Condylar Resorption of the Temporomandibular Joint: How Do We Treat It?

Larry M. Wolford, DMDa,*, João Roberto Gonçalves, DDS, PhDb

KEYWORDS Condylar resorption (CR) Adolescent internal condylar resorption (AICR) Reactive (inflammatory) arthritis Autoimmune and connective tissue diseases (AI/CT) Mitek anchor technique Patient-fitted total joint prostheses Periarticular fat grafts Orthognathic surgery

KEY POINTS There are many different temporomandibular joint (TMJ) pathologic abnormalities that can cause condylar resorption (CR). Jaw deformities, malocclusions, TMJ and jaw dysfunction, pain and headaches, and so on commonly accompany TMJ CR pathologic abnormality. MRI is an important tool for the diagnosis and treatment planning of TMJ pathologic abnormalities. Adolescent internal condylar resorption (AICR) is one of the most common causes of CR, occurs predominately in teenage girls, with onset during their pubertal growth. AICR can be predictably treated with disc repositioning using the Mitek anchor and orthognathic surgery performed in one stage, providing that the discs and condyles are salvageable. Reactive arthritis is commonly caused by bacterial/viral contamination of the TMJ. Patient-fitted total joint prostheses provide the best outcome predictability for TMJ pathologies with non-salvageable discs and condyles.

INTRODUCTION condylar resorption (ICR) is a generic term commonly used to identify CR wherein the specific Condylar resorption (CR) occurs in conditions cause is unknown. ICR has been used to encom- that cause mandibular condylar bone lysis and pass several TMJ pathologic abnormalities of loss of condylar volume. There are several different origins. Most of the cases labeled ICR suggested causes of CR, including hormonal, can be categorized into one of the following path- neoplasia, metabolic, trauma, inflammation, infec- ologic processes. tion, abnormal condylar loading, aberrant growth The most common TMJ pathologic abnormal- factors, connective tissue and autoimmune dis- ities that cause CR include (1) adolescent internal eases, and other end-stage temporomandibular condylar resorption (AICR), (2) reactive (inflamma- joint (TMJ) pathologic abnormalities. Idiopathic tory) arthritis, (3) autoimmune and connective

a Departments of Oral and Maxillofacial Surgery and Orthodontics Texas, A&M University Health Science Center Baylor College of Dentistry, Baylor University Medical Center, 3409 Worth St. Suite 400, Dallas, TX 75246, USA; b Department of Pediatric Dentistry, Faculdade de Odontologia de Araraquara, Univ Estadual Paulista - UNESP Araraquara School of Dentistry, Brazil – Rua Humaita 1680, Araraquara, SP 14801-903, Brazil * Corresponding author. 3409 Worth Street, Suite 400, Dallas, TX 75246. E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 27 (2015) 47–67 http://dx.doi.org/10.1016/j.coms.2014.09.005

tissue diseases (AI/CT), and (4) other end-stage and eliminate pain with all of the various CR path- TMJ pathologic abnormalities. These TMJ condi- ologic abnormalities. tions may be associated with dentofacial defor- The literature has clearly demonstrated the mities, malocclusion, TMJ pain, headaches, adverse affects of performing only orthognathic myofascial pain, TMJ and jaw dysfunction, ear surgery in the presence of displaced TMJ articular symptoms, and, in the more severe cases, speech discs.1–5,8–10 Our research studies1,8,9 show that in articulation problems, decreased oropharyngeal the presence of TMJ displaced discs where airway, sleep apnea, and psychosocial disorders. only orthognathic surgery is performed with the Patients with these conditions may benefit from maxilla and mandible surgically advanced, an corrective surgical intervention, including con- average anteroposterior (AP) mandibular relapse comitant TMJ and orthognathic surgery. of 30% can be expected as well as an 84% chance Some CR pathologic abnormalities occur more of developing or worsening TMJ pain, myofascial commonly within particular age ranges and pain, and headaches. A recent study using voxel- gender. Identifying the specific CR pathologic ab- based and 3-dimensional (3D) cone beam com- normality will provide insight into the nature of the puted tomography (CBCT) surface analysis pathologic abnormality; progression if untreated; showed the protective effect of disc repositioning clinical, imaging, and histologic characteristics; in condylar morphology maintenance following as well as treatment protocols proven to eliminate maxillomandibular advancement (MMA).11 Accu- the pathologic processes and provide optimal rate diagnosis and proper surgical intervention functional and esthetic outcomes. for the specific TMJ CR pathologic abnormalities Although patients with TMJ CR commonly that may be present in orthognathic surgery pa- have associated TMJ symptoms, approximately tients will provide highly predictable and stable 25% of patients with significant TMJ pathologic results. abnormality will be asymptomatic. These patients are diagnostically challenging when under- PATIENT EVALUATION going orthognathic surgery because the TMJ pathologic abnormality may be unrecognized, The authors have previously published detailed ignored, or treated inappropriately, resulting in a methods for clinical, imaging, and dental model poor treatment outcome with potential redevel- analyses as well as TMJ assessment.12,13 The opment of the skeletal and occlusal deformity most dominant facial type that experiences TMJ as further CR occurs, worsening or initiation of pathologic abnormality, specifically CR condi- pain, headaches, jaw and TMJ dysfunction, and tions, is the high occlusal plane angle facial so forth. morphology14–22 that exhibits a retruded maxilla The occurrence of TMJ CR has been identified and mandible, commonly with a decreased dimen- by many authors1–10 as having association with sion of the oropharyngeal airway. Nasal airway orthodontic treatment and orthognathic surgery. obstruction related to hypertrophied turbinates is However, these treatment modalities are usually also common in these patients. coincidental with the TMJ pathologic abnormalities and not the specific cause of the problem. The History TMJ pathologic abnormality may have been pre- existing or developed during treatment and is usu- Relative to TMJ pathologic abnormality, the ally not initiated by orthodontics or orthognathic patient history is important and aids in the diag- surgery. However, orthodontics and surgery can nosis and treatment protocol selected. Important exacerbate the CR and TMJ symptoms. Treatment factors are age of onset for TMJ-related symp- recommendations that have been previously pro- toms, change in jaw and occlusal relationship, posed for CR include (1) splint therapy to minimize cause, genetic factors, previous treatments joint loading; (2) medications to slow down the (including surgery), habitual patterns such as resorption process; (3) nonloading orthodontic clenching and bruxism, presence of other symp- and orthognathic surgical procedures (eg, maxil- tomatic joints, other disease processes such lary surgery only) after 6 to 12 months of disease as connective tissue/autoimmune or metabolic remission; (4) arthroscopic lysis and lavage; and diseases, gastrointestinal problems, recurrent (5) condylar replacement with a costochondral urinary tract infections, diabetes, cardiac condi- graft or other autogenous tissues. Although some tions, vascular compromises, airway or sleep ap- of these treatment modalities have reported suc- nea issues, smoking, alcohol or drug abuse, cess in some cases, none of these methods of glandular and hormone imbalances, and others, management will provide consistent, predictable, because these factors may affect TMJ treatment stable functional, occlusal, and esthetic outcomes, decisions. Condylar Resorption of the TMJ 49

