Average craniofacial development from 6 to 35 years of age in a mixed group of patients with juvenile idiopathic arthritis

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.

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.

Challenges in treating juvenile idiopathic arthritis

PURPOSE OF REVIEW

Juvenile idiopathic arthritis (JIA) diagnosis and classification is currently still based on clinical presentation and general laboratory tests. Some joints such as the temporomandibular joint (TMJ) and sacroiliac (SI) are hard to assess and define as actively inflamed based on clinical examination. This review addresses these difficult to assess joints and provides the latest evidence for diagnosis and treatment.

RECENT FINDINGS

Recommendations on clinical examination and radiological examination are available. Recent 2021 ACR recommendations were made for TMJ arthritis and in 2019 for sacroiliitis.

SUMMARY

New evidence to guide clinical suspicion and need for further investigations are available for these hard to assess joints. These guidelines will help healthcare providers in diagnosis and treatment assessment.

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.

Restricted upper airway dimensions in patients with dentofacial deformity from juvenile idiopathic arthritis

BACKGROUND

This retrospective, cross-sectional study aimed to assess the pharyngeal airway dimensions of patients with juvenile idiopathic arthritis (JIA) and moderate/severe JIA-related dentofacial deformity (mandibular retrognathia/micrognathia), and compare the results with JIA patients with a normal mandibular appearance and a group of non-JIA patients.

METHODS

Seventy-eight patients were retrospectively included in a 1:1:1 manner as specified below. All patients had previously been treated at the Section of Orthodontics, Aarhus University, Denmark. All had a pretreatment cone beam computed tomography (CBCT). Group 1 (JIA+); 26 JIA patients with severe arthritis-related dentofacial deformity and mandibular retrognathia/micrognathia. Group 2 (JIA-); 26 JIA patients with normal mandibular morphology/position. Group 3 (Controls); 26 non-JIA subjects. Dentofacial morphology and upper airway dimensions, excluding the nasal cavity, were assessed in a validated three-dimensional (3D) fashion. Assessment of dentofacial deformity comprised six morphometric measures. Assessment of airway dimensions comprised nine measures.

RESULTS

Five morphometric measures of dentofacial deformity were significantly deviating in the JIA+ group compared with the JIA- and control groups: Posterior mandibular height, anterior facial height, mandibular inclination, mandibular occlusal inclination, and mandibular sagittal position. Five of the airway measurements showed significant inter-group differences: JIA+ had a significantly smaller nasopharyngeal airway dimension (ad2-PNS), a smaller velopharyngeal volume, a smaller minimal cross-sectional area and a smaller minimal hydraulic diameter than JIA- and controls. No significant differences in upper airway dimensions were seen between JIA- and controls.

CONCLUSION

JIA patients with severe arthritis-related dentofacial deformity and mandibular micrognathia had significantly restricted upper airway dimensions compared with JIA patients without dentofacial deformity and controls. The restrictions of upper airway dimension seen in the JIA+ group herein were previously associated with sleep-disordered breathing in the non-JIA background population. Further studies are needed to elucidate the role of dentofacial deformity and restricted airways in the development of sleep-disordered breathing in JIA.

Temporomandibular joint involvement in children with juvenile idiopathic arthritis-Symptoms, clinical signs and radiographic findings

BACKGROUND

Although many children with juvenile idiopathic arthritis (JIA) develop arthritis and deformity of the temporomandibular joint (TMJ), many go undetected.

OBJECTIVE

This study investigates whether findings from patient history and clinical examination using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) can be used to diagnose TMJ involvement.

METHODS

As a part of the screening program, 59 consecutive JIA patients age 7-14 years underwent a clinical examination according to RDC/TMD including self-reported orofacial pain and pain related to jaw function, and cone beam computer tomography (CBCT). Data were obtained from the patient's medical charts. Patients were divided into two groups based on the presence or absence of TMJ deformities on CBCT.

