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Idiopathic condylar resorption and arthrosis of the joints


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Objective: To understand the pathophysiology of the arthrosis that lead to condylar resorption. To understand systemic, local and occlusal factors that may lead to condylar resorption. To know the diagnostic test that are recommended. To know how to adapt the treatment plan (surgical or non surgical) to patients with condylar resorption.

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Idiopathic condylar resorption and arthrosis of the joints

  1. 1. TMJ Pathologies Idiopathic Condylar Resorption Progressive Condylar Resorption Internal Condylar Resorption of Adolescents Reactive Arthritis Rheumatoid Arthritis©Dr Sylvain Chamberland Revised as of december 2012
  2. 2. Pre orthodontic treatment Anterior open bite Severe Md retrognathism Absence of articular clicking Few if any TMJ symptoms JoMa.10-09-07; 20 a 7 m©Dr Sylvain Chamberland
  3. 3. JoMa100907, 20 a 7m Microrami Flattening of the superoanterior surface of the condyle©Dr Sylvain Chamberland
  4. 4. Facial Asymmetry Lateral open bite Clicking of the left TMJ Pain on palpation of the left pre-auricular area©Dr Sylvain Chamberland NaRo.01-02-06; 16 years
  5. 5. Right Hyperplasia ? Left Hypoplasia ? NaRo010206 Elongation of right condylar neck Flattening of the anterior surface of the left condyle Antegonial notch: R ≠ L©Dr Sylvain Chamberland
  6. 6. Right Hyperplasia ? Left Hypoplasia ? NaRo010206 Or? Undiagnosed condylar fracture Healing of the left stumps, but loss of ramus height & altered condylar growth©Dr Sylvain Chamberland
  7. 7. ChLa150393ChLa150393 Female 17 y No more condylar head and neck Microrami Class II + anterior open bite No previous ortho treatment ©Dr Sylvain Chamberland
  8. 8. Adult F. 33 y 5 m Ask for a consult because her occlusion has changed since her last pregnancy No previous orthodontic treatment LyBo 180693©Dr Sylvain Chamberland
  9. 9. LyBo 180693 Microrami No condyles! Medical history non contributive (normal) ©Dr Sylvain Chamberland
  10. 10. Contemporary Findings on TMDs & Clinical Management 1 TMD: incidence in general population = 2 F: 1 M TMD: incidence in patient population = 10 F: 1 H Age distribution: 18-45 y ✦ Estrogen & progesterone receptor are present in the TMJ Current and future innovations in diagnostics and therapeutics of TMJ diseases , Temporomandibular disorders and orofacial pain: separating controversy from consensus, CFG vol 46, 2008, p 283-310 Wadhwa S, and Kapila S. TMJ disorders: future innovations in diagnostics and Therapeutics. J Dent Educ. 2008, Aug;72(8):930-47©Dr Sylvain Chamberland
  11. 11. Contemporary Findings on TMDs & Clinical Management 2 Sexual dismorphism M/F in the presence of oestrogen receptors Evidence that estrogen is involved in TMD ✦ Association between facial pain and estrogen replacement therapy or the use of oral contraceptive ✦ High pain is associated with low levels of estradiol ✦ Elevated systemic levels of estrogen in women with TMJ disease vs. those in normal controls©Dr Sylvain Chamberland Kapila S. p. 289, LeResche p.113-115, Monography #46, CFG series
  12. 12. Idiopathic condylar resorption in teenage girls Most common TMD in adolescent (9F :1M) Begin during pubertal growth phase Affect condyles bilaterally and symmetrically Progressive mandibular retrusion followed by period of remission until the entire condylar head is resorbed No consistent or proven aetiology ✦ Disc luxation without reduction, general joint hypermobility ✦ Trauma, parafonctional activity, ↓estrogen©Dr Sylvain Chamberland
  13. 13. AICR: clinical characteristics Teenage female, age of onset 11 to 15 y High occlusal plane and mandibular plane angle Predominant cl II skeletal & dental relationship with or without open bite TMJ symptoms: clicking, popping, TMJ pain, headaches, myofascial pain, earaches, tinnitus, vertigo; no other joint are involved©Dr Sylvain Chamberland
  14. 14. According to L.M. Wolford Atlas Oral Maxfacial Surgery Clin N Am 19 (2011) 243-270 1369 consecutives patients ranging from 8 to 76 y. referred for TMD ✦ F =78%; M = 22% ✦ 69% of the patients reported the onset during adolescence ✦ Therefore: TMD predominantly develop in teenage girls Thought: ✦ If occlusion would be at fault, it is likely that the ratio M/F would be more equal...©Dr Sylvain Chamberland
  15. 15. AICR During active phase ✦ Discomfort at both TMJs, hyperactivity of masticatory muscles ✦ Activity often burn out in 6 months In remission ✦ opening amplitude©Dr Sylvain Chamberland
  16. 16. (adult) Meniscal tissues and fossa may also undergo changes affecting support of mandible and dentition©Dr Sylvain Chamberland Arnett G.W. Et al, Progressive mandibular retrusion-idiopathic condylar resorption part 1 AJODO 1996; 110-8-15
  17. 17. Gunson MJ, Arnett G.W. et al, Oral contraceptive pill use and abnormal menstrual cycles with severe condylar resorption: A case for low serum 17β-estradiol as a major factor in PCR, AJODO 2009; 136:772-9 1. Seating direction 2. Seating force 3. Treatment devices 4. General anesthesia A. Bite treatment causes 5. condylar displacement 6. Splints 7. Paramandibular connective tissue 8. Unstable occlusion 1. Bruxism-clenching 2. Disc displacement B. 3. Joint anatomy 4. Macrotrauma If A +B + C = 1. Female aggressive resorption 2. 14-24 years old 3. Low estrogen (⬇) 4. Systemic arthritis C. 5. Corticosteroids 6. Hyperprolactinemia Low Vit D/Calcium ⬇ 7. Hyperparathyroidism 8. Joint Remodelling Mandibular Retrusion©Sylvain Chamberland
