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Progressive idiopathic condylar resorption: Three case reports


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Progressive condylar resorption, also known as idiopathic condylar resorption, is an uncommon, aggressive, degenerative disease of the temporomandibular joint (TMJ) seen mostly in adolescent girls and young women. This condition leads to loss of condylar bone mass, decrease of mandibular ramal height, steep mandibular and occlusal plane angles, and an anterior open bite. In 3 case reports, we review the pathogenesis of TMJ degen-erative disease and the clinical management of TMJ arthrosis. We emphasize that TMJ arthritic disease should be discussed in dental circles as a pathologic entity in the same way that orthodontists discuss arthritic disease in orthopedic circles. Regarding the degenerative pathology of the TMJ, treatment goals include restored function and pain reduction. The treatment methods used to achieve these goals can range from noninvasive therapy to minimally invasive and invasive surgery. Most patients can be treated noninvasively, and the importance of disease prevention and conservative management in the overall treatment of TMJ disease must be acknowledged. The decision to manage TMJ osteoarthrosis surgically must be based on evaluation of the patient's response to noninvasive treatments, mandibular form and function, and effect of the condition on his or her quality of life. (Am J Orthod Dentofacial Orthop 2019;156:531-44)
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Progressive idiopathic condylar
resorption: Three case reports
Sylvain Chamberland
Quebec City, Quebec, Canada
Progressive condylar resorption, also known as idiopathic condylar resorption, is an uncommon, aggressive,
degenerative disease of the temporomandibular joint (TMJ) seen mostly in adolescent girls and young women.
This condition leads to loss of condylar bone mass, decrease of mandibular ramal height, steep mandibular and
occlusal plane angles, and an anterior open bite. In 3 case reports, we review the pathogenesis of TMJ degen-
erative disease and the clinical management of TMJ arthrosis. We emphasize that TMJ arthritic disease should
be discussed in dental circles as a pathologic entity in the same way that orthodontists discuss arthritic disease in
orthopedic circles. Regarding the degenerative pathology of the TMJ, treatment goals include restored function
and pain reduction. The treatment methods used to achieve these goals can range from noninvasive therapy to
minimally invasive and invasive surgery. Most patients can be treated noninvasively, and the importance of dis-
ease prevention and conservative management in the overall treatment of TMJ disease must be acknowledged.
The decision to manage TMJ osteoarthrosis surgically must be based on evaluation of the patient's response to
noninvasive treatments, mandibular form and function, and effect of the condition on his or her quality of life. (Am
J Orthod Dentofacial Orthop 2019;156:531-44)
Progressive condylar resorption (PCR) also known
as idiopathic condylar resorption (ICR) is an un-
common, aggressive, degenerative disease of the
temporomandibular joint (TMJ) seen mostly in adoles-
cent and young women.
This disorder has a female
prevalence of 9:1. Constitutional risks factors, besides
female predilection, are hormonal imbalance
(Yestrogen, Y17b-estradiol), nutritional status
(Yvitamin D, Ydietary omega-3 fatty acids), bruxism,
and repetitive oral habits. Iatrogenic causes have been
reported to include orthodontics, orthognathic surgery,
intermaxillary xation, and improperly designed and
used occlusal appliances, all resulting in condylar
displacement and compressive TMJ overloading.
PCR is best describe as a localized noninammatory
degenerative disorder of the TMJ and is characterized
by lysis and repair of the articular brocartilage and un-
derlying subchondral bone.
This condition leads to loss
of condylar bone mass, decrease of mandibular ramal
height, steep mandibular and occlusal plane angle, and
an anterior open bite. Most of the destructive process
is localized to the bone superior to a line bisecting the
condylar poles. The active phase of PCR is often associ-
ated with limited jaw opening and TMJ pain, followed by
condylar attening. This may form a congruent articula-
tion with the opposing posterior aspect of the articular
eminence which permits redistribution of functional
loads, thereby restoring some condylar motion and
reduction in pain.
PCR occurring before the completion of growth re-
sults in a shorter condyloid process, shorter ramus,
shorter mandibular body, compensatory growth at the
gonial angle, and increased vertical dimension of the
anterior facial region. As ramus height is lost, develop-
ment of an anterior open bite is likely. There is a ten-
dency for a reduction in airway dimension secondary
to decreased mandibular growth
or, in the case of a pa-
tient who has completed growth, progressive
mandibular retrusion.
Reduction in airway dimensions can lead to the risk
of developing sleep apnea. Increased lower anterior
facial height may cause lip incompetence in repose
and reduced alveolar bone thickness at the facial aspect
of the incisors.
The orthopantomogram (OPG), as a panoramic
radiograph is termed internationally, is the least
Private practice, Quebec City, Quebec, Canada.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conicts of Interest, and none were reported.
Address correspondence to: Sylvain Chamberland, 10345 Boul de l'Ormiere,
Quebec, QC, Canada G2B 3L2; e-mail,
Submitted, March 2018; revised and accepted, May 2018.
Ó2019 by the American Association of Orthodontists. All rights reserved.
expensive imaging modality for gross evaluation of the
condyle. Loss of bone mass or attening of the anterior
or superior aspect of the condyle, as well as a distal
inclination of the condylar neck, is easily observable on
the OPG.
A cephalogram would display a shortened posterior
facial height, increased anterior facial height, increased
overjet, and open bite. Serial cephalograms taken during
the active stages of PCR would show a more mesial
position of the articulare point.
Cone-beam computed tomography (CBCT) permits
3-dimensional evaluation of the condyle and helps to di-
agnose features such as condylar degeneration, erosion,
sclerosis or attening of the dense cortical layer, and
subcortical cyst formation (Ely cyst).
Magnetic resonance imaging (MRI) is the preferred
technique for investigation of the soft tissues of the
TMJ, including cartilaginous integrity of the articular
surfaces, disk derangement, and inammation.
T1-weighted MRI is helpful in identifying disc position
and alterations in bone and soft tissue anatomy, and
T2-weighted MRI is useful for identifying inammatory
response as well as TMJ condylar bone marrow
Nuclear medicine bone scanning with the use of
technecium-99 can be used to assess whether there are
any active bony changes, but the specicity is not suf-
cient to assess the state of stability or remission of those
The most common joint pathology affecting the TMJ
is osteoarthrosis. Unlike rheumatoid arthritis, TMJ os-
teoarthrosis has a noninammatory origin. The patho-
logic process is characterized by deterioration and
abrasion of articular cartilage and local thickening and
remodeling of the underlying bone. These changes are
frequently accompanied by the superimposition of sec-
ondary inammatory changes.
