postsurgical stability of counterclockwise maxillomandibular advancement surgery: affect of...

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Oral Maxillofac Surg6:724-738, 2008

Postsurgical Stability of CounterclockwiseMaxillomandibular Advancement Surgery:

Affect of Articular Disc RepositioningJoao Roberto Gonçalves, DDS, PhD,*

Daniel Serra Cassano, DDS,† Larry M. Wolford, DMD,‡

Ary Santos-Pinto, DDS, PhD,§ and

Iris Malagoni Márquez, DDS, PhD�

Purpose: This study evaluated the affect of disc displacement and articular disc repositioning onstability after surgical counterclockwise rotation and advancement of the maxillomandibular complex.

Patients and Methods: A total of 72 patients (59 females, 13 males), with an average age of 30 years (range,15 to 60 years) were evaluated. The patients were divided into 3 groups. Group 1 (G1; n � 21), with healthytemporomandibular joints (TMJs), underwent double-jaw surgery only. Group 2 (G2; n � 35), with articular discdislocation, underwent articular disc repositioning using the Mitek anchor (Mitek Surgical Products, Westwood,MA) technique concomitantly with orthognathic surgery. Group 3 (G3; n � 16), with articular disc dislocation,underwent orthognathic surgery only. Average postsurgical follow-up was 31 months. Each patient’s lateralcephalograms were traced, digitized twice, and averaged to estimate surgical changes and postsurgical stability.

Results: After surgery, the occlusal plane angle was decreased significantly in all 3 groups: by �6.3 �5.0o in G1, by �9.6 � 4.8o in G2, and by �7.1 � 4.8o in G3. The maxillomandibular complex wasadvanced and rotated counterclockwise similarly in all 3 groups, with advancement at the menton of 12.4 �5.5 mm in G1, 13.5 � 4.3 mm in G2, and 13.6 � 5.0 mm in G3; advancement at the B point of 9.5 �4.9 mm in G1, 10.2 � 3.7 mm in G2, and 10.8 � 3.7 mm in G3; and advancement at the lower incisoredge of 7.1 � 4.6 mm in G1, 6.6 � 3.2 mm in G2, and 7.9 � 3.0 mm in G3. Postsurgery, the occlusalplane angle increased in G3 (2.6 � 3.8o; 37% relapse rate) but remained stable in G1 and G2. Postsurgicalmandibular changes in the horizontal direction demonstrated a significant relapse in G3 at the menton(�3.8 � 4.1 mm; 28%), the B point (�3.0 � 3.4 mm; 28%), and the lower incisor edge (�2.3 � 2.1 mm;34%) but remained stable in G1 and G2.

Conclusions: Maxillomandibular advancement with counterclockwise rotation of the occlusal plane is astable procedure for patients with healthy TMJs and for patients undergoing simultaneous TMJ disc reposi-tioning using the Mitek anchor technique. Those patients with preoperative TMJ articular disc displacementwho underwent double-jaw surgery and no TMJ intervention experienced significant relapse.© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:724-738, 2008
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skeptical attitude has developed toward TMJ sur-ery because of the unpredictable and sometimesevastating outcomes as a result of TMJ surgical tech-

*Assistant Professor of Orthodontics, Pediatric Dentistry Depart-

ent, Araraquara Dental School, São Paulo State University, Arara-

uara, São Paulo, Brazil; formerly Fellow in Oral and Maxillofacial

urgery, Baylor College of Dentistry, Texas A&M University System,

aylor University Medical Center, Dallas, TX.

†Fellow in Oral and Maxillofacial Surgery, Baylor College of

entistry, Texas A&M University System, Baylor University Medical

enter, Dallas, TX.

‡Clinical Professor, Department of Oral and Maxillofacial Sur-

ery, Baylor College of Dentistry, Texas A&M University, and Pri-

ate Practice, Baylor University Medical Center, Dallas, TX. d

724

iques used in the 1980s and 1990s. Poor TMJ surgeryutcomes are related to any of the following factors:isdiagnosis, wrong surgical procedure, poorly exe-

§Professor of Orthodontics, Pediatric Dentistry Department, Arara-

uara Dental School, São Paulo State University, Araraquara, São Paulo,

razil.

�Chairman, Department of Oral and Maxillofacial Surgery, Uber-

andia Dental School, Uberlandia Federal University, Uberlandia,

razil.

Address correspondence and reprint requests to Dr Wolford: 3409

orth St, Suite 400, Dallas, TX 75246; e-mail: [email protected]

2008 American Association of Oral and Maxillofacial Surgeons

278-2391/08/6604-0016$34.00/0

oi:10.1016/j.joms.2007.11.007

mailto:[email protected]

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GONÇALVES ET AL 725

uted surgery, inadequate follow-up care, and unrec-gnized or untreatable local or systemic factors affect-

ng joints. However, significant advancements in TMJiagnostics and the development of procedures toredictably treat and surgically rehabilitate a dysfunc-ional and pathological TMJ can provide good out-omes.1

Controversy surrounds the appropriate manage-ent of patients with pre-existing internal derange-ent of the TMJ who need orthognathic surgery for

orrection of malocclusion and jaw deformities.2

here are 2 significantly different philosophies; therst posits that orthognathic surgical procedures re-uce or eliminate TMJ dysfunction and symptoms,3-7

hereas the second posits that orthognathic surgeryauses further harmful effects on the TMJ and thusorsens the symptoms and dysfunction postsur-

ery.8-10 The second philosophy proposes appropri-te surgical management of the TMJ pathology in annitial separate surgical procedure or concomitantly

ith the orthognathic surgery.1

Some authors3-7 recommend that patients with co-xisting TMJ dysfunction and skeletal facial deformi-ies undergo orthodontic preparation followed by or-hognathic surgery. For the small number of patientshose TMJ symptoms do not resolve and are too

evere to permit orthodontic preparation for orthog-athic surgery, TMJ surgery may be performed beforerthognathic treatment. However, other studies1,11-32

ave shown that concomitant surgical correction ofMJ pathology and coexisting dentofacial deformities

n a single operation provides high-quality treatmentutcomes for most patients relative to function, es-hetics, elimination or significant reduction in pain,nd improved patient satisfaction.

Pre-existing TMJ pathology (symptomatic or not) that

IGURE 1. A, A retruded mandible with a displaced TMJ articularisc. B, Advancing the mandible (without TMJ disc-repositioning sur-ery) will maintain the disc in the displaced position, because theondyles will seek the most superoposterior position in the fossa as aesult of postsurgical soft tissue tension. This can initiate or worsen TMJain and dysfunction, headaches, condylar resorption, and otheromplications.

onçalves et al. Articular Disc Repositioning for Stability inaxillomandibular Advancement. J Oral Maxillofac Surg 2008.

an cause unfavorable outcomes when only orthog-GM

athic surgery is performed include articular disc dislo-ation, adolescent internal condylar resorption (AICR),ondylar hyperplasia, osteochondroma/osteoma, con-enital deformities, reactive arthritis, connective tis-ue/autoimmune diseases, nonsalvageable joints, andthers. All of these conditions can be associated withentofacial deformities, TMJ pain, headaches, myofas-ial pain, TMJ dysfunction, and other problems.1

The most common TMJ pathology is anteriornd/or medial displacement of the articular disc,hich can initiate a cascade of events leading to

rthritis and other TMJ-related symptoms.1,33 Ad-ancement of the mandible in a patient with dis-laced discs causes the discs to remain displaced ashe condyles seek a superoposterior position in theossa (Fig 1).1 Other authors have reported that pa-ients with presurgical TMJ symptoms requiring largeandibular advancement appear to be at increased

isk for condylar resorption34,35; thus, in these pa-ients, a logical approach would be to return the disco a normal anatomic and functional position. Con-omitant treatment (when the discs are salvageable)ay include articular disc repositioning and stabiliza-

ion using the Mitek anchor (Mitek Surgical Products,estwood, MA) technique (Fig 2)1,11-18 and orthog-

athic surgery as indicated.1

AICR, formally called idiopathic condylar resorp-ion,19,20 is a pathological condition primarily affect-ng teenage females. In AICR, the articular discs arenteriorly displaced, synovial tissue hyperplasia devel-ps, and internal condylar resorption occurs, creatingslow but progressive retrusion of the mandible; 25%f affected patients are asymptomatic.1,19,20 Patientsith AICR often require large mandibular advance-ent and predictably will experience postsurgical

IGURE 2. A, Cross-section of the condyle showing the Mitek mini-nchor positioned beneath the posterior cortical bone, with the wingsxpanded, locking it in position (P, posterior; A, anterior). The anchors usually inserted 5 to 8 mm below the top of the condyle and lateralo the mid-sagittal plane. B, Posterior view of the condyle showing the-0 Ethibond sutures placed through the posterior aspect of the poste-

ior band of the disc, 1 medial and 1 lateral to the mid-sagittal plane,ecuring the disc to the condyle (M, medial; L, lateral).


