, showing good stability (Figs.4B and D; 5D-F; 7C and D) with elimination of TMJ pain, headaches, myofascial pain and TMJ noises. Her jaw function and facial esthetics were improved as well. REACTIVE ARTHRITIS Reactive Arthritis (also called seronegative spondyloarthropathy) is an inflammatory process in joints commonly related to bacterial and/or viral factors. This condition usually occurs during the third to fourth decade of life, but it can develop at any age. In the TMJ, Reactive Arthritis commonly is seen in conjunction with a displaced TMJ articular disc, but it also can develop with the disc in position.
Our studies (Henry et al., 2000, 2001) have confirmed that at least 73% of patients with articular disc displacements have bacteria in the bilaminar tissues of the TMJ. The bacterial species we have identified include: Chlamydia trachomatis and psittaci, as well as Mycoplasma genitalium and fermentans (Henry et al. , 2000, 2001; Hudson et al. , 2000; Wolford et al. , 2001). Other bacteria that have been found in other joints but also may infect the TMJ creating Reactive Arthritis include: Borrelia burgdorferi (Lymes disease), Salmonella species, Shigella species, Yersina enterocolitica and Campylobacter jejuni.
167 Common TMJ Disorders Figure 7. Case 1. A: The pre-treatment cephalometric analysis shows a retruded mandible, anterior open bite, steep occlusal and mandibular plane angles, and proclined lower incisors. B: The Surgical Treatment Objective (STO prediction tracing) demonstrates the orthognathic procedures required to achieve a good functional and esthetic result, including disc repositioning as well as maxillary and mandibular osteotomies with counterclockwise rotation of the occlusal plane. C: Cephalometric analysis at three years post-surgery demonstrates good facial balance.
D: Superimposition of the immediate post-surgery (red lines) and three years follow-up (black lines) cephalometric tracings demonstrate the treatment stability achieved for this patient. 168 Wolford et al. We suspect that other bacterial/viral species also may cause Reactive Arthritis in joints, including Chlamydia pneumoniae, Mycoplasma pneumoniae, Ureaplasma, Herpes virus, Epstein-Barr virus, Cytomegalovirus and Varicella zoster. The bacteria we identified (Chlamydia and Mycoplasma species) were found in the bilaminar tissues.
They live and function like viruses and, therefore, antibiotics may not be effective in eliminating the bacteria from joints and the body. Antibiotics may affect the extracellular organisms but will not affect the intracellular bacteria, although they may be placed into a dormant state. These bacteria are known to stimulate the production of Substance P, cytokines, and tissue necrosis factor, which are all pain modulating factors (Henry et al. , 2002).
In addition, these bacterial species have been associated with Reiter’s syndrome, destructive arthritis and dysfunction of the immune system. Although we have identified the bacteria, the specific affect for each patient is difficult to quantify. We also have identified specific genetic factors, Human Leukocyte Antigen (HLA) markers that occur at a significant greater incidence in TMJ patients than the normal population (Henry et al. , 2002). These same markers also may indicate an immune dysfunctional problem for these bacterial species allowing the bacteria to have a greater affect on patients with these markers compared to people without these same markers.
Patients with localized TMJ Reactive Arthritis usually will have displaced discs, pain, TMJ and jaw dysfunction, ear symptoms and headaches. As the disease progresses, condylar resorption and/or bony deposition can occur, causing changes in the jaw and occlusal relationships. Patients with moderate to severe Reactive Arthritis may have other body systems involvement, including the genitourinary, gastrointestinal, reproductive, respiratory, cardiopulmonary, ocular, neurological, vascular, hemopoietic and immune systems as well as involvement of other joints (Wolford et al., 2004).
Most patients with mild to moderate TMJ Reactive Arthritis, without significant involvement of other body systems or other joints, usually respond well to articular disc repositioning using the Mitek anchor system and the appropriate orthognathic surgery procedures, providing the discs are salvageable and within four years of the onset of the TMJ problems. It is possible that the resection and removal of a large portion of the bilaminar tissue (where it is known that these bacteria reside) during surgery may result in a major reduction of the source of the inflammation.
