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Orthognathic surgery-related condylar resorption in patients with skeletal class III malocclusion versus class II malocclusion: a systematic review and meta-analysis

BMC Oral Health volume 25, Article number: 72 (2025) Cite this article

A Correction to this article was published on 03 May 2025

This article has been updated

Abstract

Background

Orthodontic-orthognathic treatment is the standard of care for moderate and/or severe skeletal class III (SCIII) malocclusion. Following orthognathic surgery, morphological changes in the temporomandibular joint structures (TMJ) may contribute to condylar resorption (CR).

Objectives

This systematic review aimed to identify the morphological signs of condylar resorption (changes in the condylar head, position, neck, disk, and joint space) following orthognathic surgery in patients with SCIII compared with those with skeletal class II (SCII) malocclusion. Furthermore, surgical techniques were assessed to investigate the extent to which orthognathic surgery may be related to TMJ disorders and potential muscular changes.

Methods

A systematic search was conducted using Medline, Pubmed, Scopus, Cochrane Library, Web of Science, and Grey Open literature databases [May 2023; PROSPERO: CRD42021293105)]. Articles that met the eligibility criteria were assessed for quality and the risk of bias using MINORS. A meta-analysis was also conducted.

Results

Eleven of the 1014 studies met the eligibility criteria. Of the eligible studies, 10 were considered high-quality. Our results indicated that the incidence of condylar resorption was higher in the SCII group (46.7%) than in the SCIII group (37.2%). The condylar angle was preoperatively higher in the SCII group, and this tendency did not change during the follow-up period. No statistically significant differences in condylar width (95% CI: − 0.62 to 0.43; p = 0.72), height changes (95% CI: − 0.92 to 0.46; p = 0.46), ramus angle (95% CI: − 0.63 to 2.56; p = 0.24) were found between groups. The results suggested that TMJ symptoms were similar between the groups pre- and postoperatively. However, the SCII group showed a higher incidence of anterior disc displacement. Furthermore, postoperative cross-sectional measurements of the lateral pterygoid, medial pterygoid, and masseter muscles were significantly different between the groups.

Conclusion

CR could be related to specific skeletal pattern, and the extension of surgical movements may be a risk factor. However, the definition of CR remains vague, and no categorization system regarding SCIII patients has been reported to date.

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Introduction

Skeletal class III (SCIII) malocclusion represents a diversified cluster of craniofacial anomalies that are classically characterized by a sagittal mesial discrepancy [1,2,3,4]. The prevalence of SCIII varies within different ethnic groups, ranging from 16% in East Asian populations to 2–6% in European populations [5, 6].

Treatment options for SCIII vary depending on the severity of the malocclusion and the patient’s skeletal maturation stage, with the most severe cases requiring orthodontic-orthognathic surgery management [7].

Severe SCIII (orthodontic-orthognathic surgery indicated) affects approximately 579,150 patients in the North-American regions, which represent 17.8% of all SCIII in the USA [8]. Several studies have demonstrated that SCIII negatively impacts patients’ quality of life. The main reasons patients seek treatment include impaired mastication, esthetic concerns, low self-confidence, and bullying in social settings [9, 10].

Orthognathic surgery includes different techniques, with all requiring osteotomies and fixations. Moreover, the fixation strategies utilized can significantly influence the final position of the condyle and its relationship with the temporomandibular joint (TMJ) [11,12,13]. Furthermore, orthognathic surgery is associated with risks, potential complications, and long-term consequences, including structural condylar changes [13,14,15,16,17,18]. In particular, changes in one or both maxillary bones may result in a new condylar position, leading to different load distributions that may affect the TMJ [14, 15]. To adapt, the TMJ may remodel or resorb [13], resulting in structural changes that alter the condylar shape and/or lead to dysfunction of the temporomandibular joint (DTM) [14,15,16, 19]. Additionally, condylar resorption is one of the main mechanisms contributing to long-term skeletal relapse after orthognathic surgery [20].

This systematic review aimed primarily to identify the morphological signs of condylar remodeling or condylar resorption (e.g., changes in the condylar head, position, neck, disk, and joint space) following orthognathic surgery in patients with SCIII versus those with skeletal class II (SCII) malocclusion. Secondarily we evaluated the relationship between the surgical techniques used for orthognathic surgery, TMJ disorders and related muscular changes.

