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CASE REPORT

Total alloplastic temporomandibular jointreconstruction combined with orthodontictreatment in a patient with idiopathic condylarresorption

Chooryung J. Chung,a Yoon-Jeong Choi,b In-Sil Kim,c Jong-Ki Huh,d Hyung-Gon Kim,e and Kyung-Ho Kimf

Seoul, Korea

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404

This case report describes the successful treatment of an adult patient with skeletal Class II open-bite malocclu-sion secondary to idiopathic condylar resorption. Total alloplastic joint reconstruction and counterclockwiserotation of the maxillomandibular complex combined with orthodontic treatment provided a satisfying outcomewith maximum functional and esthetic improvement. (Am J Orthod Dentofacial Orthop 2011;140:404-17)

Idiopathic condylar resorption, also known as pro-gressive condylar retrusion, is described as dysfunc-tional remodeling of the temporomandibular joint

(TMJ) manifested by morphologic changes orresorption of the condyle.1 When this occurs in an adult,progressive resorption of the condyle results in a hyperdi-vergent skeletal Class II malocclusion. In addition tothe skeletal changes, clinical signs and symptoms ofidiopathic condylar resorption include reduction in mas-ticatory performance, muscle and joint pain with func-tion, limited range of motion, and occlusal andskeletal instabilities.1 Although the incidence in adultsis rare, several authors have reported idiopathic condylarresorption and its association with orthodontics and or-thognathic surgery.2,3

The goals for managing idiopathic condylar resorp-tion are to decrease pain, increase joint function, and

Gangnam Severance Dental Hospital, Oral Science Research Center, Insti-f Craniofacial Deformity, College of Dentistry, Yonsei University, Seoul, Ko-

tant professor, Department of Orthodontics.cal assistant professor, Department of Orthodontics.ent, Department of Orthodontics.ciate professor, Department of Oral and Maxillofacial Surgery.ssor, Department of Oral and Maxillofacial Surgery.ssor and chairman, Department of Orthodontics.uthors report no commercial, proprietary, or financial interest in the prod-r companies described in this article.t requests to: Kyung-Ho Kim, Department of Orthodontics, Gangnam Sev-e Hospital, 2112 Eonjuro, Gangnam-gu, Seoul, 135-720, Korea; e-mail,@yuhs.ac.itted, October 2009; revised and accepted, December 2009.5406/$36.00ight � 2011 by the American Association of Orthodontists..1016/j.ajodo.2009.12.037

prevent further joint damage and disability.4 As a generalrule, the management of TMJ disease is to evaluate thepatient’s response to noninvasive modalities before con-sidering invasive surgical or salvaging procedures.4,5

However, for patients with advanced condylarresorption with evident changes in profile andocclusion, reconstruction therapy should also beconsidered.6,7 Here, we report the treatment processand its outcome of an adult with idiopathic condylarresorption who underwent total TMJ reconstruction.

DIAGNOSIS AND ETIOLOGY

A 28-year-old woman was referred from the TMJclinic at Gangnam Severance Dental Hospital in Seoul,Korea, for evaluation and treatment of her occlusion.She had complaints including difficulties in chewing, re-cent changes in profile, moderate joint pain in bothTMJs, headache, and neck, muscle, and shoulder pain.She reported no parafunctional habits such as bruxismor clenching.

She had a history of previous orthodontic treatmentfor 4 years with maxillary first premolar extraction. Herchief complaint before her orthodontic treatment waslip protrusion. During and after the previous orthodontictreatment, she had experienced severe pain in both TMJregions. Since the previous orthodontic treatment, shealso experienced changes in her profile and difficultyin chewing.

She had an obvious skeletal Class II profile with severechin retrusion. Occlusal canting was also noted. An an-terior open bite was present with Angle Class II molarand canine relationships. Her maxillary arch was slightly

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Fig 1. Pretreatment photographs.

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narrow with a crossbite tendency on the right. The man-dibular midline was deviated to the left (Figs 1 and 2).

Evaluation of the panoramic radiograph and the TMJtomograms showed severe condylar resorption. On theleft side, there was complete resorption to the level ofthe sigmoid notch. Magnetic resonance imaging con-firmed the complete resorption of the left side and alsoactive resorption of the right condyle, presumably fromthe loss of cortical bone coverage (Figs 3 and 4).

