Case report
A comprehensive treatment approach for idiopathic condylar resorption and anterior open bite with 3D virtual surgical planning and self-ligated customized lingual appliance

https://doi.org/10.1016/j.ajodo.2017.08.032Get rights and content

Highlights

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    This article discusses the management of an interesting case of a woman who had bilateral idiopathic condylar resorption with skeletal and dentofacial deformities.

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    SICAT jaw motion tracking was carried out to provide visualization of mandibular movement.

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    A self-ligating lingual appliance was used for presurgical orthodontic correction.

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    3D surgical planning was performed and splints delivered.

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    Le Fort I 3-piece maxillary osteotomies were performed and condylar replacement was done with the use of TMJ concept custom condyle fossa.

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    Postoperative orthodontic correction was achieved with a combination of clear braces and lingual braces.

Introduction

We report the successful treatment of a 38-year-old woman with bilateral idiopathic condylar resorption and anterior open bite. She had incompetent lips, a gummy smile, increased lower facial height, high mandibular plane angle, skeletal and dental Class II malocclusion with mild mandibular crowding, increased overjet, and mandibular midline deviation to the right.

Methods

The treatment plan included: (1) presurgical alignment and leveling of the teeth in both arches; (2) jaw motion tracking (JMT) to detect mandibular movement; (3) 3-piece maxillary osteotomies with mandibular reconstruction and bilateral coronoidectomies; and (4) postsurgical correction of the malocclusion. The orthodontic treatment was performed with the use of custom lingual braces and clear brackets and the orthognathic surgery was planned with the use of virtual surgical planning.

Results

The idiopathic condylar resorption and anterior open bite were treated, crowding was eliminated in the lower anterior segment, correction of skeletal and dental Class II malocclusion was obtained, mandibular plane angle was reduced, and facial profile improved.

Conclusions

The results suggest that esthetic and functional results can be achieved with the cooperation of 2 specialties and with the use of state-of-the-art technology.

Section snippets

Diagnosis and etiology

In January 2015, a 38-year-old woman was referred by the oral surgeon to the Department of Orthodontics at the University of Alabama, Birmingham, with the complaint of “difficulty in chewing and incising food.” She was diagnosed with Crohn disease in 2010 and her third molars were extracted in 2012. Clinical examination revealed a convex high-angle facial profile, incompetent lips, gummy smile, increased lower facial height, and strained mentalis muscle in a skeletal Class II base. Her

Treatment plan

The patient was diagnosed with bilateral ICR, Angle Class II malocclusion, anterior open bite, increased overjet, mild mandibular crowding, lower midline deviation, and gummy smile. The treatment objectives for this patient were: (1) dental: eliminate crowding in the mandibular anterior segment and correct the anterior open bite; (2) skeletal: decrease the high angle, reduce ANB by means of maxillary impaction, eradicate the TMJ resorptive phenomenon, and reconstruct the condyles bilaterally;

Treatment progress

Maxillary and mandibular high-accuracy polyvinyl siloxane (PVS) impressions were obtained and sent to Harmony. Customized self-ligating lingual appliances were fabricated with due consideration for how the final occlusion would be created. Initial leveling was started with the use of 0.014-inch NiTi (Fig 5). Wires were sequenced in 0.016 × 0.022. Dental open bite was maintained to facilitate the surgical procedure with 0.018 × 0.025 wire. Once the leveling and alignment were completed, CBCT and

Treatment results

The posttreatment records show a balanced facial profile and occlusion. ICR was treated and bilateral condylar reconstruction was accomplished exactly as estimated in VSP. Intraorally, the anterior open bite was corrected, normal overjet and overbite were achieved, teeth were properly leveled and aligned, upper and lower midlines were coincided with the facial midline, and incisor and canine guidance were obtained. The patient's soft tissue profile was straight, neck throat angle reduced, and

Discussion

Although the specific etiology of condylar degeneration has not been clearly understood, in a recent study, Sarver et al4 reported that condylar changes might occur because of several local and systemic factors and as a sequel of postoperative factors. Local possible factors are osteoarthritis, reactive arthritis, traumatic injuries, and infection. Systemic disease includes rheumatoid arthritis, systemic lupus erythromatosus, connective tissue disease, Sjögren syndrome, and psoriatic arthritis.4

Conclusion

Studies suggest that patients with ICR remain undiagnosed and unrecognized in the orthodontic clinic owing to the poorly understood etiology of the disease and lack of diagnostic tools. ICR often causes occlusal and skeletal changes, TMJ dysfunction and pain, and maxillofacial deformities. Therefore, precise diagnosis of the disease and proper treatment plan is essential. In this case report, we demonstrated a comprehensive treatment approach to achieve the patient's esthetic and functional

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      The “long face syndrome” has in the past been thought to be primarily the result of a genetic posterior growth pattern of the condyle [21,22]. More recent studies have shown that individuals, both male and female, with steep mandibular plane and dolicofacial characteristics, are at a higher risk of having had a TMJ disorder and altered skeletal morphology [26,28–30]. These skeletal characteristics become more prominent as TMJ disorder progresses in severity.

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