Hello citizens of Spear Talk,

This case is a bit of an urgent matter as the patient is booked for left TMJ replacement at the end of the month. I was not involved in the work up of this patient, I just found out recently that they had been referred to a local ENT to have this procedure done.

Patient is a 16 year old female, no medications, healthy. She presented to my office a few years ago with "pain in the left [tm] joint". Head and neck exam demonstrated a left disk click on translation and pain on palpation of masseter muscles. The pain was moderate at the time. I am going from memory here but I believe that we made her a night guard to address the muscle soreness. This was approximately 12 months ago and right after she had been taken out fo her braces. She presented to my office a week ago booked to have the left TMJ replaced. At this time the patient explained that the pain on the left was getting better but still had not gone away. Head and neck examination at this appointment showed slight pain on palpation of the left mid masseter. Below is a pain that was taken in 2021 shows that the left condyle is shaped differently than the right, and the measurement of the left condyle to angle of the mandible is shorter than on the right, which I believe is consistent with an injury to the joint early in life. Patient does not have crepitis, or pain on palpation of either TMJ. Her current level of discomfort does not require her to take pain medications to live with.

Medical CT report: "There is bony erosion and flattening of the left mandibular condyle with overhanging marginal osteophytes and reduced joint space. Frank, smooth, bony erosive change is seen involving the left mandible condyle. Ddx includes both inflammatory and degenerative arthropathy"

Medical MRI report: Paraphrasing - left anteriorly displaced disk with the condyle articulating with posterior edge of disk. Disk recapture upon opening, however at a "slightly" suboptimal posterior location. Bone marrow returns a normal sign, no other significant bone or joint abnormality. Impression: Moderate left TMJ OA (osteoarthritis?) with associated partial left TMJ dysfunction as described.

I am picking up the medical ct and MRI tomorrow.

I will confirm the details as posted, I really wanted to get this onto the forum ASAP as this surgery is booked soon!

My concerns:

- Joint replacement at 16 years of age- is her bone structure sufficiently mature to be altering a joint at this age? Will she have[image:62036016e6991_IMG_0100.jpg] to have this joint replaced later in life?

- Joint replacement to address what seems to be discomfort coming from muscle issues

- If joint replacement is the treatment of choice in this case, should we be establishing a vertical dimension of the left condyle to angle of mandible to match the right? It seems that if the pain is not coming from the joint that replacing the joint at the same vertical dimension will perpetuate the muscle problems.

THE PHOTOS ARE ORDERED RIGHT SIDE THEN LEFT SIDE.

[image:62049e551953a_Right_coronal_CT.jpg][image:62049e551da97_Left_coronal_CT.jpg][image:62049e551da97_Right_sagittal_CT.jpg][image:62049e5518d67_left_sagittal_CT.jpg][image:62049e61c9502_Right_ramis_measure.jpg][image:62049e61c95d4_Left_ramis_measure.jpg][image:62049e784537e_MRI_open.jpg][image:62049e7845304_MRI_closed.jpg]