Temporomandibular Joint
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Loading...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.
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.
Salut Dr. Chamberland,
I was recently diagnosed with ICR after visiting a TMJ specialist and doing some CT scans. I’ve had jaw pains since I was in high school (I am now 25). Since I was diagnosed, I read many articles on PubMed on ICR and also came across your Three case reports. The information you have on ICR has been very helpful for me to learn more about this disease.
I was wondering if you knew of any maxillofacial surgeons or specialists in this field that are in Toronto?
Thank you in advance for taking your time to reply!
Brenda
I would recommend Dr Marco Caminiti. He is a good friend and is currently Head and program director of Oral and Maxillofacial Surgery at the University of Toronto.
https://www.crescentoralsurgery.com/team/dr-marco-caminiti-bsc-dds-med-frcd/
Best regards
Hi, my daughter was diagnosed with idiopathic condylar resorption about a year and a half ago. She was having pain when chewing from time to time so I took her to her dentist who referred her to a specialist in Edmonton Alberta. She has just turned 11 and we will be going back to see her doctor in nest 6 months sometime. She has recently had and MRI that ruled out any rheumatoid arthritis. She is affected on only one side (as far as her last images) and her Dr felt that at the time it was in “repair” on the damaged side. I have no idea what our next steps after this are or what this even means for our daughter (I feel she is very young for this diagnosis – most others I have found on line are older that her). Right now she takes vitamin C,D and glucosamine each day. Plus she is on a soft food diet (now load on the jaw). I also give her – k2 (mk-7), boron, magnesium, vitamin E, a probiotic – each day. There will not be enough room in her mouth for all her adult teeth when they come in. She is seeing an orthodontist from the same office as her specialist. I am also then wondering if she should be seeing a surgeon as well at this time to make sure we do all the right things as she grows over the next several years. Thanks for your time.
Jackie
There is very good specialist in Edmonton. University of ALberta run a clinic for TMJ problems. The have very good rhumatologist.
It is sad that your daughter is affected by ICR. Keep in mind it could be a form of juvenile idiopathics arthritis that may affect more than the TMJ.
Did you read my article “Progressive idiopathic condylar resorption: Three case reports
https://www.sciencedirect.com/science/article/abs/pii/S0889540618311223
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.
I would recommend you Dr Larry Wolford
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.
Je vous recommande Dr Dany Morais chirurgien buccal chez Maxillo Vendôme et Dr Johanne Séguin orthodontiste ou encore Dr Jean Poirier chirurgien buccal.
Un grand merci pour votre réponse.
Au plaisir.
Also, in regard to the Tc 99 bone scan – I’ve been reading about it online, but I’m not quite sure what to ask for.
Is it standard for most radiologists know about the uptake in the condyles and what to compare the ratio to? Or would I have to get my referring doctor to specifically provide the details such as standard levels/specify the other area of the body to compare to?
Is this only done through a SPECT scan?
I am in Australia and there is barely any information about local cases of CR, so while we have SPECT scans, I’m unsure if this actual scan is ever done in relation to CR.
Dr. Chamberland, thank you very much for sharing your slide-show presentation. It has been very informative.
My problem started 10 years ago at age 22, with pain in one side. A CT scan showed degenerative changes in both condyles, but one side worse than the other. I also developed an overjet.
I didn’t seek/continue any treatment, besides a short time in a splint, as my pain went away, and the only problem was my overjet/protruding incisors. I assumed they could be treated orthodonticaly in the future.
Since 3-4 yrs ago I noticed my face and profile looking different. My lower jaw seems to be sitting further back and I feel I have extra skin under my chin/neck area. My overjet is 9mm.
This year I decided to investigate getting braces. I was referred to assess the health of my TMJs, and had a MRI recently that reported ‘severe osteoarthritis of both temporomandibular joints compatible with degeneration, tearing and resorption’.
My situation is slightly different though: I don’t have an open-bite. Rather, my bite has been getting deeper. I apparently don’t have a high-mandibular plane either. So it seems my jaw is going back, but not rotating down. Have you seen/heard of CR presenting this way before?
One surgeon told me I don’t have CR because I don’t have the open bite and high angle.
Can the mandible go back in just osteoarthritis, not CR? I am confused as to what I have.
