The role of mandibular stabilization in

orthognathic surgery
Gye Hyeong Lee, Sang Mi Lee, and Jae Hyun Park

Stability of the temporomandibular joint (TMJ) structure is a critical require-

ment for treatment that includes orthognathic surgery. If the condyles are
not positioned properly in the articular fossae during the manual positioning
of the condyle or the intermaxillary fixation, postoperative relapse can result.
However, it is difficult for the orthognathic surgeon to control the position-
ing of the mandibular condyles during orthognathic surgery due to muscle
relaxation and the harsh intraoperative environment. Well-managed presur-
gical orthodontic treatment does not always guarantee the proper position-
ing of the proximal segment either, especially if the TMJ structures are not
stable in their functional area. Therefore, the mandible should be stabilized
with a presurgical stabilization splint to provide proper stimulation that
forms a pseudodisc in the TMJ structures before surgical procedures. (Semin
Orthod 2019; 25:188–204) © 2019 Elsevier Inc. All rights reserved.

Introduction other hand, that adverse changes in the TMJs

P
are related to inadequate control of the proxi-
ostsurgical proximal segment position and
mal segments of the condyles during orthog-
the stability of the surgical results are long-
nathic surgery or intermaxillary fixation.4 6
discussed issues, not only for oral and maxillofa-
Previous studies reported that the incidence
cial surgeons, but also for orthodontists, as dental
of condylar resorption after orthognathic osteot-
occlusion is determined by the position of man-
omies ranged from 23 to 31%, which is strikingly
dibular condyles in the articular fossae. Since
higher than orthodontists might have pre-
orthodontists are usually responsible for the
sumed.7 9 Skeletal relapses after orthognathic
results of surgical orthodontics, changes in occlu-
surgery are known to result from displaced proxi-
sion derived from an unstable condylar position
mal segments that returned to their physiologi-
can be catastrophic.
cally functional area. Biomechanical loading
Many studies have suggested that certain
followed by autorotation of the mandible is the
characteristics related to a patient such as their
major component in the etiology of condylar
gender, age, steep mandibular plane angle, and
position changes with orthognathic osteotomy.
a tendency to skeletal open bite are factors that
Compressive loading during the surgical proce-
influence changes in condylar position and/or
dure can cause undesirable torque and rotation
morphology.1 3 It has been also claimed, on the
of the ramus because of autorotation of the man-
dible.10 13 When condyles are not positioned
Graduate School of Dentistry, Chonnam National University, properly in the articular fossae during autorota-
Gwangju, South Korea; Kyung Hee University, Seoul, South Korea; tion of the mandible, natural seating of the con-
Graduate School of Dentistry, Chonnam National University, dyles will occur when the intermaxillary fixation
Gwangju, South Korea; Catholic University, Seoul, South Korea;
is released, which results in an early relapse.
Postgraduate Orthodontic Program, Arizona School of Dentistry &
Oral Health, A.T. Still University, Mesa, USA; Graduate School of However, improperly positioned condyles during
Dentistry, Kyung Hee University, Seoul, South Korea. surgical procedures will eventually be seated due
Correspondening author at: Postgraduate Orthodontic Program, to focal bone resorption and apposition at the
Arizona School of Dentistry & Oral Health, A.T. Still University, condylar bone surfaces, but this takes several
5855 East Still Circle, Mesa, AZ 85206, USA. E-mail:
months and can result in a late relapse.14 16
JPark@atsu.edu
Despite its importance, positioning of the
© 2019 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 mandibular condyles during orthognathic sur-
https://doi.org/10.1053/j.sodo.2019.08.005 gery is not easy for orthognathic surgeons to

