Secondary Treatment of Malocclusion/Malunion Secondary to ...maxillary molar intrusion. In one study they showed a range of intrusion of the maxillary molars by 1.5 mm to 3.3 mm (mean,

Secondary Treatment of Malocclusion/Malunion Secondary to Condylar

KEYWORDS

� Malocclusion � Malunion � Condylar fracture � Secondary treatment

KEY POINTS

� Careful evaluation of the malocclusion, TMD symptoms, and myofascial pain dysfunction help to guide the practitioneralong appropriate treatment modalities.

� Conservative treatment involving splint therapy, physical therapy, and orthodontic correction and equilibration can beapplied to correct minor malocclusions after condylar fractures.

� Joint symptoms and functional impairment may indicate the need for arthroplasty or total joint replacement.

� Orthognathic surgery is a beneficial option for the patient with significant malocclusion; the use of virtual surgery allows forpresurgical assessment in determining if unilateral versus bilateral mandibular osteotomies are indicated.

Subcondylar and condylar fractures account for 29% to 32% ofall mandible fractures seen in the United States.1 The treat-ment of these injuries, as noted elsewhere in this issue, con-tinues to remain controversial. The results of open and closedtreatment often leave the patient with less than desiredmandibular function and occlusion. Complications associatedwith treatment of condylar and subcondylar fractures rangewidely in the oral and maxillofacial literature. Diagnostic er-rors, poor surgical technique, healing disorders, or complica-tions may lead to the establishment of posttraumaticmandibular deformities. Nonunion, malunion/malocclusion,and/or facial asymmetry can be found early during the healingprocess or as long-term sequelae after the initial mandibularfracture repair. Although occasionally these problems aresolved in a nonsurgical manner, reoperations play an importantrole in the management of these untoward outcomes.

In analyzing a patient’s condition it is also important to keepin mind the end point or goal of therapy (Box 1). The patient’scomplaints and concerns are often multifactorial and guidanceby the practitioner is essential. The factors that are most sig-nificant are also different for each patient. Some patients arehappy to be able to open normally without pain, whereas otherpatients believe even the slightest malocclusion may be

Disclosure Statement: The authors have nothing to disclose.a Private Practice, Emory School of Medicine, 5505 Peachtree

Dunwoody Road, Suite 660, Atlanta, GA 30342, USAb Department of Oral & Maxillofacial Surgery, Emory Healthcare, 930

Cumberland Road Northeast, Atlanta, GA 30306, USA* Corresponding author.E-mail address: [email protected]

Atlas Oral Maxillofacial Surg Clin N Am 25 (2017) 47–541061-3315/17/ª 2016 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.cxom.2016.10.003

unacceptable. Secondary treatment of these injuries can befrustrating, but also rewarding. Clinicians need to focustreatment plans based on listening to patients and not focus onhow a condyle may look on imaging. Ultimately success isbased on patient function and satisfaction.

Splint therapy and physical therapy

A crucial step in the course of treatment of posttraumaticmalocclusion is determining the presence or absence oftemporomandibular disorder and/or myofascial pain. If thereare no symptoms the patient should move toward evaluationfor correction of the malocclusion. When signs and symptomsare present they should be addressed conservatively usingsplint therapy, masticatory complex rest, physical therapy,nonsteroidal inflammatory drugs, and muscle relaxants whenindicated.

Splint therapy should be done with a stabilization splint thatprovides even bilateral contacts. There is no supportingevidence for anterior versus group function, particularly in thispopulation. The splint should be worn by the patient continu-ously, and close follow-up should be provided for regular ad-justments. These adjustments are necessary as the condylarprocess remodels to a stable articulation. Once the splint canbe worn without change in occlusion then treatment is dis-cussed for correction of the malocclusion.

