A Virtual TMJ Consultation

Dr. Halligan
Dr. Halligan

A Mr. PD emailed me after reading some of the articles on this website in hopes that I might be able to help him. He described symptoms of ear pain, jaw pain, Jaw joint noises, especially on the left, limited opening of the jaw and vertigo. When I replied to his email, I asked whether he had CT scans or MRI of the temporomandibular joints (TMJs) and he said he did and could forward them to me.

I let him know that if he forwarded the images to me, I could write a report of radiographic (x-ray imaging) findings and that I would also be available for a phone consultation.

The patient sent several photos and x-ray images and I’ll just review a few of them here, but there should be enough to give you a good idea how a remote consultation can go.

After I show you the images displayed on a computer screen, I’ll also highlight the various x-ray findings so that my report to the patient becomes clearer.

By the way, the patient wrote that his dentist said the images were normal.

My report and remarks:

  • Condylar hypoplasia, left side
  • Ramus hypoplasia left side
  • Posterior displacement of left condyle
  • Deviated nasal septum
  • Articular eminence sclerosis
  • Bone deposition gonial angles, both sides

Note: I would usually comment on cervical spine (neck x-rays) also, but in this case, the images I was forwarded did not include a good series of lateral cervical spine.

Dear PD,

The most obvious finding on your images is the short ramus and small condyle on the left side. The development of the ramus and condyle on the right side, on the other hand, appears to be normal. When I see that kind of asymmetry, that is, one side of the jaw significantly smaller than the other, the cause is usually a childhood (age 15 or younger) head trauma. I suspect that for you that must be the case.

Ramus length discrepancy.

In addition, the left condyle is displaced back toward the ear, and there is less disc space than normal. The disc is probably displaced anteriorly (forward), but it would require MRI to verify. I can see that the right condyle is also slightly displaced, but not as much as the left.

The part of the temporal bone—the articular eminence—where the condyle is nearly touching, shows thickening in response to years of stress on that area.

 

Bone deposition of the gonial angles is highlighted in this image.

This is a sign of extreme clenching and possibly grinding of the teeth. It is more prominent on the right side, and the teeth on the right probably hit harder than the left whenever you close.

 

There is a pronounced deviated septum. Although your airway appears to be normal, the deviated septum could lead to snoring if not actual sleep apea.

Deviated septum.

Obvious also are two retained root tips, likely fractured during what appears to be recent wisdom tooth removal.

Root tips.

Mr. PD wrote back and stated that I was “spot on!” He had indeed had a serious Moped accident at age 15 with injuries to head and neck. He did have a deviated septum but had had surgery to correct it after the images were taken. He also knew that the oral surgeon had left behind two fractured root tips but had elected to leave them in place because of proximity to the nerve.

He also acknowledged the bite feeling off, with especially hard contact on the right; in fact he had broken an upper right molar shortly before the images were taken and the tooth had been crowned and that the crowned tooth was still hitting hard when he closed.

After exchanging emails, I then had a 40-minute phone conversation with the patient. He told me about various things that had already been tried, including bite adjustment by his primary dentist and placement of a lower orthotic by another dentist. The dentist who made the orthotic, Mr. PD claimed, did not want to see the CT scans of the jaw and did not rely upon them in making the orthotic. So far, he said, nothing had helped, in fact the bite adjustment seemed to make his symptoms worse. He showed me a picture of the orthotic in his mouth with teeth closed on it. What was obvious in the photo was that the orthotic moved his lower jaw even further to the left which, of course, could only worsen the strain on the damaged left joint.

Although I told the patient that I did not want to disparage either dentist, I did think a 2nd opinion was called for and I referred him to a colleague whom I believe can do a more thorough assessment including history and physical exam, take a careful look at all CT scans, and also discuss a long-term plan including possible orthodontics to correct the obvious asymmetry of the jaw.

I told the patient that I don’t believe any short-term fix will be adequate.

He emailed me back a couple of days later to let me know he has made an appointment with the doctor I recommended.

Now, even though I did not meet with the patient personally, I think it is clear that quite a lot can be accomplished through just reviewing good x-ray images, history, and symptoms and following up with a phone call. After the fact, I can see that conferencing through Zoom or similar video format could have been even more valuable and it is something I will add in future consultations of this kind.

 

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