188 Seminars in Orthodontics, Vol 25, No 3, 2019: pp 188 204

 The role of mandibular stabilization in orthognathic surgery
control, as relaxed muscles during the surgery
are affected by gravitation, so spontaneous dis-
placement of the proximal fragment can occur.
Simultaneous bleeding and unstabilized joint
structures combine to create a harsh intraopera-
tive environment that makes it difficult to find
the best position for the condyle.17,18
The undesirable consequences of incorrectly
positioned proximal segments include condylar
sagging, TMJ pain and dysfunction, and changes
in occlusion and facial esthetics.12 When remodel-
ing of the condyles stays within the physiological
capacity of the adaptive mechanism of the TMJ,
occlusal instability is much less likely expected.
However, when mandibular condyles resorb with
substantial loss of surface bone in the condylar
heads, significant occlusal alteration and reduc-
tion of mandibular ramus height can occur.19,20
Well-managed presurgical orthodontic treat-
ment does not necessarily guarantee the proper
positioning of the proximal segment, if stability
of the TMJ structures is not maintained in their
functional area.5,11 The articular disc is attached
posteriorly to a region of loose connective tissue
that is highly vascularized and innervated which
is known as the retrodiscal tissues. Invasion of
the condyle into the retrodiscal tissues or stimula-
tion that extends the retrodiscal tissues can pro-
duce severe pain. Blood vessels and nerve cells
fill the space when the condyle moves and
changes its position, which eventually causes a
thickening of the retrodiscal tissues. If the articu-
lar disc is dislocated and retrodiscal tissue is
thickened, it will be difficult for the surgeon to
find a stable position for the condyle during the
orthognathic surgery.
Therefore, it is critical to position the condyle
within the functional area and the mandible
should be stabilized to provide proper stimula-
tion that forms a pseudodisc in the TMJ
structures.21 24
The role of a stabilization splint
Splint therapy can be a reliable way to stabilize
the TMJ before starting orthodontic and/or
orthognathic treatment in patients with temporo-
mandibular joint disorders (TMD). Stabilization
of the TMJ is a therapeutic process that allows
clinicians to identify the true mandibular posi-
tion can help to make an make an accurate
diagnosis. Stabilization also helps surgeons
189
position the proximal segments of the mandible
in a biomechanically stable position.21,22 Splints
originated in the 1860s as an intraoral appliance
designed for skeletal fixation of jaw fracture
patients but now they are also being used to treat
musculoskeletal disorders in TMJs. With splints,
clinicians can predict a patient’s response to
future occlusal reconstruction with an orthodon-
tic and/or surgical approach.23
As stabilization splints eliminate protective co-
contraction by reproducing the scheme of func-
tional occlusion, a musculoskeletally stable posi-
tion of the TMJ condyles can be achieved.
Centric relation (CR) position refers the mandib-
ular position in which the condyles are in their
most superoanterior position in the articular fos-
sae, resting against the posterior slopes of the
articular eminences with the articular disc prop-
erly interposed. This can be regarded as a muscu-
loskeletally stable position. When mandibular
movement begins from this position, orthopedic
joint stability can be maintained during heavy
contraction of the elevator muscles. This position
is therefore considered the most musculoskele-
tally stable position of the mandible.5,24
Many attempts have been made to recapture
the articular disc for patients with disc displace-
ment or derangement, but a displaced disc cannot
be recaptured or repositioned into a normal posi-
tion, since the articular disc is comprised of dense
fibrous connective tissue, not hyaline cartilage,
which naturally changes in morphology rather
than recovering under inadaptable pressure.
Instead, the retrodiscal tissue undergoes adaptive
and reparative changes and becomes fibrotic and
avascular and if it is adequately adapted, condyles
can articulate on the newly adapted retrodiscal tis-
sue that is known as “a pseudodisc” (Fig. 1). Even
though the disc is still anteriorly displaced, the con-
dyle can function on the adaptive pseudodisc with-
out pain and discomfort but with persistent sound
(click) when the condyle moves. If orthodontic sur-