  18. 18. Condylar Resorption In 2 words: ✦ Initial compression ✦ Overlaid systemic condition©Dr Sylvain Chamberland G.W. Arnett, AAO meeting, Boston 2009
  19. 19. Gunson MJ, Arnett G.W. et al, Oral contraceptive pill use and abnormal menstrual cycles with severe condylar resorption: A case for low serum 17β-estradiol as a major factor in PCR, AJODO 2009; 136:772-9 Estrogen Role 17β-estradiol ✦ Down-regulation (↓ ) MMPs transcription ✦ ↓ ✦ ↓ bone loss in women Ethinyl Estradiol (contraceptive pills or postmenopause hormonotherapy) ✦ Suppress production of naturally occurring 17β-estradiol ✦ ↑ osteoclast activity & ↑ ©Dr Sylvain Chamberland
  20. 20. Cascade of events related to estrogen ↓Estrogen ✦ ✦ Promote cytokines production ✓ Matrix degradation enzymes MMP ✦ Bone loss ✓ Progressive mandibular retrusion Arnett G.W. et al, Progressive mandibular retrusion-idiopathic condylar resorption. Part 1, AJODO 1996; 110:8-15©Dr Sylvain Chamberland
  21. 21. Cascade of events related to pregnancy Prolactin ✦ Enhances cytokines production by lymphocytes and macrophages Increased levels of endogenous corticosteroids is associated with pregnancy ✦ Corticosteroid reported has causing joint resorption (catabolic effect) Arnett G.W. et al, Progressive mandibular retrusion-idiopathic condylar resorption. Part 1, AJODO 1996; 110:8-15©Dr Sylvain Chamberland
  22. 22. Mechanical Etiologic Factors of Resorption Traumatism Parafonctional activity Unstable occlusion Altered TMJ loading Increased friction into the joint Arnett G.W. et al, Progressive mandibular retrusion-idiopathic condylar resorption. Part 1, AJODO 1996; 110:8-15©Dr Sylvain Chamberland
  23. 23. Mechanical Loading & Joint Cartilage Mechanical load of TMJ : essential to maintain its mass and integrity ✦ Adaptation to normal muscular force and orthopaedic traction ✦ Dentofacial orthopaedic appliance : ↑proliferation & chondrocytes maturation Decreased loading→ osteoarthrosis©Dr Sylvain Chamberland Wadhwa S. ,Kapila S., TMJ disorders: Future innovation in diagnostics and therapeutics, J. Dent. Educ. 2008, 72 (8), 930-947
  24. 24. Sequella of a mechanical stress to TMJ Mechanical stress (compression or luxation) Physical disruption of molecules and cells Cell death Production of free radicals Impaired cellular functions Degradation of hyaluronic acid by free radicals ↑Matrix degradation Inhibition of matrix synthesis Bone resorption Degradation of articular surface©Sylvain Chamberland Arnett G.W. et al, Progressive mandibular retrusion-idiopathic condylar resorption. Part 1, AJODO 1996; 110:8-15
  25. 25. Concept of the Process of Cartilage breakdown Tanaka E., Detamore M.S., Mercuri L.G. Degenerative disorders of the©Sylvain Chamberland
  26. 26. Osteophytes Pinch of articular interline Geodes of resorption©Sylvain Chamberland
  27. 27. Kapila S, Current and future innovations in diagnosis and therapeutics of TMJdiseases, Monograph 46, Craniofacial growth series 2008 Pathophysiology Collagen proteoglycans
  28. 28. Condylar Resorption Root causes differentiate between diagnosis ✦ (Rh. Arthr., post-traumatic arthritis, ICR, auto-immune disease) All bone loss involves common resorptive pathway Loss of columnar organization * * Acellular areas * Wadhwa S, Kapila S, JDE vol 72 #8 Gunson MJ, Arnett GW, Milam SB., Pathophysiology and pharmacologic control of osseous mandibular condylar resorption. J Oral Maxillofac Surg. 2012 Aug;70(8):1918-34. Epub 2011 Oct 19©Dr Sylvain Chamberland
  29. 29. Gunson MJ, Arnett GW, Milam SB, Pathophysiology and Pharmacologic Control ofOsseous Mandibular Condylar Resorption J Oral Maxillofac Surg 2011, october, Pathophysiology ✦Cytokyne-activated osteoclasts promote the recruitment and activity of osteoclasts that, in turn, result in the secretion of enzymes that are responsible for the breakdown of hydroxyapatite and collagenGunson MJ, Arnett GW, Milam SB.,Pathophysiology and pharmacologiccontrol of osseous mandibularcondylar resorption.J Oral Maxillofac Surg. 2012 Aug;70(8):1918-34. Epub 2011 Oct 19
  30. 30. Interleukine 6 TNF-α, IL-6 et RANKL ➡cytokines that activate catabolic Receptor Activator Nuclear Factor Kappa-beta Ligand pathways of bone resorption OsteoProteGerin OPG ➡cytokine that inhibit bone Tumor necrosis factor-α catabolism by binding to RANKL©Sylvain Chamberland
  31. 31. MMP = endopeptidases that degrade extracellular matrix molecules (collagen et elastin) MMP require Zinc as a cofactor for activity TIMPs (tissue inhibitors of MMPs) bind to MMPs and inhibit their activity Imbalance between MMPs and TIMPs favour unregulated degradation of tissue by MMP.©Sylvain Chamberland
  32. 32. Susceptibility to condylar resorption Strong female predilection Hormonal imbalance (↓estrogen, ↓17β-estradiol) Nutritional status(↓ Vit D, ↓Omega-3) Bruxism and repetitive oral habits ✦ Free radical generation through sheer stress and increased metabolic demands Iatrogenic causes: ✦ ✓ All condylar change or displacement through compression©Dr Sylvain Chamberland
