ORAL AND MAXILLOFACIAL SURGERY

Clinical Indications for Simultaneous TMJ and Orthognathic Surgery

Larry M. Wolford. D.M.D. r

0886-963^/2504273$05.00/0, THE JOURNAL OF CRANIOMANDIBULAR PRACTICE, Copyright 2007 by CHROMA, Inc,

Manuscript received OctoOer 17,2005; revised manuscript received January 9, 2007: accepted July 2, 2007 Address for correspondence: Dr. Larry M, Wolford 3409 Worth St, Suite 400 Dailas.TX 75246 E-mail. LWolford@swtiell,net

ABSTRACT: There are many temporomandibular joint (TMJ) conditions that can cause pain, TMJ and jaw dysfunction, and disability. The most common of these conditions inciude: 1, articular disk dislocation; 2. reactive artiiritis; 3. adolescent internal condylar resorption; 4, condylar hypetplasia; 5. osteochondroma or osteoma; and 6. end-stage TMJ pathology. These conditions are often associated with dentofacial defomnities, malocclusion, TMJ pain, headaches, myofascial pain, TMJ and jaw functional impairment, ear symptoms, etc. Patients with these conditions may benefit from corrective surgical intervention. Open joint surgery provides direct access to the TMJ allowing manipulation, repair, removal and/or reconstruction of the anatomical structures that cannot be accomplished by other treatment methods. TMJ surgery and orthognathic surgery can be predictably perfomied during one operation with high success rates. This paper discusses the most common TMJ pathologies and presents the surgical management considerations to correct the specific TMJ conditions and associated jaw deformities.

T
Dr. Larrj M, Wolford is a clinical professor at the Deparimem of Oral and Maxillofacial Surgery. Baylor College of Denri.stry. Te.vas A&M University System. He nutintains a private practice at Baylor University Medical Center. Dallas, Texas.

here are many temporomandibular Joint (TMJ) conditions that can cause pain. TMJ and jaw dysfunction, and disability. The most common of these conditions include: 1. Articular disk dislocation; 2. reactive arthritis: 3, adolescent internal condylar resorption: 4. condylar hyperplasia; 5. osteochondroma or osteoma: and 6. end-stage TMJ pathology (i.e., connective tissue/ autoimmune diseases, advanced reactive arthritis and osteoarthritis, multiply operated joints, failed alloplasticTMJ implants, absence of the joint, traumatic injuries., and ankylosis). These conditions are often associated with dentofacial deformities, malocclusion, TMJ pain, headaches, myofascial pain. TMJ and jaw functional impairment, ear symptoms, etc. Patients with these conditions may benefit from corrective surgical intervention. The difficulty for many clinicians may lie in identifying Ihe presence of a TMJ condition, diagnosing the specific TMJ pathology, and selecting the proper treatment for that condition. This paper discusses the most common TMJ pathologies and presents surgical management considerations to correct the specific TMJ conditions and associated jaw deformities.

273

SIMULTANEOUS TMJ AND ORTHOGNATHtC SURGERY

WOLFORD

Why Consider TMJ Surgery? The TMJs are the foundation and support for jaw position, function, occlusion, and facial balance necessary for quality treatment outcomes in dentistry, orthodontics, and orthognathic surgery. If the TMJs are not stable and healthy (nonpathological). treatment outcomes in these dental disciplines may be unsatisfactory relative to function, esthetics, stability, and pain. Contrary to popular belief, orthognathic surgery to correct a malocclusion and jaw deformity will not/(.v or eliminate coexisting TMJ pathology and symptoms. Several studies'^ have demonstrated that performing orthognathic surgery only on patients with coexisting TMJ pathology can result in unsatisfactory treatment results, such as relapse, malocclusion, jaw and facial deformity, TMJ pain, headaches, myofascial pain, and masticatory dysfunction. The above listed TMJ conditions, when occurring with dentofacial deformities, can be predictably treated by performing the appropriate TMJ surgery and orthognathic surgery during one operation. TMJ conditions can also be treated by performing TMJ and orthognathie surgery in separate operations, but the TMJ surgery should be done as the first operation. Clinical, radiographic imaging, dental model, MRI and/or CT scan evaluations, patient history and, when indicated, laboratory tests are very important for accurate diagnosis of TMJ pathology and treatment planning. With appropriate selection and execution ofthe surgical procedures and proper postsurgical management, good outcomes can usually be achieved. Two research studies' - evaluated 25 consecutive patients with jaw deformities and anteriorly displaced disks, treated with orthognathic surgery only, All but one patient had the mandible advanced. Before surgery, 36% of the patients had pain or discomfort. At an average of 2.2 years post surgery, 84% of the patients had TMJ related pain, with a 70% increase in pain severity. In addition. 25%^ of the patients developed anterior open bites from condylar resorption. New onset/aggravation of TMJ symptoms occurred at an average of 14 months post surgery. Twelve patients (48%) required TMJ surgery and repeat orthognathic surgery. Nine additional patients (36%) required long-term medications and/or splint therapy for pain controi. This study clearly demonstrates the problems associated with performing orthognathic surgery only on patients with coexi.sting TMJ disk dislocations. Also, it is apparent that unfavorable post surgical TMJ outcomes and effects (i.e., TMJ pain, headaches, myofascial pain, malocclusion. jaw deformity, TMJ and jaw dysfunction, ear symptoms, etc.) may not become apparent for a year or more after the orthognathic surgery.

