READERS' FORUM
Letters to the editor*
Distraction osteogenesis for patients
with severe idiopathic condylar
resorption
A case report in the July 2019 issue by Wang et al
reported the treatment of a 14-year-old girl with
severe bilateral idiopathic condylar resorption (ICR)
and resultant mandibular retrusion, increased overjet,
and anterior open bite. (Wang J, Veiszenbacher E, Waite
PD, Kau CH. Comprehensive treatment approach for
bilateral idiopathic condylar resorption and anterior
open bite with customized lingual braces and total joint
prostheses. Am J Orthod Dentofacial Orthop 2019;
156:125-136). The treatment mentioned in the article
included presurgical orthodontics for arch alignment
and leveling, orthognathic surgery with condylar pros-
thesis, and postsurgical orthodontics. However, there
are alternative treatments for ICR, including orthog-
nathic surgery, repositioning and stabilization of the
disc, and condylar reconstruction with a costochondral
graft,1,2 which can be used to treat active ICR and pro-
vides long-term occlusal stability.1 How did the authors
decide that the management choice for the 14-year-old
patient was temporomandibular joint prostheses
replacement instead of distraction osteogenesis or
autologous costochondral graft reconstruction?
Distraction osteogenesis is the surgical technique to
correct skeletal deformity using bone lengthening by
gradual mechanical distraction, which was developed
and popularized in the 1950s and has been accepted
as an effective method since the 1990s in the field of
maxillofacial and plastic surgery.3 It can be used to
increase the height of the mandibular ramus and the
length of the mandibular body both in growing patients
and adults. Schendel et al4 had treated cases of ICR with
mandibular distraction and the outcome was satisfac-
tory, stable and no reactivation of the disease after
4 years. Mandibular advancement shows more stability
in distraction osteogenesis cases.4 Mandibular distrac-
tion is considered beneficial to postoperative stability
because of the gradual lengthening of the soft tissues
and a generally less invasive procedure. In addition,
distraction osteogenesis using curvilinear distractors
can mimic the natural growth curve of the mandible.
In this case, we prefer mandibular distraction
* The viewpoints expressed are solely those of the author(s) and do not reflect
those of the editor(s), publisher(s), or Association.
osteogenesis combined with maxillary LeFort I osteot-
omy in considering the age of the patient and distraction
osteogenesis as an autologous reconstruction. We
recommend magnetic resonance imaging to evaluate
the blood supply of the condylar before planning. Would
magnetic resonance imaging be considerable and
valuable in the authors' opinion?
Zhenzhen Zhang
Yang Lu
Li Lu
Xiaofeng Bai
Shenyang, China
Am J Orthod Dentofacial Orthop 2020;157:439
0889-5406/$36.00
Ó 2020 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.01.007
REFERENCES
1. Peacock ZS, Lee CCY, Troulis MJ, Kaban LB. Long-term stability of
condylectomy and costochondral graft reconstruction for treatment
of idiopathic condylar resorption. J Oral Maxillofac Surg 2019;77:
792-802.
2. Mitsimponas K, Mehmet S, Kennedy R, Shakib K. Idiopathic
condylar resorption. Br J Oral Maxillofac Surg 2018;56:249-55.
3. Kloukos D, Fudalej P, Sequeira-Byron P, Katsaros C. Maxillary
distraction osteogenesis versus orthognathic surgery for cleft lip
and palate patients. Cochrane Database Syst Rev 2016;9:
CD010403.
4. Schendel SA, Tulasne JF, Linck DW 3rd. Idiopathic condylar resorp-
tion and micrognathia: the case for distraction osteogenesis. J Oral
Maxillofac Surg 2007;65:1610-6.
Authors' response
T he management of idiopathic condylar resorption is
an area that has been underreported. A number of
approaches to the management have been correctly
highlighted in the Letter to the editor, including distrac-
tion osteogenesis, growth modification appliances,
costochondral rib grafts, and orthognathic surgery
with or without joint replacements.
The evidence for the management of these cases is
still a work in progress and our clinical experience has
focused on the following factors:
1. Overall condition of the temporomandibular com-
plex. Not all patients who present with idiopathic
condylar resorption have pain and a loss of function.
In these circumstances, it would be prudent to
approach treatment in a more conservative fashion,
which might include costochondral rib grafting,1
439
440
careful or judicious distraction of the mandible, and
orthognathic surgery.2
2. Age of the patient. In the growing child with juve-
nile idiopathic arthritis, successful attempts have
been made with growth modification devices and
splints.3 In these patients, the condylar complex
was able to continue growing and achieve good
facial balance.4
3. Number of joints involved. Unilateral joints are
managed differently compared with bilateral joints.
