Managing Patients with Juvenile Idiopathic Arthritis and … · 2018-05-01 · • TERMINOLOGY –DEFINITIONS –DIAGNOSIS • MANAGEMENT AND TREATMENT ... Asymmetry Deformed mandibular

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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018

MANAGING PATIENTS WITH JUVENILE

IDIOPATHIC ARTHRITIS AND SIMILAR TMJ

PATHOLOGY

THOMAS KLIT PEDERSEN, DDS, Ph.d.

PROFESSOR in the field of growth-conditioned deformities of the jaws

CONSULTANT ORTHODONTIST


NOTHING TO DECLAIRE

THOMAS KLIT PEDERSEN, DDS, Ph.d.

PROFESSOR in the field of growth-conditioned deformities of the jaws

CONSULTANT ORTHODONTIST


LECTURE OUTLINE

ONE OF THE MOST CHALLEGING DENTOFACIAL DEFORMITY

AND MALOCCLUSION IN ORTHODONTICS

• TMJ INFLAMMATION AND DENTOFACIAL GROWTH

DEVELOPMENT

• TERMINOLOGY – DEFINITIONS – DIAGNOSIS

• MANAGEMENT AND TREATMENT

– Recognize JIA

– Possess knowledge of the influence of the pathologic process to

the dentofacial growth and development

– Demonstrate knowledge of treatment options related to JIA


ABBREVIATIONS

• JIA JUVENILE IDIOPATHIC ARTHRITIS

• ICR IDIOPATHIC CONDYLAR RESORPTION

• OA OSTEOARTHRITIS

• OAs OSTEOARTHROSIS

• TMJ TEMPOROMANDIBULAR JOINT

• PR PEDIATRIC RHEUMATOLOGIST

• PRE PEDIATRIC RHEUMATOLOGY

EXAMINATION

• GP GENERAL PHYSICIAN

• MRIc MAGNETIC RESONANCE IMAGING + CONTRAST

• CE CLINICAL EXAMINATION


TMJ INFLAMMATION

and

DENTOFACIAL GROWTH / DEVELOPMENT


Low posterior face height

Retro- or micrognathic

Asymmetry

Deformed mandibular morphology

Skeletal open bite

Proclined upper-lower incisors

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TMJ ANOMALY:

Deformity of the

condyle

Deformity of the

tuberculum

Intra-articular

abnormal

relations

Disc degeneration

Disc displacement


DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018 DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018

55 PATIENTS – ISOLATED TMJ ARTHRITIS IN JIA

Hügle B et al, Isolated Arthritis of the Temporomandibular Joint as

the Initial Manifestation of Juvenile Idiopathic Arthritis.

J Rheumatol. 2017 Nov;44(11):1632-1635.

SUBTYPE

53 OLIGOARTHRITIS

2 PSORIATIC ARTHRITIS

33% ANA +

0% RF +

12% HLA-B27 +

6 DEVELOPED ARTHRITIS

IN OTHER JOINTS BETWEEN

0.5-17 MO’s (MEDIAN 6)

SIGNIFICANTLY LONGER

DISEASE DURATION

(47 VS 29 MO’s, P=0.001

4 HAD UVEITIS PRIOR TO

TMJ ARTHRITIS – 3 ANA +

DIAGNOSTICS MIGHT FAIL TO DISTINGUISH BETWEEN ISOLATED

TMJ ARTHRITIS/JIA AND ICR FAILURE IN OPTIMAL TX OF JIA


TMJ AND DENTOFACIAL ISSUES IN JIA

• REFRACTORY TO ANTIRHEUMATIC MEDICAL TX

• CONDYLAR GROWTH DISTURBANCE

• DENTOFACIAL GROWTH DISTURBANCE

– MALOCCLUSION

– DYSMORPHIC JAWS

• OROFACIAL PAIN AND DISORDERS

– DECREASED MOBILITY

– IRRIGULAR JOINT MOVEMENT

• FUNCTIONAL INABILITIES

– MASTICATORY

– RESPIRATORY

– MUSCULAR

• AESTHETICS


TMJ – THE UNIQUE JOINT

• “Phylogenetically, the explanation for this peculiar responsiveness to mechanical force might be found in the fact that the temporomandibular joint in mammals appeared as the result of a secondary (in a way, adaptive) joining of the squamosal and the dentary bones, along with the subsequent formation of a condylarcartilage”