TMJ surgery (i.e.. disk repositioning, arthroplasties, high condylectomies. etc.) can significantly alter the position ofthe mandible and the occlusion. Therefore, the surgical sequencing for performing TMJ and orthognathic surgery in one operation or divided into two operations (the TMJ and orthognathic procedures are done separately) is important to achieve good outcomes and inciudes: TMJ surgery first, followed by mandibular ramus sagittal split osteotomies with rigid fixation, and subsequently if indicated, maxillary osteotomies with rigid fixation. With the mandibular osteotomies being performed after the TMJ surgery, the mandible will be positioned into its predetermined position regardless of the amount of mandibular displacement resulting from the TMJ surgery. The jaws are not wired together post surgery, since rigid fixation (bone plates and screws) is used to stabilize the osteotomy sites. Light vertical elastics (3/16", 3 1/2 oz) with a slight Class III vector are usually used post surgery to control the occlusion and minimize TMJ intercapsular edema. Closely monitoring and managing the occlusion in the post surgery period, as well as controlling the parafunctional habits (i.e.. clenching, bruxism), are very important to provide quality outcomes. Why Open Joint Surgery? Open joint surgery provides direct access to the TMJ, allowing manipulation, repair, removal, and/or reconstruction ofthe anatomical structures thai cannot be accomplished by other means, such as arthroscopy, arthrocenlesis. splint therapy, or other nonsurgicai treatment modalities. The author uses minimally invasive open joint surgical approaches to the TMJ that utilize small incisions and minimize soft tissue reflection from the condyle, thus maximizing the vascuhir supply to the condyle so that post surgical avascular necrosis is not an issue. This minimally invasive TMJ surgical approach and the use of mandibular ramus sagittal split osteotomies maximizing the soft tissue attachment to the proximal segments permits simultaneous orthognathic surgery to be performed wilhout concern for vascular compromise to the mandibuiar ramus or TMJ structures. Traditional open joint surgical approaches to the TMJ use much larger incisions and detach significant soft tissue off the condyle, thus increasing the risk of avascular necrosis that could result in subsequent condylar resorplion and in.stability of the occlusion and jaw relationship, as well as pain, headaches, jaw dysfunction, etc. Mandibular ramus vertical oblique osteotomies are contraindicated when simultaneous TMJ surgery is performed because of the potential vascular compromise to the TMJ bony structures.

274

THE JOURNAL OF CRANIOMANDIBULAR PRACTtCE

OCTOBER 2007, VOL. 25, NO. 4

WOLFORD

SIMULTANEOUS TMJ AND ORTHOGNATHtC SURGERY

Alihough arthroscopy and arthrocentesis may have a role in some TMJ conditions, these procedures are contraindicated when jaw deformities coexist and orthognalhic surgery is required. Arthroscopy and arthrocentesis do not reposition Ihc articular disk into a proper anatomical position with adequate stabilization to withstand the increased TMJ loading that is unavoidable in orthognathic surgery, particularly with mandibular advancements. Rather, artbroscopy and arthrocentesis tend to maintain the disk in the original presurgical dislocated position or further displace the disk. Arthroscopy, arthrocentesis. splint tberapy, etc.. performed prior to orthognatbic surgery will have the same effect on the orthognathic surgery outcome (particularly with mandibular advancement surgery) as if these procedures were never performed at all: 84% chance of having post orthognathic surgery TMJ related pain. 70% increase in pain intensity, and 25% probability of condylar resorption.' Benefits uf Simultaneous Surgeiy The benefits of simultaneous TMJ and orthognathic surgery inctude: 1. requires one operation and general anesthetic; 2. balances the occlusion. TMJs, jaws, and neuromuscular structures at tbe same time; and 3. decreases overall treatment time. Research studies'*-^bave sbown tbat simultaneous surgical correction of TMJ patbology and coexisting dentofacial deformities, in one operation, provides high quality treatment outcomes for patients relative to function, esthetics, elimination or significant reduction in pain, and patient satisfaction. Equivalent results can also be achieved by separating the TMJ and orthognathic surgical procedures into two operations, but the TMJ surgery should be performed first, at least six montbs before performing the orthognathic surgery procedures. Articular Disk Dislocation The most common TMJ pathology is an anterior and/or media! displaced disk (Figure 1). This condition can initiate a cascade of events leading to arthritis and TMJ related symptoms. Simultaneous surgical treatment would include: repositioning the TMJ disk into a normal anatomical, functional position and stabilizing it using the Mitekanehor(Mitek Surgical Products Inc.-Westwood, MA) technique.^ '- and then performing the indicated orthognathic surgery (mandible first, then the maxilla). The Mitek anchor tecbnique uses a bone anchor that is placed into the lateral aspect of the posterior head of the condyle with subsequent osseo-integration of the anchor. Two 0-Ethibond sutures (Etbicon Inc.. Somerville, NJ) are attached to the anchor and are used as artificial

Figure 1 MRI demonstrates an anteriorly displaced TMJ articular disk (white arrows).