MRI Evaluation prostheses28–33 in combination with orthognathic surgery. The procedure protocol selected is based MRI is one of the most important diagnostic tools in on diagnosis, time since onset of TMJ pathologic differentiating the specific TMJ CR pathologic ab- abnormality, progression of the disease process, normality. In general, T1 MRIs are helpful to identify presence of polyarthropathies or other systemic disc position, the presence of alteration in bone issues, and so on. Many TMJ CR patients can and soft tissue structures, and interrelationships benefit from counterclockwise rotation of the max- of the bony and soft tissue anatomy. T2 MRIs are illomandibular complex to get the best functional helpful to identify inflammatory responses in the and esthetic outcome.34–36 In this situation, it is TMJ. easier to address the TMJ pathologic abnormality first followed by repositioning the mandible before Importance of Temporomandibular Joint Disc performing the maxillary osteotomies.37 If the Position surgeon prefers to do the TMJ surgery as a sepa- The importance of disc position cannot be over- rate operation from the orthognathic surgery, then emphasized. Gonc¸ alves and colleagues8 evalu- the TMJ surgery should be done first. The specific ated 3 different patient groups that required treatment protocols are presented as each spe- counterclockwise rotation and advancement of cific CR pathologic abnormality is discussed. the maxillomandibular complex with either TMJ discs in normal position; displaced discs reposi- ADOLESCENT INTERNAL CONDYLAR tioned with Mitek anchors (Mitek Products Inc., RESORPTION (AICR) Westwood, MA, USA); or displaced discs left in Cause place. The 3 groups were well matched relative to the amount of advancement at Menton (approx- AICR, formerly referred to in generic terminology imately 13 mm in a counterclockwise direction). At as idiopathic condylar resorption,6,7,12,13 is one longest follow-up with an average of 31 months, of the most common TMJ conditions affecting the average relapse at Menton for group 1 with teenage girls. AICR is also known as cheerleader discs in normal position was 5%, or 0.5 mm for syndrome, idiopathic condylysis, condylar atro- every 10 mm of maxillomandibular counterclock- phy, and progressive CR. AICR is a well- wise advancement. Group 2 had salvageable documented disease process occurring with an displaced discs repositioned using the Mitek 8:1 female-to-male ratio; onset is between the anchor technique and orthognathic surgery with ages of 11 and 15 during pubertal growth and an average relapse of 1%, or 0.1 mm per 10 mm development and is rarely initiated before the of counterclockwise mandibular advancement. age of 11 years or after the age of 15 years.6,7,12,13 Group 3 had displaced discs where only orthog- There are other local and systemic pathologic nathic surgery was performed, with the average abnormalities or diseases that can cause CR, but AP relapse of 28% of the advancement or almost AICR is a specific disease entity different from all 3 mm for every 10 mm of mandibular advance- of the other disease processes and can create ment, indicating postsurgical CR occurring in occlusal and musculoskeletal instability resulting group 3. This study conclusively shows the impor- in the development of a dentofacial deformity, tance of having the articular discs in position for TMJ dysfunction, and pain. stability in orthognathic surgery, particularly in pa- Although the specific cause of AICR has not tients who require mandibular advancement and been clearly identified, its strong predilection for specifically for those that require counterclock- teenage girls in their pubertal growth phase wise rotation of the maxillomandibular complex. supports a theory of hormonal mediation. Estrogen receptors have been identified in the TMJs of female primates,38,39 human TMJ tis- SURGICAL SEQUENCING AND 40 CONSIDERATIONS sues, and arthritic knee joints. Estrogen is known to mediate cartilage and bone metabolism in the CR patients generally have an associated dentofa- female TMJ.41,42 An increase in receptors may pre- cial deformity. Today, the means exist to accu- dispose an exaggerated response to joint loading rately diagnose and predictably treat these from parafunctional activity, trauma, orthodontics, cases. CR cases can be successfully treated or orthognathic surgery. with concomitant TMJ surgery and orthognathic The authors’ hypothesis for this TMJ pathologic surgery. The 2 most predictable treatment abnormality is as follows: female hormones mediate methods for TMJ CR conditions include either biochemical changes within the TMJ, causing articular disc repositioning with a Mitek anchor hyperplasia of the synovial tissues that stimulate technique12,23–27 or patient-fitted total joint the production of destructive substrates that initiate 50 Wolford & Gonc¸alves

