Problem: Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children with a temporomandibular joint (TMJ) involvement of 11.6-80%. Patients with affected TMJs often develop pain, malocclusion, and dentofacial deformities. Multiple surgical techniques exist to restore function and esthetics to JIA patients; however, continuing TMJ degeneration, unpredictable autogenous condylar grafting, and donor site morbidity make alloplastic TMJ reconstruction a necessary consideration for management of severe TMJ-related destruction.
Materials and Methods: All the JIA patients with TMJ patient-fitted total joint replacement (TJR) between 2010-2018 at the University of Texas – Health at San Antonio were retrospectively analyzed. Twenty-five patients with JIA had TMJ TJR with or without concomitant orthognathic surgery within this time period. Inclusion criteria for use within this retrospective analysis were: 1) diagnosis of JIA, 2) end-stage TMJ disease, 3) TMJ reconstruction with TMJ Concepts (TMJ Concepts Inc., Ventura, CA, USA), 4) radiographic and clinical data at > 12 months follow-up. The average age at time of surgery was 18 years old (yo) (range, 14-23). Mean follow-up was 19 months (range, 1-92). Clinical, radiographic, and examination data were collected at preoperative, immediate postoperative, and longest follow-up (LFU) time points. Visual analog scales for facial pain, TMJ pain, jaw function, diet, and disability were documented at each time point. Maximum interincisal opening (MIO), lateral excursions, and physical examination were documented at each time point. Surgical data at the perioperative and longest follow-up time points were recorded for complications. Student’s t-tests were used to compare like groups with an alpha of < .05 for statistical significance.
Results: Thirteen patients, with appropriate clinical documentation, had a mean age of 18 yo (range, 16-23) at the time of TMJ TJR and an average LFU of 21 months (range, 12-68). Five had concomitant orthognathic surgery. The mean preoperative facial pain was reduced from 4.6 to 1.5 at the LFU (P = < .05). The mean preoperative TMJ pain was reduced from 5.9 to 0.85 at the LFU (P = < .05). The mean preoperative jaw function, with 0 being “normal” and 10 being “cannot move jaw,” was reduced from 3.9 to 0.6 at the LFU (P = < .05). The mean preoperative diet, with 0 being “no restriction” and 10 being “liquids only,” was reduced from 4.1 to 0.6 at the LFU (P = < .05). The mean disability, with 0 being “none” and 10 being “total,” was reduced from 4.4 to 0.23 at the LFU (P = < .05). Of the objective data points, the mean preoperative MIO with pain was increased from 33.5mm to 44mm at the LFU (P = < .05). The mean preoperative MIO without pain was increased from 31.1mm to 43mm at the LFU (P = < .05). No significance complications occurred.
Outcomes and Conclusion: All the JIA patients had statistically significant improvement in subjective VAS and objective measurements. All of the JIA patients had occlusal stability at a mean LFU of 19 months. Alloplastic TMJ reconstruction is a safe, stable, and efficacious treatment option for the surgical management of end-stage disease in JIA patients that suffer destruction of their TMJ.
Frid P, Resnick C, et al. Surgical correction of dentofacial deformities in juvenile idiopathic arthritis: a systematic literature review. Int J Oral Maxillofac Surg. 2019 Jan 28.
Resnick CM, Frid P, et al. An Algorithm for Management of Dentofacial Deformity Resulting From Juvenile Idiopathic Arthritis: Results of a Multinational Consensus Conference. J Oral Maxillofac Surg. 2019 Feb 21.