Case Report

The Temporomandibular Joint in a Rheumatoid Arthritis Patient after

Orthodontic Treatment
Kenichi Sasaguria; Rika Ishizaki-Takeuchib; Sakurako Kuramaeb; Eliana Midori Tanakac;
Takashi Sakuraid; Sadao Satoe

ABSTRACT
A 32-year-old Japanese female patient consulted the authors’ dental clinic with a 4.5-year history
of rheumatoid arthritis (RA). She complained of pain during mouth opening and difficulty in eating
due to masticatory dysfunction caused by an anterior open bite. Imaging showed severe erosion
and flattening of both condyles. RA stabilized after pharmacological therapy and became inactive
during the orthodontic therapy aimed at reconstructing an optimal occlusion capable of promoting
functional repositioning of the mandible. At present, 4 years and 2 months postretention, the
reconstructed occlusion remains stable, and both condyles continue to be remodeled. The dis-
tance from reference position to intercuspal position has gradually decreased throughout the 4-
year posttreatment and postretention periods. Orthodontic therapy that comprehensively recon-
structs occlusion and enhances the functioning of the mandible can induce remodeling of eroded
condyles, even those with a history of rheumatoid arthritis. (Angle Orthod. 2009;79:804–811.)
KEY WORDS: Rheumatoid; Condyle

INTRODUCTION retrognathia, and an anterior open bite deformity oc-

Rheumatoid arthritis (RA) is an autoimmune disease
that causes chronic inflammation in joint tissues; it is
usually seen in other joints prior to temporomandibular
joint (TMJ) involvement. The common clinical findings
in RA of the TMJ are tenderness, pain, clicking, crep-
itation, stiffness, and limitation in jaw movements.1,2 In
patients with progressive disease, the joint space be-
comes obliterated due to loss of condylar height and
a
Associate Professor, Department of Craniofacial Growth &
Development Dentistry, Kanagawa Dental College, Yokosuka
City, Japan.
b
Resident, Department of Craniofacial Growth & Develop-
ment Dentistry, Kanagawa Dental College, Yokosuka City, Ja-
pan.
c
Research Fellow, Department of Craniofacial Growth & De-
velopment Dentistry, Kanagawa Dental College, Yokosuka City,
Japan.
d
Assistant Professor, Oral and Maxillofacial Radiology, Kan-
agawa Dental College, Yokosuka City, Japan.
e
Professor, Department of Craniofacial Growth & Develop-
ment Dentistry, Kanagawa Dental College, Yokosuka City, Ja-
pan.
Corresponding author: Dr Kenichi Sasaguri, Kanagawa Den-
tal College, Department of Craniofacial Growth & Development
Dentistry, 82 Inaoka-cho, Yokosuka 238-8580, Japan
(e-mail: sasaguri@kdcnet.ac.jp)
Accepted: August 2008. Submitted: June 2008.
䊚 2009 by The EH Angle Education and Research Foundation,
Inc.
curs due to destruction, erosion, sclerosis, and flatten-
ing of the articular surface of the condyle and emi-
nence.3,4 These patients occasionally require a surgi-
cal approach, such as TMJ replacement therapy or
costochondral grafting of the TMJ to solve the anterior
open bite deformity.5–7 However, condylar resorption in
RA is multifactorial, based on the patient’s adaptive
capacity and on mechanical stimuli. When predispos-
ing patient factors are not present, occlusal treatments
(orthodontics, orthognathic surgery, prosthetics) nor-
mally result in functioning remodeling.8 TMJ is change-
able, and changes in occlusion and mandibular posi-
tion resulting from forces generated during orthodon-
tic/orthognathic manipulations can contribute to re-
modeling of the articular structures of the TMJ.9
We report the case of an RA patient in remission
with an open bite deformity who had severely eroded
articular surfaces of both condyles and in whom oc-
clusion was orthodontically reconstructed. Consider-
able improvement of the TMJ condition has been sus-
tained after approximately 4 years of follow-up.
CASE REPORT
The patient was a 32-year-old Japanese woman,
who had a severe open bite deformity with a Class I
molar relationship (Figure 1A) at the time of the initial
examination in May 2000 (Table 1). Overbite and over-