breakdown of the ligamentous structures that nor- or decreased superior joint space; (4) some cases mally support and stabilize the articular disc to the presenting with decreased vertical height of the condyle, allowing the disc to become anteriorly ramus and condyle; (5) high occlusal plane angle displaced. The hyperplastic synovial tissue then facial morphology; and (6) skeletal and occlusal surrounds the head of the condyle. The substrates class II relationship (Fig. 3A). penetrate through the outer surface of the condyle A normal MRI is seen in Fig. 4A, B. An MRI of and cause thinning of the cortical bone and break- AICR (see Fig. 4C, D) will show (1) the articular down of the subcortical bone. The condyle slowly disc anteriorly displacing and commonly becoming collapses, shrinking in size in all 3 planes as a nonreducing relatively early in the pathologic result of internal condylar bone resorption without process (nonreducing discs have an accelerated clinically apparent destruction of the fibrocartilage rate of deformation and degeneration compared on the condylar head and roof of the fossa; unlike with discs that reduce); (2) condyle getting progres- the other arthritic conditions, where the fibrocarti- sively smaller in 3 dimensions; (3) amorphous- lage and cortical bone are destroyed by an inflam- appearing tissue possibly surrounding the condyle, matory, connective tissue, or autoimmune disease with or without an increased joint space; and (4) no process. AICR can progress for a while and then inflammatory process seen. go into remission or proceed until the entire condylar head has resorbed. In cases where it Treatment Options goes into remission, excessive joint loading (ie, parafunctional habits, trauma, orthodontics, or- When the discs are still salvageable, the authors’ thognathic surgery) can reinitiate the resorption treatment protocol has proven to eliminate this process. AICR usually occurs bilaterally with sym- TMJ pathologic abnormality and allows optimal metric CR, but facial asymmetry can occur if one correction of the associated dentofacial deformity side resorbs faster than the other or with only unilat- at the same operation. The protocol includes (1) eral TMJ involvement. removing the bilaminar tissue surrounding the condyle; (2) mobilizing, repositioning, and stabiliz- Clinical Features ing the disc to the condyle with a Mitek anchor and artificial ligaments (Figs. 5 and 6); (3) performing AICR has classic clinical features that include (1) the indicated orthognathic surgery (usually double initiation during pubertal growth (ages 11–15 years) jaw) with counterclockwise rotation of the maxillo- predominately in teenage girls (8:1 female-to-male mandibular complex (see Fig. 3B); and (4) ratio); (2) progressive worsening skeletal and performing other adjunctive procedures that are occlusal deformity, although occurring at a slow indicated.6,7,12,23–27 Because this high occlusal rate (average rate of CR is 1.5 mm per year)6,7; plane angle facial morphology is commonly asso- (3) high occlusal plane angle facial morphology, ciated with decreased oropharyngeal airway class II occlusion with or without an anterior space and sleep apnea, the counterclockwise open bite; (4) possible association with TMJ symp- rotation of the maxillomandibular complex will toms, such as clicking, TMJ pain, headaches, my- also maximize the AP dimension of the oropharyn- ofascial pain, earaches, tinnitus, vertigo, and geal airway, eliminating sleep apnea symptoms others (however, 25% of patients with AICR have (see Figs. 1D–F and 2D–F). In growing patients, no overt symptoms); (5) jaw and jaw joint dysfunc- not only will this approach stop the CR but also tion; and (6) no other joint or systemic involvement the mandibular condylar growth will begin again.6,7 (Figs. 1A–C and 2A–C).6,7 Because AICR is nor- Results are best for AICR if the TMJ surgery is mally initiated during pubertal growth, CR that performed within 4 years of the onset of the path- originates before the age of 11 or after the age of ologic abnormality. After 4 years, the discs may 15 is usually not AICR, but a different TMJ patho- become significantly deformed and degenerated logic abnormality and may need a different treat- so as not to be salvageable; then the indicated ment protocol. AICR rarely occurs in low occlusal treatment would be patient-fitted total joint pros- plane angle (brachiocephalic) facial types or in theses (TMJ Concepts Inc., Ventura, CA, USA) to class III skeletal relationships. All cases are iso- repair the TMJs and advance the mandible. lated occurrences with no genetic correlation. Although this AICR surgical protocol has been successful for more than 20 years, some contro- Imaging versy still remains in the literature, specifically in Radiographic features include (1) progressive regard to the possible side effects related to decrease of condylar size and volume; (2) some open joint surgery and condylar changes after- cases having thinning cortex on top of the condyle; ward.43–45 In an ongoing study, the authors are (3) some cases presenting with increased, normal, assessing 3D condylar changes occurring 1-year Condylar Resorption of the TMJ 51

