Orthopaedic splint treatment can reduce mandibular asymmetry caused by unilateral temporomandibular involvement in juvenile idiopathic arthritis

Orthodontic and orthopedic management of dentofacial deformity from juvenile idiopathic arthritis: a systematic literature review

BACKGROUND

An update on the knowledge regarding the orthopedic/orthodontic role in treating JIA-related dentofacial deformities is relevant.

OBJECTIVES

This systematic review aimed to assess the level of evidence regarding the management of dentofacial deformity from juvenile idiopathic arthritis (JIA) with orthodontics and/or dentofacial orthopedics.

SEARCH METHODS

The following databases were searched without time or language restrictions up to 31 January 2024 (Medline, Embase, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and Latin American and Caribbean Health Sciences Literature).

SELECTION CRITERIA

Inclusion criteria were studies dealing with JIA subjects receiving treatment with orthodontic and/or dentofacial orthopedic functional appliances.

DATA COLLECTION AND ANALYSIS

After the removal of duplicate studies, data extraction, and risk of bias assessment according to ROBINS-I guidelines were conducted. Data extraction was conducted by two independent authors.

RESULTS

The electronic database search identified 397 eligible articles after the removal of duplicates. Following the application of the pre-defined inclusion and exclusion criteria, 11 articles were left for inclusion. Two trials were associated with a severe risk of bias, four trials were at moderate risk of bias, and the other five presented a low risk of bias. Various research groups employed and documented the effects of different types of appliances and methodologies. The study heterogeneity did not allow for meta-analyses. In addition, a lack of uniformity in treatment objectives was observed across the included studies. After treatment with dentofacial orthopedics skeletal improvement was demonstrated in 10 studies, and a decrease in orofacial signs and symptoms was reported in 7 studies.

CONCLUSIONS

Across the available literature, there is minor evidence to suggest that dentofacial orthopedics may be beneficial in the management of dentofacial deformities from JIA. There is little evidence to suggest that it can reduce orofacial signs and symptoms in patients with JIA. Based on current evidence, it is not possible to outline clinical recommendations for specific aspects of orthopedic management in growing subjects with JIA-related dentofacial deformity.

REGISTRATION

PROSPERO (CRD42023390746).

Management of temporomandibular joint arthritis in children and adolescents: An introduction for orthodontists

Juvenile idiopathic arthritis (JIA) is the most common inflammatory rheumatic disease of childhood. JIA can affect any joint and the temporomandibular joint (TMJ) is one of the joints most frequently involved. TMJ arthritis impacts mandibular growth and development and can result in skeletal deformity (convex profile and facial asymmetry), and malocclusion. Furthermore, when TMJs are affected, patients may present with pain at joint and masticatory muscles and dysfunction with crepitus and limited jaw movement. This review aims to describe the role of orthodontists in the management of patients with JIA and TMJ involvement. This article is an overview of evidence for the diagnosis and treatment of patients with JIA and TMJ involvement. Screening for the orofacial manifestation of JIA is important for orthodontists to identify TMJ involvement and related dentofacial deformity. The treatment protocol of JIA with TMJ involvement requires an interdisciplinary collaboration including orthopaedic/orthodontic treatment and surgical interventions for the management of growth disturbances. Orthodontists are also involved in the management of orofacial signs and symptoms; behavioural therapy, physiotherapy and occlusal splints are the suggested treatments. Patients with TMJ arthritis require specific expertise from an interdisciplinary team with members knowledgeable in JIA care. Since disorders of mandibular growth often appear during childhood, the orthodontist could be the first clinician to see the patient and can play a crucial role in the diagnosis and management of JIA patients with TMJ involvement.

Long-Term Follow-Up of Orthognathic Surgery in 19 Patients with Juvenile Idiopathic Arthritis

Objectives

Dentofacial deformity following juvenile idiopathic arthritis with temporomandibular joint involvement is associated with functional, aesthetic, and psychosocial impairment. Surgical treatment may involve combinations of orthognathic surgery. The aims of this retrospective study were to assess orofacial symptoms, functional and aesthetic status, and stability after orthognathic surgery.

Material and Methods

Nineteen patients with juvenile idiopathic arthritis of the temporomandibular joint (TMJ) and dentofacial deformities were included. All patients were treated with combinations of bilateral sagittal split osteotomy, Le Fort I and/or genioplasty, between September 10, 2007 and October 17, 2017. Analysis of patient symptoms and clinical registrations, and frontal/lateral cephalograms was performed pre- and postoperative and long-term (mean: 3.8 and 2.6 years, respectively).

Results

Patients experienced no changes in orofacial symptoms or TMJ function, and stable normalisation of horizontal and vertical incisal relations at long-term (horizontal overbite; vertical overbite: P < 0.05). Mandibular lengthening was achieved postoperatively (from mean 79.7 to 87.2 mm; P = 0.004) and was stable. Sella-nasion to A point (SNA) and sella-nasion to B point (SNB) angles increased postoperatively (SNA, mean 79.9° to 82.8°; P = 0.022 and SNB, mean 73.9° to 77.8°; P = 0.003), however, largely reverted to preoperative status at long-term.

Conclusions

Orthognathic surgery normalized incisal relations while providing stable mandibular lengthening without long-term deterioration of temporomandibular joint function or orofacial symptoms. No long-term effect on jaw advancements was observed.

Incidence of Orofacial Manifestations of Juvenile Idiopathic Arthritis From Diagnosis to Adult Care Transition: A Population-Based Cohort Study

OBJECTIVE

To estimate the cumulative incidences of orofacial conditions related to temporomandibular joint (TMJ) juvenile idiopathic arthritis (JIA) between diagnosis in childhood to transition into adult care, and to identify features in JIA associated with TMJ involvement.

METHODS

A population-based cohort analysis was conducted of patients with JIA involving longitudinal data on orofacial health from 2000 to 2018. Regardless of TMJ status, the patients were referred to the Regional Specialist Craniofacial Clinic of Western Denmark for routine orofacial examinations. Data collection included information about disease-specific background characteristics, TMJ involvement, JIA-induced dentofacial deformity, and orofacial symptoms and dysfunction.

RESULTS

A total of 613 patients were followed up with a mean clinical TMJ observation time of 4.0 years. From JIA onset to transition into adult care, the cumulative incidence of patients with JIA involvement of the TMJ was 30.1%. Furthermore, 20.6% of the cohort had developed arthritis-induced dentofacial deformity. A substantial proportion of the cohort experienced several events with orofacial symptoms (23.5%) and dentofacial dysfunction (52%). Young age at diagnosis (<9 years), female gender, and antinuclear antibody positivity were significantly associated with TMJ involvement.

