Idiopathic condylar resorption part 2

Orthodontic management
of idiopathic condylar
resorption
part 2
Dr Maher Fouda
professor of orthodontics
Mansoura Egypt

Reference:Idiopathic Condylar
Resorption What Should We Do?
Louis G. Mercuri, DDS, MSa,b,
Chester S. Handelman, DMDc,
Oral Maxillofacial Surg Clin
N Am 32 (2020) 105–116

Idiopathic Condylar Resorption What Should We Do? Louis G.
Mercuri, DDS, MSa,b, Chester S. Handelman, DMDc,
Oral Maxillofacial Surg Clin N Am 32 (2020) 105–116
Orthodontic treatment:
this is contrainicadted
during the active phase
of ICR. First, it could
accelerate condylar
resorption and second
it
would expose the
orthodontist to litigation
if the ICR progresses.
Sometimes significant osteoarthritic
changes occur in only one joint.
When this happens rapidly, the
affected condyle can collapse,
resulting in a shifting of the mandible
to that side. This is referred to as
idiopathic condylar resorption

The loss of
condylar
support in the
right condyle
caused a shift
to the right, so
that only the
right second
molar is
contacting

Once the ICR is in
remission, orthodontic
treatment without
follow-up jaw surgery
is feasible in only a few
patients with ICR—
those
with moderate skeletal
and occlusal
discrepancies.
In this patient there has been a midline shift to
the patient’s right. This shift is evident even in
the relationships of the posterior arches. This
idiopathic condylar resorption was isolated to
the patient’s right condyle.

Their condylar
resorption usually
started
after growth
completion and
their condition may
better be described
as “degenerative
joint
disease.”
A cone beam CT of the right condyle
showing the degenerative changes

Most patients with ICR
present with considerable
condylar destruction with
resulting soft tissue
disfigurement and extreme
Class II open
bite malocclusions and
require comprehensive
orthognathic surgical
procedures.

In all cases
before surgery
orthodontic
treatment is
required
to align the teeth in
both jaws for
maximum occlusion
following
repositioning of one
or both
jaws.
Progressive idiopathic
condylar resorption:
Three case reports
American Journal of
Orthodontics and
Dentofacial Orthopedics
October 2019 Vol 156 Issue 4

CASE REPORT :
Diagnosis A 19-
year-old female
presented with
incompetent lips
and retruded
mandible .

CASE REPORT :
Diagnosis In the
panoramic view,
flattening of the
condylar heads
were remarkable on
both TMJ, which
was confirmed in
the three-
dimensional
computed
tomography .

Temporomandibular joint three-dimensional
computed tomography

CASE REPORT :
Diagnosis Initial
intra-oral views
exhibited
crowding in the
upper and lower
incisors and Class
II molar
relationship on
the right side .

Arch length discrepancy
was 6.0 mm in both
arches. The upper
denture midline was
deviated 1.0 mm to the
right, and lower dental
midline was deviated
1.5 mm to the left,
respectively, relative to
the facial midline. Mild
soft tissue chin
deviation to the left was
also noted.

Initial cephalometric
analysis revealed a
Class II skeletal pattern
(ANB = 8.9°) with high
mandibular plane
angle (49.7°) [Figure 4].
Asymmetric molar
relation with Class II
molar on the right side
and incisor fl aring (U1
to SN = 112.3°, IMPA =
105.8°) were also
found.

Treatment objectives
Reflecting the patients’
demand and the
severity of the
treatment objectives
for this case included:
1. Improvement of soft
tissue profi le, 2.
Elimination of lip
incompetency, 3. Relief
of upper and lower
anterior crowding,

Treatment
objectives 4. Axes
correction of
upper and lower
incisors, 5.
Establishment of
Class I molar and
canine key, 6.
Establishment of
proper overjet
and overbite and
7. midline
correction.

Treatment alternatives
Surgical repositioning of
the mandible may be the
treatment of choice to
restructure the severe
mandibular retrusion and
related anterior
protrusion. However, the
mandible exposed to
invasive surgical
relocation may be subject
to relapse
or recurrence of the
condylar resorption.