Angle Orthodontist, Vol 79, No 4, 2009 804 DOI: 10.2319/040708-201.1

TMJ IN RHEUMATOID ARTHRITIS AFTER ORTHODONTIC TREATMENT 805

Figure 1. Intraoral photographs. (A) Pretreatment. (B) Beginning of treatment (leveling phase). (C) Multiloop edgewise arch wires. (D) Post-
treatment, immediately after debonding. (E) Postretention (2 years 3 months). (F) Postretention (4 years 2 months).

jet were ⫺4 mm and ⫹2 mm, respectively. She com-
plained mainly of pain during jaw movement and mas-
ticatory dysfunction accompanied by an anterior open
bite.
In November 1995, the patient had consulted a
nearby orthopedist because of pain in the shoulder.
She was diagnosed as having RA based on the pres-
ence of rheumatoid factor in the blood. At that time,
the patient had mild symptoms of RA. In January
1999, the patient deteriorated acutely and developed
joint stiffness in the neck, shoulder, hands, wrists, and
feet, and she was managed with oral prednisolone and

Angle Orthodontist, Vol 79, No 4, 2009

806 SASAGURI, ISHIZAKI-TAKEUCHI, KURAMAE, TANAKA, SAKURAI, SATO

Table 1. Cephalometric analysis

Retention Retention
Mean SD Pretreatment Posttreatment (2 y 3 mo) (4 y 2 mo)
SNA 82.3 3.4 86 86 86 86
SNB 78.9 3.4 80 82 81 81
ANB 3.4 1.7 6 4 5 5
U1-FH 111.1 5.5 117.5 112 112 112
U1-SN 104.5 5.5 109.5 104 104 104
Facial axis 86 3 83 84 83 83
Facial depth 87.8 3 87 90 87 86.5
Mandibular plane 28.8 5.2 31 31 31 31
LFH 49 4 49 49 50 50
Convexity, mm 4 2 8 8 8 8
L1-APO, mm 3 1.5 8.5 9 9 9
L1-APO, ⬚ 25 5 39 36 38 36
U6-PTV 11 3 16 16.5 16 16
E-plane 2 1.5 4 4 3 3

Figure 2. (A) Lateral tomogram findings of the temporomandibular joint. (B) PRE: pretreatment. (C) POST: posttreatment. (D) RET: postre-
tention.