RESULTS

Self-reported TMJ symptoms before inclusion were reported by 52% of children with and 18% of children without TMJ deformities on CBCT (p = .020). On a group level, the maximum unassisted (mouth) opening (MUO) with and without pain was within the normal range, but children with TMJ deformities showed a significantly smaller MUO with pain (p = .035). A diagnosis of osteoarthritis and osteoarthrosis was more prevalent in children with TMJ deformities.

CONCLUSION

Although there were few differences between children with and without radiographic TMJ deformities, self-reported previous TMJ symptoms and reduced MUO with pain could indicate the presence of TMJ involvement. However, radiographic examinations are needed to confirm TMJ involvement. Thus, this study indicates that the RDC/TMD protocol is a blunt tool when targeting TMJ involvement in JIA.

Three-dimensional volumetric evaluation of the different mandibular segments using CBCT in patients affected by juvenile idiopathic arthritis: a cross-sectional study

BACKGROUND

There is currently no information on how different mandibular segments are affected by juvenile idiopathic arthritis. The aim of this paper is to assess volumetric differences of different mandibular segments in subjects with unilateral and bilateral JIA and to compare them with non-JIA control volumes.

MATERIALS AND METHODS

Forty subjects with unilateral TMJ involvement and 48 with bilateral TMJ involvement were selected for the case group and 45 subjects with no known rheumatic comorbidities for the control group. The mandible of each subject was divided according to a validated method into different paired volumes (hemimandible, condyle, ramus and hemibody).

RESULTS

The ANOVA test revealed a statistically significant difference in all the groups for condylar and ramus volumes, and the pairwise comparison evidenced a statistically significant higher condylar and ramus volume in the control group (1444.47 mm³; 5715.44 mm³) than in the affected side in the unilateral JIA group (929.46 mm³; 4776.31 mm³) and the bilateral JIA group (1068.54 mm³; 5715.44 mm³). Moreover, there was also a higher condylar volume in the unaffected side in the unilateral JIA group (1419.39 mm³; 5566.24 mm³) than in the bilateral JIA group and the affected side in the unilateral JIA group.

CONCLUSIONS

The affected side of unilateral JIA patients showed statistically significant lower volumes in the hemimandible, in the condyle and in the ramus. The largest total mandibular volume was observed in the control group, followed by the unilateral JIA group and, lastly, by the bilateral JIA group.

Analysis of Earlier Temporomandibular Joint Disorders in JIA Patients: A Clinical Report

The aim of this study was to analyse the structural characteristics of the temporo-mandibular joint (TMJ) and the dysfunctional consequences induced by disease in subjects with juvenile idiopathic arthritis (JIA). The study was conducted in 25 patients with JIA (median age (IQR), 13.9 (10.9-15.3)) and 26 healthy controls (median age (IQR), 14.3 (11.6-17.2)) years. All enrolled patients were subjected to anamnestic evaluation, laboratory parameters, JIA subclass, and type of therapy for the disease. A clinical-gnathological evaluation, anamnestic and dysfunctional index (Ai and Di), and magnetic resonance imaging of TMJs were performed in all patients. The test group showed a significant reduction (p < 0.001) regarding the clinical findings such as maximal mouth opening, left and rightward laterotrusion and protrusion, and a significant difference in the reported symptoms (TMJ sounds, reduced mouth opening and pain), and Ai and Di (p < 0.001) compared to healthy patients. Correlation analysis showed a significant correlation between the median duration of disease and the maximum mouth opening and between visual analogue scale (VAS) score and maximum mouth opening, leftward laterotrusion, rightward laterotrusion, and protrusion. The results obtained in this study suggest that patients with JIA presented a cohort of symptoms in TMJs in comparison with healthy controls. Moreover, a careful TMJs evaluation and an early diagnosis of TMJs dysfunction and regular follow-ups are recommended in order to prevent and reduce functional and chewing problems in patients with JIA.

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.

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.

