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Effect of Surgery First Orthognathic Approach on the Temporomandibular Joint: A Clinical Evaluation
Abstract and Figures
Introduction:
Correction of severe malocclusions with skeletal discrepancies requires orthodontic treatment in combination with orthognathic surgery. Even though conventional orthognathic surgery (COS) is a common and well-accepted approach its influence on the signs and symptoms of temporomandibular disorders (TMDs) is still debated. Recently with the introduction of surgery first approach, a different timing for the management of dentoskeletal imbalances has been proposed. The present study is aimed at assessing the relationship between surgery first approach and temporomandibular joint (TMJ) disorders.
Methods:
The study sample consisted of 24 patients who were selected to be treated with surgery first approach. Clinical follow-ups after surgery were performed every week for the first month, at 3 months, 6 months, and at 1 year. A radiological follow-up was performed at 1 week and at 1 year after the operation with a panorex and a latero-lateral teleradiograph. To assess the effect of surgery first approach on the TMDs signs and symptoms, a clinical assessment was performed 4 days before surgery (T1), 6 months after surgery (T2), and 1 year postoperatively (T3).
Results:
The results of the authors' study show that pain assessment revealed a general improvement of this symptom in correspondence to TMJ and masticatory muscles except in the masseter and neck region. Also joint noises, TMJ functioning, migraine, and headache underwent a considerable improvement.
Conclusion:
Surgery first approach is an innovative orthognathic procedure and, by undergoing surgery first approach, patients with pre-existing TMJ dysfunction may experience a significant improvement or even resolution of the TMDs signs and symptoms.
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... However, there is still not good agreement about whether surgical-orthodontic treatment will improve or aggravate the signs and symptoms of TMD, or have no significant effect on them. Several previous studies have found a beneficial association between orthognathic surgery and TMD with the reduction of the prevalence of postoperative TMD symptomatic patients [9][10][11][12][13]. On the contrary, some studies reported that the positional changes of the condyle in the glenoid fossa during orthognathic surgery may cause TMD symptoms, even causing further deleterious effects on the TMJ and thus worsening pre-existing symptoms and dysfunction [14,15]. ...
... They concluded that patients with preexisting TMJ dysfunction are more likely to have worsening of the TMJ dysfunction after orthognathic surgery, especially after mandibular advancement. For SFA, there was only one previous report that studied the effect of SFA on the TMJ [12]. Pelo, Saponaro [12] assessed TMD signs and symptoms in 24 patients who were treated with SFA, and reported a significant improvement or resolution of the TMD signs and symptoms postoperatively in the majority of patients with preoperative TMD. ...
... For SFA, there was only one previous report that studied the effect of SFA on the TMJ [12]. Pelo, Saponaro [12] assessed TMD signs and symptoms in 24 patients who were treated with SFA, and reported a significant improvement or resolution of the TMD signs and symptoms postoperatively in the majority of patients with preoperative TMD. In our study, we assessed the changes in signs and symptoms of TMD after surgical-orthodontic treatment and compared them between OFA and SFA. ...
The purposes of this study were to investigate the influence of the orthodontics-first approach (OFA) and surgery-first approach (SFA) on changes in the signs and symptoms of temporomandibular joint disorders (TMDs) and to compare pre- and postoperative orthodontic treatment duration and total treatment duration between the two approaches. This retrospective study recruited 182 adult patients with malocclusions treated with OFA and SFA and recorded variables such as age, gender, skeletal classification, and signs and symptoms of TMD (clicking and pain disorders) before the start of the surgical-orthodontic treatment and after surgery. Changes in the signs and symptoms of TMD and treatment duration were evaluated within each approach and compared between two approaches. A binary logistic regression was performed to assess the influence of the variables on the postoperative signs and symptoms of TMD. There were no significant postoperative changes in temporomandibular joint (TMJ) pain for OFA and SFA, whereas a significant reduction was found in TMJ clicking after surgery for both approaches. According to binary logistic regression, the type of surgical-orthodontic treatment (OFA or SFA) was not a significant risk factor for postoperative TMJ clicking and pain, and the risk of postoperative TMJ clicking and pain was significant only when TMJ clicking (OR = 10.774, p < 0.001) and pain (OR = 26.876, p = 0.008) existed before the start of the entire treatment, respectively. With regard to the treatment duration, SFA (21.1 ± 10.3 months) exhibited significantly shorter total treatment duration than OFA (34.4 ± 11.9 months) (p < 0.001). The results of this study suggest that surgical-orthodontic treatment using SFA can be a feasible option of treatment for dentofacial deformities based on the equivalent effect on TMD and shorter overall treatment period compared to conventional surgical-orthodontic treatment using OFA.
