I recently met a 23 yo patient who was referred to me for an evaluation of his TMJ. He reports a history of chronic headaches. After gathering his history and conduction an evaluation, I need assistance with his differential diagnosis and with my next steps for him. Please read on...

His history: Orthodontics prior to 2008 with normal orthodontic result. Maxillary bicuspids were removed. In 2008, patient recalls having clicking in his TMJ joints, but no pain or headache. His dentist made him and upper and lower hard "stent", suggested stretching exercises, and followed up with him. The click disappeared after some time. In 2012, he began to have headaches and visited several physicians for relief including acupuncture, Botox injections, and many medications. In 2014, the clicking returned and the headaches persisted. His oral surgeon identified an anterior open bite that the patient had not been aware of. Patient saw another dentist who made a single arch hard acrylic nightguard for the maxilla, which patient wore for about 3 months. No improvement was noticed with his headaches. In 2015, his oral surgeon, orthodontist, and general dentist agreed that patient would benefit from orthognathic surgery, which was performed on the maxilla only. Patient continues to have headaches and jaw pain. He points specifically to joint area on both sides, and reports a routine click on the right side when he opens, and a click on the left side when he opens very wide. He also reports pain on either side of the bridge of his nose.

My evaluation: Patient demonstrates normal range of motion yet deviates to the left as he closes. His left joint is tender to vertical loading; both joints are tender to lateral pressure; several muscles are tender to palpation including bilateral masseters, temporalis, medial pterygoids, and SCMs. He demonstrates a generalized posterior open bite yet has initial CR contact on #'s 3 vs 30 with minimal resistance. He shows minimal signs of wear, yet has a posterior crossbite. Normal overjet and overbite. Maximum opening is 45mm, left 10mm, right 12mm, protrusion 7mm. He brought in several MRI images on film but the assessment by the physician was "thinning of the disc on the left side" and "no dislocation of the TMJ disc is seen".

My assessment: Based upon the muscle exam, I feel that I need to rule out any component of his pain that may be occlusion related with a hard CR bite splint to be worn as often as possible. I suspect that his pain also has a joint component to it based upon the history of clicking/not clicking, bite changes, and pain to lateral pressure and vertical loading.

I am wondering what may have caused his open bite to develop between 2008 and 2014. Was it condylar breakdown (avascular necrosis) with anterior displaced discs, or could there have been some odd growth pattern that was responsible? I'm skeptical of the physician's MRI report but the images are too small for me to read.

Will a splint be of value, or should I request better imaging now?

Images are attached which demonstrate photos and ceph before (anterior open bite) and after (posterior open bite) orthgnathic surgery.