gery is performed with widened retrodiscal tissue
and if the surgeon attempts to position the condyle
forcefully, the condyle will stimulate the extended
retrodiscal tissue, which can cause pain and
delayed resorption of the condylar heads.24 28
Under these conditions, proper stimulation
should be applied to form a pseudodisc and stabi-
lize the mandible. The use of a stabilization splint
can promote formation of the pseudodisc on the
posterior band of the disc. Once the condyles
190 Lee et al
Figure 1. Formation of pseudodisc after stabilization:
(A) fibrotic retrodiscal tissue; (B) posterior border of
disc; (C) a displaced articular disc.
have been seated in the most forward and upper-
most position in the articular fossae with the help
of a stabilization splint, it can be considered that
the patient’s condyle is in a reproducible and reli-
able reference position for mandibular move-
ment.29 32 A stabilization splint that reproduces
an ideal functional occlusion can eliminate pro-
tective co-contraction of the masticatory muscles
and eventually lead to an orthopedically stable
joint position of the mandible.21,33
Importance of stabilization of TMJ for
orthognathic surgery
Stabilization of the mandibular position is of spe-
cial importance in surgical orthodontics since
the use of a stabilization splint before the surgical
procedures can promote postsurgical stability by
reducing unexpected condylar remodeling. The
mandible cannot be stabilized just because a sur-
geon locates the condyles forcedly in the most
anterosuperior position during a surgical proce-
dure. If the disc is displaced and the articular
joint is in disorder, a small malposition of the
condyle will bring about adverse compression
and torque, eventually resulting in remodeling
of the condylar heads.19,34
Stabilization of the mandible does not mean
to manipulate the position of the condyle to the
designated location. It rather refers to an appro-
priate relationship of surrounding structures of
the TMJ including mandibular condyles, articu-
lar discs, retrodiscal tissues, muscles and liga-
ments. Even for highly experienced surgeons,
stabilization of the mandible cannot be guaran-
teed if surrounding structures of the TMJ are not
properly aligned.
Patients who have an open bite, facial asym-
metry and skeletal Class II high angle are fre-
quently found to have unstable condylar
positions; therefore, stabilization of the TMJ
structure using a stabilization splint should pre-
cede the orthognathic surgery for postoperation
stability (Fig. 2).
Case reports
Case 1
An 18-year-old male had the chief complaint of
anterior open bite. He explained that pain and
discomfort in the TMJ area had persisted for years
although his anterior open bite tendency had
recently become worse. The patient showed prog-
nathic facial profile and mild facial asymmetry
with his chin point deviated to the left. Intraoral
findings confirmed his anterior open bite, mild
crowding in both arches with a 0 mm overjet and
a 3.0 mm anterior open bite. A panoramic radio-
graph showed severely flattened and backwardly
inclined condylar heads on both sides. A lateral
cephalometric analysis indicated skeletal Class III
pattern (ANB, 0.5° and Wits, 3.5 mm) and the
maxillary incisors were proclined (U1-SN, 125.0°)
(Fig. 3, Table 1).
Moderate-to-severe pain was detected with
bilateral TMJ palpation in the lateral and poste-
rior aspects of his TMJ with reciprocal click
sounds on both sides of the TMJ. During the
examination, the patient revealed unstable dual
bite which indicated a centric related occlusion
(CRO) - maximal intercuspal position (MIP) dis-
crepancy. To visualize and determine the quanti-
tative amount of CRO-MIP discrepancies, his
dental models were mounted on a semiadjustable
articulator (SAM Prazisionstechnik GmbH,
Muenchen, Germany), and the mandibular posi-
tion indicator (MPI) of the SAM articulator was
used to evaluate the CRO-MIP discrepancies at
the joint level. From the mounted model, dental
midline discrepancy and an open bite were
revealed more significant. The MPI measurement
showed a 1.5 mm downward condylar distraction
on the right side and 2 mm downward on the left
side (Fig. 4).
Based on the diagnostic data, it was deter-
mined that the mandible of our patient was not
in a stable position and his occlusion was not reli-
able enough to make a definitive orthodontic
 The role of mandibular stabilization in orthognathic surgery 191

