1 of(2013)

European Journal of Orthodontics 35 8 191–198 © The Author 2011.

2011. Published
Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:10.1093/ejo/cjr116 All rights reserved. For permissions, please email: journals.permissions@oup.com
Advance Access publication 3 October 2011

Orthopaedic splint treatment can reduce mandibular asymmetry

caused by unilateral temporomandibular involvement in juvenile
idiopathic arthritis

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Peter Stoustrup*, Annelise Küseler*, Kasper D. Kristensen*, Troels Herlin** and
Thomas K. Pedersen*
*Department of Orthodontics, Faculty of Health Sciences, University of Aarhus and **Department of Pediatrics,
Aarhus University Hospital, Denmark

Correspondence to: Peter Stoustrup, Department of Orthodontics, Faculty of Health Sciences, University of Aarhus,
Vennelyst Boulevard 9, DK-8000 Aarhus C, Denmark. E-mail: pstoustrup@odont.au.dk

SUMMARY Unilateral temporomandibular joint (TMJ) arthritis in juvenile idiopathic arthritis (JIA) patients
often induces asymmetric dentofacial growth. This study evaluates the effects of an orthopaedic functional
appliance worn full time to reduce asymmetric mandibular growth in JIA patients.
Twenty-two JIA patients with unilateral TMJ involvement were included in the study (mean age 7.5
years, range: 3.8–13.8 years). They all received orthopaedic treatment with a functional appliance, a
so-called distraction splint (mean treatment time 57 months). Panoramic tomograms or cone beam-
computerized tomograms were taken before and within 12 months after treatment cessation. At both
time points, the ratio between the healthy and the affected side of the mandible was evaluated in terms
of inter-side differences in condylar height, ramus height, and total vertical mandibular height.
Orthopaedic functional treatment reduced mandibular asymmetries in terms of ramus height and total
vertical mandibular height (P < 0.05). Mandibular growth rates in the affected and the non-affected sides
were comparable in most patients.
Our study finds evidence to support that a distraction splint can normalize mandibular vertical growth
in the affected side. We therefore suggest implementation of distraction splint therapy in the treatment of
JIA patients with unilateral TMJ arthritis.

Introduction
Temporomandibular joint (TMJ) arthritis is known to alter
dentofacial development in children diagnosed with juvenile
idiopathic arthritis (JIA). In patients with TMJ arthritis, 40–50
per cent experience unilateral manifestation with a diagnosis
based on clinical examination and panoramic tomograms
(OTPs) (Pedersen et al., 2001; Twilt et al., 2004). Unilateral
TMJ arthritis can lead to asymmetric mandibular growth,
unstable occlusion, disturbed TMJ, and masticatory function
causing asymmetric loading of joints and muscles, TMJ pain,
and a compromised aesthetic appearance (Kjellberg, 1995;
Mericle et al., 1996; Pedersen et al., 2001; Sidiropoulou-
Chatzigianni et al., 2001; Twilt et al., 2006, 2008; Billiau et
al., 2007). Historical data from Stabrun et al. show that
unilateral TMJ arthritis in JIA patients leads to significant
jaw asymmetry and underdevelopment of the affected
side when compared to JIA patients with bilateral TMJ
arthritis and healthy controls (Stabrun et al., 1988).
Mandibular asymmetry is a challenging clinical situation
that calls for implementation of diverse treatment modalities.
Over the past two decades, an orthopaedic functional
appliance, a so-called distraction splint, has become a vital
orthopaedic modality in the treatment of JIA patient with
unilateral and bilateral TMJ arthritis at the Department of
Orthodontics, Aarhus University, Denmark. Good clinical
results have been obtained using the distraction splint rst
described in 1995 (Pedersen et al., 1995). The splint is an
acrylic orthopaedic functional device worn full time that
covers the occlusal surfaces of the teeth in the mandible. Its
posterior height is gradually increased with 0.25–1 mm
every 6th–10th week in the arthritic side. This controls the
development of the upper occlusal plane by maintaining the
distance between the upper and the lower jaw and thereby
creating space for normalized vertical dentoalveolar
development, which leads to an increased posterior face
height development in the affected side with the reduced
vertical dimension.
The rationale for the use of orthodontic functional
appliance in JIA patients with TMJ arthritis rests mainly on
empirical observation and scientic studies are few
(Kjellberg et al., 1995). A single study recently published
suggests limited evidence in support of a benecial effect of
the use of a functional orthodontic appliance treatment in
JIA patients with bilateral TMJ involvement (Farronato
et al., 2009). In this retrospective study, we present data
from a cohort of JIA children with unilateral TMJ arthritis
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192 P. STOUSTRUP ET AL.