Materials and methods

Protocol registration and guidelines

This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement [21] and the Center for Reviews and Dissemination [22]. The Cochrane Collaboration Reviewers’ Handbook guided our methods [23, 24] and the protocol was registered in Prospero (CRD42021293105). The research protocol was updated in May 2023 (accessible via https://www.crd.york.ac.uk/prospero/export_record_pdf.php).

Search strategy and sources of information

A systematic literature search was conducted using Medline, PubMed, Scopus, Cochrane Library, and the Web of Science, up to April 2023 with no language restrictions. A manual search was also performed. Additionally, the grey literature database was searched and a list of suitable databases from the CADTH supplementary information was used [25]. The complete search strategy is shown in Supplementary Material 2.

Eligibility criteria

The eligibility criteria were defined according to “PICOS” as follows. (P) participants: patients with SCIII malocclusion and indicated for orthodontic-orthognathic treatment; (I) intervention: orthognathic surgery with any kind of maxillary-mandibular osteotomy to correct the SCIII discrepancy; (C) comparison: patients who underwent orthognathic surgery to correct a SCII dentofacial deformity; (O) outcomes: morphological signs of condylar remodeling or condylar resorption; (S) studies: randomized clinical trials, case-control studies, cross-sectional studies, and cohort studies were included, while animal studies, clinical case reports, case series, pilot studies, reviews, books, and book chapters were excluded. The excluded studies and reasons for exclusion were registered on a pre-piloted registration form (Supplementary Information 3).

Data collection and extraction process

Two researchers (M.F.T. and F.C.) performed the literature search and independently gathered the required data. Titles, abstracts, and full texts were screened sequentially according to the eligibility criteria. Any discrepancies were resolved by consensus or a third reviewer (A.I.L). The selection process involved removing duplicates, appraising the titles and abstracts to exclude non-relevant studies, reviewing the full text of each study, and recording reasons for exclusion (Supplementary Information 3). The kappa index was used to assess the inter-rater agreement.

A pre-piloted form was used for data extraction. The data gathered included study identifiers, study characteristics [ethnicity, population, sample size, age, gender, type of 3D analysis, TMJ disorders, surgery type, postoperative assessment, post-surgical complications, skeletal stability, relapse, and muscular variables], quantitative assessment of condylar morphology and TMJ disorders, and the key conclusions of each study (Table 1) .

Table 1 Study characteristics
Full size table

Quality evaluation and risk of bias in individual studies

Two investigators assessed the quality of the methodology used in the selected studies independently. Any disagreements were discussed with a third reviewer. MINORS (Methodological Index for Non-randomized Studies) was used to conduct the evaluation. Briefly, MINORS included seven items to assess non-comparative studies, as well as five additional items for comparative studies (Table 2). Each item was scored as 0, 1, or 2 (0: not reported, 1: reported but inadequate, 2: reported and adequate). The maximum overall score for non-comparative studies is 16, and that for comparative studies is 24 [26].

Table 2 Risk of bias assessment based on the methodological items for non-randomized studies. Total score calculated by the sum of points
Full size table

For comparative studies, a score of ≥16 was considered high quality, while a score of <16 was regarded as low quality [27]. A detailed explanation of the quality assessment is presented in Table 2.

Quantitative analysis: meta-analysis

A meta-analysis was conducted to quantify changes in the condyle (width and height) and the ramus angle (Fig 1). The estimation was calculated using a random effects model with maximum likelihood (ML), Der Simonian method and z distribution (95% confidence interval (CI)) were determined The estimation results, global effect measures, and CIs are represented in the forest plot. The relative weight of each article was estimated using meta-analysis calculations. The percentage of variability of the estimated effect attributed to the heterogeneity of the true effects (I2) was determined and the chi-square test was performed. Finally, selection bias was calculated and represented using a funnel plot (Fig 2) (Epidat 3.1).