Charlier J, Petrovic A, Stutzmann J, Am J Orthod 1969; 55(1):71-74

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TMJ EVOLUTION – PHYLOGENETIC

DEVELOPMENT

SQUAMOSAL BONE=

TEMPORAL BONE

DENTARY BONE=

MANDIBLE

QUADRATE BONE=

INCUS

ARTICUALAR BONE=

MALLUS


MANDIBULAR PRE-NATAL DEVELOPMENT

MANDIBEL –

INTRAMEMBRANOUS

OSSIFICATION

• MESENCHYMAL

CONDENSATION LATERAL

TO MECKELS CARTILAGE

• OSSIFICATION STARTS AT

FORAMEN MENTALE

ENVELOPES ALVEOLARIS

NERVE

CONDYLE

• CONDYLAR CARTILAGE

DEVELOPS INDEPENDENTLY

AS A SECONDARY

CARTILAGE FUSING WITH

THE MANDIBLE 12.-15. WEEK

• INTRAMEMBRANEOUS

OSSIFICATION UNTIL WEEK

15 – ENDOCHONDRAL

OSSIFICATION


SEPARATE AREA OF MESENCHYMAL CONDENSATION WEEK 8

FUSION OF THE CONDYLAR CARTILAGE WEEK 12

CONDYLE 11 WEEKS

CC: CONDYLAR CARTILAGE, P: CORONOID PROCESS, F: MANDIBULAR

FORAMEN

Velasco et al, J Anat 2009; 214:56–64


IMPORTANT GROWTH SITES

1. ENDOCHONDRAL OSSIFICATION OF THE CONDYLE

– CC GROWTH SITE + ARTICULAR SURFACE

– LOCAL GROWTH FACTORS AND FUNCTION

2. SITES OF APPOSITION – RESORPTION

– MANDIBULAR GROWTH AND DEVELOPMENT ARE THE

SUM GENETIC AND ENVIRONMENTAL CUES

MANDIBULAR POSTNATAL GROWTH


TMJ CARTILAGE

FIBROCARTILAGE VS HYALINE

• PRIMARY CARTILAGE

– BELONGS TO PRIMARY SKELETAL CARTILAGE

– TYPE II COLLAGENE

– STABLE – RESISTENT TO INACTIVITY

– INTERSTITIAL CELL PROLIFERATION OCCURS IN CHONDROCYTES

– REACTS PRIMARILY TO SYSTEMIC GROWTH STIMULI SUCH AS

HORMONES

• SECONDARY CARTILAGE

– APPEAR LATER IN EMBRYONIC DEVELOPMENT

– TYPE I COLLAGENE – ABILITY TO GENERATE TYPE II COLLAGENE

– DEGENERATES WITH INACTIVITY AND COMPRESSION

– APPOSITIONAL PROLIFERATION

– ADDITIONAL MODULATION BY LOCAL GROWTH FACTORS


LESS SUSCEPTIBLE TO AGING

LATE MATURATION

30 y6 y

TMJ CARTILAGE


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HIGH DEGREE OF BIOLOGICAL ACTIVITY

POTENTIAL FOR METABOLIC DISTURBANCES

HIGH ABILITY FOR REPAIR AND FUNCTIONAL ADAPTATION

TMJ CARTILAGE


Remodeling due to compression


ENVIRONMENT GENETICS

GROWTH – DEVELOPMENT

ENVIRONMENT:

MECHANICAL FORCES

CELLS ARE INFLUENCED BY GENES AND ENVIRONMENTAL CUES

EPIGENETICS

EPIGENETICS:

FACTORS UP- OR DOWNREGULATING GENE EXPRESSION

(i.e. GROWTH FACTORS, CYTOKINES, HORMONES)

GENETICS:

INDIVIDUAL AND

GROUP OF GENES


GENETICS

INFLAMMATION

ENVIRONMENT

EPIGENETICS

EPIGENETICS:

