A Method of Treating the Patient With Postpubescent Juvenile Rheumatoid Arthritis

Abstract

Juvenile rheumatoid arthritis (JRA) is a perplexing and devastating disease for which establishment of a treatment protocol is difficult. The relatively low incidence and unknown cause of this disorder have made it difficult to establish when and how to intervene. Treatment protocols for the prepubescent patient (<12 years for girls and 14 years for boys), as well as for the adult, have been established. A protocol for postpubescence (ages 12 through 18 years) has yet to be established. This pilot study attempts to establish another treatment protocol for this particular subgroup of patients. Five girls between the ages of 14 and 18 years with common facial deformities who were given a diagnosis of juvenile rheumatoid arthritis were reconstructed by orthognathic surgery and costochondral rib grafts. All underwent surgery performed by the first author and were followed for 4 to 14 years. Patients were in disease remission at the time of surgery, and all presented with the same skeletal/dental deformity and condylar destruction. Serial cephalograms were taken immediately presurgically (T1), immediately postsurgically (T2), and at latest recall (T3). Tracings were done by the same orthodontist with the use of Quick Ceph Image Pro software (Quick Ceph Systems, San Diego, CA). Mandibular position as it related to the success of costochondral and orthognathic surgery was assessed by gnathion position relative to nasion-basion at the cranial center, as described by Rickett's facial analysis. Patient long-term follow-up lasted from 4 to 14 years and had a mean duration of 9.6 years. The average increase in anterior/posterior direction (T1 to T2) was 22.7 mm with an average relapse (T2 to T3) of 1.5 mm. Four of 5 patients had a stable Class I occlusion on follow-up, and 1 developed a 3-mm open bite postoperatively. This pilot study offers a treatment protocol for the postpubescent juvenile patient with rheumatoid arthritis (aged 12 to 18 years) that is based on a single surgery with relative postoperative stability.