Fig. 1
figure 1

Morphological characteristics of condylar resorption in patients with SSCIII malocclusion following orthognathic surgery. A 3D imaging of condylar head volume. Posterior inclination of condylar necks after surgically induced posterior rotation of the condyle may expose the anterior-superior condylar surface to increased loading. B the maximum loading site moves superiorly and a localized force can be generated that does not protect the disc tissues. Consequently, increased stress is generated at the site, which may lead to osteosclerotic and osteolytic lesions, thus inducing condylar volume reduction and resorption. C Resorption of the superior, anterosuperior, or all other surfaces of the condylar head. This process often results in an alteration of the condylar contour, resulting in flat or peaked condylar surfaces

Full size image
Fig. 2
figure 2

Forrest and funnel plots for changes in condylar height, condylar width, and ramus angle in the SCII versus SCIII groups

Full size image

Results

Records obtained during the search process

The electronic and manual searches yielded 1014 records. Of these, 29 relevant studies were identified. After assessing the full text for eligibility, 18 papers were rejected as they did not match the purpose of this investigation (Supplementary Information 3), resulting in 11 articles being considered for analysis (Supplementary Information 1). The inter-rater agreement was high (kappa index: 0.71 for the electronic database search).

Quality evaluation and risk of bias in individual studies

The 11 eligible studies all included selected surgical techniques. The MINORS was used to evaluate the methodological quality (Table 2). Ten of the selected studies were high quality studies (HQS) (Table 2). Previous categorization investigations described a score of 16 or more as HQS [27].

Description of individual studies and assessment of the analyzed outcomes

The overall results are summarized in Table 1. The 11 articles included were published between 1998 and 2021. The total sample size was 514 patients and the included studies ranged from 30 [28] to 74 [29] patients. All the included studies were published in English, representing data from European and Asian ethnicities.

Study characteristics and included interventions

Primary outcome analysis

Morphological signs of condylar remodeling or condylar resorption (changes in the condylar head, position, neck, disk, and joint space)

Our results confirmed that morphological condylar changes occur following orthognathic surgery in patients with either SCIII or SCII deformities. Six HQS [30,31,32,33,34,35] reported some degree of postoperative condylar resorption in both groups, while three HQS [19, 31, 34] described a relevant loss of ramus height. Moreover, two HQS [32, 34] reported no signs of resorption in the SCIII group and some degree of postoperative resorption exclusively in the SCII group. Furthermore, one HQS showed that a large condyle: fossa volume ratio correlated with smaller positional changes in the condyle in the SCIII group [28]. Additionally, morphologic evidence of condylar resorption was not evident in two low-quality studies (LQS) and 1 HQS [36, 37] despite extensive surgical movements [average mandibular advancement: 6–6.51 mm; average mandibular setback: 4.16–8 mm] (Table 1). Notably, our results suggest a higher incidence of condylar resorption in the SCII group (46.7%) (Table 1) than in the SCIII group (37.2%). Furthermore, morphological condylar changes were more severe in patients with the SCII than in those with SCIII [19, 31,32,33,34,35].

Regarding condylar dimensions, patients with SCII demonstrated significantly smaller condyles relative to patients with SCIII [28, 31, 32, 34]. In contrast, the size of the glenoid fossa did not differ between the groups [28, 32]. Furthermore, the condylar angle was preoperatively higher in the SCII group than in the SCIII group, and this tendency did not change after surgery or during the first year of follow-up [30, 34]. However, at the 1-year follow-up, the condylar thickness (p = 0.0020), condylar width (p < 0.0001), and condylar area (p < 0.0001) decreased significantly more in the SCII group than in the SCIII group [34].

Relevant positional changes of the condyle, disc, and fossa have been previously observed in both SCIII and SCII groups when comparing pre-and postsurgical imaging [28, 31]. Two HQS [28, 31] suggest that the condyle/fossa matching degree has a negative correlation with positional variation. Larger condyles and similar-sized glenoid fossae in patients with SCIII were related to better condyle/fossa matching and less condylar displacement [28, 31]. The degree of condyle/fossa matching in patients with SCII was significantly lower than that in patients with SCIII.

Secondary outcome analysis

Surgical techniques

This systematic review analyzed six HQS [19, 30, 31, 33,34,35] regarding bimaxillary surgery. Three articles [28, 29, 37] focused on single-jaw surgery, including two HQS and one LQS. Two studies [37, 38] (one HQS and one LQS) included both types of surgeries. Our results suggest that bimaxillary surgery exhibits a higher condylar resorption rate [19, 28, 29, 31,32,33,34,35,36]. The mean advancement and standard deviations in the SCII groups ranged from 4.6 mm (± 2.3 mm) [30] to 6.51 mm (± 2.41 mm) [36] and the mean setback and standard deviations in the SCIII groups ranged from 4.16 mm (± 2.77 mm) [36] to 8 mm [38] (Table 1).

