TMJ Surgery, Oral Contraceptives, and complications with osteoporosis in young women

My ASTMJS colleague at Loyloa University in Chicago, Dr. Louis Mercuri, recently sent me a very important article that appeared in the orthodontic journal: American Journal of Orthodontics and Dentofacial Orthopedics, 2009; 2=136:772-9.

This paper reported significant complications in 26 of 27 female patients undergoing orthognathic surgery for correction of skeletal jaw malocclusion that was beyond the means of orthodontia to correct by itself.

The authors studied commonality relationships of post surgical patients by looking at levels of types of estrogen at their mid-cycle of their monthly menstrual cycle.  The study group was exclusively female, ages ranging from 15-45 years of age.  The average age was 26.  All of these patients had severe progressive and aggressive resorption of the condyles of the lower jaw up to one year after the orthognathic surgery (Not TMJ Surgery of the joint itself, but jaw lengthening surgery done in the ramus of the jaw)  What was interesting about this group was that 26 of these 27 patients had laboratory confirmation of low 17-estradiol or irregular menstrual period history.  Some of this group were estrogen depressed due to use of oral contraceptives.  CT scans showed examples of complete condyle resorption in a period of under 1 year after the orthognathic surgery.

The study goes on to suggest that multiple enzyme pathways relative to inflammatory mediators and estrogen sensitive receptors interact with osteoblasts and osteoclasts in bone, creating localized osteoporosis reaction in bone, particularly bone recently stressed by a surgical procedure and other factors (blood supply) that would effect its metabolism.

You are encouraged to find this article for your own personal review.  Several thoughts come to mind about its significance.

1. If you are 26 years old (average age patient in this study) with a history of a couple of rounds of complications from orthodontic treatment, a bite problem which continues to be ever changing and unstable, and you undergo combines orthodontics and orthognathic surgery and then this happens….it is devastating.

2. This is a great article.  There are several weaknesses however.  the primary problem is that CT scans and not MRI exams were used to evaluate the patients prior to orthognathic surgery.  This would have been a very formidable contribution to the orthognathic literature if MRI had been used and Wilkes staging of derangement known prior to the orthognathic surgery.  To their credit, however, the authors at least provide CT scans throughout the pre-and post operative period  , allowing visualization of adverse consequences.  There isn’t much stated about whether many of these patients had been through all this treatment to correct their ” TMJ” problem in the first place.  I think an assumption can be made from what already is in the literature that the majority of these patients already had advanced derangement’s at an early age and that condyle development could have been impacted, leading to the abnormal growth of the lower jaw, necessitating the recommendation of the treatment from their orthodontist/surgeon.

3. I once sat in a seminar for 2 days, given by my good friend and colleague in residency at Vanderbilt, Dr. Mark Piper in St. Petersburg, Florida.  Dr. Piper showed case after case of children with MRI documented (various stages of Wilkes/Piper/Schellhas) Derangement’s and abnormalities in jaw development and growth and acquired malocclusion.  The fundamental principle in all of this was that it is prime importance to diagnose a true TMJ derangement before beginning any type of complicated and expensive orthodontic/surgical treatment for these patients, particularly those who are coming in to correct ” my TMJ problem”.  The paradigm that the “TMJ” problem is due to the problem with the way teeth/jaws fit together in many instances could not be further from the truth. ( In fact, it’s usually the opposite.  The malocclusion/skeletal problem is acquired from long standing joint derangement’s that have likely adversely impacted jaw/facial growth and malocclusion by the impact of adverse condyle growth and development.  Many of these patients reported in this paper exhibited these characteristics.  more on this topic and incidence of advanced TMJ derangement’s in adolescents in future blogs)

At the end of the 2 day seminar, the generic questions was asked if the material was useful and if so, would the orthodontists in the group consider imaging their symptomatic patients before beginning orthodontics or making recommendations for orthodontic surgery.  Only half said they would.  I was surprised but at least one brave soul opined that the reason most orthodontists would not was because of two reasons: 1) ” I would be afraid of what I might find and I would not know what to do with it, and 2) ” Most of us are only interested in the 18-24 month orthodontic treatment time, getting in and out of the case and straightening the teeth as best we can…”.  Sadly, this is the opinion of many and why I hope these authors will publish results elsewhere, particulary in a medical or surgical journal of regard.

4. Finally this is a very frustrating experience for many patients and clinicians.  This article points to the need for sophisticated classification of many of these patients, the understand that significant TMJ derangement’s can and do exist in a very young group of female patients.  Those with an associated hormonal imbalance, endometriosis, early osteoporosis etc. are a unique group of patients and perhaps a totally different approach to these patients is necessary.  The results of these 27 patients who developed significant complications creating challenging issues to correct, would argue this point.

5. I published a paper a number a years ago looking at failure of initial TMJ surgery patients.  The most frequent complication was in older patients with documented osteoporosis and advanced TM joint osteoarthritis and complications from the disease (osteoporosis).  Since the bone morrow of the jaw and condyle of the jaw is mostly a fatty marrow, it is becoming more apparent that it is extremely important to diagnose female patients with this condition or any other hormonal issue that could impact bone metabolism and repair mechanisms after any TMJ or jaw surgeryr .  this is also become to be appreciated in female patients taking drugs to manage osteoporosis.

6. See a simple biomechanical explanation in a previous blog about why females may be more vulnerable to development of TMJ derangement in the first place.

Thanks to many of you for your kind comments and encouragements in blogs sent to my email address on this web page.  More analysis of the literature to come.  My next blogs will involve MRI evaluation of dental splint therapies and studies of adolescent patients with TMJ derangement’s and the importance of early diagnosis of these at risk patients.

Dr. W. Kirk, Jr.

Charlotte.

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