End-Stage Temporomandibular Joint (TMJ) Pathology

Other TMJ end-stage conditions include

  1.  Advanced reactive arthritis, osteoarthritis
  2.  Neoplasms
  3.  Multiply operated joints
  4.  Failed TMJ alloplastic implants 
  5.  Failed autogenous tissue TMJ reconstruction
  6. Patients with these TMJ pathologies may benefit from TMJ reconstruction and mandibular repositioning with custom-fitted total joint prosthesis (TMJ Concepts system), placement of fat grafts around the articulating part of the prostheses, as well as concomitant maxillary osteotomies and other indicated adjunctive procedures to achieve the best outcome results relative to function, stability, esthetics, and elimination of pain.1,12,13,14,18

Our studies1,12,13,14,18 show good outcomes with this treatment protocol. However, the quality of results decreases as the number of previous TMJ surgeries increases, particularly in reference to pain relief. When the TMJ Concepts total joint prostheses system is used as the first or second TMJ surgery, the success rate is very good relative to jaw function, stability, facial balance, and pain relief.

Summary

Healthy and stable TMJs are necessary for quality treatment outcomes in orthognathic surgery.  If the TMJs are not stable and healthy, orthognathic surgery results may be unsatisfactory relative to function, esthetics, skeletal and occlusal stability as well as pain.  The oral and maxillofacial surgeon should be suspicious of possible TMJ problems in the following types of patients:  1) Class II high occlusal plane angle and retruded mandibular morphological type, particularly those with anterior open bites; 2) Progressively worsening Class II occlusal and jaw relationship; 3) Class III prognathism with progressive worsening; 4) Facial asymmetry, particularly with progressive worsening; and 5) Patients reporting headaches, TMJ pain, myofascial pain, clicking and popping of the TMJs, and/or ear symptoms. The surgeon should not ignore these symptoms.  With one or more of these symptoms, patients should be evaluated for possible TMJ pathology. An MRI of the TMJs can aide in identification of the specific TMJ pathology.  Failure to recognize and treat these conditions can result in significant relapse, increased pain, and a greater complexity of subsequent treatment. 

During the past 2 decades, major advancements have been made in TMJ diagnostics and the development of surgical procedures to treat and rehabilitate the pathological, dysfunctional, and painful TMJ.  Research has clearly demonstrated that TMJ and orthognathic surgery can be safely and predictably performed at the same operation, but it does necessitate the correct diagnosis and treatment plan, as well as requires the surgeon to have expertise in both TMJ and orthognathic surgery.  The surgical procedures can be separated into 2 or more surgical stages, but the TMJ surgery should be done first.  With the correct diagnosis and treatment plan, combined TMJ and orthognathic surgical approaches provide complete and comprehensive management of patients with co-existing TMJ pathology and dentofacial deformities. 


References

[i] Wolford LM:  Surgical Planning in Orthognathic Surgery.  In Booth PW, Schendel SA, Hausamen JE (Eds), Maxillofacial Surgery Volume 2.  St Louis, MO: Churchill Livingstone; 2007; pp. 1155-1210.

[ii] Mehra P, Downie M, Pita MC, Wolford LM. Pharyngeal airway space changes after counterclockwise rotation of the maxillomandibular complex. Am J Orthod Dentofacial Orthop. 2001 Aug;120(2):154-9.


1 Wolford LM, Cassano DS, Goncalves JR. Common TMJ Disorders: Orthodontic and Surgical Management. In McNamara JA, Kapila SD; Temporomandibular Disorders and Orofacial Pain: Separating Controversy from Consensus. Volume 46, Craniofacial Growth Series. The University of Michigan, Ann Arbor, MI, 2009; pp 159-198.

2 Wolford LM, Reiche-Fischel O, Mehra P. Changes in temporomandibular joint dysfunction after orthognathic surgery. J Oral and Maxillofacial Surg. 2003 Jun;61(6):655-60; discussion     661.

3 Wolford LM, Reiche-Fischel O, Mehra P. Changes in TMJ Dysfunction after Orthognathic Surgery. J Oral Maxillofac Surg 2003;61:665-660.

4 Goncalves JR, Cassano DS, Wolford LM, et. al. Postsurgical Stability of Counterclockwise Maxillomandibular Advancement Surgery: Affect of Articular Disc Repositioning. J Oral Maxillofac Surg 2008; will be published in April (article 52949).

5 Wolford LM: Surgical Planning in Orthognathic Surgery. In Booth PW, Schendel SA, Hausamen JE (Eds), Maxillofacial Surgery Volume 2. St Louis, MO: Churchill Livingstone; 2007; pp. 1155-1210.

6 Wolford LM: Facial Asymmetry: Diagnosis and Treatment Considerations. In Fonseca, Marciani, Turvey, Volume III, Oral and Maxillofacial Surgery, Second Edition, Chapter 13. St. Louis, MO:  Saunders Elsevier; 2008; pp. 272-315

7 Wolford LM, Perez D, Stevao E, Perez E. Airway space changes after nasopharyngeal adenoidectomy in conjunction with Le Fort I osteotomy. J Oral Maxillofac Surg.2012 Mar;70(3):665-71.
 
8 Mehra P, Downie M, Pita MC, Wolford LM. Pharyngeal airway space changes after counterclockwise rotation of the maxillomandibular complex. Am J Orthod Dentofacial Orthop. 2001 Aug;120(2):154-9.

9 Wolford LM: Facial Asymmetry: Diagnosis and Treatment Considerations. In Fonseca, Marciani, Turvey, Volume III, Oral and Maxillofacial Surgery, Second Edition, Chapter 13. St. Louis, MO:  Saunders Elsevier; 2008; pp. 272-315.

