O r t h o g n a t h i c S u r g e r y an d

the Temporomandibular
Joint Patient
John C. Nale, DMD, MDa,b,*

KEYWORDS
 Orthognathic surgery  TMJ  Treatment  Resorption  Reconstruction  Virtual surgical plan

KEY POINTS
 Orthognathic surgery cannot be used as a predictable treatment of temporomandibular joint disor-
ders (TMD).
 TMD symptoms should be treated independent of dentofacial deformities.
 Orthognathic surgery treatment plans should be modified in TMD patients to minimize exacerbation
of symptoms.
 Patients with a class II malocclusion secondary to condylar resorption should be managed carefully
due to their high risk of surgical relapse.
 Virtual surgical planning has improved the accuracy of combined orthognathic surgery and allo-
plastic temporomandibular joint reconstruction.

The role of orthognathic surgery for the correction
of dentofacial deformities is widely accepted.
However, its role in the treatment of temporoman-
dibular joint disorders (TMD) is quite controversial.
There are numerous studies that show improve-
ment of temporomandibular joint (TMJ) dysfunc-
tion1–3 following orthognathic surgery, whereas
there are just as many that show no significant
improvement or even worsening of symptoms
following surgery.4,5 Interestingly, data also sug-
gest that TMD patients will show some improve-
ment in symptoms with simply the passage of
time; this poses the question as to whether or
not improvement of symptoms occurs as a result
of surgery or due to the cyclic nature of TMD. It
should also be noted that a small percentage of
asymptomatic patients who undergo orthognathic
surgery actually develop TMD symptoms. With
these facts under consideration, one can infer
that orthognathic surgery cannot predictably treat
TMD. Instead, surgeons should simply recognize
that TMD coexists in a subset of patients requiring
orthognathic surgery for the correction of a skel-
etal malocclusion. Therefore, TMD and skeletal
malocclusions should be treated as separate
entities.
Given the potential for TMD symptoms to
worsen following orthognathic surgery, it is impor-
tant to recognize those patients with TMD and
manage them independently of the dentofacial
deformity. Most advocate that this should be
done before planned orthognathic surgery. Once
symptoms have significantly improved or resolved,
focus may then shift to the orthognathic phase of
treatment. The astute surgeon must then recog-
nize those patients with a high risk of surgical
relapse related to postoperative condylar remodel-
ing and modify their treatment plans and surgical
oralmaxsurgery.theclinics.com

Disclosures: None.
a
Department of Oral and Maxillofacial Surgery, Louisiana State University Health Science Center, New
Orleans, LA, USA; b Private Practice, Carolina’s Center for Oral and Facial Surgery, 8840 Blakeney Professional
Drive, Suite 300, Charlotte, NC 28277, USA
* Private Practice, Carolina’s Center for Oral and Facial Surgery, 8840 Blakeney Professional Drive, Suite 300,
Charlotte, NC 28277.
E-mail address: jnale@mycenters.com