Three main etiologies
have been proposed for the pathogenesis of the disease:
(1) trauma and or aberrant loading; (2) hormonal path-
ogenesis; and (3) a genetic basis for altered joint extra-
cellular matrix.
These are not mutually exclusive,
because a decreased adaptive capacity of the
articulating structures, hormonal factors, and excessive
physical stress on a joint can all induce dysfunctional
Functional overloading can facilitate hypoxia and
mediate the destructive processes associated with
osteoarthrosis as an autocrine factor. Vascular endothe-
lial growth factor (VEGF) induction in osteoarthritic
cartilage by functional overloading is linked to
activation of the hypoxia-induced transcription factor
1, leading to hypoxia in the joint tissue. Furthermore,
VEGF regulates the production of matrix metalloprotei-
nases (MMPs) and tissue inhibitors of theses enzymes,
which are among the effectors of extracellular matrix
Overloading also causes collapse of joint lubrica-
tion as the result of hyaluronic acid degradation by
free radicals. The regulation of hyaluronic acid pro-
duction is controlled by various proinammatory
cytokines. Of these cytokines, tumor necrosis factor
aand interleukin-1 and -6 play crucial roles in the
pathogenesis of osteoarthrosis regarding the accel-
eration and progression of cartilage degradation,
because they promote bone resorption through
the differentiation and activation of osteoclasts
(Fig 1).
The management goals of TMJ osteoarthrosis should
be: (1) decreasing joint pain, swelling, and muscle pain;
(2) increasing joint function; (3) preventing further joint
damage; and (4) preventing disability.
The rst management option includes noninvasive
modalities such as medications (nonsteroidal antiin-
ammatory drugs [NSAIDs] and muscle relaxants), phys-
iotherapy, and occlusal appliance therapy. A second set
of options includes minimally invasive modalities such
as arthrocentesis (washing out the joint), injection of hy-
aluronic acid or a corticosteroid, and arthroscopic sur-
gery. However, a recent meta-analysis concluded that
there was little evidence to support the effectiveness of
arthrocentesis in the management of TMJ osteoarthro-
Therefore, arthrocentesis can no longer be recom-
mended for the management of TMJ osteoarthrosis. The
third set of options involve invasive surgical modalities
such as arthroplasty, autogenous hemiarthroplasty, dis-
cectomy, and disc repositioning by means of orthog-
nathic surgery.
Goncalves et al
reported that
articular disc repositioning in patients treated with
maxillomandibular advancement and disc
repositioning had better long-term outcomes with less
relapse compared with a group of patients undergoing
only maxillomandibular advancement surgery. However,
the disc must be intact and the patient in the early stages
of the disease.
End-stage PCR requires salvage procedures to restore
jaw function and improve and maintain skeletal alter-
These patients require either autogenous or
alloplastic total joint replacement.
532 Chamberland
October 2019 Vol 156 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Patient 1
A woman 19 years 1 month of age presented for
consultation regarding possible orthodontic treatment
for complaints of crooked teethand TMJ pain. Her
TMJ pain problems began at age 16. At 17, she had con-
servative treatment with occlusal appliance therapy,
physiotherapy, muscle relaxants, and NSAIDs. A year
later, she was diagnosed with disc displacement without
reduction, limiting jaw opening to 20 mm. An oral sur-
geon did an inltration of a local anesthetic with
epinephrine and 40 mg triamcinolone (40 g/mL). Disc
reduction was observed after inltration, with an inter-
incisal opening of 35 mm. TMJ and myofascial pain
continued despite this treatment.
She went to a second oral surgeon for consultation,
and a month later bilateral TMJ arthrocentesis was per-
formed. One month later, she had persistent pain in the
masseters and both joints and limited mouth opening.
A third oral surgeon then inltrated 200 U Botox
(dilution 100 U/mL) into masseter muscle trigger points.
This was followed in 1 month by inltration of 1 mg
Decadron into each masseter.
Clinical examination revealed a Class III subdivision
left dental relationship, moderate crowding, and the
lower midline deviated to the right (Fig 2). The cephalo-
metric analysis demonstrated a dentoalveolar bimaxillary
protrusion, Class I skeletal relationship (Wits 1 mm), hy-
perdivergent (FMA 38), short ramus, excessive anterior
face height, and retrusive chin (Fig 3,A). Her prole
was convex, and her lips were incompetent in repose
(Fig 3,B).
The OPG revealed a attened anterosuperior surface
of the left condyle with an anterior osteophyte. The
articular eminence also appeared attened. The right
condyle appeared normal. However, both condyles had
shortened condyloid processes (Fig 4).
The treatment plan included extraction of the 4 rst
premolar teeth for maximal anterior retraction and a
functional genioplasty to help obtain lip competency
and normal anterior facial height. After 13 months of or-
thodontic treatment, her teeth were aligned and the
extraction spaces were ready to close (Fig 5,Top). Joint
pain and limited mouth opening were still issues. An MRI
revealed bilateral anterior disc displacement without
After 18 months of orthodontic treatment, bilateral
disc repositioning, extraction of all 4 third molar teeth,
and a functional genioplasty were performed. Ortho-
dontic progress records at 19 months showed a Class I
occlusion with some remaining space to be closed (Fig
5,Bottom). A prole view showed reduction of the den-
toalveolar protrusion, and a genioplasty helped in
achieving lip competence in repose (Fig 6).
Fig 1. The concept of the process of cartilage breakdown in the TMJ. From J Dent Res 2008,87:296-
307, used by permission of the publisher, Sage Publications/Corwin.
Chamberland 533
American Journal of Orthodontics and Dentofacial Orthopedics October 2019 Vol 156 Issue 4
Two months after disc repositioning, the patient's
masseter muscle and TMJ pain increased. CBCT
demonstrated a decrease in articular disc space
bilaterally (Fig 7). Physiotherapy was recommended,
and Flexeril and NSAIDs were prescribed. Three
months after surgery, the right TMJ and right
masseter muscle pain signicantly 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
at H^
opital de l'Enfant-J
esus in Quebec City. A right
TMJ discectomy was performed in February 2015. At
the September 2015 follow-up, the right condyle
showed signicant resorption, reduced interarticular
space, and attening of the articular eminence. The
left condyle showed progression of the attening 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
Fig 2. Patient 1 was a 19-year-old woman with Class III subdivision left malocclusion and moderate
crowding. The lower midline was deviated to the right.
