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Psoriatic arthropathy of the temporomandibular joint
Psoriatic arthropathy of the temporomandibular joint A. W. Wilson, FDSRCS, J. S. Brown, FDSRCS, FRCS, and R. A. Ord, FDSRCPS, FRCS, Sunderland, England SUNDERLAND DISTRICT GENERAL HOSPITAL A case of psoriatic arthritis of both temporomandibular joints is described with a brief review of the literature and discussion on the management of this condition. To date, psoriatic arthritis has been successfully treated by conservative means. In the case reported, surgical replacement of the condyles became necessary to eliminate pain and restore function. (ORAL SURC ORAL MED ORAL PATHOL 1990;70:555-8)
P
soriasis is a chronic (occasionally acute), papulosquamousskin diseaseof unknown causeaffecting 2% of the population. Psoriatic arthropathy (PA) is defined as a seronegative erosive arthritis in patients with cutaneous psoriasis and affects 20% of psoriasis patients.lT3In 1971 Boyle and Buchanan4 gave three requirements before a diagnosis of PA of the temporomandibular joint (TMJ) could be made, which are listed as follows: (1) psoriasis, (2) erosive polyarthritis (evident radiographically), and (3) negative serologic test for rheumatoid factor. PA may manifest in a range of complex patterns (Table I). Monoarticular involvement, however, has been described in the TMJ.5 The etiology is thought to be multifactorial with a strong genetic component. Histocompatibility studies6 reveal factors that explain its propensity toward association with other conditions, including ankylosing spondylitis; Crohn’s disease;Reiter’s, Behqet’s, and SjGgren’ssyndromes; and aortic incompetence.’ To date, 27 cases of PA affecting the TMJ have beendescribed in the literature (Table II). Kijnijnen’s article,8 however, suggests that involvement of the TMJs may be common. Patients usually have varying degreesof pain and tenderness of the joints with limitation of opening. Joint involvement is often symmetric. The histopathologic features of the condition make it impossible to differentiate from rheumatoid arthritis and the other seronegative arthritides. It has been postulated, however, that there is an increased tendency to fibrosis, with a predilection to a more de7/12/16064
Table I. Different groups of PA and patterns of joint involvement 1
Classic
2
Mutilans
3
Rheumatoid-like
4
Oligoarticular
5
Spondylitic
Distal interphalangeal joints Nail lesions Phalanges and metacarpals Sacroiliitis Symmetric polyarthritis Variable serologic status Interphalangeal joints Metatarsophalangeal joints PA and ankylosing spondylitis
structive arthropathy. ‘39*lo Trauma may trigger osteolysis, which may be localized to the joint in question or become generalized. Joint involvement may precede psoriasis in rare instances. Nail dystrophies are present in 80% of patients with PA, as compared with 20% of caseswith uncomplicated psoriasis. CASEREPORT
A 37-year-old white woman was referred by her general medical practitioner in June 1986 with intermittent pain over the previous year affecting the left TMJ. The pain was exacerbated by talking and eating and was associatedwith occasional locking and marked crepitus. The symptoms had gradually increased during the preceding 9 months. The medical history included PA, and various operations had been performed since the age of 18. In 1964 excision of the distal end of the left ulna and an osteotomy of the left radius was performed for a Madelung’s deformity. In 1976an operation was carried out to decompressthe left ulnar nerve, followed by a left wrist fusion 2 years later. The psoriasis affected the skin of the wrists, elbows, knees,and scalp,and was well controlled with Betnovate topical steroid cream. 555
556
Wilson, Brown, and Ord
ORAL SURGORAL MED ORAL PATH~L
November I990 Table II. Previously reported casesof PA affecting the TMJ 1 No. of
Pain
cafe.7
1965 Franks2’ 1965 Lundberg** 1975 Lowry23 1976 BlairI 1982 Rasmussanand Bakke5 1983 Wood and Stankler14 1986 Baetzand Kleinbergi2
Fig. 1. Clinical appearanceof left condyle at removal alnd radiographic appearance of right condyle before its I‘emoval. Marked erosion and flattening of both condyl ar heads are apparent.
