Facial Asymmetry, Class II subdivision, TMJ Clicking
Question :
Dear Dr Chamberland,
First off, thank you in advance for taking the time to look over my email. I hope you don’t mind my correspondence in English.
I am sincerely hoping you might be able to help me with my case as you seem to be an expert in TMJ and facial asymmetry and I’m very lost on what treatment options I should pursue.
Essentially, I am trying to determine what my situation is, as I have been told different opinions by different doctors. As you can see from my attached CT images,
Frontal photo shows mandibular deviation to the right. The profile photo shows a normal relationship of the lips to a tangent plane “tip of the nose-tip of the chin”.
I have an asymmetric jaw (right border lower than left, as you can see from lateral ceph) with a skeletal midline deviation to the right, creating a Class I relationship on left with a Class II on right.
Because of this, I have very noticeable TMJ symptoms on the right, specifically very loud clicking when I open my jaw about half way. However, there is no pain and no locking to make note of. I also have noticeable facial asymmetry where the right side of my face is higher than the left.
The doctors I have met with have suggested bite splints, neuromuscular dentistry to rearrange teeth and a sliding genioplasty as ways to fix my issues. None have suggested jaw surgery as they say my jaw is not recessed enough to warrant it. None have made note of anything significant regarding my condyles other than slight flattening which they say is within normal limits.
My question to you is, based on my images, is there anything to specifically make note of that needs attention? If my facial asymmetry is the result of normal skeletal growth and won’t worsen over time, I’m more inclined to leave things alone and perhaps use a bite splint as one oral surgeon suggested at night to help with TMJ symptoms.
However, if there’s anything you see on my scans that leads you to believe my facial asymmetry and TMJ might worsen without surgical intervention, I would really appreciate your insight on how it should be treated. BSSO? Condyle surgery? Braces only? Your insight on my case would be greatly appreciated.
Best Regards,
Cary
Réponse :
Dear Cary,
Thank you for having chosen my website to ask your question. You sent me your picture and gave me the authorization to publish it.
Your frontal photo confirms mandibular asymmetry to the right. The chin is to the right of the facial midline. The profile view shows a fairly normal relationship of your lips to the esthetic plane (tangent nose-chin).
Prominence of the lower incisors relative to the plane A-Pg
The 3D reconstruction confirm asymmetric molar relationship (Class II on the right, Class I on the left and lower midline deviated to the right). The ceph shows a moderate prominence of the dentition as one can see the tip of the lower incisors is in front of the plane A-Pg.
The panogram that you sent me, as well as the condylar view, suggest a left elongated condylar neck which explains why your left mandibular border is lower than the right mandibular border in frontal view.
Chances are that you have this kind of asymmetry since a while because it is unlikely that full cusp Class II would have developed because of a recent condylar hyperplasia. However, I would recommend a bone scan to confirm that there is no condylar growth activity.
The right condylar clicking can be explained by some torsion of the condyle in the glenoid fossa. You may have some slight medial disk displacement. As you open, the disk returns over the condylar head and you hear the click.
The important thing is that you have no pain and no limitation of jaw movements.
Your occlusion seems fairly good despite the asymmetric molar relationship and midline deviation.
My recommendation would be to do a bone scan to assess condylar growth.
If it is negative, you may consider an orthodontic treatment plan. The treatment plan would involve extraction of 2 maxillary premolars (1 left, 1 right) and one mandibular premolar (1 left). This would help to camouflage the skeletal asymmetry and obtain a symmetric Class I canine relationship.
A sliding genioplasty to the left would help to achieve frontal facial symmetry, assuming that there is no growth activity.
I would not recommend any neuromuscular dentistry. You may consider an occlusal splint for 3-4 months prior to treatment, but I am not sure this would be that much important.
I hope that helps.
Best regards.
Bonjour Docteur Chamberland,
Je présente une malocclusion classe 3. De plus, ma mandibule inférieure droite est plus longue que celle de gauche. Ce qui a pour effet une asymétrie de la mâchoire.
Je souffre de douleurs chroniques souvent quotidiennes, au niveau de la nuque côté gauche, de mon oreille gauche ainsi que de l’articulation temporo-mandibulaire gauche.
Cependant, c’est le côté droit de la mâchoire qui claque lorsque j’ouvre la bouche avec une grande amplitude, sans aucune douleur, ni aucune restriction de mouvement.
J’ai effectué une série de tests au niveau du cerveau notamment (IRM…) qui se sont révélés négatifs.
Mes questions sont :
Pensez-vous que ma malocclusion classe 3 ainsi que l’asymétrie de la mâchoire pourraient être la cause de ces symptômes ?
Un orthodontiste que j’ai consulté par le passé m’a expliqué que je devrai probablement faire une chirurgie orthognatique si je désire realigner mes dents. J’y suis plutôt reticent.
Cependant, je suis prêt à accepter si cette procédure peut me délivrer de ces douleurs qui me gênent depuis 2015.
