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424
L. Wolford
the TMJ; (7) connective tissue and autoimmune diseases; (8) trauma; and (9) other end-stage TMJ pathologies [25–28]. These TMJ conditions can be associated
with dentofacial deformities, malocclusion, TMJ pain,
headaches, myofascial pain, TMJ and jaw functional
impairment, ear symptoms, decreased oropharyngeal
airway, nasal airway obstruction, sleep apnea, etc. HOP
patients with these conditions may benet from corrective surgical intervention, including TMJ and orthognathic surgery.
Many clinicians choose to ignore the TMJ pathology and symptoms, preferring to perform only orthognathic surgery for these types of cases, but this
treatment philosophy can result in continuation or
exacerbation of the presurgery TMJ pathology, pain,
recurrence of jaw deformity, malocclusion, and other
adverse outcomes. Although most TMJ patients have
associated symptoms, approximately 25% of patients
with signicant TMJ pathology/disorders may be
asymptomatic relative to pain, TMJ noises, and jaw
dysfunction presurgery. These patients are diagnostically challenging when undergoing orthognathic surgery because the TMJ pathology may not be recognized.
Failure to recognize and properly treat the TMJ pathology in symptomatic or asymptomatic patients will
commonly result in poor treatment outcomes including
potential redevelopment of the skeletal and occlusal
deformity by continued condylar resorption or condylar overdevelopment, initiation of or worsening pain,
headaches, jaw and TMJ dysfunction, as well as other
TMJ symptoms. However, there are clinical and imaging factors that can indicate the presence of TMJ
pathology in the asymptomatic as well as the symptomatic patient.
Patients with TMJ pathology and coexisting dentofacial deformities can be corrected with concomitant
TMJ and orthognathic surgery (CTOS) in 1 surgical
stage or separated into 2 surgical stages. The 2-stage
approach requires the patient to undergo 2 separate
operations (one surgery to correct the TMJ pathology
and a second operation to perform the orthognathic
surgery) and two general anesthetics, with a signicantly
lengthened overall treatment time. Performing CTOS in
a single operation signicantly decreases treatment time,
provides better outcomes, but requires careful treatment
planning and surgical prociency in the 2 surgical areas.
Virtual surgical planning (VSP) can be a signicant
advantage in developing the treatment plan, surgical
sequencing, and projected outcome.
Many patients diagnosed with sleep apnea have
HOP facial morphologies with accompanying
decreased oropharyngeal airways and nasal airway
obstruction, but also have TMJ issues that need to be
addressed at the same time or before the orthognathic
surgery is performed to provide a stable, predictable
6 years Post-op (age 30 yrs)
Preop (age 24 yrs)
5
14
24
. Fig. 27.8 Presurgery (red dotted lines) and 6-year postsurgery
(black solid lines) super-imposed tracings of a severe rheumatoid
arthritis patient with severe sleep apnea, demonstrates the postsurgical airway changes following CCWR of the MMC including bilateral TMJ reconstruction and CCWR of the mandible using TMJ
Concepts total joint prostheses and concomitant maxillary osteotomies and bony genioplasty with pogonion advancing 24mm. At the
oropharyngeal area, the distance between the red line and posterior
black line (2mm) demonstrates the severe presurgical airway constriction. The long-term postsurgical changes are seen between the
black lines with the airway dimension of 14mm. The normal A-P
dimension in this area is 11mm±2mm
outcome and decrease preexisting pain. The normal
cephalometric A-P dimension from the posterior pharyngeal wall to the soft palate and posterior pharyngeal wall to the base of the tongue is 11 ±2 mm. In
HOP patients who have a retruded maxilla and mandible, this airway may be signicantly decreased.
Advancing the MMC in a CCWR direction improves
facial balance and the oropharyngeal airway opens signicantly, to improve breathing (.
Fig. 27.8). Our
studies [5, 29–33] have shown that double jaw surgery
with CCWR of the MMC will increase the oropharyngeal airway approximately 65–70% for the rst 10mm
of mandibular advancement. With 10–15 mm of
advancement, the oropharyngeal airway continues to
open, but at a lesser percentage of the amount of mandibular advancement of about 55–60% of the mandibular advancement. When the mandible is advanced
15–20 mm, the oropharyngeal airway continues to
open, but only about 40–45% of the amount of mandibular advancement [34].
