The Journal of Craniofacial Surgery  Volume 30, Number 1, January 2019
Orthopedic functional appliances are usually used to correct these
The Effect Evaluation of
Functional Appliance Used for
Class II Patients With
Temporomandibular Joint
Anterior Disc Displacement
Pei Shen, MS, Xiaohan Liu, MS, Qianyang Xie, MS,
Shanyong Zhang, MD, and Chi Yang, MD
Abstract: Orthopedic functional appliances are usually used to
correct patients with retrognathic mandible. However, a part of cases
have a trend of relapse after splint treatment. The aim of this study was
to explore the role of temporomandibular joint disc position in
functional appliance treatment. This study included 8 patients who
had 1 joint anterior disc displacement with reduction (ADDWR) and
the other joint anterior disc displacement without reduction
(ADDWoR) confirmed by magnetic resonance imaging (MRI). Only
the ADDWR joint could return to its normal position after wearing the
anterior repositioning appliances (ARAs). Condylar morphology,
condylar height, and disc length were evaluated 6 months after
ARA treatment. The MRI showed that new bone appeared on 7
joints with ADDWR and on 1 joint with ADDWoR. The condylar
height has increased 1.4 mm in the ADDWR group, while 0.1 mm
shorter in the ADDWoR group. Disc length has increased from 8.5 to
8.7 mm in the ADDWR group and 0.4 mm shorter in the ADDWoR
group after wearing the ARA. Our results suggested that it is none-
ffective of functional appliance used for class II malocclusion
adolescents with ADDWoR and only a normal disc-condyle relation-
ship benefits condyle growth by functional appliance. Thus it is
important to reposition the disc as soon as possible.
Key Words: Anterior disc displacement, condyle remodeling,
functional appliance, temporomandibular join
M andibular retrognathia is considered as the most common
characteristic of class II malocclusion in adolescents.
From the Department of Oral Surgery, Ninth People’s Hospital, College of
Stomatology, Shanghai Jiao Tong University School of Medicine,
Shanghai Key Laboratory of Stomatology & Shanghai Research
Institute of Stomatology, Shanghai, China.
Received April 7, 2018.
Accepted for publication July 9, 2018.
Address correspondence and reprint requests to Chi Yang, MD, Shanyong
Zhang, MD, Department of Oral Surgery, Ninth People’s Hospital,
Collage of Stomatology, Shanghai Jiao Tong University School of
Medicine, Shanghai Key Laboratory of Stomatology, Shanghai
Research Institute of Stomatology, No 639, Zhi Zao Ju Rd, 200011
Shanghai, China; E-mail: yangchi63@hotmail.com or
zhangshanyong@126.com
PS and XL contributed equally to this work.
This study was supported by the Youth Program of National Natural Science
Foundation of China (81601915), Shanghai Municipal Hospital Emer-
ging Frontier Technology United Key Project (SHDC12017101), and
Science and Technology Commission of Shanghai Municipality Science
Research Project (14DZ2294300).
The authors report no conflicts of interest.
Copyright # 2018 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004903
# 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
patients with retrognathic mandibles.1 Both the clinical and animal
researches have confirmed that by fixing the mandible in an anterior
position, a constant stretch force is exerted on the temporomandibular
joint (TMJ) which could stimulate condyle remodeling and growth.2–
4
However, a part of cases have a trend of relapse after functional
appliance treatment. Some studies speculated that it might be lack of
enough condyle remodeling because of TMJ diseases.
Anterior disc displacement (ADD) is one of the most common
TMJ disorders which occur in all ages, but with a high prevalence in
adolescents. The relationship between TMJ ADD and functional
appliance has been the material for much debate.5 –7 Most of the
attention has been paid on whether functional appliances can lead to
permanent damage to the TMJ structures.5 We have limited knowl-
edge of whether TMJ disorders could influence the treatment effect
of functional appliances for class II patients. Hayashi et al8 once
suggested that the articular disc appears to be crucial in the
regeneration of condyle by disc resection in rats. However, there
is still lack of clinical data about the treatment effect of functional
appliance on mandibular retrognathia adolescent patients with TMJ
ADD. Whether the relapse of functional appliance treatment can be
blamed to TMJ ADD? In the present study, we carried out a self-
control study to explore the role of disc position for functional
appliance.
