Author: Ryan Wennell, DO
Co Author #1: Mark E. Lavallee, MD

Patient Presentation:
22 y/o female collegiate soccer player presenting with temporomandibular joint (TMJ) hypermobility with associated pain.

History:
The patient's TMJ issues began in November 2009 when biting into an apple. Over the next four years she experimented with treatments consisting of occlusion guards, physical therapy, nerve blocks, arthrocentesis, condylotomy procedure, botox injections, duloxetine, gabapentin, pregabalin, clonazepam, and meperidine, with limited pain relief. Her laboratory work up including urinalysis, CBC with automated diff, lipid panel, C-reactive protein, comprehensive metabolic panel, and TSH were all normal. Her rheumatologic workup which included Anti-CCP IgG, ANA, C-reactive protein, and sedimentation rate, was negative. Neurology consultation ruled out primary or secondary dystonias and multiple sclerosis. MRI of the TMJ joint showed bilateral anterolateral disc subluxations. Psychology consult showed a well-adjusted college student with no overt signs of Munchausen's, depression, anxiety, or other mood personality disorders.

Her most recent surgery involved placing autologous fat grafts bilaterally into her temporomandibular joints. She currently wears a TheraBite device 24 hours a day. She periodically uses a mechanical opening device to reach her recommended TMJ range of motion. She has lost 10 pounds over 4 years as she eats only soft foods; she is otherwise healthy.

Her family history is significant for a sister with multiple shoulder dislocations without trauma. Her mother and paternal grandmother have “clicking heart sounds�. There is no family history of easy bruising, easy scaring, or aortic aneurysms before the age of 40 or 50.

Physical Exam:
HT 64 in, Wt 140.2 lbs. Skin: soft, velvety skin. Incisional scars are noted bilaterally in the pre-auricular areas with appropriate healing. There was no scarring consistent with cigarette scar paper tissue. Palm skin was "pinchable"�. No skin translucency is noted in the anterior chest wall region. HEENT: No blue color to sclera or tympanic membranes. Mandible was retracted. Dentition was normal, without erosions, and braces were present. There was notable restriction in her ability to open mouth (less than 10 mm). Cardiovascular: RRR, normal S1/S2 murmurs, gallops, rubs, or clicks. A mild dextroscolios from T3-T8 was noted. A sulcus sign was noted with with voluntary dislocation of the left shoulder. Passive dorsiflexion of metacarpophalangeal joint was possible beyond 90 degrees bilaterally. Passive opposition of the thumb to the flexor aspect of the forearm is noted bilaterally. Hyperextension of the elbows beyond 10 degrees was possible bilaterally. Hyperextension of the knees beyond 10 degrees was possible bilaterally. Forward flexion of the trunk with knees fully extended is possible so that palms of hands rest flat on the floor. There was significant sub-talar joint laxity bilaterally.

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