We identified nine articles [3,4,5,6,7, 17,18,19,20] on TMJ septic arthritis of otogenic origin in children published since 2000 in English literature. Seven articles were case reports [3, 5, 7, 17,18,19,20,21] and they did not evidence any long-term consequences of septic arthritis of TMJ. On the other hand, Luscan et al. [3] observed in a prospective study of 45 patients that 1 patient had an erosion of the temporomandibular condyle and 2 patients presented clinical diagnosis of TMJ ankylosis as long-term complication, 4 and 16 months after otomastoiditis.

Burgess et al. [6] reported nine pediatric cases of otogenic septic arthritis of the temporomandibular joint in a retrospective study and showed that six patients presented a late ankylosis of TMJ from 0.5 to 4 years after the initial middle ear infection.

In this article, we present the management of a 9 years-old female patient with reduced mandibular movement, orofacial pain and condylar resorption that arose 2 years later an otomaoiditis.

The clinical presentation of our patient was characterised by many overlapping signs and symptoms making diagnosis difficult to perform at a glance. The patient had no history of trauma and the left otomastoiditis reported occurred about 2 years before the first symptoms of temporomandibular joint involvement. Differential diagnosis is crucial in such cases, where growing patients are involved, because the sequelae of temporomandibular disease may influence growth and mandibular function leading to severe facial asymmetry and permanent mandibular impairment [21, 22]. Dental practitioners need to be able to formulate differential diagnosis hypothesis and to address the patient to the right specialists. Moreover, conservative treatment, including counselling and physiotherapy, helps the patients in managing the acute situation with minimal risks preventing complications such as fibrosis and ankyloses of the temporomandibular joint [14, 15]. To date there is no consensus on treatment of post-infectious osteoarthritis [3]. Nevertheless, there is evidence for physiotherapy in being effective in most of TMDs, improving mobility of the temporomandibular joint and preventing adherences and ankyloses [14, 15]. The bone remodelling resulting from osteoarthritis is a permanent alteration of bone structure. However, condylar cartilage has itself a potential for bone modification and in growing patients there is as well a potential for condylar growth [23]. Modulation of bone remodelling and residual growth in growing patients [24] can be effective in improving facial symmetry by addressing the condylar asymmetry [21, 25]. In order to start any orthopaedic and orthodontic treatment, the inflammatory condition of the temporomandibular joint has to be under control and the mandible has normal function [21, 25, 26]. It is important to inform the patients and the families about these opportunities and to underline the importance of preserving mandibular function.

In our case, the patient improved mandibular function and full recovery of mouth opening without any pain during mandibular movement. Moreover, the conservative therapy and the use of a nocturnal bite plate helped pain management and were effective in reducing both myalgia and arthralgia of the left temporomandibular joint. The one-year control MRI showed stable bone morphology without progression of bone erosion and with no evidence of inflammation. The patient undergoes regular follow-ups. As soon as the pubertal growth spurt starts, we will consider the opportunity of undergoing orthopaedic treatment with a mandibular asymmetrical activator to address condylar asymmetry.

As previously suggested [6], this case highlights the importance of long-term follow-ups in children with acute media otitis or otomastoiditis due to TMJ disorders that can occur up to 4 years later.

Furthermore, in the multidisciplinary management of orofacial pain the role of the pediatric dentist is crucial for the diagnostic and therapeutic pathway to avoid serious impairment of mandibular function.

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