Figure 2. Protocol of surgical orthodontic treatment: (A) presurgical orthodontic treatment is started according
to the treatment plan; (B) continue presurgical orthodontic treatment avoiding the mechanics that can induce
positional change of condyles; (C) a displaced articular disc can result due to premature contacts during the
presurgical orthodontic treatment; (D) to confirm stabilization of the mandible, dental models are mounted on
an articulator; (E) a presurgical splint is applied to stabilize the TMJ structure before surgical procedures; (F) con-
dylar positions are stabilized; (G) orthognathic surgery is performed; (H) postsurgical orthodontic treatment can
be finished with stabilized mandible.

diagnosis. To relieve his TMD symptoms and to
achieve and maintain a stable position of the
mandibular condyles, a stabilization splint was
prescribed with an ideal occlusal scheme for
mutually protected occlusion. With the use of a
stabilization splint, his pain and other symptoms
of TMD dramatically improved over the first 2
weeks. After 3 months of splint therapy, an
increase in anterior open bite (4.5 mm) and a
more severe dental midline discrepancy were
observed (Fig. 5).
Based on the poststabilization definitive ortho-
dontics diagnosis, orthognathic surgery associated
with maxillary posterior impaction and mandibu-
lar setback was decided. The patient’s maxillary
first premolars were extracted to start a full fixed
treatment and 0.022-in preadjusted edgewise
orthodontic appliances (AvexOpal Orthodontics,
Utah) were bonded on both arches for leveling
and alignment. The extraction spaces in the max-
illary arch were closed with elastomeric chains
(Fig. 6). When presurgical orthodontic treatment
was finished, we decided to apply another stabili-
zation splint before surgery. After 3 months of the
presurgical splint, his open bite became worse as
had been predicted based on the diagnostic splint
therapy (Fig. 7).
The surgical procedures consisted of a Le Fort
I maxillary osteotomy rotating the posterior max-
illa upward, and a bilateral sagittal split ramus
osteotomy (BSSRO) with setback as well as a clos-
ing rotation of the mandible. All appliances were
removed after 5 months of postsurgical ortho-
dontic treatment. The treatment produced con-
siderable improvement in the patient’s facial
esthetics with acceptable overjet and overbite.
No CRO-MIP discrepancies were found at joint
level when the MPI data was evaluated (Fig. 8).
At 5-year retention, the treatment results
remained stable. Condylar movement was
smooth with mouth opening and closing and no
recurrence of pain or other TMJ symptoms
were observed (Fig. 9).
Case 2
A 22-year old male presented with facial asymme-
try and maxillary midline diastema. The patient
had mild mandibular prognathism and severe
facial asymmetry that his chin point was deviated
to the left with a canted lip line. Large spaces
between the maxillary central incisors and the
dental midline discrepancies were seen from his
intraoral examination. A panoramic radiograph
192 Lee et al

showed mild to moderate resorption on both con-
dylar heads and shortened ramus on the left side.
A lateral cephalometric analysis indicated skeletal
Class III pattern (ANB, 2.0° and Wits, 8.0 mm)
with an anterior protrusion (Fig. 10, Table 2).
His dental models were mounted on an articula-
tor and they revealed the CRO-MIP discrepancies.
His dental midline was also more deviated to the
left side. The MPI measurement showed that his
condylar position was 1.0 mm downward and
shifted to the left on the right TMJ and 2 mm
downward on the left TMJ in the CRO position
(Fig. 11).
According to the above orthodontics diagno-
sis, orthognathic surgery associated with maxil-
lary canting correction and mandibular setback
to resolve the mandibular prognathism and skel-
etal asymmetry was decided. Maxillary and man-
dibular first premolars were extracted to start a
full fixed treatment and 0.022-in preadjusted

Figure 3. Pretreatment diagnostic data: (A) facial photographs; (B) intraoral photographs; (C) a panoramic
radiograph; (D) lateral and frontal cephalometric radiographs.
 The role of mandibular stabilization in orthognathic surgery 193

Figure 3. Continued

edgewise orthodontic appliances (AvexOpal
Orthodontics, Utah) were bonded on both
arches for leveling and alignment. Extraction
spaces in the both arches were closed with elasto-
meric chains (Fig. 12). When presurgical ortho-
dontic treatment was finished, a presurgical
splint was prescribed for stabilization of TMJ
structure before orthognathic surgery. After 4
months’ application of the stabilization splint, a
great increase in dental midline discrepancy was
observed and we thought this change would
change the surgical planning significantly

Table 1. Cephalometric measurements

Measurement Korean norm Pretreatment Poststabilization Presurgical Posttreatment
SNA (°) 82.0 81.5 81.5 81.5 80.0
SNB (°) 79.0 82.0 81.0 81.0 76.5
ANB (°) 2.5 0.5 0.5 0.5 3.5
Saddle angle (°) 126.0 115.0 112.5 112.0 113.5
Articular angle (°) 149.0 155.0 159.0 159.0 162.0
Gonial angle (°) 118.5 130.5 130.0 130.0 125.0
Upper gonial angle (°) 45.0 44.5 43.0 42.5 41.0
Lower gonial angle (°) 74.0 86.0 87.0 87.5 84.0
SUM (°) 393.0 400.5 401.5 401.0 400.5
Facial angle (Down’s) (°) 89.0 90.5 89.5 89.5 87.0
Wits (mm) 2.5 3.5 2.5 5.5 3.0
SN-MP (°) 33.5 31.0 32.0 32.0 33.0
Ramus height (mm) 51.5 49.5 50.5 52.0 45.0
Post.FH/Ant.FH (%) 66.8 62.5 63.0 64.0 61.0
U1-SN (°) 104.0 125.0 125.0 112.0 105.0
U1-FH (°) 116.0 132.5 132.5 119.5 112.5
U1-NA (°) 22.0 43.5 43.5 30.0 24.5
U1-NA (mm) 4.0 11.0 11.0 6.0 4.0
IMPA (°) 90.0 90.0 90.0 88.0 89.0
L1-NB (°) 25.0 31.0 32.0 31.0 25.5
L1-NB (mm) 4.0 9.0 9.0 9.0 8.0
U1/L1 (°) 124.0 105.0 104.0 118.0 123.0
Overjet (mm) 2.8 0.0 0.5 4.0 3.0
Overbite (mm) 3.0 3.0 4.5 1.5 3.0
Upper lip-E plane (mm) 0.0 2.0 2.0 3.0 2.5
Lower lip-E plane (mm) 0.0 3.0 3.5 2.5 2.0
194 Lee et al

