Dentofacial deformities are characterized by significant changes in the stomatognathic system that includes phonetic, masticatory, and respiratory changes. Such deformities are usually treated through orthodontics treatment associated with orthognathic surgery [1]

The temporomandibular joint (TMJ) is the basis for the stability of orthognathic surgery. Therefore, in patients with a pathological TMJ, the orthognathic results, including esthetics, functional, symptomatic, and stability, may be unsatisfactory over time [2],[3],[4].

Orthognathic surgery, especially in mandibular advancement, may worsen TMJ dysfunction if pre-existing temporomandibular disorder (TMD) is not surgically treated. Hence those patients should always be submitted to a careful preoperative evaluation and planning treatment, including the analyses of possible surgical intervention in TMJ.

The most common TMD symptoms include sounds/noises, TMJ pain, headaches, movement limitation, occlusion changes, chewing difficulties, earache, tinnitus, vertigo, and others. However, there may be asymptomatic patients or innocuous clinical symptoms [3].

Currently, the diagnosis of internal TMJ disorders can be performed using various methods and devices, such as radiographic, arthrography, tomography, and magnetic resonance. The last one has gained importance in the diagnosis of internal TMJ disorders because it presents high diagnostic precision in determining the position of the articular disc [2].

When TMDs are not diagnosed or untreated they can lead to unfavorable and low-quality results, in addition to postoperative complications [3],[5]. Some of these intra-articular pathologies may also be the direct cause of a dentofacial deformity, such as active condylar hyperplasia, idiopathic condylar resorption, chronic anterior disc displacement, osteochondromas, and others [2],[4],[6],[7].

Treatment of dentofacial deformities and temporomandibular disorders by orthognathic and TMJ surgery is still controversial, there are surgeons who advocate that this combined treatment will reduce or eliminate the TMD signals and symptoms, and others who postulate this treatment will cause further damage to TMJ, worsening symptoms and dysfunction [2],[3],[6],[8].

This is a clinical case report of a class II facial pattern patient, who underwent bilateral disc repositioning and orthognathic surgery with advancement and counterclockwise rotation of the maxillomandibular complex without the need of any kind of bone graft.

A female patient, 24 years old, attended the Oral and Maxillofacial Surgery Service of Uberlandia Clinical Hospital (Faculty of Odontology – Federal University of Uberlandia) presenting aesthetic and functional complaint, such as chewing difficult and painful symptoms while performing mandibular movements. The patient also reported breathing difficulties during the sleep period and the presence of snoring, in addition to being a mouth breather.

During the clinical evaluation, the patient presented diffuse pain during palpation of the bilateral joint region with increased intensity when performing full mouth opening, without sounds/noises. She presented a retrognathic profile, long vertical face with high mandibular plane angle (Figure 1). Temporomandibular joint magnetic resonance imaging (MRI) showed anterior displacement of the articular disc without reduction (Figure 2), compatible with stage 3 of Wilkes. Thereby, it was decided to perform bilateral replacement of articular disc with mini anchors in the first surgical moment and to perform the bimaxillary orthognathic surgery in the second moment, 45 days after the first surgery, due to the logistics of the service.

The articular disc repositioning surgery (discopexy) was performed through the endaural access, after accessing the articular capsule, the articular disc was captured and all adhesions between the disc and the articular fossa were removed. After this, an incision was made in the region of the joint capsule in the condyle head for its exposure, the retrodiscal tissue was removed, and a 1.7 mm screwed mini anchor was inserted 8 mm below the condyle head and sutured to the disc, resulting in an ideal position between the condyle and articular fossa.

After a period of 45 days, bimaxillary orthognathic surgery was performed, starting at the mandible, consisting of mandibular advancement and counterclockwise rotation of the mandibular plane in 14°, associated with 8 mm of maxillary impaction and 5 mm of maxillary advancement, and to 5 mm impaction and 8 mm advancement of chin, totaling a total Pg’ (soft tissue pogonion point) advancement of 32 mm.

In the postoperative period, teleradiograph image shown a higher airway space and a more harmonic occlusal relation (Figure 3). The patient evolved with improvement of facial aesthetics, masticatory and breathing function, and absence of painful symptoms of temporomandibular joints, besides social behavior improvement and self-esteem increasing for a period of five years (Figure 4).