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726 ARTICULAR DISC REPOSITIONING FOR STABILITY IN MAXILLOMANDIBULAR ADVANCEMENT

ondylar resorption if only orthognathic surgery with-ut advancement is performed. A treatment protocoleveloped by Wolford1,19,20 aims to eliminate theathological condition and allow optimal correctionf the associated dentofacial deformity with veryood stability and function through the followingteps: 1) remove the hypertrophied bilaminar andynovial tissues, 2) reposition and stabilize the artic-lar disc to the condyle with the Mitek mini-anchorechnique (Fig 2), and 3) concomitantly perform or-hognathic surgery.

Other factors that may contribute to skeletal re-apse and condylar resorption include patient age andender, a high mandibular plane angle, preoperativerthodontic treatment, bone healing, condylar posi-ioning, neuromuscular adaptation, instability of seg-ents, and the degree of mandibular advancementerformed.2,36

To gain insight into the controversy regarding sta-ility after surgical counterclockwise rotation and ad-ancement of the maxillomandibular complex andhe affect of articular disc repositioning in patientsith displaced discs and TMJ dysfunction, the present

tudy was designed to test the following null hypoth-sis: Articular disc repositioning surgery has no affectn the stability of orthognathic surgery in patientsith TMJ disc dislocation.

atients and Methods

PATIENTS

This retrospective study evaluated records of 72andomly selected patients (59 females, 13 males)ho underwent maxillomandibular surgical advance-ent with counterclockwise rotation of the occlusallane. Patients were selected according to the follow-

ng criteria: 1) presurgical occlusal plane anglereater than 14°; 2) treatment with bilateral man-ibular ramus sagittal split or Le Fort I osteotomyith counterclockwise rotation of the maxilloman-ibular complex and occlusal plane; 3) all surgicalrocedures performed by 1 surgeon (L.M.W.); 4) allsteotomies performed and stabilized in the sameanner with rigid internal fixation; 5) females at

east 15 years old and males at least 17 years old;nd 6) bilaterally displaced articular discs in pa-ients with TMJ dysfunction. Patients were rejectedased on the following criteria: 1) previous surgical

ntervention in the craniofacial area; 2) fewer than2 months of follow-up; 3) presence of a craniofa-ial syndrome; 4) history of connective tissue/auto-mmune disease or other systemic factors affectingoints; and 5) inadequate or poor-quality recordsradiographs).

The occlusal plane angle was decreased by poste-
ior down-grafting and/or anterior upward movement c
f the maxilla, as well as mandibular counterclock-ise rotation with bilateral ramus sagittal split osteot-my. Mean patient age at surgery was 30 years (range,5 to 60 years). The presurgical records were evalu-ted at a mean of 3 days (range, 1 to 10 days) beforeurgery (T1), the postsurgical (T2) records were eval-ated at a mean of 5 days (range, 1 to 13 days) afterurgery (T2), and the long-term follow-up recordsere evaluated at a mean of 2 years, 7 months (range,

2 months to 9 years, 3 months) after surgery (T3).The study cohort was divided into 3 groups: group 1

G1; n � 21), patients with healthy TMJs (no TMJ-elated signs or symptoms or evidence of abnormalondylar bone or joint space changes) who under-ent double-jaw surgery and no TMJ intervention;

roup 2 (G2; n � 35), patients with magnetic reso-ance imaging (MRI) and clinical verification of pre-urgical bilateral TMJ articular disc displacement (FigsA,B) who underwent articular disc repositioning us-

ng the Mitek anchor technique (Fig 2)11,14 concom-tantly with appropriate orthognathic surgical proce-ures; and group 3 (G3; n � 16), patients with MRInd clinical verification of presurgical bilateral TMJrticular disc displacement who underwent double-aw surgery and no TMJ intervention. MRI was noterformed on the G1 patients. The G2 and G3 pa-ients’ articular disc dislocation (Fig 3) was verified onRI by the senior author (L.M.W.) and an indepen-ent radiologist not involved in patient treatment.oth observers concurred on bilateral articular discislocation as a criterion for inclusion in the study. G3

IGURE 3. A, MRI of a TMJ demonstrating an anterior displacedrticular disc (arrow). B, The disc (arrow) reduces on opening (C,ondyle). C, MRI of a TMJ showing a significantly anterior displacedrticular disc (arrow). D, On opening, the disc (arrow) remains ante-iorly displaced and nonreducing with degenerative changes (C,ondyle).


omprised patients with minimal to no presurgical

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ymptoms and either were not determined to need orefused TMJ surgery. Postsurgical MRI was not per-ormed.

CEPHALOMETRIC MEASUREMENTS

Standardized lateral cephalometric radiographsQuint sectograph; American Dental Co, Hawthorne,A) were randomly traced and digitized twice by aingle investigator (DSC) approximately 1 week apart.he average values for the 2 replicates were used toecrease landmark technical errors. A total of 19 land-arks were identified (Fig 4) and digitized using DFPlus

oftware (Dentofacial Software Inc, Toronto, Ontario,anada). These landmarks were used to compute 17orizontal and vertical measurements (Fig 4) and 6 ad-itional measurements (Fig 5) describing maxilloman-ibular relationships and the position of the hyoid. Sella-asion (S-N) minus 7° was used as the horizontaleference plane (HRP); for example, Figure 4 shows theorizontal and vertical position of the menton measuredarallel and perpendicular to the HRP. Surgical changes

n the position of the menton were computed as theifference between the T2 and T1 distances, and post-

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IGURE 4. Landmarks used for cephalometric assessment. The HRP isonstructed at 7° to the SN plane. The vertical reference plane (VRP) isonstructed perpendicular to the HRP, through the sella (S). The dottedines indicate the method of measuring the Me relative to referencelanes HRP and VRP. N, nasion; S, sella turcica; Ba, basion; Ar,rticulare; ANS, anterior nasal spine (a point posterior to the tip of theedian, sharp bony process of the maxilla, on its superior surface,here the maxilla process first enlarges to a width of 5 mm); PNS,osterior nasal spine; UMT, upper molar mesial cusp tip; LMT, lowerolar distal cusp tip; LPT2, lower premolar cusp tip; UIE, upper incisordge; UIA, upper incisor apex; LIE, lower incisor edge; LIA, lowerncisor apex; B, B point; Me, menton; Go, gonion; US, upper screwmidpoint between the image of the uppermost 2 screws); LS, lowercrew (midpoint between the image of the lowermost 2 screws); Hy,yoid (most anterosuperior point of hyoid).

monçalves et al. Articular Disc Repositioning for Stability inaxillomandibular Advancement. J Oral Maxillofac Surg 2008.

urgical stability was computed as the difference be-ween the T3 and T2 distances.

