Progressive idiopathic condylar resorption: diagnosis and management

1020 ICOMS 2011—Abstracts: Invited Papers ment with less tendency to relapse over time. doi:10.1016/j.ijom.2011.07.892

53 Neonatal distraction in Pierre Robin sequence ˜ 1,2 R. Farina Maxillofacial Surgery, Hospital del Salvador, Universidad Mayor, Chile 2 Maxillofacial Surgery, Hospital de Ni˜nos Exequiel González Cortés, Universidad Mayor de Santiago, Santiago, Chile 1

Pierre Robin sequence is a pathology derived from alterations in the first and second branchial arches. Patients have breathing problems due to micrognathia and glossoptosis, causing severe upper airway obstruction and frequently requiring mechanical ventilator assistance. Classical techniques to prevent airway obstruction were prone position with a high mortality. Tracheostomy and gastrotomy were the first surgical approaches with a high morbid-mortality rate associated to them. Mandibular distraction osteogenesis, in neonatal patients, allows lengthening the mandible, improving breathing and swallowing disorders, with an etiological treatment. We recommended an intraoral approach to avoid scars on the skin, and we introduced a new way to anchor the external device, with transfixing Kirschner wire in the proximal (mandibular ramus) and distal segment (chin zone), that showed good results and stability during the period of distraction and consolidation, with optimal results on improving the upper airway, avoiding tracheostomy. doi:10.1016/j.ijom.2011.07.893

54(General Symposium VIII: Update in Distraction Osteogenesis Evolution of mandibular distraction osteogenesis C. Guerrero 1,2 1 Santa Rosa Maxillofacial Surgery Center, Venezuela 2 Orthodontics and OMS Postdoctoral Programs, Central University of Venezuela, Caracas, Venezuela

Patients suffering sleep apnea, severe mandibular AP and transverse deficiency, TMJ arthrosis and syndromic mandibles have been treated with limited success with traditional surgery. Distraction osteo-

genesis offers new possibilities, unlimited amount of controlled progressive movements and excellent bone and soft tissues healing. The original surgical techniques were based on extraoral appliances, cutaneous incisions to approach the bone and very uncomfortable devices. Scientific research, continuous evolution, psychological evaluations and engineers input have created a myriad of new surgical techniques, better instrumentation, sophisticated evaluation imaging and Orthodontics combination have opened a complete surgical subspecialty to treat the above mentioned problems with a higher level of care, improving children and young adults living standards with minimal morbidity and predictable outcomes. Minimal incisions, osteotomies under controlled temperature, different surgical designs, miniaturized distractors and special extensions for easy activation, permit the surgeons to correct deformities that were impossible in the past. Trans-mucosal devices with closed distraction chambers, lengthening the ramus protecting the temporo-mandibular joints, distraction anterior to the mental nerves to avoid paresthesias, longer consolidation periods to ensure bone healing and stability, use of blood morphogenetic proteins into the chamber to improve healing and decrease remodelling; are some of the new improvements in treating patients. Newer technologies, instrumentation and long term follow up based on 24 years experience and 1210 patients treated with Intraoral distraction osteogenesis will be discussed. doi:10.1016/j.ijom.2011.07.894

55 Orthognathic surgery: diagnosis, treatment protocols and long term results for the management of condylar resorption L. Wolford Oral and Maxillofacial Surgery, Baylor University Medical Center, Dallas, TX, USA

One of the common causes for development of dentofacial deformities and also for relapse following orthognathic surgery involves condylar resorption. Most often the pathological process creating condylar resorption (in either an active or remission state) is present prior to the orthognathic surgery, is unrecognized or untreated, resulting in predictable relapse post surgery. There are several

common conditions that cause condylar resorption that can adversely affect orthognathic surgery treatment outcomes. These include: Displaced articular discs; adolescent internal condylar resorption (AICR); reactive arthritis; and connective tissue and autoimmune diseases. Identifying these conditions prior to performing orthognathic surgery and following the appropriate treatment protocol can result in predictably good outcomes. This program will demonstrate the clinical presentation and diagnoses of each of these specific TMJ pathologies; aetiologies and pathological processes; treatment protocols to provide optimal functional and aesthetic results as well as eliminate or reduce pain; and long term treatment outcomes. The significant value of the MRI for TMJ diagnosis and treatment planning will be included. Case presentations will illustrate the various pathologic processes and outcomes following specific treatment protocols. doi:10.1016/j.ijom.2011.07.895

56 Progressive idiopathic condylar resorption: diagnosis and management B. Padwa 1,2 Plastic and Oral Surgery, Children’s Hospital, Boston, MA, USA 2 Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA, USA 1

Idiopathic condylar resorption (ICR) is a progressive alteration in condylar shape and a decrease in condylar mass and/or size for which there is no identifiable aetiology. The condition is usually bilateral and commonly occurs in females between the ages of 15 and 35 years. Patients can have temporomandibular joint (TMJ) symptoms, a Class II malocclusion with progressive anterior open bite due to clockwise rotation of mandible, retrognathism, and a decrease in posterior face height. It is important to make the distinction between active and inactive ICR. This is done by history, serial clinical examination, evaluation of serial radiographs, and 99mTc labelled methylene diphosphonate (99mTc MDP) SPECT scan. If the SPECT scan is positive the disease is likely to be active. Management of patients with idiopathic condylar resorption remains controversial. Orthognathic surgery has been advocated, but recurrence rates are high unless the resorptive process has ceased and there