METHODS
Patients
The consecutive adolescent patients who visited the TMJ Clinic
at Department of Oral Surgery in Shanghai Ninth People’s Hospital
from August 2015 to June 2016 for occlusal splint treatment were
reviewed in our study. The inclusion criteria were as follows: the
patients had 1 joint ADD with reduction (ADDWR) and the other
joint ADD without reduction (ADDWoR) confirmed by magnetic
resonance imaging (MRI); class II malocclusion adolescent patients
with mandibular retrognathia; MRI showed that the disc in
ADDWR could be recaptured when putting the mandibule in an
anterior position (Fig. 1); the patients accepted anterior reposition-
ing appliance (ARA) treatment and kept to wear the ARA 24 hours a
day for 6 months. This study was conducted in accordance with the
Ethics Committee of Shanghai Ninth People’s Hospital affiliated to
Shanghai JiaoTong University, School of Medicine and with the
Code of Ethics of the World Medical Association (Declaration of
Helsinki). Informed consent was obtained for experimentation with
patients in this study.
Magnetic Resonance Imaging Acquisition
All the included patients were performed MRI examination
before treatment and 6 months after wearing the appliance. The
MRIs were taken using a 1.5 T imager (Signa; General Electric,
Milwaukee, WI) with dual phased array dedicated TMJ surface coil
receivers, according to the routine sequence.9
Morphologic Evaluation of the Condyle
Pre- and post-treatment images of each joint were compared and
examined one by one piece for ‘‘double contour’’ images, which
were defined as periosteal reaction-like double images on the
cortical surface of condylar head.10,11
Condyle Height and Disc Length Evaluation
The MRI with the largest sectional area of condyle was chosen
for tracing. The condylar height (h1) and disc length was measured
e15
Brief Clinical Studies The Journal of Craniofacial Surgery
FIGURE 1. Magnetic resonance imaging evaluations of anterior disc
displacement (ADD) with reduction (ADDWR) and ADD without reduction
(ADDWoR) joints before and after wearing anterior repositioning appliance
(ARA). (A) Temporomandibular joint (TMJ) with ADDWR before wearing ARA.
(B) TMJ with ADDWR when wearing ARA. (C) TMJ with ADDWoR before wearing
ARA. (D) TMJ with ADDWoR when wearing ARA.
according to our previous study described by Cai et al and Xie
et al12,13 (Fig. 2A).
Statistical Analysis
Condyle height differences between ADDWoR and ADDWR
joints as well as disc length before and after ARA treatment were
analyzed with the SPSS software package, version 16.0 (SPSS,
Chicago, IL) by paired t-test. The differences were considered
significant when P < 0.05.
RESULTS
Description of Patients
This study included 8 patients (6 females and 2 males), whose
ages ranged from 11 to 16 years old at the time of their initial visit
FIGURE 2. (A) Measurements of condylar height and disc length in magnetic
resonance imaging. h1 means the condylar height and AB plus BC means the
disc length. (B) the new bone on the condylar head after wearing anterior
repositioning appliance in anterior disc displacement with reduction joint
(yellow arrow).
e16 # 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 30, Number 1, January 2019
TABLE 1. Condyle Heights Changes in ADDWR and ADDWoR Groups Before
and After ARA Treatment
Before After Changes
ADDWR 20.3  2.1 21.7  2.1 1.4
ADDWoR 18.7  1.5 18.6  1.2 0.1
Paired t-test, P < 0.01.
ADDWR, anterior disc displacement with reduction; ADDWoR, anterior disc
displacement without reduction; ARA, anterior repositioning appliance.
(13.8  1.67 years). The treatment duration ranged from 4.5 to 8
months, with a mean duration of 6.4  1.6 months.
Morphologic Changes of the Condyle
No ‘‘double contour’’ images of the condylar head were
observed before treatment in all of the joints. After ARA treatment,
‘‘double contour’’ images were seen on 7 joints with ADDWR and
on 1 joint with ADDWoR from MRI. All the new bone appeared on
the top of the condyle (Fig. 2B).
Condyle Height Changes
In the ADDWR group, the condylar height has increased 1.4 mm
on average after ARA treatment, while the condylar height differ-
ence in the ADDWoR group was 0.1 mm shorter (range: 1.6 to
0.7 mm). Paired t-test shows that there was significant difference
between the 2 groups (P < 0.01) (Table 1).