The arthropathy was controlled by steroid injections into the joints, nonsteroidal anti-inflammatory drugs, and an occasional course of low-dose systemic steroids. On examination, the patient was edentulous and was wearing a full set of upper and lower dentures. She had a mild trismus with a maximum interincisal opening of 2.5 cm (4.7 cm with dentures out). The left TMJ was tender with marked crepitus. The patient had beenwearing the sameset of dentures for 14 years. Radiographs showed someerosion
I 11 I 7 4
1 Limited opening
1
1
2
3 4 2
I 4 2
I
I
1
I
of the condylar head on the right side (Fig. l), and a diagnosis of TMJ dysfunction in association with PA was made. Steroid injections, physiotherapy, and the provision of a new set of dentures failed to control the pain. A high condylar shave was performed 4 months later in October 1986. This procedure failed to control the symptoms. An area of psoriasis developed in the preauricular scar postoperatively (Koebner effect), but it soon resolved. Further physiotherapy and steroid injections were also unsuccessful, and so a further exploration of the left TMJ was carried out in May 1987. At this operation the irregular condylar head was smoothed and the posterior nerve supply sectioned. An interpositional temporalis fascia flap was used to prevent reanastomosis.” Unfortunately, this operation was also unsuccessful, and similar symptoms had developed on the right side. At this stage, drug treatment was tried, including phenytoin, amitriptyline, and carbamazepine. Transcutaneous nerve stimulation, myoneural blocks, and a left stellate ganglion sympathetic block all failed to control the facial pain over the next 9 months. In April 1988 it was decided to remove the diseasedleft condylar head and replace it with a costochondral graft. This operation was carried out through a preauricular and high Risdon incision. The inner cortical table of the mandibular ramus was preservedto enable fixation of the graft. A 2.5 cm length of fifth rib with cartilage was harvested through a submammary incision and was fixed to the receptor site with three lag screws. Intermaxillary fixation was maintained for 6 weeks. The operation was performed without complication and resulted in an immediate relief of symptoms on the left side. A similar operation was carried out in December 1988 on the right side (Fig. 2) and so far the patient has been symptom free. The histology of both condylar heads was reported as nonspecific degenerative arthropathy with fibrosis. Seven months after replacement of the right condyle, the patient is without symptoms and has full function with an interincisal opening of 3 cm (5.2 cm with dentures out). DISCUSSION
All the casesof PA affecting the TMJ reported to date have responded to conservative treatment. This is the first casein which intractable pain has necessitated surgical intervention. With only 27 cases reported, this condition seemsto be uncommon. How-
Volume70
Psoriatic arthropathy
of TMJ
557
Number 5
Fig. 2. Final postoperative radiographic appearanceafter replacement of both condyles with costochondral grafts. Grafts were secured with titanium screws.
ever, in Kiiniinen’s article,* of the 400 patients with PA reported, 20% complained of TMJ symptoms. A similar percentage of patients with psoriasis free of arthritis also complained of similar symptoms. Without the benefit of radiographic analysis, these patients complaining of TMJ symptoms cannot be proved to have PA of the TMJ. From these figures, however, it seemslikely that this condition may be more common than hitherto believed. Psoriasis is a stressful condition, and this may predisposethesepatients to TMJ dysfunction. Trauma to a joint may precipitate PA,* and patients have been reported with an acute onset of PA of the TMJ after minor trauma.12-14Although it is known that stress can affect the joint and its associatedmusculature, the physiologic triggers or mechanism is not understood. Despite the clear requirements of Boyle and Buchanan, a diagnosis of PA of the TMJ is not always easy. Apart from the fact that psoriasis is not always
present or easily identifiable, joint symptoms may precede the skin condition. Demonstration of a polyarthritis may not be possible inasmuch as monoarticular involvement is a feature of the disease.5In addition, serology can be positive for 5% of the normal population. If a patient is likely to have PA of the TMJ, then a careful examination of the nails, scalp, and umbilicus may help in the diagnosis.12 Radiographic changes in the TMJ are readily demonstrated by specific TMJ views, which may show osteoporosisor erosion of the condylar heads5(Fig. 1). As mentioned earlier, the patients often have pain and limitation of movement. This limitation often persists after successfultreatment of the pain and may relate to the tendency of fibrosis in this condition.’ In the management of PA affecting the TMJs, the first aim of treatment is to relieve pain.15Initially, this should include counseling and reassurance, with emphasis placed on the benign nature of the dis-
