Orthognathic Surgery

1491
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
H
G
Prior to treatment
After treatment
F
F, Occlusal views
before and after reconstruction. G, Lateral
cephalometric radiographs before and
after reconstruction. H, Three-dimensional
computed tomography scan views before
and after cranial vault reconstruction.
A (right), C (left), H, from Posnick JC: The
role of plate and screw fixation in the
management of pediatric facial fractures.
In Gruss JS, Manson PM, Yaremchuk MJ,
eds: Rigid fixation of the craniomaxillofa­
cial skeleton, Stoneham, Mass, 1992,
Butterworth-Heinemann, p 416.
• Figure 35-7, cont’d

1492 SECTION 6  Post-Traumatic Dentofacial Deformities
A
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C.
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C.
C.
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o nicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
• Figure 35-8  A 16-year-old boy who had sustained a fracture of the right condyle of the mandible during
early childhood presented with resorption of the condylar fragment and resulting facial asymmetry. He previ­
ously underwent several years of compensating orthodontics to neutralize the occlusion, which resulted in
the loss of labial bone along the anterior mandibular teeth. He then underwent a comprehensive orthodontic
and orthognathic surgical approach that included Le Fort I osteotomy, left sagittal split ramus osteotomy,
reconstruction of the right condyle–ascending ramus with a costochondral graft, and osseous genioplasty.
A, Frontal facial view in repose before surgery. The computed tomography scan demonstrates facial asym­
metry that affects the maxilla and the mandible. B, Oblique facial view before surgery. The computed tomog­
raphy scan demonstrates an absent right condyle.

1493
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
D
Costochondral graft
Roll Orientation Correction
C
C, Articulated dental casts that indicate analytic model planning. D, Costo­
chondral graft is inserted through coronal scalp incision. The stabilization of the graft involves an
extended mini-plate and screws placed through a Risdon neck incision.
• Figure 35-8, cont’d 
Continued

1494 SECTION 6  Post-Traumatic Dentofacial Deformities
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
E
F
E, Frontal views in repose before and after reconstruction. F, Frontal views with smile before and after reconstruction.
• Figure 35-8, cont’d

1495
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
G
H
G
G, Maximum vertical mouth opening before and after reconstruction. H, Oblique views before and after reconstruction.
• Figure 35-8, cont’d 
Continued

1496 SECTION 6  Post-Traumatic Dentofacial Deformities
J
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
I
I, Worm’s-eye views before and after reconstruction. J, Occlusal views before and after reconstruction.
Note the recession along the labial aspects of the mandibular incisors both before and after surgery. Gingival grafting is indicated.
A (right), B (right), C, F, G, I, from Posnick JC: Management of facial fractures in children and adolescents, Ann Plast Surg 33:442-
457, 1994.
• Figure 35-8, cont’d

Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 35-9  When she was 16 years of age, this patient fell from a height of 6 meters and sustained maxillofacial and lower extremity trauma.
Her maxillofacial injuries included a displaced left condyle fracture, a displaced right condyle fracture, a comminuted left anterior mandibular fracture
with the loss of teeth, and left anterior maxillary dentoalveolar fractures. She was treated at another institution with tracheostomy, open reduction
and internal fixation of the comminuted anterior mandibular fractures, debridement of the anterior maxilla and the associated teeth, and closed
reduction of the bilateral condyle fractures. The lower extremity fractures required the placement of left and right femoral rods and open reduction
and internal fixation of the right ankle and foot fractures. The patient underwent several months of intermaxillary fixation. With the release of the fixa­
tion, radiographs confirmed bilateral temporomandibular joint (TMJ) ankylosis. One year later, the patient was taken to the operating room for the
removal of the internal fixation of the left anterior mandible.
She was referred to this surgeon when she was 20 years old for secondary reconstruction. She was found to have bilateral TMJ ankylosis, malunion
and displacement of the mandible, anterior maxillary dentoalveolar defects, the loss of multiple teeth in both arches, and impacted wisdom teeth.
She underwent a comprehensive assessment that also included the evaluation of her dental rehabilitative needs. An orthodontist and a prosth­
odontist were consulted, and perioperative orthodontic treatment was instituted. A, Frontal views in repose before and after reconstruction and
dental rehabilitation. B, Frontal views with smile before and after reconstruction and dental rehabilitation.
Continued

Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
Staged maxillofacial reconstruction included the following:
1. Left and right TMJ ankylosis release, including left and right coronoidectomies with the immediate improved mandibular range of motion
2. Six months later, maxillomandibular reconstruction that included:
• Bilateral sagittal split ramus osteotomies
• Harvesting of anterior iliac crest graft
• Oblique osteotomy of the chin
• Reconstruction of the anterior maxillary defect with autogenous corticocancellous bloc graft
• Revision of the tracheostomy scar
3. Six months later, a left parasymphyseal osteotomy and a right sagittal split ramus osteotomy to further improve the mandibular arch form
Six months after successful bloc grafting to the anterior maxilla, four dental implants were placed. Six months after successful implant placement,
restorative dentistry was carried out that included crown and bridge work in both arches. C, Profile facial views before and after reconstruction
and dental rehabilitation. D, Oblique facial views before and after reconstruction and dental rehabilitation.
• Figure 35-9, cont’d

1499
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
F
Prior to secondary reconstruction
After first stage reconstruction
After reconstruction and dental rehabilitation
E
E, Occlusal views before secondary reconstruction; after TMJ ankylosis release, bone grafting of the anterior
maxilla, and the placement of implants; and then at the completion of dental rehabilitation. F, Craniofacial computed tomography scan
views before reconstruction with demonstrated bilateral TMJ ankylosis.
• Figure 35-9, cont’d 
Continued

1500 SECTION 6  Post-Traumatic Dentofacial Deformities
After TMJ ankylosis release
After reconstruction/dental rehabilitation
G
H
G, Panorex radiographs after ankylosis release and then after the completion of recon­
struction and dental rehabilitation. H, Lateral cephalometric radiographs before and after ankylosis relapse, bone
grafting, and mandibular osteotomies.
• Figure 35-9, cont’d

