CRANIOMAXILLOFACIAL DEFORMITIES/SLEEP DISORDERS/COSMETIC SURGERY

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MRI Changes in the 60
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7 Temporomandibular Joint After 62
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9 Q1 Mandibular Advancement 65
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11 Q7 Rohit Sharma, MDS,* Chiyyarath Gopalan Muralidharan, MD, DNB,y 67
12 Munish Verma, MDS,z 68
13 Sehajbir Pannu, MD,x and Seema Patrikar, MSc, PhD, MPS, DBMk 69
14 70
Purpose: Esthetic dental and skeletal component correction can affect the temporomandibular joint
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(TMJ). Arthrogenic TMJ dysfunction can be present in the joint at the outset or it can during the treatment
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or later. The aim of the present study was to examine the changes found on magnetic resonance imaging
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(MRI) studies of the TMJ in patients with skeletal Class II malocclusion who had undergone combined or-
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thodontic and bilateral sagittal split ramus osteotomy (BSSRO) advancement. Our objective was to mea-
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sure the changes in the disc position, condylar translation, secondary bony changes, and joint effusion
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on MRI before and after treatment.
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22 Materials and Methods: An analytical, single-surgeon, single-institution, retrospective radiological 78
23 (MRI) study was designed. We included patients who had undergone combined orthodontic and BSSRO 79
24 advancement from 2011 to 2018. All 36 patients were examined using a 1.5-Tesla MRI unit (Siemens Sym- 80
25 phony, Erlangen, Germany) with a 6  8-cm diameter surface coil, which allowed for simultaneous imaging 81
26 of both TMJs. 82
27 Results: Analysis using the Wilcoxon signed rank test revealed statistically significant differences in the 83
28 pre- and post-treatment groups in the changes in the position of the disc from anterior disc displacement 84
29 with reduction (ADDWR) to the normal position (P = .008), condylar translation from excessive to normal 85
30 (P = .046), and an increase in secondary bony changes (P = .005). 86
31 87
Conclusions: Combined orthodontic and orthognathic movement in the treatment of skeletal Class II
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malocclusion can increase secondary bony changes, improve the disc position in ADDWR cases, and con-
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trol excessive translation of the TMJ. No improvement was noted in the position of the disc in those with
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anterior disc displacement without reduction, hypomobility and joint effusion.
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Ó 2020 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial
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Surgeons
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J Oral Maxillofac Surg -:1-7, 2020
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40 Orthognathic correction in conjunction with ortho- malities. The objective of the orthognathic procedure 96
41 dontic treatment after the completion of growth has is to reestablish form (stability), function, and es- 97
42 been considered to be the most appropriate and thetics. Any dental and/or skeletal correction causing 98
43 optimal treatment modality for dentoskeletal abnor- a change in occlusion will definitely have an effect 99
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45 *Classified Specialist, Department of Oral and Maxillofacial Address correspondence and reprint requests to Dr Sharma: 101
46 Surgery, 11 Corps Dental Unit, Jalandhar Cantt, India. Department of Oral and Maxillofacial Surgery, 11 Corps Dental 102
47 yCommandant, Military Hospital, Chennai, India. Unit, Jalandhar Cantt 144005, India; e-mail: capt_rohit7@yahoo.com 103
48 zGraded Specialist, Department of Orthodontics and Dentofacial Received June 1 2019 104
49 Orthopedics, Command Military Dental Centre, Western Command, Accepted December 22 2019 105
50 Chandimandir, India. Ó 2020 Published by Elsevier Inc. on behalf of the American Association of Oral 106
51 xGraded Specialist, Department of Radiodiagnosis and Imaging, and Maxillofacial Surgeons 107
52 158 Base Hospital, Bengdubi, India. 0278-2391/20/30001-X 108
53 kLecturer, Department of Preventive and Social Medicine, Armed https://doi.org/10.1016/j.joms.2019.12.028
109
54 Forces Medical College, Pune, India. 110
55 Conflict of Interest Disclosures: None of the authors have any 111
56 relevant financial relationship(s) with a commercial interest. 112