Alternatively,
considering the
amount of crowding
and lip protrusion,
nonextraction
camouflage
treatment was
excluded for the
possible flaring of
incisors creating
more protrusive lip
profile.

Alternatively, However,
orthodontic camouflage
involving extraction of
premolars may also lead
to insufficient profile
changes, due to the
limitation of anterior
retraction and Class II
molar relation.
Therefore, an
orthodontic camouflage
to address greater profile
changes was to be
designed.

Treatment plan Considering
the amount of crowding
and protrusion, extraction
of the upper and lower first
premolars was planned.
Even with the anterior
retraction under maximum
anchorage, residual
protrusion and lip
incompetency was
anticipated because of
short upper lip and severe
mandibular retrusion.

Therefore, not
only posterior
retraction of
anterior teeth, but
total arch
intrusion was
needed to induce
anterosuperior
autorotation of
the mandible.

Taken together,
extraction of the
upper and lower fi rst
premolars and 8 mm
retraction of anterior
teeth using
asymmetric
distalization of the
upper right, upper left
and lower left molars,
and additional total
arch intrusion were
planned.

Using dual miniscrews
close to the estimated
center of resistance of
the upper dental arch,
simultaneous
distalization and
intrusion of the total arch
was planned, to produce
posterosuperior force
vector(s) using dual
miniscrews at each
quadrant.

To obtain
maximum
rotation of the
mandible,
application of the
posteroinferior
force vector was
also decided using
additional
miniscrews in the
mandible . Visual treatment objective and occlusogram

Treatment progress
Extraction of 4
bicuspids (all first
premolars) and all
the third molars
was performed for
anterior teeth
retraction.
Treatment progress: Leveling and alignment stage

From the initial
stage, four
miniscrews were
placed on buccal
interproximal area
between maxillary
second premolar,
maxillary fi rst
molar and second
molar, bilaterally.
Treatment progress: Leveling and alignment stage

Using these
miniscrews, intrusive
distalization of
maxillary posterior
segment and canine
separate retraction
were done using
round 0.016˝
stainless steel
archwire.
Treatment progress: Total distalization and intrusion
using multiple miniscrews

Additional two
miniscrews were placed
on buccal interproximal
area between
mandibular first molar
and second molar,
bilaterally for intrusive
buccal uprighting of
mandibular molars .
Treatment progress: Total distalization and
intrusion using multiple miniscrews

Following the overall
leveling and alignment at 8
months, maxillary and
mandibular total arch
intrusion was commenced
with posterior-superior
force vector using four
miniscrews placed in each
arch and 0.016˝ × 0.022˝
stainless steel with 10°
palatal root torque on
anterior teeth.
Treatment progress: Total distalization and intrusion using
multiple miniscrews

Additional
mandibular
miniscrews
were also
inserted on the
mesial side of
the second
premolar .
Treatment progress: Total distalization and intrusion using
multiple miniscrews

Occlusal settling was
done with 0.016˝
stainless steel archwire
and vertical elastics
[Figure 8]. After bracket
removal, lingual fi xed
retainer and
circumferential
removable appliance was
delivered for retention.
Treatment progress: Settling of occlusion

Treatment
results :
Lip
protrusion
and
incompetenc
y were
relieved .
Posttreatment intra-oral photographs
Posttreatment extra-oral photographs
Posttreatment panoramic view

Treatment results In
the cephalometric
assessment, the
upper and lower
incisors were
retracted by 10 mm
and 8 mm,
respectively through
controlled tipping
(U1 to SN angle
reduced 17.9°, IMPA
reduced 8.9°) .
Posttreatment lateral cephalogram

The upper molars were
distalized and intruded by 2
mm, resulting in a counter-
clockwise rotation of
mandible. The SN to
mandibular plane angle was
reduced by 2.4° and soft tissue
profi le at chin area was
improved. The roots were
parallel except upper canines,
and slight root blunting of
incisors was observed. Superimposition of lateral cephalogram (Blue: Pretreatment,
Red: Posttreatment)

Orthognathic surgery: surgery places an enormous
functional demand on the compromised
adaptive capacity of even the healed condyle.
One approach is to delay surgery until the patient
is in the mid-twenties when the so-called burn
out stage has occurred.

