CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART THREE

J Oral Maxillofac Surg

65:1617-1623, 2007

Idiopathic Condylar Resorption: Current

Clinical Perspectives
Jeffrey C. Posnick, DMD, MD,* and
Joseph J. Fantuzzo, DDS, MD
In the condition of unknown origin known as idiopathic condylar resorption (ICR), the condyles of the
mandible partially resorb, causing a loss of condylar
height and alteration of the maxillofacial morphology
and occlusion.1-5 Progressive condylar resorption
(PCR) is a more general term describing conditions
resulting in loss of condylar height, including those of
known etiology (eg, juvenile rheumatoid arthritis, lupus erythematosis, trauma, steroid use).6-9
In general, ICR has the following features:1-10

Most often affects females age 15 to 35 years.

May be more frequent in teenage girls during the
pubertal growth spurt.
Generally results in bilateral and symmetric condylar involvement.
Results in progressive condylar resorption followed by stabilization without further loss of
condylar height. The only way to be certain that
the process is arrested is by documenting that
the condyles have resorbed down to the sigmoid
notch.
Has no consistent or proven inciting event or
etiology. ICR frequently occurs in the natural
course of events, not in conjunction with active
therapy. It also may coincide with or be observed

*Director, Posnick Center for Facial Plastic Surgery, Chevy Chase,

MD; Clinical Professor of Surgery and Pediatrics, Georgetown University, Washington, DC; and Adjunct Professor of Orthodontics,
University of Maryland, Baltimore College of Dental Surgery, Baltimore, MD.
Past Fellow (fellowship sponsored by the Oral and Maxillofacial
Surgery Foundation), Craniofacial/Maxillofacial Surgery, Posnick
Center for Facial Plastic Surgery, Chevy Chase, MD; and Assistant
Professor of Oral and Maxillofacial Surgery, University of Rochester
Medical Center, Rochester, NY.
Address correspondence and reprint requests to Dr Posnick:
5530 Wisconsin Avenue, Suite 1250, Chevy Chase, MD 20815;
e-mail: jposnick@drposnick.com
2007 American Association of Oral and Maxillofacial Surgeons

0278-2391/07/6508-0028$32.00/0
doi:10.1016/j.joms.2007.03.026

during or after active dental restorative, orthodontic, or surgical interventions.11-22

Results in generally good temporomandibular
joint (TMJ) function without significant limitation in vertical opening or disabling pain. During
the active phase of resorption, some TMJ discomfort and muscle hyperactivity is expected. Persistent joint noise is frequent, but an intact cartilaginous cap is generally seen on magnetic
resonance imaging (MRI) over the deflated or
diminished condylar head once resorption has
ceased.23

Maxillofacial morphological findings generally include the following:1-10

Change in shape of the condylar heads (ie, flattening and thinning)

Decrease in condylar height
Loss of overall posterior facial height
Mandibular retropositioning
Angle Class II anterior open bite malocclusion.

Various theories on the origin of ICR have been

proposed. One theory holds that the etiology of ICR is
hormonally mitigated. Sex hormones are thought to
modulate biochemical changes within the TMJ, causing hyperplasia of the synovial tissue, which results in
condylar resorption.
Adherents to this theory recommend an open joint
procedure with removal of the affected synovium to
prevent progression of ICR.10 Skeptics believe that
the lack of documented synovial inflammation and
the intact cartilaginous surface of the resorbed condylar head(s) seen on MRI is not supportive.24,25
Another theory is that avascular necrosis of the
condyle is the causative factor in ICR with condylysis,
followed by loss of condyle height, jaw deformity,
and malocclusion. Supporters of this theory suggest
that surgical revascularization of the condyle would
be a useful form of therapy. They believe that pathological compressive forces of the posterior aspect of
the condyle on the ligamentous retrodiscal soft tissues
constrict the small vessels, limiting circulation to the