Fig 3. A, Lateral cephalogram shows a hyperdivergent short ramus, excessive anterior face height,
and retrusive chin. B, Facial photograph reveals a convex prole and lip incompetency in repose.
Fig 4. OPG taken before orthodontic treatment shows a
attened anterosuperior surface of the left condyle with
an anterior osteophyte. The articular eminence also ap-
pears attened.
534 Chamberland
October 2019 Vol 156 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
overjet and overbite. The OPG revealed a progressive loss
of right condylar bone mass (Fig 8).
Four months after debanding, an anterior open bite
had developed and continued to progress to the point
that it was decided that total joint replacement was the
only management option (Fig 9). Bilateral alloplastic
total joint replacement was performed in July 2017
with the use of Zimmer Biomet (Jacksonville, Fla)
custom prostheses (Fig 10). Follow-up records demon-
strate that a functional occlusion was established (Fig
10), despite the lack of lateral movement of the jaw,
and her facial esthetics were improved (Fig 11).
Patient 2
Patient 2, a young woman, presented with a Class II
Division 1 malocclusion and an anterior open bite (Fig
12). She had been followed by her dentist for TMJ
pain for the past 7 years. She had undergone orthodon-
tic treatment 12 years earlier for a Class I malocclusion
with severe crowding and a mandibular midline devia-
tion to the left (Fig 13,Top). Four second premolars
were extracted to alleviate crowding and the orthodon-
tic treatment proceeded uneventfully. A Class I occlu-
sion was achieved, although a slight lower midline
deviation to the left remained (Fig 13,Bottom). The
OPG at debanding revealed a shortened left condyloid
process that might explain the midline deviation to
the left and facial asymmetry (Fig 14,A). Follow-up
1 year into retention showed a normal occlusion
without TMJ symptoms. The patient's prole was
straight, with lip competence in repose. The cephalo-
gram revealed a normodivergent mandibular plane,
and the gonial angle was at the level of C2. The airway
appeared normal (Fig 15).
During the period between debanding and her visit
7 years later, she had developed signicant TMJ pain.
Her general dentist made 3 splints over the years. She
stated that 1.5 years after debanding, she experienced
a sudden left TMJ lock with pain. A TMJ MRI revealed
Fig 5. Top: Progress records at 13 months. Extractions spaces are ready to close. Bottom: Progress
records at 19 months. Class I occlusion with some space remaining.
Fig 6. Prole view at 13 months shows reduction of the
dentoalveolar protrusion and lip competence in repose.
Chamberland 535
American Journal of Orthodontics and Dentofacial Orthopedics October 2019 Vol 156 Issue 4
bilateral disc displacements. On opening, the right disc
reduced, but the left side did not. No condylar degener-
ative changes were seen. Occlusal appliance therapy was
Over the ensuing years, the patient gave birth to 3
children. New occlusal appliances were made after
each birth. The OPG 4 months after the birth of the rst
child revealed noticeable changes in both condyles (Fig
14,B). A concavity was seen on the superior aspect of
left condyle, and resorption was seen in the lateral
pole of the right condyle. She was referred to a rheuma-
tologist for an autoimmune work-up. The physical ex-
amination and serology were inconclusive. However,
the patient complained of eczema and reported dull
pain in her left wrist and such acute pain in her knees
that she could no longer jog.
An OPG made after the third child's birth revealed se-
vere bilateral condylar resorption. A new occlusal appli-
ance was fabricated. The patient also noted that her
open bite had increased drastically, even with the oral
appliance. Cephalometric analysis demonstrated
decreased posterior face height, short mandibular ramus,
high mandibular plane angle, anterior open bite, and
retrognathic mandible. Study models taken at that
time could be hand articulated into a Class I occlusion,
Fig 7. CBCT 2 months after disc repositioning. Note the decreased articular disc space bilaterally.
Fig 8. Intraoral view shows that a Class I occlusion was achieved. The OPG in the background shows
loss of right condylar bone.
Fig 9. Intraoral photograph 12 months into retention
shows anterior open bite.
536 Chamberland
October 2019 Vol 156 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
demonstrating that no dental changes had occurred.
One year later, an OPG revealed complete degeneration
of the mandibular condyles bilaterally (Fig 16). The in-
traoral examination showed a Class II occlusion with a
signicant anterior open bite (Fig 12). Her prole
showed a recessive mandible and chin. She complained
of sleep apnea symptoms. The cephalogram revealed
signicant shortening of the ramus, a gonial angle
that had moved from C2 level to C1, and a signicantly
reduced airway shadow (Fig 17).
After discussion, it was decided that the best man-
agement option for this patient would be bilateral
alloplastic total joint replacement (Zimmer Biomet
custom prostheses; Fig 18).
Fifteen days after surgery the patient had a Class I
functional occlusion (Fig 19). Her prole was signi-
cantly improved, her chin/throat projection increased,
and her lips appeared competent in repose. The lateral
cephalogram demonstrated an increased airways prole
and a normal overjet and overbite (Fig 20). She had an
interincisal opening of 20 mm with 2 mm lateral excur-
sion. This can be considered normal at 15 days after
surgery. Physiotherapy was then prescribed.
Patient 3
A girl 10 years 10 months of age had a Class II sub-
division left malocclusion with slight crowding and
moderate curve of Spee. Class II correction was achieved
with the use of Class II elastic traction. Near the comple-
tion of orthodontic treatment, relapse in the occlusion
was noted. A xed twin force bite corrector (TFBC)
functional appliance was used.
She returned on an emergency basis 3 weeks later
owing to acute pain in the left TMJ and decreased inter-
incisal opening (25 mm). The TFBC was immediately
removed. A left TMJ disc displacement without reduc-
tion was diagnosed clinically. After physiotherapeutic
manipulation of her mandible, normal jaw mobility
was regained and 400 mg ibuprofen every 4 hours for
4 days was prescribed, followed by 400 mg every 6 hours
for 3 days. Follow-up at 14 days showed an interincisal
opening of 45 mm without pain.
Three weeks later, the patient developed another
closed-lock with left TMJ pain. She was then referred
to a physical therapist and instructed to take the
ibuprofen as previously prescribed for another week.
