Progressive Condylar Resorption: Pathologic

Processes and Imaging Considerations

David C. Hatcher

Progressive condylar resorption (PCR) of the temporomandibular joint (TMJ)

occurs mostly in adolescent female individuals, who are likely to request
orthodontic treatment. They can be among the most challenging of orth-
odontic patients to successfully treat, especially if orthognathic surgery is
involved in the treatment process. This article will review the basic anat-
omy, pathophysiology, detection, natural history, and progression of PCR of
the TMJ, and the local and regional growth effects of PCR also will be
discussed. PCR proceeds through 3 distinct anatomic stages that have
clinical relevance when considering orthodontic diagnosis, treatment op-
tions, and treatment timing: soft-tissue phase, destructive (active) phase,
and reparative phase. Anatomic assessment of the TMJ hard and soft tis-
sues and facial skeleton can be performed using cone-beam computed
tomography and magnetic resonance imaging. The application of these
imaging modalities to this severe clinical condition is discussed in some
detail. It is generally recommended that definitive orthodontic/orthognathic
treatment be postponed until PCR has stabilized. Imaging plays an impor-
tant role in assessing stability of the resorptive process, but other clinical
criteria also must be considered. (Semin Orthod 2013;19:97-105.) © 2013
Elsevier Inc. All rights reserved.

he mandibular condyle is an adaptive
T growth site that contributes to the sagittal,
vertical and lateral development of the mandi-
ble. There are 3 articular components of the
temporomandibular joint (TMJ): the fossa/em-
inence of the temporal bone, the mandibular
condyle, and the interposing articular disk. The
mandible is the only human bone that has joints
at both ends, which are symmetrical; both TMJs
function as ginglymo-diarthrodial joints, which
can perform both rotary and sliding movements
Adjunct Professor, Department of Orthodontics, School of Dentistry,
University of Pacific, San Francisco; Clinical Professor, School of Den-
tistry, Roseman University of Health Science, College of Dentistry, NV;
Clinical Professor, Orofacial Sciences, School of Dentistry, University of
California, San Francisco; and Private Practice, Department of Ortho-
dontics, Diagnostic Digital Imaging, Sacramento, CA.
Address correspondence to Dr David C. Hatcher, DDS, MSc,
MRCD(c), Department of Orthodontics, Diagnostic Digital
Imaging, 99. Scripps Drive, # 101, Sacramento, CA 95,825.
E-mail: david@ddicenters.com
© 2013 Elsevier Inc. All rights reserved.
1073-8746/13/1902-0$30.00/0
http://dx.doi.org/10.1053/j.sodo.2012.11.005
simultaneously (Figs 1 and 2). TMJ motion ac-
companies almost all jaw functions, including
chewing, swallowing, speaking, and at times,
breathing. The jaw is required to perform com-
plex, fine-tuned, intricate, and powerful mo-
tions. TMJ function results in diverse and vary-
ing patterns of joint loads, including static loads
during clenching and parafunction, and dy-
namic loads produced by rotational, transla-
tional, and transverse motion during mastica-
tion and speech. The dynamic and static loads
impart compressive, tensile, and shear forces on
the joint tissues.1 The disk interposed between
the condyle and temporal bone helps maintain
congruency of the joint surfaces and distribute
loads during the array of functional joint posi-
tions. The disk is surrounded by an intercon-
nected system of ligaments that secure it to the
condyle, capsule, and temporal bone, and it sep-
arates the joint into superior and inferior joint
compartments. There is a layer of fibrocartilage
lining the articular surfaces of the condyle and
temporal bone; this unique tissue further aids in