FACTORS UP- OR DOWNREGULATING GENE EXPRESSION

(i.e. GROWTH FACTORS, CYTOKINES, HORMONES)

GENETICS:

INDIVIDUAL AND

GROUP OF GENES

ENVIRONMENT:

MECHANICAL FORCES

INFLAMMATION INTERFERES WITH EPIGENETIC FACTORS

CONTROLLING REGULATION OF GENE EXPRESSION


TRIAD OF RANKL/RANK/OPGRANKL MEDIATED OSTEOCLASTOGENESIS

RANKL: RECEPTOR

ACTIVATOR FOR NUCLEAR

FACTOR κ B LIGAND

RANK: RECEPTOR

ACTIVATOR OF NUCLEAR

FACTOR κ B

OPG: OSTEOPROTEGERIN

or OSTEOCLASTOGENESIS

INHIBITORY FACTOR


Osteoclast

Bone

New

bone

Osteoblast

RANKL

OPG



Osteoclast

Bone

New

bone

RANKL/OPG

RANKL/OPG RATIO INFLUENCES THE ACTIVITY

OF BONE RESORPTION/FORMATION

RANKL/OPG

Osteoblast


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Osteoclast

Bone

New

bone

RANKL/OPG

RANKL

TNF-α, IL-1, IL-6

TNF-α, IL-1, IL-6 STIMULATES:

OSTEOCLAST ACTIVITY

RANKL PRODUCTION


OSTEOCLASTOGENIC CYTOKINES IN TMJ ARTHRITIS


TNF IN TMJ SYNOVIAL FLUID



Median (pg mL-1) IQR (pg mL-1) Range (pg mL-1) > 0 (%)

IL-6 0 0 0-101 7.1

IL-10 0 0 0-263 7.1

TNF 23 13-37 3.2-98 100

IL-1β 0 0 0-56 14.3

IL-2 1.8 0-22 0-45.5 71.4

IFG-γ 10.0 0-47 0-178 50

Kristensen KD, Alstergren P, Stoustrup P, Küseler A, Herlin T, Pedersen TK

Cytokines in healthy temporomandibular joint synovial fluid

Journal of Oral Rehabilitation 2014; 41: 250--256


Ahmed N, Petersson A, Catrina AI

Mustafa H, Alstergren P.

