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British Journal of Oral and Maxillofacial Surgery 50 (2012) 176–180

Progressive condylar resorption after mandibular

advancement
Tadaharu Kobayashi a,∗ , Naoya Izumi a , Taku Kojima a , Naoko Sakagami a ,
Isao Saito b , Chikara Saito a
a Division of Reconstructive Surgery for Oral and Maxillofacial Region, Department of Tissue, Regeneration and Reconstruction, Course for Oral Life
Science, Niigata University Graduate, School of Medical and Dental Sciences, 2-5274 Gakkocho-Dori, Cyuo-Ku, Niigata City 951-8514, Japan
b Division of Orthodontics, Department of Oral Biological Science, Course for Oral Life, Science, Niigata University Graduate School of Medical and

Dental Sciences, 2-5274 Gakkocho-Dori, Cyuo-Ku, Niigata City 951-8514, Japan

Accepted 21 February 2011
Available online 26 March 2011

Abstract

Progressive condylar resorption is an irreversible complication and a factor in the development of late skeletal relapse after orthognathic
surgery. We have evaluated cephalometric characteristics, signs and symptoms in the temporomandibular joint (TMJ), and surgical factors
in six patients (one man and five women) who developed it after orthognathic surgery. The findings in preoperative cephalograms indicated
that the patients had clockwise rotation of the mandible and retrognathism because of a small SNB angle, a wide mandibular plane angle, and
a “minus” value for inclination of the ramus. There were erosions or deformities of the condyles, or both, on three-dimensional computed
tomography (CT) taken before treatment. The mean (SD) anterior movement of the mandible at operation was 12.1 (3.9) mm and the mean
relapse was −6.4 (2.5) mm. The mean change in posterior facial height was 4.5 (2.1) mm at operation and the mean relapse was −5.3 (1.8) mm.
Two patients had click, or pain, or both, preoperatively. The click disappeared in one patient postoperatively, but one of the patients who
had been symptom-free developed crepitus postoperatively. In the classified resorption pattern, posterior–superior bone loss was seen in
three cases, anterior–superior bone loss in two, and superior bone loss in one. Progressive condylar resorption after orthognathic surgery is
multifactorial, and some of the risk factors are inter-related. Patients with clockwise rotation of the mandible and retrognathism in preoperative
cephalograms; erosion, or deformity of the condyle, or both, on preoperative CT; and wide mandibular advancement and counterclockwise
rotation of the mandibular proximal segment at operation, seemed to be at risk. The mandible should therefore be advanced only when the
condyles are stable on radiographs, and careful attention should be paid to postoperative mechanical loading on the TMJ in high-risk patients.
© 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Progressive condylar resorption; Deformity of jaw; Mandibular advancement

Introduction several clinical and radiological features and some hypotheti-

Progressive condylar resorption is an irreversible complica-
tion and a factor in the development of late skeletal relapse
after bilateral sagittal split osteotomies, Le Fort I osteotomies,
or bimaxillary osteotomies. It is characterised by severe mor-
phological changes in condylar configuration, with reduction
of volume and a decrease in the height of the ramus. Although
cal contributing factors have been reported,1–13 the aetiology
and pathogenesis are still not clear. The aim of this study was
to examine the risk factors for progressive condylar resorption
in patients treated by orthognathic surgery.
Patients and methods

A total of 505 patients with deformities of the jaws who

∗ Corresponding author. Tel.: +81 25 227 2877; fax: +81 25 223 6516. had orthognathic surgery in our department from 1998 to
E-mail address: tadaharu@dent.niigata-u.ac.jp (T. Kobayashi). 2006 were screened for progressive condylar resorption. Of

0266-4356/$ – see front matter © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2011.02.006
 T. Kobayashi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 176–180 177