The cephalometric radiographs showed a significantlyretruded mandible (SNB angle, 68�) compared witha relatively well-positioned maxilla (SNA angle, 80�),indicating a skeletal Class II malocclusion (ANB angle,

American Journal of Orthodontics and Dentofacial Orthoped

12�). A hyperdivergent profile was evident with a highmandibular plane angle (59�) and a facial height ratioof 50.0. The maxillary incisors were retroclined, possiblycaused by the previous orthodontic treatment, whichhad been focused on camouflage of the skeletal ClassII by extraction of the maxillary premolars (Fig 5, Table).

We collected preorthodontic photos and a panoramicradiograph from the previous orthodontist. Although thepatient had a poorly shaped condyle to begin with, it wasevident that the etiology of the severe Class II hyperdi-vergent profile and recent changes in occlusion andprofile were due to progressive condylar resorptionduring the 5-year postorthodontic period (Fig 6).

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Fig 2. Pretreatment study models.

Fig 3. Pretreatment radiographs.

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Fig 4. Pretreatment tomograms and magnetic resonance image.

Fig 5. Pretreatment cephalometric tracing.

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Systemic diseases such as rheumatoid arthritis can alsoproduce similar symptoms and degenerative changes inthe TMJ. Therefore, a blood sample was evaluated fordiagnosticmarkers of rheumatoid arthritis including rheu-matoid factor. Since she had no other joint symptoms andthe blood test was within normal limits, the possibility ofrheumatoid arthritis was ruled out.

According to our evaluation of the orthodontic re-cords and the patient’s history, she was diagnosed asskeletal Class II with idiopathic condylar resorption.

TREATMENT OBJECTIVES

The treatment objectives were to (1) relieve joint painand establish proper joint function, (2) correct the ante-rior open-bite malocclusion, and (3) improve facialesthetics.

TREATMENT ALTERNATIVES

Three treatment options were considered. The firstoption was conservative TMJ therapy including anocclusal splint and medication to relieve pain. Afterpain relief and remission, conventional orthodontictreatment could be performed to correct the anterioropen bite. This option would be a conservative modalityto improve the occlusion, but there would be noimprovement in facial esthetics. In addition, the uncer-tainly of the TMJ condition and its prognosis made it

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Table. Cephalometric summary

Variable Norm Pretreatment Presurgery Postsurgery Posttreatment PostretentionSkeletalSNA (�) 81.6 79.5 79.5 80.9 81.7 81.8SNB (�) 79.1 67.0 69.0 75.2 76.3 75.6ANB (�) 2.4 12.5 10.0 5.7 5.4 6.2FMA (�) 24.0 50.7 47.6 37.0 37.2 37.4Gonial angle (�) 118.6 112.3 123.6 130.1 125.1 125.7SN to MP (�) 34.0 59.1 59.2 46.1 46.0 46.4Ramus height (mm) 51.6 40.2 39.2 44.0 44.0 44.1Body length (mm) 76.0 72 72.0 81.0 81.2 81.2Facial height ratio 66.0 50.1 51.5 56.3 56.2 56.0

DentalU1 to SN (�) 106.0 83.9 88.2 88.9 95.8 95.6IMPA (�) 94.0 92.5 89.1 87.5 89.1 88.7Interincisal angle (�) 126.0 124.5 122.6 127.8 127.5 129.3Occlusal plane (�) 15.0 28.4 27.8 21.6 21.7 21.6

Soft tissueUpper lip to E-plane (mm) �1.0 6.0 5.7 2.6 �0.3 0.3Lower lip to E-plane (mm) 1.0 9.6 10.0 6.1 1.3 2.4

Fig 6. Recollected records from the previous clinic (5 years before).

408 Chung et al

difficult to decide on the proper timing for active ortho-dontic treatment.

The second option was to combine orthognathicsurgery with orthodontic treatment. After extraction ofthe mandibular first premolars and mandibular incisorretraction, maxillary impaction along with mandibularadvancement and genioplastywould correct the occlusionand improve the profile. However, the result of this optionalso depends on the prognosis of the TMJ. With complete

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resorption of the left side and active resorption still on theright side, conventional orthognathic surgery would in-stantly show improvement in the profile but couldresult in poor stability because of the preexisting TMJpathology.4,8

The third optionwas to consider total joint reconstruc-tion. Custom-made joints could be designed for maxi-mum esthetic and functional results, and replacementsurgery could be combined with maxillary surgery.7,9 To

Journal of Orthodontics and Dentofacial Orthopedics

Fig 7. Computed tomography scan after primary surgery and 3-dimensional model surgery for TMJdesigning.