Fig. 1. (A–C) This 15-year-old girl had onset of TMJ problems at the age of 12. Her mandible had become progressively more retruded. Her diagnoses included (1) bilateral TMJ AICR; (2) mandibular AP hypoplasia; (3) maxillary anterior vertical hyperplasia as well as AP, posterior vertical and transverse hypoplasia; (4) class II end-on occlusion; (5) anterior open bite of 3 mm, (6) hypertrophied turbinates causing nasal airway obstruction; (7) TMJ pain, myofascial pain, and headaches; and (8) decreased oropharyngeal airway with an AP dimension of 3 mm (normal AP dimension is 11 mm) with sleep apnea symptoms. (D–F) Patient is 2 years postsurgery following single-staged procedures: (1) bilateral TMJ articular disc repositioning and ligament repair with Mitek anchors; (2) bilateral mandibular ramus sagittal split osteotomies to advance the mandible in a counterclockwise direction (20 mm); (3) multiple maxillary osteotomies to advance in a counterclockwise direction (7 mm at the incisal tips) and expand; (4) AP augmentation genioplasty (5 mm); and (5) bilateral partial inferior turbinectomies. The patient shows improved facial balance, stable jaw and occlusal relationship, good jaw function, and elimination of pain. after surgery in 2 patient groups: group 1 consists using the SPHARM-PDM package48,49; (2) subjec- of young adult patients with normal TMJs; they tive analysis of semi-transparent overlays8,47,50,51; had MMA only. Group 2 consists of young adult and (3) condylar volume estimation using ITK- AICR patients with MMA and articular disc reposi- Snap software.10,11 The values for the voxels in tioning (MMA-Drep). For each patient, CBCTs each tomographic image were obtained in Houns- were segmented in a semi-automatic protocol46 field units, representing the opacity of the and registered in a rigid, voxelwise automatic radiographs. algorithm over the cranial base.47 Three distinct The authors’ preliminary results showed that at 1- methods were used to assess the condyles 3- year following surgery AICR patients (MMA-Drep) dimensionally: (1) surface shape correspondence had increased condylar volume compared with 52 Wolford & Gonc¸alves

Fig. 2. (A–C) Pretreatment occlusion shows class II end-on with anterior open bite. (D–F) Patient has a class I occlusion and 2-mm overbite 2 years after surgery.

86 77 3 3 19 18 3 1 7 3 5 8

30 36 -2 5 20

Fig. 3. (A) Pretreatment cephalometric analysis shows retruded mandible and maxilla, high occlusal plane angulation, anterior vertical maxillary hyperplasia, but posterior vertical hypoplasia. Arrows and associated numbers indicate the oropharyngeal airway dimension in millimeters (3). (B) The surgical treatment objective demonstrates repositioning the articular discs with the Mitek anchor technique, counterclockwise rotation of the maxillomandibular complex, turbinectomies, and genioplasty, with pogonion advancing 20 mm. Arrows and numbers represent the direction of surgical change in millimeters. Condylar Resorption of the TMJ 53

Fig. 4. MRI evaluation. (A, B) Nor- mal MRI with disc in position in the closed (A) and open (B) positions. (C, D) AICR with anteriorly displaced articular disc (red arrows) and CR in the closed (C) and open (D) positions without disc reduction on opening. (E) Reactive arthritis showing initiation of arthritic changes of the condyle (yellow arrow), moderate inflammation within the joint bilaminar tissues (red arrows), and anterior disc displacement (white arrows). (F) Reactive arthritis with significant inflammation (white arrows) between the disc (red arrows) and condyle (yellow arrow). The condyle has lost vertical height with a relatively large erosive lesion present. (G) Advanced JIA with mushrooming of the condyle, loss of condyle vertical height (yellow arrows), moderate resorption of the articular eminence (green arrow), and reactive pannus (white arrows) surrounding the disc (red arrows). (H) Further advancement of the AI/CT disease process with major erosion of the articular eminence (green arrow) and condyle (yellow arrows)as well as progressive degeneration of the disc (red arrows) with the reactive pannus (white arrow) surrounding the disc. (I) Coronal imaging shows significant loss of vertical condylar height and transverse width (yellow arrows). 54 Wolford & Gonc¸alves

Fig. 5. Mitek anchor technique. (A) Mitek Mini Anchor is 5 Â 1.8 mm in dimensions with an eyelet to support 2 artificial ligaments (0-Ethibond suture; Ethicon, Inc., Somerville, NJ). (B) Bilaminar tissues are excised and anteriorly displaced disc (green arrow) is mobilized. (C, D) The disc (green arrow) is passively positioned over the condyle and Mitek anchor is placed in the lateral aspect of the posterior head, about 8 mm below the top of the condyle; the sutures are attached to the posterior band of the disc and secured. (Courtesy of L. Wolford, DMD.)

