CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART THREE

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doidylar head(s) seen on MRI is not supportive.Another theory is that avascular necrosis of the

condyle is the causative factor in ICR with condylysis,followed by loss of condyle height, jaw deformity,and malocclusion. Supporters of this theory suggestthat surgical revascularization of the condyle wouldbe a useful form of therapy. They believe that patho-logical compressive forces of the posterior aspect ofthe condyle on the ligamentous retrodiscal soft tissuesconstrict the small vessels, limiting circulation to the

gery Foundation), Craniofacial/Maxillofacial Surgery, Posnick

ter for Facial Plastic Surgery, Chevy Chase, MD; and Assistant

fessor of Oral and Maxillofacial Surgery, University of Rochester

dical Center, Rochester, NY.

Address correspondence and reprint requests to Dr Posnick:

0 Wisconsin Avenue, Suite 1250, Chevy Chase, MD 20815;

ail: jposnick@drposnick.com

007 American Association of Oral and Maxillofacial Surgeons

8-2391/07/6508-0028$32.00/0

:10.1016/j.joms.2007.03.026

1617Idiopathic CondylarClinical Pe

Jeffrey C. Posnick

Joseph J. Fantu

the condition of unknown origin known as idio-thic condylar resorption (ICR), the condyles of thendible partially resorb, causing a loss of condylaright and alteration of the maxillofacial morphologyd occlusion.1-5 Progressive condylar resorptionR) is a more general term describing conditionsulting in loss of condylar height, including those ofown etiology (eg, juvenile rheumatoid arthritis, lu-s erythematosis, trauma, steroid use).6-9

In general, ICR has the following features:1-10

Most often affects females age 15 to 35 years. May be more frequent in teenage girls during thepubertal growth spurt.

Generally results in bilateral and symmetric con-dylar involvement.

Results in progressive condylar resorption fol-lowed by stabilization without further loss ofcondylar height. The only way to be certain thatthe process is arrested is by documenting thatthe condyles have resorbed down to the sigmoidnotch.

Has no consistent or proven inciting event oretiology. ICR frequently occurs in the naturalcourse of events, not in conjunction with activetherapy. It also may coincide with or be observed

Director, Posnick Center for Facial Plastic Surgery, Chevy Chase,

; Clinical Professor of Surgery and Pediatrics, Georgetown Uni-

sity, Washington, DC; and Adjunct Professor of Orthodontics,

iversity of Maryland, Baltimore College of Dental Surgery, Balti-J Oral Maxillofac Surg65:1617-1623, 2007

sorption: CurrentpectivesD, MD,* and

DDS, MD

during or after active dental restorative, orth-odontic, or surgical interventions.11-22

Results in generally good temporomandibularjoint (TMJ) function without significant limita-tion in vertical opening or disabling pain. Duringthe active phase of resorption, some TMJ discom-fort and muscle hyperactivity is expected. Persis-tent joint noise is frequent, but an intact cartilag-inous cap is generally seen on magneticresonance imaging (MRI) over the deflated ordiminished condylar head once resorption hasceased.23

Maxillofacial morphological findings generally in-de the following:1-10

Change in shape of the condylar heads (ie, flat-tening and thinning)

Decrease in condylar height Loss of overall posterior facial height Mandibular retropositioning Angle Class II anterior open bite malocclusion.

Various theories on the origin of ICR have beenoposed. One theory holds that the etiology of ICR isrmonally mitigated. Sex hormones are thought todulate biochemical changes within the TMJ, caus-hyperplasia of the synovial tissue, which results in

ndylar resorption.Adherents to this theory recommend an open jointocedure with removal of the affected synovium toevent progression of ICR.10 Skeptics believe thatlack of documented synovial inflammation and

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1618 IDIOPATHIC CONDYLAR RESORPTIONndyle and resulting in aseptic necrosis. They alsolieve that chronically dislocated nonreducing discmalocclusion can be causative factors in this cycleevents.26-29 Those skeptical of the nonreducingc risk factor for ICR point out that the almostiversally observed bilateral symmetric simultaneousture of this condition make it an unlikely etiology.4