STATISTICAL METHODS

After collection, all data were transferred to SPSSersion 11.5 (SPSS Inc, Chicago, IL) for statisticalnalysis. One-sample t tests were performed to eval-ate the surgical changes (T2 - T1) and postsurgicaltability (T3 - T2). The differences were then testedmong G1, G2, and G3 using analysis of varianceANOVA) and Tukey’s test. A significance level of P �05 was applied. Pearson product–moment correla-ions were used to determine the relationships amonghanges in specific anatomic measurements used toompare postsurgical changes in each group.

esults

SURGICAL MOVEMENT (T2 - T1)

Mean maxillary advancement at the anterior nasalpine (ANS) was 2.6 � 3.3 mm in G1, 2.3 � 2.3 mmn G2, and absent in G3 (Table 1; Fig 6). For verticalhanges, negative values represent upward move-ent, and positive changes represent downwardovement. ANS moved vertically by �0.9 � 1.8 mm

n G1, by �1.3 � 1.8 mm in G2, and by �1.8 � 1.7

N-S

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LI/MPMe-LI

N-S

OPA

MP-Hy

UI/NS

LI/UI

LI/MPMe-LI

IGURE 5. Distances and planes used to define linear and angulareasurements. Linear measurements include MP-Hy, the distance from

he hyoid to the mandibular plane measured on a perpendicular linerom the MP; Me-LI, the distance from the menton to the lower incisordge. Angular measurements include OPA, the angle of the occlusionlane to the N-S line; UI/NS, the angle of the upper incisor to the N-S

ine; LI/MP, the angle of the lower incisor to the mandibular plane;nd LI/UI, the incisor angle.


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oved vertically by 1.3 � 2.6 mm in G1, by 3.1 � 2.4m in G2, and by 2.7 � 3.6 mm in G3. Upper incisor

ngulation (UIE/NS) was unchanged in G1 but in-reased in angulation by 3.8 � 3.8o in G2 and by 3.4 �.9o in G3. The upper incisor edge (UIE) movedorward by 3.6 � 4.8 mm in G1, by 4.7 � 1.9 mm in2, and by 4.4 � 3.1 mm in G3, and also vertically by1.6 � 1.4 mm in G1, by �1.8 � 2.0 mm in G2, and

y �2.4 � 2.0 mm in G3. The angle between theower incisor and mandibular plane (LI/MP) de-reased by �4.0 � 4.1o in G1, by �5.3 � 4.2o in G2,nd by �3.4 � 4.4o in G3. The incisor angle (LI/UI)ncreased by 7.1 � 6.3o in G1, by 7.3 � 6.0o in G2,nd by 4.6 � 6.6o in G3.

Mandibular movement was similar in all 3 groups.his movement was represented by decreases in thecclusal plane angle (OPA) of �6.3 � 5.0o in G1,9.6 � 4.8o in G2, and �7.1 � 4.8o in G3. Theandible was advanced in a counterclockwise direc-

ion, with the lower region of the anterior mandibleemonstrating greater advancement at the menton

Table 1. SURGICAL CHANGES (HORIZONTAL AND VER

Variable

G1 (T2-T1)

Mean P SD Min Max Mean

orizontalANS 2.6 * 3.3 �7.9 8.0 2.3PNS 2.2 5.1 �6.6 11.2 0.7Ar �0.5 2.8 �5.4 6.4 �0.5B 9.5 * 4.9 0.7 17.6 10.2Me 12.4 * 5.5 2.4 22.7 13.5Go 2.6 * 3.6 �3.1 10.9 2.1UIE 3.6 * 4.8 �3.5 14.5 4.7LIE 7.1 * 4.6 �0.5 14.2 6.6Hy 5.9 * 4.7 �4.4 12.1 7.4

erticalANS �0.9 † 1.8 �4.4 4.7 �1.3PNS 1.3 † 2.6 �2.3 6.1 3.1Ar 0.0 1.9 �4.1 5.3 0.2B �0.5 2.3 �8.5 2.0 �0.3Me 0.8 2.2 �5.7 4.4 1.4Go 0.3 2.7 �6.4 5.2 1.7UIE �1.6 * 1.4 �3.5 0.7 �1.8LIE �1.9 * 2.7 �9.5 2.5 �2.5Hy 2.7 † 5.7 �9.6 10.4 1.3

engthsMe-LI 0.2 0.9 �1.2 2.0 0.2MP-Hy 2.8 † 4.7 �9.7 9.5 0.1

nglesOPA �6.3 * 5.0 �14.7 4.3 �9.6UI/NS 0.9 5.0 �9.2 8.2 3.8LI/MP �4.0 * 4.1 �9.1 9.0 �5.3LI/UI 7.1 * 6.3 �10.3 18.2 7.3

*P � .01.†P � .05.

onçalves et al. Articular Disc Repositioning for Stability in Max

Me) (12.4 � 5.5 mm in G1, 13.5 � 4.3 mm in G2, and c

3.6 � 5.0 mm in G3) compared with the middleegion at the B point (9.5 � 4.9 mm in G1, 10.2 � 3.7m in G2, and 10.8 � 3.7 mm in G3) and the upper

egion at the LIE (7.1 � 4.6 mm in G1, 6.6 � 3.2 mmn G2, and 7.9 � 3.0 mm in G3).

Hyoid movement (Hy) was similar in all 3 groups inhe horizontal direction, with advancement of 5.9 � 4.7m in G1, 7.4 � 4.9 mm in G2, and 5.0 � 6.0 mm in3. Hy in the vertical direction was 2.7 � 5.7 mm in G1nd 4.3 � 5.5 mm in G3; it remained unchanged in2. The distance between the hyoid and the mandib-lar plane (MP-Hy) was increased by 2.8 � 4.7 mm in1 and by 4.5 � 4.8 mm in G3 and remained un-hanged in G2.

POSTSURGICAL STABILITY (T3 - T2)

Horizontally, the maxilla remained stable at theNS in all 3 groups (Table 2; Fig 7). Vertically, a smallhange (0.5 � 1.1 mm) was seen in G2, whereasalues remained stable in G1 and G3. The PNS exhib-ted no vertical change in G1 and only small vertical

DIRECTIONS)

Group

(T2-T1) G3 (T2-T1)

SD Min Max Mean P SD Min Max

.3 �3.0 6.8 1.5 3.0 �3.5 8.0

.9 �8.7 9.1 1.8 4.1 �7.2 8.6

.0 �4.7 5.4 �0.1 1.5 �3.2 3.6

.7 1.6 18.3 10.8 * 3.7 3.8 17.6

.3 3.1 21.8 13.6 * 5.0 3.0 22.8

.1 �5.9 11.8 1.9 † 2.8 �2.1 7.1

.9 0.8 8.7 4.4 * 3.1 �2.1 8.8

.2 0.2 12.0 7.9 * 3.0 2.8 12.1

.9 �2.4 17.9 5.0 * 6.0 �7.1 14.7

.8 �5.8 2.6 �1.8 * 1.7 �4.6 2.6

.4 �2.0 7.5 2.7 * 3.6 �2.9 12.4

.5 �3.6 3.7 0.3 0.8 �0.7 2.1

.6 �6.0 4.7 0.1 2.2 �3.7 4.3

.5 �4.4 6.0 2.0 * 2.4 �2.3 5.7

.8 �6.9 8.8 0.0 2.6 �4.6 6.0

.0 �7.4 1.8 �2.4 * 2.0 �6.0 3.3

.1 �9.4 3.6 �1.8 † 2.9 �7.4 2.0

.5 �11.5 14.3 4.3 * 5.5 �4.2 10.7

.6 �1.3 1.5 0.2 0.6 �1.1 1.3

.8 �13.3 10.9 4.5 * 4.8 �4.0 10.9

.8 �19.5 1.4 �7.1 * 4.8 �17.2 0.7

.4 �7.4 11.0 3.4 † 5.9 �9.9 13.2

.2 �16.4 3.2 �3.4 * 4.4 �10.4 3.8

.0 �5.1 19.3 4.6 † 6.6 �4.5 20.8

ndibular Advancement. J Oral Maxillofac Surg 2008.

