condylar resorption case report aao 2019 ehandout update ... · ©sylvainchamberland.com clinical...

Progressive/Idiopathic Condylar Resorption

Three Case Reports

AAO 119th Annual Session

©sylvainchamberland.com

Biography Sylvain Chamberland

•D.M.D. (Docteur en Médecine Dentaire), University Laval, 1983

•Private practice, general dentistry 1983-1988

•Certificate in Orthodontics, University of Montreal, 1990

•M.Sc. in Dental Science, University Laval, 2008

•Private practice in orthodontics since 1990

•Publications

✦ Closer look at SARPE, JOMS 2008

✦ Short-term and long-term stability of SARPE revisited, AJODO 2011

✦ Long-term dental and skeletal changes following SARPE, letter to editor, OOOO 2013

✦ Functional genioplasty in growing patients, AO 2015,

✦ Response to : Functional geniolasty in growing patients by Chamberland et al, AO 2015,;85, 6: p1083

✦ Progressive/Idiopathic Condylar Resorption: Case Reports, AJODO 2019, In Press

• Lecturer in several graduate program and scientific meeting in USA, Canada, Europe


Milestone

1983 1990 20011984

2003 2008 2011 2014 2016

DMDCarole

Cert ortho

1996

U Wash UNC Angle EastMSc

JOMS AJODO Angle Ortho Vanessa

2017

DGKFOAAOAAO

2015

JOF

2018

AAO

2009

AAO Orthod Fr AAO

2019

SOBOR

SOBOR

AJODOIn press


Dr Louis Mercuri


Dr David Hatcher



Progressive/Idiopathic Condylar Resorption

• Localized degenerative disease of the TMJ

✦ Lysis and repair of the articular fibrocartilage and underlying bone

• Aggressive nature

• Mostly seen in young female adolescent

• Prevalence 9F: 1HHandelman CS, Greene CS. Progressive/Idiopathic Condylar Resorption: An Orthodontic Perspective. Seminars in Orthodontics 2013;19:55-70.Wolford LM, Goncalves JR. Condylar resorption of the temporomandibular joint: how do we treat it? Oral Maxillofac Surg Clin North Am 2015;27:47-67.Hatcher DC. Progressive Condylar Resorption: Pathologic Processes and Imaging Considerations. Seminars in Orthodontics 2013;19:97-105.


Constitutional Risks Factors

• Strong female predilection

• Hormonal imbalance (↓estrogen, ↓17β-estradiol)

• Nutritional status(↓ Vit D, ↓Omega-3)

• Bruxism and repetitive oral habits

✦ Free radical generation through sheer stress and increased metabolic demands

Arnett G.W., Gunson M.J., Risk Factors in the Initiation of Condylar Resorption, Semin Orthod 2013;19:81-88.


Iatrogenic Causes• Iatrogenic causes:

✦ Orthognathic surgery,

✦ Intermaxillary fixation

✦ Rigid fixation used in mandibular osteotomy

✦ Improperly designed and utilized occlusal appliances

✓ All condylar change or displacement through compression

Arnett G.W., Gunson M.J., Risk Factors in the Initiation of Condylar Resorption, Semin Orthod 2013;19:81-88.©sylvainchamberland.com

PCR/ICR

• Loss of condylar mass

• Decrease of ramus height and length

✦ Clockwise rotation of the mandible

✦ Anterior open bite

• Destruction localized to the section superior to a line bisecting condylar poles


PCR/ICR• Active phase

✦ Associated with decreased interincisal opening + TMJ pain

✦ Followed by condylar flattening and decortication

• Flattening may form a congruent articulation with opposing surface

✦ Permit redistribution of functional loads

✦ Restoration in condylar motion and reduction of pain


Associated Growth Changes•PCR\ICR occurring before

completion of growth

✦ 1-Shorter condylar process

✦ 2- Shortened ramus height

✦ 3- Increased antegonial notching

✦ 4- Compensatory appositional bone at gonial angle

✦ 5- Decreased lateral mandibular growth on the affected side

♀36y, Onset at 12-13y

Dibbets J, Müller B, Krop F, and van der Weele L. Deformed Condyles and Craniofacial Growth: Findings of the Groningen Longitudinal Temporomandibular Disorder Study. Seminars in Orthodontics. 2013, Jun;19(2):71-80.