Seminars in Orthodontics, Vol 19, No 2 (June), 2013: pp 97-105 97

98 Hatcher

Figure 1. Anatomic illustration shows the osseous and soft-tissue temporomandibular joint (TMJ) anatomy.
Soft-tissue structures are as follows: CA, capsular attachment; S, synovium; BZ, bilaminar zone; SL, superior
lamina; FC, fibrocartilage; PB, posterior band of disk; IZ, intermediate zone of disk; AB, anterior band of disk;
SLP, superior lateral pterygoid muscle; ILP, inferior lateral pterygoid muscle. Hard-tissues structures are as
follows: LPC, lateral pole of condyle; MPC, medial pole condyle. The disk attaches to the condyles slightly
inferior to LPC and MPC. Posteriorly, the capsule attaches to the condyle at a point slightly inferior to CA. An
imaginary circumferential line connecting LPC, CA, and MPC passes through the greatest height of contour at
the periphery of the condyle, and is similar in concept to an equatorial line dividing the northern and southern
hemispheres of the earth. This condylar equator is a very good landmark to aid in differentiating normal from
abnormal condyles. Most destructive processes in the TMJ are localized to the condylar fraction superior to the
equator, thus moving the superior surface of the condyle closer to the equator. (Color version of figure is
available online.)

load distribution and contributes to the mandib-
ular growth site.
Disk displacements are common in the ado-
lescent population and have been reported to
disturb ipsilateral mandibular growth, which
may have a regional growth effect on the devel-
opment of the ipsilateral facial skeleton.2-4 The
severity of the growth disturbance is associated
with severity of the joint insult and the somatic
maturity of the individual (Fig 3). A unilateral
disturbance of mandibular growth may result in
mandibular asymmetry, whereas a bilateral man-
dibular growth disturbance may result in retrog-
nathia and clockwise or dolichofacial growth
pattern (Figs 4 and 5). Disk displacement with-
out reduction has also been associated with the
development of progressive condylar resorption
(PCR)5 (Fig 6), but it is not always clear whether
that displacement occurs before or after the re-
sorptive process begins.
Progressive Condylar Resorption (PCR)
Synonyms
PCR of the TMJ is also known by the terms
idiopathic condylar resorption and condylysis.
Terms like osteoarthritis/osteoarthrosis, de-
generative joint disease (DJD), and arthrosis
deformans are used to describe the more com-
mon and less aggressive forms of TMJ degen-
eration.
Definition
PCR is a localized noninflammatory degener-
ative disorder of the TMJs that is characterized
by lysis and repair of the articular fibrocarti-
lage and underlying subchondral bone, occur-
ring most commonly during puberty in female
individuals.5-7
 Pathologic Processes and Imaging Considerations 99

Figure 2. T2-weighted TMJ magnetic resonance imaging (MRI) in the closed- and open-mouth position,
showing normal disk position. The white arrow shows the intermediate zone of the disk correctly interposed
between the functional region of the condyle and the eminence. The posterior band of the disk was near the
12-o’clock position of the adjacent condyle in the closed position.