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m). The UI/NS was decreased in G1 (�3.0 � 4.0o)ut remained stable in G2 and G3. Posterior move-ent of the UIE was relatively equal in all 3 groups

�1.6 � 1.6 mm in G1, �1.1 � 1.2 mm in G2, and1.5 � 1.4 mm in G3). The UIE exhibited a small

ertical change in G2 (0.5 � 1.2 mm) and G3 (1.1 �.6 mm) but remained unchanged in G1. The LI/MPas decreased in G2 (�2.0 � 3.8o) but remained

table in G1 and G3. The LI/UI was increased in G13.9 � 5.9o) and G2 (2.2 � 5.2o) but remained stablen G3.

Mandibular postsurgical changes were similar andtable in G1 and G2, but demonstrated significantifferences in most of the variables evaluated in G3.he occlusal plane angle (OPA) increased in G3 (2.6 �.8o, a 37% relapse) but remained stable in G1 and G2.n the horizontal direction, the Me and B point wereot changed in G1 and G2, but G3 demonstratedorizontal relapses of 28% at the Me (�3.8 � 4.1m), 28% at the B point (�3.0 � 3.4 mm), and 34%

t the LIE (�2.3 � 2.1 mm). The horizontal positionf the LIE also exhibited slight posterior movement in1 (�1.1 � 1.7 mm) and G2 (�0.5 � 1.4 mm).Hy remained unchanged in all 3 groups in the

orizontal direction. Changes in the vertical directionere similar in all 3 groups: �6.2 � 5.3 mm in G1,5.9 � 5.0 mm in G2, and �5.8 � 4.7 mm in G3. TheP-Hy decreased to a similar degree in all 3 groups:5.4 � 5.1 mm in G1, �3.8 � 4.3 mm in G2, and5.8 � 3.1 mm in G3.

CORRELATIONS BETWEEN POSTSURGICAL(T3 - T2) CHANGES

Correlation testing was done for Go_H, Go_V,e_H, Me_V, LS_H, US_V, OPA and ANS_H, ANS_V,_H, B_V, Me_H, Me_V, Go_H, Go_V, UIE_H, UIE_V,IE_H, LIE_V, LS_H, US_V, OPA (Tables 3 and 4). Theollowing descriptions relate to significant correla-ions between those landmarks that demonstratedignificant postsurgical changes.

G1 exhibited positive correlations between the ver-ical movement of the upper screw (US) and verticalhanges in the B point – B (r � 0.61; P � .01), LIEr � 0.65; P � .01) and Me (r � 0.70; P � .01). G2emonstrated positive correlations between the ver-ical movement of the US and vertical changes in thee (r � 0.57; P � .01).G3 exhibited positive correlations between the hor-

zontal movement of the gonion (Go) and horizontalhanges in the B point (r � 0.82; P � .01), Me (r �.75; P � .01), LIE (r � 0.76; P � .01), and lowercrew (LS) (r � 0.72; P � .01) and negative correla-ions between the horizontal movement of the Gond vertical changes in the B point (r � �0.73; P �01), UIE (r � �0.67; P � .01), LIE (r � �0.67; P �

GROUP I

T2-T1

OPA(-6.3**)

UIE(H 3.6** V -1.6**)

LIE(H 7.1** V -1.9**)

Me (H 12.4** V 0.8)

ANS(H 2.6** V -0.9*)

PNS (H 2.2 V 1.3*)

Hy(H 5.9** V 2.7*)

Go(H 0.3** V 2.6)

B(H 9.5** V -0.5)

MP-Hy2.8*

GROUP I

T2-T1

OPA(-6.3**)

UIE(H 3.6** V -1.6**)

LIE(H 7.1** V -1.9**)

Me (H 12.4** V 0.8)

ANS(H 2.6** V -0.9*)

PNS (H 2.2 V 1.3*)

Hy(H 5.9** V 2.7*)

Go(H 0.3** V 2.6)

B(H 9.5** V -0.5)

MP-Hy2.8*

OPA(-6.3**)

UIE(H 3.6** V -1.6**)

LIE(H 7.1** V -1.9**)

Me (H 12.4** V 0.8)

ANS(H 2.6** V -0.9*)

PNS (H 2.2 V 1.3*)

Hy(H 5.9** V 2.7*)

Go(H 0.3** V 2.6)

B(H 9.5** V -0.5)

MP-Hy2.8*

UIE (H 4.7** V -1.8**)

LIE(H 6.6** V -2.5**)

Me(H 13.5** V 1.4**)

B(H 10.2** V -0.3)

OPA (-9.6**)

ANS (H 2.3** V -1.3**)

PNS (H 2.7 V 3.1**)

Hy(H 7.4** V 1.3)

Go (H 2.1** V 1.7*)

MP-Hy(0.1)

GROUP II

T2-T1

UIE (H 4.7** V -1.8**)

LIE(H 6.6** V -2.5**)

Me(H 13.5** V 1.4**)

B(H 10.2** V -0.3)

OPA (-9.6**)

ANS (H 2.3** V -1.3**)

PNS (H 2.7 V 3.1**)

Hy(H 7.4** V 1.3)

Go (H 2.1** V 1.7*)

MP-Hy(0.1)

UIE (H 4.7** V -1.8**)

LIE(H 6.6** V -2.5**)

Me(H 13.5** V 1.4**)

B(H 10.2** V -0.3)

OPA (-9.6**)

ANS (H 2.3** V -1.3**)

PNS (H 2.7 V 3.1**)

Hy(H 7.4** V 1.3)

Go (H 2.1** V 1.7*)

MP-Hy(0.1)

GROUP II

T2-T1

OPA (-7.1**)

UIE (H 4.4** V -2.4**)

LIE(H 7.9** V -1.8*)

Me (H 13.6** V 2.0**)

ANS (H 1.5 V -1.8**)

PNS (H 1.8 V 2.7**)

Hy(H 5.0** V 4.3**)

Go(V 0.0 H 1.9*)

B(H 10.8** V 0.1)

MP-Hy(4.5**)

GROUP III

T2-T1

OPA (-7.1**)

UIE (H 4.4** V -2.4**)

LIE(H 7.9** V -1.8*)

Me (H 13.6** V 2.0**)

ANS (H 1.5 V -1.8**)

PNS (H 1.8 V 2.7**)

Hy(H 5.0** V 4.3**)

Go(V 0.0 H 1.9*)

B(H 10.8** V 0.1)

MP-Hy(4.5**)

OPA (-7.1**)

UIE (H 4.4** V -2.4**)

LIE(H 7.9** V -1.8*)

Me (H 13.6** V 2.0**)

ANS (H 1.5 V -1.8**)

PNS (H 1.8 V 2.7**)

Hy(H 5.0** V 4.3**)

Go(V 0.0 H 1.9*)

B(H 10.8** V 0.1)

MP-Hy(4.5**)

GROUP III

T2-T1

*p < .05. H: Horizontal **p < .01. V: Vertical

IGURE 6. The mean vertical and horizontal surgical changes (ANS,NS, UIE, LIE, B, Me, Go, Hy), MP-Hy distance, and OPA for the 3roups. The red lines indicate presurgery (T1); the blue lines indicate

mmediate postsurgery (T2).