CONCLUSION

Orofacial signs and symptoms were frequent findings in children and adolescents with JIA. TMJ involvement was seen in 30.1% of the cohort; and 20.6% of the total cohort developed JIA-related dentofacial deformity before transition into adult care. This is the first population-based study in the era of available biologic treatments to document these frequent orofacial complications in children with JIA.

Diagnosis of juvenile idiopathic arthritis with asymptomatic involvement of the temporomandibular joint: A case report

Juvenile idiopathic arthritis (JIA) is a broad term that describes a group of heterogeneous rheumatologic diseases, mainly characterized by inflammation in the joints of children and young people up to 16 years of age. Its etiology is still not well understood and the diagnosis, essentially clinical, begins with the exclusion of other joint diseases. When the disease affects the temporomandibular joint, diagnosis is a challenge, as many patients are asymptomatic. The objective of this paper is to present a case of JIA with severe involvement of the temporomandibular joint and to discuss the clinical, radiographic, laboratory findings and the importance of early diagnosis. The lack of diagnosis of active arthritis in the temporomandibular joint in patients with JIA can cause irreversible effects such as micrognathia, malocclusion and reduced maximum mouth opening. Early diagnosis of temporomandibular joint involvement in JIA is important and needs to be investigated early in the clinical manifestation of systemic disease. Laboratory tests and clinical history are important to define treatment and prognosis, but not to predict temporomandibular joint arthritis. Imaging exams are important diagnostic tools to identify morphological changes in soft and hard tissues of the temporomandibular joint.

Craniofacial structures, occlusal features, and TMD symptoms in juvenile idiopathic arthritis patients: a retrospective study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease in which temporomandibular joint (TMJ) arthritis commonly occurs. It may be asymptomatic and could cause problems in the growing joints. Our aim was to evaluate the craniofacial structures, occlusal features and temporomandibular dysfunction (TMD) symptoms of patients with JIA.

METHODS

The study consisted of 195 JIA patients treated at the Department of Oral and Maxillofacial Diseases, Helsinki University Hospital (HUH), Finland between 2015 and 2019. We retrospectively screened their medical and dental records and classified them according to age at JIA diagnosis (<7 and ≥7 years).

RESULTS

Most of the patients had Angle Class I occlusion in both sides. Among all the patients, the mean overjet, and overbite were 3.3 mm and 2.4 mm, respectively. There were more open bite patients in the ≥7 years old group than in the <7 years old group (P = 0.010). Of all patients, 47% reported at least one TMD symptom. The TMD symptoms were more common in participants ≥7 years old than those <7 years old (P = 0.005).

CONCLUSION

Occlusal features and the incidence of malocclusions seem to have similar tendency among the JIA patients with systematic visits in rheumatologist and orthodontist as in the healthy population, except for open bite that is more common with JIA patients. While treating JIA patients, a well-functioning collaboration between paediatric rheumatologists and orthodontists is essential, as well as a clear screening protocol to detect potentially asymptomatic TMJ arthritis. Particular attention should be paid to children with JIA under school age.

Management of Orofacial Manifestations of Juvenile Idiopathic Arthritis: Interdisciplinary Consensus-Based Recommendations

Involvement of the temporomandibular joint (TMJ) is common in juvenile idiopathic arthritis (JIA). TMJ arthritis can lead to orofacial symptoms, orofacial dysfunction, and dentofacial deformity with negative impact on quality of life. Management involves interdisciplinary collaboration. No current recommendations exist to guide clinical management. We undertook this study to develop consensus-based interdisciplinary recommendations for management of orofacial manifestations of JIA, and to create a future research agenda related to management of TMJ arthritis in children with JIA. Recommendations were developed using online surveying of relevant stakeholders, systematic literature review, evidence-informed generation of recommendations during 2 consensus meetings, and Delphi study iterations involving external experts. The process included disciplines involved in the care of orofacial manifestations of JIA: pediatric rheumatology, radiology, orthodontics, oral and maxillofacial surgery, orofacial pain specialists, and pediatric dentistry. Recommendations were accepted if agreement was >80% during a final Delphi study. Three overarching management principles and 12 recommendations for interdisciplinary management of orofacial manifestations of JIA were outlined. The 12 recommendations pertained to diagnosis (n = 4), treatment of TMJ arthritis (active TMJ inflammation) (n = 2), treatment of TMJ dysfunction and symptoms (n = 3), treatment of arthritis-related dentofacial deformity (n = 2), and other aspects related to JIA (n = 1). Additionally, a future interdisciplinary research agenda was developed. These are the first interdisciplinary recommendations to guide clinical management of TMJ JIA. The 3 overarching principles and 12 recommendations fill an important gap in current clinical practice. They emphasize the importance of an interdisciplinary approach to diagnosis and management of orofacial manifestations of JIA.

Observer agreement of imaging measurements used for evaluation of dentofacial deformity in juvenile idiopathic arthritis

OBJECTIVES

To examine the precision of imaging measures commonly used to assess mandibular morphology in children and adolescents with juvenile idiopathic arthritis (JIA). Secondly, to compare cone-beam computed tomography (CBCT) and magnetic resonance imaging (MRI) in the measurement of condylar height.

METHODS

Those included were children diagnosed with JIA during 2015-18 who had had an MRI, a CBCT of the temporomandibular joints (TMJs) and a lateral cephalogram (ceph) of the head within one month of each other. Agreement within and between observers and methods was examined using Bland-Altman mean-difference plots and 95% limits of agreement (LOA). A 95% LOA within 15% of the sample mean was considered acceptable. Minimal detectable change (MDC) within and between observers was estimated.

RESULTS

90 patients (33 males) were included, with a mean age of 12.8 years. For MRI, intra- and interobserver 95% LOA were relatively narrow for total mandibular length: 9.6% of the sample mean. For CBCT, condylar height, both intra- and interobserver 95% LOA were wide: 16.0 and 28.4% of the sample mean, respectively. For ceph, both intra- and interobserver 95% LOA were narrow for the SNA-angle and gonion angle: 5.9 and 8% of the sample mean, and 6.2 and 6.8%, respectively.

CONCLUSIONS

We have identified a set of precise measurements for facial morphology assessments in JIA, including one MRI-based (total mandibular length), one CBCT-based (condylar height), and three ceph-based. Condylar height was higher for MRI than for CBCT; however, the measurement was too imprecise for clinical use. MDC was also determined for a series of measurements.

"Multidisciplinary management of post- infective osteoarthritis and secondary condylar resorption of temporomandibular joint: a case report in a 9 years-old female patient and a review of literature"

Background

Osteoarthritis and condylar resorption of temporomandibular joint (TMJ) has rarely been reported in children as consequence of otologic disease. We describe the management of a case in a 9-year-old female as long-term complication of an otomastoiditis and review the literature currently available on this topic.