558
Wilson, Brown, and Ord
ease.iI. ‘L I6 As suggestedin this article, the stressassociated with psoriasis may exacerbate or precipitate disease in the joints. 7,8 Control of the generalized diseaseand relief of any aggravating factors are thus important. Rest and the use of nonsteroidal antiinflammatory drugs are recommended at this stage. In this case the dentures were not thought to be contributing to the problem but their replacement and adjustment to the vertical dimension was carried out to eliminate them as a possible factor. The use of steroids has a long history in the treatment of joint pain and arthritis. As well as reducing inflammatory destruction, it can induce a pharmacologically achieved arthroplasty.16. I7 The use of steroids, either topically or systemically, must of course take into account the presence of overlying skin infection related to the psoriasis. Physiotherapy was attempted throughout the treatment in this caseto reduce pain and improve function of the joints, but it invariably failed to produce significant improvement. The operation as described by Bradley,’ ’ to section the nerve supply to the joint and to prevent reanastomosis with interpositional temporalis fascia, also proved to be unsuccessful. The role of depression in facial pain, as highlighted by HarrisIs was also considered. As a result, antidepressant therapy was used to eliminate this as a factor in the etiology. The decision to try to replace one of the diseasedcondylar headswas made only after exhausting all the remaining reasonable alternatives as described in the report. The use of costochondral grafts as joint replacements19has been very successfulin relieving pain and restoring function in casesof arthritis. When surgery is considered in such cases,the small risk of development of psoriatic lesions in the subsequent scars (Koebner effect) should be discussed with the patient. *OAlthough the primary aim in these cases should be the elimination of pain, the restoration of function is also important. In this casethe use of costochondral grafts has relieved the pain, and this patient has retained a normal occlusion with a 3 cm opening 12 months after surgery. REFERENCES 1. Mall JHM, Wright V. Seronegative polyarthritis. Amsterdam: North Holland Publishing Company, 1976:169-235.
ORAL SURG ORAL MED ORAL PATHOL November 1990
5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
20.
21.
22. 23.
Reed WB. Psoriatic arthritis. Acta Derm Venereol (Stockh) 1961; 41:396-403. Wright V. Rheumatism and psoriasis: a reevaluation. Am J Med 1959;27:454-62. Boyle JA, Buchanan WW. Clinical rheumatology. Oxford: Blackwell, 1971:304-17. Rasmussan OC, Bakke M. Psoriatic arthritis of the temporomandibular joint. ORAL SURC ORAL MED ORAL PATHOL 1982;53:351-7. Brewerton DA, Albert E. HLA and disease. Copenhagen: Munksgaard. 1977:94-107. McCarty DJ, Bennett RM. Arthritis and allied conditions. 9th ed. Philadelphia: Lea & Febiger, 1979:642-55. Koniinen M. Craniomandibular disorders in psoriasis. Community Dent Oral Epidemiol 1987;15:108-12. Fassbender HG. Pathology of rheumatic disease. Berlin: Springer-Verlag. 1975:245. Gardner DL. Pathology of connective tissue diseases. London: Arnold, 196568. Bradley PF. Conservative treatment for temporomandibular joint pain dysfunction. Br J Oral MaxillofacSurg 1987;25:12531. Baetz K, Kleinberg I. Psoriatic arthritis of the temporomandibular joint. Aust Dent J 1986;31:335-9. Blair GS. Psoriatic arthritis and the temporomandibular joint. 1976;4:123-8. Wood N, Stankler L. Psoriatic arthritis of the temporomandibular joint. Br Dent J 1983;154:16-8. Loebl DH. Psoriatic arthritis. JAMA 1979;242:2447-51. Ogus HD, Toller PA. Common disorders of the temporomandibular joint. In: Derrick DD, ed. Dental practitioner handbook. No. 26. 2nd ed. Bristol: Wright, 1986:96-101. Hollander JL, Brown EM, Jesser RA. Hydrocortisone and cortisone injected into arthritic joints. J Am Dent Assoc 1951;147:1629. Harris M. Medical versus surgical management of temporomandibular joint pain and dysfunction. Br J Oral Maxillofac Surg 1987;25:113-21. Politus C, Fossion E, Bossuyt M. The use of costochondral grafts in arthroplasty of the temporomandibular joint. J Craniomaxillofac Surg 1987;15:345-54. Fitzpatrick TB, Arndt KA, Clark WH, Eisen AZ, Van Scott EJ, Vaughan JH. Dermatology in general medicine. New York: McGraw-Hill, 1971:225-6. Franks AST. Temporomandibular joint arthrosis associated with psoriasis. ORAL SURG ORAL MED ORAL PATHOL 1965; 19:301-3. Lundberg M. Rontgendiagnostik vid kakledsbesvar. Odontol F&en T 1965;29:209-40. Lowry JC. Psoriatic arthritis involving the temporomandibular joint. ORAL SURG ORAL MED ORAL PATHOL 1975;33: 206-8.