Table 1
Findings on preoperative cephalograms (◦ ).
Case no. Sex Age (years) SNA angle SNB angle Mandibular plane angle Gonial angle Inclination of ramus
1 F 26 77.8 69.5 33.0 114.4 −8.6
2 F 21 78.4 69.1 42.8 128.2 −4.6
3 F 24 80.2 70.4 44.9 125.7 −9.2
4 F 16 77.1 68.4 40.6 122.0 −8.6
5 F 17 77.8 72.5 32.0 114.4 −7.6
6 M 22 72.4 65.0 56.2 135.9 −10.3
Mean (SD) 77.3 (1.2)↓ 69.2 (1.6)↓ 41.6 (5.8)↑ 123.5 (6.4) −8.2 (1.8)↓
Normal values of Japanese adults14
Female 81.4 (3.0) 78.2 (3.0) 27.1 (5.2) 121.6 (6.0) 4.5 (5.2)
Male 81.4 (3.6) 79.6 (3.9) 25.6 (5.6) 112.4 (6.0) 5.4 (4.3)

the 505 patients, 385 had mandibular prognathism with or
without asymmetry, or open bite, or both; eighteen patients
had bimaxillary protrusion; 34 had mandibular retrognathism
with or without asymmetry, or open bite, or both; 51 had
asymmetry alone; 12 had open bite alone; and 5 had max-
illary protrusion alone. Progressive condylar resorption was
diagnosed if there was postoperative occlusal change con-
sisting of increased overjet, or reduced overbite, or both;
pronounced decrease in the height of the ramus or coun-
terclockwise rotation of the proximal segment, or both, on
lateral cephalograms; and obvious condylar resorption on
postoperative CT compared with that on pretreatment CT.
A CT was routinely taken before orthodontic treatment to
assess the skeletal and soft tissue morphology and the TMJ,
and another was taken postoperatively if the need arose.
According to the selection criteria, six patients with pro-
gressive condylar resorption were selected for this study. The
patients included one man and five women (mean age at oper-
ation 21 years, range 16–26) with mandibular retrognathism.
For correction of jaw deformities, bilateral sagittal split
osteotomy (BSSO), with or without other osteotomies, and
with advancement genioplasty, were used to correct the defor-
mities of the jaws. Mandibular segments were fixed internally
with titanium miniplates or screws. Maxillomandibular rigid
fixation lasted for 7–14 days.
Changes in the position of the mandible were evaluated
on lateral cephalograms taken with the patient in a central
occlusion immediately preoperatively, within one week of
operation, and at least one year postoperatively. The find-
ings of the cephalograms were compared with norms for
Japanese people,14 and serial cephalograms were superim-
posed using sella and nasion as the fixed cephalometric
landmarks by our original computer program. The horizontal
and vertical changes were calculated by measuring the par-
allel and perpendicular movements of the pogonion to the
Frankfurt horizontal plane. Posterior facial heights were cal-
culated by measuring the vertical distance from the sella to the
gonion. Anterior and inferior movements were given “plus”
values. The shapes of the condyles were examined on three-
dimensional CT taken before treatment and at least one year
afterwards. Dysfunction of the TMJ was judged clinically as
pain, sounds (click or crepitus), movement, and limitation.
Data are expressed as mean (SD).
Results
Findings on preoperative cephalograms indicated that the
patients had clockwise rotation of the mandible and retrog-
nathism because of a small SNB angle, a wide mandibular
plane angle, and “minus” value for inclination of the ramus
(Table 1). Erosions or deformities of the condyles, or both,
were seen in all patients on three-dimensional CT taken
before treatment. However, 14 of 28 patients (3 men and 25
women) who did not have postoperative progressive condylar
resorption and who had had mandibular advancement in our

Table 2
Changes in the position of the mandible (mm).
Case no. Changes in:

Horizontal movement Vertical movement Posterior facial height

At operation Relapse At operation Relapse At operation Relapse

1 14.8 −9.7 3.1 −1.5 7.4 −7.7
2 10.1 −7.3 0 −1.7 2.6 −6.1
3 14.6 −3.2 0 −0.7 2.2 −2.8
4 14.3 −4.5 4.5 −0.9 4.9 −5.0
5 5.9 −6.5 0.6 0.3 4.5 −5.0
6 13.1 −7.2 1.2 −0.3 5.2 −4.6
Mean (SD) 12.1 (3.9) −6.4 (2.5) 1.6 (2.0) −0.8 (0.8) 4.5 (2.1) −5.3 (1.8)
178 T. Kobayashi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 176–180

Table 3
Summary of signs and symptoms in the temporomandibular joint.
Case no. Before operation One year postoperatively
Clinical findings Incisal opening (mm) Clinical findings Incisal opening (mm)
1 Click + pain 44 Click + pain 37
2 (–) 37 (–) 33
3 Click 43 (–) 39
4 (–) 53 (–) 44
5 (–) 39 (–) 47
6 (–) 54 Crepitus 37
Mean (SD) 45 (6.2) 40 (5.6)

department from 1998 to 2006, had erosions or deformities
of the condyles before treatment.
The mean (SD) movements of the mandible are shown in
Table 2, and the effects of the operation of signs and symp-
toms in the TMJ are shown in Table 3. In all cases, pronounced
skeletal relapses and occlusal changes developed more than 6
months postoperatively, and the resorption patterns are shown
in Table 4.
Case No. 1 was the most severe case. Anterior move-
ment of the mandible at operation was 14.8 mm at the
pogonion and horizontal relapse was −9.7 mm. Change
in posterior facial height was 7.4 mm at operation and
relapse was −7.7 mm. However, the occlusion was stabilised
orthodontically and the profile was acceptable for the patient.
Comparison of three-dimensional CT taken before, and one
year after, treatment showed remarkable condylar resorption
at the posterosuperior-lateral aspects of the bilateral condyles
on postoperative images, particularly on the right side
(Fig. 1).
Discussion
It is difficult to define the junction between condylar remod-
elling and resorption on radiographs. 13 In the present study,
progressive condylar resorption was defined as appreciable
condylar resorption on CT in a patient with postoperative
occlusal change that consisted of an increase in overjet, or
a decrease in overbite, or both, and cephalometric skele-
tal changes consisting of obvious reduction in the height of
the ramus, or counterclockwise rotation of the proximal seg-
ment, or both. Three-dimensional CT was more accurate for
condylar images than those on cephalograms or panoramic
radiographs, and was therefore useful for the estimation of
condylar resorption.
The incidence of progressive condylar resorption after
mandibular advancement has been reported to vary from
1% to 31%.2–5,13 This wide range probably results partly
from the wide variations in the populations studied. In the
present study, progressive condylar resorption was seen in
6 of the 505 patients with deformities of the jaws who
had had orthognathic surgery, and 6 of the 34 patients with
mandibular retrognathism had progressive condylar resorp-
tion. Several studies have shown that the first signs of
condylar resorption were apparent 6 months or more after
mandibular advancement,3,6,12 and that it developed up to
2 years’ postoperatively.2–4,6,11 In our cases pronounced
skeletal relapses and occlusal changes were apparent more
than 6 months postoperatively. Progressive condylar resorp-
tion is therefore thought to be a factor in the development
of late skeletal relapse after orthognathic surgery.Several
risk factors have previously been reported: those related to
patients include radiological signs of osteoarthrosis; dys-
function of the TMJ; mandibular hypoplasia with a wide
mandibular plane angle; and a low posterior:anterior facial
height ratio, or a posteriorly inclined condylar neck, or

