Managing Patients with Juvenile Idiopathic Arthritis and … · 2018-05-01 · • TERMINOLOGY...
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Transcript of Managing Patients with Juvenile Idiopathic Arthritis and … · 2018-05-01 · • TERMINOLOGY...
01-05-2018
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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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
NOTHING TO DECLAIRE
THOMAS KLIT PEDERSEN, DDS, Ph.d.
PROFESSOR in the field of growth-conditioned deformities of the jaws
CONSULTANT ORTHODONTIST
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
TMJ INFLAMMATION
and
DENTOFACIAL GROWTH / DEVELOPMENT
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
Low posterior face height
Retro- or micrognathic
Asymmetry
Deformed mandibular morphology
Skeletal open bite
Proclined upper-lower incisors
01-05-2018
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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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 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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
TMJ EVOLUTION – PHYLOGENETIC
DEVELOPMENT
SQUAMOSAL BONE=
TEMPORAL BONE
DENTARY BONE=
MANDIBLE
QUADRATE BONE=
INCUS
ARTICUALAR BONE=
MALLUS
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
LESS SUSCEPTIBLE TO AGING
LATE MATURATION
30 y6 y
TMJ CARTILAGE
FIBROCARTILAGE VS HYALINE
01-05-2018
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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
HIGH DEGREE OF BIOLOGICAL ACTIVITY
POTENTIAL FOR METABOLIC DISTURBANCES
HIGH ABILITY FOR REPAIR AND FUNCTIONAL ADAPTATION
TMJ CARTILAGE
FIBROCARTILAGE VS HYALINE
Remodeling due to compression
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
Osteoclast
Bone
New
bone
Osteoblast
RANKL
OPG
TRIAD OF RANKL/RANK/OPGRANKL MEDIATED OSTEOCLASTOGENESIS
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
Osteoclast
Bone
New
bone
RANKL/OPG
RANKL/OPG RATIO INFLUENCES THE ACTIVITY
OF BONE RESORPTION/FORMATION
RANKL/OPG
Osteoblast
TRIAD OF RANKL/RANK/OPGRANKL MEDIATED OSTEOCLASTOGENESIS
01-05-2018
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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
Osteoclast
Bone
New
bone
RANKL/OPG
RANKL
TNF-α, IL-1, IL-6
TNF-α, IL-1, IL-6 STIMULATES:
OSTEOCLAST ACTIVITY
RANKL PRODUCTION
TRIAD OF RANKL/RANK/OPGRANKL MEDIATED OSTEOCLASTOGENESIS
OSTEOCLASTOGENIC CYTOKINES IN TMJ ARTHRITIS
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
TNF IN TMJ SYNOVIAL FLUID
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
TNF IN TMJ SYNOVIAL FLUID
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
TERMINOLOGY – DEFINITIONS
CLASSIFICATION – DIAGNOSIS
DIAGNOSIS OF THE TMJ
and
GENERAL DIAGNOSIS
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
01-05-2018
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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
TMD CLASSIFICATIONI TEMPOROMANDIBULAR JOINT DISORDERS
1. JOINT PAIN
2. JOINT DISORDERS
3. JOINT DISEASES
4. FRACTURES
5. CONGENITAL/DEVELOPMENTAL DISORDERS
Schiffman E. et al J Oral Facial Pain Headache 2014
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
I. TEMPOROMANDIBULAR JOINT 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
Schiffman E. et al J Oral Facial Pain Headache 2014
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
I. TEMPOROMANDIBULAR JOINT DISORDERS
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
Schiffman E. et al J Oral Facial Pain Headache 2014
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
• FUNCTIONAL INABILITY
• PAIN
• DEGENERATIVE CHANGES OF
CONDYLE, FOSSA, TUBERCULUM
• NO INFLAMMATION
• AGE RELATED
• FUNCTIONAL INABILITY
• PATHOLOGIC DEGENERATIVE
CONDITION
• UNKNOWN ORIGIN
• BONY, CONDYLAR DEFORMATION
• LOW INFLAMMATORY
• FUNCTIONAL INABILITY
• PAIN
• DISEASE WITHOUT DEFINITION
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
OAs
ICRJIA
OA
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
OAs
ICRJIA
OA
01-05-2018
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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
OAsICR
JIA
OA
ICR: AN EARLY FORM OF JUVENILE OA
OCCURS UNI- AND BILATERAL
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
OAsICR
JIA
OA
ICR: A SYNDROMIC FORM OF OA
SPECIFIC GENETIC BACKGROUND
IN COMBINATION WITH REPETITIVE
TRAUMA AND POSSIBLE
HORMONAL INTERACTIONS
OCCURS BILATERAL
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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%
01-05-2018
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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
• 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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
TMJ INVOLVEMENT IN JIA
TMJ ARTHRITIS 75-85% TMJ ANOMALY 60-70%
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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%
01-05-2018
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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018 DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
DIAGNOSIS5 RECOMMENDATIONS FOR ASSESSING TMJ INVOLVMENT IN JIA
2. The patient should be asked about
the presence of orofacial symptoms:
– Location
– Intensity
– Frequency
– Character
– Situations in which the symptoms occur
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
DIAGNOSIS5 RECOMMENDATIONS FOR ASSESSING TMJ INVOLVMENT IN JIA
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
DIAGNOSIS5 RECOMMENDATIONS FOR ASSESSING TMJ INVOLVMENT IN JIA
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
DIAGNOSIS5 RECOMMENDATIONS FOR ASSESSING TMJ INVOLVMENT IN JIA
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
JIA + TMJ INVOLVEMENT – TMJ SYMPTOMS/DYSFUNCTION
TMJ ARTHRITIS TMJ DEFORMITY DENTOFACIAL ANOMALY
ASSESSMENT OF GROWTH
STAGE AND MATURITY
3ORTHOPEDIC/
ORTHODONTIC TX
4DISTRACTION
OSTEOGENESISORTHOGNATHIC
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
• 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
euroTMjointPRILIMINARY RECOMMENDATIONS FOR JIA – DENTOFACIAL ANOMALIES
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
euroTMjointPRILIMINARY RECOMMENDATIONS FOR JIA – DENTOFACIAL ANOMALIES
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
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
euroTMjointPRILIMINARY RECOMMENDATIONS FOR JIA – DENTOFACIAL ANOMALIES
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)
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
8968U
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018 DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018 DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
Stoustrup P, Küseler, A, Kristensen KD, Herlin T, Pedersen TK. Eur J Orthod 2011 Oct 3
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
González M, Pedersen TK, Dalstra M, Herlin T, Verna C 2016
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
González M, Pedersen TK, Dalstra M, Herlin T, Verna C
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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018 DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018 DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
JIA + TMJ INVOLVEMENT – LOW ACTIVE ARTHRITIS PHASE
DENTOFACIAL ANOMALY
ASSESSMENT OF GROWTH
STAGE AND MATURITY
ORTHOPEDIC TX DISTRACTION
OSTEOGENESISORTHOGNATHIC
SURGERYIMPROVEMENT
ORTHODONTIC TX
NO IMPROVEMENT
ORTHOPEDIC TX
REEVALUATION
REEVALUATION
ORTHODONTIC TX
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DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
FROM MALOCCLUSION TO OCCLUSION
1569
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
1398
FROM OCCLUSION TO DISOCCLUSION
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018 DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018
DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018 DEPT OF OMFS AARHUS UNIVERSITY HOSPITAL – SECTION OF ORTHODONTICS AARHUS UNIVERSITY 2018