The role of total joint replacement

surgery in the orthognathic patient

Nigel Shaun Matthews, Ben L. Hechler, and Rishma Shah

Alloplastic reconstruction of the temporomandibular joint, commonly

referred to as total joint replacement, is used to treat end stage joint dis-
ease in a cohort of patients who present with a range of condylar pathol-
ogy. In considering its role in the management of the orthognathic
patient, it is helpful to categorize patients into those with primary pathol-
ogy of the mandibular condyle or those with primary dentofacial defor-
mity. The success of total joint replacement is predicated by the
predictably stable results that are achieved when used in carefully
selected clinical scenarios. In this article, we will discuss the role of total
joint replacement surgery in the orthognathic patient and highlight its clin-
ical impact by inclusion of a case study. (Semin Orthod 2019; 25:286–293)
Published by Elsevier Inc.

Introduction replacement of the temporomandibular joint

T
(TMJ) in the orthognathic patient, it is helpful to
he relationship between dentofacial defor-
categorize patients into (A) primary pathology of
mity (DFD) and temporomandibular dys-
the mandibular condyle (condylar TMD or
function (TMD) is one of the more controversial
cTMD) or (B) primary DFD (Box 1). The primary
topics within our area of expertise. DFD is diag-
cTMD patient is described as one whose pathol-
nosed objectively, but what constitutes TMD has
ogy arises from condylar abnormality. These
been contested for decades.1 4 This complicates
patients are represented by conditions including
our ability to delineate the association between
idiopathic condylar resorption (ICR), inflamma-
DFD and TMD. For example, only a subset of
tory arthritides, severe osteoarthritis, end-stage
TMD patients have pathology involving the man-
internal derangement, TMJ ankylosis, severe septic
dibular condyle itself (condylar TMD or cTMD)
TMJ arthritis and primary condylar tumors, such
that may result in DFD.
as osteochondroma. It is this primary condylar
Alloplastic reconstruction of the temporoman-
abnormality which results in secondary dentofacial
dibular joint—commonly referred to as total joint
deformity. In these patients, the mandibular con-
replacement (TJR)—involves removing the dis-
dyle is, by definition, always pathologically
eased condyle and/or fossa and replacing both
involved and requires treatment. In contrast, the
condylar and fossa components with prosthetic
primary DFD patient is described as one whose
materials (Fig. 1). Today, these materials are
pathology does not arise from a condylar abnor-
made of cobalt chromium alloy, titanium alloy,
mality, although the condyle itself may also be
and ultra-high molecular weight polyethylene
involved. These patients are represented by condi-
(UHMWPE). In considering the role of total
tions including craniofacial microsomia (CFM),
craniofacial dysostosis, and maxillary or mandibu-
Department of Oral and Maxillofacial Surgery, Adams School of
Dentistry, University of North Carolina, 149 Brauer Hall, Campus
lar hypo- or hyperplasia. In these patients, the
Box 7450, Chapel Hill, NC 27599-7450, USA; University of Tennes- condyle may or may not require treatment. Lastly,
see Medical Center, Knoxville, Tennessee, USA; Department of Ortho- one may consider condylar hyperplasia (including
dontics, Adams School of Dentistry, University of North Carolina, hemimandibular hypertrophy and hemimandibu-
Chapel Hill, North Carolina, USA. lar elongation) as a hybrid of these two primary
Corresponding author. E-mail: shaun_matthews@unc.edu
patient populations.
Published by Elsevier Inc.
1073-8746/12/1801-$30.00/0
Categorization of patients in the above fashion
https://doi.org/10.1053/j.sodo.2019.08.002 is helpful when considering treatment of the