1501
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 35-10  A recent college graduate was referred by his orthodontist for a surgical consult. He was known to have a developmental
jaw deformity that was characterized as an asymmetric mandibular excess growth pattern in combination with maxillary deficiency. He had
undergone orthodontic mechanics earlier during his life in an attempt to modify growth and then to straighten the teeth; this included four
bicuspid extractions. An asymmetric Angle Class III negative overjet malocclusion remained. The patient had a lifelong history of chronic
obstructive nasal breathing that was unresponsive to nasal sprays. At this time, he made a personal decision to proceed with orthognathic
surgical reconstruction. Just 1 week after the surgical consult, he was assaulted while walking on a city street. Maxillofacial injuries included
a displaced right parasymphyseal fracture and a displaced left condyle fracture. A, Facial views in repose before and after reconstruction.
B, Facial views with smile before and after reconstruction.
Continued

Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
This further altered the occlusion and involved a shift of the mandible to the left and a step-off between the right central
and lateral incisors. The fractures were treated with the placement of surgical arch wires; open reduction and internal fixation of the right para­
symphyseal fracture; and closed treatment of the left condyle fracture. Four weeks later, the patient was converted to orthodontic appliances,
and orthodontic treatment continued in preparation for jaw reconstruction. Six months after the maxillofacial injuries and with orthodontic prepara­
tion complete, he underwent definitive jaw and intranasal surgery to improve the airway, occlusion, and facial morphology. The patient’s procedures
included maxillary Le Fort I osteotomy (vertical lengthening and horizontal advancement); bilateral sagittal split osteotomies of the mandible
(lengthening of the left posterior facial height and horizontal advancement); septoplasty; and the reduction of the inferior turbinates. Orthodontic
maintenance and detailing continued until the appliances were removed 6 months after surgery. C, Oblique facial views before and after recon­
struction. D, Profile views before and after reconstruction.
• Figure 35-10, cont’d

1503
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
After compensating orthodontic treatment as a teenager including four-bicuspid extractions
Prior to treatment of mandibular fractures
After primary fracture treatment with orthodontics in progress, prior to reconstruction
After reconstruction
E
E, Occlusal views before retreatment, after the mandibular fractures, after primary fracture treatment with
orthodontics in progress, and after the completion of the reconstruction.
• Figure 35-10, cont’d 
Continued

1504 SECTION 6  Post-Traumatic Dentofacial Deformities
G
H
F
F and G, Articulated dental casts that indicate analytic model
planning. H, Lateral cephalometric radiographs before and after reconstruction.
• Figure 35-10, cont’d

1505
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
Prior to retreatment (after four-bicuspid extractions). Prior to mandibular fractures
Parasymphseal Fracture
Condyle
Fracture
I
I and J, Panorex radiographs taken before any surgery; after the mandibular fractures were
sustained; after treatment of the mandibular fractures but before orthognathic surgery; and after orthognathic surgery.
• Figure 35-10, cont’d 
Continued

1506 SECTION 6  Post-Traumatic Dentofacial Deformities
After ORIF right parasymphyseal fracture and closed treatment left condyle fracture
After definitive reconstruction
J
L
K
Parasymphyseal fracture
Displaced condyle fracture
K and L, Computed tomography scans that indicate the locations of the mandibular fractures (left
condyle and right parasymphysis) before treatment.
• Figure 35-10, cont’d

1507
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
B
After ORIF
condylar fx
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
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Orththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
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Su
S rg
r ery
ry
ry
ry; J.C.
C.
C.
C.
C Pos
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os
os
os
os
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os
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os
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os
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os
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os
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osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
A
• Figure 35-11  A woman in her late 20s was in a bicycle accident and sustained a displaced right condylar fracture
and anterior maxillary dentoalveolar trauma. She underwent open reduction and internal fixation of the right condyle
fracture with plate and screw fixation. There was partial necrosis of the proximal (condylar) segment with a loss of
posterior facial height. This resulted in a shift of the mandible on the ipsilateral side. There was a significant centric
relation–centric occlusion discrepancy; the patient had difficulty chewing, symptomatic temporomandibular disorder,
and facial asymmetry. She was referred to this surgeon and underwent perioperative orthodontics, bilateral sagittal split
ramus osteotomies, and an osseous genioplasty. A, Frontal facial and occlusal views before reconstruction. B, Panorex
radiograph before reconstruction.
Continued
Chapter 28).4,9,51,54,55,72,75,97,107 If the initial fracture occurred
during childhood and was followed by condylar resorption,
then additional secondary deformities of the maxilla
and chin will have also occurred during growth. In addition
to reconstruction of the ipsilateral mandible with a costo­
chondral graft, surgical correction of the maxilla above and
the chin below is often required. This includes use of Le
Fort I osteotomy (primarily for cant and dental midline
correction); contralateral sagittal split ramus osteotomy
(asymmetry correction); and osseous genioplasty7 (see
Fig. 35-8).
When a displaced condylar fracture occurs in an adult
and healing involves the loss of the ipsilateral posterior facial
height, a predictable shift in the occlusion is also expected
(Figs. 35-10 through 35-15). Depending on the individual’s
masticatory musculature and condylar (TMJ) adaptations,
a significant centric relation–centric occlusion discrepancy
may have occurred.52,130,134 This can result in difficulty with
chewing, swallowing, speech, secondary occlusal trauma,
symptomatic TMD, and significant facial asymmetry. If
so—and assuming satisfactory mandibular mobility (i.e.,
vertical mouth opening)—standard sagittal split ramus
osteotomies can generally be carried out to reestablish the
following: 1) the ipsilateral posterior facial height; 2) a
consistent preinjury occlusion; 3) the restoration of facial
Text continued on p. 1521

1508 SECTION 6  Post-Traumatic Dentofacial Deformities
D
Orth
r ognathic Surg
r ery; J.C. Posnick
C
C, Profile and cephalometric views before reconstruction. D, Articulated dental casts that indicate analytic model
planning.
• Figure 35-11, cont’d

1509
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
E
F
E, Frontal views before and after reconstruction. F, Oblique views before and after reconstruction.
• Figure 35-11, cont’d 
Continued

1510 SECTION 6  Post-Traumatic Dentofacial Deformities
H
I
G
G, Occlusal views before and after reconstruction. H, Lateral cephalometric views before
and after reconstruction. I, Panorex radiograph after reconstruction.
• Figure 35-11, cont’d