  33. 33. Role of posteriorly inclined condylar neck Hwang SJ, Haers Pe, and Sailer HF. The role of a posteriorly inlcined condylar neck in condylar resorption after orthognathic surgery. J Craniomaxillafac Surg 2000; 28 (2):85-90 Sample: 11 patients having condylar resorption selected in a sample of 240 patients who underwent orthognathic surgery Counterclockwise rotation of the proximal segment (6,7°± 3,2°) was observed in all patients©Dr Sylvain Chamberland
  34. 34. Explanation of the author When the condylar neck is posteriorly inclined (per- op), the anatomically less dense, preoperatively unloaded anterior-superior surface of the condyle is subjected to increased loading following surgery due to an increase in soft tissue tension and rotation of the condyle.©Dr Sylvain Chamberland
  35. 35. J Oral Maxillofac Surg.2012, Aug;70(8):1951-9. After moving the mandibule anteriorly and superioly ✦ Formation of a step at the buccal ostotomy site ✦ Counterclockwise rotation of the proximal segment to avoid postoperative antegonial notch ✦ Condylar axis rotated inward affect sagittal condylar height postoperatively (Park et al, JOMS 2012) Other ref: Hoppenreijis T et al. Condylar remodelling and resorption after Le Fort I and bimaxillary 0steot0mies in patients with anterior open bite A clinical and radiol0gical study. Int J. of Oral & Maxillo Surgery. 1998;27(2):81-91. Moore K et al. The Contributing Role of Condylar Resorption to Skeletal Relapse Folio wing Mandibular Advancement Surgery- Report of Five Cases. JOMS. 1991, Mar;49(5):448-460. Park SB, Yang YM, Kim YI, Cho BH, Jung YH, and Hwang DS. Effect of bimaxillary surgery on adaptive condylar head remodeling: metric analysis and image interpretation using cone-beam computed tomography volume superimposition. J Oral Maxillofac Surg.2012, Aug;70(8):1951-9.©Dr Sylvain Chamberland
  36. 36. Gunson MJ, Arnett GW, Milam SB, Pathophysiology and Pharmacologic Control ofOsseous Mandibular Condylar Resorption J Oral Maxillofac Surg 2011, october, Pharmacotherapy 1 Cytokine inhibitors ✦ every 2 weeks) MMP inactivation ✦ Tetracyclines Inhibition of prostanoids and leukotrienes ✦ Fatty acid Omega-3 ✦ (medical monitoring side effects) ©Dr Sylvain Chamberland
  37. 37. Gunson MJ, Arnett GW, Milam SB, Pathophysiology and Pharmacologic Control ofOsseous Mandibular Condylar Resorption J Oral Maxillofac Surg 2011, october, Pharmacotherapy 2 Statins ✦ Reduce the risk of myocardial infarction by lowering cholesterol levels and through RANKL inhibitor: Denosumab IL-6 receptor inhibitor: Tocilizumab ©Dr Sylvain Chamberland
  38. 38. Osseous Mandibular Condylar Resorption J Oral Maxillofac Surg 2011, october, Pharmacotherapy 3 Osteoarthritis Auto-immune arthritides ✦ Cytokines and/or MMPs inhibitors ✦ Auto-immune inhibitor ✓ Doxycycline, Feldene, Simvistatin ✓ Methotrexate, Enbrel, Simvistatin ✦ Free radical inhibitors TNFα ✓ Vit C, Vit E, fat acid omega 3 ✦ Anabolic bone metabolism facilitator ✓ Vit D, Ca2+, 17β estradiol ✦ Parafonction inhibitors ✓ Amitriptyline, Tiagabine, Klonopin, Botox ©Dr Sylvain Chamberland
  39. 39. Prophylactic pharmacotherapy ✦ 30 days pre-op and starting 14 days post op ✓ Calcium carbonate (CaCo) 500 mg/day + 1000 IU of Vit D3 (Vit D supplementation) ‣ Vitamin D supplementation (2000 IU/day) in patient with systemic lupus erythematous is recommendated because subsequent clinical improvement. Trial J Rheumatol published 1 December 2012, 10.3899/jrheum.111594 ✓ Celebrex 200mg id, (or bid if over 70kg) Courtesy Dr Marco Caminiti,©Dr Sylvain Chamberland
  40. 40. Prophylactic pharmacotherapy If they are symptomatic post op ✦ Pain, occlusal change, sign of active resorption, limited opening ✓ Clodronate (clasteon) 2400mg OD for 30 days ✓ Get a rheumatologist consultation ASAP ✓ Internist md help to monitor the patient Courtesy Dr Marco Caminiti,©Dr Sylvain Chamberland
  41. 41. Cevidanes et al, Condylar resorption in patients with TMD, monograph 46, Cranifacial Growth Series, 2008, p 147-157 Resorption CBCT of TMJs (mouth open) Extraction of volumes of interest condylar morphology compared to non symptomatic patients TMDs patients = resorption of anterior surface of the lateral pole + posterior articular surface. ©Dr Sylvain Chamberland
  42. 42. Initial stage: ★Flattening of anterior surface + cortical thickening (sclerosis)in loading area ★Possibility of reducing anteriorly displaced disc Advance stage: Non reducing displaced disc Pain, limited open + cessation of a clicking DD seems to be a risk factor for onset of DJD Erosive lesion progressing to be articular surface + re-cortication Late stages: Formation of osteophytes through un-corticated surface → sub-chondral bone cyst Hatcher D, CBCT (3D imaging): application for selected articular disorders and associated facial growth, monograph 46, Craniofacial Growth Series,©Sylvain Chamberland 2008, p 125-145
  43. 43. Initial stage ✦ Flattening of anterior surface + cortical thickening (sclerosis)in loading area ✦ Possibility of reducing anteriorly displaced disc Hatcher D, CBCT (3D imaging): application for selected articular disorders and associated©Dr Sylvain Chamberland facial growth, monograph 46, Craniofacial Growth Series, 2008, p 125-145
  44. 44. Advance stage ✦ Non reducing displaced disc ✓ Pain, limited open + cessation of a clicking ✓ DD seems to be a risk factor for onset of DJD (or the effect of degenerative change) ✦ Erosive lesion progressing to be surface + re-cortication Hatcher D, CBCT (3D imaging): application for selected articular disorders and associated©Dr Sylvain Chamberland facial growth, monograph 46, Craniofacial Growth Series, 2008, p 125-145