Two months later, at debanding, her interincisal
Fig 10. OPG 1 month after Zimmer Biomet custom total joint replacement. Class I functional occlusion
was achieved.
Fig 11. Prole view, 1 month after total joint replacement.
Chamberland 537
American Journal of Orthodontics and Dentofacial Orthopedics October 2019 Vol 156 Issue 4
opening was 41 mm with no pain and a Class I occlu-
sion (Fig 21,A). However, the OPG revealed at-
tening of the anterosuperior surfaces of both
condyles (Fig 22,A). This suggested incipient
condylar morphology change likely due to resorption.
showed progressive bite opening (Figs 21,Band C).
The OPG 9 months into retention revealed signs of
signicant TMJ PCR (Fig 22,B), and the OPG at de-
banding showed bilateral condylar attening. This
Fig 13. Initial photos (top) show class I occlusion with moderate crowding. Final photos (bottom) show
Class I occlusion after extraction of 4 second premolars.
Fig 14. A, OPG after at debanding shows a shortened left condyloid process, similar to initial OPG. B,
OPG 4 months after the birth of her rst child shows concavity on the top of the left condyle and resorp-
tion of the lateral pole of the right condyle.
Fig 12. Patient 2. Adult woman with Class II Division 1 malocclusion, anterior open bite, and a 7-year
history of TMJ pain.
538 Chamberland
October 2019 Vol 156 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
may explain relapse toward class II that was noted
toward the end of treatment.
Calcium (500 mg) plus vitamin D (1000 UI) once per
day was prescribed for 30 days. She was referred to an
oral surgeon and a rheumatologist. Blood testing was
negative for any systemic pathology (rheumatoid factor,
anticyclic citrullinated peptide, C-reactive protein,
antinuclear antibody, 17b-estradiol, and vitamin D
levels were normal).
Twenty months into retention, she had an ante-
rior open bite of 3 mm, slightly more severe on the
left side (Fig 23). She reported often feeling dull
pain in the right joint. On OPG, both condyles
showed signicant attening of the anterosuperior
aspect and the condylar neck was inclined posteri-
orly. The right joint showed more attening than
the left joint, suggesting more resorption (Fig 24).
This might explain why the bite was more open
on the left side.
Instructions were reinforced that the patient should
not chew gum and should resume daily vitamin D and
calcium. Despite the rheumatologist nding no evi-
dence, we suspected that this could be a case of oligoar-
ticular subtype of juvenile idiopathic arthritis (JIA) rather
than ICR. Further investigation is necessary to obtain a
nal diagnosis.
Patients 1 and 2 had end-stage condylar resorption
resulting in end-stage diseased TMJs requiring salvage
total joint replacement. Patients 1 and 3 had the onset
of symptoms at ages 13-15 years and could be diag-
nosed with ICR. Case 2 developed symptoms in her
mid-20s when she reported sudden locking of her left
TMJ. Because she also reported mild knee and wrist
pain and eczema, a form of inammatory arthritis was
suspected. Further, 3 pregnancies likely played a role
in dysfunctional TMJ condylar remodeling and
Fig 15. Prole and cephalogram at the end of orthodontic treatment revealed a normodivergent
mandibular plane as well as normal airway width and lip competence in repose.
Fig 16. OPG 1 year after the birth of her third child shows
complete degeneration of mandibular condyles bilater-
Chamberland 539
American Journal of Orthodontics and Dentofacial Orthopedics October 2019 Vol 156 Issue 4
There is growing evidence that sustained inamma-
tion induces degeneration of the TMJ
and can
lead to deterioration of the joint's mechanical
properties as well as alteration of the disc
ultrastructure which might contribute to TMJ disc
This agrees with Wolford's hypothesis
that female
hormones can inuence biomechanical change within
the TMJ, causing hyperplasia of the synovial tissues.
This would stimulate the production of cytokines that
initiate breakdown of the ligamentous structure that
normally support and stabilize the articular disc with
Fig 17. Prole view shows recessive mandible and chin. Cephalogram reveals signicant shortening
of the ramus. Gonial angle moved from C2 to C1 and reduced oropharyngeal airway shadow.
Fig 18. Left total joint prosthesis (Zimmer Biomet).
540 Chamberland
October 2019 Vol 156 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
the condyle, resulting in anterior disc displacement. Ac-
cording to this hypothesis, the cytokines penetrate
through the outer surface of the condyle and cause thin-
ning of the cortical bone leading to breakdown of the
subcortical bone. The condyle slowly collapses without
clinically apparent destruction of the brocartilage. In
patients where the pathologic process is in remission,
excessive joint loading (ie, parafunctional habits,
trauma, orthodontics, orthognathic surgery) can
reinitiate the resorption process.
Symptoms of TMJ synovitis include pain during jaw
movement, crepitus, and restricted mouth opening. Iso-
lated TMJ synovitis can be a presentation of the oligoar-
ticular subtype of JIA.
It remains unknown whether
JIA-related TMJ arthrosis and ICR are distinct condi-
tions. Isolated TMJ arthrosis may be the rst or only
Fig 19. Intraoral photograph 15 days after surgery shows a Class I occlusion.
Fig 20. Prole photograph 15 days after surgery shows improved chin projection, decreased anterior
facial height, and lip competence in repose. The cephalogram demonstrates an increased airway pro-
le and a normal dental overjet and overbite.
Fig 21. Patient 3. A, Frontal view at debanding. B, Follow-up at 3 months. C, Follow-up at 9 months.
Note progressive bite opening within 9 months.
Chamberland 541
American Journal of Orthodontics and Dentofacial Orthopedics October 2019 Vol 156 Issue 4
manifestation of JIA and may not be as rare as previously
reported. Many patients are seen initially by a dentist or
an orthodontist who may not be familiar with JIA, so
they misdiagnose the patient with either ICR or some
other TMJ disorder.
Epidemiologic studies have conrmed the higher
prevalence of TMJ disease and pain in women than in
men. Estrogen receptors have been identied in TMJs
and may regulate the synthesis of proteins involved in
articular tissue turnover in the TMJ. Estrogens enhance
responses to relaxin, a polypeptide implicated in MMP
synthesis and activation. MMPs have been implicated
in the degradation of the cartilaginous matrices in
degenerative TMJ diseases.
There is evidence that
relaxin contributes to the degradative remodeling of
joint brocartilage and that there is an association be-
tween relaxin-induced MMPs and matrix loss, suggest-
ing a potential mechanism of action of relaxin in
contributing to TMJ diseases in a subset of women
with these disorders.