Background and Etiology
The TMJ is a loaded joint that is subjected to a
combination of compression, tension, and shear
forces, and the joint loads or stress concentra-
tions (force/area) may be similar to other load-
bearing joints.1 Current theories for explaining
the onset of PCR in the TMJ include a combina-
tion of chemical transduction and mechano-
transduction processes. The basic concept is that
lysis of the hard and soft tissues occur when
adaptive capacity has been exceeded by the func-
tional demands. Chemical and mechanotrans-
duction can play a role in either reducing or
exceeding the adaptive capacity threshold.8-13
Elevated or reduced serum levels of ␤-estradiol
and elevated serum levels of relaxin are thought
to be significant.6,7 Elevated serum ␤-estradiol
and relaxin separately or in combination have
been shown to have a negative effect on the
articular soft tissues, including the TMJ disk.
Serum ␤-estradiol has an osteoprotective effect
in enhancing osteoprogerin expression and de-
creasing osteoclast activity. Therefore, reduced
estrogen may predispose to a bone degenerative
process.7
Clinically, many cases of TMJ PCR are pre-
ceded by a disk displacement, so theories that
consider soft-tissue changes as well as osseous
changes are attractive. It is important to under-
stand the dynamic aspects of interacting joint
surfaces in relative motion (tribology).1 The
joint surfaces of the TMJ include the fibrocarti-
laginous covering of the condyle and eminence
and the subchondral bone, and between these is
the disk and synovial fluid for lubrication and
nutrition. The TMJ disk is a fibrocartilagenous
tissue, which does not have a homogeneous
composition; it is composed mostly of collagen
(type I), proteoglycans (sulfated glycosaminogly-
cans), and water. The disk is divided into 3 areas
or zones: the anterior band, the intermediate
zone, and the posterior band. The distribution
and arrangement of the disk components are not
uniform throughout the zones of the disk (Fig 1).
These zones, like anatomic regions, have material
property differences related to their anatomic
composition. Therefore, the single-cell biome-
chanics of each of the zones reflect a structural
relationship to the functional demands.
Clinical Issues
Demographics
The onset of TMJ PCR frequently occurs around
the time of puberty and decreases after the age
of 20 years.5-7 Female individuals are signifi-
cantly affected more than their male counter-
parts (9:1). Female individuals often have bilat-
eral involvement, but the timing and expression
of the disease may not be symmetrical.
100 Hatcher
Figure 3. Mandibular growth. The figure indicates pa-
tient age on the horizontal axis and mandibular growth
on the vertical axis. The top line shows the phases of
normal growth. The blue line indicates that a minor
insult, such as disk displacement (DD), during the pu-
bertal growth phase will temporarily retard growth and
result in a minor growth deficit. The 2 yellow lines
indicate that a major TMJ pathosis, such as progressive
condylar resorption (PCR-1, PCR-2), results in a greater
growth deficit than did the minor insult. PCR-1 occur-
ring at an earlier age than PCR-2 results in a greater
growth deficit because the TMJs and both jaws had a
shorter growth period before the process was inter-
rupted. (Color version of figure is available online.)
Natural History and Prognosis
Soft-tissue Phase
The soft-tissue changes precede the osseous
changes. It is suspected that joint laxity or hy-
permobility may be contributing factor. A
nonreducing displaced disk often occurs before
PCR. The acute clinical phase immediately after
the occurrence of a nonreducing displaced disk
includes limited oral opening (approximately 25
mm) and pain. Generally, little or no significant
osseous changes are present immediately after a
displaced disk. The displacement of the disk may
be a risk factor, that is, one of many initiating
factors for the development of ordinary DJD, or
more rarely of the destructive phase of PCR.
Destructive/Active Phase
It is hypothesized that the sequence of events oc-
curs in the following order: loss of cortex occurs
along the anterosuperior surface of the condyles,
and a cavitation defect extends into the subchon-
dral bone, resulting in loss of condylar volume (Fig
7). The active phase of PCR may be associated with
limited condylar motion and pain. It is during the
active phase that the TMJs may be particularly
vulnerable to biomechanical forces. It is suspected
that condylar resorption progresses until the com-
pressive forces within the TMJ are normalized.
Reparative Phase
The active phase is followed by condylar flattening
and recortication. The flattening may form a con-
gruent articulation with the opposing surface. Flat-
tening and congruent articulations are thought to
be adaptions to distribute functional loads over a
larger stress-bearing area. There is a restoration of
condylar motion and reduction in pain as the re-
pair process completes. It can be difficult to clini-
cally identify individuals with end-stage PCR.
Associated Growth Changes
PCR occurring before the completion of somatic
growth results in a reduction in growth of the
involved condyle and ipsilateral half of the mandi-
ble. In unilateral cases, there may be regional ad-
aptations involving the ipsilateral cranial base and
maxilla. The regional adaptations include a de-
crease in the vertical dimension of the condylar
process, ascending ramus, and body of the mandi-
ble. The occlusal plane is elevated on the involved
side. The lateral development of the mandible is
decreased on the involved side, and the osseous
midline of the mandible is shifted to the short side.
The maxilla may mirror some of the mandibular
changes, and the cranial base (fossa) may be de-
pressed on the involved side.
Individuals with bilateral PCR may develop a
dolichofacial growth pattern. The dolicofacial
growth pattern may be associated with short condylar
processes, short rami, short mandibular body, and an
increased vertical dimension of the anterior region
of the mandible along with labiolingual reduction in
the dimensions of the alveolar process. The mandib-
ular plane may be steep, and the gonial angles ob-
tuse. There is a tendency for a reduction in airway
dimensions secondary to small mandibular growth,
and posteroinferior repositioning of the mandibular
symphysis.14
Clinical Significance of PCR
Displaced TMJ disks in children and adolescents
have been shown to limit condylar and mandib-
 Pathologic Processes and Imaging Considerations 101