Disc Length Changes
After recapture the displaced disc in the ADDWR group, disc
length has increased from 8.5 to 8.7 mm. However, the disc length
in the ADDWoR group was 0.4 mm shorter on average after
wearing the ARA. Paired t-test shows that there was significant
difference between the 2 groups (P < 0.05) (Table 2).
DISCUSSION
The ADD is one of the most common TMJ disorders and it has a
high prevalence in adolescents. Numerous studies have indicated
that ADD in adolescent has a high relationship with dentoskeletal
deformities, especial for mandibular retrognathia. Schellhas et al14
once evaluated the correlation between ADD and disturbed facial
skeleton growth within 128 consecutive children and concluded that
ADD is both common in children and may contribute to the
development of retrognathia. Thus, it is necessary for us to find
an effective treatment protocol for these patients.
Functional appliances are usually used to correct these patients
with class II malocclusion; however, some studies15 found that a
part of retrognathic patients are prone to exhibit more unfavorable
mandibular growth changes than prognathic patients. Latkauskiene
et al16 reported that 12% patients showed relapse after functional
TABLE 2. Disc Length Changes in ADDWR and ADDWoR Groups Before and
After ARA Treatment
Before After Changes
ADDWR 8.5  1.3 8.7  1.7 0.2
ADDWoR 6.5  1.0 6.1  0.8 0.4
Paired t-test, P < 0.05.
ADDWR, anterior disc displacement with reduction; ADDWoR, anterior disc
displacement without reduction; ARA, anterior repositioning appliance.
The Journal of Craniofacial Surgery  Volume 30, Number 1, January 2019
appliance for class II patients. However, there are few studies to
explain why do these patients are prone to relapse after functional
appliance. Besides there are little attention paid on the importance
of normal disc position. For this reason, we conducted a self-control
study to explore the role of disc position in the effect of functional
appliance treatment. Our hypothesis is that ADDWoR would pre-
vent condyle remodeling or new bone formation.
In the present study, all the included patients were diagnosed
that one side was ADDWR and the other was ADDWoR. Besides all
the joints with ADDWR were confirmed that the disc could return to
its normal position after wearing the appliances. Six months later,
new bone was seen in 7 out of 8 joints in disc reposition side while
only 1 joint had condyle remodeling in ADDWoR side. Quantitative
analysis showed that condyle height in ADDWR joints increased
1.4 mm on average after ARA treatment, while the condylar height
difference in the ADDWoR group was 0.1 mm shorter. These
results supported that condyle growth mainly happened when the
disc-condyle reposition was normal. As we know, the disc can
buffer the stress on the condyle and the stress could significantly
increase when the disc become anterior displacement. The
increased stress on the top of condyle would prevent the condylar
growth which resulted in mandibule clockwise rotation and an
increasing retrognathic mandible. On the contrary, the stress on the
top of condyle is released when repositioning the disc to its normal
position. This made the condyle growing rapidly as the adolescent
patients were in their growth spurt period. These results enlightened
us that it is necessary to recapture the anterior displaced disc as soon
as possible to remove the growth inhibition of condyle.
Comparing the disc length changes in 2 groups, we found that
after wearing the ARA, the disc length in the ADDWR group was
increased while it decreased in the ADDWoR group. This
might be that the disc was extruded when it anteriorly displaced
and the extrusion become more severe after putting the mandible
forward in the ADDWoR group. In contrast, the disc stretched to
its normal length when restoring to its normal position in the
ADDWR group. For this reason, we deprecated that functional
appliances were used for ADDWoR joints as it can deteriorate the
disc condition.
CONCLUSION
In conclusion, our study suggested that it is noneffective of func-
tional appliance used for class II malocclusion adolescents with
ADDWoR and only a normal disc-condyle relationship benefits
condyle growth by functional appliance. Thus, it is important to
reposition the disc as soon as possible.