patients with healthy TMJs with MMA only that ex- Henry and colleagues52,53 demonstrated that perienced a reduction of condylar volume (P<.01). 73% of patients with TMJ articular disc displace- The values measured for each anatomic region ments have bacteria in the bilaminar tissues. The demonstrated important differences between the 2 bacterial species the authors have identified in groups (Fig. 7). The distance maps show the magni- the TMJ include Chlamydia trachomatis and Chla- tude of changes between 2 point-based correspon- mydia psittaci as well as Mycoplasma genitalium dent models, while the vector maps provide the and Mycoplasma fermentans.52–55 Other bacteria directionality of these positional displacements. that have been found in other joints but also may Positive and negative numbers represent outward infect the TMJ include Borrelia burgdorferi (Lyme and inward displacement, respectively. disease), Salmonella species, Shigella species, Yersina enterocolitica, and Campylobacter jejuni. The authors suspect that other bacterial/viral spe- REACTIVE (INFLAMMATORY) ARTHRITIS cies may cause reactive arthritis in joints, including Cause Chlamydia pneumoniae, Mycoplasma pneumo- Reactive arthritis (also called seronegative spon- niae, Ureaplasma, Herpes virus, Epstein-Barr vi- dyloarthropathy) is an inflammatory process in rus, Cytomegalovirus, and Varicella zoster, joints commonly related to bacterial or viral fac- among others. Kim and colleagues56 analyzed tors. This condition reportedly occurs during the TMJ synovial fluids for specific bacteria and found third to fourth decade of life, but it can develop M genitalium and M fermentans/orale as well as at any age. In the TMJ, it more commonly develops Staphlococcus aureus, Actinobacillus actinomy- in the late teens through the fourth decade. Reac- cetemcomitans, and Streptococcus mitis present tive arthritis commonly is seen in conjunction with in 86%, 51%, 37%, 26%, and 7% of samples, a displaced TMJ articular disc, but it also can respectively. They did not test for the Chlamydia develop with the disc in position. species. Condylar Resorption of the TMJ 55

Fig. 6. (A) Right TMJ in AICR showing the hyperplastic synovial tissues overlying the condyle. (B) Bilaminar/synovial tissues are excised. (C) The fibrocartilage is observed covering the condyle (white arrow) and fossa (green arrow). (D) Mitek anchor has been placed and the disc is secured into normal position.

Chlamydia and Mycoplasma bacterium species Patients with localized TMJ reactive arthritis live and function like viruses and, therefore, antibi- may have displaced discs, pain, TMJ and jaw otics may not be effective in eliminating these bac- dysfunction, headaches, and ear symptoms. teria from joints and the body. Antibiotics may As the disease progresses, CR and/or bony affect the extracellular organisms but will not affect deposition can occur, causing changes in the the intracellular bacteria, although the microbes jaw and occlusal relationships. Patients with mod- may be placed into a dormant state. These bacte- erate to severe reactive arthritis may have other ria are known to stimulate the production of Sub- body systems involvement, including the genito- stance P, cytokines, and tissue necrosis factor, urinary, gastrointestinal, reproductive, respiratory, which are all pain-modulating factors and con- cardiopulmonary, ocular, neurologic, vascular, tribute to the destruction of the bone and cartilage hemopoietic, immune system, as well as involve- of the joint.57–59 In addition, these bacterial spe- ment of other joints.61 cies have been associated with Reiter syndrome and dysfunction of the immune system. Clinical Features The authors also have identified specific genetic factors, human leukocyte antigen markers, that Although this condition commonly occurs bilater- occur at a significant greater incidence in TMJ pa- ally, it can occur unilaterally. In some patients, tients than the normal population.60 These same there may not be any significant CR and therefore markers also may indicate an immune dysfunc- may not have an adverse affect on facial mor- tional problem for these bacterial species, allowing phology or occlusion. However, when causing the bacteria to have a greater affect on patients CR, the following features may be observed: (1) with these markers compared with people without mandible may become progressively retruded; these same markers. (2) jaw and occlusal deformity may progressively 56 Wolford & Gonc¸alves Condylar Resorption of the TMJ 57

Fig. 8. (A–C) This 22-year-old woman had the onset of her TMJ problems at age 18 with the development of a retruded mandible, TMJ pain, and sleep apnea symptoms. She has no other joint involvement or other systemic issues. Her diagnosis was (1) bilateral TMJ reactive arthritis and articular discs anteriorly displaced; (2) mandibular and maxillary hypoplasia; (3) class II end-on occlusion; (4) anterior open bite; (5) high occlusal plane angle; (6) hypertrophied turbinates causing nasal airway obstruction; (7) decreased oropharyngeal airway and sleep apnea symptoms; and (8) TMJ pain. (D–F) The patient 3 years after surgery for the following single-stage procedures: (1) bilateral TMJ articular disc repositioning with Mitek anchor technique; (2) bilateral mandibular sagittal split osteotomies with counterclockwise rotation to normalize the occlusal plane angle; (3) multiple maxillary osteotomies to down graft the posterior aspect for counterclockwise rotation of the maxillomandibular complex; (4) bilateral partial inferior turbinectomies. With the above treatment plan, pogonion advanced 18 mm, while sleep apnea symptoms and pain were eliminated.