There are a triad of factors that commonly go
together in HOP patients and they include (1) a high
OPA facial morphology associated with a retruded maxilla and mandible with an accompanying decreased oropharyngeal airway, (2) nasal airway obstruction related
ab
Counterclockwise Rotation of the Maxillomandibular Complex for the Correction of Dentofacial…
425
. Fig. 27.9 Bilateral MRIs of a patient with AICR.The condyles generally appear small in size and the cortical bone on top of the condyle
may be somewhat thin. The articular discs are anteriorly displaced. In AICR patients, the articular discs may or may not reduce on opening
27
to hypertrophied turbinates and/or nasal septal deviation or spurring, and (3) TMJ pathology. Our study [35]
evaluated 1234 consecutive patients referred to the
and degenerative changes can be present, may not make
noise or cause pain, but may contribute to poor outcomes if only orthognathic surgery is performed.
author for orthognathic surgery requiring at least maxillary osteotomies. There were 603 patients (49%) with
hypertrophied turbinates that required partial turbinectomies and 278 patients (23%) required nasal septoplasty. For patients requiring partial turbinectomies
(n=603), 84% had maxillary hypoplasia, 72% had mandibular hypoplasia, 69% had a high occlusal plane angle,
and 49% of the patients required CTOS.A strong correlation was established between hypertrophied inferior
turbinates, hypoplastic maxilla and mandible, as well as
a steep occlusal plane. Our ndings correlate with other
studies evaluating the facial morphology of mouth
breathing and nasally obstructed patients [36–38].
Therefore, patients with the HOP facial morphology
with a retruded maxilla and mandible should be assessed
for nasal airway obstruction, decreased oropharyngeal
airway and sleep apnea, as well as TMJ pathology (even
if asymptomatic).
27.3.7 TMJ Disc Displacement
When discs are anteriorly displaced, there is a 4-year
window from onset of the disc displacement to perform
the repair for a predictable outcome, providing there is
no coexisting reactive arthritis, connective tissue/autoimmune disease, metabolic disease, etc., that could continue
a degenerative process within the TMJ with resultant
failure of the disc repair. TMJ conditions that respond
well to disc repositioning include disc displacement and
adolescent internal condylar resorption (AICR) with or
without reduction of the disc on opening as long as the
disc and condyle are in good condition without signicant adhesions, degeneration and the afore-mentioned
TMJ diseases, and less than 4years from the onset of the
disc displacement (.
Fig.27.9). The Mitek anchor tech-
nique is the only proven method to predictably reposition the disc onto the condyle (. Fig. 27.10). Disc
27.3.6 MRI Evaluation
Magnetic resonance imaging (MRI) is one of the most
important diagnostic tools that we have to evaluate,
diagnose, and treatment plan for TMJ pathology as it
allows evaluation of bone and soft tissue structures,
TMJ disc position, morphology, mobility, extent of
joint degenerative changes, inammation, the presence
of connective tissue/autoimmune diseases, and so forth
(. Fig.27.9). MRI can help in the diagnosis of TMJ
disorders in the silent joint in which disc displacement
repositioning with the Mitek anchor can be done concomitantly with orthognathic surgery [22, 23, 25–28].
However, after 4years, the discs may become nonreducing, deformed with loss of the intermediate zone,
thickening of the posterior and anterior bands, degenerative changes within the disc, and vascular invasion.
Displaced discs initiate a cascade of events that lead to
TMJ arthritis. When discs are displaced and become
non-reducing, the degenerative process of the disc progresses more rapidly as compared to displaced discs that
reduce. When discs advance to a certain level of defor-
27
ab
cd
426
L. Wolford
. Fig. 27.10 Mitek anchor
technique: a The Mitek mini
anchor is 5 x 1.8mm in
dimension with an eyelet to
support 2 articial ligaments
(0-Ethibond suture). b Bilaminar
tissues are excised and disc
mobilized. c The disc is passively
positioned over the condyle and
Mitek anchor placed in the
lateral aspect of the posterior
head, about 8mm below the top
of the condyle. d The sutures are
attached to the posterior band
of the disc and secured
0-Ethibond
Sutures
5 x 1.8 mm
Mitek Anchor
Posterior View
M L
Remove
Bilaminar
Tissues
mation and degeneration, they become non-salvageable
requiring TMJ reconstruction with patient-tted total
joint prostheses. Concomitant TMJ reconstruction and
orthognathic surgery may be indicated to produce to
most predictable and high-quality outcomes.