1511
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
A
After ORIF condylar fracture
Malunion angle fracture
Orth
r ognathic Surg
r ery; J.C. Posnick
• Figure 35-12  A woman in her late 20s
was a pedestrian who was struck by a motor
vehicle. She sustained a right condylar frac­
ture, a right parasymphyseal fracture, and
maxillary dentoalveolar trauma. Primary frac­
ture management included open reduction
and internal fixation of the right condyle
fracture, closed reduction of the right para­
symphyseal fracture, and closed reduction of
the dentoalveolar injury. She arrived to this
surgeon for the evaluation of secondary
deformities that included the partial resorption
of the condylar segment, malunion of the
parasymphyseal fracture (widening), and
the loss of maxillary dentoalveolar compo­
nents. Comprehensive evaluation included
additional consultations with an orthodontist,
a periodontist, and a restorative dentist.
Surgery included bilateral sagittal split ramus
osteotomies (correction of asymmetry), right
parasymphyseal osteotomy (narrowing), and
bloc iliac grafting of the maxillary dentoalveo­
lar defects. Dental implants were placed
4 months later. Restorative work was com­
pleted 6 months after implant placement.
A, Frontal view before secondary reconstruc­
tion. The Panorex radiograph indicates the
loss of condylar height. The anteroposterior
cephalometric radiograph and facial views
indicate mandibular width asymmetry.
Continued

1512 SECTION 6  Post-Traumatic Dentofacial Deformities
B
Pre-reconstruction occlusion
Planned changes
B, Dental casts before and after model surgery planning.
• Figure 35-12, cont’d

1513
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Facial views before and after reconstruction and rehabilitation. D, Oblique views before and after reconstruction and
rehabilitation.
• Figure 35-12, cont’d 
Continued

1514 SECTION 6  Post-Traumatic Dentofacial Deformities
E
After reconstruction/dental rehabilitation
A - Bone defect requires grafting
B - Injured teeth with root canals/crowns in place
A
B
B
A
A
F
E, Occlusal views before and after reconstruction and rehabilitation. F, Panorex radiograph after reconstruction and
rehabilitation.
• Figure 35-12, cont’d

1515
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
B
After ORIF with malunion
Displaced
condyle
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatathicic Su
Su
Su
Surg
r ery
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
A
X - required extractions
X
X
• Figure 35-13  A woman in her 20s was in a moped accident and sustained maxillofacial trauma that included a displaced left
condyle fracture, a right parasymphyseal fracture, maxillary dentoalveolar trauma, and the laceration of the upper lip. She was initially
treated with closed reduction of the left condyle fracture, open reduction and internal fixation of the right parasymphyseal fracture,
debridement of the right maxillary incisors, and reimplantation of the left maxillary incisors. By 3 months after treatment, malunion
of the mandible resulted in malocclusion, difficulty chewing, symptomatic temporomandibular disorder, and facial asymmetry. The
patient was referred to this surgeon for comprehensive evaluation included additional consultation with a periodontist, and an ortho­
dontist. She underwent preoperative orthodontics and reconstruction that included bilateral sagittal split ramus osteotomies. A bloc
corticocancellous graft was simultaneously crafted and secured to the anterior maxillary dentoalveolar defect. Four months later,
four dental implants were placed. This was followed 4 months later by the placement of crowns. A, Frontal and occlusal views 1
week after the accident and primary fracture management. B, Panorex radiograph taken just after primary fracture management.
Continued

1516 SECTION 6  Post-Traumatic Dentofacial Deformities
D
Pre-maxillary defect
Bloc iliac graft in place
C
C, Three months after primary fracture management, analytic model planning indicates details for the
mandibular reconstruction. D, Intraoperative view of the maxillary dentoalveolar defect and the crafted bloc corticocancellous iliac
graft fixed in place.
• Figure 35-13, cont’d

1517
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
F
E
4 months after injury with orthodontics in progress
Prior to grafting
6 months after injury
2 months after iliac grafting and jaw reconstruction
4 months after grafting
Stint-implant placement
4 months after grafting
4 implants have just been placed
E, Close-up views of the anterior maxilla indicate the sequence of events: 4 months after injury but
before grafting; 6 months after injury and 2 months after grafting; 4 months after grafting with stent and implant placement; and
then just after the placement of four implants. F, Panorex radiograph after mandibular and maxillary reconstruction and dental
rehabilitation.
• Figure 35-13, cont’d 
Continued

1518 SECTION 6  Post-Traumatic Dentofacial Deformities
I
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
G
H
G, Frontal views before and after reconstruction and rehabilitation. H, Oblique views
before and after reconstruction and rehabilitation. I, Occlusal views before and after reconstruction and dental
rehabilitation.
• Figure 35-13, cont’d

1519
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
• Figure 35-14  When he was between 13 and 15 years old, this patient underwent standard orthodontic treatment and achieved a
normal occlusion without a centric relation–centric occlusion (CR-CO) discrepancy. When he was 16 years of age, he was in a motor
vehicle accident and sustained injuries that included a displaced left condyle of the mandible fracture. The fracture was treated with closed
treatment and intermaxillary fixation for 2 weeks followed by guiding elastics for an additional 4 weeks. The patient also sustained fracture
of the left mandibular first and second molars, which required the placement of full crowns. With healing, there was a loss of posterior
facial height and a shift of the mandible toward the fracture. There was a significant CR-CO slide with masticatory muscle discomfort and
left temporomandibular joint noise. The patient underwent computed tomography scanning and magnetic resonance imaging of the tem­
poromandibular joint, which indicated the following: left condylar head flattening and remodeling; the meniscus being in good alignment
with a deformed condylar head; and, on the right side, the mandibular condyle and meniscus appear to be unremarkable. The patient
maintained an adequate range of mandibular motion. He was being treated with a splint that prevented CR-CO slide, and his temporo­
mandibular disorder has improved. Bilateral sagittal split osteotomies of the mandible were recommended to establish a consistent CR-CO
without prematurities. A, Facial views 2 years after left condyle fracture with closed reduction. B, Intraoral views with the patient in CR
bite. C, Intraoral views with the patient in CO bite.
Centric relation (CR) bite
Centric occlusion (CO) bite
C
B
Or
Or
Or
Or
Or
Or
Orthththththththth
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C Pos
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Su
Su
Su
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Su
Su
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ry
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A