Figure 4. (A) Pretreatment intraoral photographs in maximum intercuspal position (MIP); (B) pretreatment
dental casts mounted in centric related occlusion (CRO); (C) mandible position indicator (MPI) data. MPI data
shows CRO MIP discrepancies at joint level. Our patient presented a downward direction of CRO MIP condylar
distraction.

(Fig. 13). After the surgical procedures, consist- favorable improvement in the esthetics and func-
ing of a Le Fort I maxillary osteotomy and a tion of our patient. No CRO-MIP discrepancies
BSSRO, postsurgical orthodontic treatment was at joint level were found when evaluated by MPI
conducted for 6 months. The results showed data (Fig. 14).

Figure 5. Comparison of pre- and poststabilization mounted in centric related occlusion (CRO). Increase of
open bite was observed after using a stabilization splint so surgical intervention was needed to correct the signifi-
cant amount of bite opening.
 The role of mandibular stabilization in orthognathic surgery 195

Figure 6. Treatment progress of presurgical orthodontics: (A) 6 months; (B) 15 months.

Figure 7. Comparison of before (A) and after (C) stabilization. As TMJ structures were stabilized and the condyle
moved to musculoskeletally stable position with the use of the presurgical splint (B), patient’s open bite worsened
due to clockwise rotation of the mandible.
196 Lee et al

Figure 8. Posttreatment diagnostic data: (A) facial photographs; (B) intraoral photographs; (C) a panoramic radio-
graph; (D) lateral and frontal cephalometric radiographs; (E) dental casts mounted in CRO; (F) posttreatment MPI
data confirmed no CRO MIP discrepancy.
The role of mandibular stabilization in orthognathic surgery 197

Figure 8. Continued
198 Lee et al

Figure 9. Retention 24 months: (A) facial photographs; (B) intraoral photographs.

Figure 10. Pretreatment diagnostic data: (A) facial photographs; (B) intraoral photographs; (C) a panoramic
radiograph; (D) lateral and frontal cephalometric radiographs.
 The role of mandibular stabilization in orthognathic surgery 199

Figure 10. Continued

Table 2. Cephalometric measurements

Measurement Korean norm Pretreatment Presurgical Posttreatment
SNA (°) 82.0 80.5 80.5 80.0
SNB (°) 79.0 82.0 80.5 81.0
ANB (°) 2.5 2.0 0.0 1.0
Saddle angle (°) 126.0 120.0 120.0 120.0
Articular angle (°) 149.0 149.0 152.0 149.5
Gonial angle (°) 118.5 131.0 129.5 132.0
Upper gonial angle (°) 45.0 46.0 45.0 46.5
Lower gonial angle (°) 74.0 85.0 84.5 85.5
SUM (°) 393.0 400.0 401.5 401.5
Facial angle (Down’s) (°) 89.0 92.0 90.5 91.0
Wits (mm) 2.5 8.0 4.0 6.0
SN-MP (°) 33.5 39.0 40.0 39.0
Ramus height (mm) 51.5 48.0 47.0 48.0
Post.FH/Ant.FH (%) 66.8 63.0 62.0 62.5
U1-SN (°) 104.0 119.0 119.0 112.0
U1-FH (°) 116.0 129.0 129.0 122.0
U1-NA (°) 22.0 39.0 39.0 33.0
U1-NA (mm) 4.0 14.0 14.0 9.0
IMPA (°) 90.0 106.0 106.0 83.0
L1-NB (°) 25.0 29.0 30.0 28.0
L1-NB (mm) 4.0 9.0 8.0 6.0
U1/L1 (°) 124.0 112.0 111.0 119.0
Overjet (mm) 2.8 1.0 5.0 3.5
Overbite (mm) 3.0 0.5 1.0 3.0
Upper lip-E plane (mm) 0.0 1.0 2.0 2.0
Lower lip-E plane (mm) 0.0 7.0 6.0 6.0
200 Lee et al

