Case report

Severe Isolated Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis

We present a retrospective study to report the outcomes of total temporomandibular joint (TMJ TJR) replacement with alloplastic devices in patients suffering from systemic inflammatory arthropathies.

A total of 39 patients with a diagnosis of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PA), juvenile idiopathic rheumatoid arthritis (JIA), or systemic lupus, underwent alloplastic total joint replacement(s) (TJR) from 1999 to 2019. Maximal interincisal opening (in mm) was recorded before surgery (T0), at 1-year post-surgery (T1) and at last follow-up (T2). A visual analog scale (from 0 to 10) was used for subjective examination of pain before surgery (T0) and at last follow-up (T2). Comparisons were conducted with statistical significance set at P < .05.

Seventy-four joints were replaced in 39 patients. Thirty-two were female. The mean age was 36 years old (range 18-61) and the mean follow-up was 45.9 months (SD 49.4). The most common diagnosis was RA (n = 21), followed by JIA (n = 5) and AS (n = 5), PA (n = 4), lupus (n = 3), and mixed connective tissue disorder (n = 1). The mean pain score had fallen from 6.8 (SD 3.2) at T0 to 1.3 (SD 2.4) (P < .001) at T2. The maximal interincisal opening had improved from a mean of 22.1 mm (SD 13.3) at T0 to 34.3 mm (SD 8.5) (P < .001) at T2. One patient got persistent dysesthesia in the V3 distribution. There were no serious late complications.

Patients suffering from systemic inflammatory arthropathies involving the TMJs can be successfully treated by TJR with alloplastic devices. The long-term reduction of TMJ symptoms and functional improvement in this initial study suggest good predictability for this treatment

The purpose was to determine whether there are regional differences in temporomandibular joint (TMJ) inflammation in patients with juvenile idiopathic arthritis (JIA). This was a retrospective study of all patients with dynamic, contrast-enhanced magnetic resonance imaging through the TMJs at Massachusetts General Hospital between January 2015 and July 2016. The patient cohort included those with a history of JIA and control patients who underwent MRI for other routine clinical purposes. TMJ inflammation was quantified as the difference between post-gadolinium and pre-gadolinium articular T1 signal intensity normalized to post-gadolinium signal intensity of the longus capitis muscle. TMJ enhancement profiles were generated for the lateral, central, and medial portions of the TMJ. Regional differences in TMJ enhancement were investigated using basic descriptive statistics. Medial edge enhancement of the TMJs was highest in symptomatic JIA joints, followed by asymptomatic JIA, then control joints. Medial edge enhancement was a significant discriminator between symptomatic JIA TMJs and control joints (P = 0.0001), between symptomatic and asymptomatic JIA TMJs (P = 0.0003), and between asymptomatic JIA TMJs and controls (P = 0.0019). A shift in distribution of TMJ enhancement towards the medial edge that was seen uniquely in both asymptomatic and symptomatic JIA TMJs compared to control joints was found. This suggests a pattern of worsening medial edge inflammation with disease.

The objective of this study was to investigate the effect of temporomandibular intra-articular corticosteroid injections (IACS) on pain and mouth opening in children with juvenile idiopathic arthritis (JIA) with temporomandibular joint (TMJ) involvement.

Systematic review and meta-analysis methodology was used, beginning with a comprehensive literature search using MEDLINE, PubMed, EMBASE, Web of Science, and the Cochrane library. The population in question was pediatric patients with a JIA diagnosis and TMJ involvement; the intervention was IACS injections to treat TMJ arthritis; a strict control group was not considered necessary; the outcome was clinical signs of improvement of the TMJ arthritis based on pain and mouth opening capacity (MIO). Data on pain and MIO were extracted from the selected studies, and the methodological quality of studies was assessed according to the ROBINS-I tool. Results from the different studies were combined to calculate the pooled proportion with 95% confidence intervals (CIs) for pain resolution, and pooled mean differences with 95% CIs for improvement in MIO. Heterogeneity of the results among studies was tested using I² statistics.