Jaw exercises for increased range of motion should bepromoted, which may also help if the patient has pain withfunction.2 Adjunctive physical therapy may be warranted by aphysical therapist trained in TMD depending on the patient’ssymptoms. Therapy should be geared toward improvement inmobility and pain. Thermal, transcutaneous electrical nerve

oralmaxsurgeryatlas.theclinics.com

Box 1. Goals of therapy in late secondarytreatment of mandibular condylar processfractures

� Obtain stable occlusion� Restore interincisal opening� Establish a full range of mandibular excursivemovements

� Minimize deviation of the mandible� Produce a pain-free masticatory complex at rest andduring function

� Avoid internal derangement of the temporomandibularjoint on the injured or the contralateral side

� Avoid the long-term complication of growth disturbance

Fig. 1 TMJ concepts total joint prosthesis.

48 Maron et al.

stimulation unit, and dry needling may be used to treat theinflammation and pain. Exercise therapy and heat may be usedfor hypomobility.

If the patient’s symptoms resolve the practitioner and pa-tient can be more assured that if the malocclusion is corrected,then the symptoms will likely improve. When the symptoms ofTMD remain with the previously fractured condyle, one shouldconsider a temporomandibular joint (TMJ) total joint pros-thesis or concomitant open joint surgery with or withoutorthognathic surgery for correction of the malocclusion. If thepatient develops symptoms in the joint not affected by thetraumatic event, then the splint may be inappropriatelyloading that joint. If the patient’s symptoms resolve with splinttherapy and the malocclusion is minor, the patient could bemonitored for dental compensation without any treatment orwith the use of orthodontic therapy.

Conservative treatment

The common types of malocclusion for condylar fracturesdepend on a unilateral versus bilateral condylar fractures.Posttraumatic malocclusion from a unilateral condylar processfracturewith displacement likely results in a unilateral open biteof the contralateral side of the fracture with deviation onopening to the ipsilateral side. This is caused by the loss ofmandibular ramus height and decreased posterior facial heighton the ipsilateral side. This results in a clockwise or posteriorrotation of the mandibular plane on the ipsilateral side of thefracture. The common malocclusion for a bilateral condylarfracture is an anterior open bite (AOB). This is caused by the lossof mandibular ramus height bilaterally causing clockwise orposterior rotation of the mandibular plane bilaterally. Both ofthese problems may cause significant problems for a patient.Their functional imbalance could lead to dysphonia, alteration intheir anterior guidance, reduction in functional activity, pain,and poor aesthetics. As an oral and maxillofacial surgeon, onemust determine if it is appropriate to perform surgical correctionof the malocclusion. The answer must be discerned by the pa-tient’s desire for surgery, what the goals of treatment are for thepatient, andwhether the issue can be correctedwithout surgery.

Equilibration

Dental equilibration can be completed through occlusal ad-justments. Two studies that looked at using occlusal

adjustment for closure of an AOB found a mean closure of openbite anteriorly by an average of 2.28 mm and another by2.38 mm. There was 33.3% relapse among the patients of thefirst study.3,4 This procedure can also cause the risk of dentinhypersensitivity depending on the amount of reduction alongwith future occlusal wear leading to dentin exposure. Onestudy found resolution of the dentin hypersensitivity by thefifth month.4 There is little literature in support of this courseof treatment and its use should be weighed heavily againstother treatment options. However, for minor malocclusions,this treatment option could be considered.

Orthodontic correction of bilateral condylarprocess fractures

The long-time accepted treatment of a skeletal open bite hasbeen orthodontics followed by orthognathic surgery. Becausebilateral condylar process fractures create a skeletal AOB,surgery is the best option. In certain instances, the patient maybe averse to undergoing surgical correction of this problem ortheir AOB may be minimal. After a minimum of 6 months ofmonitoring, any condylar resorption should be consideredstable. With the use of orthodontics alone to close an AOB therelapse rates are high. At 10-year follow-up after correction ofpatients with an AOB, an open bite of 3 mm or more was foundin more than 35% of patients.5 Other studies have looked at theuse of skeletal anchorage devices for orthodontic closure ofAOB, and there are even several case reports of closure of anAOB in patients with previous condylar fractures.6e8 Thesedevices are able to intrude the lower molars by 3 to 5 mm.9