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 2 MRI CHANGES IN TMJ AFTER MANDIBULAR ADVANCEMENT Q2

113 on the temporomandibular joint (TMJ). Arthrogenic 169

114 TMJ dysfunction can be present in the joint at the start 170
115 of orthodontic treatment or it can develop during the 171
116 treatment itself. It should be the joint responsibility of 172
117 the oral and maxillofacial surgeon and the orthodontist 173
118 to evaluate the TMJs clinically and radiologically 174
119 before the treatment begins. Magnetic resonance im- 175
120 aging (MRI) has achieved an important role in the diag- 176
121 nosis of TMJ disorders because it can be used to 177
122 directly visualize the hard and soft tissue component 178
123 of the TMJs without any radiation hazard.1 The correct 179
124 positioning of the condyle in the glenoid fossa is a crit- 180
125 ical component of orthognathic surgery. The informa- 181
126 tion regarding condylar morphology and the position 182
127 obtained at the pretreatment evaluation can be useful 183
128 during orthognathic surgery. Despite the recent ad- 184
129 vances in the orthognathic procedure, retaining the 185

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130 exact condylar position in the glenoid fossa in patients 186
131 with mandibular deformities has remained chal- 187
132 lenging. The aim is to realize an ideal occlusion and 188
133 also to consider the physiologic position of the TMJ. 189
134 Prefixation techniques and/or positioning appliances FIGURE 1. Single miniplate-fixed osteotomized bilateral sagittal 190
135 have been used by many during bilateral sagittal split split ramus osteotomy segments. 191
136 ramus osteotomy (BSSRO), with various results. A Sharma et al. MRI Changes in TMJ After Mandibular Advance- 192
137 manual technique of repositioning the condyle after ment. J Oral Maxillofac Surg 2020. 193
138 the BSSRO split and before fixation has produced 194
139 equally stable results.2 At our organization, we ensure 195
140 repositioning of the condyle manually during BSSRO or less; and 2) completion of preoperative orthodontic 196
141 advancement. The aim of the present study was to treatment. The exclusion criteria were as follows: 1) 197
142 examine the changes in the TMJs found on MRI studies facial asymmetry; 2) any pathologic features in the 198
143 in patients with skeletal Class II malocclusion who had TMJ region; 3) bruxism; 4) deleterious oral habits; 5) 199
144 undergone combined orthodontic and BSSRO any systemic disorder affecting the bone metabolism 200
145 advancement. The objectives were to measure the or any joint, including the TMJ; 6) obvious misregistra- 201
146 changes in disc position, condylar translation, second- tion artifacts found on MRI; 7) the performance of any 202
147 ary bony changes, and joint effusion on the pre- and other associated midface orthognathic procedure; 8) 203
148 post-treatment MRI studies. medically unfit to undergo a surgical procedure under 204
149 general anesthesia; and 9) unilateral radiologic (MRI) 205
150 parameters of arthrogenic TMJ dysfunction. All the pa- 206
Materials and Methods
151 tients had undergone MRI examination of the bilateral 207
152 An analytical, single-surgeon, single-institution, TMJs before beginning orthodontic treatment and 208
153 retrospective radiologic (MRI) study was designed. 1 year after completion of postoperative orthodontic 209
154 We included patients who had undergone complete treatment. A 1.5-Tesla MRI unit (Siemens Symphony, 210
155 combined orthodontic and orthognathic (BSSRO Erlangen, Germany) with a 6  8-cm diameter surface 211
156 advancement) treatment of isolated skeletal Class II coil, which allowed for simultaneous imaging of both 212
157 malocclusion from 2011 to 2018. The institutional TMJs, was used. The imaging protocol consisted of a 213
158 ethical committee and local institutional review board T1-weighted axial spin echo image, which acted as 214
159 approved the present study. All the patients had pro- the localizer. The scans included 3-mm sections, 15- 215
160 vided written informed consent before the beginning cm field of view, and a 256  224 matrix. T1- 216
161 of the study. The inclusion criteria were age 18 years weighted images were obtained using a 520-ms/11- 217
162 or older and the receipt of single-plate, fixation for ms repetition time/echo time (TR/TE) sequence. T2- 218
163 BSSRO advancement using titanium miniplates (pro- weighted images were obtained using a 2740-ms/ 219
164 file height, 1.0 mm; Stryker, Kalamazoo, MI) and 107-ms TR/TE sequence. The TMJs were imaged in 220
165 screws (2.0-mm self-tapping screws; Stryker) on each the coronal and sagittal planes. A mouth opening de- 221
166 side (Fig 1). The following criteria were used to vice was used, which allowed for incremental opening 222
167 mandate BSSRO advancement: 1) the presence of skel- at 1-mm intervals. The MRI scans were evaluated inde- 223
168 etal Class II malocclusion with a discrepancy of 7 mm pendently by 2 experienced radiologists. Q3 224