The initial search yielded a total of 330 articles; 11 of these were selected for inclusion in the review. 325 participants were included from the combined studies, with the mean age of participants ranging from 5.3 to 13.6 years. Between 24 and 137 TMJs were selected for each of the studies. The pooled proportion of patients with pain resolution following IACS injection was 78% (95% CI: 59–90%), with large heterogeneity (I² = 62%). The pooled gain in MIO following IACS injection was 4.38 mm (95% CI: 2.76–6.00), also with high heterogeneity (I² = 67%).

The results suggest that in children diagnosed with JIA with TMJ involvement, IACS injections can help in reducing reported pain and improving mouth opening capacity, albeit with an important variation between studies.

To evaluate clinical outcomes in patients with autoimmune or connective tissue (CT) disease undergoing temporomandibular joint (TMJ) reconstruction.

Patients were divided into 2 groups based on type of TMJ reconstruction. Patients in group 1 (n = 9) underwent autogenous reconstruction and had a diagnosis of rheumatoid arthritis (5), lupus arthritis (1), and psoriatic arthritis (3). Patients in group 2 (n = 2l) had alloplastic reconstruction with a patient-fitted total joint prosthesis (TMJ Concepts, Ventura, CA) and had a diagnosis of rheumatoid arthritis (15), lupus (3), and psoriatic arthritis (3). Standardized clinical and radiographic examinations were performed before surgery, immediately after surgery, and at longest follow-up after surgery (T3).

Group l showed no meaningful improvement in maximal opening without pain, a decrease in lateral excursions, minimal decrease in TMJ pain, and a 32% relapse of chin projection at point B at T3. Average postsurgery follow-up time was 58 months. Postsurgical ankylosis was seen in 22% of patients. In contrast, group 2 showed a statistically meaningful decrease in subjective TMJ pain and lateral excursive movements and improvement in jaw function, diet, maximal incisal opening without pain, and only 5% showed a relapse at point B at T3. Average postsurgical follow-up in this group was 78 months.

Improved treatment outcomes were obtained with alloplastic TMJ total joint reconstruction compared with autogenous TMJ reconstruction in patients with autoimmune or CT disease.

The aim of the present investigation was to evaluate, in patients with juvenile idiopathic arthritis, the effect of lavage with or without intra-articular corticosteroid (IACS) injection on clinical temporomandibular joint (TMJ) signs and symptoms of inflammation and changes in acute inflammation as assessed using magnetic resonance imaging (MRI).

Forty-one patients (mean age, 13.6 ± 4.0 yr) with juvenile idiopathic arthritis participating in a large prospective juvenile inflammatory rheumatism cohort study (JIRcohorte) were included in this study. Clinical history, examination, and MRI were carried out at baseline and 6 months after intervention, if any. Twenty-one patients underwent lavage and IACS injection in at least 1 TMJ, 8 patients underwent lavage of at least 1 TMJ, and 12 patients were followed with no intervention. Outcomes measured were maximal mouth opening, Helkimo dysfunction index scores, pain intensity, and acute inflammation as assessed using MRI.

All groups showed a mean increase in mouth opening and mean decrease in pain intensity. The mean Helkimo clinical dysfunction score decreased for the 2 intervention groups but not for the control group. The mean Helkimo anamnestic dysfunction score decreased for the lavage with IACS group but not for the lavage-only group. The only statistically relevant difference was found for the Helkimo anamnestic dysfunction score comparing the lavage-only with the lavage with IACS group, with a more positive effect found in the lavage with IACS group. More than 50% of joints in each group showed no change at MRI examination. Joints with lavage and ICAS injection showed better improvement than joints that had lavage only or no intervention.

TMJ lavage with or without IACS injection cannot be claimed to systematically decrease pain, increase mouth opening, or resolve acute inflammation. Despite a tendency for improvement, response to this treatment is very patient dependent and can be determined by an array of other variables.