1520 SECTION 6  Post-Traumatic Dentofacial Deformities
• Figure 35-15  A middle-aged man had a syncopal episode and sustained a displaced right condyle fracture of the mandible and maxillary
dentoalveolar trauma. This was managed with closed treatment and 2 weeks of intermaxillary fixation followed by elastics, masticatory muscle
retraining, and then dental rehabilitation. A comfortable occlusion with minimal centric relation–centric occlusion discrepancy and resolution of
temporomandibular disorder was possible without the need for surgical intervention. A, Facial and occlusal views 2 days after injury. B, Panorex
radiograph 4 weeks after injury that indicates right subcondylar fracture and dislocation and left maxillary dentoalveolar trauma.
B
Displaced
condyle fx
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
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Orththththththththththththththththththththththththththththththththth
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g atatatatathicicicici Su
Su
Su
Su
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Su
Su
Surg
r ery
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ry
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r ; J.C.
C.
C Pos
os
os
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A

1521
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
Or
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r ogn
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Su
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r ery
ry
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C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
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osnicicicicicicicicicicicicicici k
C
C, Frontal view at 18 months after injury. Effective muscle retraining achieved
a stable occlusion. With wide vertical opening, there is a shift of the chin to the right. The centric
occlusion view is shown 18 months after injury with successful dental rehabilitation.
• Figure 35-15, cont’d 
symmetry; and 4) the relief of TMD (see Chapter 4 and
Figs. 35-10 through 35-15). In most cases, after the indi­
vidual sustains a displaced condyle fracture, the combina­
tion of condylar remodeling and masticatory muscle
adaptation will result in a manageable occlusion and an
adequate range of motion without the need for secondary
reconstruction (see Fig. 35-15).
Posttraumatic Segmental
Dentoalveolar Defects
A frequently seen pattern of posttraumatic secondary defor­
mity occurs after the avulsion or devascularization of an
anterior dentoalveolar segment (i.e., the maxilla, the man­
dible, or both).39 This may occur as an isolated injury or
in conjunction with other jaw fractures (Figs. 35-16 and
35-17; see also Figs. 35-4, 35-9, 35-12, and 35-13). To
secondarily correct this segmental dentoalveolar deformity
with a loss of teeth, an autogenous corticocancellous iliac
bone graft fixed in place with microplates and screws is
generally a reliable option (see Figs. 35-4, 35-9, 35-12,
35-13, 35-16, and 35-17). This is followed by a soft-tissue
vestibuloplasty and a keratinized mucosa grafting proce­
dure, when required. Approximately 4 months after success­
ful bone grafting and soft tissue re-arrangment, dental
implants are placed. This is followed several months later
with crown restorations. Comprehensive skeletal recon­
struction and dental rehabilitation of segmental dentoalveo­
lar defects generally involves a surgeon, a periodontist, and
a restorative dentist and is best coordinated from the onset.87
Conclusions
Despite every attempt to ensure the optimal primary treat­
ment of craniomaxillofacial fractures, a percentage of indi­
viduals present with residual facial deformities and head and
neck dysfunction that require secondary reconstruction.
Specific patterns of secondary maxillofacial deformities are
frequently seen, including TMJ ankylosis, saddle-nose

• Figure 35-16  A 28-year-old woman was in a motor vehicle accident and sustained maxillary dentoalveolar trauma with a loss of five anterior
teeth and associated alveolar bone. She had previously undergone orthodontic treatment including 4 bicuspid extractions to close an anterior open
bite. A, Frontal view with temporary partial denture in place. Occlusal view with the removal of the partial denture indicates the extent of dentoalveolar
injury and bone loss. B, Intraoperative view with a crafted corticocancellous iliac graft fixed in place. A prefabricated stent was used to assist with
graft positioning and contouring. C, Occlusal views after successful grafting, placement of 5 implants and then dental restorative work. D, Panorex
radiograph after successful grafting and the placement of five dental implants.
B
Bloc iliac graft in place
Cancellous bone added
Surgical stent
©Elsevier Inc.
Orthth
r ogn
gn
gn
gn
gnatatathicic Surg
r ery
ry
ry; J.C. Pos
osnicicick
A
D
C

1523
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
A
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
• Figure 35-17  A 21-year-old woman was in a motor vehicle accident and sustained naso–orbital–ethmoid fractures, left anterior maxillary den­
toalveolar trauma with a loss of three teeth, and associated alveolar bone and left posterior mandibular dental injuries. She was initially treated at
another institution. She was referred to this surgeon 6 months later, with left and right enophthalmus, saddle-nose deformity, and right and left
medial canthal drift. She underwent left and right orbital reconstruction, left and right medial canthopexies, and the correction of the saddle-nose
deformity with a full-thickness cranial graft (radix to tip) through a coronal scalp incision. She was treated by her local dentist with a removable
maxillary partial denture. She returned to this surgeon for further maxillofacial evaluation 14 years later in the hopes of achieving improved dental
rehabilitation. Examination confirmed left anterior maxillary dentoalveolar defect, left posterior mandibular absent second bicuspid and first molar,
and several teeth with root canals. She agreed to a comprehensive dental rehabilitation approach. Additional evaluation by a periodontist, and a
prosthodontist, was carried out. The patient also complained of chronic obstructed nasal breathing. Intranasal examination confirmed septal devia­
tion and enlarged inferior turbinates. She underwent periodontal treatment followed by temporization of the dentition. Surgical procedures included
septoplasty; inferior turbinate reduction; and reconstruction of the maxillary dentoalveolar defect with an autogenous corticocancellous iliac bloc
graft. Four months later, three dental implants were placed in the anterior maxillary region. She also underwent implant placement in the left posterior
mandible and the right posterior maxilla. Six months after implant placement, definitive crown placement and bridgework were initiated. A, Frontal
views with smile before and after comprehensive secondary jaw and dental rehabilitation.
Continued

1524 SECTION 6  Post-Traumatic Dentofacial Deformities
C
B
B and C, Occlusal and palatal views before grafting and then after grafting, implant placement, and dental
restorative work.
• Figure 35-17, cont’d

1525
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
D
D, Panorex radiographs before and then after successful secondary jaw and dental rehabilitation including
grafting and the placement of dental implants.
• Figure 35-17, cont’d 
Continued

1526 SECTION 6  Post-Traumatic Dentofacial Deformities
F
Iliac (corticocancellous) graft in place
Fixation securing graft
G
Fixation securing graft
Labial flap advanced and sutured in place
E
Labial flap elevated
Dento-alveolar defect demonstrated
E, F, and G, Intraoperative views of autogenous iliac corticocancellous graft reconstruction of the left maxillary dento­
alveolar defect.
• Figure 35-17, cont’d