Case presentation

A nine-years-old female patient referred to Emergency Room of Bambino Gesù Children’s Research Hospital, IRCCS (Rome,Italy) for an acute pain in the left preauricular area and reduced mandibular movements. In the medical history an otomastoiditis and periorbital cellulitis was reported at the age of six with complete remission of symptoms after antibiotic treatment. No recent history of facial trauma and no previous orthodontic treatment were reported. She was referred to a pediatric dentist that conducted a clinical examination according to the Diagnostic Criteria of Temporomandibular Disorders (DC/TMD) and was diagnosed with bilateral myalgia of the masticatory muscles and arthralgia at the level of the left TMJ. Then, a complete diagnostic path was performed that included multidisciplinary examinations by a rheumatologist, infectious disease specialist, ear nose and throat (ENT) doctor, a maxillofacial surgeon and a medical imaging specialist. Differential diagnosis included juvenile idiopathic arthritis, idiopathic condylar resorption, trauma, degenerative joint disease, neurological disease. Finally, unilateral post-infective osteoarthritis of the left TMJ with resorption of mandibular condyle was diagnosed. The patient went through a pharmacological therapy with paracetamol associated to counselling, jaw exercises and occlusal bite plate. After 1 month, the patient showed significant reduction of orofacial pain and functional recovery that was confirmed also one-year post-treatment. The novelty of this clinical case lies in the accurate description of the multidisciplinary approach with clinical examination, the differential diagnosis process and the management of TMD with conservative treatment in a growing patient.

Conclusions

Septic arthritis of temporomandibular joint and condylar resorption were described as complications of acute otitis media and/or otomastoiditis in children. We evidenced the importance of long-term follow-up in children with acute media otitis or otomastoiditis due to the onset of TMJ diseases. Furthermore, in the multidisciplinary management of orofacial pain the role of pediatric dentist is crucial for the diagnostic and therapeutic pathway to avoid serious impairment of mandibular function.

Clinical Practice Guideline: The Diagnosis and Treatment of Rheumatoid Arthritis and Juvenile Idiopathic Arthritis of the Temporomandibular Joint

BACKGROUND

Involvement of the temporomandibular joint can be shown in 40-90% of patients with rheumatoid arthritis and juvenile idiopathic arthritis (JIA), although it is often asymptomatic. Restricted jaw mobility and jaw pain can be found in approximately 20% of patients with JIA (prevalence: 70 per 100 000 persons). Early diagnosis and treatment of the underlying disease are essential for a good outcome, but uniform, consensus-based management is still lacking.

METHODS

The clinical practice guideline is based on the findings of a systematic literature review in multiple databases and a Delphi procedure to obtain consensus on the recommendations.

RESULTS

Most of the identified studies were retrospective. Patients with JIA should undergo clinical screening with a structured examination protocol once per year in childhood and adolescence, and thereafter as well if the temporomandibular joint is involved. The diagnosis of chronic rheumatoid arthritis of the temporomandibular joint is established with contrastenhanced magnetic resonance imaging. Conservative treatment (antirheumatic basal therapy, local measures) is unsuccessful in less than 10% of patients. In such cases, arthroscopy and arthrocentesis can be used for temporary symptom relief and functional improvement. Intraarticular corticosteroid injections should be given only once, and only in otherwise intractable cases. In severe cases where all other options have been exhausted (<1%), open surgical treatment can be considered, including alloplastic joint replacement.

CONCLUSION

Oligosymptomatic and asymptomatic cases are common even with radiologic evidence of marked joint damage. The possibility of rheumatic involvement of the temporomandibular joint must be kept in mind so that serious complications can be avoided. Regular clinical evaluation of the temporomandibular joint is recommended, particularly for patients with juvenile idiopathic arthritis.

Initial radiological signs of dentofacial deformity in juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in childhood and the temporomandibular joint (TMJ) is often involved. TMJ arthritis in growing individuals can cause deformation of facial skeleton (dentofacial deformity) and TMJ components (TMJ deformity). Treatment outcome hinges on early initiation of anti-inflammatory treatment and orthopaedic treatment with dental splints. The aim of the present study was to characterize the radiological signs of dentofacial deformity in patients with a JIA-induced need for orthopaedic treatment. We retrospectively studied 96 patients with JIA and 20 non-JIA controls to identify the initial radiological signs of JIA-induced dentofacial deformity leading to initiation of orthopaedic treatment. We found that initial radiological signs of dentofacial deformities were subtle and characterized by minor mandibular asymmetry and occlusal plane steepening. Radiological findings of TMJ deformity associated with initial dentofacial deformity were frequent and characterized by condylar articular surface flattening (OR 8.42), condylar subcortical cyst (OR 5.94), condylar surface erosion (OR 5.38) and condylar deviation in form (OR 25.39). Radiological signs of TMJ deformity were also documented in TMJs considered “healthy” during initial clinical and radiological examination. This study presents new knowledge of importance for early diagnosis of dentofacial deformity in JIA. Early diagnosis of dentofacial deformity is important as treatment outcome is greatly influenced by timely initiation.

Management of juvenile idiopathic arthritis: Preliminary qualitative findings from the National Dental Practice-Based Research Network

INTRODUCTION

Juvenile idiopathic arthritis (JIA) is the most common chronic arthritis in childhood and represents a series of chronic inflammatory arthritides that develop before 16 years of age.

METHODS

In 2020, investigators with an interest in the management of JIA engaged the National Dental Practice-Based Research Network by conducting a preliminary qualitative questionnaire ("Quick Poll") that comprised 6 questions about JIA management.

RESULTS

A total of 604 persons responded. Results suggested that there was an interest in the management of JIA, but many clinicians did not feel that they had the necessary knowledge or experience to treat these patients.

CONCLUSIONS

The study clearly highlights a distinct gap in awareness and understanding of JIA among clinicians polled. Future work in this area should focus on education and awareness across multiple specialties, clinical guidelines for the management of JIA, and a data repository of long-term outcomes.

Comprehensive Management of Rheumatic Diseases Affecting the Temporomandibular Joint

The temporomandibular joint (TMJ) is a synovial joint and thus is vulnerable to the afflictions that may affect other joints in the fields of rheumatology and orthopedics. Too often temporomandibular complaints are seen strictly as dental or orofacial concerns. Similarly, patients with known rheumatic disease may not have their TMJs included in routine screening and monitoring protocols. The purpose of this review is to highlight the rheumatic conditions likely to affect the TMJ and outline medical and surgical management in these patients with a focus on the need for continued patient reassessment and monitoring.