Tumor necrosis factor mediates

temporomandibular joint bone tissue

resorption in rheumatoid arthritis,

Acta Odontologica Scandinavica 2015; 72(3):232-40



TERMINOLOGY – DEFINITIONS

CLASSIFICATION – DIAGNOSIS

DIAGNOSIS OF THE TMJ

and

GENERAL DIAGNOSIS


TMD CLASSIFICATION, DC-TMD

I. TEMPOROMANDIBULAR JOINT DISORDERS

II. MASTICATORY MUSCLES DISORDERS

III. HEAD ACHE

IV. ASSOCIATED STRUCTURES

Schiffman E. et al J Oral Facial Pain Headache 2014

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TMD CLASSIFICATIONI TEMPOROMANDIBULAR JOINT DISORDERS

1. JOINT PAIN

2. JOINT DISORDERS

3. JOINT DISEASES

4. FRACTURES

5. CONGENITAL/DEVELOPMENTAL DISORDERS




1. JOINT PAIN

A. Arthralgia

B. Arthritis

2. JOINT DISORDERS

A. disc disorders

1. disc displacement with reduction

2. disc displacement with reduction with intermittent locking

3. disc displacement without reduction with limited opening

4. disc displacement without reduction without limited opening

B. hypomobility disorders other than disc disorders

1. adhesions/adherences

2. ankylosis

a. fibrous

b. osseous

C. hypermobility disorders

1. dislocations

a. subluxation

b. luxation




3. JOINT DISEASES

A. Degenerative joint disease

1. osteoarthrosis *

2. osteoarthritis *

B. Systemic arthritides *C. Condylysis/idiopathic condylar resorption *

D. Osteochondritis dissecans

E. Osteonecrosis

F. Neoplasm

G. Synovial chondromatosis

4. FRACTURES

5. CONGENITAL/DEVELOPMENTAL DISORDERS

A. Aplasia

B. Hypoplasia

C. Hyperplasia



TMJ OSTEOARTHRITIS TMJ OSTEOARTHROSIS

TMJ ARTHRITIS IN JIA TMJ ICR

• AUTO-IMMUNE CONDITION IN CHILDREN

• INFLAMMATION OF THE SYNOVIAL

TISSUE

• JOINT DEFORMITIES

• GROWTH DISTURBANCES

• HIGH RISK FOR TMJ INVOLVEMENT

• HIGH INFLAMMATORY

• FUNCTIONAL INABILITY

• PAIN

• CARTILAGE DEGENERATION

• ACCOMPANYING PERIARTICULAR BONE

RESPONSE

• PRIMARILY NON – INFLAMMATORY

• SECONDARY LOW INFLAMMATORY

• MECHANICAL STRESS VULNERABILITY

• LOW RESISTANCE WITHSTANDING AND

REPAIR


• PAIN

• DEGENERATIVE CHANGES OF

CONDYLE, FOSSA, TUBERCULUM

• NO INFLAMMATION

• AGE RELATED


• PATHOLOGIC DEGENERATIVE

CONDITION

• UNKNOWN ORIGIN

• BONY, CONDYLAR DEFORMATION

• LOW INFLAMMATORY


• PAIN

• DISEASE WITHOUT DEFINITION


OAs

ICRJIA

OA


OAs

ICRJIA

OA

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OAsICR

JIA

OA

ICR: AN EARLY FORM OF JUVENILE OA

OCCURS UNI- AND BILATERAL


OAsICR

JIA

OA

ICR: A SYNDROMIC FORM OF OA

SPECIFIC GENETIC BACKGROUND

IN COMBINATION WITH REPETITIVE

TRAUMA AND POSSIBLE

HORMONAL INTERACTIONS

OCCURS BILATERAL


OAsICR

JIA

OA

A CERTAIN OVERLAP EXISTS WHERE

THE DIAGNOSIS BECOMES UNCERTAIN

ICR IS NOT A WELL-DEFINED DISEASE

MOST PATIENTS HAS OROFACIAL

SIGNS AND SYMPTOMS Kristensen et al, Am J OrthodDentofacial Orthop

2017;152:214-23


OAs

ADAPTED/

REPAIRED

STAGE OF OA

ICRJIA

OA

ISOLAT-

ED TMJ

ARTHRI-

TIS JIA

JIA IS A GENERAL DIAGNOSIS WITH

HIGH RISK OF TMJ INVOLVEMENT

COLLABORATION BETWEEN PEDIATRIC RHEUMATOLOGISTS,

ORTHODONTISTS, OMF SURGEONS, OROFACIAL PAIN SPECIALISTS


JUVENILE IDIOPATHIC ARTHRITIS, JIA

• MOST COMMON AUTOIMMUNE DISEASE IN CHILDHOOD Berntson L et al. J Rheumatol 2003;30(10):2275–2282

• 150 CHILDREN/100.000 GLOBAL Ravelli A, Martini A. Juvenile Idiopathic

Arthritis. Lancet 2007;369:767-78.

• 7 CATEGORIES WITH DIFFERENT PROGNOSIS AND CLINIC

ACCORDING TO ILAR CLASSIFICATION Petty et al. J Rheumatol

2004;31(2):390-2

• ARTHRITIS BEFORE THE AGE OF 16 OF UNKNOWN

ETIOLOGY PERSISTING > 6 WEEKS; OTHER KNOWN

CONDITIONS EXCLUDED Petty et al. J Rheumatol 2004;31(2):390-2

• DIAGNOSTIC CRITERIA ARE CLINICAL


JUVENILE IDIOPATHIC ARTHRITISCATEGORIES (Petty et al, J Rheumatol 2004;31(2):390-2.)