... Class III with openbite and asymmetry cases with SFA are the other published studies. SFA in Class II cases and in some deformities like TMJ disorders or condylar hyperplasia is rare [27][28][29]. ...
... On the other side, due to the early correction of skeletal and soft tissue problems, orthodontic treatment may be easier due to normalized surrounding soft tissue [23]. It was reported that the patients with preexisting TMJ dysfunction might experience a significant improvement of TMD signs and symptoms after SFA [29]. ...
... 9 After orthognathic surgery, a postoperative orthodontic treatment is continued, which helps to stabilize the surgical results and improves the occlusal relationship. 10 Orthognathic surgery is used to correct severe dentofacial deformities and achieve balance among the patient's facial features. 11 Bilateral sagittal osteotomy of the mandibular ramus is the most commonly used jaw reduction technique in cases of prognathism between 3 and 9 mm. ...
Objective:
Evaluate the electromyographic changes in the Masseter (MM) and Temporalis (TM) muscles during voluntary clenching of the teeth both before and after orthognathic surgery in patients aged 18 years and older and diagnosed with mandibular prognathism.
Methods:
Eleven patients with prognathism were included in the study, in all of whom the initial phase of orthodontic treatment had been completed. The orthognathic procedure to reduce prognathism comprised intraoral oblique sliding (or subsigmoid) osteotomy, after which intermaxillary fixation with ligaments in the maxilla and mandible was undertaken in all patients for 6 weeks post-surgery. Electromyographic activity was recorded during the baseline maximum voluntary contraction of the teeth, with the same measurement taken 3 and then 6 months after orthognathic surgery.
Results:
Significant differences were found in the mean amplitude (17.0 vs 14.7, P = 0.020) and peak-to-peak amplitude (left [761.6 vs 457.0, P = 0.003] and right [676.9 vs 357.4, P = 0.007]) for the MM between the baseline score and 6 months after surgery. Likewise, significant differences were found in the mean amplitude (18.2 vs 25.6, P = 0.009) and peak-to-peak amplitude (left [856.4 vs 1594.2, P = 0.004] and right [804.4 vs 1813.4, P = 0.004]) for the TM between the baseline score and that taken 6 months post-surgery. Only 18.2% (2/11) presented orthodontic appliances problem in the 3 months post-surgery.
Conclusion:
Electromyographic activity was restored 6 months after the orthognathic surgery. From a clinical perspective, the results obtained confirm that orthognathic surgery has not only an esthetic but also a functional objective in terms of achieving equilibrium and occlusal harmony.
... 3,4 Patients without pre-existing TMJ problems can also develop postoperative TMJ-related symptoms and even condylar resorption. 5 In a systematic review of the available literature between 1980 and 2008, Jerjes et al 6 (2011) concluded that TMJ symptoms present before surgery were significantly reduced after orthognathic treatment of the lower jaw. They also concluded that a percentage of dysgnathic patients who were preoperatively asymptomatic may develop TMD after surgery, but this risk is low. ...
The aim was to postoperatively evaluate a conservative treatment approach to bilateral condylar resorption after orthognathic surgery. A retrospective study was carried out on 730 consecutive patients undergoing sagittal split osteotomy, 2013 to 2016. The mean follow-up period was 2.29 years. Clinical and radiographic findings of patients with postoperative bilateral condylar resorption were searched. Syndromic patients and patients with juvenile rheumatoid arthritis were excluded from this study. Of the 730 patients, 6 (0.82%) required treatments because of bilateral postoperative condylar resorption but had no surgery at the temporomandibular joint (TMJ). Five patients with TMJ symptoms because of postoperative condylar resorption were managed with conservative treatment. About 2 of the 6 patients were successfully retreated with orthognathic surgery in the upper jaw to close the open bite. The TMJ symptoms can successfully be managed with conservative therapy, whereas skeletal relapse can be retreated with orthognathic surgery in the upper jaw, depending on the amount of overjet. Patient undergoing orthognathic surgery may develop bilateral condylar resorption though the frequency is <1%, most of these patients can be managed conservatively.