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1618
condyle and resulting in aseptic necrosis. They also
believe that chronically dislocated nonreducing disc
or malocclusion can be causative factors in this cycle
of events.26-29 Those skeptical of the nonreducing
disc risk factor for ICR point out that the almost
universally observed bilateral symmetric simultaneous
nature of this condition make it an unlikely etiology.4
The foregoing theories remain unproven, and it is
just as likely that an as-yet undefined etiology or combination of events better explains the cause of ICR.
Some clinicians suggest that with no certainty about
either the etiology or the endpoint of ICR in any given
patient, removal of the affected condyle and reconstruction with a costochondral (rib) graft or alloplast
(total joint replacement) is the preferred (or at least
the only sure) method of management.30-37 Proponents of joint replacement to manage ICR are correct
in their thinking that the only way to be certain that
condylar resorption will not continue and result in
further alteration of mandibular morphology and occlusion is to replace the joint. Given the limited longterm TMJ pain, good long-term mandibular range of
motion, and inevitable condylar stabilization (burnout) typically seen in patients with ICR, this approach seems radical to most clinicians.
Recommendations for the prevention and treatment of ICR depend on the clinicians belief about the
disorders etiology and pathophysiology. Most of the
clinical recommendations given in the literature attempt to limit mechanical (compressive) TMJ forces
in the hopes that less resorption (condylysis) will
occur.27-29,38 Despite a lack of evidence-based research to support these treatment recommendations,
a spectrum of clinical opinions and statements can be
found in the literature. Some authors believe that ICR
may be more common in individuals with highangle mandibular retrognathism (angle Class II anterior open-bite malocclusion).39 Others believe that
this morphology is the result of ICR rather than the
cause of it. Still others believe that ICR may occur or
progress more frequently when the TMJ is loaded.
Clinical settings of TMJ loading might include compressive orthodontic, surgical, or dental forces, often
in the presence of a developmental or acquired malocclusion.
After orthognathic surgery, ICR may be more likely
to progress in the setting of increased condylar loading, abnormal disk displacement, and/or pressure on
the condyles during the immobilization phase of treatment. ICR may be more frequent after orthognathic
surgery, when posteriorization and medial and/or
lateral condylar torquing occur.11-22,40,41
To limit the progression of ICR or at least diminish
muscle hyperactivity, stabilization of the TMJ (by, eg,
unloading splint therapy, use of muscle relaxants
and/or anti-inflammatory agents) preceding definitive

IDIOPATHIC CONDYLAR RESORPTION

occlusal correction (ie, orthodontics, restorative dentistry, and/or corrective jaw surgery) may be useful.1-5
To limit progression of condylar resorption in ICR,
the orthodontic, surgical (orthognathic), or dental
restorative correction of the malocclusion should
strive to achieve noncompressive forces on the condyles.1-5,39
The earlier in the clinical course of ICR that decompressive TMJ treatment is initiated, the less condylar
resorption may occur.42 Others believe that once the
resorptive process has begun, it will run its course
despite treatment.43,44
Some authors believe that performing counterclockwise rotation of the occlusal plane as part of the
orthognathic (surgical) correction may increase compressive condylar forces, with the risk of ongoing
ICR.22,41 Skeletal stability after these surgical maneuvers in non-ICR patients has been documented.45,46
Some have suggested that correction of the mandibular deformity associated with ICR using distraction
osteogenesis (DO) techniques may cause further injury to the TMJ, whereas others have come to the
opposite conclusion.47-51
ICR patients with persistent TMJ symptoms (popping, clicking, limited opening) after treatment of
malocclusion (eg, orthodontic, corrective orthognathic surgery, restorative dentistry) may be at increased risk for progression.11-22,52,53