Condylar changes in patients with idiopathic condylar resorption: retrospective 2-year follow-up CBCT-based case-control study

OBJECTIVES

To compare condylar development and changes in condylar radiological appearance in patients with idiopathic condylar resorption (ICR) to a healthy, age- and gender matched, control group.

MATERIALS AND METHODS

This case-control study included 16 ICR patients [mean age: 15years, 9 months; standard deviation (SD): 4 years) and 16 controls (mean age: 16 years, 8 months; SD: 4 years, 7 months), with diagnostic (T0) and 2-year follow-up (T1) CBCT examinations. Condylar changes were evaluated through changes in condylar neck angle (CNA), and the transversal, vertical and anteroposterior displacement of five condylar points between T0 and T1. The magnitude and direction of condylar changes were evaluated using vector analyses. A qualitative radiological evaluation of the TMJ was performed based on healthy, erosive and repaired morphological appearance. Linear and angular measurements were assessed using ANOVA and a Tukey post-hoc test, and vectors were tested using an independent-sample 2-tailed t-test. Fisher's exact test was used for the qualitative evaluation.

RESULTS

At T0, ICR patients exhibited decreased condylar height, smaller condylar width and posteriorly inclined CNA compared with the control group (P < 0.05). During observation, condylar vertical growth was smaller in the ICR group than in the control group (P < 0.05). Vector analysis showed an upward direction of vertical displacement for all condylar points in the control group; the ICR group showed a downward direction (P < 0.003). The radiological appearance of 75% of the ICR condyles and 94% of the control condyles did not change during the 2-year follow-up period.

CONCLUSIONS

ICR condyles displayed reduced vertical development compared with control condyles. The radiological appearance remained unchanged for most joints. Observed changes in radiological appearance did not always follow a progressive model of degenerative joint disease.

Comparing Clinical and Radiological Manifestations of Adolescent Idiopathic Condylar Resorption and Juvenile Idiopathic Arthritis in the Temporomandibular Joint

PURPOSE

This cross-sectional study compared orofacial manifestations at the time of diagnosis in 2 temporomandibular joint (TMJ) conditions: adolescent idiopathic condylar resorption (ICR) and TMJ involvement from juvenile idiopathic arthritis (JIA).

MATERIALS AND METHODS

This retrospective study included 19 JIAs, 19 ICRs, and 19 control patients, all treated at the Section of Orthodontics, Aarhus University Craniofacial Clinic, Denmark. From patient files, we retrieved radiological data from cone-beam computed tomographies along with information on symptoms and orofacial function at the time of diagnosis. Validated methodologies were used to evaluate TMJ and dentofacial morphology.

RESULTS

We found no statistically significant intergroup differences in severity of deformation of TMJ structures (TMJ deformity) between JIA and ICR patients. However, the ICR group showed significantly greater signs of dentofacial deformity on 4 outcome variables: mandibular inclination, posterior/anterior lower face height ratio, mandibular sagittal position, and mandibular occlusal plane inclination. Significant intergroup differences in clinical presentation were seen in 5 of 20 variables. Thus, the JIA group reported significantly more symptoms of TMJ pain, TMJ morning stiffness, and TMJ pain on palpation during the clinical examination, whereas the ICR group reported significantly more TMJ clicking during function and had a higher proportion of patients with anterior open bite.

CONCLUSIONS

Cone-beam computed tomography examination showed a similar degree of TMJ deformity in ICR and JIA patients at the time of diagnosis. ICR patients presented with a significantly higher degree of dentofacial deformity than JIA patients and healthy controls, which relates to the timing of the diagnosis. Arthralgia, TMJ morning stiffness, and TMJ palpitation pain were more common in JIA patients, whereas TMJ clicking during function and anterior open bites were more common in ICR patients.

Cumulative Incidence of Orofacial Manifestations in Early Juvenile Idiopathic Arthritis: A Regional, Three-Year Cohort Study

OBJECTIVE

To estimate the cumulative incidence of arthritis-induced orofacial symptoms, dysfunction, and dentofacial deformities in growing individuals with juvenile idiopathic arthritis (JIA) in a 36-month regional cohort study and to identify predictors for the development of arthritis-induced dentofacial deformities.

METHODS

Data were retrieved from the Aarhus JIA temporomandibular joint (TMJ) cohort register, which contains standardized, longitudinal, observational data regarding orofacial conditions in patients with JIA (n = 1,040). This regional cohort represents the majority of all subjects with JIA from the western part of Denmark between 1990 and 2016, regardless of TMJ arthritis status. Cumulative incidences of orofacial conditions were reported using Kaplan-Meier methods, and predictors for dentofacial deformity were identified using Cox proportional hazards analysis.

RESULTS

Follow-up data from 351 subjects for 36 months were included in this study. Median age at first clinical examination was 6.6 years (interquartile range 4.8-9.9 years). Orofacial symptoms and dysfunctions were common findings at 36 months after the first clinical examination and 5 years after JIA onset, with a cumulative incidence of 38% and 53%, respectively. Dentofacial deformities were found in 35% of subjects at the 36-month follow-up and were significantly associated with the presence of orofacial dysfunction.

CONCLUSION

Orofacial conditions were frequently observed in individuals with JIA and were represented in all JIA subcategories in this regional study. One-third of subjects had arthritis-induced dentofacial deformities that required orthopedic appliance treatment at the 36-month follow-up.

Evaluation of vertical ramus osteotomy for the surgical correction of unilateral mandibular posterior vertical insufficiency: Long-term follow-up results

PURPOSE

Unilateral posterior vertical insufficiency (PVI) is a growth defect of the mandibular condyle that results in a facial asymmetry. Various surgical procedures can be used to elongate the hypoplastic ramus. The aim of this study was to evaluate long-term aesthetic and architectural outcomes of vertical ramus osteotomy (VRO) in patients with unilateral PVI.

MATERIALS AND METHODS

Patients operated on with unilateral VRO were included in this retrospective study. Aesthetic and architectural parameters were evaluated on frontal photographs as well as on frontal and lateral cephalograms preoperatively, postoperatively, at 1-year and at the end of the follow-up.

RESULTS

A total of 48 patients were analyzed. The aesthetic assessment revealed significant correction of the chin deviation (CD) and of the lip commissural line tilt after VRO (p1 = 0.0038 and p2 = 0.0067, respectively) with stable results. The architectural analysis revealed significant improvement in the maxillary and mandibular occlusal planes, as well as the chin deviation (p < 0.0001). A tendency to relapse was noted for the mandibular canting and the CD during the follow-up. VRO allowed for a mean mandibular lengthening of 8.39 mm (ranging from 2.5 to 14 mm).