  45. 45. Late stage ✦ Formation of osteophytes ✦ corticated surface → sub-chondral bone cyst Hatcher D, CBCT (3D imaging): application for selected articular disorders and associated©Dr Sylvain Chamberland facial growth, monograph 46, Craniofacial Growth Series, 2008, p 125-145
  46. 46. Normal mandibular growth Disc Displacement reducing or non- reducing associated with interruption in mandibular growth The earlier the onset and severity of DJD have a proportional relationship with the severity of md growth defect DJD is self-limiting process and despite progression, there is a point of remission and stability (no evolution. Signs and symptoms reduce to level associated with normal.©Sylvain Chamberland
  47. 47. Joint Hypermobility & TMD Hirsch, C. John, M.T., Stang, A., Association between generalized joint hypermobility and signs and diagnoses of TMD Eur. J Oral Sciences 2008; v.116 #6 525-530 N = 893; F = 56,7%; Mean age: F=39,9; M=41,2 Results: ✦ Hypermobile subjects (> 4 joints on the 0 à 9 scale) ✓ Higher risk for reproducible reciprocal TMJ clicking (OR = 1,68) ✓ Lower risk for limited mouth opening (<35 mm) (OR = 0,26) ✓ No association between hypermobility and myalgia/arthralgia©Dr Sylvain Chamberland
  48. 48. conditions Degenerative joint disease (Osteoarthritis/osteoarthrosis) Post-traumatic arthritis Infectious arthritis Rheumatoid arthritis (adult and juvenile) Gouty arthritis Psoriasis arthritis Lupus erythematosus Ankylosis spondylitis Reiters syndrome Arthritis associated with ulcerative©Dr Sylvain Chamberland colitis
  49. 49. Diagnostic of TMJ degenerative changes Clinical history Noise (clicking, crepitus) present or past A-A.St-O.T 0711 Close lock, hypomobility present or past Anterior open-bite, or antero-lateral Ka.Tu 1111©Dr Sylvain Chamberland
  50. 50. Diagnostic of TMJ degenerative changes Occ. Centrée (C.O.) Difference RC/OC > 2 to 4 mm ✦ The functional shift is not the cause of the TMD, but rather the effect of degenerative change of the TMJ Me.Po. 0610 ✦ To reach a 2:1 odds ratio threshold Rel. Centrée (C.R.) for notable risk of association with degenerative changes, a slide > 5 mm would be necessaryJ Prosthet Dent 2000; 83:66-75MacNamara JA, Seligman DA, Okeson JP, Occlusion, orthognathic treatment and temporomandibular disorders: A review,J Orofacial Pain, 1995; 9:73-90©Dr Sylvain Chamberland
  51. 51. Diagnostic of TMJ degenerative changes Pain ✦ Arises from the soft tissues and masticatory muscle around the affected joint ✦ movements in response to intra-articular injury, thus protecting it form further damage Facial deformity due to pathologic osteolysis decreasing the height of the condyle + its neck Tanaka E, Detamore MS Mercuri LG, Degenerative disorders of the TMJ: Etiology, Diagnosis and Treatment, J Dent Res 2008 87: 296©Dr Sylvain Chamberland
  52. 52. Shintaku WH et al, Imaging modalities Imaging Modalitiesto access bony tumors andhyperplastic reaction of the TMJ,JOMS 68:1911-1921, 2010 degenerative changes Panorexes: D.D.N.-R. ✦ ∆ TMJ shape Al.Be. 0810 Jo.Ma. 0907 ✓ Flattening of the anterior surface of the condyle ✓ ∆ size Me.Po. 0610 ✓ ∆ articular eminence shape ✓ ©Dr Sylvain Chamberland Ma.La.Br.La.0410
  53. 53. Imaging Modalities TMJ tomograms, mouth open Me.Po. 0610©Dr Sylvain Chamberland A-A.St-O-T. 0711
  54. 54. Imaging Modalities Mouth closed CBCT 3D mouth open ✦ Condyle assessment ✓ A-A.St-O-T. 16-08-01 ✓ Mouth open ✦ Dose effective & cost effective for evaluation of osseous abnormalities N.R. 17-10-11©Dr Sylvain Chamberland
  55. 55. Imaging Modalities Magnetic resonance imaging: ✦ Useful for soft tissue (disc) Reducing disc displacement ✦ Less useful for osseous degenerative changes Non-reducing disc displacement Disk displacements & osteoarthritis = 30% of asymptomatics volunteers Non-reducing disc displacement & Severe Osteoarthrosis (bone oedema, joint effusion, synovitis) to Tanaka E, Detaore MS, Mercuri LG Degenerative disorders of the joint pain©Dr Sylvain Chamberland MRI sensitivity =78%; predictive value =54% bone marrow and intra-articular soft tissues of the temporomandibular joint, Sem Ortho 2012;18:30-43
  56. 56. Imaging Modalities Mean Maximum Jo.Ma. Bone scan Tc-99 Right 1,02 0,93 april 2009 p ✦ Assess bone activity Left 1,01 0,91 Pre surg ✓ Growing or degenerative Right 1,3 1,73 november ✦ 2010 Left 1,26 1,68 Post surg symmetric hypermetabolism in 2010©Dr Sylvain Chamberland
  57. 57. Additional diagnostic aid Blood test mid-cycle ✦ Female ✓ Dosage de Estrogen & 17β-estradiol at debut and mid-cycle, FSH, LH,Vit D ✦ Men ✓ ✦ Level of rheumatoid factor, antinuclear antibodies and anti CCP ✦©Dr Sylvain Chamberland
  58. 58. Principles for management of TMJ osteoarthritis Noninvasive management modalities ✦ Medications ✓ ✓ Muscle relaxant ✦ Physiotherapy ✓ ∆ body posture ✦ Oral appliance (occlusal splint) ✓ Mercuri LG, Osteoarthritis, Osteoarthrosis and Idiopathic Condylar Resorption, Oral Maxillofacial Surg Clin N Am 2008 May;20(2): 169-183©Dr Sylvain Chamberland