Craniofacial morphology of HIV-infected adolescents undergoing highly active antiretroviral therapy (HAART): An original research

OBJECTIVES:

To analyze the craniofacial morphology in child patients and adolescents by evaluating the skeletal cephalometric profile of the HIV infected patients in this age group and comparing them with the HIV-negative controls.

MATERIALS AND METHODS:

The present study was a planned case-control study which included 25 HIV-positive adolescent patients aged between 10 and 18 years (the study group) who were compared with 25 age- and sex-matched HIV-negative adolescent controls (the control group). All the patients had been HIV infected via a vertical transmission with positive serology confirmed in two different tests and had been kept on HAART since they were born. The diagnostic aids used for orthodontic documentation included facial photographs, digital orthopantomographs, lateral teleradiographs, and study models.

RESULTS:

With reference to the methodologies used for taking the cephalometric values, all the methods used were in strong agreement with each other for almost all the variables studied and had high intra-class correlation coefficient values except Co-A, SN.ANSPNS, and SNB which, too, had a good agreement of 60%. Nevertheless, the agreement was positive for these variables, too, since the P values obtained were found to be statistically significant (P < 0.05).

CONCLUSION:

Most of the measurements in the HIV-infected adolescents were found to be similar to the ones obtained for the HIV-negative controls, although, the study results highlighted the significance of further studies to be conducted in this regard, especially, the longitudinal study designs wherein the said variables can be studied on a follow-up basis in longitudinal studies to have an idea of the exact changes observed and their pattern in the included groups.

Limited Mandibular Movements as a Consequence of Unilateral or Asymmetrical Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis Patients

This study aimed to assess the asymmetry of the lower face and motor dysfunction of the masticatory system resulting from unilateral or asymmetrical bilateral temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA) patients. The study consisted of clinical examination and cone beam computed tomography (CBCT) of TMJs. Statistical analysis showed correlations between several factors: facial asymmetry and mandibular lateral deviation; the direction of mandibular deviation and the degree of radiological deformities in TMJs; the child's age at the time of the onset and the range of lateral movement towards the healthy or less destructed joint. In addition, there was a significant difference in ranges of lateral movements; a significantly smaller range was observed for the joint with fewer condylar abnormalities compared to the range in the opposite direction. In JIA children, among the clinical markers of unilateral or asymmetrical TMJ involvement, the asymmetry of the lower face, deviation of the mandible on opening, and an uneven range of mandibular lateral movements deserve attention. The obtained results do not show a relationship between the degree of condylar changes and the asymmetry of the lower face and the presence and degree of mandibular motor dysfunction.

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.

Oral health in children and adolescents with juvenile idiopathic arthritis - a systematic review and meta-analysis

BACKGROUND

Observational studies examining the association between oral health and juvenile idiopathic arthritis (JIA) among children and adolescents have reported inconsistent findings. The aims of this systematic review and meta-analysis were to ascertain a potential difference in oral health and oral health-related quality of life (OHRQoL) among children and adolescents with JIA and healthy peers, and to assess the association of prevalence of oral diseases/conditions, temporomandibular disorders (TMD), including temporomandibular joint (TMJ) diseases, in relation to activity and severity of JIA.

METHOD

Medline Ovid, Embase, CINAHL, SweMed+ and Cochrane Library were searched up to 25 November 2018. All articles published in English, German and Scandinavian languages focusing on children and adolescents with JIA and without JIA in relation to oral health measures, were considered. Two authors independently evaluated observational studies for inclusion. The study quality was assessed using modified Newcastle Ottawa Scale. Meta-analysis was performed for studies focusing on dental caries as an outcome.

RESULTS

Nineteen articles met the inclusion criteria, covering a range of oral diseases/conditions and OHRQoL. Eighteen studies had cross-sectional design. No mean difference of dmft/DMFT indices (decayed/missed/filled teeth) was observed between the JIA - and healthy group. None of the oral health measures including dental erosive wear, enamel defects, dental maturation and OHRQoL, indicated better oral health among children and adolescents with JIA compared to healthy group. However, periodontal conditions and TMD were more predominant among children and adolescents with JIA compared to healthy peers.