CONCLUSION

VRO allows for immediate restoration of the symmetry of the lower third of the face in patients with unilateral PVI. A revisional procedure may be needed due to a tendency for the chin deviation to relapse.

Interdisciplinary Management of Dentofacial Deformity in Juvenile Idiopathic Arthritis

Temporomandibular joint (TMJ) arthritis impacts mandibular growth and development. This can result in skeletal deformity, such as facial asymmetry and/or malocclusion asymmetry. This article reviews the unique properties of TMJ and dentofacial growth and development in the setting of juvenile idiopathic arthritis (JIA). Specific orthopedic/orthodontic and surgical management of children with JIA and TMJ arthritis is discussed. The importance of interdisciplinary collaboration is highlighted.

The impact of temporomandibular joint arthritis on functional disability and global health in patients with juvenile idiopathic arthritis

OBJECTIVES

The objective of the study was to evaluate the impact of temporomandibular joint (TMJ) arthritis on the functional disability and quality of life in patients affected by juvenile idiopathic arthritis (JIA).

MATERIALS AND METHODS

Sixty-two consecutive patients with JIA with or without TMJ arthritis and 35 healthy control subjects were enrolled in the study. The demographic data, disease activity and clinical characteristics were obtained from all patients. The functional disability was assessed using the Italian version of the Childhood Health Assessment Questionnaire (C-HAQ). The oral health-related quality of life (OHRQoL) was assessed using the Child Perception Questionnaire (CPQ11-14). Possible determining factors of TMJ arthritis comprised demographic, disease characteristics and scores derived from questionnaires that were assessed by a uni and multivariable logistic regression analysis.

RESULTS

Compared with patients without TMJs arthritis, JIA patients with TMJ arthritis presented higher functional disability. The multivariable logistic regression analysis performed showed that female subjects (OR = 1.5, P = 0.041), with a JIA duration over 3.9 years (OR = 2.7, P = 0.033) and presenting higher C-HAQ and CPQ11-14 scores (OR = 2.7, P = 0.012 and OR = 2.9, P = 0.015, respectively) were the greatest determining factors for TMJ arthritis.

CONCLUSIONS

JIA patients with TMJ arthritis presented higher functional disability and lower OHRQoL scores compared with JIA patients without TMJ arthritis. TMJ arthritis was strongly associated with JIA duration and activity, especially in female patients.

Surgical correction of dentofacial deformities in juvenile idiopathic arthritis: a systematic literature review

The aim of this study was to assess current evidence for the surgical correction of dentofacial deformities in patients with temporomandibular joint (TMJ) involvement from juvenile idiopathic arthritis (JIA). A systematic literature review, according to the PRISMA guidelines, was conducted. Meta-analyses, randomized controlled trials, cohort studies, observational studies, and case reports were eligible for inclusion. Exclusion criteria were no JIA diagnosis, no clearly defined outcomes, dual publications (except meta-analyses), non peer-reviewed studies, non English language publications, and animal studies. The outcome measures assessed were TMJ function, skeletal alignment, and morbidity. The database search identified 255 citations, of which 28 met the eligibility criteria. Of these, 24 were case reports or case series with a low level of evidence that did not allow for meta-analysis. Extrapolated evidence supports orthognathic surgery in skeletally mature patients with controlled or quiescent JIA and a stable dentofacial deformity. Distraction osteogenesis was recommended for severe deformities. Some authors demonstrated unpredictable postoperative mandibular growth with costochondral grafts. Alloplastic TMJ reconstruction was efficacious, but should be used cautiously in skeletally immature patients. TMJ function and skeletal alignment was improved with reconstruction by any technique and morbidity was low. The surgical correction of arthritis-induced dentofacial deformities is indicated but the level of evidence is low. Prospective multicenter studies are needed.

Surgical Treatment of Posttraumatic Laterognathia: A Case Report and a Literature Review, Focused on the Effects of a Condylar Fracture on the Face

Facial asymmetry, following early childhood condylar trauma, is a common complaint among patients who seek surgical treatment. G.D.M., a 27-year-old male patient, sought professional help to correct his cosmetic flaw, caused by a condylar fracture when he was 8-years-old. After the proper orthodontic treatment, he underwent a double jaw orthognathic surgery and, 9 months later, a second one to correct the remaining asymmetry. Two years after this second procedure, the patient is still under surveillance and has no complaints.

Temporomandibular joint arthritis in juvenile idiopathic arthritis, now what?

BACKGROUND

Arthritis involving the temporomandibular joint (TMJ) complicates 40 - 96% of cases of juvenile idiopathic arthritis (JIA), potentially leading to devastating changes to form and function. Optimal evaluation and management of this joint remains a matter of ongoing discussion.

METHODS

We performed a PubMed search for all articles with keywords "temporomandibular" and "arthritis", covering the dates 2002 through February 28, 2018. A separate PubMed search was performed for all articles with keywords "temporomandibular joint", "arthritis", and "treatment" covering the same dates.

FINDINGS

The TMJ is a particularly challenging joint to assess, both clinically and with imaging studies. Clinical assessment of the TMJ is hampered by the low sensitivity of joint pain as well as the absence of physical exam findings early in the disease process. As with all joints, plain radiography and computed tomography only detect arthritic sequelae. Additionally, there is mixed data on the sensitivity of ultrasound, leaving magnetic resonance imaging (MRI) as the optimal diagnostic modality. However, several recent studies have shown that non-arthritic children can have subtle findings on MRI consistent with TMJ arthritis, such as joint effusion and contrast enhancement. Consequently, there has been an intense effort to identify features that can be used to differentiate mild TMJ arthritis from normal TMJs, such as the ratio of the enhancement within the TMJ itself compared to the enhancement in surrounding musculature. With respect to treatment of TMJ arthritis, there is minimal prospective data on medical therapy of this complicated joint. Retrospective studies have suggested that the response to medical therapy of the TMJ may lag behind that of other joints, prompting use of intraarticular (IA) therapy. Although most studies have shown short-term effectiveness of corticosteroids, the long-term safety of this therapy on local growth as well as on the development of IA heterotopic bone have prompted recommendations to limit use of IA corticosteroids. Severe TMJ disease from JIA can also be managed non-operatively with splints in a growing child, as well as with surgery.

CONCLUSION

In this review, we summarize literature on the diagnosis and management of TMJ arthritis in JIA and suggest a diagnostic and therapeutic algorithm for children with refractory TMJ arthritis.