Figure 11. (A) Pretreatment dental casts mounted in CRO; (B) pretreatment dental casts in MIP; (C) MPI data
shows CRO MIP discrepancies at joint level.

Figure 12. Treatment progress of presurgical orthodontics: (A) 8 months; (B) 19 months.
 The role of mandibular stabilization in orthognathic surgery 201

Figure 13. Comparison of pre- (A) and poststabilization (C). After 3 months with the presurgical splint (B), man-
dibular dental midline was shifted to the further left side (D).
202 Lee et al

Figure 14. Posttreatment diagnostic data: (A) facial photographs; (B) intraoral photographs; (C) a panoramic
radiograph; (D) lateral and frontal cephalometric radiographs; (E) dental casts mounted in CRO; (F) posttreatment
MPI data confirmed no CRO MIP discrepancy.
 The role of mandibular stabilization in orthognathic surgery 203

Figure 14. Continued

Conclusions a stabilization splint is needed to stabilize the

TMJ structures and to confirm the definitive
Dental and skeletal stability, function and facial orthognathic treatment plan, particularly for
esthetics are important factors when planning patients with preexisting characteristics of unsta-
orthognathic treatment. For reasons of stability, ble position of the condyle.
204 Lee et al
References
1. Arnett GW, McLaughlin RP. Facial and Dental Planning for
Orthodontists and Oral Surgeons. St. Louis: Mosby; 93 133.
2. Kertstens HCJ, Tuinzing DB, Golding RP, et al. Condylar
atrophy and osteoarthrosis after bimaxillary surgery. Oral
Surg Oral Med Oral Pathol. 1990;69:274–280.
3. Moore KE, Goorus PJJ, Stoelinga PJW. The contributing
role of condylar resorption to skeletal relapse following
mandibular advancement surgery. Report of 5 cases. J
Oral Maxillofac Surg. 1990;49:448–460.
4. Landes CA, Sterz M. Proximal segment positioning in
bilateral sagittal split osteotomy. Intraoperative con-
trolled positioning by a positioning splint. J Oral Maxillo-
fac Surg. 2003;61:14–23.
5. Campos AA, Nathanson D, Rose L. Reproducibility and
condylar position of a physiologic maxillomandibular
centric relation in upright and supine body position. J
Prosthet Dent. 1997;76:28–32.
6. Rotskoff KS, Herbosa EG, Villa P. Maintenance of con-
dyle proximal segment position in orthognathic surgery. J
Oral Maxillofac Surg. 1991;49:221–230.
7. Okeson JP. Evolution of occlusion and temporomandibu-
lar disorder in orthodontics: past, present, and future.
Am J Orthod Dentofac Orthop. 2015;147:216–223.
8. Kertstens HCJ, Tuinzing DB, Golding RP, et al. Condylar
atrophy and osteoarthrosis after bimaxillary surgery. Oral
Surg Oral Med Oral Pathol. 1990;69:274–280.
9. van't Hof MA. Condylar remodeling and resorption after
Le Fort I and bimaxillary osteotomies in patients with
anterior open bite. A clinical and radiological study. Int J
Oral Maxillofim Surg. 1998;27:81–91.
10. Arnett GW, Milam SB, Gottesman L. Progressive mandib-
ular retrusion idiopathic condylar resorption. Am J Orthod
Dentofacial Orthop. 1996;110:117–127.
11. Landes CA, Sterz M. Proximal segment positioning in
bilateral sagittal split osteotomy. Intraoperative con-
trolled positioning by a positioning splint. J Oral Maxillo-
fac Surg. 2003;61:14–23.
12. Hiatt WR, Schelkun PM, Moore DL. Condylar positioning
in orthognathic surgery. J Oral Maxillofac Surg. 1988;46:
111–120.
13. Isaacson R, Kopytov O, Bevis R, et al. Movement of the
proximal and distal segments after mandibular ramus
osteotomies. J Oral Surg. 1978;36:26–33.
14. Hoppenreijs TJ, Freihofer HP, Stoelinga PJ, et al. Condy-