who have received distraction splint treatment during the Orthodontic visitation
past 15 years. To our knowledge, this is the rst study aimed
The presence of previous/current unilateral TMJ arthritis
at evaluating the effects of an orthopaedic appliance worn
was a critical inclusion criterion. At every visit, the patients
full time by JIA patients with unilateral TMJ arthritis. The
were thoroughly examined in conformity with a standardized
objectives of the present study were to evaluate the effect of
orthodontic clinical examination protocol to assess the
distraction splint treatment used to reduce asymmetry of
status of both the affected TMJ and the contralateral, non-
mandibular growth between the affected and the non-
affected TMJ. The orthodontic examination protocol
affected side in terms of condylar height, ramus height, and

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contained two parts: one part featured the patient’s self-
total vertical mandibular height.
assessment of the present TMJ status. The patient answered
14 questions addressing subjects like pain level, TMJ
Subjects and methods function, chewing capability, etc. The protocol’s second
part contained 57 clinically relevant parameters, which
A group of 54 JIA patients with unilateral TMJ arthritis
were assessed by the examiner, e.g. maximum opening
were identied as candidates for inclusion in this
capacity, symmetry during opening, capability of
retrospective study. All patients were diagnosed with JIA
laterotrusion and protrusion, etc. The clinical examinations
according to the International League for Associations for
were supplemented with radiological evaluation.
Rheumatology criteria (Petty et al., 2004). They all received
splint treatment at the Department of Orthodontics, Aarhus
Distraction splint
University, Denmark, in the years between 1995 and 2010.
A total of 22 out of 54 pre-selected candidates complied All patients included were treated with a distraction splint
with the criteria for inclusion in the present study. These in accordance with the protocol for the treatment of
patients (mean age 7.5 years, range: 3.8–13.8 years) were JIA patients with TMJ arthritis at the Department of
diagnosed with unilateral TMJ arthritis based on clinical Orthodontics, the School of Dentistry, Aarhus University,
and radiological TMJ examinations. Denmark (mean treatment time 57 months; range 14–99
months). The distraction splint effects a slight, gradual
Inclusion change in the mandibular position around the z-axis,
which is achieved by a continuous, gradual increase in the
The inclusion criteria were as follows: (1) JIA with
posterior height of the splint in the affected side (Pedersen,
unilateral TMJ arthritis treated orthopaedically with a
1998). The splint allows the clinicians to guide eruption
distraction splint. (2) Clear signs of unilateral TMJ arthritis
of the molars in a manner that prevents the lower rst
based on clinical examination and radiological skeletal
molar from erupting while the splint is being adjusted so
asymmetry with reference to the mandibular lower border
that the upper rst molar is allowed to erupt in coordination
and the occlusal plane. (3) Persistent unilateral affection
with eruption of the rst upper molar in the unaffected
during treatment with the distraction splint. (4) Treatment
side. This maintains the occlusal plane and corrects
was terminated if a sufcient clinical mandibular symmetry
canting related to the z-axis (Figure 1). The splint is
was achieved or if mandibular growth was estimated as
replaced approximately every second year due to the
ceased. The mandibular growth was evaluated based on a
eruption of new teeth and general wear of the splint and
clinical assessment involving aspects such as total body
it can be placed in the upper as well as in the lower. The
height and Tanner stage. (5) Compliance with good patient
splint placement is decided based on convenience in
cooperation and with a continuous and uninterrupted
relation to changes in the dentition and is continued until
treatment course. (6) Radiological documentation with
an acceptable mandibular skeletal symmetry is achieved.
OTPs or cone beam-computerized tomographic (CBCT)
Minor orthodontic interceptive treatments are conducted
scans within 6 months before initiation of orthopaedic
concurrently with the distraction splint treatment. In
treatment and with radiological documentation within
addition to this orthopaedic distraction splint treatment,
12 months after treatment termination. (7) Sufficient
all patients received individual medication monitored
radiological quality of the scans allowing assessment of
by the paediatric rheumatologist. For detailed information
anatomical mandibular structures of importance in this
on distraction splint fabrication as well as treatment
study. (8) No administration of intra-articular TMJ steroid
protocol, we refer to Pedersen et al. (1995)
injections throughout the course of the distraction splint
treatment.
Radiological evaluation
The data collection process was blinded to the clinical
and radiological data to avoid issues about selection bias of The TMJ arthritis diagnosis was obtained from an interplay
the included candidates. This means that all patients between the standardized clinical examination and regular
included were identied before the radiological and clinical radiological examinations. Radiological examinations
material was evaluated. consisted of CBCT investigations from 2005 and forward
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Figure 1 Mode of action of distraction splint. (a) Frontal view of JIA patient with clearly asymmetric mandible due to TMJ arthritis in right TMJ
illustrated by the vertical line. The z-axis is perpendicular to the vertical line. (b) Frontal view after distraction splint insertion. Condylar, ramus, and
dentoalveolar vertical development normalizes and frontal facial asymmetry is reduced as illustrated by the vertical line. (c and d) Dentoalveolar effect of
splint: eruption of rst lower molar prevented by splint, which leaves space for eruption of rst upper molar. Adjustment of acrylic splint and prevention
of rst lower molar eruption enables control of upper dentoalveolar development. Teeth are illustrated with their FDI World Dental Federation notation. (e)
Later, second upper molar is allowed eruption into occlusion from the maxilla. Subsequently, splint is adjusted to guide remaining teeth into occlusion. This
approach optimizes dentoalveolar development and avoids occlusal collapse in affected side—both aspects are crucial for optimal condylar growth pattern
indicated by dotted lines.

