20 year old male who said he was so sore yesterday that he nearly threw up and nearly passed out. He says the problem is "my jawbone". He describes how pain moves from one spot to another around most of his face, mostly near the right ear. He has headaches 24/7 across his temple. He described that his pain would pass through his temples and out his ear. His molars feel like they are "under pressure". The patient has suffered "multiple concussions", mostly from snowboarding. Two months ago he hit his jaw in an accident. He was punched in the jaw 6 mos ago. His mother is a nurse and he has been taking "Norco" (I'm not familiar with this but it seems to be a strong form of Vicodin), nsaid's and muscle relaxants on and off for the last six months.

He uses a lot of ice.

During the last year he has experienced loud popping and daily pain. He says he has clicking, popping and grinding in both joints. He has pain in the morning, when talking and during any jaw movement.

During the last two weeks his symptoms seem to have worsened. He wakes up and his jaw is "super tight and stiff". It feels like concrete is pouring out of his right ear and his left side feels like it's ready to "snap". He says he feels like he has an ear infection. He sais that during this time he experienced both closed lock and open lock.

Clinical Exam: Muscle palpation revealed a level 6 of 10 tenderness over the right masseter. All other muscles and both joint capsules were negative to palpation.

Provocation tests elicited pain when the mandible was advanced directly forward against pressure from my hands. There was similar pain when moving against a load in right lateral and on opening. The area of pain was mostly in front of the right ear. The mandible could be loaded in a seated position without discomfort.

Bite stick test: no pain was elicited when biting on a stick on either side. The patient felt that the pain was alleviated on the right side when he bit on the stick in the right side.

Range of motion was normal in all directions. There was no noticeable clickcing or popping. His other was surprised that she did not hear the popping during my exam.

There was a soft "end feel".

Upon opening the mandible deflected immediately to the right in a straight line to the end of opening and returned along the same path. It was apparent that his right condyle was not translating during opening.

The patient's general dentist gave him an appliance which I think was a soft full coverage appliance without indentations (smooth flat biting surface). He wore it full time for 2 months and said that it did not help and that he did not bite evenly on it.

The patient has a severe Class III skeletal open bite. His mandible seemed to manipulate easily into a seated condylar position. His max opening was 55mm.

Photos are attached. Due to his history of trauma, I wonder if a cone beam would be helpful for me.

I haven't yet but I will likely point him towards a local practitioner who devotes his practice to facial pain issues, however, I'm hoping I can learn something from the patient and from the SPEAR folks.

Due to his history of trauma

My thinking is that he has a displaced disc without reduction on his right side (closed lock). There is associated muscle pain. I gave him an aqualyzer and told them to consider physical therapy and continued nsaid's if they are helpling. He has seen a Kaiser physician. Kaiser wants me to tell them if the problem is due to his bite or not. If it is his bite then they want me to fix it. I he should be treated medically until his symptoms resolve with Kaiser. Once his symptoms begin to improve then I can put him on a full coverage splint and see if I am able to get him comfortable. If I can get him comfortable, then we can discuss fixing his bite.

Ok now let me see if I remember this right from the videos: he has no pain on loading when the condyle is seated. HE has pain on translation. Therefore it's a lateral pole issue and any appliance should protect the condyle during excursions meaning it needs balancing contacts. Dang, I need to watch the video again to see if I got that right!!

Any input greatly appreciated![image:Bonner_image.jpg]