Ann. rheum. Dis. (1967), 26, 538

RHEUMATOID ARTHRITIS OFTHE TEMPOROMANDIBULAR JOINTS*

BY

JOSEPH J. MARBACH AND HARRY SPIERAFrom the Departments of Dentistry and Medicine,

The Mount Sinai Hospital and Mount Sinai School of Medicine,New York, New York 10029

Although temporomandibular-joint involvementby rheumatoid arthritis is well recognized, itsincidence is unknown. Russel and Bayles (1941)estimated that the temporomandibular joints be-came involved in 50 per cent. of patients, Ragan(1949) 4 7 per cent., Markowitz and Gerry (1950)8 *7 per cent., and Einaudi and Viara (1964) 29 3 percent in 260 rheumatoid arthritics. These variationsmay be explained by the use of different diagnosticcriteria and different populations. The presentstudy describes two patients in whom temporo-mandibular-joint arthritis is a prominent feature,and our attempts to treat them in a rational mannerbased upon an understanding of the mechanics ofthe temporomandibular joints.

Case ReportsCase 1, a 37-year-old woman, complained of progressive

elongation of the lower one-third of her face, a change inthe relationship of her upper and lower teeth, anddifficulty in chewing of 2 years' duration. She had hadrheumatoid arthritis for 27 years with typical rheumatoiddeformity of the hands, wrists, knees, and shoulders.She had been treated with salicylates and gold salts, andhad had multiple synovectomies. The latex fixationtest was strongly positive and the erythrocyte sedimen-tation rate 60 mm./hr (Westergren). Histologicalexamination of tissue removed at the time of ortho-paedic surgery showed changes typical of rheumatoidarthritis.

Clinical Examination.-Mandibular movements wereco-ordinated but restricted, especially the straight protru-sive movement (forward thrust) of the mandibularcondyles. The left manibular condyle could not bepalpated. The right masseter and temporalis and the leftmasseter muscles were painful on palpation. Thementalis and depressor labii inferioris muscles appearedlengthened.

*Read in part at the Annual Meeting ofthe New York RheumatismAssociation on April 18, 1967.

Dental Examination.-Only the maxillary and mandi-bular second molar teeth made contact when the patientbrought her teeth together. She stated that before theonset of rheumatoid arthritis her teeth had made normalcontact, and this was verified by wear facets on her teeththat evidenced years of contact. An interincisal openingof 2 mm. existed with the molar teeth in contact (Fig. 1).She had difficulty in chewing, and a frontal or labial lispdistorted her speech.

Fig. l.-Case 1. With the second molar teeth in contact there is anincreasing opening anteriorly.

Radiographs.-The left mandibular condyle wasflattened on the anterior and superior aspects (Figs2, 3, 4, 5, opposite). A round radiolucent area was seennear the superior border of the condylar head. A spurwas present on the anterior surface at the site of thetendinous insertion of the lateral pterygoid muscle.The articular eminence of the temporal bone was flattenedwhile the joint space was greatly enlarged. The right

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RHEUMATOID ARTHRITIS OF THE TEMPOROMANDIBULAR JOINTS 539

Fig. 3.-Normal right temporomandibular joint in open position.F ~~~~~~~~~Noteanterior movement of entire condylar head. In the action of

opening the condyle first rotates and then translates.

Fig. 2.-Normal right temporomandibular joint in closed position.(M) internal auditory canal. (MC) mandibular condyle. (E)articular eminence of temporal bone. (F) glenoid fossa of temporalbone. Note smooth cortical plate with cancellous bone in centre and

smooth concave congruous glenoid fossa of temporal bone.

Fig. 4.-Case 1. Left temporomandibular joint in closed position,showing flattening of anterior and superior aspects of mandibularcondyle. A radiolucent area is seen near the superior border. Aspur is present on the anterior surface. There is a flattening of the Fig. 5.-Case 1. Left temporomandibular joint in open position.

glenoid fossa. There is little forward movement of the mandibular condyle.

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ANNALS OF THE RHEUMATIC DISEASES

mandibular condyle was flattened superiorly. Bothmandibular condyles showed sclerotic changes.