Figure 4. Cone-beam CT (CBCT) images of a 17-year-old female individual with end-stage PCR in the left TMJ. (A)
A volume-rendered face. There is a soft-tissue asymmetry with the midline of the mandible shifted to the left, and the
left lip commissure is elevated on the left side. (B) A skeletal asymmetry with the osseous midline of the mandible
shifted to the left. The lateral development of the left half of the mandible is less than the right. The occlusal plane
is elevated on the left side. The left angle of the mandible is superior to the right side. (C) Reconstructed panoramic
projection demonstrating a skeletal asymmetry with the height of the left condylar process, ascending ramus, and
body of the mandible being less than the right. The occlusal plane is elevated on the left side, indicating a maxillary
compensation. The vertical dimension of the anterior region of the mandible is large. (D) A recessive mandible,
convex facial profile, and steep mandibular plane. (Color version of figure is available online.)

ular growth, although the effects are generally
small and easily managed by orthodontic treat-
ment. However, the occurrence of PCR has the
potential to significantly limit mandibular growth
more than a disk displacement alone. Bilateral
PCR may be associated with a clockwise facial
growth pattern and the development of an an-
terior open bite. The combination of a small
mandible and dolicofacial growth pattern may al-
low posteroinferior repositioning of the tongue
and suprahyoid tissues, leading to a reduction
in airway dimensions. A small airway dimension
is a risk factor for obstructive sleep-disordered
breathing.
102 Hatcher
Figure 5. CBCT series of a 16-year-old female individ-
ual with bilateral end-stage PCR. (A) Reconstructed
panoramic projection showing short condylar pro-
cesses. (B) Volume-rendered CBCT scan showing a
convex facial profile, steep mandibular plane, obtuse
gonial angles, and an anterior open bite. (Color ver-
sion of figure is available online.)
During the active phase of PCR, the TMJs are
vulnerable to biomechanical interactions, and
therefore, excessive joint loads can further dam-
age joints. The active phase of PCR will diminish
and repair at some point, but studies suggest
that the involved joints will always have a re-
duced adaptive capacity; therefore, excessive
changes in the functional demands on the TMJs
may reactivate the destructive phase even in
adulthood.
The elongated symphysis in individuals with a
dolicofacial growth may be associated with a labio-
lingually deficient alveolar trough of bone to sup-
port the incisor teeth. Orthodontic manipulations
of the teeth in a narrowed alveolar trough may
exceed the anatomic boundary of the mandible
and result in root resorption, periodontal disease,
and tooth loss. Facial soft tissues are supported by
the skeleton and teeth. Individuals with PCR often
have a convex facial profile. Postorthodontic and
postorthognathic treatment stability is reduced in
individuals with PCR.
Radiographic Features of PCR of
the TMJ
The best radiographic feature to characterize
TMJ PCR is unilateral or bilateral resorption of
the superior portions of the condyles (Fig 7A-
F).5 The initial site of occurrence is the antero-
superior surface of the condyle, opposite the
contact area with the posterior slope of the em-
inence. Initially, there is a focal defect with loss
of articular soft tissues and subjacent bone. The
lesion enlarges resulting in a significant loss of
condylar volume, which results in a loss of con-
dylar height. The destructive phase is followed
by a reparative phase that reconstitutes a condy-
lar cortex. The optimal treatment of patients
with PCR of TMJ and their associated skeletal/
dental anomalies requires a determination of
TMJ PCR stability. It is prudent to postpone
definitive orthodontic and orthognathic treat-
ment of patients during the active stage of PCR.
TMJs with active disease may be unfavorably in-
fluenced by various orthodontic or surgical ma-
nipulations, particularly by those treatments that
increase loads or functional demands on the
TMJs. Progression of PCR from an early minor
expression of PCR to an advanced expression of
the disease may also be associated with a change
in mandibular posture, occlusion, and change in
facial growth pattern, and therefore may result
in a corresponding change in the orthodontic
diagnosis, treatment objectives, and treatment
plan. Imaging can complement the clinical eval-
uation in determining the stability of PCR.
Two main imaging strategies have been used
in clinical cases of PCR to determine stability.
The first option uses nuclear medicine and pro-
vides immediate results. The second option re-
evaluates and compares anatomy after specific
periods. The scientific community has not vali-
dated either method for determining PCR sta-
bility; therefore, a pragmatic strategy will be pre-
sented in this article. The nuclear medicine
approach uses a bone scan imaging technique,
such as technetium-99m methylene-diphospho-
nate (99mTc-MDP) standard bone scans, Tc-MDP
 Pathologic Processes and Imaging Considerations 103