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 SHARMA ET AL 3

225 Disagreement in the interpretation of the findings was 281

226 resolved by consensus. The TMJs were assessed for the 282
227 disc position: whether normal or displaced anteriorly, 283
228 and if the disc was displaced, whether with or without 284
229 reduction (anterior disc displacement with reduction 285
230 [ADDWR] or anterior disc displacement without 286
231 reduction [ADDWoR], respectively). The TMJs were 287
232 also assessed for the presence or absence of joint effu- 288
233 sion, secondary bony changes (condylar resorption), 289
234 and condylar translation. The condylar translation 290
235 was considered restricted if the condylar head was un- 291
236 able to translate until the articular eminence, normal if 292
237 the condylar head translated until or just beyond the 293
238 posterior slope of the articular eminence, and exces- 294
239 sive if the condylar head translated beyond the artic- 295
240 ular eminence. The Wilcoxon signed rank test was 296
241 used to determine whether any statistically significant 297

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242 differences were present the pre- and post-treatment 298
243 MRI changes. 299
244 300
245 Results 301
246 FIGURE 2. T2-weighted sagittal turbo spin echo preoperative im-
302
247 A total of 36 patients with Class II skeletal malocclu- 303
age with findings suggestive of anterior disc displacement without
248 sion who had undergone BSSRO advancement had reduction disc with condylar resorption. 304
249 been identified in accordance with the study criteria. Sharma et al. MRI Changes in TMJ After Mandibular Advance- 305
250 Their data were compared before and after surgery. ment. J Oral Maxillofac Surg 2020. 306
251 Of the 36 patients, 19 were women and 17 were 307
252 men. Their average age was 20.52  3.1 years (range, 308
cally significant differences from pre- to postopera-
253 18 to 25 years; Table 1). Preoperatively, 3 patients had 309
tively in the change in the position of disc from
254 had ADDWoR and 29 had had ADDWR. Mobility of the 310
ADDWR to the normal position (P = .008), condylar
255 TMJ was excessive in 16 patients and restricted in 2. 311
translation from excessive to normal (P = .046), and in-
256 Secondary bony changes were present in 3 patients, 312
crease in secondary bony changes (P = .005; Table 3).
257 and joint effusion was present in 2 patients. Postoper- 313
258 atively, the same 3 patients continued to have ADD- 314
WoR. However, the number of patients with ADDWR Discussion
259 315
260 had decreased to 22. The number of patients with BSSRO advancement and setback are well- 316
261 excessive translation had decreased to 12 but had re- established orthognathic procedures for repositioning 317
262 mained restricted in 2 patients. The patients with sec- the mandibular dental arch and/or distal segment in a 318
263 ondary bony changes (Figs 2-4) had increased to 11 sagittal direction to provide broad medullary contact 319
264 from 3, and the number of patients with joint between the osteotomized segments for stable bone 320
265 effusion had remained the same (Table 2). The analysis healing. The results achieved after BSSRO fixation 321
266 using the Wilcoxon signed rank test showed statisti- are not only predictable but also stable.3 Pre- and post- 322
267 operative orthodontic treatment is required to achieve 323
268 stable dental occlusion before moving the skeletal ba- 324
Table 1. DEMOGRAPHIC DATA
269 ses. In the present study, orthodontic treatment 325
270 Demographic Data Patients (n) included fixed mechanotherapy using a preadjusted 326
271 edgewise appliance and retention using a fixed lingual 327
272 Sample size 36 and upper wrap-around retainer. Almost 12 months of 328
273 Gender preoperative and 6 months of postoperative orthodon- 329
274 Male 17 tic treatment were undertaken. After the split and 330
275 Female 19 before fixation of the osteotomized segments, it is 331
276 Age (yr) very important to ensure that the movement (advance- 332
277 Mean  standard deviation 20.52  3.1 ment) should solely occur in the dentoalveolar and/or 333
278 Range 18-25 distal segment. Temporary intermaxillary fixation 334
279 Sharma et al. MRI Changes in TMJ After Mandibular Advance- (IMF) was performed after placement of the surgical 335
280 ment. J Oral Maxillofac Surg 2020. splint (made after mock surgery on a semiadjustable 336