1. SYSTEMIC 4-17% fever, rash,

lymph node, hepato- splenomegali,

serositis, TMJ: 43% (Pedersen et al, J

Rheumatol 2001; 28(9): 2109-15)

2. OLIGOARTICULAR 27-56%, TMJ: 45%

1. PERSISTENT 1-4 joints

throughout disease course

2. EXTENDED 1-4 joints cumultative

> 5 joints

3. POLY RF÷ 11-28% 5 ore more

joints, rheumafactor negative, TMJ:

66%

4. POLY RF+ 2-7% 5 or more joints

rheumafactor positive

5. PSORIATIC 2-11% arthritis+psoriasis or arthritis + 1)

dactylitis 2)nail abnormalities 3)family

history of psoriasis

6. ENTHESITIS RELATED 3-11%HLA-B27, sacro-iliac joint

7. UNDIFFERENTIATED

ARTHRITIS 11-21%

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• DIAGNOSIS IS CLINICAL

• SEROLOGY

– SUPPORTS THE DIAGNOSIS AND SUBTYPE

– ASSESS ACTIVITY

– PROGNOSTIC

• ANA 40% CORRELATES TO UVEITIS, FEMALES,

YOUNG AGE AT DIAGNOSIS

• RF 2-7% LATE ONSET, POOR PROGNOSIS

• HLA-B27 SACRO-ILIAC JOINT ARTHRITIS

• TMJ ARTHRITIS PRESENTS A PARTICULAR

ISSUE IN JIA

JUVENILE IDIOPATHIC ARTHRITISDIAGNOSIS


euroTMjointNAME IS ABOUT TO BE CHANGED LIKELY TO BE ”TMJaw”

TEMPOROMANDIBULAR JOINT JUVENILE ARTHRITIS WORKGROUP

AN INTERNATIONAL RESEARCH NET-WORK ORGANIZATION

GERMANY, EU SWITZERLAND, EU

DENMARK, EU ALABAMA, USA

ITALY, EU BOSTON, USA

FRANCE, EU ATLANTA, USA

NORWAY, EU CALGARY, CA

LATVIA, EU TORONTO, CA

FINLAND, EU

Oslo Meeting April 19. – 21. 2018

Bernd Koos, Hannah Finke, Krisjane Zane, Josefine Halbig, Paula Frid, Ellen Nordal,

Kasper Dahl Kristensen, Carlalberta Verna, Joachim Weber, Severine Guillaume Czitrom,

Chung Kau, Gregory Antonarakis, Thomas Klit Pedersen, Peter Stoustrup, Annelise

Küseler, Troels Herlin, Mia Glerup,Sven Erik Nørholt, Marinka Tvilt, Cory Resnick, Shelley

Abramowicz, Lynn Spiegel, Linda Arvidsson, Tore Larheim, Bjørn Øgaard, Timo

Peltomäki, Christian Kellenberger, Iveta Janovska, Sven Kreiborg, Eva Kirkhus, Traudel