Figure 6. (A) T1-weighted MRI of the left TMJ in the closed- and open-mouth positions in a 15-year-old female
individual. The images demonstrate a nonreducing anteriorly displaced disk. The black arrow indicates that the
posterior band of the disk is anterior to the condyle in closed- and open-mouth positions. The white arrows show
a missing low-signal rim along the anterosuperior surfaces of the condyle. The missing low-signal rim
indicates an active erosive defect with a minor loss of condylar volume. (B) T1-weighted MRI of the right
TMJ of same patient. There is a nonreducing anteriorly displaced disk (black arrows). The anteroposterior
dimensions of the disk have shortened, and the disk has a biconvex shape. The right condyle demonstrates
a stable stage of PCR, and this is characterized by a loss of vertical dimension, flattening, and reestablishing
a low-signal rim.

single-photon emission computed tomography
(CT), or Tc-MDP single-photon emission CT
with lumbar vertebra and clivus uptake ra-
tios.15,16 Bone scans are efficient for assessing
some medical conditions, but the specificity is
not sufficient to be useful for determination of
TMJ PCR stability. Time is the most useful tool
in the determination of PCR stability. Once the
radiographic features (cone-beam CT [CBCT]
or comparable imaging) of end-stage PCR are
present, it would be prudent to wait 6-12 months
to radiographically reevaluate the TMJs. Radio-
graphic stability exists when the size, shape, and
quality of the osseous components remain con-
stant over time.
Imaging strategies include hard- and soft-tissue
imaging. The goals of imaging include determin-
ing the size, shape, quality, and spatial relation-
ships of the osseous components of the TMJs. The
current imaging of choice for hard tissues includes
CBCT or conventional CT. CBCT has an advan-
tage of low cost, relatively low dose, and high res-
olution when compared with conventional CT.
Magnetic resonance imaging (MRI) is the pre-
ferred technique for the investigation of the soft
tissues within and adjacent to the TMJs. Reduction
in the dimension of the superior joint space, as
detected on cone-beam scans, suggests that the
soft tissues, including the disk, may be displaced or
thinned. All TMJ imaging should use an axially
corrected technique to acquire sectional images
perpendicular and parallel to the mediolateral
long axis of the condyles.
Differential Diagnosis
The differential diagnosis for PCR includes the
following.
104 Hatcher

