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Case presentation: Chief complaint/ Brief History: The patient is a 30 year-old left handed female who presented with the following complaints: 1) moderate pain in her left jaw joint 2) mild pain in her right jaw joint, 3) pain radiating from the back left side of her head, and 4) bite changes. She reports having been struck in the face seven years ago while she was attending a concert. She immediately had clicking and popping sound in her left jaw joint. In the last two years she started having pain in the left jaw joint. Her bite began to change during the last six months. She has seen by an Oral and Maxillofacial Surgeon who did arthrocentesis twice in her left jaw joint and has injected steroid medication recently. A report from a Medical MRI detailed a normal left temporomandibular joint with mild changes on the right.

Extra-oral findings: Moderate tenderness to palpation of the left temporomandibular joint. Palpation of the left masticatory and cervical muscles revealed tenderness and multiple trigger points.

Intra-oral findings: In the closed position she only contacts her left second molars. No other teeth occlude. Range of motion 50 mm intra-incisal with good lateral movement. Crepitus is noted in the left temporomandibular joint with movement. Working diagnosis Capsulitis of the Left Temporomandibular Joint, Severe Malocclusion, and Myofascial Pain Dysfunction.

Imaging: The MRI report did not seem to correlate to the clinical findings. The patient was referred to the UCLA School of Dentistry Radiology Department. for Morita Cone-Beam Volumetric Tomography. The films were taken and reviewed by their Oral and Maxillofacial Radiologist, Sotirios Tetradis, DDS, PhD. A diagnosis of Osteoarthritic Changes of the left temporomandibular joint was made. This diagnosis correlated to the clinical findings. (See attachment of images)

Differential Diagnosis: Traumatic Arthrits, Idiopathic Condylar resorption, R/O Autoimmune arthrits (Rheumatoid, Psoriatic arthritis, etc) Laboratory and clinical evaluation revealed no positive findings.

Final Diagnois: Traumatic Osteoarthtis of the Left Temporomandibular Joint with bite changes.

Brief Discussion: It is interesting to see the late development of pain and developing malocclusion after the initial trauma. There is some discussion in the literature of this being associated more frequently with females with estrogen dysregulation. One wonders if TNF reducing medications such as Enbrel would be of any benefit (if it were not for their potential side effects). Could such medication be placed in the joint directly? For now watching for occlusion changes on a balanced occlusal splint (worn part-time) to monitor changes and the use of non-steriodal anti-inflamatory medication as needed to reduce pain and swelling.This is included with a myofascial protocol to limit her facial pain. The patient has been told when her occlusion does not change and she is pain free for at least six months corrective orthodontic and possible orthognathic procedures will be considered with no guarantee that her bite will remain stable.

Thanks to the UCLA School of Dentistry Radiology Department and Sotirios Tetradis, DDS, PhD Douglas R. Wall, DDS is in private practice in Long Beach, California He is a Visiting Lecturer and Part-Time faculty at the UCLA School of Dentistry Orofacial Pain and Sleep Medicine Residency as well as an Associate Professor and Part-time faculty at the USC School of Dentistry Orofacial Pain and Oral Medicine Residency