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allow the maximum amount of mandibular advance-ment, mandibular premolar extraction and retractioncould be done before jaw surgery. Conservative jointtherapy could also be performed in conjunction withpreoperative orthodontic treatment to relieve pain.8,9

After thorough discussion with the patient, the thirdoption was selected. The patient had high hopes of im-proving her profile, and, considering the severity of herTMJ condition and age, TMJ replacement was a promis-ing option.

TREAMENT PROGRESS

We bonded 0.022-in preadjusted edgewise bracketsto all teeth. In the maxillary arch, a precision transpalatalarch with a 0.032 3 0.032-in beta-titanium alloy wirewas placed for correction of the upper first molar rota-tions and mild expansion of the arch. Maxillary incisortorque was improved by adding a compensating curveto the archwire during the initial stage of treatment. Inthe mandibular arch, anterior retraction was achieved af-ter extraction of the mandibular first premolars.

Three months before the main reconstruction sur-gery, gap arthroplasty was performed to remove theresorbed condyle and articular fossa followed by inter-positional silastic block implantation. A computedtomography scan was taken, and a 3-dimensional poly-mer model was constructed for 3-dimensional modelsurgery. To increase the amount of mandibular


advancement, which is the key for esthetic improvement,counterclockwise rotation with ANS impaction, cantingcorrection of the maxilla, and additional advancementgenioplasty were planned along with mandibularadvancement (Fig 7). The counterclockwise rotation ofthe maxilla also can improve the maxillary incisor torque.Total TMJ prostheses (TMJ Concepts, Ventura, Calif) in-clude a mandibular component and a fossa component.According to the model surgery, both components canbe custom-made for a patient.10,11

After 14 months of preorthodontic treatment, totaljoint reconstruction surgery was done as reported, alongwith LeFort I osteotomy and genioplasty.9,10 Dramaticchanges were shown after the surgery, and the joint painwas relieved. In addition, the patient also reportedimprovement in her sleeping pattern, because breathingwas much easier after the surgery, as has been previouslyreported.12,13 The occlusion was corrected to Angle ClassI molar and canine relationships with ideal overjet andoverbite (Figs 8 and 9). Analysis of the cephalometricsuperimposition showed total impaction with counter-clockwise rotation of the maxilla (the amount of anteriornasal spine impaction was greater than that of posteriornasal spine impaction) and a significant amount ofmandibular advancement. Advancement genioplasty alsoimproved the prominence of the chin. According to thehard-tissue changes, soft-tissue profile changes were alsoevident, and the airway was enlarged (Fig 10).


Fig 9. Postsurgical radiographs.

Fig 8. Presurgical and postsurgical intraoral photographs.

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Fig 10. Cephalometric superimposition before treatmentand after surgery.

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After the primary healing period, active physical ther-apy was recommended 3 weeks postoperatively. Twomonths after surgery, orthodontic treatment was initi-ated for detailing with intermaxillary elastics. After a to-tal treatment time of 24 months, the brackets weredebonded. Class I molar and canine relationships wereachieved with ideal overjet and overbite (Figs 11-13).Total alloplastic TMJ reconstruction and combinedorthognathic surgery resulted in counterclockwiserotation of the maxillomandibular complex, improvingboth esthetics and function (Fig 14).

After debonding, lingual fixed retainers were bondedfrom canine to canine in both arches. Additional circum-ferential retainers were delivered and used full time for 6months. The maxillary circumferential retainer wasslightly activated to close the minor space left from themolar bands. During the retention period, old restora-tions on the mandibular molars were replaced withnew gold crowns, and the surgical plates were removedafter 6 months. In addition these changes, the patient’socclusion and skeletal relationship were stable after 1year of retention (Figs 15-17). No TMJ-related symp-toms were reported during or after the orthodontic


treatment, and she was fully satisfied with the functionaland esthetic outcome.

