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Temporomandibular Joint

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Osteoarthritis of the temporomandibular joint

Here is the keynote conference on temporomandibular disorders on the theme of condylar resorption and osteoarthrosis.

This is an advanced course for orthodontists and oral surgeons and dentists. This lecture was presented at the Dental Society of Quebec to the  resident students specialty of orthodontics at the University of Montreal and residents in oral and maxillofacial surgery at the Hoopital de l’Enfant-Jesus.

Resident students in orthodontics at the University of Toronto and the University of Manitoba will receive this training, in English of course. October 18, 2012 in Toronto. December 5, 2012 in Manitoba

The general public is likely to find the content quite complex. I lack the time to do a webpage for the general public, but it will come.

 

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Objectives:

To understand the pathophysiology of the arthrosis that lead to condylar resorption.

To understand systemic, local and occlusal factors that may lead to condylar resorption.

To know the diagnostic test that are recommended.

To know how to adapt the treatment plan (surgical or non surgical) to patients with condylar resorption.

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Questions and comments

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  1. Emm says:

    Hi,
    I am really struggling after being given the diagnosis of idiopathic condylar resorption. I would really like to email you to ask some advice and explain my case to you to see if you can help me.

    I underwent bimax (saggital split and le fot 1 ) surgery in 2010 and my bite and appearance has relapsed. I found your slides very interesting and i am very worried that my surgery was for nothing and that my jaw may totally receed. I have full case notes and x rays that I can show you if that helps. I just feel a bit let down by my UK surgeon as he just says i have to wait and see as my bite gets worse and worse. It would be great to hear from you as you seem to be an expert in this field.

    Please can you explain if it is unbalanced estrogen and progesterone that causes condylar resorption or just low estrogen. What is the effect of PCOS on condylar resorption also?

    I had one more question: I noticed you mentioned about low Estrogen causing condylar resorption and the pill containing ethinestridiol making it worse as it reduces the amount of 17 beta estrogen in the body.

    I am taking a contraceptive pill called Qlaria which contains Estradiol Valerete and dienogest ( I think this is the same type of estrogen that is in HRT) – As this is mean’t to mimic the natural estrogen in a womans body will this stop condylar resorption or make it worse in your opinion.
    I was also wondering is progesterone made it worse and testosterone in females?

    I am 27 years old so really want a stable outcome. I constantly find myself looking at my jaw and it has relapsed from an overjet of 2mm to 6mm 2 years post operatively. I had an 8mm overjet to start off with before surgery so i feel i look the same as when i started. I also have an open bite which seems to be widening.
    Do you know anything i could do to halt this condylar resoption ?

    I was also wondering at what age condylar resorption is likely to stop as you refer to it as self limiting – is this only when the whole condyle is absorbed?

    Can anything else cause relapse other than condylar resorption i.e muscle memory etc?

    Any advice would be really appreciated.
    Many Thanks
    Emm

    1. Thank for for you questions.

      I wish I can help in some manner.

      Estrogen (17β-estradiol) help to reduce bone loss in women. It reduces the cytokynes and inflammatory markers and  matrix matalloproteinase transcription (MMPs). Therefore, low estrogen levels will inhibit the fibrocartilage synthesis, promote cytokine production (promote MMPs) and bone loss may occur at the condyle which lead to progressive mandibular retrusion. It is not unbalanced estrogen and progesterone that cause condylar resorption. Non susceptible patient to arthrosis can have low estrogen and not have condylar resorption.

      Contraceptive pills (Ethynil estradiol)  suppress the production of naturally occuring 17β-estradiol. Hence, it mimic low estrogen status. I am not an endocrinologist, nor an obtetrician. I can not tell if estradiol valerate is different than ethynil estradiol. But hormone replacement therapy (HRT) is more likely to make condylar resorption worse than better. Pain is associated with the level of estrogen and progesterone. In pregnancy, lower level of TMJ pain is associated with higher level of progesterone and estradiol.

      Thus, the pregnancy and menstrual cycle studies suggest that in women who have TMD, pain is associated with low levels of estradiol. The initial hormone replacement study, however, found that the use of exogenous estradiol was associated with increased risk of experiencing TMJ pain. (monography #46, CFGS page 114).

      You said you underwent a bimaxillary surgery (Le Fort 1 and BSSO) in 2010. SInce then you overjet that was 2 mm increase to 6 mm which is closed the the 8 mm overjet you had initially. You have an open bite that is widening. Those are typical signs of postoperative condylar resorption (POCR).

      Open-bite-and-mandibular-retrusion--associated-with--bilateral-condylar-resporption-ArLa-Chamberland-orthodontiste-quebecWe can’t not tell if it will stop, changes may occurs up to 6 years after the initial changes. It is often self limiting, but it may cause a significant  disfunctionnal deformity (the open bite and the mandibular retrusion). The patient of the left photo will undergo bilateral condylar replacement (costochondral graft). Her resorption was not associated with any systemic inflammatory disease (like rheumatoid arthritis).

      A scintigraphy will help to asses the bone remodeling activity wheter it is resorbing or proliferating. You need 2 consecutives Tc99 bone scan at 6 months intervals to be sure there is no resorptive activity.

      I recommend that you have blood exam, dosage of estrogen and 17β-estradiol at debut and midcycle,  FSH, LH, Vit D, level of rheumatoid factor, antinuclear anbodies, anti CCP, inflammatory status.

      You may need an occlusal splint to help reduce parafunction and get some rest of your masticatory muscle. You can take Calcium Carbonante 500mg/day and up to 1000iu of vit D. Your doctor could prescribe you NSAI.