(3D reconstructions, multiplanar cross sectional cuts, and
panoramic pictures). Before 2005, regular OTPs, lateral
cephalograms, and tomograms were used for the radiological
evaluation. In the present study, the evaluation of the
radiological study material was based on bilateral
measurements on panoramic pictures of condylar height,
ramus height, and total mandibular vertical height as
described by Kjellberg et al. (1995). CBCT-derived
panoramic pictures were used for the vertical measurements
to uniformize the radiological study material because the
majority of the patients had received a radiological T1
examination based on regular OTPs. At T1 and T2, a ratio
between the affected and the non-affected side was
calculated for each of the three variables of interest to
measure the present mandibular asymmetry (affected/
non-affected side). These data were used for statistical
evaluation of inter-side differences in the mandibular ratios
between T1 and T2 in terms of condylar height, ramus
height, and total mandibular vertical height. Reference
points and lines used for mandibular growth evaluation are
described in Figure 2. Radiological evaluation was blinded
to the clinical data.
Statistics
The reproducibility of condylar height, ramus height,
and total mandibular vertical height was evaluated by the
same observer (PS) with duplicate assessment of 10
randomly chosen scans 2 months apart. All variables
were evaluated for normal distribution. We hypothesized
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194 P. STOUSTRUP ET AL.

that mandibular symmetry ideally would agree with a Results

mandibular inter-side ratio of 1. T-tests were performed
for the evaluation of T1 and T2 asymmetry in ratios
between our study group and a hypothetical symmetrical
group. Additionally, for all variables, paired t-tests
between T1 and T2 inter-side ratios of our study group
were performed. A P value of <0.05 was considered
signicant.
Exclusion of patients
From the pre-selected group of 54 candidates, 32 patients
were excluded due to insufcient radiological documentation
or insufcient clinical data describing the basis for the use
of the distraction splint (27 persons), arthritis of their
contralateral TMJ was diagnosed during the distraction

