Cases 5 and 6
Reactive arthritis (also called seronegative spondyloarthropathy) is an inflammatory process that can occur in the TMJs commonly with displaced discs, with or without condylar resorption usually related to bacterial and/or viral pathology. This condition is most commonly seen in females and does not usually begin until the late teenage years and later. Our preliminary studies have identified bacteria species from the Chlamydia and Mycoplasma families. These bacteria live and function like viruses and stimulate the production of substance P, cytokines, and tissue necrosis factor, which are pain modulators and may also contribute to the hard and soft tissue degeneration process occurring in the joints. We suspect that other bacterial and viral elements could also be causative factors. Advanced cases, a dentofacial deformity can develop secondary to condylar resorption.
An MRI may show displaced disc, inflammation, and progression of disc and condylar degeneration. Patients with localized TMJ reactive arthritis and displaced discs may respond well to joint debridement and disc repositioning with the Mitek anchor technique and the appropriate orthognathic surgery procedures to correct a co-existing dentofacial deformity. In more aggressive forms of the disease or presence of polyarthropathy, TMJ custom-fitted total joint prostheses with fat grafts may be indicated.
Figure 49. Case 5: A-D) Presurgery clinical and intraoral images, E-H) Clinical and intraoral images at 8 year post surgery.
Figure 50. Case 5: A) Presurgical cephalometric tracings, where green (dashed-line) represents the left side and red (solid line) represent the right side, B) Surgical treatment objective represents the planned surgery, C) Sagittal T1 MRI presenting anteriorly displaced disc and resorbed condyle.
Case 6 Reactive Arthritis (Figures 50 Through 54)
Figure 51: (A,C) This 27-year-old female had the onset of her TMJ problems at age 23 with development of significant pain, facial asymmetry, mandibular retrusion, and sleep apnea issues.
Her diagnosis was:
- Left TMJ mild arthritis and articular disc anterior displacement (FIGRUE 51, B)
- Right TMJ severe reactive arthritis and condylar resorption with destruction of the disc (FIGRUE 51, C)
- Mandibular hypoplasia and asymmetry; Maxillary hypoplasia and asymmetry
- Class II occlusion with premature contact on the right side; Anterior and left posterior open bite
- Decreased oropharyngeal airway and sleep apnea symptoms
- Severe pain.
B-D) The patient is seen 1 year post surgery for the following single stage procedures:
- Unilateral right TMJ reconstruction and mandibular counter-clockwise advancement and transverse leveling with custom fitted TMJ total joint prosthesis (TMJ Concepts system)
- Unilateral right TMJ fat graft placement (harvest from abdomen)
- Unilateral right coronoidectomy
- Unilateral left TMJ disc repositioning with Mitek anchor
- Sagittal split osteotomy of the left mandibular ramus with counter-clockwise rotation of occlusal plane angle
- Multiple maxillary osteotomies to down graft the posterior aspect transversely level and upright the incisors. With the above treatment plan, pogonion advanced 17 mm.
Figure 53: A-C) Presurgery occlusion shows left side open bite and right side posterior cross bite, D-F) shows the occlusion at one year post surgery at the one year postsurgery, she shows good skeletal and occlusal stability, free from TMJ pain, headaches and myofascial pain; improved facial balance, increased orpharyngeal airway, and elimination of sleep apnea.
Figure 54: A) Presurgical cephalometric analysis shows the retruded maxilla and mandible with a high occluslal plane angulation and class II skeletal and occlusal relationship. B) Surgical treatment objective shows repositioning the left articular disc and advancing the mandible with sagittal split osteotomy. C) The right TMJ is reconstructed and advanced with a custom-fitted total joint prosthesis. D) The lateral cephalogram at 1 year post surgery showing good facial balance and normal oropharyngeal airway.
Figure 55: A) The custom-fitted TMJ concept total joint prosthesis is observed on the stereolythic model. B) Postsurgical panogram.
Figure 51, Case 6: A) Coronal presurgery MRI of the bilateral TMJs showing large inflammatory reaction in the right TMJ, and a medially displaced disc in the left TMJ. B) Right Sagittal T1 MRI of TMJ demonstrates severe condylar resorption, significant inflammation surrounding the condyle, and resorption of the condyle and the articular eminence, C) T1 MRI of the left TMJ shows mild arthritis and anteriorly displaced disc.