DISCUSSION

The pathophysiology of idiopathic condylar resorp-tion might be partially due to excessive mechanical load-ing of the TMJ that exceeds the normal host adaptivecapacity, resulting in dysfunctional remodeling. Me-chanical factors capable of initiating changes in the con-dylar structure are largely divided into occlusal therapy,internal derangement, parafunction, trauma, and unsta-ble occlusion. Combined with the degree of mechanicaloverloading, the host adaptive capacity factors such asage, hormones, and systemic illness are thought to de-termine the degrees of TMJ, occlusal, and skeletalchanges.1,2 Similar to the previously reported cases ofidiopathic condylar resorption, this woman was in hertwenties and had received previous orthodontictreatment. Although the initial cause of herdysfunctional remodeling is unknown, as it wasinitiated, predisposing unstable occlusion or occlusaltherapy might have caused additional condylarcompression, leading to further unstable occlusion andaccentuating the resorption.2,6

In the case of active idiopathic condylar resorptionwith major skeletal discrepancies, occlusal stabilizationthrough orthodontic treatment alone might not be suf-ficient; therefore, invasive protocols such as orthog-nathic surgery are combined for functional andesthetic recovery. Unfortunately, it is well documentedthat preexisting TMJ pathology can lead to unfavorablesurgical outcomes, with only a few reports of successfulmanagement.4,8,14 Wolford and Cardenas6 and Wolford8

developed a specific treatment protocol for idiopathiccondylar resorption that includes TMJ surgery toremove hyperplastic synovial and bilaminar tissue, diskrepositioning, and ligament repair, followed by orthog-nathic surgery with favorable outcomes and stability.However, this protocol is based on early detection andsurgical intervention with an adequate remainingcondyle and salvageable disks. In our patient, the leftcondyle was completely lost with no detectable diskapparatus, and there was still active resorption on theright side. Alloplastic implants are reported to be anacceptable approach to achieve optimal symptomaticand functional improvement for extensively damaged,degenerated, or lost condyles.4,7,8,10

The patient desired maximum improvement in bothfunction and esthetics. Therefore, orthodontic andsurgical procedures were focused to increase the amountof mandibular advancement. Orthodontically, the man-dibularfirst premolars were extracted, and themandibularanterior teeth were completely retracted. Since the


Fig 11. Posttreatment photographs.

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previous camouflage orthodontic treatment with maxil-lary premolar extraction induced retroclination of themaxillary incisors, the maxillary incisor torque was con-trolled during the early phase with an additional compen-sating curve. Surgically, counterclockwise rotation of themaxillomandibular complex, which rotates the anterioraspect of the maxillomandibular complex upwardand the posterior aspect downward, and additionaladvancement genioplasty were performed.9,10 Thecounterclockwise rotation of the maxilla not onlyallowed more forward movement of the mandible, butalso improved the maxillary incisor torque. The steepocclusal plane and mandibular plane angles were also


decreased. Conventionally, counterclockwise rotation ofthe maxillomandibular complex can create a large gapbetween the fossa and the mandibular ramus. But, withthe custom-made joint prosthesis, accurate adaptationto the surrounding anatomic structure was possible.10

As with any other treatment modality, long-termstability is important. Because the concept of alloplastictotal joint reconstruction is rather new, the longest studyreporting its outcome and stability is based on a 14- to18-year follow-up.7,12,13,15 According to these reports,improvements in mandibular function and quality of lifewere clearly noted, indicating effective and reliablelong-term management.7,12,13,16 When long-term


Fig 12. Posttreatment study models.

Fig 13. Posttreatment radiographs.

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Fig 14. Posttreatment cephalometric tracing and superimposition.

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stability in terms of surgical relapse was evaluated in pa-tients with total alloplastic TMJ reconstruction combinedwith LeFort I osteotomy by using the same prosthetic sys-tem, it also showed improved functional and esthetic out-comes with good surgical stability.7,9 Our patient also hada stable occlusion and excellent surgical stability after the1-year follow-up. In addition, there were decreased TMJsymptoms including pain, improvement in her breathingpattern at nights, and increased quality of life.

Identical to the well-proven orthopedic joint recon-struction devices for hip and knee replacements, thematerials used for TMJ prostheses are composed oftitanium covered with ultrahigh molecular weight poly-ethylene and titanium with chromium, cobalt, and mo-lybdenum.10 Therefore, disadvantages associated withany implantable alloplast such as material wear andpotential device failure are possible in the long term;this calls for careful monitoring. Because of its complex-ity, total joint reconstruction surgery is performed withan extraoral approach through preauricular and sub-mandibular incisions, which leave minor scar tissue after


surgery. However, satisfying and predictable outcomesof total joint reconstruction combined with orthodontictreatment in patients with severely damaged TMJs farexceed these limitations, as demonstrated in this patient.

