Time to Reconsider Management of the Temporomandibular Joint in Juvenile Idiopathic Arthritis

Recent Advances in Temporomandibular Joint Surgery

Temporomandibular disorders (TMDs) affect a high percentage of children and adults worldwide. Surgery may be indicated in severe or recalcitrant cases. Several recent advancements in TMD and temporomandibular joint (TMJ) surgery have elevated understanding and the ability to treat affected patients. We discuss recent advances in TMD epidemiology, juvenile idiopathic arthritis (JIA) of the TMJ, and surgical techniques and technologies. Technical advancements have been identified in TMJ arthroscopy, the treatment of TMJ subluxation and dislocation, and extended prosthetic total TMJ reconstruction (eTMJR). Overall, this review provides valuable insights into significant recent advancements in TMJ disorders and their surgical management.

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.

Controversial Aspects of Diagnostics and Therapy of Arthritis of the Temporomandibular Joint in Rheumatoid and Juvenile Idiopathic Arthritis-An Analysis of Evidence- and Consensus-Based Recommendations Based on an Interdisciplinary Guideline Project

Introduction: Due to potentially severe sequelae (impaired growth, condylar resorption, and ankylosis) early diagnosis of chronic rheumatic arthritis of the temporomandibular joint (TMJ) and timely onset of therapy are essential. Aim: Owing to very limited evidence the aim of the study was to identify and discuss controversial topics in the guideline development to promote further focused research. Methods: Through a systematic literature search, 394 out of 3771 publications were included in a German interdisciplinary guideline draft. Two workgroups (1: oral and maxillofacial surgery, 2: interdisciplinary) voted on 77 recommendations/statements, in 2 independent anonymized and blinded consensus phases (Delphi process). Results: The voting results were relatively homogenous, except for a greater proportion of abstentions amongst the interdisciplinary group (p < 0.001). Eighty-four percent of recommendations/statements were approved in the first round, 89% with strong consensus. Fourteen recommendations/statements (18.2%) required a prolonged consensus phase and further discussion. Discussion: Contrast-enhanced MRI was confirmed as the method of choice for the diagnosis of TMJ arthritis. Intraarticular corticosteroid injection is to be limited to therapy-refractory cases and single injection only. In adults, alloplastic joint replacement is preferable to autologous replacement. In children/adolescents, autologous reconstruction may be performed lacking viable alternatives. Alloplastic options are currently still considered experimental.

Temporomandibular joint involvement in children with juvenile idiopathic arthritis: A single tertiary-center experience

OBJECTIVES

To describe the clinical and laboratory characteristic, state the treatment and outcome of patients with juvenile idiopathic arthritis (JIA), and describe temporomandibular joint (TMJ) involvement as observed in a large tertiary center.

METHODS

A retrospective cross-sectional study of children diagnosed with JIA was assessed at King Abdullah Specialist Children's Hospital, Riyadh, Saudi Arabia (2015-2019), which included a descriptive analysis of children who had TMJ involvement among our study group. Subjects diagnosed with the TMJ arthritis were based either on clinical musculoskeletal examination or using contrast-enhanced MRI.

RESULTS

We reviewed 123 cases with different JIA subtypes (57% females). The most frequent subtype is the oligoarticular (36%). TMJ involvement was found in 16% (n=20/123) of the patients, of whom 45% had Polyarticular JIA. The rheumatoid factor was positive in 25%; antinuclear antibody (ANA) in 45% and none showed positivity to HLAB27. Treatment resulted in complete resolution in 95% of cases, while Micrognathia and obstructive sleep apnea were the complications reported in 5% of cases.

CONCLUSION

TMJ involvement in JIA is not uncommon. Females with polyarticular disease were more frequently affected with TMJ arthritis. Positive ANA could be a risk factor for TMJ involvement, while positive HLAB27 might have some protective effects. Early treatment for TMJ arthritis is essential to avoid possible complications.

A conceptual framework for treating jaw deformities in patients with abnormal condyles: preservation versus replacement of the glenoid fossa-disc-condyle-ramus

This article outlines a conceptual approach to the reconstruction of jaw deformities associated with abnormalities in the mandibular condyle. The authors describe a hierarchy of reconstruction, emphasizing use of the least invasive and progressing to the most complex and invasive techniques, depending on the nature and severity of the underlying deformity, prior operations, patient age, and stage of growth. Consider joint preservation orthognathic surgical correction, followed by biological techniques for replacement of the condyle, and avoid replacing a functional temporomandibular joint based only on radiographic remodeling and concerns about potential future flare-ups of disease based on anecdotal data.

Management of inflammatory temporomandibular joint collapse in children

Juvenile idiopathic arthritis is the most common pediatric rheumatologic condition.( Abramowicz et al., 2016 Jul) 2 The etiology and pathogenesis have not been fully elucidated; a combination of environmental and certain immunogenic factors is suspected. This review will provide current knowledge and concepts of diagnosis and management of children with JIA and TMJ arthritis.

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.

Is Temporomandibular Joint Arthroscopy Effective in Managing Pediatric Temporomandibular Joint Disorders in the Short- and Long-Term?

PURPOSE

Although temporomandibular joint (TMJ) arthroscopy outcomes have been well documented in the adult population, conclusive data are lacking for pediatric patients with TMJ disorders. The aim of the present study was to evaluate the early and late outcomes of TMJ arthroscopy in the pediatric population.

PATIENTS AND METHODS

We performed a retrospective analysis to evaluate the short- (1-month) and long-term (1-year) improvements in the visual analog scale (VAS) scores for pain after pediatric TMJ arthroscopy from 2008 to 2016. The arthroscopic interventions varied according to the diagnostic findings and Wilkes classification. The primary outcome variable was the magnitude of VAS score for pain (0, no pain; 100, worst pain) at 1 year postoperatively. The secondary outcome variables were the short-term for the VAS score for pain and the short- and long-term outcomes for perceived jaw dysfunction (0, normal jaw function; 100, complete jaw dysfunction), mouth opening, joint loading (contralateral joint pain when biting on the canine), joint noise, and muscle pain. Univariate, bivariate, and multivariate statistical analyses were performed with the significance level set at P < .05.

RESULTS

A total of 23 patients (37 joints), with a mean age of 14.1 years (range, 12.8 to 16.7 years) had undergone TMJ arthroscopic surgery with short- and long-term postoperative follow-up data available. The VAS scores for pain showed average improvements of 26% in the short-term (P < .0001) and 25% in the long-term (P < .0008). Perceived jaw dysfunction showed an average improvement of 23.8% in the short-term (P < .0001) and 19.2% in the long-term (P < .0008). The average mouth opening had improved by 5.4 mm in the short-term (P < .0016) and 8.2 mm in the long-term (P < .0001). Controlling for stage and diagnosis, the patients with Wilkes III showed the most benefit with statistically significant improvements in pain, jaw dysfunction, maximum interincisal opening, and joint loading pain.

CONCLUSIONS

TMJ arthroscopy could be an effective and minimally invasive form of surgical intervention for treating Wilkes II, III, and IV TMJ disorders in the pediatric population.