Reprint requests to: Dr. A. W. Wilson Sunderland District General Hospital Kay11 Road Sunderland SR4 7TP, England, U.K.
P
soriasis is a chronic (occasionally acute), papulosquamousskin diseaseof unknown causeaffecting 2% of the population. Psoriatic arthropathy (PA) is defined as a seronegative erosive arthritis in patients with cutaneous psoriasis and affects 20% of psoriasis patients.lT3In 1971 Boyle and Buchanan4 gave three requirements before a diagnosis of PA of the temporomandibular joint (TMJ) could be made, which are listed as follows: (1) psoriasis, (2) erosive polyarthritis (evident radiographically), and (3) negative serologic test for rheumatoid factor. PA may manifest in a range of complex patterns (Table I). Monoarticular involvement, however, has been described in the TMJ.5 The etiology is thought to be multifactorial with a strong genetic component. Histocompatibility studies6 reveal factors that explain its propensity toward association with other conditions, including ankylosing spondylitis; Crohn’s disease;Reiter’s, Behqet’s, and SjGgren’ssyndromes; and aortic incompetence.’ To date, 27 cases of PA affecting the TMJ have beendescribed in the literature (Table II). Kijnijnen’s article,8 however, suggests that involvement of the TMJs may be common. Patients usually have varying degreesof pain and tenderness of the joints with limitation of opening. Joint involvement is often symmetric. The histopathologic features of the condition make it impossible to differentiate from rheumatoid arthritis and the other seronegative arthritides. It has been postulated, however, that there is an increased tendency to fibrosis, with a predilection to a more de7/12/16064
Table I. Different groups of PA and patterns of joint involvement 1
Classic
2
Mutilans
3
Rheumatoid-like
4
Oligoarticular
5
Spondylitic
Distal interphalangeal joints Nail lesions Phalanges and metacarpals Sacroiliitis Symmetric polyarthritis Variable serologic status Interphalangeal joints Metatarsophalangeal joints PA and ankylosing spondylitis
structive arthropathy. ‘39*lo Trauma may trigger osteolysis, which may be localized to the joint in question or become generalized. Joint involvement may precede psoriasis in rare instances. Nail dystrophies are present in 80% of patients with PA, as compared with 20% of caseswith uncomplicated psoriasis. CASEREPORT
A 37-year-old white woman was referred by her general medical practitioner in June 1986 with intermittent pain over the previous year affecting the left TMJ. The pain was exacerbated by talking and eating and was associatedwith occasional locking and marked crepitus. The symptoms had gradually increased during the preceding 9 months. The medical history included PA, and various operations had been performed since the age of 18. In 1964 excision of the distal end of the left ulna and an osteotomy of the left radius was performed for a Madelung’s deformity. In 1976an operation was carried out to decompressthe left ulnar nerve, followed by a left wrist fusion 2 years later. The psoriasis affected the skin of the wrists, elbows, knees,and scalp,and was well controlled with Betnovate topical steroid cream. 555
556
Wilson, Brown, and Ord
ORAL SURGORAL MED ORAL PATH~L
November I990 Table II. Previously reported casesof PA affecting the TMJ 1 No. of
Pain
cafe.7
1965 Franks2’ 1965 Lundberg** 1975 Lowry23 1976 BlairI 1982 Rasmussanand Bakke5 1983 Wood and Stankler14 1986 Baetzand Kleinbergi2
Fig. 1. Clinical appearanceof left condyle at removal alnd radiographic appearance of right condyle before its I‘emoval. Marked erosion and flattening of both condyl ar heads are apparent.