  59. 59. Principles for management of TMJ osteoarthritis Minimally invasive modalities ✦ ✓ ✦ Arthrocentesis ✓ ↓ intra-articular pressure ‣ Nitzan D.W., Arthrocentesis-Incentives for using this minimally invasive approach for TMD, Oral Maxillo Surg Clin N Am 18 (2006)311-328 Richie Wai Kit Yeung et al, Short-term therapeutic outcome of intra-articular high molecular weight hyaluronic acid injection for nonreducing disc displacement of the temporomandibular joint, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102: 453-61) Xing Long, et al, A Randomized Controlled Trial of Superior and Inferior Temporomandibular Joint Space Injection With Hyaluronic Acid in Treatment of Anterior Disc Displacement Without Reduction, J Oral Maxillofac Surg 67:357-361, 2009 Guo C, Shi Z, Revington P, Arthrocenthesis and lavage for treating temporomandibular joint disorders, Cochrane database of systematic reviews 2009, Issue 4. Art.No.:CD004973 Shi Z, Guo C, Awad M. Hyaluronate for the temporomandibular joint, Cochrane database of systematic reviews 2003, Issue 1. Art.No.: CD002970©Dr Sylvain Chamberland
  60. 60. Minimally invasive modalitie vs corticosteroid, after 6 months ✦ Reported pain (mm on VAS), ✦ Pain on palpation of the affected TMJ ✦ Pain on palpation of contralateral TMJ ✦ Pain on palpation of masticatory muscle ✦ None of the mean differences between©Dr Sylvain Chamberland Hyaluronate for temporomandibular joint disorders (Review). Cochrane Database of Systematic Reviews 2003. 2003;(1):
  61. 61. Principles for management of TMJ osteoarthritis Moderately invasive approach ✦ Splint therapy ✦ Nonsurgical orthodontic treatment ✓ Use of TAD for the vertical changes instead of surgery©Dr Sylvain Chamberland
  62. 62. Principles for management of TMJ osteoarthritis Invasive surgical modalities ✦ Ortho treatment and orthognathic surgery (mono or bimax) ✓ Clockwise rotation ✓ Counterclockwise rotation (Arnett, Wolford, Posnick), disk repositioning ✦ Autogenous hemiarthroplasty ✓ ‣ Orthopaedic literature show long-term poor experience with hemiarthroplasty ‣ It would seem logical that using this method in management of TMJ arthritic©Dr Sylvain Chamberland disease might only lead to the same outcome
  63. 63. Principles for management of TMJ osteoarthritis Salvage procedures— Total joint replacement ✦ Autogenous total joint replacements: Costochondral graft ✓ ✓©Dr Sylvain Chamberland
  64. 64. Principles for management of TMJ osteoarthritis Salvage procedures— Total joint replacement ✦ Alloplastic total joint replacements: ✓ Biomet ✓ ‣ Louis Mercuri: "Based on these data (14 years follow-up) and a paper we are presently working on with 19-22 years follow-up of the TMJ Concepts custom device, we believe that "custom" TMJ TJR devices will have at least 15-25 years longevity, or more since they have not shown any polyethylene wear-related osteolysis. The©Dr Sylvain Chamberland
  65. 65. Case 1©Dr Sylvain Chamberland
  66. 66. RCIA17 ans 1. Female Estrogen ⬇ 2. 14-24 years old ChLa150393 ChLa010695/ surgeon: Dr Denis Gagnon 3. 4. Systemic arthritis 5. Corticosteroid Ortho surgical treatment 6. Hyperprolactinemy Vit D/Calcium ⬇ 7. Hyperparathyroidism 8. Bimax surgery, clockwise rotation: ✦ Le Fort 1, BSSO, genioChLa150393 ChLa-10695 Tomo Chantal ©Dr Sylvain Chamberland
  67. 67. Case 2©Dr Sylvain Chamberland
  68. 68. Resorption post pregnancy LyBo 180693 LyBo 190396/ ~1 an post ortho LyBo 0997/ ~2 ans post ortho Ortho treatment only, exo 4 Pm1 Genioplasty only Note the possibility of posterior intrusion©Dr Sylvain Chamberland
  69. 69. LyBo93/ pre-ortho No condyle before No condyle after But stable occlusion LyBo97/ 2 years post-ortho©Dr Sylvain Chamberland
  70. 70. Case 3©Dr Sylvain Chamberland
  71. 71. F. 30 years Ortho Tx at adolescence Progressive anterior openbite developed during the past 5 years Menses: regular, contraceptive ceased 1½ year ago Occasional TMJ pain Investigation rheumato = normal Invisalign since 12 months...Courtesy: Dr Dany Morais©Dr Sylvain Chamberland
  72. 72. Bimaxillary surgery: clockwise rotation ✦ Le Fort 1, BSSO There is no more condyle to resorb, it should be stable! Esthetic and functional outcome...may be questionable.©Dr Sylvain Chamberland Courtesy: Dr Dany Morais
  73. 73. Common denominator Hormonal aetiology probable Condyles were completely resorbed©Dr Sylvain Chamberland
  74. 74. Differential Diagnosis Juvenile rheumatoid arthritis ✦ Bilateral resorption ✦ Short ramus ElCr 2010 ✦ Lack of condylar growth©Dr Sylvain Chamberland Courtesy Dre Claudia Giambastini ElCr 2007
  75. 75. Adjunct treatment Advancement genioplasty to improve lip function at repose & aesthetics of the chin Favour bone remodelling and apposition at the buccal aspect of the incisors roots Reassessment during treatment and in adulthood Bone apposition site ElCr 2011-post©Dr Sylvain Chamberland genio Courtesy Dr Dany Morais ElCr 2011-post genio
  76. 76. Progress late 2011 apposition labial Bone apposition to incisors site roots ElCr 2011-post genio Reassessment during treatment A new genioplasty can be done Uprigthing of lower incisors could be achieved (root mvt)??©Dr Sylvain Chamberland Courtesy Dr Claudia GIambastini
  77. 77. La.Va.0109, end of ortho A limitation of jaw opening & unstable occlusion was noted postop Finishing with occlusal tooth equilibration & elastics Parafonction persisting (bruxism & sygmatism) Progressive open bite noted in retention: the surgeon is advisedLa.Va.0107/ 14 a 3 m/ pré-ortho La.Va.0311/ 2 ans post ortho ©Dr Sylvain Chamberland