27.3.8 Adolescent Internal Condylar
Resorption (AICR)
Adolescent internal condylar resorption (AICR) is a
condition that develops usually during pubertal growth
between the ages of 11 and 15 years, predominantly in
females (ratio 8:1 females to males) [39, 40]. Clinically,
the mandible will be noted to slowly retrude into a Class
II occlusal and skeletal relationship with a tendency
toward anterior open bite. These patients all have HOP
facial morphological proles. On the MRI, these cases
present with a condyle that is slowly becoming smaller
in size in all 3 planes of space and the disc is anteriorly
displaced similar to (.
signicant thinning of the cortical bone on top of the
condyle contributing to the inward collapse of the condylar head in this pathological process. The articular
discs are anteriorly displaced and may or may not reduce
on opening. Commonly, the disc becomes non-reducing
relatively early in the pathological progression. Nonreducing discs will degenerate and deform at a more
rapid rate as compared to discs that reduce.
Fig.27.9. In some cases, there is
Mitek
anchor
Our studies [39, 40] demonstrate that AICR is
arrested if the articular discs are put back into position
on top of the condyle and stabilized with the Mitek
anchor technique. It is so predictable for stopping the
resorption that the indicated orthognathic surgery can
be done at the same operation. Results of this treatment
protocol are best for AICR if the TMJ surgery for disc
repositioning is performed within 4years of the onset of
the pathology. After 4years, the discs may become nonsalvageable and condyles signicantly resorbed with the
indicated treatment transitioning to patient-tted total
joint prostheses to repair the TMJs and CCWR the
MMC with concomitant orthognathic surgery.
27.3.9 Reactive Arthritis
Reactive arthritis is commonly caused by bacterial or
viral entities [41–47] and may show a localized area of
inammation (synovitis) with erosion of the condyle
and/or fossa. It also can present as a more profuse
inammatory process through the bilaminar tissues,
capsule, surrounding the disc but can progress to the
destruction of the disc and condylar resorption. The
most common bacteria causing reactive arthritis in the
knees and TMJs are the following: Chlamydia trachomatis and Chlamydia pneumoniae, as well as
Mycoplasma pneumoniae and Mycoplasma genitalium
[46–52]. These are non-culturable, non-motile, obligate
Counterclockwise Rotation of the Maxillomandibular Complex for the Correction of Dentofacial…
427
27
intracellular bacteria that stimulate the production of
pro-inammatory/pain mediators: TNFα, cytokines,
chemokines, substance P, etc., with subsequent breakdown of cartilage and bone and generation of pain.
They have an anti-apoptosis effect on host cells (including monocytes and macrophages) and create immunodysfunction. Standard antibiotic therapy can be
effective for urinary tract, genital, ocular, respiratory,
and GI infections involving these bacteria, but are not
effective for synovial infections, making it very difcult
to eliminate these bacteria from joints including the
TMJs [46–52]. Currently, there are no predictable methods to conservatively treat reactive arthritis involving
these particular bacteria. However, when the infection
is conned to a small portion of the synovial and bilaminar tissues, in the TMJ, debridement may be indicated,
but prognosis is guarded. Surgical indication may
include removal of the nidus of inammation and reposition the articular disc if salvageable. When signicant
TMJ involvement and particularly with extensive
destruction of the TMJ tissues, a total joint prosthesis
may be indicated.