The arthropathy was controlled by steroid injections into the joints, nonsteroidal anti-inflammatory drugs, and an occasional course of low-dose systemic steroids. On examination, the patient was edentulous and was wearing a full set of upper and lower dentures. She had a mild trismus with a maximum interincisal opening of 2.5 cm (4.7 cm with dentures out). The left TMJ was tender with marked crepitus. The patient had beenwearing the sameset of dentures for 14 years. Radiographs showed someerosion
I 11 I 7 4
1 Limited opening
1
1
2
3 4 2
I 4 2
I
I
1
I
of the condylar head on the right side (Fig. l), and a diagnosis of TMJ dysfunction in association with PA was made. Steroid injections, physiotherapy, and the provision of a new set of dentures failed to control the pain. A high condylar shave was performed 4 months later in October 1986. This procedure failed to control the symptoms. An area of psoriasis developed in the preauricular scar postoperatively (Koebner effect), but it soon resolved. Further physiotherapy and steroid injections were also unsuccessful, and so a further exploration of the left TMJ was carried out in May 1987. At this operation the irregular condylar head was smoothed and the posterior nerve supply sectioned. An interpositional temporalis fascia flap was used to prevent reanastomosis.” Unfortunately, this operation was also unsuccessful, and similar symptoms had developed on the right side. At this stage, drug treatment was tried, including phenytoin, amitriptyline, and carbamazepine. Transcutaneous nerve stimulation, myoneural blocks, and a left stellate ganglion sympathetic block all failed to control the facial pain over the next 9 months. In April 1988 it was decided to remove the diseasedleft condylar head and replace it with a costochondral graft. This operation was carried out through a preauricular and high Risdon incision. The inner cortical table of the mandibular ramus was preservedto enable fixation of the graft. A 2.5 cm length of fifth rib with cartilage was harvested through a submammary incision and was fixed to the receptor site with three lag screws. Intermaxillary fixation was maintained for 6 weeks. The operation was performed without complication and resulted in an immediate relief of symptoms on the left side. A similar operation was carried out in December 1988 on the right side (Fig. 2) and so far the patient has been symptom free. The histology of both condylar heads was reported as nonspecific degenerative arthropathy with fibrosis. Seven months after replacement of the right condyle, the patient is without symptoms and has full function with an interincisal opening of 3 cm (5.2 cm with dentures out). DISCUSSION
All the casesof PA affecting the TMJ reported to date have responded to conservative treatment. This is the first casein which intractable pain has necessitated surgical intervention. With only 27 cases reported, this condition seemsto be uncommon. How-
Volume70
Psoriatic arthropathy
of TMJ
557
Number 5
Fig. 2. Final postoperative radiographic appearanceafter replacement of both condyles with costochondral grafts. Grafts were secured with titanium screws.
ever, in Kiiniinen’s article,* of the 400 patients with PA reported, 20% complained of TMJ symptoms. A similar percentage of patients with psoriasis free of arthritis also complained of similar symptoms. Without the benefit of radiographic analysis, these patients complaining of TMJ symptoms cannot be proved to have PA of the TMJ. From these figures, however, it seemslikely that this condition may be more common than hitherto believed. Psoriasis is a stressful condition, and this may predisposethesepatients to TMJ dysfunction. Trauma to a joint may precipitate PA,* and patients have been reported with an acute onset of PA of the TMJ after minor trauma.12-14Although it is known that stress can affect the joint and its associatedmusculature, the physiologic triggers or mechanism is not understood. Despite the clear requirements of Boyle and Buchanan, a diagnosis of PA of the TMJ is not always easy. Apart from the fact that psoriasis is not always
present or easily identifiable, joint symptoms may precede the skin condition. Demonstration of a polyarthritis may not be possible inasmuch as monoarticular involvement is a feature of the disease.5In addition, serology can be positive for 5% of the normal population. If a patient is likely to have PA of the TMJ, then a careful examination of the nails, scalp, and umbilicus may help in the diagnosis.12 Radiographic changes in the TMJ are readily demonstrated by specific TMJ views, which may show osteoporosisor erosion of the condylar heads5(Fig. 1). As mentioned earlier, the patients often have pain and limitation of movement. This limitation often persists after successfultreatment of the pain and may relate to the tendency of fibrosis in this condition.’ In the management of PA affecting the TMJs, the first aim of treatment is to relieve pain.15Initially, this should include counseling and reassurance, with emphasis placed on the benign nature of the dis-
558
Wilson, Brown, and Ord
ease.iI. ‘L I6 As suggestedin this article, the stressassociated with psoriasis may exacerbate or precipitate disease in the joints. 7,8 Control of the generalized diseaseand relief of any aggravating factors are thus important. Rest and the use of nonsteroidal antiinflammatory drugs are recommended at this stage. In this case the dentures were not thought to be contributing to the problem but their replacement and adjustment to the vertical dimension was carried out to eliminate them as a possible factor. The use of steroids has a long history in the treatment of joint pain and arthritis. As well as reducing inflammatory destruction, it can induce a pharmacologically achieved arthroplasty.16. I7 The use of steroids, either topically or systemically, must of course take into account the presence of overlying skin infection related to the psoriasis. Physiotherapy was attempted throughout the treatment in this caseto reduce pain and improve function of the joints, but it invariably failed to produce significant improvement. The operation as described by Bradley,’ ’ to section the nerve supply to the joint and to prevent reanastomosis with interpositional temporalis fascia, also proved to be unsuccessful. The role of depression in facial pain, as highlighted by HarrisIs was also considered. As a result, antidepressant therapy was used to eliminate this as a factor in the etiology. The decision to try to replace one of the diseasedcondylar headswas made only after exhausting all the remaining reasonable alternatives as described in the report. The use of costochondral grafts as joint replacements19has been very successfulin relieving pain and restoring function in casesof arthritis. When surgery is considered in such cases,the small risk of development of psoriatic lesions in the subsequent scars (Koebner effect) should be discussed with the patient. *OAlthough the primary aim in these cases should be the elimination of pain, the restoration of function is also important. In this casethe use of costochondral grafts has relieved the pain, and this patient has retained a normal occlusion with a 3 cm opening 12 months after surgery. REFERENCES 1. Mall JHM, Wright V. Seronegative polyarthritis. Amsterdam: North Holland Publishing Company, 1976:169-235.