Variable postsurgical
relapse may still occur. Patients
with the usual disfiguring
malformation associated with
ICR often
wish correction before the
college years when
the disease may still be active.

There are several
papers that indicate that
30% of women following
orthognathic surgery
for Class II open bite
develop
postsurgical relapse of
variable amounts of the
correction.

Medical management with orthognathic surgery:
Arnette and Gunson have proposed pharmacologic
and physiologic control of the resorptive process
for a period of time both before and after
orthognathic reconstruction.

Medical management with orthognathic surgery:
They recommend
antiinflammatory medication such as the nonsteroidal
antiinflammatory drugs (Naproxen, Celebrex,
Feldene), vitamin D and calcium
supplementation (both of which are known to increase
bone density), and an antioxidant diet.

When pursuing the medical management route
proposed by Arnett and Gunson, it is essential
that a colleague rheumatologist with an
understanding
of this pathology prescribe and monitor
any biological medication such as methotrexate
or etanercept used as part of this regimen.

Gunson and Arnette have
reported success in
individual
cases using these
procedures. The advantage
of medical management of
TMJ surgery is
lifetime maintenance of the
patient’s own TMJ.

Surgical management of ICR using total alloplastic
temporomandibular joint replacement (TMJR):
the presence of an adverse mechanical and biological
environment promoting osteoclastic pathologic
activity over osteoblastic activity as found
with ICR compromises the surgical options of
autogenous reconstruction with a costochondral
graft, orthognathic surgery,and/or distraction
osteogenesis.

Wolford and Gonc¸ alves reported a protocol using
salvageable intraarticular discs. The protocol
includes removing the tissue pathology from the
joint, repositioning and stabilizing the disc to the
condyle with a Mitek anchor bimaxillary surgery with
counterclockwise rotation of the maxillomandibular
complex, and other adjunctive procedures
such as turbinectomy and genioplasty.

However,
these investigators stated that the results using
this protocol are best when it is used within 4 years
of ICR signs and symptoms and most importantly,
when the articular disc is intact. After 4 years,
discs in this disease may become significantly
deformed or fragmented and are unsalvageable.
In such cases, the investigators recommend
alloplastic
TMJ replacement.

It seems that an ICR
surgical management
option
that does not depend on
the compromised
mechanical and biological
adaptive capacity of
the TMJ and surrounding
tissues should be
considered.

Total alloplastic TMJ replacement,
because it is a biomechanical rather
than biological
solution to the management of
anatomically
distorted dysfunctional joints resulting
from pathology
or end-stage disease, provides such an
option.

Individually customized patient-fitted
TMJR fossa and ramus (condyle) components
are designed and manufactured from a stereolithic
model generated from the patient’s protocol
computed tomographic scan data to mimic the
anatomic contours of the structures they are
intended to replace .

Image of custom TMJR
on stereolithic model.
Fossa component is
ultrahigh molecular
weight polyethylene
bearing surface backed
by a commercially
pure titanium mesh.
Ramus component is
titanium
alloy with a cobalt
chrome molybdenum
condylar
head. Screws are
titanium alloy .

At implantation, these
TMJR components are
adapted and fixed in a
stable and close fashion
to the bony surfaces of
the temporal bone and
mandibular ramus.

There is always a component of counterclockwise
mandibular rotation in the surgical management
of ICR.

remnant after orthognathic surgery or distraction to
withstand the muscle and other soft tissue forces
generated by such movements under functional
loading short or long term seems fraught with the
potential for relapse if one considers the effects of
muscle forces on bone. The long-term stability
using TMJR in the management of ICR cases is
well documented (Table 1).
Expecting an avascular autogenous
rib graft or an ICR-compromised condyloid process

The relative disadvantages of
TMJR include (1)
cost of the device; (2) material
wear and failure;
3) uncertainty about long-
term stability; and (4)
the fact that alloplastic
implants will not follow a
patient’s growth.