These ndings show that relaxin,
which is found systemically in cycling and pregnant
women but not in men, causes the targeted induction
of tissue-degrading enzymes of the MMP family in the
brocartilaginous tissues of the TMJ, potentially predis-
posing to TMJ disease. Moreover, it has been found that
the TMJ disc and pubic symphysis show the greatest in-
duction of MMPs and matrix loss in response to relaxin
and 17b-estradiol.
This helps to explain the role of
hormones in the disease of patient 2.
Fig 22. A, OPG at debanding. Flattening of both anterosuperior superior surfaces of both condyles is
evident. B, Follow-up at 9 months after orthodontic treatment.
Fig 23. Follow-up at 20 months after treatment shows 3 mm anterior open bite.
Fig 24. OPG at 20 months' follow-up. Both condyles
show signicant attening of the anterosuperior aspect,
and the condylar neck is inclined posteriorly. The right
joint shows more attening than the left, suggesting
more resorption.
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October 2019 Vol 156 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Early diagnosis of TMJ degenerative change should
include a careful examination of the condyle and condy-
loid 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 consul-
tation. Blood tests should include erythrocyte sedimen-
tation rate and C-reactive protein, antinuclear antibody,
rheumatoid factor, anticyclic citrullinated peptide,
vitamin D, and 17b-estradiol levels.
Antiinammatory medication such as the NSAIDs
(Naproxen, Celebrex, Feldene), as well as vitamin D
and calcium supplementation, both of which are known
to increase bone density, should be prescribed.
Colleague rheumatologists with an understanding of
this TMJ pathology should manage medications such
as methotrexate or etanercept.
Cases such as the 3 reported here can be found in any
orthodontic practice. If we are at fault, it is likely because
we looked at this pathology as a dental problem. Maybe
it is time that we look at TMJ arthrosis as a systemic pa-
thology. To avoid the outcome of deleterious skeletal
change and unsalvageable TMJ, the orthodontist should
be able to make an early diagnosis and early treatment
en amont(upstream) of the skeletal changes.
The mandible contains teeth as the end-organ for
TMJ function. This has led some within the dental pro-
fession to embrace the concept that the presence of
teeth makes the TMJ a unique articulation. This has in
the past resulted in those practitioners focusing their
diagnosis and management of TMJ disorders on the
occlusion, despite no supporting evidence.
All 3 patients were treated to a Class I functional oc-
clusion. The postorthodontic continuation of joint prob-
lems does not support the theory that Class I occlusion,
canine guidance, incisor guidance, or balanced occlusal
contact would avoid or prevent TMJ problems. Given the
cycle of TMJ arthrosis that can go from active to inac-
tive, it may mean that using a TMJ splint for pain relief
may be a matter of chance that splint use is initiated
before the remission period.
In conclusion, it is essential that TMJ arthritic disease
be discussed in dental circles as a pathologic entity in the
same way our colleagues discuss arthritic disease in or-
thopedic circles. Not doing this only exacerbates the
problem that everyone has with TMJ disorders in genera
patients, clinicians, insurance carriers, etcbecause
they do not consider TMJ pathology as orthopedic pa-
thology, but as just dental.
Further studies are necessary to determine the true
frequency of isolated TMJ arthrosis in JIA and explore
other possible causes for isolated TMJ arthrosis as well
as the optimal therapy.
The author thanks Louis Cadotte (1962-2018) for
providing permission to use the records of patient 1,
Carl Bouchard for providing careful surgical treatment
and providing some photos of patients 1 and 2, and
Louis Mercuri and William Proft for reviewing the
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... Conservative therapy measures include functional therapy (e.g., occlusal splints) [35,36], accompanying orthodontic treatment [26], physiotherapy/manual therapy [10] and pharmacotherapy [1,10,33,37]. In the case of symptomatic active condylar resorption (pain, functional complaints), initially, attempts should be made to contain the symptoms with such conservative therapy procedures (LoE 4/k+, B). ...
... The guideline group refrained from establishing specific recommendations regarding possible pharmacotherapy for idiopathic condylar resorption due to the still very limited evidence on this topic. It remains to be evaluated which medication will be successful in the long term in the treatment of condylar resorption, and what overall role medication will play in the treatment of ICR, especially considering the sometimes serious side effects, possible interactions and contraindications [1,10,33,37]. ...
... Basically, the following surgical procedures are available for the treatment of idiopathic condylar resorption: arthrocentesis [23]; arthroplasty in terms of discopexy [6,23] or discectomy [23]; arthroscopic condylectomy [10,19,[42][43][44]; gap osteotomy [29]; partial autogenous TMJ reconstruction, e.g., by costochondral grafts (CCG) [10,19,43,44]; total alloplastic TMJ reconstruction [6,9,23,37,45]; and orthognathic surgery, e.g., BSSO, Le Fort I osteotomy, distraction osteogenesis and genioplasty (to establish stable occlusion and to correct accompanying deformities) [1,6,9,10,14,23,36]. However, due to the poor evidence base, some issues regarding surgical therapy remained to be addressed. ...
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Idiopathic condylar resorption (ICR), though a rare event, is associated with severe detrimental sequelae for the patient. To date, the etiology remains unknown, and treatment strategies are highly controversial. Therefore, the aim of this study is to present an analysis of the consensus- and evidence-based approach to ICR by a German interdisciplinary guideline project of the AWMF (Association of the Scientific Medical Societies in Germany). Following a systematic literature search, including 56 (out of an initial 97) publications, with a predominantly low level of evidence (LoE), two independent working groups (oral and maxillofacial surgery and interdisciplinary, respectively) voted on a draft comprising 25 recommendations in a standardized anonymized and blinded Delphi procedure. While the results of the votes were relatively homogeneous, the interdisciplinary phase required a significantly higher number of rounds (p < 0.001). Most of the controversial recommendations were related to initial imaging (with consensus on CT/CBCT as the current diagnostic standard for imaging), pharmacotherapy (no recommendation due to lack of evidence), discopexy (no recommendation possible due to low LoE) and timing of orthognathic surgery (with consensus on two-staged procedures after invasive TMJ surgery, except for single-stage procedures if combined with total joint reconstruction). Overall, the Delphi procedure resulted in an interdisciplinary guideline offering the best possible evidence- and consensus-based expertise to date in the diagnosis and treatment of ICR.
