Patrick Grossman Wilkes Case

Introduction

This case describes the complex treatment of a 16 yr old girl who was referred in 2008 by her GDP on account of her ongoing and debilitating headaches, TMJ pain, clicking and left-sided locking. Since 2001 she had attended an osteopath on a regular basis for head and neck pain, right foot/calf pain and lower back pain. She had consulted other musculo-skeletal specialists who diagnosed

• restriction of atlanto-axial joint
• leg length discrepancy
• asymmetric gait pattern

Treatment from 2006 included lower intra-oral orthotic, upper ALF appliance, acupuncture, medication, and psychotherapy. None of these treatment modalities had given her any appreciable relief.

An MRI report (2006) of her TMJs stated “anteriorly displaced non-reducing disc on left side (Wilkes IV) with rotated anteriorly displaced partially reducing disc on right (Wilkes III).”

See Fig 1

Note that the occlusion in 2006 gives no indication as to the degree of degenerative joint disease (see MRI report).

Diagnosis and Treatment

At her consultation with me in 2008, the patient reported two significant facts, namely that she was a forceps delivery and aged 5 years, she had fallen down the stairs and banged her jaw. Her chief concerns were

• jaw pain
• headaches
• backache
• chronic fatigue

Clinical examination revealed 35 symptoms related to TMJ dysfunction including reduced vertical and lateral movements.
Maximum opening  =  40mm (normal value 48-52mm)
Left and right lateral movement = 10mm (normal value 12-15mm)

A diagnosis was made of bilateral internal derangement of the TMJs associated with muscle spasm.

A further MRI was taken in 2008 which reported that the left side was unchanged although the right was relatively normal.

See Fig 2

Treatment was carried out in accordance with the protocol developed by Dr B C Stack ,namely splint treatment to decompress both joints combined with disc plication surgery to restore normal anatomy and function. This constitutes Stage 1 treatment. When the patient is stable and painfree then Stage 2 orthodontic treatment is undertaken to close the posterior open bite without altering the corrected maxillo-mandibular relationship. Splint height is determined by use of A.K testing and the position in which the patient is comfortable. 

See Fig 3

As can be seen from the photos, the splint height was unusually high which complicated Stage 2 stabilization orthodontic treatment.

At a joint consultation in 2008 with a max-fac consultant surgeon it was decided to continue splint treatment for a further 5 months prior to carrying out a left disc plication procedure. Surgery was supported by intensive physiotherapy in the form of the Therabite exerciser.  One week post op, the patient reported no headaches and no back pain. Her symptoms continued to fluctuate over the following 6 months with a recurring pain over the left joint and now discomfort in the right joint. In 2009 a right disc plication procedure was undertaken following which the patient reported a significant improvement in her headaches and back ache. Five months post surgery she completed a7 mile walk which she could not have contemplated previously.

Over the course of the following 6 months she felt well and it was decided to undertake Stage 2 orthodontic treatment.  Soon after the treatment had started the patient reported “cracking sounds in both joints” and so orthodontic treatment was suspended. She was advised to continue wearing her lower splint and following a further maxillo facial consultation and new MRI, revision surgery on both joints was undertaken in 2011.  The patient restarted Stage 2 stabilisation treatment in 2013 and treatment was completed 18 months later.

Fig 5  note that after composite blocks were removed terminal molars are now in good occlusion

Conclusion

This case was extremely challenging given the lengthy treatment time and the complex orthodontics necessary to close the severe posterior open bite. It also highlights how difficult it can be for the clinician to inform a patient as to how long their treatment will take.