TMJ disorders assessment

Our results suggest that TMJ symptoms in the SCII and SCIII groups did not differ significantly pre and postoperatively [19, 31, 33, 35, 38]. However, the SCII group showed a higher incidence of anterior disc displacement when compared with the SCIII group [19, 29,30,31, 35] (Table 1). Furthermore, three studies [19, 31, 35] demonstrated that patients with high-angle SCII tended to experience anteriorly displaced discs and posteriorly inclined condylar necks, suggesting substantially less condylar loading than that in low-angle SCII cases.

A detailed magnetic resonance imaging (MRI) assessment of the TMJ [19, 29, 30, 33, 35, 39] was carried out in several studies. The results highlighted differences between the two groups in the distribution of the disc position preoperatively (p < 0.0001) (Table 1) [29, 31]. The classification based on disc position did not change significantly in the two groups postoperatively despite positional changes of the condyle, disc, and glenoid fossa [29, 40,41,42,43]. However, postoperatively, more patients with SCIII had minor disc dislocation and disc degeneration than those with SCII [43].

In the present review, anteriorly displaced discs with or without reduction were classified as anterior, fully covered, and posterior types, according to previous classifications [44, 45]. Our results demonstrated that the anterior type was predominant in the SCII group, and the fully covered and posterior types were mainly found in the SCIII group [19, 30, 31].

Results relating to the joint space assessment were not unanimous across the included studies [29, 31, 33, 36]. Two HQS suggested that despite a significant increase in the joint space immediately postoperatively (p < 0.05) [40] in both groups, the joint space did not significantly increase at the follow-up assessment [33]. In contrast, three HQS [29, 31, 36] suggested a larger anterior and posterior joint space in the SCII group at the 1-year follow-up.

Muscular changes

Two 3D studies [30, 34] investigated the differences between the cross-sectional measurements of relevant muscular structures. Preoperatively, the medial pterygoid width was significantly smaller in the SCII group than in the SCIII group [34]. One year after orthognathic surgery, the SCII group exhibited larger cross sectional measurements than the SCIII regarding the medial pterygoid muscle (P. 0.0343) [34]. Preoperatively, the SCII group exhibited higher cross sectional measurements than the SCIII group regarding the lateral pterygoid area, masseter width (p = 0.0068), masseter area (p < 0.0001), and medial pterygoid length (p < 0.0001) [34]. Moreover, this tendency did not change after surgery [30].

Interestingly, masseter and medial pterygoid areas and lengths showed a tendency to increase one year after orthognathic surgery in the SCIII group and to decrease in the SCII group [34] (Table 1).

Quantitative synthesis

Seven studies were included in the meta-analysis (Fig. 2) to analyze changes in the condylar structure (width [19, 31, 33,34,35, 37], height [19, 33, 35, 37], and ramus angle [32, 19, 35]. Table 1 shows the study characteristics. When comparing the absolute condylar width changes (p = 0.89; I2 = 0%), absolute condylar height changes (p = 0.81; I2 = 0%) and ramus angle changes (p = 0.5; I2 = 0%) following orthognathic surgery in SSCIII vs. SSCII cases, the studies demonstrated low heterogeneity. Furthermore, no statistically significant differences were found when comparing the absolute condylar width (95% CI, − 0.62 to 0.43; p = 0.72), height changes (95% CI, − 0.92 to 0.43; p = 0.46), and ramus angle (95% CI, − 0.63 to 2.56; p = 0.24) (Fig. 2).

Discussion

This is the first systematic review to assess the relationship between orthognathic surgery and postsurgical TMJ alterations, including clinical signs of condylar resorption in patients with SCIII and SCII malocclusions.

Sagittal split ramus osteotomy (SSRO) and bilateral sagittal split ramus osteotomy (BSSO) are often used to treat SCIII and SCII [46]. The advantages of sagittal split osteotomies include a regular bone interface between adjacent fragments and easy rigid fixation using bicortical screws or monocortical plates and screws) that reduce the need for intermaxillary fixation [13]. Despite the numerous intraoperative benefits, condylar positional changes are a major concern. When the mandibular position is modified, variations in the TMJ space occur [28].

Condylar resorption and positional changes following orthognathic surgery have been extensively studied in patients with SCII malocclusion [14, 17, 18]. However, there is a scarcity of evidence regarding the diagnosis, identification of risk factors, and prognosis of condylar resorption in patients with SCIII malocclusion.