{Hatcher 2013}


Clinical Significance of PCR/ICR• Clockwise facial growth pattern and

development of an anterior open bite.

• Reduction in airway dimensions is a risk factor for sleep apnea.

• Increased lower anterior facial height may cause lip incompetence in repose

• Reduced bone thickness facial to the roots of incisors


Imaging Modalities•Panoramic (OPG) imaging:

✦ Readily available, easily performed, low cost

✦ Gross examination,

✓ ∆ size, loss of condylar bone mass,

✓ ∆ articular eminence

✓ Flattening of the anterosuperior surface

✓ Distal inclination of the condylar neck

✦ Sensitivity 97%; specificity 45% (Fx-positive)


Imaging Modalities• Cephalogram

✦ Serial cephs taken during active phase will show progression of the disease and mesial migration of Articulare point

✦ Hyperdivergency

✓Shortened posterior face height

✓ Increased anterior face height

✦ ↑OJ & OB


Imaging Modalities joint osteoarthritis

•CBCT images

•Symptomatic patient with TMJ OA =

✦ Resorption of the anterior surface of the lateral pole, the posterior surface of the medial pole, and flattening of the articular surface & subcortical cyst formation (Ely’s cyst)

✦ Significant positive correlation between the location and extent of condylar resorption and pain intensity and duration

Cevidanes et al, Quantification of condylar resorption in temporomandibular joint osteoarthritis, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:110-117)Cevidanes et al, Condylar resorption in patients with TMD, monograph 46, Cranifacial Growth Series, 2008, p 147-157 Handelman, Chester S, and Charles S Greene. "Progressive/Idiopathic Condylar Resorption: An Orthodontic Perspective." Seminars in Orthodontics 19, no. 2 (2013): doi:10.1053/j.sodo.2012.11.004


Imaging Modalities• Magnetic Resonance Imaging:

✦ Cartilaginous integrity of the condylar surface, disc derangement inflammation

• T1-weighted MRI: disc position, presence of alteration in bone + soft tissue anatomy

• T2-weighted MRI: inflammation response in the TMJ + bone marrow edema

• Gold Standard for evaluation of inflammatory arthritis

• MRI sensitivity =78%; predictive value =54%Larheim TA et al, Clinical significance of changes in the bone marrow and intra-articular soft tissues of the temporomandibular joint, Sem Ortho 2012;18:30-43

Martini G,Isolated temporomandibular synovitis as unique presentation of juvenile idiopathic arthritisJ Rheum 2001; 28:1689-92


Imaging Modalities• Nuclear medicine bone scanning with Tc-99

✦ Assess if there are any active bony change

✦ Specificity not sufficient to assess state of stability/remission


Pathogenesis of TMJ diseases• TMJ osteoarthritis has a non-inflammatory origin;

✦ ≠ rheumatoid arthritis

• Deterioration + abrasion of articular cartilage

• Local thickening + remodeling of underlying bone

• Changes accompanied by secondary inflammatory changes


Three Main Etiologies

• 1-Trauma or aberrant loading

• 2-Hormonal pathogenesis

• 3-Genetic basis for altered joint extracellular matrix

• 1, 2 and 3: Not mutually exclusive

Milan SB, Pathogenesis of degenerative temporomandibular joint arthritides, Odontology, September 2005, Volume 93, Issue 1, pp 7–15


Pathophysiology Concept of the Process of Cartilage Breakdown

Tanaka E., Detamore M.S., Mercuri L.G. Degenerative disorders of the temporomandibular joint: Etiology, diagnosis and treatment, J Dent Res 2008; 87:296-307

Kapila S, Current and future innovations in diagnosis and therapeutics of TMJ diseases, Monograph 46, Craniofacial growth series 2008

• Loss of matrix molecules• Inability to sustain function• Degenerative joint disease

Hormones or other agents


Options For Management of TMJ Osteoarthritis

• Goals

✦ Decreasing joint pain, swelling and muscle pain

✦ Increasing joint function

✦ Preventing further joint damage

✦ Preventing disability.