Oral Maxillofacial Surg Clin N Am - (2014) -–-

http://dx.doi.org/10.1016/j.coms.2014.08.012
1042-3699/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
2 Nale
technique to minimize the potential for early and
late postoperative malocclusion (Box 1).
TMD can be defined as a collection of signs and
symptoms related to the masticatory system.
Those signs and symptoms include TMJ pain,
pain associated with the muscles of mastication,
headache, limited mouth opening, and joint noise.
It has been reported that at least one of these
symptoms occurs in approximately 50% of all pa-
tients seeking treatment of skeletal malocclu-
sion.1,6 These patients require a thorough workup
to establish the primary cause of their TMD
symptoms. The work-up for TMD should include
a history, physical examination, radiologic exami-
nation, and laboratory evaluation if indicated.
HISTORY
A detailed questionnaire given to the patient
before the initial appointment is the typical avenue
to assemble the collection of TMD symptoms. The
surgeon’s interview with the patient should focus
on the chief complaint and symptom descriptors
such as location, onset of occurrence, condition
or character, alleviating or aggravating factors,
timing, and so on.
PHYSICAL EXAMINATION
Evaluation of the patient’s mandibular range of
motion should be detailed. Pain-free maximum
incisor opening should be noted, followed by
maximum opening with passive stretching. The
onset and location of pain during opening should
also be recorded because this may help in the
establishment of the origin of pain. Next, the mus-
cles of mastication should be evaluated. Each
muscle group should be palpated individually and
assessed for pain, spasms, or fasciculations.
Next, the joints should be loaded by having the pa-
tient bite on a tongue blade. Contralateral pain may
indicate an intracapsular origin of pain, where ipsi-
lateral pain may suggest a muscular origin. Next,
the lateral and posterior aspects of the condyles
Box 1
Primary goals of orthognathic surgery on the
TMJ patient
Identify cause of TMD symptoms
Successfully treat TMD symptoms
Correct the dentofacial deformity
Minimize the risk of relapse
Minimize the risk of postoperative TMD symp-
toms
should be palpated. Palpation is useful for detect-
ing intracapsular pain and joint noise and for estab-
lishing the amount of translation of the condylar
head during mouth opening. Lastly, an otoscopic
examination should be performed to rule out any
potential cause for pain located within the ear.
RADIOLOGIC EXAMINATION
The panoramic radiograph is useful for the
screening of the mandibular condyle and its rela-
tionship to the glenoid fossa. It also allows for visu-
alization of the coronoid process of the mandible.
Computed tomography (CT) and cone beam
computed tomography (CBCT) allow for a more
detailed and 3-dimensional view of TMJ. These
modalities allow for the visualization of any asym-
metries, cortical erosions, subchondral cysts, tu-
mors, heterotopic bone, ankylosis, or any other
bony abnormality. Newer software also allows se-
rial images to be superimposed to evaluate for
active growth or resorption (Fig. 1). However, a
panoramic radiograph, CT, or CBCT cannot visu-
alize the TMJ disc.
Magnetic resonance imaging is considered the
“gold standard” for the evaluation of the soft tis-
sues of the joint. Its multiplanar images allow for
direct visualization of disc position at rest and dur-
ing mouth opening. On occasion, a technetium 99
bone scan may be indicated. This modality is sen-
sitive in the detection of bone activity such as re-
modeling or resorption. Unfortunately, it cannot
differentiate between the two.
LABORATORY EVALUATION
Laboratory testing is generally reserved for those
patients who are suspected to have a systemic
disease process. An erythrocyte sedimentation
rate and C-reactive protein may be ordered to
check for these acute phase reactants. A positive
test result indicates the presence of a systemic in-
flammatory process, but is not specific for the
cause. More specific tests for various immune fac-
tors such as rheumatoid factor and antinuclear
antibody may also be indicated.
Once the appropriate data have been
collected, an accurate diagnosis can be estab-
lished and the patient treated appropriately.
Reversible measures are indicated as the first
line of treatment. Such reversible measures
include patient education, medications, physical
therapy, and occlusal splint therapy. Generally
patients respond favorably to this form of treat-
ment, but occasionally pain and TMJ dysfunction
persist. In this subset of patients, irreversible
treatments such as trigger point injections, botox
 Orthognathic Surgery and the TMJ Patient 3

Fig. 1. Superimposition of cone-beam CT scans of the same patient taken 1 year apart.