10 Wolford LM, Karras SC, Mehra P. Concomitant Temporomandibular Joint and Orthognathic Surgery: a Preliminary Report. J Oral Maxillofac Surg 2002; 60:356-362.

11 Mehra P, Wolford LM. The Mitek Mini Anchor for TMJ Disc Repositioning: Surgical Technique and Results. Int J Oral Maxillofac Surg 2001; 30:497-503.

12 Wolford LM, Cottrell DA, Henry CH. Temporomandibular Joint Reconstruction of the Complex Patient with the Techmedica Custom-Made Total Joint Prosthesis. J Oral Maxillofac Surg 1994; 52:2-10.

13 Pinto LP, Wolford LM, Buschang PH, et. al. Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: part III–pain and dysfunction outcomes. Int J Oral Maxillofac Surg. 2009; 38:326-31.

14 Mehra P, Wolford LM, Baran S, et. al. Single-Stage Comprehensive Surgical Treatment of the Rheumatoid Arthritis Temporomandibular Joint Patient. J Oral Maxillofac Surg. 2009;67:1859-1872.

15 Wolford LM, Karras SC. Autologous Fat Transplantation Around Temporomandibular Joint Total Joint Prostheses: Preliminary Treatment Outcomes. J Oral Maxillofac Surg 1997; 55:245-251.

16 Wolford LM, Cassano DS: Autologous Fat Grafts Around Temporomandibular Joint (TMJ) Total Joint Prostheses to Prevent Heterotopic Bone. In M.A. Shiffman (Ed.) Autologous Fat Transfer. Springer- Verlag Berlin Heidelberg: 2010. pp. 361-382.

17 Riolo ML, Moyers RE, McNamara JA, Hunter WS. An Atlas of Craniofacial Growth: Cephalometric Standards from the University School Growth Study, The University of Michigan. Ann Arbor, MI: University of Michigan,1974:105–106.

18 Wolford LM, Karras SC, Mehra P: Considerations for Orthognathic Surgery During Growth, Part 1:Mandibular Deformities. Am J Orthod Dentofac Orthop 2001; 119:95-101.

19 Wolford LM, Karras SC, Mehra P: Considerations for Orthognathic Surgery During Growth, Part 2: Maxillary Deformities. Am J Orthod Dentofac Orthop, 2001; 119:102-105.

20 Wolford LM, Rodrigues DB: Orthognathic Considerations in the Young Patient and Effects on Facial Growth. In Preedy VR (ED) Handbook of Growth and Growth Monitoring in Health and Disease. Springer, New York, pp1789-1808, 2012.

21 Wolford LM, Rodrigues DB: Temporomandibular Joint (TMJ) Pathologies in Growing Patients: Effects on Facial Growth and Development. In Preedy VR (ED) Handbook of Growth and Growth Monitoring in Health and Disease. Springer, New York, pp 1809-1828, 2012.

22 Wolford LM, Mehra P, Reiche-Fischel O, et. al. Efficacy of High Condylectomy for Management of Condylar Hyperplasia. Am J Orthod Dentofacial Orthop 2002; 121:136-151.

23 Wolford LM, Morales-Ryan CA, et. al.: Surgical Management of Mandibular Condylar Hyperplasia Type 1. Bayl Univ Med Cent Proc, 2009; 22:321-329.

24 Wolford LM, Mehra P, Franco P. Use of Conservative Condylectomy for Treatment of Osteochondroma of the Mandibular Condyle. J Oral Maxillofac Surg 2002; 60:262-263.

25 Wolford LM, Karras SC, Mehra P. Concomitant Temporomandibular Joint and Orthognathic Surgery: a Preliminary Report. J Oral Maxillofac Surg 2002; 60:356-362.

26 Wolford LM, Cardenas L. Idiopathic Condylar Resorption: Diagnosis, Treatment Protocol, and Outcomes. Am J Orthod Dentofacial Orthop 1999; 116:667-676.

27 Wolford LM: Idiopathic Condylar Resorption of the Temporomandibular Joint in Teenage Girls (Cheerleaders Syndrome). Bayl Univ Med Cent Proc, 2001; 14:246-252.

28 Henry CH, Hughes CV, Gerard HC, et. al. Reactive Arthritis: Preliminary Microbiologic Analysis of the Human Temporomandibular Joint. J Oral Maxillofac Surg 2000; 58:1137-1142
 
29 Henry CH; Pitta MC; Wolford LM. Frequency of Chlamydial Antibodies in Patients with Internal Derangement of the Temporomandibular Joint. O Surg O Med O Pathol O Radiol Endod 2001; 91:287- 292.

30 Mercuri LG, Wolford LM, Sanders B, et al: Long-term follow-up of the CAD/CAM patient fitted total temporomandibular joint reconstruction system. J Oral Maxillofac Surg 2002; 60:1440-1448.

31 Dela Coleta KE, Wolford LM, Gonçalves JR, Pinto Ados S, Pinto LP, Cassano DS.Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: part I– skeletal and dental stability. Int J Oral Maxillofac Surg. 2009 Feb;38(2):126-38.

32 Coleta KE, Wolford LM, Gonçalves JR, Pinto Ados S, Cassano DS, Gonçalves DA. Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: part II– airway changes and stability. Int J Oral Maxillofac Surg. 2009 Mar;38(3):228-35.

33 Coleta KE, Wolford LM, Gonçalves JR, Pinto Ados S, Cassano DS, Gonçalves DA. Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: part IV-soft tissue response. Int J Oral Maxillofac Surg. 2009 Jun;38(6):637-46. Epub 2009 Jan 9.