01), and Me (r � �0.54; P � .05). G3 also exhibited

pm(00hiPP�

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ositive correlations between the horizontal move-ent of the Me and horizontal changes in the B point

r � 0.95; P � .01), Go (r � 0.75; P � .01), UIE (r �.55; P � .05), LIE (r � 0.84; P � .01), and LS (r �.73; P � .01), but negative correlations between theorizontal movement of the Me and vertical changes

n the ANS (r � �0.59; P � .05), B point (r � �0.79;� .01), UIE (r � �0.69; P � .01), LIE (r � �0.87;� .01), OPA (r � �0.70; P � .01), and Me (r �0.49; P � .05).In G3, the horizontal change in the LS postsurgery

ad positive correlations with postsurgical horizontalhanges in the B point (r � 0.85; P � .01), Me (r �.73; P � .01), Go (r � 0.72; P � .01), and LIE (r �.78; P � .01), and negative correlations with post-urgical vertical changes in the ANS (r � �0.63; P �01), B point (r � �0.77; P � .01), UIE (r � �0.78;

� .01), LIE (r � �0.75; P � .01), and Me (r �0.77; P � .01). G3 also demonstrated a positive

Table 2. POSTSURGICAL STABILITY (HORIZONTAL AND

Variable

G1 (T3–T2)

Mean P SD Min Max Mean

orizontalANS �0.6 2.3 �4.9 5.5 �0.5PNS �1.4 4.0 �9.8 7.9 �0.7Ar 0.1 2.3 �5.5 4.1 �0.3B �0.5 1.8 �5.3 1.4 0.1Me �1.1 2.5 �8.3 3.0 �0.4Go �0.9 3.4 �9.2 3.9 0.1UIE �1.6 * 1.6 �4.0 1.0 �1.1LIE �1.1 † 1.7 �5.0 1.6 �0.5Hy 0.3 4.7 �7.9 10.3 �1.3LS �0.3 1.8 �4.0 2.4 0.2

erticalANS �0.2 1.5 �4.4 1.6 0.5PNS �0.1 1.8 �4.2 3.1 �0.6Ar 0.1 1.8 �4.8 3.8 0.5B �0.1 1.5 �2.5 2.4 0.1Me �0.4 1.5 �2.9 1.6 �0.1Go �1.1 3.5 �9.5 3.5 �0.9UIE 0.5 1.3 �2.5 2.9 0.5LIE �0.2 1.5 �3.0 1.8 0.3Hy �6.2 * 5.3 �15.9 5.2 �5.9US �1.0 * 1.3 �4.4 1.2 �0.1

engthsMe-LI �0.2 1.1 �3.6 1.5 �0.4MP-Hy �5.4 * 5.1 �14.9 6.0 �3.8

nglesOPA �0.3 2.9 �7.8 3.9 0.1UI/NS �3.0 * 4.0 �11.3 4.9 �1.0LI/MP �1.3 4.2 �10.4 6.6 �2.0LI/UI 3.9 * 5.9 �7.4 19.7 2.2

*P � .01.†P � .05.


orrelation between the vertical movement of the US i

nd the vertical change in the Go (r � 0.59; P � .05).lso in G3, the OPA had positive correlations withostsurgical changes in the horizontal direction of theNS (r � 0.50; P � .05) and the vertical direction of theIE (r � 0.70; P � .01) and negative correlations withostsurgical changes in the horizontal direction of the Boint (r � �0.52; P � .05) and Me (r � �0.70; P �

01) and in the vertical direction of the UIE (r �0.51; P � .01) and the Go (r � �0.51; P � .05).

CASE 1

A 41-year-old female from G2 presented with bilat-ral TMJ anteriorly displaced articular discs (con-rmed by MRI) and a Class II skeletal and occlusalentofacial deformity (Figs 8A,C; Figs 9A-C; 10A). Sheomplained of moderate to severe TMJ pain, head-ches, and myofascial pain, as well as clicking in theMJs and difficulty eating. After orthodontic prepara-

ion, surgery was performed in a single operation,

ICAL DIRECTIONS)

Group

(T3–T2) G3 (T3–T2)

D Min Max Mean P SD Min Max

.6 �4.4 3.1 �1.1 2.8 �4.8 6.7

.9 �8.6 3.8 �0.1 2.2 �4.4 4.4

.6 �3.8 5.1 0.3 1.5 �2.4 2.8

.1 �6.0 4.4 �3.0 * 3.4 �10.4 0.5

.3 �5.6 4.6 �3.8 * 4.1 �11.8 0.8

.3 �6.5 6.3 �1.9 † 2.9 �8.9 1.3

.2 �4.0 0.9 �1.5 * 1.4 �4.3 0.5

.4 �2.8 2.4 �2.3 * 2.1 �6.8 0.1

.4 �12.8 7.8 �0.1 4.4 �7.5 5.6

.1 �5.7 4.1 �2.7 * 2.9 �10.1 0.2

.1 �1.8 2.9 0.8 1.8 �1.4 5.9

.4 �4.4 3.0 �1.0 * 1.3 �3.0 1.3

.2 �2.5 3.3 0.0 1.0 �1.4 1.6

.0 �6.3 3.7 0.4 2.3 �1.8 5.5

.9 �6.8 3.3 �0.4 2.1 �3.0 5.4

.1 �8.0 5.5 �1.8 3.6 �7.9 6.7

.2 �2.6 2.6 1.1 † 1.6 �1.7 5.3

.6 �2.3 4.1 1.0 2.3 �1.5 4.7

.0 �16.3 12.7 �5.8 * 4.7 �13.2 1.6

.6 �4.0 4.4 �1.7 † 2.9 �10.2 3.8

.3 �6.3 1.4 �0.3 1.5 �2.9 2.8

.3 �9.6 11.1 �5.8 * 3.1 �10.1 �0.8

.7 �5.7 6.2 2.6 † 3.8 �2.5 13.3

.8 �9.9 6.8 �2.0 4.5 �12.0 4.8

.8 �10.6 5.2 0.5 4.1 �6.3 5.6

.2 �7.8 14.4 �0.3 4.7 �11.2 8.6


VERT

G2

P S

121222

* 1† 1

42

† 1† 1† 1

213

† 11

* 51

1* 4

23

* 3† 5

ncluding: bilateral TMJ disc repositioning with Mitek

avout9ap

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D

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FcO(

Gonçalves et al. Articular Disc Repositioning for Stability inMaxillomandibular Advancement. J Oral Maxillofac Surg 2008.


nchors, 20 mm of mandibular counterclockwise ad-ancement at the pogonion, and multiple maxillarysteotomies to down-graft the posterior aspect andpright the incisors (Fig 10B). At 3 years postsurgery,he patient demonstrated good stability (Figs 8B,D;D-F; 10C,D), with elimination of TMJ pain, head-ches, myofascial pain and TMJ noise, as well as im-roved jaw function and facial esthetics.

CASE 2

A 17-year-old female from G3 presented with bilat-ral TMJ anteriorly displaced articular discs (con-rmed by MRI) and Class II skeletal and occlusalentofacial deformity with an anterior open bite (Fig1A,C; Fig 12A,C; 13A) but no TMJ symptoms, pain,eadache, or TMJ dysfunction. After orthodonticreparation, surgery was performed comprising max-

llary and mandibular osteotomies with counterclock-ise rotation and augmentation genioplasty. Theogonion was advanced by 22 mm (Fig 13B). Postsur-ery, the patient’s outcome was unstable as a result ofondylar resorption. At 4 years postsurgery, she dem-nstrated a skeletal and occlusal Class II open bite,ith a mandibular relapse of 10 mm (45% of theriginal advancement) (Figs 11B,D; 12D-F; 13C,D). Inddition, she complained of TMJ pain, headaches,yofascial pain, and increased difficulty eating.

iscussion

This retrospective study evaluated the records of 72atients who underwent maxillomandibular surgicaldvancement with counterclockwise rotation of thecclusal plane. The occlusal plane angle was de-reased by posterior downward positioning and/ornterior upward positioning of the maxilla, as well asandibular counterclockwise rotation by bilateral ra-us sagittal split osteotomy. The study sample was

ivided into 3 groups to address the influence of TMJealth and articular disc surgical repositioning (Miteknchor technique)1,11-18 relative to postsurgical stabil-ty. Presurgical characteristics of the study samplencluded high occlusal plane angle, maxillary and

andibular retrusion, and increased anterior facialeight. The mean patient age was 34 years in G1, 28.4ears in G2, and 27.4 years in G3. Gender composi-ion was 76.2% females and 23.8% males in G1, 88.6%emales and 11.4% males in G2, and 68.8% femalesnd 31.2% males in G3. All 3 patient groups hadimilar dentofacial deformities and underwent orthog-athic surgical procedures performed by the sameurgeon in the same manner with rigid fixation.