CONCLUSIONS

Based on the cross-sectional studies, periodontal diseases and TMD were found to be more frequent in children and adolescents with JIA compared to healthy peers. Furthermore, more high-quality studies with large sample size are needed before we infer any concrete conclusion regarding the association between the prevalence of oral and TMJ diseases or oral conditions in relation to activity and severity of JIA.

Standardizing the Clinical Orofacial Examination in Juvenile Idiopathic Arthritis: An Interdisciplinary, Consensus-based, Short Screening Protocol

OBJECTIVE

To develop a consensus-based, standardized, short (< 3 min) clinical examination protocol to assess the multidimensional, orofacial manifestations of juvenile idiopathic arthritis (JIA).

METHODS

The study was conducted by a multidisciplinary task force from the Temporomandibular Joint Juvenile Arthritis Working Group (TMJaw). The study used an acknowledged sequential approach involving (1) a global multidisciplinary online questionnaire study, (2) a systematic literature review and consensus meetings to identify items for inclusion, (3) pilot testing of included items, (4) test of reliability in 22 subjects with JIA by 4 examiners, (5) test of construct validity in a case-control study involving 167 subjects, and (6) establishment of final recommendations.

RESULTS

Six items were recommended for the final examination protocol: (1) clinician-assessed pain location, (2) temporomandibular (TMJ) joint pain on palpation (open and closed mouth), (3) mandibular deviation at maximal mouth opening (≥ 3 mm), (4) maximal unassisted mouth opening capacity, (5) frontal facial symmetry, and (6) facial profile. All recommended items showed acceptable reliability and construct validity. The average mean examination time was 2 min and 42 s (SD ± 38.5 s).

CONCLUSION

A consensus-based, short clinical examination protocol was developed. The protocol takes less than 3 min to complete and provides information about orofacial symptoms, TMJ dysfunction, and dentofacial deformity. The standardized examination protocol is applicable to routine clinical care, as well as future research studies.

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.

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.

Craniofacial morphology of HIV-positive children and adolescents undergoing antiretroviral therapy: A pilot study

INTRODUCTION

In this study, we aimed to analyze craniofacial morphology by assessing the skeletal cephalometric profiles of HIV-positive patients receiving antiretroviral therapy.

METHODS

For this study, 21 HIV-positive patients aged between 6 and 17 years (study group) were selected and compared with 21 normoreactive patients (control group), paired by sex and age. The patients were also divided into 3 age ranges (6-8, 9-12, and 13-17 years) considering the pubertal growth spurt as the central event. Eighteen (linear and angular) measurements were traced on teleradiographs by using 2 methodologies. The mean values of each measurement were compared between the study and control groups by age range.

RESULTS

The majority of the measurements checked in the HIV-positive children and adolescents for the 13-to-17 year age range were diminished, but not enough to generate a statistically significant difference in craniofacial growth. Statistically significant differences (P <0.05) were found only in the inclination of the palatal plane (6-8 years) and the position of the maxilla in the anteroposterior direction (13-17 years).

CONCLUSIONS

These results led us to conclude that some cephalometric measurements of HIV-positive children and adolescents may be similar to those of normoreactive subjects.

Clinical Orofacial Examination in Juvenile Idiopathic Arthritis: International Consensus-based Recommendations for Monitoring Patients in Clinical Practice and Research Studies

OBJECTIVE

To develop international consensus-based recommendations for the orofacial examination of patients with juvenile idiopathic arthritis (JIA), for use in clinical practice and research.