There are several case reports of using mini-implants formaxillary molar intrusion. In one study they showed a range ofintrusion of the maxillary molars by 1.5 mm to 3.3 mm (mean,1.9 mm) with closure at the incisors of 3 mm to 4.5 mm.10

Although these results are promising it has been shown thatlong-term stability is low and many studies do not have long-term follow-up.11 Most studies advocate for a postretentionperiod of at least 4 months before removal of the anchoragedevices.10 Others advocate for excessive intrusion to accountfor relapse.12 It should also be taken into account that forthese bodily movements of the posterior dentition, a longtreatment period is required. The use of these devices may

Fig. 2 Preoperative computed tomography demonstrating position of a 52-year-old woman 12 weeks after undiagnosed right mandibularcondylar process fracture resulting in loss of right mandibular vertical ramus height and left posterior open bite malocclusion.

Secondary Treatment of Malocclusion/Malunion 49

prove to be a viable treatment option in the population ofpatients with posttraumatic open bites, but further scientificinvestigation is warranted.

Arthroplasty/Total joint replacement

In open and closed treatment of condylar fractures, post-operative malocclusion can occur. Reductions in ramus heightand those with dislocated fractures are prone to functional

Fig. 3 Preoperative VSP evaluating feasibility of performing only aamount of remodeling that had already taken place at the fractureaccommodate this method of treatment. The red areas over the left c

disorders of TMJ but also occlusal disorders.13 Soft tissue injuryof the joint can occur at the time of condylar fracture and caninvolve hemarthrosis and disk displacement. Also, injury of thetemporomandibular disk at the time of fracture can beresponsible for disk degeneration.14 After injury, the TMJ mayincur secondary osteoarthrosis (arthritis), aseptic necrosis,bifid deformity of the condyle, fibrous ankylosis, or osseousankylosis. Also, condylar head fractures are more prone to leadto postoperative ankylosis of the TMJ.15

reosteotomy of the right condylar process. This demonstrated thesite and the inability of the contralateral left condylar/fossa toondylar head demonstrate the interferences this would result in.

Fig. 4 Preoperative VSP evaluating feasibility of performing a left mandibular sagittal split osteotomy (LSSO) with concurrent reosteotomyof the right condylar process fracture. This again revealed the significant “gap” that would result at the right side without bony contact.

50 Maron et al.

Significant variations in tolerating occlusal disturbance varyamong individuals. Occlusal disorders can involve working ornonworking side interferences, premature contact, or the lackof contact in an area of the dentition. Patients should beinterviewed regarding subjective symptoms, such as TMJ pain,limitation to daily activities, and alleviating and aggravatingfactors. The clinical examination involves palpation of themasticatory muscles for pain, measuring the maximum inter-incisal opening, lateral excursive movements, protrusivemovement, joint sounds, and occlusal evaluation. In fibrousankylosis the involved condyle only demonstrates rotationalmovement with a maximum opening of less than 20 mm withdeviation to the affected side with no translational. In bonyankylosis the patient’s range of motion is further limited to 5mm to 7 mm.16 This clinical information in conjunction withimaging, such as computed tomography and/or MRI, can helpaid in diagnosis.

Conservative therapies previously discussed, such as phys-ical therapy and splint therapy, are initiated and ongoingmonitoring is used to evaluate the patient’s progress. Splinttherapy also is used as a diagnostic aid to determine the sta-bility of the condylar ramus unit.

A gap arthroplasty is a surgical option in this patient popu-lation. An osteotomy is created inferior to the posttraumaticaltered condyle to allow free movement of the mandible andimprove range of motion. Autogenous or alloplastic interposi-tional materials can be used to decrease the risk of reankylosis.

Autogenous materials include temporalis muscle/fascia, fat,dermis, and auricular cartilage. Silicone, acrylic, polyethylene,metals, and ceramic have been described as possible allo-plastic interpositional materials.17 Material migration, foreignbody reaction, and fragmentation may occur with alloplasticmaterials. After the resection of the condyle, the mandible ismobilized to determine if adequate range of motion has beenachieved. If inadequate mandibular movement is presentfurther dissection of the temporalis/coronoidectomy,masseter, and medial pterygoid musculature can be consid-ered.18 The temporomandibular disk can also be inspectedduring this procedure for pathology and if present can becorrected.