ligaments to secure and stabilize the disk to tbe condylar head (Figure 2, A and B). One 0-Ethibond suture is placed in a mattress fashion medially through the posterior aspect of the posterior band of the disk and the second suture is placed in the same manner, but more laterally. The sutures are then tied to secure the disk to tbe condylar head. This recreates a relatively normal disk to condyle to fossa relationship and function. Another study'" using this treatment protocol on 70 patients sbowed tbat presurgery, 80% of the patients bad TMJ pain, but at longest follow-up. 60% had complete relief of pain, and an additional 33%' had significant reduction in pain. All but one patient had stable orthognathic surgery outcomes. Using the criteria of incisal opening greater than 35 mm, stable skeletal and occlusal relationships, and significant reduction in pain, the success rate was 9\%. The success rate was significantly better (95%) if the TMJ disks were surgically repositioned within the first four years of onset of tbe TMJ dysfunction. After four years, tbe progression of irreversible TMJ degenerative changes may result in a lower success rate. Another study" evaluated 88 different patients with simultaneous TMJ disk repositioning with the Mitek anchor and orthognathic surgery that likewise demonstrated a very similar statistically significant decrease in TMJ pain and headaches, while improving jaw function and providing stable occiusal and skeletal results. Reactive Arthritis

Reactive arthritis (also called seronegative spondyloarthropathy) is an inflammatory process in joints

OCTOBER 2007, VOL. 25, NO. 4

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

275

SIMULTANEOUS TMJ A N D ORTHOGNATHIC SURGERY

WOLFORD

Posterior band

t
A Placing sutures Ihrough the disk { postenor a/-! view ) 1 ij.;nrf 3 MKl demonstrates advanced TMJ reacive arthritis with condylar resorption. anierior beaking (black arrows), as well as anterior dislocation ofthe articular disk (white arrows). Figure 2 A. The Mitek Mini anchor has an eyelet that will support 2. 0Ethibond suiurcs lhat function as artiticial ligaments. The anchor is inserted into the posterior head of ihe condyle. lateral to the mid.sagittal plane and five to eight mm below the lop. One suture is placed in a mattress fashion through the medial aspect ofthe posterior pan of the posterior band. The other suture is placed in a similar manner, but more lateral in the posterior band.B. Cross-sectional sagittal view shows the Mitek Mini Anchor position and supporlive artifieial ligaments. This stabilizes ihe disk to the condylar head with relatively normal anatomy and function.
Repaired t)ilaminar HBSUC

Superior joinl space

Anchot suture

Disk

commonly related to bacterial and/or viral factors, usually occurring in the 3rd to 4th decade, but can develop at any age. In the TMJ. reactive arthritis is usually seen in conjunction with a displaced TMJ articular disk (Figure 3), but can also develop with the disk in position. Studies-'^ = ^ have confirmed lhat at least 73% of patients with articular disk displacements have bacteria in the bilaniinar tissues of the TMJ. The bacterium species we have identified include: chlamydia trachomatis and psittaci, as well as mycopiasma genitalium and fernientans.-'^--'' Other bacterium that have been found in other joints but may also infect the TMJ. creating reactive arthritis include: borrelia burgdorferi (Lymes disease), salmonella species, shigella species, yersina enterocolit-

ica, and eainpylobacter jejuni. It is suspected that other bacterial/viral species may also cause reactive arthritis in joints, including: chlamydia pneumonia, tnycoplasma pneumonia, ureapiasma. herpes virus, Epstein-Barr syndrome, cytomega-lovirus, varicella zoster, etc. The bacteriutn we identified (chlamydia and mycopiasma species) Vk'ere found in the bilaminar tissues. These bacterium live and function like viruses and therefore, antibiotics may not be effective in eliminating the bacterium from joints and the body. These bacterium are known to stimulate the production of Substance P. cytokines. and tissue necrosis factor, which are all pain modulating factors.'" In addition, these bacterium species have been associated with Reiter's syndrome, destructive arthritis, and dysfunction ofthe immune system. Although the bacterium are identified, the specific affect for each patient is difficult to quantify. We have also identified specific genetic factors. Human Leukocyte Antigen (HLA) markers that occur at a significantly greater incidence in TMJ patients than in the normal population.'^ These same markers may also indicate an immune dysfunctional probletn lor these bacterium species, allowing the bacterium to have a greater affect on patients with these markers compared to people without these same markers. Patients with localized TMJ reactive arthritis usually have displaced disks, pain. TMJ and jaw dysfunction, ear symptoms, headaches, etc. As the disease progresses, condylar resorption and/or bony deposition can occur, causing changes in the jaw. occlusal relationships, and function. Patients with moderate to severe reactive arthritis may have other body systems involvement, such as other joints, genitourinary, gastrointestinal, reproductive.