= Fig. 7. (A) Left and right condyle surfaces of AICR patient submitted to MMA-Drep. T2 represents the condyle morphology immediately after surgery (red) and T3 at 1-year follow-up (blue). Right-side and left-side postsurgical condylar volume increased 23.12 mm3 and 85.5 mm3, respectively. The directions of bone remodeling/ displacement are shown in semi-transparent overlays and at the vectors color map. Specific region changes are shown below the images. (B) MMA. Left and right condyle surfaces of patient submitted to MMA and no articular disc repositioning (normal TMJs). T2 represents the condyle morphology immediately after surgery (red) and T3 at 1-year follow-up (blue). Right-side and left-side after surgical condylar volume decreased 304.13 mm3 and 599.87 mm3, respectively. The directions of bone remodeling/displacement are shown in semi- transparent overlays and at the vectors color map. Specific region changes are showed below the images. 58 Wolford & Gonc¸alves

Fig. 9. (A–C) Presurgery shows anterior open bite and end-on class II occlusion. (D–F) The patient, 3 years after surgery, has good skeletal and occlusal stability.

worsen, although it may occur at a slow rate; (2) (4) other joints and body systems may be class II occlusion and anterior open bite with involved. premature contact on the posterior teeth (Figs. 8A–C and 9A–C); (3) common associated TMJ Imaging symptoms may include clicking, popping, crepitus, TMJ dysfunction and pain, headaches, Radiographic features of reactive arthritis causing myofascial pain, earaches, tinnitus, vertigo; and CR can include (1) loss of vertical dimension and

79 86 6 21 21 8 6

5 35

Fig. 10. (A) Presurgical cephalometric analysis shows the retruded maxilla and mandible with a high occlusal plane angulation and class II skeletal and occlusal relationship. Arrows and associated numbers indicate the oropharyngeal airway dimensions in millimeters (5). (B) Surgical treatment objective shows repositioning the articular discs, advancing the mandible, and maxilla with a counterclockwise rotation. Pogonion advanced 15 mm. Arrows and numbers represent the direction of surgical change in millimeters. Condylar Resorption of the TMJ 59 volume of the condyle; (2) articular surface of the If there is significant destruction of the condyle condyle eroded with loss of the fibrocartilage and the disc is not salvageable, or polyarthritis or covering the condyle and fossa; (3) retruded systemic disease is present, then the most pre- mandible; (4) class II occlusion with anterior open dictable treatment procedure is the patient-fitted bite; and (5) decreased vertical height of the ramus total joint prosthesis (TMJ Concepts System) and condyle (Fig. 10A). (Fig. 11) to reconstruct the TMJ as well as re- MRI will commonly show (1) articular disc ante- position the mandible to its proper position riorly displaced or in normal position; (2) joint effu- (Figs. 12–14).28–33 Fat grafts packed around the sion and inflammation in T2 imaging; (3) resorbing total joint prosthesis are an important component condyle; and (4) condylar and fossa erosions in to help prevent fibrous tissue and heterotopic advanced conditions (see Fig. 4E, F). bone from forming.62,63

Treatment Options AUTOIMMUNE AND CONNECTIVE TISSUE The approach to treating this TMJ pathologic ab- DISEASES normality and associated deformity depends on Cause the length of time that the pathologic abnormality Conditions included in the classification of AI/ has been present, the amount of destruction to CT that can affect the TMJs are rheumatoid the disc and condyle at the time of surgery, and arthritis, juvenile idiopathic arthritis (JIA), psori- the presence of other joint involvement (polyarthri- atic arthritis, ankylosing spondylitis, Sjogren tis) or other related systemic conditions. If the TMJ syndrome, systemic lupus erythematosus, condition is identified within the first 4 years of the scleroderma, and mixed connective tissue dis- onset of the disc dislocation, the destruction is ease, among others. The triggers and precise not significant, and there are no other joints or pathophysiology are unknown for most of these systemic conditions present, then removing the disorders. Multiple systems are usually involved. bilaminar tissues around the condyle and reposi- Joint damage may be mediated by cytokines, tioning the articular disc with the Mitek anchor chemokines, and metalloproteases. Peripheral technique may work well to preserve the normal joints are usually symmetrically inflamed, result- 12,23–27 anatomic structures (see Fig. 5). It is ing in progressive destruction of articular struc- possible that the resection and removal of a large tures, commonly accompanied by systemic portion of the bilaminar tissue (where it is known symptoms. that these bacteria reside) during surgery may result in a major reduction of the source of the Clinical Features inflammation. The orthognathic surgery can be done at the same time as the joints are repaired Adult onset in some patients may affect the TMJs (see Figs. 8D–F, 9D–F, and 10B). but not cause significant CR, particularly if caught

