Mandibular Distraction Osteogenesis in 23 Patients With Juvenile Idiopathic Arthritis

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Statement of the Problem: Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease occurring before the age of 16. The temporomandibular joint is frequently involved and this can result in growth impairment of the mandible with an asymmetric growth in cases of unilateral involvement. In severe cases, conventional orthognathic surgery has a risk of relapse, and in an attempt to avoid this we have used distraction osteogenesis (DO) in a group of JIA patients. Only few publications have described the use of DO in JIA patients. Materials and Methods: Twenty-three patients with JIA underwent unilateral distraction osteogenesis. There were 14 females and 9 males. Mean age was 16 years (range 11-34 years). All patients were treated according to a standardized protocol with preoperative orthodontic planning, cephalometric analysis with calculation of distraction vector, and transfer of the vector to the surgical procedure. An occlusal splint was used full-time during distraction. Data from five examinations of symptoms and function were included in this study: T1: before distraction osteogenesis, T2: after removal of distraction device, T3: 6 months after DO, T4: 12 months after DO, and T5: the latest follow-up visit. Radiographic evaluation was performed by comparing the normal and the affected side on frontal and lateral cephalograms and orthopantomograms. Methods of Data Analysis: Data describing the functional status was analyzed by descriptive statistics. The results from the cephalometric analysis before and after treatment were compared by paired t-test by use of SPSS 18.0 for Windows. Results of Investigation: Subjective: TMJ function was good both before and after distraction osteogenesis and nearly all the patients reported normal chewing and opening capacity. Pain related to TMJ arthritis was reduced after treatment (5 patients before, none after) in contrast to muscle pain and muscular headache which were more frequent at long-term follow-up. Objective: The mandibular asymmetry was corrected. The lip function was improved and the respiratory pattern was normalized for most of the patients. A tongue dysfunction was present in eight patients before treatment and in two patients at follow-up. The dental occlusion was normalized for all but 2 patients, who still had a distal molar relationship. The mandibular range of motion before treatment was 47.6 mm with laterotrusion and protrusion within the normal range. In the early post-distraction period the mobility was significantly reduced but throughout the follow-up period it increased to normal range and close to the preoperative values. Cephalometric analysis demonstrated skeletal stability of the treatment result. Conclusion: The use of DO in patients with previous JIA in the TMJ resulted in a good skeletal and occlusal stability. It appears that good function of the joints is preserved at long-term follow-up. The affected joint should be guarded by use of occlusal splint during and after the distraction process.