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TMJ IN RHEUMATOID ARTHRITIS AFTER ORTHODONTIC TREATMENT
Figure 3. (A) Magnetic resonance imaging findings of the temporomandibular joint. (B) PRE: pretreatment. (C) POST: posttreatment. (D) RET:
postretention (2 years, 3 months).
bucillamine, as well as injections of gold sodium thiom-
alat. By June 1999, the RA had compromised both
TMJs, and clinical examination revealed a very limited
mouth opening (33 mm) with bilateral TMJ pain during
jaw movement and when eating slightly harder food.
By then, she had also developed a substantial anterior
open bite.
On cephalometric analysis, the patient demonstrat-
ed a skeletal Class II tendency with bimaxillary protru-
sion. Sagittal tomography showed severe erosion of
the condyles on both sides (Figure 2-Pre). Magnetic
resonance imaging (MRI) revealed medial-anterior
disc displacement without reduction based on coronal
and lateral images (data not shown), and there were
marked morphological changes in the condyles of both
sides (Figure 3-Pre). Based on these findings, rees-
tablishment of a normal disc-condyle relationship was
807
considered difficult, and the patient chose not to have
surgery. Therefore, an orthodontic approach was car-
ried out in an attempt to improve the patient’s occlusal
and articular conditions by reconstructing the occlu-
sion, promoting functional mandibular adaptation, and
creating an unloaded situation of the TMJ that may
lead to some type of condylar adaptive remodeling.
At the beginning of the orthodontic treatment, the
patient’s RA condition was considered stable, and her
general condition improved as a positive response to
the pharmacologic therapy, with a negative rheuma-
toid factor test. Fortunately, her RA status changed
from stable to inactive or asymptomatic disease during
the orthodontic treatment, and her RA remained in-
active after the completion of the treatment without any
pharmacologic support.
In August 2000, orthodontic treatment was started
Angle Orthodontist, Vol 79, No 4, 2009
808
Figure 4. Superimposition of cephalometric tracings. (A) Pretreatment and 2 years 3 months posttreatment (shadow). (B) Posttreatment and
4 years 2 months postretention (shadow).
using 0.018- ⫻ 0.025-in slot standard edgewise brack-
ets, and very light and continuous forces were slowly
applied with 0.014-in Ni-Ti archwires during the initial
leveling, to minimize mechanical loading on the TMJ
as much as possible (Figure 1B). After leveling, 0.016-
⫻ 0.016-in Ni-Ti and stainless-steel archwires were
placed for alignment. From January to October 2002,
0.016- ⫻ 0.022-in blue Elgiloy multiloop edgewise arch
wires (MEAW) with tip back bend activation and bend-
ing of crown lingual torque gradually from first pre-
molar to second molar in both arches, and the use of
short Class II or up and down elastics (3/16, 6 oz) at
the anterior part,10,11 were simultaneously started. This
was to control the occlusal plane and to prevent flaring
of the anterior teeth (Figure 1C). Detailing was done
with 0.016- ⫻ 0.016-in stainless-steel archwires and
up and down elastics (1/4, 3.5 oz) while asleep at night
to settle the occlusion until debonding in August 2003.
The retention phase was accomplished using Hawley
retainers, which were worn at all times during the first
12 months after braces were removed and then only
at night for another year.
After a total treatment time of 3 years, a reconstruct-
ed stable occlusion was attained and almost all of the
TMD symptoms disappeared (Figure 1D). Sagittal to-
mograms and MRI of the TMJ showed that both con-
dyles were remodeled adaptively (Figure 2-Post and
Figure 3-Post), even though the reference position
(RP) ⫺ intercuspal position (ICP) difference at post-
treatment was longer than that of pretreatment on the
MPI analysis (Figure 5A,B).12 However, adaptive mor-
phological change of the condyles was continuously
induced (Figure 2-Ret and Figure 3-Ret) from post-
Angle Orthodontist, Vol 79, No 4, 2009
SASAGURI, ISHIZAKI-TAKEUCHI, KURAMAE, TANAKA, SAKURAI, SATO
treatment to postretention at 4 years 2 months. In ad-
dition, the reconstructed occlusion was acceptable
(Figure 1E,F). The stability of the advanced mandib-
ular position obtained at the end of the treatment was
evaluated by cephalometric analysis and superimpo-
sition of lateral cephalographic tracings of pretreat-
ment, posttreatment, and postretention at 4 years 2
months. It was evident that the final advanced position
has been well maintained through the follow-up period
(Figure 4A,B). Furthermore, the RP-ICP difference
gradually decreased during the postretention period
from 2 to 4 years (Figure 5C,D). Her RA, fortunately,
was inactive and remains asymptomatic during post-
treatment and postretention, even though she has dis-
continued all medications.
It is worth noting that informed consent was given
by the patient to publish the previous data.
DISCUSSION
The TMJ is often involved in patients with RA, al-
though, in general, the TMJ symptoms have been
thought to be not as severe as those in other joints.
Nevertheless, occasionally some patients develop pro-
gressive TMJ arthritis, which ultimately results in dis-
tracted condylar surface-induced pain, dysfunction of
mandibular movement, and the development of an an-
terior open bite.1–4
Our case developed an anterior open bite deformity
(Figure 1A) due to the severely eroded articular sur-
faces of both side condyles, as noted on the lateral
tomograms and MRI (Figures 2 and 3). In general,
TMJ replacement therapy or costochondral grafting of
TMJ IN RHEUMATOID ARTHRITIS AFTER ORTHODONTIC TREATMENT 809

Figure 5. MPI analysis. (A) Before treatment. (B) Posttreatment. (C) Postretention (2 years 3 months). (D) Postretention (4 years 2 months).