The foregoing theories remain unproven, and it ist as likely that an as-yet undefined etiology or com-ation of events better explains the cause of ICR.me clinicians suggest that with no certainty abouther the etiology or the endpoint of ICR in any giventient, removal of the affected condyle and recon-uction with a costochondral (rib) graft or alloplasttal joint replacement) is the preferred (or at leastonly sure) method of management.30-37 Propo-

nts of joint replacement to manage ICR are correcttheir thinking that the only way to be certain thatndylar resorption will not continue and result inther alteration of mandibular morphology and oc-sion is to replace the joint. Given the limited long-m TMJ pain, good long-term mandibular range oftion, and inevitable condylar stabilization (burn-t) typically seen in patients with ICR, this ap-oach seems radical to most clinicians.Recommendations for the prevention and treat-nt of ICR depend on the clinicians belief about theorders etiology and pathophysiology. Most of thenical recommendations given in the literature at-pt to limit mechanical (compressive) TMJ forcesthe hopes that less resorption (condylysis) willcur.27-29,38 Despite a lack of evidence-based re-rch to support these treatment recommendations,pectrum of clinical opinions and statements can bend in the literature. Some authors believe that ICRy be more common in individuals with high-gle mandibular retrognathism (angle Class II ante-r open-bite malocclusion).39 Others believe thats morphology is the result of ICR rather than theuse of it. Still others believe that ICR may occur orogress more frequently when the TMJ is loaded.nical settings of TMJ loading might include com-essive orthodontic, surgical, or dental forces, oftenthe presence of a developmental or acquired mal-clusion.After orthognathic surgery, ICR may be more likelyprogress in the setting of increased condylar load-, abnormal disk displacement, and/or pressure oncondyles during the immobilization phase of treat-nt. ICR may be more frequent after orthognathicrgery, when posteriorization and medial and/oreral condylar torquing occur.11-22,40,41

To limit the progression of ICR or at least diminishscle hyperactivity, stabilization of the TMJ (by, eg,nloading splint therapy, use of muscle relaxantsd/or anti-inflammatory agents) preceding definitiveclusal correction (ie, orthodontics, restorative den-try, and/or corrective jaw surgery) may be useful.1-5

limit progression of condylar resorption in ICR,orthodontic, surgical (orthognathic), or dental

torative correction of the malocclusion shouldive to achieve noncompressive forces on the con-les.1-5,39

The earlier in the clinical course of ICR that decom-essive TMJ treatment is initiated, the less condylarorption may occur.42 Others believe that once theorptive process has begun, it will run its coursespite treatment.43,44

Some authors believe that performing counter-ckwise rotation of the occlusal plane as part of thehognathic (surgical) correction may increase com-essive condylar forces, with the risk of ongoingR.22,41 Skeletal stability after these surgical maneu-rs in non-ICR patients has been documented.45,46

me have suggested that correction of the mandib-r deformity associated with ICR using distractionteogenesis (DO) techniques may cause further in-y to the TMJ, whereas others have come to theposite conclusion.47-51

ICR patients with persistent TMJ symptoms (pop-g, clicking, limited opening) after treatment oflocclusion (eg, orthodontic, corrective orthog-thic surgery, restorative dentistry) may be at in-ased risk for progression.11-22,52,53

rrent Perspectives andinical Approach

Once the diagnosis of ICR is made, splint therapy tonload the condyles may be helpful to preventogression or at least relieve discomfort and muscleperactivity. In the absence of a more completederstanding of the ICR disease process, it is best tostpone definitive occlusal treatment (orthodontics,rrective jaw surgery, or restorative dentistry) untilre is sufficient evidence indicating that the condy-resorption has burnt out.Orthognathic (corrective) jaw surgery, orthodon-s, and/or restorative dentistry to definitively correctlocclusion is more likely to be successful if condy-resorption has been stable for at least 1 year beforeatment and if an intact cartilaginous cap over theorbed condyle is confirmed. Tc 99m MDP quanti-ive condylar bone scintigraphy can be a useful toolassess whether or not condylysis is active.54-62

fortunately, false positives and false negatives maycur. Evaluating the cartilaginous integrity of thendylar head surface by MRI may be helpful.In end-stage ICR, maxillofacial dysmorphology mayect mastication, speech articulation, breathing, andclosure. ICP rarely results in disabling pain orited vertical mouth opening. Once condylar re-