METHODS

Using a sequential phased approach, a multidisciplinary task force developed and evaluated a set of recommendations for the orofacial examination of patients with JIA. Phase 1: A Delphi survey was conducted among 40 expert physicians and dentists with the aim of identifying and ranking the importance of items for inclusion. Phase 2: The task force developed consensus about the domains and items to be included in the recommendations. Phase 3: A systematic literature review was performed to assess the evidence supporting the consensus-based recommendations. Phase 4: An independent group of orofacial and JIA experts were invited to assess the content validity of the task force's recommendations.

RESULTS

Five recommendations were developed to assess the following 5 domains: medical history, orofacial symptoms, muscle and temporomandibular joint function, orofacial function, and dentofacial growth. After application of data search criteria, 56 articles were included in the systematic review. The level of evidence for the 5 recommendations was derived primarily from descriptive studies, such as cross-sectional and case-control studies.

CONCLUSION

Five recommendations are proposed for the orofacial examination of patients with JIA to improve the clinical practice and aid standardized data collection for future studies. The task force has formulated a future research program based on the proposed recommendations.

3D evaluation of mandibular skeletal changes in juvenile arthritis patients treated with a distraction splint: A retrospective follow-up

OBJECTIVE

To evaluate three-dimensional (3D) condylar and mandibular growth in patients with juvenile idiopathic arthritis (JIA) with unilateral temporomandibular joint involvement treated with a distraction splint.

MATERIALS AND METHODS

Cone-beam computed tomography (CBCT) scans were taken for 16 patients with JIA with unilateral TMJ involvement before treatment (T0) and 2 years after treatment (T1). All patients received orthopedic treatment with a distraction splint. Eleven patients without JIA who were undergoing orthodontic treatment without a functional appliance or Class II mechanics and who had taken CBCT scans before and after treatment, served as controls. Reconstructed 3D models of the mandibles at T0 and T1 were superimposed on stable structures. Intra- and intergroup growth differences in condylar and mandibular ramus modifications and growth vector direction of the mandibular ramus were evaluated.

RESULTS

In all patients with JIA there were asymmetric condylar volume, distal and vertical condylar displacement, and ramus length differences that were smaller on the affected side. Condylar displacement was more distal and less vertical in the JIA group than in the control group. A larger distal growth of the condylar head and a more medial rotation of the ramus on the affected side were found in the JIA group.

CONCLUSION

The orthopedic functional treatment for patients with JIA allows for condylar adaptation and modeling, thereby hindering, although with a widely variable response, a further worsening of the asymmetry. Unilateral affection has a possible influence on the growth of the nonaffected side.

Facial morphology in children and adolescents with juvenile idiopathic arthritis and moderate to severe temporomandibular joint involvement

INTRODUCTION

The aims of this study were to (1) assess lateral facial morphology in children and adolescents with juvenile idiopathic arthritis and moderate to severe temporomandibular joint (TMJ) involvement, (2) compare the lateral facial morphology of these subjects with and without TMJ involvement using cephalograms and 3-dimensional (3D) facial photographs, and (3) compare and correlate the results of the 3D photographic and cephalometric analyses.

METHODS

Sixty patients with juvenile idiopathic arthritis were included and grouped as follows: group 1, juvenile idiopathic arthritis patients without TMJ involvement; group 2, juvenile idiopathic arthritis patients with moderate to severe unilateral TMJ involvement; and group 3, juvenile idiopathic arthritis patients with moderate to severe bilateral TMJ involvement. Lateral cephalograms were used to assess and compare lateral facial morphologies between the groups. Lateral projections of oriented 3D photographs were superimposed on the lateral cephalograms. The results of the lateral 3D photographic analysis were correlated with those of lateral cephalometric analysis.

RESULTS

Group 3 showed the most severe growth disturbances, including more retrognathic mandible and retruded chin, steep occlusal and mandibular planes, and more hyperdivergent type (P <0.01). Group 2 showed similar growth disturbances, but to a lesser extent than did group 3. Photographic variables were significantly correlated with the soft tissue and skeletal variables of cephalograms (0.5 < r < 0.9; P <0.001).