Options For Managementof TMJ Osteoarthritis

• Non-invasive management modalities

✦ Medications: NSAIDs, muscle relaxant

✦ Physiotherapy: active jaw movement, manual therapy

✦ Occlusal splint: Provide relief from muscle contraction/pain, decrease potential joint overload

Mercuri LG, Osteoarthritis, Osteoarthrosis and Idiopathic Condylar Resorption, Oral Maxillofacial Surg Clin N Am 2008 May;20(2): 169-183©sylvainchamberland.com


• Orthodontic treatment + TADs

✦ Mx & Md dental intrusion of buccal segment

• Minimally invasive modalities

✦ Arthroscopic surgery

✦ Arthrocentesis

✓ Little evidence to support the effectiveness of arthrocentesis in the management of TMJ osteoarthriti

✓ Should no longer be recommended• Mercuri LG, Osteoarthritis, Osteoarthrosis and Idiopathic Condylar Resorption, Oral Maxillofacial Surg Clin N Am 2008 May;20(2): 169-183• Bouchard C, Goulet JP, El-Ouazzani M, Turgeon AF. Temporomandibular Lavage Versus Nonsurgical Treatments for Temporomandibular

Disorders: A Systematic Review and Meta-Analysis. J Oral Maxillofac Surg 2017;75:1352-1362.

Courtoisie Dr Jean-Philipe Fréchette

ChOlGa030914



• Invasive surgical modalities: bone & joint procedures

✦ Arthroplasty

✦ Autogenous hemiarthroplasty

✦ Discectomy

✦ Bimaxillary osteotomy and disc repositioning

• Mercuri LG, Osteoarthritis, Osteoarthrosis and Idiopathic Condylar Resorption, Oral Maxillofacial Surg Clin N Am 2008 May;20(2): 169-183• Wolford LM, Goncalves JR. Condylar resorption of the temporomandibular joint: how do we treat it? Oral Maxillofac Surg Clin North Am

2015;27:47-67. ©sylvainchamberland.com

Disc Repositoning: Does it Really Works?

•Disc repo + MxMd advancement (MMA)

✦ Better long-term outcomes

✦ Condylar bone apposition of at least 1.5 mm at the superior surface in 26.4%, the anterior surface in 23.4%, the posterior surface in 29.4%, the medial surface in 5.9%, or the lateral surface in 38.2%

•Whereas bone apposition was not observed in patients treated with MMA.

•Disc must be intact + the patient in the early stages of the disease.

MMA only, Patient without DD

MMA -Drep, Patient with DD

• Goçalves, João Roberto, Daniel Serra Cassano, Luciano Rezende, and Larry M Wolford. "Disc Repositioning: Does It Really Work?" Oral Maxillofac Surg Clin North Am 27, no. 1 (2015): doi:10.1016/j.coms.2014.09.007

• Goncalves JR, Wolford LM, Cassano DS, et al. Temporomandibular joint condylar changes following maxillomandibular advancement and articular disc repositioning. J Oral Maxillofac Surg 2013;71(10):1759.e1–15;


End Stage TMJ Osteoarthritis• Salvage procedures—Total Joint Replacement

✦ Autogenous TJR

✦ Alloplastic TJR

Mercuri LG, Osteoarthritis, Osteoarthrosis and Idiopathic Condylar Resorption, Oral Maxillofacial Surg Clin N Am 2008 May;20(2): 169-183

1 m. post op

2y post-surg1m post-surg

2y post-surg

8

Condylar ResorptionCase Reports


Case 1

• Acknowledgement

✦ This case is courtesy of Dr Louis Cadotte (orthodontist) and Carl Bouchard (oral surgeon)

1962-2018/02/23


Case 2

• My own case.