Angle Orthodontist, Vol 79, No 4, 2009

810 SASAGURI, ISHIZAKI-TAKEUCHI, KURAMAE, TANAKA, SAKURAI, SATO
the TMJ provides a surgical solution for such pa-
tients.4–6 At the time of diagnosis, we explained the
benefit of a surgical procedure in her case, but the
patient did not wish to have surgery. Therefore, she
was managed orthodontically after the RA was con-
sidered stable and the seronegative rheumatoid factor
was confirmed by blood tests. After orthodontic treat-
ment (Figure 1D), the patient’s occlusal and articular
conditions improved considerably and the TMD symp-
toms had almost totally disappeared. There were
some significant morphologic changes in the eroded
condyles based on radiographic and MRI findings (Fig-
ure 2-Post, Figure 3-Post).
Remodeling of the articular structures of the TMJ is
reported when orthodontic-orthopedic forces are ap-
plied in adolescents and young adults.13,14 However,
Tanaka et al15 reported that splint therapy together
with an orthodontic approach might be able to induce
adaptive change of the condyle in an adult patient with
severe osteoarthrosis of the TMJ accompanied by an
anterior open bite. Although repositioning of the disc
was not achieved, the reason for such adaptive re-
sponses of the eroded condyle was attributed to the
achievement of a stable occlusion, reestablishment of
uniform joint spaces (antero-superior), and elimination
of excessive or unbalanced stress on the condyle that
may have reduced TMJ loading because of an opti-
mum condylar position. Moreover, Sato et al16 also
demonstrated that occlusal reconstruction using a
prosthetic approach might be of considerable value for
inducing the desirable remodeling of the condylar
heads on a topographical study in two of six adult RA
cases. Therefore, after our patient had undergone RA
remission, we used an orthodontic approach with
MEAW10,11 techniques plus short Class II elastics with
a vertical component to provide a mandibular position
with reduction of TMJ loading, creation of proper joint
space, and establishment of stable occlusion.
Our outcomes are especially interesting, since our
case not only maintained the reconstructed occlusion
(Figure 1E,F) but also continued to exhibit adaptive
morphological changes of the eroded condyles from
posttreatment to postretention. These findings are
based on topographic and MPI follow-up data despite
the difference between the deranged RP-ICP, result-
ing in a bigger distance at posttreatment (Figure 2-Ret
and Figure 3-Ret). The induced mandible position was
obviously maintained during the postretention period
(Figure 4). Also interesting is that MPI findings indi-
cated that the RP-ICP difference decreased during
postretention from 2 years 3 months to 4 years 2
months (Figure 5C,D). It could be speculated that the
stable and/or functional occlusion might be responsi-
ble for continuously promoting the displayed adaptive
remodeling of the eroded condyles. Therefore, it may
Angle Orthodontist, Vol 79, No 4, 2009
be possible that the reconstructed functional occlusion
by orthodontics was effective in promoting the remod-
eling of the resorbed condyles even in a patient with
a history of RA of the TMJ.
In conclusion, this case suggests that an orthodon-
tic, rather than a surgical, approach to eliminate molar
interference, change occlusal contacts, and recon-
struct a stable functional occlusion was associated
with a functional remodeling of destroyed condyles.
This occurred by reducing their mechanical loads at
the same time that the open bite condition was cor-
rected by anterior mandibular rotation (Figure 4A).
These changes remained stable in the postretention
period (Figure 4B) (functional repositioning), even
though this middle-aged patient had a history of RA of
the TMJ. However, further clinical and basic research
regarding this treatment approach, in these particular
cases, is necessary.
ACKNOWLEDGMENTS
This work was performed at Kanagawa Dental College, Re-
search Institute of Occlusion Medicine, and supported by a
Grant-in-Aid for Open Research from the Ministry of Education,
Culture, Sports, Science and Technology–Japan. This work was
also supported by a Grant-in-Aid for Scientific Research from
the Ministry of Education, Culture, Sports, Science and Tech-
nology–Japan (18592254).
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