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POSNICK AND FANTUZZO 1619rption is assumed to have reached an endpoint (ie,nprogression for at least 1 year), any further changeorsening) in maxillofacial dysmorphology is un-ely. For these reasons, preventive joint resectiond replacement with either an autograft (rib) orograft (total joint prosthesis) is rarely indicated.The unfavorable facial esthetics observed in sometients with ICR result from the skeletal dysmorphol-y, which then results in secondary distortions ofsoft tissue envelope. The soft tissues of the lips,

eeks, and neck can be normalized only by correct-the skeletal deformities. Achieving acceptable fa-l esthetics often requires surgical repositioning ofmaxilla (Le Fort I), mandible (ramus osteotomies),

d chin (oblique osteotomy). Limiting the surgery toher the maxilla or mandible with the idea of achiev-a more stable result is not substantiated in therature and is likely to result in suboptimal esthet-.The suggestion that using DO rather than classichniques to surgically reposition the mandible inR will achieve a more stable long-term result is notpported by the literature. The DO approach alsoits the region of reconstruction to the mandible,uires greater patient compliance, and frequentlyds to a suboptimal esthetic result.The key to a favorable result for an individual withd-stage ICR or PCR is to define the esthetic andctional abnormalities, understand the patients ob-tives, and then successfully perform orthognathicocedures and dental rehabilitation. A team ap-oach involving an orthodontist, an orthognathicrgeon, and a TMJ specialist is essential to achievetimal results. Periodontal and restorative dentalrk also may be needed.

se Presentations

CASE 1: PROGRESSIVE CONDYLAR RESORPTION

HistoryThis patient was a 23-year-old Caucasian femaleth juvenile rheumatoid arthritis (JRA) diagnosed ate 10 affecting primarily the knees and ankles. JRAolvement of both TMJs beginning at age 12 resultedrapidly progressive PCR that remained unchangedrnt out) for at least the past 5 years. She reportedin-free satisfactory range of motion of both TMJs.ere has been minimal TMD since age 15.At age 19, she sustained trauma to the maxillary 4isors, with loss of the right lateral incisor and theed for RCT and crown placement of the right cen-l incisor. Temporary restorations were in place.

EvaluationThe patient arrived for consultation with the hopeachieving improved facial esthetics and functionastication, breathing, lip posture, and speech artic-tion). She underwent additional evaluation by aeech pathologist, an otolaryngologist/head andck surgeon, an orthodontist, a periodontist, a re-rative dentist, a rheumatologist, and a TMJ special-.

TreatmentPreoperative orthodontic treatment included re-val of the mandibular first bicuspid teeth to un-wd the arch and upright the incisors. Unfortu-tely, due to previous dentoalveolar trauma, onlynimal repositioning of the maxillary anterior teeths possible, preventing optimal incisor positioning.The surgical plan for this patient included the fol-ing:

Maxillary Le Fort I osteotomy, involving verticalintrusion at the incisors (1 mm), counterclock-wise rotation of the maxillary plane (1 mm), andhorizontal advancement at the incisors (4 mm)

Bilateral sagittal split osteotomies of the mandibleto occlude the mandibular dentition into themaxillary dentition, with counterclockwise rota-tion of the mandibular plane

Oblique osteotomy of the chin, with horizontaladvancement (6 mm) and vertical shortening (2mm)

Septoplasty and reduction of the inferior turbinates,to manage chronic obstructive nasal breathing.