Ethics/miscellaneous
The non-surgical orthodontic functional treatment applied
complies with the rules of the Danish Government of Health
for clinical paediatric orthodontic treatment. Handling of
the condential data was approved by the Danish Data
Protection Agency. Before initiating the study, the full
protocol was made available on the www.clinicaltrials.
gov website.
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splint treatment, and the treatment strategy had to be
changed to bilateral distraction (three persons), insufcient
quality of the OTPs (one person), and due to insufcient
cooperation throughout the treatment course (one person).
A total of 22 candidates were enrolled in the present study.
Radiological evaluation
At T1, the distribution of the radiological material was
OTPs in 18 patients and CBCT-derived OTPs in four
patients. At T2, the mandibular asymmetry was evaluated
on regular OTPs in three patients and on CBCT-derived
OTPs in 19 patients.

Figure 2 Illustration of reference points and lines used for measurement
of condylar height (a), ramus height (b), and total mandibular vertical
height ratio (a + b). Reference points used were condylar head (CH),
incisoral point (INC), and gonion point (GO). Condylar head point was
dened as point of intersection between a line from upper sagittal margin
of condylar head perpendicular to ramus line (RL). Incisoral point was
dened as point of intersection between a line from most inferior point in
concavity between condylar neck and coronoid process perpendicular to
ramus line. Gonion point was dened as point of intersection between
ramus line and mandibular line (ML) at most inferior and posterior point
on ramus. Condylar height variable (CH–INC), ramus height variable
(INC–GO), and total mandibular vertical height ratio (CH–GO) were
measured bilaterally at T1 and T2.
Duplicate assessments
The reproducibility showed acceptable 5 per cent
coefcients of variations in the condylar height
measurements and 3 per cent in the total vertical mandibular
height measurements. No coefcient of variation was
calculated for the ramus height variable because it was
calculated from the total mandibular vertical height
subtracted the condylar height.
Mandibular ratios
Table 1 shows the comparison of mandibular inter-side
asymmetry in ratios between our study cohort and a hypo-
thetical symmetrical group. At T1, signicant mandibular
asymmetry was seen in all three variables examined when
compared to a hypothetical symmetrical group. At T2, a
reduced mandibular asymmetry was seen in all three variables

Table 1 Evaluation of asymmetry between study cohort and a hypothetical symmetric group.

Symmetric group Study cohort Difference in ratio (SD) 95% Condence interval of difference P value

T1
Condylar height 1 0.88 0.12 (0.14) 0.06–0.19 P < 0.001
Ramus height 1 0.92 0.08 (0.12) 0.03–0.14 P < 0.05
Total vertical 1 0.90 0.10 (0.09) 0.06–0.14 P < 0.001
mandibular height
T2
Condylar height 1 0.91 0.09 (0.16) 0.02–0.16 P < 0.05
Ramus height 1 1.03 −0.03 (0.13) −0.09 to 0.02 n.s.
Total vertical 1 0.95 0.05 (0.08) 0.02–0.09 P < 0.05
mandibular height

Clinical measures are in ratios before (T1) and after treatment (T2). Mean differences between symmetric group and study cohort are included together
with the 95% condence intervals. P values are symmetric group versus study cohort. n.s., not signicant; SD, standard deviation.
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examined in comparison to T1 levels. However, sustained
signicant mandibular T2 asymmetries were seen in terms of
condylar height and in the total mandibular vertical height,
whereas the signicant mandibular asymmetry in terms of
ramus height was eliminated in comparison with the
hypothetical symmetrical group.
Table 2 depicts the mandibular mean ratios, which reect
the intra-individual progression in mandibular asymmetry
mandibular vertical height as depicted in Figure 3. Sustained
mandibular asymmetry was seen in the condylar height
ratio. Figure 3a features three patients with a T1 condylar
height ratio above 1. These patients had clinically obvious
functional impairments that indicated the presence of
unilateral TMJ arthritis and radiological signs of condylar
deformation were few, which made it possible for these
patients to have a ratio above 1 at T1. Three patients showed

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between T1 and T2. As can be seen, all three variables signs of angular osseous apposition in the affected side at
showed reduced asymmetry. Statistically signicant T1, which may explain why the T1 ratio between the affected
differences were seen in terms of ramus height and total and the non-affected side was above 1 (Figure 3b and 3c).