Condylar resorption is defined as a progressive pathological structural change of the condyle accompanied by a loss in vertical height and/or volume [41]. However, the etiology and pathogenesis of condylar resorption following orthognathic surgery remain unclear [43]. The potential risk factors for condylar resorption include female sex, age (20–30 years), a high mandibular angle, TMJ dysfunction, large surgical mandibular advancement, counterclockwise rotation of the proximal segment in mandibular sagittal split osteotomies, use of inappropriate fixation, and rigid intermaxillary fixation [14, 42, 47]. Frequent TMJ pathological abnormalities related to condylar resorption include inflammatory arthritis, and autoimmune and connective tissue diseases [48]. CR can occur 6 months to 2–6 years after the orthognathic surgery during which both clinical and radiological signs should be examined [49, 50].

Most studies analyzed in this systematic review assessed condylar resorption through 3D imaging. The latest available evidence defines morphological 3D diagnostic criteria for temporomandibular disorders in terms of bone density/quality and condylar morphology/cartilage [51, 52]. Furthermore, 3D visualization of the condyles facilitates condylar volumetric analysis via similar and validated segmentation techniques and specific protocols [19, 30, 31, 34, 35].

However, some limitations in identifying and quantifying condylar resorption using computed tomography (CT), cone-beam computed tomography (CBCT), and MRI scans exist, since the definition and cut-off values for condylar resorption are indefinite [31].

Current research diagnostic criteria for temporomandibular disorders (RDC/TMD) suggest that osseous diagnosis with CT and disc diagnosis with MRI are relevant to diagnose condylar resorption [51]. Hard tissue assessment using MRI and CT was scored on a number of parameters, including subcortical sclerosis [51, 53]. However, the definitions of the items assessed were vague and not quantitative.

Quantitative assessment of the osseous tissue of the TMJ is essential. The voxel-based superimposition of pre-and postoperative CT allows a comparative assessment of condylar morphological changes [49]. However, TMJ anatomy is complex, thus, defining specific reference points for measurements is crucial. Although points, such as the nasal spine, can be clearly identified, small deviations caused by the voxel size (0.125 mm) or variables of reconstruction data tend to persist [36].

Assessing the CT values of condylar surfaces may be important for predicting the incidence of condylar resorption after orthognathic surgery [19, 50]. However, a categorization system for CT values of condyles before and after orthognathic surgery is not available [19]. Furthermore, as the definition of condylar resorption is vague, quantitative measurements of condylar volumetric reductions cannot be objectively performed using CT as yet [54, 55].

Recent evidence suggests that CBCTs may be useful for assessing all aspects of the condyle, including the identification and quantification of condylar resorption [51]. Using this 3D imaging technique the condylar head volume may be estimated. Results from a previous study also reported that CBCT is potentially efficient and comprehensive for recognizing and quantifying condylar resorption [56]. This particular research, proposed a cut-off value of 17% reduction in condylar volume to identify the process of condylar resorption leading to skeletal relapse [57]. However, it should be noticed that this cut-off value was based on a sample composed by SC II patients exclusively.

While analyzing the results of the present work, we underline that none of the included studies calculated condylar volumes to assess CR. Instead, they used measurements in the sagittal, axial, and coronal planes to study condylar morphology. The conserved methodologies observed throughout the literature are possibly related to the lack of consensus on the definition of condylar resorption. Moreover, specific and accurate parameters for assessing the condylar resorption process are unavailable.

This systematic review found that relevant morphological condylar changes were observed in patients with either SCIII or SCII malocclusion. Specifically, a higher incidence was noted in the SCII group (46.7%) than in the SCIII group (37.2%). Morphological condylar changes were also more severe in the SCII than in the SCIII group [19, 31,32,33,34,35]. We hypothesized that the higher prevalence of condylar resorption observed in patients with SCII could be related to several predisposing factors, such as a high trabecular pattern of the condyles, reduced preoperative condylar volume [16], a short ramus, mandibular retrognathia [19, 47], high mandibular plane angles [58, 59], anterior open bite, and a posteriorly inclined condylar neck [42, 60]. Posterior inclination of the condylar necks after surgically induced posterior rotation of the condyle tends to expose the anterior-superior condylar surface to increased loading; this may lead to condylar resorption in patients with SCII [14, 15, 57]. Another factor to consider is female sex [61]. The included studies that analyzed exclusively female patients [19, 30, 34, 35] (Table 1; n = 178) showed that 49.4% of these patients exhibited condylar resorption in both SCII and SCIII groups, but were more noticeable in the SCII group [19, 30]. These observations further support the hypothesis that female hormones, such as 17β-estradiol, could potentially modulate condylar resorption [41, 42]. Nevertheless, when analyzing a mixed sample, no sex-dependent differences were reported in the included studies.

