Long-term follow-up of corrective jaw surgery including distraction osteogenesis in 32 patients with juvenile idiopathic arthritis.

Dentofacial deformity following juvenile idiopathic arthritis (JIA) with temporomandibular joint (TMJ) involvement is associated with functional, aesthetic, and psychosocial impairment. Corrective surgical treatment includes combinations of orthognathic surgeries (OS). The aims of this study were to assess orofacial symptoms, functional and aesthetic status, and stability after OS including mandibular distraction osteogenesis (MDO). A prospective study was conducted of 32 patients with JIA of the TMJ and dentofacial deformities who underwent MDO as the only surgery or in combination with bilateral sagittal split osteotomy, Le Fort I, and/or genioplastybetween 2003 and 2018. Data from clinical examinations and cephalograms performed pre- and postoperative and at long-term (mean 4 years) were analysed. Patients experienced unchanged orofacial symptoms (all P > 0.05), short-term TMJ functional impairment (all P < 0.001), and long-term morphological improvements in SNB angle (P < 0.001), anterior facial height (P < 0.001), mandibular length (P = 0.049), overjet (P < 0.001 and P = 0.005), and posterior facial symmetry (P = 0.046). MDO as the only surgery or with secondary adjunctive OS improved dentofacial morphology in terms of mandibular advancement, anterior facial height, posterior facial symmetry, and incisal relationships without long-term deterioration in TMJ function or orofacial symptoms.

Normative values for mandibular mobility in Scandinavian individuals 4-17 years of age.

Assessment of mandibular mobility is an important part of the clinical oro-facial examination of paediatric and adolescent patients. The aims of the present cross-sectional study were to establish age-related normative values for mandibular mobility in a Scandinavian paediatric and adolescent cohort and to assess the validity of universal cut-off values for lower 'normal' mandibular ranges of motion. A total of 1114 Danish individuals between 4-17 years of age were included. Maximal mouth opening capacity and laterotrusion capacity were assessed, in each individual, according to a standardised measurement protocol. The mean maximal mouth opening capacity gradually increased from 38 mm (SD 6·1 mm) at age 4 to 54·5 mm (SD 6·8 mm) at age 17. No inter-gender difference in maximal mouth opening capacity was observed (P > 0·15). The mean maximal laterotrusion capacity gradually increased from 7·4 mm (SD. 1·1 mm) at age four to 10·1 mm (SD 1·9 mm) at age 17. A statistical significant inter-gender difference of 0·8 mm (SD 0·4 mm) was observed in relation to the total laterotrusion capacity; however, the clinical relevance of this significant difference is questionable. Normative values of mandibular function was established in individuals 4-17 years of age. Our findings oppose the use of a single universal cut-off value for 'normal' range of motion in paediatric and adolescent patients. Instead, we recommend to use the age-related normative values of mandibular range of motion as basis for the assessment of the development of oro-facial function.

Effect of unilateral mandibular distraction osteogenesis on mandibular morphology in rabbits with antigen-induced temporomandibular joint arthritis.

Aim was to evaluate effect of unilateral distraction osteogenesis (DO) on mandibular morphology in rabbits with antigen-induced arthritis in the temporomandibular joint (TMJ). Forty 8-week-old rabbits were divided into four groups. In groups A,C, arthritis was induced in the right TMJ. Groups A,B underwent DO. Group D served as control group. Cephalometric analysis of mandibular angle, mandibular ramus height, mandibular collum height, and total posterior mandibular height was done on CT-scans preoperatively (T0), after distraction (T1), and at euthanasia (T2). Two-factor ANOVA evaluated the effect of DO and antigen-induced arthritis. No effect of DO or arthritis was observed on mandibular angle or mandibular collum height. For T0-T1, DO increased mandibular ramus height 12.3% (95% CI 5.2-19.4%) in group B (P=0.001) and total posterior mandibular height 6.2% (95% CI 0.3-12.1%) in group A (P=0.04) and 10.0% (95% CI 4.3-15.7%) in group B (P=0.001). For T1-T2, no significant changes occurred in arthritic rabbits (group A). In conclusion, DO increased total posterior mandibular height in rabbits with arthritis. Postoperatively, no significant effect of DO was observed in rabbits with arthritis. Mandibular DO could be a viable treatment modality in patients with TMJ-arthritis.