Treatment.-This comprised therapeutic exercises,reduction in the height of the posterior teeth, andretraining of the tongue. Because of the progressivenessof the patient's rheumatoid arthritis, dental treatment wasconfined to the reduction of the natural tooth structureof the posterior teeth. Gold crowns were not usedbecause they in turn might have to be ground down.Thermal sensitivity of the teeth was controlled with theuse of a desensitizing dentifrice. Stretching exercisesincreased the mandibular opening from 43 to 49 mm.The straight protrusive movement remained restricted.The patient's speech was improved by retraining tonguemovements.*

Case 2, a 31-year-old woman, complained of changes inher bite, elongation of her face, and difficulty in chewing.The onset of polyarthritis involving wrists, knees, and theproximal interphalangeal joints of the hands had occurred2 years before. At that time the latex fixation test waspositive. She had been treated initially with prednisoneand then with aspirin with good response.

Physical Examination.-There were bilateral flexiondeformities of the elbows and tenderness and swelling atthe proximal interphalangeal joints. The erythrocytesedimentation rate was 16 mm./hr (Westergren), and thelatex fixation test for rheumatoid factor was negative.

Clinical Examination.-There was an interincisalopening of 3 mm. with the molar teeth in contact (Fig. 6).Mandibular movements, especially the straight protrusivemovement (forward thrust) of the mandibular condyles,were coordinated but restricted. The mentalis anddepressor labii inferioris muscles appeared lengthened(Fig. 7).

Radiographs.-There was a flattening of the glenoidfossa and the anterior aspects of the left and rightmandibular condyles. The right condyle showed thecortical bone intact (Fig. 8, opposite). The left showedan irregular outline and sclerotic bone.

openingfromsecondmolarf;_ g | ~~~ ~ ~ ~~~.|.... -.

Fig. 6.--ase 2. Increasing opening from second molar forwards.

*It is interesting to note the comments of Goodwill and Steggles(1966) with regard to treatment of the teeth in rheumatoid arthritis ofthe temporomandibular joints:

"Since this is a progressive process, restoration ofocclusion functionpresents a problem. The best solution seems to be restoration of theocclusion by means of a prosthesis causing as little interference withfree mandibular movement as possible; this allows for variations in therelationships of the head of the mandible in the region of the glenoidfossa."

In our opinion, it is important to make clear that the prosthesisshould be fixed whenever possible. The patient described by Good-will and Steggles was an edentulous individual for whom completedentures were constructed. The shortcomings of removable ap-pliances with their inherent instability, resting on the oral mucousmembrane, often tax the adaptive capacities of a healthy person.When this capacity is decreased as in disease, the success of theprosthesis is likewise decreased, and it is therefore wise to attempt torestore and maintain all the natural teeth. We also wish to commenton the relationship of the head of the mandible to the glenoid fossa.It should be emphasized that this relationship is governed primarilyby the musculature of the joint and not by the teeth. Thus treatmentshould begin with and concentrate upon the muscles involved beforeany dental therapy is started.

Fig. 7.-Case 2. Upward displacement of soft tissue overlying bonygnathion with lips in contact.

Treatment.-This comprised therapeutic exercises,reduction in the height of the posterior teeth, retrainingof the tongue, and orthodontic movement of the upperanterior teeth.

Examination initially and at the second visit revealeda maximum mandibular opening of 33 mm. measuredfrom the incisal edges of the upper and lower centralincisor teeth, which was a restricted opening for thispatient. Increased mandibular range was achieved withthe following exercise:

The patient was first to stretch her mouth open tentimes and then to place her fist under her chin and openher mouth three times against the gentle upward pressure

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RHEUMATOID ARTHRITIS OF THE TEMPOROMANDIBULAR JOINTS

Fig. 8.-Case 2. Left temporomandibular joint in open position,showing erosion of anterior and superior aspects ofmandibular condyle

and flattening of temporal fossa.

of her fist. She was to do this three times daily, beforeeach meal. This technique acts reflexly to relax the mas-seter and medial pterygoid muscles. Within 4 weeks,the maximum mandibular opening was increased by11 mm. to 44 mm. Only the straight protrusive move-ment remained restricted, probably because of thedestruction of the tendinous insertion of the lateralpterygoid muscles.