276

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

OCTOBER 2007, VOL. 25, NO. 4

WOLFORD

SIMULTANEOUS TMJ AND OFTTHOGNATHIC SURGERY

respiratory, cardio-pulmonary. ocular, neurological, vascular, hemopoictic. immune, etc.^' Most patients with mild lo moderate reactive arthritis, without significant involveinent of other body systems, usually respond well to articular disk repositioning using ihe Mitek anchor system and the appropriate orthognathic surgery procedures, providing the disks are salvageable and wilhin lour years ofthe onset ofthe TMJ problems. It is possible ihal the resection and removal of a large portion of the bilaminar tissue (where it is known that these bacteria reside) during surgery may result in a significant reduction ofthe source ofthe inflammation. In more advanced reactive arthritis cases, particularly those with significant destruction of the TMJ structures (i.e.. disk, condyle. fossa) and/or involvement of other body sysleiTis. the best TMJ treatment iiiay be reconstruction with a lotal joint prosthesis (TMJ Concepts Inc.. Camarillo, CA), {Figures 4 A and B). Adolescent Internal Condylar Resorptiun (AICR) AICR (formerly known as idiopathic condylar resorption"'-') is a pathological, noiiinfiammatory. homionallymediated condition primarily affecting TMJs in teenage females (ratio 9:1. females to males), usually initiated as iliey enter Iheir pubertal gi'owth pha,se. No other joints or body systems are involved in this pathological process. Patients with AICR exhibit TMJ condylar resorption and anteriorly displaced articular disks (Figure 5, A). They have a classic facial morphology (Figure 5. B): 1. retruded mandible that progressively worseiis, and retruded iiiaxilla: 2, high occlusal plane angle; 3. tendency for a Class II open bite that worsens with time: and 4. a decreased orophai'yngeal airway in the more severe cases that can cause sleep apiiea. In AICR. it is postulated that the female hormones stimulate hyperplasia of the synovial tissues which then produce chemical substrates that destroy the ligaments that iiomially stabilize the disk to the condyle- The disk becomes anteriorly displaced, and the condyle is then surrounded by the hyperplastic synovial tissue that continues to release chemical substrates that penetrate the condylar head causing internal condylar resorption. creating a slow but progressive decrease in size of the condyle and retrusion of the mandible (Figure 5, A). In AICR. the condylar resorption is internal with inward collapse of the overlying thinned cortical boiie and fibrocartilage. The fibrocartilage covering the condyle and fossa remains intact. Other TMJ resorptive pathologies resorb the condyle from the outside destroying the fibrocartilage on the condyle and fossa. Interestitigly, 25% of the patietits with AICR are asymptomatic relative to pain and joint noises. The only

Figure 4 A, The TMJ Concepts tolal joini prusthesis is a custom-made device IllleJ 10 eath piuietii\ specific analomical rt'ijuiremenls, 7"lio fossa componeni is made of lilaniiiin and poiyethylent', lln; manJibular cnmponenl shat'l is made ol titanium alloy and ihc heai! is cliromitimcnbali alloy, B, Post surgery radiograpliic image ot llie TMJ Concepis total joint prosthesis shows the metal components. The polyethylene does not ittiage and appears as space belwecn the metal components.

treatment protocol proven to eliminate the TMJ pathology and allow optimal correction ofthe associated dentofacial deformity with high predictability, was developed by the author'' '-^ and includes: 1. removal of the hyperplastic synovial and bilaminar tissues around the condyle; 2. reposition and stabilize the disk to the condyle with the Mitek anchor technique (Figure 2): and 3. perform the indicatedorthognalhic surgery, usually inquiring mandibular and maxillary osteotomies to get the best functional and esthetic results. An Initial study" involved 12 patients with active AICR, who underwent simultatieous TMJ and orthognathic surgery. The average post surgical follow-up was 33 months, with very stable results, excellent jaw and masticatory function, and elimination or significant reduction in pain in all patients. A more recent study'^ evaluated 44 patients with active AICR, divided into two groups. Group 1 (n=10) underwent orthognathic surgery only, with no TMJ surgical treatment. Group 2 (n=34) underwent TMJ disk repositioning with the Mitek anchor technique and simultaneous orthognathic surgery. In Group I. AICR continued in all ten patients post surgery resulting in statistically significant skeletal and occlusal instability and relapse. Al! Group 2 patients maintained stable Class I skeletal and occlusal outcomes, with .statistically significant reduced pain and improved jaw function, compared to Group 1. Condylar Hyperptasia (CH) Normal facial and jaw growth is usually 98% complete

OCTOBER 2007, VOL, 25, NO, 4

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

277

SIMULTANEOUS TMJ AND ORTHOGNATHIC SURGERY

WOLFORD

Female with CH 15 years old 17 years old

Figure 5
A. TMJ MRI demonstrates cla.'^.'iic AtCR. The articular disk (white arrows) is anteriorly displaced, the superior condylar conex is thinned (small black arrows), and ihe condyle is smaller in ail three planes of space. There is hypertrophy of ihe synovial tissues between ihe condyle and fossa crealing an increased joint space (large hiack arrows). B. This lateral cephalometric tracing demonstrates ihe typical facial morphologic paitem for patients with AlCR: 1. high occlusal plane angle; 2. retruded mandible and to a lesser extent the maxilla; and 3. tendency for skeletal and occlusal Class II open bite relationships.