Cytokines in healthy temporomandibular joint synovial fluid.

Analysis of temporomandibular joint (TMJ) synovial fluid may elucidate the aetiology of temporomandibular disorders and arthritic conditions, as well as the inflammatory mechanisms involved. Knowledge about healthy synovial fluid is necessary to understand TMJ pathologies. We aimed to quantify the proinflammatory cytokines interleukin (IL)-1ß, IL-2, IL-6 and tumour necrosis factor (TNF), and the anti-inflammatory cytokines IL-10 and interferon (IFN)-γ in healthy TMJ synovial fluid to serve as reference values for future studies on TMJ pathologies. Twenty healthy, young adult volunteers without temporomandibular dysfunction were included. Bilateral synovial fluid samples were obtained using the push-pull technique with hydroxocobalamin described by Alstergren in 1999. Cytokines were quantified with Luminex multiplex assays and compared using nonparametric statistical analysis. No serious adverse effects were reported. Of 40 possible samples, 14 fulfilled the strict sampling criteria and were included in the analysis. Cytokine values (reported as medians with interquartile ranges) were as follows: TNF, 23 (13-37) pg mL(-1) ; IL-2, 1·8 (0-22) pg mL(-1) ; and INF-γ, 10 (0-47) pg mL(-1) . IL-1ß, IL-6 and IL-10 were almost undetectable. In addition, TNF and INF-γ cytokine levels correlated. We demonstrated that TNF was consistently detected and IFN-γ and IL-2 sporadically detected in the TMJ synovial fluid of healthy individuals using the hydroxocobalamin method and a multiplex assay. The cytokines IL-10, IL-1ß and IL-6 were barely detectable in this sample of healthy TMJs.

Management of temporomandibular joint arthritis-related orofacial symptoms in juvenile idiopathic arthritis by the use of a stabilization splint.

OBJECTIVES: Temporomandibular joint (TMJ) inflammation in patients with juvenile idiopathic arthritis (JIA) may interfere with optimal joint and muscle function. Orofacial symptoms are common findings in relation to TMJ arthritis. Previous research on management of TMJ arthritis-related orofacial symptoms in patients with JIA has focused on pharmacological treatment modalities without involving physical pain management strategies. The aim of this study was to evaluate changes in orofacial pain and TMJ function after stabilization splint treatment. METHOD: Twenty-eight consecutive patients with JIA and arthritis-related orofacial symptoms (mean age 15.5 years, range 8.2-25 years) were included in this prospective observational study. All patients received stabilization splint treatment. A comparable group of 110 healthy children served as controls for the assessments of TMJ mobility. RESULTS: After splint treatment for 8 weeks, a significant reduction in orofacial pain frequency and intensity was reported, and significant improvement in TMJ function was observed. However, TMJ mobility at follow-up remained significantly reduced when compared to the control group. CONCLUSIONS: The stabilization splint is a safe, reversible, low-cost treatment, and familiar to most dental practitioners. Based on our findings, we propose the implementation of stabilization splint therapy for the treatment of JIA patients with TMJ arthritis-related symptoms.

Smallest detectable differences in clinical functional temporomandibular joint examination variables in juvenile idiopathic arthritis.