286 Seminars in Orthodontics, Vol 25, No 3, 2019: pp 286 293

 The role of total joint replacement surgery in the orthognathic patient
Figure 1. Zimmer Biomet TJR prosthesis. Shown are
the mandibular component fixated to the mandibular
ramus and the fossa component fixated to the poste-
rior aspect of the zygomatic arch.
TMJ. Primary cTMD patients by definition have
unstable, potentially unstable, and/or malfunc-
tional condyles either unamenable to traditional
orthognathic surgery or prone to adverse post-
operative changes following traditional orthog-
nathic surgery. Even in patients with quiescent
ICR or arthritic processes, the risk of disease
recurrence remains after surgery.5 In the pri-
mary cTMD patient group, presentation is often
skeletal Class II with a high mandibular occlusal
plane angle whereby surgical correction with
advancement and counterclockwise rotation of
the maxillomandibular complex further stresses
the TMJ lever arm. The primary cTMD patient,
in particular, may benefit from TMJ TJR in com-
bination with orthognathic correction of the pre-
senting dentofacial deformity (Table 1).
Table 1. Categorization of the primary abnormality can aid treatment planning for the dentofacial deformity
patient
Primary Examples
abnormality
Pathology of the  Severe osteoarthritis
mandibular con-  Inflammatory arthritides
dyle (cTMD)  Idiopathic condylar resorption (ICR)
 TMJ ankylosis
 TMJ septic arthritis
 Condylar tumors
Dentofacial  Maxillary hypoplasia/hyperplasia
deformity (DFD)  Mandibular hypoplasia/hyperplasia
 Craniofacial microsomia
 Craniofacial dysostosis syndromes
287
Management of DFD in patients with
TMD when TJR is not indicated
In addition to controversy regarding the associa-
tion of DFD and TMD, controversy exists regarding
how to manage traditional DFD patients with TMD
signs and/or symptoms. A determination should
be made as to whether the patient is seeking cor-
rective treatment for the DFD or TMD. The treat-
ment of one will not automatically improve the
other.
Many patients presenting with DFD and a his-
tory of TMD signs and/or symptoms do not have
cTMD. These patients should be considered pri-
mary DFD patients with an overlying TMD. The
two most common presentations falling into this
category are patients presenting with myofascial
pain or internal derangement of the disc-condyle
complex. Myofascial pain patients often have par-
afunctional and/or psychosocial etiologies.6 The
associated chronic, persistent, regional pain is in
the absence of radiographic signs of TMJ abnor-
mality. This type of patient is not a TMJ surgical
candidate, including TJR, and is best treated con-
servatively by a dedicated orofacial pain team.
Internal derangement patients present with vari-
ous joint signs and symptoms (noises, popping,
locking and/or limited range of motion) and
demonstrate an abnormal disc-condyle relation-
ship on soft tissue imaging (MRI).7 Although
these patients are rarely TJR candidates, they may
benefit from TMJ surgery, including arthrocente-
sis, operative arthroscopy, and a range of open
joint procedures beyond the scope of this chap-
ter.8,9 Both TMD patient types—myofascial pain
and internal derangement patients—benefit from
Implications for treatment
The condyle is definitively involved and is a source
of any resulting dentofacial deformity. Treatment
of the condyle is required for stable correction of
the dentofacial deformity.
The condyle may be involved, but is not a source
of the resulting dentofacial deformity and may or
may not benefit from treatment.
288 Matthews et al
the management of presenting TMD signs and/or
symptoms by methods other than TJR, before any
dentofacial deformity correction utilizing tradi-
tional orthognathic surgical techniques.
Management of DFD in patients with
TMD - Indications for TJR in
orthognathic surgery
Compared to the primary DFD patient, the primary
cTMD patient presents with dentofacial deformity
as a direct result of condylar pathology. The deci-
sion on TJR is dependent on the (1) patient’s
growth status and (2) the pathologic process.
Growth status
The universal presentation of patients with
cTMD is skeletal Class II with an increased man-
dibular occlusal plane angle. Correction of the