CONCLUSIONS

Subjects with juvenile idiopathic arthritis and unilateral or bilateral moderate to severe TMJ involvement had significant growth disturbances. Early intervention is recommended for these patients to prevent unfavorable facial development. Furthermore, with proper orientation, 3D photographs can be used as an alternative to conventional lateral cephalograms and 2-dimensional photographs.

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.

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.

A cohort study of patients with juvenile idiopathic arthritis and arthritis of the temporomandibular joint: outcome of arthrocentesis with and without the use of steroids

The purpose of this study was to evaluate the effects of intra-articular temporomandibular joint (TMJ) treatment in patients with juvenile idiopathic arthritis (JIA). The inclusion criteria were met by 21 patients (38 joints). Joints were randomly selected for either arthrocentesis alone (n=17) or arthrocentesis with the additional use of triamcinolone hexacetonide (n=21) using a closed single-needle system. Measurements of pain and function were performed at baseline and at follow-up after 3 and 8 months. Pain on opening and lateral excursion improved significantly after injections. Pain decreased significantly from baseline to first and second control on a visual analogue scale (VAS) for overall pain (49-18-8) and overall function (41-19-4). Significant improvement was recorded for pain on palpation of muscles and joints. There was no statistically significant difference between the treatment modalities, with or without glucocorticoid injection. Arthrocentesis in the TMJ treatment of patients with JIA may be beneficial and steroids had no additional effect. Further studies are needed to evaluate the long-term effects on the TMJ structures and on condylar growth from arthrocentesis and intra-articular steroid injections.

Intra-articular steroid injection for temporomandibular joint arthritis in juvenile idiopathic arthritis: A systematic review on efficacy and safety

OBJECTIVE

To determine the current level of evidence for the use of intra-articular corticosteroid injections (IACI) against temporomandibular joint (TMJ) arthritis in patients with juvenile idiopathic arthritis (JIA) with a particular focus on clinical and radiological improvements and safety profile.

METHODS

A comprehensive electronic search strategy was performed in all major medical databases in February 2012. Studies were selected independently by two reviewers in accordance with a pre-specified protocol and a risk of bias assessment for all included studies.

RESULTS

Ninety-four unique citations were identified of which seven remained after the inclusion criteria were applied and all of these were assessed to have a high risk of bias. The current limited level of evidence suggests potential beneficial properties of IACI in patients with TMJ arthritis-related symptoms and/or MRI-verified signs of TMJ inflammation. Currently, no scientific evidence substantiates the effect of IACI in terms of (I) improving maximal mouth opening capacity significantly, (II) reducing radiological disease progression, (III) normalising/improving mandibular growth, and (IV) increasing efficacy upon repeated injections.

CONCLUSION

The current level of evidence allows only very limited conclusions on the effect of IACI therapy in patients with TMJ arthritis. Knowledge on the long-term impact of IACI on mandibular growth is not available. Future studies designed in accordance with evidence-based standards are needed to allow a more general conclusion on efficacy and safety of this treatment modality in patients with TMJ arthritis.

Dentofacial characteristics of patients with rheumatoid arthritis

OBJECTIVES

The aims of this study are to evaluate the dentofacial morphology of patients with rheumatoid arthritis (RA) and to compare the morphological data with those of healthy age- and sex-matched control subjects.

METHODS

Twenty-seven RA patients (mean age, 45.77 ± 8.64 years) and 25 healthy subjects (mean age, 44.80 ± 8.24 years) participated in this prospective study. Clinical and functional evaluations of the RA patients were assessed. The erythrocyte sedimentation rate, C-reactive protein level, rheumatoid factor level, and anti-citrullinated peptide antibodies (ACPA) titers of RA patients were determined, and DAS28 scores were calculated. Linear and angular measurements were performed on cephalometric tracings and condylar erosion was evaluated on lateral panoramic radiographs. Statistical comparison of the two groups was performed with an independent samples t test. Pearson correlation analysis was used to assess the relationship between the clinical and laboratory parameters.