Saurenmann, Mirkamal Tolend


TERMINOLOGY FOR OROFACIAL CONDITIONS IN JIA

ON BEHALF OF THE euroTMjoint RESEARCH NET-WORK

1. TMJ ARTHRITIS:– ACTIVE INFLAMMATION IN THE TMJ

2. TMJ INVOLVEMENT:– ABNORMALITIES CAUSED BY TMJ ARTHRITIS

3. TMJ SYMPTOMS:– PATIENT OR PARENTS REPORTED CONDITIONS RELATED

TO TMJ ARTHRITIS OR INVOLVEMENT

4. TMJ DYSFUNCTION:– PHYSICIAN-REPORTED FUNCTIONAL EXAMINATION

ABNORMALITIES RELATED TO TMJ ARTHRITIS OR

INVOLVEMENT

Stoustrup et al, in preparation


METHOD OF ASSESSMENTON BEHALF OF THE euroTMjoint RESEARCH NET-WORK

1. TMJ ARTHRITIS:

– MRI CONTRAST ENHANCED

2. TMJ INVOLVEMENT:

– MRI, CBCT, CLINICAL EXAMINATION

3. TMJ SYMPTOMS:

– PATIENT REPORTED

4. TMJ DYSFUNCTION:

– CLINICAL EXAMINATION

Stoustrup et al, in preparation


TMJ INVOLVEMENT IN JIA

TMJ ARTHRITIS 75-85% TMJ ANOMALY 60-70%


TMJ INVOLVEMENT IN JIA

TMJ DYSFUNCTION

53%

• OROFACIAL PAIN

• FREQUENCY

• INTENSITY

• LOCATION

• CLICK/LOCKING

• DECREASED MOBILITY

• INABILITY CHEWING

TMJ SYMPTOMS

55% PAIN + FUNCTIONAL DISABILITY

DENTOFACIAL ANOMALIES 35%

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DIAGNOSIS5 RECOMMENDATIONS FOR ASSESSING TMJ INVOLVMENT IN JIA

1. The medical history should include:

– Sex

– Age at time of examination

– JIA category

– Disease duration

– Previous/current medications

– Previous/current orthodontic treatment

– Disease activity



2. The patient should be asked about

the presence of orofacial symptoms:

– Location

– Intensity

– Frequency

– Character

– Situations in which the symptoms occur



3. The clinical examination of orofacial

signs should include

– palpation of the temporomandibular joint

(lateral pole)

– masticatory muscles (masseter and

temporal muscles)

– assessment of pain on palpation

– TMJ pain on mandibular movement

– assessment of joint sounds



4. The clinical examination of orofacial

function should include assessment

of temporomandibular joint function:

– Maximal mouth opening

– Mouth opening deviation

– Protrusion – laterotrusion

– Condylar translation during opening



5. The clinical examination should

include assessment of facial

morphology and symmetry:

– mandibular sagittal position (convexity

of the facial profile)

– lower face asymmetry in the frontal

plane

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ALGORITHM FOR MANAGING


JIA + TMJ INVOLVEMENT – NO TMJ SYMPTOMS/DYSFUNCTION

TMJ ARTHRITIS TMJ DEFORMITY DENTOFACIAL ANOMALY

SYSTEMIC TX

FOLLOW-UP ON

DENTOFACIAL

DEVELOPMENT

ASSESSMENT OF GROWTH

STAGE AND MATURITY

3ORTHOPEDIC/

ORTHODONTIC TX

4DISTRACTION

OSTEOGENESISORTHOGNATHIC

SURGERY

INDIVIDUAL TREATMENT PLAN

FOLLOW-UP ON

DENTOFACIAL

DEVELOPMENT

CONSIDER

ORTHOPEDIC TX

1MRIc CBCT, CE, MRIc 2CBCT, CE

1Tolend et al, Arthritis Care Res 2018;70(5):758-767 and Kellenberger et al, Pediatr Radiol 2018; 48(3):411-4262Stoustrup et al, PLOSone, 2018; 13(3)3Pedersen et al, Euro J Orthod 1995; 17:385-394 and Stoustrup et al, Eur J Orthod. 2013 Apr;35(2):191-84Pedersen TK, Nørholt SE, Sem in Orthod 2011 (17): 235-245


JIA + TMJ INVOLVEMENT – TMJ SYMPTOMS/DYSFUNCTION

TMJ ARTHRITIS TMJ DEFORMITY DENTOFACIAL ANOMALY


STAGE AND MATURITY

3ORTHOPEDIC/

ORTHODONTIC TX

4DISTRACTION


SURGERY

INDIVIDUAL TREATMENT PLAN

1MRIc CBCT, CE, MRIc 2CBCT, CE

SYSTEMIC TX

PHYSICAL THERAPY5DENTAL

STABILIZATION

SPLINT

(ORTHOPEDIC TX)

TMJ LAVAGE6IA. TMJ STEROID

(GROWTH STAGE

ASSESSMENT!)

PHYSICAL THERAPY

DENTAL

STABILIZATION

SPLINT

(ORTHOPEDIC TX)

TMJ LAVAGE

5Stoustrup et al, Scand J Rheumatol. 2014;43(2):137-456Stoustrup et al, Sem in Arthritis Rheum 2013; 43(1):63-70 and Ringold et al, J Rheumatol 2008;35:1157-64

and Lochbühler et al, J Rheumatol 2015;42:1514-22


euroTMjointPRILIMINARY RECOMMENDATIONS FOR JIA – DENTOFACIAL ANOMALIES

• Orthopedic/functional treatment is recommended in JIA

patients with TMJ symptoms and dysfunctions

• Orthopedic/functional treatment is recommended in JIA

patients with TMJ involvement in order to support normal

growth

• TMJ involvement implies development of a dentofacial

deformity.