  78. 78. anterior surface of the condylar head La.Va.0107/ 14 a 3 m/ pré-ortho Pre orthognathic surgery ✦ Remodelling noted in the right condyle Should have done bone scan La.Va.0408/ pre-surg Tc99 presurg & pre ortho 2 years post ortho ✦ Remodelling +++ La.Va.0311/2 y post tx Surgeon: Dr Patrick Giroux©Dr Sylvain Chamberland
  79. 79. Initial Pre surgery End of ortho Retrospectively, would it be legitimate to extract 2 1st Pm 2 y post ortho However, does not mean that the outcome would have been any better?©Dr Sylvain Chamberland
  80. 80. LuBo070706 preortho; en RC LuBo.17a.1 m. Cl II div 1. Md Laterodeviation to right COCR functional shift AP LuBo070706 preortho Bilateral condylar resorption (R>L) ✦ Disc displacement with reduction in the right©Dr Sylvain Chamberland
  81. 81. LuBo070706 préortho Parafonction: clenching Rheumato: no systemic disorder ✦ Complete blood, sedimentation, protein C reactive = normal ✦ Antinuclear factor normal, Rheumatoid factor negative November 2006: Scinti = negative pretreatment October 2007: Scinti = positive right TMJ, negative in left (the orthodontist was never told!)©Dr Sylvain Chamberland
  82. 82. Treatment Plan Occlusal splint therapy: 6 months Tx ortho June 2008 (pre-op): Scinti positive in right TMJ, negative in left . The orthodontist was never told! Surgery plan ✦ Le Fort 1: Posterior impaction ✦ Md: autorotation; genio only©Dr Sylvain Chamberland
  83. 83. Le Fort 1OSMBGenio LuBo261007 préchir LuBo161208 19a 6 m Functional Cl I Surgeon: Dr Michel Fortin ©Dr Sylvain Chamberland
  84. 84. LuBo070211 21a 8 m PCR Progressive postsurgical condylar resorption Cant of the mandibular incisor occlusal plane to the left LuBo070211©Dr Sylvain Chamberland
  85. 85. LuBo070706 preortho LuBo070211; 2 ans post ortho Decreased ramus height: condylar head & neck©Dr Sylvain Chamberland
  86. 86. JoMa.10-09-07; 20 a 7 mJoMa100907, 20 a 7m Investigation in Rheumato: negative Scinti Tc99: normal pre surgically Tx plan: SARPE, Le Fort 1, BSSO, genio ©Dr Sylvain Chamberland
  87. 87. JoMa.28-10-09; 22 a 8 m Bone scan normal preop Chir: Dr Michel Fortin Condyle looked normal at debonding©Dr Sylvain Chamberland
  88. 88. 2 year post ortho JoMa.24-11-11; 24 a 9 m Bite reopening was observed 3 months after debonding Fact Rh = n; 17β-oest. = n Note root resorption of lower (fev2010) molars Scinti Tc 99 positive in October 2010 condyle©Dr Sylvain Chamberland
  89. 89. Progressive Md retrusion Relative stability between 2011-2010 Note upper molar extrusion Note condylar resorption©Dr Sylvain Chamberland
  90. 90. Common Denominator They had condyles presurgery Progressive condylar resorption postsurgery What happened during or after surgery? ✦ ✦ They all had stiffness during jaw opening? ✦ Hypomobility? ✦ Counterclockwise rotation of the proximal segment©Dr Sylvain Chamberland
  91. 91. According to G. W. Arnett Progressive mandibular retrusion-idiopathic condylar resorption. Part II, AJODO, 1996, 110:117-127 Posteriorization of the condyle in the fossa ✦ Could favour anterior disc displacement, a disc compression or an hypomobility (protective muscular spasm) Dysfunctional remodelling in susceptible patients©Dr Sylvain Chamberland
  92. 92. According to G. W. Arnett Progressive mandibular retrusion-idiopathic condylar resorption. Part !!, AJODO, 1996, 110:117-127 ✦ No possible adjustment between proximal and distal segments ✦ Possible adjustment in the early stage of healing these observation©Dr Sylvain Chamberland
  93. 93. According to G. W. Arnett AAO meeting Boston 2009 Control surgical compression Early mobilization Class II elastics Cocktail of drugs (pills medicines)©Dr Sylvain Chamberland
  94. 94. Risk factor of surgical TMJ compression Post surgical visit ✦ Contact anteriorly ✦ Slight posterior open bite Occlusal load is distributed between the condyles and incisor contact during use of intermaxillary elastics to close the posterior openbite©Dr Sylvain Chamberland
  95. 95. Why I dont like posterior openbite after orthognathic surgery? Pressure Condyle resorb Lack of posterior occlusion may increase pressure at the condyle and cause non-physiologic remodelling or condylar resorption Screwed Setting Jam-packed Slight progressive occlusion retrusion The bite open©Dr Sylvain Chamberland
  96. 96. KaTu031105, 15 a 1 m Courtesy Dr Maryse Gendron Preortho: had previous blockages in both side Ortho tx limited to mx arch only Joint hypermobility: luxation knee, ankle, synd. fémoroplatellaire Had disc displacement without reduction (16 mm of opening)©Dr Sylvain Chamberland
  97. 97. KaTu160107, 16 a 4 m Post ortho: fairly acceptable occlusion Except slight right lateral openbite No Xray taken at debonding©Dr Sylvain Chamberland
  98. 98. KaTu161107, 17 a 1 m Left condylar resorption in November 07 Probably in remission in may 10©Dr Sylvain Chamberland KaTu030510, 19 a 7 m
  99. 99. KaTu031111, 21 a 1 m May 2011 ✦ MRI: degeneration of the left disc ✦ Scinti Tc99= No metabolic activity (it’s normal) Condylar resorption in remission Wear an occlusal splint KaTu031111, 21 a 1 m©Dr Sylvain Chamberland
  100. 100. appliances (Oct 2008- Nov 2010) CRCO functional slide of 4 mm Pain was reported shortly after the bionator was placed Notes were made Nov08, Dec08, Jan09, June09©Dr Sylvain Chamberland Vi.Pr.120312; 15 y 6 m
  101. 101. neck Flatness of the anterior surface of the left condyle Vi.Pr.120312; 15 y 6 m Increased left antegonial notching 2 levels of occlusal plane &©Dr Sylvain Chamberland lower mandibular border
