title: Single-stage comprehensive surgical treatment of the rheumatoid arthritis temporomandibular joint patient.
abstract: OBJECTIVE
  To prospectively evaluate the outcomes of single-stage reconstruction of patients with rheumatoid arthritis (RA) with temporomandibular joint (TMJ) pathologic features and an associated dentofacial deformity.
  
  
  METHODS
  Fifteen patients (12 females, 3 males) with RA underwent TMJ reconstruction, with or without a Le Fort I osteotomy in a single operation. Clinical and radiographic examinations were performed before surgery, immediately after surgery, and at the longest follow-up intervals. Numeric analog scales were used for subjective evaluation of TMJ pain, jaw function, diet, and disability. The maximal interincisal opening, lateral excursions, and TMJ crepitus were recorded at each visit. Standardized cephalometric acetate tracings were superimposed to assess for surgical (immediately after surgery compared with before surgery) and postoperative (longest follow-up interval compared with immediately after surgery) changes.
  
  
  RESULTS
  The average patient age was 27.4 years (range 15 to 61), and the follow-up was 34.3 months (range 10 to 77). At the longest follow-up interval, all 15 patients had had a statistically significant reduction in the incidence and severity of TMJ pain and headaches. The average maximal interincisal opening increased after surgery, but the difference was not statistically significant. Lateral excursions decreased significantly after surgery. Dietary restrictions and disability were significantly improved, and TMJ crepitus had reduced significantly. The average advancement at point B was 21.7 mm (range 14 to 28), and the postoperative change at the longest follow-up interval was 0.1 mm (range 0 to 1). The average pogonion advancement was 29.2 mm (range 19.5 to 38), with a postoperative change of 0.2 mm (range 0 to 1). The average gonion vertical lengthening was 20.7 mm (range 10.5 to 29) with a postoperative change of 1.4 mm (range 0 to 4.5). The average occlusal plane angle change was a decrease of 20.7 degrees (range 16 degrees to 26 degrees), with a postoperative change of 0.4 degrees (range 0 degrees to 2 degrees). Of the 15 patients, 10 had undergone maxillary orthognathic surgery performed at the same operation. The average advancement of these 10 patients at point A was 3 mm (range 2 to 7), and the postoperative change was 0.5 mm (range 0 to 1).
  
  
  CONCLUSIONS
  Surgical correction of rheumatoid-associated TMJ disease and the resulting dentofacial deformity can successfully be performed in a single operation using custom-made TMJ total joint prostheses to reconstruct the TMJs and advance the mandible, with maxillary orthognathic surgery and genioplasty performed at the same operation when indicated. The significant reduction in TMJ dysfunction symptoms and the long-term stability of the orthognathic surgery movements show the benefits and predictability of treating these complex patients with this treatment protocol.
authors.affiliation: Department of Oral and Maxillofacial Surgery, Boston University School of Dental Medicine, Boston MA 02118, USA. pushkar.mehra@bmc.org
authors.forename: Pushkar
authors.initials: P
authors.lastname: Mehra
authors.forename: Larry M
authors.initials: LM
authors.lastname: Wolford
authors.forename: Shant
authors.initials: S
authors.lastname: Baran
authors.forename: Daniel Serra
authors.initials: DS
authors.lastname: Cassano
mesh_terms: D000293:Adolescent; D000328:Adult; D001172:Arthritis, Rheumatoid / Q000150:complications / Q000601:surgery*; D019643:Arthroplasty, Replacement / Q000379:methods*; D002508:Cephalometry; D005157:Facial Pain / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008310:Malocclusion / Q000209:etiology / Q000601:surgery*; D008334:Mandible / Q000601:surgery; D019186:Mandibular Advancement / Q000379:methods*; D008437:Maxilla / Q000601:surgery; D008875:Middle Aged; D011446:Prospective Studies; D016059:Range of Motion, Articular; D063173:Retrognathia / Q000209:etiology / Q000601:surgery; D013704:Temporomandibular Joint / Q000601:surgery*; D013705:Temporomandibular Joint Disorders / Q000150:complications / Q000601:surgery*; D055815:Young Adult