... Early diagnosis of ICR is essential for appropriate management of the condition, and several imaging modalities were reported to be helpful in making a diagnosis. A panoramic radiograph is a common and inexpensive imaging modality and allows for gross evaluation of the condyle [7]. Similarly, a cephalogram radiograph is common in orthodontic treatment and can display shortened posterior facial height, increased anterior facial height, increased ...
... overjet, and open bite associated with ICR [7]. Cone-beam computed tomography (CBCT) allows for 3-dimensional evaluation of the condylar features, while magnetic resonance imaging (MRI) ...
... is best for evaluating the soft tissues of the TMJ [7]. Nuclear medicine bone scanning with the use of technecium-99 can assess active bony changes, but is not sufficient in assessing the state of stability or remission of bony changes as it relates to active cases of ICR [7]. ...
... Anterior open bite has various causes, including genetic backgrounds, oral dysfunction, bad oral habits and abnormal skeletal or alveolar bone development [1][2][3][4][5]. Finding the aetiology is important because it affects the stability after the treatment [3,6]. ...
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Background: Temporomandibular joint (TMJ) disorders are closely related to high-angle and skeletal Class II malocclusion. Sometimes pathological changes in the mandibular condyle can cause open bite to occur after growth is complete. Case summary: This article is about the treatment of an adult male patient with a severe hyperdivergent skeletal Class II base, an unusual and gradually occurring open bite and an abnormal mandibular condyle anterior displacement. Because the patient refused surgery, four second molars with cavities and root canal therapy were extracted, and four mini-screws were used for intrusion of the posterior teeth. The treatment duration was 22 mo, and after the treatment, the open bite was corrected and the displaced mandibular condyles were seated back to the articular fossa as shown by cone-beam computed tomography (CBCT). Based on the patient's open bite history, the result of clinical examinations and CBCT comparisons, we believe it is possible that the occlusion interference was eliminated after the four second molars were extracted and the posterior teeth were intruded, and the patient's condyle spontaneously returned to its physiologic position. Finally, a normal overbite was established, and stable occlusion was achieved. Conclusion: This case report suggested that identifying the cause of open bite is essential, and the TMJ factors for hyperdivergent skeletal Class II cases should be particularly examined. For these cases, intruding posterior teeth may place the condyle in a more appropriate position and provide an environment suitable for TMJ recovery.
... It is proved that the occlusion and jaw are the consequence of the balance among multiple functional systems involving the masticatory system, respiratory system, etc., which also serves as the theoretical basis to prevent and correct jaw deformity and malocclusion in adolescence [22]. In addition, the function of TMJ is also closely related to the masticatory muscles, whose long-term discoordination and hyperactivity results in structural variation of TMJ [23], which was observed even in adult patients with a stable tendency [24]. Therefore, we conducted this study on the masticatory complex composed of the three (muscle-occlusion-joint complex) ( Figure 1A). ...
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The physiological homeostasis of the masticatory complex in short-faced patients is too robust to be disintegrated and reconstructed due to the powerful masseter muscle. This study innovatively introduced the botulinum toxin-A (BTX-A) into the field of dental occlusal treatment, providing a novel and minimally invasive therapy perspective for the two major clinical problems in these patients (low treatment efficiency and high rates of complications). In total, 10 adult patients with skeletal low angle seeking occlusal treatment (age: 27.0 ± 6.1 years; 4 males and 6 females) were administered 30–50 U of BTX-A in each masseter muscle and evaluated before and 3 months after injection based on cone-beam computed tomography (CBCT). We found a significant reduction in the thickness of the masseter muscle (MMT) (p < 0.0001). With regards to occlusion, we found a significant increase in the height of the maxillary second molar (U7-PP) (p < 0.05) with significantly flattened occlusal curves (the curve of Spee [COS] (p < 0.01), and the curve of Wilson [COW] (p < 0.05)). Furthermore, the variations in the temporomandibular joint exhibited a significant reduction in the anterior joint space (AJS) (p < 0.05) and superior joint space (SJS) (p < 0.05). In addition, the correlation analysis of the masticatory complex provided the basis for the following multiple regression equation: MMT = 10.08–0.11 COW + 2.73 AJS. The findings from our pilot study indicate that BTX-A, as a new adjuvant treatment attempt of occlusal therapy for short-faced patients, can provide a more favorable muscular environment for subsequent occlusal therapy through the adjustment of the biting force and may contribute to the reconstruction of healthier homeostasis of the masticatory complex. However, further research is required to establish the reliability and validity of these findings.
Introduction Matching the maxillomandibular basal bone width is essential to the stability of orthodontic treatment. We aimed to determine the relationship between basal bone width mismatching and the vertical and sagittal skeletal pattern in patients with skeletal Class III malocclusion through shape analysis and structural equation modeling (SEM). Methods Cone-beam computed tomography images were collected from 45 men and 51 women. Width mismatching of the basal bone was determined using generalized Procrustes analysis. Twenty-two parameters from the synthesized cephalogram were measured, followed by factor analysis and SEM. Results Mismatch occurred at the second molar (men, −4.29 ± 4.32 mm; women, −5.55 ± 4.43 mm) and retromolar regions (men, −8.49 ± 5.11 mm; women: −8.93 ± 5.25 mm). The sum of angles had the largest loading for vertical-1 (extracted from 18 vertical cephalometric measurements) (men, 0.9477; women, 0.9489), followed by MP-SN angle (0.9408) in men and N-Me/S-Go (0.9342) in women. Wits appraisal and anteroposterior dysplasia indicator were largest for Sagittal-1. SEM showed a positive effect of male vertical-1 and 2 on width difference in the retromolar region (P <0.001; B >0). Female vertical-1 had a significant positive effect on DW7 (P <0.001; B = 5.535) and DWR (P = 0.016; B = 3.427) as vertical-2. Sagittal-1 showed a negative correlation with DW7 in both genders (P <0.05; B <0) and with DWR in men. Conclusions Basal bone width mismatching occurred at the second molar and retromolar regions, especially in low-angle and patients with severe skeletal Class III malocclusion.