ICOMS 2011—Abstracts: Invited Papers have been no documented occlusal changes and TMJ symptoms for a period of time before institution of treatment. Condylectomy and costochondral graft (CCG) reconstruction represents an alternative strategy for management of idiopathic condylar resorption. This treatment should be considered for stable patients requiring bimaxillary surgery and large mandibular advancements and all patients with active ICR. doi:10.1016/j.ijom.2011.07.896

57 Ideopathic condylar resorption: a clinical challenge P.J. Stoelinga Maxillofacial Surgery, Univ. Medical Centre, Nijmegen, The Netherlands

Ideopathic condylar resorption is most often associated with orthognathic surgery but it may also occur in relation to conditions such as rheumatoid arthritis, systemic lupus erythematosis or be the result of treatment with steroids, trauma or even orthodontic treatment. The figures, as presented in the somewhat sparse literature, however, are alarming in that fairly high percentages are reported, particularly associated with some rather specific procedures, including anterior open bite associated with mandibular hypoplasia. Signs and symptoms that are pointing towards the development of condylar resorption post surgery will be highlighted and the natural course of events described. Unfortunately, no known measures exist, at the present day, to stop the process. The existing literature on the aetiology and presentation of this condition will be presented along with some general guidelines for treatment. doi:10.1016/j.ijom.2011.07.897

58 Condylar resorption in severe malocclusion before and after surgery K. Wangerin Dep of Oral and Maxillofacial Surgery, Marienhospital, Stuttgart, Germany

In the last five years we have corrected nearly 750 cases of severe malocclusion by bimaxillary surgery. 76% were Angle class II patients, 5% had an open bite, 19% were Angle class III patients.

In the anamnesis the TMJ was compromised in 3,6% of the cases. Probably these patients underwent a period of juvenile osteoarthritis during puberty. Most of the cases had a class II malocclusion and an open bite. We have seen more unilateral cases than bilateral ones. More than 90% were female. On the X-rays we found an impressive posterior rotation of the mandible with increasing of the overjet. In the last five years we found reasons for this phenomenon in 13 patients before operation: professional sports, such as athletics, golf, tennis and professional playing the violin. All of them underwent gynaecological examination. There was found amenorrhoea, irregular menorrhoea, inadequate contraceptive. Hormonal treatment was done to normalise the cycle period. The amount of jaw advancement was determined our treatment success. The more we elongated the mandible, the more condylar resorption was found. Because of this risk factor we changed our protocol of planning surgery: We reduced the distance of jaw movement in bimaxillary surgery. For example we reduced the maxillary advancement in class II patients. In severe cases the correction was performed in two surgical steps within one year. At first vertical ramus distraction or SARPE and after one year bimaxillary surgery. One year after surgery we have seen stable results in more than 97% of our patients. In the post op follow up we found only one case of unilateral progressive condylar resorption. Two different corrections by distraction and secondary BSSO were performed. We reached an improved but not a sufficient result. doi:10.1016/j.ijom.2011.07.898

59 Management of condylar resorption before, during, and after orthognathic surgery G.W. Arnett ∗ , M.J. Gunson Oral and Maxillofacial Surgery, The Center for Corrective Jaw Surgery, Santa Barbara, CA, USA

This prospective study selected 21 patients who underwent orthognathic surgery for bite correction. Study selection included preexisting CBCT condylar resorption and class II malocclusion. No patient was dropped from the study. Bimaxillary counter clockwise advancements were accomplished following treatment planning as described by Arnett3 . The average advancement

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at ANS was .62 mm, maxillary incisor 6.73 mm, mandibular incisor 12 mm, and Pogonion 22.5 mm. The mandibular occlusal plane decreased from an average of 109–93◦ . No concomitant TMJ surgery was done. Surgical techniques were utilized to minimize post surgical mandibular relapse including, pre and post surgical TMJ medical management4 , non-compressive condylar seating1,2 , short BSSO splitting technique, BSSO mini plating without clamping5 , and postsurgical skeletal and Class II elastics. The patients were followed for a minimum of 12 months post surgically. At longest time point (average 36 months) all patient were without TMJ pain, had normal opening range, and had clinically stable occlusions.

References 1 Arnett. (1992). Temporomandibular joint ramifications of orthognathic surgery. In Bell (Ed.), Modern Practice in Orthognathic and Reconstructive Surgery. Saunders. 2 Arnett. (1993). A redefinition of bilateral sagittal osteotomy (BSO) advancement relapse. AM J Orthod Dentofac Orthop, 104, 506–515. 3 Arnett. (1999). Soft-tissue cephalometric analysis: diagnosis and treatment planning of facial deformity. Am J Orthod Dentofac Orthop, 116(September (3)), 239–253. 4 Gunson, Arnett, Milam. (2011) Medical management of condylar resorption. In press. 5 Joss. (2009). Stability after bilateral sagittal split osteotomy advancement surgery with rigid internal fixation: a systematic review. JOMS, 67(February), 301–313.

doi:10.1016/j.ijom.2011.07.899

60 State of the art in dento-alveolar trauma L. Andersson Department of Surgical Sciences, Health Sciences Center, Faculty of Dentistry, Kuwait University, Kuwait, Kuwait

This state of the art lecture will give an overview of recent research and clinic in dentoalveolar traumatology aimed at Oral & Maxillofacial Surgeons, who often are the only specialists available in the hospital for this type of injuries outside office hours. Recent evidence from scientific literature and currently recommended treatment according to the new guidelines for emergency treatment of dentoalveolar injuries from International Association of Dental Traumatology (www.iadt-dentaltrauma.org) will be presented. Emphasis will be put on what