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FIGURE 3. Postoperative proton-density, T2-weighted, sagittal fat FIGURE 4. Postoperative T1-weighted sagittal turbo spin echo
357 saturated, open mouth magnetic resonance image suggestive of magnetic resonance image suggestive of condylar head flattening 413
358 condylar head flattening. with an osteophyte. 414
359 Sharma et al. MRI Changes in TMJ After Mandibular Advance- Sharma et al. MRI Changes in TMJ After Mandibular Advance- 415
360 ment. J Oral Maxillofac Surg 2020. ment. J Oral Maxillofac Surg 2020. 416
361 417
362 articulator to achieve the desired occlusion). Screws under the influence of the lateral pterygoid muscle.5 418
363 on the proximal segment were placed first, and then In a skeletal Class II malocclusion, because of the ret- 419
364 the condyle was carefully pushed superiorly and roposition of the mandible in relationship to the 420
365 slightly anterior in the glenoid fossa by holding the maxilla/cranial base, the disc will be mostly anteriorly 421
366 distal end of the plate, with digital force on the displaced. Reduction occurs because of the ability of 422
367 mandibular angle. The screws were then placed on condyle to negotiate around the disc and the ability 423
368 the distal end. Fixation was performed using titanium of the disc to assume a normal position in relationship 424
369 miniplates and screws. If any change at all occurs in to the condyle and glenoid fossa.6 In the present study, 425
370 the position of the condyle in the glenoid fossa or 29 patients had ADDWR preoperatively. MRI studies 426
371 proximal segment (condylar–ramal segment), it will have revealed the absence of symptoms in 30% of pa- 427
372 be reflected in the postoperative period as an occlusal tients with ADDWR.7 The neo-neuromuscular engram 428
373 discrepancy, leading to either de novo TMJ symptoms will stabilize the desired occlusion, keeping the prox- 429
374 or worsening of existing TMJ symptoms. In experi- imal segment/condyle in its physiologic position, lead- 430
375 enced hands, the condyle will assume a physiologic ing to attainment of a normal disc position. Another 431
376 position in the glenoid fossa and the movement will reason could be the change in the condylar head shape 432
377 occur solely in the dentoalveolar/distal segment. resulting from resorption and/or remodeling. In the 433
378 Thus, arthrogenic TMJ dysfunction symptoms can present study, 7 patients attained the normal disc posi- 434
379 improve or be aggravated after BSSRO.4 tion after ADDWR. However, this was not the case for 435
380 All the cases of BSSRO in the present study were the patients with ADDWoR because the disc loses the 436
381 semirigidly fixed using miniplates and screws without capability to recapture. The mouth opening is 437
382 any postoperative IMF. In the postoperative period, af- restricted because the mandibular condyle cannot 438
383 ter the edema has subsided, the surgical splint (made pass over the posterior band of the articular disc.8 439
384 after mock surgery on the semiadjustable articulator, Thus, the patients with ADDWoR and a restricted 440
385 which was used intraoperatively to achieve the desired mouth opening did not experience any changes. Cases 441
386 Q4 occlusion) was luted to the upper jaw, and guiding of ADDWR and occlusal discrepancy are well-known 442
387 elastics were placed for 4 to 6 weeks to achieve neo- causes of hypermobility of the TMJ but only during 443
388 neuromuscular engram. the initial phases. Over time, ADDWR will change to 444
389 In the presence of ADDWR, the articular disc will ADDWoR, which will restrict the mouth opening.9 445
390 move in an anteromedial position, following the shape The achievement of stable occlusion and a corrected 446
391 of the condyle and anterior slope of the glenoid fossa articular disc position after BSSRO can reduce the 447
392 448