injections, arthrocentesis, arthroscopy, or even

Box 2
open arthroplasty can improve symptoms refrac-
Treatment of TMD symptoms in patients with a
tory to conservative therapy (Box 2). If a patient dentofacial deformity
fails to respond to these treatments, there is no
reason to think that they will improve with orthog- Reversible Treatment of TMD
nathic surgery. Fig. 2 suggests an algorithm for Patient Education
the treatment of TMD symptoms in patients with
Medications
a dentofacial deformity.
Although treatment of symptomatic disc de- Nonsteroidal antiinflammatory drugs (anti-
rangements is typically performed before any RA meds)
planned orthognathic procedure, some argue Muscle relaxants
that it is safe and predictable for both to be done Antidepressants
simultaneously. Wolford7 suggests that the bene-
fits of concomitant surgery include the following: Physical Therapy
ROM exercises
1. Requires one operation and general anesthetic
2. Balances occlusion, TMJs, jaws, and neuro- Passive stretching
muscular structures Spray and stretch
3. Decreases overall treatment time Ultrasound
4. Eliminates unfavorable TMJ sequelae that can
Transcutaneous electrical nerve stimulation
occur when performing orthognathic surgery
only Occlusal Splint Therapy
5. Avoids iatrogenic malocclusion that can occur
Irreversible Treatment of TMD
when performing open TMJ surgery only
Trigger Point Injections
The case against concomitant surgery is that the Botox
condyle-fossa relationship becomes vulnerable to
the experience of the surgeon.8 That is, there is Arthrocentesis
potentially a higher chance of postoperative Arthroscopy
malocclusion related to a change in the condyle- Open Arthroplasty
fossa relationship following surgery.
4 Nale

Fig. 2. Flow diagram and treatment algorithm for patients with a dentofacial deformity and TMD symptoms.
NSAID, nonsteroidal antiinflammatory drug.
 Orthognathic Surgery and the TMJ Patient 5

SURGICAL CONSIDERATIONS UNIQUE TO

SPECIFIC SKELETAL MALOCCLUSIONS
Once a patient has responded to the treatment of
TMD symptoms, correction of the dentofacial
deformity may be addressed. Surgical patients
will likely present with a class II or class III skeletal
malocclusion with or without asymmetry. Before
any surgical treatment plan is formulated, the
surgeon should be familiar with the jaw relation-
ships that are more susceptible to the develop-
ment of postoperative pain, TMJ dysfunction,
and condylar resorption. Only with this knowledge
can a treatment plan be tailored to minimize the
patient’s risk.