Progressive condylar resorption (PCR) is an atypical situation in orthodontic patients and requires special attention due to its occlusal instability. Its exact etiology is not clear. The present paper describes a surgical-orthodontic treatment of a PCR case, with a 10-year follow-up. A 25 years-old female patient was referred for orthodontic treatment, having reported that she had been already orthodontically treated during her teenage. She described having a progressive opening of the bite, and a Class II open bite clinically was established. Literature shows some controversies around PCR treatment options. She underwent an arthrocentesis followed by an orthodontic-surgical treatment. Occlusal splint was used before, during and after treatment. Although such intervention would be unpredictable for stability, a long-term follow-up demonstrated no worsening of the PCR and the patient remained in an good occlusion condition. Studies in this field are still required to better understand the etiology of the disease and evaluate treatment options.
Purpose: The aim of this study was to evaluate the effect of two types of mandibular autorotation concept (MAC) surgery using maxillary impaction combined with a straight locking miniplate (SLM) technique on the condyles of patients with skeletal Class II open bite. Materials and methods: Fourteen female patients with skeletal Class II mandibular retrusion with open bite were included in this study. The patients were divided into two groups based on the type of MAC surgery performed: a group of subjects who underwent maxillary impaction only (MAC-1 group) and a group of subjects who underwent maxillary impaction combined with mandibular osteotomy (MAC-2 group). A 3D-printing CAD/CAM wafer was fabricated. The SLM technique was performed to stabilize the vertical maxillomandibular relationship during surgery. A computed tomographic image was obtained preoperatively as well as on the third post-surgical day and 1 year post-surgically to evaluate the relapse by assessing changes in cephalometric measurements, condylar volume, and condylar surface area. Results: Neither the MAC-1 group nor the MAC-2 group showed significant changes in their condylar surface area that could have led to skeletal relapse. The condylar volume was significantly decreased in the MAC-2 group, but the affected location did not contribute to the relapse of the mandibular position. Conclusion: Our findings suggest that MAC surgery with the SLM technique in patients with skeletal Class II retrognathia did not result in post-surgical relapse or further deformation and resorption of the condyle; rather, it yielded promising functional and morphological stability.
Background: Bone modelling evaluation is important for monitoring idiopathic condylar resorption (ICR) progress. Objective: To compare condylar modelling in ICR patients treated with or without stabilisation splints (SSs). Methods: 84 condyles from 84 ICR patients were studied: 42 received SS therapy (SS group); 42 received conventional therapy (control group). Cone-beam computed tomography images at diagnosis (T0) and after at least 6 months (T1) were used for three-dimensional reconstruction. Volume differences between T0 and T1 (δV) were used to evaluate the amount of modelling. Percentage of growth area (PCT) was used to assess the condylar surface growth tendency. Results: No significant change in condylar volume was found in the SS group, whereas that in the control group was significantly decreased at T1 (P<0.0001). The amount of modelling differed among condylar subregions within the SS group: among 6 subregions (P=0.0137), between anterior and posterior regions (P=0.0336) and between lateral, intermediate, and medial regions (P=0.0275). Control group condylar subregions showed no significant differences in the amount of modelling. The anabolic modelling tendency of the total condylar surface in the SS group was greater than that in the control group (P=0.0251); however, there were no statistical differences in PCTs among condylar subregions in either group. Conclusions: SS therapy effectively reduced further bone destruction and promoted condylar modelling. Three-dimensional morphological analysis is a novel method that can accurately evaluate the amount of bone modelling and growth tendency in ICR patients.
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Condylar resorption (CR) is a common sequela of some temporomandibular joint (TMJ) abnormalities. CR can result in jaw deformities and dysfunction, malocclusion, pain, headaches, and airway obstruction. Most cases can be classified into 1 of 4 categories based on cause: (1) adolescent internal CR; (2) reactive (inflammatory) arthritis; (3) autoimmune and connective tissue diseases; and (4) other end-stage TMJ pathologic abnormality. MRI is helpful in differentiating the cause and defining treatment options. This article presents the nature and progression of the different TMJ CR pathologic abnormalities, clinical and imaging characteristics, and treatment options to produce predictable and stable outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.
Full-text available
Progressive condylar resorption (PCR) of the temporomandibular joint (TMJ) occurs mostly in adolescent female individuals, who are likely to request orthodontic treatment. They can be among the most challenging of orthodontic patients to successfully treat, especially if orthognathic surgery is involved in the treatment process. This article will review the basic anatomy, pathophysiology, detection, natural history, and progression of PCR of the TMJ, and the local and regional growth effects of PCR also will be discussed. PCR proceeds through 3 distinct anatomic stages that have clinical relevance when considering orthodontic diagnosis, treatment options, and treatment timing: soft-tissue phase, destructive (active) phase, and reparative phase. Anatomic assessment of the TMJ hard and soft tissues and facial skeleton can be performed using cone-beam computed tomography and magnetic resonance imaging. The application of these imaging modalities to this severe clinical condition is discussed in some detail. It is generally recommended that definitive orthodontic/orthognathic treatment be postponed until PCR has stabilized. Imaging plays an important role in assessing stability of the resorptive process, but other clinical criteria also must be considered.
Objective: To describe characteristics of patients with juvenile idiopathic arthritis (JIA) presenting with isolated arthritis of the temporomandibular joints (TMJ). Methods: Patients with JIA with isolated TMJ arthritis from 4 large tertiary pediatric rheumatology centers were included. Demographic and clinical data were analyzed using descriptive statistics. Results: Fifty-five patients were identified (65% bilateral presentation). Six patients developed arthritis in other joints (median time 6 mos); 4 patients developed uveitis, all prior to arthritis. At last followup, 9% were still taking antirheumatic medications. Conclusion: JIA TMJ arthritis can occur in isolation, and is probably underdiagnosed. Care providers including dentists and orthodontists should be aware of this presentation.
To answer a clinical research question: ‘is there any association between features of dental occlusion and temporomandibular disorders (TMD)?’ A systematic literature review was performed. Inclusion was based on: (i) the type of study, viz., clinical studies on adults assessing the association between TMD (e.g., signs, symptoms, specific diagnoses) and features of dental occlusion by means of single or multiple variable analysis, and (ii) their internal validity, viz., use of clinical assessment approaches to TMD diagnosis. The search accounted for 25 papers included in the review, 10 of which with multiple variable analysis. Quality assessment showed some possible shortcomings, mainly related with the unspecified representativeness of study populations. Seventeen (N = 17) articles compared TMD patients with non-TMD individuals, whilst eight papers compared the features of dental occlusion in individuals with TMD signs/symptoms and healthy subjects in non-patient populations. Findings are quite consistent towards a lack of clinically relevant association between TMD and dental occlusion. Only two (i.e., centric relation [CR]-maximum intercuspation [MI] slide and mediotrusive interferences) of the almost forty occlusion features evaluated in the various studies were associated with TMD in the majority (e.g., at least 50%) of single variable analyses in patient populations. Only mediotrusive interferences are associated with TMD in the majority of multiple variable analyses. Such association does not imply a causal relationship and may even have opposite implications than commonly believed (i.e., interferences being the result, and not the cause, of TMD). Findings support the absence of a disease-specific association. Based on that, there seems to lack ground to further hypothesise a role for dental occlusion in the pathophysiology of TMD. Clinicians are encouraged to abandon the old gnathological paradigm in TMD practice.