dentofacial deformity associated with pathology
necessitates condylar surgery in addition to
orthognathic surgery. In growing patients pre-
senting with cTMD—most notably those with
juvenile idiopathic arthritis (JIA) or adolescent
females with ICR—one must consider the possi-
bility of the patient outgrowing any surgical cor-
rection. This is no different to timing treatment
after cessation of active growth for the traditional
orthognathic surgical patient. Fortunately, for
reasons not entirely clear, many young patients
with cTMD cease skeletal growth earlier than
their peers.10 Alloplastic TJR involves implanta-
tion of static tissue unable to grow with the
patient, but this may be of no detriment due to
earlier patient growth cessation. Over the past
decade, reports have supported alloplastic TJR as
the more predictable treatment option over sup-
posedly dynamic tissue grafts, such as costochon-
dral or sternoclavicular grafts.11
Pathologic process
The indication for TJR in the orthognathic surgi-
cal patient is when the dentofacial deformity is a
direct result of condylar pathology. Idiopathic con-
dylar resorption (ICR),12,13 inflammatory arthrit-
ides,10,14,15 severe osteoarthritis, end-stage
internal derangement, TMJ ankylosis,16 18 severe
septic TMJ arthritis, and primary condylar
tumors, such as osteochondroma,19 are prime
examples of cTMD conditions. The mandibular
condyle is likely to remain significantly abnormal
or unstable thereby committing the patient to
treatment. The British Association of Oral and
Maxillofacial Surgeons (BAOMS) and the United
Kingdom’s National Institute for Health and
Care Excellence (NICE) have adopted guide-
lines to identify patients who may benefit from
TMJ TJR. According to the BAOMS/NICE guide-
lines,20 a patient with indication for TJR will typi-
cally have a combination of the following: (1)
dietary score <5/10 (liquid scores 0, full diet
scores 10), (2) restricted mouth opening
<35 mm, (3) occlusal collapse (anterior open
bite and/or retrusion), (4) excessive condylar
resorption and loss of height of the vertical
ramus, (5) pain score >5/10 on the visual ana-
logue scale, and (6) other quality of life issues
(Table 2). Of note, the American Association of
Oral and Maxillofacial Surgeons (AAOMS) have
yet to adopt official guidelines for TMJ TJR.
In addition to published guidelines, the type
of condylar pathology can serve as an indication
for TJR. This is exemplified in cases of dentofa-
cial deformity patients with cTMD who are
completely asymptomatic and demonstrate a
smaller degree of occlusal change and/or condy-
lar resorption. The very real possibility of
long-term instability itself serves as a potential
indication for TJR in the setting of orthognathic
surgical intervention. This is most evidenced in
ICR where the disease process is classically said
to “burn out” at some point in time, after which
the clinician can supposedly rely on the condyles
to remain stable. In a subset of patients whose
cTMD disease process has been deemed “stable”,
resurgence is seen post-operatively. This is likely
to be attributed to increased stress on the TMJ
Table 2. Guidelines adopted by the British Associa-
tion of Oral and Maxillofacial Surgeons (BAOMS)
and UK National Institute for Health and Care Excel-
lence (NICE) to consider prior to TJR adapted
from Sidebottom20
Patient signs and symptoms which may indicate a potential
benefit from TJR
 Dietary score <5/10 (liquid scores 0, full diet scores 10)
 Pain score >5/10 on the visual analogue scale
 Restricted mouth opening <35 mm
 Occlusal collapse (including anterior open bite and/or ret-
rusion)
 Excessive condylar resorption with loss of posterior vertical
ramus height
 Other quality of life issues
 The role of total joint replacement surgery in the orthognathic patient
created by extension of the TMJ complex lever
arm secondary to mandibular advancement and
counterclockwise rotation.21,22 Management
approaches, including alloplastic TJR, can obvi-
ate the concern of disease resurgence.
Orthodontic treatment in primary cTMD
patients undergoing TJR and
orthognathic surgery
The orthodontist is an integral team member man-
aging patients undergoing TJR and orthognathic