Case 3

Lac de la Ponsonnière ©sylvainchamberland.com

• See article in AJODO who will be published soon

Discussion


Discussion• Case 1 & 2

✦ End-stage condylar resorption ➙ TMJ non salvageable ➙ Alloplastic TJR

• Case 1 & 3

✦ Onset during teenage years (13-15y)

✓Can be AICR or Isolated TMJ juvenile idiopathic arthritis (JIA)

• Case 2

✦ Onset during early adulthood (mid 20s)

✓ Inflammatory TMJ arthritis, may be related to past condition during teenage years + reactivation during pregnancy . Likely hormone related: estrogen + relaxin

24


Sustained Inflammation Of The TMJ• Induces degeneration of TMJ

• Lead to deterioration of the joint’s mechanical properties

• Alteration of the disc ultrastructure

✦ Might contribute to TMJ disc displacement

Wang XD, Kou XX, et al.Sustained inflammation induces degeneration of the temporomandibular joint. J Dent Res. 2012 May;91(5):499-505. doi: 10.1177/0022034512441946. Epub 2012 Mar 15. Wang XD, CUI SJ et al.Deterioration of mechanical properties of discs in chronically inflamed TMJ, J Dent Res. 2014 Nov;93(11):1170-6. doi: 10.1177/0022034514552825. Epub 2014 Sep 29. ©sylvainchamberland.com

Hormonal relationship• Female hormone mediate biomechanical change within the TMJ,

✦ Causing hyperplasia of the synovial tissues that stimulate the production of cytokines that

✓ Initiate breakdown of the ligamentous structure that normally support and stabilize the articular disc to the condyle

‣ allowing the disc to be anteriorly displaced.

• Cytokines penetrate through the outer surface of the condyle

✦ Cause thinning of the cortical bone leading to breakdown to subcortical bone

✦ The condyle slowly collapse without clinically apparent destruction of the fibrocartilage.

Wolford LM, Goncalves JR. Condylar resorption of the temporomandibular joint: how do we treat it? Oral Maxillofac Surg Clin North Am 2015;27:47-67


If ICR is in Remission• Excessive joint loading

✦ Parafunctional habits,

✦ Trauma,

✦ Orthodontics,

✦ Orthognathic surgery

• Can reinitiate the resorption process

Wolford LM, Goncalves JR. Condylar resorption of the temporomandibular joint: how do we treat it? Oral Maxillofac Surg Clin North Am 2015;27:47-67 ©sylvainchamberland.com

TMJ Synovitis’ Symptoms

• Pain during jaw movement, crepitus and restricted mouth opening capacity

• Isolated TMJ synovitis

✦ Can be a presentation of the oligoarticular subtype JIA

Martini G, Bacciliero U, Tregnaghi A, Montesco MC, Zulian F. Isolated temporomandibular synovitis as unique presentation of juvenile idiopathic arthritis. The Journal of Rheumatology 2001;28:1689-1692.


Isolated TMJ Arthritis

• May be the 1st and only manifestation of JIA

✦ Probably not as rare as previously reported

• JIA-related TMJ arthritis & ICR

✦ 2 distinct conditions?

✦ Or ICR constitutes a differential diagnosis to isolated TMJ JIAHugle B, Spiegel L, Hotte J, Wiens S, Herlin T, Cron RQ et al. Isolated Arthritis of the Temporomandibular Joint as the Initial Manifestation of Juvenile Idiopathic Arthritis. J Rheumatol 2017;44:1632-1635Martini G, Bacciliero U, Tregnaghi A, Montesco MC, Zulian F. Isolated temporomandibular synovitis as unique presentation of juvenile idiopathic arthritis. The Journal of Rheumatology 2001;28:1689-1692. ©sylvainchamberland.com

Epidemiological Studies

• Higher prevalence of TMJ disease and pain in women than men

• Estrogen receptors identified in TMJ


Estrogens Receptors in TMJs• Role of Estrogen

✦Regulate the synthesis of proteins involved in articular tissue turnover

✦Enhance responses to relaxin, a polypeptide implicated in matrix metalloproteinase (MMP) synthesis and activation