One of the challenges of orthognathic surgery (OS) is maintaining condylar position during osteosynthesis. It is believed that the post-surgical condylar position is related to postoperative morphological changes in the temporomandibular joint (TMJ), as well as surgical stability. Therefore, the aim of this study is to perform fractal analysis of the mandibular ramus in class II and class III patients undergoing OS, analyzing cone beam computed tomography (CBCT) images one month before surgery (T0), one month after surgery (T1), and six to eight months after surgery (T2). Fractal analysis was performed on coronal and sagittal reconstructions. Regions of interest (ROIs) were selected for each patient and evaluated region. The ROIs underwent a processing method described by White & Rudolph in 1999. After processing, fractal analysis calculation was performed using the box-counting method by the "Fractal Box Count" function of the ImageJ software. When examining the different periods (T0, T1, and T2) among class II and class III patients, no statistically significant differences were identified (p > 0.05). This finding suggests stability in the fractal characteristics of the analyzed region, regardless of skeletal class. Thus, OS for correction of Class II and Class III malocclusions did not demonstrate a significant impact on the microstructure of the mandibular ramus over time.
The management of patients with pre-existing temporomandibular disorders (TMDs) undergoing orthognathic surgery remains a subject of ongoing debate. This study aimed to profile these individuals and evaluate the correlation between orthognathic surgery and alterations in TMD indicators and symptoms. We conducted a retrospective cohort investigation involving patients with skeletal malocclusion and established TMDs. Variables of interest encompassed the performance of orthognathic surgery, documented TMDs (including temporomandibular joint (TMJ) sounds, TMJ pain, muscle discomfort, and jaw locking), and patients’ self-assessments of TMJ and muscle pain using a visual analog scale (VAS). The primary outcome measures focused on changes in TMD indicators and symptoms. Among the study cohort, 73.4% exhibited skeletal class III malocclusion, while 26.6% presented with skeletal class II malocclusion. Notably, patients classified as skeletal class III were significantly younger than their skeletal class II counterparts (mean age: 23.06±5.37 vs. 26.71±7.33; P =0.034). The most prevalent pre-existing TMD complaint was TMJ sounds (65.5%), followed by TMJ pain (39.1%), muscle discomfort (23.4%), and jaw locking (12.5%). Skeletal class II patients were more likely to experience TMJ sounds compared to skeletal class III patients (88.2% vs. 57.4%; P =0.022). Statistically significant improvements were observed in the VAS assessments among class III patients following surgery. A majority of patients with pre-existing TMDs seeking orthognathic surgery exhibited skeletal class III malocclusion and were younger than those with skeletal class II malocclusion. Importantly, orthognathic surgery was associated with positive changes in TMD indicators and symptoms in these patients.
Background:
Orthognathic surgery is done to treat a variety of dentofacial abnormalities, but a wide gap still remains on how it can result in temporomandibular joint dysfunction (TMD). The primary goal of this review was to assess the effects of various orthognathic surgical techniques on the emergence or exacerbation of TMJ dysfunction.
Methods:
A comprehensive search was conducted across several databases using Boolean operators and MeSH keywords related to temporomandibular joint disorders (TMDs) and orthognathic surgical interventions, with no limitation on the year of publication. Two independent reviewers screened the identified studies based on predetermined inclusion and exclusion criteria, followed by a risk of bias assessment using a standardized tool.
Results:
Five articles were considered for inclusion in this review. A greater number of females opted for surgical options than their male cohorts. 3 studies were of prospective design, 1 of retrospective and 1 of observational type. Mobility on lateral excursion, tenderness on palpation, arthralgia and popping sounds were the TMD characteristics that showed significant differences. Overall, orthognathic surgical intervention did not show an increase in TMD signs and symptoms as compared to non-surgical counterparts.