surgery. The patient may present to the surgeon or
the orthodontist. In some cases, patients demon-
strate failed treatment, including occlusal equilibra-
tion, orthognathic surgery, occlusal splint therapy
and orthodontic treatment. One survey found 81%
of patients presenting for a consultation had under-
gone 1 or more treatments that had failed.23 The
correct diagnosis is key to developing a successful
treatment plan. Careful attention must be paid to
the skeletal discrepancy in all three planes of space.
cTMD patients often present with a Class II skeletal
base associated with mandibular retrognathia. Not
uncommonly, patients may present with bimaxillary
sagittal hypoplasia. There is an increased mandibu-
lar occlusal plane angle leading to increased lower
anterior face height and reduced overbite or ante-
rior open bite.14,23 There may also be mandibular
asymmetry with chin deviation to the side of the
unilaterally affected TMJ and possible maxillary
and mandibular occlusal cants. Depending on the
rate of change in the unilateral affected TMJ and
ensuing occlusal compensation, there may be a uni-
lateral posterior open bite, crossbite and dental
centerline discrepancies. Dental compensation
needs to be identified in all three planes of space.
Radiographs, photographs and study models
aid diagnosis and treatment planning. The lateral
cephalogram often demonstrates an increased
gonial angle and pronounced antegonial notch,
and also confirms the increased mandibular and
occlusal planes, decreased posterior face height
and Class II skeletal pattern.13,14 The lateral ceph-
alogram may also demonstrate a reduced oropha-
ryngeal space24,25; patients occasionally complain
of breathing problems.25 In growing patients not
in immediate need of TJR, sequential standard-
ized photographs and study models provide non-
invasive methods of monitoring progression of the
disease as it relates to the developing
289
malocclusion. In certain cases, technetium bone
scans can confirm absence of active disease.
The orthodontist will work with the surgeon to
develop the treatment plan. The surgeon provides
information on the desired surgical movements to
correct the skeletal problem and the orthodontist
will work to provide the correct tooth positioning
to facilitate surgical jaw repositioning. Particular
attention needs to be given to the anticipated
maxillary incisor inclination following counter-
clockwise rotation of the maxilla. The lower inci-
sors will need to be decompensated in cases of
proclination associated with a Class II skeletal pat-
tern, and the dental arches need to be coordi-
nated. In the presence of maxillary and
mandibular cants, the lip-incisor relationship will
influence the side to be corrected. The surgeon
and orthodontist must work together to decide if
this is to be corrected surgically or orthodontically.
Post-surgical orthodontics will utilize guiding inter-
maxillary elastics for the patient while detailing of
the occlusion is undertaken.
On occasion, patients will need to have the
original TJR explanted for reasons such as infec-
tion. As an interim measure between removal of
the original TJR and implantation of the new
TJR, the orthodontist can help with the provision
of removable bite planes or guiding elastics
attached to removable or fixed appliances.
Operative sequencing of TJR and
orthognathic surgery
As in traditional orthognathic surgery, intraopera-
tive surgical sequencing can be performed in vari-
ous ways. Previously with bimaxillary surgery, the
maxillary osteotomy and application of fixation
was performed before the mandibular osteotomy
and fixation. The use of semi-rigid wire fixation
relied on the midfacial skeleton to provide a more
stable intermediate base to which to move the
proximal segments of the mandible. With the
introduction of rigid plate and screw fixation in
maxillofacial surgery, the above concerns have
become less problematic. Simultaneous TJR and
orthognathic surgery cases can now be performed
reliably with TJR and mandibular surgery taking
place before maxillary surgery. The following rea-
sons account for the surgical sequence:
1. Consideration must be given to the intermedi-
ate position of the maxilla and mandible. The
290 Matthews et al