Figure 6 Serial lateral cephalometric tracing for active CH will usually show: 1. elongated condylar head and neck; 2. Class III skeletal and occlusat relationship with progressive worsening; and 3. accelerated :uid proionged mandibular growth. This female patient demonstrated six mm of excessive mandibular growth in two years after the age of 15 years, indicating active CH.

in females at age 15 years and in males at age 17 to 18 years. CH is an abnormal growth condition affecting tbe mandibular condyles. bilateral or unilateral, creating accelerated and excessive overgrowth of the mandible (prognatbism) (Figure 6), often continuing into the patient's mid 2O'.s. Bilateral active CH causes progressive and worsening prognathism. but is relatively asymptomatic for TMJ symptoms. On MRI, the articular disks in CH patients are commonly very thin and somefimes very difficult to identify. Tbe condylar heads and necks are usually excessively long. Unilateral CH can cause progressively worsening deviated prognathism.

facial asymmetry, contralateral TMJ arthritic changes and disk dislocation from functional overload. TMJ pain, headaches, masticatory dysfunction, etc. Not all prognathic mandibles are caused by CH: only those demonstrating accelerated, excessive mandibular growth and/or growth continuing beyond the normal growth years. Differential diagnosis includes: 1. CH: 2. prognathism with normal and ptoportionate growth of both jaws; and 3. deficient maxillary growth with a normal growing mandible. Tbe treatment protocol'^'^ developed by the author for patients with active CH includes: 1. high condylectomy to arrest the condylar growth; 2. TMJ disk repositioning; and 3. simultaneous orthognathic surgery. This protocol predictably stops mandibular growth and provides highly predictable and stable outcomes with normal jaw function and good esthetics. A previous study'^ evaluated 54 patient.s (32 females. 22 males) with confirmed active CH, average age 17 years, followed for five years post surgery, and divided into two groups. Group 1 patients (n=l2) were treated witb orthognathic surgery only, and Group 2 patients (n=42) were treated witb simultaneous high condylectomies, disks repositioned over tbe remaining condyle, and orthognathic surgery. All patients in Group 1 redeveloped skeletal and occlusal Class III relationships.

278

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

OCTOBER 2007. VOL. 25, NO. 4

WOLFORD

SIMULTANEOUS TMJ AND ORTHOGNATHIC SURGERY

In Group 2. all 42 patients remained in a stable Class I skeletal and occlusal relationship with normal jaw function. Condylar Osteochondrotna/Osteoma Osteochondromas or osteomas can occur at any age and are unilateral palhological processes that cause enlargement of the mandibular eondyle, creating a progressive, vertically asymmetric dentofacial deformity and malocclusion. TMJ pain, headaches, and masticatory dysfunction. An osteochondroma is a tumor in the condylar head producing excessive bone and cartilage that enlarges the condyle (Figure 7). An osteoma can have a similar growth pattern, but produces only excessive bone in the condyle and may progress at a slower growth rate. These lumors can become very large and cause severe dentofacial and occlusal deformities resulting in ipsilateral excessive vertical facial over-growth including: enlarged and elongated condylar head and neck, vertically elongated mandibular ramus and body, ipsilateral lateral open bite, unilateral ipsilateral vertical maxillary hyperplasia. and commonly eontraiateral TMJ arthritis and articular disk dislocation from functional overload on that joint. These condylar pathologies can be predictably treated with a low condylectomy. preserving the condylar neck, which is recontoured to function as a new condyle. and the disk is stabilized to it with a Mitek anchor (Figure 2).

Simultaneous eontraiateral disk repositioning with the Mitek anchor (if indicated), orthognathic surgery, as well as an ipsilateral horizontal mandibular inferior border ostectomy (to improve vertical facial symmetry) can be performed to provide optimal functional and esthetic results. One study'^ on six patients treated by this protocol showed, at four years post surgery, no recurrence of the tumors, jaw structures and occlusions that were stable, good jaw function, and patients who were pain free. End-Stage TMJ Pathology The TMJ can become end-stage, nonsalvageable (not amendable to autogenous tissue reconstruction) as a result of the following conditions: I. connective tissue/ autoimmune diseases (i.e.. rheumatoid arthritis jFigure 8], psoriatic arthritis, lupus, scleroderma, Sjogren's syndrome, ankylosing spondylitis. etc.); 2. reactive arthritis (i.e. Reiter's syndrome): 3. osteoarthritis; 4. neoplasms; 5. multiply operated joints; 6. failed TMJ alloplastic implants; 7. traumatized joints; 8. absence of the joint (i.e., hemifacial microsomia); or 9. ankylosis (Figure 9). Some patients with these conditiotis may have severe pain, severe TMJ and jaw dysfunction, severe facial deformities, and major disability issues. Patients with these TMJ pathologies, regardless of the severity, may benefit from TMJ reconstruction and mandibular reposi-

Figure 7 MR] iniagt; lit' a nuimlibular condylar osleochondroma shows unilateral enlarged deformed condyle with an anterior exophyiic bone urowtli (while arrows). This palhological process will cuii^e vcriicul cinngaiion of ipsilateral mandibular ramus and buKly. vcriical facial asymnieiry. ipsilateral laleial open bile, ami commonly a contralaleral TMJ arlhrilis and articular disk disloealion because of the iticreiLsed loading on llial joini. The black line indicaies the level of condylar ostectomy lo remove the lumorand prevent reoccurence.

Figure 8 Classic MRI appearance of advanced TMJ rheumatoid arthritis includes: 1. severe condylar resorption (small black arrows denote superior condylar cortex); 2. erosion of the articular eminence (large black arrow); and 3. reactive pannus (gray tissue between condylcdisk and disk-fossa) surrounds (he arlicular disk (white arrows) that will eventually lead to further deslruction of ihe condyle. disk, and articular eminence.

