TMJ Surgery: Joint Derangement in Pre-adolescents Part II

This is a MRI scan of an 11 year old patient who was referred for management after 2 years of clinically significant and progressive joint instability, locking and pain. In the lateral aspect of the joint, one can see impressive osteophyte formation in several locations about the lateral aspects of the joint. The patient had no systemic arthritic condition to explain these findings and work up for juvenile rheumatoid arthritis or other degenerative arthritic condition known to evolve in children. The only systemic condition of possible importance was long term history of ear infections, requiring several myringotomy tubes for management.

The Patient has a developing impingement (Type III) since the condyle is involved as well. More often, pre-adolescent and adolescent patients with longstanding functional problems of the joint will exhibit impingement of the lateral rim and eminence areas of the fossa component. Condyle involvement is rare.

The patient’s mother confirmed progressing pain and joint noise in all range of motion but particularly with chewing/loading since about age 8. Joint instability and pain were particulary noticeable in side to side jaw movements.

Months of orthotic (splint) wear was unsuccessful . The referring orthodontist could not manage orthodontic treatment due to well localized joint pain and progressive difficulty with mouth opening. Surgical exploration revealed near complete rupture or detachment of the disc/capsule at its lateral pole and posterior-lateral aspects. Reconstructive  arthroplasty repair of the torn disc/capsule  after removal of osteophytic processes restored range of motion and eliminated pain. She will complete her orthodontic treatment in early 2011.

The important point here is that significant joint pathology can be present in pre-adolescent patient populations. Diagosis of etiology is important rather than to assume the “TMJ” problem is related to or will always respond to occlusion related treatment modalities.