Class III Malocclusion

Patients having a class III skeletal malocclusion
are the least likely of all jaw relationships to have
preoperative TMD. However, the risk of devel-
oping postoperative TMD does exist. Therefore,
they should be managed accordingly. Class III
patients undergoing a bilateral sagittal split osteot-
omy (BSSO) do show some degree of postopera-
tive posterior or lateral displacement of the
condyle, but in large this does not cause a signifi-
cant change in TMJ disc position nor result in sig-
nificant postoperative pain.9–11 Therefore, a
surgeon should have no reservations using this
technique when performing mandibular setback
surgery in patients with a history of TMD.
An intraoral vertical ramus osteotomy (IVRO) has
been advocated by some as the technique of
choice in TMD patients with a class III skeletal
malocclusion (Fig. 3). The rational is that an IVRO
will result in an anterior and inferior displacement
of the condyle. This displacement increases the
joint space and promotes disc reduction in joints
with disc displacement with reduction or recent
progression to disc displacement without reduc-
tion.12 Hu and colleagues13 showed that 75% of
patients undergoing an IVRO had an improvement
or resolution of TMJ pain and no asymptomatic
patients developed new pain, whereas only 40%
of patients undergoing BSSO showed improve-
ment in symptoms and 8% of asymptomatic pa-
tients developed new symptoms. The debate
over which surgery to perform exists because pa-
tients undergoing IVRO must be placed in maxillo-
mandibular fixation (MMF) for an extended period
of time postoperatively; this may increase the
risk of developing limited mouth opening. Also,
because of the condylar sag that occurs as a result
of an IVRO, the condyle may reseat in a more su-
perior position, due to muscle pull, following the
release of MMF. Consequently, this would lead
to an open-bite deformity.
Fig. 3. Intraoral vertical ramus osteotomy. This surgi-
cal option may minimize postoperative TMD symp-
toms in patients requiring mandibular setback.
Class II Malocclusion—Progressive/Idiopathic
Condylar Resorption
It has been proposed that TMJ remodeling can be
both functional and dysfunctional.14–18 Functional
remodeling involves morphologic changes of the
articular surfaces of the TMJ that does not cause
any significant alterations of the joint or the occlu-
sion. Conversely, remodeling of the TMJ is consid-
ered to be dysfunctional if the morphologic
changes lead to a loss of condylar-ramus height,
resulting in mandibular retrusion and a class II
malocclusion. In some, it may also lead to an ante-
rior open bite. Dysfunctional remodeling has
historically been termed condylar resorption.
Condylar resorption may occur as a result of
several reasons. A few examples include systemic
and local arthritidis and trauma. If no obvious
cause is identified, it is termed idiopathic condylar
resorption (ICR).
Patients with a history of condylar resorption
pose a difficult challenge to the treating orthodon-
tist and orthognathic surgeon. The difficulty arises
because any treatment that causes excessive me-
chanical loading may predispose the patient to
further condylar resorption and the resulting class
II open-bite deformity (Fig. 4). The surgical treat-
ment of class II open-bite patients usually involves
6 Nale
Fig. 4. Cephalometric radiographs depicting postoperative relapse following orthognathic surgery for correction
of a class II skeletal malocclusion. (A) Pre-op. (B) Post-op day 1. (C) Completion of orthodontics at 3 months post-
op. (D) 3 years post-op.
a Le Fort I osteotomy in conjunction with a bilateral
sagittal split of the mandible, with or without coun-
terclockwise rotation of the maxillomandibular
complex. This combination of procedures in-
creases the mechanical load of the TMJ19 and
may result in postsurgical relapse. The key to suc-
cessful treatment is recognition of those patients
who are at high risk for postsurgical condylar
resorption and to modify treatment to minimize
their risk.
Predisposing factors for developing postsur-
gical relapse secondary to condylar resorption
have been well documented. Patients with
systemic diseases such as rheumatoid arthritis,
scleroderma, systemic lupus erythematosus,
and other vascular collagen diseases have been
reported as high risk.20–23 Predisposing factors
for ICR include TMJ dysfunction, being a young
woman, having a high mandibular plane angle,
and having a posteriorly inclined condylar
neck.21,23–29
Preoperatively, patients with a systemic dis-
ease should be referred to a rheumatologist for
evaluation and treatment. It has been suggested
that all high-risk patients be placed on antiinflam-
matory medication, tumor necrosis factor a
inhibitors, or matrix metalloproteinase inhibitors,
because targeted pharmacotherapy might be
able to prevent further condylar resorption.30
Occlusal splints are also recommended for those
patients with TMJ pain and dysfunction. The
splint serves 2 purposes. The first purpose is to
limit joint loading; the second is to determine
cessation of the resorptive process. Patients are
fitted with a splint with registered contact of the
mandibular teeth. If the lower incisors lose con-
tact over time, this indicates active resorption.31
Serial radiologic imaging, orthopantogram and
cephalometric radiographs, and CBCT can be
used to evaluate change in condylar shape. A
technetium 99 bone scan may also be useful in
determining active resorption. Timing of surgery