Conclusion:
Though orthognathic surgery reported greater cases of some TMD symptoms and signs as compared to the non-surgical cohorts in four studies, the conclusive evidence is debatable. Further studies are recommended with longer follow up period and greater sample size to determine the impact of orthognathic surgery on TMJ.
Purpose
This study aimed to evaluate the difference in prevalence of temporomandibular disorder (TMD) before and after orthognathic surgery (OGS), particularly in patients with mandibular asymmetry.
Materials and methods
A prospective cohort study of patients undergoing corrective orthognathic surgery was conducted. Pre-operative and post-operative (3 months, 6 months and 1 year) TMD assessment were performed according to the Diagnostic Criteria for TMD (DC/TMD) protocol.
Results
Overall, there was a significant reduction of 26.5% in TMD prevalence from 60.9% pre-operatively to 34.4% 1-year post-operatively (p = 0.003). In all, 37.5% of patients had their TMD condition treated, 50% had no change in their symptoms while 12.5% experienced a worsening of their symptoms. No significant difference in terms of change in TMJ status was observed among the different ramus procedures, the type and magnitude of mandibular movement, skeletal class, and presence of mandibular asymmetry.
Conclusion
In conclusion, it appears that corrective orthognathic surgery for dentofacial deformities might provide a secondary benefit of treating TMD. However, surgeons have to be aware that a small percentage of patients might experience a deterioration of their TMD condition, and that those who were previously asymptomatic may develop TMD symptoms after surgery.
The occlusal plane angle is an important factor in lateral facial aesthetics. Low occlusal plane facial profiles appear planar and long-faced, whereas high occlusal plane facial profiles are considered more attractive, especially in Asian regions. Clockwise rotation of the occlusal plane for truly aesthetic purposes can be accomplished with double jaw surgery, without need for orthodontic treatments. Patients with normal occlusion who desired to improve their lateral facial aesthetics were included in this study. A conventional Le Fort I osteotomy was followed by a sagittal split ramus osteotomy under general anesthesia. The movement of the maxillomandibular complex was determined in accord with a preoperative analysis. From 2015 to 2017, 43 patients with normal occlusion underwent double jaw surgery without orthodontic treatment. Whereas all patients were subjectively satisfied with the surgery, two underwent orthodontic treatment to correct mild occlusal discrepancies noticed after surgery. There were no delayed occlusal problems or relapses reported during the study. For patients who desired to improve their lateral facial aesthetics but had normal occlusion, orthognathic surgery without orthodontic treatment can be effective. Clockwise rotation of the occlusal plane by double jaw surgery without orthodontic treatment resulted in satisfactory aesthetic outcomes with stable and reliable long-term results.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, IV.
The introduction of "surgery first" has resulted in a new requirement to compare and resolve medical legal problems which previously did not exist in traditional orthognathic surgery. The first issue relates to the relationship between the doctor and the patient and, in particular, the need to create a new informed consent form for surgery first. The second problem that has arisen with the arrival of surgery first concerns the relationship between health workers, namely the surgeon, and the orthodontist. The authors of this article propose a new template for informed consent specifically created for surgery first and also a model for the new working relationship between surgeons and orthodontists which will facilitate and improve co-operation between them. This will improve results, and guarantee a greater level of protection for the surgeon. It will also enable the identification the individual responsibilities of each person.
The aim of this article is to review temporomandibular joint symptoms as well as the effects of orthognathic surgery(OGS) on temporomandibular joint(TMJ). The causes of temporomandibular joint disease(TMD) are multifactorial, and the symptoms of TMD manifest as a limited range of motion of mandible, pain in masticatory muscles and TMJ, Joint noise (clicking, popping, or crepitus), myofascial pain, and other functional limitations. Treatment must be started based on the proper diagnosis, and almost symptoms could be subsided by reversible options. Minimally invasive options and open arthroplasty are also available following reversible treatment when indicated.
TMD manifesting in a variety of symptoms, also can apply abnormal stress to mandibular condyles and affect its growth pattern of mandible. Thus, adaptive developmental changes on mandibular condyles and post-developmental degenerative changes of mandibular condyles can create alteration on facial skeleton and occlusion. The changes of facial skeleton in DFD patients following OGS have an impact on TMJ, masticatory musculature, and surrounding soft tissues, and the changes of TMJ symptoms. Maxillofacial surgeons must remind that any surgical procedures involving mandibular osteotomy can directly affect TMJ symptoms, thus pre-existing TMJ symptoms and diagnoses should be considered prior to treatment planning and OGS.