  102. 102. Vi.Pr.120312; 15 y 6 m Normal right condylar growth Progressive left condylar resorption ➡ Anterolateral bite opening©Dr Sylvain Chamberland
  103. 103. CBCT Normal condylar head and Shorten condylar neck neck Flatten condylar head©Dr Sylvain Chamberland
  104. 104. MaPiBe240203, 13 a 9 m Fall in a gym at age 11 Kicking on the right side of the face Blockage + DD without reduction Physiotherapy Show at 13 years old for ortho tx Standard tx, exo 3 Pm, intermaxillary elastics prn©Dr Sylvain Chamberland
  105. 105. MaPiBe290604, 15 a 1 m Functional occlusion Right TMJ ✦ ??± similar???©Dr Sylvain Chamberland
  106. 106. MaPiBe151204, 15 a 6 m MaPiBe190207, 17 a 9 m Left anterolateral openbite ✦ This open bite has manifested itself within 6 months post ortho ©Dr Sylvain Chamberland
  107. 107. MaPiBe190207, 17 a 9 m MaPiBe140308, 18 a 9 m Progression during the following year©Dr Sylvain Chamberland
  108. 108. MaPiBe040112, 22 a 7 m Follow up ✦ 6½ years post ortho ✓ Cortical layer appears normal©Dr Sylvain Chamberland
  109. 109. NaRo010206 NaRo.01-02-06; 16 ans Undiagnosed fracture of the left condyle Normal growth to the right, affected (↓)to the left NaRo.01-04-08; 18 ans Progressive condylar resorption unilateral All possible exams were done NaRo.01-05-11; 21 ans Unilateral condylar resorption→ Controlateral open bite©Dr Sylvain Chamberland
  110. 110. CBCT Long right condylar neck Short left condylar neck Anterosuperior resorption Patient N.R.©Dr Sylvain Chamberland
  111. 111. Common Denominator Impact to the TMJ : ischemia Disc displacement without reduction Adolescent 14-18 years old Non functional remodelling →resorption©Dr Sylvain Chamberland
  112. 112. According to L.M. Wolford Atlas Oral Maxfacial Surgery Clin N Am 19 (2011) 243-270 Disc repositioning & ligature Bimaxillary osteotomy & counterclockwise rotation ✦ Le Fort 1 ✦ BSSO + genio prn 91% success rate (stability)©Dr Sylvain Chamberland
  113. 113. According to G. W. Arnett AAO meeting Boston 2009 Bimaxillary osteotomy ✦ Counterclockwise rotation MxMd ✦ Cocktail of drugs©Dr Sylvain Chamberland
  114. 114. Case 1©Dr Sylvain Chamberland
  115. 115. Alternative to surgical ortho tx AnGr 0609, 14a 4 m Class II div 1 Hyperdivergent Anterior open bite Tx exo ⅘ & microimplants©Dr Sylvain Chamberland
  116. 116. AnGr 131009 Microimplants Mx Microimplants Md AnGr 071209 Note posterior openbite & anterior deep bite AnGr 080310©Dr Sylvain Chamberland
  117. 117. AnGr 0911, 16a 10 m Clockwise rotation Few if any molar extrusion Surgery avoided©Dr Sylvain Chamberland
  118. 118. Case 2©Dr Sylvain Chamberland
  119. 119. Progressive condylar resorption post JuBo260404 surgically Aggressive development in 1 y ✦ Rheumato: Ø JuBo3101005 Stabilization the following year Recall at 5 years ✦ Dental compensation JuBo0801106 noted ✓ Tx limited Md JuBo020511©Dr Sylvain Chamberland
  120. 120. TAD and posterior intrusion JuBo250511 Selective intrusion of buccal segment JuBo231111 JuBo310512©Dr Sylvain Chamberland
  121. 121. TAD and posterior intrusion JuBo250511 At debonding, positive overbite achieved JuBo220812©Dr Sylvain Chamberland
  122. 122. JuBo250511 JuBo220812 Comparison tracing shows ✦ Posterior intrusion ✦ Counterclockwise rotation of Md ✦ Positive overbite is obtained©Dr Sylvain Chamberland
  123. 123. JuBo250511 JuBo220812 JuBo081112 ✦ Post genioplasty JuBo250511 JuBo250511 JuBo081112 JuBo081112©Dr Sylvain Chamberland
  124. 124. JuBo020511 JuBo220812©Dr Sylvain Chamberland
  125. 125. Case 3©Dr Sylvain Chamberland
  126. 126. MaLaBrLa041110MaLaBrLa041110 F. Rhum. Ø; Oestradiol < normal en 2009, Pregnancy 2010-11 Investigation Rheumato: Ø in November 2011 Blood test non contributive TAD MaLaBrLa141211 ✦ Intrusion of buccal segment ✦ Positive overbite obtained ©Dr Sylvain Chamberland MaLaBrLa160812
  127. 127. MaLaBrLa041110MaLaBrLa041110 Class I occlusion is achieved MaLaBrLa160812 Positive overbite maintained MaLaBrLa081112 ©Dr Sylvain Chamberland
  128. 128. MaLaBrLa041110 MaLaBrLa041110 MaLaBrLa081112 Dentoalveolar protrusion is reduced ©Dr Sylvain Chamberland
  129. 129. Case 4©Dr Sylvain Chamberland
  130. 130. AA.St.Tr. 130711, 22ans Class I, anterior open bite Md deviation to the right (midline to right) Normal facial proportion Symptoms began at age 19 Started contraceptive pills at 19 or 19½©Dr Sylvain Chamberland
  131. 131. Concavity on the superior surface of the right condyle Flatness of the anterior surface of the left condyle Rheumato: Ø 17β-estradiol: 84 pmol/L début cycle (n=180-550) <73 pmol/L mid cycle (n= 110-1470) ANF: positive, moucheté, titre1:80 (normal) Scinti Tc99: Slight increased intake left TMJ Blood test: normal©Dr Sylvain Chamberland Rh factor: negative
  132. 132. Rheumato: Ø 17β-estradiol: 84 pmol/L début cycle (n=180-550) <73 pmol/L mid cycle (n= 110-1470) ANF: positive, moucheté, titre1:80 (normal) Scinti Tc99: Slight increased intake left TMJ Blood test: normal Rh factor: negative©Dr Sylvain Chamberland
  133. 133. Tx Plan Intrude maxillary buccal segment Intrude & mesialize mandibular buccal segments Rotate the maxillary occlusal plane©Dr Sylvain Chamberland
  134. 134. Mechanotherapy Bond md arch + Mx occlusal splint for 3 months Bond Mx arch at 3 months or so TAD between /6-7 + LLA 32x32SS + E-link AA St-O 211111©Dr Sylvain Chamberland