should also be strongly considered. ICR is most
active in the teenage years and mid 20s; there-
fore, surgeons should consider waiting until after
the age of 25 years to correct the dentofacial
deformity.
Intraoperatively, special considerations exist
for patients who are at a high risk of developing
postoperative condylar resorption. Joss and
Vassalli32 reported long-term relapse (condylar
resorption) for cases treated with bicortical
screws (2%–50.3%), whereas miniplates had
comparatively much less relapse (1.5%–8.9%).
Arnett and Gunson26 relate this statistical differ-
ence to condylar torquing as a result of bicortical
screws displacing the proximal segment during
fixation of BSSOs. He, therefore, recommends
the use of monocortical miniplates for fixation of
BSSOs (Fig. 5). If possible, one might also
consider limiting the surgical correction to just
the maxilla. Hoppenreijs and colleagues27 re-
ported that the incidence of condylar resorption
after surgery performed only on the maxilla for
correction of class II open bite was less than
that after bimaxillary osteotomies (9% compared
with 23%). Lastly, if bimaxillary surgery is
required, one might consider minimizing mandib-
ular advancement because larger advancements
stretch the surrounding soft-tissue components
and this tension can lead to greater compression
and mechanical loading of the condyle, resulting
in resorption.33–35
Postsurgical management should include medi-
cations as needed, class II elastics, and occlusal
splint therapy after debanding. Patients should
be observed on a regular basis because relapse
Fig. 5. Sagittal split osteotomy using miniplate fixa-
tion for mandibular advancement.
Orthognathic Surgery and the TMJ Patient 7
usually presents with an anterior open bite
between 6 months and 3 years following surgery.19
It should also be noted that repeating an osteot-
omy on the condylar resorption patient whose first
orthognathic surgery was unsuccessful has close
to a 50% failure rate reported in the litera-
ture.19,25,36 To minimize failure rate, total joint
replacement may be considered, especially in
those patients with symptomatic or active resorp-
tion (Fig. 6).
COMBINED ORTHOGNATHIC SURGERY AND
ALLOPLASTIC TEMPOROMANDIBULAR JOINT
RECONSTRUCTION
Occasionally, a patient may present with both a
skeletal-facial deformity and an end-stage TMJ
pathologic condition. In this scenario, orthognathic
surgery combined with alloplastic TMJ reconstruc-
tion should be considered. Commonly, the dento-
facial deformity occurs as a result of the TMJ
disease due to resorption or decreased condylar
growth. Often times these patients have had
numerous failed treatment attempts or suffer
from chronic joint pain or dysfunction.
TMJ disorders commonly associated with
skeletal-facial deformities include reactive arthritis,
condylar hyper- or hypoplasia, ICR, congenital
deformation, trauma, or other end-stage TMJ
pathologic conditions. These common TMJ disor-
ders often result in a loss of condylar-ramus height.
Patients with advanced disorders will have a steep
mandibular plane angle, loss of chin projection,
and possibly an anterior open bite. Their chief
complaints may include joint or facial pain, diffi-
culty chewing, and esthetics. For patients diag-
nosed with end-stage TMJ pathologic condition,
one might consider a combination of orthognathic
surgery and alloplastic joint reconstruction (Fig. 7).
For unilateral TMJ pathologic condition, one would
consider a Le Fort I osteotomy combined with a
mandibular unilateral sagittal split and total joint
reconstruction on the contralateral side. For bilat-
eral TMJ pathologic condition, one would consider
a Le Fort I osteotomy combined with a bilateral to-
tal joint reconstruction.
TMJ reconstruction and mandibular advance-
ment with custom alloplastic total joint prostheses
in conjunction with maxillary osteotomies, for
counterclockwise rotation of the maxillomandibu-
lar complex, has been shown to be a stable proce-
dure.37 However, the surgery requires meticulous
planning to restore form and function to the pa-
tient. The difficulty of the surgery arises from the
fact that the joint prosthesis must be manufac-
tured to correspond with the planned new position
of the maxilla and mandible. Any inaccuracy may
8 Nale
Fig. 6. (A, B) Total joint reconstruction used to correct an open-bite malocclusion after surgical relapse following
orthognathic surgery. This patient had developed chronic pain and limited mouth opening before joint
replacement.
result in a persistent malocclusion and compro-
mised facial esthetics.
Traditionally, planning begins with cephalometric
analysis to predict the final position of the maxillary
incisors; this likely requires a counterclockwise
rotation of the maxillomandibular complex. Jaw
relation records are taken and transferred to stone
models. Model surgery based off of the cephalo-
metric analysis is then performed to produce an
intermediate and final splint. Also, a 2-piece stereo-
lithographic model of the patient’s skull is fabri-
cated from a preoperative CT scan. Bilateral
condylectomies or a condylectomy and sagittal
split osteotomy are performed on the model
(Fig. 8). Once completed, the intermediate splint
is used to establish the new position of the
mandible (Fig. 9). The stereolithographic model is
then sent to TMJ Concepts (Ventura, CA, USA) for
a wax-up and ultimately, final production of the
patient-specific joint prosthesis. With this method,
the joints are placed first during surgery and the final
position of the maxilla is established off of the new
position of the mandible.
During the planning phase of treatment, there
are many steps in which inaccuracies may occur.
Errors with impressions, bite registration, and
face-bow transfer would result in inaccurate
mounted stone models. Of course this would
then perpetuate into an intermediate splint that
places the mandible into a position other than
that which is planned. Another step that may
introduce error during planning is when the inter-
mediate occlusion is established on the stereoli-
thographic model. It is very common for these
models to have gross inaccuracies in tooth anat-
omy (Fig. 10). There are 2 reasons for this. The
first is that patients typically have their images
taken in the CT scanner with their mouths closed.
Having their upper and lower teeth touch during
the imaging process ultimately distorts the image
quality of the occlusal surfaces of the teeth. The
other reason is that metallic restorations cause
scattering of the image. This scattering is then
transferred to the stereolithographic model.
Regardless of the cause, the surgeon may find it
difficult to seat the intermediate splint onto the
model because of these inaccuracies. If the upper
and lower teeth are not placed into the exact rela-
tionship relative to the stone model, the joints will
be fabricated based off of an inaccurate mandib-
ular position. This inaccuracy would then be
transferred to the patient’s final occlusion.
VIRTUAL SURGICAL PLANNING
Recently, there has been a paradigm shift in or-
thognathic surgery planning. To minimize the inac-
curacies associated with traditional planning
methods, it is becoming more common for sur-
geons to plan surgeries virtually using computer-
aided surgical simulation (CASS). Gelesko and
colleagues38 described CASS as a method that
generally consists of 4 phases:
1. Data acquisition phase: clinical examination
with bite registrations and anthropometric mea-
surements; radiographic examination/CT scan
2. Planning phase: importation of 3D CT data into
proprietary planning software
3. Surgical phase: translation of the virtual surgi-
cal plan to patients using stereolithographic
models, cutting guide stents, occlusal splints,
or intraoperative navigation
4. Assessment phase: evaluation of the accuracy
of virtual surgical plan transfer using intraoper-
ative or postoperative CT imaging
It has been demonstrated that the CASS proto-
col39 is not only feasible40,41 but also can
 Orthognathic Surgery and the TMJ Patient 9