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449 Table 2. CROSS-TABULATION OF RADIOLOGIC (MRI) PARAMETERS OF ARTHROGENIC TMJ DYSFUNCTION

505
450 506
451 Preoperatively Postoperatively (n) Total 507
452 508
453 Disc Position Normal ADDWoR ADDWR 509
454 Normal 4 0 0 4 510
455 ADDWoR 0 3 0 3 511
456 ADDWR 7 0 22 29 512
457 Total 11 3 22 36 513
Condylar translation Excessive Normal Restricted
458 514
Excessive 12 4 0 16
459 Normal 0 18 0 18
515
460 Restricted 0 0 2 2 516
461 Total 12 22 02 36 517
462 Secondary bony changes Absent Present 518
463 Absent 25 8 33 519
464 Present 0 3 3 520
465 Total 25 11 36 521
466 Joint effusion Absent Present 522
467 Absent 34 0 34 523
468 Present 0 2 2 524
Total 34 2 36
469 525
470 Abbreviations: ADDWoR, anterior disc displacement without reduction; ADDWR, anterior disc displacement with reduction; 526
471 MRI, magnetic resonance imaging; TMJ, temporomandibular joint. 527
472 Sharma et al. MRI Changes in TMJ After Mandibular Advancement. J Oral Maxillofac Surg 2020. 528
473 529
474 530
excessive translation; however, it can never correct In our study, miniplate fixation was used to avoid the
475 531
the restricted translation of the joint. The results use of prolonged IMF. Aragon et al12 recommended a
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from the present study have proved this because a sta- sound postoperative rehabilitation program after or-
477 533
tistically significant number of patients (n = 4) had thognathic procedures to prevent hypomobility.
478 534
normal condylar translation postoperatively compared It is well-known that MRI is the modality of choice
479 535
with excessive condylar translation preoperatively. No for the evaluation of the soft tissue structures of the
480 536
influence on mandibular mobility was reported by TMJ. An accuracy of 95% has been reported for assess-
481 537
Zimmer et al10 in bilateral jaw orthognathic surgery ing the anatomy and position of the disc and the asso-
482 538
compared with single jaw surgery, in which maxillary ciated soft tissue structures. In addition, MRI has been
483 539
advancement and mandibular setback were per- shown to be 93% accurate in assessing the osseous
484 540
formed.10 Mandibular hypomobility is a common con- changes of the joint components.13 Several bony
485 541
dition after BSSRO advancement, especially with changes, including flattening, osteophytic changes,
486 542
prolonged IMF, owing to the degenerative changes erosion, sclerosis, avascular necrosis, narrowing of
487 543
that occur during periods of IMF, masticatory muscle the joint spaces, eburnation, and regressive remodel-
488 544
atrophy, and the decrease in muscle energy reserves ing, can be identified using MRI. MRI has been
489 545
resulting from immobilization. One of the most typical routinely used for the diagnosis of osteoarthritis and
490 546
adaptations to immobilization is muscle atrophy, advanced stages of internal derangement of
491 547
accompanied by decreases in functional capacity.11 the TMJ.14
492 548
493 549
494 Table 3. COMPARATIVE ANALYSIS OF RADIOLOGIC (MRI) PARAMETERS OF ARTHROGENIC TMJ DYSFUNCTION* 550
Q6
495 551
496 Postoperative Changes Compared With Preoperatively 552
497 553
498 Variable Disc Position Condylar Translation Secondary Bony Changes Joint Effusion 554
499 555
Z score 2.646 2.000 2.828 0.000
500 556
P value (asymptotic .008 .046 .005 1.000
501 significance; 2-tailed)
557
502 558
503 * Wilcoxon signed rank test. 559
504 Sharma et al. MRI Changes in TMJ After Mandibular Advancement. J Oral Maxillofac Surg 2020. 560