  135. 135. AA St-O 211111 Mx: posterosuprerior vector of traction AA St-O 150212 Posterior open bite is obtained & positive anterior OB AA St-O 100512©Dr Sylvain Chamberland
  136. 136. AA St-O 100512 Mx: Midline correction AA St-O 130812 AA St-O 100912©Dr Sylvain Chamberland
  137. 137. AA St-O 211111 TPA help derotate 6’s/ AA St-O 150212 LLA help helped to avoid expansion AA St-O 100512©Dr Sylvain Chamberland
  138. 138. Md forward rotation occurred /1-MP change from 88° to 95°©Dr Sylvain Chamberland
  139. 139. Monitor root resorption If superimpositions are accurate ✦ lower dentition intrude & advance ✦ Mx dentition: ✓ no posterior intrusion, no anterior extrusion©Dr Sylvain Chamberland
  140. 140. Bone level change distal to molar may demonstrate molar intrusion©Dr Sylvain Chamberland
  141. 141. AA.St.Tr. 130711, 22ans Tx time: 66 weeks AA St-O 271112, 14 days post debonding©Dr Sylvain Chamberland
  142. 142. Initial Stability... Time will tell©Dr Sylvain Chamberland
  143. 143. Case 5©Dr Sylvain Chamberland
  144. 144. MePo 030610 Notable CO/CR discrepancy MePo 030610 After 4 months of splint therapy MePo 021110©Dr Sylvain Chamberland
  145. 145. ©Dr Sylvain Chamberland
  146. 146. Cl I open bite Bimaxillary protrusion Lower lip is prominent Slightly long LAFH©Dr Sylvain Chamberland
  147. 147. MePo310112 TAD inserted un January between 6-7/ (not the best place!) the buccal segment MePo310512©Dr Sylvain Chamberland
  148. 148. MePo310112 MePo310512 At 60 weeks into tx Class I relationship & positive OB is achieved MePo040912©Dr Sylvain Chamberland
  149. 149. MePo040912 MePo310112 MePo310512 At 100 weeks into tx MePo021012 At 105 weeks into tx MePo071112©Dr Sylvain Chamberland
  150. 150. Initial Progress 0512 If superimposition is accurate ✦ 1/ retraction and extrusion ✦ Slight increase of FMA Progress MePo040912©Dr Sylvain Chamberland
  151. 151. MePo040912 Superimposition show ✦ Mx molar intrusion & slight incisor extrusion ✓ Similar to differential mx impaction ✦ Md molar protraction. Lower incisor AP is maintained Smile display is acceptable©Dr Sylvain Chamberland
  152. 152. Case 6©Dr Sylvain Chamberland
  153. 153. At 13 until 15 years old (may 04-June 06) ✦ Ortho tx: HG + Fixed app. ✦ Began oral contraceptive when she was 14-15 TMJ consultation begins in 2007©Dr Sylvain Chamberland ArLa 30082012
  154. 154. Mouth closed Mouth open Severe resorption in right TMJ, moderate in the left Note: her sister was recently diagnose of rheumatoid arthritis©Dr Sylvain Chamberland
  155. 155. Medical & dental history MRI in 2007 ✦ Left: ✓ DD without reduction ✓ Degenerative changes ✦ Right ArLa 19092007 ✓ DD with reduction + possibility of perforation (Surgeon: Early click noted on opening) ✓ Degenerative changes Occlusal splint therapy initiated. ( ✦ Helped to reduce pain slightly (~ 35%)©Dr Sylvain Chamberland
  156. 156. Current exam MRI 2011 ✦ osteophytes, bone signal: "hypointense". DD with reduction ✦ normal. DD NR Blood test ✦ ANF negative, Rh factor normal, sedimentation normal ✦ Estogen: result pending©Dr Sylvain Chamberland
  157. 157. Bone scan Tc99 Maxi Mean Ar.La. mum Increased uptake in right Right 1,67 1,43 Sept Ratio right/left mean 0,79 2011 Left 2,12 2,35 Ratio right/left maximum 0,61 Increased bone metabolism in the left joint revealing condylar resorption Right condyle seem in remission©Dr Sylvain Chamberland
  158. 158. Splint therapy since fall 2007 Picture with the splint will be added. ArLa240912 Since March 2011 ✦ Naproxen 500 mg bid ✦ Ran pantotrazole 40mg 1co le matin ✦ Cyclobenzaprine 10mg 1co hs©Dr Sylvain Chamberland
  159. 159. Tx Plan 82 74 100 8 80 86 111 -1 Genioplasty early into ortho treatment 18 52 -3 115 3 12 40 108 42 6 Total joint replacement 45 -13 101 22 ✦ Alloplastic ✦ Autogenous (costochondral) ✓ Audience: discuss why one would be choose over the other? Bimax surgery advancement + counterclokwise rotation + another genioplasty prn©Dr Sylvain Chamberland
  160. 160. Final Thoughts "Facial asymmetry commonly involves TMJ pathology or disorders. Therefore, the TMJs should always be evaluated (whether symptomatic or asymptomatic) to determine if the TMJs are the etiologic factor, a problem that developed because of facial asymmetry, a coexisting pretreatment condition, or that Progressive worsening facial asymmetry usually indicates that TMJ pathology is present with one condyle either resorbing or growing." ✦ Wolford L.M., Mandibular Asymmetry: Temporomandibular Joint Degeneration , Chap. 82, p.696-725©Dr Sylvain Chamberland
  161. 161. Final Thoughts "In conclusion, it is essential that TMJ osteoarthritis be presented as the pathologic entity it is in the same terms as our colleagues discuss osteoarthritis in orthopaedic circles. To not do this only exacerbates the problem that everyone dealing with this entity — patients, clinicians, insurance carriers, and so forth — has with TMJ osteoarthritis, because they do not consider it as the orthopaedic (medical) pathology that it is, but rather a purely dental TMJ problem." Mercuri L.G., Oral Max Surg Clin N Am 20 (2008) 169-183©Dr Sylvain Chamberland
  162. 162. Thank you Dr Wiltshire Dear colleagues Thank you for your attention©Dr Sylvain Chamberland
  163. 163. Thank you Dr Wilson and Dr Tompson Dear colleagues Thank you for your attention©Dr Sylvain Chamberland