Table 2 Clinical measures of our cohort before treatment (T1) and after treatment (T2) in terms of condylar height ratio, ramus height
ratio, and total vertical mandibular height ratio.

T1 mean ratio (SD) T2 mean ratio (SD) Difference T1 − T2 (SD) 95% CI P value

Condylar height ratio 0.88 (0.14) 0.91 (0.16) 0.03 (0.16) −0.04 to 0.11 n.s.
Ramus height ratio 0.92 (0.12) 1.03 (0.13) 0.12 (0.21) 0.03–0.21 P < 0.05
Total vertical 0.90 (0.08) 0.95 (0.09) 0.05 (0.07) 0.02–0.07 P < 0.05
mandibular height ratio

Data are mean ratios [standard deviation (SD)]. 95% Condence intervals of the differences are listed (95% CI). The P values are T2 mean ratio against
T1 mean ratio; n.s., not signicant.

a b
2,0
2,0 Condylar height
Condylar height ratios
ratios 1,8
1,8 Ramus height ratios
Ramus height ratios

1,8
1,8 1,6
1,6

1,6
1,6
1,4
1,4
1,4
1,4
1,2
1,2
1,2
1,2
1,0
1,0
1,0
1,0
0,8
0,8
0,8
0,8

0,6
0,6 0,6
0,6
*
Before treatment
Before treatment After treatment
After treatment Before treatment
Before treatment After treatment
After treatment

c
1,6
1,6 Total posterior mandibular
Total posterior mandibular vertical
vertical height
height ratios
ratios

1,4
1,4

1,2
1,2

1,0
1,0

0,8
0,8

0,6
0,6
*
Before treatment
Before treatment After treatment
After treatment

Figure 3 Mandibular ratios before and after treatment. Ascending lines indicate improvements during treatment, whereas descending lines indicate
exacerbation of the given parameter. (a) Condylar height ratios with intra-individual lines. (b) Ramus height ratios. (c) Total posterior mandibular vertical
height ratios. *, Statistical signicant difference (P < 0.05) between T1 and T2 ratios.
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196 P. STOUSTRUP ET AL.

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Figure 4 (a) cone beam-computerized tomographic (CBCT) frontal view of an oligoarticular juvenile idiopathic arthritis (JIA) patient (age 10 years) with
asymmetric mandible due to arthritis in the left temporomandibular joint (TMJ). Distraction splint treatment was initiated at this point. (b) CBCT frontal
view of the same JIA patient (age 12 years) after 24 months of distraction splint treatment. Comparable mandibular growth rates have been achieved
between affected and non-affected sides. No exacerbation of the mandibular asymmetry occurred during treatment. (c) Potential long-term outcome of
untreated unilateral TMJ arthritis: CBCT frontal view of another oligoarticular JIA patient (age 17 years) with unilateral arthritis in left TMJ during
childhood and adolescence. This patient never received distraction splint treatment due to lack of compliance. Notice the distinct mandibular asymmetry.

Patients referred to surgical correction distraction splint optimizes dentoalveolar development in