OCTOBER 2007, VOL. 25. NO. 4

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

279

SIMULTANEOUS TMJ AND ORTHOGNATHIC SURGERY

WOLFORD

logical, dysfunctional, and painful TMJ. Research has clearly demonstrated that TMJ and orthognathic surgery can be safely and predictably performed in the same operation, but it does necessitate the correct diagnosis and treatment plan, as well as requires the surgeon to have expertise in both TMJ and orthognathic surgery. The surgical procedures can be separated, but the TMJ surgery should be done first. Poor TMJ surgery outcomes are usually related to: wrong diagnosis, wrong surgical procedure, poorly executed surgery, inadequate follow-up care, and/or unrecognized or untreatable local and/or systemic factors. With the correct diagnosis and treatment plan, the simultaneous TMJ and orthognathic surgical approach provides complete and comprehensive management of patients with coexisting TMJ pathology and dentofacial deformities. Patients who develop significant changes in their occlusion, jaw alignment, and masticatory function (with or without TMJ pain, headaches, myofascial pain, ear symptoms, etc.) commonly have TMJ pathology that is either causing condylar resorption (i.e., adolescent internal condytar resorption. reactive arthritis, connective tissue/autoimmune diseases, etc.) or condylar growth (i.e., condylar hyperplasia. osteochondroma. osteoma, etc.). Post orthognathic surgery outcome instability (relapse) is usually reiated to poor surgical technique, jaws improperly positioned, or inadequately stabilized) and/or undiagnosed and untreated TMJ pathology. In cases with poorly performed or inadequately stabilized surgical procedures, relapse is usually evident immediately or within two to three weeks post surgery. TMJ pathology that causes relapse usually involves condylar resorption or condylar growth and occurs over time, often taking months to years until the problem is identified. Case Examples The following are case examples of patients, treated only with traditional methods of orthognathic surgery, who suffered adverse outcomes from pre-existing, unrecognized, or untreated TMJ pathology. Case 1: A 15-year-old female with a retruded mandible. Class II open bite that developed over the past 3 years. high occiusal plane angle, but no TMJ symptoms, underwent surgical mandibular advancement to correct a Class II open bite. Appropriate rigid fixation was used and initially a stable result was achieved. However, at one year post surgery, she developed a Class II anterior open bite, as well as headaches and TMJ pain. This patient had an undiagnosed, untreated, presurgica! TMJ adolescent internal condylar resorption with articular disk dislocation that probably developed as she entered her pubertal

Figure 9 Tomographic imaging of a TMJ bony ankylosis demonstrates hypertrophie-reactive bone deposition surrciiinding the right TMJ structures.

tioning with total joint prostheses (Figure 4), as well as simultaneous maxillary orthognathic surgery, if indicated, to achieve the best outcome results relative to function, stability, esthetics, and pain.'^ -' Studies'**-" have shown very good outcomes in treating connective tissue/autoimmune diseases affecting the TMJ with custom-made total joint prostheses (TMJ Concepts system) for TMJ reconstruction and mandibular advancement, as well as simultaneous maxillary orthognathic surgery. The average mandibular advancement was 15 mm with very stable results and significant improvement in pain levels and jaw function. Another study'** demonstrated good outcomes using these custom-made total joint prostheses and orthognathic surgery in treating other TMJ disorders, including multiply operated joints and those having failed alloplastic TMJ implants. However, the quality of results decreased as the number of previous surgeries increased, particularly in reference to pain relief. When the TMJ Concepts total joint prostheses system is u.sed as the first or second TMJ surgery, the suecess rate is very good relative to jaw function, stability, facial balance, and pain relief. Discussion During the past two decades, major advancements have been made in TMJ diagnostics and the development of surgical procedures to treat and rehabilitate the patho-

280

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

OCTOBER 2007. VOL. 25, NO. 4

WOLFORD

SIMULTANEOUS TMJ AND ORTHOGNATHIC SURGERY

growth phase. An appropriate preoperative history, TMJ evaluation, radiographs, and MR! could have diagnosed the condition. The patient had to undergo a second surgery to reposition the articular disks with Mitek anchors and simultaneous mandibular and maxillary orthognathic surgery to stop the disease process, eliminate or significantly decrease the subsequent pain and headaches, as well as to provide a highly predictable and stable functional and esthetic treatment outcome. The presurgical differential diagnosis would include other pathological conditions that could cause condylar resorption, such as connective tissue/autoimmune diseases (i.e., rheumatoid arthritis, psoriatic arthritis, lupus, Sjogren's syndrome, etc.), reactive arthritis, or other TMJ resorplive pathosis. However, appropriate presurgical evaluations would help in the differential process. Case 2: A 19-year-o!(J man had his mandibular prognathism corrected with bilateral mandibular ramus sagittal split osteotomies with a stable immediate post surgical result. However, at six months post surgery, he began to shift into a Class III end-on occlusal relationship. By one year, he was four mm Class III and getting progressively worse. This patient has active bilateral condylar hyperplasia that could continue to grow into his mid twenties. Serial lateral cephalograms and tomograms taken al six to 12 months intervals, presurgery, could have identified CH so that the appropriate TMJ procedure could have been performed at the first surgery. Bilateral mandibular high condylectomies. articular disk repositioning, and the required orthognathic surgery would eliminate the TMJ pathology and provide predictably stable results. Case 3: A 3S-year-old female developed facial asymmetry over the past seven years with the left side of the face significantly longer vertically than the right side. She had pain and clicking in the right TMJ. She had an open bite on the left side and a transverse eant to the occlusion with the left side significantly lower than the right. The left condyle was much larger than the right and had an unusual shape. The surgeon decided to do maxillary and mandibular osteotomies to reestablish facial symmetry and a good occlusion. The initial result was very good, but after six months, the orthodontist noted that the patient was developing an open bite again on the left side and the right TMJ was getting more painful. This patient had a left mandibular condylar osteochondroma with eontraiateral TMJ arthritis and articular disk displacement from the overloading of that joint. Appropriate presurgical work-up should have included an MRI of the TMJ as well as tomograms or CT scan of the TMJ to evaluate the pathology. A bone scan may be of little value since both sides will show bone reactivity. Repeat surgery included: a left side low condylectomy, bilateral disk

