Condylar Degeneration and DiseasesLocalaD * a

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W hen the words condylar resorption ismentioned, most orthodontists think of 3thcotochnapleca

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gies of condylar disease and/or morphologicchanges to the condyle as well as surrounding

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menwaings: (1) idiopathic condylar resorption, (2)ndylar changes as a result of traumatic injurythe mandible and/or condyle, or (3) condylaranges as unfortunate sequelae of orthog-thic surgery. However, this is a very incom-te list of possibilities to be considered in suchses.The purpose of this article is to offer aoader and more realistic look at the etiolo-

hard- and soft-tissue structures. We presentthis information in such a way as to improvethe differential diagnostic capabilities whenconfronted with unclear symptoms and theirpotential etiologies. The obvious desired re-sult is more informed decision making in re-acting to problems and improving the qualityof care of our patients.

After evaluating problems encountered inpractice and an evaluation of the literature, werecommend the division of condylar problemsinto 3 broad categories: (1) localized etiologicfactors, such as osteoarthritis and traumatic in-juries, (2) systemic etiologic factors, that is, thesystemic disease entities that can result in con-dylar degeneration and other changes, and (3)condylar resorption as either an unfortunate se-quelae of orthognathic surgery or as a totallyspontaneous occurrence. To help create a sys-tematic approach to diagnosis and treatment, wepresent the individual elements of each disease,beginning with a general description, expected

*Clinical Professor, Department of Orthodontics, University ofbama at Birmingham, Birmingham, AL; and Adjunct Professor,artment of Orthodontics, University of North Carolina, Chapell, NC. **Former Research Assistant, Department of Orthodon-, University of Alabama at Birmingham, School of Dentistry,mingham, AL. ***Professor of Pediatrics & Medicine, Director,ision of Pediatric Rheumatology, Childrens Hospital of Ala-a/University of Alabama at Birmingham, Birmingham, AL.Address correspondence to David M. Sarver, DMD, MS, Depart-t of Orthodontics, University of Alabama, 1705 Vestavia Park-y, Birmingham, AL. E-mail: Sarverd@sarverortho.com 2013 Elsevier Inc. All rights reserved.1073-8746/13/1902-0$30.00/0http://dx.doi.org/10.1053/j.sodo.2012.11.008

89Seminars in Orthodontics, Vol 19, No 2 (June), 2013: pp 89-96nd Systemic Etiologiesavid M. Sarver,* Sridhar Janyavula,*

The temporomandibular joint condyleof problems, ranging from simple ostetion. This article will focus on issues rtions. Condylar resorption (also knownin normal orthodontic practice, but woccurrence and often puzzling and insents an aggressive and fast-moving fwill be discussed in this article, mandegenerative joint disease arise frombut others (especially condylysis) havethe authors opinion that the term idan explanation. When something hapoften it is not known what that reasoused as a quick and easy explanationtigating deeper to find the real causecannot be found in every case, but themany are aware of, and some of thOrthod 2013;19:89-96.) 2013 Elseviend Randy Q. Cron***

usceptible to developing a varietythrosis to severe condylar resorp-ed to the etiology of these condi-condylysis) is an event rarely seenn it occurs, it is a very unhappylicable. This phenomenon repre-of degenerative joint disease. As

ases of temporomandibular jointcific local or systemic etiologies,en described as idiopathic. It isthic might be too easily used ass, there is usually a reason, but. Hence, the term idiopathic isthe occurrence rather than inves-the problem. Certainly, the causere more areas to investigate thanwill be presented here. (Semin. All rights reserved.

findings on physical examination, common ra-dioan

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90 Sarver, Janyavula, and Crongraphic characteristics, the clinical features,d finally, treatment.

calized Etiologic Factors

teoarthritis

Description

so known as osteochondritis dessicans, this pro-ss is described as a result of chronic inflamma-n of the synovial and discal tissues.1-3 Thenical outcome is an inflammatory responseng with degenerative changes in the cartilagevering and possible necrosis of the bony artic-r and even subarticular surfaces. The nonin-mmatory version of this process is often re-red to as osteoarthrosis.

Physical Examination

nderness of one condyle is the most commonaracteristic in osteoarthritis. Auscultation mayveal crepitus in the effected joint, and second-muscular soreness in the masticatory musclesy also be present.