Fig. 11. Patient-fitted total joint prostheses are indicated when the articular discs and condyles are considered nonsalvageable. (A) The 3D stereolithic model of the patient is prepared with the mandible placed into the final predetermined position. A condylectomy has been performed and lateral aspect of the ramus was prepared for construction of the prostheses. (B) The prostheses are manufactured based on the patient’s specific anatomic requirements. The numbers represent the length of the 2-mm-diameter screws that are required for bicortical engagement. 60 Wolford & Gonc¸alves

Fig. 12. (A–C) This 56-year-old woman had onset of TMJ symptoms at age 39 and was diagnosed with the following: (1) bilateral TMJ reactive arthritis; (2) retruded maxilla and mandible; (3) decreased oropharyngeal airway and sleep apnea requiring continuous positive airway pressure apparatus (CPAP); (4) severe TMJ pain, headaches, myofascial pain; and (5) nonsalvageable TMJs. (D–F) The patient is seen 2 years after surgery for (1) bilateral TMJ reconstruction and mandibular counterclockwise rotation advancement (17 mm at pogonion); (2) bilateral TMJ fat grafts harvested from the abdomen; (3) bilateral coronoidectomies; and (4) maxillary osteotomies for counterclockwise rotation. She has no pain, and sleep apnea is eliminated. Incisal opening is improved, and good facial balance is established.

early and placed on appropriate medications. Imaging However, when the disease onset is in the first Features may include (1) loss of condylar vertical or second decade or adult onset with TMJ dimension and volume, residual condyle may involvement and CR, then the following character- become broad in the AP direction, but with signifi- istics may be present: (1) progressive retrusion of cant mediolateral narrowing; (2) in advanced dis- the mandible with worsening skeletal and occlusal ease, resorption of the articular eminences; (3) deformity; (2) indirect involvement of the maxilla residual condyle may function forward beneath with posterior vertical hypoplasia particularly the remaining articular eminence; (4) decreased when occurring in growing patients; (3) class II oc- vertical height of the ramus and condyle; (5) skeletal clusion with or without an anterior open bite; (4) and occlusal class II relationship, high occlusal TMJ symptoms, which could include clicking, plane angle facial morphology, with or without crepitus, TMJ dysfunction and pain, headaches, anterior open bite; and (6) decreased oropharyn- myofascial pain, earaches, tinnitus, vertigo, and geal airway (Fig. 17A). so forth; and (5) other joints and systems com- MRI may show (1) articular discs in position but monly involved (Figs. 15A–C and 16A–C). usually surrounded by a reactive pannus that Condylar Resorption of the TMJ 61

Fig. 13. (A–C) Patient has had extensive dental reconstruction that helped correct the malocclusion that developed from the TMJ pathology establishing basically class I occlusion. (D–F) At 2 years after surgery, the patient has a stable occlusion.

86 79 6 13 1212 22 3 16 8 3 1 2 6.5

21 2

Fig. 14. (A) Presurgical cephalometric analysis shows retruded maxilla and mandible, high occlusal plane angle, and decreased oropharyngeal airway. Arrows and associated numbers indicate the oropharyngeal airway dimensions in millimeters (3). (B) The prediction tracing demonstrates the TMJ reconstruction and counterclockwise mandibular advancement with the TMJ patient-fitted total joint prostheses and maxillary osteotomies with pogonion advancing 17 mm. Arrows and numbers represent the direction of surgical change in millimeters. 62 Wolford & Gonc¸alves

Fig. 15. (A–C) This 16-year-old girl presented with progressive retrusion of the mandible and maxilla. She was diagnosed with (1) JIA; (2) significant and progressive CR; (3) progressive retrusion of the mandible and maxilla; (4) class II skeletal and occlusal dentofacial deformity; (5) anterior open bite; (6) decreased oropharyngeal airway with sleep apnea symptoms; (7) hypertrophied nasal turbinates and nasopharyngeal adenoid tissue with nasal airway obstruction; and (8) TMJ pain and headaches. (D–F) The patient is seen 2 years after surgery for the following procedures: (1) bilateral TMJ reconstruction and mandibular counterclockwise advancement with patient-fitted TMJ total joint prostheses (TMJ Concepts System); (2) bilateral TMJ fat grafts (harvest from abdomen) packed around the functional component of the prostheses; (3) bilateral coronoidectomies; (4) multiple maxillary osteotomies to down graft the posterior aspect and upright the incisors; (5) bilateral partial inferior turbinectomies and nasopharyngeal adenoidectomy; and (6) chin augmentation with an alloplastic implant.

causes resorption of the condyles and articular advanced or vertically lengthened with the prosthe- eminences and eventually destroy the discs; (2) ses; (3) autogenous fat graft packed around the AP mushrooming of the residual condyle, but articulation area of the prostheses (harvested narrow medial-lateral width; (3) a possible inflam- from the abdomen or buttock)62,63; (4) maxillary matory response (see Fig. 4G–I). osteotomies if indicated; and (5) any additional adjunctive procedures indicated (ie, genioplasty, rhinoplasty, turbinectomies, septoplasty) (see Treatment Figs. 15D–F, 16D–F, and 17B). These diseases The most predictable treatment of the TMJ affected can stimulate reactive or heterotopic bone for- by AI/CT diseases includes (1) reconstruction of mation around the prostheses. Therefore, it is the TMJs and advancement of the mandible in a necessary that fat grafts be packed around the counterclockwise direction with patient-fitted total articulating parts of the prostheses to prevent this joint prosthesis (TMJ Concepts System)27–33,64; (2) occurrence and minimize fibrotic tissue forma- bilateral coronoidectomy if the rami are significantly tion.62,63 Orthognathic surgery can be performed 63

Fig. 16. (A–C) The presurgical occlusion demonstrated an anterior open bite and class II end-on cuspid relationship. (D–F) The occlusion remains class I with normal overbite at 2 years after surgery.