repositioning with Mitek anchors, followed by mandibular then maxillary osteotomies to provide a predictable functional, esthetic and stable outcome. Case 4: A 42-year-old female was evaluated for a Class II occlusion, sleep apnea, a previous history of bilateral TMJ clicking that stopped five years ago, TMJ pain, headaches, and significant problems with other joints. She was treated with splint therapy and her TMJ pain significantly improved. Since the joints were declared "stable." the surgeon decided to proceed with maxillary and mandibular osteotomies to advance the jaws to correct the sleep apnea. The surgery went very well, but at eight months post surgery, the patient experienced increased pain and headaches, and the bite shifted toward a Class II open bite occlusion. With the presence of multiple other joint problems, other health issues, and the fact that the disks were displaced without reduction, it indicated that the patient may have a connective tissue/ autoimmune disease or systemic reactive arthritis and probably nonsalvageable articular disks. Appropriate presurgical lab tests, MRI. and consultation wiih a rhcumatologist could have helped with the diagnosis. Surgical treatment to correct the probletns included: bilateral TMJ reconstruction and mandibular advancement with TMJ Concepts total joint prostheses, as well as maxillary osteotomies to achieve the best tunctional and esthetic result and the best probability of significant decrease or elimination of pain and correction of her sleep apnea. Conclusions There are many temporomandibular joint (TMJ) conditions that cause pain. TMJ and jaw dysfunction, and disability. This paper presents the most common conditions that can affect patients and discusses the diagnostics and surgical treatment options. Appropriate diagnostic steps, proper treatment planning and completion, correct .selection and performance ofthe surgical procedures, and suitable post surgical management will usually provide good quaiity and predictable outcomes. References
Wollbrd LM, RciL-he-Fischel O. Melira P: Changes in TMJ dysfunction afler orthognathic f.urgcTy..lOralMa\ill(>fiicSurg 2(X0; fil:665-66(). Fuselier C. Wolford LM. Piilu M. Talwiir R: Cimdylar changes aflcr orthognaihif surgerj' with untreated TMJ inieniHl dLT.ingemenl. J Oral Ma.ullofac Surg IWM; Suppi 4. 56:61KeratensHC, Tuin/ing DB. Golding RP. Van dcr Kwasl WA: Cwndylar atrophy and oslcoanhrosls afler biniaxillary surgery, OraiSurg Oral MedOral Paihol IWO: 69:274-28(1. Moore KG. Goods PJ, Stoelinga PJ: The conlribuiing roie of condylar resorplion in onhognuthic surgery: a retrospective study. yOro/MoifWo/afSurs 1991; 49:448-460. DeClercq CA. Neyl LF, Mommaens MY, Abeloos JV. DeMo[ BM: Condylar

OCTOBER 2007, VOL. 25, NO. 4

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

281

SIMULTANEOUS TlUU AND ORTHOGNATHIC SURGERY

WOLFORD

6.

7,

9.

10.

11.

12.

13.

14.

15.

16.

17.

IS.