Once the range and character of mandibular move-ments improved, reduction of the occlusal surfaces ofthe posterior teeth was begun. Enamel was removedand underlying dentin was exposed. This necessitatedtooth restoration by means of gold crowns. The patientwas much more comfortable with her congruous bite, andestablishment of a normal diet followed. With a reduc-tion in tooth height, the soft tissues of the chin were

realigned over the bony tissue to their natural position.The patient was no longer required to stretch her lowerlip upwards excessively to make contact with the upperlip.During the reduction in tooth height, the patient was

instructed in a method of preventing tongue thrusting.This resulted in an improvement in speech, with completeelimination of the lisp (Jann, Whitman, and Jann, 1966).The upper six anterior teeth were moved with a simple

orthodontic appliance, which closed the gap between theupper and lower teeth.

Temporomandibular Joints in RheumatoidArthritis

The earliest changes occur in the synovial mem-brane, which becomes hyperaemic and infiltratedwith lymphocytes and plasma cells. There is athickening of the membrane and fluid accumulationin the joint cavity. Examination reveals swollenand tender temporomandibular joints. Pain and

muscle spasm may limit joint movement. Noradiographic changes may be discernible (Grokoestand Schwartz, 1959).When the course of the temporomandibular-joint

involvement is progressive, cartilage and bonebecome eroded. Adhesions may form between thesynovial membrane and the capsular ligament.There is a characteristic flattening of the anteriorsurface of the mandibular condyle due to destructionof the fibrocartilage and denuded bone. Erosion ofthe ligamentous attachment of the lateral pterygoidmuscle occurs in conjunction with the cartilaginousand bony tissue changes (Blackwood, 1963).

Degenerative joint disease may be superimposedon the rheumatoid arthritis. The anterior surfacemay develop a spur which is characteristic of de-generative joint disease (Schwartz and Marbach,1965). This area becomes the site of new boneformation by a process of vascular invasion of thecartilage. Adhesions of the soft tissue may occupythe joint space and ultimately result in fibrousankylosis.The most characteristic change observable in

radiographs of the temporomandibular joint inrheumatoid arthritis is the flattening of the anterioraspect of the condylar head. This is seen as aragged outline of the cortical and subcortical bone.The subcortical erosions may appear as a radio-lucency within the head of the condyle. In normaljoints, the anterior movement of the condyle isreadily seen in a radiograph as the patient opens hismouth. In rheumatoid arthritis, however, there islittle difference in the position of the temporo-mandibular joints with the mouth open and with themouth closed.

Clinical Signs and Symptoms.-An early sign maybe a malocclusion characterized by an openingbetween the anterior teeth when the molar teeth arein contact. This opening may occur for two reasons:the destruction of the anterior and superior aspectsof the mandibular condyle with disruption oflateral pterygoid function; and flexion contractureof the muscles of mastication, primarily the masseterand medial pterygoid muscles. These large elevatormuscles of the mandible-the temporalis, masseter,and medial pterygoid muscles-pull the mandibleupward and forward.When flexion contracture occurs in these muscles,

the primary site of pressure is just on those surfacesof the mandibular condyle that are seen to be erodedin the roentgenograms and histological sections frompatients with rheumatoid arthritis. The erodedsurfaces are the anterior and superior surfaces. Ifdestruction of the condyle or flexion contracture is

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ANNALS OF THE RHEUMATIC DISEASES

Fig. 9A.-Normal relationship of mandibular condyle to interiorauditory canal and temporal fossa. The masseter and lateral

pterygoid muscles are shown in part.

absent, the teeth would prevent the open bite. Butin the presence of both phenomena, the molar teethact as an axis on which the mandible rotates (Fig. 9).Once an opening appears between the front teeth,

the patient may increase the opening by thrustinghis tongue into the space. He does this unconscious-ly in an attempt to reestablish an anterior seal whileswallowing. (A conscious effort must be made tokeep the tongue from darting forward while swallow-ing when the anterior teeth are parted.) Thisopening causes a frontal or lingual lisp (Van Riper,1954). To allow contact of the upper and lowerlips, they are constantly stretched, and this lengthensthe mentalis and depressor labii inferioris muscles.The result is an upward migration of the point of thechin that normally overlies the bony gnathion. Thischin displacement, with its accompanying effect on