The present systematic review suggests that the nature of condylar resorption susceptibility is associated with specific skeletal patterns and with the direction and extension of surgical movements. These observations [19, 31, 35] concurred with findings from previous experimental studies [20, 41, 59]. For example, patients with high-angle SCII frequently exhibited anteriorly displaced discs and posteriorly inclined condylar necks, suggesting substantially less condylar loading than in low-angle SCII cases. Patients with SCII also exhibited reduced condyles compared with those with SCIII, although both groups had similar glenoid fossa volumes [28, 31]. Moreover, the degree of condyle/fossa matching negatively correlated with positional variations. Larger condyles and similar glenoid fossae in SCIII are related to a better degree of condyle/fossa matching and less condylar displacement [28, 31]. Therefore, the degree of condyle/fossa matching and articular stability are likely significantly smaller in patients with SCII than those with SCIII.

Before orthognathic surgery, the anterior region of the condyle was frequently the maximum loading site. After mandibular advancement, counterclockwise rotation and posterior displacement of the proximal segment frequently occur [19]. As a result, the maximum loading site moves superiorly, but the joint disc remains in the same position. Even if the resultant force does not increase over the entire condylar surface, a localized force can be generated that does not protect the disc tissues. Therefore, increased stress is generated at this site, which may lead to osteosclerotic and osteolytic lesions inducing condylar volume reduction and condylar resorption in patients with SCII [19]. Furthermore, articular surface flattening and subcortical sclerosis have been reported as signs of condylar remodeling or a physiological response to increased loading [62].

Regarding the secondary outcomes, surgical risk factors, such as counterclockwise rotation of the mandible and large surgical movements, should also be contemplated [63]. Excessive rotation of the proximal fragments and an extended operating time may lead to TMJ problems (TMJ sounds/clicking, pain, deviations, etc.), an open-bite tendency, and increased stress on mandibular movements [64]. Moreover, changes in the condylar position during surgery influence general remodeling, particularly of the gonial angle [64].

Our results suggest that TMJ symptoms did not differ significantly between SCII and SCIII pre- and postoperatively [19, 31, 33, 35, 38]. Additionally, the incidence of TMJ symptoms tended to improve postoperatively in both groups, and was possibly unrelated to disc position [19, 31, 35]. However, the SCII group showed a higher incidence of anterior disc displacement [29,30,31, 33, 35] correlating with the condylar angle at the upper and lower levels (p < 0.0001) [30] (Table 1). Joint discs exhibiting anterior disc displacement were classified as anterior, fully covered, and posterior types, according to previous classifications [44, 45]. In our study, we found that the anterior type was predominant in the SCII group, while the fully covered and posterior types were predominantly found in the SCIII group [19, 30, 31].

In the literature, anterior disc displacement has been frequently reported in patients with SCII [65,66,67,68]. Furthermore, the Wilkes staging criteria for internal derangement of the TMJ suggests that the progression of TMJ abnormalities occurs in five stages (early, early-intermediate, intermediate, intermediate-late, and late) with condylar resorption possibly included in the late stage [48]. Morphological findings frequently include deformities of the disc and hard tissue, which are associated with degenerative changes [19]. However, the analysis of joint space was not unanimous across the included studies. Two HQS suggest that despite a significant increase in joint space was observed immediately postoperatively (p < 0.05) [36] in both groups, further increases were not seen at the follow-up assessment [33]. In contrast, three HQS [29, 31, 36] suggested a larger anterior and posterior joint space in the SCII group than in the SCIII group at 1 year follow-up.