• Orthopedic/functional treatment in JIA patients is a highly

specialized treatment

• Orthopedic/functional treatment in JIA patients is a medical

requirement


TMJ AND DENTOFACIAL ISSUES RELATED TO

EARLY TMJ PATHOLOGY

• CONDYLAR GROWTH DISTURBANCE/DEFORMATION

• DENTOFACIAL GROWTH DISTURBANCE

– MALOCCLUSION

– DYSMORPHIC JAWS

• PAIN

• JOINT DISORDERS

– DECREASED MOBILITY

– IRREGULAR JOINT MOVEMENTS

• FUNCTIONAL INABILITIES

– MASTICATORY

– RESPIRATORY

– MUSCULAR – SKELETAL IMBALANCE

• AESTHETICS

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• Treatment should be preceded by assessment of:

– Growth stage and maturity

– Dental stage

– Growth type

• During orthopedic/functional, it is recommended, in JIA

patients with TMJ involvement, clinically to reevaluate

status currently using at least the euroTMjoint

recommendations and additionally with respect to possible

TMD

• Orthopedic/functional treatment in JIA patients should be

reviewed in case of treatment default, latest after 6 months



ORTHOPEDIC/FUNCTIONAL TREATMENT

DENTAL STABILIZATION SPLINT

DISTRACTION SPLINT

ACTIVATOR – TWIN-BLOCK

APPLIANCE USE DEPENDENT ON:

• DISEASE ACTIVITY

• TYPE OF CURRENT

MEDICATION

• GROWTH TYPE

• GENDER

• AGE AND DENTAL STAGE

DESIGNED WITH RESPECT TO:

• STABILIZATION OF OCCLUSION ON

POSTERIOR TEETH

• CONSOLIDATE THE MIDLINE

• CONSTRUCTION BITE: REST POSITION

– NO TEETH IN CONTACT



The aims of the appliance in the active arthritis phase are to:

– Positioning the condyles and mandible in an orthopedic

stable position

– Stabilize the joint

– Consolidate the midline

– Pain relief

– Joint collapse prevention – keeping the joint space

– Avoid dental compensations



The aims of the appliance in the low active arthritis phase

according to clinical assessment and MRI are to:

– Support normal growth with respect to any malocclusion

– Improve existing dentofacial deformity and asymmetry

– Attempting to prevent development of deformity and

asymmetry

– Avoid dental compensations

The orthopedic appliance should be designed with respect to:

– Stabilization of occlusion on posterior teeth

– Consolidate the midline

– Construction bite should be taken in relaxed muscular

position without teeth in contact (rest position)


8968U


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Stoustrup P, Küseler, A, Kristensen KD, Herlin T, Pedersen TK. Eur J Orthod 2011 Oct 3


González M, Pedersen TK, Dalstra M, Herlin T, Verna C 2016


González M, Pedersen TK, Dalstra M, Herlin T, Verna C

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JIA + TMJ INVOLVEMENT – LOW ACTIVE ARTHRITIS PHASE

DENTOFACIAL ANOMALY


STAGE AND MATURITY

ORTHOPEDIC TX DISTRACTION


SURGERYIMPROVEMENT

ORTHODONTIC TX

NO IMPROVEMENT

ORTHOPEDIC TX

REEVALUATION

REEVALUATION

ORTHODONTIC TX

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FROM MALOCCLUSION TO OCCLUSION

1569


1398

FROM OCCLUSION TO DISOCCLUSION



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POSTSURGICALPRESURGICAL

Managing Patients with Juvenile Idiopathic Arthritis and … · 2018-05-01 · • TERMINOLOGY –DEFINITIONS –DIAGNOSIS • MANAGEMENT AND TREATMENT ... Asymmetry Deformed mandibular

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