27.3.10 Connective Tissue/Autoimmune
Diseases
The MRI presentation of connective tissue/autoimmune
diseases is fairly pathognomonic. These diseases include
rheumatoid arthritis, idiopathic condylar resorption,
juvenile idiopathic arthritis, psoriatic arthritis, Sjogren’s
syndrome, lupus, scleroderma, etc. In these conditions,
the articular disc oftentimes is in a relatively normal position but surrounded by a reactive pannus. There is usually progressive condylar resorption, “mushrooming” of
the remaining condyle, and often resorption of the articular eminence, with slow but progressive destruction of
the articular disc. This presentation almost always indicates the requirement of total joint prostheses for jaw
reconstruction to eliminate the pathologic process in the
joint as well as concomitant orthognathic surgery to correct the associated jaw deformity and malocclusion, eliminate pain, establish a good airway, and provide good
facial balance [25–28]. Use of autogenous tissues in this
scenario could result in the disease process attacking the
autogenous tissues placed into the joint with subsequent
failure.
27.3.11 Other End-Stage TMJ Pathologies
Other end-stage TMJ pathologies may include (1) ankylosis, (2) absence of condyle or TMJ secondary to
trauma or congenital deformities such as hemifacial
microsomia and Treacher Collins syndrome, (3) tumor,
(4) metabolic joint diseases, (5) failed autogenous grafts,
(6) failed alloplastic TMJ implants, etc. These conditions will generally have the best outcomes with customtted TMJ total joint prostheses.
27.3.12 Repositioning theMandible First
withConcomitant TMJ Surgery
(Salvageable Discs)
The TMJ surgery must be performed rst since the surgery may include disc repositioning and/or high or low
condylectomies (if active condylar hyperplasia present),
which will alter the spatial position of the mandible.
Repositioning the mandible following the TMJ surgery
will place the mandible into its nal position, no matter
how much mandibular positional change occurred with
the TMJ surgery. The only effect will be a difference in
the amount of mandibular positional change resultant
from the TMJ surgery to the nal mandibular position.
The maxillary surgery then follows. For patients with
high OPAs, this is the best surgical sequencing. When
the mandible is repositioned rst before the maxilla, the
surgical sequencing is as follows: (1) TMJ surgery that
may include disc repositioning and high or low condylectomies, or other intra-capsular procedures; (2) mandibular sagittal split osteotomies, removal of third
molars if indicated, repositioning the mandible with an
intermediate splint, application of intermaxillary xation (MMF), and application of rigid xation; (3) maxillary osteotomies and mobilization, removal of third
molars if indicated and segmentalization if necessary;
(4) intranasal procedures such as turbinectomies and
nasoseptoplasty if indicated; (5) application of the palatal splint, MMF, rigid xation for the maxilla, and
appropriate bone grafting, if indicated, with bone or
porous block hydroxyapatite. Release MMF and check
occlusion; and (6) other ancillary procedures (i.e., genioplasty, rhinoplasty, etc.).
27.3.13 Repositioning theMaxilla First
withConcomitant TMJ Surgery
(Salvageable Disc)
Some surgeons prefer to reposition the maxilla rst in
these cases, so the sequencing is different. With sequencing the maxillary surgery before the mandibular surgery, the maxilla must be repositioned before the TMJ
surgery since the TMJ surgery will change the position
of the mandible, which would then create a malposition
of the maxilla if the TMJ surgery was done rst. If it is
decided to do the maxillary surgery rst, then the
sequencing changes as follows: (1) completion of maxillary osteotomies and mobilization, removal of third
molars if indicated and segmentalization if necessary;
428
L. Wolford
27
(2) intranasal procedures such as turbinectomies and
nasoseptoplasty if indicated; (3) application of the palatal splint and the intermediate splint, MMF, rigid xation to the maxilla, and appropriate bone grafting, if
indicated, with bone or porous block hydroxyapatite;
(4) release of MMF and checking of occlusion with
intermediate splint, removal of intermediate splint; (5)
TMJ surgery that may include disc repositioning and
high or low condylectomies, or other intra-capsular
procedures; (6) mandibular sagittal split osteotomies,
removal of third molars if indicated, reposition into the
best occlusal t, placement of MMF, and application of
rigid xation, release of MMF and check occlusion;
and (7) other ancillary procedures (i.e., genioplasty, rhinoplasty, etc.).