      I wish those information can help.

      Best regards

      Dr Sylvain Chamberland

       

       

       

       

       

      1. emm says:

        Thank you for your advice. You mention HRT makes condylar reorption worse. If lack of 17 beta estradiol causes bone resoprtion, then shouldn’t taking extra 17 beta estradiol help with bone resorption as it is helping to increase levels of estrogen in the body? I was reading the journal article ‘condylar resorption Matrix Metalloproteinases,and Tetracyclines’ Michael J. Gunson, DDS, MD and it mentions there is promising research with HRT and the cessation of condylar resorption.
        It would be interestignt o get your thoughts on this and if in theory this would work?

        If the resorption started when I was 19 (i am now 27) – went into remission and is now worsening does this mean the six year period has started over again before it will stop?

        Many Thanks

        1. Patterns-of-estradiol-and-progesteron-across-a-prototypical-menstrual-cycle-Chamberland-Orthodontiste-QuebecI think we should differentiate Hormone Replacement Therapy (HRT) from the use of Oral Contraceptive Pill (OCP). You said that resorption started at age 19 and you are now 27. Chances are that you were taking OCP during that period which is different than HRT for a menopause women. Like I said before, i am not a gynecologist but HRT might be useful for a 50 years or so women to prevent osteoporosis if she have sign of such problem.

          The diagram on the left  (from monography #46, CranioFacial growth Series, page 115) depict the patterns of estradiol and progesterone across a prototypical menstrual cycle. Circulating levels of estradiol in women on HRT correspond to those of the early follicular phase of the cycle(arrow). Naturally secreted 17β-estradiol has been shown to decrease inflammation and reduce bone loss in women. Ethinyl Estradiol (the hormone use in HRT) on the other hand, has beeen shown to increased inflammation and periodontal bone loss. This pattern of inflammatory bone loss could be responsible for agressive condylar resorption in some women.

          But you are 27.

          The mecanism of bone regulation by 17 β-estradiol

          How does 17b-estradiol affect the OsteroProteGerin / Receptor Activator for Nuclear Factor k B Ligand (OPG/RANKL) balance?

          17b-estradiol has been shown to be a potentiator of osteoprotegerin (OPG) release, thus protecting bone in the face of local and systemic inflammatory factors. Conversely, when 17β-estradiol is deficient, OPG is not promoted, allowing local and systemic inflammatory factors to inhibit new bone formation or promote resorption of bone mass. Liang et al showed OPG up-regulation
          in human periodontal cells when exposed to 17β-estradiol.

          In addition to the OPG/RANKL effect, women with consistently low circulating 17β-estradiol levels have increased inflammatory cytokines and resultant increases in arthritic symptoms and decreases in bone mineral density. (AJODO. 2009, Dec;136(6):772-9)

          I recommended you some test to do (blood test, Tc99 bone scan) You should have those information in hand to validate or invalidate possible diagnostic and support further treatment.

          I wish you will accept to send me your xray for further comments and recommendations. Your case is very interesting.

          Best regards

          Dr Sylvain Chamberland

          Gunson MJ, Arnett GW, Formby B, Falzone C, Mathur R, and Alexander C. Oral contraceptive pill use and abnormal menstrual cycles in women with severe condylar resorption: a case for low serum 17beta-estradiol as a major factor in progressive condylar resorption. Am J Orthod Dentofacial Orthop. 2009, Dec;136(6):772-9.
          Gunson MJ, Arnett GW, and Milam SB. Pathophysiology and Pharmacologic Control of Osseous Mandibular Condylar Resorption. J Oral Maxillofac Surg. 2011, Oct 17;70(8):1918-34.

           

  2. Claire says:

    Hello, I have condylar resorption which causes me very severe pain. I am from the UK and therefore wondered if you knew of any UK surgeons who specialise in this area. Thanks

    1. Hi Claire,

      Living in Canada, i don’t know UK oral surgeon, but my good friend Dr Louis Mercury does. Therefore I forwarded him your question.
      This is his recommendation:

      Sylvain:
      I know these gentlemen personally. They are THE TMJ surgeons in UK and are well versed in management of ICR cases.

      In London – Mr. Robert Hensher
      In Birmingham – Mr. Bernard Speculand
      In Nottingham – Mr. Andrew Sidebottom
      In Oxford – Mr. Nadim Saeed
      In Bradford – Mr. Stephen Worrall

      Thank you for the inquiry, i hope this helps this patient.

      Hope all is well with you and your family.

      Regards,
      Lou

      Claire, I wish you all the best.

      1. Claire says:

        Thank you, that is most helpful.

        Best wishes,

        Claire

  3. Marie-Paule says:

    Bonjour Dr Chamberland,
    À Montreal depuis peu, je suis une adulte avec une polyarthrite rhumatoïde juvénile avec résorption condilaire très sévère. Je dois faire un traitement orthodontique pour ma malocclusion. Auriez-vous des confrères orthodontistes (et même chirurgiens maxillos) à référer à Montréal? Je recherche désespérément des personnes qui ont l’expérience de ce genre de pathologies pour un traitement adapté.
    Merci de votre aide.

    1. Je vous recommande Dr Dany Morais chirurgien buccal chez Maxillo Vendôme et Dr Johanne Séguin orthodontiste ou encore Dr Jean Poirier chirurgien buccal.

      1. Marie-Paule says:

        Un grand merci pour votre réponse.
        Au plaisir.

  4. Julie says:

    Where can I find a list of top surgeons in the world who specifically trained in ICR corrective surgery? I’m willing to travel almost any where to get the best surgeon.

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