Table 4
Summary of resorption patterns.
Case no. Affected side Resorption pattern
1 Both Posterosuperior
2 Both Anterosuperior
3 Both Superior
4 Left Anterosuperior
5 Left Posterosuperior Fig. 1. Buccal and backward views of the right condyle in three-dimensional
6 Both Posterosuperior computed tomographic images of case 1 (A) before treatment and (B) one
year postoperatively.
 T. Kobayashi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 176–180
both.2–4,6–12 In the present study all patients with postoper-
ative progressive condylar resorption had clockwise rotation
of the mandible, mandibular retrognathism, and erosions or
deformities of the condyles, or both, before treatment. It
is more common among young women than men or older
women,2–4,7–9 though one man was affected in the present
study. Contributing surgical factors include wide mandibular
advancement, counterclockwise rotation of the mandibular
proximal segment, intermaxillary fixation, rigid internal fix-
ation, bimaxillary osteotomies, and avascular necrosis of the
condyle.1–4,6,9–11
The aetiology of progressive condylar resorption is still
not clear. Mandibular advancement stretches the surrounding
soft-tissue components, and this tension causes the condyle to
be retruded forcefully into the fossa, which generates pressure
on the condylar head. This may cause condylar resorption
when mechanical loading exceeds the adaptive capacity of
the condyle.2,3,7–11 The anterosuperior surface of the condyle
is located more superiorly when the condyle is autorotated
posteriorly with counterclockwise rotation of the proximal
mandibular segment.3,9,11 This surface of the condyle, orig-
inally not loaded, is less dense because no trabeculae extend
from the anterior aspect of the articular condylar surfaces in
angle class II malocclusion.9,11 As far as aetiology is con-
cerned, it might be worthwhile to investigate blood flow
to the condyle after a BSSO.1 Relative reduction in the
vascular supply to the condyle may trigger the cause of pro-
gressive condylar resorption in some patients who are at
risk.1,9 Mandibular lengthening using the principle of dis-
traction osteogenesis without compromising vascular supply
would probably circumvent this problem, because it has been
reported that patients who had had distraction osteogenesis
for mandibular advancement of between 6 and 10 mm had
a lower incidence of condylar resorption than that among
patients who had had a BSSO.15 However, when the biome-
chanical effects of loading on the condyle are the most likely
cause, distraction osteogenesis for wide mandibular advance-
ment will not be able to prevent condylar resorption, because
loading of the TMJ may be considerable over a longer period
of time.9,16 Because condylar resorption is more common
among women, it has been thought that a prominent factor
might be sex hormones. Oestrogen mediates the metabolism
of cartilage and bone in the female TMJ. Animal studies have
implicated oestrogen as a potential mediator of degenera-
tive remodelling of the TMJ, decreased bone volume, and
osteophytic formation.17,18 An increase in receptors may pre-
dispose to an exaggerated response to loading of the joint
after orthognathic surgery. Further studies are necessary to
clarify the influence of various factors that play a part in the
aetiology of progressive condylar resorption.
The treatment of patients with the condition is still open to
debate, because little information is available on its natural
course after treatment. The decision about this depends on
factors such as the severity of skeletal relapse and malocclu-
sion, the desire of the patient to have an optimal result despite
relapse, and the possibility of compensating orthodontically
179
for malocclusion or of attaining reasonable occlusal stabil-
ity after adjustment or restorative dentistry. When either the
occlusion or the profile is not acceptable to the patient, how-
ever, reoperation might be justifiable. All the present cases