27.3.14 Repositioning theMandible First
withConcomitant TMJ Total Joint
Replacement
When the condyles and discs are non-salvageable with
end-stage TMJ pathology, then TMJ replacement surgery is usually indicated. The most predictable treatment method is with a TMJ total joint prosthesis
system. There are 2 basic types of TMJ total joint
prostheses: stock and patient-tted devices. Stock
devices have different choices of prefabricated components including fossa components and mandibular
components. The surgeon picks the size and shape of
fossa and mandibular components that best t the
patient’s anatomy. The patient-tted devices are custom designed to t the patient’s specic anatomical
requirements. When mandibular advancement is indicated, patient-tted devices can be constructed to
advance the mandible with the TMJ prostheses. When
the orthognathic and TMJ surgeries are performed
concomitantly, the surgical sequencing is as follows:
(1) through an endaural or preauricular incision, condylectomy, discectomy, and joint debridement; (2) coronoidectomy with detachment of the temporalis
muscle if the mandible is to be signicantly advanced
or vertically lengthened; (3) through a submandibular
incision, detach the masseter and medial pterygoid
muscles, mobilize the mandible to obtain the new position of the mandible; (4) apply intermediate splint and
MMF; (5) place TMJ prostheses; (6) harvest fat graft
from the abdomen (or from elsewhere if preferred) and
pack around articulating area of TMJ prostheses; (7)
remove MMF and intermediate splint; (8) maxillary
osteotomies, mobilization, segmentation if indicated,
application of palatal splint; (9) intranasal procedures
such as turbinectomies and nasoseptoplasty if indi-
cated; (10) maximize occlusal t, apply MMF, rigid
xation to the maxilla and appropriate bone grafting,
if indicated, with bone or porous block hydroxyapatite. Release MMF and check occlusion; and 11) other
procedures (i.e., genioplasty, facial augmentation, or
rhinoplasty).
27.4 Case 1 (. Figs.27.3, 27.4, and27.5)
This 18-year-old female reported the onset of her TMJ
symptoms at about the age of 13 when her joints started
to click and pop. By the age of 16, the clicking stopped
but her pain involving the TMJs and headaches had signicantly increased. She was referred for treatment at
the age of 18years. Although she had good facial symmetry in the frontal view, in prole she had the HOP
facial morphology commonly seen with AICR with the
retruded mandible and chin as well as an end-on Class II
occlusion (.
Figs.27.3a,b, 27.4a,b, and 27.5a). On a
scale of 0 to 10, where 0 equals no pain and 10 the worse
pain imaginable, she rated her headaches at 6, TMJ pain
at 7, and myofascial pain at 8. She had signicant difculties eating and chewing related to her pain issues and
was on a relatively soft diet. She rated her disability at 7,
where 0 indicates no disability and 10 means totally disabled. She had previous extensive orthodontics with an
unstable outcome. She was in orthodontic treatment for
a second time, at the initial surgical evaluation. Her
diagnoses consisted of the following: (1) bilateral TMJ
AICR; (2) maxillary anteroposterior (AP) and posterior
vertical hypoplasia; (3) mandibular AP and posterior
vertical hypoplasia; (4) Class II end-on occlusion; (5)
high occlusal plane angle; (6) impacted third molars x 4;
(7) hypertrophied turbinates with nasal airway obstruction; and (8) TMJ pain, myofascial pain, and headaches.
The single-stage surgical treatment consisted of the following: (1) bilateral TMJ articular disc repositioning
and ligament repair with Mitek anchors (. Fig.27.10);
(2) bilateral mandibular ramus osteotomies to advance
the mandible in a counterclockwise direction; (3) multiple maxillary osteotomies to down graft the posterior
aspect; (4) anterior mandibular horizontal osteotomy to
augment the chin (.
Fig. 27.5b); (5) removal of
impacted third molars x4; and (5) bilateral partial inferior turbinectomies.
The patient was evaluated three years postsurgery
with the following ndings: no TMJ pain, headaches,
myofascial pain was observed; incisal opening was
43mm (presurgery was 28mm); excursion movements
of 5mm in each direction were observed; good jaw function and no disability were noted; and good facial balance (. Fig. 27.3c, d) and stable occlusion
(. Fig.27.4c,d) were observed.