Considering the demographics of ICR/PCR,
longevity of any TMJR must be an important
consideration. Because this is a biomechanical
rather than a biological solution, future planning
must be made for revision surgery to remove
scar tissue from the articulating components of
the implant. Eventually replacement of the implant
over time due to material wear and/or failure may
be required.

At present, patients are advised that
these devices may have a functional
life span of
10 to 15 years based on the
orthopedic experience
in total joint arthroplasty and recent
TMJR
long-term outcomes results.

At present, patients are
advised that
these devices may have a
functional life span of
10 to 15 years based on
the orthopedic experience
in total joint arthroplasty
and recent TMJR
long-term outcomes
results.

CASE EXAMPLE
A 15-year-old girl
presented from her
orthodontist
with a chief complaint of
progressive bilateral TMJ
pain and increasing
anterior open bite over the
past 2 years

Her past medical history
was unremarkable except
for dysmenorrhea
managed with b-estradiol
medication. Rheumatoid
workup was negative.

Physical examination revealed decreased
maximal interincisal opening (MIO), mandibular
retrognathia, anterior open bite, steep mandibular
and occlusal planes, and bilateral TMJ and
masticatory
muscle pain to palpation. Orthopantomogram
demonstrated loss of condylar bone stock
bilaterally . Cephalometric imaging
confirmed the clinical findings .

A diagnosis of progressive
condylar resorption
was made and a management
plan was designed
to include bilateral TMJ
replacements with patient
fitted
alloplastic prostheses (TMJ
Concepts, Ventura,
CA) as well as an
advancement genioplasty.

Six years postoperatively, she has good
mandibular function, facial form, stable and
repeatable occlusion, and no complaints of joint
pain . Orthopantomogram and
cephalometric imaging demonstrate good
positioning of the TMJ replacement components,
good facial form, as well as stable skeletal
and occlusal relationships .

This is a 15-year-old who
presented
from her orthodontist
with a
chief complaint of
increasing bilateral
temporomandibular joint
pain and
increasing anterior open
bite. Her
past medical history was
unremarkable
except for dysmenorrhea
managed with birth
control medication.
Rheumatoid work-up
was
negative.

Orthopanto
mogram
demonstrat
ed
bilateral
condylar
resorption.

A diagnosis of progressive
condylar (PCR) resorption was
made and a management plan
was designed to
include bilateral
temporomandibular joint
replacements with patient-fitted
alloplastic prostheses (TMJ
Concepts,
Ventura, CA) as well as an
advancement genioplasty. 6
years post-operatively, she has
good mandibular function,
facial form, stable and
repeatable occlusion and no
complaints of joint pain.

6-year
post-
operative
orthopan
tomogra
phic
images.

6-year post-
operative
cephalometric
image
reveal
improved
maxillomandi
bular
relationships.

CASE REPORTS
Patient 1
A woman 19 years
1 month of age
presented for
consultation
regarding possible
orthodontic
treatment
for complaints of
“crooked teeth”
and TMJ pain.
B, Facial photograph
reveals a convex
profile and lip
incompetency in
repose.
Class III subdivision left
malocclusion and moderate
crowding. The lower midline
was deviated to the right

CASE REPORTS
Patient 1
Her
TMJ pain problems
began at age 16. At
17, she had
conservative
treatment with
occlusal appliance
therapy,
physiotherapy, .
muscle relaxants,
and NSAIDs.
Class III subdivision left
malocclusion and moderate
crowding. The lower midline
was deviated to the right
Her profile
was convex,
and her lips
were
incompetent in
repose

What are the aims
of physiotherapy?
· To reduce pain
· To minimise
stiffness
· To restore
function
· To teach
management
strategies

Physiotherapy can be used to
treat TMD by reducing pain
and inflammation in the joint
and improving the movement
and function of your TMJ. As
in other cases, physiotherapy
treats TMD in a holistic
manner: Looking at both the
TMJ and the other
surrounding body parts that
are contributing to the
problem.

Some common exercises
used by physiotherapists
include:
•Posture correction
•Jaw movement exercises
•Manual therapy including
massage, stretching, and
joint mobilization
•Laser and ultrasound
treatments
•Relaxation training

Since TMD and its
treatment options
involve the mouth
and jaw
physiotherapist may
also consult with the
dentist or
orthodontist when
they are crafting
individual treatment
plan.