OBJECTIVE: Temporomandibular joint (TMJ) arthritis in juvenile patients may interfere with optimal joint function and mouth opening patterns. Clinical assessment of maximal mouth opening capacity, laterotrusion and protrusion is critical to TMJ arthritis diagnosis, treatment choice and evaluation of a therapeutic intervention. The aim of the study was to determine the smallest minimal threshold at which differences in maximal mouth opening capacity, laterotrusion, and protrusion between two consecutive observations can be determined. SETTING AND SAMPLE POPULATION: Department of Orthodontics, University of Aarhus, Denmark. Forty-two consecutive patients with juvenile idiopathic arthritis. MATERIAL AND METHODS: Two experienced dentists used a calibrated metallic ruler to measure maximal mouth opening capacity, laterotrusion, and protrusion. Each measurement was carried out thrice by each observer. Intra- and inter-observer variation and the smallest detectable difference were calculated for each variable. RESULTS: The smallest detectable differences were as follows: maximal mouth opening capacity 4.9 mm, laterotrusion 2.4 mm, and protrusion 2.8 mm (one observer and one measurement). These differences declined when measurements were repeated; maximal mouth opening capacity 3.3 mm, laterotrusion 1.4 mm, and protrusion 1.8 mm (two observers with three measurements each). We found no support for a relationship between measurement variation and patient age, measurement variation and TMJ pain, or between measurement variation and previous/current TMJ arthritis. CONCLUSION: The importance of the implementation of a standardized measurement protocol is emphasized including repeated measurements to reduce the smallest detectable difference.

Functional changes following distraction osteogenesis treatment of asymmetric mandibular growth deviation in unilateral juvenile idiopathic arthritis: a prospective study with long-term follow-up.

In juvenile idiopathic arthritis (JIA), temporomandibular joint involvement is a frequent complication leading to deficient mandibular growth. Occurring unilaterally this will give rise to mandibular and maxillary asymmetry that will affect the soft tissue and the muscles and result in complex dentofacial anomaly. In the case of severe dentofacial malformation, orthognathic surgery is the only treatment option. Vertical osseodistraction of the mandibular ramus has been suggested as a means of rectifying the mandibular growth deviation and soft-tissue problems. Whether such treatment introduces dysfunctional side effects of the temporomandibular joint and muscles has been debated and concern has been raised that treatment impairs the patient's mouth opening capacity and mandibular movement. The present study prospectively evaluated 23 patients with JIA and mandibular asymmetry caused by unilateral temporomandibular joint arthritis. The authors found a clinical effect on the asymmetry with only minor subjective complaints and limited objective changes in functional parameters.

Condylar lesions in relation to mandibular growth in untreated and intra-articular corticosteroid-treated experimental temporomandibular joint arthritis.

OBJECTIVES: To evaluate condylar lesions in relation to mandibular growth in experimental temporomandibular joint (TMJ) arthritis and to assess the outcome of treating this condition with repeated intra-articular corticosteroid injections (IACIs). METHODS: Forty-two 10-week-old rabbits were randomly divided into four groups. Seven animals served as controls. Experimental TMJ arthritis was induced in five animals which received intra-articular TMJ saline injections. Fifteen animals had TMJ arthritis induced and were left untreated and 15 animals had TMJ arthritis induced and were treated with IACIs one week after each TMJ antigen-challenge procedure. Inter-group growth differences were evaluated from head computerised tomography scans taken at the time of arthritis induction and 12 weeks later. The variables assessed were: progression of condylar lesions (erosions/flattening/osteophytes), mandibular bone volume changes, condylar and sagittal ramus growth. RESULTS: No inter-group differences in the progression of condylar lesions were observed despite reduced mandibular growth in all three experimental groups. The most pronounced unfavourable mandibular growth alterations were observed in the corticosteroid-treated arthritis animals. CONCLUSIONS: No evidence was found in support of a relation between reduced mandibular growth and condylar lesions. We propose that: 1) condylar lesions are not the only causative factor of reduced mandibular growth in experimental TMJ arthritis, and 2) repeated IACIs have a very unfavourable impact on mandibular growth in experimental TMJ arthritis - treatment is more detrimental to mandibular growth than the TMJ arthritis itself.

Le Fort I miniplate osteosynthesis: a randomized, prospective study comparing resorbable PLLA/PGA with titanium.