REFERENCES
1. Santamaria-Villegas A, Manrique-Hernandez R, Alvarez-Varela E, et al.
Effect of removable functional appliances on mandibular length in
patients with class II with retrognathism: systematic review and meta-
analysis. BMC Oral Health 2017;17:52
2. Al-Saleh MA, Alsufyani N, Flores-Mir C, et al. Changes in
temporomandibular joint morphology in class II patients treated with
fixed mandibular repositioning and evaluated through 3D imaging: a
systematic review. Orthod Craniofac Res 2015;18:185–201
3. Chavan SJ, Bhad WA, Doshi UH. Comparison of temporomandibular
joint changes in Twin Block and Bionator appliance therapy: a magnetic
resonance imaging study. Prog Orthod 2014;15:57
4. Wangsrimongkol T, Manosudprasit M, Pisek P, et al.
Temporomandibular joint growth adaptation and articular disc
positional changes in functional orthopedic treatment: magnetic
resonance imaging investigation. J Med Assoc Thai 2012;95(Suppl 11):
s106–s115
5. Luther F. Orthodontics and the temporomandibular joint: where are we
now? Part 1. Orthodontic treatment and temporomandibular disorders.
Angle Orthod 1998;68:295–304
# 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
6. Kim MR, Graber TM, Viana MA. Orthodontics and temporomandibular
disorder: a meta-analysis. Am J Orthod Dentofacial Orthop
2002;121:438–446
7. Ferri J, Nicot R, Maes JM, et al. Condylar resorptions and
orthodontic-surgical treatment: state of the art. Int Orthod
2016;14:503–527
8. Hayashi H, Fujita T, Shirakura M, et al. Role of articular disc in condylar
regeneration of the mandible. Exp Anim 2014;63:395–401
9. Shen P, Huo L, Zhang SY, et al. Magnetic resonance imaging applied
to the diagnosis of perforation of the temporomandibular joint.
J Craniomaxillofac Surg 2014;42:874–878
10. Yano K, Nishikawa K, Sano T, et al. Relationship between appearance
of a double contour on the mandibular condyle and the change in
articular disc position after splint therapy. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2009;108:e30–e34
11. Liu MQ, Chen HM, Yap AU, et al. Condylar remodeling
accompanying splint therapy: a cone-beam computerized
tomography study of patients with temporomandibular joint disk
displacement. Oral Surg Oral Med Oral Pathol Oral Radiol
2012;114:259–265
12. Cai XY, Jin JM, Yang C. Changes in disc position, disc length,
and condylar height in the temporomandibular joint with anterior
disc displacement: a longitudinal retrospective magnetic
resonance imaging study. J Oral Maxillofac Surg 2011;69:
e340–e346
13. Xie Q, Yang C, He D, et al. Is mandibular asymmetry more frequent and
severe with unilateral disc displacement? J Craniomaxillofac Surg
2015;43:81–86
14. Schellhas KP, Pollei SR, Wilkes CH. Pediatric internal derangements of
the temporomandibular joint: effect on facial development. Am J Orthod
Dentofacial Orthop 1993;104:51–59
15. Bock N, Pancherz H. Herbst treatment of class II division 1
malocclusions in retrognathic and prognathic facial types. Angle
Orthod 2006;76:930–941
16. Latkauskiene D, Jakobsone G, McNamara JA. A prospective study on
the clinical effectiveness of the stainless steel crown Herbst appliance.
Prog Orthod 2012;13:100–108
Neonatal Teratoma:
Craniofacial Treatment
John Oommen, MS, MCh, Hafiz Mohammed, MS, MCh,
Shanker Ayyappan Kutty, MS, MCh,y
Abraham Mammen, MS, MCh,z Kader Kalathingal, MS, MCh,
Chandrabose Vellani Thamunni, MS, MCh,
Anand Sivadasan, MBBS, and Santhy Nair, MBBS
Abstract: Teratomas are rare congenital neoplasms. Head and neck
locations of the tumor are uncommon with combined intracranial
and extracranial extensions being even more rare. The authors
present a case of teratoma involving the temporal, buccal, maxil-
lary, orbital and extending to the intracranial regions, which was
successfully managed by surgical resection.
From the Department of Plastic Surgery, Baby Memorial Hospital;
yDepartment of Neurosurgery; and zDepartment of Pediatric Surgery,
Aster MIMS, Calicut, India.
Received May 22, 2018.
Accepted for publication July 9, 2018.
Address correspondence and reprint requests to Dr Anand Sivadasan,
MBBS, Department of Plastic Surgery, Baby Memorial Hospital,
Calicut, India; E-mail: anand6527@gmail.com
The authors report no conflicts of interest.
Copyright # 2018 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004906
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