Current Perspectives and

Clinical Approach
Once the diagnosis of ICR is made, splint therapy to
unload the condyles may be helpful to prevent
progression or at least relieve discomfort and muscle
hyperactivity. In the absence of a more complete
understanding of the ICR disease process, it is best to
postpone definitive occlusal treatment (orthodontics,
corrective jaw surgery, or restorative dentistry) until
there is sufficient evidence indicating that the condylar resorption has burnt out.
Orthognathic (corrective) jaw surgery, orthodontics, and/or restorative dentistry to definitively correct
malocclusion is more likely to be successful if condylar resorption has been stable for at least 1 year before
treatment and if an intact cartilaginous cap over the
resorbed condyle is confirmed. Tc 99m MDP quantitative condylar bone scintigraphy can be a useful tool
to assess whether or not condylysis is active.54-62
Unfortunately, false positives and false negatives may
occur. Evaluating the cartilaginous integrity of the
condylar head surface by MRI may be helpful.
In end-stage ICR, maxillofacial dysmorphology may
effect mastication, speech articulation, breathing, and
lip closure. ICP rarely results in disabling pain or
limited vertical mouth opening. Once condylar re-

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POSNICK AND FANTUZZO

sorption is assumed to have reached an endpoint (ie,

nonprogression for at least 1 year), any further change
(worsening) in maxillofacial dysmorphology is unlikely. For these reasons, preventive joint resection
and replacement with either an autograft (rib) or
allograft (total joint prosthesis) is rarely indicated.
The unfavorable facial esthetics observed in some
patients with ICR result from the skeletal dysmorphology, which then results in secondary distortions of
the soft tissue envelope. The soft tissues of the lips,
cheeks, and neck can be normalized only by correcting the skeletal deformities. Achieving acceptable facial esthetics often requires surgical repositioning of
the maxilla (Le Fort I), mandible (ramus osteotomies),
and chin (oblique osteotomy). Limiting the surgery to
either the maxilla or mandible with the idea of achieving a more stable result is not substantiated in the
literature and is likely to result in suboptimal esthetics.
The suggestion that using DO rather than classic
techniques to surgically reposition the mandible in
ICR will achieve a more stable long-term result is not
supported by the literature. The DO approach also
limits the region of reconstruction to the mandible,
requires greater patient compliance, and frequently
leads to a suboptimal esthetic result.
The key to a favorable result for an individual with
end-stage ICR or PCR is to define the esthetic and
functional abnormalities, understand the patients objectives, and then successfully perform orthognathic
procedures and dental rehabilitation. A team approach involving an orthodontist, an orthognathic
surgeon, and a TMJ specialist is essential to achieve
optimal results. Periodontal and restorative dental
work also may be needed.

Case Presentations
CASE 1: PROGRESSIVE CONDYLAR RESORPTION

History
This patient was a 23-year-old Caucasian female
with juvenile rheumatoid arthritis (JRA) diagnosed at
age 10 affecting primarily the knees and ankles. JRA
involvement of both TMJs beginning at age 12 resulted
in rapidly progressive PCR that remained unchanged
(burnt out) for at least the past 5 years. She reported
pain-free satisfactory range of motion of both TMJs.
There has been minimal TMD since age 15.
At age 19, she sustained trauma to the maxillary 4
incisors, with loss of the right lateral incisor and the
need for RCT and crown placement of the right central incisor. Temporary restorations were in place.
Evaluation
The patient arrived for consultation with the hope
of achieving improved facial esthetics and function

(mastication, breathing, lip posture, and speech articulation). She underwent additional evaluation by a
speech pathologist, an otolaryngologist/head and
neck surgeon, an orthodontist, a periodontist, a restorative dentist, a rheumatologist, and a TMJ specialist.
Treatment
Preoperative orthodontic treatment included removal of the mandibular first bicuspid teeth to uncrowd the arch and upright the incisors. Unfortunately, due to previous dentoalveolar trauma, only
minimal repositioning of the maxillary anterior teeth
was possible, preventing optimal incisor positioning.
The surgical plan for this patient included the following:

Maxillary Le Fort I osteotomy, involving vertical

intrusion at the incisors (1 mm), counterclockwise rotation of the maxillary plane (1 mm), and
horizontal advancement at the incisors (4 mm)
Bilateral sagittal split osteotomies of the mandible
to occlude the mandibular dentition into the
maxillary dentition, with counterclockwise rotation of the mandibular plane
Oblique osteotomy of the chin, with horizontal
advancement (6 mm) and vertical shortening (2
mm)
Septoplasty and reduction of the inferior turbinates,
to manage chronic obstructive nasal breathing.