1527
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
result in a favorable outcome for most patients. A team
approach with coordinated efforts by the maxillofacial
surgeon, the orthodontist, the restorative dentist, and the
periodontist is often advantageous for the achievement of
optimal results.
deformities, orthognathic deformities, and segmental den­
toalveolar defects. Although there are few published reports
that specifically address the management of posttraumatic
secondary maxillofacial deformities, the application of basic
orthognathic and dento-alveolar restorative principles will
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1529
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
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1530

36
Idiopathic Condylar Resorption:
Evaluation and Treatment
JEFFREY C. POSNICK, DMD, MD
• Theories of Etiology
• Clinical Perspectives
• Current Clinical Approach to Correction of
the Secondary Jaw Deformities
• Brief Overview of Author’s Current Thinking
• Case Presentations
• Conclusions
during or after active dental restorative, orthodontic, or
surgical interventions.
• During the active phase of condylar resorption, TMJ and
masticatory muscle discomfort is expected. The active
phase often subsides within 6 to 12 months.
• When the condition becomes quiescent, the individual
is generally left with satisfactory TMJ function without
significant limitations in mouth opening or intracapsular
pain. Persistent joint noise is frequent.
• Head and neck functions are likely to be negatively
impacted including: chewing; breathing; speech articula­
tion; and body image.
• When the condition is in remission, a cartilaginous cap
over an intact cortical rim can generally be documented.
A deflated or diminished condylar head is generally seen
on imaging (e.g., magnetic resonance imaging or com­
puted tomography scanning). The glenoid fossa and the
articular disc typically remain biologically intact.
Mandibular and occlusal findings generally include the
following:
• Change in the shape of the condylar heads (i.e., flatten­
ing and thinning)
• Decrease in condylar height
• Loss of overall posterior facial height
• Mandibular retropositioning with clockwise rotation
(high angle)
• Angle Class II anterior open bite, excess overjet
malocclusion
Theories of Etiology
The current dominant theory holds that the etiology of ICR
is hormonally mitigated, immunologically controlled and
may arise in genetically susceptible individuals in conjunc­
tion with environmental factors.* Sex hormones are thought
to modulate biochemical changes within the TMJ, which
In patients with the condition of uncertain etiology that
is commonly referred to as idiopathic condylar resorption
(ICR)*, the condyles of the mandible partially resorb,
thereby causing a loss of condylar height with secondary
alterations of the maxillofacial morphology, occlusion, and
head and neck function.34,43,100 Progressive condylar resorption
(PCR)* is a general term that is used to describe conditions
that result in a similar loss of condylar height and secondary
effects but with known associations (e.g., juvenile idiopathic
arthritis, including any of its seven subtypes).13,24,59,76,92,93
In general, ICR has the following features:
• It generally affects girls and women who are between the
ages of 15 and 35 years.
• It is most frequent among teenage girls during the puber­
tal growth spurt.
• It typically results in bilateral symmetric condylar
involvement followed by stabilization (remission). In the
majority of affected individuals, limited further resorp­
tion occurs. Unfortunately, in some, a second episode
will result in the further loss of condylar height.
• There is no agreed-upon and proven etiology. ICR fre­
quently seems to occur as part of the natural course of
events rather than in conjunction with active therapy or
treatment. It may also coincide with or be observed
*References 1, 3-7, 15, 23, 28, 29, 31, 42, 51, 58, 65, 79, 86, 99,
111, 113
*These terms are likely to change as further knowledge becomes
available.