Purpose: To investigate the efficacy of temporomandibular joint (TMJ) lavage (arthrocentesis or arthroscopy) for the treatment of temporomandibular disorders in reducing pain and improving jaw motion. Patients and methods: We performed a systematic review of the literature and meta-analysis of randomized controlled trials (RCTs) comparing TMJ lavage with conservative measures. The data sources were MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), Scopus, Web of Science, and reference lists of relevant articles. Two independent reviewers identified RCTs by using controlled vocabulary (MeSH, Emtree) and free text terms. Data extracted from the selected studies included population characteristics, interventions, outcomes, and funding sources. Risk of bias was assessed with the Cochrane Collaboration risk assessment tool for RCTs. Results: Five studies met the inclusion criteria, for a total of 308 patients. Of these studies, 3 were categorized as having a high risk of bias and 2 had a low risk. The summary effect of the 5 studies showed a reduction in pain in the intervention group at 6 months (-0.63; 95% confidence interval [CI], -0.90 to -0.37; P < .00001; I(2) = 88%) and 3 months (-0.47; 95% CI, -0.75 to -0.19; P = .001; I(2) = 85%). This was not the case at 1 month. No difference in mouth opening was observed at 6 months (-0.21; 95% CI, -1.82 to 1.40; P < .80; I(2) = 74%), 3 months (0.20; 95% CI, -1.81 to 2.20; P = .85; I(2) = 68%), and 1 month (-1.18; 95% CI, -2.90 to 0.55; P = .18; I(2) = 0%). Conclusions: Given the relatively small number of patients included in this meta-analysis, the high risk of bias in 3 studies, and the statistical and clinical heterogeneity of the included studies, the use of TMJ lavage for the treatment of temporomandibular disorders should be recommended with caution because of the lack of strong evidence to support its use.
The temporomandibular joint (TMJ) is one of the many joints involved in the inflammatory arthritides. As imaging of joints has developed, so have the data regarding extent and prevalence of TMJ involvement in these diseases. TMJ disease is especially prevalent in juvenile arthritis. The adult and pediatric inflammatory arthritides share common pathophysiology but are still markedly different. The preponderance of TMJ arthritis research exists in juvenile arthritis. This article discusses classification, treatment, and TMJ involvement in juvenile idiopathic arthritis. Copyright © 2015 Elsevier Inc. All rights reserved.
Although limited, there is evidence to support the assumption that temporomandibular joint (TMJ) articular disc repositioning indeed works; to date, there is no evidence that TMJ articular disc repositioning does not work. Despite the controversy among professionals in private practice and academia, TMJ articular disc repositioning is a procedure based on (still limited) evidence; the opposition is based solely on clinical preference and influenced by the ability to perform it or not. Copyright © 2015 Elsevier Inc. All rights reserved.
Temporomandibular joint (TMJ) discs frequently undergo degenerative changes in arthritis. However, the biomechanical properties of pathogenic discs remain to be explored. In this study, we evaluated the effects of chronic inflammation on the biomechanical properties of TMJ discs in rats. Chronic inflammation of TMJs was induced by double intra-articular injections of complete Freund's adjuvant for 5 weeks, and biomechanical properties and ultrastructure of the discs were examined by mechanical testing, scanning electron microscopy, and transmission electron microscopy. The instantaneous compressive moduli of the anterior and posterior bands of discs in inflamed TMJs were decreased significantly compared with those in the control group. The instantaneous tensile moduli of the discs of inflamed TMJs also showed significant decreases in both the anterior-posterior and mesial-lateral directions. The relaxation moduli of the discs of inflamed TMJs showed nearly the same tendency as the instantaneous moduli. The surfaces of the discs of inflamed TMJs became rough and porous due to the loss of the superficial gel-like stratum, with many collagen fibers exposed and degradation of the sub-superficial collagen fibrils. Our results suggested that chronic inflammation of TMJ could lead to deterioration of mechanical properties and alteration of disc ultrastructure, which might contribute to TMJ disc displacement.
This article opens with a definition of progressive/idiopathic condylar resorption (PCR/ICR), which is a severe form of degenerative joint disease that selectively affects the temporomandibular joint. The demographics of this relatively rare condition have been reported, and it is clear that female adolescents are the main affected group. Some cases occur spontaneously, whereas others appear during orthodontic therapy or as sequelae to orthognathic surgical procedures. Whereas the condylar cartilage and bone are the main tissues involved, the role of the articular disk remains controversial. The authors report the results of a survey of orthodontists regarding their experience with PCR/ICR, and based on those results, an estimate of 1 case per 5000 orthodontic patients was reached. The next section of this article discusses practical aspects of recognizing and managing PCR/ICR in the orthodontic practice. It is essential for orthodontists to recognize the onset of this condition in their own patients as early as possible, and if cases are referred from outside the practice, they may not present with an established diagnosis. Imaging techniques such as tomograms and cone beam computed tomography scans have been shown to have value in the initial diagnostic process as well as in monitoring the condition over time. Management of PCR/ICR patients with oral appliances and surgical procedures requires continuous collaboration between the orthodontist and other professional colleagues. The final section includes 2 case reports of patients treated by a combination of orthodontic treatment and orthognathic surgery. These are followed by an in-depth discussion of the medico-legal aspects of managing PCR/ICR in the orthodontic practice.
Progressive condylar resorption is a process that involves the temporomandibular joint (TMJ) and the occlusion. During growth, condylar resorption may decrease the projection of the mandible and be unrecognized as the source of a Class II malocclusion. After growth completion, as the condyle resorbs, the occlusion becomes progressively Class II, with or without open bite. Broadly speaking, condylar resorption is initiated or maintained by a combination of systemic factors and any form of TMJ compression, including pressure resulting from dental treatment.