Pensez-vous qu’une chirurgie orthognatique en vue de corriger ma classe 3 ainsi que l’asymétrie des mâchoires pourrait entraîner une disparition des symptomes douleureux ?
Je vous remercie d’avance pour votre réponse et votre disponibilité.
Bien cordialement,
Kevin
Il faaut déterminer l’état de votre condyle gauche, mais il est vraisemblable qu’une chirurgie orthognathique soit le meilleur traitement pour votre cas.
Dear Dr. Chamberland,
I am writing to you after coming across your PowerPoint presentations describing two-phase TMD and orthodontic treatment. Because of your uncommon experience with both TMD and orthodontics, I was hoping you might answer a question for me.
Basically: is “stabilizing” the TMD necessary before beginning orthodontic treatment? I have reached no consensus on this after consulting orofacial pain specialists (Mass General, Tufts, etc.) and orthodontists alike.
I have had clicking all my life. Feelings of bite awkwardness started in 2013. Pain symptoms began in 2014. I wore a splint for 4 months which helped 85%. My doctor weaned me off and told me just to wear it whenever I needed it. Since then, my pain is intermittent and correlated with my stress levels. That is, permanent “stabilization” of my TMD seems unlikely – I’ve accepted it as a chronic condition. On the other hand, I understand the rationale for stabilizing it in order for the success of subsequent orthodontic treatment: I wonder if the unresolved TMD pain will be compounded and unbearable with orthodontics, and I have noticeable deviated jaw opening. It seems that an orthodontist correcting the patient’s bite is impossible when that bite is constantly shifting due to TMD.
I would just like to know if it would be a bad decision to proceed with orthodontics without more TMD treatment and leaving the symptoms as they are.
I would be deeply grateful for any time you could spare to help me, given your unique background. I felt lucky to have stumbled across you via the Internet!
Thank you very much.
Sincerely, Jennifer
I think the important thing is to get a proper diagnosis of your TMJ pain. Is it arthrosis? Is it disk luxation with reduction? Is it mainly muscle pain?
You say that pain is intermittent and correlated with stress level. Chances are that you clench your teeth when the stress is high and it create compression (and inflammation) in the joint, then you have pain.
On the other hand, clicking in joint is not a contraindication of an orthodontic treatment. Your bite may be shifting because of the underlying malocclusion.
You seem to live in te area of Boston. I would recommend that you have a consultation with my very godd friend Dr David Briss.
Keep us informed.
Best regards
Dr Sylvain Chamberland
Dear Dr. Chamberland,
Thank you so much for your insight and referral. I am currently out of the country but have wanted to find another reputable doctor in Boston for a long time.
In the meantime, if this additional info makes anything more certain for you, kindly let me know: the few doctors I have seen have concluded it is a muscular problem and only recommended a splint once I started experiencing pain symptoms. I had a pernicious habit of jutting my chin/jaw forward to compensate for lack of projection. No CBCT has ever been taken to examine for condylar resorption. I am just concerned since even though the pain is intermittent, the overall trend over the last 1.5 years has been intensifying pain, spreading from my lower left jawline to my chin and right jawline. That is, the pain I’m sometimes in now is more severe than the pain I was sometimes in before. I have stopped that old habit as far as I know. I don’t know if the worsening pain 1) is indicative of a different underlying cause other than muscular, at least the current underlying cause; and 2) will damage my joints and cause other symptoms like worse deviated opening, and if these are contraindicative of orthodontic treatment.
Again, you’ve provided an invaluable resource for those of us trying to do our homework and your time is so appreciated.
Sincerely, Jennifer
I don’t think I can help you further at this point without having a clinical exam. I recommend that you visit Dr Briss once you are back to Boston.
And thanks again for all your help. Dr. Briss was great! Truly insightful. In the end, he felt my case wasn’t severe enough to really consider jaw surgery, which I was actually happy to hear.
Do you give the permission to publish a short report of your consultation with Dr David Briss?
Yes, you have my permission to publish anything related to my case. I only ask that sensitive information or anything among those lines be covered.
Looking forward to seeing the story!
I met Cary at my office yesterday, and on clinical exam he is Class II div 1 subdivision right malocclusion, maxillary midline deviated approximately 1mm left and mandibular midline deviated approximately 3mm right.
There is slight bimaxillary crowding and an overbite of approximately 3mm. He has the remnant of a crossbite on the right side (1.6 and 4.6 are end-on transversely). Significant dental history is a PFM crown on 2.1, and he had orthodontics as a child, but no palate expansion was done. His chief complaint is facial asymmetry, particularly mandibular asymmetry and chin deviation.
The radiographic reconstructions he provided me seem to show the condyles positioned relatively well in the fossae. The cortex is intact, there is virtually no evidence of flattening of either condyle. There does not seem to be any evidence of pathology.
The panoramic reconstruction appears to show a deviation of the nasal septum to the right, but this is not obvious on the PA cephalogram reconstruction. In PA he does have a significant sloping of the floor of the nasal cavity, higher on the right than the left. The J points do not appear to be as asymmetric as the nasal floor finding might indicate. On facial examination his right orbit is noticeably higher than his left orbit. The chin is deviated to the right of the facial midline.