resorplion in orthognaihk surgery: a relrospeciivesludy. \ni J Aduli Orihod Orihognaih .Siirg 1994:9:233-240. Amen GW, Tamborcllo JA: Progressive Class I I dcvelopmenl: female idiopuihic eondyiar resorplion. Oral Maxilhfac Surii Clin North Am 1990: 2:699-716, Crawford JG. Stoelinga PJ, Blijdmp PA. Brown JJ: Stubilily afler reope ral ion lor pmgressive eondyiar resorplion afier onhiignalhic surgery: report of seven cases,,/ Oral Maxillofac Sur^ 1994: 52:460-466, Wolford L M . Cotlrell DA. Karra.s SC: Miiek mini anchor in maxillofacial surgery. Proceedings ofSMST-94, the First Imernaiionut Conference on Shape Memory and Superelastic Technologies 1995, Monterey. CA. MIAS:477-482. Wollord L M : Temporomandihular joint devices: treaimeni factors and outcomes. Oral Sur^ Oral Med Oral Patliol Oral Radiol Endo 1997: 83:143149. Wolford L M . Karras SC, Mehra P: Concomilani lempuromandibular joint and orthognalhic surgery: a preliminary reporl. J Oral Maxillofac Surg 2(X)2: 60:356-362, Mehra P, Wollbrd LM: The Milek mini anehor for TMJ disk repositioning: surgicu! technique and resulls. Im J Oral Maxillofac Suri> 2001: 3{l:4y7503. Downie MJ, Wullord L M . Morales-Ryiin CA: Outcome assessment following simultaneous onhognathic and TMJ surgery.,/ Oral Maxillofac Surg 2mi: Suppi 59:51. Wolford L M , Cardenas L: Idiopathic condylar resorption: diagnosis, treatment protocol, and ouxcomes. Am J Orthod Dentofacial Orlhop 1999: 116:667-676. Morales-Ryan CA. Garcia-Morales P. Wolford L M : Idiopathic i.ortdylar resorption; outcome assessmeni of TMJ disk repositioning and orthognathic surgery. J Oral Masillofac Smg 2t)O2: Suppi 1.60:53. Wolford L M , Mehra P. Reiehe-Fl.^ehel O. Morales-Ryan CA. GarciaMorales P: Efficacy of high condylectomy for management of eondyiar hyperplasia. Am J Oriliod Deniofacial Ortlwp 2{X)2; 121:136-151. Gat\:ia-Morales P. Wolford L M . Mehra P. Reichc-Fischel O. Morales-Ryan CA; Effieaey of high eondylectiimy Cor managemeni of condylar hyperplasia. 7 Or<v/jMu.viYfo/t/i.Sw,!; 2(XH; Suppi L.WiHfe. Wolford L M . Mehra P, Franco P: Use of conservative eondylectomy for trealment of osteochondroma of the mandibular condyle.,/ Oral Ma.\illofac .Vuru 2(102: 60:262-263. Wolford L M . Cottrell DA. Henry CH: Temporomandibular joint reconstruelion of Ihe complex patient with the techmediea cuslom-made total joint prosthesis,,/ Oral Maxillofac Surg 1994: 52:2-10.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

Freitas RZ. Mehra P. Wolford LW: Autogenous versus alloplastii: TMJ reconsimction in rheumaioid-induced TMJ disca.se.,/O/M(j.v;7/o/ac.SHr^ 2002: Suppi 1.58:43. Mehra P. Wolford L M : Cusiom-made TMJ reconstruction and simultaneous mandibuUiradvancemeni in auioimniune/connective tissue diseases, ./(7ru/ Maxillofac Surg 2(KK): Suppi 1. 5K:95. Wolford L M , Karras SC: Autologous fal transplantation around temporomandihular joint tolal joini prostheses: preliminary trealment outcomes. ./ Oral Maxillofac Surj- 1997: 55:245-251, Mercuri LG, Wollord L M , Sanders B. White RD. Giobbie-Hurder A; Longterm follow-up of the CAD/CAM piuient I'tttetl total lemporomandibular joint reconstruction aysl<:m. J Oral Ma.xiliqfac Surg 21X12; 60:1440-1448. Wolford L M . Pitta MC. Reiche-Fischel. Franco PF: TMJ Concepts/Techmedica custom-made TMJ total joint prosihesis: 5-year follow-up. Im J Oral Maxithfac Surg 2003; 32:268-274. Nicker.son JW, Boring G: Natural course of osteoarthrosis as it relates lo intemai derangement of the temporomandibular joini. Oral Maxillofac Surg Clin North Am 1989: 1:27-45, Henry CH, Hudson AP, Gerard HC. Franco PF. Wolford L M : Identincaiion of chlamydia trachomatis in Ihe hum;ui temporomandibular joint.,/ Oral Maxillofac Surg 1999: 57:683-688. Henry CH. Hughes CV. Gerard HC. Hudson AP. Wollord L M : Reaaive arthrilis: preliminary microbiologic analysis of the human temporomandibular joint.,/ Oral Ma.xillofac Surg 21W; 58:1137-1142. Henry CH, Pitta MC, Wolford L M : Frequency of chlamydial antibodies in patients wilh internal derangement of the temporomandibular joint. Oral .Surg Oral Med Oral Paihol Oral Radiol Endod 2(XII: 91:287-292. Wolford L M . Gerard HC. Hetiry CH. Hud.son AP: Chkunydia Psittaci infection may he involved in development of lemjxminianJibular joint dysfunction, J Oral Ma.xillolac Surg 2(XH: Suppi I, .i9;3O, Hudsoti AP. Henry C. Wolford L, Gerard MC: Chlamydia Psittaci infection may influence development of temporomandibular joint dysfunction. J Arih Rheum 20CX); 4.3:S 174. Henry CH, Wolford L M : .Substance P and masl cells; ptieliminary hislologic jinaiysis of the human tempoamandibular joint. Oral Surg Oral Med Oral Patliol Oral Radiol Endod 2001: J2:?<)i4-W). Henry CH. Nikaein A. Wolford LM: Analysis of human leukocyte antigens in paiients wiih internal derangemenl of ihe temporomandibular joint. ,/ Oral Mcixillofat Surg 21X12: 60:778-783, Wolford L M . Henry CH. Goncaives JR: TMJ and systemic affects associated with chlamydia Psittaci. J Oral Maxillofac Surg 2(XM; 62;50-51,

282

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

OCTOBER 2007, VOL. 25, NO, 4