majority of patients benefiting from TJR at the Long-Term stability of orthognathic

time of orthognathic surgery fall into the surgery with and without TJR
increased mandibular plane, Class II open
Total joint replacement with orthognathic sur-
bite category. Surgical correction requires
gery for end-stage, non-functional joints
advancement and counterclockwise rotation
improves the quality of life in patients who are
of the maxillomandibular complex. If maxil-
unable to masticate or speak normally secondary
lary surgery is performed first with anterior
to severely limited mouth opening. Total joint
and inferior movement of the posterior max-
replacement surgery in combination with orthog-
illa, the mandible must rotate clockwise to
nathic surgery has been shown to be as stable or
accommodate the intermediate surgical splint
more stable than traditional orthognathic sur-
and fixation of the maxilla (Fig. 2). This posi-
gery alone, dependent partly on the initial dis-
tion of the mandible and the TMJs, especially
ease process. Maxillary surgical impaction is a
in the presence of TMJ pathology, is inher-
stable movement.26 However, counterclockwise
ently less reproducible than when the mandi-
rotation of the posterior maxilla has the potential
ble is in centric relation.
to be unstable due to inadvertent stretching of
2. In the setting of a patient whose cTMD has
the pterygomasseteric sling.
progressed to significant limitation in mouth
Patients with JIA and rheumatoid arthritis
opening—with complete bony ankylosis rep-
(RA) undergo periods of remission and recur-
resenting the extreme end of this spectrum—
rence of symptoms. Theoretically, patients with
one may not physically be able to mobilize the
remission of arthritis affecting the TMJs may
maxilla until a gap arthroplasty of pathologic
undergo traditional orthognathic surgery alone
mandibular bone is performed.
with a predictably stable outcome. Oye and col-
3. Surgical efficiency and infection control also
leagues performed mandibular surgery (genio-
dictate the surgical sequence. Starting with
plasty with or without sagittal split osteotomies)
the maxillary osteotomy would result in
on 18 patients with JIA with variable lengths of
accessing the ‘clean-contaminated’ environ-
follow-up.27 Two of these patients did not com-
ment of the mouth followed by pre-auricular
plete the study because of “worsening of the JIA”.
and neck incisions in a ‘clean’ environment.
Of the 16 patients who did return for follow-up,
Conversely, starting surgical correction with
50% of them showed significant relapse mea-
the TMJs and mandible minimizes the num-
sured at Pogonion, with a full one-third of
ber of times the surgeon must progress from a
the entire cohort relapsing >4 mm and a full
clean-contaminated to a clean environment,
one-fourth of the entire cohort requiring reoper-
theoretically reducing the risk of cross-con-
ation. Similarly, Leshem and colleagues per-
tamination and improving infection control.
formed mandibular surgery (sagittal split