Figure 7. Imaging stages of PCR. A series of CBCT TMJ images (top) and associated anatomic illustrations
(bottom) displayed in the paracoronal and parasagittal planes. The images (A-F) show the progression of PCR.
(A) This figure represents a normal TMJ and is characterized by smooth and rounded outline of the osseous TMJ
components without evidence of subchondral defects. Note the height of contour (equator shown in Fig 1) is
normally positioned. The height of contour is indicated on the sagittal view anatomic illustrations with a black
arrow. Developing condyles do not have a superior cortex, but the density of the trabecular bone at the superior
surface gives the appearance of a well-defined surface. (B) The beginning of the destructive/active phase, which
is characterized by a break in the anterosuperior surface integrity and a slight loss of condylar volume. (C) A
“cup”-shaped defect in the superior surface of the condyle. The stages represented by (B) and (C) are very
vulnerable to biomechanical forces. In these vulnerable stages, the trabecular bone is exposed to functional
forces, and the irregular contour of the superior surface creates opportunity for stress concentrations. (D) The
beginning of the repair stage. The superior surface of the condyle and opposing eminence are beginning to
flatten in a way that will ultimately increase the congruency of the opposing articular surfaces. The articular
surface is relatively well defined but not particularly well corticated. The condyle has lost significant volume (equator
near superior surface). (E) A relatively advanced repair phase of PCR. The condyle has lost volume, and the opposing
articular surfaces are congruent. The superior surface of the condyle has a cortex, but the cortex may not be
completely eburnated, suggesting that the repair process has not been completed. (F) A radiographically stable stage
of PCR. The condyle is small (equator near superior surface), and opposing articular surfaces are nearly congruent.
The superior surface of the condyle is corticated and smooth, and has an eburnated appearance. This figure also
shows the result of modeling along the posterior surface of the condylar process, resulting in a more convex form and
creating the impression that the condyle is reaching posteriorly toward the fossa.

Juvenile Idiopathic Arthritis
Juvenile idiopathic arthritis is an autoimmune
musculoskeletal inflammatory disease of child-
hood. JIA is more likely to involve other large
joints, such as spine, knees, wrists, and ankles. In
the TMJ, there is generally a bilateral and sym-
metrical expression of the disease that is charac-
terized by short condyles with a broad flat artic-
ular surface and a wide glenoid fossa.17,18
Degenerative Joint Disease
DJD is a localized noninflammatory degenerative
disorder of synovial joints characterized by the de-
struction and repair of the articular fibrocartilage
 Pathologic Processes and Imaging Considerations
and underlying subchondral bone. This condition
is very similar to PCR, except that the age of onset
is later and the degree and rate of tissue destruc-
tion is generally much milder. The progression
and radiographic findings are similar, except that
DJD is more likely than PCR to form osteophytes
and subchondral bone cysts.18,19
Conclusion
PCR of the TMJ is defined as a lytic process
primarily affecting adolescent female individu-
als, and it has radiographic features that are very
similar to DJD in adults, but more severe quan-
titatively. PCR may be part of the spectrum of
DJD, as suggested by Haskin and Milam more
than 15 years ago.20 DJD can be defined as a
situation where the adaptive capacity of the artic-
ular tissues has been exceeded by the functional
demands, resulting in a loss of hard and soft tis-
sues. The term situation can be used to include
factors that reduce the adaptive capacity of the
articular tissues; these factors can include hor-
mones, trauma, microtrauma, disk position, and
genetic makeup of the connective tissues. PCR,
because of its onset in adolescents before comple-
tion of somatic growth, has negative influences on
condylar and mandibular growth. The presence of
PCR should be considered in the differential diag-
nosis of adolescent female individuals who exhibit
mandibular asymmetry, dolichofacial growth, re-
cessive mandible, anterior open bite, and progres-
sive changes in occlusion. Imaging can be partic-
ularly useful in identifying or ruling out PCR,
staging the progression of PCR, and determining
the stability of the end stages of PCR. Decisions to
perform corrective surgical procedures for PCR
patients will depend heavily on information ob-
tained from imaging, in combination with other
clinical assessments of TMJ stability.
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