Radiographic Features

diographic features may be highly variable,t in the classic presentation, there is an osteo-yte on the anteroposterior aspect of the con-le4 (Fig 1). Irregularities of the cortical platethe condylar head may be noted, dependingthe quality of the image.

ure 1. This 49-year-old patient was referred with aief complaint of temporomandibular joint. Shed unilateral joint pain, and the panoramic radio-ph revealed an osteophyte on the anterosuperiorect of the condyle, characteristic of localized os-arthritis.erapy is similar to the orthopedic approach toer joints. Aspirin or nonsteroidal anti-inflam-tory drugs (NSAIDs) are commonly pre-ibed.5-7 Muscular symptoms may be treatedth muscle relaxants, or drugs from the benzo-zepine family are useful. We most commonlyescribe 1.0 mg of Klonopin (clonazepam)enentech USA, Inc., South San Francisco,) at bedtime.

nctional Load

general terms, bone morphology is a functionthe load put on it because of bones inherentaracteristics of plasticity.8-10 The shape andm of the temporomandibular joint (TMJ)ndyle are a result of the functional forcesced on it, but in addition, human condylarriability is remarkable.

Physical Examination

nerally unremarkable, but various complaintsch as joint soreness or crepitus are the mostquent when abnormal loads are placed on ant, or when normal loads are placed on ampromised joint.

Radiographic Features

hat does a normal condyle look like? Theriability can be enormous, as would be ex-cted because of the multitude of influencingtors, with genetics being only one of them.erefore, one must be cautious in decidingw much diagnostic interpretation can bede from a panoramic film, a tomogram, or ane-beam CT examination.

Case example

ure 2A represents the condyle of a patientth a severe Class II malocclusion with 8 mm oferjet. She had bilateral joint and facial pain,d she had consulted an oral and maxillofacialrgeon who diagnosed her as having degener-ve joint disease secondary to internal derange-nt of the joint. The pencil line on the filmpresents where the surgeon had drawn theocedure he proposed: disk plication and con-lar shave11 designed to reshape the erodedndyle. Instead, the patient chose the course of

orthodontics and mandibular advancement fol-lowtioormaFigmefuco

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91Condylar Degeneration and Diseasesed by re-evaluation of the joint. After correc-n of the skeletal deformity and finishing ofthodontics, her symptoms were reduced dra-tically, and she pursued no further treatment.ure 2B is the same condyle 1 year after treat-nt was completed; with a dramatic change innction, there was a resulting change in thendylar anatomy.

aumatic Injury

Description

aumatic injury to a condyle is the most fre-ent cause of mandibular asymmetry in grow-children. A blow to the mandible that resultstraumatic compression of the condylar headainst the posterior glenoid fossa can produceimmediate loss of some portion of the carti-e cover of the condylar head, resulting in lossnourishment and protection along with sub-uent bony condylar lysis.12-14 Fracture of thendylar neck also results in either functionals of the condylar head itself or interruption ofe blood supply, possibly leading to condylaris. In trauma cases, limitation of opening oreral deviation is usually a result of either 1 orth condyles being affected by a traumatic in-y. If scarring of the temporomandibular areacurs so that the translation of the mandible ispeded, there will likely also be an interferenceth normal mandibular growth.

Physical Examination

adolescents, if restricted range of motion ofe affected TMJ occurs, skeletal asymmetry isely to occur and to get progressively worse asowth continues. The greater the inhibition ofnslation, the more progressive the deformityll be.

Treatment

e primary guideline in both children andults is to restore function as soon as possible tooid ankylosis or the formation of fibrous tissuerring. Treatment in the child who has expe-nced condylar trauma often includes the usea hybrid functional appliance,15 or a unilat-al hyperpropulsion device (such as a fixedrbst appliance16); these may be used to guidebsequent growth and maintain as much free-ure 2. (A) This adult patient presented with ass II malocclusion with 8 mm of overjet. She wasgnosed as having degenerative joint disease sec-dary to internal derangement of the joint, resultingthe erosion of the condylar head. A surgeon pro-sed a condylar shave designed to reshape theoded condyle. (B) The same condyle 1 year afteratment with orthodontics and surgical mandibularvancement. With a dramatic change in function,re was a resulting change in the condylar anatomy.

dom of movement as possible. Any form of sur-gicwitretio

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come (Fig 3D and E). Comparison of the pre-

Fig cularun lassort e righco proof tingof

92 Sarver, Janyavula, and Cronal treatment should not be used in childrenth mandibular asymmetry until conservativeatment with some form of growth modifica-n has been attempted and failed.

se Presentation: Use of a Unilateralperpropulsion Appliance

16-year-old girl (Fig 3A) was involved in ator vehicular accident in which she suffered aomatic fracture and a right condylar fracture,sulting in a unilateral Class II malocclusionig 3B). She was placed into full orthodonticpliances and a Herbst appliance, which hase advantage of promoting a growth modifica-n or remodeling effect. The Herbst appliances activated every 6 weeks on the affected righte only to the point of overcorrection. Theopulsion arms of the Herbst appliance weremoved for an 8-week period to assess any re-se, and then fixed appliance treatment wassumed to an excellent facial and occlusal out-

ure 3. (A) This patient was involved in a motor vehiilateral Class II malocclusion. (B) The unilateral Chodontics appliances and a Herbst appliance, with thndyle. (D) The resulting facial symmetry was greatly imthe pretreatment and posttreatment films demonstrafigure is available online.)atment and posttreatment films shows the re-deling of the injured condyle (Fig 3F).