Fig. 7. (A–D) This patient developed facial asymmetry, chronic pain, and limited mouth opening following an un-
diagnosed condyle fracture as a child. A treatment plan consisting of a left total joint replacement in conjunction
with orthognathic surgery was chosen due to the end-staged nature of the left joint.
10 Nale
Fig. 8. A 2-piece stereolithographic model depicting a
left-sided unilateral sagittal split performed in
conjunction with a right-sided total joint replacement
for the correction of a skeletal malocclusion.
accurately and consistently be transferred to the
patient’s maxilla and mandible at the time of sur-
gery.42–45 Once the final position of the occlusion
is established, an intermediate and final splint can
be manufactured based on the virtual image.
This technique may also be used to improve the
accuracy of combined orthognathic and joint
reconstruction surgery. Planning begins with the
data acquisition phase of the CASS system. Natu-
ral head position is established with either fiducial
markers placed onto the patient’s face along the
true vertical and horizontal lines or with the use
of a gyroscope. Next, another fiducial marker is
placed into a bite jig and placed into the patient’s
mouth, which captures an occlusal record. With
the fiducial markers in place, a CT or CBCT scan
is taken. Stone models of the patient’s occlusion
are then obtained and placed into the previously
Fig. 9. The intermediate occlusion is established on
the stereolithographic model using an acrylic splint
fabricated from dental stone models following tradi-
tional model surgery.
Fig. 10. The occlusal surfaces of the teeth are grossly
distorted on this stereolithographic model. The distor-
tion may occur as a result of scatter from the CT scan
or if the patient had their teeth occluded while taking
the CT scan.
used bite jig. The stone models are then digitized
with either a laser surface scanner or a CBCT
scanner. Lastly, the final occlusion is established
on the stone models and then scanned.
The planning phase begins by uploading the
Digital Imaging and Communications in Medicine
data from CT scans or CBCT scans and digital
models obtained from a laser scanner to a third-
party service provider to facilitate software manip-
ulation and splint fabrication (Medical Modeling
Inc, Golden, CO, USA). The software engineers
then integrate the different datasets to create an
accurate digital image of the patient (Fig. 11).
Next, a planning session involves establishing
the final position of the maxilla based off of the
desired incisor position relative to the upper lip.
Next, the mandibular position is established using
the predetermined final occlusion. Symmetry of
Fig. 11. Datasets from a CT or CBCT and dental stone
models are integrated to create an accurate digital
image of the patient’s bony skeleton and teeth.
 Orthognathic Surgery and the TMJ Patient 11