In more advanced Reactive Arthritis cases, particularly 169 Common TMJ Disorders those with involvement of other body systems and other joints, the best TMJ treatment may be reconstruction with a total joint prostheses (TMJ Concepts Inc. , Ventura, CA).
Case 2 This 27-year-old female presented with Reactive Arthritis, bilateral TMJ involvement with articular disc displaced in the left side (Fig. 10A) and significant right TMJ condylar destruction and resorption (Fig.10B), Class II skeletal and occlusal dentofacial deformity, left side posterior open bite, significant asymmetry of the mandible, decreased oropharyngeal airway with sleep apnea symptoms.
(Figs. 8A and C; 9A-C; 11A), TMJ symptoms, pain and headaches. Following orthodontic preparation, surgery was performed that consisted of: 1. Unilateral right TMJ reconstruction and mandibular counter-clockwise advancement with custom-made TMJ total joint prosthesis (TMJ Concepts system; Fig. 12); 2. Unilateral right TMJ fat graft placement (harvested from abdomen); 3. Unilateral right coronoidectomy; 4.
Unilateral left TMJ disc repositioning with Mitek anchor; 5. Sagittal split osteotomy of the left mandibular ramus with counter-clockwise rotation of occlusal plane angle; and 6. Multiple maxillary osteotomies to down graft the posterior aspect and upright the incisors (Fig. 11B and C). Pogonion advanced 17 mm. The patient was evaluated one year postsurgery, showing good stability (Figs. 8B and D; 9D-F; 11D), free from TMJ pain, headaches and myofascial pain; as well as improved facial esthetics and increased orpharyngeal airway, eliminating her sleep apnea.
Figure 10. Case 2. A: MRI of left TMJ shows the anteriorly displaced articular disc (C = condyle, arrows denote the disc). B: MRI of right TMJ shows Reactive Arthritis with severe degenerative and resorptive changes. 170 Wolford et al. Figure 8. Case 2. A and C: A 27-year-old female is seen with a unilaterally left TMJ displaced articular disc and Reactive Arthritis of the right TMJ with significant condylar resorption. The mandible is retruded significantly, shifted off to the right side, with a high occlusal plane angle and associated facial morphology.
B and D: The patient is seen one year post-surgery, following unilateral left TMJ articular disc repositioning with Mitek anchor, unilateral right TMJ reconstruction and mandibular advancement with custom-made TMJ total joint prosthesis (TMJ Concepts system), unilateral right coronoidectomy, unilateral right TMJ fat graft, left mandibular ramus sagittal split osteotomy and multiple maxillary osteotomies. Figure 9. Case 2. A-C: The pre-surgical occlusion demonstrates Class II occlusal relationship and left side posterior open bite. D-F: The occlusion remained stable one year post-surgery. 171.
Common TMJ Disorders Figure 11. Case 2. A: The pre-treatment cephalometric analysis shows a retruded mandible, asymmetry of mandibular base and level of teeth, steep occlusal and mandibular plane angles, and proclined lower incisors and a significant decreased oropharyngeal airway. B: The Surgical Treatment Objective (prediction tracing) of the left side demonstrates the TMJ disc repositioning with a Mitek anchor and orthognathic procedures required to achieve a good functional and esthetic result including maxillary and mandibular osteotomies with counterclockwise rotation of the occlusal plane.
C: The STO of the right side demonstrates right TMJ reconstruction and mandibular advancement with custommade TMJ total joint prosthesis (TMJ Concepts system), unilateral right coronoidectomy, unilateral right TMJ fat graft (harvest from the abdomen), maxillary osteotomies for counter-clockwise rotation of the maxillomandibular complex and occlusal plane angle. D: Cephalometric analysis at one year postsurgery demonstrates good facial balance and a normal oropharyngeal airway. 172 Wolford et al. Figure 12.
