Title Changes in Temporomandibular Disorders (pain and clicking) after Orthognathic Surgery: A Meta-Analysis
Clinical Question For an adult patient with skeletal Class II malocclusion undergoing orthognathic surgery, is this patient at higher risk of developing TMD compared to not undergoing orthognathic surgery?
Clinical Bottom Line Though not evidence supported, patients undergoing orthognathic surgery to correct dentofacial deformities in general are more likely to show improvement in TMD pain and clicking than deterioration. An exception is for TMJ crepitus which may not show improvement.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
19892270Al-Riyami/2009A Meta-analysis: Subjects were pooled from 5 studies (276 patients)A Systematic Review with Meta-Analysis
Key resultsThe author concluded that “patients having orthognathic surgery for correction of their dentofacial deformities and who are also suffering from TMD appear more likely to see improvement in their signs and symptoms than deterioration.”
Evidence Search TMD and “Orthognathic Surgery” (Filters limited to meta-analysis).
Comments on
The Evidence
This systematic review included a meta-analysis based on 5 studies conducted in 3 different countries (Greece, Finland, and USA) with a total of 276 patients, using the Helkimo Index to classify TMD in patients at pre-surgery and post surgery. In 2 of the studies, patients with skeletal Class II malocclusions were having bilaterial sagittal split osteotomy (BSSO) advancement procedures that included either fragment fixation using biodegradable self-reinforced poly-L-lactide (SR-PLLA) screws, or rigid internal fixation. In 3 of the studies, patients with vertical maxillary excess (VME) were having LeFort 1 maxillary impaction procedures. The systematic review examines change from before to after surgery, but does not compare patients undergoing surgery versus patients not undergoing surgery. Thus, a serious limitation of the research in this area is the lack of controls for placebo effects, and the relative short follow-up periods. Furthermore, with a subjective outcome like pain, it is highly possible that the patient will report less pain after surgery just due to the demand characteristics of the setting. In addition, the newer TMD indices were not used in the studies included in the meta-analysis.
Applicability These results are relevant to adult patients with skeletal Class II malocclusions having bilateral sagittal split osteotomy (BSSO) advancement procedures, and/or patients with vertical maxillary excess (VME) having LeFort 1 maxillary impaction procedures.
Specialty (General Dentistry) (Oral Surgery) (Orthodontics)
Keywords TMD, Orthognathic Surgery
ID# 2311
Date of submission 08/08/2012
E-mail Bsoule@uthscsa.edu
Author Enas Bsoul
Co-author(s) e-mail
Faculty mentor John D. Rugh, PhD
Faculty mentor e-mail Rugh@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
by Enas Bsoul (San Antonio, Texas) on 09/21/2012
The rationale for the hypotheses that TMD symptoms may increase after orthognathic surgery might have been based upon the deep-rooted theory that malocclusions cause TMD; the temporary malocclusion induced by surgery might cause TMD. This turns out not to be the case as shown by the citation referenced in this CAT. TMD symptoms do not appear to increase after orthognathic surgery. These results further question the original assumption that malocclusion is an etiological factor for TMD (publication PMID: 20406353). This theory has not received strong support for some time now.
Comments and Evidence-Based Updates on the CAT
by Ed Wright (San Antonio, TX) on 05/11/2016
The 2016 systematic review found similar results. Their results are that following mandibular advancement surgery, some studies found TMD symptom improvement and others did not, so this surgery can not be said that it will improve nor worsen TMD symptoms. They also found if this surgery is performed in conjunction with disc repositioning, there tends to be some TMD symptom improvement. If there was condylar resorption, the surgery tended to accelerate the resorption, but this is not a contraindication to this procedure. Ref: Bermell-Baviera A, Bellot-Arcís C, Montiel-Company JM, Almerich-Silla JM. Effects of mandibular advancement surgery on the temporomandibular joint and muscular and articular adaptive changes-a systematic review. Int J Oral Maxillofac Surg 2016;45(5):545-52. (PMID: 26644217)