CONCLUSIONS

This case report illustrates the treatment process ofa skeletal Class II malocclusion associated with idio-pathic condylar resorption. Total alloplastic joint recon-struction was successfully designed to improve bothesthetics and function with posttreatment stability.

REFERENCES

1. Arnett GW, Milam SB, Gottesman L. Progressive mandibularretrusion—idiopathic condylar resorption. Part I. Am J OrthodDentofacial Orthop 1996;110:8-15.

2. Arnett GW, Milam SB, Gottesman L. Progressive mandibularretrusion—idiopathic condylar resorption. Part II. Am J OrthodDentofacial Orthop 1996;110:117-27.

3. De Clercq CA, Neyt LF, Mommaerts MY, Abeloos JV, De Mot BM.Condylar resorption in orthognathic surgery: a retrospective study.Int J Adult Orthod Orthognath Surg 1994;9:233-40.


Fig 15. Postretention photographs.

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4. Mercuri LG. Osteoarthritis, osteoarthrosis, and idiopathic condylarresorption. Oral Maxillofac Surg Clin North Am 2008;20:169-83,v-vi.

5. Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. NEngl J Med 2008;359:2693-705.

6. Wolford LM, Cardenas L. Idiopathic condylar resorption: diagnosis,treatment protocol, and outcomes. Am J Orthod DentofacialOrthop 1999;116:667-77.

7. Dela Coleta KE, Wolford LM, Goncalves JR, Pinto Ados S, Pinto LP,Cassano DS. Maxillo-mandibular counter-clockwise rotation andmandibular advancement with TMJ Concepts total joint prosthe-ses: part I—skeletal and dental stability. Int J Oral MaxillofacSurg 2009;38:126-38.

8. Wolford LM. Concomitant temporomandibular joint andorthognathic surgery. J Oral Maxillofac Surg 2003;61:1198-204.


9. Mehra P, Wolford LM, Baran S, Cassano DS. Single-stage compre-hensive surgical treatment of the rheumatoid arthritis temporoman-dibular joint patient. J Oral Maxillofac Surg 2009;67:1859-72.

10. Wolford LM, Pitta MC, Reiche-Fischel O, Franco PF. TMJConcepts/Techmedica custom-made TMJ total joint prosthesis:5-year follow-up study. Int J Oral Maxillofac Surg 2003;32:268-74.

11. Mercuri LG, Wolford LM, Sanders B, White RD, Giobbie-Hurder A.Long-term follow-up of the CAD/CAM patient fitted total tempo-romandibular joint reconstruction system. J Oral Maxillofac Surg2002;60:1440-8.

12. Coleta KE, Wolford LM, Goncalves JR, Pinto Ados S, Cassano DS,Goncalves DA. Maxillo-mandibular counter-clockwise rotationand mandibular advancement with TMJ Concepts total joint pros-theses: part II—airway changes and stability. Int J Oral MaxillofacSurg 2009;38:228-35.


Fig 16. Postretention study models.

Fig 17. Postretention radiographs.

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13. Coleta KE, Wolford LM, Goncalves JR, Pinto Ados S, Cassano DS,Goncalves DA. Maxillo-mandibular counter-clockwise rotationand mandibular advancement with TMJ Concepts total joint pros-theses: part IV—soft tissue response. Int J Oral Maxillofac Surg2009;38:637-46.

14. Wolford LM, Reiche-Fischel O, Mehra P. Changes in temporoman-dibular joint dysfunction after orthognathic surgery. J OralMaxillofac Surg 2003;61:655-60.


15. Mercuri LG, Edibam NR, Giobbie-Hurder A. Fourteen-yearfollow-up of a patient-fitted total temporomandibular joint re-construction system. J Oral Maxillofac Surg 2007;65:1140-8.

16. Pinto LP, Wolford LM, Buschang PH, Bernardi FH, Goncalves JR,Cassano DS. Maxillo-mandibular counter-clockwise rotation andmandibular advancement with TMJ Concepts total joint prosthe-ses: part III—pain and dysfunction outcomes. Int J Oral MaxillofacSurg 2009;38:326-31.


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