stemic Etiologic Factors

ndylar degeneration or growth interferencen occur as a result of many systemic diseases. Aview of the literature reveals at least 12 docu-nted diseases that can be associated with con-lar resorption. These include the following:

Rheumatoid arthritis (RA): a chronic autoim-mune inflammatory disorder that typically af-fects the small joints of the hands and feet.Unlike osteoarthritis, RA affects the lining ofthe joints, causing pain and swelling that caneventually result in bone erosion and jointdeformity.17

Psoriatic arthritis: a chronic inflammatory dis-ease causing symptoms such as inflammationin joints and overproduction of skin cells,with similar results as RA.18

accident, with left condylar fracture resulting in aII malocclusion. (C) The patient was placed int side periodically activated to protract the injuredved. (E) The final occlusal results. (F) Comparisonremodeling of the injured condyle. (Color versiontremo

Sy

Cocaremedy

1.

2.

3. Juvenile idiopathic arthritis (JIA)19-22: it is an

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93Condylar Degeneration and Diseasesautoimmune disease of unknown etiologythat affects 1 in 1000 children in the UnitedStates. Previously referenced in the literatureas juvenile RA, the change in terms occurredbecause rheumatologists determined that thiscondition in adolescents is not simply a ju-nior version of RA. Laboratory workupsshow that these young patients do not havethe rheumatoid factor (RF) that is indicativeof RA; hence, the term idiopathic has be-come the new label.Exercise-induced osteopenia23,24

Scleroderma25-27

Lupus erythematosus28

Familial Mediterranean fever29,30

Marfan syndrome31

Sjogren syndrome32

. Sarcoidosis

. Mixed connective tissue disease33

. Dermatomyositis34

the following sections, we discuss RA and JIAdetail.

eumatoid Arthritis

Clinical Features

e most striking aspect is the change in occlu-n, with a progressive anterior open bite,ereas the other common feature is significantange in condylar size and morphology. Therea difference between the adult and adolescentrsions of these condylar changes becauseults may have actual condylar resorption,ich is radiographically detectable, whereas ad-scents may experience an attenuation ofowth, resulting in severely restricted mandib-r growth, but their condyles may appear morermal. These changes at the condylar level re-lt in typical clinical characteristics such asndibular recession, anterior open bite, andrrowing of the bigonial width.

Radiographic Features

proximately 30% of RA patients exhibit radio-aphic changes that are gross enough to beserved on plain films or tomograms. The char-teristic cephalometric presentation is flatten-of the anterosuperior aspect of the condyles

d irregular destruction of the temporal fossa,ich is seen as flattening of the fossa that isnt pain but not these radiographic changes,en localized osteoarthritis is a possible differ-tial diagnosis, but systemic RA is always a pos-ility. Therefore, the history is very important,d the following questions need to be asked: Isere any history of arthritis in the family? ando any other of your joints hurt? Other jointsed to be examined for swelling or diminishedge of motion. Blood assays to identify RF ander inflammation markers are also indicatedd are detailed later in this article.

Treatment

eatment for the TMJ pain and dysfunctionds to be localized and palliative, includingirin or NSAID therapy, therapeutic exercises,al appliances, and steroid injections. Intra-ar-ular steroids are probably best for active in-mmation. The open bite malocclusion can beated conventionally with orthognathic sur-ry, which is the most common approach, but

ure 4. The characteristic cephalometric radio-phic presentation of juvenile idiopathic arthritisws flattening of the anterosuperior aspect of the

ndyles and irregular destruction of the temporalsa, seen as flattening of the fossa.

the use of temporary anchorage devices to facil-itacamerethalothchasscudethtopresuneenfor

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94 Sarver, Janyavula, and Cronte orthodontic correction may also be indi-ted in milder cases. Prosthetic joint replace-nt may be included as an option. Wecommend that before treatment is pursued,e patients should be followed with serial ceph-metric radiographs every 6 months untilere are 3 consecutive films with no detectableange. Although this is far from being a perfectessment method, it probably is the most ac-rate way to determine when the active andstructive disease process is burned out. Al-ough some recommend technetium radioiso-e uptake studies to see whether excessive

modeling activity is continuing on the jointrfaces, these may be difficult to interpret. Mag-tic resonance imaging (MRI) with contrasthancement is both very sensitive and specificactive TMJ inflammation.

venile Idiopathic Arthritis

Clinical Features

ny JIA patients have severe micrognathia duethe disruption of mandibular growth. This isnerally bilateral, but can be occasionally uni-eral. Complaint of pain is uncommon, partic-rly in younger children, with the exception ofovitis (inflammation of the synovial lining ofe TMJ), which can be treated as a separateue if necessary. Open bite in JIA patients iser than in adult RA patients.