Assessment of dentofacial growth deviation in juvenile idiopathic arthritis: Reliability and validity of three-dimensional morphometric measures

Introduction

Patients with juvenile idiopathic arthritis (JIA) and involvement of the temporomandibular joint (TMJ) often experience abnormal facial growth. Three-dimensional (3D) assessment of dentofacial growth deviation has become more common with advancement and commercialization of imaging technologies. However, no standardized guidelines exist for interpretation of 3D imaging in patients with JIA. The aim of this study was to propose and validate morphometric measures for the 3D radiographic assessment of dentofacial growth deviation in patients with JIA to enhance: 1) Description of dentofacial growth deviation; 2) Treatment planning; 3) Longitudinal follow-up.

Methods

The study was conducted in a standardized sequential-phased approach involving: 1) Preliminary decision-making; 2) Item generation; 3) Test of content-validity; 4) Test of reliability; 5) Test of construct validity; 6) Establishment of final recommendations.

Results

Twenty-one morphometric measures were evaluated. Based on results of reliability and validity-testing including subjects with JIA (n = 70) and non-JIA controls (n = 19), seven measures received a “high recommendation” score. Those measures were associated with posterior mandibular height, occlusal cant, mandibular asymmetry, mandibular inclination, and anterior/posterior lower face height. Nine other measures were “moderately recommended” and five received a “somewhat recommendation” score.

Conclusion

Seven morphometric measures were considered very useful in the 3D assessment of growth deviation in patients with TMJ disease associated with JIA. These variables can be used to standardize the description of dentofacial deformities and to plan corrective interventions.

Nonsurgical Management of Pediatric Temporomandibular Joint Dysfunction

Temporomandibular disorders (TMD) are a subgroup of craniofacial pain problems involving the temporomandibular joint (TMJ), masticatory muscles, and associated head and neck musculoskeletal structures. These disorders are subclassified into TMJ articular disorders and masticatory muscle disorders. Patients with TMD most commonly present with pain, restricted or asymmetric mandibular motion, and TMJ sounds during mandibular movements. The prevalence tends to increase with age. Management of TMJ articular disorders consists of a combination of patient education, home-care plan, biobehavioral therapy, physical therapy, orthotic jaw appliance therapy, pharmacotherapy, and/or surgery. The goal is to increase function, reduce pain, and improve quality of life.

Surgical Treatment of Dentofacial Deformities Caused by Juvenile Idiopathic Arthritis

The purpose of our retrospective study was to evaluate the results of orthognathic treatment, distraction osteogenesis, and/or prosthetic reconstruction of the temporomandibular joints in patients with juvenile idiopathic arthritis (JIA).Twelve patients with severely affected temporomandibular joints (TMJs) and reduced ramus height were treated with mandibular advancement with orthognathic surgery (11) and additional bilateral or unilateral mandibular ramus distraction (3) or additional bilateral or unilateral prosthetic reconstruction of the TMJ (3). One patient was treated surgically with bilateral TMJ prosthetic reconstruction only. The patients were followed up clinically and radiologically with emphasis on healing, TMJ function, stability of the occlusion, skeletal stability, and facial appearance for an average of 2.3 years after the final surgery. The mean mandibular advancement was 10.1 mm. The mean relapse at pogonion was 2.1 mm, which represents 20.8% of the surgical advancement. The occlusion was stable in 11/12 patients. The TMJ function was good and the facial esthetics improved in all patients. Orthognathic treatment and mandibular ramus distraction osteogenesis provide beneficial lengthening of the mandibular body in JIA patients with asymptomatic and stabile condyles. In adult patients with relapse of the disease or postoperative condylar relapse prosthetic total joint replacement is a reliable and safe alternative.

Histologic effects of mandibular protrusion splints in antigen-induced TMJ arthritis in rabbits

BACKGROUND

Although it is common clinical practice to treat children with Juvenile Idiopathic Arthritis (JIA) with functional appliances, the scientific evidence for this is limited. The aim of this study was to study the histologic effects of mandibular protrusion splints in temporomandibular joint (TMJ) arthritis in rabbits.

METHODS

Twenty-eight ten-week old New Zealand white rabbits were randomly divided into four groups: AO (TMJ arthritis, no splint), AS (TMJ arthritis, mandibular splint advancement), OS (no arthritis, mandibular splint advancement) and OO (no arthritis, no splint). TMJ arthritis was induced in the groups AO and AS; 1 week later mandibular protrusion splints were placed on the upper incisors of the AS and OS animals. After 60 days the animals were sacrificed and a semiquantitative histologic evaluation of each TMJ was carried out to analyze the amount of inflammation and bone modeling.

RESULTS

AO and AS animals had a higher inflammation score (AO = 1.3; AS = 1.8) than the non-arthritis groups (OO = 0.6; OS = 0.4). Whereas in the untreated control (OO) the amount of apposition and resorption was almost in balance (+1), OS animals displayed significantly more apposition (+9) and AO animals significantly more resorption (-3) than the untreated control. Arthritis animals with protrusion appliances (AS), however, had remarkably more bone apposition (+3) than resorption, indicating a similar bony reaction as in healthy animals, although reduced in extent.

CONCLUSIONS

Mandibular advancement in rabbits with TMJ arthritis is possible without detrimental histologic reactions and appears to partially compensate for the bone loss seen in rabbits with TMJ arthritis but without protrusion splints.

Contemporary management of TMJ involvement in JIA patients and its orofacial consequences

Juvenile idiopathic arthritis is the most common chronic rheumatic condition during childhood. Temporomandibular joint arthritis is frequently asymptomatic. When it takes place during childhood, it may affect condylar growth; therefore, these children are at risk of unfavorable long-term outcomes from the associated joint damage. The etiology is not completely understood, but it is considered as multifactorial with both genetic and environmental factors involved.

The standardized examination and imaging protocols serve important purpose to diagnose temporomandibular joint (TMJ) arthritis not only to establish an early interventional strategy but also to assess craniofacial growth and the progression of signs and symptoms in those patients. Although the treatment of juvenile idiopathic arthritis (JIA) has changed dramatically over the last decades due to new therapeutic options, TMJ arthritis still can develop during the course of the disease. In clinical experience, TMJs appear to respond less well to the standard of care used to treat other joints. More individualized approach to the patient’s treatment serves as the main goal of personalized medicine. It could be achieved by adopting new methods of medical imaging such as conebeam computer tomography as well as developing reliable biomarkers which may assist with predicting disease type, course, or severity and predicting response to medication.

This article provides an overview of current information on orofacial complications in JIA and its management. Based on information provided in this review, more precise diagnosis, proper tools for recognizing people at risk, and more efficient treatment approaches could be implemented. This may lead to more personalized treatment management strategies of TMJ complications of JIA patients.