Because of the created bony gap often the vertical height ofthe ramus is further decreased. This can result in a worseningmalocclusion. A consideration to help stabilize the verticaldimension is joint reconstruction. The two most widely dis-cussed joint reconstruction options include TMJ prosthesis/total joint reconstruction (alloplast) and autogenous methods,such as costochondral graft or a ramus osteotomy.

Markowitz and coworkers19 described the possibility ofreconstructing the mandibular condyle by performing a ramusosteotomy and sliding the proximal segment superiorly into thearticular fossa. This approach has the benefit of being autog-enous without donor site morbidity. The costochondral grafthas the benefit of being biologically compatible with growthpotential. Nelson and Buttrum20 discussed that the biologic

Fig. 5 PreoperativeVSPevaluating feasibility of performing a traditional bilateral sagittal split osteotomy.Thedifficult intraoperative rightproximal segment positioning likely to be encountered is now readily visualized, despite the relatively small moves at the Dalpont sites.

Secondary Treatment of Malocclusion/Malunion 51

reconstruction of the adult TMJ is preferable to alloplasticreconstructions because just as in the growing child, the adultarticulation must adapt to the demands of the functional ma-trix. However, the growth is unpredictable and this graft optionin comparison with a prosthesis has the added disadvantage ofresorption, reankylosis, and donor site morbidity. A furtherdisadvantage is that an immobilization period is usuallynecessary until consolidation and functional stability of thegrafts has taken place.21

A TMJ prosthesis (Fig. 1) has the advantages of no donor sitemorbidity, early/immediate return to function, and consistent

Fig. 6 Final position of virtual surgical plann

condyle and fossa anatomy. Disadvantages of alloplastic jointreplacement include higher cost and hardware failure.16 Allpatients undergoing gap arthroplasty or joint reconstructionrun the risk of potential injury to the facial nerve, Frey syn-drome, and parotid gland injury. The postoperative use of archbars/elastics to help guide the patient into reproducible oc-clusion should be considered. Physical therapy is an importantadjunct to ensure the improvement of function and decrease indiscomfort. Physical therapy is an important adjunct to ensurethe improvement of function and decrease in discomfort. Useof tongue blades or Therabite (Atos Medical, Inc, West Allis,

ing for bilateral sagittal split osteotomies.

Fig. 7 Panoramic film.

52 Maron et al.

WI) for opening should be considered in the early postoperativeperiod to prevent decreased maximal incisal opening caused byscar tissue formation. As in management of patients with TMD,a surgical plan that includes total joint replacement should beconsidered as the last option when other procedures do notachieve the desired goals. Counseling the patient about allpotential risks is crucial before surgery.

Orthodontics and orthognathic surgery

Once it has been determined that a malocclusion or malunion istoo significant to be treated by occlusal equilibration or or-thodontic therapy alone, one must consider the surgical op-tions for these patients. Philosophically speaking, combiningorthodontic therapy with orthognathic surgery to correctmalocclusion provides the most ideal result. However, if idealocclusion exists on articulated models one can consider pro-ceeding without orthodontics. Combining orthodontics with

Fig. 8 (AeC) Postoperative 3D com

surgery allows for correction of major malocclusions as long asthe posttrauma condyles are functional, and within the fossae.