Counterclockwise Rotation of the Maxillomandibular Complex for the Correction of Dentofacial…
429
27
27.4.1 The Importance oftheArticular Disc
inOrthognathic Surgery Stability
Goncalves etal. [53] reported a retrospective study that
evaluated the records of 72 patients who underwent
CCWR of the MMC.The sample was divided into three
groups to address the inuence of TMJ health and articular disc surgical repositioning relative to postoperative
stability. Group 1, with healthy TMJs, underwent double jaw surgery only. Group 2, with articular disc dislocation, underwent articular disc repositioning using the
Mitek anchor technique concomitantly with orthognathic surgery. Group 3, with articular disc dislocation,
underwent orthognathic surgery only. Preoperative
characteristics for all patients included high occlusal
plane angle, maxillary and mandibular retrusion, and
increased anterior facial height. All 3 patient groups had
similar dentofacial deformities and underwent orthognathic surgical procedures performed by the same surgeon in the same manner with rigid xation. Each
patient’s lateral cephalograms were traced, digitized
twice, and averaged to estimate surgical changes and
postoperative stability. The MMC was advanced with
CCWR similarly in all 3 groups; approximately 13mm
measured at menton. Postoperatively, the occlusal plane
angle increased in Group 3 (37% relapse rate), but
remained stable in Groups 1 and 2. Postoperative mandibular changes in the horizontal direction demonstrated a signicant A-P relapse in Group 3 at menton
(28%), B point (28%), and lower incisor edge (34%), but
remained stable in Groups 1 and 2. MMC advancement
with CCWR of the OPA is a stable procedure for
patients with healthy TMJs and for patients undergoing
simultaneous TMJ disc repositioning using the Mitek
anchor technique. Those patients with preoperative
TMJ articular disc displacement who underwent double
jaw surgery and no TMJ intervention experienced signicant relapse.
Chemello et al. [6] and Satrom etal. [54] reported
that mandibular advancement in double jaw surgery
(with or without CCWR) using rigid internal xation
with healthy TMJs is a stable procedure over the long
term, with a mean A-P relapse at point B of 6% regardless of the amount of surgical advancement performed.
On the other hand, Wolford etal. [55] evaluated 25 consecutive patients (23 females and 2 males) with jaw
deformities and displaced articular discs (conrmed by
MRI) who were treated with orthognathic surgery only,
including mandibular advancement, and stabilized with
rigid xation. The average postoperative relapse at
point B was 36% of the mandibular advancement, and
the average distance from the condyle to point B
decreased by 34%, indicating condylar resorption. Six
patients (24%) demonstrated signicant postoperative
condylar resorption (3–8 mm), resulting in Class II
anterior open bite malocclusion. The increased loading
of the TMJs as a result of the mandibular advancement
most likely stimulated the resorption process. New
onset or aggravation of TMJ symptoms (e.g., pain,
TMJ dysfunction) occurred at an average of 14months
after surgery. At the completion of the study, 48% of
the patients required TMJ and repeat orthognathic surgery. Before surgery, 36% of the patients complained of
pain or discomfort, but at 2.2years postoperatively, and
84% of the patients reported pain with a 75% increase
in pain intensity compared with the preoperative pain
level. Only 4 of the 25 patients (16%) had a stable outcome without pain. This study clearly demonstrates the
problems associated with performing orthognathic surgery only on patients with coexisting TMJ articular disc
dislocations.
27.5 Case 2 (. Figs.27.11, 27.12,
and27.13)
This 20-year-old female presented with juvenile idiopathic arthritis (JIA) with onset at approximately age 5
but rst noted clinically to be affecting the TMJs at
age 12, with progressively worsening facial deformity
related to condylar resorption (. Figs. 27.11a, b,
27.12a,b, and 27.13a). She had polyarthritis involving
the neck, hands, feet, and TMJs, and moderate pain
issues around the head and neck (4 on a scale of 0 to
10), with jaw function rated at 3 and diet at 2. Her incisal opening was 38 mm and excursions 6 mm to the
right and left. Her diagnosis included (1) bilateral TMJ
JIA; (2) maxillary A-P and posterior vertical hypoplasia; (3) mandibular A-P and posterior vertical hypoplasia; (4) Class II occlusion with anterior open bite; (5)
microgenia; (6) decreased oropharyngeal airway (A-P
dimension 3 mm) with signicant sleep apnea symptoms; and (7) hypertrophied turbinates creating nasal
airway obstruction. The MRIs demonstrate the severe
destruction of the condyles resorption of the articular
eminences, and reactive pannus surrounding the discs
Fig.27.14a, b). Presurgical orthodontics prepared
(.
the patient for surgery.
