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Juvenile idiopathic arthritis of the temporomandibular joint - no longer the forgotten joint. Br J Oral Maxillofac Surg 2021; 60:247-256. [PMID: 35249742 DOI: 10.1016/j.bjoms.2021.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/25/2021] [Indexed: 11/22/2022]
Abstract
Juvenile idiopathic arthritis (JIA) of the temporomandibular joint (TMJ) is common in children, with an increasing awareness of the condition in all healthcare professionals. TMJ involvement presents a challenge in both diagnosis and treatment, as late presentation can still occur as the disease often develops asymptomatically. This can result in facial deformity and/or functional difficulties including obstructive sleep apnoea. Early diagnosis is therefore essential, requiring a high index of clinical suspicion coupled with the judicious use of gadolinium contrast magnetic resonance imaging (MRI). Long-term management is best provided by a multidisciplinary team as patients often need a combination of pharmacological management, surgical interventions, orthodontics, and psychological support. End stage deformity can be treated by different surgical options, each with their own risks and benefits, however recently there is increasing recognition for the role of total alloplastic TMJ replacement. This review focuses on the diagnosis and management of TMJ arthritis and aims to highlight the important role of maxillofacial surgeons in JIA treatment.
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Frid P, Augdal TA, Larheim TA, Halbig J, Rypdal V, Songstad NT, Rosén A, Tylleskär KB, Berstad JR, Flatø B, Stoustrup P, Rosendahl K, Kirkhus E, Nordal E. Efficacy and safety of intraarticular corticosteroid injections in adolescents with juvenile idiopathic arthritis in the temporomandibular joint: a Norwegian 2-year prospective multicenter pilot study. Pediatr Rheumatol Online J 2020; 18:75. [PMID: 32998740 PMCID: PMC7528594 DOI: 10.1186/s12969-020-00464-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/03/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Intraarticular corticosteroids (IACs) have been used to treat temporomandibular joint (TMJ) arthritis. However, prospective clinical studies with magnetic resonance imaging (MRI) scoring are lacking. The aim of this study was to examine efficacy and safety of a single IAC in the TMJ in adolescents with juvenile idiopathic arthritis (JIA) in a clinical setting. METHODS In this Norwegian prospective multicenter pilot study 15 patients with JIA (mostly persistent oligoarthritis or RF negative polyarthritis categories) and a clinically and MRI-verified diagnosis of TMJ arthritis were treated with IACs and followed for 2 years. Demographics, systemic medication, general disease activity and outcome measures were recorded including a pain-index score and maximal incisal opening (MIO). Inflammation and bone damage scores were assessed, using two recently published MRI scoring systems with masked radiological evaluation. RESULTS Among the 15 patients, 13 received a single IAC (5 bilateral), and 2 repeated IACs once unilaterally. Thus, the total number of IACs was 22. Median age was 15 years and the majority had an age not thought of as critical regarding mandibular growth retardation due to steroid injection. During the 2-year observation period systemic medication with disease modifying antirheumatic drugs (DMARDs) including biologics was initiated or adjusted in 10/15 (67%) patients. At the 2-months study visit after injection we observed a minimal improvement in MIO from median 44 (1st, 3rd quartiles; 36, 48) mm to 45 (43, 47) mm, p = 0.045 and decreased MRI mean additive inflammatory score from 4.4 ± 1.8 standard deviations (SD) to 3.4 ± 2.0, p = 0.040. From baseline to the 2-months follow-up pain improved in 6/11 patients but pain scores were not significantly improved. MRI-assessed damage increased in two patients with repeated IACs, and decreased in 3 patients but most of the patients were stable over the 2-year follow-up. Intra-rater repeatability of the MRI scoring system domains varied from poor to excellent. CONCLUSIONS In this pilot study of predominately single IACs to the TMJ in combination with systemic treatment we observed improvement in MRI-assessed inflammation, mostly stable condylar bone conditions and minimal clinical improvement in adolescents with JIA and TMJ arthritis. No severe side effects were seen.
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Affiliation(s)
- Paula Frid
- Department of Otorhinolaryngology, Division of Oral and Maxillofacial Surgery, University Hospital North Norway, Tromsø, Norway.
- Public Dental Service Competence Centre of North Norway, Tromsø, Norway.