A: The TMJ Concepts total joint prosthesis is a custom-made device fitted to each patient’s specific anatomical requirements. The fossa component is made of titanium (T) and ultra high molecular weight polyethylene (P). The mandibular component shaft (M) is made of titanium alloy and the head is chromium-cobalt alloy. B: Case 2. The 3D polymer model was prepared with the mandible advanced to the predetermined position relative to the unoperated maxilla. The TMJ Concepts custom-made total joint prosthesis was constructed on the prepared model.
C: The panograph shows the TMJ Concepts total joint prosthesis of the right side, Mitek anchor in the left mandibular condyle and bone plates and screws in the maxilla and left mandibular body. Ramus area shows good healing one year post-surgery. 173 Common TMJ Disorders ADOLESCENT INTERNAL CONDYLAR RESORPTION (AICR) AICR is a pathological, hormonally mediated condition primarily affecting teenage females (ratio 9:1, females to males), usually initiated as they enter their pubertal growth phase.
In AICR, it is postulated that the female hormones stimulate hyperplasia of the synovial tissues that then produce chemical substrates that destroy the ligaments that normally stabilize the disc to the condyle. The disc becomes displaced anteriorly, and the condyle then is surrounded by the hyperplastic synovial tissue that continues to release chemical substrates which penetrate the condylar head, causing internal condylar resorption and creating a slow but progressive decrease in size of the condyle and retrusion of the mandible.
In AICR, condylar resorption is internal with inward collapse of the overlying thinned outer cortical bone and fibrocartilage. Other TMJ resorptive pathologies resorb the condyle from the outside. Interestingly, 25% of the patients with AICR are asymptomatic relative to pain and joint noises. The only treatment protocol proven to eliminate the TMJ pathology and allow optimal correction of the associated dentofacial deformity was developed by the senior author (Wolford and Cardenas, 1999; Morales-Ryan et al. , 2002; Wolford et al. , 2002) and includes: 1.
Removal of the hyperplastic bilaminar and synovial tissues around the condyle; 2. Repositioning and stabilizing the disc to the condyle with the Mitek anchor technique (Fig. 3); and 3. Performing the indicated orthognathic surgery. Our initial study (Wolford and Cardenas, 1999) involved 12 patients with active AICR (formerly called idiopathic condylar resorption) who underwent simultaneous TMJ and orthognathic surgery. The average post-surgical follow-up was 33 months with stable results, excellent jaw and masticatory function, and elimination or significant reduction in pain in all patients.
Our more recent study (Wolford et al. , 2002) evaluated 44 patients with active AICR who were divided into two groups. Group 1 (n = 10) underwent orthognathic surgery only, with no TMJ surgical treatment. Group 2 (n = 34) underwent TMJ disc repositioning with the Mitek anchor technique, and simultaneous orthognathic surgery. In Group 1, AICR continued in all 10 patients post-surgery resulting in statistically 174 Wolford et al. significant skeletal and occlusal instability and relapse with redevelopment of Class II occlusion and anterior open bite as well as continued pain.
Group 2 patients all maintained stable Class I skeletal and occlusal outcomes, with statistically significant reduced pain and improved jaw function compared to Group 1. Case 3 This 15-year-old female presented with bilateral TMJ AICR, anteriorly displaced articular discs, internal condylar resorption with decrease in size of the condyle (confirmed by MRI; Fig. 15A and B) and a Class II skeletal and occlusal dentofacial deformity that was slowly becoming progressively worse (Figs. 13A and C; 14A-C; 16A). She had headaches, myofascial pain, as well as clicking in the TMJs.
Following orthodontic preparation, surgery was performed in one operation including: 1. Bilateral TMJ disc repositioning with Mitek anchors; 2. Bilateral sagittal split osteotomy with mandibular counter-clockwise rotation and advancement of 6. 5 mm at pogonion; and, 3. Multiple maxillary osteotomies to move the anterior aspect of the maxilla upward, decrease the occlusal plane angle, as well as upright the incisors (Fig. 16B).