1531
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
may then result in condylar resorption. For some time, it
has been suggested that there is alteration in the serum
hormonal levels in at least some affected girls and women
with ICR.31 Gunson and colleagues described endocrine
function among women who arrived at their clinic with a
history, physical examination, and radiographic findings
that were consistent with ICR. The average age at presenta­
tion was 26 years (range, 15 to 45 years).31 Twenty-five of
the 27 patients (93%) had low levels of serum 17-beta
estradiol at the mid-menstrual cycle. Two subgroups were
further differentiated. The first group did not produce estro­
gen naturally (8 out of 27 patients), and the second group
(19 out of 27 patients) had low 17-beta estradiol levels that
were presumed to be the result of oral contraceptive pill
usage. The authors theorize that, whether the condition is
induced by ethinyl estradiol (i.e., oral contraceptive pills)
or by premature ovarian failure, a low circulating 17-beta
estradiol serum level negatively affects the natural reparative
capacity of the condyles. The authors believe that, when
17-beta estradiol deficiency is coupled with the presence of
local factors that cause compressive forces, condylar lysis is
more likely to occur and to ultimately result in the observed
condition called ICR.8,14,27,46,64 Unfortunately, the study did
not include a control group for oral contraceptive pill use
or precise knowledge of the phase of the menstrual cycle at
the time of hormone serum sampling. Although hormone
influences no doubt play a role, an autoimmune aspect is
also likely.31
Gunson and Arnett comment that whatever the underly­
ing etiology of ICR, all bone loss at the condylar level
involves a common resorptive pathway that includes cytokine-
activated osteoblasts that then recruit and promote the
activity of osteoclasts.32 This in turn results in the secretion
of enzymes that are responsible for the breakdown of
hydroxyapatite and collagen. A case in point is juvenile
idiopathic arthritis (ex. polyarticular arthritis, rheumatoid
factor positive), which is caused by a B-cell–mediated auto­
immune reaction to synovial tissues.33,80,105 A consequence
of this reaction is the presence of local inflammatory cells,
which secrete cytokines that cause the activation of
osteoblast-mediated osteoclast catabolism.89 The end result
is bone breakdown through the common resorptive
pathway.30 In patients with juvenile idiopathic arthritis
(JIA), a current treatment approach is to minimize articular
bone loss by using pharmacologic drugs that interfere with
specific cytokines and enzymes along the common resorp­
tive pathway rather than open joint or joint replacement
procedures. This may include non-steroidal anti-inflamma­
tories (NSAIDS) or other drugs such as methotrexate or a
newer class of medications called biologicals. 10,35,36,39,48,52,80,105
Gunson and Arnett point out that a similar approach to
ICR may prove to be useful.32
Another theory of the cause of ICR is avascular necrosis
of the condyle as a result of the compression of specific
vessels that supply the condyle followed by condylysis, loss
of condyle height with secondary jaw deformity and maloc­
clusion.16,17,45,62,72,81-84 Piper and Choung had speculated
that pathologic compressive forces of the posterior aspect of
the condyle on the ligamentous retrodiscal soft tissues con­
strict the small vessels, thereby limiting circulation to the
condyles with resulting in aseptic necrosis that accounts for
the observed condylysis in patients with ICR.17,72 They went
on to hypothesize that either a chronically dislocated non-
reducing disc or specific patterns of malocclusion may also
cause this cycle of events. As an extension of this thinking,
preventative open-joint procedures were offered to alleviate
the theoretical compression of the condylar circulation.
Those of us that are skeptical of the non-reducing disc cause
of ICR point out that the almost universally observed bilat­
eral symmetric simultaneous nature of this condition and
its occurrence only in females make the theory an improb­
able explanation.
Clinical Perspectives
The foregoing theories remain unproven, but the effects
of estrogen on condylar resorption and repair with or
without an autoimmune component seem indisputable.
Further studies will be required to determine the additive
effects of occlusion and masticatory muscle forces on the
TMJ in the presence of hormonal imbalance, autoimmune
influences, genetic predisposition and other environmental
factors.
Some clinicians suggest that, with a lack of clarity about
either the etiology of the condition or the effects of various
treatment modalities and without a guaranteed endpoint to
the condylar degeneration in any given patient, it is best to
remove the affected condyles and either reconstruct them
with a costochondral (rib) graft or to remove the whole joint
(i.e., the condyle, the disc, and the glenoid fossa) and
replace it with an alloplastic total joint. Proponents of a
partial or total joint replacement approach to the manage­
ment of ICR are correct in their thinking that the only
way to be certain that a further loss of posterior facial
height will not continue is to remove and replace the
condyle.55,56,107,110 For the great majority of patients with
ICR, joint replacement treatment seems radical on the basis
of the following: 1) the unlikely probability of long-term
TMJ pain 2) the expected satis­factory long-term mandibu­
lar (mouth) opening 3) the expected condylar stabilization
(“burn-out”) that is typically seen and 4) the known poten­
tial for perioperative complications with invasive open joint
procedures and the long-term failure rates of total joint
replacement.
Mercuri presents an alternative point of view with a
recommendation for total joint replacement to “eliminate
the variable issue of ongoing condylar resorption.”55,56 He
offers total alloplastic reconstruction as a definitive solution.
He also states that the non-alloplastic (biologic) condyle
option (e.g., costochondral grafting) requires stabilization
of the graft with minimal mobility while integration (union)
to the host mandibular occurs. This limits early masticatory
muscle rehabilitation, which he feels is contrary to the
tenets of physical rehabilitation after joint surgery. The

1532 SECTION 6  Post-Traumatic Dentofacial Deformities
modification) to “unload” and “stabilize” the condyles or
at least to relieve masticatory muscle hyperactivity and
discomfort are initiated. Orthognathic procedures and orth­
odontic treatment carried out to correct the secondary mal­
occlusion, the facial dysmorphology, and to open the airway
are more likely to be maintained if the condylar resorption
process has been stable for a period of time.49,77,112 Stability
can be documented by minimal ongoing change in the
occlusion, an intact cartilaginous cap, and an underlying
rim of cortical bone over the partially resorbed condyle.
The judicious use of technetium-99m methylene diphos­
phonate quantitative condylar bone scintigraphy can be
a helpful tool for assessing whether or not condylysis is
active.9,18,26,53,69,70,73,78,90,103 Unfortunately, these and other
tests only confirm the current anatomy and activity level;
they cannot predict the future.
The
resulting
maxillomandibular
dysmorphology
observed in patients with ICR can affect speech, swallow­
ing, chewing, breathing, and lip closure. ICR rarely results
in disabling facial or TMJ pain or significant limitations in
vertical mouth opening. The observed facial aesthetic con­
sequences of ICR are the result of the maxillo-mandibular
changes which distort but do not actually deform the soft-
tissue envelope. The overlying soft tissues of the lips,
cheeks, and neck and the underlying soft tissues of the
tongue and soft palate can be normalized only by correct­
ing the skeletal deformities. The achievement of favorable
facial aesthetics and the opening of the airway generally
require the surgical repositioning of the maxilla (Le Fort I
osteotomy), the mandible (ramus osteotomies), and the
chin region (oblique osteotomy). Limiting the surgery to
either the maxilla or the mandible with the idea of achiev­
ing a more stable occlusal result is not substantiated in the
literature and is likely to result in suboptimal results. The
key to achieving a successful outcome (i.e., enhanced
aesthetics, improved occlusion, and an open airway)
for the majority of patients with ICR is to surgically
accomplish adequate horizontal advancement of the entire
maxilloman­dibular complex often with counterclockwise
rotation.
The suggestion that, for the patient who has experienced
ICR, the use of distraction osteogenesis techniques rather
than standard orthognathic procedures will achieve a more
stable long-term occlusion is not supported by the litera­
ture.38,54,68,91,94,95,102 The distraction approach 1) generally
limits the region of reconstruction to the mandible 2) it
requires greater patient convalescences and compliance, and
3) it may increase (rather than decrease) the compressive
forces on the condyles.
When the condylar resorption process is believed to be
“burnt out,” a comprehensive approach to correct the
secondary deformities that involves an orthodontist, an
orthognathic surgeon, a TMJ specialist, and appropriate
imaging studies is recommended. Periodontal and restor­
ative dental work may also be needed. Evaluation by a
rheumatologist should also be considered. A thorough
disadvantages of alloplastic total TMJ reconstruction
include the following: 1) the cost of the device 2) the
expected material wear 3) the potential for long-term insta­
bility and failure 4) the incidence of both early and late
complications including infections with the associated need
for device removal and 5) the fact that alloplastic implants
will not follow a patient’s normal growth pattern. Joint
replacement advocates admit that patients must be advised
that alloplastic total TMJ reconstruction devices are expected
to have a limited functional life. In addition, the total joint
replacement approach requires the removal of the func­
tional glenoid fossa and disc along with excision of the
condylar head, neck, and posterior ramus on both sides.
Recommendations regarding how best to limit progres­
sion of condylar resorption and then how to treat the con­
sequences of ICR depend on the clinician’s beliefs about
the following 1) the disorder’s likely etiology 2) the effects
of malocclusion and the masticatory muscle forces and
3) the natural history of the degenerative process.
Some clinicians speculate that, if “decompressive” TMJ
treatment is initiated early during the clinical course of
active ICR, then less condylar resorption will occur. Others
believe that, after the resorptive process has begun, it runs
its course despite any attempt to “unload” the joint. Even
with a lack of evidence-based research into the subject,
most clinicians recommend attempts to limit mechanical
compressive TMJ forces through the use of conservative
measures (i.e., splints, muscle relaxants, medications and,
diet modifications) in the hopes that less resorption (con­
dylysis) will occur.11,12,19,21,25,37,40,47,63,66,101 Some authors
believe that counterclockwise rotation of the maxilloman­
dibular complex as part of the orthognathic correction
will increase the compressive condylar forces, whereas
others state that it is actually a method of “unloading” the
joint.20,22,41,44,50,57,61,71,85,88,105,108 I agree with the published
studies that document long-term skeletal stability when
counterclockwise rotation of the maxillomandibular
complex is carried out as part of the correction of
mandibular-deficient dentofacial deformity.74,75,77,109 A
common concern is that TMJ “loading” (i.e., the presence
of compressive forces) will occur if the condyles are “over­
seating” or if medial or lateral condylar torquing is allowed
to occur during orthognathic surgery.3-6 Some clinicians
speculate that individuals who have persistent TMJ symp­
toms (e.g., popping, clicking) after the orthodontic treat­
ment and corrective orthognathic surgery are at higher risk
for progression.2 Most published studies confirm that joint
noise (e.g., popping, clicking, grating) is not in itself an
indicator of future condylar resorption.60,87,104
Current Clinical Approach to Correction
of the Secondary Jaw Deformities
After the diagnosis of ICR is made, non-invasive measures
(e.g., splint therapy, muscle relaxants, medications, and diet

