Here's a case I've been reviewing with Jim McKee lately that we wanted to share for some collective input.

This 15 year old patient presented to my office last year with a concern for her facial asymmetry and challenging bite. She reported no history of joint pain or difficulty opening or closing, but due to her presentation, diagnostic imaging was obtained to understand her joint condition before recommending treatment. As seen below, we discovered slight hypertrophy of the left condyle on the CBCT, and bilateral anterior disc displacement via MRI. Incidentally, I had an opportunity for Mark Piper to review the case at a local meeting, and he suggested bilateral fat graft surgery to repair the joints followed by orthognathics and orthodontics to correct the asymmetry and occlusion.

The patient's mother declined a referral to see Dr Shah in St. Petersburg, and over the past several months has sought out the opinion and advice of TM joint surgeons across the country... surgeons that are well known for their knowledge and skill. None of the surgeons support the concept of a fat graft, and they all are recommending bilateral total joint replacement.

The surgeon they have expressed interest in admits that there are no long term studies for total joints after 20 years, but also is quick to advise me that there are no studies about the success of fat grafts. He showed several cases of fat grafts done on small atrophic joints which relapsed over time. He is recommending total joint replacements for my 15 year old patient asap to restore her form and function, improve her airway, and prevent her from suffering "social ridicule".

After reviewing the following images, how would you advise this patient to proceed? What are your thoughts on a total joint replacement for a 15 year old patient? Or, are you likely to recommend orthognathics and orthodontics without any treatment at the joint level?

Notes from joint exam:

S: Patient presents with concern for her TMJ. She reports no pain or symptoms but presents with an altered occlusion that is often consistent with TMJ structural alteration. Patient recently completed orthodontics. She reports no history of joint locking, but has had intermittent clicking in her joints but cannot recall which joint. She is able to function normally but is concerned about why her bite is off and her chin is offset. Trauma history includes getting hit very hard with a playground ball during the eighth grade which struck the right side of her face. Patient's mother expresses concern with patient's airway and progression of receding chin.

O: Conducted joint and muscle examination, and evaluated occlusion. Patient demonstrates a significant skeletal chin point to the right side and a steep mandibular plane angle. She demonstrates a normal ROM, path of motion, and rate of motion. No pain on either joint to palpation or loading. Patient struggles to move into left lateral excursion but with effort can do so without pain. There is a faint click in the right joint with seated translation. In FSCP, patient demonstrates a lower midline shift to the right of 5mm, a 5mm overjet, and an anterior open bite. She demonstrates a Class II molar relationship on the right side, and Class I relationship on the left. ROM: Max opening 52mm, L/R 10mm, protrusive 12mm. She demonstrates bilateral group function. Patient demonstrates vertical maxillary excess, a narrow palatal vault, and strained lip competency.

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