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 com- monly 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 1042-3699/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved. oralmaxsurgery.theclinics.com 48 Wolford & Gonc¸alves 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 pa- tients 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