A year
later, she was
diagnosed with
disc
displacement
without
reduction,
limiting jaw
opening to 20
mm.

TMJ anterior
disc
displacement
without
reduction
(ADDwoR).

Disc displacement
Disc displacement of the TMJ is a condition whereby the articular disc
is displaced from its normal functional relationship with the condylar
head and the articular fossa of the temporal bone ( Fig. 1 ). Disc
displacement is considered to have 4 clinical stages.
•• Stage I (disc displacement with reduction): the articular disc is
displaced in closed-mouth position, and reduces to normal
relationship, that is, the central narrow zone of the disc is in contact
with the condylar head and articular eminence, in open-mouth position
•• Stage II (disc displacement with reduction with intermittent locking):
the disc is displaced in closed-mouth position, and intermittently locks
in open-mouth position
•• Stage III (disc displacement without reduction): the disc is displaced
in closed-mouth position, and does not reduce to normal contact in
open-mouth position (also referred to as closed lock)
•• Stage IV (disc displacement without reduction): the disc is displaced
and does not reduce, with perforation of the disc or posterior
attachment tissues

Relationship between bone and
articular disc of the
temporomandibular joint. ( A )
Normal disc location in closed-
and open-mouth position. In the
closed-mouth position, the
posterior band of the articular disc
is located between 11:30 and 12:30
of a clock face. The central narrow
zone of the disc is in contact with
the condylar surface and the
articular fossa. In the open-mouth
position, the central narrow zone
of the disc remains in contact with
the condylar head and the articular
eminence

( B ) Disc displacement with
reduction. In the closed-
mouth position, the posterior
band of the articular disc is
displaced anterior to 11:30.
The central narrow zone of the
disc is not in contact with the
condyle or the articular fossa.
In the open-mouth position,
the central narrow zone of the
disc is in contact with the
condylar head and articular
eminence

( C ) Disc displacement
without reduction. In the
closed-mouth position, the
posterior band of the
articular disc is displaced
anterior to 11:30. The central
narrow zone of the disc is
not in contact with the
condyle or the articular
fossa. In the open-mouth
position, the disc is
anteriorly displaced, and
may assume a normal
biconcave shape or become
deformed.

Temperomandibular joint displacement,
also known as internal disc derangement,
is an abnormal relationship between the
articular disc, the mandibular condyle and
the mandibular fossa. The most frequent
displacement of the disc is anterior to the
mandibular condyle however, in rare
cases it can be posteriorly. The prognosis
for these conditions is good and normally
recover with minimal intervention or
conservative management.

Imaging studies have
demonstrated that a more
anterior disc position is
relatively common in the
asymptomatic
population. It is also
thought that in the
majority of people the TMJ
adapts to the disc position
and rarely produces pain
from being in a different
position.

Symptoms
•Pain or discomfort associated with anyone or combination
of: chewing, yawning, talking, bruxism[5]
•Headaches
•Ear pain
•TMJ range of movement may be restricted
•Crepitus/clicking during movement of the jaw
•Pain or discomfort can be acute or chronic that can
fluctuate in intensity.
•Emotional issues such as depression is commonly
associated with TMJ pain
Duration of symptoms may vary from hours to days

1.Disc displacement with reduction
(DDWR): The articular disc displaces
anteriorly to the condylar head, when the
mouth is opened the disc relocates on
the the condylar head.
1.Hearing and palpating joint noises
during opening and closing
2.Protrusive opening and closings
stops the reciprocal click
3.There is unlikely to be any
restriction in ROM due to the disc
relocating when the mouth opens

Disc displacement
with reduction
(DDWR). A:
Articular disc
anteriorly
displaced with
retrodiscal fibrosis
(red arrow); B:
Reduced disc,
retrodiscal fibrosis
(red arrow)

An oral surgeon
did an infiltration of a
local anesthetic with
epinephrine and 40 mg
triamcinolone (40
g/mL). Disc
reduction was
observed after
infiltration, with an
interincisal
opening of 35 mm. TMJ
and myofascial pain
continued despite this
treatment.
Her profile
was convex,
and her lips
were
incompetent
in repose