Fig. 9B.-The mandibular condyle is destroyed in characteristicfashion. Upper arrow shows direction of contraction of lateralpterygoid muscle and lower arrow that of masseter muscle. This

results in the characteristic open bite.

the patient's appearance, is often his chief com-plaint, and it may be the primary reason for thepatient seeking care.

SummaryThe histology, radiography, and clinical signs

and symptoms of rheumatoid arthritis of thetemporomandibular joint are discussed, and twoillustrative case histories are presented. In the firstcase the signs and symptoms associated with thetemporomandibular joints were but one aspect of apolyarthritis. In the second case they were themajor manifestation of the disease. Treatmentwas followed by improvement of mastication, and areversal of the progressive facial deformity. In bothcases, these improvements resulted in a greatersense of well being.

REFERENCESBlackwood, H. J. J. (1963). Brit. dent. J., 115, 317 (Arthritis of the mandibular joint).Einaudi, G., and Viara, M. (1964). Reumatismo, 16, 341 (I1 comportamento deli' articolazione

temporo-mandibolare nei pazienti affetti da artrite reumatoide).Goodwill, C. J., and Steggles, B. G. (1966). Ann. rheum. Dis., 25, 133 (Destruction of the temporo-

mandibular joints in rheumatoid arthritis).Grokoest, A., and Schwartz, L. (1959). In Schwartz, L. "Disorders of the Temporomandibular

Joint", p. 388. Saunders, Philadelphia and London.Jann, G. R., Whitman, D. F., and Jann, H. W. (1966). J. Amer. dent. Ass., 73, 91 (Course to re-

educate orthodontic patients in swallowing patterns).Markowitz, H. A., and Gerry, R. G. (1950). Oral Surg., 3, 75 (Temporomandibular joint disease).Ragan, C. (1949). J. Amer. med. Ass., 141, 124 (The general management of rheumatoid arthritis).Russell, L. A., and Bayles, T. B. (1941). J. Amer. dent. Ass., 28, 533 (The temporomandibular joint

in rheumatoid arthritis).Schwartz L., and Marbach, J. J. (1965). J. Amer. Soc. Periodontists, 3, 184 (Changes in the temporo-

mandibular joints with age).Van Riper, C. (1954). "Speech Correction", 3rd ed., p. 260. Prentice-Hall, New York.

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L'arthrite rhumatismale de I'articulation temporo-maxillaire

RESUMm

On discute les symptomes et les signes cliniques, radio-graphiques et histologiques de l'atteinte temporo-maxillaire au cours de l'arthrite rhumatismale. On pre-sente deux observations pour illustrer ceci. Dans lepremier cas les signes et les sympt6mes associes A

l'atteinte temporo-maxillaire n'etaient qu'un des aspectsd'une polyarthrite. Dans le deuxieme cas ils etaient lamanifestation majeure de la maladie. Le traitemententraina une amelioration de la mastication et uner6gression de la deformation faciale. Dans les deux casl'amelioration se traduisit par une plus grande sensationde bien-etre.

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La artritis reumatoide de la articulacion temporo-mandibular

SUMARIO

Se discute la sintomatologia clinica, histol6gica yradiografica de la artritis reumatoide de la articulaci6ntemporo-mandibular. Se describen dos casos ilustrativos.En el primer caso los sintomas asociados con las articu-laciones temporo-mandibulares representaron s6lo unaspecto de una poliartritis. En el segundo caso estossintomas fueron la mayor manifestaci6n de la enferme-dad. El tratamiento fue seguido de una mejoria de lamasticaci6n y de la deformaci6n de la cara. En amboscasos esta mejoria trajo a los enfermos una sensaci6n debienestar.

RHEUMATOID ARTHRITIS OF THE TEMPOROMANDIBULAR JOINTS

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