The patient was evaluated 13 months post-surgery showing good stability (Figs.13B and D; 14D-F; 16C and D), with elimination of headaches, myofascial pain and TMJ noises; as well as improved facial esthetics. Figure 13. Case 3. A and C: A 15-year-old female is seen with bilaterally displaced articular discs, AICR and TMJ dysfunction. The mandible is retruded with a high occlusal plane angle, and the maxilla shows vertical excess. B and D: The patient is seen 13 months post-surgery following bilateral TMJ articular disc repositioning with Mitek anchors and simultaneous double-jaw orthognathic surgery.
175 Common TMJ Disorders Figure 14. Case 3. A-C: The pre-surgical occlusion demonstrates a Class II occlusal relationship. D-F: the occlusion remained stable 13 months post-surgery. Figure 15. Case 3. MRIs of the TMJs show a significantly anterior displaced articular discs (left and right side) and significant internal condylar resorption (C = condyle, arrows denote the disc). CONDYLAR HYPERPLASIA (CH) Normal facial and jaw growth usually is 98% complete in females at age 15 years, and in males at age 17 to 18 years.
CH is an abnormal growth condition affecting the mandibular condyles, creating accelerated and excessive overgrowth of the mandible (prognathism) that often continues into the patient’s mid-20s. Bilateral active CH causes progressive and worsening prognathism and occlusion, but relatively asymptomatic for TMJ symptoms. Unilateral CH can cause progressive deviated prognathism, facial asymmetry, disc dislocations, TMJ pain, headaches and masticatory dysfunction. Not all prognathic mandibles are caused by CH; only those demonstrating accelerated, excessive mandibular growth and/or growth continuing beyond the normal growth years.
176 Wolford et al. Figure 16. Case 3. A: The pre-treatment cephalometric analysis shows a retruded mandible, high occlusal and mandibular plane angles, anterior vertical excess of the maxilla, and proclined lower incisors. B: The Surgical Treatment Objective (prediction tracing) demonstrates the orthognathic procedures required to achieve a good functional and esthetic result including disc repositioning as well as maxillary and mandibular osteotomies with counterclockwise rotation of the occlusal plane.
C: Cephalometric analysis at 13 months post-surgery demonstrates good facial balance. D: Superimposition of the immediate post-surgery (red lines) and 13 months follow-up (black lines) cephalometric tracings demonstrate the treatment stability achieved for this patient. 177 Common TMJ Disorders The treatment protocol developed by the senior author (Garcia-Morales et al. , 2001; Wolford et al. , 2002) for these patients includes: 1. High condylectomy to arrest condylar growth; 2. TMJ disc repositioning (Fig. 3); and 3. Simultaneous orthognathic surgery.
This protocol predictably stops mandibular growth and provides stable outcomes with normal jaw function and good esthetics. Our study (Wolford et al. , 2002) evaluated 54 patients (32 females, 22 males) with confirmed active CH, average age 17 years, followed for five-years post-surgery and divided into two groups. Group 1 patients (n = 12) were treated with orthognathic surgery only, and Group 2 patients (n = 42) were treated with simultaneous high condylectomies, discs repositioned over the remaining condyle, and orthognathic surgery.
All patients in Group 1 redeveloped skeletal and occlusal Class III relationships. In Group 2, all 42 patients remained in a stable Class 1 skeletal and occlusal relationship with normal jaw function. Case 4 This female patient presented with bilateral CH with the right side worse than the left side, creating a deviated mandibular prognathism, maxilla retrusion and a Class III skeletal and occlusal dentofacial deformity (Figs. 17A and C; 18A-C; 20A). Active CH caused worsening of a deviated prognathism. This patient had displaced discs, TMJ pain, headaches and myofascial pain. Followi.