✦MMPs

✓ Implicated in the degradation of the cartilaginous matrices in degenerative

Milam SB. Pathogenesis of degenerative temporomandibular joint arthritides. Odontology 2005;93:7-15©sylvainchamberland.com

Relaxin & TMJ Diseases

• Relaxin contributes to the degradative remodeling of joint fibrocartilage

• Association between relaxin-induced MMPs and matrix loss

Tabassum N TTD, Giahn H, Momotoshi S, Qin Z, Kapila S. Relaxin's induction of metalloproteinases is associated with the loss of collagen and glycosaminoglycans in synovial joint fibrocartilaginous explants. Arthritis Res Ther. 2005;7:R1-R11Hashem G, Zhang Q, Hayami T, Chen J, Wang W, Kapila S. Relaxin and beta-estradiol modulate targeted matrix degradation in specific synovial joint fibrocartilages: progesterone prevents matrix loss. Arthritis Res Ther 2006;8:R98Kapila S, Wang W, Uston K. Matrix metalloproteinase induction by relaxin causes cartilage matrix degradation in target synovial joints. Ann N Y Acad Sci 2009;1160:322-328.


Relaxin & TMJ Diseases• Relaxin

✦ 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 fibrocartilaginous tissues of the TMJ

• Potentially predisposing to TMJ disease

✦ TMJ disc and pubic symphysis show the greatest induction of MMPs and matrix loss in response to relaxin and ß-estradiol

• This help to explain the role of hormone in the disease of case #2


What should we do?• Look at the condyles on the orthopantomogram

✦Signs of degenerative change of the condyles may be present

✦While clinical symptoms may be absent

• Be aware of condylar shape, volume

• Suspicion and recognition of these imaging changes, plus awareness of any clinical sign and symptoms, may be an indication for more sophisticated imaging (CBCT, MRI, Nuclear Medicine Scan), blood testing and consultation.


What should we do?• Early diagnosis

✦ Complete blood count, Sed rate, C-reative proetin, ANA, Rh factor, Anti-CCP, Vit D, 17B-estradiol

✦ Orthopantomogram, MRI + CBCT

• Medication

✦ NSAID (Naproxen, Celebrex, Feldene)

✦ Vit D 1000UI, Ca++ 500mg

• Rheumatologist with understanding of this TMJ pathology should manage medication

✦ Methotrexate (DMARD), Etanercept (TNF-a inhibitor)


Conclusion• Cases like this can be found in any orthodontic practice

• If we are at fault, it is likely because we looked at this pathology like a dental problem.

• Maybe it is time that we look at TMJ arthrosis like medical orthopedic pathology

• To avoid the outcome of deleterious skeletal change and unsalvageable TMJ, early diagnosis and early treatment “en amont” (upstream) of the skeletal changes.


Bones with Articulating Surface at Each End

• Femur:

✦ Each extremity can have OA

• Mandible

✦ Each extremity can have OA

✦ Physicians say dentist will take care of it

✦ Dentists say: I will fix the occlusion and it will fix the joints


• The dental profession embraced the concept that the TMJ is a unique articulation.

• This has led, in the past to focused diagnostic and therapeutic modalities on the occlusion, and more recently focused on the intra-articular disc position despite no evidence to that effect.

The Holy Grail

=Courtesy of ©Dr Louis Mercuri


Conclusion

• All 3 cases were treated into a class I functional occlusion.

• The post orthodontic problem does not support the theory that class I occlusion, canine guidance, incisor guidance, balanced occlusal contact can avoid TMJ problem.

• Given the cycle of TMJ arthritis that can go active to inactive, it may mean that using a TMJ splint and get relief maybe a matter of chance that the splint is initiated prior to the remission period


Conclusion•In conclusion, it is essential that TMJ osteoarthritis be presented as the

pathologic entity it is in the same terms as our colleagues discuss osteoarthritis in orthopaedic circles.