Appropriate evaluation of mounted models or analysis ofdigital virtual treatment plan via systems, such as Suresmile(OraMetrix, Inc, Richardson, TX) or 3D systems, gives the bestidea of the potential benefits and pitfalls of combined surgicaland orthodontic case planning. With the advent of computedtomography scanning, 3D imaging and virtual surgical planning(VSP) have gained a foothold in orthognathic surgery. VSP israpidly replacing traditional model surgery in many parts of thecountry and the world. It allows the ability to show the patientwhat can be accomplished before beginning any actual treat-ment. In the event of a unilateral fracture malunion, previousauthors have suggested unilateral mandibular osteotomies tocorrect the malocclusion, whereas if there was a bilateralcondylar fracture with resulting functioning condyles but adeveloped AOB, Le Fort maxillary surgery may be the bestoption. The use of VSP allows one to perform osteotomies in 3Dand assess how this will impact the occlusion in a much moreprecise manner than traditional model surgery (Figs. 2e6). Theability to view segment movement and bone position change inmultiple planes is unparalleled. In a retrospective study 21patients with posttraumatic malocclusion caused by condylarprocess fractures, orthognathic surgery was used to success-fully restore proper occlusion. Group I with 15 patients wastreated with unilateral or bilateral mandibular ramus osteot-omies for asymmetric malocclusion. In group II six patientswere treated with either a Le Fort I osteotomy (n Z 5) orbilateral ramus osteotomies (n Z 1) for AOB.4

The timing of surgery should be at least 6 months after theinitial injury because the risk of remobilizing a malunion withinthe first 6 months after the failed initial surgery compromisesthe result. The benefit of Le Fort osteotomy for treatment of

puted tomography reconstruction.

Fig. 9 Treatment protocol.

Secondary Treatment of Malocclusion/Malunion 53

the open bite deformity lies in not having to manipulate thecondyles in this patient pool. This is similar to how we managepatients with TMD internal derangement or those with idio-pathic condylar resorption. Any time we can avoid operating onthe lower jaw we decrease the risk of redeveloping or reac-tivating pain or altered function. However, in cases where thepatient has an asymmetry of the mandible as a result of thefracture, obviously mandibular surgery is indicated. Review ofthe literature supports the use of either unilateral or bilateralramus osteotomies. We have found that clinically, even incases of a unilateral fracture, the use of bilateral sagittalramus surgery provides a better result. Additionally, the use ofthe sagittal split osteotomy with rigid fixation has the benefitof earlier function thus preventing risk of long-term trismus.

Case report

A.L. is a 52-year-old woman status post bilateral subcondylarand symphysis mandible fracture in November 2009. The pa-tient was treated at another facility with 8 weeks of maxillo-mandibular fixation. After release of fixation the patient had asignificant malocclusion with pain and condylar deformity(Fig. 7). She was referred to us at that time. Late in 2010, thepatient underwent a revision arthroplasty and plication pro-cedure to reconstruct a stable left TMJ. The patient gainedstability and did well using an oral orthodontic splint. Despite astable and functional joint, the patient was still concernedabout the significant posttraumatic malocclusion and had

orthodontic treatment followed by maxillary and mandibularorthognathic surgery (Fig. 8). The patient was followed for2 years after surgery and has a stable and repeatable occlusionwith no pain and good range of motion.

Treatment protocol

Developing a protocol for dealing in this patient population ishelpful for the surgeon when evaluating and managing thesepatients after their initial trauma and treatment. We hope topropose a logical treatment regimen for patients with minormalocclusions and those with significant malunions (Fig. 9).This decision tree is an initial guide in considering managementdecisions to best achieve treatment goals.

Summary

The patient who presents with the sequela of malocclusion ormalunion after suffering subcondylar or condylar fractures hasthe right to expect that clinicians can provide solutions fortheir dilemma. Treatments can be simple or complicateddepending on the severity of the problem. The ultimate goal isto restore function and occlusion, in a pain-free manner, asclose to the preinjury architecture as possible. As technologyadvances, the tools that can be applied to these situations alsoadvance and expand. In our literature search for this article wecame upon a paper that was written in 1945 that stated “it isinevitable that there would be disappointment with the

54 Maron et al.

outcome of the treatment for the fractured mandible.”22 Cli-nicians have come so far since that time and are continuing todevelop better treatment protocols for patients. The focus alsohas to remain on listening to the patient’s goals and desires andnot allow treatment plans to be solely guided by radiographfindings and the inherent desire as surgeons to “fix” things.

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