I suspect the etiology of his malocclusion and asymmetry is related to maxillary constriction, possibly a crossbite and mandibular functional shift that was never skeletally corrected during his prior orthodontic treatment.
In the absence of a current posterior or anterior open bite, and with images of well defined condyles I do not feel that there is either condylar hyperplasia on the left nor resorption on the right. It probably warrants followup at some time in the future, but at the moment it does not appear to be a progressive problem.
The only orthodontic treatment option that might satisfy his chief complaint would be combined orthodontics/orthognathic surgery. This most likely would be SARPE followed by limited orthodontics, then a Le Fort 1 for rotation of the maxilla (to the right) and asymmetrical BSSO with rotation to the left. However, this amount of treatment may result in only a small gain in aesthetics compared to a sliding genioplasty, and I would not recommend surgical orthodontics at this time. Additionally, an orthodontic-only treatment plan would perhaps correct the malocclusion to Class I bilaterally, but with no affect on the facial aesthetics, and is therefore not indicated either.
Dr David Briss
Orthodontist
5 Village Square
Chelmsford, MA 01824
Thank you Dr. Briss for this thorough report. You were my eyes at far distance.
Your tentative treatment plan is close to one of my hypotheses: extraction of 3 premolars and a sliding genioplasty. It is unfortunate that I missed the posterior right crossbite, but I could not see this from the reconstruction xray.
We went as far as we could get with an internet consultation.
I wish you all the best.
It was my pleasure to meet with Cary and go over his case.
In my note I left out our discussion of the disc displacement; I did find anteromedial disc displacement with reduction, but with no limitation in any excursive movements, no history of pain or locking.
He did indicate to me that he has intermittent right ear pain, perhaps this is related to the more narrow nasal cavity on the right side, possibly some blockage resulting in intermittent middle ear inflammation.
Given the appearance of the condyles and the lack of a functional shift I doubt that the ear symptoms are related to the joint sounds.
Merci David for the clarification.
Thank you so much Dr. Chamberland for your detailed reply. Would you mind looking over a few follow up questions I have?
– First off, for my case, would you not recommend considering jaw surgery? I was told previously by one oral surgeon that despite the fact my jaw is only slightly recessed, I would still benefit from CCW rotation and correction of the midline deivation which could only result from jaw surgery.
– Also, with regards to molar extraction, would this not cause the mandible to recess even further back?
– Finally, in your opinion, do you believe my facial asymmetry (not just jaw, but eyes, and ears as well) could be the result in the differing sizes of my condyles? Or, do you believe my facial asymmetry was simply more skeletal growth related?
I actually just had an MRI yesterday, so I hope they can tell from that whether the condyle is still growing or not.
Merci, Doctor.
Regards to surgery, you may benefit from orthognathic surgery if you want to have a straighter profile or correct the vertical asymmetry in the frontal plane.
I am not sure you would need counterclockwise rotation of the occlusal plane (decrease pitch) because the 3D and ceph view shows a fairly normal angulation of the occlusal plane to the Frankfort plane (FH).
My concern is that you don’t have an increase overjet, therefore, there is no room to advance the mandible. Extraction would be necessary to create an overjet that would allow mandibular advancement. If so, extraction of 1 lower left premolar may be what is needed (non-extraction in the maxillary arch).
Your facial asymmetry, if one wants to correct it, need “yaw” correction of the mandible and “roll” correction of both maxilla and mandible.
Finally, I would like to clarify that if you elect to do an ortho treatment with or without surgery, the joint clicking may still remain. Orthodontic treatment of orthognatic surgery don’t cure TMJ derangement.
The MRI will tell something about the disk relationship in the glenoid fossae. It does not say anything about growth activity. To assess growth activity, you need to have a bone scan (scintigraphy with Tc99).
Thank you Doctor, I will try to get a bone scan as soon as possible and let you know. Based on the initial CT images though, do you see any evidence of condylar hyperplasia?
I just got my MRI report back which my oral surgeon said the findings were “insignificant” but I thought I would share with you anyway since to me, the results seemed quite the opposite. Perhaps you know a better oral surgeon in the Boston area?
Any input would be greatly appreciated.
Thanks.
Your MRI report says there is no evidence of a disk dislocation which is good news. I would not worry that much about the other findings since you have no pain and no limitation of jaw opening.
It is difficult to assess condylar length with the pict I received. The panoramic view is reconstructed from 3D. No doubt there some left condylar hyperplasia that has occurred. The important thing to assess is if it is still growing or it is in remission.
I would like to remind you that the information I gave to you is a hypothesis. It is not intended to be a thorough diagnosis nor any suggestion I made would be considered final treatment plan.
I don’t think I can help you further than I did. I saw that you come from Boston. I would recommend you my good friend Dr. David Briss. He practises in Boston and teaches at Boston University.
Hi Cary, I have been informed that you visited Dr. David Briss. How was the consultation with him?