TRIAMCINOLONE is a
corticosteroid. It helps
to reduce swelling,
redness, itching, and
allergic reactions.
This medicine is used
to treat allergies,
arthritis, asthma, skin
problems, and many
other conditions
Most people
can open their mout
h 35 to 55
millimeters

She went to a
second oral
surgeon for
consultation,
and a month
later bilateral
TMJ
arthrocentesis
was
performed.
Her profile
was convex, and
her lips were
incompetent in
repose

TMJ / Jaw Joint
Arthrocentesis (the
washing out of the jaw
joint space) is a procedure
during which the jaw
joint is washed out with
sterile saline ± anti-
inflammatory steroids,
long-acting local
anæsthetics, painkillers
or collagen components.

TMJ / Jaw Joint Arthrocentesis of the (upper) joint
space reduces jaw joint pain by
•diluting / flushing out the inflammatory
chemicals from the jaw joint
•increasing mandibular (lower jaw) movements
by removing intra-articular adhesions (scarring within
the joint
space)
•eliminating the negative pressure within the jaw joint
recovering disc and fossa space and
improving disc mobility (return the disc of cartilage to its
normal position
within the joint) which reduces the
mechanical obstruction caused by the anterior (forward)
position of the disc.
The majority of restricted opening is secondary to upper
joint space problems, particularly ‘anchored disc’
phenomenon, where arthrocentesis is particularly
beneficial

•Indications for arthrocentesis
are:
dislocation of the articular
disc ± reduction
•limitations of mouth opening
originating in the jaw joint
•joint pain and other internal
derangements of the TMJ

One month
later, she had
persistent
pain in the
masseters
and both
joints and
limited mouth
opening.
Her profile
was convex, and
her lips were
incompetent in
repose

A third oral
surgeon then
infiltrated 200
U Botox
(dilution 100
U/mL) into
masseter
muscle
trigger
points.
Her profile
was convex, and her lips
were incompetent in
repose

Injection
sites of
the
botulinum
toxin, 3
sites per
masseter
and 2 per
temporalis
muscles.
BTX should be
considered as an
alternative treatment for
TMD when other
conservative methods
fail to yield satisfactory
results.
Assessing the effectiveness of
botulinum toxin injections into
masticatory muscles in the
treatment of temporomandibular
disorders
J Oral Med Oral Surg 2018;24:107-111

This was
followed
in 1 month
by
infiltration
of 1 mg
Decadron
into each
masseter.
Injection of the masseter
muscle

Clinical examination
revealed a Class III
subdivision
left dental
relationship,
moderate crowding,
and the
lower midline
deviated to the right.
Her profile
was convex,
and her lips
were
incompetent
in repose

The cephalometric
analysis demonstrated
a dentoalveolar
bimaxillary
A, Lateral cephalogram shows a hyperdivergent
short ramus, excessive anterior face height,
and retrusive chin.
protrusion, Class I skeletal
relationship (Wits 1 mm),
hyperdivergent
(FMA 38), short ramus,
excessive anterior
face height, and retrusive
chin.

The OPG revealed a flattened anterosuperior surface
of the left condyle with an anterior osteophyte..
Osteophytes are exostoses (bony projections) that
form along joint margins

Degenerative bone changes (arrows) in the mandibular
condyle and articular eminence. The changes consisted
of: no bone changes (a); osteophytes (b); flattening (c);
sclerosis (d); erosion (e); and pseudocysts (f)

Temporomandibul
ar joint cone beam
computed
tomography. A.
Complete
flattening of the
condylar head and
the articular
eminence.
Anterior
positioning of the
condyle. B. Erosion
of the cortical and
subcortical bone.

The
articular
eminence also
appeared
flattened. The
right
condyle appeared
normal. However,
both condyles
had
shortened
condyloid
processes .
Classification
of articular
eminence
shapes: (A)
box, (B)
sigmoid, (C)
flattened, (D)
deformed.