Surgery included (. Fig.27.13b): (1) bilateral TMJ
reconstruction and counterclockwise rotation of the
mandible with TMJ Concepts patient-tted total joint
prostheses; (2) bilateral coronoidectomies; (3) bilateral
TMJ fat grafts packed around the articulating area of
the prostheses, harvested from abdomen; (4) multiple
maxillary osteotomies for counterclockwise rotation
and advancement; (5) anterior mandibular horizontal
osteotomy to augment the chin; and (6) bilateral partial
inferior turbinectomies.
430
cd
L. Wolford
27
a
b
. Fig. 27.11 Case 2: a, b a 20-year-old female with JIA and grossly
resorbed mandibular condyles, retruded mandible and maxilla, posterior maxillary vertical hypoplasia, high occlusal plane angle facial
morphology, decreased oropharyngeal dimension (3mm) and sleep
apnea symptoms as well as hypertrophied turbinates and difculty
breathing through the nose. c, d The patient is seen 4years postsurgery demonstrating signicantly improved facial balance and function with a stable occlusion
ab
Counterclockwise Rotation of the Maxillomandibular Complex for the Correction of Dentofacial…
431
27
a
c
. Fig. 27.12 Case 2 a, b The patient has a Class II occlusion presurgery with an anterior open bite. c, d At 4years postsurgery she demon-
strates a stable Class I occlusion
b
d
4 yrs Post Surgery
89
75
3
3
. Fig. 27.13 Case 2: a Cephalometric analysis shows severe jaw
deformity with retruded maxilla-mandible, high occlusal plane
angulation, and decreased oropharyngeal airway. b The 4-year postsurgery cephalometric analysis demonstrates the counter- clockwise
rotation of the maxillomandibular complex with TMJ Concepts
31
43
29
14
22
9
-1
3
11
-2
12
13
total joint prostheses. The chin is augmented with a bony genioplasty. Maxillary incisors advanced 4 mm, Pogonion advanced
32 mm, and the occlusal plane decreased 22 degrees, creating
improved function and facial balance. There is a normal oropharyngeal airway of 13mm
43
90
88
424
32
4
4
27
ab
432
L. Wolford
. Fig. 27.14 Case 2: MRIs of the TMJs; a right TMJ sagittal view,
b left TMJ sagittal view showing the destruction of the condyles and
articular eminences, common in JIA cases. Notice the “mushroom-
At four years post-surgery she was pain-free and the
following were observed: incisal opening at 42 mm,
excursive movements 3 mm bilaterally, stable Class I
occlusion, improved facial balance, normal diet, good
nasal and oropharyngeal airway, and elimination of
sleep apnea symptoms (. Figs.27.11c,d and 27.12c,d).
ing” of the remainder of the condylar neck process. The articular
discs are in a relatively normal position but surrounded by a reactive
pannus
studies demonstrated that end-stage TMJ patients could
be treated in one operation with TMJ Concepts patienttted TMJ total joint prostheses, fat grafts, and MMC
CCWR for correction of an associated dentofacial
deformity with good stability and improvement in pain
and TMJ function.
Although the life expectancy of this device is
unknown, Wolford etal [58] published a 20-year fol-
27.5.1 Outcome Stability withTMJ
Concepts Patient-Fitted Total
JointProstheses
Dela Coleta etal. [56] evaluated 47 female patients for
surgical stability following bilateral TMJ reconstruction
using TMJ Concepts patient-tted TMJ total joint prostheses, TMJ fat grafts, and CCWR of the MMC with
Menton advancing an average of 18.4mm and the OPA
decreasing an average of 14.9 degrees. Average follow up was 40.6months. Results demonstrated minor maxillary horizontal changes while the mandibular
measurements remained very stable.