- Pediatric Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.
| | - Thomas A Augdal
- Pediatric Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
- Section for Pediatric Radiology, Department of Radiology, University Hospital of North Norway, Tromsø, Norway
| | - Tore A Larheim
- Department of Clinical Dentistry, UiT The Arctic University of Norway, Tromsø, Norway
| | - Josefine Halbig
- Public Dental Service Competence Centre of North Norway, Tromsø, Norway
- Pediatric Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Veronika Rypdal
- Pediatric Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
- Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Nils Thomas Songstad
- Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Annika Rosén
- Department of Clinical Dentistry, University of Bergen, Bergen, Norway
- Department of Oral and Maxillofacial Surgery, Haukeland University Hospital, Bergen, Norway
| | - Karin B Tylleskär
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Johanna Rykke Berstad
- Department of ENT and Oral and Maxillofacial Surgery, Oslo University Hospital, Oslo, Norway
| | - Berit Flatø
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Peter Stoustrup
- Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Karen Rosendahl
- Pediatric Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
- Section for Pediatric Radiology, Department of Radiology, University Hospital of North Norway, Tromsø, Norway
| | - Eva Kirkhus
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Ellen Nordal
- Pediatric Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
- Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway
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Brown Z, Rushing DC, Perez DE. Alloplastic Temporomandibular Joint Reconstruction for Patients With Juvenile Idiopathic Arthritis. J Oral Maxillofac Surg 2020; 78:1492-1498. [PMID: 32540323 DOI: 10.1016/j.joms.2020.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/06/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE The purpose of this study was to assess the efficacy of alloplastic temporomandibular joint (TMJ) total joint replacement (TJR) in patients with juvenile idiopathic arthritis (JIA). MATERIALS AND METHODS All patients with a formal diagnosis of JIA requiring a TMJ patient-specific TJR between 2010 and 2018 at The University of Texas-Health at San Antonio were retrospectively analyzed. To be included, patients must have had a formal diagnosis of JIA, complete records, and TMJ reconstruction with the TMJ Concepts patient-specific total joint prosthesis (TMJ Concepts, Ventura, CA). Clinical data acquisition was required at a minimum of 12 months after surgery (longest follow-up [LFU]). Subjective and objective analyses were performed using a 10-point visual analog scale at the preoperative and LFU time points. Surgical data at the perioperative and LFU time points were recorded for comparison. RESULTS Twenty patients with JIA met the inclusion criteria. The mean visual analog scale measurements for facial pain, TMJ pain, jaw function, diet, and disability were all significantly reduced at LFU. The maximal interincisal opening with pain was increased from 33.5 mm preoperatively to 44 mm at LFU, and the mean maximal interincisal opening without pain was increased from 31.1 mm preoperatively to 43 mm at LFU. None of the patients had complications from their TMJ TJR. CONCLUSIONS Alloplastic TMJ reconstruction is a safe and efficacious treatment option for the surgical management of end-stage TMJ disease in JIA patients.
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Affiliation(s)
- Zachary Brown
- Resident, Oral and Maxillofacial Surgery Department, The University of Texas-Health at San Antonio, San Antonio, TX
| | - Denae C Rushing
- Resident, Oral and Maxillofacial Surgery Department, The University of Texas-Health at San Antonio, San Antonio, TX
| | - Daniel E Perez
- Program Director,Oral and Maxillofacial Surgery Department, The University of Texas-Health at San Antonio, San Antonio, TX.
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Frid P, Resnick C, Abramowicz S, Stoustrup P, Nørholt SE. Surgical correction of dentofacial deformities in juvenile idiopathic arthritis: a systematic literature review. Int J Oral Maxillofac Surg 2019; 48:1032-1042. [PMID: 30704836 DOI: 10.1016/j.ijom.2019.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/19/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- P Frid
- Department of Otorhinolaryngology, Division of Oral and Maxillofacial Surgery, University Hospital North Norway and Public Dental Service Competence Centre of North Norway and Department of Clinical Medicine, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway.
| | - C Resnick
- Harvard School of Dental Medicine and Harvard Medical School, Boston, MS, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MS, USA
| | - S Abramowicz
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University School of Medicine, and Section of Dentistry/Oral and Maxillofacial Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - P Stoustrup
- Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - S E Nørholt
- Department of Oral and Maxillofacial Surgery, Aarhus University Hospital and Section of Oral Surgery and Oral Pathology, Aarhus University, Aarhus, Denmark
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