Temporomandibular joint diagnostics using CBCT

The present review will give an update on temporomandibular joint (TMJ) imaging using CBCT. It will focus on diagnostic accuracy and the value of CBCT compared with other imaging modalities for the evaluation of TMJs in different categories of patients; osteoarthritis (OA), juvenile OA, rheumatoid arthritis and related joint diseases, juvenile idiopathic arthritis and other intra-articular conditions. Finally, sections on other aspects of CBCT research related to the TMJ, clinical decision-making and concluding remarks are added. CBCT has emerged as a cost- and dose-effective imaging modality for the diagnostic assessment of a variety of TMJ conditions. The imaging modality has been found to be superior to conventional radiographical examinations as well as MRI in assessment of the TMJ. However, it should be emphasized that the diagnostic information obtained is limited to the morphology of the osseous joint components, cortical bone integrity and subcortical bone destruction/production. For evaluation of soft-tissue abnormalities, MRI is mandatory. There is an obvious need for research on the impact of CBCT examinations on patient outcome.

Signs and symptoms after temporomandibular joint washing and cannula placement assessed by cone beam computerized tomography

OBJECTIVE

Analyses of temporomandibular joint synovial fluid using the hydroxocobalamin push-pull technique are increasingly used. However, objective complications and subjective experiences from this procedure have not been described. Firstly, this study aimed to describe discomfort and potential side-effects of this method with special emphasis on symptoms related to the arthrocentesis to be used for future patient information and Ethical Committee applications. Secondly, this study aimed to evaluate the use of cone beam computed tomography (CBCT) as control of intra-capsular cannula placement.

METHODS

Twenty healthy, young adult volunteers were included. Extensive objective and subjective questionnaires were completed before and 14 days after the synovial fluid sampling. With the cannula inside the joints a CBCT was done to investigate if this procedure can be used to verify intra-capsular cannula position.

RESULTS

The subjective findings: Most subjects did experience mild pain or discomfort post-operatively. In 12 of 20 subjects symptoms had resolved after 2 days and no subjects had symptoms for more than a week. The longer lasting symptoms were mainly transient joint sounds on mandibular movement. Objective findings: 14 days after the sampling mandibular protrusion had improved 1 mm, but all other objective measures were equal compared to baseline. CBCT showed a large variation in cannula position and no conclusions could be drawn from this.

CONCLUSION

The hydroxocobalamin push-pull synovial fluid sampling may cause minor, transient symptoms. CBCT does not seem to provide any clinical benefits concerning the correct cannula position in relation to the upper joint compartment and disc.

Effect of methotrexate on the mandibular development of arthritic rabbits

INTRODUCTION

Juvenile idiopathic arthritis affecting the temporomandibular joint (TMJ) can cause severe disturbances of the mandibular development. Methotrexate (MTX) is often administered as a common used remission-inducing agent to treat this disease. The aim of this study was to investigate the effect of low dose MTX on the mandibular growth in arthritic rabbits.

SUBJECTS AND METHODS

Eighteen 10-week-old female New Zealand white rabbits were randomly assigned to three groups with six animals in each group. After being sensitized to ovalbumin (OA), the first and the second group received intra-articular injections with OA. The first group remained untreated, the second was treated by weekly injections of MTX. Cephalograms were taken from each animal at 10, 13, 16, 19, and 22 weeks of age and six mandibular distances measured.

RESULTS

All distances showed an increase between 10 and 20 per cent, whereas growth was more accentuated in the sagittal dimension. Significant differences in the overall growth could be observed between the arthritic and the control animals and less accentuated between the arthritic and the MTX animals. In contrast, existing differences between the groups were not significant during the intervals, but time had the greatest influence on mandibular growth.

CONCLUSIONS

MTX seems to have a positive impact on growth in rabbits suffering from experimental arthritis of the TMJ.

Effect of methotrexate upon antigen-induced arthritis of the rabbit temporomandibular joint

BACKGROUND

Juvenile idiopathic arthritis (JIA) of the temporomandibular joint (TMJ) can cause severe growth disturbances of the craniomandibular system. Antigen-induced arthritis (AIA) of the rabbit TMJ is simulating the inflammatory process of the TMJ in JIA. The aim of this study was to investigate the effect of a systemic administration of methotrexate (MTX) on AIA in rabbits by means of three different histological staining methods.

METHODS

After sensitization, a bilateral arthritis of the TMJ was induced by an intra-articular administration of ovalbumin in 12 New Zealand white rabbits aged 10 weeks. From the 13th week of age, six of the 12 rabbits received weekly intramuscular injections of MTX, and the other six animals remained without therapy. Another six animals served as controls, receiving no treatment or intra-articular injections at all. After euthanasia at the age of 22 weeks, all TMJs were retrieved en bloc. Sagittal sections were cut and stained with haematoxylin-eosin (H-E), Safranin-O for the evaluation of the Mankin score and tartrate-resistant acid phosphatase (TRAP).

RESULTS

In the arthritis group, a chronic inflammation with degeneration of the articular cartilage was visible. In the MTX group, the signs of cartilage degeneration were significantly reduced compared with the arthritis group. In contrast, the joints in the control group were inconspicuous. A correlation between the Mankin score and TRAP-positive cells could be found.

CONCLUSIONS

Systemic administration of MTX seems to have a positive effect upon the inflammatory process in the rabbit TMJ but fails to eliminate the sign of arthritis completely.

What does an adult rheumatologist need to know about juvenile idiopathic arthritis?

JIA is the most common chronic inflammatory arthritis in children and young people and an estimated one-third of individuals will have persistent active disease into adulthood. There are a number of key differences in the clinical manifestations, assessment and management of JIA compared with adult-onset arthritis. Transition and transfer to adult services present significant challenges for many patients, their families and health care professionals. We describe key clinical issues relevant to adult rheumatology health care teams responsible for ongoing care of these young people.

Histomorphometry in antigen-induced arthritis of the rabbit temporomandibular joint

BACKGROUND

Juvenile idiopathic arthritis (JIA) of the temporomandibular joint (TMJ) can cause severe growth disturbances of the craniomandibular system. Antigen-induced arthritis (AIA) of the rabbit TMJ is simulating the inflammatory process of the TMJ in JIA. The aim of this study was to investigate the effect of a systemic administration of the tumor necrosis factor-alpha (TNF-α) antagonist etanercept on AIA in rabbits by means of three different histological staining methods.