ORAL SURG ORAL MED ORAL PATHOL November 1990
5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
20.
21.
22. 23.
Reed WB. Psoriatic arthritis. Acta Derm Venereol (Stockh) 1961; 41:396-403. Wright V. Rheumatism and psoriasis: a reevaluation. Am J Med 1959;27:454-62. Boyle JA, Buchanan WW. Clinical rheumatology. Oxford: Blackwell, 1971:304-17. Rasmussan OC, Bakke M. Psoriatic arthritis of the temporomandibular joint. ORAL SURC ORAL MED ORAL PATHOL 1982;53:351-7. Brewerton DA, Albert E. HLA and disease. Copenhagen: Munksgaard. 1977:94-107. McCarty DJ, Bennett RM. Arthritis and allied conditions. 9th ed. Philadelphia: Lea & Febiger, 1979:642-55. Koniinen M. Craniomandibular disorders in psoriasis. Community Dent Oral Epidemiol 1987;15:108-12. Fassbender HG. Pathology of rheumatic disease. Berlin: Springer-Verlag. 1975:245. Gardner DL. Pathology of connective tissue diseases. London: Arnold, 196568. Bradley PF. Conservative treatment for temporomandibular joint pain dysfunction. Br J Oral MaxillofacSurg 1987;25:12531. Baetz K, Kleinberg I. Psoriatic arthritis of the temporomandibular joint. Aust Dent J 1986;31:335-9. Blair GS. Psoriatic arthritis and the temporomandibular joint. 1976;4:123-8. Wood N, Stankler L. Psoriatic arthritis of the temporomandibular joint. Br Dent J 1983;154:16-8. Loebl DH. Psoriatic arthritis. JAMA 1979;242:2447-51. Ogus HD, Toller PA. Common disorders of the temporomandibular joint. In: Derrick DD, ed. Dental practitioner handbook. No. 26. 2nd ed. Bristol: Wright, 1986:96-101. Hollander JL, Brown EM, Jesser RA. Hydrocortisone and cortisone injected into arthritic joints. J Am Dent Assoc 1951;147:1629. Harris M. Medical versus surgical management of temporomandibular joint pain and dysfunction. Br J Oral Maxillofac Surg 1987;25:113-21. Politus C, Fossion E, Bossuyt M. The use of costochondral grafts in arthroplasty of the temporomandibular joint. J Craniomaxillofac Surg 1987;15:345-54. Fitzpatrick TB, Arndt KA, Clark WH, Eisen AZ, Van Scott EJ, Vaughan JH. Dermatology in general medicine. New York: McGraw-Hill, 1971:225-6. Franks AST. Temporomandibular joint arthrosis associated with psoriasis. ORAL SURG ORAL MED ORAL PATHOL 1965; 19:301-3. Lundberg M. Rontgendiagnostik vid kakledsbesvar. Odontol F&en T 1965;29:209-40. Lowry JC. Psoriatic arthritis involving the temporomandibular joint. ORAL SURG ORAL MED ORAL PATHOL 1975;33: 206-8.
Reprint requests to: Dr. A. W. Wilson Sunderland District General Hospital Kay11 Road Sunderland SR4 7TP, England, U.K.