However,
both
condyles
had
shortened
condyloid
processes
OPG after shows a shortened left condyloid process,

The treatment plan
included extraction
of the 4 first
premolar teeth for
maximal anterior
retraction and a
functional
genioplasty to help
obtain lip
competency
and normal
anterior facial
height.

A profile view
showed
reduction of
the
dentoalveolar
protrusion,
and a
genioplasty
helped in
achieving lip
competence in
repose .

After 13
months of
orthodontic
treatment,
her teeth
were aligned
and the
extraction
spaces were
ready to
close .

Joint
pain and
limited mouth
opening were
still issues.
An MRI
revealed
bilateral
anterior disc
displacement
without
reduction. Bilateral anterior disc displacement in the sagittal plane without reduction in
the right temporomandibular joint (above).

Bilateral
anterior disc
displacemen
t in the
sagittal
plane
without
reduction in
both
temporoman
dibular joints
(below)

After 18 months of
orthodontic treatment,
bilateral
disc repositioning,
extraction of all 4 third molar
teeth,
and a functional genioplasty
were performed. Orthodontic
progress records at 19
months showed a Class I
occlusion with some
remaining space to be
closed .
(a) Normal temporomandibular joint
anatomy with a harmonious disc-condyle
relationship. A indicates anterior; P,
posterior. (b) The disc is anteriorly
displaced, with the bilaminar tissues
interposed between the condyle and fossa

Two months after
disc repositioning,
the patient's
masseter muscle
and TMJ pain
increased. CBCT
demonstrated a
decrease in articular
disc space
bilaterally .
CBCT 2 months
after disc
repositioning.
Note the
decreased
articular disc
space bilaterally.

Physiotherapy was
recommended,
and Flexeril and NSAIDs were
prescribed. Three
months after surgery, the right
TMJ and right
masseter muscle pain
significantly increased (7/10).
One mL dexamethasone was
injected into the right
TMJ. One week later at follow-
up, the TMJ pain
decreased to 1/10.

The patient was then
transferred to an oral surgeon.
A right TMJ discectomy was
performed in February 2015. At
the September 2015 follow-up,
the right condyle
showed significant resorption,
reduced interarticular
space, and flattening of the
articular eminence. The
left condyle showed
progression of the flattening of
the anterosuperior surface. In
February 2016, a left
TMJ discectomy was
performed

At 40 months,
orthodontic
treatment was
completed.
A functional
occlusion was
achieved with
minimal
overjet and
overbite. The OPG
revealed a
progressive loss
of right condylar
bone mass .

Four months
after
debanding,
an anterior
open bite
had
developed
Intraoral photograph 12
months into retention
shows anterior open bite.

Open bite
continued to
progress to the
point
that it was
decided that total
joint replacement
was the
only management
option .
OPG 1 month after Zimmer
Biomet custom total joint
replacement. Class I functional
occlusion
was achieved.

Bilateral
alloplastic
total joint
replacement was
performed in July
2017
with the use of
Zimmer Biomet
(Jacksonville, Fla)
custom prostheses .

Follow-up
records
demonstrate
that a
functional
occlusion was
established .
Profile view, 1 month after total joint replacement.

despite the
lack of lateral
movement of
the jaw,
and her facial
esthetics
were
improved .
Profile view, 1 month after total joint replacement.

Early diagnosis of TMJ
degenerative change should
include a careful examination of
the condyle and condyloid
process on the screening OPG.
Signs of degenerative
bony condylar changes or
condyloid process shortening
may be present despite absence
of clinical symptoms.

The suspicion and recognition of
these imaging changes,
plus awareness of any clinical
signs and symptoms, may
be an indication for more
sophisticated imaging (CBCT,
MRI, nuclear medicine scan),
blood testing, and consultation.

Blood tests should include
erythrocyte sedimentation
rate and C-reactive protein,
antinuclear antibody,
rheumatoid factor, anti–cyclic
citrullinated peptide,
vitamin D, and 17b-estradiol
levels.

Idiopathic condylar resorption part 2

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Idiopathic condylar resorption part 2

Similar to Idiopathic condylar resorption part 2 (20)

Recently uploaded

Recently uploaded (20)

Idiopathic condylar resorption part 2