Pinto etal [57] evaluated the same 47 female patients
relative to pain and dysfunctional outcomes. Patients
were divided into two groups based on the number of
previous surgeries: Group 1 had 0–1 previous surgeries
while Group 2 had 2 or more previous surgeries.
Signicant improvements (37–52%) were observed for
TMJ pain, headaches, jaw function, diet, and disability.
MIO increased 14%. Group 1 patients had better pain
and jaw function results than Group 2 patients. For
patients who did not receive fat grafts around the prostheses and had previous failure of alloplastic TMJ
implants, more than half required secondary surgery
including TMJ debridement for removal of foreignbody giant-cell reaction, brosis, and/or heterotopic
bone formation. The Dela Coleta etal. and Pinto etal.
low- up study of 56 patients who had received the
Techmedica total joint prostheses between 1989 and
1993. There were statistically signicant improvements
in all parameters including incisal opening, jaw function, TMJ pain, and diet, with 85.7% of the patients
reporting signicant improvement in their quality of
life. The greater the number of previous TMJ surgeries, patients reported a lower degree of subjective
improvement, but they did report increased objective
mandibular function and improved quality of life.
There were no reports of device removal due to material wear or failure.
Wolford et al [56–65], Mercuri et al [66–72], and
others [73–76] have published numerous studies in reference to outcome data using patient-tted TMJ total
joint prostheses. A summary of these publications have
produced the following facts in reference to the TMJ
Concepts total joint prostheses: (1) TMJ Concepts
prostheses are superior to autogenous tissues for endstage TMJ reconstruction relative to subjective and
objective outcomes; (2) after two previous TMJ surgeries, autogenous tissues have a very high failure rate,
whereas patient- tted total joint prostheses have a high
success rate; (3) no donor site morbidity; (4) increased
number of previous TMJ surgeries produces a lower
level of improvement related to pain and function outcomes compared to patients with 0 to 1 previous TMJ
surgeries; (5) failed TMJ alloplastic reconstruction
Counterclockwise Rotation of the Maxillomandibular Complex for the Correction of Dentofacial…
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27
(i.e., P/T, silastic, metal- on- metal articulation, etc.) can
create a foreign-body giant-cell reaction and/or metallosis, best treated by joint debridement and reconstruction with patient-tted total joint prostheses; (6) fat
grafts packed around the articulating area of the prostheses improve outcomes relative to decreased pain,
improved jaw function, and decreased requirement for
repeat surgery [77–80]; (7) osseo-integration of the
TMJ Concepts fossa and mandibular components
occur and is important for long- term stability; (8) posterior stop on the fossa component is important to stabilize the joint, jaw position, and occlusion; (9)
concomitant orthognathic surgery can be performed at
the same time as the TMJs are reconstructed; and (10)
20-year follow-up study [58] demonstrated improvements in pain, jaw function, diet, incisal opening, and
quality of life.
27.6 Summary
CCWR of the MMC is highly predictable for quality
treatment outcomes in orthognathic surgery in the presence of healthy and stable TMJs. If the TMJs are not
stable and healthy, CCWR for orthognathic surgery 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) high
occlusal plane angle facial morphologies with retruded
maxilla and mandible; (2) progressive development of
anterior or lateral open bites; (3) progressively worsening occlusal and jaw relationships; (4) facial asymmetry,
particularly with progressive worsening; and (5) patients
reporting headaches, TMJ pain, myofascial pain, history of 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 the identication of the
specic TMJ pathology. Failure to recognize and treat
these conditions can result in signicant orthognathic
surgery relapse, increased pain, and a greater complexity
of subsequent treatment for patients.
During the past 30years, 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 that involves CCWR of the MMC can be safely
and predictably performed at the same operation, but it
does necessitate the correct diagnosis and treatment, 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 rst. With the correct diagnosis and treatment plan, combined TMJ and orthognathic surgical approaches provide complete and
comprehensive management of patients with coexisting
TMJ pathology and dentofacial deformities requiring
CCWR of the MMC.
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