were treated by orthodontic compensation, and accepted their
postoperative occlusions and aesthetic results.
Ways to prevent progressive condylar resorption have not
yet been established. Orthognathic surgery should be done
only when the condyles are stable as assessed by clinical
examination and radiographs. We now routinely take cone-
beam CT before treatment, because it is useful to assess
skeletal morphology and the exposure dose is comparatively
low. We have tried to use Class II elastics for 6 or more months
postoperatively to reduce mechanical loading in patients at
high risk. However, we think it is difficult to prevent it com-
pletely. We therefore recommend that such patients be given
explicit information regarding the possibility of relapse and
condylar resorption.
Conflict of interest
There is no conflict of interest.
References
1. Schellhas KP, Wilks CH, Fritts HM, Omlie MR, Lagrotteria LB. MR
of osteochondritis desiccans and avascular necrosis of the mandibular
condyle. AJR 1989;152:551–60.
2. Kerstens HC, Tuinzing DB, Golding RP, Van der Kwast WA. Condylar
atrophy and osteoarthrosis after bimaxillary surgery. Oral Surg Oral
Med Oral Pathol 1990;69:274–80.
3. Moore KE, Gooris PJJ, Stoelinga PJ. The contributing role of condy-
lar resorption to skeletal relapse following mandibular advancement
surgery: report of five cases. J Oral Maxillofac Surg 1991;49:448–60.
4. Bouwman JP, Kerstens HC, Tuinzing DB. Condylar resorption in
orthodontic surgery. The role of intermaxillary fixation. Oral Surg Oral
Med Oral Pathol 1994;78:138–41.
5. De Clercq CA, Neyt LF, Mommaerts MY, Abeloos JV, de Mot BM.
Condylar resorption in orthognathic surgery: a retrospective study. Int J
Adult Orthodon Orthognath Surg 1994;9:233–40.
6. Merkx MA, Van Damme PA. Condylar resorption after orthognathic
surgery. Evaluation of treatment in 8 patients. J Craniomaxillofac Surg
1994;22:53–8.
7. Arnett GW, Milam SB, Gottesman L. Progressive mandibular
retrusion–idiopathic condylar resorption. Part I. Am J Orthod Dento-
facial Orthop 1996;110:8–15.
8. Arnett GW, Milam SB, Gottesman L. Progressive mandibular remission-
idiopathic condylar resorption. Part II. Am J Orthod Dentofac Orthop
1996;110:117–27.
9. Hoppenreijs TJ, Freihofer M, Stoelinga PJ, Tninzing DB, van’t Hof
MA. Condylar 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.
10. Cutbirth M, Van Sickels JE, Thrash WJ. Condylar resorption after bicor-
tical screw fixation of mandibular advancement. J Oral Maxillofac Surg
1998;56:178–83.
11. Hwang SJ, Haers PE, Sailer HF. The role of a posteriorly inclined
condylar neck in condylar resorption after orthognathic surgery. J Cran-
iomaxillofac Surg 2000;28:85–90.
180 T. Kobayashi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 176–180
12. Hwang SJ, Haers PE, Zimmermann A, Oechslin C, Seifert B, Sailer HF.
Surgical risk factors for condylar resorption after orthognathic surgery.
Oral Surg Oral Med Oral Pathol 2000;89:542–52.
13. Hwang SJ, Haers PE, Seifert B, Sailer HF. Non-surgical risk factors for
condylar resorption after orthognathic surgery. J Craniomaxillofac Surg
2004;32:103–11.
14. Nagaoka K, Kuwahara Y. Normal standards for various roentgen
cephalometric and cast model analyses in present day Japanese adults.
Part I. J Jpn Orthod Soc 1993;52:467–80.
15. Ow A, Cheung LK. Skeletal stability and complications of bilat-
eral sagittal split osteotomies and mandibular distraction osteogenesis:
an evidence-based review. J Oral Maxillofac Surg 2009;67:
2344–53.
16. van Strijen PJ, Breuning KH, Becking AG, Tuinzing DB. Condylar
resorption following distraction osteogenesis: a case report. J Oral Max-
illofac Surg 2001;59:1104–8.
17. Okuda T, Yasuoka T, Nakashima M, Oka N. The effect of ovariectomy
on the temporomandibular joints of growing rats. J Oral Maxillofac Surg
1996;54:1201–11.
18. Yasuoka T, Nakashima M, Okuda T, Tatematsu N. Effect of estrogen
replacement on temporomandibular joint remodeling in ovareiec-
tomized rats. J Oral Maxillofac Surg 2000;58:189–97.