The aim of this study was to compare the use of resorbable osteosynthesis material (LactoSorb) with titanium osteosynthesis for the fixation of Le Fort I osteotomies with respect to long-term stability and morbidity. To achieve exact cephalometric measures, five tantalum micro implants were inserted in the maxilla during surgery. A total of 60 patients undergoing a non-segmented Le Fort I osteotomy were randomized to one of the treatments and were followed for 1 year postoperatively. For the osteotomies fixated with LactoSorb, the lateral cephalometric analysis demonstrated a statistically significant difference in the vertical position of the maxilla after 6 weeks as the position became more superior compared with the postoperative situation (mean change of 0.6 mm). In the titanium group no significant changes in position were observed. There were no statistically significant changes in the position of the maxilla from 6 weeks to 12 months in either of the treatment groups. The changes in maxillary postion were not clinically noticeable in either of the treatment groups, and all treatments were completed with satisfactory results. There were two cases of infection and wound dehiscence in the LactoSorb group, whereas titanium osteosynthesis was more often palpable after 6-12 months and required surgical removal in three cases.

Contrast-enhanced MRI compared to histological findings in the temporomandibular joint of antigen-induced arthritis in young rabbits.

OBJECTIVE: To study the correlation between histological findings and Magnetic Resonance Imaging (MRI) findings in experimentally induced arthritis in the temporomandibular joint (TMJ) of growing rabbits and to study the effect of intraarticular corticosteroid injections. METHODS: Arthritis was induced by ovalbumin in the left TMJ of 44 pre-sensibilized rabbits. Nine animals died during this procedure. Eight of the remaining animals with induced arthritis were treated with intraarticular corticosteroid injections one week after induction of arthritis. Twelve rabbits served as controls. MRI enhanced with Gadolinium-DTPA was performed on all animals 1 to 2 weeks after induction of arthritis and again before sacrifice and the degree of enhancement was calculated. Histology of the condyle was performed and degree of villous hyperplasia, synovial thickness, infiltration of inflammatory cells and pannus was graded. RESULTS: TMJ arthritis was successfully induced in the rabbits and was verified by enhancement of the MRI and by histological changes one week after the induction. Joints treated with intraarticular corticosteroid injections revealed complete inhibition of the inflammation. CONCLUSION: Enhancement of MRI in antigen-induced arthritis in the TMJ associated well with inflammatory changes shown histologically. An intraarticular corticosteroid injection prevents the initial inflammatory response in experimentally induced TMJ arthritis.

Resorption of the temporomandibular condylar bone according to subtypes of juvenile chronic arthritis.

OBJECTIVE: To evaluate the relative impact of sex, type of onset, course of disease, age at onset, duration of disease and status of HLA-B27, antinuclear antibodies (ANA), and rheumatoid factor on the risk of developing a condylar erosion. METHODS: Condylar changes of the temporomandibular joint (TMJ) were diagnosed on orthopantomograms from 169 consecutive patients with juvenile chronic arthritis (JCA). A multiple regression analysis was applied to establish the relative weight of the independent variables affecting the severity of the condylar erosion. RESULTS: It was found that 62.1% of the patients exhibited condylar resorption. The highest prevalence was seen in children with a polyarticular onset or course of disease and early age at onset and severe resorption was also frequent in these groups. Patients with positive ANA also had a high prevalence but with a mild degree of resorption. In contrast, HLA-B27 positive patients had a lower risk of TMJ involvement and resorptive changes of the condyle. CONCLUSION: Polyarticular and early onset arthritis are associated with a high risk for TMJ involvement and a severe condylar bone loss can be expected. ANA positive patients have a high prevalence, and B27 positive patients have a low prevalence of TMJ arthritis but in both subgroups, the outcome of the bone resorptive process is mild.

Spontaneous resolution of amniotic bands.