Often, mechanical rehabilitation of the bilateral
joint complex needs to be considered. Clinicians
may opt to replace the complex with a total joint
at a later stage.5
4. Best rehabilitation outcome for the joint. Patients
presenting with pain and an acute inability to
function require the most practical and quickest
approach to the rehabilitative outcome.6,7 Total
joint replacement has so far proven to be a safe
and reliable method of temporomandibular joint
reconstruction. Although the long-term prognosis
is unknown, we remain hopeful for this type of
rehabilitation.8
Finally, we would agree on the use of magnetic reso-
nance imaging technology to evaluate the joint space,
cartilage, ligament attachments, presence of inflamma-
tory cells, and vascular supply. An atlas of the joint in the
pediatric literature is available,9 and more needs to be
done for the betterment of our patients and profession.
Jue Wang
Eva Veiszenbacher
Peter D. Waite
Chung H. Kau
Birmingham, Ala
Am J Orthod Dentofacial Orthop 2020;157:439–440
0889-5406/$36.00
Ó 2020 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.01.006
REFERENCES
1. Christou T, Kau CH, Abou-Kheir NS, Louis PJ. The use of three-
dimensional evaluation in the management of a complex patient
with mandibular fracture: a 5-year evaluation. J Craniofac Surg
2014;25:e223-8.
2. Christou T, Kau CH, Waite PD, Kheir NA, Mouritsen D. Modified
method of analysis for surgical correction of facial asymmetry.
Ann Maxillofac Surg 2013;3:185-91.
3. Stoll ML, Kau CH, Waite PD, Cron RQ. Temporomandibular joint
arthritis in juvenile idiopathic arthritis, now what? Pediatr Rheuma-
tol Online J 2018;16:32.
4. Stoustrup P, K€ useler A, Kristensen KD, Herlin T, Pedersen TK. Ortho-
paedic splint treatment can reduce mandibular asymmetry caused
April 2020  Vol 157  Issue 4
Readers' forum
by unilateral temporomandibular involvement in juvenile idiopathic
arthritis. Eur J Orthod 2013;35:191-8.
5. Kau CH, Bejemir MP. Application of virtual three-dimensional sur-
gery planning in management of open bite with idiopathic condylar
resorption. Ann Maxillofac Surg 2015;5:249-54.
6. Rahman F, Celebi AA, Louis PJ, Kau CH. A comprehensive treatment
approach for idiopathic condylar resorption and anterior open bite
with 3D virtual surgical planning and self-ligated customized
lingual appliance. Am J Orthod Dentofacial Orthop 2019;155:
560-71.
7. Wang J, Veiszenbacher E, Waite PD, Kau CH. Comprehensive
treatment approach for bilateral idiopathic condylar resorption
and anterior open bite with customized lingual braces and total
joint prostheses. Am J Orthod Dentofacial Orthop 2019;156:
125-36.
8. Zou L, He D, Ellis E. A comparison of clinical follow-up of different
total temporomandibular joint replacement prostheses: A system-
atic review and meta-analysis. J Oral Maxillofac Surg 2018;76:
294-303.
9. Kellenberger CJ, Junhasavasdikul T, Tolend M, Doria AS. Temporo-
mandibular joint atlas for detection and grading of juvenile idio-
pathic arthritis involvement by magnetic resonance imaging.
Pediatr Radiol 2018;48:411-26.
Extracting one mandibular incisor
W e read with keen interest an article in the October
2019 issue reporting orthodontic treatment with
an incisor extraction (Vilhjalmsson G, Zermeno JP, Prof-
fit WR. Orthodontic treatment with removal of one
mandibular incisor: Outcome data and the importance
of extraction site preparation. Am J Orthod Dentofacial
Orthop 2019;156:453-63). The article is indeed an
informative one, and the authors have summarized the
various aspects of mandibular incisor extraction in an
excellent and elaborate manner.
Orthodontic treatment with mandibular incisor
extraction is being routinely done in our department,
and thus we would like to share some additional appli-
cations regarding the same. Apart from treating mild
Class III malocclusions with mandibular anterior
crowding or crossbites, extraction of 1 mandibular
incisor has also proved beneficial in the following situ-
ations:
1. Angle Class I occlusion on a Class I skeletal base with
good cusp-to-groove relationship in the posterior
segment and mandibular anterior crowding
$5 mm.
2. Angle Class II Division 1 malocclusion with 1 full
cusp discrepancy on either side (full-step Class II
molar relationship) and crowding of mandibular
anterior teeth $5 mm. Here, the extraction of
both maxillary first premolars along with 1 mandib-
ular incisor can bring about a good occlusion. The
American Journal of Orthodontics and Dentofacial Orthopedics