Muscular variables also contribute to stomatognathic balance and TMJ stability. The LPM plays a central role in disc and condyle rotation and movement of the condyle [69]. Different studies have hypothesized that morphological changes in the LPM could be related to internal derangement, abnormal movements of the disc, and TMD [69, 70]. In the present study, patients with SCII exhibited larger masseter widths and areas and medial pterygoid widths, as well as a higher LPM length (p < 0.05) [34] when compared with patients with SCIII [34]. Sex has been suggested to affect muscle volume, and men have been speculated to exhibit larger muscular structures than women. To exclude the sex factor, the included studies [30, 34] analyzing the masticatory muscles comprised only female patients.

The main reasons for relapse after orthognathic surgery remain unclear. Stability seems to be related to multiple adaptations in response to different stimuli, including neuromuscular adaptation, muscular morphology, postsurgical fixation methods, masticatory function, and craniofacial pattern. Thus, further evidence-based research is needed to identify and quantify condylar resorption and its ramifications on skeletal stability following orthognathic surgery.

Conclusions

This systematic review determined that:

  1. (1)

    The signs of condylar remodeling/resorption were more prevalent and severe in the SCII group (46.7%) than in the SCIII group (37.2%).

  2. (2)

    The incidence of TMJ symptoms did not differ significantly between groups and tended to improve postoperatively. However, a higher incidence of anterior disc displacement in the SCII group than in the SCIII group was noted.

  3. (3)

    Significant postoperative differences in the cross-sectional measurements of the masticatory muscles were detected between the two groups. Masseter and medial pterygoid areas and lengths showed a tendency to increase one year after orthognathic surgery in the SCIII group and to decrease in the SCII group.

Data availability

All supplementary data is available upon reasonable request to the corresponding author.

Change history

Abbreviations

BSSRO:

Bilateral sagittal split ramus osteotomy

CADTH:

Canada´s Drug and Health Technology agency

CBCT:

Cone beam computerized tomography

CR:

Condylar resorption

CRD:

Centre for Reviews and Dissemination

CT:

computerized tomography

HQS:

High quality study

LPM:

Lateral pterygoid muscles

LQS:

Low quality study

MINORS:

Methodological index for non-randomized studies

MRI:

Magnetic resonance imaging

PRISMA:

Preferred reporting items for systematic reviews and meta-analysis

SCIII:

Skeletal class III

SCII:

Skeletal class II

SSRO:

Sagittal split ramus osteotomy

TMD:

Temporomandibular dysfunction

TMJ:

Temporomandibular joint

2D:

Two dimensions

3D:

Three dimensions

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Acknowledgements

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Funding

This study was funded by the Complutense University of Madrid, Faculty of Dentistry, and the University of Lisbon, Stomatology Clinic of the Faculty of Medicine.

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Authors and Affiliations

  1. School of Dentistry, Complutense University of Madrid, Madrid, 28040, Spain

    Maria Cristina Faria-Teixeira, Rosa María Yáñez-Vico & Alejandro Iglesias-Linares

  2. School of Medicine, University of Lisbon, Lisbon, 1200, Portugal

    Maria Cristina Faria-Teixeira, Francisco Azevedo-Coutinho, Ângelo David Serrano, Francisco Salvado e Silva & António Vaz-Carneiro

  3. Institute for Evidence-Based Healthcare, Lisbon, 1200, Portugal

    António Vaz-Carneiro

  4. BIOCRAN (Craniofacial Biology) Research Group, Complutense University, Madrid, 28040, Spain

    Rosa María Yáñez-Vico & Alejandro Iglesias-Linares

  5. Instituto Português da Face, Lisbon, Portugal

    Ângelo David Serrano

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Contributions

M.F.T. and A.I.L. contributed to the elaboration and design of the study. Data collection and analysis were performed by M.F.T. and F.C.; RM.Y.V conducted the meta-analysis and quantitative synthesis. The first draft of the manuscript was written by M.F.T. and all authors commented on the following versions of the manuscript. A. I. L., RM.Y.V, F.S., and A.V.C. substantially contributed to the conception of the study, particularly to data interpretation and analysis. All authors have revised and approved the final manuscript. The corresponding author (A.I.L) attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

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Correspondence to Alejandro Iglesias-Linares.

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Faria-Teixeira, M.C., Azevedo-Coutinho, F., Serrano, Â.D. et al. Orthognathic surgery-related condylar resorption in patients with skeletal class III malocclusion versus class II malocclusion: a systematic review and meta-analysis. BMC Oral Health 25, 72 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12903-024-04921-3

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BMC Oral Health

ISSN: 1472-6831

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