1533
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
mouth opening of 39 mm. Kaban and colleagues stressed
the importance of making a distinction between active and
inactive ICR and the patient’s refusal to wait for the pre­
sumed remission of the active condylar resorption phase.
Only those who were unwilling to risk recurrence are offered
the condylar replacement option; all others undergo a stan­
dard orthognathic approach.
Brief Overview of Author’s
Current Thinking
With the osteoarthritic condition known as ICR or PCR,
after the acute process “runs its course” (i.e., after 6 to 12
months for most individual’s), a degree of bilateral condylar
resorption will have occurred. This is typically followed by
relative condylar stability, satisfactory range of motion of
the mandible, and no significant TMJ limitations. The
resulting anterior open bite Class II malocclusion may be
responsible for masticatory muscle discomfort during func­
tion. Temporary relief of these symptoms with a neutraliz­
ing splint is generally possible.
The definitive correction of the secondary maxilloman­
dibular deformity through standard osteotomies in combi­
nation with appropriate orthodontics has proven beneficial
to improve the occlusion, to open the airway, and to
enhance facial aesthetics. Concern about further resorp­
tion of the “fragile” condyles is best managed by avoiding
masticatory activities that “load” (i.e., compress) the
joint and with the use of systemic medications when
indicated.32
The treatment of juvenile idiopathic arthritis (JIA) has
improved dramatically during recent years with the advent
of disease-modifying anti-rheumatoid drugs. The orthogna­
thic surgeon will encounter patients on a drug regimen
that consists of nonsteroidal anti-inflammatory drugs
[NSAIDS], glucocorticoids, methotrexate, and biologic
agents. In these cases, consultation with a rheumatologist is
recommended, but the surgeon should also be aware of
these medications, because their presence could affect surgi­
cal outcome. Prudent perioperative management of these
drugs is necessary to optimize surgical outcome. A balance
must be struck between minimizing potential surgical com­
plications and maintaining disease control to prevent further
joint damage (i.e., condylar resorption) that would nega­
tively affect the outcome.41A
To review, ICR should not be managed either as a stan­
dard internal derangement or as a typical temporomandibu­
lar disorder (TMD). The concept of resolving the problem
through either an open-joint procedure or through joint
replacement continues to seem off the mark given the
known natural history of this entity for the majority
of affected individuals. A joint-replacement approach is
generally reserved for those few patient who have under­
gone failed surgical procedures with additive iatrogenic
TMJ dysfunction.
evaluation of the upper airway is essential to clarify any day
and nighttime breathing difficulties. The simultaneous cor­
rection of chronic nasal airway obstruction and any baseline
obstructive sleep apnea should be a primary objective (see
Chapters 10 and 26).
The key to a favorable reconstruction for an individual
with end-stage ICR or PCR is to define the functional
disability (i.e., breathing, chewing, speech, swallowing,
lip closure) and the extent of skeletal dysmorphology.
The establishment of a functional occlusion that limits
stress in the entire masticatory system without significant
centric relation–centric occlusion discrepancies and without
parafunctional habits is desirable (see Chapter 9). The suc­
cessful performance of orthognathic, intranasal, and dental
procedures to achieve these objectives represents our stan­
dard approach; see the case presentations later in this
chapter.
Kaban and colleagues offers an alternative approach
when the patient is not willing to take the risk that a
degree of resorption may continue or reoccur at some point
in the future.24,43,67,92,96-98 The authors completed a retro­
spective case series of 15 patients with the diagnosis of active
bilateral ICR who chose a condylar replacement approach
between 1999 and 2004. Each patient underwent bilateral
endoscopic-assisted condylectomy and autogenous costo­
chondral graft reconstruction. Patients with the following
characteristics were included:
1. Active bilateral ICR documented by worsening Class
II malocclusion with open bite on serial clinical
examinations, radiographs, photographs, and dental
casts
2. A positive technetium-99m methylene diphospho­
nate bone scan
3. A minimum of 12 months of postoperative follow up
Symptoms such as myofascial pain and occlusal discom­
fort are managed by splint therapy, physical therapy, muscle
relaxants, nonsteroidal anti-inflammatory drugs, and other
modalities as indicated. Patients who respond to treatment
as documented by the relief of symptoms, no occlusal radio­
graph changes over a 2-year period, and a negative bone
scan begin orthodontic treatment in preparation for stan­
dard orthognathic surgery. Patients with active ICR who do
not respond to the previously described treatment modali­
ties or who prefer not to follow the protocol for a variety
of reasons are considered candidates for condylectomy and
costochondral graft reconstruction. Fifteen patients fell into
this latter category and underwent bilateral endoscopic con­
dylectomies and costochondral graft reconstruction. None
of the 15 study patients suffered significant surgical com­
plications, such as fractures or the erroneous placement of
the graft within the fossa. Postoperatively, all patients
showed Class I occlusion with no anterior open bite. All
patients maintained a clinically acceptable and reproducible
occlusion one year later with a mean maximum incisor