Currently, the exact role of malocclusion performance related to the development of temporomandibular disorder is still uncertain. Riolo et al. (1987) [9] and Abrahamsson (2013) [10] reported that the prevalence of TMD in patients with severe malocclusion, especially associated with dentofacial malocclusions is higher than in the general population.

The orthognathic surgery may cause complications during and after surgery. According to Zaroni et al. (2019) [11], the most frequent complications occurred in mandibular procedures and included poor postoperative occlusion, hemorrhage, inferior alveolar nerve injury, bad split, and infection. These authors also reported two cases of TMJ disorders after orthognathic surgery.

In cases where there is the presence of dentofacial deformities and active joint diseases, such as condylar hyperplasias, idiopathic resorption, and osteochondroma, orthognathic and TMJ surgery become complementary to provide more predictable results since only intervention in the joint is able to reduce, interrupt, or eliminate TMD processes. In cases of joint dysfunction such as chronic articular disc displacement, orthognathic surgery can aggravate the present symptoms, in addition to initiating degenerative processes [2],[4],[7].

The TMJs are an essential component of the stomatognathic system, which unfortunately are often ignored in the preparation of patient to orthognathic surgery. Failure to diagnose or properly treat can result in unpredictable, low-quality results, relapses, aesthetic and functional dissatisfaction, joint pain, and headache. In cases where the TMJ pathology has not been identified or treated, TMJ surgery and reoperating orthognathic surgery may be necessary to stabilize TMJ and correct the mandible/maxillary position and occlusion [11].

Regarding the effects of orthognathic surgery on TMJ, several authors corroborate the improvement of symptoms after orthognathic procedures [8],[12],[13],[14]. In this reported case the patient was with a class II profile and who presented anterior displacement of articular disc with intense painful symptoms that evolved with improved functionality, aesthetics, and painful symptoms after orthognathic surgery and TMJ surgery. This case corroborates the results found in the study by Castro et al. (2021) [15] that evaluated the position of the articular disc by magnetic resonance imaging before and after orthognathic surgery of mandibular advancement with counterclockwise rotation, with and without disc repositioning and concluded that the previous repositioning of articular disc associated with orthognathic surgery can develop stable results and benefit in improving symptoms in individuals with disc displacement and TMJ pain.

According to Gonçalves et al. (2015) [2] pre-existing TMJ pathologies, which include dislocation of articular disc, condylar resorption, condylar hyperplasia, osteochondroma, congenital deformities, reactive arthritis, autoimmune diseases, and others, whether symptomatic or not, can cause unfavorable results when only orthognathic surgery is performed. The most common TMJ pathology is the anterior and/or medial dislocation of the articular disc, which can lead to several events including the evolution of arthritis or other symptoms related to the TMJ.

Regarding postoperative stability, Al-Moraissi and Wolford (2017) [6] did a systematic review with meta-analysis and found that postoperative stability of the occlusal plane and point B suffered a relapse when the chronic disc displacement was not treated, due to the change in condylar load, leading to changes in its morphology and movement relapse.

According to Dolwick and Widmer (2018) [16], a mandibular advancement greater than 7 mm combined with a counterclockwise rotation can promote an increased risk of postoperative relapse and pain in TMJ and masticatory muscles, while smaller advances with a counterclockwise rotation has a predominant effect on increasing muscle symptoms. Orthognathic surgery cannot be used as a predictable treatment for TMJ disorders alone. Temporomandibular disorder symptoms should be treated regardless of dentofacial deformities [17].

The postoperative management of the patient is an important aspect of treatment to provide optimal results for the patient. Orthognathic surgery with excessive trauma can damage the joints or overload the TMJs by creating an open bite later in the surgery [11].

Regarding risk factors for the presence of TMD symptoms, bruxism and dysfunctional oral habits were shown to be risk factors for the presence of TMD symptoms, also after combined orthodontic and surgical treatment. The treatment of these habits prior to orthognathic surgery can help prevent TMD [18].

Active pathologies of the temporomandibular joint in patients who have dentofacial deformity and will undergo orthognathic surgery procedure may compromise the predictability and stability of orthognathic surgery if the diagnosis and treatment of joint disorders have not been carried out properly. Although there are controversies about the surgical repositioning of chronic articular disc displacements, this treatment modality has demonstrated pain relief, long-term stability, restoration of the mandibular movement, and improvement of the condyle morphology.