73 86 3 25 18 5 1 3333 8 3 4 7 13 43 45 -4 9 38

Fig. 17. (A) Presurgical cephalometric analysis shows the retruded maxilla and mandible, high occlusal plane angulation, hypertrophied nasopharyngeal adenoid tissue and decreased oropharyngeal airway. Arrows and associated numbers indicate the oropharyngeal airway dimensions in millimeters (1). (B) Surgical treatment objective illustrates the planned procedures to advance the maxillomandibular complex in a counterclockwise direction, advancing pogonion 38 mm, including the alloplastic chin implant. Arrows and numbers represent the direction of surgical change in millimeters. 64 Wolford & Gonc¸alves

at the same time as the TMJ is reconstructed or after-surgery follow-up of 31 months demon- performed at a later surgery, but the TMJ surgery strated significant improvement in jaw opening should be performed as the first step in either and function after surgery with no radiographic or approach. clinical evidence of heterotopic bone or significant Other techniques that have been advocated for fibrosis. TMJ reconstruction in the AI/CT diseases include using autogenous tissues such as temporal fascia OTHER END-STAGE TEMPOROMANDIBULAR and muscle flaps, rib grafts, sternoclavicular JOINT PATHOLOGIC ABNORMALITY grafts, and vertical sliding osteotomy. However, the disease process that created the original Other conditions that can cause CR include (1) TMJ pathologic abnormality can attack the autog- neoplasms; (2) multiple operated joints; (3) failed enous tissues used in the TMJ reconstruction, TMJ autogenous grafts or alloplastic implants; (4) causing failure of the grafts.65 The patient-fitted to- traumatic injuries; (5) avascular necrosis; (6) meta- tal joint prosthesis with a fat graft packed around it bolic diseases; (7) ICR. Some patients with these is a superior technique relative to elimination of the conditions may have severe pain, TMJ and jaw disease process in the TMJ, improved function dysfunction, facial deformities, and major disability and esthetics, stability, as well as elimination or issues. Patients with these TMJ pathologic abnor- decrease in pain. malities, regardless of the severity, may benefit When treating young growing patients (8– from TMJ reconstruction and mandibular reposi- 10 years of age or older), the total joint prosthesis tioning with patient-fitted total joint prosthesis, as is still the best option to eliminate the disease well as simultaneous maxillary orthognathic sur- process. However, because there would be no gery to achieve the best outcome results relative growth potential on the involved side or sides of to function, stability, esthetics, and reduction of the mandible, orthognathic surgery will likely be pain. necessary later, but can be delayed until the patient The authors have demonstrated good outcomes has most of the facial growth complete. Then dou- using patient-fitted total joint prostheses and ble jaw surgery can be performed, including the orthognathic surgery in treating other TMJ disor- mandibular ramus sagittal split osteotomies (pref- ders including multiply operated joints, neo- erable to use an extra-oral approach so as not to plasms, and those having failed alloplastic TMJ contaminate the prostheses) to reposition the implants. However, the quality of results de- jaws into the best alignment, or repositioning of creases as the number of previous TMJ surgeries the mandibular components of the prostheses, or increases, particularly in reference to pain relief manufacturing new longer mandibular compo- and function. When the TMJ Concepts total joint nents to achieve advancement of the mandible in prostheses system is used as the first or second conjunction with maxillary osteotomies, genio- TMJ surgery, the success rate is predictable and plasty, and others. These secondary procedures good relative to jaw function, stability, facial bal- are highly predictable when performed at age ance, and pain relief. 14 years or older in girls and 16 years or older in boys. However, the vector of facial growth will SUMMARY change in younger patients to a downward and backward direction as the maxillary and man- During the past 3 decades, major advancements dibular dentoalveolus continue to grow vertically have been made in TMJ diagnostics and the until growth cessation.66,67 development of surgical protocols to treat and The authors’ studies28–31,33,64,65,68 show good rehabilitate the pathologic, dysfunctional, and outcomes in treating connective tissue/auto- painful TMJ as well as the associated dentofacial immune diseases affecting the TMJ with custom- deformity. Research has clearly demonstrated fitted total joint prostheses (TMJ Concepts that TMJ and orthognathic surgery can be safely System) for TMJ reconstruction and mandibular and predictably performed at the same operation, advancement, fat grafts, and simultaneous maxil- but it does necessitate the correct diagnosis and lary orthognathic surgery. The authors have evalu- treatment protocol as well as requires the surgeon ated the efficacy of using fat grafts around the to have expertise in both TMJ and orthognathic prostheses and demonstrated significant improve- surgery. The surgical procedures can be sepa- ment in function and decrease in pain for patients rated into 2 or more surgical stages, but the TMJ when using the fat grafts as compared with surgery should be done first. 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