Figure 2. (A) Native occlusion in a patient requiring counterclockwise rotation of the maxillomandibular com-
plex for TJR. (B) Demonstration of articulator opening (pin “up”) when maxillary surgery is performed first with
posterior and inferior positioning of the maxilla.
 The role of total joint replacement surgery in the orthognathic patient
osteotomies with or without genioplasty) on eight
patients with JIA (where “none of the patients
had ongoing rheumatic disease”) with variable
lengths of follow-up.28 The average relapse at
Gnathion was 22% with at least one patient
relapsing to an anterior open bite. Additionally,
all three cases showcased with photographs in
the report demonstrated a fair orthognathic out-
come at best, with continued lip incompetence
or mentalis strain. Pagnoni and colleagues
attempted to avoid mandibular advancement sur-
gery entirely on their cohort of JIA patients by
performing maxillary impactions with mandibu-
lar autorotation and advancement genioplas-
ties.29 Again, all cases highlighted demonstrated
only fair improvement in appearance, with all
patients retaining a convex facial profile associ-
ated with mandibular retrognathia. In support of
TJR, Stoor and colleagues treated a cohort of JIA
patients with either traditional orthognathic sur-
gery alone or TJR in combination with orthog-
nathic surgery and found that the inclusion of
patients treated with TJR decreased the relapse
rate.10 Wolford and Mehra also presented a case
of a patient with RA involving the TMJs who
underwent TJR with LeFort I osteotomy and
mandibular advancement. At 7 years of follow-
up, overlay cephalometric tracings demonstrated
maintenance of mandibular advancement.15 The
authors have also treated numerous patients with
rheumatologic TMJ disease via TJR and have also
appreciated long-term stability.
Patients with ICR frequently develop progres-
sive condylar resorption in adolescence or young
adulthood with a variable period of active remod-
eling. Similar to the rheumatoid patient, a patient
whose ICR has been deemed “burnt out” may the-
oretically be able to undergo traditional orthog-
nathic surgery alone with a predictably stable
outcome. Interestingly, very little is published in
the literature regarding outcomes of traditional
orthognathic surgery in ICR patients. Crawford
and colleagues reoperated on seven female
patients between the ages of 18 30 who experi-
enced “progressive condylar resorption” following
traditional orthognathic surgery.30 The initial diag-
nosis was mandibular hypoplasia with or without
an increased mandibular plane angle. Relapse was
almost 100% approximately 12 months post-opera-
tively. The occlusal and condylar conditions were
monitored for each patient after “stabilization” for
at least 12 months before considering reoperation.
291
The patients universally developed continued
relapse following their second operation, even on
the “stable” TMJs. In contrast, Mehra retrospec-
tively reviewed 21 patients with ICR who under-
went TJR and had a minimum follow-up of
5 years. Mean surgical advancement at B point
was 34.3 mm with the average change at longest
follow-up of only 0.22 mm.13
Conclusion
The authors are aware that TJR surgery is not
without additional risks as compared to tradi-
tional orthognathic surgery, including pre-auric-
ular and neck scarring, bleeding, infection,
implant dislocation and facial nerve injury. These
risks should be discussed with each patient when
determining the ideal, individualized treatment
plan. There should be no question, however,
that TJR with orthognathic surgery in this popu-
lation results in better long-term stability than
traditional orthognathic surgery alone.
Case study
A 30-year female with a history of rheumatoid
arthritis (RA) presented with a chief complaint
of bilateral temporomandibular joint pain, lim-
ited mouth opening, difficulty eating, and self-
consciousness regarding her facial appearance.
On examination, the patient demonstrated a
convex facial profile with marked mandibular
retrognathia, retrogenia and lip incompetence
(Fig. 3). Intraoral examination revealed a Class
II, division 1 occlusion with a 9 mm overjet and
crowding in the maxillary arch. She was missing
multiple maxillary posterior teeth. Radiographic
examination revealed significant erosion of the
bilateral condylar units (Fig. 4). The patient’s his-
tory, clinical exam, and radiographic exam were
all consistent with a cTMD secondary to RA.
Therefore, definitive surgical resection of the
condyles was indicated.
The patient’s treatment plan comprised a
“surgery first” approach involving bilateral TJR to
advance the mandible and replace the condylar
units, as well as an advancement genioplasty. A
virtual surgical planning session was performed
to determine the mandibular osteotomies, man-
dibular movements, and design of the final pros-
theses (bilateral custom TJR). The patient
underwent the proposed surgical intervention
292 Matthews et al

Figure 5. Clinical and intraoral photographs of the

Figure 3. Clinical and intraoral photographs of the patient following bilateral custom TJR, advancement
patient demonstrating a convex facial profile, marked genioplasty, and orthodontic therapy in the maxillary
mandibular retrognathia, retrogenia, lip incompe- arch.
tence and Class II, division 1 malocclusion.

Figure 4. Cephalometric and panoramic radiographic Figure 6. Cephalometric and panoramic radio-
images of the patient confirming erosion of the bilat- graphic images of the patient following bilateral cus-
eral condylar units and its contribution to the patient’s tom TJR, advancement genioplasty, and orthodontic
presenting dentofacial deformity. therapy in the maxillary arch.
 The role of total joint replacement surgery in the orthognathic patient
followed by orthodontic therapy in the maxillary
arch to level and align the teeth. Her post-opera-
tive clinical photographs (Fig. 5) and radio-
graphic images (Fig. 6) are presented.
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