Radiographic Features

e condyles may appear eroded and flattened,d the density of the condyles may appear rar-d. The glenoid fossa is shallow, and there mayabnormal articular tubercles. A prominentture in JIA may include antegonial notchingthe body of the mandible. MRI with contrasthancement can also reveal synovial fluid,ne marrow edema, pannus, disk thinning andplacement, and synovial lining enhancement.igh prevalence of TMJ arthritis at onset of theease in children with JIA can be detected byI, but not by ultrasonography.35

Treatment

ain, localized treatment can be administeredrough intra-articular long-acting corticoste-ids, and the clinician also can use aspirin orn be followed clinically when pain or discom-t is present by measuring mouth opening andge of mandibular movement, and also usingI with contrast enhancement. In case of pain-

l synovitis, a soft-tissue synovectomy may bessible for the relief of pain. As in the adultth rheumatoid joint destruction, observationd serial cephalometric follow-up for cessationthe disease process is the assessment methodchoice, to be followed by correction of thelocclusion.Blood tests may be administered to confirmrule out a diagnosis of JIA. Most commonly,ythrocyte sedimentation rate assays may dem-strate the presence of systemic inflammation.positive antinuclear antibody assay is associ-d with increased uveitis in children withronic arthritis. The genetic marker HLA-B27associated with enthesitis-related JIA. RF orti-cyclic citrullinated peptide antibodies arend in 4% of children with JIA. The use oftinuclear antibody assay can detect those spe-c antibodies that are proteins commonly as-ciated with autoimmune disease such as arthri-, and the RF is an antibody found inividuals with RA. In JIA cases, however, RF isen not found in children, and therefore, itssence in a test does not mean the patient isgative for JIA.

nclusions

the outset of this article, we described 3 broadas by which we define condylar changesd/or degeneration: (1) problems due to lo-lized etiologic factors, (2) problems due totemic etiologic factors, and (3) severe resorp-e problems due to postoperative factors or ofopathic origin. This systematic approach toese problems is meant to provide a frameworkthe differential diagnosis of condylar change,d is meant to help lead clinicians in a logicalnner to a reasonable diagnosis before recom-nding therapy. Although some cases in everytegory may seem to be of mysterious origin, ittoo simple to lean on the crutch of the termiopathic. We encourage the reader to followwith investigation into the literature of otherologic concepts, such as the potential linkagehormonal changes to condylar resorption36-39

(refer to the article by Arnett and Gunson in thisiss

cocusenriabeclepoothorexeticlievisThapringmetruare

Re1.

2.

3.

4.

5.

6.

7.

8.

9. Motta AT, Cevidanes LH, Carvalho FA, et al: Three-dimensional regional displacements after mandibular

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

95Condylar Degeneration and Diseasesue).The topic of postoperative and idiopathicndylar resorption was introduced and dis-ssed briefly in this article, but it was not pre-ted in detail because of the volume of mate-l that would need to be covered,40-47 and alsocause it is discussed thoroughly in other arti-s in this issue. Very often, the response tostoperative condylar resorption (CR) is an-er recommendation of either orthognathicTMJ surgery (or both), rather than a carefulamination of what may have been potentialologies of the postoperative event. When thenician is confronted with the unfortunateent of postoperative condylar degeneration, itimportant to react as logically as possible.erefore, we hope that we have at least providedframework to facilitate a more thoughtful ap-oach to dealing with these events, thereby lead-

to appropriate diagnostic and therapeuticthodologies. Although some of the cases arely mysterious and idiopathic, not all of them.

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Condylar Degeneration and DiseasesLocal and Systemic EtiologiesLocalized Etiologic FactorsOsteoarthritisDescriptionPhysical ExaminationRadiographic FeaturesTreatment

Functional LoadPhysical ExaminationRadiographic FeaturesCase example

Traumatic InjuryDescriptionPhysical ExaminationTreatment

Case Presentation: Use of a Unilateral Hyperpropulsion Appliance

Systemic Etiologic FactorsRheumatoid ArthritisClinical FeaturesRadiographic FeaturesTreatment

Juvenile Idiopathic ArthritisClinical FeaturesRadiographic FeaturesTreatment

ConclusionsReferences