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 6 MRI CHANGES IN TMJ AFTER MANDIBULAR ADVANCEMENT

561 Secondary bony changes in the form of condylar uating the TMJ. The standard imaging protocol con- 617
562 resorption are a known phenomenon after orthog- sists of oblique sagittal and coronal images of the 618
563 nathic surgery. The bony changes are secondary to TMJ obtained perpendicular and parallel to the long 619
564 condylar remodeling in the glenoid fossa after occlusal axis of the mandibular condyle in both open and 620
565 changes and might result from pressure resorption af- closed mouth positions. The disc position and 621
566 ter fixation or adjustment of the proximal segment morphology and bony structures can be clearly visual- 622
567 during BSSRO. It is very difficult to comment on the eti- ized on MRI with both open and closed mouth posi- 623
568 ology of bone resorption.3 However, Chigurupati and tions. Open mouth images can be used to evaluate 624
569 Mehra15 recently postulated that advancing the lower the function of the disc and condyle, and the disc po- 625
570 jaw would physically lengthen the Class III lever arm sition can be compared with that on the closed mouth 626
571 of the mandible, which is known to increase the images and to differentiate between ADDWR and 627
572 load on the TMJ. Thus, any mandibular advancement ADDWoR. Additionally, T1- and T2-weighted MRI 628
573 surgery will increase the risk of postoperative studies could be required to delineate intra-articular 629
574 condylar remodeling and, possibly, renewed resorp- fluid accumulation, interstitial synovial inflammation, 630
575 tion.15 In the present study, we found secondary and the overall disc morphology.8 Sano et al18 reported 631
576 bony changes attributable to both remodeling and an increased T2-weighted signal in the retrodiscal soft 632
577 pressure resorption, with differences that were statis- tissues in the presence of symptomatic TMJ disease, 633
578 tically significant. To prevent condylar resorption sec- reflective of the presence of hyperemia and perivascu- 634
579 ondary to stretching of the surrounding soft tissues, lar inflammation. A sensitivity and specificity of 90 and 635
580 large mandibular advancements should be avoided.3 83.3%, respectively, for disc displacement on MRI 636
581 We only advanced the mandible up to 7 mm, less closely correlated with a symptomatic and asymptom- 637
582 than the physiologic limits of BSSRO. Also, compared atic TMJ.19 In our study, a reduction in the number of 638
583 with bicortical screw fixation, monocortical miniplate patients with excessive translation of the TMJ on the 639
584 and screw (semirigid) fixation have resulted in less postoperative MRI scans from 16 of 36 (44%) to 12 640
585 resorption. Resorption occurs from the torque forces of 36 (33%). The number of patients with secondary 641
586 created on condyles during engagement of both bony changes increased from 2 to 11 of 36, which 642
587 cortices.3 In a recent study, stress on the TMJs was could be reflective of the signs of remodeling. MRI of 643
588 evaluated using different methods of fixation.16 They the TMJ has been used for the past 20 years or more 644
589 concluded that the use of bicortical screws increases and has undergone technological evolution, including 645
590 the stress on the condyle and in such cases in which changes in the coils, magnetic strength, and se- 646
591 patients have a tendency toward temporomandibular quences. The use of dedicated surface coils has 647
592 disorders, miniplate and screw fixation should be improved the resolution, leading to better visualiza- 648
593 used.16 In the present study, only single-plate mono- tion of the TMJ anatomy, synovium, and inflammatory 649
594 cortical miniplate fixation was performed. The relapse activity. Although the TMJ has been imaged in all 650
595 of an open bite from condylar resorption will usually planes; however, the sagittal plane has been preferred 651
596 occur 6 months to 3 years postoperatively; thus, regu- over the coronal and axial planes. The sagittal plane re- 652
597 lar follow-up examinations are important to allow for sults in better visualization of the disc signal intensity 653
598 intervention early in the process. Pharmacotherapy, and its identification, condylar morphology, bone 654
599 focusing on decreasing the inflammation, and the marrow edema, and joint effusion. The coronal plane 655
600 use of occlusal splints will reduce the load on the joint is better suited for evaluation of condylar erosion 656
601 and its resorption. Total joint replacement is an option and flattening. The synovium can be visualized best 657
602 that should be the last resort if the resorption process on axial and contrast-enhanced MRI.20 658
603 continues.5 No such radical treatment modalities have Regarding the magnetic strength, a theoretical 659
604 ever been used at our institute for patients after post- advantage exists for the use of 3 Tesla compared 660
605 operative orthognathic surgery. with 1.5 Tesla because of the higher signal/noise ratio. 661
606 Joint effusion occurs secondary to the release of in- However, that is offset by the artifacts that occur with 662
607 flammatory products in TMJ dysfunction. BSSRO will 3-Tesla MRI scanners.21 Although studies have shown 663
608 lead to the attainment of stable occlusion but without that TMJ arthrography has greater diagnostic value 664
609 changes in the synovium after orthognathic surgery. than computed tomography or MRI scans in the diag- 665
610 Similar results were noted in our study. The use of nosis of arthrogenic TMJ dysfunction, it has the disad- 666
611 computer-aided design (CAD)/computer-aided vantage of being an invasive imaging modality that, 667
612 manufacturing (CAM) to design a condyle positioning currently, is rarely used.22 668
613 jig has been suggested to minimize the occurrence of In conclusion, although during BSSRO advance- Q5 669
614 significant condylar displacement or torque.17 Howev- ment, the movement is only in the distal/dentoalveolar 670
615 er, CAD/CAM is not available at our organization. MRI segment, changes in the TMJ are inevitable. Significant 671
616 has become the imaging modality of choice when eval- MRI changes will occur in the disc position, resulting 672