The amniotic band syndrome comprises a group of sporadic congenital anomalies characterized by amputations, constriction bands, pseudosyndactylism and multiple craniofacial, visceral and body wall defects. It occurs in approximately 1 in 1200 to 1 in 15 000 live births. Some of the cases present with congenital anomalies that are incompatible with life, but a selected group shows isolated limb constrictions. Repeated sonographic examinations afforded us the opportunity of observing the in utero process of limb strangulation and subsequent spontaneous lysis of an amniotic band attached to a fetal elbow. Surgical fetal therapy with lysis of the constriction ring in utero is an option, but intervention is probably not always warranted. Spontaneous resolution does occur.

Contrast enhanced magnetic resonance imaging as a method to diagnose early inflammatory changes in the temporomandibular joint in children with juvenile chronic arthritis.

OBJECTIVE: Recent studies have stressed early diagnosis of temporomandibular joint (TMJ) involvement in children with juvenile chronic arthritis (JCA) to initiate treatment before destruction of the condylar head and growth alterations take place. TMJ involvement is often asymptomatic, but studies with contrast enhanced magnetic resonance imaging (MRI) in other joints have shown that it is possible to detect the early inflammatory changes. METHODS: Thirty TMJ in 15 children with newly diagnosed JCA (mean age 12.0 years) were examined clinically, with radiographs and with MRI enhanced with gadolinium diethylene thiamine pentaacetic acid (Gd-DTPA). A control group of 10 healthy children (mean age 11.5 yrs) were examined clinically and with MRI. The MRI variables included T1 weighted images before and after administration of Gd-DTPA with and without fat suppression. RESULTS: MRI enhanced with Gd-DTPA indicated inflammatory activity in 87% of the patients. Conventional MRI without contrast medium proved to be insignificant in diagnosing early inflammatory changes. CONCLUSION: Enhanced MRI is very efficient in diagnosing early inflammatory changes of the TMJ and is a more sensitive method than the clinical examination and radiographs.

Clinical aspects of orthodontic treatment for children with juvenile chronic arthritis.

Growth abnormalities as a consequence of temporomandibular joint arthritis in children with juvenile chronic arthritis are difficult and complicated problems to treat. The diagnosis of the inflammatory condition in the joint is difficult but important to the success of the interceptive treatment. The diagnostic problems, treatment objectives, and treatment suggestions are discussed in this article.

[Antibiotic prophylaxis in cesarean section]. / Antibiotikaprofylakse ved sectio caesarea.

We investigated the guidelines for patient selection and drug regimens for use of antibiotic prophylaxis in relation to Caesarean section in the maternity clinics in Denmark. A questionnaire was sent to all the Danish maternity clinics that perform Caesarean section, concerning indications for use of antibiotic prophylaxis and antibiotic regimens to patients undergoing acute and elective Caesarean section. All departments (n = 48) returned the questionnaire. Twenty departments (46%) provided written guidelines for antibiotic prophylaxis. Four departments (8%) used antibiotic prophylaxis in elective Caesarean sections, 25 departments (52%) used antibiotics in all emergency sections. In the presence of rupture of the membranes or prolongation of labour (> 12 hrs) 58 and 63% of the departments used antibiotic prophylaxis, respectively. The most frequent first choice drug was cefuroxim, employed by 27 departments (56%). Concerning timing, 21 departments (44%) gave antibiotics after cord clamping and 13 departments (27%) before incision. We propose a nation-wide prospective investigation on the rate of infections associated with Caesarean section to set up rational guidelines for antibiotic prophylaxis.

Antibiotic prophylaxis in cesarean section.

BACKGROUND: To investigate the guidelines for patient selection and drug regimens for application of antibiotic prophylaxis in relation to cesarean section in the maternity clinics in Denmark. METHODS: A questionnaire to all the Danish maternity clinics that perform cesarean section, concerning indications for application of antibiotic prophylaxis and antibiotic regimens to patients undergoing acute and elective cesarean section. RESULTS: All departments (n = 48) returned the questionnaire. Twenty departments (46%) provided written guidelines for antibiotic prophylaxis. Four departments (8%) used antibiotic prophylaxis to elective cesarean sections, 25 departments (52%) applied antibiotics to all emergency sections. In the presence of the rupture of membranes or prolongation of labor (> 12 hrs) 58% and 63% of the departments applied antibiotic prophylaxis, respectively. The most infrequent first choice drug was cefuroxim, employed by 27 departments (56%). Concerning timing, 21 departments (44%) applied antibiotics after cord clamping and 13 departments (27%) before incision. CONCLUSION: We propose a nation-wide prospective investigation on the rate of infections associated with cesarean section to set up rational guidelines for antibiotic prophylaxis.