METHODS

After sensitization, a bilateral arthritis of the TMJ was induced and maintained by repeated intra-articular administrations of ovalbumin in 12 New Zealand white rabbits aged 10 weeks. From the 13th week of age, 6 of the 12 rabbits received weekly subcutaneous injections of etanercept, and the other 6 animals remained without therapy. Another 6 animals served as controls, receiving no treatment or intra-articular injections at all. After euthanasia at the age of 22 weeks, all TMJs were retrieved en bloc. Sagittal sections were cut and stained with hematoxylin-eosin (H-E), Safranin-O for the evaluation of the Mankin score, and tartrate-resistant acid phosphatase (TRAP).

RESULTS

In the arthritis group, a chronic inflammation with degeneration of the articular cartilage was visible. In the etanercept group, the signs of cartilage degeneration were significantly reduced but present. In contrast, the joints in the control group were inconspicuous. A strong correlation between the Mankin score and TRAP-positive cells could be found.

CONCLUSIONS

Antigen-induced arthritis causes severe damage in the TMJ of young rabbits. An improvement seems to be achievable by a systemic administration of etanercept.

Cytokines in healthy temporomandibular joint synovial fluid

Analysis of temporomandibular joint (TMJ) synovial fluid may elucidate the aetiology of temporomandibular disorders and arthritic conditions, as well as the inflammatory mechanisms involved. Knowledge about healthy synovial fluid is necessary to understand TMJ pathologies. We aimed to quantify the proinflammatory cytokines interleukin (IL)-1β, IL-2, IL-6 and tumour necrosis factor (TNF), and the anti-inflammatory cytokines IL-10 and interferon (IFN)-γ in healthy TMJ synovial fluid to serve as reference values for future studies on TMJ pathologies. Twenty healthy, young adult volunteers without temporomandibular dysfunction were included. Bilateral synovial fluid samples were obtained using the push-pull technique with hydroxocobalamin described by Alstergren in 1999. Cytokines were quantified with Luminex multiplex assays and compared using nonparametric statistical analysis. No serious adverse effects were reported. Of 40 possible samples, 14 fulfilled the strict sampling criteria and were included in the analysis. Cytokine values (reported as medians with interquartile ranges) were as follows: TNF, 23 (13-37) pg mL(-1) ; IL-2, 1·8 (0-22) pg mL(-1) ; and INF-γ, 10 (0-47) pg mL(-1) . IL-1β, IL-6 and IL-10 were almost undetectable. In addition, TNF and INF-γ cytokine levels correlated. We demonstrated that TNF was consistently detected and IFN-γ and IL-2 sporadically detected in the TMJ synovial fluid of healthy individuals using the hydroxocobalamin method and a multiplex assay. The cytokines IL-10, IL-1β and IL-6 were barely detectable in this sample of healthy TMJs.

Posteroanterior cephalometric changes in subjects with temporomandibular joint disorders

OBJECTIVES

The aim of the study was to establish the changes in posteroanterior cephalometric variables in subjects with temporomandibular joint disorders (TMDs).

METHODS

Posteroanterior cephalograms of 61 subjects (age range 16-36.6 years, standard deviation 4.88 years) were used to determine cephalometric differences. Subjects were classified according to the Research Diagnostic Criteria for Temporomandibular Joint Disorders into three groups: unilateral TMD, bilateral TMD and no TMD. 14 linear and angular measurements were assessed on the posteroanterior cephalogram. For assessing facial asymmetry, the asymmetry index for bilateral measurements was calculated between the right and the left side. In cases with unilateral TMD, the asymmetry index was calculated using the difference between the unaffected and affected side. The differences among multiple groups were analysed using the one-way analysis of variance test and Scheffé post hoc test.

RESULTS

47 subjects were females (77%) and 14 were males (23%). 19 subjects had unilateral TMDs and 16 subjects had bilateral TMDs. The asymmetry index of the distance from the horizontal plane to the antegonion was higher in subjects with unilateral TMD than in patients with bilateral or no TMD (p < 0.05). Also, the asymmetry index of the distances from the vertical plane to the condyle (p = 0.05), gonion (Go) (p = 0.0004), antegonion (p = 0.002) and chin (Ch) (p = 0.02) was higher in subjects with unilateral TMDs. The asymmetry index of the O point-Go-Go' and O point-Ch-Ch' angles differed significantly in subjects with unilateral TMDs (p < 0.05).

CONCLUSIONS

Unilateral TMDs are associated with changes in posteroanterior cephalometric measurements. The assessment of posteroanterior cephalometric variables could be used as a key factor for evaluating the presence of TMDs.

Functional changes following distraction osteogenesis treatment of asymmetric mandibular growth deviation in unilateral juvenile idiopathic arthritis: a prospective study with long-term follow-up

In juvenile idiopathic arthritis (JIA), temporomandibular joint involvement is a frequent complication leading to deficient mandibular growth. Occurring unilaterally this will give rise to mandibular and maxillary asymmetry that will affect the soft tissue and the muscles and result in complex dentofacial anomaly. In the case of severe dentofacial malformation, orthognathic surgery is the only treatment option. Vertical osseodistraction of the mandibular ramus has been suggested as a means of rectifying the mandibular growth deviation and soft-tissue problems. Whether such treatment introduces dysfunctional side effects of the temporomandibular joint and muscles has been debated and concern has been raised that treatment impairs the patient's mouth opening capacity and mandibular movement. The present study prospectively evaluated 23 patients with JIA and mandibular asymmetry caused by unilateral temporomandibular joint arthritis. The authors found a clinical effect on the asymmetry with only minor subjective complaints and limited objective changes in functional parameters.

Management of temporomandibular joint arthritis in adult rheumatology practices: a survey of adult rheumatologists

BACKGROUND

The temporomandibular (TMJ) is frequently involved in juvenile idiopathic arthritis (JIA), however little is known about management of this joint once a patient transitions from pediatric to adult care and about how rheumatologists approach TMJ involvement in rheumatoid arthritis (RA). The objective of this project was to describe adult rheumatologists' approaches to the diagnosis and treatment of TMJ arthritis in adults with JIA or RA.

FINDINGS

One hundred and eighteen rheumatologists responded to an online survey of adult rheumatologists in the United States and Canada. Respondents estimated that 1-25% of their patients with RA or JIA had TMJ arthritis. Respondents reported lower rates of MRI use (19%) and higher rates of use of splinting/functional devices (50%) than anticipated. Approximately 80% of respondents reported that their practice had a standardized approach to the evaluation of patients with TMJ arthritis. The most commonly used medical therapies were non-steroid anti-inflammatory drugs, anti-tumor necrosis factor alpha medications, and methotrexate.

CONCLUSIONS

Despite the majority of respondents stating that their practices had a standardized approach to the diagnosis and treatment of TMJ disease, there nevertheless appeared to be a range of practices reported. Standardizing the evaluation and treatment of TMJ arthritis across practices may benefit both adult and pediatric patients.