After initial healing (5 weeks), finishing orthodon-s continued for 3 months. Removal of orthodonticpliances was followed by preventative splint ther-y and orthodontic retention (removable retainers)ed primarily while sleeping.Figure 1 shows the patient before and 1 year afterhodontics and jaw surgery. Preoperative panorexd preoperative and postoperative lateral cephalo-tric radiographs are shown. Final maxillary restor-ve dental work is to be completed.

CASE 2: IDIOPATHIC CONDYLAR RESORPTION

HistoryThis systemically healthy 11-year-old girl experi-ced severe TMJ discomfort with limited and painfuluth opening. Mandibular retrusion and anterioren bite deformity were progressive. At age 13, thetients orthodontist offered a combined orthodon-/orthognathic approach versus maxillary first bicus-extractions with orthodontic treatment only to

utralize the bite. The family chose orthodonticatment only. From age 13 to 15, orthodontic treat-nt progressed with a resulting neutralized bite. Ate 16, concerned about facial esthetics, airway and

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1620 IDIOPATHIC CONDYLAR RESORPTIONURE 1. Case 1. A, Frontal views in repose before and 1 year after surgery. B, Frontal views with smile before and 1 year after surgery. C,lique views before and 1 year after surgery. D, Profile views before and 1 year after surgery. E, Occlusal views before, 5 weeks, and 1 yearr surgery. F, Panorex view before surgery. G, Model surgery planning. H, Lateral cephalometric views before and after surgery.

nick and Fantuzzo. Idiopathic Condylar Resorption. J Oral Maxillofac Surg 2007.

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POSNICK AND FANTUZZO 1621URE 2. Case 2. A, Frontal views in repose before and 1 year after surgery. B, Frontal views with smile before and 1 year after surgery. C,lique views before and 1 year after surgery. D, Profile views before and 1 year after surgery. E, Occlusal views before and 1 year after surgery.anorex view before surgery. G, Model surgery planning. H, Lateral cephalometric views before and after surgery.

nick and Fantuzzo. Idiopathic Condylar Resorption. J Oral Maxillofac Surg 2007.

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1622 IDIOPATHIC CONDYLAR RESORPTIONriodontal health, the family chose redo orthodon-s, including mandibular bicuspid extractions andhognathic surgery.

EvaluationA complete workup for systemic joint disease wasgative. The patient underwent evaluation by aeech pathologist, a otolaryngologist/head and neckrgeon, and her general dentist. She was found tove a deviated septum and hypertrophic inferiorbinates, with difficulty breathing through the nose.age 16, she was pain free in the TMJ and facialion, with good vertical mouth opening and noogressive condylar resorption for at least the pre-ding 2 years. Radiographs confirmed no furtherogression of condylar resorption.

TreatmentPreoperative redo orthodontic treatment includedoval of the mandibular first bicuspid teeth to un-wd the arch and upright the incisors. The surgicaln included the following procedures:

Maxillary Le Fort I osteotomy, involving verticalintrusion at the incisors (1 mm), counterclock-wise rotation of maxillary plane (1 mm), andhorizontal advancement at the incisors (4 mm)

Bilateral sagittal split osteotomies of the mandibleto occlude the mandibular dentition into themaxillary dentition, with counterclockwise rota-tion of the mandibular plane

Oblique osteotomy of the chin, with horizontaladvancement (6 mm) and vertical shortening (1mm)

Septoplasty and reduction of the inferior turbi-nates, to manage chronic obstructive nasalbreathing.

After initial healing (5 weeks), finishing orthodon-s continued for 6 months. Removal of orthodonticpliances was followed by the use of routine remov-le retainers. Figure 2 shows the patient before andear after completion of orthodontics and jaw sur-ry. Preoperative panorex and preoperative andstoperative lateral cephalometric radiographs areown.

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Idiopathic Condylar Resorption: Current Clinical PerspectivesCurrent Perspectives and Clinical ApproachCase PresentationsCASE 1: PROGRESSIVE CONDYLAR RESORPTIONHistoryEvaluationTreatment

CASE 2: IDIOPATHIC CONDYLAR RESORPTIONHistoryEvaluationTreatment

References