Relations between maxillo-mandibular deformities and TMJ disorders have been the object of different studies in medical literature and there are various opinions concerning the alteration of TMJ dysfunction after orthognathic surgery. The purpose of the present study was to evaluate TMJ disorders changes before and after orthognathic surgery, and to assess the risk of creating new TMJ symptoms on asymptomatic patients.
A questionnaire was sent to 176 patients operated at the Maxillo-Facial Service of the Lille's 2 Universitary Hospital Center (Chairman Pr Joël Ferri) from 01.01.2006 to 01.01.2008. 57 patients (35 females and 22 males), age range from 16 to 65 years old, filled the questionnaire. The prevalence and the results on pain, sounds, clicking, joint locking, limited mouth opening, and tenseness were evaluated comparing different subgroups of patients.
TMJ symptoms were significantly reduced after treatment for patients with pre-operative symptoms. The overall subjective treatment outcome was: improvement for 80.0% of patients, no change for 16.4% of patients, and an increase of symptoms for 3.6% of them. Thus, most patients were very satisfied with the results. However the appearance of new onset of TMJ symptoms is common. There was no statistical difference in the prevalence of preoperative TMJ symptoms and on postoperative results in class II compared to class III patients.
These observations demonstrate that: there is a high prevalence of TMJ disorders in dysgnathic patients; most of patients with preoperative TMJ signs and symptoms can improve TMJ dysfunction and pain levels can be reduced by orthognathic treatment; a percentage of dysgnathic patients who were preoperatively asymptomatic can develop TMJ disorders after surgery but this risk is low.
Objective:
To evaluate the influence of orthognathic surgery on the clinical signs and symptoms of temporomandibular disorders (TMDs).
Study design:
In a cohort study, 54 patients undergoing orthognathic surgery were evaluated with regard to the signs and symptoms of TMDs through subjective and objective assessments. These evaluations were performed 1 week preoperatively (T1), 1 month postoperatively (T2), and 6 months postoperatively (T3). The evaluations included patient variables and surgery. Univariate analyzes were performed to verify the association of the variables (P < .05).
Results:
The incidence of TMD 6 months after orthognathic surgery was significantly lower (P < .001). TMD intensity decreases significantly in the postoperative period. Females had a higher prevalence of TMD (P = .003) and muscular disorders preoperatively (P = .001). There was a decrease in clicks between T1 and T3 (P = .013). Mouth opening without pain worsened from T1 to T2 (P < .001) and improved from T1 to T3 (P = .015) and T2 to T3 (P < .001). The results were similar for mouth opening with pain (P < .001). In patients undergoing jaw fixation with bicortical screws, mouth opening without pain was significantly less in T3 patients than in patients undergoing fixation with plate and monocortical screws (P = .048).
Conclusions:
Orthognathic surgery reduces the clinical signs and symptoms of TMD.
This retrospective study was designed to analyze the relationships between temporomandibular joint (TMJ) disk displacement and skeletal deformities in orthodontic patients. Subjects consisted of 460 adult patients. Before treatment, lateral cephalograms and TMJ magnetic resonance imaging (MRI) were recorded. Subjects were divided into six groups based on TMJ MRI according to increasing severity of TMJ disk displacement, in the following order: bilateral normal TMJs, unilateral disk displacement with reduction (DDR) and contralateral normal, bilateral DDR, unilateral disk displacement without reduction (DDNR) and contralateral normal, unilateral DDR and contralateral DDNR, and bilateral DDNR. Subjects were subdivided sagittally into skeletal Class I, II, and III deformities based on the ANB (point A, nasion, point B) angle and subdivided vertically into hypodivergent, normodivergent, and hyperdivergent deformities based on the facial height ratio. Linear trends between severity of TMJ disk displacement and sagittal or vertical deformities were analyzed by Cochran-Mantel-Haenszel test. The severity of TMJ disk displacement increased as the sagittal skeletal classification changed from skeletal Class III to skeletal Class II and the vertical skeletal classification changed from hypodivergent to hyperdivergent. There were no significant differences in the linear trend of TMJ disk displacement severity between the sexes according to the skeletal deformities. This study suggests that subjects with skeletal Class II and/or hyperdivergent deformities have a high possibility of severe TMJ disk displacement, regardless of sex.