Several authors have described presurgical morpho-ogical characteristics that could be possible risk fac-ors for skeletal relapse and condylar resorption after

OPA(-0.3)

UIE (H -1.1** V 0.5*)

LIE(H -0.5* V 0.3)

Me (H -0.4 V -0.1)

ANS (H -0.5 V 0.5*)

PNS(H -0.7 V -0.6*)

Hy(H -1.3 V -5.9*)

Go (H 0.1 V -0.9)

B(H 0.1 V 0.1)

MP-Hy(-3.8**)

GROUP I

T3-T2

OPA(-0.3)

UIE (H -1.1** V 0.5*)

LIE(H -0.5* V 0.3)

Me (H -0.4 V -0.1)

ANS (H -0.5 V 0.5*)

PNS(H -0.7 V -0.6*)

Hy(H -1.3 V -5.9*)

Go (H 0.1 V -0.9)

B(H 0.1 V 0.1)

MP-Hy(-3.8**)

OPA(-0.3)

UIE (H -1.1** V 0.5*)

LIE(H -0.5* V 0.3)

Me (H -0.4 V -0.1)

ANS (H -0.5 V 0.5*)

PNS(H -0.7 V -0.6*)

Hy(H -1.3 V -5.9*)

Go (H 0.1 V -0.9)

B(H 0.1 V 0.1)

MP-Hy(-3.8**)

GROUP I

T3-T2

OPA (0.1)

UIE (H 1.6** V 0.5)

LIE(H -1.1* V -0.2)

Me (H -1.1 V -0.4)

ANS (H -0.6 V -0.2)

PNS(H 1.4 V -0.1)

Hy(H 0.3 V -6.2*)

Go(H -0.9 V -1.1)

B(H -0.5 V -0.1)

MP-Hy(-5.4**)

GROUP II

T3-T2

OPA (0.1)

UIE (H 1.6** V 0.5)

LIE(H -1.1* V -0.2)

Me (H -1.1 V -0.4)

ANS (H -0.6 V -0.2)

PNS(H 1.4 V -0.1)

Hy(H 0.3 V -6.2*)

Go(H -0.9 V -1.1)

B(H -0.5 V -0.1)

MP-Hy(-5.4**)

OPA (0.1)

UIE (H 1.6** V 0.5)

LIE(H -1.1* V -0.2)

Me (H -1.1 V -0.4)

ANS (H -0.6 V -0.2)

PNS(H 1.4 V -0.1)

Hy(H 0.3 V -6.2*)

Go(H -0.9 V -1.1)

B(H -0.5 V -0.1)

MP-Hy(-5.4**)

GROUP II

T3-T2

OPA (2.6*)

UIE (H -1.5** V 1.1*)

LIE(H -2.3** V 1.0)

Me (H -3.8** V -0.4)

ANS (H -1.1 V 0.8)

PNS(H -0.1 V -1.0**)

Hy(H -0.1 V -5.8**)

Go (H -1.9* V -1.8)

B(H -3.0** V 0.4)

MP-Hy(-5.8**)

GROUP III

T3-T2

OPA (2.6*)

UIE (H -1.5** V 1.1*)

LIE(H -2.3** V 1.0)

Me (H -3.8** V -0.4)

ANS (H -1.1 V 0.8)

PNS(H -0.1 V -1.0**)

Hy(H -0.1 V -5.8**)

Go (H -1.9* V -1.8)

B(H -3.0** V 0.4)

MP-Hy(-5.8**)

OPA (2.6*)

UIE (H -1.5** V 1.1*)

LIE(H -2.3** V 1.0)

Me (H -3.8** V -0.4)

ANS (H -1.1 V 0.8)

PNS(H -0.1 V -1.0**)

Hy(H -0.1 V -5.8**)

Go (H -1.9* V -1.8)

B(H -3.0** V 0.4)

MP-Hy(-5.8**)

GROUP III

T3-T2

*p < .05. H: Horizontal **p < .01. V: Vertical

IGURE 7. The mean vertical and horizontal postsurgical skeletalhanges (ANS, PNS, UIE, LIE, B, Me, Go, Hy), MP-Hy distance, andPA for the 3 groups. The blue lines indicate immediate postsurgery

T2); the dashed lines indicate long-term postsurgery (T3).

rthognathic surgery, including high mandibular

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lane angle, shortened posterior facial height, andmall posterior/anterior facial height ratio.2,36,37 Buthese same characteristics are commonly seen in pa-ients with TMJ pathology, and those authors appar-

Table 3. PEARSON CORRELATION COEFFICIENTS OF SIG

Go_H Go_V

G1 G2 G3 G1 G2

NS_H 0.27 �0.02 �0.13 0.30 0.01 �0NS_V 0.00 �0.07 �0.45 0.16 0.05 0_H 0.43 0.51* 0.82* 0.32 0.20 0_V �0.41 �0.28 �0.73* 0.01 0.14 0e_H 0.56* 0.55* 0.75* 0.51† 0.29 0e_V �0.34 �0.20 �0.54† 0.09 0.19 0o_H 1.00 1.00 1.00 0.82* 0.11 0o_V 0.82* 0.11 0.32 1.00 1.00 1IE_H 0.42 0.44* 0.27 0.09 0.15 0IE_V �0.48† �0.35† �0.67* �0.14 0.04 0IE_H 0.50† 0.57* 0.76* 0.38 0.24 0IE_V �0.30 �0.13 �0.67* 0.04 0.05 �0S_H 0.18 0.66* 0.72� �0.03 �0.07 �0S_V 0.03 0.11 0.15 0.30 0.31 0PA 0.09 0.23 �0.42 0.08 �0.11 �0

Abbreviations: ANS_H, horizontal position of the anterior nasal sosition of B point; B_V, vertical position of B point; Me_H, hoorizontal position of the gonion; Go_V, vertical position of the gonosition of the upper incisor edge; LIE_H, horizontal position of thS_H, horizontal position of the lower screw; US_V, vertical positi*P � .01.†P � .05.


Table 4. PEARSON CORRELATION COEFFICIENTS OF SIG

LS_H

G1 G2 G3 G1

NS_H 0.02 �0.19 �0.22 �0.02NS_V �0.29 �0.32 �0.63* 0.29_H 0.68* 0.66* 0.85* 0.25_V �0.37 �0.24 �0.77* 0.61*e_H 0.63* 0.67* 0.73* 0.30e_V �0.20 �0.23 �0.77* 0.70*o_H 0.18 0.66* 0.72* 0.03o_V �0.03 �0.07 �0.20 0.30IE_H 0.50† 0.53* 0.41 �0.13IE_V �0.27 �0.56* �0.78* 0.33IE_H 0.50† 0.60* 0.78* 0.24IE_V �0.22 �0.32 �0.75* 0.65*S_H 1.00 1.00 1.00 0.09S_V 0.09 0.09 �0.42 1.00PA �0.42 0.14 �0.29 0.21

Abbreviations: ANS_H, horizontal position of anterior nasal spinef B point; B_V, vertical position of B point; Me_H, horizontal poosition of gonion; Go_V, vertical position of gonion; UIE_H, hor

ncisor edge; LIE_H, horizontal position of lower incisor edge; LIEower screw; US_V, vertical position of upper screw.

*P � .01.†P � .05.

onçalves et al. Articular Disc Repositioning for Stability in Maxilloma

ntly did not recognize that the patients who experi-nced postsurgical relapse and condylar resorptionikely had presurgical TMJ pathology. Schellhas et al38

nvestigated 100 patients clinically and by radiogra-

ANT VARIABLES

Me_H Me_V

G1 G2 G3 G1 G2 G3

0.40 �0.16 �0.28 �0.07 �0.10 �0.07�0.30 �0.39† �0.59† 0.34 0.60* 0.66*

0.91* 0.91* 0.95* �0.12 �0.35† �0.66*�0.32 �0.28 �0.79* 0.94* 0.95* 0.86*

1.00 1.00 1.00 �0.10 �0.23 �0.49†�0.10 �0.23 �0.49† 1.00 1.00 1.00

0.56* 0.55* 0.75* �0.34 �0.20 �0.54†0.51† 0.29 0.23 0.09 0.19 0.410.62* 0.73* 0.55† �0.46† �0.28 �0.61

�0.44† �0.47* �0.69* 0.56* 0.56 0.72*0.85* 0.90* 0.84* �0.17 �0.67 �0.65*

�0.21 �0.43† �0.87* 0.66* 0.70* 0.55†0.63* 0.67* 0.73* �0.20 �0.23 �0.77*0.30 0.18 �0.05 0.70* 0.57* 0.46

�0.43 �0.01 �0.70* 0.19 0.25 0.07

NS_V, vertical position of the anterior nasal spine; B_H, horizontall position of menton; Me_V, vertical position of menton; Go_H,E_H, horizontal position of the upper incisor edge; UIE_V, verticalr incisor edge; LIE_V, vertical position of the lower incisor edge;

he upper screw.