I have come across only one article that mentions a deep bite:
Int J Oral Maxillofac Surg. 1999 Dec;28(6):411-8.
Long-term evaluation of patients with progressive condylar resorption following orthognathic surgery.
Hoppenreijs TJ1, Stoelinga PJ, Grace KL, Robben CM.
Any input would be greatly appreciated, thank you.
Best regards
Progressive condylar resorption
You have a good question. Is it possible to have a condylar resorption AND a deep bite? I don’t recall in any of the cases I have seen, and I have quite quite a fair number, that thse 2 conditions coexist.
Is someone have condylar resorption, the ramus become shorter and a the bite will likely open anteriorely with fulcrum at the 1st-2nd molar area.
The surgeon might be right when he say you don’t have CR because your don’t have a high mandibular plane angle and you have a deep bite. A simple panoramic xray can provide good information on the possibility of having condylar resorption. If so, then a CBCT scan of your TMJs would be the next imaging I would recommend. A MRI is a good imaging approach, but studies have shown that the sensitivity is 78% and the predictive value is only 54%.
The key factor is do you have pain? Did the ovejet increased recently? Did you had a bone scan to asses if you have bone remodeling activities?
If you can send me a panoramic xray via my professional facebook page, I could give you an opinion.
Hi Docter
Some feedback: I saw the specialized scans of my joints. I need a TMJ replacement on the one side.
It does not appear to be related to condylar resorption. The fracture (split diagonal below the condyle) from an earlier ‘complication’ during orthognactic surgery has not closed as the bone didn’t make contact. This has left my jaw very unstable.
My problem now is finding the right surgeon.
Thank you again for your kind assistance.
Regards
Ellena
I finally remembered a name of a famous oral surgeon from Pretoria, South Africa. He has written texbooks that the residents in oral and maxillofacial surgery used here in the program of Maxillofacial surgery of Hôpital l’Enfant-Jésus.
Therefore, I would receommend you Prof. JP Reyneke or any member of his team, Dr van der Linden or De Beukes. Their website is minimalist but Dr Reyneme’s textbook is excellent.
Thank you very much!
It would be much appreciated if you keep us informed.
Cordialement,
Dr Sylvain Chamberland
It is very generous of you and I really appreciate it.
Thank you very much indeed for your reply! I will follow your advice.
I would be very grateful if you could enquire from your friends if they could recommend specialists that are good with treating this condition in the Gauteng area. I live in Pretoria.
Kind regards
I forwarded your request.
Will get back to you if they reply.
Best regards.
Hi
Your input will be greatly appreciated.
I am 58 yrs old. I had orthognactic surgery 5 years ago to correct an openbite. There were complications. The surgeon bust my jaw into small bits. My upper and lower jaw were fastened for 6 weeks. The alignment was wrong so agter 6 months a second oprration was neededmto correct it. I have significant hardware left in my bones.
Progessively over the years the prosthodontist has had to file away at my back teeth to correct my occlusion. (All teeth are crowned). No more filing can be done. I discovered the condition progessive idiopathic condylar resorption myself and know it explains what is going on. I am very frightened.
I was on HRT (hormone replacement therapy) for years (including this period). I stopped it 2 months ago because I was estrogen dominant. I take bioidentical progesterone now.
Do you think the HRT could be the cause of all this? What are the chances of remission now?
What is the long term outlook if this condition continues? A joint replacement?
I woukd also like to know whether you think Wolford and Cardenas protocol which includes the Mitek anchor would be a solution to consider?
Kind regards
Ellena
Hi Elena
You may have had condylar resorption prior to your fist surgery and you may have had progressive condylar resorption after surgery that may explain the relapse and the open bite.
Hormone replacement therapy may have pay a role, but i doubt it would make a significant difference at 58 yrs.
Wolford protocol may be a solution to consider. If your condyle are destroyed, it may be a case of total joint replacement.
I receommend that you visit an orthodontist and get a comprehensive treatment plan. He will likely recommend you a surgeon that is aware of condylar resorption.
There is very good orthodontist in South Africa. I know a couple of friends who leaves in Canada but are south african. They may recommend me good names.
Best regards
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
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.
Thank you, that is most helpful.
Best wishes,
Claire
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
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).
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
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
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?
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