Fig. 12. (A) Virtual image of a healed, 1-year-old condyle fracture in a 63-year-old woman. (B) A virtual condy-
lectomy is performed after the engineer has corrected the yaw, pitch, and roll deformities.

the maxilla and mandible are also established by
correcting deformities of yaw, pitch, and roll.
Lastly, virtual condylectomies are performed
(Fig. 12). It is this last step that differentiates com-
bined orthognathic and temporomandibular joint
reconstruction CASS from that of traditional or-
thognathic surgery. The condylectomies are per-
formed approximately 5 mm below the sigmoid
notch, if anatomy allows, to create space for the
fossa component of the prosthesis.

Fig. 13. (A) Stereolithographic model reflecting a virtual surgical plan. (B) Wax-up of the alloplastic joint pros-
thesis on the stereolithographic model. (C) Virtual cutting guide for the condylectomy. (D) Actual cutting guide
used during surgery.
12 Nale
Once the virtual condylectomy is performed,
Medical Modeling will produce a stereolitho-
graphic model reflecting the virtual reconstruction
of the maxilla and mandible. It is from this model
that the custom joints will be manufactured. To
insure accuracy of the location of the condylec-
tomy, cutting guides may also be fabricated
(Fig. 13). The CASS model is also used to generate
an intermediate and final interocclusal splint via
CAD/CAM technology. Movahed and colleagues46
suggest that for patients undergoing active ortho-
dontics, fabrication of interocclusal splints should
be delayed, in relation to fabrication of the stereo-
lithographic model, until 2 weeks before surgery.
At that time new dental models should be obtained
and incorporated into the virtual plan. This step will
improve the accuracy of the splints.
The newly created custom joints and interoc-
clusal splints are then used to transition the virtual
plan to the surgical phase of treatment. Surgery is
sequenced by first positioning a K-wire into nasion
as a vertical reference. Bilateral or unilateral con-
dylectomy and unilateral sagittal split are per-
formed. Next, the patient is placed into MMF
with the intermediate splint interposed. If the pa-
tient is undergoing a unilateral sagittal split, the
proximal and distal segments are fixated while
the surgeon is still working in the patient’s mouth.
Otherwise, the joint prosthesis is then secured.
Next, MMF is released and intermediate occlusion
confirmed, followed by the Le Fort I osteotomy.
The patient is then placed into MMF with the final
splint interposed and the maxilla is secured into
its final vertical position. MMF is released and
the final occlusion is confirmed.
The assessment phase of the treatment proto-
col is accomplished by superimposing a postoper-
ative CT scan or CBCT scan and the virtually
planned models. The software engineers at Medi-
cal Modeling Inc will overlay static anatomic land-
marks of the cranium. The difference in position of
specific landmarks of the maxilla and mandible
can then be measured.
SUMMARY
The role of orthognathic surgery in the treatment of
TMD has been debated for years. The difficulty in
establishing a cause-and-effect relationship be-
tween orthognathic surgery and improvement in
symptoms stems from the multifactorial nature of
TMD combined with variables in surgical tech-
nique. As a result, it is advocated that TMD and
dentofacial deformities be treated independent of
one another. Most advocate the treatment of
TMD first. Only once symptoms have improved,
may treatment of the skeletal malocclusion be
addressed. Also, understanding that TMD can
potentially worsen following orthognathic surgery,
it is important to modify the surgical treatment plan
to minimize the risk of exacerbation of TMJ pain,
dysfunction, and condylar resorption.
Lastly, those patients with end-stage TMD and a
dentofacial deformity may require combined or-
thognathic surgery and alloplastic TMJ recon-
struction. The success of this surgery greatly
depends on the experience of the surgeon. How-
ever, the efficiency and accuracy of the procedure
can be optimized with the use of virtual surgical
planning.
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