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673 in secondary bony changes and excessive translation 7. Sener S, Akgunlu F: MRI characteristics of anterior disc displace- 715
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677 improve the form, function, and esthetics, but also Shelton, CT, People’s Medical Publishing House, 2011,
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678 the disc fossa relationship in cases of ADDWR and pp 1123–1154 720
679 excessive translation of the TMJ. However, no disc po- 9. Machon V, Sedy J, Klima K, et al: Arthroscopic lysis and lavage in 721
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680 sition was found to have worsened on the postopera- without reduction. Int J Oral Maxillofac Surg 41:109, 2012
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681 tive MRI studies. The increase in secondary bony 10. Zimmer B, Schwestka R, Kubein-Meesenburg D: Changes in 723
682 changes after BSSRO advancement could be secondary mandibular mobility after different procedures of orthognathic 724
surgery. Eur J Orthod 14:188, 1992
683 to pressure resorption or remodeling. Combined or- 11. Bogdanis GC: Effects of physical activity and inactivity on mus-
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684 thodontic and orthognathic movement will have no ef- cle fatigue. Front Physiol 3:142, 2012 726
685 fect on preexisting ADDWoR, restricted condylar 12. Aragon SB, Van Sickles JE, Dolwick MF, Flanary CM: The effects 727
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686 translation, and joint effusion. Definitive operative Maxillofac Surg 43:938, 1985
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687 and nonoperative measures, whether open or closed, 13. Katzberg RW: Temporomandibular joint imaging. Radiology 729
688 are required for correction of these aspects of arthro- 170:297, 1989 730
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690 nathic surgery for a healthy TMJ in patients with 15. Chigurupati R, Mehra P: Surgical management of idiopathic 732
691 skeletal Class II malocclusion. condylar resorption. Oral Maxillofacial Surg Clin N Am 30:355, 733
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692 16. Ureturk EU, Apaydin A: Does fixation method affects temporo-
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