ANT VARIABLES

US_V OPA

G2 G3 G1 G2 G3

0.36† �0.02 �0.16 �0.15 0.50†0.43† 0.44 0.33 0.17 0.250.09 �0.08 �0.36 0.02 �0.52†0.59� 0.29 0.34 0.25 0.340.18 �0.05 �0.43 �0.01 �0.70*0.57* 0.46 0.19 0.25 0.070.11 0.15 0.09 0.23 �0.420.31 0.59† 0.08 �0.11 �0.51†0.03 �0.12 �0.32 �0.14 �0.51†0.15 0.29 0.44† 0.07 0.260.16 �0.11 �0.30 0.20 �0.420.48* 0.22 0.45† 0.31 0.70*0.09 �0.42 �0.42 0.14 �0.291.00 1.00 0.21 0.12 �0.060.12 �0.06 1.00 1.00 1.00

, vertical position of anterior nasal spine; B_H, horizontal positionof menton; Me_V, vertical position of menton; Go_H, horizontalposition of upper incisor edge; UIE_V, vertical position of upperrtical position of lower incisor edge; LS_H, horizontal position of

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hy, computed tomography, and high-field surface-oil MRI to identify risk factors for TMJ degeneration.n their study, 40 patients (52 joints) underwent anpen arthroplasty procedure, in which the main sur-ical and pathological findings included disc displace-ent, disc degeneration, and cartilage hypertrophy.MJ internal derangement was posited to be the mainause of both acquired facial skeleton remodeling andnstable occlusion in patients with intact dentitionnd without previous mandibular fracture. Similarndings were described previously by Schellhas,39

ho concluded that internal derangement of the TMJs an irreversible and generally progressive disorder.

In the present study, surgical movements were sim-lar in all 3 groups: mandibular advancement at the

enton of 12.4 mm in G1, 13.5 mm in G2, and 13.6m in G3; maxillary advancement at the ANS of 2.6m in G1, 2.3 mm in G2, and 1.5 mm in G3; vertical

hange in the ANS of �0.9 mm in G1, �1.3 mm in G2,nd �1.8 mm in G3; and counterclockwise rotation ofhe occlusal plane of �6.3o in G1, �9.6o in G2, and7.1o in G3. In fact, counterclockwise rotation of the

cclusal plane was at least 35% greater in G2 com-ared with G1 and G3.

IGURE 8. Case 1. A and C, This 41-year-old female presented wiignificantly retruded, with a high occlusal plane angle and associateilateral TMJ articular disc repositioning with Mitek mini-anchors and


IGURE 9. Case 1. A, B, and C, Presurgical occlusion demonstraticclusion remained stable 3 years postsurgery.


Surgical counterclockwise rotation of the maxillo-andibular complex lengthens the functional mo-ent arm (mandible), thereby increasing loading to

he TMJs due to stretch and tension of the suprahyoiduscles, periostium, skin, and other soft tissue ele-ents. It may take several months for the soft tissues

o adapt and reestablish a state of equilibrium.40 Ourrevious studies40-42 have shown that maxilloman-ibular advancement with counterclockwise rotationf the occlusal plane is a stable procedure in patientsith healthy TMJs. The TMJs are the foundation for

table results in orthognathic surgical procedures; ifhe TMJs are not stable and healthy (pathological),hen orthognathic surgery outcomes may be unsatis-actory relative to function, esthetics, stability, andain. Orthognathic surgery to correct dentofacial de-

ormities requiring mandibular advancement cannotliminate coexisting TMJ pathology, and those pa-ients may have unsatisfactory outcomes.1,2,8,9,43-47

The anterior region of the maxilla at the ANS ex-ibited no postsurgical change in the horizontal di-ection in any of the 3 groups, but in the verticalirection, a downward movement of 0.5 mm waseen in G2. The PNS remained stable in G1 but dem-

ral articular disc displacement and TMJ dysfunction. The mandible isl morphology. B and D, This same patient 3 years after undergoingeous double-jaw orthognathic surgery.


nterior open bite and class II occlusal relationship. D, E, and F, The

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nstrated changes in the vertical direction in G2�0.6 mm) and G3 (�1 mm). Most of the patients inhe study underwent a 3-piece multisegmental maxil-ary osteotomy that included a midsagittal palatal os-eotomy ending at the posterior nasal spine. Changesn the PNS may be related, at least in part, to remod-ling at this region. Postsurgical changes demon-trated similar UIE changes in all 3 groups (�1.1 to1.6 mm). Differences in LIE horizontal relapse were

een, with relapse in G3 approximately twice that in1 and 4 times that in G2 (�1.1 mm in G1, �0.5 mm

n G2, and �2.3 mm in G3). Incisor changes demon-trated less variation in the vertical direction. Postsur-ical incisor changes may be related to postsurgical

IGURE 10. Case 1. A, Pretreatment cephalometric analysis showilane angles, and overangulated lower incisors. B, Surgical treatmeequired to achieve a good functional and esthetic result, includingcclusal plane. C, Cephalometric analysis 3 years postsurgery demonsred lines) and 3-year follow-up (black lines) cephalometric tracings d


rthodontic efforts to maximize the occlusion, but e

he significantly greater relapse of the lower incisorsn G3 is likely related, at least in part, to condylarhanges.No postsurgical vertical changes in the mandibleere seen in any of the 3 groups, except for vertical

hanges in US position in G1 (�1 mm) and G3 (�1.7m). US displacement suggests condylar remodeling

r resorption, probably due to additional loading tohe TMJs secondary to mandibular advancement andounterclockwise rotation. The patients in G3 (un-reated internal derangement) exhibited 70% greaterhange in US position compared with those in G1healthy TMJ), with those in G2 (disc repositioning)emonstrating no significant change. It seems that

truded mandible, anterior open bite, steep occlusal and mandibularctive (prediction tracing) demonstrating the orthognathic proceduresy and mandibular osteotomies with counterclockwise rotation of thegood facial balance. D, Superimposition of the immediate postsurgeryating the stability achieved for this patient.


ng a rent objemaxillartratingemonstr

ven though healthy TMJs can adapt to additional

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oading, slightly more remodeling occurred in the G1atients compared with the G2 patients who under-ent disc repositioning.Horizontally, dramatic instability in the mandibular

andmarks was seen in G3, whereas G1 and G2 ex-ibited sound mandibular stability. In G3, the anteriorandible demonstrated a B point and Me horizontal

elapse greater than 28% of the surgical change. Che-ello et al40 and Satrom et al41 reported that mandib-

lar advancement in double-jaw surgery (with orithout counterclockwise rotation) using rigid inter-al fixation with healthy TMJs is a stable procedurever the long term, with a mean anteroposterior re-

apse at point B of 6% regardless of the amount ofurgical advancement performed. On the other hand,

olford et al2 evaluated 25 consecutive patients (23emales and 2 males) with jaw deformities and dis-laced articular discs (confirmed by MRI) who werereated with orthognathic surgery only, includingandibular advancement, and stabilized with rigid

xation. The average postsurgical relapse at point Bas 36% of the mandibular advancement, and the

verage distance from the condyle to point B de-reased by 34%, indicating condylar resorption. Six

IGURE 11. Case 2. A and C, This 17-year-old girl had bilateraletruded mandible, a high occlusal plane angle and associated facirthognathic surgery only (no TMJ surgery), exhibiting significant insta