1534 SECTION 6  Post-Traumatic Dentofacial Deformities
Case Presentations
CASE 36-1 
Progressive Condylar Resorption (Fig. 36-1)
History
A 23-year-old Caucasian female was diagnosed with juve-
nile rheumatoid arthritis when she was 10 years old; the
disease primarily affects her knees and ankles. Involvement
of both of her TMJs began when she was 12 years old and
resulted in PCR that stabilized when she was 14 years old.
She underwent compensatory orthodontics when she was
between the ages of 14 and 16 years, and she has reported
pain-free satisfactory mandibular range of motion since that
time. When she was 19 years old, she sustained trauma to
• Figure 36-1  The patient before and after treatment. Final maxillary restorative dental work is not yet completed.
A, Frontal views in repose before and after surgery. B, Frontal views with smile before and after surgery.
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A
B

1535
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
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D
C, Oblique views before and after surgery. D, Profile views before and after surgery.
• Figure 36-1, cont’d 
Continued

1536 SECTION 6  Post-Traumatic Dentofacial Deformities
Prior to retreatment
Pre surgery after mandibular bicuspid extractions and orthodontics
After treatment
E
E, Occlusal views before retreatment, before surgery but after bicuspid extractions, and after surgery.
• Figure 36-1, cont’d

1537
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
G
Bilateral condylar head erosion
X
H
Maxillary
counter-
clockwise
rotation
Mandibular
advancement
F
Pharyngeal
airway
expansion
F, Lateral cephalometric views before and after surgery. G, Panorex view before
surgery. An “X” is on a root tip that requires extraction. A question mark is on an incisor that may require
extraction. H, Articulated dental casts that indicate analytic model planning. From Posnick JC, Fantuzzo JJ:
Idiopathic condylar resorption: current clinical perspectives, J Oral Maxillofac Surg 65:1617-1623, 2007.
• Figure 36-1, cont’d

1538 SECTION 6  Post-Traumatic Dentofacial Deformities
the four maxillary incisors with a loss of the right lateral
incisor and the need for root canal treatment of the right
central incisor. Temporary restorations were placed. The
patient then continued to follow up with a general dentist
and orthodontist when she was between 19 and 23 years
old, with no changes noted in her occlusion (i.e., no prog-
ress of the condylar resorption).
Evaluation
The 23 year old woman arrived for surgical consultation in
the hope of achieving enhanced facial aesthetics and
improved function (i.e., mastication, breathing, lip posture,
and speech articulation). She underwent evaluations by a
speech pathologist, an otolaryngologist/head and neck
surgeon, an orthodontist, a periodontist, a restorative
dentist, a rheumatologist, and a TMJ specialist.
Treatment
Preoperative orthodontic treatment included the removal of
the mandibular first bicuspids to uncrowd the arch. Unfor-
tunately, as a result of previous dentoalveolar trauma, only
minimal repositioning of the maxillary anterior teeth was
possible, thereby preventing optimal incisor positioning.
The patient’s surgery included the following:
• Maxillary Le Fort I osteotomy
• Vertical intrusion at the incisors
• Maxillary plane counterclockwise rotation
• Horizontal advancement at the incisors
• Bilateral sagittal split ramus osteotomies
• Mandibular plane counterclockwise rotation
• Horizontal advancement
• Oblique osteotomy of the chin
• Horizontal advancement
• Vertical shortening
• Intranasal procedures
• Septoplasty
• Reduction of the inferior turbinates
After the initial surgical healing (5 weeks), finishing ortho-
dontics continued for 6 months. The removal of the ortho­
dontic appliances was followed by maintenance splint
therapy and orthodontic retention that was primarily used
while the patient was sleeping.
CASE 36-2 
Idiopathic Condylar Resorption (Fig. 36-2)
History
This systemically healthy 12-year-old girl experienced severe
TMJ discomfort with limited and painful mouth opening.
Mandibular retrusion and anterior open-bite deformity
were progressive over the subsequent 6 months. When the
patient was 13 years old, her orthodontist offered maxillary
first bicuspid extractions with orthodontic retraction to
neutralize the occlusion. From the ages of 13 to 15 years,
orthodontic treatment accomplished this objective. When
the patient reached the age of 16 years, concerns about her
facial aesthetics, her airway, and her periodontal health were
voiced, and alternative treatment was sought.
Evaluation
A 16 year old teenager arrived for surgical evaluation
without pain in the TMJ and facial region. Vertical mouth
opening was to 35 mm. Radiographs confirmed no progres-
sion of condylar resorption for at least 2 years. A complete
workup for systemic joint disease was negative. The patient
described having difficulty breathing through her nose, and
she was found to have a deviated septum and hypertrophic
inferior turbinates.
Treatment
Redo orthodontic treatment included the removal of the
mandibular first bicuspid teeth to uncrowd the arch and
upright the incisors. The patient’s surgery included the
following:
• Maxillary Le Fort I osteotomy
• Vertical intrusion at the incisors
• Maxillary plane counter clockwise rotation
• Horizontal advancement at the incisors
• Cant correction
• Bilateral sagittal split ramus osteotomies
• Mandibular plane counterclockwise rotation
• Horizontal advancement
• Oblique osteotomy of the chin
• Horizontal advancement
• Vertical shortening
• Intranasal procedures
• Septoplasty
• Reduction of the inferior turbinates
• Removal of wisdom teeth
After initial surgical healing (5 weeks), finishing orthodon-
tics continued for 6 months. Removal of orthodontic
appliances was followed by the use of routine removable
retainers.

1539
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
• Figure 36-2  Patient before and after the completion of orthodontics and jaw surgery. A, Frontal views in repose before and after surgery.
B, Frontal views with smile before and after surgery.
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A
B
Continued