lar remodeling and resorption after Le Fort I and bimax-
illary osteotomies in patients with anterior open bite. A
clinical and radiological study. Int J Oral Maxillofac Surg.
1998;27:81–91.
15. Raveh J, Vuillemin T, Ladrach K, et al. New techniques
for reproduction of the condyle relation and reduction
of complications after sagittal ramus split osteotomy of
the mandible. J Oral Maxillofac Surg. 1988;46:751–757.
16. Epker BN, Wylie GA. Control of the condylar-proximal
mandibular segments after sagittal split osteotomies to
advance the mandible. Oral Surg Oral Med Oral Pathol.
1986;62:613–617.
17. Freihofer HP, Petresevic D. Late results after advancing
the mandible by sagittal splitting of the rami. J Maxillofac
Surg. 1975;3:25–30.
18. Isaacson R, Kopytov O, Bevis R, et al. Movement of the
proximal and distal segments after mandibular ramus
osteotomies. J Oral Surg. 1978;36:26–33.
19. Arnett GW, Milam SB, Gottesman L. Progressive mandib-
ular retrusion—Idiopathic condylar resorption. Part I.
Am J Orthod Dentofacial Orthop. 1996;110:8–15.
20. Wohlwender I, Daake G, Weingart D, et al. Condylar
resorption and functional outcome after unilateral sagit-
tal split osteotomy. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2011;112:315–321.
21. Roth RH, Rolfs DA. Functional occlusion for the ortho-
dontist. Part II. J Clin Orthod. 1981;15:100–123.
22. Dyer EH. Importance of a stable maxillomandibular rela-
tion. J Prosthet Dent. 1973;30:241–251.
23. Lee GH, Park JH, Lee SM, et al. Orthodontic treatment
protocols for patients with idiopathic condylar resorp-
tion. J Clin Pediatr Dent. 2019;43:292–303.
24. Okeson JP. Management of Temporomandibular Disorder and
Occlusion. 7th ed. St Louis: Elsevier; 2012:358.
25. Dawson PE. Functional Occlusion: From TMJ to Smile
Design, Chapter 32 Occlusal Splints. St. Louis: Mosby;
2007:391.
26. Choi BH, Yoo JH, Lee WY. Comparison of magnetic reso-
nance imaging before and after nonsurgical treatment of
closed lock. Oral Surg Oral Med Oral Pathol. 1994;78:301–305.
27. Schmitter M, Zahran M, Duc JM, et al. Conservative ther-
apy in patients with anterior disc displacement without
reduction using 2 common splints a randomized clinical
trial. J Oral Maxillofac Surg. 2005;63:1295–1303.
28. Lundh H, Westesson PL, Kopp S, et al. Anterior reposi-
tioning splint in the treatment of temporomandibular
joints with reciprocal clicking comparison with a flat
occlusal splint and an untreated control group. Oral Surg
Oral Med Oral Pathol. 1985;60:131–136.
29. Isberg A, Isacsson G, Johansson AS, et al. Hyperplastic
soft-tissue formation in the temporomandibular joint
associated with internal derangement. A radiographic
and histologic study. Oral Surg Oral Med Oral Pathol.
1986;61:32–38.
30. Hall MB, Brown RW, Baughman RA. Histologic appear-
ance of the bilaminar zone in internal derangement of
the temporomandibular joint. Oral Surg Oral Med Oral
Pathol. 1984;58:375–381.
31. Scapino RP. Histopathology associated with malposition
of the human temporomandibular joint disc. Oral Surg
Oral Med Oral Pathol. 1983;55:382–397.
32. Dawson PE. New definition for relating occlusion to vary-
ing conditions of the temporomandibular joint. J Prosthet
Dent. 1995;74:619–627.
33. Kazumi I. Stabilization of the TMJ. In: Kazumi I, ed. TMJ
1st Orthodontics Concepts, Mechanics, and Stability. 1st ed.
Tokyo: TOPNOTCH KIKAKU Ltd; 2014:85–94.
34. Arnett W. Handbook of Arnett Facial Reconstruction
Course. 2011.