IGURE 12. Case 2. A, B, and C, Presurgical occlusion demonstrat, E, and F, Significant occlusal relapse occurred 4 years after orthogislocation.


atients (24%) demonstrated significant postsurgicalondylar resorption (3 to 8 mm) resulting in Class IInterior open-bite malocclusion. The increased load-ng of the TMJs as a result of the mandibular advance-

ent most likely stimulated the resorption process.ew onset/aggravation of TMJ symptoms (eg, pain,MJ dysfunction) occurred an average of 14 monthsfter surgery. At the completion of the study, 48% ofhe patients required TMJ and repeat orthognathicurgery. Before surgery, 36% of the patients com-lained of pain or discomfort, but at 2.2 years post-urgery, 84% of the patients reported, with a 75%ncrease in pain intensity compared with the presur-ical pain. Only 4 of the 25 patients (16%) were painree at the longest follow-up. This study clearly dem-nstrates the problems associated with performingrthognathic surgery only on patients with coexistingMJ articular disc dislocations.In the present study, the G3 patients had similar

utcomes to those reported by Wolford et al,2 whereashe G1 and G2 patients had very stable postsurgicalesults. This indicates that the Mitek anchor tech-ique1,11-18 provided the same good results as thosebtained by the patients with healthy TMJs. Similar

ced articular discs that were relatively asymptomatic, a significantlyhology. B and D, The patient 4 years after undergoing double-jawd relapse of the functional and esthetic outcome.


anterior open bite and a Class II end-on canine occlusal relationship.surgery only in the presence of presurgical bilateral TMJ articular disc

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esults have been demonstrated in other studies inhich TMJ pathology was surgically corrected duringrthognathic surgery.1,11-32 We found that the occlu-al plane angle was stable postsurgery in G1 and G2ut relapsed significantly in G3 (mean, 2.6o; range,2.5 to 13.3o). The magnitude of clockwise rotation

trongly indicates condylar resorption as the etiologicactor.

The Mitek anchor was developed for ligament andendon repair procedures in orthopedics. The Mitekini-anchor is specifically approved by the FDA for

se in stabilizing the articular disc in the TMJ. Theini-anchor is bullet-shaped, 1.8 mm in diameter and

IGURE 13. Case 2. A, Pretreatment cephalometric analysis showingandibular plane angles, and overangulated lower incisors. B, Surgrocedures needed to achieve a good functional and esthetic result, inf the occlusal plane. C, Cephalometric analysis 4 years postsurgery df the immediate postsurgery (red lines) and 4-year follow-up (black lin10 mm) and increased occlusal plane (10o) as a result of condylar r


mm long, with a titanium alloy body and nickel- o

itanium alloy wings with superelastic shape-memoryroperties. Two-0 Ethibond sutures (Ethicon Inc,omerville, NJ) are passed through the distal eyelet ofhe anchor to serve as artificial ligaments. The mini-nchor is usually placed toward the lateral aspect ofhe posterior head of the condyle, where it becomessseointegrated.18 The 2 artificial ligaments areassed through the posterior aspect of the posteriorand of the disc to secure and stabilize the disc to theondylar head (Fig 2). The mini-anchor has been usedith good success in the TMJ.13-16 Mehra and Wol-

ord14 evaluated 88 patients with simultaneous TMJisc repositioning using the Mitek mini-anchor and

ded maxilla and mandible, an anterior open bite, steep occlusal andatment objective (prediction tracing) demonstrating the orthognathicmaxillary and mandibular osteotomies with counterclockwise rotation

rating poor facial balance and significant relapse. D, Superimpositionhalometric tracings demonstrating significant relapse of the mandiblen.


a retruical trecludingemonstes) cepesorptio

rthognathic surgery and found that this technique

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rovided statistically significant decreases in TMJain, facial pain, headaches, TMJ noises, and disabilitynd significant improvements in jaw function andiet, along with stable occlusal and skeletal results.Patients with AICR have progressive mandibular

etrusion but, importantly, no other systemic jointnvolvement. A consistent finding in this specific TMJathology is anteriorly displaced TMJ articular discsith hypertrophy of the synovial tissues that produce

he chemical substrates causing internal condylar re-orption. But the fibrocartilage remains intact on theondylar head and fossa, even as the condylar headrogressively decreases in size. In addition, these pa-ients usually have a coexisting dentofacial deformityomprising a retruded mandible, a high occlusal planengle, a Class II occlusion, and an anterior open bite.s mentioned earlier, in the early 1990s, Wolford19,20

eveloped a treatment protocol for these patientsonsisting of removal of the hyperplastic synovial andilaminar tissues, articular disc repositioning with theitek anchor (Fig 2), and appropriate concomitantrthognathic surgery to correct the dentofacial defor-ity, usually requiring counterclockwise rotation and

dvancement of the maxillomandibular complex. Re-ositioning the articular disc and removing the hyper-lastic synovial and bilaminar tissue predictably haltshe condylar resorption process, allowing for orthog-athic surgery during the same operation to provideignificantly improved function and esthetics, as wells good long-term skeletal and occlusal stability.19,20

The postsurgical relapse changes were significantlyreater in G3 than in G1 and G2, suggesting that per-orming only orthognathic surgery in patients with TMJnternal derangements is an unpredictable procedure,ossibly leading to condylar resorption. Bayley et al48

eported that most of the postsurgical relapse changeseen in their study occurred in just a few subjects out ofheir entire sample. For this reason, they felt it wasisleading to use statistics based on normal distribution

o describe post-treatment changes, stating that for eachndividual patient, predictability is certainly more impor-ant than averages. But these authors evaluated orthog-athic surgery patient outcomes without specifically

dentifying those patients with presurgical TMJ patho-ogy—the patient population most likely to experienceignificant relapse related to condylar resorption.

The patients in G1 demonstrated a positive corre-ation between the vertical changes in the US and theertical changes in all of the bone and dental land-arks located in the anterior mandible, likely due to

ome condylar remodeling and adaptation. The pa-ients in G2 exhibited a positive correlation betweenertical change in the US and the Me. The patients in3 exhibited a variety of correlations, mostly indicat-

ng significant condylar changes. The further the Go
as moved back postsurgery, the greater the anterior
andibular landmarks moved backward postsurgery;he further the LS was moved back, the greater thenterior maxillary and mandibular landmarks movedackward; and the more the occlusal plane was in-reased, the more the B point, Me, and UIE movedackward. All of these changes indicate relapse oc-urring at the condyles, not at the sagittal split osteot-my site.The hyoid demonstrated no postsurgical change in

he horizontal direction but returned to its originalertical position in all 3 groups, as did the distancerom the hyoid to the mandibular plane. Similar find-ngs were previously reported by Gonçalves et al.49

In conclusion, our findings indicate that maxillo-andibular surgical advancement with counterclock-ise rotation of the occlusal plane is a stable proce-ure for patients with healthy TMJs and for patientsndergoing simultaneous TMJ articular disc reposi-ioning with the Mitek mini-anchor. The patients in1 (healthy TMJs) and G2 (disc repositioning) dem-nstrated similar stable results. The patients in G3,ho had TMJ articular disc displacement but under-ent only orthognathic surgery, demonstrated a sta-

istically significant rate of skeletal relapse related toondylar remodeling and resorption.

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2. Cottrell DA, Sugimoto RM, Wolford LM, et al: Condylar changesafter upward and forward rotation of the maxillomandibularcomplex. Am J Orthod Dentofacial Orthop 111:156, 1997

3. Kerstens HC, Tuinzing DB, Golding RP, et al: Condylar atrophyand osteoarthrosis after bimaxillary surgery. Oral Surg OralMed Oral Pathol 69:274, 1990

4. Moore KG, Cooris PJ, Stoelinga PJ: The contributing role ofcondylar resorption in orthognathic surgery: A retrospectivestudy. J Oral Maxillofac Surg 49:448, 1991

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Maxillofac Surg 64:755, 2006

postsurgical stability of counterclockwise maxillomandibular advancement surgery: affect of...

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