After initial healing (5 weeks), finishing orthodontics continued for 3 months. Removal of orthodontic
appliances was followed by preventative splint therapy and orthodontic retention (removable retainers)
used primarily while sleeping.
Figure 1 shows the patient before and 1 year after
orthodontics and jaw surgery. Preoperative panorex
and preoperative and postoperative lateral cephalometric radiographs are shown. Final maxillary restorative dental work is to be completed.
CASE 2: IDIOPATHIC CONDYLAR RESORPTION

History
This systemically healthy 11-year-old girl experienced severe TMJ discomfort with limited and painful
mouth opening. Mandibular retrusion and anterior
open bite deformity were progressive. At age 13, the
patients orthodontist offered a combined orthodontic/orthognathic approach versus maxillary first bicuspid extractions with orthodontic treatment only to
neutralize the bite. The family chose orthodontic
treatment only. From age 13 to 15, orthodontic treatment progressed with a resulting neutralized bite. At
age 16, concerned about facial esthetics, airway and

1620

IDIOPATHIC CONDYLAR RESORPTION

FIGURE 1. Case 1. A, Frontal views in repose before and 1 year after surgery. B, Frontal views with smile before and 1 year after surgery. C,
Oblique views before and 1 year after surgery. D, Profile views before and 1 year after surgery. E, Occlusal views before, 5 weeks, and 1 year
after surgery. F, Panorex view before surgery. G, Model surgery planning. H, Lateral cephalometric views before and after surgery.
Posnick and Fantuzzo. Idiopathic Condylar Resorption. J Oral Maxillofac Surg 2007.

POSNICK AND FANTUZZO

1621

FIGURE 2. Case 2. A, Frontal views in repose before and 1 year after surgery. B, Frontal views with smile before and 1 year after surgery. C,
Oblique views before and 1 year after surgery. D, Profile views before and 1 year after surgery. E, Occlusal views before and 1 year after surgery.
F, Panorex view before surgery. G, Model surgery planning. H, Lateral cephalometric views before and after surgery.
Posnick and Fantuzzo. Idiopathic Condylar Resorption. J Oral Maxillofac Surg 2007.

1622
periodontal health, the family chose redo orthodontics, including mandibular bicuspid extractions and
orthognathic surgery.
Evaluation
A complete workup for systemic joint disease was
negative. The patient underwent evaluation by a
speech pathologist, a otolaryngologist/head and neck
surgeon, and her general dentist. She was found to
have a deviated septum and hypertrophic inferior
turbinates, with difficulty breathing through the nose.
At age 16, she was pain free in the TMJ and facial
region, with good vertical mouth opening and no
progressive condylar resorption for at least the preceding 2 years. Radiographs confirmed no further
progression of condylar resorption.
Treatment
Preoperative redo orthodontic treatment included
removal of the mandibular first bicuspid teeth to uncrowd the arch and upright the incisors. The surgical
plan included the following procedures:

Maxillary Le Fort I osteotomy, involving vertical

intrusion at the incisors (1 mm), counterclockwise rotation of maxillary plane (1 mm), and
horizontal advancement at the incisors (4 mm)
Bilateral sagittal split osteotomies of the mandible
to occlude the mandibular dentition into the
maxillary dentition, with counterclockwise rotation of the mandibular plane
Oblique osteotomy of the chin, with horizontal
advancement (6 mm) and vertical shortening (1
mm)
Septoplasty and reduction of the inferior turbinates, to manage chronic obstructive nasal
breathing.

After initial healing (5 weeks), finishing orthodontics continued for 6 months. Removal of orthodontic
appliances was followed by the use of routine removable retainers. Figure 2 shows the patient before and
1 year after completion of orthodontics and jaw surgery. Preoperative panorex and preoperative and
postoperative lateral cephalometric radiographs are
shown.

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