[Laparoscopic sterilization. Late complications of the endocoagulation method]. / Laparoskopisk sterilisation. Senkomplikationer til endokoagulationsmetoden.

The objective of this analysis was to assess the failure rate and incidence of regret of tubal sterilization performed by the endocoagulation technique. The design was a register-based retrospective study. A total of 585 sterilizations were performed from January 1986 to December 1992 in the county hospital of Sønderborg. The patients who had undergone sterilization were identified by diagnosis from the database of "Kommune-data". Forty patients were excluded due to different reasons. The frequency of hospitalization from the operation to July 94 was registered. The actual case records were examined. The failure rate following endocoagulation was 0.92% (one intrauterine and four extrauterine pregnancies) corresponding to an incidence of 1.77/1000 women/year. Two women (0.37%) developed hydrosalpinx after the operation. Ten patients (1.8%) wanted a reversal of sterilization. It was concluded, that tubal sterilization by the endocoagulation method is cheap and safe. The failure rate is similar to that of other methods. Implantation in the peritoneal space is avoided. Thermic destruction is minimized, and the risk of peroperative burning of the tissue is therefore reduced.

Condylar condition and mandibular growth during early functional treatment of children with juvenile chronic arthritis.

TMJ involvement in children with Juvenile Chronic Arthritis (JCA) will frequently cause disturbance of the growth of the mandible. Orthodontic treatment of these patients often includes orthognathic surgery, and are complicated to handle with respect to the damaged joint and impaired function. The aim of this presentation is to suggest an early treatment with a functional splint appliance, a distraction splint, with the purpose of increasing function of the joint and ensuring continuous growth of the mandible.

Prefrontal cortical mediation of rats' place learning in a modified water maze.

The acquisition of a place learning task in a water maze modified from the "standard" set-up by restriction of distal cues and addition of "proximal" cues (ping-pong balls in fixed positions on the surface of the water) was tested in three groups of rats: (I) animals subjected to bilateral ablation of the anteromedial prefrontal cortex, (II) rats in which the parietal "association" cortex had been removed bilaterally, and (III) a sham operated control group. The task acquisition of the prefrontally ablated group was significantly impaired, whereas the animals in which the parietal cortex had been removed acquired the task as quickly as the control group. Upon reaching criterion level performance all animals were tested on "challenge" sessions on which the cues were manipulated. Such "challenges" demonstrated that the animals of all three groups discriminated between the distal cues and utilized such a discrimination for navigational purposes.

Effects of chronic imipramine on exploration, locomotion, and food/water intake in rats.

Three groups of rats were subjected to 15 daily injections of imipramine (10 or 20 mg/kg) or vehicle control injections, respectively. During the treatment period, both imipramine groups failed to grow while the control group gained weight normally. Both dosages of imipramine suppressed food intake significantly, while water intake was only reduced by 20 mg/kg of imipramine and only during the first 5 days of treatment. Twenty-four hours after the last imipramine injection, the animals were subjected to a test battery designed to demonstrate potential changes in locomotion and/or exploration. While locomotion appeared unaffected by both dosages of imipramine, the group receiving 20 mg/kg of imipramine demonstrated a significantly reduced exploration. The exploration of the group receiving imipramine in the concentration of 10 mg/kg was only marginally changed. The temporal pattern of exploration of the animals receiving 20 mg/kg of imipramine revealed that chronic imipramine treatment was associated with an initial "hyperexploration" followed by an "overhabituation," resulting in an overall reduction of exploration during a 15-min period.