From 1989 to 2009, at the Department of Cranio-Maxillo-Facial Surgery, Umberto I Polyclinic, "Sapienza" University of Rome, 3236 patients affected by maxillo-mandibular malformations were submitted to orthognathic surgery, by means of rigid internal fixation. Follow-up highlighted the surgical complications and the possible functional and/or esthetical disorders in the treatment of those pathologies. The data collected have been compared with the ones reported in the literature.
3236 patients were evaluated clinically and radiographically. The X-rays have been performed before the study, after 24-48 hours, at 6 months and year after surgery.
The most frequent surgical complication was the mandibular nerve sensitivity deficit (19%), irreversible only in 2% of the cases. Temporomandibular joint disorders (TMD), which are widely reported in the international literature, have been relevant in our study too. In particular, TMD occurred in those patients who were already affected by the disorder (from 28.3% to 18.1%); besides, in 11% of cases the symptom appeared after surgery and was treated by means of splint or physiotherapy. Infectious complications occurred in 2% of cases and fractures of the bone elements in 1.5% of cases. The other complications quoted internationally occurred in an irrelevant percentage in our study.
We believe that orthognathic surgery complications are quite rare and the percentages reported both in our study and in the literature have to be considered as surgical mistakes related to the surgeon experience or as real complications of the orthognathic surgery. Furthermore, as the success of this kind of surgery depends upon many factors, surgical complications represent only one of the causes of the failure. Other causes could be mistakes in planning, unsuitable orthodontic treatment and, finally, an unsuitable assessment of the patients' esthetical and functional problems.
Seventy-five patients were studied retrospectively to assess the prevalence and variance of temporomandibular dysfunction in an orthognathic surgery population. Preoperatively, 49.3% of the sample presented with temporomandibular dysfunction. After orthognathic surgery, of the symptomatic patients, 89.1% had improved temporomandibular function after surgery, 2.7% were unchanged, and 8.1% had increased symptoms. Of the patients asymptomatic prior to surgery, 7.9% developed temporomandibular dysfunction postoperatively. Temporomandibular dysfunction was significantly more prevalent in patients with a Class II skeletal deformity than in those with a Class III deformity, and temporomandibular function generally improved in both groups postsurgically.
The aims of this study were to determine patients' perceptions of pain, paresthesia, and swelling after orthognathic surgery and to analyze the association between these perceptions and neuroticism, temporomandibular joint dysfunction, and mood states among the patients. Levels of pain, paresthesia, and swelling were measured by two self-appraisals that were developed for this research. Perceptions of facial discomfort decreased with time and varied according to the surgical procedure. Patients who scored high on neuroticism tests reported greater levels of temporomandibular joint symptoms before surgery and greater experiences of pain 2 years after surgery. Perceived pain appeared to exert a negative influence on mood states up to 2 years following surgery. These results reveal the importance of continued psychological support for orthognathic surgery patients throughout their course of treatment.
Overbite and overjet were studied as continuous variables to examine for any relationship to diagnostic groups of temporomandibular disorders (TMD) compared with symptom-free controls. This avoided the bias of arbitrary definitions of normal and abnormal for these occlusal variables and also avoided the masking effect of studying symptoms rather than diagnostic entities. Incisal overbite in primary osteoarthrosis (OA) was shifted toward the minimal and open bite ranges as compared with the controls (p less than 0.02). Open bite occurred in only the two OA classes studied and in a few cases with myalgia only but was absent in the symptom-free controls. Overbite in myalgia was slightly skewed to the lower range. Deep bite was not more common in the myalgia, disk displacement (with or without reduction), or the OA groups. Increased overjet characterized OA groups, especially when there was a history of derangement (p less than 0.004), but did not characterize the other diagnostic groups. Except for open bite, overbite and overjet characteristics as isolated variables did not distinguish TMD patient groups. It is hypothesized that open bite in OA can be the result of joint changes rather than a predisposing occlusal cause.