•Not doing this only exacerbates the problem that everyone has with TMJ disorders in general —patients, clinicians, insurance carriers, etc., because they do not consider TMJ pathology orthopaedic pathology, but rather that TMJ disorders are just dental.

•Further studies are necessary to determine the true frequency of isolated TMJ arthritis in JIA and explore other possible causes for isolated TMJ arthritis as well as the optimal therapy

• Mercuri L.G., Osteoarthritis, Osteoarthrosis, and Idiopathic Condylar Resorption, Oral Max Surg Clin N Am 20 (2008) 169-183

©sylvainchamberland.com323

À la mémoire de William Robert Proffit

Sylvain CHAMBERLAND*

* Auteur pour correspondance : [email protected]

Orthod Fr 2018;89:323–326© EDP Sciences, SFODF, 2018https://doi.org/10.1051/orthodfr/2018038

Disponible en ligne sur :www.orthodfr.org

In Memoriam

C’est avec une très grande tristesse que j’ai appris, au lendemain du 30 septembre 2018, le décès du Dr William Robert Proffit, dit Bill ou Prof. J’aurais aimé le revoir dans d’autres circonstances que pour assister à son service commémoratif, le 6 octobre à la Carol Woods Retirement Community de Chapel Hill, NC.

J’ai fait la connaissance du Dr Proffit en 2001, lors d’un séminaire d’une semaine à l’université de Caroline du Nord. Cette rencontre a eu un impact déterminant et indélébile sur ma carrière professionnelle, comme sur celle de plusieurs autres et j’aimerais lui rendre hommage ici.

Je me rappelle encore très bien notre discussion à propos de l’expansion palatine assistée chirurgicalement. En applanissant nos divergences d’appréciation sur la stabilité après Le Fort 1, il m’avait jeté un regard particu-lier en proposant de m’aider à publier mes données de cas, qui étaient systématiquement consignées en vue de pouvoir éventuellement les analyser ultérieurement de façon rigoureuse. Ceux qui connaissent Prof se rappellent ce regard. J’ai pu comprendre, en discutant avec le Dr David Sarver, que j’avais alors goutté à la technique de motivation préférée du Dr Proffit, celle de la carotte et du bâton. La carotte était l’article à publier. Le bâton, lui, était la condition pour atteindre ce but : il faut travailler très dur. Une de ses qualités les plus merveilleuses était son aptitude extraordinaire à mobiliser, guider, encadrer et maintenir l’effort et l’action. William Proffit savait générer la motivation en créant des opportunités de coopération où vous appreniez la signification du mot travail. C’est ainsi que s’est établie une collaboration de 17 ans menant à la publication de trois articles et un quatrième « sous-presse » lorsqu’il nous a quitté.

L’impact de William R. Proffit sur l’Orthodontie dépasse son influence sur la pléthore d’orthodontistes ayant eu le privilège de collaborer avec lui de près ou de loin. Sa rigueur scientifique, dont ses pairs gardent un souvenir personnel, a contribué à établir les jalons de la recherche clinique en orthodontie. Plusieurs s’enten-dront pour dire qu’il a élevé la profession orthodontique en promouvant des standards scientifiques appuyés par les données probantes (evidence-based practice). Il prônait d’ailleurs la réserve et un ton posé dans l’écriture académique. Il disait souvent : « Si tu affirmes quelque chose, c’est soit un fait, soit une opinion. Si c’est un fait, tu dois être capable de citer la référence ; si c’est une opinion, dis que c’est une opinion ».

Ce ton était d’ailleurs combiné à un judicieux sens de l’observation. Lorsque je ressentais un doute quant à la validité des résultats d’une étude, je lui demandais souvent conseil. Il avait le don d’identifier correctement l’erreur dans un article. Voici un commentaire qui revenait régulièrement : « This study is an excellent example of misplaying soft variables in an attempt to support predetermined conclusions, which in fact were not supported by the data they reported » (cette étude est un excellent exemple de mauvaise utilisation de variables confondantes dans le but de soutenir des conclusions prédéterminées, qui en fait n’étaient pas corroborées par les données rapportées).

Merci, Dr Proffit

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