RESULTS

Based on DAS28 scores, no patient with RA was in the remission period, 3 patients had low, 23 had medium, and 1 had high disease activity. Sixteen (59.26 %) patients with RA had positive ACPA titers. Lateral cephalometric radiographs revealed statistically significant difference between the two groups for the measurement of U1-NA (millimeter; p = 0.047), U1-NA (degrees; p = 0.031), L1-NB (degrees; p = 0.030), IMPA (L1-MP; p = 0.001), interincisal angle (U1-L1; degrees; p = 0.022) and midface length (Co-A; millimeter; p = 0.033). A significant positive linear correlation was found between disease duration time and DAS28 scores (r = 0.066, p = 0.040).

CONCLUSIONS

Dentoalveolar effects of RA on dentofacial morphology are more significant than the skeletal effects. Future studies with larger sample sizes are required to evaluate the exact effects of RA on dentofacial morphology.

CLINICAL RELEVANCE

Clinicians should consider the fact that RA-associated dentoalveolar changes can be observed and may affect the orthodontic treatment process.

Juvenile idiopathic arthritis-and now?: a systematic literature review of changes in craniofacial morphology

AIM

To conduct a systematic literature review on the impact of juvenile idiopathic arthritis (JIA) on craniofacial morphology.

MATERIALS AND METHODS

Several electronic databases (PubMed, Medpilot, Web of Science, DIMDI) were systematically searched for studies that were published up to and including May 2011. In addition, a manual search of the orthodontic and rheumatologic literature was conducted, and reference lists of the selected articles were checked for relevant publications. The identified articles were independently assessed by two investigators and selected according to a three-step process (title/abstract/full text).

RESULTS

After completion of the selection procedure, 19 articles were identified possessing great heterogeneity. In most of them, no differentiated analysis of the various JIA subtypes was performed, and type-specific analyses according to mandibular joint effects were seldom. Additional factors such as patient age, disease duration, medication, previous orthodontic treatment as well as the inclusion of a control group were also highly inhomogeneous, which made a meta-analysis of the data impossible. Nevertheless, it appears as if JIA patients tend to develop a hyperdivergent vertical jaw base relationship and a skeletal Class II pattern.

CONCLUSION

Due to the heterogeneous patient samples, it is currently not possible to draw a differentiated conclusion on the influence of various types of JIA on craniofacial morphology.

Relationship between disease course in the temporomandibular joints and mandibular growth rotation in patients with juvenile idiopathic arthritis followed from childhood to adulthood

OBJECTIVE

To investigate the relationship between radiographic JIA disease course in the TMJs and mandibular growth rotation, compared with growth in healthy individuals.

METHODS

From a larger series of JIA patients followed from childhood to adulthood, 26 were included; 11 without and 15 with bilateral radiographic TMJ involvement. Joint morphology and function were assessed at baseline, 2-, 4-, 6- and 27 years follow-up. Mandibular growth rotation (anterior, posterior or none) was assessed from cephalometric evaluations at childhood and adulthood, with observations from 16 healthy individuals as controls. TMJ disease course and mandibular growth rotation were assessed independently and their relationship analysed. Non-parametric statistical methods were applied to test differences between groups.

RESULTS

In the normal TMJ group of JIA patients the joint morphology was similar at the follow-ups and all patients had good function both in childhood and in adulthood. The mandibular growth rotation was similar to that of healthy controls, i.e. predominantly in anterior direction. In the abnormal TMJ group different JIA TMJ disease courses were observed and associated with changes in the mandibular growth rotation (p = 0.007).Progressing JIA TMJ disease course was related to posterior mandibular growth rotation and improving disease course to anterior mandibular growth rotation.

CONCLUSION

A relationship was found between JIA disease course in the TMJs and mandibular growth rotation, suggesting that a favourable growth could be regained in patients with improvement in TMJ morphology and/or TMJ function. To confirm this, further research on larger patient series is needed.