Among the 22 JIA patients, three were referred to surgical
correction due to insufcient response to the functional
treatment. In Figure 3, the three most descending lines
between T1 and T2 mandibular inter-side ratios represent
the patients referred for to surgical correction. In a post-trial
analysis with exclusion of these three patients, we found a
signicant T1 difference in condylar height ratio between
the affected and the non-affected side. However, this inter-
side mandibular T2 asymmetry in condylar height ratio
remained even if the three patients referred to surgical
correction were excluded.
In a population of patients with unilateral TMJ arthritis,
we would expect an equal distribution of arthritis between
the right and the left side. An unexpected, but interesting
nding of this study was that 17 out of the 22 patients
included had unilateral TMJ involvement in the left side
(77 per cent).
Discussion
During mandibular growth, the amount and direction of
condylar growth depends on the development of the
dentoalveolar area and its surrounding soft tissue (Enlow
and Hans, 1996a). Dysmorphic condylar growth seems to
affect bone formation of the ramus, the mandibular basis,
and the dentoalveolar area in the affected side of patients
with TMJ arthritis. The main ndings of this study show,
rst, that an orthopaedic functional appliance treatment
approach that deploys a distraction splint can reduce
mandibular asymmetry between the affected and the non-
affected side. Second, distraction splint treatment causes
mandibular growth rates to become comparable in the
affected and the non-affected side in most patients. The
the affected side to the extent that occlusal collapse may be
avoided (Figure 4). Avoiding such collapse is vital to the
condylar and dentoalveolar developmental coordination
required to achieve optimal vertical mandibular growth. It
is unlikely that the orthopaedic treatment causes the condyle
to grow more than is indicated by the individual’s normal
genetic predisposition, but we here present evidence to
support benecial skeletal improvement in facial asymmetry
in JIA patients treated with a distraction splint for unilateral
TMJ arthritis. The clinical merit of early application of a
distraction splint also lies in its ability to induce comparable
bilateral growth so that asymmetry is minimal when the
mandibular growth period draws towards its end, even in
patients who suffer from unilateral arthritis.
Our observations are consistent with the results reported
in the sparse literature on JIA patients published on this
matter. In 1995, Kjellberg et al. found only limited skeletal
changes after orthopaedic treatment with a functional
activator appliance in JIA with bilateral TMJ arthritis
(Kjellberg et al., 1995). They concluded, however, that
skeletal changes in combination with the occlusal
improvements after treatment with fully xed orthodontic
appliance may result in better dentofacial aesthetics. In
2009, Farronato et al. described a benecial skeletal effect
of functional appliance treatment in JIA patients with
bilateral TMJ arthritis. They observed that functional
appliance therapy reduces the severity of facial alterations
improving mandibular and condylar growth (Farronato
et al., 2009). These ndings are in keeping with our results.
In the present study, both the ramus height ratio and the
total posterior vertical mandibular height ratio were
signicantly reduced, whereas no inter-side difference was
seen in the condylar height ratio. This is in keeping with
Enlow and Hans (1996a) who stressed the importance of
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understanding mandibular vertical growth as an interplay
between condylar, ramus, and dentoalveolar growth where
the condylar growth follows rather than leads the growth of
the whole ramus (Enlow and Hans, 1996b). It could be
speculated that the signicant reduction in the ramus height
ratio could be ascribed to an increased bone apposition in
the angular area. However, we found only little radiological
evidence to support this hypothesis. According to Enlow
and Hans, mandibular orthopaedics must target both the
ramus and the mandibular condyle to achieve maximal
effect. The principal clinical target for mandibular
orthopaedic treatment is therefore the entire ramus and the
muscles attached to it, not just the condyle (Enlow and
Hans, 1996b). Apart from having a dentoalveolar effect, we
hypothesize that the distraction splint may have a protective
effect against overloading of the involved TMJ in periods
with acute arthritis, thereby relieving symptoms and
reducing joint contraction and stiffness. We also hypothesize
that the distraction splint has a favourable effect on the
potential unbenecial soft tissue and muscle alterations that
accompany TMJ arthritis in the affected side. In addition,
similar to the development of the dentoalveolar process, the
progressive increase in height will prevent the vertical
collapse of the affected side due to the maintained distance
between the upper and lower jaw.
Several clinical and experimental studies have suggested
a relationship between masticatory muscle function and
craniofacial growth (Kiliaridis, 1995; Bresin, 2001; Bresin
and Kiliaridis, 2002; Mavropoulos et al., 2004; Pepicelli
et al., 2005). Thus, experimental interference with jaw and
facial muscle development has been shown to entail major
changes in the mandibular shape (Pepicelli et al., 2005).
This was supported by Tsolakis and Spyropoulos who
observed vertical mandibular growth in rats after
condylectomy had been performed if function was
stimulated by having the rats wear a protrusive functional
appliance (Tsolakis et al., 1997). Recently, Nakano et al.
described how a functional appliance led to correction of an
asymmetric mandibular growth pattern in rats after
unilateral condylectomy (Nakano et al., 2009).
There are a number of limitations in this study that need
consideration. Orthopaedic treatment of TMJ arthritis and
mandibular growth disturbances proceeds over a long
period, involves substantial intervention, and requires
excellent patient cooperation. In this study, the long duration
of treatment (mean 57 months) is a limitation to this
treatment approach. However, it should be emphasized that
the splint adaptation is relatively unproblematic in the
majority of the patients. They rapidly adapt to the new
occlusion and do not consider the use of the splint as a
liability.
Despite general good compliance from the patients, not
all achieved a completely symmetric mandibular appearance
following the distraction splint treatment. However, it is
important to emphasize that the distraction splint treatment
1978
reduced the mandibular and craniofacial asymmetry to such
an extent that most of the patients in this study had no need
for further correction. With these ndings, we present an
argument in favour of instituting early intervention using
the splint appliance rather than awaiting asymmetric
mandibular growth to occur and only then seek to increase
the growth rate in the affected side.
Mandibular vertical growth was evaluated based on
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OTPs. The sensitivity of panoramic radiography in detecting
osseous changes is low (Ahmad et al., 2009). The use of
panoramic pictures to evaluate mandibular linear distances
is also controversial and is associated with potential study
weaknesses such as distortion and magnication errors as
well as variation in the orientation of the head (Kjellberg,
1995). However, the reproducibility of panoramic pictures
has been found acceptable for the evaluation of mandibular
vertical dimensions as long as the variables measured do
not cross the midline of the mandible (Catic et al., 1998;
Kambylafkas et al., 2006; Van Elslande et al., 2008).
A small relative mean side-to-side distortion of conventional
panoramic pictures has been reported (Catic et al., 1998). In
the present study, the minimal amount of time between the
radiological T1 and T2 comparison was 14 months. The
mean time between comparisons was 57 months (range
14–99 months) and with that time frame we assume that
longitudinal changes in mandibular vertical ratios can be
distinguished reliably with the panoramic technique.
To avoid issues about magnication errors from the
different machines used for the radiological examinations,
no statistical analyses were conducted based on linear
measurements in the present study. Instead, we calculated
ratios for mandibular inter-side differences as an expression
of mandibular asymmetry. Kjellberg et al. found that this
method is not affected by positioning error, distortion, or
magnication (Kjellberg et al., 1994).
The present study does not contain an untreated control
group. A comparison between our cohort and historical data
on unilateral TMJ arthritis patients was considered of
limited value. Instead, we chose a within-patient setup with
a comparison between the non-affected and affected side,
which eliminates the inuence of age, sex, general disease
variables, and medication in addition to the radiological
advantages of such design.
Conclusion
Further research on the effect of the use of the distraction
splint is necessary. However, we believe that the results
published in this study are of importance for clinicians as
we nd evidence to support that distraction splint treatment
can reduce mandibular asymmetry in JIA patients with
unilateral TMJ arthritis. Based on our ndings, we therefore
propose implementation of distraction splint therapy in the
treatment of JIA patients with unilateral affection of
mandibular growth caused by TMJ arthritis, which may, in
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198
most patients, cause comparable mandibular growth rates in
the affected and the non-affected side.
Acknowledgements
The authors would like to thank the entire staff in the
rheumatology team at the Orthodontic Department,
Aarhus University, Denmark. Additionally, we would
like to thank our colleagues Carlaberta Verna (DDS PhD)
and Lene Boldrup Birn (DDS PhD) who have participated
in the treatment of some of the patients. We also thank
graphic designer Nikolai Lander for his help with the
illustrations.
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